Reinforced antimyeloma therapy via dual-lymphoid activation mediated by a panel of antibodies armed with bridging-BiTE

Immunotherapy using bispecific antibodies including bispecific T-cell engager (BiTE) has the potential to enhance the efficacy of treatment for relapsed/refractory multiple myeloma. However, myeloma may still recur after treatment because of downregulation of a target antigen and/or myeloma cell heterogeneity. To strengthen immunotherapy for myeloma while overcoming its characteristics, we have newly developed a BiTE-based modality, referred to as bridging-BiTE (B-BiTE). B-BiTE was able to bind to both a human immunoglobulin G-Fc domain and the CD3 molecule. Clinically available monoclonal antibodies (mAbs) were bound with B-BiTE before administration, and the mAb/B-BiTE complex induced antitumor T-cell responses successfully while preserving and supporting natural killer cell reactivity, resulting in enhanced antimyeloma effects via dual-lymphoid activation. In contrast, any unwanted off-target immune-cell reactivity mediated by mAb/B-BiTE complexes or B-BiTE itself appeared not to be observed in vitro and in vivo. Importantly, sequential immunotherapy using 2 different mAb/B-BiTE complexes appeared to circumvent myeloma cell antigen escape, and further augmented immune responses to myeloma relative to those induced by mAb/B-BiTE monotherapy or sequential therapy with 2 mAbs in the absence of B-BiTE. Therefore, this modality facilitates easy and prompt generation of a broad panel of bispecific antibodies that can induce deep and durable antitumor responses in the presence of clinically available mAbs, supporting further advancement of reinforced immunotherapy for multiple myeloma and other refractory hematologic malignancies.

Quality of clinical practice guidelines in Japan remains low: A cross-sectional meta-epidemiological study

OBJECTIVES

We aimed to evaluate the characteristics, quality, and related factors of the Japanese Clinical Practice Guidelines (CPGs) published in recent years.

STUDY DESIGN AND SETTING

In this cross-sectional, meta-epidemiological study, we conducted a Google search for CPGs published by 30 Japanese medical societies that are the basis for training specialties between 2018 and 2019. We used the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool and the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement to evaluate the quality.

RESULTS

We included 53 systematic review-based CPGs. The median score was 0.54 (IQR, 0.38-0.62) for Stakeholder involvement, 0.57 (IQR, 0.51-0.66) in Rigor of development, 0.33 (IQR 0.21-0.46) in Applicability, and 0.63 (IQR 0.46-0.73) in Editorial independence. The number of guideline developers/clinical question ratio (odds ratio [OR]: 4.14, 95% confidence interval [CI]: 1.97, 8.70) and the adopted guideline development methods (OR: 3.69, 95% CI: 1.14, 12.0) were significantly related to the Rigor of development.

CONCLUSION

The quality of Japanese CPGs published in recent years remains low. Our study suggests that increasing contributors and adopting the latest guideline development methods at the beginning of the project may improve the quality of the Japanese CPGs.

A single-chain antibody generation system yielding CAR-T cells with superior antitumor function

Cancer immunotherapy using T cells redirected with chimeric antigen receptor (CAR) has shown a lot of promise. We have established a single-chain antibody (scFv) generation system in which scFv library-expressing CAR-T cells can be screened appropriately based on their antitumor functions. A variable region library containing the variable and J regions of the human immunoglobulin light or heavy chain was fused with the variable region of a heavy or light chain encoded by an existing tumor-specific antibody to generate a new scFv library. Then, scFv library-expressing CAR-T cells were generated and stimulated with target cells to concentrate the antigen-specific population. Using this system, target-specific recognition of CAR-T cells appeared to be finely tuned by selecting a new variable region. Importantly, we have demonstrated that the newly optimized scFv-expressing CAR-T cells had better proliferation capacity and durable phenotypes, enabling superior reactivity against advanced tumors in vivo in comparison with the original CAR-T cells. Therefore, the optimization of an scFv is needed to maximize the in vivo antitumor functions of CAR-T cells. This system may allow us to adjust an immunological synapse formed by an scFv expressed by CAR-T cells and a target antigen, representing an ideal form of CAR-T-cell immunotherapy.

Abstract B031: Development of antimyeloma immunotherapy by exploiting modified antibodies specific for A2/NY-ESO-1

