Association of perioperative oral swallowing function with post-esophagectomy outcomes and nutritional statuses in patients with esophageal cancer

Dysphagia after esophagectomy is a serious complication; however, no method has been established to accurately assess swallowing function. We evaluated the association of swallowing function tests with patients' post-esophagectomy complications and nutritional statuses. We retrospectively reviewed the data of 95 patients with esophageal cancer who underwent esophagectomy between 2016 and 2021. We performed perioperative swallowing function tests, including the repetitive saliva swallowing test (RSST), maximum phonation time (MPT), and laryngeal elevation (LE). Patients with recurrent laryngeal nerve palsy (RLNP) and respiratory complications (RC) had significantly lower postoperative RSST scores than patients without them; the scores in patients with or without anastomotic leakage (AL) were similar. Postoperative MPT in patients with RLNP was shorter than that in patients without RLNP; however, it was similar to that in patients with or without AL and RC. LE was not associated with any complications. Patients with an RSST score ≤2 at 2 weeks post-esophagectomy had significant weight loss at 1, 6, and 12 months postoperatively compared with patients with an RSST score ≥3. The proportion of patients with severe weight loss (≥20% weight loss) within 1 year of esophagectomy was significantly greater in patients with RSST scores ≤2 than in those with RSST scores ≥3. Multivariate analysis showed that an RSST score ≤2 was the only predictor of severe post-esophagectomy weight loss. RSST scoring is a simple tool for evaluating post-esophagectomy swallowing function. A lower RSST score is associated with postoperative RLNP, RC, and poor nutritional status.

Effect of Oral Nutritional Supplementation on the Prognostic Nutritional Index in Gastric Cancer Patients

This prospective study was undertaken to investigate whether preoperative oral nutritional supplementation (ONS) would increase the prognostic nutritional index (PNI) in gastric cancer patients undergoing gastrectomy. Before surgery for resectable gastric cancer, Racol® NF (Otsuka Pharmaceutical Factory, Japan) was administered orally at a recommended dose of 600 kcal/600 ml per day to patients with a PNI of <48. The primary endpoint was the change in the PNI, which was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm³). Forty-six patients received Racol^® NF. The mean PNI at baseline and before surgery was 44 ± 3.9 and 43 ± 4.4, respectively (p = 0.049). The mean serum albumin level was significantly decreased after the administration of Racol^® NF (p = 0.001), while the mean total lymphocyte count (p = 0.001) and body weight (p = 0.004) were significantly increased. The mean daily intake and duration of Racol^® NF administration were 340 ml and 22.6 day, respectively. Adverse events during the administration of Racol^® NF were observed in 12 (26.1%) patients. The present study indicated that preoperative ONS did not increase the PNI in gastric cancer patients with low PNI values.

Risk Factors and Risk Scores for Predicting Early Recurrence After Curative Gastrectomy in Patients with Stage III Gastric Cancer

BACKGROUND

We revealed patients with pathological stage (pStage) III gastric cancer (GC) who had early recurrence within 12 months after curative surgery. We identified risk factors for predicting early recurrence in patients with pStage III GC who underwent curative gastrectomy.

METHODS

Between January 2007 and December 2016, 758 patients underwent gastrectomy in our institution. This retrospective study included 96 patients with pStage III who were divided into two groups: early recurrence within 12 months (ERec) and non-ERec (nERec). We investigated clinicopathological differences between ERec and nERec and extracted risk factors, and constructed risk scores for ERec.

RESULTS

Of the 96 patients, 20 (20.8%) were ERec and 76 (79.2%) were nERec. Pathological lymph node metastasis (pN) ≥ 14 (P = 0.03), preoperative carbohydrate antigen 19-9 (CA19-9) ≥ 37 IU/ml (P = 0.02), and blood loss (BL) ≥ 445 ml (P < 0.01) were independent risk factors for ERec in the multivariate analysis. In subgroup analysis, tumor size, clinical lymph node metastasis (cN), and CA19-9 were extracted for preoperative predictors for ERec. Risk scores were assigned to tumor size (< 65 mm, 0; ≥ 65 mm, 1), cN (cN-, 0; cN+, 2), and CA19-9 (< 37 IU/ml, 0; ≥ 37 IU/ml, 2). High-risk group (score, 4, 5) for ERec had significantly shorter relapse-free survival than those with low-risk group (score, 0-3) (P = 0.02).

CONCLUSIONS

We found pN ≥ 14, CA19-9 ≥ 37 IU/ml, and BL ≥ 445 ml were independent risk factors for ERec after curative gastrectomy in pStage III GC. Our risk score system may be useful to select patients with high risk of ERec preoperatively.

Ring box protein-1 is associated with a poor prognosis and tumor progression in esophageal cancer

Ring box protein-1 (RBX1) is an essential component of the S-phase kinase-associated protein, Cullin and F-box containing ubiquitin ligases. Overexpression of RBX1 has been reported in several cancer types; however, little is known regarding the prognostic value and role of RBX1 in esophageal cancer. The present study examined 120 patients with esophageal cancer (EC) who underwent curative esophagectomy and 61 patients with EC who underwent neoadjuvant combination chemotherapy with docetaxel, cisplatin and 5-fluorouracil (5-FU; DCF) using immunohistochemistry. All specimens were classified into two groups according to the percentage of RBX1-positive tumor cells. In addition, the impact of RBX1 expression on cancer cell proliferation was analyzed in vitro using a small interfering RNA silencing technique. RBX1 expression levels showed significant differences according to tumor size (P<0.001), tumor depth (P=0.002), lymph node metastasis (P=0.004), pathological stage (P=0.001), lymphatic invasion (P=0.001) and venous invasion (P=0.001). The overall survival (OS) rate in the RBX1 high expression group was significantly lower compared with that in the low group (P=0.004). Multivariate analysis demonstrated that RBX1 status was an independent prognostic factor. RBX1 gene silencing inhibited the proliferation of human EC cells and enhanced the antitumor effect of 5-FU. Among patients who underwent neoadjuvant DCF therapy, the RBX1 high expression group had a significantly lower OS rate compared with that of the RBX1-low group (P<0.001). In conclusion, RBX1 has notable prognostic value, and RBX1 may serve an important function in the tumor progression of EC.

Predicting Early Cancer-related Deaths after Curative Esophagectomy for Esophageal Cancer

Esophagectomy is the primary treatment for esophageal cancers, but a few patients still suffer from early recurrence and die within one year after surgery. The aim of this study was to identify preoperative predictive risk factors for early cancer-related deaths after curative esophagectomy for esophageal squamous cell carcinoma. The records of 200 consecutive patients with esophageal cancer who underwent esophagectomy between 1990 and 2009 were retrospectively reviewed. The preoperative clinical characteristics of the remaining 32 patients who died of cancer within one year were compared with those of 168 patients who survived for more than one year postsurgery. The most frequent cause of death was lymph node recurrence followed by local recurrence and lung metastases. A tumor size 60 mm or greater and lymph node metastases in two fields on preoperative imaging were identified as prognostic factors on multivariate analysis. The one-year survival rate and median survival time of patients with both these risk factors were 40 per cent and 12 months, respectively. Aggressive additional treatment may be needed if both a tumor size 60 mm or greater and lymph node metastases in two fields are found during diagnostic imaging before esophagectomy for esophageal squamous cell carcinoma.

RNF126 as a Marker of Prognosis and Proliferation of Gastric Cancer

BACKGROUND/AIM

Ring finger protein 126 (RNF126) belongs to the family of RING E3 ubiquitin ligases. Although RNF126 has been reported to be overexpressed in several cancers, the role of RNF126 in gastric cancer remains unclear.

