Estrogen Receptor Mutations as Novel Targets for Immunotherapy in Metastatic Estrogen Receptor-positive Breast Cancer.

Estrogen receptor-positive (ER+) breast cancer is not considered immunogenic and, to date, has been proven resistant to immunotherapy. Endocrine therapy remains the cornerstone of treatment for ER+ breast cancers. However, constitutively activating mutations in the estrogen receptor alpha (ESR1) gene can emerge during treatment, rendering tumors resistant to endocrine therapy. Although these mutations represent a pathway of resistance, they also represent a potential source of neoepitopes that can be targeted by immunotherapy. In this study, we investigated ESR1 mutations as novel targets for breast cancer immunotherapy. Using machine learning algorithms, we identified ESR1-derived peptides predicted to form stable complexes with HLA-A*0201. We then validated the binding affinity and stability of the top predicted peptides through in vitro binding and dissociation assays and showed that these peptides bind HLA-A*0201 with high affinity and stability. Using tetramer assays, we confirmed the presence and expansion potential of antigen-specific CTLs from healthy female donors. Finally, using in vitro cytotoxicity assays, we showed the lysis of peptide-pulsed targets and breast cancer cells expressing common ESR1 mutations by expanded antigen-specific CTLs. Ultimately, we identified five peptides derived from the three most common ESR1 mutations (D538G, Y537S, and E380Q) and their associated wild-type peptides, which were the most immunogenic. Overall, these data confirm the immunogenicity of epitopes derived from ESR1 and highlight the potential of these peptides to be targeted by novel immunotherapy strategies. SIGNIFICANCE: Estrogen receptor (ESR1) mutations have emerged as a key factor in endocrine therapy resistance. We identified and validated five novel, immunogenic ESR1-derived peptides that could be targeted through vaccine-based immunotherapy.

Sex-based differences and aging in tactile function loss in persons with type 2 diabetes.

BACKGROUND: Recent evidence of significant sex-based differences in the presentation of Type 2 Diabetes Mellitus (DM) and its complications has been found in humans, which may contribute to sex-based differences in reduced functionality and quality of life. Some functionality, such as tactile function of the hands, has significant direct impact on quality of life. The purpose of the current study was to explore the impact of DM and sex on tactile function, with consideration of variability in health state measures. RESEARCH DESIGN AND METHODS: A case-control single time point observational study from 2012-2020 in an ethnically diverse population-based community setting. The sample consists of 132 adult individuals: 70 independent community dwelling persons with DM (PwDM) and 62 age- and sex-matched controls (42 males and 90 females in total). The Semmes-Weinstein monofilament test was used to evaluate tactile sensation of the hands. RESULTS: Tactile sensation thresholds were adversely impacted by sex, age, degree of handedness, high A1c, diagnosis of DM, and neuropathy. Overall, strongly right-handed older adult males with poorly controlled DM and neuropathy possessed the poorest tactile discrimination thresholds. When self-identified minority status was included in a secondary analysis, DM diagnosis was no longer significant; negative impacts of age, neuropathy, degree of handedness, and high A1c remained significant. CONCLUSIONS: The data indicate significant impacts of male sex, age, degree of handedness, self-identified minority status, and metabolic health on the development of poor tactile sensation. This combination of modifiable and non-modifiable factors are important considerations in the monitoring and treatment of DM complications.

Hepatoid adenocarcinoma of the stomach.

Although gastric cancer occurs frequently in Japan, few cases of hepatoid adenocarcinoma, a cancer with an extremely poor prognosis, have been reported. Here, we describe a 67-year-old Japanese man referred to our hospital with suspected gastric cancer. Gastrointestinal fiberscopy revealed an elevated lesion with a central depression on the lesser curvature, extending from the antrum to the body of the stomach. On the preoperative examinations, abdominal computed tomography scan, magnetic resonance imaging, and abdominal ultrasonography revealed multiple metastases to the liver and no cirrhotic change. The serum level of alpha-fetoprotein (AFP) was markedly elevated (10,084 ng/ml). After a diagnosis of AFP-producing gastric cancer with multiple liver metastases was made, total gastrectomy, without liver resection, was performed. Microscopically, the tumor showed two main histological features. The main part of the tumor resembled moderately differentiated hepatocellular carcinoma, and the rest showed fetal-type adenocarcinoma. Some parts of the hepatoma-like lesion showed periodic acid-Schiff (PAS)-positive granules. Furthermore, the tumor showed diffuse immunohistochemical positivity for AFP, alpha-1 antitrypsin, and alpha-1 antichymotrypsin. According to these histopathological findings, the tumor was diagnosed as hepatoid adenocarcinoma of the stomach. Although anastomotic leakage occurred postoperatively and the liver metastases have increased in size, the patient remains alive 11 months after the operation. Because of the poor prognosis for this histological type of tumor, accurate diagnosis of hepatoid adenocarcinoma is important, and long-term follow-up is required. We describe this rare case of hepatoid adenocarcinoma of the stomach, and review the literature concerning the clinicopathological aspects.