Background: T-cell therapy can be a promising treatment option even in patients with refractory malignancies including myeloma. NY-ESO-1 is a well-known cancer-testis antigen which is expressed by refractory myeloma cells, and a NY-ESO-1_157-165 peptide presented by an HLA-A*02:01 molecule (A2/NY-ESO-1_157) has been demonstrated. Adoptive transfer therapy using T-cells modified with T-cell receptor (TCR) specific for A2/NY-ESO-1_157 successfully induced clinical responses in patients with advanced myeloma. However, TCR-transduced T-cells are laborious to generate and possess the cross-reactivity induced by mispaired and/or introduced TCRs, resulting in increase of unwanted toxicities. T-cell therapy utilizing modified antibodies containing single chain fragment variables (scFvs), such as chimeric antigen receptor (CAR) and bispecific antibody (BiTE) would overcome the issues concerning TCR-T therapy and expand clinical versatility of T-cell therapy targeting NY-ESO-1 in the treatment of refractory myeloma. In this study, we have generated both CAR and BiTE which recognize A2/NY-ESO-1_157, and assessed their anti-myeloma reactivity and cross-reactivity in vitro and in vivo. Methods: Expression of NY-ESO-1 in a panel of myeloma cell lines was examined by real-time PCR and Western blotting. Based on the structure of previously reported monoclonal antibody specific for A2/NY-ESO-1_157 (clone: 3M4E5), we newly synthesized an A2/NY-ESO-1_157-specific scFv. Second generation CAR possessing an scFv linked with CD28 and CD3z was generated. A BiTE composed of an A2/NY-ESO-1_157-specific scFv and a CD3e-binding scFv was also generated. A2/NY-ESO-1_157-specific reactivity mediated by CAR and BiTE-redirected T-cells were assessed by A2/NY-ESO-1_157 tetramer and multiple cytokine assays. Specific lysis of targeT-cells by those T-cells was measured by standard Cr-release assay. Alanine scanning of NY-ESO-1_157 peptide was performed, and nine peptides homologous to NY-ESO-1_157 were synthesized. Cross-reactivity of CAR and BiTE-redirected T-cells for these peptides and NY-ESO-1_157 peptide presented by HLA-A2 alleles was evaluated. NOG mice engrafted with a luciferase-transduced A2+NY-ESO-1+ myeloma cell line (U266/SLR) were treated with CAR-T-cells or T-cells with BiTE, and tumor sizes were measured by bioluminescence imaging assays. Results: Three out of six myeloma cell lines we tested abundantly expressed NY-ESO-1 mRNA and protein. CAR-T-cells established from five out of five donors showed A2/NY-ESO-1_157-specific reactivity. These gene-modified T-cells recognized and killed targeT-cells which naturally process and present A2/NY-ESO-1_157, resulting in anti-myeloma reactivity to A2+NY-ESO-1+ U266 myeloma cells. Newly generated BiTE successfully engaged A2/NY-ESO-1_157 expressing targeT-cells with CD3+ T-cells, thereby peripheral T-cells produced multiple cytokines against A2+NY-ESO-1+ targeT-cells, and lysed them. CAR and BiTE-redirected T-cells can possess cross-reactivity for some of homologous peptides and NY-ESO-1_157 peptide presented by HLA-A2 alleles. Functional avidity of BiTE-redirected T-cells for A2/NY-ESO-1_157 was comparable with that of CAR-T-cells. Importantly, tumor growth was suppressed by intravenous injection of CAR-T-cells and T-cells in combination with BiTE, and their antitumor effects were similarly observed. Conclusions: T-cells redirected with CAR and BiTE both successfully showed anti-myeloma reactivity in an A2/NY-ESO-1_157-specific manner. An A2/NY-ESO-1_157-specific BiTE displayed a potential to induce sufficient antitumor T-cell responses against myeloma cells in vivo. These two scFv-based modalities also require to pay attention to unwanted cross-reactivity; however, they can provide efficacious and flexible options for the treatment of HLA-A2-positive patients with refractory myeloma.

Citation Format: Toshiki Ochi, Masaki Maruta, Kazushi Tanimoto, Hiroaki Asai, Takashi Saitou, Yoshihiro Yakushijin, Hiroshi Fujiwara, Takeshi Imamura, Katsuto Takenaka, Masaki Yasukawa. Development of antimyeloma immunotherapy by exploiting modified antibodies specific for A2/NY-ESO-1 [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B031.

Development of an FVIII Inhibitor in a Mild Hemophilia Patient with a Phe595Cys Mutation

Mild hemophilia A is caused by a missense mutation in the FVIII gene that is responsible for a decrease in the FVIII:C to between 5% and 40%. The development of FVIII inhibitors has been reported in 3-13% of patients with mild hemophilia. Genetic risk factors for the development of inhibitors in mild hemophilia have been investigated. In the present study, we encountered a case of mild hemophilia with an FVIII inhibitor and identified the mutation responsible: a novel Phe595Cys mutation in the FVIII gene. In addition, this study showed that the inhibitor recognized exogenous wild-type FVIII and autologous mutant FVIII.

A patient with severe fever with thrombocytopenia syndrome and hemophagocytic lymphohistiocytosis-associated involvement of the central nervous system

Severe fever with thrombocytopenia syndrome (SFTS), a severe infectious disease caused by novel bunyavirus, SFTS virus (SFTSV), is endemic to China, Korea, and Japan. Most SFTS patients show abnormalities in consciousness. Pathological findings in the central nervous system (CNS) of SFTS patients are not reported. A 53-year-old Japanese man was admitted to Uwajima City Hospital with an 8-day history of fever and diarrhea. Laboratory tests revealed leukopenia, thrombocytopenia, and liver enzyme elevation. He was diagnosed as having severe fever with thrombocytopenia syndrome (SFTS) following detection of the SFTSV genome in his blood. Bone marrow aspiration revealed hemophagocytic lymphohistiocytosis. He suffered progressive CNS disturbance and died on day 13 from onset of first symptoms. The SFTSV genome load in blood and levels of certain cytokines increased over the disease course. Necrotizing lymphadenitis with systemic lymphoid tissues positive for nucleocapsid protein (NP) of SFTSV was revealed by immunohistochemical (IHC) analysis. SFTSV-NP-positive immunoblasts were detected in all organs examined, including the CNS, and in the vascular lumina of each organ. Parenchymal cells of all organs examined were negative for SFTSV-NP on IHC analysis. Microscopic examination of the pons showed focal neuronal cell degeneration with hemosiderin-laden macrophages around extended microvessels with perivascular inflammatory cell infiltration and intravascular fibrin deposition. Autopsy confirmed this patient with SFTS was positive for systemic hemophagocytic lymphohistiocytosis including in the CNS. This patient's neurological abnormalities may have been caused by both functional and organic abnormalities. These novel findings provide important insights into the pathophysiology of SFTS.

