GATA3-Positive Adnexal Adenocarcinoma: Report of a Confusing Case with a Potential Pitfall of Leading to a Misdiagnosis of Urothelial Carcinoma and a Review of Published Work

We describe a confusing case of GATA3-positive adnexal adenocarcinoma with a potential pitfall of leading to a misdiagnosis of urothelial carcinoma. A 62-year-old male presented with a subcutaneous nodule on the right lower abdomen around a scar from surgery for urothelial carcinoma in the right urinary tract, which had been resected 8 years previously. Histologically, atypical cells possessing ample cytoplasm and partial intracytoplasmic lumens were densely grouped in the subcutaneous expansive nodule and bilateral inguinal lymph nodes dissected. Decapitation secretion could not be seen. Neoplastic cells were positive for CK7, GATA3, and GCDFP15, and negative for CK5/6, CK20, p63, CD10, PAX8, HER-2, and uroplakin-II. Neoplastic cells in the urothelium and the metastasized lung were positive for CK7, CK5/6, and GATA3, and negative for CK20, p63, GCDFP15, and TTF-1. A variable level of GATA3 expression in malignant tumors with apocrine and eccrine differentiation should be recognized by dermatologists.

Two cases of BRAF-mutated, bulbar conjunctival melanoma, and review of the published literature

We describe two patients with BRAF-mutated melanoma of the epithelioid cell type arising from primary acquired melanosis with severe atypia of the right bulbar conjunctiva. Patient 1 was a 71-year-old Japanese man. After adjuvant cryotherapy and enucleation of the right eyeball, therapy with vemurafenib was administered for a distant metastasis to a lumbar vertebra, accompanied by erythema multiforme and two keratinous tumours. The patient died due to metastases to the liver and multiple vertebrae, despite therapy with nivolumab and combination therapy with dabrafenib plus trametinib. Patient 2 was a 72-year-old Japanese man. After adjuvant cryotherapy, periodic mitomycin C eye drops, and excision of the superficial portion of the right parotid gland and the dissection of cervical lymph nodes, he was treated with adjuvant combination therapy with dabrafenib plus trametinib. Dermatologists should be familiar with BRAF-mutated conjunctival melanoma, which is usually located on the bulbar conjunctiva and associated with more frequent distant metastasis.

In-transit recurrence of Merkel cell carcinoma associated with Bowen's disease: The first reported case successfully treated by avelumab

A 65-year-old Japanese man presented with a dome-shaped nodule, the base of which was contiguous with a dull brown plaque, on the left leg. After local excision of the cutaneous lesion and left inguinal lymph node dissection, several dermal and subcutaneous nodules developed successively on the left lower extremity. Hematoxylin-eosin staining of the primary cutaneous lesion demonstrated uniform neoplastic cells arranged in a trabecular pattern extending from the dermis to subcutis. Mitotic figures were abundant. Although the overlying epidermis was substantially intact, the Merkel cells had invaded the epidermis, resulting in Pautrier-like microabscesses. The hyperplastic epidermis adjacent to the nodule consisted of abnormally growing atypical keratinocytes. The enlarged left inguinal lymph node and successive secondary nodules contained Merkel cells similar to those in the primary nodule. Immunohistochemically, most tumor cells were positive for CAM5.2, synaptophysin, chromogranin A, CD56 and vimentin. The tumor cells in the left inguinal lymph node were positive for CAM5.2, synaptophysin and cytokeratin 20 but negative for CM2B4, and less than 1% of the cells expressed programmed cell death ligand 1. The patient was treated with avelumab, which showed significant efficacy against the in-transit recurrence. Two months later, all nodules had disappeared completely. We describe a case of in-transit recurrence of Merkel cell carcinoma that was associated histologically with Bowen's disease and was successfully treated with avelumab. Although accumulation of additional cases is needed, avelumab therapy may be a useful treatment for in-transit recurrence of Merkel cell carcinoma.

Malignant solitary fibrous tumor in the subcutis: Report of a rare superficial malignant type and review of published work

An 82-year-old Japanese man presented with a 90 mm × 80 mm subcutaneous nodule on the left chest, not connected to the pleura, described as hypointense on T₁ -weighted magnetic resonance imaging. Histologically, a well-demarcated nodule demonstrated a patternless pattern composed of hemangiopericytoma-like and short storiform patterns from the subcutis into deeper tissue. Antler-like branching blood vessels and keloidal-type collagen bundles were seen. Myxoid change was seen in hypocellular areas. Bizarre cells and multinucleated giant cells could be easily identified. Approximately 5 mitoses per 10 high-power fields could be detected. The majority of proliferating spindle cells were positive for CD34, CD99 and BCL2 expression. Signal transducer and activator of transcription (STAT)6 was strongly expressed in the nuclei. The Ki-67 proliferation index was 60%. We performed wide local excision with a 30-mm margin, along with resection of intercostal muscles, fasciae and periostea. Neither local recurrence nor distant metastases have occurred in 16 months of follow up. The present case is consistent with malignant solitary fibrous tumor in the subcutis histologically mimicking myxofibrosarcoma or undifferentiated pleomorphic sarcoma, definitively diagnosed by immunoexpression of STAT6. We performed a review of the published work and identified six previously reported patients with malignant superficial solitary fibrous tumor to validate the characteristics of this rare type. Four men and two women were included. The sarcomas involved the head area, trunk and thigh. Only one tumor-associated death occurred despite excision and radiotherapy. Complete excision is a possible treatment choice for this tumor type.

