Preoperative Rapid Weight Loss as a Prognostic Predictor After Surgical Resection for Pancreatic Cancer

OBJECTIVE

The aim of the study is to evaluate the influence of cachexia at the time of diagnosis of pancreatic ductal adenocarcinoma (PDAC) on prognosis in patients undergoing surgical resection.

METHODS

Patients with data on preoperative body weight (BW) change followed by surgical resection during 2008-2017 were selected. Large BW loss was defined as weight loss >5% or >2% in individuals with body mass index less than 20 kg/m2 within 1 year preoperatively. Influence of large BW loss, ΔBW defined as preoperative BW change (%) per month, prognostic nutrition index, and indices of sarcopenia.

RESULTS

We evaluated 165 patients with PDAC. Preoperatively, 78 patients were categorized as having large BW loss. ΔBW was ≤ -1.34% per month (rapid) and > -1.34% per month (slow) in 95 and 70 patients, respectively. The median postoperative overall survival of rapid and slow ΔBW groups was 1.4 and 4.4 years, respectively (P < 0.001). In multivariate analyses rapid ΔBW (hazard ratio [HR], 3.88); intraoperative blood loss ≥430 mL (HR, 1.89); tumor size ≥2.9 cm (HR, 1.74); and R1/2 resection (HR, 1.77) were independent predictors of worse survival.

CONCLUSIONS

Preoperative rapid BW loss ≥1.34% per month was an independent predictor of worse survival of patients with PDAC.

A locally advanced pancreatic body cancer presenting common bile duct invasion resected via distal pancreatectomy after gemcitabine plus nab-paclitaxel chemotherapy: A case report

Introduction

The locally advanced pancreatic cancer has been steadily recognized as a potentially curable disease by a combination of chemotherapy and surgery. The remarkable effect of advanced chemotherapy would help surgeons do a function-preserving operation for advanced pancreatic cancer.

Presentation of case

A 73-year-old woman presenting with obstructive jaundice was diagnosed to have a 3-cm pancreatic body cancer invading the celiac axis (CA), superior mesenteric artery (SMA), portal/splenic vein confluence, and the common bile duct (CBD). A plastic internal stent tube was placed endoscopically. After 11 cycles (231 days) of a weekly doublet chemotherapy with 1000 mg/m² of gemcitabine and 125 mg/m² of albumin-bound paclitaxel, the tumor shrunk based on imaging done every four months during chemotherapy, with residual periarterial high-density area around CA and proximal SMA and the patient was referred for surgery. During the operation, the absence of cancer cells was confirmed at (1) the origin of the proper hepatic artery, gastroduodenal artery and the left gastric artery, and (2) pancreatic cut stump along the right border of the portal vein; thus, distal pancreatectomy with coeliac axis resection was done. The patient had postoperative adjuvant chemotherapy with 100 mg/day of tegafur/gimeracil/oteracil for half a year and is currently alive and well, without signs of recurrence and diabetes mellitus a year after surgery.

Discussion

Although surgical techniques aimed at local radicality are important, especially for conversion surgery for locally advanced pancreatic cancer, surgeons should consider the balance between radicality, safety, and functional preservation of surgery.

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A locally advanced pancreatic cancer has been curable by chemotherapy and surgery.

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The arterial invasion by imaging diagnostics is sometimes released by chemotherapy.

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The common bile duct invasion was dissolved after chemotherapy.

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The effect of chemotherapy would help surgeons do a function-preserving operation.

Risk factors for hepatitis B virus recurrence after living donor liver transplantation: A 22-year experience at a single center

The factors associated with hepatitis B virus (HBV) recurrence after living donor liver transplantation (LDLT) have not been fully clarified. The aim of this study was to determine the risk factors associated with HBV recurrence after LDLT. From January 1996 to December 2018, a total of 609 LDLT operations were performed at our center. A retrospective review was performed of 70 patients (male, n = 59; female, n = 11; median age = 54 years) who underwent LDLT for HBV-related liver disease. The virologic and biochemical data, tumor burden, antiviral and immunosuppressive therapy were evaluated and compared between the HBV recurrence and non-recurrence groups. Eleven of 70 patients (16%) developed post-LDLT HBV recurrence. The overall actuarial rates of HBV recurrence at 1, 3, 5, 10, and 20 years were 0%, 13%, 16.7%, 18.8%, and 18.8%, respectively. The median interval between LDLT and HBV recurrence was 57 months (range, 18-124 months). Based on the univariate and multivariate analyses, a serum HBV DNA level of ≥ 4 log copies/mL (hazard ratio [HR], 4.861; 95% confidence interval [95% CI], 1.172-20.165; P = 0.029), and hepatocellular carcinoma (HCC) beyond the Milan criteria (HR, 10.083; 95% CI, 2.749-36.982; P < 0.001) were independent risk factors for HBV recurrence after LDLT. In LDLT patients, high pre-LT HBV DNA levels and HCC beyond the Milan criteria were risk factors for HBV recurrence. With the current expansion of the LT criteria for HCC, we should remain cautious regarding the risk of HBV recurrence, particularly in these groups.

