[Tolvaptan, a vasopressin V2 receptor antagonist, is the world's first approved drug for treatment of autosomal dominant polycystic kidney disease (ADPKD)]

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney disease. Fluid-filled cysts develop and enlarge in both kidneys, eventually leading to kidney failure. Tolvaptan is a selective vasopressin V₂ receptor antagonist and the first and only drug approved for treatment of ADPKD. It blocks binding of arginine vasopressin (AVP) to V₂ receptors in the collecting duct of kidney, thereby inducing water diuresis (aquaresis) without losing electrolytes. Therefore, tolvaptan was originally developed and approved as the first oral aquaretic agent for treatment of hyponatremia and fluid volume overload in heart failure and cirrhosis. During the development of tolvaptan as aquaretics, efficacy of V₂ antagonist in polycystic kidney animal model was reported and then the development of tolvaptan for ADPKD was also initiated. Cyclic adenosine monophosphate (cAMP) plays an important role in cyst growth by promoting cell proliferation and fluid secretion. Tolvaptan showed suppression of cyst growth through inhibiting AVP-induced cAMP production and delayed the onset of end-stage renal disease in an animal model. In the phase 3 clinical trial in ADPKD patients (TEMPO 3:4 trial), 3-year treatment with tolvaptan slowed the disease progression including increase of kidney volume and decline in renal function. Efficacy of tolvaptan in patients with late-stage ADPKD was confirmed in another 1-year phase 3 REPRISE trial. Tolvaptan is approved for treatment of ADPKD in more than 40 countries and we expect it can contribute to more ADPKD patients worldwide. We also expect that drugs with new mechanisms will be available in the near future.

Damage accrual related to pregnancies before and after diagnosis of systemic lupus erythematosus: a cross-sectional and nested case-control analysis from a lupus registry

OBJECTIVE

The objective of this study was to evaluate the chronic damage associated with pregnancies before and after the diagnosis of systemic lupus erythematosus (SLE).

METHODS

Using childbearing-aged female SLE patient data registered at the Okayama and Showa University Hospitals, a nested case-control analysis was performed to investigate the relationship between pregnancy and chronic damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI).

RESULTS

Pregnancy occurred in 22 patients before and 13 patients after the diagnosis of SLE in 104 eligible patients. Live births occurred in 82% (33/40) and 50% (9/18) of the pregnancies before and after the diagnosis of SLE, respectively. After matching age and disease duration, 33 case patients with chronic damage (SDI ≥ 1) and 33 control patients without chronic damage (SDI = 0) were selected. Hypertension was more frequent in cases than in controls (48% vs. 24%, p = 0.041). Pregnancies before and after the diagnosis of SLE were comparable between cases and controls (before the diagnosis: nine case patients and eight control patients; after the diagnosis: three case patients and five control patients; p = 1.00). Even after adjusting for hypertension using multivariate analysis, the pregnancies before and after the diagnosis were not significant predictors for chronic damage (odds ratio = 1.48 (95% confidence interval 0.33-6.65)), p = 0.60 of the pregnancy before the diagnosis; odds ratio = 0.78 (95% confidence interval 0.13-4.74), p = 0.78 of the pregnancy after the diagnosis).

CONCLUSION

Pregnancies, either before or after the diagnosis of SLE, did not show any differences in chronic damage. Our results help alleviate fears regarding childbearing in female patients with SLE and their families.

Progressive reduction of serum complement levels: a risk factor for relapse in patients with hypocomplementemia in systemic lupus erythematosus

Objective

Serologically active clinically quiescent (SACQ)-SLE is a subtype of systemic lupus erythematosus (SLE); most SACQ-SLE patients relapse. Although complement and/or anti-dsDNA level fluctuations during SACQ status are reportedly not useful for predicting relapse, they might be useful in specific clinical settings. We aimed to assess the correlation between future relapse and progressive reductions in serum complement levels following remission in patients with hypocomplementemia .

Methods

We retrospectively reviewed patients aged ≥15 years who were treated with ≥20 mg/day of prednisolone for remission induction. After achieving remission, the patients treated with prednisolone tapered to ≤15 mg/day without relapse and followed by hypocomplementemia (first hypocomplementemia point) were analyzed. The primary outcome was the relapse during the first 24 months.

Results

Seventy-six patients were enrolled; 31 (40.8%) relapsed. A ≥10% reduction after the first hypocomplementemia point in serum C3, C4, and CH50 levels was found in 10, 21, and 16 patients, respectively. Hazard ratios (95% confidence intervals) for relapse were 2.32 (0.92–5.12) for serum C3 levels and 2.46 (1.18–5.01) for serum C4 levels. Progressive reductions in serum C3 and C4 levels had relatively high specificity (93.3% and 82.2%) but limited sensitivity (22.6% and 41.9%) for predicting relapse. However, simultaneous progressive reduction in C3 levels and increase in anti-dsDNA antibody levels had the highest specificity (97.8%), and simultaneous progressive reduction in C4 levels or increase in anti-dsDNA antibody levels had the highest sensitivity (71.0%).

Conclusion

Simultaneous progressive reductions in complement levels and increases in anti-dsDNA antibody levels may indicate future relapse SACQ-SLE patients.

Prevalence and correlates of cervical HPV infection in a clinic-based sample of HIV-positive Hispanic women

Objectives

Puerto Rico (PR), is the fifth highest jurisdiction of the United States of America (US) with respect to HIV prevalence and the leading in cervical cancer incidence. This cross-sectional study describes the prevalence and correlates of cervical HPV infection among a clinic-based sample of 302 women living with HIV/AIDS in PR.

Methods

Data collection included questionnaires, blood and cervical samples. Multivariable logistic regression models were used to estimate the magnitude of association (adjusted Prevalence odds ratio [aPOR]) between HPV cervical infection and other covariates.

Results

Mean age of participants was 40.3 years (± 10.3 SD). The prevalence of HPV infection was 50.3%; 41.1% for low-risk types and 29.5% for high-risk types. Having ≥ 10 lifetime sexual partners (aPOR = 2.10, 95% CI:1.02–4.29), an abnormal Pap (aPOR = 3.58, 95% CI:1.93–6.62), active genital warts (aPOR = 3.45, 95% CI:1.60–7.42), and CD4 counts ≤ 200 (aPOR = 4.24, 95% CI: 1.67–10.78) were positively associated with any cervical HPV infection. Similar results were observed for HR HPV infection.