Indeterminate dendritic cell neoplasm accompanied by eosinophilic pneumonia successfully treated by systemic steroid therapy: Report of the first case with muscular and parotid involvement and review of published work

A 34-year-old Japanese man presented with an indolent nodule on the right flank. Computed tomography of the chest and abdomen demonstrated a large nodule measuring 55 mm × 50 mm in the abdominal oblique muscle layer of the right flank, and several small nodules were seen in the muscle layer throughout the body and subcutaneous tissue of the lower abdomen. ¹⁸ F-fluorodeoxyglucose-positron emission tomography/computed tomography revealed nodular lesions in the bilateral parotid glands, bilateral cervical lymph nodes and lower lobe of the right lung. Intermittently, ground-glass shadows developed in the bilateral lungs. Histologically, sheet-like nodules in the abdominal oblique muscle layer and parotid gland were composed of large polygonal cells with convoluted nuclei and ample eosinophilic cytoplasm. Several lymphocytes and considerable eosinophils were intermingled. Lung biopsy demonstrated an inflammatory infiltrate of lymphocytes and considerable eosinophils in the alveoli. Immunohistochemically, polygonal cells were positive for S100 protein and CD1a, but negative for langerin and BRAF^V600E . Some cells were positive for CD68. Electron microscopy demonstrated histiocytic cells with phagosomes and interdigitating processes. However, no Birbeck granules were observed. Eosinophilia was seen in the peripheral blood. Multifocal nodules and ground-glass shadows gradually diminished following systemic administration of oral prednisolone. We describe a case of indeterminate dendritic cell neoplasm with multifocal involvement of the muscle, subcutis, lymph node and parotid gland accompanied by chronic eosinophilic pneumonia that was successfully treated by systemic steroid therapy. Neither muscular nor parotid indeterminate dendritic cell neoplasms accompanied by eosinophilic pneumonia have been previously reported.

Pseudovascular squamous cell carcinoma: A review of the published work and reassessment of prognosis

A 90-year-old Japanese woman presented with a dome-shaped, dark-red, ulcerated nodule measuring 23 mm × 19 mm × 9 mm on the right side of the nasal root. Histologically, anastomosing cord-like arrays of atypical polygonal keratinocytes exhibiting internal pseudolumina containing detached cells and erythrocytes were observed. Although acantholytic and cohesive areas overlapped, cancer pearls were not detected. The lower epidermis partially demonstrated scattered dyskeratotic and acantholytic keratinocytes with loss of polarity, continuous with an underlying tumor mass. The tumor cells were positive for a variety of cytokeratins, p40 and vimentin. The Ki-67 proliferation index was 50-60%. Both CD31 and CD34 were expressed in reactive blood vessels of the tumor. A local excision margined by 1 mm was performed, followed by X rays and electron beam irradiation. Neither lymph node nor distant metastasis has appeared over the 14 months since the excision. We performed a review of the published work and identified 24 previously reported patients with pseudovascular squamous cell carcinoma of the skin, oral mucosa and vulva to reassess the prognosis of this tumor. In 12 of these patients (50%), sites other than the head and neck were involved. Eight (33%) tumor-associated deaths occurred. It is believed that pseudovascular squamous cell carcinoma has a tendency to develop at morbid skin and mucous membranes sites in organs other than the face and neck and to possess an aggressive clinical behavior.

Spontaneous endometriosis in cynomolgus monkeys as a clinically relevant experimental model

STUDY QUESTION

Does spontaneous endometriosis in cynomolgus monkeys have the characteristics required of a good experimental model?

SUMMARY ANSWER

Spontaneous endometriosis in cynomolgus monkeys exhibited similar clinicopathological characteristics to the human disease and was useful as an experimental model.

WHAT IS KNOWN ALREADY

The prevalence of endometriosis in autopsied cynomolgus monkeys (Macaca fascicularis) in a breeding colony was reported to be 28.7% in 1993. The histopathological findings we reported recently showed that components of spontaneous endometriosis were not only endometriotic epithelium and stromal cells (CD10-positive) with hemorrhage and inflammation, but also smooth muscle metaplasia and nerve fibers.

STUDY DESIGN, SIZE, DURATION

During routine medical examinations at a research facility from 2008 to 2012, 614 female cynomolgus monkeys of reproductive age (6-25 years) were screened for endometriosis by the presence of regular menstrual bleeding, serum CA125 levels and palpation of the abdomen. In total, 29 monkeys were selected as subjects for the following study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 29 monkeys selected, 15 were diagnosed with endometriosis by laparoscopy and/or open surgery. The monkeys were monitored by observing their general condition, and eight of these were monitored using laparoscopy and MRI. In addition, to investigate appropriate screening parameters and endometriosis-associated biological parameters in monkeys, we retrospectively examined general laboratory parameters that correlate to the menstrual cycle and disease status.

