High therapeutic potential for systemic delivery of a liposome-conjugated herpes simplex virus.

PURPOSE: Oncolytic viral therapy is a newly developed modality to treat tumors. Many clinical trials worldwide have examined the efficacy of locally injected oncolytic viruses. However, systemic intravascular injections are limited by the humoral immune response, which dramatically decreases the level of infection. To overcome this limitation, we encapsulated the oncolytic virus in liposomes. METHODS: The infectious properties of the herpes simplex virus type 1 (HSV-1) mutant, hrR3, with or without liposomes in the presence of neutralizing antibodies were evaluated using replication and cytotoxicity assays in vitro. To evaluate the efficacy of intravascular virus therapy with liposomes in the presence of neutralizing antibodies, immunized mice bearing multiple liver metastases were intraportally or peritoneally administered hrR3 or hrR3 complexed with liposomes. RESULTS: Anti-HSV antibodies attenuated the infectiousness and cytotoxicity of hrR3, whereas hrR3/liposome complexes were not attenuated by these anti-HSV antibodies. Although the survival rate of non-immunized mice treated with hrR3 alone was similar to that of mice treated with the hrR3/liposome complexes, the survival rates of immunized mice treated with hrR3 alone were significantly reduced compared to mice treated with the hrR3/liposome complexes. CONCLUSIONS: This systemic intravascular delivery of hrR3/liposome complexes in the presence of pre-existing neutralizing antibodies is effective to treat multiple liver metastases.

Pancreatic head resection with segmental duodenectomy for pancreatic neoplasms.

BACKGROUND/PURPOSE: We have experienced 67 cases of pancreatic head resection with segmental duodenectomy (PHRSD) for benign or low-grade malignant tumor of the pancreatic head region. Here we introduce our operative technique for these 67 cases. METHODS: Pancreatic head resection is performed with segmental duodenectomy including minor and major papilla. By conserving the right gastric artery and the gastroduodenal artery, 5-7 cm of the first portion of the duodenum is preserved with good arterial circulation. In addition, by conserving the anterior inferior pancreatoduodenal artery, the third portion and anal side or the second portion of the duodenum are preserved with good arterial circulation. Cholecystectomy is performed. The procedure is completed by resection of the pancreatic head with 3-4 cm of segmental duodenectomy including minor and major papilla. Reconstruction of the alimentary tract is performed with pancreatogastrostomy, end-to-end duodenoduodenostomy and end-to-side choledochoduodenostomy. RESULTS: In 67 cases with diseases of the pancreatic head region, chiefly intraductal papillary mucinous neoplasms, this procedure was successfully performed without operative or hospital death. Postoperative quality of life was quite satisfactory. CONCLUSION: Total resection of the pancreatic head can be performed safely and effectively by this procedure.

Leukemia inhibitory factor receptor (LIFR) is detected as a novel suppressor gene of hepatocellular carcinoma using double-combination array.

Hepatocellular carcinoma (HCC) is one of the world's top five causes of cancer-related deaths and treatment options are limited in this type of cancer. In the present study, we attempt to identify the novel suppressor genes of HCC using a double-combination array we designed. Leukemia inhibitory factor receptor (LIFR) is one of suppressor genes using this method. We found that 23 of 48 (47.9%) tumor tissues showed promoter hypermethylation of LIFR gene, and the expression level was clearly reduced in tumor tissues (P<0.0001). The present study suggests that our method is a meaning technique able to detect novel genes and that LIFR gene is a new suppressor gene of HCC.

Middle pancreatectomy: safety and long-term results.

