Difference between delayed anastomosis and early anastomosis in damage control laparotomy affecting the infusion volume and NPWT output volume: is infusion restriction necessary in delayed anastomosis? A single-center retrospective analysis.

Objectives: During temporary abdominal closure (TAC) with damage control laparotomy (DCL), infusion volume and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure. The same may also hold true for anastomosis. The aim of this research is to evaluate whether the difference between early anastomosis and delayed anastomosis in DCL is related to infusion volume and NPWT output volume. Methods: This single-center retrospective analysis targeted patients managed with TAC during emergency surgery for trauma or intra-abdominal sepsis between January 2011 and December 2019. It included patients who underwent repair/anastomosis/colostomy in the first surgery and patients who underwent intestinal resection in the first surgery followed by delayed anastomosis with no intestinal continuity. Results: Seventy-three patients were managed with TAC using NPWT, including 19 cases of repair, 17 of colostomy, and 37 of anastomosis. In 16 patients (trauma 5, sepsis 11) with early anastomosis and 21 patients (trauma 16, sepsis 5) with delayed anastomosis, there was no difference in the infusion volume (p=0.2318) or NPWT output volume (p=0.7128) 48 hours after surgery. Additionally, there was no difference in the occurrence of suture failure (p=0.8428). During the second-look surgery after 48 hours, the anastomosis was further postponed for 48% of the patients who underwent delayed anastomosis. There was no difference in the infusion volume (p=0.0783) up to the second-look surgery between the patients whose delayed anastomosis was postponed and those who underwent delayed anastomosis, but there was a tendency toward a large NPWT output volume (p=0.024) in the postponed delayed anastomosis group. Conclusion: Delayed anastomosis may be managed with the same infusion volume as that used for early anastomosis. There is also the option of postponing anastomosis if the planned delayed anastomosis is complicated. Level of evidence: Therapeutic/Care Management, Level IV.

Regulating migration of esophageal stents - management using a Sengstaken-Blakemore tube: A case report and review of literature.

Stent migration, which causes issues in stent therapy for esophageal perforations, can counteract the therapeutic effects and lead to complications. Therefore, techniques to regulate stent migration are important and lead to effective stent therapy. Here, in these cases, we placed a removable fully covered self-expandable metallic stent (FSEMS) in a 52-year-old man with suture failure after surgery to treat Boerhaave syndrome, and in a 53-year-old man with a perforation in the lower esophagus due to acute esophageal necrosis. At the same time, we nasally inserted a Sengstaken-Blakemore tube (SBT), passing it through the stent lumen. By inflating a gastric balloon, the lower end of the stent was supported. When the stent migration was confirmed, the gastric balloon was lifted slightly toward the oral side to correct the stent migration. In this manner, the therapy was completed for these two patients. Using a FSEMS and SBT is a therapeutic method for correcting stent migration and regulating the complete migration of the stent into the stomach without the patient undergoing endoscopic rearrangement of the stent. It was effective for positioning a stent crossing the esophagogastric junction.

Inhibition of PI3K suppresses propagation of drug-tolerant cancer cell subpopulations enriched by 5-fluorouracil.

Drug-tolerant cancer cell subpopulations are responsible for relapse after chemotherapy. By continuously exposing the gastric cancer cell line MKN45 to 5-FU for >100 passages, we established a 5-fluorouracil (5-FU)-tolerant line, MKN45/5FU. Orthotopic xenografts of MKN45/5FU cells in the stomach of nude mice revealed that these cells had a high potential to metastasize to sites such as the liver. Levels of phosphorylated phosphatidylinositide 3-kinase (PI3K) increased both in 5-FU-tolerant subpopulations according to the 5-FU dose, and in gastric submucosal orthotopic xenografts of MKN45/5FU cells. Sequential administration of 5-FU and a PI3K inhibitor, GDC-0941, targeted the downstream ribosomal S6 kinase phosphorylation to significantly suppress 5-FU-tolerant subpopulations and tumor propagation of orthotopic MKN45/5FU xenografts. These results suggest that administration of 5-FU followed by GDC-0941 may suppress disease relapse after 5-FU-based gastric cancer chemotherapy.

