Reduced Risk of Severe Radiation-Induced Lymphopenia in Carbon Ion Radiation Therapy for Locally Advanced Pancreatic Cancer: A Comparative Analysis of Carbon Versus Photon Therapy

PURPOSE

Radiation-induced lymphopenia (RIL) is associated with poor prognosis in patients with locally advanced pancreatic cancers. However, there are no reports comparing the effects of carbon ion radiation therapy (CIRT) and photon beam radiation therapy (RT) on the development of RIL. Differences in RIL after CIRT or photon beam RT and predictive factors for RIL in patients with locally advanced pancreatic cancer were investigated.

MATERIALS AND METHODS

This retrospective study cohort included 834 patients who received concurrent chemoradiotherapy (CCRT) in 2 separate institutions: 337 and 497 in the CIRT and photon beam RT groups, respectively. Severe RIL was defined as an absolute lymphocyte count (ALC) <0.5 × 109 cells/L. A 1:1 propensity score-matching analysis was performed between the CIRT and photon beam RT groups. Patients were categorized into 3 groups according to the development of recovery from severe RIL: no severe RIL (Group A), recovery from severe RIL (Group B), and no recovery from severe RIL (Group C). Logistic regression analysis was performed to identify the predictive value of severe RIL. The prognostic factors of overall survival (OS) were determined using Cox regression analysis.

RESULTS

After propensity score matching, the baseline ALC and planning target volume of the CIRT and photon beam RT groups were comparable. During CCRT, the ALC of the entire cohort decreased and was significantly lower in the photon beam RT group than in the CIRT group (P < .001). Multivariate logistic regression analysis showed that CIRT reduced severe RIL more than photon beam RT. After adjusting for other factors, the RT modality and RIL were significantly associated with OS. Photon beam RT showed a significantly worse OS than CIRT, and Group C showed a significantly worse OS than Group A.

CONCLUSIONS

CIRT seems to reduce the development of severe RIL. The RT modality and development/recovery from severe RIL were associated with OS in patients who received CCRT for locally advanced pancreatic cancer. The reduction of severe RIL through optimized RT may be essential for improving treatment outcomes.

Efficacy of stereotactic ablative radiotherapy in patients with oligometastatic hepatocellular carcinoma: A phase II study

BACKGROUND & AIMS

Stereotactic ablative radiotherapy (SABR) can extend survival and offers the potential for cure in some patients with oligometastatic disease (OMD). However, limited evidence exists regarding its use in oligometastatic hepatocellular carcinoma (HCC). We aimed to prospectively investigate the efficacy and safety of SABR in patients with oligometastatic HCC.

METHODS

We enrolled patients with controlled primary HCC and one to five metastatic lesions amenable to SABR. The primary endpoint was treatment efficacy defined as overall survival (OS) and progression-free survival (PFS). The secondary endpoints included time to local progression, objective response rate, disease control rate, toxicities, and quality of life (QOL), assessed using the EORTC QLQ-C30 before, and 0, 1, and 3 months after SABR.

RESULTS

Overall, 40 consecutive patients received SABR on 62 lesions between 2021 and 2022. The most common locations for OMD were the lungs (48.4%), lymph nodes (22.6%), and bone (17.7%). After a median follow-up of 15.5 months, the 2-year OS was 80%. Median PFS was 5.3 months, with 1- and 2-year PFS rates of 21.2% and 0%, respectively. A shorter time to OMD from the controlled primary independently correlated with PFS (p = 0.039, hazard ratio 2.127) alongside age, Child-Pugh class, and alpha-fetoprotein (p = 0.002, 0.004, 0.019, respectively). The 2-year time to local progression, objective response rate, and disease control rate were 91.1%, 75.8%, and 98.4%, respectively. Overall, 10% of patients experienced acute toxicity, and 7.5% experienced late toxicity, with no grade 3+ toxicity. All QOL scores remained stable, whereas the patients without systemic treatments had improved insomnia and social functioning scores.

CONCLUSIONS

SABR is an effective and feasible option for oligometastatic HCC that leads to excellent local tumor control and improves survival without adversely affecting QOL.

IMPACT AND IMPLICATIONS

Stereotactic ablative radiotherapy (SABR) is a non-invasive treatment approach capable of efficiently ablating the target lesion; however, neither the oligometastatic disease concept nor the potential benefits of SABR have been well-defined in hepatocellular carcinoma (HCC). According to this study, SABR is an effective and safe treatment option for oligometastatic HCC, yielding excellent local tumor control and survival improvement without worsening patients' quality of life, regardless of tumor sites. We also demonstrated that patients with a later presentation of OMD from the controlled primary and lower alpha-fetoprotein levels achieved better survival outcomes. This is the first prospective study of SABR in oligometastatic HCC, providing insights for the development of novel strategies to improve oncologic outcomes.

CLINICAL TRIAL NUMBER

NCT05173610.

Experience of Implementing Deep Learning-Based Automatic Contouring in Breast Radiation Therapy Planning: Insights From Over 2000 Cases

PURPOSE

This study evaluated the impact and clinical utility of an auto-contouring system for radiation therapy treatments.

METHODS AND MATERIALS

The auto-contouring system was implemented in 2019. We evaluated data from 2428 patients who underwent adjuvant breast radiation therapy before and after the system's introduction. We collected the treatment's finalized contours, which were reviewed and revised by a multidisciplinary team. After implementation, the treatment contours underwent a finalization process that involved manual review and adjustment of the initial auto-contours. For the preimplementation group (n = 369), auto-contours were generated retrospectively. We compared the auto-contours and final contours using the Dice similarity coefficient (DSC) and the 95% Hausdorff distance (HD95).

RESULTS

We analyzed 22,215 structures from final and corresponding auto-contours. The final contours were generally larger, encompassing more slices in the superior or inferior directions. Among organs at risk (OAR), the heart, esophagus, spinal cord, and contralateral breast demonstrated significantly increased DSC and decreased HD95 postimplementation (all P < .05), except for the lungs, which presented inaccurate segmentation. Among target volumes, CTVn_L2, L3, L4, and the internal mammary node showed increased DSC and decreased HD95 postimplementation (all P < .05), although the increase was less pronounced than the OAR outcomes. The analysis also covered factors contributing to significant differences, pattern identification, and outlier detection.

CONCLUSIONS

In our study, the adoption of an auto-contouring system was associated with an increased reliance on automated settings, underscoring its utility and the potential risk of automation bias. Given these findings, we underscore the importance of considering the integration of stringent risk assessments and quality management strategies as a precautionary measure for the optimal use of such systems.

