Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Population-based incidence and outcomes of acute aortic dissection in Japan

Background

The population-based incidence and outcomes of acute aortic dissection (AAD) are still unknown because some patients are already dead on arrival at the hospital, and the accurate diagnosis of AAD is difficult due to the low autopsy rate for patients with cardiopulmonary arrest outside of the hospital. We performed a population-based review of all patients with AAD in a well-defined geographical area in the southern part of Japan between 2016 and 2018.

Methods

Data of all patients with AAD at our Hospital, which performs medical care for 120,000 residents, were collected retrospectively. The emergency medical service is dedicated to the transfer of all patients in this area to the MPNH. For all patients who were dead on arrival, the diagnosis of AAD was made by autopsy imaging (AI) using computed tomography. The age-adjusted incidence and mortality per 100,000 population were calculated using the Japanese population distribution model in 2015.

Results

The total incidence of AAD was 79 (type A: 64.5%, n=51). Of those, 60.8% (31/51) of patients with type A and 21.4% (6/28) with type B were dead on arrival and diagnosed by AI. The 30-day mortality rates after the onset of AAD were 74.5% (38/51) in type A and 25.0% (7/28) in type B. Excluding the dead-on-arrival patients, the 30-day mortality rates were 35.0% (7/20) in type A and 4.5% (1/22) in type B. The age-adjusted incidence and mortality of AAD per 100,000 inhabitants were 17.3 (type A: 11.3, type B: 6.0) and 9.6 (type A: 8.4, type B: 1.2), respectively. Both values were significantly higher in men than in women.

Conclusions

The population-based survey of emergency medical care for AAD showed that the age-adjusted incidence of AAD was two-fold higher than in previous reports, and the actual mortality rates after AAD onset were markedly higher due to the high incidence of dead-on-arrival.

Funding Acknowledgement

Type of funding sources: None. Representative CT images of type A AAD

Use of ATP bioluminescence to survey the spread of aerosol and splatter during dental treatments

Aerosol and splatter produced during dental treatments (ultrasonic scaling and professional mechanical tooth cleaning) are potential sources of infection. Contamination patterns on the mask, goggles, chest and gowned right arm of operators, and on the goggles of patients before and after dental treatments were investigated using ATP bioluminescence analysis. Contamination on every surface tested increased significantly after dental treatment. Maximum contamination was found on the goggles of patients. Aerosol and splatter produced during dental treatments therefore have the potential to spread infection to operators and patients. ATP bioluminescence is a useful tool for monitoring surface contamination.

Checkup Interval and Cancers in Automated Multiphasic Health Testing and Services

The purpose of this study was to disclose which types of cancer and how many persons with cancer were detected among the AMHTS examinees of our AMHTS center by using the hospital information retrieval system, and to study the relationship between cancer and the number of examinees, checkup intervals, and frequency in AMHTS. The examinees who had checkups more than twice were divided into three groups based on their checkup intervals: within one year, one to two years, and over two years. The relationship between cancer ratios and checkup intervals was evaluated in each group of examinees. In those having checkups within one year and from one to two years the cancer rate was 2.9 patients per 1,000 persons. However, in those having checkups after a two-year period or longer, the cancer rate was 4.3, clearly greater than the rate of the other two groups.

Plasma membrane expression of ZNF185 is a prognostic factor in pancreatic ductal carcinoma

