Clinicopathological characteristics of Lynch-like syndrome

BACKGROUND

Lynch-like syndrome (LLS) has recently been proposed as a third type of microsatellite instability (MSI) tumor after Lynch syndrome (LS) and sporadic MSI colorectal cancer (CRC) without either a germline variant of mismatch repair (MMR) genes or hypermethylation of the MLH1 gene. The present study aimed to clarify and compare the clinicopathological characteristics of LLS with those of the other MSI CRC subtypes.

METHODS

In total, 2634 consecutive patients with CRC who underwent surgical resection and subsequently received universal tumor screening (UTS), including MSI analysis were enrolled between January 2008 and November 2019. Genetic testing was performed in patients suspected of having Lynch syndrome.

RESULTS

UTS of the cohort found 146 patients with MSI CRC (5.5%). Of these, excluding sporadic MSI CRC, 30 (1.1%) had a diagnosis of LS, and 19 (0.7%) had no germline pathogenic variants of the MMR gene. The CRC type in the latter group was identified as LLS. LLS occurred significantly more often in young patients, was left-sided, involved a KRAS variant and BRAF wild-type, and had a higher concordance rate with the Revised Bethesda Guidelines than sporadic MSI CRC. No significant differences were observed in terms of the clinicopathological factors between LLS and LS-associated MSI CRC; however, LLS had a lower frequency of LS-related neoplasms compared with LS.

CONCLUSIONS

Distinguishing clinically between LS and LLS was challenging, but the incidence of neoplasms was higher in LS than in LLS, suggesting the need for different screening and surveillance methods for the two subtypes.

Hazard function analysis of prognosis after recurrent colorectal cancer

BACKGROUND AND OBJECTIVES

Mean survival time (MST) is used as the indicator of prognosis in patients with a colorectal cancer (CRC) recurrence. The present study aimed to visualize the changes in death risk after a CRC recurrence using hazard function analysis (HFA) to provide an alternative prognostic indicator to MST.

METHODS

The medical records of 725 consecutive patients with a recurrence following R0 radical surgery for CRC were retrospectively reviewed.

RESULTS

The five-year, post-recurrence survival rate was 37.8%, and the MST was 3.5 years while the risk of death peaked at 2.9 years post-recurrence. Seven variables were found to predict short-term survival, including the number of metastatic organs ≥ 2, non-surgical treatment for the recurrence, and a short interval before recurrence. In patients with a recurrence in one organ, the MST was four years, the peak time of death predicted by HFA was 2.9 years, and the five-year survival rate was 45.8%. In patients with a surgical resection of the recurrence, the MST was 8 years, the peak time of death was 3.3 years, and the five-year survival rate was 62%.

CONCLUSIONS

The present study established a novel method of assessing changes in mortality risk over time using HFA in patients with a CRC recurrence.

Modified neoadjuvant rectal score as a novel prognostic model for rectal cancer patients who underwent chemoradiotherapy

BACKGROUND

The neoadjuvant rectal score (NAR score) has recently been proposed as a better prognostic model than the conventional TNM classification for rectal cancer patients that have undergone neoadjuvant chemoradiotherapy. We recently developed an apoptosis-detection technique for assessing the viability of residual tumors in resected specimens after chemoradiotherapy. This study aimed to establish an improved prognostic classification by combining the NAR score and the assessment of the apoptosis of residual cancer cells.

METHODS

We retrospectively enrolled 319 rectal cancer patients who underwent chemoradiotherapy followed by radical surgery. The recurrence-free survival and overall survival of the four models were compared: TNM stage, NAR score, modified TNM stage by re-staging according to cancer cell viability, and modified NAR score also by re-staging.

RESULTS

Downstaging of the ypT stage was observed in 15.5% of cases, whereas only 4.5% showed downstaging of ypN stage. C-index was highest for the modified NAR score (0.715), followed by the modified TNM, TNM, and NAR score. Similarly, Akaike's information criterion was smallest in the modified NAR score (926.2), followed by modified TNM, TNM, and NAR score, suggesting that the modified NAR score was the best among these four models. The overall survival results were similar: C-index was the highest (0.767) and Akaike's information criterion was the smallest (383.9) for the modified NAR score among the four models tested.

CONCLUSION

We established a novel prognostic model, for rectal cancer patients that have undergone neoadjuvant chemoradiotherapy, using a combination of apoptosis-detecting immunohistochemistry and neoadjuvant rectal scores.

Risk of gastric adenoma and adenocarcinoma in patients with familial adenomatous polyposis in Japan: a nationwide multicenter study

BACKGROUND

Patients with familial adenomatous polyposis (FAP) have an increased risk of developing gastric neoplasms. However, the clinical course of FAP with these gastric lesions has not yet been fully clarified. The present study aimed to clarify the changes in the incidence risk of developing gastric adenoma or gastric cancer during the lifespan of patients with FAP.

METHODS

Four hundred forty-three patients with data regarding gastric adenoma and gastric cancer retrospectively registered in a nationwide Japanese multicenter study were enrolled. The cumulative incidences and hazard rates (HRs) of gastric neoplasms were evaluated.