BACKGROUND: Pancreaticoduodenectomy and distal pancreatectomy for lesions of the neck or body of the pancreas sacrifice a large amount of normal pancreatic tissue. Middle pancreatectomy (MP) is a parenchyma sparing technique that reduces the risk of postoperative endocrine and exocrine insufficiency. This study aims to evaluate the perioperative and long-term results of MP and to clarify whether MP can be performed with outcomes comparable with traditional pancreatectomies. METHOD: Twenty-six patients who underwent MP for benign or low-grade malignant tumor of the pancreas between 1991 and 2006 at the Department of Surgery II, Nagoya University Graduate School of Medicine, were identified. Their outcomes were compared with 2 separate control groups, 35 left-side pancreatectomies (LSP) and 60 right-side pancreatectomies (RSP). RESULTS: The mean operating time of the MP group was 295 minutes, which was significantly shorter than that for RSP (P=.0001). The rate of pancreatic fistula formation was higher in the MP group than in the 2 control groups, although the differences did not reach statistical significance. After a mean follow-up of 71 months, postoperative endocrine function was equivalent to the pre-operative values in the MP group, and none of the patients developed diabetes mellitus postoperatively. Only 1 patient in the MP group required enzyme substitution postoperatively for exocrine insufficiency. The MP group was inclined to be superior to the other 2 control groups in terms of postoperative nutritional status. CONCLUSION: Middle pancreatectomy is a reasonable technique that is indicated for selected patients with benign or low malignant tumors in the neck and body of the pancreas. Middle pancreatectomy seems to result in better preservation of exocrine and endocrine functions as well as in better nutritional status postoperatively.

Detection of metallothionein 1G as a methylated tumor suppressor gene in human hepatocellular carcinoma using a novel method of double combination array analysis.

Gene expression profiling or karyotyping analysis has made it possible to identify novel genes with altered expressions or copy numbers that have not been previously reported in liver cancer. On the same HCC sample, we performed double array analysis, both expression profiling and karyotyping analysis using a single nucleotide polymorphism (SNP) array in an attempt to find a novel tumor suppressor gene for its prognostic marker. We conducted expression array and SNP chip array using tumor and corresponding non-tumor tissues from the resected liver specimen of a 68-year-old woman who had chronic hepatitis type C. Additionally, we performed quantitative real-time reverse transcription polymerase chain reaction (PCR) and methylation-specific PCR (MSP) for gene detection using specimens from 48 patients with HCC, and investigated their correlation with the prognosis. Metallothionein (MT) 1G gene located on 16q13 showed a decreased expression in tumor tissue. The copy number by SNP chip array revealed no loss of heterozygosity since no deletions were detected in 16q13, and HCC tissue showed AB call in both SNPs next to MT1G. In quantitative real-time PCR using 48 HCC clinical samples, mRNA expression of MT1G decreased significantly compared with that in corresponding non-cancerous liver tissues (p<0.0323). Twenty-nine (60.4%) of 48 HCCs gave a positive result in MSP, indicating a poorer prognosis than the negative group, although the difference was not significant (p<0.0978). Our results indicated that MT1G acts as a tumor suppressor gene in HCC. Moreover, findings suggested that the mechanisms of MT1G silencing are related to promoter hypermethylation.

Prognostic factors for survival after extended pancreatectomy for pancreatic head cancer: influence of resection margin status on survival.

OBJECTIVES: Although a positive resection margin has been reported to be a strong prognostic factor after resection for pancreatic cancer, several studies indicated that resection status did not independently affect survival. The aim of this study was to examine the influence of resection margin status on survival after extended radical resection for pancreatic head cancer. METHODS: One hundred thirty-eight cases of pancreatoduodenectomy and 38 cases of pylorus-preserving pancreatoduodenectomy for invasive ductal carcinoma of the pancreas were retrospectively analyzed. RESULTS: The resection margins were negative (R0) in 115 patients (65.3%), microscopically positive (R1) in 38 patients (21.6%), and grossly positive (R2) in 23 patients (13.1%). Patients with R1 resection survived significantly shorter (median survival time [MST], 9.4 months) than R0 resection patients (MST, 15.2 months) but survived longer than R2 resection patients (MST, 6.2 months). By multivariate analysis, R2 resection, together with lymph node metastasis, portal venous system, and extrapancreatic nerve plexus invasions, independently affected the overall survival, but R1 resection was not significantly influential. CONCLUSIONS: R2 resection was an independent predictor of poor prognosis after pancreatoduodenectomy/pylorus-preserving pancreatoduodenectomy, whereas R1 resection did not independently affect the survival.

Autologous blood storage before hepatectomy for hepatocellular carcinoma.