Comparison between pancreatoduodenectomy and hepatopancreatoduodenectomy for bile duct cancer.

BACKGROUND/AIMS: Pancreatoduodenectomy has been accepted as a standard operative procedure for distal bile duct cancer with low operative mortality. However, hepatopancreatoduodenectomy has not been accepted as a standard treatment modality for diffuse bile duct cancer. METHODOLOGY: From December 12, 1992 to December 15, 2000, 37 patients with the diagnosis of extrahepatic bile duct adenocarcinoma (cholangiocarcinoma) underwent pancreatoduodenectomy or hepatopancreatoduodenectomy, at the department of surgery, Ibaraki Prefectural Central Hospital and the Cancer Center. The differences in indications and results of both operative procedures were investigated retrospectively. RESULTS: Thirty-day operative mortality was 0% after either pancreatoduodenectomy or hepatopancreatoduodenectomy. One- to 5-year cumulative survival rates for the 24 patients after pancreatoduodenectomy were 76.3%, 41.5%, 41.5%, 41.5%, 41.5%, respectively. One- to 4-year cumulative survival rates for the 13 patients after hepatopancreatoduodenectomy were 48.0%, 32.0%, 32.0%, 16.0%, respectively. There were no statistically significant differences between cumulative survival rates after pancreatoduodenectomy and hepatopancreatoduodenectomy either in all the patients or in patients with UICC stage IV. CONCLUSIONS: Hepatopancreatoduodenectomy should be tried for patients with diffuse bile duct cancer, because only hepatopancreatoduodenectomy has the possibility of a cure at this time.

Peripancreatic arteries in thin-section multislice helical CT.

BACKGROUND: The normal and pathologic anatomies of the peripancreatic arteries were demonstrated using thin-section multislice computed tomography (CT). METHODS: Triple-phase dynamic CT was performed in 304 consecutive patients without pancreatic pathology and in 22 patients with pancreatic carcinoma. CT angiographies images (2.5-mm collimation, multihelical pitch 3, HQ mode) and a 1.25-mm reconstruction interval were obtained with a GE Lightspeed Qx/i at 25, 40, and 80 s after bolus injection of 130-150 mL of iodinated contrast medium at a rate of 3-5 mL/s. The images were assessed mainly by the manual cine paging method. RESULTS: The anterior and posterior arcades and the dorsal pancreatic artery were frequently visualized. However, small-caliber arteries smaller than 1.5 mm in diameter, such as the pancreaticomagna, caudal pancreatic, and transverse pancreatic arteries, were infrequently visualized. In some cases, the peripancreatic arteries were very useful for differentiating the origin of tumors. CONCLUSION: Multislice helical CT enables the recognition of small peripancreatic arteries, and evaluation of these arteries should be considered when assessing tumors in the pancreaticoduodenal region.

[Ineffective and recurrent cases of thoracoscopic sympathectomy for hyperhidrosis and intractable pain].

We reported the cases of thoracoscopic sympathectomy, that is, six cases of hyperhidrosis, three of post herpetic neuralgia, and four of reflex sympathetic dystrophy, including recurrent or incompletely resected or ineffective ones. Recently this procedure for hyperhidrosis had been performed frequently because of its effectiveness, less pain, early discharge and cosmetic aspect. For an ineffective case of hyperhidrosis abdominal respiration which emphasized the exhalation and using an upper abdomen decreased the sweating. The balance of autonomic nerve system, toward parasympathetic dominant, was thought to be improved by conscious respiration. The decrease of sweating right after the operation in a case of incomplete resection indicated that intraoperative maneuver could restrict the sympathetic nerve. This procedure for a pain control could be less effective than that for hyperhidrosis, so an adequate preoperative informed consent was thought to be necessary.

[A case of spontaneous hemopneumothorax associated with uncontrolled massive bleeding after inserting thorathic drain].