RESULTS

The cumulative incidence rates in 50-year-old patients with FAP were 22.8% for gastric adenoma and 7.6% for gastric cancer, respectively. No significant association was found between gastric neoplasms and the colonic phenotype. The peak age for the HR of gastric adenoma was 65 years, with the highest HR (0.043). Regarding the incidence of gastric cancer, the HR increased moderately up to the age of 40 years, but the increase accelerated from the age of 50 years (HR = 0.0067).

CONCLUSION

Careful surveillance of the upper gastrointestinal tract in elderly patients with FAP, such as shortening the interval of follow-up according to age, may be helpful for early diagnosis of gastric cancer.

Clinical features and distribution of the APC variant in duodenal and ampullary polyps in patients with familial adenomatous polyposis: a multicenter retrospective cohort study in Japan

BACKGROUND

Management of duodenal or ampullary adenomas in patients with familial adenomatous polyposis (FAP) is a major challenge for clinicians. Insufficient data are available to evaluate the clinical manifestations and distribution of adenomatous polyposis coli (APC) variants in these patients.

METHODS

We enrolled 451 patients with data regarding duodenal or ampullary polyps from 632 patients with FAP retrospectively registered in a nationwide Japanese multicenter study. Clinicopathological features and distribution of APC variants were compared between patients with and without duodenal or ampullary polyps.

RESULTS

Duodenal and ampullary polyps were found in 59% and 18% of patients with FAP, respectively. The incidence of duodenal cancer was 4.7% in patients with duodenal polyps, and that of ampullary cancer was 18% in patients with ampullary polyps. Duodenal polyps were significantly associated with the presence of ampullary polyps and jejunal/ileal polyps. Duodenal polyps progressed in 35% of patients with a median follow-up of 776 days, mostly in those with early Spigelman stage lesions. Ampullary polyps progressed in 50% of patients with a follow-up of 1484 days. However, only one patient developed a malignancy. The proportion of patients with duodenal polyps was significantly higher among those with intermediate- or profuse-type APC variants than attenuated-type APC variants. The presence of duodenal polyps was significantly associated with ampullary and jejunal/ileal polyps in patients with intermediate- or profuse-type APC variants.

CONCLUSIONS

Periodic endoscopic surveillance of the papilla of Vater and small intestine should be planned for patients with FAP with duodenal polyps.

Usefulness of genotyping APC gene for individualizing management of patients with familial adenomatous polyposis

BACKGROUND

Colorectal polyp burden is crucial for the management of patients with familial adenomatous polyposis (FAP). However, accurate evaluation of polyp burden is difficult to standardize. This study aimed to examine the possible utility of genotype-oriented management of colorectal neoplasms in patients with FAP.

METHODS

Clinicopathological data from genetically proven patients with FAP was analyzed using the database of a nationwide retrospective Japanese multicenter study. The cumulative incidence of CRC was evaluated between different genotype groups. Genotype-1 were defined as germline variants on attenuated FAP-associated regions (codons 1-177, alternative splice site of exon 10 (codon 312), 1581-2843) and Genotype-2 as the other variants. Weibull and Joinpoint analyses were performed to determine the annual percentage changes in CRC risk.

RESULTS

Overall, 69 men and 102 women were included. Forty-eight patients underwent colorectal resection for the first CRC, and five patients underwent resection for first cancer in the remnant anorectal segment after prophylactic surgery. The 70-year cumulative incidence of CRC in all patients was 59.3%. Patients with Genotype-1 (n = 23) demonstrated a lower risk of CRC stages II-IV than those with Genotype-2 (n = 148, P = 0.04). The risk of stage II-IV CRC was estimated to increase markedly at the age of 49 years in the Genotype-1 patients and 34 years in the Genotype-2 patients, respectively.

CONCLUSIONS

Different interventional strategies based on genotypes may be proposed for the clinical management of patients with FAP. This policy needs to be validated in further prospective studies focusing on long-term endoscopic intervention and optimal age at prophylactic (procto)colectomy.

A rare case of localized peliosis hepatis during adjuvant chemotherapy including oxaliplatin mimicking a liver metastasis of colon cancer

BACKGROUND

Oxaliplatin-based regimens are commonly used as adjuvant chemotherapy following surgery for colorectal cancer. Adverse events associated with oxaliplatin include blue liver, which is caused by sinusoidal dilation and diffuse peliosis hepatis. We report herein a case of localized peliosis hepatis closely resembling a metastatic liver tumor.

CASE PRESENTATION

The patient, a 50-year-old male, underwent a robotically assisted colectomy for rectosigmoid colon cancer, which was discovered when hematochezia occurred. The patient received a diagnosis of pStage IIIb and was treated with four courses of CAPOX as adjuvant chemotherapy starting at postoperative month 1. At postoperative month 4, contrast-enhanced computed tomography (CT) of the abdomen revealed a 20-mm, low-density area with heterogeneous internal structure in S6/7 of the liver. Abdominal ultrasound and gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) findings led to a diagnosis of metastatic liver tumor, for which a laparoscopic partial hepatectomy was performed. The resected lesion was a dark reddish-brown nodule with indistinct margins that appeared to be continuous with the surrounding area. Histopathological analysis revealed severe, localized dilatation of the sinusoids and congestion consistent with the gross nodule. Based on these findings, localized peliosis hepatis associated with oxaliplatin-induced sinusoidal damage was diagnosed.