Pancreatic ductal carcinoma (PDC) is one of the major causes of cancer-associated mortality globally due to its high potential for distant metastasis. To understand hematogenous metastasis, the molecular expression profiles of weak metastatic PDC cell subline BxPC-3 and highly liver-metastatic cell subline LM-BxPC-3 were compared, and zinc finger protein 185 (ZNF185) was identified as a molecule that is upregulated in LM-BxPC-3 cells. The aim of the present study was to evaluate the clinicopathological significance of ZNF185 in PDC. Using immunohistochemistry, ZNF185 expression was investigated in 182 patients with PDC, in association with numerous clinicopathological variables. The expression profile of ZNF185 was also characterized using xenograft models. In contrast to parent BxPC-3 cells in subcutaneous transplanted tumor foci, which only expressed ZNF185 on their plasma membrane (m)ZNF185, LM-BxPC-3 cells in liver-metastatic foci that were formed subsequent to transplantation all expressed cytoplasmic (c)ZNF185. Additionally, 51% of the cells at the periphery of the tumor foci expressed mZNF185. Expression of cZNF185, and of mZNF185 and cZNF185 combined was identified in 93 and 39% of clinical patients with PDC, respectively. Patients with mZNF185-negative and -positive PDC exhibited a median survival time of 30.2 months and 21.3 months, respectively. Multivariate analysis indicated that the expression of mZNF185 is closely associated with a shorter overall survival time. Increased marked venous invasion was more prevalent in patients who were mZNF185-positive, as compared with patients who were mZNF185-negative. These data suggest that the expression of mZNF185 is an independent and unfavorable prognosticator in patients with PDC. The results suggested that the amount and subcellular location of ZNF185 are correlated with the position of the cancer cells expressing it within the nests. Additionally, the subcellular location of ZNF185 may be important to its biological function.

Monitoring of bacterial contamination of dental unit water lines using adenosine triphosphate bioluminescence

Bacterial contamination of dental unit waterlines (DUWLs) was evaluated using ATP bioluminescence analysis and a conventional culture method. Water samples (N=44) from DUWLs were investigated for heterotrophic bacteria by culture on R2A agar, which gave counts ranging from 1.4×10³ to 2.7×10⁵ cfu/mL. The ATP bioluminescence results for DUWL samples ranged from 6 to 1189 relative light units and could be obtained within 1min; these correlated well with the culture results (r=0.727-0.855). We conclude that the results of the ATP bioluminescence assay accurately reflect the results of conventional culture-based testing. This method is potentially useful for rapid and simple monitoring of DUWL bacterial contamination.

Abstract 1543: Clinical significance of ZNF185 intracellular localization in pancreatic ductal carcinoma

Pancreatic cancer is one of the most aggressive human tumors because of the challenges associated with detecting it at an early stage and its high potential for dissemination and distant metastasis. Therefore, clarifying the biological mechanisms underlying distant metastasis from pancreatic cancer and accelerating the development of new treatment strategies are needed. We previously isolated ZNF185, a metastasis-related protein, using a global quantitative proteome analysis. ZNF185 contains two zinc-finger motifs in the C-terminus that fit the consensus pattern of the LIM domains inducing tumor formation and cytoskeleton organization. In the present study, we investigated the expression of ZNF185 in human pancreatic cancer in vivo and in clinical cases, and also evaluated its prognostic significance. Immunohistochemical staining of resected specimens and a xenograft model of liver metastasis was used to examine the relationship between distant metastasis in and the prognosis of pancreatic cancer and the expression of ZNF185. Cells expressing ZNF185 in the plasma membrane were detected in 71 (39.0%) out of 182 patients with resected pancreatic cancer. Patients not expressing ZNF185 in the plasma membrane had a median survival of 30.2 months, whereas those expressing ZNF185 in the plasma membrane had a median survival of 21.3 months. A multivariate analysis indicated that the expression of ZNF185 in the plasma membrane was an independent poor prognostic factor (p = 0.016). A multivariate analysis indicated that patients with cells expressing ZNF185 in the plasma membrane were more likely to develop hematogenous metastasis (p = 0.081). NOD/Shi-scid/IL-2Rγnull(NOG) mice were used to compare the expression of ZNF185 in the subcutaneous tumors of the parent cell line BxPC-3 and liver metastatic tumors of the highly liver-metastatic subline LM-BxPC-3 established in our laboratory. Cells expressing ZNF185 in the plasma membrane were more prevalent in metastatic disease in the liver than in subcutaneous tumors, and these cells were often located at the tumor margins rather than in the center of the tumor. In conclusion, ZNF185 is a protein related to hematogenous metastasis, the expression of which in the plasma membrane was identified as an independent prognostic factor for pancreatic cancer.