Conclusions

A high burden of HPV co-infection exists among women living with HIV/AIDS in this population. Given the high incidence of HIV in PR and the higher risk of cervical cancer among women living with HIV/AIDS, HPV vaccination should be promoted in this population.

Adhesive-free adhesion between polytetrafluoroethylene (PTFE) and isobutylene–isoprene rubber (IIR) via heat-assisted plasma treatment

A polytetrafluoroethylene (PTFE) surface was modified using atmospheric pressure plasma treatment under heating (heat-assisted plasma treatment) to promote its direct adhesion to isobutylene–isoprene rubber (IIR) without any adhesives.

An Acute Mercuric Mercury Poisoning: Chemical Speciation of Hair Mercury Shows a Peak of Inorganic Mercury Value

A woman ingested a dose of sublimate (approximately 0.9 g) in an attempted suicide. She survived and recovered in response to a combination of therapies including chelate (BAL) therapy, plasma exchange, haemodialysis and peritoneal dialysis.

Serum inorganic mercury concentration, urinary inorganic mercury excretion and hair inorganic and organic mercury and selenium concentrations, along the length from the scalp to the distal part, were measured. Longitudinal analysis of hair, revealed a peak in inorganic mercury corresponding to the time of mercury ingestion. Organic mercury and selenium in the hair had different patterns of longitudinal variation from that of inorganic mercury. The biological half-life (23.5 d) of serum inorganic mercury levels was in good agreement with values previously reported in the literature.

Long-term quality of life after laparoscopic distal gastrectomy for early gastric cancer: results of a prospective multi-institutional comparative trial

BACKGROUND

The aim of this study was to compare the postoperative health-related quality of life (HRQOL) between open and laparoscopic distal gastrectomy.

METHODS

A multi-institutional nonrandomized study was conducted. Patients with clinical T1 gastric cancer were prospectively enrolled and underwent distal gastrectomy by either the open or laparoscopic approach. HRQOL was measured using the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire-Core 30 and the site-specific module for gastric cancer. Questionnaires were completed at baseline and at 1, 3, 6, and 12 months postoperatively. Clinicopathological characteristics and short-term outcome including postoperative morbidity and HRQOL were compared between the approaches.

RESULTS

A total of 145 patients (open, n = 72; laparoscopic, n = 73) were enrolled between September 2008 and January 2011 and analyzed. The laparoscopic approach was associated with longer operating time, less blood loss, and a similar incidence of postoperative complications. At each time point, the questionnaires were retrieved from more than 90 % of the patients. The worst scores for most of the scales were observed at 1 month postoperatively and improved thereafter. No statistically significant differences were observed regarding physical functioning, the primary endpoint. On the other hand, role, emotional, cognitive, and social functioning scores were superior in the laparoscopic group at 6 and 12 months postoperatively. Symptom scales including fatigue, pain, eating restriction, taste problems, and anxiety were better in the laparoscopic group before 6 months but not at 12 months.

CONCLUSIONS

The study was considered to be negative because no benefit of the laparoscopic approach was observed in terms of physical functioning. However, more favorable scores for some of the symptom scales during the first 6 months and several functioning scales at 12 months after surgery suggest a potential benefit of the laparoscopic approach.

Tolvaptan delays the onset of end-stage renal disease in a polycystic kidney disease model by suppressing increases in kidney volume and renal injury

Tolvaptan, a selective vasopressin V2 receptor antagonist, slows the increase in total kidney volume and the decline in kidney function in patients with the results of the Tolvaptan Efficacy and Safety in Management of Autosomal Dominant Polycystic Kidney Disease and Outcome (TEMPO) 3:4 trial. However, it was unclear which dose of tolvaptan was optimal or whether tolvaptan was able to delay progression to end-stage renal disease (ESRD). Here we examined the relationship with aquaresis and the inhibitory effect on cyst development in short-term treatment and mortality as an index of ESRD in long-term treatment with tolvaptan using DBA/2FG-pcy mice, an animal model of nephronophthisis. With short-term treatment from 5 to 15 weeks of age, tolvaptan (0.01-0.3% via diet) dose-dependently enhanced aquaresis, prevented increases in kidney weight and cyst volume, and was associated with significant reductions in kidney cAMP levels and extracellular signal-regulated kinase activity. Maximal effects of tolvaptan on aquaresis and the prevention of development of polycystic kidney disease (PKD) were obtained at 0.1%. Interestingly, tolvaptan also dose-dependently reduced urinary neutrophil gelatinase-associated lipocalin levels in correlation with the kidney volume. With long-term treatment from 5 to 29 weeks of age, tolvaptan significantly attenuated the increase in kidney volume by up to 50% and reduced urinary albumin excretion. Furthermore, tolvaptan significantly reduced the mortality rate to 20%, compared with 60% in the control group. These data indicate that tolvaptan may delay the onset of ESRD in PKD by suppressing the increases in kidney volume and renal injury, providing a promising treatment for PKD.

Tolvaptan, an orally active non-peptide arginine vasopressin V2 receptor antagonist, reduces ascites in rats with chronic liver injury

AIM

This is a non-clinical, proof of concept study, showing that tolvaptan has efficacy in reducing ascites in chronic liver injury, using a rat model induced by repeated dimethylnitrosamine (DMNA) injection.

METHODS

A rat model of chronic liver injury was induced by 10 mg/kg of repeated i.p. injection with DMNA for 6-9 weeks. Tolvaptan was administrated to rats that showed obvious and stable ascites, and abdominal circumference was evaluated as a surrogate marker of ascites volume. Rats were placed in metabolic cages with free access to food and water to collect urine over a 24-h period.

RESULTS

Oral tolvaptan (1 and 3 mg/kg) promoted a remarkable diuretic effect, decreasing bodyweight and abdominal circumference in a dose-dependent manner. Plasma sodium concentration was increased by tolvaptan due to the large amount of free-water excretion following tolvaptan administration.