Abstract 2484: Development of a gene expression database of pancreatic ductal adenocarcinoma cases by NGS-combined HiCEP to identify tumor markers

Objectives: High coverage expression profiling (HiCEP) is an AFLP-based comprehensive gene expression analysis invented in Japan. There are two advantages of HiCEP compared with existing methods, such as DNA microarrays and RNA sequencing. First, it can efficiently detect an especially low amount of mRNA with high sensitivity and reliability, and second, it enables us to analyze mRNA expression much more quantitatively and reproducibly. On the other hand, it requires complicated processes, including TA cloning of isolated transcripts, to obtain the sequence information of the detected peaks. In order to solve this problem, we established the gene expression database of human cancers by combining the next-generation sequencing (NGS) with HiCEP method.

Materials and methods: We applied the NGS-combined HiCEP method to analyze pancreatic ductal adenocarcinoma(PDAC) cases in this study, and tried to establish the gene expression database of PDAC to identify effective tumor markers. We collected samples of both the cancerous and macroscopically non-cancerous tissues from 49 patients diagnosed with PDAC who underwent surgical resection at our institute. Among them, four cases were analyzed by HiCEP. Total RNA was extracted from the cancerous and normal tissues of the four PDAC cases, and transcribed to cDNA. The cDNA was synthesized and subjected to digestion with the restriction enzymes, MspI and MseI, followed by adapter ligation. Selective PCR by 256 kinds of primer pairs was used to amplify the HiCEP fragments, and products with fluorescently-labeled primer were then analyzed by capillary electrophoresis. HiCEP fragments were sequenced by the next-generation sequencer (ion PGM, Thermo Fisher Scientific). Furthermore, we compared the expression levels of HiCEP peaks in cancerous tissues with those in normal tissues.

Results: We detected multiple HiCEP peaks that showed higher expression in cancerous tissues than in normal tissues in all four cases, and also found out different peaks showing higher expression in cancerous tissues of cases which had a recurrence of cancer after surgery than in cancerous tissues of cases without recurrences. We determined the sequences of the HiCEP fragments by NGS, and developed the first ever HiCEP fragment database for PDAC.

Conclusion: We successfully established a PDAC gene expression database by NGS-combined HiCEP method. We are now performing replication analyses with the other PDAC cases, and further analyses of blood samples from the same PDAC cases, aiming to identify diagnostic and prognostic markers of PDAC.

Citation Format: Mikiya Takao, Hirotaka Matsuo, Ryoko Araki, Seiko Shimizu, Makoto Kawaguchi, Akiyoshi Nakayama, Yosuke Kitamura, Yusuke Kawamura, Kazuki Maehara, Masumi Abe, Keiichi Ito, Mayumi Hoshikawa, Junji Yamamoto, Yoji Kishi, Nariyoshi Shinomiya. Development of a gene expression database of pancreatic ductal adenocarcinoma cases by NGS-combined HiCEP to identify tumor markers [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2484.

Prognostic Impact of Budding Grade in Patients With Residual Liver Recurrence of Colorectal Cancer After Initial Hepatectomy

BACKGROUND

Many patients undergoing hepatectomy for colorectal liver metastases (CRLM) experience recurrence. However, no criteria for screening candidates to undergo repeat hepatectomy (RH) for CRLM have been established. Budding, one form by which colorectal carcinoma malignancies are expressed, is a new pathologic index. This study aimed to analyze prognostic factors, including budding, and to provide criteria for screening candidates to undergo RH for recurrent CRLM.

METHODS

Data of 186 consecutive patients who underwent hepatectomy for CRLM between April 2008 and December 2015 were collected. Survival was calculated using the Kaplan-Meier method. Uni- and multivariate analyses were performed to determine factors significantly affecting mortality.

RESULTS

Of 186 patients, 131 experienced recurrence after hepatectomy, with 83 of the 131 patients showing recurrence in the liver, and 52 of these 83 patients undergoing primary surgery at the authors' institution and having information on budding grade. In the univariate analysis, preoperative chemotherapy, budding grade, extrahepatic metastases, and number of liver metastases at the time of recurrence were associated with overall survival (OS) for the 52 patients. In the multivariate analysis, budding grade and number of liver metastases at the time of recurrence were associated with OS.

CONCLUSION

The study examined simple prognostic factors that could help to screen patients better for RH. Repeat hepatectomy improved the prognosis for patients with recurrent CRLM. The independent prognostic factors for OS were number of liver metastases at recurrence as a conventional factor and budding grade as a new pathologic factor. With budding used as an index, patients who could benefit from hepatectomy can be screened more precisely.