MAIN RESULTS AND THE ROLE OF CHANCE

The combination of CA125 serum levels (this was a useful marker for chocolate cysts), palpation of the abdomen, and fecal abnormalities was the most efficient screening method for diagnosing monkeys with endometriosis. Each animal could be diagnosed and assigned a disease stage by laparoscopy. While monitoring the disease stage by laparoscopy and/or MRI, disease status in individual monkeys was mainly stable or was progressive for 2-7 months. The detection rate by screening was low (15/614) but age-specific analysis suggests that screening would be more efficient if a colony for an endometriosis model is maintained with 11-20-year olds. As an endometriosis-associated biological parameter, the decrease in food consumption that coincided with menstruation was selected and correlated well (R2 value = 0.8239) with disease status (according to a modified adhesion revised American Fertility Society score).

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

Peritoneal fluid was not analyzed because a smaller amount is produced in cynomolgus monkeys than in baboons. Although clinical endometriosis-associated pain is evaluated in women using a visual analog scale, pain could not be directly evaluated in this non-human primate model.

WIDER IMPLICATIONS OF THE FINDINGS

Although cynomolgus monkeys are relatively small (2-5 kg) primates, laparoscopy and MRI make it possible to evaluate spontaneous endometriosis in these monkeys and to monitor its development over time. Spontaneous endometriosis in cynomolgus monkeys is a useful model for evaluating disease progress and drug efficacy because they have similar lesions to those in humans, and conventional laboratory methods and parameters for assessment are well established.

STUDY FUNDING/COMPETING INTEREST(S)

No external funds were used for this study. A.N.-K., K.T., H.T., A.K. and M.S. are full-time employees of Chugai Pharmaceutical Co., Ltd. R.K. received a consultancy fee from Chugai Pharmaceutical Co., Ltd. and lecture fees from Chugai Pharmaceuticals, Japan Vaccine Co. Ltd., Merck & Co., Mochida Co. Ltd., Roche Diagnostics, and BD, unrelated to the submitted work. S.N., S.O. and T.S. have nothing to declare.

Two cases of infundibular squamous cell carcinoma on the nose with aggressive clinical behavior: Case report and review of the published work

Case 1 was a 75-year-old Japanese man who presented with a poorly demarcated, dark-red nodule with a destructive defect in the center, measuring 3 cm × 2 cm on the right wing of his nose. The histological diagnosis was a common form of infundibular squamous cell carcinoma. Atypical neoplastic cells radiated from the wall of a follicular infundibulum. The majority of neoplastic cells were positive for AE1/AE3 and 34βE12. Cytokeratin 17 expression was seen in the suprabasal cells of the deeply situated neoplastic components. Case 2 was a 73-year-old Japanese man who presented with a poorly demarcated, dark-red nodule with an irregularly shaped ulcer in the center, measuring 3 cm × 2 cm on the left wing of his nose. The histological diagnosis was a crater form of infundibular squamous cell carcinoma. Atypical neoplastic cells radiated from the broad base of the central keratin-filled crater, continuous with two infundibular canals. In both cases, some of the more deeply situated aggregations were composed of neoplastic keratinocytes with eosinophilic glassy or pale cytoplasm. In addition, no atypical keratinocytes could be seen in the interfollicular epidermis. In case 1, a hematogenous metastasis to the vocal cord and the forehead occurred in addition to a lymph node metastasis. In case 2, a local recurrence occurred with an intralymphatic dissemination. We describe two cases of infundibular squamous cell carcinoma on the nose with aggressive clinical behavior, one of which was accompanied by a hematogenous metastasis while another revealed a local recurrence.

Spindle cell squamous cell carcinoma arising in Bowen's disease: Case report and review of the published work

A 79-year-old Japanese woman presented with an ulcerated, brown-red nodule in the center of a sharply demarcated, tan-brown plaque situated on the left side of her right breast. Histologically, the plaque demonstrated an acanthosis with an intraepidermal epithelioma of Borst-Jadassohn. Small oval nests of bland-appearing basophilic cells in the periphery gradually enlarged into nests of various sizes and irregular shapes, composed of densely cohesive, atypical basophilic cells above the central nodule. The atypical keratinocytes shifted to atypical spindle cells beneath the acanthotic epidermis, penetrating deep into the subcutaneous tissue. In addition to vimentin and p63, the spindle cells were positive for several cytokeratin (CK) markers, including AE1/AE3, 34βE12 and CK5/6, which showed more intense signals closer to the epidermis. Basophilic cells in the clonal nests were positive for p63, AE1/AE3, 34βE12 and CK5/6. The MIB-1 index was estimated at approximately 40-50% in both the bland-appearing and the atypical basophilic cells. We describe the first case of spindle cell squamous cell carcinoma arising in an intraepidermal epithelioma expressed by clonal Bowen's disease, which was difficult to differentiate from clonal seborrheic keratosis.