MATERIALS AND METHODS

We investigated the RNF126 expression in 170 primary gastric cancer tissues by immunohistochemistry, and explored its prognostic impact. The effect of the RNF126 expression on the proliferation of cancer cells was evaluated in vitro.

RESULTS

The RNF126 expression was significantly associated with tumor depth and presence of venous invasion. The RNF126 status was identified as an independent prognostic factor (p<0.001). RNF126 gene silencing significantly inhibited the proliferation of gastric cancer cells, induced G₁ phase arrest and increased the p21 protein level.

CONCLUSION

RNF126 expression has a significant prognostic value in gastric cancer. RNF126 may play an important role in tumor progression of gastric cancer.

Risk factors for stage underestimation in patients with clinical T1N0 gastric cancer

PURPOSE

Limited gastrectomy has been generally performed in clinical T1N0 gastric cancer. The aim of this study was to identify risk factors for stage underestimation in clinical T1N0 gastric cancer.

METHODS

This study reviewed the medical records of 566 patients who underwent gastrectomy for clinical T1N0 gastric cancer.

RESULTS

The tumor stage was underestimated in 122 (21.6%) patients. The relapse-free survival rate was significantly lower in the patients with pathological stage II (P = 0.021) and III (P < 0.001) disease than in those with pathological stage IA disease. In the multivariate analysis, a location in the upper third of the stomach, tumor size of ≥ 30 mm, undifferentiated adenocarcinoma and clinical tumor depth of SM were identified as independent risk factors for pathological stages II and III. The rate of pathological stages II and III was 0% in the patients with no risk factors, 3% in those with 1 risk factor, 10.5% in those with 2 risk factors, 19.8% in those with 3 risk factors and 50% in those with 4 risk factors.

CONCLUSIONS

Location, tumor size, undifferentiated adenocarcinoma and clinical tumor depth were independent risk factors for pathological stages II and III in clinical T1N0 gastric cancer.

Overexpression of Cullin4A correlates with a poor prognosis and tumor progression in esophageal squamous cell carcinoma

BACKGROUND

Cullin4A (CUL4A), which is a component of E3 ubiquitin ligase, is implicated in many cellular events. Although the altered expression of CUL4A has been reported in several human cancers, the role of CUL4A in esophageal cancer remains unknown.

METHODS

We investigated the CUL4A expression in primary esophageal squamous cell carcinoma (ESCC) tissue specimens from 120 patients by immunohistochemistry and explored its clinical relevance and prognostic value. Furthermore, the effect of the expression of CUL4A on cancer cell proliferation was analyzed in vitro using an siRNA silencing technique.

RESULTS

The higher expression of CUL4A was significantly associated with a deeper depth of tumor invasion (P < 0.001) and the presence of venous invasion (P = 0.014). The disease-specific survival (DSS) rate in patients with tumors that showed high CUL4A expression levels was significantly lower than that in patients whose tumors showed low CUL4A expression levels (P = 0.001). Importantly, the CUL4A status was identified as an independent prognostic factor for DSS (P = 0.045). Our results suggested that the CUL4A expression has significant prognostic value in ESCC. Furthermore, CUL4A gene silencing significantly inhibited the proliferation of ESCC cells in vitro. In addition, the knockdown of the CUL4A expression induced G1 phase arrest and increased the p21 and p27 protein levels.

CONCLUSIONS

CUL4A might play an important role in regulating the proliferation of ESCC cells and promoting the development of postoperative recurrence.

Postoperative Serum C-Reactive Protein Level Predicts Long-term Outcomes in Stage I Gastric Cancer

BACKGROUND

The aim of this study was to investigate the prognostic impact of postoperative systemic inflammation in patients with stage I gastric cancer.

METHODS

This study reviewed the medical records of 470 patients with stage I gastric cancer who underwent gastrectomy. The postoperative serum C-reactive protein (CRP) level on postoperative days (PODs) 1 and 3 and its peak value were evaluated as prognostic factors. A receiver operating characteristics curve analysis was performed to determine their cut-off values.

RESULTS

The CRP level on POD 3 (P = 0.001) and the peak CRP level (P = 0.007) were significantly associated with the overall survival rate. In the multivariate analysis, the CRP level on POD 3 (P = 0.002) and the peak CRP level (P = 0.008) were identified as independent predictors of the overall survival. The high CRP on POD3 group had significantly higher mortality rate from relapse of gastric cancer (P = 0.001) and infectious disease (P = 0.003) than the low CRP on POD 3 group. The CRP level on POD 3 was significantly associated with the patient sex, surgical procedure, duration of the operation, amount of blood loss, postoperative infectious complication, and peak CRP level.

CONCLUSIONS

The serum CRP level during the early postoperative period predicts the long-term outcomes in stage I gastric cancer. The present study suggests a significant influence of postoperative systemic inflammation on the survival of patients with stage I gastric cancer.

Prognostic value of the fibrinogen-to-platelet ratio as an inflammatory and coagulative index in patients with gastric cancer

PURPOSE

We assessed the prognostic value of the fibrinogen-to-platelet ratio (FPR) as an inflammatory and coagulative index by examining its clinicopathologic and prognostic efficiency in patients with gastric cancer (GC).

METHODS

The subjects of this retrospective study were 182 GC patients whose FPR was measured preoperatively between January, 2001 and December, 2006. The FPR was defined as the plasma fibrinogen divided by the platelet counts.

RESULTS

Patients aged ≥ 65 years and with venous invasion had a significantly higher FPR (p = 0.02 and p < 0.01, respectively) than those aged < 65 years and without venous invasion. We found a correlation between the FPR and all recurrences (p < 0.01). Patients with a low FPR had significantly better overall survival (OS) and relapse-free survival (RFS) rates than patients with a high FPR (p = 0.001 for both). Furthermore, the FPR was an independent predictor of OS and RFS (p = 0.02 and 0.001, respectively), but the fibrinogen level was not. In a subgroup analysis, the FPR was a significant prognostic factor for OS and RFS in patients with pathological stages II/III disease and in patients aged < 65 years.

CONCLUSION

The FPR can be calculated easily and is more useful than the fibrinogen level for predicting the prognosis of GC patients. Patients with a high FPR, particularly those with undifferentiated tumors, those with pStage II/III disease, and those aged < 65 years, require more intensive chemotherapy.

The Prognostic Significance of the Geriatric Nutritional Risk Index in Patients with Esophageal Squamous Cell Carcinoma

The aim of this study was to investigate the impact of the geriatric nutritional risk index (GNRI) on the long-term outcomes in 137 esophageal squamous cell carcinoma (ESCC) patients who underwent curative esophagectomy. The GNRI was calculated from the serum albumin value and the body weight. The cutoff value of the GNRI was set at 98. A multivariate analysis was performed to identify prognostic factors for the overall survival (OS). The mean preoperative GNRI was 99.9 ± 7.8. Forty-five (32.8%) patients had a GNRI of <98. The GNRI was significantly associated with the tumor depth (p = 0.001), level of carcinoembryonic antigen (CEA; p = 0.009) and level of C-reactive protein (CRP; p = 0.028). The GRNI was significantly associated with the OS (p < 0.001). The multivariate analysis identified the GNRI as an independent predictor for the OS. Death due to EC was more frequent in the patients with a low GNRI than in the patients with a high GNRI (p = 0.004). Our results suggest that the GRNI is a simple and reliable predictor of the postoperative survival in ESCC patients. A low preoperative GNRI may indicate a higher risk of EC death.

A neuroendocrine carcinoma with a well-differentiated adenocarcinoma component arising in Barrett's esophagus: a case report and literature review

Background

An esophageal neuroendocrine carcinoma arising in Barrett’s esophagus is extremely rare. Here, we report a case of an esophageal neuroendocrine carcinoma with a well-differentiated adenocarcinoma component arising in Barrett’s esophagus and review the literature.