Successful resection of a granulocyte colony-stimulating factor-producing carcinoma of the pancreas: A case report

Granulocyte colony-stimulating factor (G-CSF) is a naturally occurring glycoprotein that stimulates the proliferation of precursor cells in the bone marrow and their maturation into fully differentiated neutrophils. G-CSF-producing cancers rarely occur in the digestive system, particularly the pancreas. Herein we report the rare case of a G-CSF-producing pancreatic carcinoma associated with severe anemia due to bleeding in the duodenum, which was successfully treated with surgery. A 79 year-old man presented with epigastralgia and anemia at our institution. Esophagogastroduodenoscopy revealed a duodenal tumor, which was diagnosed as a poorly differentiated adenocarcinoma. To control breeding, subtotal stomach-preserving pancreaticoduodenectomy was performed. The excised tumor measured 86×55×54 mm. It was primarily located in the pancreas and compressed the pancreatic parenchyma and main bile duct. It comprised poorly differentiated adenocarcinoma, and prominent neutrophil infiltration was noted around the tumor. Immunohistochemical examination revelaed that the tumor was positive for G-CSF expression. Based on these results, a final diagnosis of G-CSF-producing primary pancreatic cancer was made. At 18 months following surgery, the patient was alive without recurrence.

Laparoscopic fenestration for a large ruptured splenic cyst combined with an elevated serum carbohydrate antigen 19-9 level: a case report

Background

Non-parasitic splenic cysts are associated with elevated serum carbohydrate antigen (CA) 19–9 levels. We report a case in which a 23-year-old female exhibited a large ruptured splenic cyst and an elevated serum CA19–9 level.

Case presentation

The patient, who experienced postprandial abdominal pain and vomiting, was transferred to our hospital and was found to have a large splenic cyst during an abdominal computed tomography (CT) scan. On physical examination, her vital signs were stable, and she demonstrated rebound tenderness in the epigastric region. An abdominal CT scan revealed abdominal fluid and a low-density region (12 × 12 × 8 cm) with enhanced margins in the spleen. The patient’s serum levels of CA19–9 and CA125 were elevated to 17,580 U/mL and 909 U/mL, respectively. A cytological examination of the ascitic fluid resulted in it being categorized as class II. Finally, we made a diagnosis of a ruptured splenic epidermoid cyst and performed laparoscopic splenic fenestration. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 5. The cystic lesion was histopathologically diagnosed as a true cyst, and the epithelial cells were positive for CA19–9. Follow-up laboratory tests performed at 4 postoperative months showed normal CA19–9 (24.6 U/L) and CA125 (26.8 U/L) levels. No recurrence of the splenic cyst was detected during the 6 months after surgery.

Conclusion

Laparoscopic fenestration of a ruptured splenic cyst was performed to preserve the spleen, after the results of abdominal fluid cytology and MRI were negative for malignancy.

Pathomorphological features of metastatic lymph nodes as predictors of postoperative prognosis in pancreatic cancer

To investigate the pathological features of metastatic lymph nodes (LN) in pancreatic ductal adenocarcinoma (PDAC) and to determine factors with prognostic implications.Metastatic LN status is a proven significant factor for predicting postoperative prognosis in pancreatic cancer patients. However, the effective prognostic criteria regarding metastatic LNs for such disease remain unknown.We retrospectively reviewed 98 patients with R0/1 resection for PDAC. All metastatic LNs were evaluated for the pathomorphological features of metastasis and analyzed in terms of postoperative outcomes. Various morphological patterns of metastasis were assessed in 440 positive LNs and then classified into 4 groups: common type, direct type (continuously invaded by the main tumor), scatter type (multiple tumor clusters among the normal LN tissues), and isolated tumor cell (ITC).The pathological stage was defined as stage IIA in 10% and IIB in 90% patients. Common-type metastasis was noted in 55% positive LNs of 75% node-positive patients; direct type in 36% LNs of 69% patients; scatter type in 5% LNs of 14% patients; and ITCs in 5% LNs of 18% patients. Significant difference was noted only in recurrence-free survival (RFS) but not in overall survival (OS) in the common-type; only in OS but not in RFS for the scatter type; and neither in RFS nor OS for both direct type and ITC. Multivariate analysis revealed that only LN ratio and curability were independent predictive factors of poor.The tumor distribution patterns in metastatic LNs are the postoperative prognostic factors in pancreatic cancer.