Machine learning‑based radiomics models for prediction of locoregional recurrence in patients with breast cancer

Locoregional recurrence (LRR) is the predominant pattern of relapse after definitive breast cancer treatment. The present study aimed to develop machine learning (ML)-based radiomics models to predict LRR in patients with breast cancer by using preoperative magnetic resonance imaging (MRI) data. Data from patients with localized breast cancer that underwent preoperative MRI between January 2013 and December 2017 were collected. Propensity score matching (PSM) was performed to adjust for clinical factors between patients with and without LRR. Radiomics features were obtained from T2-weighted with and without fat-suppressed MRI and contrast-enhanced T1-weighted with fat-suppressed MRI. In the present study five ML models were designed, three base models (support vector machine, random forest, and logistic regression) and two ensemble models (voting model and stacking model) composed of the three base models, and the performance of each base model was compared with the stacking model. After PSM, 28 patients with LRR and 86 patients without LRR were included. Of these 114 patients, 80 patients were randomly selected to train the models, and the remaining 34 patients were used to evaluate the performance of the trained models. In total, 5,064 features were obtained from each patient, and 47-51 features were selected by applying variance threshold and least absolute shrinkage and selection operator. The stacking model demonstrated superior performance in area under the receiver operating characteristic curve (AUC), with an AUC of 0.78 compared to a range of 0.61 to 0.70 for the other models. An external validation study to investigate the efficacy of the stacking model of the present study was initiated and is still ongoing (Korean Radiation Oncology Group 2206).

Importance of Local Ablative Therapies for Lung Metastases in Patients With Colorectal Cancer

OBJECTIVE

To assess the effect of local ablative therapy (LAT) on overall survival in patients with lung metastases from colorectal cancer (CRC) compared with patients treated with systemic therapy.

SUMMARY BACKGROUND DATA

CRC affects approximately 1.4 million individuals worldwide every year. The lungs are commonly affected by CRC, and there is no treatment standard for a secondary lung metastasis from CRC.

METHODS

This longitudinal, retrospective cohort study (2010-2018) quantified the pulmonary and extrapulmonary tumor burden of 1143 patients by retrospectively reviewing computed tomography images captured at diagnosis. A comprehensive multidisciplinary approach informed how and when surgery and/or stereotactic body radiotherapy was administered.

RESULTS

Among 1143 patients, 473 patients (41%) received LAT, with surgery first (n = 421) or stereotactic ablative radiation therapy first (n = 52) either at the time of diagnosis (n = 288), within 1 year (n = 132), or after 1 year (n = 53). LAT was repeated in 158 patients (33.4%, 384 total sessions) when new lung metastases were detected. The 5- and 10-year survival rates for patients treated with LAT (71.2% and 64.0%, respectively) were significantly higher than those of patients treated with systemic therapy alone (14.2% and 10.0%, respectively; P <0.001). The overall survival of patients who received LAT intervention increased as the total tumor burden decreased.

CONCLUSIONS

A high long-term survival rate was achievable in a significant portion of patients with lung metastasis from CRC by the timely administrations of LAT to standard systemic therapy. The tumor burden and LAT feasibility should be included in a discussion during the follow-up period.

Radiotherapy in recurrent ovarian cancer: updated results of involved-field radiation therapy

OBJECTIVE

This study aimed to update the possible clinical benefits of radiation therapy in recurrent ovarian cancer.

METHODS

The medical records of 495 patients with recurrent ovarian cancer after initially undergoing maximal cytoreductive surgery and adjuvant platinum-based chemotherapy based on the pathologic stage between January 2010 and December 2020 were analyzed: 309 and 186 patients were treated without and with involved-field radiation therapy, respectively. Involved-field radiation therapy is defined as radiation therapy only to the areas of the body involved by tumor. The prescribed doses were ≥45 Gy (equivalent dose in 2 Gy/fraction). Overall survival was compared between patients treated with and without involved-field radiation therapy. The favorable group was defined as patients who satisfied at least four of the following factors: good performance, no ascites, normal CA-125, platinum-sensitive tumor, and nodal recurrence.

RESULTS

The median age of the patients was 56 years (range 49-63) and median time to recurrence was 11.1 months (range 6.1-15.5). 217 patients (43.8%) were treated at a single site. Radiation therapy, performance status, CA-125, platinum sensitivity, residual disease, and ascites were all significant prognostic factors. The 3-year overall survival of all patients, patients treated without radiation therapy, and patients treated with radiation therapy was 54.0%, 44.8%, and 69.3%, respectively. Radiation therapy was associated with higher overall survival rates in the unfavorable and favorable patient groups. Patient characteristics showed higher rates of normal CA-125, lymph node metastasis only, lower platinum sensitivity, and higher rates of ascites in the radiation therapy group. After propensity score matching, the radiation therapy group showed superior overall survival to the non-radiation therapy group. Normal CA-125, good performance status, and platinum sensitivity were associated with a good prognosis in patients treated with radiation therapy.

CONCLUSION

Our study showed that higher overall survival was observed in patients treated with radiation therapy in recurrent ovarian cancer.

High energy dissipation-based process to improve the rheological properties of bentonite drilling muds by reducing the particle size

Drilling mud is a multi-phase fluid that is used in the petroleum drilling process. Bentonite is the most important constituent of drilling mud; it endows the drilling mud with its rheological behaviors, such as viscosity, yield stress, and shear thinning. The process of manufacturing microscale bentonite at the nanoscale level is very promising for commercializing nano-based drilling mud. In contrast to the conventional method using the impeller, bentonite was manufactured in its nanoparticle state in the present work through ultrasonic and homogenizer processes in the solution state. In case of the ultrasonic process, the viscosity increase in the low shear rate region before and after processing of the 5 wt% bentonite-based mud and the rheological properties in the presence of polymer additive were compared. In case of the homogenizer process, the rheological properties of 3 wt% bentonite-based mud employed through the homogenizer process and 5 wt% mud prepared generally were compared. Both processes reported improvement of rheological properties, in which shear thinning behavior strongly occurred when particle size decreased through FE-SEM, TEM image analysis, and particle size analyzer. A regularized Herschel-Bulkley model suitable for rheological quantitative explanation of drilling mud including yield stress was selected. The homogenizer process has the potential to be applied in the petroleum drilling industry for large-scale production, and the mechanism was confirmed by numerical analyses. In conclusion, we presented a simple and easy-to-apply process to rapidly produce nano-based drilling mud.

Automated Computer-aided Detection of Lung Nodules in Metastatic Colorectal Cancer Patients for the Identification of Pulmonary Oligometastatic Disease

PURPOSE

This study aims to explore the possibility and clinical utility of existing artificial intelligence (AI)-based computer-aided detection (CAD) of lung nodules to identify pulmonary oligometastases.

PATIENTS AND METHODS

The chest computed tomography (CT) scans of patients with lung metastasis from colorectal cancer between March 2006 and November 2018 were analyzed. The patients were selected from a database of 1,395 patients and studied in two cohorts. The first cohort included 50 patients and the CT scans of these patients were independently evaluated for lung nodule (≥3 mm) detection by a CAD-assisted radiation oncologist (CAD-RO) as well as an expert radiologist. Inter-observer variability in additional two radiation oncologists and two thoracic surgeons was also measured. In the second cohort of 305 patients, survival outcomes were evaluated based on the number of CAD-RO-detected nodules.

