Satoshi Nishizuka

Ten‐year experience of totally laparoscopic liver resection in a single institution

Recent developments in liver surgery include the introduction of laparoscopic liver resection. The aim of the present study was to review a single institutions 10‐year experience of totally laparoscopic liver resection (TLLR).

Promoter Methylation Status of E-Cadherin, hMLH1, and p16 Genes in Nonneoplastic Gastric Epithelia

Silencing of tumor suppressor and tumor-related genes by hypermethylation at promoter CpG islands is one of the major events in human tumorigenesis. Promoter methylation is also present in nonneoplastic cells as an age-related tissue-specific phenomenon that precedes the development of neoplasia. To clarify the significance of promoter methylation in nonneoplastic gastric epithelia as a precancerous signal, we investigated promoter methylation status of E-cadherin, hMLH1, and p16 genes in nonneoplastic cells of various organs obtained at autopsy, and compared the results with those of nonneoplastic epithelia of a cancerous stomach. Methylation of these genes was not seen in nonneoplastic cells of organs from people who were 22 years and younger (0%, 0 of 6). In contrast, E-cadherin and p16 were methylated in nonneoplastic gastric epithelia of persons who were 45 years or older. The numbers were 86% (12 of 14) and 29% (4 of 14), respectively. E-cadherin methylation occurred preferentially in the intestines, whereas p16 methylation was almost restricted to the stomach. For samples obtained from patients with stomach cancer, methylation was frequently observed in both neoplastic and corresponding nonneoplastic gastric epithelia: 47% (44 of 94) and 67% (63 of 94) for E-cadherin, 32% (30 of 94) and 24% (23 of 94) for hMLH1, and 22% (21 of 94) and 44% (41 of 94) for p16, respectively. hMLH1 methylation was not seen in nonneoplastic gastric epithelia from autopsy samples but occurred significantly in samples from nonneoplastic tissues of individuals with stomach cancer. Therefore, detection of hMLH1 methylation in nonneoplastic gastric epithelia may be useful for screening patients who may be at risk of developing gastric cancer.

Mutations in mitochondrial control region DNA in gastric tumours of Japanese patients.

The non-coding control region of mitochondrial DNA (mtDNA), containing the hypervariable regions HV1 and HV2 and the D-loop region, was screened for mutations in 45 gastric tumours (15 tumours each of adenoma, differentiated adenocarcinoma and undifferentiated carcinoma). We found mutations in two of the 45 tumours (4%); a 1 bp A deletion at nucleotide position 248 in a differentiated adenocarcinoma and a G to A transition at nucleotide position 16,129 in an adenoma. We also observed 10 polymorphisms, four of which were not previously recorded. Both mtDNA mutations were present in replication error negative (RER-) tumours. Short mono- or dinucleotide repeats in the control region, such as (C)7, (A)5 or (CA)5, were not altered regardless of nuclear genetic instability. In summary, mtDNA is mutated in a subset of benign and malignant gastric tumours, but, disruption of the mtDNA repair system appears not to be significantly involved in gastric tumours of Japanese patients.

Inactivation of the E-Cadherin Gene in Primary Gastric Carcinomas and Gastric Carcinoma Cell Lines

We investigated the E (epithelial)‐cadherin gene for mutations and loss of heterozygosity (LOH) in 24 primary gastric carcinomas (12 differentiated and 12 undifferentiated types, including 3 signet‐ring cell carcinomas), as well as 4 gastric carcinoma cell lines of the undifferentiated type (MKN‐45, GCIY, HGC‐27 and GT3TKB). We utilized PCR‐SSCP and RT‐PCR followed hy direct sequencing to detect gene mutations and skipped exons, and RT‐PCR‐SSCP to examine LOH. In primary carcinomas, gene mutations or skipped exons, were detected in 4 of 9 (44%) undifferentiated carcinomas of the scattered type, including 2 signet‐ring cell carcinomas, and in none of the 3 undifferentiated carcinomas of the adherent type and 12 differentiated carcinomas. Demonstrated mutations of the E‐cadherin gene included an 18 bp deletion (codon 418‐423) and a 3 bp deletion (codon 400, calcium‐binding domain), both located in exon 9. Skipping of exon 9 with a 1 bp insertion at codon 337, and skipping of exon 8 with a 1 bp deletion at codon 336, also were detected. LOH was confirmed in all of the carcinomas in which gene mutations or skipped exons (3/3 informative cases) were demonstrated. The MKN‐45 cell line exhibited an 18 bp deletion at the exon 6‐intron 6 boundary with loss of the wild‐type allele, and 2 of the remaining 3 cell lines (HGC‐27 and GT3TKB) had lost expression without detectable structural alteration of the E‐cadherin gene. These data provide support for classic two‐hit inactivation of the E‐cadherin gene in a high percentage of undifferentiated carcinomas of the scattered type.