CONCLUSIONS

Localized peliosis hepatis associated with oxaliplatin use can be difficult to distinguish from a metastatic liver tumor on imaging studies.

MR Imaging Detection of CNS Lesions in Tuberous Sclerosis Complex: The Usefulness of T1WI with Chemical Shift Selective Images

BACKGROUND AND PURPOSE

CNS lesions of tuberous sclerosis complex are diagnosed mainly by T2WI, FLAIR, and sometimes T1WI with magnetization transfer contrast. The usefulness of T1WI with chemical shift selective images was recently reported in focal cortical dysplasia type IIb, which has histopathologic and imaging features similar to those of tuberous sclerosis complex. We investigated the usefulness of the T1WI with chemical shift selective images in detecting CNS lesions of tuberous sclerosis complex.

MATERIALS AND METHODS

We retrospectively reviewed 25 consecutive patients with tuberous sclerosis complex (mean age, 11.9 [SD, 8.9] years; 14 males) who underwent MR imaging including T1WI, T1WI with magnetization transfer contrast, T1WI with chemical shift selective, T2WI, and FLAIR images. Two neuroradiologists assessed the number of CNS lesions in each sequence and compared them in 2 steps: among T1WI, T1WI with magnetization transfer contrast and T1WI with chemical shift selective images, and among T2WI, FLAIR, and T1WI with chemical shift selective images. We calculated the contrast ratio of the cortical tubers and of adjacent normal-appearing gray matter and the contrast ratio of radial migration lines and adjacent normal-appearing white matter in each sequence and compared them.

RESULTS

T1WI with chemical shift selective images was significantly superior to T1WI with magnetization transfer contrast for the detection of radial migration lines and contrast ratio of radial migration lines. There was no significant difference between T1WI with chemical shift selective images and T1WI with magnetization transfer contrast for the detection of cortical tubers and the contrast ratio of the cortical tubers. Both T2WI and FLAIR were statistically superior to T1WI with chemical shift selective images for the detection of cortical tubers. T1WI with chemical shift selective images was significantly superior to T2WI and FLAIR for the detection of radial migration lines.

CONCLUSIONS

The usefulness of T1WI with chemical shift selective images in detecting radial migration lines was demonstrated. Our findings suggest that the combination of T1WI with chemical shift selective images, T2WI, and FLAIR would be useful to evaluate the CNS lesions of patients with tuberous sclerosis complex in daily clinical practice.

Fusobacterium nucleatum load in MSI colorectal cancer subtypes

BACKGROUND

Fusobacterium nucleatum (F. nucleatum) infection may lead to colorectal cancer (CRC) development in the context of microsatellite instability (MSI). To date, however, the relationship between F. nucleatum load and MSI CRC subtypes has not been clarified.

METHODS

One hundred seventy-nine consecutive patients with CRC were enrolled in the present study. In 94 patients with MSI CRC, 32 had hereditary MSI CRC from Lynch syndrome, 62 had sporadic MSI CRC, while the remaining 85 had microsatellite stable (MSS) CRC. The association of the F. nucleatum load with each CRC subtype and the patients' clinicopathological characteristics was examined.

RESULTS

Of the 179 patients with CRC, 158 (88.3%) were F. nucleatum-positive. A high F. nucleatum load was found in 84.4% (27/32), 96.8% (60/62), and 83.5% (71/85) of the patients with hereditary MSI CRC, sporadic MSI CRC, and MSS CRC, respectively (P = 0.024). In terms of clinicopathological features, a high F. nucleatum load was significantly associated with female, right-sided CRC, BRAF V600E, CpG island methylator phenotype-positive CRC, and MSI CRC (P = 0.008, P = 0.015, P = 0.007, P = 0.006, and P < 0.001, respectively). However, the clinicopathological characteristics did not differ significantly by F. nucleatum load between hereditary and sporadic MSI CRCs without tumor depth.

CONCLUSIONS

The F. nucleatum load was higher in hereditary MSI CRC than in MSS CRC as well as sporadic MSI CRC. These findings may contribute to preventing CRC in hereditary MSI CRC through appropriate intervention.

Upper gastrointestinal tumors are unrelated to the APC genotype in APC-associated polyposis

BACKGROUND

In patients with APC-associated polyposis, the prevalence of upper gastrointestinal tumors and the relationship between these and Helicobacter pylori infection have not been clarified in detail. The present study aimed to clarify the features of upper gastrointestinal lesions in patients with APC-associated polyposis.

METHODS

Consecutive patients with APC-associated polyposis who underwent esophagogastroduodenoscopy between 2004 and 2018 were recruited.