Case presentation

A 71-year-old man with no symptoms was admitted to our hospital because of the detection of an esophagogastric junction tumor on regular upper endoscopy screening. Endoscopy revealed a sliding hiatal hernia and an approximately 10 mm elevated mass at the esophagogastric junction. Biopsy showed a moderately differentiated tubular adenocarcinoma. Computed tomography did not indicate lymph node metastasis or distant metastasis. Proximal gastrectomy with D1 lymph node dissection was performed along with jejunal interposition. On immunohistochemical staining, the tumor was positive for chromogranin A and synaptophysin. Ki-67 was positive in 40% of the tumor cells. The histological diagnosis was a neuroendocrine carcinoma with a well-differentiated adenocarcinoma component arising in Barrett’s esophagus. The postoperative course was good, and the patient was discharged on the twentieth postoperative day. He has remained free of the disease at 36 months postoperatively.

Conclusions

Barrett’s esophagus may be related to the development of a neuroendocrine carcinoma.

Predictive Factors for Delayed Gastric Emptying after Distal Gastrectomy with Roux-en-Y Reconstruction

Delayed gastric emptying (DGE) after distal gastrectomy (DG) followed by Roux-en-Y (R-Y) reconstruction is one of the most worrisome complications, and the course of DGE has not been completely elucidated. This retrospective study aimed to evaluate the frequency of DGE after DG followed by R-Y reconstruction for gastric cancer and identify the risk factors for its development. This study included 266 patients with gastric cancer who underwent DG followed by R-Y reconstruction between 2005 and 2016. We compared clinicopathological characteristics and surgical procedures between the DGE group and non-DGE group. DGE occurred in 24 of the 266 patients. There were no relationships of gender, age, TNM stage, historical grade, surgical approach, extent of lymphadenectomy, preservation of the vagal nerve, and reconstruction route with DGE development. Body mass index (BMI) was higher in DGE patients than in non-DGE patients (P = 0.053). Univariate analysis revealed that a tumor located in the lower third of the stomach (P = 0.005) and isoperistaltic reconstruction (P = 0.043) were significant factors for DGE. Multivariate analysis showed that a tumor located in the lower third of the stomach (P = 0.007), isoperistaltic reconstruction (P = 0.044), and BMI (P = 0.034) were significant predictors of DGE. Our findings suggest that tumor location, the direction of peristalsis for gastrojejunostomy, and BMI are associated with DGE after R-Y reconstruction.

Predictive Factors for Delayed Gastric Emptying after Distal Gastrectomy with Roux-en-Y Reconstruction

Delayed gastric emptying (DGE) after distal gastrectomy (DG) followed by Roux-en-Y (R-Y) reconstruction is one of the most worrisome complications, and the course of DGE has not been completely elucidated. This retrospective study aimed to evaluate the frequency of DGE after DG followed by R-Y reconstruction for gastric cancer and identify the risk factors for its development. This study included 266 patients with gastric cancer who underwent DG followed by R-Y reconstruction between 2005 and 2016. We compared clinicopathological characteristics and surgical procedures between the DGE group and non-DGE group. DGE occurred in 24 of the 266 patients. There were no relationships of gender, age, TNM stage, historical grade, surgical approach, extent of lymphadenectomy, preservation of the vagal nerve, and reconstruction route with DGE development. Body mass index (BMI) was higher in DGE patients than in non-DGE patients (P = 0.053). Univariate analysis revealed that a tumor located in the lower third of the stomach (P = 0.005) and isoperistaltic reconstruction (P = 0.043) were significant factors for DGE. Multivariate analysis showed that a tumor located in the lower third of the stomach (P = 0.007), isoperistaltic reconstruction (P = 0.044), and BMI (P = 0.034) were significant predictors of DGE. Our findings suggest that tumor location, the direction of peristalsis for gastrojejunostomy, and BMI are associated with DGE after R-Y reconstruction.

The prognostic significance of inflammation-based markers in patients with recurrent gastric cancer

PURPOSE

The aim of this study was to evaluate the prognostic impact of inflammation-based markers, including the neutrophil-to-lymphocyte ratio (NLR) and prognostic nutritional index (PNI), in patients with recurrent gastric cancer (RGC).

METHODS

This study reviewed 167 patients with RGC. A receiver operating characteristics (ROC) curve analysis was performed to determine the NLR and PNI cutoff values. The prognostic significance of the NLR and PNI was evaluated by a multivariate analysis.

RESULTS

The optimal NLR and PNI cutoff values for predicting the 1-year survival after recurrence were 2.2 and 47, respectively. A univariate analysis revealed that the NLR (p < 0.001) and PNI (p < 0.001) were significantly associated with the survival time after recurrence, along with the histology, peritoneal recurrence, carbohydrate antigen 19-9, and chemotherapy for recurrence. In the multivariate analysis, a higher NLR (p < 0.001) and a lower PNI (p = 0.002) were independent predictors of a shorter survival time. Among the patients who underwent chemotherapy, the NLR and PNI were also independent prognostic factors.

CONCLUSIONS

Inflammation-based markers, including the NLR and PNI, are simple and useful clinical biomarkers that can be used to predict the survival time of patients with RGC.

Prognostic significance of the prognostic nutritional index in esophageal cancer patients undergoing neoadjuvant chemotherapy

Nutritional status is one of the most important issues faced by cancer patients. Several studies have shown that a low preoperative nutritional status is associated with a worse prognosis in patients with various types of cancer, including esophageal cancer (EC). Recently, neoadjuvant chemotherapy (NAC) and/or radiotherapy have been accepted as the standard treatment for resectable advanced EC. However, NAC has the potential to deteriorate the nutritional status of a patient. This study aimed to evaluate the prognostic significance of the nutritional status for EC patients who underwent NAC. We retrospectively reviewed 66 squamous cell EC patients who underwent NAC consisting of docetaxel, cisplatin, and 5-fluorouracil followed by subtotal esophagectomy at Nara Medical University Hospital between January 2009 and August 2015. To assess the patients' nutritional status, the prognostic nutritional index (PNI) before commencing NAC and prior to the operation was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count in the peripheral blood (per mm3). The cutoff value of the PNI was set at 45. A multivariable analysis was performed to identify prognostic factors for overall survival (OS) and relapse-free survival (RFS). The mean pre-NAC and preoperative PNI were 50.2 ± 5.7 and 48.1 ± 4.7, respectively (P = 0.005). The PNI decreased following NAC in 44 (66.7%) patients. Before initiating NAC, 9 (13.6%) patients had a low PNI, and 12 (18.2%) patients had a low PNI prior to the operation. The pre-NAC PNI and preoperative PNI were significantly associated with the OS (P = 0.013 and P = 0.004, respectively) and RFS (P = 0.036 and P = 0.005, respectively) rates. The multivariable analysis identified the preoperative PNI as an independent prognostic factor for poor OS and RFS, although the pre-NAC PNI was not an independent predictor. Our results suggest that the preoperative PNI is a useful marker for predicting the long-term outcomes of EC patients undergoing NAC and subsequent subtotal esophagectomy. Therefore, patients with a low preoperative nutritional status may be at a higher risk of EC recurrence.