A 31-year-old man admitted to our hospital complaining of right chest pain. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the right thorax. A chest tube drainage was carried out, but hemorrhagic pleural fluid was drainaged. Forty minutes later, an anemia developed and chest X-ray showed increased massive right pleural collection. Therefore, emergent surgery was performed. An operation under thoracoscopic guidance was converted into thoracotomy because of massive blood clots and fresh bleeding. A bleeding originating from the branch of 1st intercostal artery and a bulla on upper lobes were noted. The artery was coagulated with electrocoutary and ligated using Endo-loop. This artery is not congenital abnormal one but collateral expanded one of which the elastic lamina is thickened. Spontaneous hemopneumothorax is life-threatening, emergent operation should be undergone.

Pancreatoduodenectomy for locally advanced or recurrent colon cancer: report of two cases.

A 66-year-old man, who had ascending colon cancer which invaded the duodenum, pancreas, and superior mesenteric vein, underwent a curative resection including an extended right hemicolectomy, pylorus-preserving pancreatoduodenectomy, and a partial resection of the superior mesenteric vein. The pathological examination revealed adenocarcinoma of the colon, which directly invaded the duodenum and pancreas, thus causing duodenocolic fistula. Tumor infiltration to the superior mesenteric vein was not histologically proven. Two out of 40 lymph nodes were also involved. The patient is still alive and disease-free 37 months after the operation. A 72-year-old man, with a history of surgery two previous times for ascending colon cancer and its recurrence, underwent a third operation including a resection of the former ileocolic anastomosis en bloc by means of a pylorus-preserving pancreatoduodenectomy with a curative intent. The pathological examination revealed adenocarcinoma of the colon, which directly invaded the duodenum and pancreas. Seven out of 31 lymph nodes were also involved. The patient died of recurrence 24 months after the third operation. These two cases demonstrated the usefulness of a resection of the colon en bloc by means of a pancreatoduodenectomy in patients with either locally advanced colon cancer or locally advanced recurrent colon cancer.

[Treatment for advanced colorectal carcinoma with 5-fluorouracil plus low-dose leucovorin].

From July 1992 to May 1996, 16 patients with non-curative postoperative or recurrent colorectal carcinomas were treated with 5-fluorouracil (5-FU) plus leucovorin (LV) systemic chemotherapy. LV was given at a dose of 20 mg/m2/d immediately followed by 5-FU at 370 mg/m2/d. LV was given by rapid intravenous (i.v.) injection and 5-FU by rapid or drip i.v. for 5 consecutive days. Courses were repeated once every 4 weeks for two months and then once every 5 weeks. All patients took 3 or more courses. The toxicity was tolerable, but one patient needed hospitalization because of severe gastro-intestinal toxicity. We observed 3 PR cases, no CR and an overall response rate of 19%. The response duration was 6 to 8 months, averaging 7.3 months, and median survival was 12 months. It was possible to perform this chemotherapy on an outpatient basis, so we think this chemotherapy is superior to in-hospital chemotherapy considering the issue of quality of life. However, the response rate was low and its duration was short. We must investigate chemotherapy further with new and more powerful chemical modulations to increase the response rate and to prolong the response duration.

Determination of estrogen receptor in primary breast cancer using two different monoclonal antibodies, and correlation with its mRNA expression.

Estrogen receptor (ER) protein status was investigated in the MCF-7 cell line and 70 invasive ductal carcinomas of the breast. This was achieved by immunohistochemical assay (IHA) using two different monoclonal antibodies (ER-1D5 and AER311), which are able to recognize either the amino or carboxyl terminal. The staining results were assessed in terms of index score, and compared with the ERalpha mRNA expression, which was determined by reverse transcription-polymerase chain reaction for the positions of exons 5 and 7. MCF-7 showed similar immunoreactions with both antibodies, and expressed the wild-type (WT) ER mRNA coexpressing deletions of exons 5 and 7. Although there was a significant difference between the ER-1 D5 and AER311 indices in the tissue samples (20.5 +/- 27.2 and 5.7 +/- 16.4; P < 0.001), in the majority of cases ER mRNA expression patterns were similar to that of MCF-7, and WT ER mRNA was expressed in all cases that yielded PCR products. It was concluded that a number of palpable breast cancers lack the carboxyl terminal of the ER protein, regardless of WT ER mRNA expression. These results suggest that the incidence of WT ER mRNA in such cancers is lower than that in the MCF-7 cell line, or that WT ER is less stable.

Hypermethylation of the Estrogen Receptor Alpha Gene Is Not Related to Lack of Receptor Protein in Human Breast Cancer.