RESULTS

In total, 36 patients were enrolled. The types of gastrointestinal tumor observed were fundic gland polyposis in 28 patients (77.8%), gastric adenoma in 15 patients (41.7%), duodenal adenoma in 27 patients (75.0%) and periampullary adenoma in 20 patients (55.6%). The phenotype of these upper gastrointestinal tumors was not necessarily the same in patients belonging to the same family. Germline variants in the APC gene were distributed across various sites, regardless of the presence or absence of upper gastrointestinal lesions, and none of the tumors correlated with the genotype or phenotype of upper gastrointestinal tumors. Fundic gland polyposis was observed in 28 of 31 patients without a H. pylori infection and in none of the patients with a H. pylori infection (P = 0.00015). After eradication therapy for H. pylori, fundic gland polyposis developed in one, previously infected patient.

CONCLUSION

The upper gastrointestinal tumor phenotype was not associated with the genotype in patients with APC-associated polyposis. Ascertaining the H. pylori infection status is helpful for endoscopic surveillance of upper gastrointestinal tumors in patients with APC-associated polyposis.

Clinicopathological features of sporadic MSI colorectal cancer and Lynch syndrome: a single-center retrospective cohort study

BACKGROUND

The clinical and pathological features of sporadic microsatellite instability-high (MSI) colorectal cancer (CRC) are still unclear. The present study aimed to clarify the clinicopathological features of sporadic MSI CRC in comparison with those of Lynch syndrome (LS) exploratorily.

METHODS

The present study was a single-center, retrospective cohort study. Sporadic MSI CRC was defined as MSI CRC with aberrant promoter hypermethylation of the MLH1 gene, while hereditary MSI CRC was defined colorectal cancer in patients with LS.

RESULTS

In total, 2653 patients were enrolled; of these, 120 (4.5%) had MSI CRC, 98 had sporadic MSI CRC, and 22 had LS. Patients with sporadic MSI CRC were significantly older (p < 0.001) than those with LS and had a right-sided colonic tumor (p < 0.001) which was pathologically poorly differentiated or mucinous (p = 0.025). The overall survival rate was significantly lower in patients with stage I, II or III MSI CRC than in those with LS (p = 0.024). However, the recurrence-free survival rate did not differ significantly (p = 0.85).

CONCLUSIONS

We concluded that patients with sporadic MSI are significantly older, tumors more likely to locate in the right-sided colon, pathologically poorly differentiated or mucinous, and worse overall survival than in those with LS.

APC germline variant analysis in the adenomatous polyposis phenotype in Japanese patients

BACKGROUND

Familial adenomatous polyposis (FAP), an autosomal dominant disorder characterized by multiple colonic polyps, is caused by a germline pathogenic variant of the APC gene. However, this variant is not detected in up to 30% of patients with the adenomatous polyposis phenotype.

METHODS

We performed next-generation sequencing (NGS) to identify the causative genes in FAP patients with 10 or more polyps. For patients in whom the APC germline variant was not able to be identified, we screened for APC mosaicism using high-coverage NGS of APC with DNA from leucocytes and/or frozen tissue.

RESULTS

The pathogenic APC germline variant was found in 93.3%, 71.6%, and 17.1% of patients with profuse-type polyposis, sparse-type polyposis, and oligo-polyposis, respectively. The APC germline variant detection rate in patients with FAP-related diseases was 69.7% for fundic gland polyposis, 79.7% for duodenal adenoma, 94.7% for desmoid tumor, and 71.4% for thyroid cancer, with increasing numbers of extracolonic lesions associated with an increasing APC germline variant detection rate. A mosaic test detected nine patients with APC mosaicism. A comparison of APC-associated polyposis with APC mosaicism showed that patients with APC mosaicism had a low frequency of duodenal adenoma and a family history of colonic polyposis.

CONCLUSIONS

We determined the detection rate of the APC germline variant by phenotype and identified APC mosaicism. Genetic testing of FAP patients is important because it can help with surgical decision-making, monitoring, and genetic counseling. Furthermore, genetic testing by NGS proved to be an effective method of detecting APC germline variants.

[A Case of Transverse Colon Cancer Undergoing Laparoscopic Right Hemicolectomy after Distal Gastrectomy with Billroth Ⅱ Reconstruction]

A 79-year-old man was diagnosed with transverse colon cancer who had a history of distal gastrectomy and antecolic Billroth Ⅱ(B-Ⅱ)reconstruction for duodenal ulcer. We performed laparoscopic right hemicolectomy. Surgical findings indicated that the tumor was located in the center of the transverse colon. After we performed mobilization of right colon and lymph node dissection, we performed mobilization of left colon and we peeled off those adhesions with the jejunal limb and transverse colon mesentery. Then, we resected transverse colon and removed right hemicolon. We reconstructed a functional end-to-end anastomosis on the ventral side of the jejunal limb. The patient was discharged without complications on the 10th postoperative day. In post B-Ⅱ reconstruction cases, we can perform laparoscopic colectomy safely with preoperative CT confirmation and adequate colon mobilization.

Femoral morphology asymmetry in hip dysplasia makes radiological leg length measurement inaccurate

AIMS

The aim of this study was to examine whether hips with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH) have significant asymmetry in femoral length, and to determine potential related factors.

