Measuring Competence in Surgical Training through Assessment of Surgical Entrustable Professional Activities

OBJECTIVE

To assess competency in surgical residents with bundled assessments using a surgical entrustable professional activity (SEPA) framework.

DESIGN

A pilot study was conducted using a combination of validated assessment tools (multiple choice exam (MCE) questions from the Surgical Council on Resident Education [SCORE], the Clinical Assessment and Management Examination - Outpatient (CAMEO) form, the Virtual Surgical Patient (VSP) website, and a procedure-specific Operative Performance Rating System [OPRS]) to determine competency in surgical residents in the treatment of breast cancer and gallbladder disease, respectively.

SETTING

A large academic institution with a surgical training program in the Mid West of the United States.

PARTICIPANTS

A total of 10 categorical surgical residents were invited to participate. Five completed the breast surgical EPA (SEPA) and 5 different residents completed the gallbladder SEPA.

RESULTS

In terms of performance on the assessments, for the breast SEPA, scores did not appear to be related to PGY level, and residents' performance in general was the least strong on the MCE and the VSP case. The gallbladder SEPA showed a more expected pattern, distinguishing between junior and senior residents. As expected, all junior residents were required to remediate the OPRS assessment, while the senior residents passed. For the OPRS, senior level residents consistently were rated as "excellent" in terms of operative flow (5/5), while junior residents were all given a score of "good" (3/5).

CONCLUSIONS

Assessing competence among surgical residents has been a discussion for several years. Varying methods of assessing competence have been proposed, but surgical competence is presently defined in a very general way through both the ACGME and American Board of Surgery (ABS). Using a SEPA format, as proposed, we could ensure specific understanding of each graduating resident's ability. These results show that the SEPA may be a valid tool for defining and capturing multiple areas of competence that are associated with different disease processes.

How to teach uncommon and highly complex operations

The Surgical Council on Resident Education (SCORE) was officially formed by six surgical organizations in 2006 with the goal of improving general surgery residency training through the development of an explicit curriculum. As a result, SCORE has identified a group of "essential" operations which believes that residents should be competent to perform by the end of training. Other "complex" operations require additional training beyond residency. Currently, operative data submitted by residents suggest that there are significant gaps between ideal and actual operative experience. A particularly difficult challenge is to train residents to perform procedures that are rarely encountered.

Residents' self-reported learning needs for intraoperative knowledge: are we missing the bar?

BACKGROUND

The purpose of this study was to compare the intraoperative learning needs and educational resource use of junior and senior residents. Our goal was to gain a better understanding of the progression of learning needs in surgical training.

METHODS

Residents (n = 125) completed a previously validated, 27-item survey indicating the following: (1) the extent to which traditional learning resources are used when preparing for cases in the operating room, and (2) which intraoperative management topics in which they believed they were deficient despite preoperative preparation.

RESULTS

On a scale of 1 to 5, with 5 indicating frequent use, postgraduate year (PGY)-5 residents (n = 39) indicated surgical atlases (4.15; SD, .90) and surgical texts (4.15; SD, .90) were their most frequently used resources when preparing for a case in the operating room. In contrast, PGY-1 residents (n = 32) indicated anatomy atlases (3.97; SD, .93) and advice from colleagues (3.64; SD, .90) were their most frequently used resources when preparing for a case in the operating room. Despite the differences in how the PGY-5 group and the PGY-1 group prepared for a case, of 12 intraoperative management topics both groups believed they were the least prepared for instrument use/selection and suture selection.

CONCLUSIONS

Today's residents represent a heterogeneous group of individuals with different learning needs based on level of experience, knowledge, and learning style. Our study highlights unexpected but critical learning needs for senior-level residents that can and should be readily addressed.

Attitudes, training experiences, and professional expectations of US general surgery residents: a national survey

CONTEXT

General surgery residency programs are facing multiple pressures, including attracting and retaining residents. Despite the importance of resident perspectives in designing effective responses to these pressures, understanding of residents' views is limited.

OBJECTIVE

To profile US general surgery residents; characterize resident attitudes, experiences, and expectations regarding training; and examine differences by sex and training year.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of all general surgery residents completing a survey in January 2008 following administration of the American Board of Surgery In-Training Examination.

MAIN OUTCOME MEASURES

Resident satisfaction; perceived supports, strains and concern; career motivations; and professional expectations.