BACKGROUND/AIMS: Perioperative homologous blood transfusion (HBT) has been reported to be a significant prognostic factor for recurrence in hepatocellular carcinoma (HCC) patients after hepatectomy. Autologous blood storage (ABS) has been used to avoid perioperative HBT. The aim of this study was to evaluate the benefit of ABS before the surgery in HCC patients. METHODOLOGY: We retrospectively analyzed 196 patients undergoing hepatectomy for HCC between January 1991 and December 2000. ABS was employed in 113 patients (ABS group), and the remaining 83 patients underwent hepatectomy without ABS (non-ABS group). RESULTS: The overall survival rates in patients who required HBT were significantly lower than in patients operated without HBT (P=0.0001). The need for HBT was significantly less frequent in the ABS group (43 of 113, 38.1%) than in the non-ABS group (51 of 83, 61.4%) (P=0.0012). In multivariate analysis, HBT and multiple HCCs were found to independently affect the overall survival. The differences of overall survival rates between the ABS group and the non-ABS group were not statistically significant (P=0.1063). CONCLUSIONS: ABS significantly reduced the HBT requirement in HCC patients undergoing hepatectomy. Although perioperative HBT adversely affected the overall survival in HCC patients, ABS was not significantly influential on survival.

Pancreatic cancer with distant metastases: a contraindication for radical surgery?

BACKGROUND/AIMS: The purpose of this study was to analyze cases of resected pancreatic cancer with distant metastasis (M1) and to review the surgical indication for these patients. METHODOLOGY: Between July 1981 and December 2007, 542 patients with pancreatic cancer underwent surgery at the Department of Surgery II, Nagoya University. These patients included 48 cases of paraaortic lymph node metastases, 11 cases of hepatic metastases and 6 cases of peritoneal metastases. The overall survival rates were evaluated using the Kaplan-Meier method. RESULTS: Overall survival in patients stratified by M0 and M1 showed significant differences between M0 and M1 cases. As for hepatic metastases and peritoneal metastases, no significant difference in survival was observed between resected and unresected cases. However, survival in cases of paraaortic lymph node metastases was better than that in unresected cases, although this observation was not statistically significant. CONCLUSIONS: Hepatic or peritoneal metastases are contraindications for radical surgery for pancreatic cancer. On the other hand, patients with paraaortic lymph node metastases are relatively promising targets for radical surgery, and radical resection with extended lymphadenectomy remain an option for these patients.

Nonfunctioning neuroendocrine pancreatic tumors: our experience and management.

BACKGROUND AND PURPOSE: We present our experience in the treatment of nonfunctioning neuroendocrine pancreatic tumors (NFNPTs) to define the clinical and pathological characteristics and to suggest proper management. METHODS: The records of 17 patients with NFNPTs operated on between 1998 and 2008 were retrospectively reviewed, and all tumors were classified clinicopathologically as benign, uncertain, and malignant, based on the World Health Organization (WHO) classification of neuroendocrine tumors. RESULTS: There were four benign, six uncertain, and seven malignant NFNPTs. The most frequent symptoms were abdominal pain (five patients) and obstructive jaundice (one patient). Most of these symptomatic patients had malignant tumors. Mean tumor size of benign, uncertain, and malignant tumors were 1.0 +/- 0.3, 3.2 +/- 1.6, and 5.3 +/- 2.4 cm, respectively. Metastatic lesions of malignant tumors were lymph node (six patients), liver (four patients), and adrenal gland (one patient). Six of seven patients with malignant tumors underwent curative rejection. There were recurrences in four of six patients with curatively rejected malignant tumors. Two patients underwent more rejection, three patients received systemic chemotherapy, and two patients underwent radiofrequency ablation and transcatheter arterial chemoembolization for liver metastases. Survival of patients with malignant tumors was significantly shorter than that of patients with benign and uncertain tumors. However, three patients with malignant tumors had long survival of more than 3 years, even with metastases or recurrences. CONCLUSIONS: Aggressive surgical resection should be performed in patients with resectable NFNPTs, even with metastases. Even when a tumor was unresectable or there were recurrences, long-time palliation could be achieved by a multidisciplinary approach.