PATIENTS AND METHODS

We enrolled 90 patients (82 female, eight male) with DDH showing unilateral OA changes, and 43 healthy volunteers (26 female, 17 male) as controls. The mean age was 61.8 years (39 to 93) for the DDH groups, and 71.2 years (57 to 84) for the control group. Using a CT-based coordinate measurement system, we evaluated the following vertical distances: top of the greater trochanter to the knee centre (femoral length GT), most medial prominence of the lesser trochanter to the knee centre (femoral length LT), and top of the greater trochanter to the medial prominence of the lesser trochanter (intertrochanteric distance), along with assessments of femoral neck anteversion and neck shaft angle.

RESULTS

The percentages of hips with an absolute difference of > 5 mm in femoral GT and LT lengths were significantly larger in the DDH group (24% for both) compared with those of the control group (2% and 7%, respectively). The femoral length GT of the affected femur was significantly shorter in Crowe I and longer in Crowe IV than that of the unaffected side. The affected-to-unaffected difference of the intertrochanteric distance showed positive correlation with that of the femoral length GT in Crowe I and Crowe II/III, and negative correlation with that of the femoral length LT in the Crowe I and Crowe IV groups.

CONCLUSION

Hips with unilateral end-stage OA secondary to DDH show significant asymmetry in femoral length between both the greater and lesser trochanter and the knee compared with controls. The intertrochanteric distance was a morphological factor related to femoral-length asymmetry. When undertaking total hip arthroplasty (THA) in the presence of DDH, long leg radiographs or CT measurements should be used to assess true leg-length discrepancy. Cite this article: Bone Joint J 2019;101-B:297-302.

More Hippocampal Weight and Cells in Cardiac Allograft Transplanted Mice

The hippocampus is a brain structure that plays a fundamental role in memory and learning. Many animal studies have demonstrated that the structure of the hippocampus has evolved through exercise and play. However, little is known on the relationship between the brain and immunological reaction. In this study, we investigated the correlation between the weight of the hippocampus and transplant immunology in a murine heart transplant model. Fully vascularized heterotopic hearts from CBA (H2^k, allogeneic group) or C57BL/6 (H2^b, syngeneic group) donors were transplanted into C57BL/6 recipients by using microsurgical techniques. The weights of the whole brain and hippocampus from syngeneic and allogeneic groups were recorded 1, 2, and 4 weeks after grafting, and histologic assessments were performed. The syngeneic group maintained beating cardiac grafts for over 30 days, but the allogeneic group rejected CBA cardiac allografts acutely within 8 days. The average weight of whole brain from syngeneic and allogeneic group 1, 2, and 4 weeks had no significant differences. However, the average weight of hippocampus at 2 and 4 weeks was considerably increased in the allogeneic group compared with the syngeneic group. Histologic assessments with hematoxylin-eosin and Kluver-Barrera staining of hippocampus from allogeneic group 1 week after grafting demonstrated a greater number of granule and pyramidal cells in the hippocampus. Alloimmune responses in our model increase the weight of hippocampus.

Tumor development in Japanese patients with Lynch syndrome

Background

Lynch syndrome (LS) patients have a high risk of developing various tumors. This study aimed to clarify the characteristics of tumors developing in LS patients.

Methods

This is a retrospective review of 55 LS patients treated at Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital.

Results

The median age at the diagnosis of the first malignant tumor and first LS-related tumor was 44 (range, 19−65) and 44 (range, 24−66) years, respectively. Of the 55 LS patients with developing malignant tumors, 45 (93.8%) developed an LS-related tumor as the first malignant tumor. Colorectal cancer (CRC) developed in 47 patients (85.4%), followed by endometrial cancer (n = 13, 56.5%) in females and gastric cancer (n = 10, 18.1%). In 6 gastric cancer patients, Helicobacter pylori was detected in resected specimens. Twenty-nine patients (52.7%) developed CRC and extra-colonic tumors; of these, 15 patients (48.3%) had mutations in MLH1, 10 (58.8%) in MSH2, and 4 (57.1%) in MSH6. At the age of 50, the cumulative incidence was 50.9% [95% confidence interval (CI), 36.9−63.3%] for CRC, 17.4% (95% CI, 5.2−35.6%) for endometrial cancer, and 5.5% (95% CI, 1.4−13.8%) for gastric cancer. Eight gastric cancer, one breast cancer patient, five bladder cancer patients, and one prostate cancer patient demonstrated loss of expression of the mismatch repair (MMR) protein; patients with thyroid cancer, spindle cell sarcoma, and giant cell tumors did not demonstrate this.

Conclusion

Gastric cancer incidence was high in Japanese patients with LS and associated with H. pylori infection. MMR protein deficiency caused the development of malignant tumors in LS patients.