RESULTS

In the first cohort, the sensitivity and specificity of the CAD-RO for the identification of oligometastatic disease (OMD) from varying criteria by ≤2 nodules, ≤3 nodules, ≤4 nodules, and ≤5 nodules were 71.9% and 88.9%; 82.9% and 93.3%; 97.1% and 73.3%; and 97.5% and 90.0%, respectively. The sensitivity of the CAD-RO in the nodule detection compared with the radiologist was 81.6%. The average (standard deviation) sensitivity in inter-observer variability analysis was 80.0% (3.7%). In the second cohort, the 5-year survival rates of patients with 1, 2, 3, 4, or ≥5 metastatic nodules were 75.2%, 52.9%, 45.7%, 29.1%, and 22.7%, respectively.

CONCLUSIONS

Proper identification of the pulmonary OMD and the correlation between the number of CAD-RO-detected nodules and survival suggest the potential practicality of AI in OMD recognition. Developing a deep learning-based model specific to the metastatic setting, which enables a quick estimation of disease burden and identification of OMD, is underway.

Significance of mid-radiotherapy 18F-fluorodeoxyglucose positron emission tomography/computed tomography in esophageal cancer

BACKGROUND AND PURPOSE

Metabolic parameters evaluated by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) are known as prognostic markers in various cancers. We aimed to validate the predictive value of mid-radiotherapy (RT) FDG PET/CT parameters in esophageal cancer.

MATERIALS AND METHODS

Eighty-three patients treated with RT with or without chemotherapy between 2015 and 2020 were included. PET parameters including metabolic tumor volume (MTV), total lesion glycolysis, and mean (SUV_mean) and maximum standardized uptake value (SUV_max) were analyzed. Locoregional recurrence-free rate (LRFR) and distant metastasis-free rate (DMFR) were analyzed.

RESULTS

The median follow-up period was 10.5 months. Mid-RT SUV_max was significantly associated with LRFR (HR 1.07, p = 0.009) and DMFR (HR 1.13, p=0.047) while mid-RT MTV was associated with DMFR (HR 1.06, p=0.007). Treatment response after RT was associated with overall survival (HR, 1.52, p=0.025). Further, treatment response was significantly associated with mid-RT SUV_max. The optimal cutoff value for mid-RT SUV_max in predicting LRFR and DMFR was 11 while cutoff value for mid-RT MTV was 15. The patients with mid-RT SUV_max≤11 showed superior LRFR and DMFR compared to SUV_max>11 (1-year LRFR; 73.4% vs 48.4%, p=0.028, 1-year DMFR; 74.6% vs 40.7%, p=0.007). The 1-year DMFR was significantly different between patients with mid-RT MTV≤15 and >15 (1-year DMFR; 78.2% vs 31.9%, p=0.002).

CONCLUSION

Tumor metabolism changes during RT can be a useful predictive tool for treatment response and recurrence in patients with esophageal cancer. Clinicians may consider early response evaluation with PET during RT for information about prognosis.

Early experience of combining immune checkpoint inhibitor and radiotherapy in heavily pretreated hepatobiliary cancer

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Background: Promising therapeutic results of immune checkpoint inhibitor (ICI) have been reported in various solid tumors. Radiotherapy (RT) is known to enhance the immunogenic effect. The immunogenic effect of RT is expected to improve the therapeutic effect of ICI. In this study, we aimed to investigate the efficacy and toxicity of combining ICI and RT in hepatobiliary cancer. Methods: Patients who received RT and ICI combination therapy for hepatobiliary cancer from January 2020 to April 2021 were retrospectively reviewed. Baseline patient characteristics such as age at diagnosis, stage, previous treatment, radiation dose, tumor volume, and lymphocyte count were recorded. The primary endpoints were in-field and out-field control rate. The secondary endpoint was treatment-related toxicities. Overall survival and progression-free survival were also evaluated. The disease control rate and survival were assessed using the Kaplan-Meier method. Results: In total, 17 patients and 35 treated lesions were included for analysis. The median follow up period was 5.5 months (range 2.4 – 19.8 months). Of the 17 patients, 14 were diagnosed hepatocellular carcinoma (82.4%). Twelve patients had distant metastasis (70.6%). Various treatments were administered to the patients prior to ICI and RT combination treatment. The 6-month overall survival and progression-free survival was 62.7% and 26.5%, respectively. The 6-month in-field control rate was 67.4% and 6-month out-field control rate was 26.6%. Higher BED (≥ 90 Gy) was a significant prognostic factor for both in-field and out-field control, and lymphopenia (≤ 800 /μL) at the time of RT start was a poor prognostic factor for outfield control. Fractional dose of less than 5 Gy showed improved in-field and out-field control. Treatment related toxicity occurred in 10 patients (58.8%). The most frequent adverse event was GI disorders such as esophagitis (n = 3) and epigastric pain (n = 3). Patients who experienced treatment-related toxicity were well recovered after conservative care. There was no grade 3 or 4 toxicity. Conclusions: The combination of ICI and RT showed substantial efficacy with acceptable toxicity in heavily pretreated advanced hepatobiliary cancer patients. Dose per fraction of less than 5 Gy may be appropriate for better efficacy in future study of combining ICI and RT. The results of this study provides a basis for future prospective study in hepatobiliary cancer.

Long-term survival after multimodal treatment involving radiotherapy for huge hepatocellular carcinoma with oligometastasis: a case report

The clinical efficacy of local ablative treatment for oligometastasis is widely accepted in most cancers. However, due to limited data, this has not been the case for hepatocellular carcinoma (HCC). Here, we report a case of pulmonary oligometastasis of a huge HCC that was treated by multimodality with liver-directed concurrent chemoradiotherapy (CCRT) plus subsequent resection of the primary lesion and local ablative radiotherapy (RT) for subsequent lung oligometastatic lesions. In this patient, liver-directed CCRT induced significant tumor shrinkage with compensatory hypertrophy of the non-tumor liver, followed by curative resection. Surgical resection of the first and second pulmonary metastatic lesions as well as local ablative RT of the third lesion achieved complete tumor regression, which led to long-term survival of 6 years. Therefore, the active use of local ablative RT requires full consideration in cases of oligometastatic HCC.

Radiotherapy as an immune checkpoint blockade combination strategy for hepatocellular carcinoma

In the immune oncology era, the clinical efficacy of immune checkpoint inhibitors (ICIs) against most solid cancers is well known. In hepatocellular carcinoma, the recent success of combination therapy with targeting agents has accelerated the search for novel combination strategies. Radiotherapy (RT), an attractive modality, can be combined with ICIs, which act as strong modulators of the tumor immune microenvironment. Herein, we discuss immune modulation caused by radiation and the current trials of RT–ICI combination treatment as well as future perspectives.