A first reported case of metastatic anorectal amelanotic melanoma with a marked response to anti-PD-1 antibody nivolumab: A case report

•

We report a first case of nivolumab reduction of metastatic anorectal amelanotic melanoma (AAMM).

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Multimodal therapy including nivolumab will be effective also for non-cutaneous AAMM.

Introduction

Anorectal amelanotic melanoma (AAMM) is a rare disease with poor prognosis. A standard treatment strategy for AAMM has not been established.

Presentation of case

We report a case of successful treatment of AAMM with nivolumab. A 67-year-old man was referred for colonoscopy which revealed type I tumor in the rectum. AAMM was diagnosed with immunostaining histopathological biopsy findings. Enhanced computed tomography (ECT) revealed the rectal tumor without distant organ metastasis. We performed laparoscopy-assisted abdominoperineal resection. ECT at three months after surgery revealed liver metastases and right ischial bone metastasis. Although we had started dacarbazine monotherapy, black spots that were suspicious of skin metastases had appeared on systemic skin. Therefore, we started nivolumab therapy. ECT at 3 months after initiation of nivolumab showed shrinkage of liver metastasis. We have continued strict follow-up every 2 months and checked no oncologic progression at 17 months after initiation of nivolumab.

Discussion

The anti-PD-1 antibody have improved prognosis of malignant melanoma. However, there are no reports of nivolumab for treatment of AAMM.

Conclusions

Our patient is the first reported case of AAMM treated with nivolumab. We consider that nivolumab will be effective for non-cutaneous malignant melanoma.

Serum levels of soluble CD163 as a specific marker of macrophage/monocyte activity in sarcoidosis patients

BACKGROUND

Monocyte-macrophage lineage cells are the main immunocompetent cells in sarcoidosis. The main cellular elements of sarcoidal granulomas are epithelioid cells and multinucleated giant cells (MGC). MGC are also produced in vitro by human blood monocytes following various stimuli. The in vitro formation of MGC is a useful tool for understanding granulomas. CD163, a scavenger receptor for the hemoglobin-haptoglobin complex, is expressed on monocytes/macrophages and shed into blood in a soluble form (sCD163) after stimulation from Toll-like receptors and oxidative stress. sCD163 serum levels have been reported to increase in inflammatory or infectious conditions.

OBJECTIVE

The aim of the present study was to examine the relationship between serum levels of sCD163 and the conventional disease markers of sarcoidosis, and also to evaluate sCD163 levels in culture supernatants following the formation of MGC by human peripheral monocytes in vitro.

PATIENTS AND METHODS

Twenty sarcoidosis patients and twenty healthy subjects were enrolled in the study. sCD163 serum levels were evaluated using sCD163 ELISA. MGC were formed from peripheral blood monocytes by treatment with supernatant of concanavalin A-stimulated peripheral blood mononuclear cells, and sCD163 levels in the culture supernatants were measured by ELISA.

RESULTS

sCD163 serum levels were significantly higher in sarcoidosis patients than in healthy controls and correlated with ACE and soluble interleukin-2 receptor serum levels. sCD163 levels in culture supernatants increased with the production of MGC.

CONCLUSIONS

sCD163 may be used as a favorable specific marker of macrophage/monocyte activity in order to more clearly understand the disease activity of sarcoidosis.

State-resolved ultrafast dynamics of impact ionization in InSb

Impact ionization (IMP) is a fundamental process in semiconductors, which results in carrier multiplication through the decay of a hot electron into a low-energy state while generating an electron-hole pair. IMP is essentially a state selective process, which is triggered by electron-electron interaction involving four electronic states specified precisely by energy and momentum conservations. However, important state-selective features remain undetermined due to methodological limitations in identifying the energy and momentum of the states involved, at sufficient temporal resolution, to reveal the fundamental dynamics. Here we report state-resolved ultrafast hot electron dynamics of IMP in InSb, a semiconductor with the lowest band-gap energy. The ultrafast decay of state-resolved hot-electron populations and the corresponding population increase at the conduction band minimum are directly captured, and the rate of IMP is unambiguously determined. Our analysis, based on the direct knowledge of state-resolved hot electrons, provides far deeper insight into the physics of ultrafast electron correlation in semiconductors.

Elevated serum BAFF levels in patients with sarcoidosis: association with disease activity

OBJECTIVE

The purpose of this study was to determine serum levels of B-cell-activating factor (BAFF) and its clinical association in patients with sarcoidosis. METHODS; Serum levels of BAFF from 37 patients and 21 healthy subjects were examined by ELISA. Serum angiotensin-converting enzyme (ACE), lysozyme and IFN-γ levels in sarcoidosis patients were also measured. Isolated monocytes cultured with IFN-γ, IL-4 or IL-10 and their expression of membrane and soluble BAFF were analysed by flow cytometry or ELISA. Peripheral B cell subsets were analysed by flow cytometry. BAFF expression in the granuloma of the skin was examined by immunohistochemistry. ANAs were determined by indirect IF using HEp-2 cells as a substrate.