The tumor suppressor NPRL2 in hepatocellular carcinoma plays an important role in progression and can be served as an independent prognostic factor.

BACKGROUND/AIMS: Hepatocarcinogenesis is a multifactorial, multistep process that involves the activation of oncogenes or the inactivation of tumor suppressor genes throughout the different stages of hepatocellular carcinoma (HCC) progression. NPRL2 is one of the candidate tumor suppressor genes identified on chromosome 3p21.3, a region which frequently contains genetic abnormalities found in the early stages of the development of various human cancers. In the current study, we aimed to evaluate NPRL2 expression in HCC and to explore the prognostic significance of NPRL2. METHOD: We investigated NPRL2 mRNA expression in 70 HCC specimens, using quantitative real-time reverse transcription polymerase chain reaction analysis, and the correlation between NPRL2 expression and clinicopathologic parameters. RESULTS: NPRL2 mRNA was found to be expressed equally in both HCC tissues and corresponding non-cancerous liver tissues. However, higher NPRL2 expression correlated significantly with tumor size (P = 0.0062) and serum PIVKA-II levels (P = 0.0002). Univariate and multivariate analyses revealed that higher NPRL2 mRNA expression was an independent prognostic factor for overall survival (risk ratio 0.39; P < 0.0001). CONCLUSION: Our results suggest that NPRL2 mRNA expression has prognostic significance for the survival of patients with HCC.

Considerations for intravascular administration of oncolytic herpes virus for the treatment of multiple liver metastases.

PURPOSE: Oncolytic viral therapy is a newly developed modality for treating tumors. Many clinical trials using oncolytic virus have been performed worldwide, but most of them have used local injection in the tumor. Determination of the effect and safety of intravascular virus injection instead of local injection is necessary for clinical use against multiple liver metastases and systemic metastases. METHODS: To evaluate the efficacy and safety of intravascular virus therapy, mice bearing multiple liver metastases were treated by intraportal or intravenous administration of the herpes simplex virus type 1 (HSV-1) mutant, hrR3. Mice treated with hrR3 were killed and organs were harvested for lacZ staining and PCR analysis. Inactivation of oncolytic virus in bloodstream was assessed by neutralization assay in vitro. Infectious activity of hrR3 with vascular endothelial cells was evaluated by replication and cytotoxicity assay. RESULTS: The survival rate of animals treated by hrR3 was significantly improved compared with the untreated group. lacZ staining and PCR analysis demonstrated detectable virus in the tumor but not in normal tissue or other organs except for the adrenal glands. We also showed that vascular endothelial cells allowed virus replication, while normal hepatocytes did not, and human anti-HSV antibody revealed attenuation of the infectious activity of hrR3. CONCLUSIONS: Intravascular delivery of hrR3 is effective in treating multiple liver metastases, however, several points must be kept in mind at the time of human clinical trials using intravascular virus administration in order to avoid critical side effects.

Pancreatic cancer with paraaortic lymph node metastasis: a contraindication for radical surgery?

OBJECTIVES: The purpose of this study was to determine the operative indications for pancreatic cancer with paraaortic lymph node metastases (No. 16 [+]). METHODS: Between July 1981 and March 2007, 335 patients with pancreatic cancer including 45 No. 16 (+) patients underwent extended radical surgery at the Department of Surgery II, Nagoya University. The overall survival rates and clinicopathological parameters were analyzed using univariate and multivariate analyses. RESULTS: Although there was no significant difference in survival between the No. 16 (+) patients and the unresectable cases, there were some long-term survivors among the No. 16 (+) patients. Multivariate analysis of the No. 16 (+) patients identified age (59 years or younger), tumor size (>4 cm), and pathologically confirmed portal invasion (pPV[+]) as independent prognostic factors. The survival of No. 16 (+) patients without these factors was significantly better than the unresectable cases. The survival of patients with only 1 metastatic paraaortic lymph node also was significantly better than the unresectable cases, and tended to be better than those with more than 2 metastatic nodes. CONCLUSIONS: No. 16 (+) pancreatic cancer patients with age 60 years or older, tumor size 4 cm or less, and pPV(-) may benefit from resection.