Citation Format: Daisuke Furukawa, Tsuyoshi Chijiwa, Masahiro Matsuyama, Masaya Mukai, Ei-ichi Matsuo, Osamu Nishimura, Kenji Kawai, Hiroshi Suemizu, Toshio Nakagohri, Seiei Yasuda, Kazuaki Shimada, Nobuyoshi Hiroka, Masato Nakamura. Clinical significance of ZNF185 intracellular localization in pancreatic ductal carcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1543.

Bax deficiency extends the survival of Ku70 knockout mice that develop lung and heart diseases

Ku70 (Lupus Ku autoantigen p70) is essential in nonhomologous end joining DNA double-strand break repair, and ku70^−/− mice age prematurely because of increased genomic instability and DNA damage responses. Previously, we found that Ku70 also inhibits Bax, a key mediator of apoptosis. We hypothesized that Bax-mediated apoptosis would be enhanced in the absence of Ku70 and contribute to premature death observed in ku70^−/− mice. Here, we show that ku70^−/−bax^+/− and ku70^−/−bax^−/− mice have better survival, especially in females, than ku70^−/− mice, even though Bax deficiency did not decrease the incidence of lymphoma observed in a Ku70-null background. Moreover, we found that ku70^−/− mice develop lung diseases, like emphysema and pulmonary arterial (PA) occlusion, by 3 months of age. These lung abnormalities can trigger secondary health problems such as heart failure that may account for the poor survival of ku70^−/− mice. Importantly, Bax deficiency appeared to delay the development of emphysema. This study suggests that enhanced Bax activity exacerbates the negative impact of Ku70 deletion. Furthermore, the underlying mechanisms of emphysema and pulmonary hypertension due to PA occlusion are not well understood, and therefore ku70^−/− and Bax-deficient ku70^−/− mice may be useful models to study these diseases.

Abstract 49: Zinc finger protein 185 is a key molecule of liver metastasis in colon cancer

Colorectal cancer is among the three leading causes of cancer-related deaths worldwide. Nearly 50% of patients with colon cancer develop liver metastases. Mortality associated with the advanced stage of colon cancer has principally been attributed to the development of liver metastases. Therefore, clarifying the biological mechanisms underlying liver metastasis from colon cancer and accelerating the development of new treatment strategies are needed. We isolated Zinc finger protein 185 (ZNF185) as a metastasis-related protein by global quantitative proteome analysis of the in vivo liver metastasis model of super immunodeficient NOG mice with the highly liver-metastatic subline SW48-LM2 (Matsuo E, et al. AACR, #3947, 2008). LIM domain proteins have many fundamental biological processes including cell lineage specification, cytoskeleton organization, and organ development. ZNF185 is one of the LIM domain proteins and is considered to be involved in regulating cellular differentiation and/or proliferation. However, the functions and properties of ZNF185 in the multi-step process of cancer biology have not yet been elucidated in detail. In the present study, we analyzed the relationships between ZNF185 and the clinicopathological features of colon cancer (age, gender, histological type, lymphatic involvement, venous involvement, T and N statuses, liver metastasis, and stage). The expression of the ZNF185 protein was immunohistochemically analyzed. The expression of ZNF185 was detected in the cancer cells of 78 of 87 colon cancer patients. A correlation was observed between ZNF185 and the histological type (p=0.010, G-test). The expression of ZNF185 was also correlated with liver metastasis (p=0.030, G-test). Multivariate analysis using the Cox proportional hazards model was performed among the cause-specific survival rate, ZNF185 expression, and clinicopathological features. The histological type, liver metastasis, and ZNF185 expression were found to be independent prognostic indicators (p= 0.028, p<0.0001, p=0.036, respectively). ZNF185 expression was found to be an independent indicator of liver metastasis and prognosis in colon cancer.