A case of intrahepatic cholangiocarcinoma that was difficult to diagnose prior to surgery: A case report

The present study reports a case of mass-forming intrahepatic cholangiocarcinoma (ICC), which mimicked cholangiocellular carcinoma (CoCC) during imaging and a needle biopsy examination. A 51-year-old female with no relevant medical history was referred to the National Defense Medical College hospital with an intrahepatic tumor. Computed tomography demonstrated non-homogeneous enhancement in the early arterial phase and persistent enhancement in the portal and equilibrium phases, together with notable swelling of the para-aortic lymph nodes. Gadolinium-ethoxybenzyl diethylenetriamine-pentaacetic acid-enhanced magnetic resonance imaging revealed low signal intensity in the hepatobiliary phase. The liver tumor and lymph nodes exhibited increased radiotracer uptake (maximum standardized uptake value=14.0) with positron emission tomography. A histological examination of a percutaneous needle biopsy specimen of the liver tumor indicated a diagnosis of CoCC. The patient underwent left hepatectomy and lymphadenectomy. The surgical specimen contained a poorly differentiated adenocarcinoma with anaplastic changes, which was immunohistochemically positive for epithelial membrane antigen (at the luminal membrane), cytokeratins 7 and 19, and negative for α-fetoprotein, hepatocyte-specific antigen, cluster of differentiation 56 and KIT. Based on these histopathological and immunohistochemical findings, the patient was diagnosed with ICC.

Relationship between desmoplastic pattern and lymphocytes infiltration in pancreatic cancer

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Background: The proposed histologic desmoplastic reaction (DR) categorization and lymphocyte infiltration (LI) directly reflects tumor behavior in a modulating stromal environment and could provide valuable prognostic information for colorectal cancer patients, but the prognostic role of DR and LI has not been investigated in pancreatic cancer patients. Methods: A total of 87 pancreatic cancer patients who underwent potentially curative surgery for their tumors in our hospital (2008 to 2013) were included. DR was classified as mature, intermediate, or immature on the basis of the existence of keloid-like collagen and myxoid stroma-distinctive histologic products of extracellular matrix remodeling. LI was classified as Pattern I; circumferential lymphocytes zone without disruptions around tumor, Pattern II; lymphocytes zone with partial disruptions and thinning around tumor, Pattern III; focal lymphocytes foci around tumor at most invasive border without lymphocyte zone, and Pattern IV; no lymphocyte foci around tumor. Results: With regard to DR, 0, 23, and 64 patients were classified as mature, intermediate, and immature, respectively. Five-year overall survival rates (#%) were higher in immature group (p=0.0040) than those of intermediate group (#%). Multivariate analysis revealed that DR was an independent prognostic factor along with residual tumor (p=0.0300). With regard to LI, 0, 6, 70, and 11 patients were classified as Pattern I, Pattern II, Pattern III, and Pattern IV, respectively. There was no relationship between DR and LI. Conclusions: The DR categorization seemed to reflect tumor behavior and could provide valuable prognostic information for pancreatic cancer patients. We did not show any relationship between DR and LI in pancreatic cancer.

Stromal remodeling by the BET bromodomain inhibitor JQ1 suppresses the progression of human pancreatic cancer

Inhibitors of bromodomain and extraterminal domain (BET) proteins, a family of chromatin reader proteins, have therapeutic efficacy against various malignancies. However, the detailed mechanisms underlying the anti-tumor effects in distinct tumor types remain elusive. Here, we show a novel antitumor mechanism of BET inhibition in pancreatic ductal adenocarcinoma (PDAC). We found that JQ1, a BET inhibitor, decreased desmoplastic stroma, a hallmark of PDAC, and suppressed the growth of patient-derived tumor xenografts (PDX) of PDACs. In vivo antitumor effects of JQ1 were not always associated with the JQ1 sensitivity of respective PDAC cells, and were rather dependent on the suppression of tumor-promoting activity in cancer-associated fibroblasts (CAFs). JQ1 inhibited Hedgehog and TGF-β pathways as potent regulators of CAF activation and suppressed the expression of α-SMA, extracellular matrix, cytokines, and growth factors in human primary CAFs. Consistently, conditioned media (CM) from CAFs promoted the proliferation of PDAC cells along with the activation of ERK, AKT, and STAT3 pathways, though these effects were suppressed when CM from JQ1-treated CAFs was used. Mechanistically, chromatin immunoprecipitation experiments revealed that JQ1 reduced TGF-β–dependent gene expression by disrupting the recruitment of the transcriptional machinery containing BET proteins. Finally, combination therapy with gemcitabine plus JQ1 showed greater efficacy than gemcitabine monotherapy against PDAC in vivo. Thus, our results reveal BET proteins as the critical regulators of CAF-activation and also provide evidence that stromal remodeling by epigenetic modulators can be a novel therapeutic option for PDAC.