Overexpression of E3 ubiquitin ligase tripartite motif 32 correlates with a poor prognosis in patients with gastric cancer

Tripartite motif protein (TRIM) 32 belongs to the TRIM family, which is composed of RING finger, B-box and coiled-coil domains. TRIM32 has been reported to function as an enzyme 3 ubiquitin ligase and is overexpressed in numerous types of cancer. The present study evaluated the clinical significance of TRIM32 expression levels in gastric cancer. The current study also investigated the TRIM32 expression levels in 142 patients with gastric cancer using immunohistochemistry and examined its clinical importance and potential as a prognostic marker. Furthermore, the function of TRIM32 was examined in vitro. High TRIM32 expression levels were detected in gastric cancer tissues. The postoperative overall and relapse-free survival rates were significantly reduced in patients with tumors with high levels of TRIM32 expression compared with those with tumors expressing low levels of TRIM32. Tumors expressing high levels of TRIM32 were associated with an increased risk of postoperative recurrence, particularly hematogenous recurrence. Multivariate analysis identified TRIM32 status as an independent prognostic factor. Furthermore, TRIM32 gene silencing induced apoptosis and inhibited the proliferation of gastric cancer cells in vitro. Therefore, TRIM32 expression levels may be of potential prognostic value in gastric cancer.

A decrease in the prognostic nutritional index is associated with a worse long-term outcome in gastric cancer patients undergoing neoadjuvant chemotherapy

PURPOSE

The aim of this study was to evaluate the prognostic impact of the prognostic nutritional index (PNI) in gastric cancer patients undergoing neoadjuvant chemotherapy (NAC).

METHODS

This study reviewed 54 patients with gastric cancer who underwent NAC and a subsequent R0 gastrectomy. The PNI before starting NAC and before gastrectomy were calculated using the following formula: 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm³). A multivariate analysis was performed to identify the predictors of overall survival (OS).

RESULTS

The mean pre-NAC and preoperative PNI were 48.3 ± 5.1 and 48.2 ± 4.7, respectively (p = 0.934). The PNI decreased after NAC in 31 patients (57.4%). The pre-NAC PNI and preoperative PNI were not significantly associated with the OS rate. The 3-year OS rate in patients with the decreased PNI values was significantly lower than that in the patients whose PNI values were either maintained or increased (41 vs. 76.4%, p = 0.003). A multivariate analysis revealed that a decreased PNI value was an independent predictor of a poor OS (p = 0.006).

CONCLUSIONS

Decreased PNI values were associated with worse long-term outcomes in gastric cancer patients undergoing NAC.

The anatomical location of the pancreas is associated with the incidence of pancreatic fistula after laparoscopic gastrectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the major complications after laparoscopic gastrectomy (LG). We investigated the impact of the anatomical location of the pancreas, especially in relation to the suprapancreatic lymph nodes, on the incidence of POPF after LG.

METHODS

We retrospectively reviewed the preoperative computed tomography (CT) images of 246 patients who underwent LG with the suprapancreatic lymph node dissection between November 2008 and November 2015. The length between the levels of the pancreatic body surface and the root of the common hepatic artery (LPC) was measured on a CT image with an axial view. A receiver operating characteristics (ROC) curve analysis was performed to determine the cutoff LPC value. A multivariate analysis was performed to determine the predictive factors for POPF.

RESULTS

POPF occurred in 11 patients (4.5 %). The median LPC was significantly longer in the patients with POPF than in those without (26 mm vs. 21 mm, p = 0.026). The ROC curve analysis revealed that the optimal cutoff LPC value for predicting POPF was 25 mm. The POPF rate was significantly higher in the long LPC group than in the short LPC group (10 vs. 1.3 %, p = 0.002). A multivariate analysis demonstrated that a long LPC (p = 0.018) and dissection of the lymph nodes along the distal splenic artery (p = 0.042) were independent predictors of POPF. The amylase level in the drainage fluid on postoperative day 1 was significantly higher in the long LPC group than in the short LPC group.

CONCLUSIONS

The LPC is a simple and reliable predictor of POPF after LG. Surgeons should take the anatomical location of the pancreas into consideration when performing LG with suprapancreatic lymph node dissection.

Prevention of intestinal ischemia-reperfusion injury in humanized mice

BACKGROUND

Ischemia-reperfusion injury (I/R) is an inflammatory response to hypoxia that is dependent on antibodies. We have previously shown that the N2 peptide blocks binding of autoreactive antibody to ischemic tissue and reduces I/R injury in rodents. Whether these same antibodies exist and target the same antigen in humans is unknown. In this study, we create a novel "humanized" mice model of intestinal I/R and test the efficacy of N2.

METHODS

Humanized mice were generated by transplanting human lymphocytes into immunodeficient mice. Human T- and B-cell engraftment in the spleen and peritoneum was confirmed using flow cytometry, and circulating human antibody in mouse serum was measured with ELISA. Injury in the small intestine and lung after intestinal I/R was measured in the presence or absence of N2. Immunohistochemistry was used to assess for human antibody deposition in the small intestine.

RESULTS

Humanized mice engrafted with functional CD20+ B cells generated high circulating serum levels of human antibody. N2 treatment significantly reduced intestinal injury severity scores after I/R (control: 28 ± 1.5, N2: 9.1 ± 3.4; P < .05). N2 also attenuated remote lung inflammation after I/R (control: 28 ± 4, N2: 5.4 ± 1.3; P < .05). Protection from I/R injury correlated with blockade of human antibody deposition on small intestine.

CONCLUSION

N2 is an effective therapy for I/R injury in the presence of human immunity, supporting a conserved target of inflammatory attack in human reperfusion injury.

[Long-Term Disease-Free Survival through Postoperative Chemotherapy in a Case of Gastric Cancer with Peritoneal Dissemination]

An 80-year-old man with type 4 gastric cancer in the mid-gastric region underwent total gastrectomy and D2-No.10 lymph-node dissection (cT4a, N0, M0, cStageⅡB). Several nodules were detected under the left diaphragm, some of which were biopsied. Pathological findings indicated a poorly differentiated adenocarcinoma, pT4a (SE), pN3b, pM1 (P1, CY1), pStage Ⅳ. Systemic chemotherapy was initiated, using a regimen of S-1/docetaxel (DOC). After 6 courses of combination therapy, we switched to S-1 alone, which was continued for 1 year. Eighteen months after the surgery the patient discontinued S-1 treatment and has since survived for 5 years with no obvious cancer recurrence.

Palliative Surgery for Gastric Cancer with Gastric Outlet Obstruction or Anemia due to Tumor Bleeding

BACKGROUND/AIMS

The aim of this study was to evaluate the surgical outcomes after palliative surgery for patients with incurable gastric cancer.

METHODOLOGY

This retrospective study included 45 patients with gastric outlet obstruction (GOO) who needed parental nutrition and 33 patients with anemia due to tumor bleeding who required blood transfusions. We compared the surgical outcomes of palliative gastrectomy (PG) and bypass surgery (BS) in each group.

RESULTS

In the GOO patients, the clinical success rate, as indicated by a resumption of an oral diet, was similar in the PG and BS groups. The time to treatment failure, when the GOO patients again required parental nutrition, was also similar between the two groups. In the anemia patients, the clinical success rate of the PG group was higher than that of BS group, and the post-operative performance status (PS) of the PG group was also better than that of the BS group, although the pre-operative PS were similar in both groups.

CONCLUSIONS

PG for the GOO patients gave little advantage compared to BS, and was associated with a longer operation, higher blood loss and more frequent complications. PG may be recommended for patients with GOO when they simultaneously have anemia due to tumor bleeding.

Short-term and long-term outcomes after gastrectomy for gastric cancer in patients with chronic kidney disease

BACKGROUND

The incidence of chronic kidney disease (CKD) is increasing, which might be an obstacle to various aspects of gastric cancer treatment, such as perisurgical management and postsurgical follow-up. The present study aimed to evaluate the short- and long-term surgical outcomes following gastrectomy in patients with CKD.