RESULTS

Of 5345 categorical general surgery residents, 4402 (82.4%) responded, representing 248 of 249 surgical residency programs. Most respondents expressed satisfaction with training (3686 [85.2%]; 95% confidence interval [CI], 84.1%-86.3%) and supportive peer relationships (3433 [84.2%]; 95% CI, 83.1%-85.3%). However, residents also reported unmet needs and apprehensions about training and careers. Worry that they will not feel confident performing procedures independently was reported by 1185 (27.5%; 95% CI, 26.2%-28.8%), while 2681 (63.8%; 95% CI, 62.4%-65.3%) reported that they must complete specialty training to be competitive. Perceptions of program support differ, with men more likely than women to report that their program provides support (2188 [74.5%] vs 895 [65.6%]; P < .001), and that they can turn to faculty when having difficulties (2193 [74.5%] vs 901 [66.4%]; P < .001). Reports of having considered leaving training in the prior year differed significantly across years (P < .001), highest in postgraduate year 2 (19.2%) and lowest in postgraduate year 5 (7.2%).

CONCLUSIONS

General surgery residents' attitudes, experiences, and expectations regarding training reflect both high levels of satisfaction and sources of strain. These factors vary by sex and training year.

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients

OBJECTIVES

To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians.

DESIGN

A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness.

SETTING

A metropolitan tertiary care center.

MAIN OUTCOME MEASURES

Identification of adverse event patterns and completeness of reporting.

RESULTS

From September 2005 to August 2007, 15,524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful.

CONCLUSIONS

We have developed a user-friendly Web-based system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities.

Overexpression of 5-lipoxygenase in colon polyps and cancer and the effect of 5-LOX inhibitors in vitro and in a murine model

PURPOSE

Arachidonic acid metabolism via the cyclooxygenase (COX) and 5-lipoxygenase (5-LOX) pathways modulates cell growth and apoptosis. Many studies have examined the effects of COX inhibitors on human colorectal cancer, but the role of 5-LOX in colonic cancer development has not been well studied. The purpose of this study was to evaluate the expression of 5-LOX in colonic polyps and cancer and the effect of 5-LOX inhibition on colon cancer cell proliferation.

EXPERIMENTAL DESIGN

Colonic polyps, cancer, and normal mucosa were evaluated for 5-LOX expression by immunohistochemistry. Reverse transcription-PCR was used to establish 5-LOX expression in colon cancer cells. Thymidine incorporation and cell counts were used to determine the effect of the nonspecific LOX inhibitor Nordihydroguaiaretic Acid and the 5-LOX inhibitor Rev5901 on DNA synthesis. A heterotopic xenograft model in athymic mice using HT29 and LoVo human colon cancer cells was used to evaluate the effect of the 5-LOX inhibitor zileuton on tumor growth.

RESULTS

5-LOX is overexpressed in adenomatous polyps and cancer compared with that of normal colonic mucosa. LOX inhibition and 5-LOX inhibition decreased DNA synthesis in a concentration- and time-dependent manner in the Lovo cell line (P < 0.05). Inhibition of 5-LOX in an in vivo colon cancer xenograft model inhibited tumor growth compared with that of controls (P < 0.05).

CONCLUSIONS

This study showed that 5-LOX is up-regulated in adenomatous colon polyps and cancer compared with normal colonic mucosa. The blockade of 5-LOX inhibits colon cancer cell proliferation both in vitro and in vivo and may prove a beneficial chemopreventive therapy in colon cancer.

On the role of transforming growth factor-beta in the growth inhibitory effects of retinoic acid in human pancreatic cancer cells

Background

Retinoids are potent growth inhibitory and differentiating agents in a variety of cancer cell types. We have shown that retinoids induce growth arrest in all pancreatic cancer cell lines studied, regardless of their p53 and differentiation status. However, the mechanism of growth inhibition is not known. Since TGF-β2 is markedly induced by retinoids in other cancers and mediates MUC4 expression in pancreatic cancer cells, we investigated the role of TGF-β in retinoic acid-mediated growth inhibition in pancreatic cancer cells.

Results

Retinoic acid markedly inhibited proliferation of two cell lines (Capan-2 and Hs766T) in a concentration and time-dependent manner. Retinoic acid increased TGF-β2 mRNA content and secretion of the active and latent forms of TGF-β2 (measured by ELISA and bioassay). The concentrations of active and TGF-β2 secreted in response to 0.1 – 10 μM retinoic acid were between 1–5 pM. TGF-β2 concentrations within this range also inhibited proliferation. A TGF-β neutralizing antibody blocked the growth inhibitory effects of retinoic acid in Capan-2 cells and partially inhibitory the effects in Hs766T cells.