Unusual presentation of a severely ill patient having severe fever with thrombocytopenia syndrome: a case report

BACKGROUND

Severe fever with thrombocytopenia syndrome is an emerging infectious disease caused by a novel phlebovirus belonging to the family Bunyaviridate. Emergence of encephalitis/encephalopathy during severe fever with thrombocytopenia syndrome progression has been identified as a major risk factor associated with a poor prognosis. Here we report the case of a severely ill patient with severe fever with thrombocytopenia syndrome virus-associated encephalitis/encephalopathy characterized by a lesion of the splenium, which resolved later.

CASE PRESENTATION

A 56-year-old Japanese man presented with fever and diarrhea, followed by dysarthria. Diffusion-weighted magnetic resonance imaging demonstrated high signal intensity in the splenium of the corpus callosum. The severe fever with thrombocytopenia syndrome virus genome was detected in our patient's serum, and the clinical course was characterized by convulsion, stupor, and hemorrhagic manifestations, with disseminated intravascular coagulation and hemophagocytic lymphohistiocytosis. Supportive therapy not including administration of corticosteroids led to gradual improvement of the clinical and laboratory findings, and magnetic resonance imaging demonstrated resolution of the splenial lesion. The serum severe fever with thrombocytopenia syndrome viral copy number, which was determined with the quantitative reverse-transcription polymerase chain reaction, rapidly decreased despite the severe clinical course. Our patient's overall condition improved, allowing him to be eventually discharged.

CONCLUSIONS

Patients with encephalitis/encephalopathy due to severe fever with thrombocytopenia syndrome virus infection may have a favorable outcome, even if they exhibit splenial lesions and a severe clinical course; monitoring the serum viral load may be of value for prediction of outcome and potentially enables the avoidance of corticosteroids to intentionally cause opportunistic infection.

Diffuse large B-cell lymphoma, not otherwise specified presenting with bone and bone marrow involvement in the absence of lymphadenopathy

A 74-year-old woman visited our hospital because of right chest pain and fatigue. Laboratory examinations revealed pancytopenia and an elevated level of serum lactate dehydrogenase. Although bone lesions were detected by computed tomography, there was no lymphadenopathy. Blastoid cells were evident in the bone marrow. From the patient's medical history and results of immunohistological and chromosomal analysis, she was diagnosed as having diffuse large B-cell lymphoma, not otherwise specified. This form of presentation of diffuse large B-cell lymphoma is very rare, and emphasizes the need for careful evaluation of such cases, including bone marrow biopsy for accurate diagnosis.

Acute abdomen due to group A streptococcus bacteremia caused by an isolate with a mutation in the csrS gene

Streptococcus pyogenes (group A streptococcus) is an aerobic gram-positive coccus that causes infections ranging from non-invasive pharyngitis to severely invasive necrotizing fasciitis. Mutations in csrS/csrR and rgg, negative regulator genes of group A streptococcus, are crucial factors in the pathogenesis of streptococcal toxic shock syndrome, which is a severe, invasive infection characterized by sudden onset of shock and multiorgan failure, resulting in a high mortality rate. Here we present a case of group A streptococcal bacteremia in a 28-year-old Japanese woman with no relevant previous medical history. The patient developed progressive abdominal symptoms that may have been due to spontaneous bacterial peritonitis, followed by a state of shock, which did not fulfill the proposed criteria for streptococcal toxic shock. The isolate was found to harbor a mutation in the negative regulator csrS gene, whereas the csrR and rgg genes were intact. It was noteworthy that this strain carrying a csrS mutation had caused group A streptococcal bacteremia characterized by acute abdomen as the presenting symptom in a young individual who had been previously healthy. This case indicates that group A streptococcus with csrS mutations has potential virulence factors that are associated with the onset of group A streptococcal bacteremia that does not meet the diagnostic criteria for streptococcal toxic shock syndrome.

[Diagnosis of disseminated bone marrow carcinomatosis from gastric carcinoma initially presenting as asymptomatic anemia]

A 75-year-old man who had undergone subtotal gastrectomy for advanced gastric cancer 18 years previously with no signs of recurrence visited our hospital because of anemia detected by medical examination. Although no clinical abnormalities were evident, treatment with iron and vitamin B12 was started. However, because serum ALP was elevated, metastatic bone cancer was suspected. Subsequently, upper gastrointestinal endoscopy revealed findings suggestive of residual gastric cancer, and examination of a biopsy specimen demonstrated signet ring cell carcinoma. Furthermore, cells in a bone marrow biopsy sample showed morphology similar to that of cells obtained by stomach biopsy. FDG-PET demonstrated FDG accumulation only in the bone and residual stomach. The final diagnosis was bone metastasis from residual gastric cancer, and disseminated carcinomatosis of the bone marrow. Thereafter, pancytopenia progressed rapidly, and the patient died due to disseminated intravascular coagulation. When serum ALP is elevated in patients with a history of gastric cancer, bone marrow carcinomatosis should be suspected irrespective of symptoms, and imaging studies and bone marrow examination should be performed.

Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele

BACKGROUND

We evaluated functional and morphological outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele.

METHODS

Ten women (median 68 years) underwent transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele. Symptoms and continence were monitored before and after surgery. Manovolumetric study and defecography were performed in 9 of 10 patients before and 3-6 months after surgery. Twenty-one females without anorectal diseases were used as controls in manovolumetric study. The patients were followed up after a median of 89 months (range, 3-103).

RESULTS

Main symptoms (defecatory disorders in 9 patients, vaginal mass in 6, perineal discomfort in 2) disappeared after surgery. Six patients performed digitation preoperatively and gave up digitation on defecation after surgery. Stool incontinence disappeared in 4 of 5 preoperatively incontinent patients (Cleveland clinic score, 5-12) and continence score improved from 5 to 2 in the remaining patient. Three patients with urinary cough incontinence preoperatively did not experience incontinence after surgery but cough incontinence occurred occasionally in an 81-year-old patient postoperatively. Rectocele demonstrated on defecography disappeared postoperatively in all 9 patients who underwent defecography. High threshold volume and maximum tolerable volume, which were observed preoperatively, decreased to control levels after surgery.

CONCLUSION

Transvaginal anterior levatorplasty with posterior colporrhaphy might be an option for symptomatic rectocele to improve anorectal and urinary dysfunctions with morphological disorders.

Trends in the treatment for liver metastasis of colorectal cancer in Japan

The rate of liver metastasis before surgery of colorectal cancer is 11% in Japan. The survival rate of radical surgery with D-3 lymph node adenectomy is 83.7% in colon cancer and 77.1% in rectal cancer. The percentage of recurrent liver metastasis after curative surgery with D-3 lymph node extent resection is 7.1% within 5 years. Hepatectomy has the best survival rate: 52.8% after 3 years, 39.2% after 5 years. There is no difference in patients' survival rate between systemic anatomical hepatectomy and non-anatomical limited resection. For recurrent hepatic metastasis after curative surgery, hepatectomy should be done if no other metastasis is found in any other organ and the patient is suitable for surgery. Hepatic artery infusion chemotherapy (HAI) for metastasis of the liver is no longer used today. Radiofrequency ablation or microwave coagulation therapy may prolong the survival time but is not a curative procedure.

Colorectal cancer in Japan

There is the increase in colorectal cancer incidence in Japan. The increase in the rate of colon cancer compared with rectal cancer was noticed. The proximal migration of the tumor site from the left colon to right colon is shown in the study. The evident shift toward earlier stage was clearly revealed. According to the extended lymph node resection, the improvement of overall 5-year survival rate from 55% to 69% is important trend.

Who can get the beneficial effect from lateral lymph node dissection for Dukes C rectal carcinoma below the peritoneal reflection?

PURPOSE

This study was designed to identify those patients with Dukes C rectal carcinoma below the peritoneal reflection who might benefit from lateral lymph node dissection.

METHODS

The study involved 104 consecutive Dukes C patients who received total mesorectal excision with lateral lymph node dissection for rectal carcinoma below the peritoneal reflection between 1990 and 2002. The patients were retrospectively divided into three groups: patients without lateral spread (Group I: n = 52), patients with nodal involvement between the inferior hypogastric nerve and the internal iliac artery (Group II: n = 16), and patients with nodal involvement in the obturator space (Group III: n = 36). The patients also were divided into two groups according to the number of lateral nodes involved: less than four (n = 42) and at least four (lateral nodes involved: n = 10). Nodal involvement was determined histologically.

RESULTS

The local recurrence and overall five-year survival rates were 5.8 and 66.9 percent in Group I, 18.8 and 59.8 percent in Group II, and 33.3 and 23.6 percent in Group III, respectively. These outcomes did not differ significantly between Groups I and II, but they were significantly worse in Group III than in Groups I and II, with the survival being significantly better in the patients with less than four histologically positive lateral nodes involved (43.2 percent) than in those with at least four positive lateral nodes involved (0 percent).

CONCLUSIONS

Lateral lymph node dissection was effective for Dukes C rectal carcinoma below the peritoneal reflection with positive lateral nodes involved in the space between the autonomic nerve and the internal iliac artery and in patients with less than four positive lateral nodes.

Mucinous adenocarcinoma associated with chronic anal fistula reconstructed by gracilis myocutaneous flaps

Mucinous adenocarcinoma associated with chronic anal fistula is extremely rare, and such tumors have often reached an advanced stage at the time of presentation. Here we report a case of mucinous adenocarcinoma associated with chronic anal fistula that involved repair with gracilis myocutaneous flaps and review other reported cases. A 67-year-old man with an approximate 30-year history of an anal fistula was referred to our hospital due to enlargement of the perianal induration accompanied by mucinous secretion and pain. Physical examination of the perianal region revealed an ulcerated and discharging lesion on the buttocks. Histologic examination of a biopsy specimen of the ulcerated lesion revealed mucinous adenocarcinoma. An abdominoperineal resection was performed with resection of the ischiorectal fossa, coccyx, part of the gluteus maximus, and the obturator internus. The extensive defect was repaired with bilateral gracilis myocutaneous flaps. The patient did not experience a decrease in the strength of hip adduction and survived for 58 months without recurrence until he died of pneumonia. The repair using myocutaneous flaps was considered to contribute to a physically active life without recurrence.