α-Amanitin Restrains Cancer Relapse from Drug-Tolerant Cell Subpopulations via TAF15.

Cancer relapse occurs with substantial frequency even after treatment with curative intent. Here we studied drug-tolerant colonies (DTCs), which are subpopulations of cancer cells that survive in the presence of drugs. Proteomic characterization of DTCs identified stemness- and epithelial-dominant subpopulations, but functional screening suggested that DTC formation was regulated at the transcriptional level independent from protein expression patterns. We consistently found that α-amanitin, an RNA polymerase II (RNAPII) inhibitor, effectively inhibited DTCs by suppressing TAF15 expression, which binds to RNA to modulate transcription and RNA processing. Sequential administration of α-amanitin and cisplatin extended overall survival in a cancer-relapse mouse model, namely peritonitis carcinomatosa. Therefore, post-treatment cancer relapse may occur through non-distinct subpopulations and may be effectively prevented by α-amanitin to disrupt transcriptional machinery, including TAF15.

[Basic Studies on Locoregional Injection of a Newly Designed Chitin Sol].

BACKGROUND: Systemic chemotherapy in advanced cancer cases often provokes serious adverse events. PURPOSE: We aimed to examine the fundamental properties and efficacy of a novel chitin sol, an anti-cancer agent with minor side effects designed to avoid the adverse effects of chemotherapy and enhance the QOL and ADL of patients. METHODS: DAC-70 was used to create the novel agent termed DAC-70 sol. The anti-proliferative activity was assayed by the WST method using different types of cell lines. The anti-cancer efficacy of the novel agent was examined using cancer-bearing mice. RESULTS: DAC-70 sol was easily injectable through a 21-G needle. The sol suppressed proliferation of the cells in vitro. Intra-tumor injection of DAC-70 sol inhibited the rapid growth of solid tumors in the mice. CDDP-loaded DAC-70 sol, CDDP/DAC-70 sol, successfully controlled malignant ascites in the mice (p<0.05). Neither recurrence nor severe complications were encountered in these animals. DISCUSSION: These basic data strongly suggest that locoregional administration of our newly designed DAC-70 sol and CDDP/DAC-70 sol is clinically useful as novel cancer chemotherapy for advanced cases. This warrants further clinical studies in cancer chemotherapy.

[Efficacy and safety of panitumumab for K-ras wild-type unresectable or recurrent colorectal cancer - a study focusing on first-line treatment].

Panitumumab was approved in June 2010 for use in the treatment of unresectable advanced/recurrent colorectal cancer. Here, we report outcomes and adverse events of panitumumab combination therapy or single-agent chemotherapy for K-ras wild-type unresectable or recurrent colorectal cancers. Our study focused on first-line treatments. The study involved 18 patients who started receiving panitumumab in October 2010. Nine patients received panitumumab as a first-line treatment; 4, as a second-line treatment; and 5, as a third-line or subsequent treatment. The overall response rate was 27.8%. Among the patients who received panitumumab as a first-line treatment, the response rate was 55.6%. Grade 1 and 2 skin disorders were common adverse events. Grade 2 interstitial pneumonia was observed in 1 patient(5.6%). Grade 3 or higher events comprised peripheral neuropathy in 1 patient(5.6%)and neutropenia in another patient(5.6%). The treatment was beneficial, and metastatic foci were resected in 3 patients. In this study, the only adverse events of Grade 3 or higher were 1 case each of peripheral neuropathy and neutropenia. Accordingly, adequate control seemed possible. The specific line of treatment that panitumumab should belong to remains controversial. However, active initiation as first-line treatment should be considered for cases in which resection of metastatic foci can be expected from tumor reductions due to panitumumab.

Hyperglycemia 3 days after esophageal cancer surgery is associated with an increased risk of postoperative infection.