Conclusion

These findings indicate that TGF-β can cause growth inhibition of pancreatic cancer cells, in a p53-independent manner. Furthermore, it demonstrates the fundamental role of TGF-β in growth inhibition in response to retinoic acid treatment is preserved in vitro.

National efforts to reform residency education in surgery

Major changes in surgical practice and myriad external mandates have affected residency education in surgery. The traditional surgery residency education and training model has come under scrutiny, and calls for major reform of this model have been made by a variety of stakeholders. The American Surgical Association appointed a Blue Ribbon Committee in 2002 to consider the recent changes in surgical practice and surgical education and propose solutions that would ensure a well-educated and well-trained surgical workforce for the future. This committee included representatives from the American Surgical Association, the American College of Surgeons, the American Board of Surgery, and the Residency Review Committee for Surgery. The committee made several far-reaching recommendations relating to residency education in surgery. After the Blue Ribbon Committee completed its task in 2004, representatives from the aforementioned four organizations, the Association of Program Directors in Surgery, and the Association for Surgical Education created a national consortium called the Surgical Council on Resident Education (SCORE). This consortium is pursuing efforts to reform residency education in surgery and implement several key recommendations of the Blue Ribbon Committee. The principal area of focus of SCORE is the development of a national curriculum for surgery residency education and training. Other activities of SCORE include the development of a Web site to support surgery residency education and pursuit of international collaboration. SCORE's efforts will be key to offering surgery residents the best educational experiences, preparing residents for future practice, and supporting delivery of surgical care of the highest quality. The authors examine the current state of residency education in surgery and explore efforts underway to reform this educational model.

Graduate medical education in surgery in the United States

Each year, approximately 1000 graduating medical students enter 5-year residency programs in general surgery. Their salaries are funded by the federal government. Following 5 years of general surgery training, approximately 70% of graduates enroll in a specialty fellowship. Surgery training currently faces a number of challenges, including the diminishing attractiveness of surgery as a career, attrition from residency programs, mandated work hour limits, extensive service requirements in the hospital environment, increasing specialization, and changing patient expectations about the role of residents in their care, among others. In the face of these challenges, the profession is beginning to respond to the need for positive change in the process of training surgeons.

A comparison of faculty and resident perception of resident learning needs in the operating room

OBJECTIVES

The purpose of this study was to gain an understanding of faculty and resident perception of residents' learning needs regarding operative management. Our hypothesis is that surgical faculty and residents have significantly different perceptions of residents' learning needs.

DESIGN

This study used a 27-item survey designed to determine (1) the extent to which traditional learning resources are used by residents when preparing for cases in the operating room, (2) which Web-based resources residents use for operating room preparation, and (3) which operative management topics residents were deficient in despite preoperative preparation.

SETTING

The settings for this study were the exhibit hall area during the 90th American College of Surgeons' Clinical Congress Meeting and a weekly resident conference.

PARTICIPANTS

Participants for this study included a convenience sample of faculty and resident volunteers from the Clinical Congress and residents of our program (N = 246).

RESULTS

On a scale of 1-5, with 5 indicating frequent use, residents rated their most frequently used resources as Major Surgical Texts (3.99) and Advice from colleagues (3.97). The top 3 operative management topics residents felt least prepared for after studying were "instrument use" (67.7%), "suture selection" (65.3%), and "operative field exposure" (50.0%). The top 3 operative management topics faculty felt residents were least prepared for were "anatomy" (73.9%), "natural history of disease" (73.9%), and "procedure choices" (69.6%). Chi-square analysis comparing faculty and resident perceptions of resident learning needs showed significant differences (p < 0.05) in 12 of the 12 operative management topics rated.

CONCLUSION

A critical step in guiding development and proper use of learning technologies for surgical education is the conduct of needs assessments. The disparity between faculty and resident perception of residents' learning needs in the operating room underscores the need for residents to be included in needs assessments relating to surgical training.

Implementation and evaluation of a new surgical residency model

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour requirements prompted program directors to rethink the organizational structure of their residency programs. Many surgical educators have expressed concerns that duty-hour restrictions would negatively affect quality of resident education. This article summarizes evaluation research results collected to study the impact of our reengineered residency program designed to preserve important educational activities while meeting duty-hour accreditation requirements.

STUDY DESIGN

The traditional residency structure was redesigned to include a mixture of apprenticeship, small team, and night-float models. Impact evaluation data were collected using operative case logs, standardized test scores, quality assurance data, resident perception surveys, a faculty survey, and process evaluation measures.