Prognostic Significance of Sarcopenia in Advanced Biliary Tract Cancer Patients

Background: Sarcopenia, systemic inflammation, and low muscularity significantly impact the survival of cancer patients. However, few studies have investigated how sarcopenia and systemic inflammation affect the prognosis of biliary tract cancer with distant metastasis. In this study, we investigated the association between sarcopenia with systemic inflammation and prognosis of metastatic biliary tract cancer. Materials and Methods: Data collected from 353 metastatic biliary tract cancer patients from 2007 to 2016 were analyzed. To evaluate the skeletal muscle mass, computed tomography images at the upper level of the third lumbar vertebra (L3) were used. Sarcopenia was defined using the Japan Society of Hepatology guideline; L3 muscle index <42 cm²/m² for male and <38 cm²/m² for female patients. Systemic inflammation was evaluated using the neutrophil lymphocyte ratio (NLR). Patients with NLR > 3 were categorized into the inflammatory category. The overall survival (OS) and progression free survival (PFS) were analyzed. Subgroup analysis was performed on those who received gemcitabine/cisplatin (GP) chemotherapy and depending on the presence of sarcopenia and inflammation. Results: Patients with sarcopenia showed lesser 1-year OS than those without (25.5 vs. 38.2%, p = 0.019). The patients with high NLR (NLR > 3) were associated with a shorter OS than were those with a low NLR (NLR ≤ 3) (21.0 vs. 52.8%, p < 0.001). Based on these results, we categorized the patients into three groups; sarcopenia accompanied by high NLR, no sarcopenia and low NLR, and either sarcopenia or high NLR. The OS of patients was well-stratified according to this grouping (1-year OS; 18.3 vs. 30.3 vs. 55.8%, p < 0.001). Concordant with OS results, the PFS was well-stratified based on the presence of either sarcopenia or high NLR (Sarcopenia; 9.5 vs. 19.4%, p < 0.001, NLR; 10.0 vs. 23.4%, p < 0.001). The PFS was significantly associated with high NLR and sarcopenia (1-year PFS; 7.8 vs. 13.0 vs. 27.9%, p < 0.001). Conclusion: Sarcopenia with inflammation was associated with inferior OS and PFS. In addition, sarcopenia accompanied by inflammation was associated with poor prognosis. Conservative treatments such as nutritional support, exercise, and pharmacologic intervention could help metastatic biliary tract cancer patients to overcome sarcopenia and the inflammatory status.

Significance of lymphocyte recovery from treatment-related lymphopenia in locally advanced pancreatic cancer

BACKGROUND AND PURPOSE

Radiation-induced lymphopenia is associated with poor prognosis in resected pancreatic cancer and locally advanced pancreatic cancer. However, whether lymphocyte recovery contributes to pancreatic cancer prognosis has not been well-investigated.

MATERIALS AND METHODS

We evaluated 497 locally advanced pancreatic cancer patients who underwent concurrent chemoradiotherapy (CCRT). Complete blood counts of patients were obtained before, during, and after CCRT until the 12-month follow-up visit. Patients were categorized into 3 groups according to the development of and recovery from acutte severe lymphopenia (ASL): no ASL (group A, n = 198), recovery from ASL (group B, n = 141), and no recovery from ASL (group C, n = 89). Prognostic factors of overall survival (OS) and progression-free survival (PFS) were determined using Cox regression analyses.

RESULTS

In groups A, B, and C, the 2-year OS rates were 40.4%, 31.9%, and 14.6%, respectively, and the 2-year PFS rates were 23.7%, 18.4%, and 10.1%, respectively. OS and PFS were comparable between Groups A and B, while group C had poor OS and PFS (p < 0.001). Recovery from ASL was associated with superior OS (HR 0.42, 95% CI: 0.32-0.55, p < 0.001) and PFS (HR 0.53, 95% CI: 0.41-0.70, p < 0.001). The baseline lymphocyte counts and target volume independently predicted development and recovery from ASL.

CONCLUSION

Recovery from ASL was associated with both superior OS and PFS in patients who received CCRT for locally advanced pancreatic cancer. Baseline lymphocyte counts and target volume were associated with both the development of and recovery from treatment-related ASL.

Hypofractionated Radiotherapy Dose Scheme and Application of New Techniques Are Associated to a Lower Incidence of Radiation Pneumonitis in Breast Cancer Patients

Purpose: Radiation pneumonitis (RP) is one of the most severe toxicities experienced by patients with breast cancer after radiotherapy (RT). RT fractionation schemes and techniques for breast cancer have undergone numerous changes over the past decades. This study aimed to investigate the incidence of RP as a function of such changes in patients with breast cancer undergoing RT and to identify dosimetric markers that predict the risk of this adverse event.

Methods and Materials: We identified 1,847 women with breast cancer who received adjuvant RT at our institution between 2015 and 2017. The RT technique was individually tailored based on each patient's clinicopathological features. Deep inspiration breath hold technique or prone positioning were used for patients who underwent left whole-breast irradiation for cardiac sparing, while those requiring regional lymph node irradiation underwent volumetric-modulated arc therapy (VMAT).

Results: Of 1,847 patients who received RT, 21.2% received the conventional dose scheme, while 78.8% received the hypofractionated dose scheme (mostly 40 Gy in 15 fractions). The median follow-up period was 14.5 months, and the overall RP rate was 2.1%. The irradiated organ at risk was corrected concerning biologically equivalent dose. The ipsilateral lung V₃₀ in equivalent dose in 2 Gy (EQD2) was the most significant dosimetric factor associated with RP development. Administering RT using VMAT, and hypofractionated dose scheme significantly reduced ipsilateral lung V₃₀.

Conclusions: Application of new RT techniques and hypofractionated scheme significantly reduce the ipsilateral lung dose. Our data demonstrated that ipsilateral lung V₃₀ in EQD2 is the most relevant dosimetric predictor of RP in patients with breast cancer.

The Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio Are Prognostic Factors in Patients with Locally Advanced Pancreatic Cancer Treated with Chemoradiotherapy

Background/Aims

We investigated whether inflammatory markers such as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) independently and in combination would be significant prognostic factors for survival in patients with locally advanced pancreatic cancer.

Methods

A total of 497 patients with locally advanced pancreatic cancer who received neoadjuvant or definitive chemoradiotherapy from 2005 to 2015 were evaluated. We divided the patients into groups according to the median values of NLR and PLR: NLR<1.89 (n=156), NLR≥1.89 (n=341), PLR <149 (n=248) and PLR≥149 (n=249).

Results

For NLR <1.89 and ≥1.89 groups, respectively, the 1-year overall survival (OS) rates were 73.2% and 60.8% (p<0.001) and 1-year progression-free survival (PFS) rates were 43.9% and 31.3% (p<0.001). For PLR <149 and ≥149 groups, respectively, the 1-year OS rates were 68.1% and 61.3% (p=0.029) and 1-year PFS rates were 37.9% and 32.5% (p=0.027). Patients with both high NLR and high PLR showed the worst OS and PFS rates compared with those with both lower NLR and lower PLR.

Conclusions

Elevated pretreatment NLR and PLR independently and in combination significantly predicted poor OS and PFS.

External validation of IBTR! 2.0 nomogram for prediction of ipsilateral breast tumor recurrence

Purpose

IBTR! 2.0 nomogram is web-based nomogram that predicts ipsilateral breast tumor recurrence (IBTR). We aimed to validate the IBTR! 2.0 using an external data set.

Materials and Methods

The cohort consisted of 2,206 patients, who received breast conserving surgery and radiation therapy from 1992 to 2012 at our institution, where wide surgical excision is been routinely performed. Discrimination and calibration were used for assessing model performance. Patients with predicted 10-year IBTR risk based on an IBTR! 2.0 nomogram score of <3%, 3%–5%, 5%–10%, and >10% were assigned to groups 1, 2, 3, and 4, respectively. We also plotted calibration values to observe the actual IBTR rate against the nomogram-derived 10-year IBTR probabilities.