PURPOSE: Postoperative hyperglycemia is associated with infectious complications after various types of surgery. Our objective was to determine whether postoperative blood glucose levels up to 1 week after highly invasive esophageal cancer surgery are associated with the incidence of postoperative infections (POIs). METHODS: We conducted a retrospective chart review of 109 consecutive thoracic esophageal squamous cell cancer patients who underwent invasive esophagectomy with thoracotomy and laparotomy. The incidence of postoperative POIs and risk factors for POIs, including postoperative blood glucose levels, were evaluated. RESULTS: Of the 109 patients, 37 (34.0 %) developed POIs. Clinically, 73.0 % of the POIs became evident on or after postoperative day 4 (median, 5.25 days; interquartile range, 3.00-9.25 days). On and after postoperative day 3, chronological changes in blood glucose levels were significantly different between two groups of patients with or without POIs, as indicated by repeated measures ANOVA (P = 0.006). Multivariate logistic regression analysis results showed that an increased blood glucose concentration on postoperative day 3 was a significant risk factor for POIs. CONCLUSIONS: Our findings suggested that postoperative hyperglycemia on postoperative day 3 was a predictive factor of POIs after highly invasive esophageal cancer surgery.

A compensatory role of NF-κB to p53 in response to 5-FU-based chemotherapy for gastric cancer cell lines.

Despite of remarkable improvement of postoperative 5-FU-based adjuvant chemotherapy, the relapse rate of gastric cancer patients who undergo curative resection followed by the adjuvant chemotherapy remains substantial. Therefore, it is important to identify prediction markers for the chemotherapeutic efficacy of 5-FU. We recently identified NF-κB as a candidate relapse prediction biomarker in gastric cancer. To evaluate the biological significance of NF-κB in the context of 5-FU-based chemotherapy, we analyzed the NF-κB-dependent biological response upon 5-FU treatment in gastric cancer cell lines. Seven genes induced by 5-FU treatment in an NF-κB-dependent manner were identified, five of which are known p53 targets. Knockdown of RELA, which encodes the p65 subunit of NF-κB, decreased both p53 and p53 target protein levels. In contrast, NF-κB was not affected by TP53 knockdown. We also demonstrated that cell lines bearing Pro/Pro homozygosity in codon72 of p53 exon4, which is important for NF-κB binding to p53, are more resistant to 5-FU than those with Arg/Arg homozygosity. We conclude that NF-κB plays an important role in the response to 5-FU treatment in gastric cancer cell lines, with a possible compensatory function of p53. These results suggest that NF-κB is a potential 5-FU-chemosensitivity prediction marker that may reflect 5-FU-induced stress-response pathways, including p53.

Contrasting expression patterns of histone mRNA and microRNA 760 in patients with gastric cancer.

PURPOSE: Recent studies revealed that both disseminated tumor cells and noncancerous cells contributed to cancer progression cooperatively in the bone marrow. Here, RNA-seq analysis of bone marrow from gastric cancer patients was performed to identify prognostic markers for gastric cancer. EXPERIMENTAL DESIGN: Bone marrow samples from eight gastric cancer patients (stages I and IV: n = 4 each) were used for RNA-seq analysis. Results were validated through quantitative real-time PCR (qRT-PCR) analysis of HIST1H3D expression in 175 bone marrow, 92 peripheral blood, and 115 primary tumor samples from gastric cancer patients. miR-760 expression was assayed using qRT-PCR in 105 bone marrow and 96 primary tumor samples. Luciferase reporter assays were performed to confirm whether histone mRNAs were direct targets of miR-760. miR-760 expression was also evaluated in noncancerous cells from gastric cancer patients. RESULTS: RNA-seq analysis of bone marrow samples from gastric cancer patients revealed higher expression of multiple histone mRNAs in stage IV patients. HIST1H3D expression in the bone marrow, peripheral blood, and primary tumor of stage IV patients was higher than that in stage I patients (P = 0.0284, 0.0243, and 0.0006, respectively). In contrast, miR-760 was downregulated in the bone marrow and primary tumor of stage IV patients compared with stage I patients (P = 0.0094 and 0.0018, respectively). Histone mRNA and miR-760 interacted directly. Furthermore, miR-760 was downregulated in noncancerous mucosa in stage IV gastric cancer patients. CONCLUSION: Histone mRNA was upregulated, whereas miR-760 was downregulated in the bone marrow and primary tumor of advanced gastric cancer patients, suggesting that the histone mRNA/miR-760 axis had a crucial role in the development of gastric cancer.