RESULTS

Serum BAFF levels were significantly elevated in sarcoidosis patients when compared with healthy controls. The frequency of skin and eye involvement was significantly higher in patients with elevated serum BAFF than in patients with normal levels. Serum BAFF levels were correlated with serum levels of ACE, lysozyme and IFN-γ. Immunostaining of anti-BAFF in the skin revealed BAFF expression by epithelioid cells of granuloma. In vitro, IFN-γ induced membrane-bound BAFF expression on monocytes and secretion of soluble BAFF by isolated monocytes. In the peripheral blood, sarcoidosis patients showed increased naïve B cells with a reciprocal decrease in memory B cells and plasmablasts. Seventeen of 26 (65%) sarcoidosis patients exhibited ANA positivity.

CONCLUSION

Serum BAFF levels can be used as a surrogate marker of disease activity in sarcoidosis patients. Increased BAFF may be related to the pathogenesis of sarcoidosis.

Activation of the human multidrug resistance-1 (mdr1) gene promoter in response to inhibitors of DNA topoisomerases

The multidrug resistance (MDR1) gene encodes a Mr 170,000 energy-dependent membrane efflux pump termed P-glycoprotein, and the P-glycoprotein is often expressed in various human tumors before and after cancer chemotherapy. In this study, we have established a human cancer KB cell line (Kst-6) which stably expressed the CAT gene (pMDRCAT1) driven by the human MDR1 promoter. Exposure to inhibitors of DNA topoisomerase I (camptothecin: CPT-11) and II (etoposide: VP-16 and teniposide: VM-26) could efficiently induce CAT activities in both time- and dose-dependent manners. However, CAT activity could not be significantly induced when treated with an ATP-antagoist, novobiocin. Northern blot analysis showed about 5-fold increase in CAT mRNA levels in Kst-6 cells treated with CPT-11 or VP-16, but not with novobiocin. Proximal MDR1 promoter-binding activities of transacting factor were augmented in nuclear extracts from KB cells treated with CPT-11, VM-26, and VP-16.

Helicobacter bilis infection in biliary tract cancer

BACKGROUND

Biliary tract cancer is a highly fatal disease with poor prognosis, but the aetiology is poorly understood.

AIM

We aimed to identify Helicobacter bilis infection in the gallbladder in patients with biliary tract disease.

METHODS

Archival gallbladder specimens from 34 patients (14 males and 20 females) with an average age of 61.4 +/- 12.2 years (mean +/- SE) were retrieved, consisting of 11 cases of gallbladder cancer, three of bile duct cancer, 16 of cholecystolithiasis and four of pancreatic cancer. DNA was extracted and nested PCR using primers specific for 16S rRNA of H. bilis was performed.

RESULTS

Amplification was observed in 3 of 11 gallbladder cancer cases (27.2%) and one of three cases with biliary duct cancer (33.3%). In total, four of 14 cases with biliary tract cancer were positive for H. bilis (28.6%). In addition, the presence of H. bilis was shown in two of 16 cases (12.5%) with cholecystolithiasis. Notably, although the number of cases examined was small, none of the four cases with pancreatic cancer showed the presence of H. bilis infection in the gallbladder without apparent abnormalities.

CONCLUSION

H. bilis infection may play a role in biliary tract disease, particularly in biliary tract cancer.

Specific T-cell immunity against Ki-ras peptides in patients with pancreatic and colorectal cancers

Mutations of codon 12 in the Ki-ras gene are frequently found in pancreatic and colorectal cancers. It has been demonstrated that human T-cells have the potential to recognise tumours expressing mutated ras-derived peptides. However, it remains unclear whether T-cells from a given individual can recognise the mutant peptides, which are expressed in that individual's tumour tissues. Mutations of the Ki-ras oncogene were analysed by the mutant-allele-specific amplification (MASA) method in pancreatic and colorectal tumour tissues, and T-cell responses against mutated Ki-ras-derived peptides were measured by [(3)H]thymidine incorporation and IFN-gamma production assays. Specific T-cell responses against Ki-ras-products were found in cancer patients, whereas no immune response was observed in normal individuals (P<0.01). Six of the eight pancreatic cancer patients (75%) and nine of 26 colorectal cancer patients (35%) had T-cell responses to mutated Ki-ras-derived-peptides. T-cell response in a given individual cannot recognise the same mutated ras peptide, which is expressed in that individual's tumour tissues. However, pancreatic and colorectal cancer patients have T-cell immunity against Ki-ras-peptides, and this provides potential target for cancer immunotherapy.

Differentiated basal cell carcinoma in a Cape clawless otter (Aonyx capensis)

Basal cell carcinoma with folliculoapocrine differentiation was diagnosed in a male Cape clawless otter (Aonyx capensis) aged >8 years. A tumour mass in the left submandibular region was removed surgically, but another tumour subsequently appeared on the left cheek. In addition, necropsy revealed a subcutaneous tumour mass at the excision site. Histologically, the tumours consisted of lobules or islands of basaloid cells, frequently with central keratinization and tubular structures. The presence of isthmic keratinization and apocrine differentiation was confirmed by immunolabelling for cytokeratins, and a few cytokeratin-positive tumour cells were found in a submandibular lymph node. The neoplasm, characterized by its metachronous and recurrent nature, metastasis to the local lymph node and amyloidosis, closely resembled human differentiated basal cell carcinoma, both clinically and pathologically.