CONCLUSION

Tolvaptan had therapeutic efficacy in the reduction of ascites in rats with chronic liver injury. These results are consistent with the clinical data showing tolvaptan has therapeutic implications in the reduction of ascites in patients with decompensated cirrhosis.

Gene expression analysis of a Helicobacter pylori-infected and high-salt diet-treated mouse gastric tumor model: identification of CD177 as a novel prognostic factor in patients with gastric cancer

BACKGROUND

Helicobacter pylori (H. pylori) infection and excessive salt intake are known as important risk factors for stomach cancer in humans. However, interactions of these two factors with gene expression profiles during gastric carcinogenesis remain unclear. In the present study, we investigated the global gene expression associated with stomach carcinogenesis and prognosis of human gastric cancer using a mouse model.

METHODS

To find candidate genes involved in stomach carcinogenesis, we firstly constructed a carcinogen-induced mouse gastric tumor model combined with H. pylori infection and high-salt diet. C57BL/6J mice were given N-methyl-N-nitrosourea in their drinking water and sacrificed after 40 weeks. Animals of a combination group were inoculated with H. pylori and fed a high-salt diet. Gene expression profiles in glandular stomach of the mice were investigated by oligonucleotide microarray. Second, we examined an availability of the candidate gene as prognostic factor for human patients. Immunohistochemical analysis of CD177, one of the up-regulated genes, was performed in human advanced gastric cancer specimens to evaluate the association with prognosis.

RESULTS

The multiplicity of gastric tumor in carcinogen-treated mice was significantly increased by combination of H. pylori infection and high-salt diet. In the microarray analysis, 35 and 31 more than two-fold up-regulated and down-regulated genes, respectively, were detected in the H. pylori-infection and high-salt diet combined group compared with the other groups. Quantitative RT-PCR confirmed significant over-expression of two candidate genes including Cd177 and Reg3g. On immunohistochemical analysis of CD177 in human advanced gastric cancer specimens, over-expression was evident in 33 (60.0%) of 55 cases, significantly correlating with a favorable prognosis (P = 0.0294). Multivariate analysis including clinicopathological factors as covariates revealed high expression of CD177 to be an independent prognostic factor for overall survival.

CONCLUSIONS

These results suggest that our mouse model combined with H. pylori infection and high-salt diet is useful for gene expression profiling in gastric carcinogenesis, providing evidence that CD177 is a novel prognostic factor for stomach cancer. This is the first report showing a prognostic correlation between CD177 expression and solid tumor behavior.

ANGPTL4 is a secreted tumor suppressor that inhibits angiogenesis

Tumor suppressors with extracellular function are likely to have advantages as targets for cancer therapy, but few are known. Here, we focused on angiopoietin-like 4 (ANGPTL4), which is a secreted glycoprotein involved in lipoprotein metabolism and angiogenesis, is methylation-silenced in human cancers, but has unclear roles in cancer development and progression. We found a deletion mutation in its coiled-coil domain at its N-terminal in human gastric cancers, in addition to hypermethylation of the ANGPTL4 promoter CpG islands. Forced expression of wild-type ANGPTL4, but not ANGPTL4 with the deletion, at physiological levels markedly suppressed in vivo tumorigenicity and tumor angiogenesis, indicating that the latter caused the former. Tumor-derived ANGPTL4 suppressed in vitro vascular tube formation and proliferation of human umbilical vascular endothelial cells, partly due to suppression of ERK signaling. These showed that ANGPTL4 is a genetically and epigenetically inactivated secreted tumor suppressor that inhibits tumor angiogenesis.

A comparison of postoperative quality of life after open and laparoscopic gastrectomy for early gastric cancer: A multicenter, nonrandomized, controlled study (CCOG 0802)

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Background: The aim of this study was to compare the postoperative health-related quality of life (HRQoL) between open and laparoscopic distal gastrectomy. Methods: A multi-institutional non-randomized study was conducted, and early gastric cancer patients were prospectively enrolled and underwent distal gastrectomy either by the open or laparoscopic approach. HRQoL was measured using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Cancer (QLQ-C30) and the site-specific module for gastric cancer (QLQ-STO22). Questionnaires were completed at baseline and at 1, 3, 6 and 12 months postoperatively. Clinicopathological characteristics and short term outcome including postoperative morbidity and HRQoL were compared between the approaches. Results: A total of 159 patients with clinical T1 tumors were enrolled between September 2008 and January 2011. Those who were found upon pathologic examination to have ≥aStage II disease (n=14) were excluded, and the remaining 145 patients (open: n=72, laparoscopic: n=73) were analyzed. There were no significant differences between the two groups regarding age, gender, macroscopic type, depth of invasion, lymph node metastasis, and pathologic type. Laparoscopic approach was associated with longer operating time, smaller blood loss, and similar incidence of postoperative complications. At each time point, the questionnaires were sent to the data center from >90% of the patients. The worst scores for most of the items were observed at 1 month postoperatively and improved thereafter. The role, emotional, cognitive, and social functioning scores were superior in the laparoscopic group at 6 and 12 months postoperatively. Symptom scales including fatigue, pain, anxiety, eating restriction, and taste problem were better in the laparoscopic group before 6 months but not at 12 months. Conclusions: Patients treated by the laparoscopic approach benefitted from better HRQoL in terms of symptoms scores during the first 6 months, while the superiority in several functioning scores lasted for 12 months.

Clinical, pathologic and genetic studies on autosomal recessive early-onset parkinsonism with diurnal fluctuation

To clarify the genetic mode and clinical characteristics of familial early-onset parkinsonism with diurnal fluctuation, we studied 43 patients from 22 families. The estimated segregation ratio (0.2963) and absence of gender preponderance indicated autosomal recessive inheritance. Clinical features included the average age at onset of 26.1 years, parkinsonism with marked diurnal fluctuation, remarkable effect of levodopa, dyskinesias, dystonia, hyperreflexia, absence of dementia, and a benign course; autonomic symptoms were only mild if present. Autopsy study in one of our patients disclosed neuronal loss without Lewy bodies and the presence of melanin-poor neurons in the substantia nigra. Linkage analysis on 16 families mapped the disease gene to chromosome 6q25.2-27.