Predictive model for high-frequency microsatellite instability in colorectal cancer patients over 50 years of age

Microsatellite instability (MSI) is an important biomarker for screening for Lynch syndrome, and also of response to immune checkpoint inhibitors. The aim of this study is to create a predictive model to determine which elderly patients with colorectal cancer (CRC) should undergo MSI and/or immunohistochemistry testing on the basis of clinicopathological data. We analyzed a test cohort of CRC patients aged ≥50 years (n = 2219) by multivariate logistic regression analyses to identify predictors of high‐frequency MSI (MSI‐H). The created prediction model was validated in an external cohort (n = 992). The frequency of MSI‐H was 5.5% among CRC patients aged ≥ 50 years. The following five predictors of MSI‐H were identified in the test cohort: female (1 point), mucinous component (2 points), tumor size ≥ 60 mm (2 points), location in proximal colon (3 points), and BRAF mutation (6 points). The area under curve (AUC) in the receiver‐operating characteristic (ROC) analysis of this prediction model was 0.832 (95% confidence interval: 0.790–0.874). The sensitivity and specificity were 74.4% and 77.7%, respectively, for a cut‐off score of 4 points. The receiver‐operating characteristic curve of the validation cohort also showed an AUC of 0.856 (95% CI: 0.806–0.905). This prediction model is useful to select elderly CRC patients who should undergo MSI testing, and who may benefit from treatment with 5‐FU‐based adjuvant chemotherapy and cancer immunotherapy.

Morning-Evening Type and Stress-Related Personality in Japanese College Students

An earlier report by Mecacci and Rocchetti showed a significant, weak, and positive correlation between Evening type as measured by the Morningness–Eveningness Questionnaire and Type A personality as measured by the Jenkins Activity Survey and the Bortner Type A Scale in Italian college students. The present study of 503 Japanese college students yielded a significant and weakly negative correlation. The bases for the different results were discussed in a psychophysiological context.

Arthroscopic anatomical reconstruction of the lateral ankle ligaments

Chronic ankle instability secondary to lateral ligament insufficiency is common after sports injury. Many surgical techniques have been described for the treatment of the lateral ankle ligament complex. They can be classified into repair or reconstruction, and non-anatomical or anatomical. A few authors have recently published innovative techniques for arthroscopic ankle ligament management. This paper describes the arthroscopic techniques enabling anatomical lateral ligament reconstruction using gracilis autograft or allograft for chronic ankle instability. This technique and the steps have been developed by the Ankle Instability Group to make this a reproducible procedure. The purpose of this presentation is to document the technique in the future with a view to a clinical study investigating the results of such surgery in a cohort of suitable patients with chronic ankle instability.

LEVEL OF EVIDENCE

V.

Three-dimensional morphology and bony range of movement in hip joints in patients with hip dysplasia

To confirm whether developmental dysplasia of the hip has a risk of hip impingement, we analysed maximum ranges of movement to the point of bony impingement, and impingement location using three-dimensional (3D) surface models of the pelvis and femur in combination with 3D morphology of the hip joint using computer-assisted methods. Results of computed tomography were examined for 52 hip joints with DDH and 73 normal healthy hip joints. DDH shows larger maximum extension (p = 0.001) and internal rotation at 90° flexion (p < 0.001). Similar maximum flexion (p = 0.835) and external rotation (p = 0.713) were observed between groups, while high rates of extra-articular impingement were noticed in these directions in DDH (p < 0.001). Smaller cranial acetabular anteversion (p = 0.048), centre-edge angles (p < 0.001), a circumferentially shallower acetabulum, larger femoral neck anteversion (p < 0.001), and larger alpha angle were identified in DDH. Risk of anterior impingement in retroverted DDH hips is similar to that in retroverted normal hips in excessive adduction but minimal in less adduction. These findings might be borne in mind when considering the possibility of extra-articular posterior impingement in DDH being a source of pain, particularly for patients with a highly anteverted femoral neck.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Optimization of surgical planning of total hip arthroplasty based on computational anatomy

This paper describes a method for automated optimization of total hip arthroplasty (THA) planning incorporating joint functionalities. The optimal planning is formulated as maximum a posterior (MAP) estimation, which ensures the best-balance of joint functionalities and bone-implant spatial relations based on their statistical models derived from the training datasets prepared by an experienced surgeon. According to the performance evaluation, four of the six functionalities of the automatically optimized plans were almost equivalent to those of surgeon's plans, and two of them were improved. We consider these results showed a potential usefulness of the proposed method.

Differences in the locations and modes of labral tearing between dysplastic hips and those with femoroacetabular impingement

We investigated differences in the location and mode of labral tears between dysplastic hips and hips with femoroacetabular impingement (FAI). We also investigated the relationship between labral tear and adjacent cartilage damage. We retrospectively studied 72 symptomatic hips (in 68 patients: 19 men and 49 women) with radiological evidence of dysplasia or FAI on high-resolution CT arthrography. The incidence and location of labral tears and modes of tear associated with the base of the labrum (Mode 1) or body of the labrum (Mode 2) were compared among FAI, mildly dysplastic and severely dysplastic hips. The locations predominantly involved with labral tears were different in FAI and mild dysplastic hips (anterior and anterosuperior zones) and in severely dysplastic hips (anterosuperior and superior zones) around the acetabulum. Significant differences were observed in the prevalence of Mode 1 versus Mode 2 tears in FAI hips (72% (n = 13) vs 28% (n = 5)) and severe dysplastic hips (25% (n = 2) vs 75% (n = 6)). The frequency of cartilage damage adjacent to Mode 1 tears was significantly higher (42% (n = 14)) than that adjacent to Mode 2 tears (14% (n = 3)).

Hip pathology is significantly related to the locations and modes of labral tears. Mode 1 tears may be a risk factor for the development of adjacent acetabular cartilage damage.