METHODS

We retrospectively analyzed surgical complications and prognosis of patients with gastric cancer. These patients were divided into three groups according to the glomerular filtration rate (GFR): 49 patients with severe CKD (GFR < 29 ml/min/1.73 m(2)), 128 with mild CKD (GFR 30-59), and 798 in the controls (GFR ≥ 60).

RESULTS

The incidences of anastomotic leakage and intraabdominal abscess in the mild and severe CKD groups were higher than that in the control group. The incidences of wound infection, cardiovascular and pulmonary events, and in-hospital mortality in the severe CKD group were higher than those in the other two groups. Severe surgical complications were associated with co-morbidities other than CKD, serum albumin level, estimated blood loss, surgery duration in the mild and severe CKD group. The 3-year overall survival rates for the severe CKD, mild CKD, and control groups were 48.6, 80.9, and 85.0 %, respectively, indicating significant differences between the severe CKD group and other two groups.

CONCLUSIONS

Patients with severe CKD show an increased risk of morbidity and mortality following gastrectomy, and their prognosis is usually poor. Studies with a large cohort are essential to refine the risk stratification for gastrectomy in this high-risk population.

[Treatment of type four gastric cancer in our institution]

Since 2011, we have performed routine staging laparoscopy on 7 patients presenting with type 4 gastric cancer at our department. After staging laparoscopy, the patients received neoadjuvant chemotherapy with docetaxel, cisplatin, and S-1 (DCS). After the completion of 2 courses of chemotherapy, radical gastrectomy with D2 gastrectomy or greater was performed, followed by postoperative adjuvant chemotherapy with S-1 for 1 year. In the present study, we evaluate the outcomes of the treatment strategies for the type 4 gastric cancer patients treated at our institution. Staging laparoscopy and peritoneal lavage cytology revealed that none of the patients had peritoneal metastasis, while peritoneal cytology detected carcinoma cells in 3 patients. Grade 3 or greater neutropenia developed in 3 patients, and Grade 3 or greater nonhematological toxicity developed in 3 patients after neoadjuvant chemotherapy. The disease control rate was 100% and all patients underwent radical gastrectomy. Of the 3 patients who had positive peritoneal cytology on staging laparoscopy, 2 patients had no peritoneal cancer cells at the time of gastrectomy. Six patients underwent R0 surgery after DCS chemotherapy, and the response rate was 57.1%. The median survival time was 540 days. Four patients experienced peritoneal recurrence, and 1 developed lymph node recurrence. Our therapeutic strategy for type 4 gastric cancer contributed to prolonged survival; however, it is necessary to develop better strategies that can prevent or control the peritoneal recurrence.

Prognostic impact of RING box protein-1 (RBX1) expression in gastric cancer

BACKGROUND

RING box protein-1 (RBX1) is an essential component of the E3 ubiquitin ligase Skp1/Cullin/RBX1/F-box protein complex. Although an altered expression of RBX1 has been reported in several human cancers, the role of RBX1 in gastric cancer remains unknown.

METHODS

We investigated the RBX1 expression in primary gastric cancer tissues from 145 patients by immunohistochemistry, and explored its clinical relevance and prognostic value. Furthermore, the effect of RBX1 expression on cancer cell proliferation was analyzed in vitro using a siRNA silencing technique.

RESULTS

The RBX1 expression was abundant in gastric cancer tissues. There was a significant difference in the expression level of RBX1 in terms of the tumor depth (P = 0.008), presence of distant metastasis (P = 0.016) and venous invasion (P = 0.005). The postoperative overall (P < 0.001) and relapse-free survival (P < 0.001) rates were significantly poorer in patients with RBX1-high tumors than in patients with RBX1-low tumors. There was a significant correlation of the RBX1 status with postoperative hematogenous recurrence (P = 0.013). Importantly, the RBX1 status was identified as an independent prognostic factor for gastric cancer (P = 0.002). Furthermore, RBX1 gene silencing significantly inhibited the proliferation of gastric cancer cells in vitro.

CONCLUSIONS

The RBX1 expression has a significant prognostic value in gastric cancer. RBX1 might play an important role in regulating the proliferation of gastric cancer cells and promoting the development of postoperative recurrence. Our data provide a rationale for developing a novel therapy targeting RBX1 for gastric cancer.

Novel laparoscopic procedure for treating proximal early gastric cancer: laparoscopy-assisted pylorus-preserving nearly total gastrectomy

PURPOSE

Pylorus-preserving nearly total gastrectomy (PPNTG) is a function-preserving gastrectomy for treating proximal early gastric cancer that prevents rapid gastric emptying and reflux. In this report, we present a surgical technique for performing laparoscopy-assisted PPNTG (LAPPNTG).

METHODS

The resection of the stomach was similar to that during conventional total gastrectomy, with the key difference being that the pyloric cuff was preserved to a length of 3-4 cm. Compared with standard total gastrectomy, the lymph node dissection along the right gastric vessels and the infrapyloric vessels were omitted. Reconstruction was performed with a jejunal interposition that was 30 cm in length, with preservation of the marginal vessels in a retrocolic fashion.

RESULTS

Thirteen patients with cT1 cN0 proximal gastric cancer underwent LAPPNTG at our institution. The median length of the operation and estimated blood loss were 329 min and 138 ml, respectively. All resected specimens had tumor-free margins, and the median number of removed lymph nodes was 40. There were no serious postoperative complications and no patients underwent conversion to laparotomy.

CONCLUSIONS

Performing LAPPNTG with a jejunal interposition is feasible and might be an appropriate treatment for proximal early gastric cancer.

Impact of bacterial culture positivity of the drainage fluid during the early postoperative period on the development of intra-abdominal abscesses after gastrectomy

PURPOSE

The aim of this study was to evaluate the impact of positive bacterial cultures of the drainage fluid (D-cultures) during the early postoperative period on the incidence of intra-abdominal abscess formation following gastrectomy.

METHODS

From January 2012 to June 2013, we prospectively performed D-cultures on postoperative day (POD) 1 in consecutive gastric cancer patients who underwent gastrectomy. The univariate and multivariate analyses were performed to identify the risk factors for intra-abdominal abscess formation without anastomotic leakage.

RESULTS

The rate of positive D-cultures was 6.4 % on POD 1. According to a univariate analysis, the use of combined organ resection (P = 0.011), the drain amylase level on POD 1 (P = 0.016) and the D-culture status on POD 1 (P = 0.004) were found to be significantly associated with the incidence of intra-abdominal abscesses. A multivariate analysis demonstrated that D-culture positivity on POD 1 was the only independent predictor of intra-abdominal abscess formation (P = 0.011).

CONCLUSIONS

The present study demonstrated that bacterial culture positivity of drainage fluid during the early postoperative period has a significant impact on the development of intra-abdominal abscesses after gastrectomy.

Endothelin B receptor expression correlates with tumour angiogenesis and prognosis in oesophageal squamous cell carcinoma

Background:

The endothelin axis has been shown to have a pivotal role in several human malignancies. The aim of this study was to clarify the clinical importance of endothelin receptor type B (ETBR) in human oesophageal squamous cell carcinoma (OSCC).

Methods:

We evaluated ETBR expression in 107 patients with OSCC by immunohistochemistry. Microvessel density (MVD) and lymphatic vessel density were assessed by CD31 and D2-40 immunostaining, respectively. Furthermore, CD4, CD8, and CD45RO+ tumour-infiltrating lymphocytes (TILs) were immunohistochemically analysed.