DNA demethylating agent decitabine increases AQP5 expression and restores salivary function

Xerostomia is the symptom of oral dryness resulting most frequently, but not exclusively, from salivary gland hypofunction. Because the prevalence of xerostomia may increase with age, it has multiple oral health consequences in aging populations. In the present study, we demonstrate that the in vivo administration of 5-aza-2'-deoxycytidine (5-Aza-CdR; decitabine), a DNA demethylating agent, to the murine aging model C57BL/6CrSlc mice (24 wks old) increased the volumes of salivary flow compared with those of control mice. Western blot analysis and immunohistochemical staining demonstrated the augmented expression of AQP5 protein in the salivary glands of 5-Aza-CdR-treated mice compared with those of control mice. In addition, AQP5 protein expression levels in 5-Aza-CdR-treated old mice (27 wks old) were much higher than those in untreated and young mice (6 wks old). Global methylation levels in the salivary glands were significantly lower in the 5-Aza-CdR-treated mice than in the untreated mice. Moreover, the induction of demethylation in the AQP5 promoter of 5-Aza-CdR-treated mice was stronger than in the control mice. Analysis of our data therefore suggests that a DNA demethylating agent may be a useful drug for restoring hyposalivation in elderly individuals, thereby leading to the resolution of xerostomia.

Postoperative long-term evaluation of interposition reconstruction compared with Roux-en-Y after total gastrectomy in gastric cancer: prospective randomized controlled trial

BACKGROUND

The postoperative clinical superiority of the interposition of jejunum reconstruction (INT) to Roux-en-Y reconstruction (RY) after total gastrectomy has not been clarified. Postoperative quality of life (QOL) was evaluated between the 2 methods by a multi-institutional prospective randomized trial.

METHODS

A total of 103 patients with gastric cancer were prospectively randomly divided into groups for RY (n = 51) or INT reconstruction (n = 52) after total gastrectomy. They were stratified by sex, age, institute, histology, and degree of lymph node dissection. Postoperatively, body mass index (BMI) and nutritional conditions were measured serially, and QOL and postoperative squalor scores were evaluated at 3, 12, and 60 months and compared between the 2 groups.

RESULTS

After removing patients who did not complete the follow-up survey or censured cases, 24 patients in the RY group and 18 patients in the INT group were clinically available and their postoperative status was assessed. QOL scores were increased and complication scores were improved in the postoperative periods (P < .01). Postoperative BMI significantly deteriorated compared with preoperative BMI in each group. The postoperative QOL and complication scores at 60 months after surgery were significantly better than those at 3 months after surgery in each group (P < .01). However, there was no significant difference of QOL scores and postoperative complication scores between the 2 reconstruction groups. The nutritional condition in the INT group was nearly the same as that in the RY group.

CONCLUSIONS

Although our patient sample was small and patients who did not complete the follow-up survey were present, we could not identify any clinical difference between INT and RY after total gastrectomy 60 months after surgery. The safer and simpler RY method may be a more suitable reconstruction method than INT after total gastrectomy.

Lentinan prolonged survival in patients with gastric cancer receiving S-1-based chemotherapy

AIM: To examine whether administration of lentinan, purified β-1, 3-glucan, can prolong survival in advanced gastric cancer patients receiving S-1-based chemotherapy.

METHODS: Since 2004, 78 patients with metastatic or recurrent gastric cancer have received S-1-based chemotherapy as first-line treatment. Survival, side effects, and the ratio of granulocytes/lymphocytes (G/L ratio) were compared between 2 groups of patients who received chemo-immunotherapy using lentinan and chemotherapy alone.

RESULTS: Median overall survival was significantly longer in the former group than in the latter group [689 d (95% CI: 431-2339 d) vs 565 d (95% CI: 323-662 d), P = 0.0406]. In addition, the G/L ratio in patients who received lentinan was maintained around or below 2, which was significantly lower than that in patients who received chemotherapy alone (P < 0.001).

CONCLUSION: Chemo-immunotherapy with lentinan offers a significant advantage over S-1-based chemotherapy alone in terms of survival in patients with advanced gastric cancer.

Polysaccharides of Mycobacterium bovis Ushi 10, Mycobacterium smegmatis, Mycobacterium phlei, and Atypical Mycobacterium P1

Four kinds of polysaccharides, glucan, mannan, arabinomannan, and arabinogalactan, were purified from the defatted cells of four strains of mycobacteria. By the chemical and immunological analyses, we concluded that arabinomannan and arabinogalactan are common serologically active polysaccharides in mycobacteria.

Expression of L1 cell adhesion molecule is a significant prognostic factor in pT3-stage gastric cancer

BACKGROUND

L1, a 200-220 kDa transmembrane glycoprotein of the immunoglobulin superfamily, has been shown to affect prognosis of various types of cancer and was shown to enhance peritoneal metastasis in ovarian cancer in vivo.

PATIENTS AND METHODS

Immunostaining with anti-L1 antibody was performed with 72 surgically resected pT3-stage gastric cancer specimens. Correlation of immunoreactivity with clinicopathological variables was evaluated and survival curves were compared between L1-positive and negative cases.

RESULTS

L1 was detected in 15 specimens (21%), more often among the intestinal-type cancer. No correlation was observed between L1 expression and presence of free cancer cells in the peritoneal cavity or development of peritoneal carcinomatosis during the follow-up. Nevertheless, prognosis of patients with L1-positive cancer was significantly inferior (p=0.024), particularly among the diffuse-type cancer cases.

CONCLUSION

L1 was associated with poor outcome in gastric carcinoma. However, its association with the formation of peritoneal metastases or the presence of free cancer cells in the abdominal cavity was not observed. Further study to identify the role of L1 in gastric cancer progression and metastasis is warranted.