Study of alkyl organic monolayers with different molecular chain lengths directly attached to silicon.

Alkyl organic monolayers with different alkyl molecular chain lengths directly attached to silicon were prepared at 160 degrees C from 1-decene (C10), 1-dodecene (C12), 1-tetradecene (C14), 1-hexadecene (C16), and 1-octadecene (C18). These monolayers were characterized on the basis of water contact angle measurement, ellipsometry, X-ray reflectivity (XR), X-ray photoelectron spectroscopy (XPS), and grazing incidence X-ray diffraction (GIXD) to elucidate the effect of the molecular chain length on the molecular arrangement and packing density of the monolayers. Water contact angle and XPS measurements showed that C12, C14, and C16 monolayers have a comparably higher quality, while the quality of C10 and C18 monolayers is worse. GIXD revealed that the alkyl monolayers directly attached to the Si were all amorphously structured regardless of their alkyl chain length. The amorphous structure of the alkyl monolayers could be attributed to the rigid Si-C bonding, low quality of hydrogen-terminated silicon substrate, and/or low mobility of physisorbed molecules.

Coexistence of esophageal superficial carcinoma and multiple leiomyomas: A case report.

Leiomyomas are the most common benign tumors of the esophagus. They usually occur as a single lesion or as two or three nodules. Only two cases of esophageal multiple leiomyomas comprising more than 10 nodules have been reported previously. Moreover, there have been few reports of esophageal squamous cell carcinoma overlying submucosal tumors. We describe a 71-year-old man who was diagnosed as having a superficial esophageal cancer coexisting with two or three leiomyoma nodules. During surgery, 10 or more nodules that had not been evident preoperatively were palpable in the submucosal and muscular layers throughout the esophagus. As intramural metastasis of the esophageal cancer was suspected, we considered additional lymphadenectomy, but had to rule out this option because of the patient's severe anoxemia. Microscopic examination revealed that all the nodules were leiomyomas (20 lesions, up to 3 cm in diameter), and that invasion of the carcinoma cells was limited to the submucosal layer overlying a relatively large leiomyoma. This is the first report of superficial esophageal cancer coexisting with numerous solitary leiomyomas. Multiple minute leiomyomas are often misdiagnosed as intramural metastasis, and a leiomyoma at the base of a carcinoma lesion can also be misdiagnosed as tumor invasion. The present case shows that accurate diagnosis is required for the management of patients with coexisting superficial esophageal cancer and multiple leiomyomas.

Infrequent mutation of the human envoplakin gene is closely linked to the tylosis oesophageal cancer locus in sporadic oesophageal squamous cell carcinomas.

Envoplakin (EVPL) is a member of the desmosomal plaque proteins attached to desmosomal cadherin and keratin filaments. The EVPL gene has been mapped to the tylosis oesophageal cancer (TOC) locus on chromosome 17q25, where it has been demonstrated to be frequently deleted in both familial and sporadic forms of oesophageal squamous cell carcinoma (OSC). In this study, we examined EVPL gene mutations in 10 OSC cell lines and 20 sporadic OSCs using reverse transcription-polymerase chain reaction single-strand conformational analysis (RT-PCR SSCP) followed by direct sequencing. We observed one somatic mutation (GCG to ACG at codon 1104, Ala to Thr: 1/20, 5%) in the central rod domain and 5 intragenic polymorphic sites, where frequent loss of heterozygosity (LOH) (63%) was detected. No mutations were detected in the OSC cell lines. The rate of EVPL gene mutation was quite low in contrast to the frequency of LOH on the TOC locus in sporadic OSCs, and the high incidence of oesophageal cancer development in tylosis families. Our results suggest that EVPL might not be the target gene responsible for OSC, despite its strong candidacy in terms of character and localization.

Phase II study of cisplatin and 5-fluorouracil with concurrent radiotherapy in advanced squamous cell carcinoma of the esophagus: a Japan Esophageal Oncology Group (JEOG)/Japan Clinical Oncology Group trial (JCOG9516).