Citation Format: Daisuke Furukawa, Tsuyoshi Chijiwa, Masahiro Matsuyama, Masaya Mukai, Ei-ichi Matsuo, Osamu Nishimura, Kenji Kawai, Hiroshi Suemizu, Nobuyoshi Hiraoka, Toshio Nakagohri, Seiei Yasuda, Masato Nakamura. Zinc finger protein 185 is a key molecule of liver metastasis in colon cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 49. doi:10.1158/1538-7445.AM2014-49

Zinc finger protein 185 is a liver metastasis-associated factor in colon cancer patients

LIM domain proteins are involved in several fundamental biological processes, including cell lineage specification, cytoskeleton organization and organ development. Zinc finger protein 185 (ZNF185) is one of the LIM domain proteins considered to be involved in the regulation of cellular differentiation and/or proliferation. However, the detailed functions and properties of ZNF185 in the multistep process of cancer biology have not yet been elucidated. In this study, we analyzed the association between ZNF185 and the clinicopathological characteristics of colon cancer, such as patient age and gender, histological type, lymphatic and venous involvement, T and N status, liver metastasis and stage. ZNF185 protein expression was immunohistochemically analyzed and ZNF185 was detected in the cancer cells of 78 of the 87 colon cancer patients. The correlation between ZNF185 and histological type was significant (P=0.010, G-test). ZNF185 expression was also significantly correlated with liver metastasis (P=0.030, G-test). A multivariate analysis using the Cox proportional hazards model was performed among cause-specific survival rate, ZNF185 expression and clinicopathological characteristics. Histological type, liver metastasis and ZNF185 expression were found to be independent prognostic indicators (P=0.028, P<0.0001 and P=0.036, respectively). Therefore, ZNF185 expression was found to be an independent indicator of liver metastasis and prognosis in patients with colon cancer.

Clinical significance of wall invasion pattern of subserosa-invasive gallbladder carcinoma

We have previously classified wall invasion patterns of gallbladder carcinoma (GBC) cases into two groups, i.e., the infiltrative growth type (IG type) and destructive growth type (DG type). The DG type was significantly associated with poor differentiation, aggressive infiltration and decreased postoperative survival in terms of its histological differentiation, lymphatic invasion, venous invasion, lymph node status, neural invasion and mode of subserosal infiltration. In the present study, we analyzed 42 surgically-resected subserosal invasive gallbladder adenocarcinomas, invading the perimuscular connective tissue (pT2). The cumulative 5-year survival rate in the series was 48.7%. Lymphatic invasion (p=0.021), venous invasion (p=0.020), mode of subserosal infiltration (p<0.001), histological differentiation (p=0.030) and biliary infiltration (p=0.007) were noted, respectively, at a significantly higher incidence in more aggressive infiltration or poor differentiation in the DG type. The cumulative 5-year survival rate of curative resection cases was lower in patients with the DG type than in those with the IG type (68.9 versus 20.2%, respectively, p=0.006, log-rank test). On Cox’s proportional hazard regression modeling, the low degree of venous/perineural invasion and IG type of wall invasion pattern were associated with a significant improvement in overall survival. Our data suggest that the wall invasion pattern is an independent predictor of survival in subserosal invasive GBC. Regarding the clinical application of our concept, on the classification of patients with subserosal invasive GBC based on a combination of the wall invasion pattern and lymph node status, the overall survival rate in patients with the DG type and/or N2 metastasis (n=21) was lower than in patients with the IG type and N0, 1 metastasis (n=21) (p=0.0023, log-rank test). The wall invasion pattern could contribute to decision-making concerning curative resection for subserosal invasive GBC.

[Cardiovascular surgery with multiple myeloma]

There are few case reports of cardiovascular surgery with multiple myeloma. We report 3 cases of cardiovascular surgery with multiple myeloma. CASE 1: A 73-year-old male hemodialytic patient with multiple myeloma was performed off-pump coronary artery bypass grafting (OPCAB) for angina. He was dead on the 72th postoperative day because of sepsis. CASE 2: A 68-year-old female patient with multiple myeloma was performed mitral valve replacement for mitral regurgitation. The postoperative course was uneventful. CASE 3: A 78-year-old male patient, the aorta was replaced with a artificial graft for impending rupture of thoracoabdominal aortic aneurysm. He was diagnosed with multiple myeloma after surgery. He was dead on the 99th postoperative day because of sepsis. One of the affecting prognosis factors is infection and it is intractable.