Results:

Sixty-one (57%) cases showed high expression of ETBR. Endothelin receptor type B expression was correlated with several clinicopathological factors including tumour differentiation, tumour depth, and lymph node metastasis. The overall and disease-specific survival rates were significantly lower in patients with high ETBR expression than patients with low expression. Furthermore, multivariate analysis revealed that ETBR status was an independent prognostic factor for patient survival. Mechanistic analysis indicated that MVD was significantly higher in tumour tissues with high ETBR expression compared with those with low expression, suggesting that angiogenesis may be a key mechanism in tumour progression and metastasis of OSCC mediated by ETBR expression. By contrast, there were no significant correlations between TILs and ETBR expression.

Conclusion:

Endothelin receptor type B has a pivotal role in oesophageal cancer and may be therapeutic target for this intractable malignancy.

Significant involvement of herpesvirus entry mediator in human esophageal squamous cell carcinoma

BACKGROUND

Herpesvirus entry mediator (HVEM) is known to regulate immune response and to be expressed in several human malignancies. However, to the authors's knowledge, the precise role of HVEM in human cancer biology remains unknown. The objective of the current study was to clarify the clinical significance of HVEM in human esophageal squamous cell carcinoma as well as its in vivo functions.

METHODS

HVEM expression was evaluated in 103 patients with esophageal squamous cell carcinoma to explore its clinical relevance and prognostic value. The functions of HVEM in tumors were analyzed in vitro and in vivo using the small interfering RNA (siRNA) silencing technique.

RESULTS

HVEM expression was found to be significantly correlated with depth of tumor invasion and lymph node metastasis. Furthermore, it was found to be inversely correlated with tumor-infiltrating CD4(+) , CD8(+) , and CD45RO(+) lymphocytes. It is important to note that HVEM status was identified as an independent prognostic marker. HVEM gene silencing significantly inhibited cancer cell proliferation in vitro and cancer growth in vivo. This antitumor effect was associated with reduced cell proliferation activity. The effect was also correlated with the induction of CD8(+) cells and upregulation of local immune response.

CONCLUSIONS

HVEM plays a critical role in both tumor progression and the evasion of host antitumor immune responses, possibly through direct and indirect mechanisms. Therefore, HVEM may be a promising therapeutic target for human esophageal cancer.

Postoperative functional evaluation after pylorus-preserving nearly-total gastrectomy with jejunal interposition for gastric cancer

BACKGROUND/AIMS

Pylorus-preserving nearly-total gastrectomy (PPNTG) for gastric cancer is based on the principle that the operation prevents the rapid gastric emptying and reflux that occurs after traditional gastrectomy. In this study, we evaluate the postoperative functional status of patients undergoing PPNTG in comparison with total gastrectomy with Roux-en-Y reconstruction (TG-RY).

METHODOLOGY

Ninety-six patients with gastric cancer underwent PPNTG or TG-RY at Nara Medical University Hospital. Short-term outcomes were analyzed retrospectively through medical records from hospitalization. Long-term outcomes were evaluated via questionnaires concerning postoperative function.

RESULTS

Of the 96 cases, 32 underwent PPNTG and 64 underwent TG-RY. There were no significant differences in operation time, intraoperative blood loss, postoperative complications, or length of stay. Forty-eight patients responded to the questionnaire (PPNTG: 18, TG-RY: 30). The incidence of general malaise, headaches, chest pain, heartburn and cold sweats was significantly lower in the PPNTG group. Nutritional assessment revealed no differences between the groups.

CONCLUSIONS

For gastric cancer of the proximal stomach, PPNTG is a safe alternative to TG-RY, and improves patients' long-term quality of life.

A defect of the abdominal wall with intestinal fistulas after the repair of incisional hernia using Composix Kugel Patch

INTRODUCTION

In the present paper, we show a rare case of the large abdominal wall defect and enterocutaneous fistulas after the tension free repair using prostheses for incisional hernia.

PRESENTATION OF CASE

The patient, a 70-year-old man, had a history of a hemicolectomy for a perforating colon cancer, complicated by a large incisional hernia that was closed primarily but recurred. Three years later, the hernia was repaired at the time of a second colectomy using a Composix Kugel Patch. His course was complicated by a chronic postoperative wound infection with eventual development of enterocutaneous fistulas. The patient was successfully treated with extirpation of the prosthesis, resection of the fistulized bowel, and placement of a tensor fasciae latae myocutaneous flap.

DISCUSSION

Enterocutaneous fistulas are a known complication of incisional hernia repairs using prostheses. Additional clinical data are required to confirm the safety and efficacy of this procedure as it becomes more widely adopted.

CONCLUSION

Extirpation of the prosthesis should be performed without delay to prevent serious complications. Reconstruction with a tensor fasciae latae myocutaneous flap was useful for the large abdominal wall defect.

Simultaneous blockade of programmed death 1 and vascular endothelial growth factor receptor 2 (VEGFR2) induces synergistic anti-tumour effect in vivo

Recent basic and clinical studies have shown that the programmed death ligand (PD-L)/PD-1 pathway has a significant role in tumour immunity, and its blockade has a therapeutic potential against several human cancers. We hypothesized that anti-angiogeneic treatment might augment the efficacy of PD-1 blockade. To this end, we evaluated combining the blockade of PD-1 and vascular endothelial growth factor receptor 2 (VEGFR2) in a murine cancer model using Colon-26 adenocarcinoma. Interestingly, simultaneous treatment with anti-PD-1 and anti-VEGFR2 monoclonal antibodies (mAbs) inhibited tumour growth synergistically in vivo without overt toxicity. Blocking VEGFR2 inhibited tumour neovascularization significantly, as demonstrated by the reduced number of microvessels, while PD-1 blockade had no impact on tumour angiogenesis. PD-1 blockade might promote T cell infiltration into tumours and significantly enhanced local immune activation, as shown by the up-regulation of several proinflammatory cytokine expressions. Importantly, VEGFR2 blockade did not interfere with T cell infiltration and immunological activation induced by PD-1 blockade. In conclusion, simultaneous blockade of PD-1 and VEGFR2 induced a synergistic in-vivo anti-tumour effect, possibly through different mechanisms that might not be mutually exclusive. This unique therapeutic strategy may hold significant promise for future clinical application.

Predicting early cancer-related deaths after curative esophagectomy for esophageal cancer

Esophagectomy is the primary treatment for esophageal cancers, but a few patients still suffer from early recurrence and die within one year after surgery. The aim of this study was to identify preoperative predictive risk factors for early cancer-related deaths after curative esophagectomy for esophageal squamous cell carcinoma. The records of 200 consecutive patients with esophageal cancer who underwent esophagectomy between 1990 and 2009 were retrospectively reviewed. The preoperative clinical characteristics of the remaining 32 patients who died of cancer within one year were compared with those of 168 patients who survived for more than one year postsurgery. The most frequent cause of death was lymph node recurrence followed by local recurrence and lung metastases. A tumor size 60 mm or greater and lymph node metastases in two fields on preoperative imaging were identified as prognostic factors on multivariate analysis. The one-year survival rate and median survival time of patients with both these risk factors were 40 per cent and 12 months, respectively. Aggressive additional treatment may be needed if both a tumor size 60 mm or greater and lymph node metastases in two fields are found during diagnostic imaging before esophagectomy for esophageal squamous cell carcinoma.

The prognostic nutritional index predicts long-term outcomes of gastric cancer patients independent of tumor stage

PURPOSE

The aim of this study was to investigate the impact of the prognostic nutritional index (PNI) on the long-term outcomes in gastric cancer patients.

METHODS

This study reviewed the medical records of 548 patients with gastric cancer who underwent gastrectomy. The PNI was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm(3)). The receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of the PNI. The multivariate analysis was performed to identify the prognostic factors.