RESULTS

PGY1s and PGY2s enjoyed a substantial increase in operative cases. Operative cases increased overall and no resident has failed to meet ACGME volume or distribution requirements. American Board of Surgery In-Training Examination performance improved for PGY1s and PGY2s. Patient outcomes measures, including monthly mortality and number of and charges for admissions, showed no changes. Anonymously completed rotation evaluation forms showed stable or improved resident perceptions of case load, continuity, operating room teaching, appropriate level of faculty involvement and supervision, encouragement to attend conferences, and general assessment of the learning environment. A quality-of-life survey completed by residents before and after implementation of the new program structure showed substantial improvements. Faculty surveys showed perceived increases in work hours and job dissatisfaction. New physician assistant and nurse positions directly attributed to duty-hour restrictions amounted to about 0.2 full-time equivalent per resident.

CONCLUSIONS

Duty-hour restrictions produce new challenges and might require additional resources but need not cause a deterioration of surgical residents' educational experience.

Leukotriene B4 receptor antagonist LY293111 induces S-phase cell cycle arrest and apoptosis in human pancreatic cancer cells

We have previously shown that the leukotriene B4 receptor antagonist, LY293111 inhibits proliferation and induces apoptosis in human pancreatic cancer cells both in vitro and in vivo. In the current study, we investigated the molecular mechanisms of LY293111-induced apoptosis and cell cycle arrest. Two human pancreatic cancer cell lines were used in this study, MiaPaCa-2 and AsPC-1. Cell cycle analysis by flow cytometry showed a dramatic increase in the percentage of apoptotic cells as well as S-phase arrest after treatment with 250 nmol/l LY293111 for up to 48 h. Western blotting indicated that LY293111 treatment induced cytochrome c release from the mitochondria into the cytosol, accompanied by caspase-9, caspase-7 and caspase-3 activation, and cleavage of poly ADP-ribose polymerase. Caspase-8 was not activated by LY293111. A decrease was found in the expression of the antiapoptotic proteins, Bcl-2 and Mcl-1, and an increase in the proapoptotic protein, Bax. LY293111 reduced the expression of CDK2, cyclin A and cyclin E, consistent with the S-phase arrest observed in these cells. The expression of cyclin-dependent kinase inhibitors, p21 and p27 was not affected by LY293111 treatment. In conclusion, LY293111 induces apoptosis in human pancreatic cancer cells through the mitochondria-mediated pathway. LY293111 also induces S-phase arrest with downregulation of CDK2, cyclin A and cyclin E. Blockade of leukotriene B4 metabolic pathway may provide a novel treatment for human pancreatic cancer.

Assessing surgical knowledge: a primer on the examination policies of the American Board of Surgery

Specialty board certification is very important to both physicians and patients. Although certification does not imply or assess competence per se, it does positively correlate with other quality measures. The assessment of knowledge is a critical part of certification by the American Board of Surgery (ABS) because knowledge is fundamental to understanding, judgment, and clinical decision making in surgery. The relationship between knowledge and performance is underscored by advances in the field of cognitive psychology. Given the importance of certification, ABS examination development and scoring processes use widely accepted psychometric principles to ensure a high degree of validity and reliability. The ABS also closely monitors the examinations to maintain the integrity of the examination process. This article details some processes the ABS uses to achieve these ends.

Surgical council on resident education: a new organization devoted to graduate surgical education

The Surgical Council on Resident Education (SCORE) is a voluntary consortium of six organizations with responsibility for resident education in surgery and an interest in improving the training of surgeons. The founding organizations are the American Board of Surgery (ABS), the American College of Surgeons (ACS), the American Surgical Association (ASA), the Association of Program Directors in Surgery (APDS), the Association for Surgical Education (ASE), and the Residency Review Committee for Surgery of the Accreditation Council on Graduate Medical Education (RRC-S). SCORE emerged from a concerted desire to strengthen the graduate education of surgeons and to assure the competence of surgical trainees in the US. SCORE has a unique ability to foster change in resident education because it brings together the major regulatory organizations (ABS and RRC-S), the major professional organization in surgery (ACS), the senior academic organization in surgery (ASA), and the major surgical education organizations (APDS and ASE). SCORE envisions an ambitious agenda. At its meeting in Philadelphia on November 20, 2006, it began developing a standardized curriculum in general surgery to span the period from medical school to practice, and it defined the scope of the curriculum. It approved continued work of building a national Web site to deliver educational content to general surgery residents and to assist program directors. It endorsed continued development of a basic surgery curriculum for all first-year surgery residents and development of a comprehensive technical skills curriculum for all levels of general surgery training, both of which have been initiated by the ACS. In the future, SCORE plans to examine issues such as the assessment of technical competency, the role of simulation in surgical education, the teaching and assessment of professional behaviors, the practicing surgeon's view of the adequacy of residency training, faculty development, and the attrition of residents from surgery residencies. Members of SCORE intend to investigate best practices in surgical education in other countries. SCORE hopes to take a leadership position in improving the quality of surgical education and surgery in the US.