Association of prostate stem cell antigen gene polymorphisms with the risk of stomach cancer in Japanese

A recent whole-genome association study identified a strong association between polymorphisms in the prostate stem cell antigen (PSCA) gene and stomach cancer risk. In this case-control study, we aimed to validate this association, and further to explore environmental factors possibly interacting with PSCA polymorphisms in 708 incident stomach cancer cases and 708 age-sex matched controls. The association between PSCA polymorphisms and Helicobacter pylori infection was also examined. We found that rs2294008 and rs2976392, which were strongly linked to each other (D' = 1.00), were significantly associated with stomach cancer risk. Per allele odds ratio for rs2994008 was 1.40 (95% confidence interval: 1.19-1.65; p = 3.7 x 10(-5)). We found significant interaction with a family history of stomach cancer in first-degree relatives (p-heterogeneity = 0.009). Similar to originally reported association, we found significant heterogeneity between diffuse and intestinal type (p-heterogeneity = 0.007). No association was seen between PSCA polymorphisms and H. pylori infection. In conclusion, PSCA polymorphisms are associated with stomach cancer risk in Japanese. A possible interaction with family history warrants further evaluation.

Expression of CXCL12 and CXCR4 in pT3-stage gastric cancer does not correlate with peritoneal metastasis

CXCR4, a chemokine receptor, is considered to be involved in the metastastic formation of various types of cancer and could influence survival. More recently, CXCR4 was reported to be associated with peritoneal metastasis in gastric cancer, and CXCL12, its ligand, as a prognostic determinant among gastric cancer of various stages. In order to more specifically delineate the relevance of CXCR4 in peritoneal metastasis, 98 patients with pT3-stage gastric cancer who underwent gastrectomy and detection of intra-abdominal free cancer cells in the peritoneal washing samples were evaluated. Immunostaining with anti-CXCL12 and anti-CXCR4 antibodies were performed for the primary tumor specimens, and correlation of the immunoreactivities with various clinicopathologic factors was evaluated. CXCR4 was detected in 61 specimens and CXCL12 in 76 specimens. No significant correlation was observed between presence of free cancer cells in the peritoneal cavity or development of clinical peritoneal carcinomatosis and expression of either the chemokine or the receptor. On the other hand, there was a trend towards correlation of expression of these molecules with recurrences to the distant lymph nodes or to the liver, although the number of events in these categories were insufficient to reach a statistical significance. In gastric cancer, CXCL12/ CXCR4 axis seems to be more strongly associated with lymphatic or hematogenous metastasis than the establishment of peritoneal deposits.

Chemotherapy for gastric cancer that recurs after adjuvant chemotherapy with S-1

We retrospectively analyzed the efficacy of chemotherapy in patients whose gastric cancer recurred after adjuvant chemotherapy with S-1. A total of 51 patients were evaluated. Twenty-one patients received S-1-containing chemotherapy as first-line treatment after recurrence [cohort A: S-1 plus cisplatin (n = 10), S-1 monotherapy (n = 7), S-1 plus irinotecan (n = 3) and S-1 plus docetaxel (n = 1)]. The other 30 patients received a non-S-1-containing regimen [cohort B: paclitaxel or docetaxel (n = 22), irinotecan plus cisplatin (n = 6) and other drugs (n = 2)]. No objective responses occurred in cohort A, while five patients achieved a partial response in cohort B (response rate, 0 versus 16%; P = 0.04). Median progression-free survival was significantly longer in cohort B than in cohort A (4.3 versus 2.3 months, P = 0.02). S-1-containing chemotherapy does not appear to be effective in patients whose gastric cancer recurs after adjuvant S-1 chemotherapy. Other chemotherapeutic agents should be evaluated in this setting.

D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer

BACKGROUND

Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia. Whether the addition of para-aortic nodal dissection (PAND) to D2 lymphadenectomy for stage T2, T3, or T4 tumors improves survival is controversial. We conducted a randomized, controlled trial at 24 hospitals in Japan to compare D2 lymphadenectomy alone with D2 lymphadenectomy plus PAND in patients undergoing gastrectomy for curable gastric cancer.

METHODS

Between July 1995 and April 2001, 523 patients with curable stage T2b, T3, or T4 gastric cancer were randomly assigned during surgery to D2 lymphadenectomy alone (263 patients) or to D2 lymphadenectomy plus PAND (260 patients). We did not permit any adjuvant therapy before the recurrence of cancer. The primary end point was overall survival.

RESULTS

The rates of surgery-related complications among patients assigned to D2 lymphadenectomy alone and those assigned to D2 lymphadenectomy plus PAND were 20.9% and 28.1%, respectively (P=0.07). There were no significant differences between the two groups in the frequencies of anastomotic leakage, pancreatic fistula, abdominal abscess, pneumonia, or death from any cause within 30 days after surgery (the rate of death was 0.8% in each group). The median operation time was 63 minutes longer and the median blood loss was 230 ml greater in the group assigned to D2 lymphadenectomy plus PAND. The 5-year overall survival rate was 69.2% for the group assigned to D2 lymphadenectomy alone and 70.3% for the group assigned to D2 lymphadenectomy plus PAND; the hazard ratio for death was 1.03 (95% confidence interval [CI], 0.77 to 1.37; P=0.85). There were no significant differences in recurrence-free survival between the two groups; the hazard ratio for recurrence was 1.08 (95% CI, 0.83 to 1.42; P=0.56).

CONCLUSIONS

As compared with D2 lymphadenectomy alone, treatment with D2 lymphadenectomy plus PAND does not improve the survival rate in curable gastric cancer. (ClinicalTrials.gov number, NCT00149279.)

D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer

BACKGROUND

Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia. Whether the addition of para-aortic nodal dissection (PAND) to D2 lymphadenectomy for stage T2, T3, or T4 tumors improves survival is controversial. We conducted a randomized, controlled trial at 24 hospitals in Japan to compare D2 lymphadenectomy alone with D2 lymphadenectomy plus PAND in patients undergoing gastrectomy for curable gastric cancer.

METHODS

Between July 1995 and April 2001, 523 patients with curable stage T2b, T3, or T4 gastric cancer were randomly assigned during surgery to D2 lymphadenectomy alone (263 patients) or to D2 lymphadenectomy plus PAND (260 patients). We did not permit any adjuvant therapy before the recurrence of cancer. The primary end point was overall survival.