Distribution of ASIC4 transcripts in the adult wild-type mouse brain

Acid-sensing ion channel 4 (ASIC4) belongs to the ASIC gene family of neuronal proton-gated cation channels, and is the least understood subtype among the members. Previous studies of ASIC4 expression in the mammalian central nervous system have shown that ASIC4 is abundantly expressed in the spinal cord and in various brain regions, such as the cerebral cortex, the hippocampus, and the cerebellum. However, the detailed distribution of ASIC4 transcripts in mammalian brains still remains to be elucidated. In the present study, radioactive in situ hybridization histochemistry with an ASIC4-specific cRNA probe was performed on wild-type mouse brains, followed by X-gal staining experiments with Asic4-lacZ reporter mice Asic4^{tm1a(KOMP)Mbp}. It was found that ASIC4 mRNAs were widely expressed throughout the wild-type brain, but preferentially concentrated in the olfactory bulb, the piriform cortex, the caudate putamen, the preoptic area, the paraventricular nucleus, the medial habenular nucleus, the pretectal area, the lateral geniculate nucleus, the amygdaloid complex, the superior colliculus, the interpeduncular nucleus, and the granule cell layer of the ventral hippocampus, and these results were in agreement with the X-gal-positive reactions observed in the mutant brain. In addition, X-gal staining combined with immunohistochemistry identified intense signals for ASIC4 transcriptional activity in most of the choline acetyltransferase (ChAT)-positive principal neurons located in the basal forebrain cholinergic nuclei. Our data provide useful information to speculate possible roles of ASIC4 in diverse brain functions.

Adjuvant combination therapy with gemcitabine and autologous γδ T-cell transfer in patients with curatively resected pancreatic cancer

BACKGROUND AIMS

The outcome for pancreatic cancer after surgery remains highly unsatisfactory, and development of more effective therapies is urgently needed. Therefore, we conducted a phase I clinical study of a novel combination of gemcitabine (GEM) and autologous γδ T-cell therapy for patients with curatively resected pancreatic cancer (University Hospital Medical Information Clinical Trials Registry identifier 000000931).

METHODS

From July 2008 to December 2012, 56 consenting patients were recruited. After preliminary testing of γδ T-cell proliferative capacity, 28 patients were eligible to receive combined GEM plus γδ T-cell therapy.

RESULTS

During treatment, most of the adverse events observed were due to GEM, including myelosuppression and gastrointestinal disorders. No severe adverse events were obviously related to the γδ T-cell therapy. To evaluate clinical efficacy, patients receiving combined therapy (Group A, n = 28) were compared with those receiving GEM alone (Group B, n = 20). No significant differences were observed between the two groups in recurrence-free survival or overall survival. However, we found that, relative to progressing patients, more γδ T-cells were detectable in the blood of recurrence-free patients after only two injections (P < .0388) and more so five injections (P < .0175). Patients with >15% peripheral γδ T-cells after two injections and >20% after five injections had a chance of a more favorable clinical outcome. Accumulation of γδ T cells was positively related to the quality of the infused products, with those having >80% γδ T cells being optimal.

DISCUSSION

High quality of the γδ T-cell product is crucial to achieve a high percentage of γδ T cells in the blood and to achieve better clinical outcome.

Abstract B66: BET inhibition remodels tumor stroma and suppresses progression of human pancreatic cancer

Background and Aims: Pancreatic ductal adenocarcinoma (PDAC) is well characterized by dense fibrotic stroma with abundant cancer-associated fibroblasts (CAFs). As CAFs are activated during tumorigenesis and acquire tumor-promoting properties, activated CAFs have been implicated in PDAC progression; however, the precise mechanisms of their activation remain largely unknown. The bromodomain and extraterminal (BET) domain proteins are epigenetic reader proteins that recognize acetylated amino acid residues on histone tails and facilitate gene transcription. Recent studies have demonstrated therapeutic efficacy of BET inhibitors on various cancers including PDAC, mainly through suppression of c-myc transcription; however, how BET inhibitors suppress PDAC growth and their effects on CAFs remains largely unknown. Using patient-derived tumor xenografts (PDX) and primary CAFs, we investigated the therapeutic efficacy and dissected the underlying mechanisms of a BET inhibitor, JQ1, on human PDAC and CAFs.

Methods: We established PDX lines and primary CAFs from surgically resected human PDAC specimen. For in vivo analyses, mice bearing subcutaneous tumor were treated with vehicle or JQ1. For in vitro analyses, patient-derived PDAC cells and CAFs were treated with vehicle or JQ1 and analyzed separately. To explore the pro-tumorigenic role of secretion from CAFs, PDAC cells were cultured with conditioned medium (CM) that was collected from DMSO- or JQ1- treated CAFs. Chromatin immunoprecipitation (ChIP) assay was performed to assess the binding of transcription factors and histone modifications which are associated with altered gene expression in CAFs by JQ1 treatment.