Adenosquamous carcinoma of the pancreas: successful treatment with extended radical surgery, intraoperative radiation therapy, and locoregional chemotherapy

BACKGROUND

Adenosquamous carcinoma of the pancreas is a rare tumor with an extremely poor survival rate. No obvious evidence that multidisciplinary treatments improves the prognosis and survival has been reported.

PATIENT AND RESULTS

A 63-yr-old female with adenosquamous carcinoma of the pancreas underwent extended radical surgery, intraoperative radiation therapy, postoperative intraarterial chemotherapy, and external beam radiation therapy. The patient is alive at 40 mo after surgery with no recurrence.

CONCLUSIONS

Multidisciplinary treatments including aggressive surgery, intraoperative radiation therapy, and locoregional chemotherapy might improve the survival of patients with adenosquamous carcinoma of the pancreas to inhibit liver metastasis and local recurrence.

[Guidelines for adequate antibiotic prophylaxis after hepatic, biliary, and pancreatic surgery]

The recent spectrum of bacteria isolated from patients with hepatic, biliary, and pancreatic infections mostly consists of Gram negative rods translocated from their intestinal flora. Cephem or carbapenem antibiotics should be selected based on the severity of surgical infection and risk to each patient to prevent postoperative infections. Once postoperative infection occurs, surgical procedures such as ultrasonography-guided percutaneous biliary drainage should be performed to reduce inflammation and to obtain samples for bacterial culture. The most commonly identified bacteria after hepatic, biliary, and pancreatic surgery are Pseudomonas species, MRSA, and Enterococcus species. Previously administered antimicrobial agents should be immediately interrupted and empiric antibiotic therapy with carbapenem started. Vancomycin or teicoplanin is selected when MRSA or Enterococcus faecium infection is suspected. Infection control systems should be in place for prevention of postoperative MRSA infections.

Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature

HYPOTHESIS

Hepatic portal venous gas (HPVG) has been considered a rare entity associated with a grave prognosis. Since 1978, when Liebman et al reviewed 64 cases of HPVG and reported a mortality of 75%, the number of reported cases has been increasing.

DESIGN

Case series.

PATIENTS AND METHODS

We reviewed the literature on 182 cases of HPVG in adults, including 4 of our patients, (transplantation and abdominal trauma cases were excluded) and analyzed the cause, pathogenesis, and clinical features.

RESULTS

In this series, the underlying clinical events associated with HPVG were bowel necrosis (43%), digestive tract dilatation (12%), intraperitoneal abscess (11%), ulcerative colitis (4%), gastric ulcer (4%), Crohn disease (4%), complications of endoscopic procedures (4%), intraperitoneal tumor (3%), and other (15%). The overall mortality was 39% but varied depending on the underlying disease.

CONCLUSIONS

Hepatic portal venous gas is a lethal or curable entity caused by various diseases. The underlying disease associated with HPVG determines the clinical features and prognosis of the patients. The treatment of patients with HPVG should be directed to the underlying disease.

In vitro antitumor activity of TAS-103 against freshly-isolated human colorectal cancer

DNA topoisomerases (Topo) are enzymes that relieve the secondary twist on the DNA strand in the process of DNA synthesis and transcription; therefore they are unique targeting molecules for the chemotherapy of colorectal cancer. TAS-103 (6-[[2-(dimethylamino)ethyl]amino]-3-hydroxy-7H-in-deno [2,1-c]quinolin-7-one dihydrochloride, MW; 406.31), a novel quinoline derivative, has recently been established as a Topo I and Topo II inhibitor. The aim of the present study was to investigate the antitumor activity of TAS-103 by the MTT assay in human highly-purified and freshly-isolated colorectal cancer cells. To our knowledge, this is the first data concerning the antitumor activity of TAS-103 in highly-purified and isolated human colorectal cancer cells. TAS-103 showed the strongest antitumor activity among the conventional anticancer agents for colorectal cancer (p<0.05). The combination with CDDP augmented the antitumor activity of TAS-103 (p<0.05), indicating that CDDP is one of the most potent candidates to be used in combination with TAS-103. To predict the clinical effect of TAS-103, the expressions of Topo I and Topo II were measured by quantitative PCR. However, a correlation between the expression of Topo and the antitumor activity of TAS-103 was not established. In conclusion, according to this data, TAS-103 may be useful in the chemotherapy of colorectal cancer.