Resveratrol Inhibits Pancreatic Cancer Cell Proliferation Through Transcriptional Induction of Macrophage Inhibitory Cytokine-1

INTRODUCTION

Resveratrol is a phenolic compound found in grape skins, mulberries, and certain nuts that has been shown to have antitumorigenic and anti-inflammatory properties. Macrophage inhibitory cytokine (MIC-1) is a member of the transforming growth factor beta (TGF-beta) superfamily that has been shown to have antitumorigenic activity and is up-regulated in resveratrol-treated cancer cells. Resveratrol inhibits proliferation of human pancreatic cancer cells; however, the exact mechanism of action is not known. In this study, we investigated the role of MIC-1 in resveratrol-induced growth inhibition of human pancreatic cancer cell lines.

METHODS AND RESULTS

Proliferation assays conducted with resveratrol-treated human pancreatic cancer cell lines (CD18 and S2-013) at 24, 48, and 72 h revealed inhibition of cell proliferation compared to controls. Using oligonucleotide microarray analysis, we identified marked up-regulation of MIC-1 gene expression in resveratrol-treated human pancreatic cancer S2-013 cells. Real-time RT-PCR performed in CD18 and S2-013 cells treated with resveratrol (0-100 mum) for 24 h confirmed concentration and time-dependent up-regulation of expression of one particular gene, MIC-1. Both cell lines pretreated with actinomycin D (a transcriptional inhibitor) and then resveratrol had reduced up-regulation of MIC-1 gene expression compared to those treated with resveratrol alone. Finally, resveratrol-induced growth inhibition was abolished in CD18 cells transfected with MIC-1 short interfering RNA.

CONCLUSIONS

Resveratrol up-regulates MIC-1 gene expression in part at the transcriptional level in pancreatic cancer cells. Furthermore, MIC-1 appears to play a key role in resveratrol-induced growth inhibition in these cells.

On the mechanisms of 12-O-tetradecanoylphorbol-13-acetate-induced growth arrest in pancreatic cancer cells

OBJECTIVES

Protein kinase C (PKC) is involved in cell growth, differentiation, and apoptosis. We investigated the effects of the PKC activator, the tetradecanylphorbol acetate (TPA), in human pancreatic cancer cells.

METHODS

Cell proliferation was measured by thymidine incorporation. Expression of cell cycle proteins was investigated by Western blot. Real-time reverse transcriptase-polymerase chain reaction was used to measure p21 messenger RNA expression, whereas knockdown of its expression was accomplished with a specific small interferring RNA. Cell cycle phases were determined by flow cytometry.

RESULTS

TPA time and concentration dependently inhibited thymidine incorporation in Panc-1 and CD18 cells and induced G2/M cell cycle arrest. The TPA decreased cyclin A and B expression, increased cyclin E, and markedly increased the expression of p21 at both the messenger RNA and protein levels. TPA-induced p21 expression and growth inhibition were blocked by the PKC inhibitor, bisindoylmaleimide. TPA induced extracellular signal-regulated kinase1/2 phosphorylation, whereas the MEK inhibitor, PD98059, blocked the TPA-induced p21 expression. Small interferring RNA targeted to p21 blocked TPA-induced p21 protein expression but not TPA-induced cell growth arrest.

CONCLUSIONS

TPA-induced p21 expression is mediated by the MEK/ERK pathway but is not involved in TPA-induced growth inhibition. In contrast, cyclin A and cyclin B are likely involved in TPA-induced G2/M arrest because both proteins are involved in S phase and G2/M transition during cell proliferation.

Incidence of benign inflammatory disease in patients undergoing Whipple procedure for clinically suspected carcinoma: a single-institution experience

BACKGROUND

We evaluated the incidence of chronic pancreatitis and chronic bile duct inflammation in patients undergoing pancreaticoduodenectomy (PD) for suspected periampullary cancer.

METHODS

Differences between clinical presentation, surgical management, and outcomes were compared between patients with malignancy and benign inflammatory disease.