RESULTS

The mean PNI was significantly lower in patients with T3-T4 tumors (P < 0.001) and lymph node metastasis (P < 0.001) than in those without such factors. Patients who had a postoperative complication had a lower mean PNI than those without (P = 0.023). When the ROC curve analysis was performed, the optimal cutoff value of the PNI for predicting the 5-year survival was 48. In the multivariate analysis, a low PNI was an independent predictor for poor overall survival (P < 0.001). In the subgroup analysis, the overall and relapse-free survival rates were significantly lower in the PNI-low group than in the PNI-high group among patients with stage I and stage III disease.

CONCLUSIONS

The PNI is a simple and useful marker for predicting the long-term outcomes of gastric cancer patients independent of the tumor stage. Based on our results, we suggest that the PNI should be included in the routine assessment of gastric cancer patients.

Clinical impact of tumor-infiltrating CD45RO⁺ memory T cells on human gastric cancer

Memory T cells survive for months and even years and are critical for host defense in humans. They have been recently suggested to play a significant role in tumor immunity. In this study, we aimed to investigate the clinical impact of tumor-infiltrating memory T cells on human gastric cancer. We evaluated CD45RO(+)T cells infiltrating into primary gastric cancer tissues by immunohistochemistry in 101 patients with gastric cancer. Patients were classified into 2 groups (CD45RO(+Hi) and CD45RO(+Lo)) based on the number of positively stained T cells. There was no significant correlation observed between CD45RO status and post-operative prognosis in early gastric cancer. By contrast, in advanced cancer, the post-operative overall and disease-free survival of patients with CD45RO(+Hi) were significantly improved compared to those of patients with CD45RO(+Lo). In addition, CD45RO status in the primary tumors significantly correlated with the development of post-operative recurrence, particularly peritoneal recurrence. Furthermore, the local expression of interferon-γ (IFN-γ) in the CD45RO(+Hi) tumors was significantly higher than that in the CD45RO(+Lo) tumors, suggesting that CD45RO(+) T cells induced local immune activation. Multivariate analysis indicated that the CD45RO(+) status was an independent prognostic factor in advanced gastric cancer. In conclusion, tumor-infiltrating CD45RO(+) memory T cells are functional and have significant prognostic value in human gastric cancer. Our data suggest that adaptive immune response is clinically critical in gastric cancer.

Surgical outcomes for cancer at the gastroesophageal junction

The aim of this study was to evaluate the clinicopathological characteristics and prognostic factors of cancer at the gastroesophageal junction (GEJ) whose center is situated at a site within 2 cm above and below the junction. This retrospective study included 90 patients with cancer at the GEJ, including 58 with adenocarcinoma (ADC) and 32 with squamous cell carcinoma (SCC). ADC tumors were larger in size than SCC tumors. ADC and SCC at the GEJ showed a similar distribution of the pattern of lymphatic spread. The rate of lower mediastinal lymph node metastasis was approximately 20 per cent, which is similar to the nodes along the celiac artery and the nodes along the common hepatic artery. The overall survival rates were similar between the groups. The presence of five or more lymph node metastases was an independent prognostic factor according to a multivariate analysis. When two or more lymph nodes larger than 10 mm were detected preoperatively, five or more lymph node metastases were proven by histology in most cases. The most frequent sites of recurrence of ADC and SCC were the peritoneum and lymph nodes, respectively. Aggressive additional treatment may be needed if two or more lymph nodes are seen on preoperative imaging.

Prognostic importance of tumour-infiltrating memory T cells in oesophageal squamous cell carcinoma

Memory T cells survive for many months and years and are critically important for host defence in humans. In tumour immunity, they have been also suggested to play a significant role in tumour progression and metastasis. However, the role of memory T cells in actual human cancer remains largely unknown. In this study, the clinical importance of tumour-infiltrating CD45RO(+) memory T cells was investigated in human oesophageal squamous cell carcinoma (OSCC). CD45RO(+) T cells were evaluated by immunohistochemistry in primary OSCC tumours from 105 patients. Patients were classified into two groups as CD45RO(+hi) or CD45RO(+lo) based on the number of cells stained positively for CD45RO. No significant difference was observed between CD45RO status and several clinicopathological prognostic factors. However, the postoperative overall and disease-free survival for CD45RO(+hi) patients was significantly better than for CD45RO(+lo) patients. Furthermore, there were significant correlations of CD45RO status in the primary tumour with postoperative lymph node and pulmonary recurrence, suggesting that memory T cells may control postoperative metastatic recurrence. Most importantly, CD45RO(+) memory T cell status has a significant prognostic value for OSCC independently of conventional tumour-node-metastasis (TNM) classification. Our study may provide a rationale for developing a novel immunotherapy in intentional induction of memory T cells for the treatment of oesophageal cancer.

[A case report of advanced gastric cancer with peritoneal dissemination effectively treated by combination chemotherapy of S-1 and docetaxel]

The present patient was a 69-year-old male diagnosed as gastric cancer with peritoneal dissemination by staging laparoscopy. He was treated with chemotherapy using S-1 (120 mg/body/day) and docetaxel (70 mg/body/day 1) administered for 2 weeks, followed by one drug-free week in three-week courses. After 4 courses of treatment, the primary tumor regressed, but only slightly. Because of an adverse event, we continued with a lower dose. After 4 more courses of treatment, the primary tumor and dissemination were undetectable on abdominal CT scan but were endoscopically detected. The patient has been followed on an outpatient basis without surgical treatment for 2 years.

Abstract 3532: The effect of B cell depletion on tumor phenotype

Introduction There are past indications that the adaptive immune response of B cells plays a role in tumor development. We examined this issue in vivo by examining the growth of Lewis Lung Carcinoma (LLC) and murine melanoma in B cell knockout (Bcell ko) mice. Methods Cultured LLC or melanoma cells were implanted into hindlimbs of C57BL/6 (B6) and Bcell ko mice. Tumors were measured every 3-4 days, and tissue was harvested for histological examination 2-3 weeks after tumor implantation. Tissues were stained with labeled anti-IgG, -CD4, -CD8, and -CD31 antibody. Results Melanomas in B6 and B cell ko mice enlarged at the same rate. However, tumor growth of LLC was significantly slower in B cell KO mice compared to B6 (p=0.02). Though both tumor-infiltrating CD4+ T cells and CD8+ T cells were identified in B6 mice, tumor-infiltrating CD4+ T cells but no tumor-infiltrating CD8+ T cells were seen in B cell KO mice in LLC. Angiogenesis was significantly inhibited in LLC in B cell KO mice. Conclusions The absence of B cells selectively inhibited tumor growth for LLC, and was associated with less tumor angiogenesis and an absence of CD8+ T cells. Blocking this aspect of the B cell response might be useful therapy for selected tumors.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3532. doi:1538-7445.AM2012-3532

A comparison of surgery and radiation therapy for cT1 esophageal squamous cell carcinoma

Surgery and radiation therapy have been used to treat esophageal squamous cell carcinoma. However, treatment outcomes have not yet been extensively investigated. The aim of this study was to compare surgery and radiation therapy for clinical T1 esophageal squamous cell carcinoma. A total of 67 clinical T1 esophageal squamous cell carcinoma patients were treated between January 1997 and December 2005; 29 had undergone radical esophagectomy (surgery group) and 38 were treated with definitive radiation therapy (radiation group). The mean patient age was lower in the surgery group than in the radiation group. In surgery group, respiratory complications, anastomotic leaks, recurrent nerve palsies, and anastomotic stenosis occurred in 7, 8, 6, and 5 patients, respectively. In radiation group, leucopenia, esophagitis, pericarditis were observed in 15, 3, and 3 patients, respectively. The 5-year overall survival rate for the surgery group was 68.9%, and 74.3% for the radiation group. There were no significant difference between groups (P= 0.3780). The 5-year relapse-free survival rate in the surgery group was 61.8% and 38.8% in the radiation group. The relapse-free survival rate was significantly higher in the surgery group than in the radiation group (P= 0.0051). The 5-year overall and relapse-free survival rates for tumors invaded into but not through the muscularis mucosa were 83.3% and 75.0%, respectively, in the surgery group and 78.8% and 33.3%, respectively, in the radiation group. There were no significant differences. The 5-year overall survival rates for patients with tumors that invaded the submucosal layer was 64.9% in the surgery group and 66.5% in the radiation group. This difference was not significant (P= 0.8712). The 5-year relapse-free survival rate in the surgery group (56.0%) was significantly higher than that in the radiation group (41.8%; P= 0.0219). In conclusion, surgery may become a standard treatment for cT1 esophageal cancer that can offer longer relapse-free survival, particularly for patients with tumors that invade the submucosa.