Correlations of the expression of vascular endothelial growth factor B and its isoforms in hepatocellular carcinoma with clinico-pathological parameters.

BACKGROUND: The vascular endothelial growth factor (VEGF) is involved in the growth of cancer cells through angiogenesis. At present the role of VEGF-B has not been clarified completely. We investigated correlations of the expression of VEGF-B and its isoforms, VEGF-B167 and VEGF-B186, by alternative splicing in hepatocellular carcinoma (HCC) with the pathological findings and prognosis. METHODS: Forty-eight patients with HCC were investigated. We examined the mRNA expression of total VEGF-B, VEGF-B167 and VEGF-B186 in primary HCC and non-cancerous tissues using quantitative real-time reverse transcription polymerase chain reaction (RT-PCR) analysis. RESULTS: In 16 (33.3%) of 48 HCCs, the expression of total VEGF-B increased compared with the corresponding non-cancerous liver tissues. Regarding the isoforms, the expression of VEGF-B167 and VEGF-B186 was increased in 17 (35.4%) of 48 and 33 (68.75%) of 48 HCCs, respectively. Cases with high expression level of total VEGF-B in HCC significantly correlated with the advanced pathological stage (P < 0.018), tumor multiplicity (P < 0.033), vascular invasion (P < 0.045) and lack of capsule formation (P < 0.027). The result in VEGF-B167 was similar to total VEGF-B. CONCLUSIONS: Our results indicated that the expression of VEGF-B is correlated with tumor growth and invasiveness in HCC. VEGF-B167 seemed to be the clinically dominant isoform.

Intra-operative application of real-time tissue elastography for the diagnosis of liver tumours.

OBJECTIVE: Real-time tissue elastography (RTE) has made it possible to visualize tissue elasticity. The aim of this study was to evaluate the usefulness of RTE for the differential diagnosis of liver tumours during surgical exploration. METHODS: Fifty-five liver tumours in 44 patients were examined with RTE, concomitant with routine intra-operative ultrasonography. Elasticity images were classified into four types, from type A (even strain) to type D (no strain), according to the distribution and the degree of the strain contrasted with that of the surrounding liver [elasticity type of liver tumour (ETLT)]. We evaluated the consistency of the findings of RTE with the pathological diagnosis as a reference standard. RESULTS: All malignant lesions showed various degrees of strain reduction in the tumour tissue. Twenty-one of 22 hepatocellular carcinomas (HCCs) were classified as type B with a sensitivity of 95.5%, a specificity of 90.9% and an accuracy of 92.7%, while all 24 metastatic adenocarcinomas were classified as either type C or type D with a sensitivity of 100%, a specificity of 80.6% and an accuracy of 89.1%. CONCLUSION: Application of RTE in surgical exploration provided significant information about the elasticity of liver tumours. RTE, using a new criterion, ETLT, enabled us to distinguish rather accurately between two common malignancies: HCC and metastatic adenocarcinoma.

Cystic lymphangioma of the gallbladder: report of a case.

Abdominal lymphangioma is usually diagnosed within the first 2 years of life and is extremely rare in adults. The most common location of abdominal lymphangioma is the mesentery, but there are sporadic reports of its development in the gallbladder. A 66-year-old woman was found to have a cystic lesion near the gallbladder. Preoperative studies, including endoscopic ultrasonography, computed tomography, and magnetic resonance imaging, showed a tumor with multilocular cystic structure, originating in the gallbladder fossa. The patient underwent exploratory laparotomy, and the mass was resected en bloc with the gallbladder, as there was no evidence of malignancy on intraoperative ultrasonography. Macroscopically, the tumor was a multilocular cystic mass, 6 x 3 x 2 cm in size, with a rough, sponge-like appearance. Histologically, the cystic tumor was diagnosed as a lymphangioma, originating in the gallbladder. To our knowledge, only three other cases of a cystic lymphangioma originating in the gallbladder have been reported in the medical literature of the world.

Effects of tumor selective replication-competent herpes viruses in combination with gemcitabine on pancreatic cancer.