Results

The median follow-up period was 73 months (range, 6 to 277 months). The area under the receiver operating characteristic curve was 0.607, showing poor accordance between the estimated and observed recurrence rate. Calibration plot confirmed that the IBTR! 2.0 nomogram predicted the 10-year IBTR risk higher than the observed IBTR rates in all groups. High discrepancies between nomogram IBTR predictions and observed IBTR rates were observed in overall risk groups. Compared with the original development dataset, our patients had fewer high grade tumors, less margin positivity, and less lymphovascular invasion, and more use of modern systemic therapies.

conclusions

IBTR! 2.0 nomogram seems to have the moderate discriminative ability with a tendency to over-estimating risk rate. Continued efforts are needed to ensure external applicability of published nomograms by validating the program using an external patient population.

Factors associated with pulmonary toxicity after myeloablative conditioning using fractionated total body irradiation

Purpose

Pulmonary toxicities, including infectious pneumonia (IP) and idiopathic pneumonia syndrome (IPS), are serious side effects of total body irradiation (TBI) used for myeloablative conditioning. This study aimed to evaluate clinical factors associated with IP and IPS following TBI.

Materials and Methods

Fifty-eight patients with hematologic malignancies who underwent TBI before allogeneic hematopoietic stem cell transplantation between 2005 and 2014 were reviewed. Most patients (91%) received 12 Gy in 1.5 Gy fractions twice a day. Pulmonary toxicities were diagnosed based on either radiographic evidence or reduced pulmonary function, and were subdivided into IP and IPS based on the presence or absence of concurrent infection.

Results

Pulmonary toxicities developed in 36 patients (62%); 16 (28%) had IP and 20 (34%) had IPS. IP was significantly associated with increased treatment-related mortality (p = 0.028) and decreased survival (p = 0.039). Multivariate analysis revealed that the risk of developing IPS was significantly higher in patients who received stem cells from a matched unrelated donor than from a matched sibling donor (p = 0.021; hazard ratio [HR] = 12.67; 95% confidence interval [CI], 1.46–110.30). Combining other conditioning agents with cyclophosphamide produced a higher tendency to develop IP (p = 0.064; HR = 6.19; 95% CI, 0.90–42.56).

Conclusion

IP and IPS involve different risk factors and distinct pathogeneses that should be considered when planning treatments before and after TBI.

Dose escalation in locally advanced pancreatic cancer patients receiving chemoradiotherapy

PURPOSE

To investigate whether radiotherapy (RT) dose escalation would improve treatment outcomes without increasing severe toxicity in locally advanced pancreatic cancer patients.

METHODS

From 2005 to 2015, 497 locally advanced pancreatic cancer patients who received neoadjuvant or definitive chemoradiotherapy (CCRT) were included. Patients were divided according to the total dose (TD). Overall survival (OS), progression-free survival (PFS), local failure-free rate (LFFR), distant failure-free rate (DFFR), and toxicity rates were compared between <61Gy (n=345) and ≥61Gy groups (n=152). Additionally, propensity score matching was performed.

RESULTS

At a median follow-up of 19.3months (range, 4.8-128.5months), the 1-year OS, PFS, LFFR, and DFFR were significantly higher in the ≥61Gy group. After multivariate analysis, a TD of ≥61Gy remained a significant favorable factor for OS (p=0.019), PFS (p=0.001), LFFR (p=0.004), and DFFR (p=0.008). After propensity score matching, the ≥61Gy group still showed higher OS, PFS, and LFFR, but not DFFR (p=0.205). The acute and late toxicity rates showed no significant difference between the two groups.

CONCLUSION

Patients who received a higher RT dose showed not only improved PFS and LFFR, but also improved OS without an increase in severe toxicity. Dose-escalated CCRT can be a favorable treatment option in locally advanced pancreatic cancer patients.

Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as prognostic factors for locally advanced pancreatic cancer patients

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Background: It is well known that locally advanced pancreatic cancer patients have a poor prognosis. Recently, hematologic markers showing systemic inflammatory status such as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have aroused much attention due to its potential to predict patient survival. In this study, we investigated whether pre-treatment NLR and PLR independently and in combination would be significant prognostic factors for survival in locally advanced pancreatic cancer patients. Methods: A total of 497 locally advanced (borderline resectable and unresectable) pancreatic cancer patients who received neoadjuvant or definitive chemoradiotherapy (CCRT) between January 2005 and December 2015 were included in this study. NLR and PLR prior to the start of treatment within 2 weeks were defined as pre-treatment NLR and PLR. We divided the patients with the median values of pre-treatment NLR and PLR; NLR < 2.44 group (n = 248), NLR ≥ 2.44 group (n = 249), PLR < 149 group (n = 248) and PLR ≥ 149 (n = 249) group. Overall survival (OS) and progression-free survival (PFS) were compared between each group for NLR and PLR. Results: Median overall survival was 15.7 months (range, 2.3-128.5 months). For NLR, the OS, PFS rates were significantly lower in the NLR ≥ 2.44 group, with 1-year OS rates of 67.9% and 61.5% (p = 0.003) and 1-year PFS rates of 38.1% and 32.4% (p = 0.003), for NLR < 2.44 and ≥ 2.44 group, respectively. The PLR ≥ 149 group also showed significantly poorer OS and PFS than PLR < 149 group. The 1-year OS rates were 68.1% and 61.3% (p = 0.029) and 1-year PFS rates were 37.9% and 32.5% (p = 0.027), for PLR < 149 and ≥ 149 group, respectively. When multivariate analysis was performed, NLR ≥ 2.44 remained as a significant adverse factor for OS (p = 0.011) and PFS (p = 0.026). PLR > 149 also proved to be a significant factor for poorer OS (p = 0.003) and PFS (p = 0.021). Conclusions: Elevated pre-treatment NLR and PLR independently and in combination significantly predicted poor OS and PFS. Pre-treatment NLR and PLR are useful prognostic factors for OS and PFS in locally advanced pancreatic cancer patients.