RESULTS

The incidence of chronic inflammatory disease was 12.9% (21/162). Patients with chronic inflammatory disease were associated with a higher incidence of smoking (75.0% versus 64.7%) and chronic alcohol use (66.7% versus 46.2%). Jaundice was significantly more frequent in patients with malignant disease (83.6% versus 42.9%, P < .05). Surgery for chronic inflammatory disease was associated with significantly more intraoperative bleeding (P < .05).

CONCLUSIONS

The finding of chronic inflammatory disease after PD for suspected carcinoma is justifiable because (1) none of the available diagnostic modalities are infallible, (2) early treatment of pancreatic cancer is crucial for achieving cure, and (3) PD may relieve clinical symptoms in patients with chronic pancreatitis or pancreatic cancer.

A novel peptide sansalvamide analogue inhibits pancreatic cancer cell growth through G0/G1 cell-cycle arrest

Patients with pancreatic cancer have little hope for cure because no effective therapies are available. Sansalvamide A is a cyclic depsipeptide produced by a marine fungus. We investigated the effect of a novel sansalvamide A analogue on growth, cell-cycle phases, and induction of apoptosis in human pancreatic cancer cells in vitro. The sansalvamide analogue caused marked time- and concentration-dependent inhibition of DNA synthesis and cell proliferation of two human pancreatic cancer cell lines (AsPC-1 and S2-013). The analogue induced G0/G1 phase cell-cycle arrest and morphological changes suggesting induction of apoptosis. Apoptosis was confirmed by annexin V binding. This novel sansalvamide analogue inhibits growth of pancreatic cancer cells through G0/G1 arrest and induces apoptosis. Sansalvamide analogues may be valuable for the treatment of pancreatic cancer.

Limited Gastric Resection

Despite recent advancements in the staging and treatment of gastric cancer, overall survival remains poor. Extended or radical resections, to include the entire stomach, regional lymph nodes,or contiguous organs, have thus been proposed to alter the course of this fatal disease; however, no prospective randomized trial has validated this approach in a Western center. Furthermore, there are other malignant tumors that occur in the stomach and that may be successfully treated with a limited, nonanatomic, or subtotal gastrectomy, or in the case of gastric lymphoma, without surgery at all. Palliative approaches to patients who have advanced gastric cancer, which should be conservative by nature, are also outlined.

LY293111 improves efficacy of gemcitabine therapy on pancreatic cancer in a fluorescent orthotopic model in athymic mice

Pancreatic cancer has an abysmal prognosis because of late diagnosis and lack of effective therapeutics. New drugs are desperately needed. The present study determined the effect of the LTB4 receptor antagonist, LY293111, on tumor growth and metastases in a fluorescent orthotopic model of pancreatic cancer. Pancreatic cancer cells (S2-013) with stable expression of enhanced green fluorescent protein were implanted into the duodenal pancreatic lobe of athymic mice. Animals were allocated to four groups (eight mice per group): control (no treatment); LY293111; gemcitabine; and LY293111 + gemcitabine. Monitoring of the surgical procedure and follow-up examinations at 2, 3, and 4 weeks after implantation to monitor tumor growth and metastases were performed using a fluorescence microscope and the reversible skin-flap technique. A staging and scoring system was developed to evaluate tumor progression, based on the TNM classification. Control animals developed end-stage disease with invasive cancer, metastases, and cachexia. Tumor growth and incidence of metastases were significantly reduced in all treated mice. However, combined treatment with LY293111 and gemcitabine was most effective. LY293111 is a novel therapeutic agent for pancreatic cancer, which improves the efficacy of gemcitabine. It is well tolerated and can be administered orally and, therefore, provides a new hope for patients suffering from pancreatic adenocarcinoma.

A novel anti-pancreatic cancer agent, LY293111

Arachidonic acid is metabolized by two major pathways, cyclooxygenases and lipoxygenases. The metabolites catalyzed by these enzymes are important mediators of acute and chronic inflammation. Both enzymes and their metabolites are well recognized to be involved in cancer development and progress. It is well documented that inhibition of cyclooxygenase 2 (COX-2) activity decreases cancer incidence and inhibits tumor growth. It has also been reported that 5-lipoxygenase is involved in cancer cell survival and proliferation. 5-lipoxygenase metabolites including both 5-HETE and leukotriene (LT) B4 directly mediate cancer cell growth. Although 5-HETE receptors are still elusive, two LTB4 receptor subtypes (BLT1 and BLT2) have been characterized. Both 5-lipoxygenase and LTB4 receptors are upregulated in both pancreatic cancer and early pancreatic cancer lesions; hence, these proteins are potential targets for cancer treatment and prevention. Recent studies have shown that an orally stable leukotriene (LT) B4 receptor antagonist, LY293111, has a potent anti-pancreatic cancer effect. LY293111 inhibits pancreatic cancer growth, induces tumor cell apoptosis both in vitro and in vivo, and enhances the anti-pancreatic cancer effect of gemcitabine. LY293111 exhibits its anti-cancer effects through LTB4 receptors and peroxisome-proliferator activated receptor-gamma. A phase I clinical trial indicated that LY293111 is well tolerated by patients with no significant side-effects. LY293111 may be a valuable drug for treatment of pancreatic cancer, especially in combination with gemcitabine. A double-blinded, placebo-controlled phase II clinical trial with LY293111 is currently underway. This review summarizes the current research status of LY293111 as an anti-cancer agent with a focus on pancreatic cancer.