A case of living-donor renal transplantation for chronic renal failure caused by secondary amyloidosis

In Japan, amyloidosis is a rare cause of renal failure and of renal transplantation. We treated a patient who underwent a renal transplantation because of chronic renal failure caused by secondary amyloidosis with a good result. The patient was a 50-year-old woman who was diagnosed with secondary amyloidosis and an amyloid kidney. She underwent living donor renal transplantation after about 7 years of hemodialysis. During the 3-year posttransplantation period, she maintained good allograft function with a serum creatinine level about 1.2 mg/dL. Because of amyloidosis is a systemic disease, amyloid kidney patients often experience fatal complications, so the indications for renal transplantation in amyloid patients are still controversial. But if the patient's general condition is good, renal transplantation can be an effective therapy for patients with kidney failure caused by amyloidosis.

An annular pancreas associated with carcinoma of the papilla of Vater: report of a case

An annular pancreas is an uncommon congenital anomaly that usually presents early in childhood. Malignancy in the setting of an annular pancreas is unusual. We herein report a case of annular pancreas with carcinoma of the papilla of Vater. A 59-year-old man presented with epigastric discomfort and was referred to us after gastroduodenal endoscopy showed a tumor of the papilla of Vater. Preoperative imaging showed the pancreatic parenchyma encircling the descending duodenum and a tumor at the papilla of Vater. A pancreaticoduodenectomy was performed for the annular pancreas and the ampullary tumor. Histological examination confirmed a complete annular pancreas and carcinoma in situ of the papilla of Vater. We also provide a review of the reported cases of an annular pancreas with periampullary neoplasms and discuss the clinical characteristics of this anomaly.

Rare spontaneous remission of hepatic artery aneurysm following ABO incompatible living donor liver transplantation: a case report

A 60-year-old male patient with an unknown cause for cirrhosis and a hepatoma underwent an ABO incompatible living donor liver transplantation (LDLT) from his son. The transplanted graft was his son's right lobe. For ABO incompatible transplantation, splenectomy was performed for desensitization. A catheter was inserted into the recipient's right hepatic artery for subsequent local immunosuppression. On the 15th postoperative day, a fusiform 15 × 10 mm aneurysm was observed in the graft right hepatic artery using ultrasonography and hepatic arteriography. At that time, the patient was also diagnosed to have an intraperitoneal abscess at the bottom of his left diaphragm. Administering antibiotics, we tried to embolize the aneurysm because of fear of rupture, but this manever failed because it was difficult to insert the wire in to the aneurysm to produce a stenosis around its proximal neck. However, because the aneurysm was not detectable on the 37th postoperative day, it was assumed to have embolized spontaneously. This relatively rare case revealed a hepatic artery aneurysm that spontaneously regressed after ABO incompatible LDLT.

Abstract 4948: Overexpressions of miR-34 family suppress the invasive growth of malignant melanoma with wild type p53 genes

Malignant melanoma is a highly aggressive neoplasm with severe metastatic potential. In recent decades, the incidence of malignant melanoma has steadily increased. Particularly worrying features of this tumor are its increasing incidence and its capacity for rapid metastatic spread. MicroRNAs represent a class of endogenously expressed, small non-coding RNAs that regulate gene expression. As a consequence of disease, the translation of these mRNAs is inhibited or destabilized resulting in downregulation of the encoded protein. A few microRNAs have been classified as oncogenes or tumor suppressor genes as their expression is altered in tumors, and in some cases, this has been shown to contribute to the phenotypes of cancer cells. Recently, microRNA-34 (miR-34) was identified as a mediator of tumor suppression by p53. The miR-34 family comprises three processed microRNAs (miR-34a/b/c) that are encoded by two different genes: miR-34a is encoded by its own transcript, whereas miR-34b and miR-34c share a common primary transcript. Many reports have suggested that miR-34s contribute to inhibition of invasion or metastasis in various tumors. These reports suggest that miR-34s play important roles as inhibitors of tumor growth. However, the biological characteristics of miR-34s in human malignant melanoma are not well understood. In this study, we performed real-time reverse transcription PCR to evaluate expressions of the miR-34 family in four human melanoma cell lines that contained the wild type p53 gene (A375, G361, SK-MEL-24, and C32TG). We also examined the generative and invasive characteristics of these cell lines using the cell proliferation assay and invasion/migration assay. All four melanoma cell lines showed significant expression of miR-34s; A375, miR-34a 0.6176, miR-34b 0.7625, miR-34c 0.7877; G361, 7.6424, 16.4127, 22.0332; SK-MEL-24, 0.3621, 2.5659, 8.5907; C32TG, 2.1630, 2.1091, 8.4425. The cell doubling times of these cell lines were as follows; A375 23:23, G361 68:24, SK-MEL-24 67:03, and C32TG 47:22. In vitro generation times of G361 and SK-MEL-24, which showed increased expressions of miR-34c, were significantly longer than that of A375 with decreased expression of miR-34c (p=0.0063, ANOVA). %Invasions of four cell lines were as follows; A375 44.0%, G361 22.4%, SK-MEL-24 45.0%, and C32TG 13.8%. In vitro invasiveness of G361 and C32TG, which showed increased expressions of miR-34a were significantly suppressed (p=0.005, ANOVA). These findings suggest that overexpressions of miR-34a and c suppress invasive and generative potentials respectively in human malignant melanoma.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4948. doi:10.1158/1538-7445.AM2011-4948