Enterocele associated with rectocele revealed by dynamic pelvic CT

Enterocele is often associated with other pelvic floor disorders but it is not always possible to detect by clinical examination. Defecography with peritoneography and/or barium meal intake has recently been developed as a new method to identify enterocele, but this method is an invasive procedure. Multislice computed tomography was performed at rest and during simulated defecation to evaluate an 80-year-old female patient who had a defecation disorder and was diagnosed as having rectocele based on results from defecography and clinical findings. Multiplanar reconstruction images were generated for image evaluation. Using this novel method of dynamic pelvic computed tomography, a third-degree enterocele was clearly demonstrated in this case.

Local correction of a transverse loop colostomy prolapse by means of a stapler device

Prolapse is a common complication in patients with a transverse loop colostomy. In most cases, the prolapse can be managed conservatively awaiting time for closure eventually. However, loop stoma may also be intentionally permanent or the patient may be too fragile to have the colostomy closed and in these cases a laparotomy is required for correction of the prolapse. A simple method allowing local correction of the prolapsed loop stoma is described.

A new technique of laparoscopic surgery for rectal disease

Laparoscopic rectal surgery is a technique that has to be done in a narrow space: the pelvis. If an immoderate operation is performed with a difficult view, for example in female where the field is disturbed by uterus, it is possible to produce organ trauma or an unexpected bleeding. Taking these problems in mind, we performed laparoscopic surgery in 44 cases of rectal disease with several techniques which we have invented. In these cases either the uterus or the rectum was retracted in the narrow space, and if an anterior resection was to be done, the tape was tied tightly around the rectum below the tumor to avoid touching the tumor and leaving adequate vascular irrigation to the remnant rectum. With the use of our techniques, we did not have female intestinal injury or unexpected bleeding. In addition laparoscopic anterior resection of rectum did not cause any intestinal injury, or unexpected bleeding or anastomotic leakage; also we did not have any local tumor recurrence. It is our belief that these techniques can decrease complications that traumatize the grasping intestine with intestinal forceps and prevent implantation in the anastomosis. This technical report validate that our technique modifications for rectal laparoscopic surgery are useful when a surgeon has to work in a narrow space.

Pathophysiology and prevention of loop stomal prolapse in the transverse colon

We investigated both pathogenesis and prevention of loop transverse stomal prolapse. Seven patients with reducible prolapsed stoma were studied under fluoroscopy after staining the prolapsed stoma and the colon by barium medium while prolapsing or reducing the stoma with or without the stomal wall pressed on to the abdominal wall of fascial plane. All prolapses occurred in the distal limbs of the loop stoma with the distal transverse colons redundant. The prolapse started around the mucocutaneous suture with the stoma inflated and the colon in it depressed and proceeded in accordance with an addition of abdominal pressure, but did not occur by pressing of the stomal wall. Prolapse of transverse loop stoma occurs when redundant colon invades the stoma with an abdominal pressure. Stomal prolapse might be prevented by fixation of the colon to the fascia.

Minimally invasive surgery for carcinoid tumors in the rectum

Most carcinoid tumors of the rectum are confined to the submucosa with a size less than 1-2 cm and are usually suitable for local excision, as metastasis to the regional nodes is limited. Endoscopic excision of carcinoid tumors has been performed for this entity as a least invasive method but incomplete resection and/or unclear surgical margin and curability have been reported to occur in 24-42% of cases because of a limited resection up to the submucosal layer and burn effect. Transanal local excision has often been applied for rectal carcinoid tumor as a least invasive method among local excision procedures to accomplish full thickness excision for determining the curability. However, it is often difficult to obtain free access with a sufficient surgical field by the conventional method. Transanal endoscopic microsurgery (TEM) has appeared as a useful option to access a high tumor with fine visibility but special caution has to be taken for tumors sited above the peritoneal reflection. To facilitate full thickness excision even for high tumors, novel local excisional technique called minimally invasive transanal surgery (MITAS) has been developed and used for local removal of carcinoid tumors in the rectum. A specially designed anal retractor connected to the Octopus retractor holder with several novel techniques facilitated excisional procedures around the anus with a sufficient fixed surgical field and an ENDO-stapler allowed the simultaneous excision and anastomosis to be performed. The technique facilitated total excisional biopsy with less operative time and blood loss, and no mobility or mortality in 12 patients with rectal carcinoid tumors.

Bladder and male sexual functions after autonomic nerve-sparing TME with or without lateral node dissection for rectal cancer

BACKGROUND

We evaluated to what extent lateral lymph node dissection (LND) interferes with bladder and male sexual functions after radical rectal excision with adoption of careful total autonomic nerve preservation.

METHODS

The study comprised 77 patients resected for mid-rectal or lower rectal cancer. Bladder and male sexual functions were studied by means of a questionnaire more than one year after surgery. Outcomes were compared between patients who received lateral LND (group 1, 65 patients) and those who did not (group 2, 12 patients).