Cite this article: Bone Joint J 2013;95-B:1320–5.

Grafting with hydroxyapatite granules for defects of acetabular bone at revision total hip replacement

The long-term results of grafting with hydroxyapatite granules for acetabular deficiency in revision total hip replacement are not well known. We have evaluated the results of revision using a modular cup with hydroxyapatite grafting for Paprosky type 2 and 3 acetabular defects at a minimum of ten years’ follow-up. We retrospectively reviewed 49 acetabular revisions at a mean of 135 months (120 to 178). There was one type 2B, ten 2C, 28 3A and ten 3B hips. With loosening as the endpoint, the survival rate was 74.2% (95% confidence interval 58.3 to 90.1). Radiologically, four of the type 3A hips (14%) and six of the type 3B hips (60%) showed aseptic loosening with collapse of the hydroxyapatite layer, whereas no loosening occurred in type 2 hips. There was consolidation of the hydroxyapatite layer in 33 hips (66%). Loosening was detected in nine of 29 hips (31%) without cement and in one of 20 hips (5%) with cement (p = 0.03, Fisher’s exact probability test). The linear wear and annual wear rate did not correlate with loosening.

These results suggest that the long-term results of hydroxyapatite grafting with cement for type 2 and 3A hips are encouraging.

Genetic Rearrangement of Plasmids: In Vivo Recombination between a Dehalogenation Plasmid and Multiple-Resistance Plasmid RP4 in Pseudomonas sp

When Moraxella plasmid pUO1 encoding haloacetate dehalogenase and mercury resistance coexisted with IncP-1 plasmid RP4 in Pseudomonas sp., genetic exchange between the plasmids often occurred, probably by site-specific recombination. The recombinant plasmids obtained were classified into four groups on the basis of phenotype. Representative plasmids for each group were analyzed for DNA composition and function, and the mechanism for the formation of these plasmids was sought. They were inherited stably in Escherichia coli and a Pseudomonas sp.

A modular femoral neck and head system works well in cementless total hip replacement for patients with developmental dysplasia of the hip

We compared a modular neck system with a non-modular system in a cementless anatomical total hip replacement (THR). Each group consisted of 74 hips with developmental hip dysplasia. Both groups had the same cementless acetabular component and the same articulation, which consisted of a conventional polyethylene liner and a 28 mm alumina head. The mean follow-up was 14.5 years (13 to 15), at which point there were significant differences in the mean total Harris hip score (modular/non-modular: 98.6 (64 to 100)/93.8 (68 to 100)), the mean range of abduction (32° (15° to 40°)/28 (0° to 40°)), use of a 10° elevated liner (31%/100%), the incidence of osteolysis (27%/79.7%) and the incidence of equal leg lengths (≥ 6 mm, 92%/61%). There was no disassociation or fracture of the modular neck.

The modular system reduces the need for an elevated liner, thereby reducing the incidence of osteolysis. It gives a better range of movement and allows the surgeon to make an accurate adjustment of leg length.

Association of epidermal growth factor receptor mutations in lung cancer with chemosensitivity to gefitinib in isolated cancer cells from Japanese patients

Somatic mutations in the tyrosine kinase domain of the epidermal growth factor receptor (EGFR) gene are reported to be associated with clinical responsiveness of lung cancer to gefitinib, an EGFR tyrosine kinase inhibitor. To elucidate the association between somatic mutations and the pharmacological actions of gefitinib, the chemosensitivity of isolated cancer cells from the lungs of Japanese patients to gefitinib was examined by the collagen gel-droplet embedded culture drug sensitivity test in vitro. In 30 specimens isolated from non-small-cell lung cancer patients, mutations were observed in eight tumour specimens (27%) and chemosensitivity to gefitinib was observed in seven specimens (23%). However, somatic mutations were not predominantly associated with chemosensitivity to gefitinib in vitro. Both mutation and chemosensitivity frequencies in this study were higher than those reported in studies from the United States, indicating a possible ethnic difference. Moreover, both frequencies were much higher in females than in males. Since a gender difference in chemosensitivity to gefitinib was observed in isolated cancer cells in vitro, this suggests that gefitinib works in part through the suppression of EGFR signalling, but that other factors, including sex-related factors, may participate in gefitinib action.

Disorders of acetabular labrum and articular cartilage in hip dysplasia: evaluation using isotropic high-resolutional CT arthrography with sequential radial reformation

OBJECTIVE

Acetabular labral tear may predispose to adjacent articular cartilage disorder and hip osteoarthritis in patients with hip dysplasia. We evaluated the diagnostic ability of isotropic computed tomography (CT) arthrography with radial reformation technique for detection of acetabular labral and articular cartilage disorders, and evaluate those interactions in hip dysplasia.

METHODS

Forty-one hips in 29 patients with hip dysplasia received CT arthrography with isotropic spatial resolution of 0.5mm. After processing of multiplanar radial reformation over the whole acetabular circumference, frequencies of labral tear and acetabular cartilage disorder were evaluated at six divided zones of the weight-bearing areas. Of the 41 hips, 20 hips underwent arthroscopic examinations, and sensitivity, specificity and accuracy for detecting labral tear and acetabular cartilage disorder by CT arthrography were calculated using the arthroscopic findings as the standard of reference.