BACKGROUND: In Japan, concurrent chemoradiotherapy is the standard treatment for unresectable esophageal cancer. The optimal combination of chemotherapeutic agents and radiotherapy dose remains controversial. The present study consists of a phase II trial of a cisplatin (CDDP)/5-fluorouracil (5-FU) infusion with concurrent radiotherapy in patients with unresectable, advanced esophageal cancer. METHODS: Between March 13, 1996, and April 28, 1998, 60 patients with advanced squamous cell carcinoma of the thoracic esophagus having either T4 tumor or distant lymph node metastasis (M1 Lym) were enrolled in this study. CDDP 70 mg/m(2) was administered on days 1 and 29, and 5-FU 700 mg/m(2)/day was administered on days 1-4 and 29-32. Fractionated radiotherapy was performed on days 1-21 and 29-49; a total dose of 60 Gy was delivered at the rate of 2 Gy per fraction. RESULTS: The overall response rate of all the 60 registered patients was 68.3% (41/60), and the complete response rate was 15% (9/60). The median survival time was 305.5 days, and the 2-year survival rate was 31.5%. One toxicity-related death occurred. The major form of toxicity exceeding grade 2 was found to be myelosuppression; grade 4 toxicity was observed in five patients. CONCLUSION: Based on the overall response rate, the results obtained from the present trial do not appear to be promising. However, it is currently suitable for the treatment of patients with unresectable, advanced esophageal cancer because of certain clinical advantages, a higher CR rate and a lower incidence of fistula formation. A phase II/III trial will be started in order to compare low-dose continual CDDP/5-FU infusion and concurrent radiotherapy with the results obtained in this study.

Human PinX1, a potent telomerase inhibitor, is not involved in human gastrointestinal tract carcinoma.

PinX1 was isolated as a Pin2/TRF1 binding protein that also binds to the telomerase catalytic subunit hTERT. The gene is a potent telomerase inhibitor and a putative tumor suppressor since it inhibits telomerase activity and affects tumorigenicity in nude mice. This study investigated aberrations of PinX1 gene in gastrointestinal tract carcinomas (GITCs). We examined mutations, mRNA expression and promoter methylation of PinX1 gene in 15 GITC cell lines, and 20 patients with primary GITC. We found a missense mutation at codon 254 (AGC/TGC) in a colon and an esophageal carcinoma cell line, and in cancerous and matching normal tissues of 2 patients with primary GITC (10%). It might be a benign polymorphism. No hyper-methylation was found in the promoter region and the treatment by 5-Aza-2'-deoxycytidine did not affect PinX1 mRNA expression level in any of the cell lines. It was concluded that the human PinX1 does not affect tumorigenesis of human GITC.

[Perioperative nutrition for gastrointestinal surgery].

In elective gastrointestinal (GI) surgery, the patients' nutritional status should be assessed and if protein-energy malnutrition exists, preoperative nutritional support should be scheduled 7 to 14 days before surgery. In malnourished patients in particular, preoperative nutrition with total parenteral nutrition (TPN) reduces postoperative complication rates of infection. Preoperative enteral nutrition (EN) is considered to be as effective as TPN in improving postoperative surgical outcome. Many prospective randomized trials or meta-analyses comparing postoperative EN and TPN have revealed that postoperative EN improves surgical outcomes and lowers postoperative complication rates of infection to a degree similar to TPN. Although two recent prospective multicenter randomized trials in malnourished patients undergoing elective GI cancer surgery are controversial, no evidence that EN was less effective than TPN was recognized. Thus postoperative EN, prior to TPN, is recommended in patients with malnutrition or insufficient oral intake for 7 days or more after surgery. When TPN is administered, hyperglycemia due to overfeeding should be carefully controlled. Patients who undergo distal gastrectomy or colectomy can start oral intake 3 to 4 days after surgery, with pertinent peripheral infusion. Immunonutrition containing immune-enhancing nutrients such as arginine, n-3 polyunsaturated fatty acid, glutamine, etc., especially administered preoperatively, is a promising nutritional therapy for reducing postoperative infectious complications.

Surgery plus chemotherapy compared with surgery alone for localized squamous cell carcinoma of the thoracic esophagus: a Japan Clinical Oncology Group Study--JCOG9204.