RESULTS

The rates of surgery-related complications among patients assigned to D2 lymphadenectomy alone and those assigned to D2 lymphadenectomy plus PAND were 20.9% and 28.1%, respectively (P=0.07). There were no significant differences between the two groups in the frequencies of anastomotic leakage, pancreatic fistula, abdominal abscess, pneumonia, or death from any cause within 30 days after surgery (the rate of death was 0.8% in each group). The median operation time was 63 minutes longer and the median blood loss was 230 ml greater in the group assigned to D2 lymphadenectomy plus PAND. The 5-year overall survival rate was 69.2% for the group assigned to D2 lymphadenectomy alone and 70.3% for the group assigned to D2 lymphadenectomy plus PAND; the hazard ratio for death was 1.03 (95% confidence interval [CI], 0.77 to 1.37; P=0.85). There were no significant differences in recurrence-free survival between the two groups; the hazard ratio for recurrence was 1.08 (95% CI, 0.83 to 1.42; P=0.56).

CONCLUSIONS

As compared with D2 lymphadenectomy alone, treatment with D2 lymphadenectomy plus PAND does not improve the survival rate in curable gastric cancer. (ClinicalTrials.gov number, NCT00149279.)

Gastric cancer risk and erythrocyte composition of docosahexaenoic acid with anti-inflammatory effects

Infection with Helicobacter pylori is linked to inflammation and is the main cause of peptic ulcer, gastritis, and gastric malignancies. To examine associations between gastric cancer risk and the erythrocyte composition of docosahexaenoic acid (DHA), a fatty acid with anti-inflammatory and apoptosis-inducing effects, here we conducted a case-control study of 179 incident gastric cancer cases and 357 noncancer controls (matched by age, sex, and season of sample collection). Dietary information and blood samples were collected from all subjects, and erythrocyte fatty acid levels were measured using accelerated solvent extraction and gas-liquid chromatography. Gastric cancer risk did not seem to be directly associated with dietary intake of fish and n-3 highly unsaturated fatty acids (HUFAs), such as DHA, derived from fish. However, risk was inversely associated with erythrocyte compositions of n-3 HUFAs [the highest to the lowest tertile, odds ratio (OR), 0.39; 95% confidence interval (95% CI), 0.23-0.68; P(trend)<0.005] and DHA (OR, 0.47; 95% CI, 0.28-0.79; P(trend)<0.01). Particularly strong associations were noted for well-differentiated type lesions and n-3 HUFAs (OR, 0.10; 95% CI, 0.03-0.35; P(trend)=0.0005) as well as DHA (OR, 0.20; 95% CI, 0.07-0.58; P(trend)<0.01) values. In conclusion, the erythrocyte composition of DHA was found to be negatively linked to risk of gastric cancer, especially of well-differentiated adenocarcinoma. Further studies are needed to investigate mechanisms of action of DHA relevant to antitumor effects in the stomach.

Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine

BACKGROUND

Advanced gastric cancer can respond to S-1, an oral fluoropyrimidine. We tested S-1 as adjuvant chemotherapy in patients with curatively resected gastric cancer.

METHODS

Patients in Japan with stage II or III gastric cancer who underwent gastrectomy with extended (D2) lymph-node dissection were randomly assigned to undergo surgery followed by adjuvant therapy with S-1 or to undergo surgery only. In the S-1 group, administration of S-1 was started within 6 weeks after surgery and continued for 1 year. The treatment regimen consisted of 6-week cycles in which, in principle, 80 mg of oral S-1 per square meter of body-surface area per day was given for 4 weeks and no chemotherapy was given for the following 2 weeks. The primary end point was overall survival.

RESULTS

We randomly assigned 529 patients to the S-1 group and 530 patients to the surgery-only group between October 2001 and December 2004. The trial was stopped on the recommendation of the independent data and safety monitoring committee, because the first interim analysis, performed 1 year after enrollment was completed, showed that the S-1 group had a higher rate of overall survival than the surgery-only group (P=0.002). Analysis of follow-up data showed that the 3-year overall survival rate was 80.1% in the S-1 group and 70.1% in the surgery-only group. The hazard ratio for death in the S-1 group, as compared with the surgery-only group, was 0.68 (95% confidence interval, 0.52 to 0.87; P=0.003). Adverse events of grade 3 or grade 4 (defined according to the Common Toxicity Criteria of the National Cancer Institute) that were relatively common in the S-1 group were anorexia (6.0%), nausea (3.7%), and diarrhea (3.1%).

CONCLUSIONS

S-1 is an effective adjuvant treatment for East Asian patients who have undergone a D2 dissection for locally advanced gastric cancer. (ClinicalTrials.gov number, NCT00152217 [ClinicalTrials.gov].).

Intraoperative quantitative detection of CEA mRNA in the peritoneal lavage of gastric cancer patients with transcription reverse-transcription concerted (TRC) method. A comparative study with real-time quantitative RT-PCR

BACKGROUND

Real-time quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) for detection of carcinoembryonic antigen (CEA) mRNA in the peritoneal lavage of gastric cancer patients is now recognized as a useful method for the prediction of peritoneal recurrence after curative surgery. One problem with this method is that it is time-consuming and difficult to perform an intraoperative diagnosis, which is essential for intraperitoneal adjuvant chemotherapy.

PATIENTS AND METHODS

In order to overcome these problems, we introduced a transcription-reverse transcription concerted reaction (TRC), which is a non-PCR-based, isothermal mRNA amplification method, as an ultrarapid diagnostic method, and compared its diagnostic power with qRT-PCR for peritoneal washes from 112 gastric cancer patients.

RESULTS

TRC measurement could be completed within 1.0-1.5 h and showed the same detection sensitivity ranging from 10(2) to 10(6) copies for standard CEA mRNA as qRT-PCR. The CEA mRNA copy number, as determined by TRC, was well correlated with the depth of tumor invasion (pT category), similar to the result obtained using qRT-PCR. With CEA mRNA copy numbers of 100 as a TRC cut-off value, the resultant sensitivity and specificity of TRC (85% and 100%, respectively) were higher than for cytology (62%, 100%) and comparable to qRT-PCR (92%, 100%).

CONCLUSION

TRC has a diagnostic power almost equivalent to qRT-PCR but with the advantage of ultra-rapid detection. TRC would therefore be available for intraoperative sensitive diagnosis of occult tumor cells in the peritoneal cavity of gastric cancer patients.