[Bacteria isolated from surgical infections and their susceptibilities to antimicrobial agents. Special references to bacteria isolated between April 1998 and March 1999]

The annual multicenter studies on isolated bacteria from infections in general surgery and their antimicrobial susceptibility have been conducted in Japan since July 1982. This paper describes the results obtained in fiscal 1998 (from April 1998 to March 1999). The number of cases investigated as objectives was 225 for one year. A total of 429 strains (121 strains from primary infections and 308 strains from postoperative infections) were isolated from 183 cases (81.3% of total cases). In primary infections, the isolation rates of anaerobes and Escherichia coli were higher than in postoperative infections, while in postoperative infections, those of Gram-positive aerobes and Pseudomonas aeruginosa were higher than in primary infections. On the whole, among Gram-positive aerobes, the isolation rate of Enterococcus faecalis was the highest, followed by Staphylococcus aureus with high frequency in isolation from postoperative infections. Among Gram-positive anaerobes, Peptostreptococcus spp. and Streptococcus spp. were predominantly isolated. Among Gram-negative aerobes, E. coli, P. aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were frequently isolated. Among Gram-negative anaerobes, Bacteroides fragilis group was the majority of isolates. In primary infections, the percentage of Gram-negative aerobes has gradually increased since fiscal 1995 or 1996 with these years as the turning point, while those of Gram-positive and Gram-negative anaerobes have gradually declined. In postoperative infections, the percentage of Gram-negative anaerobes has increased continuously since the mid-1980s. The percentage of MRSA among S. aureus rose to 89.7%, which was the highest level since the beginning of this study. The susceptibilities of B. fragilis, which did not show apparent changes, were recognized to have decreased against cephems in fiscal 1998. Among other bacteria in B. fragilis group, development of resistance to cephems has continued on a long-term basis since the mid-1980s. E. coli and K. pneuminiae have obviously not changed in susceptibilities, however, the susceptibilities of isolated strains in fiscal 1998 against high-generation cephems, oxacephems and monobactams have declined. We found neither vancomycin-resistant nor teicoplanin-resistant strains of S. aureus and Enterococcus spp.

Complete response of highly advanced gastric cancer with peritoneal dissemination after new combined chemotherapy of S-1 and low-dose cisplatin: report of a case

TS-1(S-1) has been developed as a new oral anticancer drug based on the biological modulation of 5-fluorouracil. We treated a patient with highly advanced gastric carcinoma with a new combination chemotherapy of S-1 and low-dose cisplatin. Remarkable tumor reduction was observed after two cycles of this therapy in the primary tumor and metastatic lymph nodes, and the ascites disappeared. This was concluded to be a partial response. The only adverse effect was skin pigmentation of the fingers (grade 1), leading to early timing of operation after chemotherapy. The gastric tumor showed evident invasion to the serosa. Lymph nodes around the stomach were swollen. Peritoneal dissemination was also recognized in the omentum and mesocolon. Total gastrectomy with regional lymph node dissection was performed. Disseminated tumors were all resected. Histological examination showed that no tumor cells were detected in the gastric primary lesion, metastatic lymph nodes or disseminated peritoneal tumors, suggesting pathological complete remission. It was suggested that this regimen could be a potent combined therapy for the treatment of patients with highly advanced gastric carcinoma, and it could be useful as neoadjuvant chemotherapy. Further studies are necessary to evaluate the efficacy of this therapy.

Carcinoembryonic antigen-specific suicide gene therapy of cytosine deaminase/5-fluorocytosine enhanced by the cre/loxP system in the orthotopic gastric carcinoma model

Tumor-specific gene delivery is crucial to achieving successful effects in suicide gene therapy. Carcinoembryonic antigen (CEA) promoter has been widely used for this purpose, but the expression level of tumor-specific promoters such as CEA promoter is generally low. In the previous study, we used the Cre/loxP system and showed that LacZ expression by the CEA promoter was remarkably enhanced and maintained its specificity using the Cre/loxP regulation system. In this study, the Cre/loxP system was first applied to augmentation of selective expression of the cytosine deaminase (CD) gene as a suicide gene therapy in CEA-producing cells. The double infection with AxCEANCre expressing Cre recombinase under the control of the CEA promoter and AxCALNLCD expressing the CD gene under the control of the CAG promoter by the Cre switching system rendered CEA-producing tumor cells 13-fold more sensitive to 5-fluorocytosine (5-FC) compared with the single infection with AxCEACD expressing CD gene driven by the CEA promoter. The therapeutic efficacy of the enhanced CD/5-FC suicide gene therapy was evaluated in orthotopic implantation models of human gastric carcinoma. Adenovirus vectors (1 x 10(9) plaque-forming units) were administered i.p. into mice three times, and then 5-FC was administered i.p. for the next 10 days. Tumor volume and weight in mice treated with AxCEANCre and AxCALNLCD/5-FC were significantly reduced as compared with those in mice treated not only with Mock (AxCALacZ) but also with AxCEACD/5-FC (P < 0.0001). This beneficial effect on tumor burden was also reflected in the overall survival. The survival periods of the mice treated with AxCEANCre and AxCALNLCD/5-FC were longer than those of mice treated with Mock or AxCEACD/5-FC (P < 0.01). These results suggested that application of the Cre/loxP system could provide a new approach for enhanced selective suicide gene therapy of CD/5-FC for the treatment of advanced gastric carcinoma.