PURPOSE: Pancreatic cancer still has a poor prognosis, even if aggressive therapy is pursued. Currently, new modalities of oncolytic virus therapy are being tested against this cancer. The combination of one of two representative mutant herpes simplex viruses (R3616: gamma(1)34.5 inactivated, hrR3: UL39 inactivated) with a standard anti-pancreatic cancer chemotherapy drug (gemcitabine), was investigated in this study. EXPERIMENTAL DESIGN: The intracellular concentration of ribonucleotide reductase was estimated by Western blotting. The effect of gemcitabine on viral replication and the total cytotoxic effect of the combination therapy were investigated on pancreatic cancer cell lines. We compared the results of two oncolytic viruses, R3616 and hrR3. A mouse model of pancreatic cancer with peritoneal dissemination was used to evaluate the in vivo effect of the combination therapy. RESULTS: Although the replication of both viruses was inhibited by gemcitabine, the combination caused more tumor cell cytotoxicity than did virus alone in vitro. The results with R3616 were more striking. Although the difference was not statistically significant, R3616 with gemcitabine had a greater effect than did R3616 alone, while hrR3 with gemcitabine had a weaker effect than did hrR3 alone in vivo experiments. CONCLUSION: The combination of oncolytic virus with gemcitabine is a promising new strategy against advanced pancreatic cancer. Each virus has different functional characteristics, and can affect the results of the combination of viruses and chemotherapy drugs. The results indicate that there is a complicated interaction among viruses, cells, and chemotherapy drugs and that the best combination of oncolytic virus and chemotherapeutic agents should be studied more extensively before embarking on a clinical trial.

Clinical implications of peritoneal cytology in potentially resectable pancreatic cancer: positive peritoneal cytology may not confer an adverse prognosis.

OBJECTIVES: To determine the value of peritoneal washing cytology (CY) in determining resectability of pancreatic cancer. SUMMARY BACKGROUND DATA: CY has been used widely in the diagnosis and staging of several cancers. However, its predictive value in identifying potentially resectable pancreatic cancer is undetermined. METHODS: Peritoneal washing samples were collected from 233 patients with pancreatic cancer between June 1991 and August 2006. A total of 157 patients had resectable and 76 had unresectable lesions. Correlations between CY status and clinicopathologic parameters with overall survival rates were analyzed. RESULTS: Malignant cells were identified in samples from 21 patients (13.4%) with resectable tumors and 27 patients (35.5%) with unresectable tumors. CY+ was more frequent in large tumors (> or =2 cm) than small tumors (<2 cm; P = 0.034). CY status did not correlate with any other clinicopathologic parameter. The overall survival of CY+ patients was worse than that of CY- patients (P = 0.047). Median survival following resection was 13.6 months for CY+ patients and 13.5 months for CY- patients. Among the patients who had unresectable lesions, median survival time was 5.9 months for CY+ and 6.1 months for CY- patients. However, among CY+ patients, those who underwent resection lived longer than those who did not (P = 0.019). CONCLUSIONS: Cytologic status has little predictive value for survival, and patients whose pancreatic cancer would otherwise be considered resectable should not be denied curative resection solely because they are CY+.

Frequent promoter methylation of M-cadherin in hepatocellular carcinoma is associated with poor prognosis.

BACKGROUND: Many cadherins (CDH) are associated with various types of cancer and their genetic and epigenetic alterations might be involved in carcinogenesis. MATERIALS AND METHODS: We examined the methylation status of CDH genes in primary hepatocellular carcinoma (HCC) and corresponding noncancerous liver tissues derived from 47 patients, and evaluated the correlation with clinicopathological parameters. RESULTS: Hypermethylation was detected at a ratio ranging from 0% to 55.3%. In particular, M-cadherin (CDH15) was the most hypermethylated of 7 CDH genes. Patients with methylated M-cadherin had shorter 5-year survival rates than patients with unmethylated M-cadherin (overall survival rates, 67.4% vs. 82.7%; p = 0.0167) when assessed using Kaplan-Meier curves. Multivariate analysis revealed that M-cadherin methylation status was an independent predictor of survival. CONCLUSION: We found that M-cadherin methylation status has prognostic significance for the poorer survival of patients with HCC. This is the first definitive report of a correlation between M-cadherin and the prognosis of patients with HCC.