PURPOSE: We performed a multicenter randomized controlled trial to determine whether postoperative adjuvant chemotherapy improves outcome in patients with esophageal squamous cell carcinoma undergoing radical surgery. PATIENTS AND METHODS: Patients undergoing transthoracic esophagectomy with lymphadenectomy between July 1992 and January 1997 at 17 institutions were randomly assigned to receive surgery alone or surgery plus chemotherapy including two courses of cisplatin (80 mg/m2 of body-surface area x 1 day) and fluorouracil (800 mg/m2 x 5 days) within 2 months after surgery. Adaptive stratification factors were institution and lymph node status (pN0 versus pN1). The primary end point was disease-free survival. RESULTS: Of the 242 patients, 122 were assigned to surgery alone, and 120 to surgery plus chemotherapy. In the surgery plus chemotherapy group, 91 patients (75%) received both full courses of chemotherapy; grade 3 or 4 hematologic or nonhematologic toxicities were limited. The 5-year disease-free survival rate was 45% with surgery alone, and 55% with surgery plus chemotherapy (one-sided log-rank, P =.037). The 5-year overall survival rate was 52% and 61%, respectively (P =.13). Risk reduction by postoperative chemotherapy was remarkable in the subgroup with lymph node metastasis. CONCLUSION: Postoperative adjuvant chemotherapy with cisplatin and fluorouracil is better able to prevent relapse in patients with esophageal cancer than surgery alone.

A rapid biosensor chip assay for measuring of telomerase activity using surface plasmon resonance.

Considerable interest has been focused on telomerase because of its potential use in assays for cancer diagnosis, and for anti-telomerase drugs as a strategy for cancer chemotherapy. A number of assays based on the polymerase chain reaction (PCR) have been developed for evaluation of telomerase activity. To overcome the disadvantages of the conventional telomerase assay [telomeric repeat amplification protocol (TRAP)] related to PCR artifacts and troublesome post-PCR procedures, we have developed a telomeric repeat elongation (TRE) assay which directly measures telomerase activity as the telomeric elongation rate by biosensor technology using surface plasmon resonance (SPR). 5'-Biotinylated oligomers containing telomeric repeats were immobilized on streptavidin-pretreated dextran sensor surfaces in situ using the BIACORE apparatus. Subsequently, the oligomers associated with the telomerase extracts were elongated in the BIACORE apparatus. The rate of TRE was calculated by measuring the SPR signals. We examined elongation rates by the TRE assay in 18 cancer and three normal human fibroblast cell lines, and 12 human primary carcinomas and matching normal tissues. The elongation rates increased in a concentration- and time-dependent manner. Those of cancer cells were two to 10 times higher than fibroblast cell lines and normal tissues. Telomerase activities and its inhibitory effects of anti-telomerase agents as measured by both the TRE and TRAP assays showed a good correlation. Our assay allows precise quantitative comparison of a wide range of human cells from somatic cells to carcinoma cells. TRE assay is suitable for practical use in the assessment of telomerase activity in preclinical and clinical trials of telomerase-based therapies, because of its reproducibility, rapidity and simplicity.

Failure in presumption of residual disease by quantification of FDG uptake in esophageal squamous cell carcinoma immediately after radiotherapy.

To assess whether differentiation is possible between residual disease and complete response, 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography was performed in 17 cases of primary squamous cell carcinoma of the thoracic esophagus before (five control cases) or immediately after full-dose irradiation (12 treated cases). The FDG counts in the esophageal tumors were corrected by the dose of injected isotope and the weight of the patient, to produce a standardized uptake value (SUV). Endoscopy for post-treatment evaluation showed almost complete clearance of the tumor in seven treated cases (good-responders) and apparent residual tumor in the other five cases (poor-responders). There was a significant difference in the average median SUV between the controls and the treated (8.1 +/- 1.6 vs. 3.3 +/- 1.1), and between the poor-responders and good-responders (4.1 +/- 0.8 vs. 2.7 +/- 0.9). Three of the good-responders showed locoregional recurrence after four, six, and 18 months. Among the good-responders, the SUV of the cases of local recurrence was not inevitably higher than that of the others. The rate of FDG uptake in irradiated esophageal cancer approximately represents tumor response to radiotherapy, but it seemed impossible to differentiate residual disease from complete response.