Tolvaptan, an orally active vasopressin V(2)-receptor antagonist - pharmacology and clinical trials

Tolvaptan is an orally effective nonpeptide arginine vasopressin (AVP) V(2)-receptor antagonist synthesized by Otsuka Pharmaceutical Co., Ltd. In in vitro receptor-binding studies, tolvaptan blocked the binding of [(3)H]AVP to human V(2) receptors with 29-fold greater selectivity than that for V(1a) receptors, and showed no inhibition of V(1b) receptors. Tolvaptan inhibited not only the binding of [(3)H]AVP but also the AVP-induced production of cyclic AMP in human V(2)-receptor-expressing HeLa cells. In addition, tolvaptan has no intrinsic V(2) receptor agonistic effect. In in vivo studies, tolvaptan showed marked aquaresis in healthy and diseased animals. In rat models with acute and chronic hyponatremia, tolvaptan improved hyponatremia, resulting in the prevention of death, and improved organ water retention. Tolvaptan reduced cardiac preload without unfavorable effects on renal functions, systemic hemodynamics, or circulating neurohormones in dogs with heart failure (HF). Furthermore, in animal models of human polycystic kidney disease (PKD), tolvaptan showed a decrease in kidney weight as well as in cyst and fibrosis volume. In clinical trials including the "ACTIV in CHF" study, tolvaptan in addition to standard therapy increased fluid loss resulting in decreased body weight, and improved edema and serum sodium without affecting blood pressure, heart rate, or renal functions in patients with HF. In patients with hyponatremia, treatment with tolvaptan without fluid restriction appeared to be more effective than fluid restriction alone at correcting hyponatremia without an increase in adverse events. A phase III trial EVEREST is currently being conducted to evaluate the long-term efficacy and safety of tolvaptan in hospitalized patients with severe HF. In conclusion, tolvaptan offers the possibility of a useful therapy in hyponatremia, congestive heart failure, and various other diseases that are associated with volume overload. Furthermore, tolvaptan is also expected to be effective in the treatment of PKD.

Comparative analysis of intraperitoneal minimal free cancer cells between colorectal and gastric cancer patients using quantitative RT-PCR: possible reason for rare peritoneal recurrence in colorectal cancer

Peritoneal recurrence has a much lower incidence in colorectal cancer (CRC) patients than gastric cancer (GC) patients. The aim of this study is to clarify the reason for the rare peritoneal recurrence in CRC as compared with GC. The incidence and the abundance of free tumor cells in the peritoneal lavages from 102 CRC and 126 GC patients who underwent curative surgery were assessed by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) with carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) as genetic markers. Prognostic significance of CEA and CK20 mRNA was also compared between CRC and GC after 2 years of follow-up by Kaplan-Meyer method with overall and peritoneal recurrence-free survival as endpoints. Positivity rate and average values of CEA and CK20 mRNA in peritoneal lavages of CRC patients, which are correlated to the depth of tumor invasion (pT category), were essentially the same as those of GC cases. Overall survival was significantly (marginally) worse in CEA mRNA (CK20 mRNA)-positive CRC patients than negatives like GC. However, peritoneal recurrence-free survival was not different between CEA (CK20) mRNA-positive and -negative CRC patients, in quite contrast to GC cases. Multivariate analysis showed that CEA mRNA was an independent prognostic factor for overall survival in GC patients, but not in CRC patients. These results suggest that the rare peritoneal recurrence in CRC patients is not due to the low incidence or the small number of intraperitoneal free cancer cells, but more likely reflects due to the low-peritoneal metastatic potential of CRC cells.

Intraperitoneal paclitaxel: a possible impact of regional delivery for prevention of peritoneal carcinomatosis in patients with gastric carcinoma

BACKGROUND/AIMS

Peritoneal carcinomatosis is a common pattern of failure among gastric cancer patients. Adequate postoperative adjuvant chemotherapy could reduce the risk of this lethal recurrence.

METHODOLOGY

Intraperitoneal (IP) paclitaxel, a useful option for treatment of ovarian cancer, was tested in a phase I trial involving gastric carcinoma patients. The eligibility criteria included confirmed gastric carcinoma patients with uncontrollable ascites, Eastern Cooperative Oncology Group performance status < or = 2, adequate major organ functions, and clinical disease progression following prior treatment(s) with oral or intravenous anticancer drugs. The starting dose (Level 1) was 60 mg/m2 weekly for 3 weeks followed by a week of rest, and the treatment was to be continued for at least 2 cycles unless unacceptable toxicity occurred. Peritoneal and plasma samples were obtained 0 hour, 3 hours, 24 hours, and one week after the end of drug instillation for pharmacokinetic analysis

RESULTS

Of 4 patients enrolled, 3 were eligible and evaluable for toxicity. Three of the 4 patients failed to receive two cycles of treatment chiefly because of failure in the drug delivery, resulting in termination of the trial in the current form. Peak IP/plasma ratio of > 2000 was obtained at 3 hours after administration. Half-life of the drug ranged from 17.4 to 65.3 hours. Ascites diminished in 2 of 3 patients during the course of the treatment.

CONCLUSIONS

High intraperitoneal concentration was maintained following IP administration at 60 mg/m2. IP paclitaxel could be a promising component of radical or prophylactic treatment for the peritoneal disease when combined with concurrent or sequential systemic administration of other anticancer drugs.

Distribution of free cancer cells in the abdominal cavity suggests limitations of bursectomy as an essential component of radical surgery for gastric carcinoma

BACKGROUND

Bursectomy, which has been performed so as to resect peritoneal deposits disseminated within the omental bursa, is considered as an essential component of radical surgery for gastric carcinoma in Japan. Bursectomy has also been described in the Japanese Treatment Guidelines for Gastric Carcinoma as a mandatory procedure for the treatment of serosa-positive cancer. However, no evidence to support the prognostic significance of this procedure has been reported to date.

METHODS

Cytologic examination and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of the peritoneal washes obtained from the Douglas pouch, left subphrenic cavity, and inside the omental bursa were performed for 136 patients who underwent potentially curative surgery for gastric carcinoma.

RESULTS

Carcinoembryonic antigen (CEA) or cytokeratin (CK) 20 mRNA was detected in one or more samples from the three different sites of peritoneal washes in 43 of the 136 patients. In 14 patients, the mRNAs were detected in samples obtained from the bursa omentalis (10.3% of all patients and 32.6% of patients with positive RT-PCR results). In 12 of these 14 patients, the mRNAs were also detected in samples taken from either or both of the remaining two sites. Only in the 2 other patients was the sample only from inside the omental bursa positive for CEA.