[Retroperitoneal liposarcoma: a case report]

A 35-year-old woman who had visited an other hospital because of epigastralgia and anorexia was found to have a giant abdominal tumor, and was referred to our hospital. On admission, the abdomen was markedly distended. Abdominal CT scan and MRI showed the presence of a retroperitoneal tumor which occupied almost the entire abdominal cavity. She was operated a under a diagnosis of retroperitoneal liposarcoma. The tumor was located between the subphrenic space and the pelvic cavity, and was compressing the stomach, duodenum, pancreas and colon. Removal of the retroperitoneal tumor, including the right kidney, was performed. The resected tumor was 34 × 28 × 20 cm, weighed 5.5 kg and showed a variety of finding. The pathological diagnosis was a mixed type of retroperitoneal liposarcoma, consisting of well-differentiated type and myxoid type. We reported a case of giant retroperitoneal liposarcoma, with a review of the literature.

Stromal thrombospondin-1 expression is a prognostic indicator and a new marker of invasiveness in intraductal papillary-mucinous neoplasm of the pancreas

The invasion of intraductal papillary-mucinous neoplasm (IPMN) is sometimes difficult to diagnose using only ordinary hematoxylin-eosin sections. The aim of this study was to evaluate the invasion of IPMN more precisely using thrombospondin-1 (TSP1) immunohistochemistry as a useful adjunct to morphological examination. Eighty patients that underwent primary resection for pancreatic IPMNs were retrospectively analyzed. The 80 IPMNs were studied for the expression of TSP1, MUC1-CORE, MUC2, and MUC5AC. The cases were evaluated for dysplasia, the presence of invasion, hisological subtypes, and survival. The 80 IPMNs were classified into 29 intraductal papillary-mucinous adenomas (IPMAs), 10 borderline IPMNs, 18 noninvasive intraductal papillary-mucinous carcinomas (IPMCs), and 23 invasive IPMCs according to the WHO classification. Invasive IPMCs were further divided into 12 minimally invasive IPMCs (MI-IPMCs) and 11 invasive carcinomas originating from IPMCs (IC-IPMCs) according to the Japan Pancreatic Society classification. The rate of strongly positive cases with more than 30% of the cancer stroma area expressing TSP1 was significantly higher in MI-IPMC and IC-IPMC than in noninvasive IPMC (P = 0.035, 0.005). Furthermore, patients in the strongly positive group had a significantly poorer prognosis compared to patients in the negative-weakly positive group (P = 0.008, log-rank test). Of the 80 tumors, 22 were classified into gastric-, 45 into intestinal-, 7 into pancreatobiliary-, and 6 into oncocytic-type IPMNs according to criteria described previously. The cases with a strongly positive expression of TSP1 were frequently detected in the pancreatobiliary and oncocytic types (P = 0.001). In conclusion, stromal TSP1 expression is a prognostic indicator and a new marker of invasiveness in IPMN.