Generation of cytotoxic T cell responses to an HLA-A24 restricted epitope peptide derived from wild-type p53

Mutations in the p53 gene are the most common genetic alterations found in human tumours, and these mutations result in high levels of p53 protein in the tumour cells. Since the expression levels of wild-type p53 in nonmalignant tissue are usually much lower in contrast, the p53 protein is an attractive target for cancer immunotherapy. We tested p53 encoded HLA-A24 binding peptides for their capacity to elicit anti-tumour cytotoxic T lymphocytes (CTL) in vitro. These peptides were in murine p53-derived cytotoxic peptides, which were being presented to CTL by H-2K(d)and H-2K(b)molecules, because the HLA-A24 peptide binding motifs were similar to the H-2K(d)and H-2K(b). For CTL induction, we used CD8(+)T lymphocytes from the peripheral blood mononuclear cells (PBMC) of healthy donors and the peptides from pulsed dendritic cells as antigen-presenting cells. We identified the peptide, p53-161 (AIYKQSQHM), which was capable of eliciting CTL lines that lysed tumour cells expressing HLA-A24 and p53. The effectors lysed C1RA24 cells (p53(+), HLA-A*2402 transfectant), but not their parental cell lines C1R (p53(+), HLA-A,B null cell). These results strongly indicate that the CTL exerts cytotoxic activity in HLA-A24's restricted manner. The identification of this novel p53 epitope for CTL offers the possibility to design and develop specific immunotherapeutic approaches for treating tumours with p53 mutation in HLA-A24-positive patients.

Mapping the HLA-A24-restricted T-cell epitope peptide from a tumour-associated antigen HER2 / neu: possible immunotherapy for colorectal carcinomas

HER2 / neu is a potential antigen candidate for immunotherapy because of its correlation to a poor prognosis and high expressions in many kinds of epithelial tumours. Especially in the colorectal carcinomas, the higher expression of HER2 / neu is recognized in metastatic regions as well as in primary sites. Several CTL epitopes restricted by HLA-A2.1 and -A3 were identified so far, however epitopes restricted by HLA-A24, that is one of the most common allele in Japanese and Caucasians, have not been identified. In this paper, we showed identification of a CTL epitope peptide of HER2 / neu restricted by HLA-A24. HLA-A24 binding peptides selected by an analysis based on HLA-A24 binding motifs were determined for their binding affinities to HLA-A24 molecules. The peptide with a sequence of RWGLLLALL (position 8-16) named HE1 showed the highest affinity. We induced CTLs from CD8(+)cells of HLA-A24 healthy donors by stimulation with HE1-pulsed autologous dendritic cells. The CTLs showed cytotoxic activity against not only the peptide-pulsed target cells but also HLA-A24 colorectal tumour cell lines that endogenously overexpressed HER2 / neu. The antigen-specificity was confirmed by cold target inhibition assay using HE1-pulsed target cells. In summary, HER2 / neu peptide, RWGLLLALL, may contribute to the induction of antitumour immunity with the peptide-based immunotherapy for the colorectal carcinomas.

Clinical features and imaging diagnosis of biliary cystadenocarcinoma of the liver

Biliary cystadenocarcinoma of the liver is a relatively rare disease. Herein, we reported a case of biliary cystadenocarcinoma with a review of the literature. A 71-year-old female was admitted with the chief complaint of epigastralgia. The imaging studies revealed a biliary cystadenocarcinoma in the left hepatic lobe with suspicion of direct invasion to the left and middle hepatic veins and inferior vena cava. However, there was no direct invasion of the tumor to these veins in operation findings, and an extended left hepatic resection was performed without resection of inferior vena cava. The tumor was histologically diagnosed as biliary cystadenocarcinoma of the liver. Diagnosis of biliary cystadenocarcinoma is usually difficult preoperatively, however, a diagnosis was possible with the use of imaging studies. It was suggested that this tumor originated from a benign cystadenoma because of the existence of a transitional zone between normal cells and atypical cells in the cystic wall. Systematic hepatectomy was recommended as the initial treatment in consideration of the features of cystadenocarcinoma.

Upregulated expression of angiogenesis genes and down regulation of cell cycle genes in human colorectal cancer tissue determined by cDNA macroarray

The differential expression of hundreds of tightly, transcriptionally controlled genes in isolated human colorectal cancer and respective normal mucosa from two patients was analyzed by the cDNA macroarray technique. mRNA prepared from the colorectal cancer tumors was compared with 588 genes spotted onto the filter. Case A showed down-regulation of the expression of cell-cycle-related genes including cyclins, cyclin-dependent kinase (CDK) 2, and CDK-activating kinase, as compared with normal mucosa from the same patient. The tumors showed up-regulation of expression of angiogenesis-related genes such as type II cytoskeletal 8 keratin, metalloproteinase subtypes, VEGF, and bFGF, to over 5-fold the levels in normal mucosa. Thus, colorectal carcinoma tissues are characterized by the upregulation of molecules related with angiogenesis. These results suggest that angiogenesis-related molecules are suitable candidates for target-based therapies for colorectal cancer patients. In case B, the largest difference in expression between the tumor and mucosal tissues was observed in the MMP-1 gene. In contrast to the first case, there was no increase in expression of angiogenesis-related molecules or decrease in expression of cell-cycle-regulatory molecules. The expression profile was quite different between these two patients. This approach may eventually provide a mean of selecting target-based drugs in individual colon cancer patients.