CONCLUSION

It is unlikely that viable cancer cells disseminated into the bursa remain restricted to this cavity without migrating into the free abdominal cavity. Routine bursectomy may not be an essential procedure for resecting gastric cancer, from the viewpoint of eliminating microscopic peritoneal deposits within the omental bursa.

Gene expression of 5-fluorouracil metabolic enzymes in primary gastric cancer: correlation with drug sensitivity against 5-fluorouracil

Thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), thymidine phosphorylase (TP), and orotate phosphoribosyltransferase (OPRT) have been reported to be predictive parameters for the efficacy of fluoropyrimidine-based chemotherapy. mRNA expression of TS, DPD, TP, and OPRT were quantified by reverse-transcriptase polymerase chain reaction after harvesting cancer cells from 93 paraffin-embedded specimens of gastric cancer through laser capture microdissection. In vitro chemosensitivity testing by histoculture drug response assay was performed with surgically resected primary lesions of the same 93 patients. No significant correlation was observed between the mRNA expression and location of the tumor, histopathologic type, clinical stage, and other clinicopathologic variables, with the exception that OPRT mRNA had a weak correlation with drug sensitivity against 5FU (R=0.219, p=0.0343). OPRT was considered to have a major impact on drug sensitivity, although not sufficiently so to enable prediction of 5FU sensitivity solely based on the mRNA expression of this enzyme.

Gastric and intestinal phenotypic correlation between exocrine and endocrine components in human stomach tumors

We have previously suggested that an origin of a stomach cancer is from a progenitor cell specializing toward exocrine cell (Exo-cell) lineages. To clarify whether our hypothesis is correct or not, we analyzed the expression of Exo-cell and endocrine cell (End-cell) markers in a series of lesions for comparison. We evaluated chromogranin A (CgA) expression in 37 early and 73 advanced stomach cancers, in 30 stomach adenomas, in 8 carcinoid tumors, and in 4 endocrine cell carcinomas (ECCs) with assessment of gastric and/or intestinal (G/I) phenotypes in both Exo-cell and End-cell by immunohistochemistry. CgA expression was observed in 10.8% of the early and 16.4% of the advanced stomach cancers, respectively. The End-cell G/I phenotypes were in line with the Exo-cell counterparts in the CgA-positive stomach cancerous areas, and there was strong association between Cdx2 expression and the intestinal End-cell markers. All of the adenoma cases had the intestinal Exo-cell phenotypic expression, with the positive link between Exo-cell and End-cell G/I phenotypes. All stomach carcinoids had CgA expression but no expression of Exo-cell markers. In conclusion, most stomach cancers might develop from a progenitor cell specializing towards Exo-cell lineages, but some cases possessed both Exo-cell and End-cell markers with maturely differentiated phenotypes. In such cases, Exo-cell and End-cell phenotypes were found to correlate strongly, suggesting the possibility of histogenesis from "cancer stem cells".

In vitro chemosensitivity test to predict chemosensitivity for paclitaxel, using human gastric carcinoma tissues

BACKGROUND

Therapy guided by chemotherapy sensitivity and resistance assays may lead to rational treatment decisions. Paclitaxel, one of several new drugs for gastric carcinoma, has not been extensively evaluated by in vitro chemosensitivity tests.

METHODS

Chemosensitivity testing by histoculture drug response assay (HDRA) was performed with fresh specimens of primary tumor from 113 patients with gastric carcinoma. The test was performed in medium containing paclitaxel at three different concentrations for the initial 45 samples. Correlations between the results of chemosensitivity testing, determined at the optimal concentration, and the patients' clinicopathologic factors and outcome were then assessed for all patients.

RESULTS

By analyzing the initial 45 samples, 10 microg/ml was considered the optimal concentration of paclitaxel for this test. HDRA was successfully performed for 100 of 113 samples and chemosensitivity, calculated as the percentage of optical density of a tumor treated with anticancer drugs in relation to the optical density of the tumor cultured in the medium only, was distributed widely at this concentration. No significant correlation was observed between chemosensitivity and age, sex, clinical stage, histopathologic type, and outcome of patients with gastric carcinoma.

CONCLUSION

A histoculture drug response assay can now be performed to predict the chemosensitivity of paclitaxel at the concentration found in the current study. The accuracy of the assay to actually predict survival needs to be validated by a prospective clinical trial involving patients who have received paclitaxel in the postoperative adjuvant setting.

Influence of overweight on surgical complications for gastric cancer: results from a randomized control trial comparing D2 and extended para-aortic D3 lymphadenectomy (JCOG9501)

BACKGROUND

The impact of overweight on the outcome of gastrectomy with lymphadenectomy is controversial, and data from a well-controlled, randomized study are needed to identify a possible relationship.

METHODS

We used data from 523 patients registered for a prospective randomized trial comparing D2 and extended para-aortic D3 lymphadenectomy to compare the effects of body mass index (BMI) and the extent of lymphadenectomy for the development of general or major surgical complications (anastomotic leakage, abdominal abscess, and pancreatic fistula).

RESULTS

Seventy-seven patients were classified as overweight with BMI >or= 25, and 38 and 39 of these patients underwent a D2 or D3 lymphadenectomy, respectively. Among the 446 patients classified as nonoverweight with BMI < 25, 225 received D2 and 221 received D3 lymphadenectomy. Surgical complications, operation time, and blood loss were statistically significantly associated with BMI, and logistic regression analysis revealed that overweight directly affected the occurrence of surgical complications even after considering operation time and blood loss as intermediate factors instead of outcome variables. Among patients undergoing D2 lymphadenectomy, being overweight increased the risk for surgical complications and blood loss, whereas overweight was associated with only blood loss and operation time among patients receiving D3 lymphadenectomy.

CONCLUSIONS

Overweight increased the risk of surgical complications in patients undergoing gastrectomy both directly and indirectly through operation time and blood loss. The impact of overweight on surgical complications was more evident in patients undergoing a D2 dissection.