Prognostic significance of splenic hilar nodal involvement in proximal third gastric carcinoma

BACKGROUND/AIMS

The utility of prophylactic splenectomy in patients with proximal third gastric carcinoma is controversial. In this study, we investigated the significance of nodal involvement in the splenic hilum and the impact of splenectomy.

METHODOLOGY

A total of 129 patients who underwent D2 radical resection with splenectomy for gastric carcinoma involving the upper portion of the stomach were analyzed.

RESULTS

Lymph node metastasis at the splenic hilum was found in 21 (16.3%) of 129 cases. Multivariate analysis revealed that the number of metastatic lymph nodes was an independent risk factor for lymph node metastasis at the splenic hilum. The 5-year survival rate for patients with lymph node metastasis at the splenic hilum was 17.9%. There were significant differences in survival among patients grouped according to the extent of extraperigastric nodal involvement. While nodal involvement in the splenic hilum was found to be an independent prognostic factor, the number of metastatic lymph nodes was not.

CONCLUSIONS

The prognosis of patients with lymph node metastasis at the splenic hilum was significantly poorer compared to that for patients with metastases in the other extraperigastric nodes. Furthermore, prophylactic splenectomy appears not to improve survival of patients with proximal third gastric carcinoma.

Therapeutic potential of the TWEAK/Fn14 pathway in intractable gastrointestinal cancer

Tumor necrosis factor-like weak inducer of apoptosis (TWEAK) is a member of the TNF superfamily. It has been suggested that it plays a pivotal role in various physiological and pathological conditions due to its proinflammatory properties. Fibroblast growth-inducible 14 (Fn14) has been identified as a TWEAK receptor. A number of studies have suggested that TWEAK-Fn14 interaction results in the promotion of apoptosis, cell growth as well as angiogenesis. Although recent studies have indicated that TWEAK and Fn14 are expressed in a number of tumor lines and tissues, the therapeutic potential of this pathway has yet to be elucidated. This study investigated the potential of TWEAK and Fn14 in esophageal and pancreatic cancer as novel molecular targets for anti-cancer therapy. TWEAK and Fn14 protein expression was evaluated in 43 patients with esophageal cancer and 51 patients with pancreatic cancer by immunohistochemistry. As a result, either TWEAK or Fn14 expression was observed in 58.1% of the cases with esophageal cancer and 74.5% of the cases with pancreatic cancer. Furthermore, TWEAK/Fn14 gene expression was identified in the majority of the human esophageal and pancreatic cancer cell lines. Therapeutic efficacies of blocking TWEAK and Fn14 were evaluated by tumor growth inhibition assay in TWEAK- and Fn14-expressing human esophageal and pancreatic cancer cell lines. Coculture with anti-TWEAK or -Fn14 mAb was found to induce a 22-65% cell growth inhibition of these cells. Finally, the significant therapeutic effect of targeting this pathway under in vivo physiological conditions was confirmed using a murine gastrointestinal cancer model. In conclusion, the TWEAK/Fn14 pathway may be functional and critical in intractable gastrointestinal cancers. Therefore, TWEAK and/or Fn14 may be novel molecular targets for anti-cancer therapy.

Abstract 3815: Murine tumors demonstrate variable responses to ischemia-reperfusion injury

Introduction: Acute ischemia/reperfusion (I/R) of normal tissues causes an inflammatory reaction initiated by binding of auto-reactive IgM antibody to an ischemia-induced self-antigen. Whether this inflammatory cascade also affects cancers - for example, after acute I/R during surgical resection or in conditions of chronic ischemia - is unclear. We examined the effect of I/R injury in three murine tumor models: B16F10 melanoma, Lewis lung carcinoma (LLC), and small intestinal adenomas of the APCmin/+ mouse.

Methods: LLC and B16F10 cell lines were implanted into the hindlimbs of C57BL/6 mice. Ischemia was induced by external tourniquet ligation of the femoral vessels. Small intestinal tumors in APC min/+ mice were subjected to ischemia by vascular clip occlusion of the superior mesenteric artery. Control animals underwent hindlimb ischemia to the non-tumor bearing hindlimb or laparotomy alone. Following graded times of ischemia and reperfusion, tumors and surrounding normal tissue were harvested for histological examination. Immunohistochemistry was performed for IgM and activated caspase-3. For hindlimb injury, mice were recovered and followed for LLC and B16F10 tumor growth.

Results: Ischemia-reperfusion causes injury of LLC and B16F10 tumors. In contrast, intestinal adenomas of APCmin/+ mice showed no signs of injury following ischemia, despite induction of necrosis and apoptosis of adjacent normal intestinal epithelium. Tumor susceptibility to ischemic injury correlated with immuno-histochemical deposition of IgM antibody. Ischemic injury of B16F10 significantly reduced tumor growth (36% volume reduction compared to control injury, p &lt;0.05). In contrast, LLC tumor growth was significantly increased after ischemia (35% increased compared to control injury, p &lt; 0.01)

Conclusions: The three murine tumor models examined are each affected differently by an acute I/R injury, in contrast to the conserved inflammatory cascade induced in normal tissues following ischemia. APCmin/+ adenomas evade ischemia-induced IgM binding and injury. While both LLC and B16F10 are acutely injured, the long term effects on growth are divergent. Targeted manipulation of the host inflammatory response to ischemia-reperfusion may be a method to influence tumor progression and growth.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3815.

Clinicopathological and prognostic significance of mucin phenotype in gastric cancer

BACKGROUND AND OBJECTIVES

Gastric and intestinal mucin phenotype cell markers are widely expressed in gastric carcinoma cells, irrespective of their tumor histological type. In the present study, we tried to reveal the clinicopathological significance of mucin phenotype in human gastric carcinomas. Moreover, we investigated the clinical significance of RUNX3 in association with mucin phenotype.

METHODS

The mucin expression of MUC5AC, MUC6, MUC2, and CD10 was evaluated in 97 gastric carcinomas by immunohistochemistry. Tumors were classified into gastric (G), gastric and intestinal mixed (GI), intestinal (I), and null (N) phenotype according to combination of mucin expression.

RESULTS

The rate of G, GI, I, and N phenotype was 40.0%, 38.1%, 10.3%, and 19.6%, respectively. Mucin phenotype was also significantly correlated with several clinicopathological findings. Patients with I phenotype had a significantly poorer prognosis than those with any other phenotypes. They also had a higher rate of postoperative liver metastasis. Multivariate analysis revealed that mucin phenotype was a significant independent prognostic factor. We suggested that Loss of RUNX3 expression might correlate with intestinal phenotype and postoperative outcome.

CONCLUSIONS

Mucin phenotype has a significant prognostic value and may be a useful marker for the treatment of human gastric carcinoma.