RESULTS

Only minor disturbances of bladder function were reported in 10 patients (15%) of group 1, and in 3 patients (25%) of group 2. Ten out of 37 preoperatively sexually active patients (27%) in group 1 males and one of 5 patients (20%) in group 2 males had partial or total impotency after surgery and retrograde ejaculation occurred in 3 of 27 patients (11%) and one of 4 patients (25%), respectively. Erectile impotency occurred less frequently when patients were operated during the period 1993-1996 than during 1988-1992 (11% vs. 42%, p<0.05). The age was significantly greater among patients who had loss of ejaculation.

CONCLUSIONS

If lateral lymph node dissection should be used with the aim of improving radicality in rectal excision for cancer, it should be combined with careful nerve-preserving technique--which may reduce the risk of bladder and male sexual dysfunctions.

Does perifascial rectal excision (i.e. TME) when combined with the autonomic nerve-sparing technique interfere with operative radicality?

OBJECTIVE: The lymphatic drainage from the rectum was studied to evaluate if the autonomic nerve sparing dissection may interfere with the operative radicality and might result in metastatic lymph nodes being overlooked and left in situ. PATIENTS AND METHODS: 50 consecutive patients had an extended extrafascial rectal excision resection for cancer. In 19 of the 50 patients activated carbon particles (CH40) were injected preoperatively into the rectum. The autonomic nerves with surrounding connective tissue were serially dissected from the resected specimen, carefully sliced at 5-mm intervals and collected for histological study. Lymph nodes along the axial and lateral drainage routes were examined, and the inclusion of CH40 in the nodes was microscopically studied according to the site of CH40 injection. RESULTS: Lymph nodes within the connective tissue along the dissected autonomic nerves were demonstrated in 47 of the 50 cases. Two of 50 cases had positive nodes along preaortic plexus or pelvic plexus, and a case with nodal involvement along the pelvic plexus had poor prognosis in spite of nerve excision. CH40 when injected into the rectum above the peritoneal reflection was demonstrated in the vast majority of the axial nodes, while in only one lymph node along the preaortic plexus when injected in the rectum above the peritoneal reflection. On the other hand when injected in the rectum below the peritoneal reflection, CH40 was demonstrated both in axial and lateral nodes as well as in lymph nodes along bilateral pelvic plexuses, right hypogastric nerve, superior hypogastric plexus, preaortic plexus and mesenteric plexus as well. CONCLUSIONS: When located above the peritoneal reflection a rectal carcinoma will spread preferentially along the upper axial route, while a carcinoma located below the peritoneal reflection will also spread laterally and along the autonomic nerves. It was inferred that lymphatic flow along the autonomic nerves came up from the rectum below the peritoneal reflection mainly through a so-called lateral ligament but its clinical significance was negligible. Therefore doing TME with autonomic nerve preservation does not imply a less radical surgery from the point of lymphatic spread.

Effect of oral diazepam on anal continence after low anterior resection: a preliminary study

The aim of the present study was to investigate the effect of oral diazepam on anal incontinence after low anterior resection for rectal cancer. Five patients with persistent incontinence after low anterior resection for rectal cancer (median level of anastomosis was 4.0 cm from the anal verge) were treated with oral diazepam (2 mg/day) 9-90 months after surgery. Grade and frequency of anal incontinence, the need for a protective pad and changes of lifestyle were recorded to the Cleveland Clinic's continence grading scale; anorectal manometry was performed before and after 3 months of treatment. All patients improved on treatment although occasional minor soiling persisted in two patients. Continence score improved from 14 (median, range 9-16) to 0 (range 0-12) after taking diazepam. Improvement occurred within a week after administration of diazepam. Although the patients improved symptomatically, anorectal manometry failed to demonstrate any significant changes. In conclusion, oral administration of diazepam may be worthwhile in the attempt to improve anal continence after low anterior resection.

Minimally invasive transanal surgery for localized rectal carcinoid tumors

Local excision is often fully justified for rectal carcinoid tumors. However insufficient surgical field and difficult access to proximal tumors have been drawbacks in performing pre-existing local excision procedures. A novel local excisional technique called minimally invasive transanal surgery (MITAS) has been experimented for local removal of carcinoid tumors in the rectum. A specially designed anal retractor connected to the Octopus retractor holder was used and an ENDO-stapler allowed the simultaneous excision and anastomosis to be performed. Eight patients with carcinoid tumors in the rectum (4 tumors in the upper rectum) underwent MITAS. Median distance from anal verge to proximal tumor was 6.5 cm (range, 5-12 cm). The median diameter of the tumor was 9 mm. Median operative time was 18.5 minutes and blood loss was minimal. No analgesics were needed postoperatively, and there was no morbidity or mortality. Full-thickness excision of the rectum was accomplished and the tumors confined in the submucosa were demonstrated histologically to be with free surgical margins. No recurrences have been observed with a median follow-up period of 39 months. The technique facilitates total excisional biopsy for rectal carcinoid tumors and reduces operative time, blood loss and complications.