Results: In vivo experiments revealed that volumes and weights of subcutaneous PDX tumors were significantly smaller in JQ1-treated mice than vehicle-treated mice. Unexpectedly, however, JQ1 exerted only minimal effects to the proliferation of PDAC cells that were isolated from PDX tumors and cultured in vitro, suggesting the involvement of cell-extrinsic mechanisms in the JQ1-mediated suppression of tumor growth in vivo. Of note, histopathological analysis of PDX tumors revealed that JQ1 treatment dramatically ameliorated desmoplastic change, with reduction in extracellular matrix (ECM) deposition and α-SMA expressing CAFs. As α-SMA expression and ECM production is a hallmark of activated CAFs, we hypothesized that JQ1 might inactivate CAFs, thereby reducing their tumor-promoting properties. To test this hypothesis, qPCR was performed to analyze gene expression in primary CAFs cultured in vitro and also in stromal cells in PDX tumors in vivo. As expectedly, JQ1 suppressed the expression of genes implicated in the properties of activated CAF, including ECM, cytokines and growth factors both in vitro and in vivo. Furthermore, when PDAC cells were cultured with CM from DMSO–treated CAFs, proliferation of PDAC cells were promoted along with activation of MAPK, AKT, and STAT3 pathways, which was abrogated when cultured with CM from JQ1-treated CAFs. Consistently, immunoblotting and immunohistochemistry of PDX tumors demonstrated that JQ1 reduced phosphorylation of ERK, AKT, and STAT3 in PDAC cells in vivo. Mechanistically, we found that JQ1 suppressed hedgehog and TGF-β/SMAD3 pathways, both of which play central roles in CAF activation, through disruption of BRD4 recruitment to the promoter regions of their target genes.

Conclusions: BET proteins are critical regulators of CAF-activation in PDAC. Inactivation of CAFs by BET inhibition offers a novel therapeutic approach for PDAC.

Citation Format: Keisuke Yamamoto, Keisuke Tateishi, Yotaro Kudo, Mayumi Hoshikawa, Mariko Tanaka, Takuma Nakatsuka, Hiroaki Fujiwara, Koji Miyabayashi, Ryota Takahashi, Yasuo Tanaka, Hideaki Ijichi, Yousuke Nakai, Hiroyuki Isayama, Yasuyuki Morishita, Taku Aoki, Yoshihiro Sakamoto, Kiyoshi Hasegawa, Norihiro Kokudo, Masashi Fukayama, Kazuhiko Koike.{Authors}. BET inhibition remodels tumor stroma and suppresses progression of human pancreatic cancer. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr B66.

Synchronous neuroendocrine tumors in both the pancreas and ileum: A case report

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This is the first case of synchronous pancreatic and ileal NET in a non-MEN 1 patient.

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Both morphologic and immunophenotypic findings were different.

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The synchronous occurrence of these tumors may be considered as a chance occurrence.

Introduction

Although it is well-known that in multiple endocrine neoplasia type 1 (MEN 1) disease, multiple endocrine lesions frequently occur, synchronous or metachronous neuroendocrine tumors (NETs) in non-MEN 1 patients are extremely rare.

Presentation of case

An asymptomatic 72-year-old woman with an ileal NET was referred to our hospital. Abdominal computed tomography revealed another circular tumor within the pancreatic head. She was classified as a non-MEN 1 patient. An operative procedure was performed with a preoperative diagnosis of synchronous NET, which was confirmed by pathological examination.

Discussion

Both morphologic and immunophenotypic findings were different between in the ileum and pancreas. Therefore, it was reasonable to consider that both tumors were primary tumors. The synchronous occurrence of these tumors is unusual, and it may be considered as a chance occurrence.

Conclusion

We here report the first case of synchronous pancreatic NET and ileal NET in a non-MEN 1 patient.

Inframesocolic Superior Mesenteric Artery First Approach as an Introductory Procedure of Radical Antegrade Modular Pancreatosplenectomy for Carcinoma of the Pancreatic Body and Tail

Superior mesenteric artery (SMA)-first approaches are operative tactics used to determine tumor resectability early during pancreatoduodenectomy. With locally advanced carcinoma of the pancreatic body and tail, early determination of SMA involvement also helps establish whether curative resection is feasible. During either radical antegrade modular pancreatosplenectomy (RAMPS) or classic left-to-right distal pancreatectomy, dissection of the SMA is performed after transection of the pancreas or wide detachment of the distal pancreas and spleen. Herein, we describe an inframesocolic SMA-first approach as an introductory procedure when treating carcinoma of the pancreatic body and tail. This first approach procedure provides a reliable and safe introduction to RAMPS.

Ectopic Jejunal Variceal Rupture in a Liver Transplant Recipient Successfully Treated With Percutaneous Transhepatic Coil Embolization: A Case Report

Here we present the rupture of ectopic jejunal varices developing in a liver transplant recipient without portal hypertension, which was successfully treated with percutaneous transhepatic coil embolization.A 48-year-old man with massive melena was admitted to our department. He had undergone liver transplantation for hepatitis B virus-related liver cirrhosis 8 months before, and his postoperative course was satisfactory except for an acute cellular rejection. No evidence of bleeding was detected by upper endoscopy or colonoscopy, but dynamic multidetector computed tomography of the whole abdomen revealed an intestinal varix protruding into the lumen of the jejunum with suspected extravasation. There was no evidence of portal venous stenosis or thrombosis. Immediately upon diagnosis of the ruptured ectopic jejunal varix, percutaneous transhepatic coil embolization was performed, achieving complete hemostasis. The portal venous pressure measured during the procedure was within normal limits. He was discharged from the hospital 11 days after embolization and remained in stable condition without re-bleeding 6 months after discharge.This is the first report of an ectopic intestinal variceal rupture in an uneventful liver transplant recipient that was successfully treated with interventional percutaneous transhepatic coil embolization. Clinicians encountering liver transplant recipients with melena should be aware of the possibility of late-onset rupture of ectopic varices, even in those having an uneventful post-transplant course without portal hypertension.