Dose escalation in locally advanced pancreatic cancer patients receiving chemoradiotherapy

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Background: In locally advanced pancreatic cancer, radiotherapy (RT) is an effective treatment modality, but challenged by conflicting results. Now, in the era of intensity-modulated radiation therapy (IMRT), dose escalation is possible without increasing the dose to organs-at-risk. We investigated whether RT dose escalation would improve treatment outcomes without increasing severe toxicity. Methods: From 2005 to 2015, a total of 497 locally advanced - including both borderline resectable and unresectable - pancreatic cancer patients who received neoadjuvant or definitive chemoradiotherapy were included. A total of 281 (56.5%) patients received 3D conformal RT and 216 (43.5%) patients received IMRT. Most common dose scheme for IMRT was 58.42 Gy in 23 fractions (EQD2 61.05 Gy). Patients were divided into two groups; < 61 Gy group (n = 345) and ≥ 61 Gy group (n = 152). Overall survival (OS), progression-free survival (PFS), local failure-free rate (LFFR), distant failure-free rate (DFFR) and toxicity rates were assessed. Results: At a median follow-up time of 14.1 months (range, 2.3-128.5 months), OS, PFS, LFFR, and DFFR rates were significantly higher in ≥ 61 Gy group. The 1-year OS rates were 74.7% and 60.6% (p = 0.001) and 1-year PFS rates were 46.2% and 30.9% (p < 0.001), for ≥ 61 Gy and < 61 Gy group, respectively. The 1-year LFFR was 86.9% and 70.9% (p = 0.001) and 1-year DFFR was 56.4% and 45.8% (p = 0.007), respectively. After multivariate analysis, ≥ 61 Gy group remained a favorable significant factor for OS (p = 0.019), PFS (p = 0.001), LFFR (p = 0.004), and DFFR (p = 0.008). When 152 patients in each group were matched by propensity score matching, ≥ 61 Gy group still showed higher OS (p = 0.011), PFS (p = 0.016), and LFFR (p = 0.002), but not DFFR (p = 0.205). There was no acute gastrointestinal toxicity higher than Grade 3 in both groups. Late toxicity rates were also similar, with RT-related duodenal and gastric hemorrhage ( ≥ Grade 3) in 19 patients (5.5%) in < 61 Gy group and 7 patients (4.6%) in ≥ 61 Gy group. Conclusions: Patients who received higher RT dose showed not only improved PFS and LFFR but improved OS without an increase in severe toxicity. Dose escalation via IMRT is recommended for RT in locally advanced pancreatic cancer patients.

Extracellular ATP Induces Calcium Signaling in Odontoblasts

Odontoblasts form dentin at the outermost surface of tooth pulp. An increasing level of evidence in recent years, along with their locational advantage, implicates odontoblasts as a secondary role as sensory or immune cells. Extracellular adenosine triphosphate (ATP) is a well-characterized signaling molecule in the neuronal and immune systems, and its potential involvement in interodontoblast communications was recently demonstrated. In an effort to elaborate the ATP-mediated signaling pathway in odontoblasts, the current study performed single-cell reverse transcription polymerase chain reaction (RT-PCR) and immunofluorescent detection to investigate the expression of ATP receptors related to calcium signal in odontoblasts from incisal teeth of 8- to 10-wk-old rats, and demonstrated an in vitro response to ATP application via calcium imaging experiments. While whole tissue RT-PCR analysis detected P2Y₂, P2Y₄, and all 7 subtypes (P2X₁ to P2X₇) in tooth pulp, single-cell RT-PCR analysis of acutely isolated rat odontoblasts revealed P2Y₂, P2Y₄, P2X₂, P2X₄, P2X₆, and P2X₇ expression in only a subset (23% to 47%) of cells tested, with no evidence for P2X₁, P2X₃, and P2X₅ expression. An increase of intracellular Ca²⁺ concentration in response to 100μM ATP, which was repeated after pretreatment of thapsigargin or under the Ca²⁺-free condition, suggested function of both ionotropic and metabotropic ATP receptors in odontoblasts. The enhancement of ATP-induced calcium response by ivermectin and inhibition by 5-(3-bromophenyl)-1,3-dihydro-2H-benzofuro[3,2-e]-1,4-diazepin-2-one (5-BDBD) confirmed a functional P2X₄ subtype in odontoblasts. Positive calcium response to 2',3'-O-(benzoyl-4-benzoyl)-ATP (BzATP) and negative response to α,β-methylene ATP suggested P2X₂, P2X₄, and P2X₇ as functional subunits in rat odontoblasts. Single-cell RT-PCR analysis of the cells with confirmed calcium response and immunofluorescent detection further corroborated the expression of P2X₄ and P2X₇ in odontoblasts. Overall, this study demonstrated heterogeneous expression of calcium-related ATP receptor subtypes in subsets of individual odontoblasts, suggesting extracellular ATP as a potential signal mediator for odontoblastic functions.

Synthesis of two distinct pyrrole moiety-containing arenes from nitroanilines using Paal–Knorr followed by an indium-mediated reaction

Synthesis of arenes substituted with two different substituted-pyrrole moieties was investigated.

Impact of anesthesia on cancer recurrence

Surgery remains the mainstay treatment in the majority of solid cancers. Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammation and angiogenesis, and have a direct effect on cancer cells that could ultimately modify oncological outcomes. For instance, volatile anesthetics and opioid analgesics have shown predominantly pro-tumor effects, while propofol, non-steroid anti-inflammatory drugs have mostly anticancer effects. Researchers have been especially interested in investigating the association between the use of regional anesthesia techniques and the postoperative survival of patients with cancers. Since the results of the current retrospective studies are conflicting, several researchers are conducting prospective randomized trials.

Homologous expression and quantitative analysis of T3SS-dependent secretion of TAP-tagged XoAvrBs2 in Xanthomonas oryzae pv. oryzae induced by rice leaf extract

Xanthomonas oryzae pv. oryzae (Xoo) produces a putative effector, XoAvrBs2. We expressed XoAvrBs2 homologously in Xoo with a TAP-tag at the C-terminus to enable quantitative analysis of protein expression and secretion. Addition of rice leaf extracts from both Xoo-sensitive and Xoo-resistant rice cultivars to the Xoo cells induced expression of the XoAvrBs2 gene at the transcriptional and translational levels, and also stimulated a remarkable amount of XoAvrBs2 secretion into the medium. In a T3SS-defective Xoo mutant strain, secretion of the TAPtagged XoAvrBs2 was blocked. Thus, we elucidated the transcriptional and translational expressions of the XoAvrBs2 gene in Xoo was induced in vitro by the interaction with rice and the induced secretion of XoAvrBs2 was T3SSdependent. It is the first report to measure the homologous expression and secretion of XoAvrBs2 in vitro by rice leaf extract. Our system for the quantitative analysis of effector protein expression and secretion could be generally used for the study of host-pathogen interactions.

Oral administration of Salmonella enterica serovar Typhimurium expressing swine interleukin-18 induces Th1-biased protective immunity against inactivated vaccine of pseudorabies virus

Enhancing and/or modulating innate and adaptive immunity by cytokines appears to be greatly useful to provide effective protective immunity against infectious diseases. However, an effective delivery system for mass administration in livestock industry is needed because of limitations such as cost, labor, time, and protein stability. Here the immunomodulatory functions of swine interleukine-18 (swIL-18), known as IFN-γ-inducing factor (IGIF), were evaluated in a vaccination model of pseudorabies virus (PrV) using attenuated Salmonella enterica serovar Typhimurium as the oral delivery system. The oral administration of S. enterica serovar Typhimurium expressing swIL-18 prior to vaccination with inactivated PrV vaccine induced enhanced levels of serum PrV-specific IgG and its IgG2 isotype, compared to administration of S. enterica serovar Typhimurium harboring the empty vector. Furthermore, S. enterica serovar Typhimurium expressing swIL-18 mounted Th1-biased cellular immune responses against PrV antigen, as evaluated by the production of IFN-γ and IL-4 from peripheral blood mononuclear cells of piglets. Subsequently, Th1-biased immunity induced by S. enterica serovar Typhimurium expressing swIL-18 showed rapid response and rendered piglets displayed more alleviated clinical signs following the virulent PrV challenge. Also, this alleviation of clinical signs was further confirmed by the reduction of nasal excretion of PrV after challenge. The present study demonstrates the extended use of immunomodulatory functions of swIL-18 orally delivered by attenuated S. enterica serovar Typhimurium.