BACKGROUND: Expression and transcriptional activity of genes are regulated byseveral factors, including DNA methylation. We examined the frequency of DNA hypermethylation at two nucleotide positions, the proximal promoter region (PPR) in exon 1 and the distal promoter region (DPR) in exon 1' of the estrogen-receptor alpha (ER alpha) gene in human breast cancer, and the correlation between ER and progesterone receptor (PgR) status. METHODS: The frequency of hypermethylation of PPR and DPR in 124 breast cancerswas examined by the semiquantitative competitive polymerase chain reaction (COM-PCR) assay with restriction enzymes. ER and PgR proteins were analyzed by enzyme immunoassay (EIA; fmol/mg) to determine whether DNA hypermethylation influences the status of either protein. RESULTS: There were no significant differences in ER protein status between DNAmethylated and unmethylated groups for either PPR (71.2 +/- 190.1 versus 60.7 +/- 88.4) or DPR (70.0 +/- 183.6 versus 60.9 +/- 89.3). There was a significant differencein PgR protein status between these two groups for PPR (46.8 +/- 67.1 versus 169.1 +/- 394.9, P< 0.01). When one positional methylation was regarded as the criterion for hypermethylation, the frequency of hypermethylation in the ER(+)PgR(-)phenotype was significantly higher than in the ER(+)PgR(+), ER(-)PgR( +) and ER(-)PgR(-) phenotypes (72.7% versus 31.3%, 40.0% and 28.6%, P< 0.01). CONCLUSION: Hypermethylation of the 5'-upstream side of the ER alpha gene did notcorrelate with lack of ER, but did correlate with lack of PgR, and particularlywith the expression of the ER(+)PgR(-) phenotype. We conclude that DNA hypermethylation of PPR and DPR in the Er alpha gene reflects the expression of the ER target gene rather than the ER gene itself and may account for anti-estrogen resistance in ER-positive breast cancer.

Expression of Bcl-2 in human breast cancer: correlation between hormone receptor status, p53 protein accumulation and DNA strand breaks associated with apoptosis.

The expression of Bcl-2, a suppressor of apoptotic cell death, was investigated in 52 invasive carcinomas of the breast using reverse transcription-polymerase chain reaction and immunohistochemical methods. After consideration of both sets of results, 42 tumors (80.8%) were confirmed to be positive (Bcl-2(+)) and 10 (19.2%) were judged negative (Bcl-2(-)) for Bcl-2 expression. Related factors (p53 protein accumulation, hormone receptor status and apoptotic cell index) were also examined using immunohistochemical and in situ end-labeling methods to elucidate their correlations with Bcl-2 expression. Bcl-2 expression correlated significantly with the hormone receptor status, whereas it showed significant inverse correlations with p53 accumulation and the apoptotic index. It was concluded that estrogen and mutant p53 are related to the regulation of Bcl-2 expression and that the ability to prevent tumor cell death due to Bcl-2 can be developed by breast cancers.

Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy in patients undergoing pancreatoduodenectomy to promote earlier discharge from hospital.

Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy was performed in 11 consecutive patients undergoing pancreatoduodenectomy between July 1992, and July 1994, to promote earlier discharge from hospital. Although minor leakage of the pancreaticojejunostomy occurred in 4 patients, this resolved within a short period and all 11 patients were able to be discharged by the 29th postoperative day in good health and without any intubation. Follow-up abdominal X-ray and computed tomography (CT) scans proved that all 22 of the stenting tubes had spontaneously fallen out by the 176th postoperative day. No complication related to the stenting tubes occurred in any of our patients.

Application of three-dimensional spiral computed tomographic angiography prior to hepatectomy for hepatocellular carcinoma.

A newly developed method of spiral computed tomography (CT) angiography was employed for 19 consecutive hepatocellular carcinoma (HCC) patients who underwent hepatectomy. Fine images of the intrahepatic vascular structure, portal venous branches and hepatic veins, and HCC nodules were obtained in 16 patients. A more accurate and easier understanding of the relationship between the intrahepatic vascular structure and the HCC nodules was provided by this spiral CT angiography compared with any other imaging modality.

Hepatocellular carcinoma with a solitary adrenal metastasis and poor hepatic functional reserve: report of a case.

A 54-year-old man with a 15-year history of liver disease, was found by his family physician to have multiple tumors in the right lobe of the liver and a large right retroperitoneal tumor. He was referred and admitted to our institute where a preoperative diagnosis of liver cirrhosis complicated by hepatocellular carcinoma and probable right adrenal metastasis was made. Because his hepatic functional reserve was so poor, only resection of the right adrenal tumor with a splenectomy for hypersplenism and a cholecystectomy for the prevention of cholecystitis secondary to the scheduled transcatheter arterial embolization was performed. The patient was discharged in good clinical condition 5 weeks after surgery.