LTB4 stimulates growth of human pancreatic cancer cells via MAPK and PI-3 kinase pathways

We have previously shown the importance of LTB4 in human pancreatic cancer. LTB4 receptor antagonists block growth and induce apoptosis in pancreatic cancer cells both in vitro and in vivo. Therefore, we investigated the effect of LTB4 on proliferation of human pancreatic cancer cells and the mechanisms involved. LTB4 stimulated DNA synthesis and proliferation of both PANC-1 and AsPC-1 human pancreatic cancer cells, as measured by thymidine incorporation and cell number. LTB4 stimulated rapid and transient activation of MEK and ERK1/2 kinases. The MEK inhibitors, PD98059 and U0126, blocked LTB4-stimulated ERK1/2 activation and cell proliferation. LTB4 also stimulated phosphorylation of p38 MAPK; however, the p38 MAPK inhibitor, SB203580, failed to block LTB4-stimulated growth. The activity of JNK/SAPK was not affected by LTB4 treatment. Phosphorylation of Akt was also induced by LTB4 and this effect was blocked by the PI-3 kinase inhibitor wortmannin, which also partially blocked LTB4-stimulated cell proliferation. In conclusion, LTB4 stimulates proliferation of human pancreatic cancer cells through MEK/ERK and PI-3 kinase/Akt pathways, while p38 MPAK and JNK/SAPK are not involved.

Pancreatic stellate cells (PSCs) express cyclooxygenase-2 (COX-2) and pancreatic cancer stimulates COX-2 in PSCs

Background

Cyclooxygenase 2 (COX-2), the inducible form of prostaglandin G/H synthase, is associated with several human cancers including pancreatic adenocarcinoma. Pancreatic stellate cells (PSCs) play a central role in the intense desmoplasia that surrounds pancreatic adenocarcinoma. The present study examined COX-2 expression in PSCs. PSCs isolated from normal rats, were cultured and exposed to conditioned medium (CM) from the human pancreatic cell line, PANC-1.

Methods

COX-2 expression was evaluated by immunostaining and western blotting. Proliferation of PSCs was determined by thymidine incorporation and cell counting.

Results

COX-2 was found to be constitutively expressed in PSCs, and COX-2 protein was up-regulated by PANC-1 CM. Moreover, the induction of COX-2 by PANC-1 CM was prevented by U0126, an extracellular signal-regulated kinase (ERK) 1/2 inhibitor suggesting that activation of ERK 1/2 is needed for stimulation of COX-2. Finally, NS398, a selective COX-2 inhibitor, reduced the growth of PSCs by PANC-1 CM, indicating that activation of COX-2 is required for cancer stimulated PSC proliferation.

Conclusion

The results suggest that COX-2 may play an important role in the regulation of PSC proliferation in response to pancreatic cancer.

5-Lipoxygenase, a Marker for Early Pancreatic Intraepithelial Neoplastic Lesions

Pancreatic cancer has an abysmal prognosis because of late diagnosis. Therefore, it is important to identify risk factors if we are to be able to prevent and detect this cancer in an early, noninvasive stage. Pancreatic intraepithelial neoplasias (PanIN) are the precursor lesions which could be an ideal target for chemoprevention. This study shows up-regulation of 5-lipoxygenase (5-LOX) in all grades of human PanINs and early lesions of pancreatic cancer in two different animal models (EL-Kras mice and N-nitrosobis(2-oxopropyl)amine-treated hamsters) by immunohistochemistry. The results were consistent in all tissues examined, including seven chronic pancreatitis patients, four pancreatic cancer patients, one multiorgan donor, nine EL-Kras mice, and three N-nitrosobis(2-oxopropyl)amine-treated hamsters, all with PanINs. Overexpression of 5-LOX in NIH3T3 cells resulted in greater sensitivity of these cells to the growth inhibitory effects of the 5-LOX inhibitor Rev5901. These findings provide evidence that 5-LOX plays a key role in the development of pancreatic cancer. Furthermore, the lipoxygenase pathway may be a target for the prevention of this devastating disease.