Intraosseous tumors of the skull. A pictorial review

Radiologists often encounter intraosseous tumors of the calvarium. Compared with parenchymal lesions, information is limited. In this review, we list the calvarial tumors and correlate the radiologic appearance with the pathologic findings. We discuss primary intraosseous tumors and tumor secondary to systemic disease as well as metastatic malignant tumor. Differentiation between primary tumors and tumors secondary to systemic disease can be difficult. Physicians should explore the systematic disease. In the case of primary tumors, it is important to verify any soft-tissue component since this is an important differential diagnostic feature with the potential for malignant transformation.

Contralateral cervicomediastinal lymph node metastases from clinically occult adenocarcinoma of the lung

A 69-year-old woman with a right cervical lymphadenopathy presented with an adenocarcinoma on excisional biopsy. Computed tomography (CT) scans and a positron emission tomography scan demonstrated that the tumor was localized in the right paratracheal and cervical region. A clinical diagnosis of lung cancer arising from an unknown primary site was made based on the radiologic and immunohistochemical findings. Serial CT scans showed a growing nodule in the left apex from pinpoint size to 1 cm in diameter after several months, which was defined as the primary site at autopsy. The finding of a clinically occult lung cancer directly spreading to the contralateral mediastinal and cervical nodes by skipping ipsilateral hilar and mediastinal nodes is rare.

Identification of a novel fibroblast growth factor, FGF-22, preferentially expressed in the inner root sheath of the hair follicle

We isolated cDNA encoding a novel fibroblast growth factor (FGF-22) (170 amino acids) from human placenta. Of the FGF family members, FGF-22, which appears to be a secreted protein, is most similar to FGF-10 and FGF-7 (approximately 46% and approximately 40% amino acid identities, respectively). The human FGF-22 gene was localized on chromosome 19p13.3. We also isolated mouse cDNA encoding FGF-22 (162 amino acids) from the skin. Mouse FGF-22 shows high homology (87% amino acid identity) to human FGF-22. Mouse FGF-22 mRNA was found to be preferentially expressed in the skin among the mouse adult tissues examined by Northern blotting analysis. By in situ hybridization, FGF-22 mRNA in the skin was found to be preferentially expressed in the inner root sheath of the hair follicle. Therefore, FGF-22 is expected to be a unique FGF that plays a role in hair development.

Absence of nuclear p16 from Epstein-Barr virus-associated undifferentiated nasopharyngeal carcinomas

OBJECTIVE

Epstein-Barr virus (EBV) is detected in the majority of undifferentiated nasopharyngeal carcinomas (UNPCs, World Health Organization type III). However, the exact mechanism involved in the carcinogenesis of EBV-associated UNPCs remains to be elucidated. An important unresolved question is: how is the normal cell cycle deregulated during EBV-associated UNPC development? The p16CDKN2 gene encodes a nuclear protein, p16, which inhibits the D-type cyclin/cyclin-dependent kinase complexes that phosphorylate the retinoblastoma gene product (pRb), thus blocking G1 cell cycle progression. The objective of this study was to determine whether p16 absence is involved in the development of EBV-associated UNPCs.

METHODS

We performed immunohistochemistry to detect p16 and pRb and in situ hybridization to detect EBV-encoded small RNA (EBER) in UNPCs from 28 patients.

RESULTS

No p16 was detected in 23 of 28 UNPCs (82.1%), whereas pRb was expressed in all those examined and EBER was detected in 22 of 28 (78.6%). The absence of p16 was associated with the presence of EBER in UNPCs (P < .0001): none of the 22 EBER+ UNPCs expressed p16, whereas 5 of 6 EBER- UNPCs did.

CONCLUSION

Our data suggest that loss of p16-related cell cycle regulation plays an important role in the development of EBV-associated UNPCs.

Antibiotic stress induces a large amount of outer membrane protein in Pseudomonas aeruginosa

To investigate the bacterial response to antibiotic stress, we analyzed the outer membrane proteins of Pseudomonas aeruginosa grown in the presence of a sub-minimum inhibitory concentration of antibiotics. Among the antibiotics tested, fluoroquinolones and streptonigrin induced a large amount of outer membrane protein with a molecular mass of 43 kDa. This protein is most likely the stress-responsive protein, since the quinolone-resistant mutants with a higher minimum inhibitory concentration of antibiotic than the wild-type strain produced a large amount of 43-kDa protein only in the presence of sub-minimum inhibitory concentration of the mutants itself, but not that of the antibiotic-susceptible wild-type strain. The sequence of N-terminal 15 amino acids of the 43-kDa protein was identical to that of pyocin R1. However, purified pyocin R1 failed to accumulate in the outer membrane. Thus, we concluded that the 43-kDa protein (pyocin R1) is the antibiotic-stress-induced outer membrane protein.