RESULTS

The sensitivity, specificity and accuracy of CT arthrography were 97%/87%/92% for labral tear and 88%/82%/85% for acetabular cartilage disorder, respectively, using arthroscopic findings as the reference. The CT arthrography showed significantly higher frequency of labral and acetabular cartilage disorders at the anterior zones. Those zones with labral tear had significantly higher frequency of adjacent cartilage disorder than zones without labral tear.

CONCLUSIONS

Isotropic CT arthrography with radial reformation technique allowed simultaneous, accurate assessment of labral and cartilage disorders in the whole acetabular circumference. Our findings indicated that labral tear is closely associated with adjacent cartilage disorder in hip dysplasia.

Psychopathological features of patients with prolonged anorexia nervosa as assessed by the Minnesota Multiphasic Personality Inventory

OBJECTIVE

The duration of illness is quite long in some anorexia nervosa (AN) patients. In the present study, we investigated the psychopathological features of patients with prolonged AN as assessed by the Minnesota Multiphasic Personality Inventory-1 (MMPI-1).

METHODS

Fifty-five AN patients completed the MMPI-1 on admission to Kyushu University Hospital from 1999 to 2002. The patients were divided into three groups on the basis of their illness duration: a short-term group, less than 5 years of illness duration (n=31); a middle-term group, from 5 to 10 years (n=14); and a prolonged group, 10 years or more (n=10).

RESULTS

The prolonged group scored significantly higher on the MPPI-1 scales of hysteria (Hy), low back pain (Lb) and family conflict than the short-term group.

DISCUSSION

AN patients whose illness duration was prolonged characteristically had more hysteria with family conflict. This should be considered in their treatment.

A randomized phase III trial of adjuvant chemotherapy with UFT for completely resected pathological stage I non-small-cell lung cancer: the West Japan Study Group for Lung Cancer Surgery (WJSG)--the 4th study

PURPOSE

To examine the efficacy of UFT, an oral 5-fluorouracil derivative agent, as post-operative adjuvant therapy for pathologic (p-) stage I non-small-cell lung cancer (NSCLC), because a previous randomized study had suggested it was efficacious for early-stage NSCLC patients.

PATIENTS AND METHODS

Patients with completely resected p-stage I, adenocarcinoma or squamous cell carcinoma were eligible. A total of 332 patients were randomized to the surgery-alone group (control group) and the treatment group (UFT 400 mg/m(2) for 1 year after surgery, UFT group) after stratification by the histologic types.

RESULTS

For all patients, the 5- and 8-year survival rates for the UFT group were 82.2% and 73.0%, and those for the control group were 75.9% and 61.2%, respectively; no statistically significant improvement of survival was achieved by UFT administration (P=0.105). For Ad patients, the 5- and 8-year survival rates of the UFT group (n=120) were 85.2% and 79.5%, respectively, which seemed better than those of the control group (n=121) (79.2% and 64.0%, respectively; P=0.081). For squamous cell carcinoma patients, there was also no difference in survival between the control group (n=48) and the UFT group (n=43) (P=0.762). For all pT1 patients, the 5- and 8-year survival rates of the UFT group were 83.6% and 82.1%, respectively, significantly better than those of the control group (77.9% and 57.6%, respectively, P=0.036); UFT was not significantly effective for pT2 patients. For pT1 adenocarcinoma patients, UFT administration markedly improved the survival (P=0.011).

CONCLUSION

Post-operative UFT administration did not significantly improve post-operative survival of p-stage I NSCLC patients. Subset analyses suggested that UFT might be effective in pT1N0M0 adenocarcinoma patients.

[Clinicopathologic study of thymic epithelial tumors]

OBJECTIVE

We analyzed clinicopathologic characters and long-term results of 11 thymic epithelial tumors.

METHODS

Five cases of thymic carcinoma and 6 cases of thymoma treated in our hospital from September 1991 to June 2002 were retrospectively analyzed.

RESULTS

The histological subtypes of thymic carcinoma were basaloid carcinoma in 2 cases, epidermoid non-keratinizing carcinoma in 1 case, undifferentiated carcinoma in 1 case and sarcomatoid carcinoma in 1 case. Four cases underwent chemotherapy and radiotherapy. Three cases underwent midsternal thoracotomy, 1 had total resection and 2 had exploratory thoracotomy due to tumor invasion of the right upper lobe and cardiac sac. Two cases of basaloid carcinoma had been alive more than 10 years since the operation. The histological subtypes of thymoma were 1, 2, 1, 1 and 1 cases with type A, AB, B 1, B 2 and B 3. All cases underwent midsternal thoracotomy, 4 cases had thymothymectomy and 2 cases had extended thymothymectomy. Five cases have been alive since the operation. Strong immunoreactivity for bcl-2 and p 53 expression of epidermoid non-keratinizing carcinoma and undifferentiated carcinoma were seen. ki-67 labeling index of epidermoid non-keratinizing carcinoma and undifferentiated carcinoma and type B 3 thymoma were higher than those of the other carcinomas and thymomas.