Mucinous cystadenocarcinoma in the appendix in a patient with nonrotation: report of a case

Mucinous cystadenocarcinoma in the appendix is uncommon. An anomaly in the rotation of the intestine is also uncommon in adults. We herein report a case of mucinous cystadenocarcinoma in the appendix in a patient with nonrotation. To the best of our knowledge, this is the first report of appendiceal carcinoma in a patient with an anomaly of intestinal rotation. A 76-year-old woman was admitted to our hospital with left low abdominal pain. Physical examination revealed tenderness with muscle rigidity in the left lower quadrant. The patient was diagnosed to have intussusception by computed tomography and ultrasonography. An emergency operation showed nonrotation and the top of the appendix situated in the left iliac fossa. An appendectomy was performed because of gangrenous acute appendicitis. However, the cut surface of the appendix showed a mucocele measuring 4 x 4 cm in size. It was diagnosed to be mucinous cystadenocarcinoma histopathologically. A right hemicolectomy with lymph node dissection was performed, and no remaining cancer cells or lymph node metastases were found in the resected specimen pathologically. The patient had an uneventful postoperative course. No signs of recurrence have been observed for 23 months since her last operation.

Efficacy of oral UFT as adjuvant chemotherapy to curative resection of colorectal cancer: multicenter prospective randomized trial

BACKGROUND

The purpose of this study is to evaluate the efficacy of postoperative adjuvant chemotherapy using uracil and tegafur (UFT) for colorectal cancer.

METHODS

In a multicenter trial among 43 institutions for patients who underwent curative resection of Dukes' B or C colorectal cancer, a surgery alone group (control group) and a treatment group (UFT group) to which UFT was administered at 400 mg/day for 2 years following surgery were compared. A total of 320 patients were registered between March 1991 and April 1994, and 289 of these patients were analyzed as a full-analysis set.

RESULTS

The 5-year disease-free survival rate was 75.7% in the UFT group and 60.1% in the control group, respectively, and the stratified log-rank test showed the statistical significance ( P=0.0081). This difference was marked in rectal cancer ( P=0.0016) and, in particular, the local recurrence was reduced. No significant difference was observed in the 5-year survival rate. The incidence of adverse reactions on administration of UFT was low, and there was no serious adverse reaction.

CONCLUSION

It is suggested that the consecutive administration of UFT at 400 mg/day was an effective and highly safe therapeutic method as postoperative adjuvant chemotherapy for rectal cancer.

Elevated steroid sulfatase expression in breast cancers

In situ estrogen synthesis makes an important contribution to the high estrogen concentration found in breast cancer tissues. Steroid sulfatase which hydrolyzes several sulfated steroids such as estrone sulfate, dehydroepiandrosterone sulfate, and cholesterol sulfate may be involved. In the present study, we therefore, assessed steroid sulfatase mRNA levels in breast malignancies and background tissues from 38 patients by reverse transcription and polymerase chain reaction. The levels in breast cancer tissues were significantly increased at 1458.4+/-2119.7 attomoles/mg RNA (mean +/- SD) as compared with 535.6+/-663.4 attomoles/mg RNA for non-malignant tissues (P<0.001). Thus, increased steroid sulfatase expression may be partly responsible for local overproduction of estrogen and provide a growth advantage for tumor cells.

[Indications for and limitations of low anterior resection]

The indications for low anterior resection are based mainly on tumor location, penetration depth, histology, macroscopic appearance, etc. Patients with tumors located 2 cm above the puborectal muscle by digital examination can undergo low anterior resection. Distal surgical margins should be at least 1 cm from the tumor in cases of differentiated cancer and localized tumors of stage T2 or less and more than 2 cm in poorly differentiated cancer and tumors of stage T3 or greater with total mesorectal excision (TME). Longer distal surgical margins should be provided in patients with unlocalized tumors and extensive node metastasis. The final decision on whether low anterior resection is appropriate should be made after mesorectal preparation down to the levator muscles with adequate surgical margins. Low anterior resection is contraindicated in patients with poor anorectal function and high age. A rectal stump 1 to 2 cm from the dentate line should be maintained for better postoperative anorectal function if radical excision can still be performed.

Correlation of cyclin D1 MRNA levels with clinico-pathological parameters and clinical outcome in human breast carcinomas

In order to evaluate the prognostic significance of cyclin D1 mRNA expression in mammary neoplasia, its levels were measured in 97 breast cancers by reverse transcription-polymerase chain reaction (PCR) using fluorescent primer and standard RNA along with estrogen receptor (ER). The median value of cyclin D1 mRNA was 1.60 amol/microg RNA (range, 0.01 to 5.63 amol/microg RNA). ER mRNA was detectable in 70 breast cancer samples (72.2%) and cyclin D1 mRNA levels were significantly higher in ER mRNA-positive than in ER mRNA-negative tumors (p = 0.009). Furthermore, cyclin D1 mRNA levels were significantly (p = 0.001) lower in patients who experienced a recurrence during the follow-up period (mean of 40.8 months, median of 39 months) compared with those with no evidence of recurrent disease (mean of 49.2 months, median of 48 months), and in those who died from disease (mean follow-up period of 30.5 months, median of 26 months) than in the survivors (mean of 50.5 months and median of 48 months) (p = 0.005). Setting the median value (= 1.60 amol/microg RNA) as the cutoff point, expression was significantly associated with relapse-free survival (p = 0.002). Similarly, a significant correlation was observed between the cyclin D1 mRNA level and overall survival (p = 0.015). The expression was found to be an independent factor for predicting relapse-free survival using multivariate analysis.