Structure and expression of the mRNA encoding a novel fibroblast growth factor, FGF-18

We isolated the cDNA encoding a novel member (207 amino acids) of the fibroblast growth factor (FGF) family from rat embryos. Because this protein is the 18th documented member of the FGF family, we tentatively termed it FGF-18. We have also determined mouse and human FGF-18 with high amino acid identity (99.5 and 99.0%) to rat FGF-18, respectively. Among FGF family members, FGF-18 is most similar (52.7% amino acid identity) to FGF-8 and FGF-17. FGF-18 has a typical signal sequence at its amino terminus. Recombinant rat FGF-18, which was efficiently secreted by High Five insect cells infected with recombinant baculovirus containing the cDNA, induced neurite outgrowth in PC12 cells. The expression of FGF-18 mRNA was examined in adult rat tissues and embryos by Northern blotting analysis and in situ hybridization. FGF-18 mRNA of approximately 2. 7 kilobases was preferentially detected in the lung among adult rat tissues examined. In rat embryos, FGF-18 mRNA was detected in several discrete regions at embryonic days 14.5 and 19.5 but not at E10.5. The temporal and spatial patterns of FGF-18 mRNA expression in embryos are quite different from those of FGF-8 and FGF-17 mRNAs reported. The present results indicate that FGF-18 is a unique secreted signaling molecule in the adult lung and developing tissues.

Comparison of the expression of three highly related genes, Fgf8, Fgf17 and Fgf18, in the mouse embryo

In mammals, 16 members of the Fgf family have so far been described with diverse roles in embryonic cell growth and differentiation. Here, we report the expression from early streak stage to midgestation of two newly-identified murine genes, Fgf17 and Fgf18, that are most closely related to Fgf8 (63.7% and 56.8% identical, respectively, at the amino acid level). Fgf17 is expressed during gastrulation but at lower levels than Fgf8, while Fgf18 RNA is not expressed until later, in paraxial mesoderm. In the developing tail bud, each Fgf gene shows a different pattern of transcription. Distinct and overlapping expression patterns are also described in the developing brain and limbs.

Structure and expression of a novel fibroblast growth factor, FGF-17, preferentially expressed in the embryonic brain

We isolated the cDNA encoding a novel member (216 amino acids) of the fibroblast growth factor (FGF) family from rat embryos. As this protein is the 17th documented member of the FGF family, we tentatively termed it FGF-17. We have also determined the structures of mouse and human FGF-17 with high amino acid identity (100 and 98.6%) to rat FGF-17, respectively. Among FGF family members, FGF-17 is most similar (53.7% amino acid identity) to FGF-8. FGF-17 has a typical signal sequence at its amino terminus. As expected, recombinant rat FGF-17 was efficiently secreted by High Five insect cells infected with recombinant baculovirus containing the cDNA indicating that FGF-17 is a secreted protein. FGF-17 mRNA of approximately 2.1 kb was detected in rat embryos at E14.5, but not at E10.5 and E19.5 by Northern analysis. The mRNA was found to be preferentially expressed in the neuroepithelia of the isthmus and septum of the rat embryonic brain at E14.5 by in situ hybridization. The present results indicate that FGF-17 might be a novel secreted signaling molecule in the induction and patterning of the embryonic brain.

Involvement of cell-mediated killing in apoptosis in histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease)

Histiocytic necrotizing lymphadenitis, also called Kikuchi-Fujimoto (KF) disease, is a benign disorder characterized histologically by paracortical necrotic foci surrounded by histiocytic aggregates. We analysed affected lymph node tissues from 34 patients with the disease in an attempt to elucidate its histogenesis. The 'necrotizing' cells showed typical apoptotic changes, including cell shrinkage and condensed and fragmented nuclei. Apoptotic bodies with a peculiar ultrastructure were demonstrated, and DNA fragmentation was detected in these cells by in situ end labelling. Immunostaining for the apoptosis-regulating proteins bcl-2, bax, c-myc and p53 failed to show their involvement in KF disease. However, perforin, a killer cell-specific cytolytic protein essential for provoking apoptosis in target cells, was found to be expressed abundantly by the infiltrating cells, which were thought to be cytotoxic T-lymphocytes. Perforin-expressing cells were present in the apoptotic foci of 28 of the 34 patients (82.4%). Virtually no cells containing perforin granules were present in non-pathological regions, lymph node tissues from control subjects with reactive or tuberculous lymphadenitis or those from patients with KF disease with negligible apoptosis. Therefore, the 'necrosis' associated with KF disease appears to be attributable to trans apoptotic death of the killer cell target in the affected nodes. We propose that KF disease should be called apoptotic lymphadenitis.