Enhanced protection against infection with transmissible gastroenteritis virus in piglets by oral co-administration of live attenuated Salmonella enterica serovar Typhimurium expressing swine interferon-α and interleukin-18

The enhanced effect of cytokine combinations has been assessed empirically, based on their immunobiological mechanisms. However, far less is known of the enhanced protection of practical cytokine combinations against viral infection in the livestock industry, due to cost and production issues associated with mass administration. This study demonstrates the enhanced protection of oral co-administration of swine interferon-α (swIFN-α) and interleukin-18 (swIL-18) against infection with transmissible gastroenteritis virus (TGEV) in piglets using attenuated Salmonella enterica serovar Typhimurium as carrier of cytokine proteins. A single oral co-administration of S. enterica serovar Typhimurium expressing swIFN-α and swIL-18 induced enhanced alleviation of the severity of diarrhea caused by TGEV infection, compared to piglets administered S. enterica serovar Typhimurium expressing swIFN-α or swIL-18 alone. This enhancement was further observed by the reduction of TGEV shedding and replication, and the expression of IFN-stimulated gene products in the intestinal tract. The results suggest that the combined administration of the swIFN-α and swIL-18 cytokines using attenuated S. enterica serovar Typhimurium as an oral carrier provides enhanced protection against intestinal tract infection with TGEV.

Systemic and mucosal immunity induced by attenuated Salmonella enterica serovar Typhimurium expressing ORF7 of porcine reproductive and respiratory syndrome virus

Oral administration of attenuated Salmonella vaccine may provide valuable advantages such as low cost, easy preparation, and safety. Attenuated Salmonella vaccines also serve as carriers of foreign antigens and immunomodulatory cytokines. Presently, an attenuated Salmonella enterica serovar Typhimurium strain was used as a carrier for open reading frame 7 (ORF7) protein of porcine reproductive and respiratory syndrome virus (PRRSV), a swine pathogen of significant global economic importance. Initially, an attenuated S. enterica serovar Typhimurium expressing ORF7 gene derived from PRRSV Korean isolate was constructed. Following oral administration of a single dose of the attenuated Salmonella vaccine expressing PRRSV ORF7, humoral and cell-mediated immune responses specific for ORF7 were induced at both systemic and mucosal sites including spleen, mesenteric lymph node, Peyer's patch, and laminar propria, as evaluated by determining serum ORF7-specific IgG and mucosal IgA responses, as well as Th1- and Th2-type cytokine production from antigen-stimulated T cells. The induced humoral responses were sustained for at least 12weeks post-immunization. In particular, the immunized mice displayed immune responses to both the foreign ORF7 antigen and Salmonella itself. The results indicate the value of attenuated S. enterica serovar Typhimurium as an oral carrier of PRRSV antigenic proteins to induce effective systemic and mucosal immunity.

Live attenuated Salmonella enterica serovar Typhimurium expressing swine interferon-alpha has antiviral activity and alleviates clinical signs induced by infection with transmissible gastroenteritis virus in piglets

Enhancing innate and acquired immunity by cytokines such as IFN-alpha appears to be useful as a first line of defense against viral infection. However, the practical use of cytokines in livestock is not evident due to cost and production issues associated with mass administration. In this study, we tested the efficacy of live attenuated Salmonella enterica serovar Typhimurium designed to secrete swine IFN-alpha (swIFN-alpha) protein for preventing the clinical signs caused by infection with transmissible gastroenteritis virus (TGEV), one of the diarrhea-causing viruses in the swine industry. Attenuated Salmonella vaccine (chi8501) containing swIFN-alpha-encoding pYA3560 vector (chi8501/swIFN-alpha) successfully induced the secretion of swIFN-alpha protein into the culture supernatants, as confirmed by SDS-PAGE and Western blot. The culture supernatants of chi8501/swIFN-alpha had antiviral activity against TGEV with 50% effective dose (ED(50)) of 320 per mg of supernatant protein. In addition, oral administration of chi8501/swIFN-alpha reduced the severity of clinical signs caused by TGEV infection with the effect more apparent at 6-8 days post-infection, and reduced excretion of TGEV in feces. Similarly, the amount of TGEV in intestinal tissues and mesenteric lymph node of chi8501/swIFN-alpha-administered piglets was lower than in piglets that were treated with control bacteria. These results indicate the value of attenuated Salmonella vaccines as delivery systems of cytokines that can be used for mass administration, thereby overcoming cost and production issues.

Predicting the ideal serum creatinine of kidney transplant recipients by a simple formula based on the balance between metabolic demands of recipients and renal mass supply from donors

Serum creatinine (Scr) is the most frequently used test to estimate graft function after kidney transplantation. Our previous study demonstrated that the independent predictors of recipient posttransplantation Scr included the ratio of graft weight to recipient body weight, the ratio of graft weight to recipient body surface area (BSA), and the ratio of graft weight to recipient body mass index (BMI). A prospective analysis about the impact of the balance between metabolic demands and renal supply on posttransplantation Scr of recipients was previously reported. We plotted the scatter graph using the X-axis as the independent predictors of Scr by linear regression and the Y-axis as the recipient Scr. To generate the predictive formula of Scr, we calculated a fit of the line of plotted cases using a linear regression method with 2 regression lines for prediction of the upper and lower 95% confidence intervals. Each line was converted into a predictive formula: Scr = -0.0033* (Graft weight(g)/Recipient BSA(m2))+1.75. Under 95% confidence, the Scr ranges from -0.0033* (Graft weight(g)/Recipient BSA(m2))+1.07 to -0.0033* (Graft weight(g)/Recipient BSA (m2))+2.44. Scr = -0.1049* (Graft weight(g)/Recipient body weight(kg))+1.72, which ranges from -0.1049* (Graft weight(g)/Recipient body weight(kg))+1.06 to -0.1049* (Graft weight(g)/Recipient body weight(kg))+2.37. Scr = -0.0158* (Graft weight(g)/Recipient BMI(kg/m2))+1.56, which ranges from -0.0158* (Graft weight(g)/Recipient BMI(kg/m2))+0.75 to -0.0158* (Graft weight(g)/Recipient BMI(kg/m2))+2.26. Prediction of posttransplantation Scr may be achieved by measuring graft weight as well as recipient weight and height. When recipient Scr is significantly higher than that predicted by the formula, a clinician should suspect an underlying graft injury.