Identification and in silico characterization of a novel gene: TPA induced trans-membrane protein

12-O-Tetradecanoylphorbol-13-acetate (TPA) is a potent tumor promoter with wide ranging, diverse, and sometimes opposite cellular effects. Using oligonucleotide microarray analysis, we have identified a novel gene that is upregulated following treatment with TPA in the pancreatic cancer cell line CD18. Real-time PCR validated the microarray results in CD18 and HeLa cells, and showed that upregulation of the gene is time- and concentration-dependent. In silico analysis showed the gene product to be a single-pass transmembrane protein of 217 residues that is localized to the endoplasmic reticulum, thus the name TPA induced trans-membrane protein (TTMP). A luciferase reporter assay demonstrated that upregulation of TTMP by TPA is triggered at the promoter level.

Chromosomal instability in pancreatic ductal cells from patients with chronic pancreatitis and pancreatic adenocarcinoma

Pancreatic adenocarcinoma is a disease with high mortality for which chronic pancreatitis confers a markedly increased risk. We hypothesize that chromosome instability and genomic damage occur in pre-neoplastic pancreatic ductal epithelium, and that this damage may be related to oxidative stress. We used dual-color fluorescence in situ hybridization with centromere probes and locus-specific arm probes for chromosome arms 11q, 17p, and 18q to identify genomic instability in cultures of normal-appearing human pancreatic ductal epithelium from normal organ donor controls compared to patients with chronic pancreatitis or pancreatic adenocarcinoma. To examine early pancreatic tumorigenesis, we studied only normal-appearing pancreatic ductal cells adjacent to pancreatitis or carcinoma. We found that, compared to the finding in normal controls, chromosomal abnormalities are present in normal-appearing human pancreatic ductal epithelia obtained from patients with chronic pancreatitis or pancreatic adenocarcinoma. Furthermore, these chromosomal abnormalities could be induced in cultured pancreatic ductal epithelium from normal organ donors by chronic exposure to dilute hydrogen peroxide, suggesting that oxidative stress may contribute to the development of chromosomal instability in the pancreas. These results elucidate a potential mechanism linking chronic pancreatitis to pancreatic cancer and suggest that chromosomal instability may be an early event in the pathogenesis of pancreatic cancer.

Neural invasion in the staging of pancreatic cancer

The natural history of pancreatic ductal adenocarcinoma makes it one of the most malignant human diseases. Unknown etiology, lack of early symptoms, explosive outcome, short survival, and resistance to therapy are hallmarks of this cancer. Although surgery has been shown to be an effective therapeutic approach, the inevitable tendency for recurrence, even after apparently curative operation, has remained a mystery. Ironically, the reasons for this recurrence, which usually leads to the death of the patient within 1 or 2 years after surgery, have not been a focus of research. Several studies highlighting this problem and the possible explanations have been performed by Japanese investigators.

Outcome after pancreaticoduodenectomy for periampullary cancer: an analysis from the Veterans Affairs National Surgical Quality Improvement Program

The aim of this study is to define the risk factors that predict adverse outcomes for patients undergoing pancreaticoduodenectomy for periampullary cancer in the Department of Veterans Affairs Healthcare System (VA). The VA National Surgical Quality Improvement Program prospectively collected data on 462 patients undergoing pancreaticoduodenectomy in 123 VA medical centers from 1990 to 2000. Independent variables included 68 preoperative and 12 intraoperative variables. The main outcome measures were 30-day postoperative mortality and morbidity, as measured by a set of 20 pre-defined complications. Predictive models for 30-day morbidity and mortality were constructed using logistic regression analysis. The 30-day morbidity rate was 45.9% (212/462). The 30-day postoperative mortality rate was 9.3% (43/462). Significant predictors of mortality included: preoperative serum albumin, American Society of Anesthesiologists classification, preoperative bilirubin >20mg/dl, and operative time. The use of preoperative biliary tract instrumentation did not predict postoperative death or septic complications. This study provides a set of preoperative risk factors that are predictive of adverse outcome following pancreaticoduodenectomy. These factors may assist in patient selection for this procedure and are likely to facilitate risk-adjusted comparison of pancreaticoduodenectomy outcomes between different health care systems.