[Minimally invasive transanal surgery]

A new anal retractor connected to an Octopus retractor holder and automatic suture clamp were used for local excision of rectal tumors to obtain easy access to proximal tumors with an adequate surgical field and to avoid complications. Shortening techniques and invagination techniques were adopted to pull down proximal tumors. This surgical procedure resulted in shorter operating time, less bleeding, earlier oral intake, shorter hospital stay, and fewer complications.

Significance of Steroid Sulfatase Expression in Human Breast Cancer

The sulfatase pathway has been thought to be a primary means of local production of estrone in human breast cancer tissue. We measured steroid sulfatase (STS) mRNA levels in 97 breast cancers and evaluated its association with disease-free survival. High levels of STS mRNA proved to be a significant predictor of reduced relapse-free survival, both as a continuous variable (log STS mRNA; P = 0.028) and as a dichotomous variable with an optimized cutoff point (P=0.002). In multivariate analysis a high level of STS mRNA was an independent factor for predicting relapse-free survival. These results suggest a putative role of STS in breast cancer growth and metastasis, and administration of sulfatase inhibitors to breast cancer patients with high levels of STS mRNA might be an additional treatment option.

[Weekly hepatic arterial infusion of high dose 5-fluorouracil for liver metastasis from colorectal cancer]

A weekly infusion of high dose 5-fluorouracil by way of the hepatic artery has been performed in 23 cases with synchronous metastasis from colorectal cancer since 1993. The prognosis in these cases was compared with 94 cases treated without infusion chemotherapy in 94 cases before 1992. The overall one-year and three-year survival rate was 64.8% and 30.2%, respectively, in cases with infusion chemotherapy. The one-year and three-year survival rate was 42.8% and 18.6%, respectively, in cases without infusion chemotherapy. Overall survival rate was significantly different between cases with and without infusion chemotherapy (p < 0.05). In conclusion, weekly infusion chemotherapy resulted in a better survival rate than without infusion chemotherapy.

Steroid sulfatase expression is an independent predictor of recurrence in human breast cancer

Steroid sulfatase (STS) hydrolyzes several sulfated steroids such as estrone sulfate, dehydroepiandrosterone sulfate, and cholesterol sulfate. In the present study, we have measured STS mRNA levels in 97 breast cancers by reverse transcription-PCR using a fluorescent primer in the presence of an internal standard RNA and evaluated its association with disease-free and overall survival. The median value was 728.0 amol/ng RNA (range, 0-11,778 amol/ng RNA). Levels were significantly higher in tumors demonstrating lymph node metastasis than in those without nodal involvement (P = 0.033) and in patients who experienced a recurrence during the follow-up period (mean, 40.8 months; median, 39 months) compared with those with no evidence of further disease (mean, 49.2 months; median, 48 months; P = 0.029). No significant associations were found between STS mRNA expression and age, menopausal status, tumor size, histological grade, estrogen receptor status, or postoperative adjuvant therapy. High levels of STS mRNA proved to be a significant predictor of reduced relapse-free survival as a continuous variable (log STS mRNA; P = 0.028). As a dichotomous variable with an optimized cutoff point of 1,240 amol/ng RNA, expression was also associated with a significantly shorter relapse-free survival rate (P = 0.002), but no significant correlation was found between the STS mRNA level and overall survival. Expression was found to be an independent factor for predicting relapse-free survival on multivariate analysis. The results thus support a putative role of STS in breast cancer growth and metastasis.

[Minute carcinoid tumor in the rectum with liver metastasis]

A 65-year-old woman was admitted to our hospital for evaluation of multiple liver tumors following endoscopic polypectomy for rectal polyp a year earlier. The polypectomy specimen was reexamined and showed inclusion of a carcinoid tumor 3 mm in diameter. The perirectal lymph node was palpated by digital examination on readmission. The patient died one mouth after readmission due to liver failure. Autopsy revealed metastatic carcinoid tumor in the liver and perirectal nodes.

Presence of alternatively spliced transcripts of aromatase gene in human breast cancer

The expression of aromatase (estrogen synthetase) is tissue specifically regulated through the alternative use of multiple exons 1 and promotors. We have determined the amounts of aromatase messenger ribonucleic acid (mRNA) and which type of multiple exons 1 of the human aromatase gene is used in breast tissues of 49 patients with breast cancer by reverse transcription-PCR analysis. The aromatase mRNA levels in these breast cancer tissues (4.53 +/- 0.66 x 10(-3) attomoles/micrograms RNA) were significantly (P < 0.01) higher than those in 16 nonmalignant breast tissues (1.73 +/- 0.40 x 10(-3) amol/micrograms RNA). Aromatase mRNA in all nonmalignant breast tissue were transcribed from skin fibroblast/fetal liver-specific exon 1 (exon 1b) of the gene. In 23 breast cancer tissues, the utilization of multiple exons 1 in the aromatase mRNA was the same as that in nonmalignant breast tissues, whereas in the other 26 cases, it changed from exon 1b to ovary-specific exon 1 (exon 1c). Such switching of tissue-specific exons 1 may affect strict regulation of the tissue-specific expression of aromatase, leading to abnormal expression of the aromatase. The consequent overproduction of local estrogen might promote carcinogenesis or the proliferation of breast cancers.