Preparation of doxorubicin-containing chitosan microspheres for transcatheter arterial chemoembolization of hepatocellular carcinoma

A new form of doxorubicin hydrochloride (DRH)-containing chitosan microspheres (CMs) was prepared by employing an expanding-loading-shrinking (E-L-S) process. One hundred mg of pre-formed CMs were soaked in absolute ethanol and then placed in reduced pressure (the expanding process). Ten mg of DRH (2 mg ml(-1)) were added into the expanded CMs (the loading process). Next the microspheres were freeze-dried (the shrinking process). As a result of this E-L-S process, 10% (w/w) DRH-containing CMs (DRH-CM) were made. During 7 days, 22.6% of the DRH was observed to be released on the in vitro drug release study. In addition, these new DRH-CMs could be used for transcatheter arterial chemoembolization (TACE) procedure in VX2 hepatic tumour models of rabbit and the anti-tumour effects of DRH-CMs were investigated. On the post-CT scan 7 days after the TACE, total infarctions of the VX2 tumour were observed in 5 rabbits among the 6 total rabbits.

Effective anatomic reconstruction of the middle hepatic vein in modified right lobe graft living donor liver transplantation

INTRODUCTION

Adult liver transplantation using the right lobe graft without a middle hepatic vein (MHV; modified right lobe graft) has widely been used to compensate for the cadaveric organ shortage. To provide appropriate functional graft volume in the right lobe graft used for living donor liver transplantation (LDLT), successful reconstruction of the MHV is required. We have described herein the effectiveness of an anatomic MHV reconstruction technique with tailoring donor hepatectomy and uniformed MHV reconstruction for modified right lobe grafts.

MATERIALS AND METHODS

From December 2005 to August 2006, 15 adult patients received modified right lobe graft LDLT using a donor hepatectomy technique that exposed the right side of the MHV combined with a bench procedure that reconstructed the modified right lobe graft into the shape of extended right lobe graft, and a modified piggyback anastomosis.

RESULTS

A total of 42 V5/V8s were reconstructed with 15 newly formed MHVs. The mean estimated congestion area was 4.2+/-2.7% of the total graft volume on computed tomography. The mean pressure gradient between the reconstructed MHV and the recipient inferior vena cava was 2.1+/-1.6 mmHg on postoperative day (POD) 7. None of the patients required any procedure for an outflow problem. The patency rates of the reconstructed MHV and its tributaries were 100% (15/15) and 95.2% (40/42), respectively, at POD 30; 100% (15/15) and 73.8% (31/42) at POD 60; and 86.7% (13/15) and 54.8% (23/42) at POD 90. All recipients are currently alive with good liver function.

CONCLUSION

Our procedure seems to be effective for the reconstruction of MHV and its tributaries, and could make modified right lobe graft into the anatomic figure of extended right lobe graft as well as achieve the physiologic advantages of an extended right lobe graft.

Reductive heterocyclizations via indium–iodine-promoted conversion of 2-nitroaryl imines or 2-nitroarenes to 2,3-diaryl-substituted indazoles

While N-(2-nitrobenzylidene)anilines produced mixtures of 2,1-benzisoxazoles and 3-anilino-2-aryl-2H-indazoles in the presence of indium and iodine in MeOH, N-(2-nitrobenzylidene)anilines were transformed into 3-anilino-2-aryl-2H-indazoles as the predominant major product through the change of the solvent from protic MeOH to aprotic THF. In an indium-mediated one-pot reductive reaction, 2-benzaldehydes and anilines in THF were also successfully transformed into the corresponding indazoles.

Fractional creatinine clearance of the donated kidney using Cockcroft-Gault formula as a predictor of graft function after living donor transplantation

To prevent hyperfiltration of the renal allograft, it is important to initially provide adequate functioning nephrons to meet the metabolic demands of a recipient. During the preoperative evaluation of a potential kidney donor, it is necessary to estimate the renal function of donated kidney compared with the metabolic needs of the recipient. The functional ratio of each kidney was measured using technetium-99m diethylenetriaminepentaacetic acid. The serum creatinine (Scr, mg/dL) and estimated creatinine clearance (Ccr, mL/min/1.73 m(2)) using the Cockcroft-Gault formula were measured and calculated in 82 donors. We excluded recipients who had an episode of rejection, and followed all recipients for more than 6 months posttransplantation. The average functional proportion of the donated kidney was 50.5% +/- 4.7% of the total Ccr 83.4 +/- 18.3 of donors. The Scr of recipients at 1, 3, 6, and 9 months posttransplantation were significantly (P < .05) correlated with the fractional Ccr of the donated kidney; however, Scr at 1 year was not correlated (P = .307). Furthermore, the Ccr of the recipient at 1, 3, and 6 months posttransplantation were significantly (P < .05) correlated with the fractional Ccr of the donated kidney; however, the Ccr at 9 months and 1 year were not correlated (P = .094 and .141, respectively). The Scr and Ccr of recipients within 6 months after transplantation may depend on the functional mass of the donated kidney, which should be estimated prior to kidney donation and compared with the metabolic demands of the potential recipient.

Preparation and drug release activity of scaffolds containing collagen and poly(caprolactone)

A new biodegradable polymeric scaffold was prepared by using collagen and poly(caprolatctone) (PCL). These scaffolds were found to be soft, spongy, and transparent in nature and characterized by thermogravimetric analysis and FTIR spectrum. To these biodegradable polymeric scaffolds, antibiotic drugs namely amikacin and gentamycin were incorporated separately to study their release pattern from scaffolds. Amikacin and gentamycin release activity of the scaffolds containing a constant quantity of collagen but different quantities of PCL were studied at various time intervals viz. 1, 4, 24, and 48 h by measuring the optical density at 257 and 255 nm, respectively.

Routine Screening for the Functional Asymmetry of Potential Kidney Donors

The functional capacity of each kidney of a healthy donor may change under the influence of genetic and environmental factors. An assumption that the donor kidneys show equal function is not always true. As part of the pre-nephrectomy evaluation of potential donors, radioisotope renal scintigraphy using technetium-99m diethylenetriaminepentaacetic acid (99mTcDTPA) was routinely included to evaluate renal functional asymmetry of undetermined etiology. The functional ratios of each kidney using 99mTcDTPA as well as serum creatinine (Scr) and creatinine clearance (Ccr) in a 24-hour urine were measured and calculated from a hundred donors. The left kidneys showed greater function (51.67%-53.35% under 95% confidence interval [CI]) and the average left versus right ratio was 52.5 versus 47.5. The average fraction of Ccr of left kidneys was 57.8 mL/min/1.73 m +/- 10.99 compared with right kidneys at 52.6 mL/min/1.73 m +/- 11.63. Seventy-three healthy volunteers donated their left kidneys, and 27, their right kidney. The average fraction of Ccr of the donated kidneys was 55.9 mL/min/1.73 m +/- 11.78 compared with that of the remnant kidneys (54.5 mL/min/1.73 m +/- 11.39). After kidney donation, the Scr of the donors increased from 0.85 mg/dL +/- 0.17 to 1.33 mg/dL +/- 0.27. The average postnephrectomy Ccr was 68.0 mL/min/1.73 m +/- 14.29. Even though the Ccr after kidney donation was higher than that of the remnant kidney estimated before the donation, one must pay attention to possible functional kidney asymmetry to select the nephrectomy site.