ALLELOTYPE OF ADENOMA AND DIFFERENTIATED ADENOCARCINOMA OF THE STOMACH

The molecular mechanism of gastric tumourigenesis has not yet been clarified, although investigators have postulated that differentiated adenocarcinoma may arise from pre‐existing adenoma, similarly to the colorectal adenoma–carcinoma sequence. An allelotype analysis has been performed to identify chromosomal regions which are frequently deleted in gastric tumours and to examine the significance of the adenoma–carcinoma sequence in gastric tumourigenesis. Forty‐five gastric tumours, 20 adenomas, and 25 differentiated adenocarcinomas were examined for loss of heterozygosity (LOH) using 39 microsatellite markers covering each non‐acrocentric chromosome arm. Frequent LOH in the adenocarcinomas was observed on chromosomes 2q (33 per cent), 4p (33 per cent), 5q (50 per cent), 6p (33 per cent), 7q (43 per cent), 11q (36 per cent), 14q (38 per cent), 17p (45 per cent), 18q (36 per cent), and 21q (40 per cent). In contrast, the incidence of LOH in adenomas did not exceed 10 per cent at any of the loci examined. In addition to the p53 gene on 17p and the DCC gene on 18q, which are known to be frequently deleted in differentiated adenocarcinomas of the stomach, other unknown tumour suppressor genes on the above‐mentioned chromosomes may also be inactivated. These observations suggest that the adenoma–carcinoma sequence is not a major pathway in gastric tumourigenesis.

Promoter methylation status of DAP-kinase and RUNX3 genes in neoplastic and non-neoplastic gastric epithelia.

Silencing of tumor suppressor and tumor‐related genes by hyper‐methylation at promoter CpG islands is frequently found in human tumors, including gastric cancer. Promoter methylation is not restricted to cancer cells, and is also present in non‐neoplastic cells as an age‐related tissue‐specific phenomenon. To clarify the physiological consequence of DAP‐kinase and RUNX3 age‐related methylation in gastric epithelia, we investigated the promoter methylation status of these genes in both neoplastic and non‐neoplastic gastric epithelia obtained at autopsy and surgery, as well as in 10 gastric cancer cell lines. Methylation of DAP‐kinase and RUNX3 was detected in 10% (1/10) and 70% (7/10) of the cell lines, respectively, and was almost concordant with their expression status. Among autopsy samples, methylation of these genes was not seen in non‐neoplastic gastric epithelia from persons who were aged 22 years and below (0%; 0/4). DAP‐kinase was methylated in 87% (13/15) of non‐neoplastic gastric epithelia of persons who were aged 45 years or older, while RUNX3 methylation in non‐neoplastic gastric epithelia was restricted to individuals who were aged 77 years or older. Among samples obtained from patients with stomach cancer, methylation was observed in both the neoplastic and the corresponding non‐neoplastic gastric epithelia; 43% (40/93) and 73% (68/93) for DAP‐kinase, and 45% (42/93) and 8% (7/93) for RUNX3, respectively. Frequencies of DAP‐kinase and RUNX3 methylation differed significantly in non‐neoplastic gastric epithelia (P<0.01), although those in gastric cancers were almost the same. RUNX3 methylation is mostly cancer‐specific, except for very old individuals, and therefore may be a possible molecular diagnostic marker and malignancy predictor. (Cancer Sci 2003; 94: 360–364)

Loss of heterozygosity during the development and progression of differentiated adenocarcinoma of the stomach

In a recent allelotypic analysis of differentiated adenocarcinoma of the stomach, loss of heterozygosity (LOH) was found frequently on chromosomes 2q, 4p, 5q, 6p, 7q, 11q, 14q, 17p, 18q, and 21q. To clarify the sequence of these chromosomal losses during gastric carcinogenesis, microsatellite analysis of the chromosome arms described above was performed in 25 early and 29 advanced differentiated adenocarcinomas of the stomach. LOH on these chromosome arms fell within a range of 20–50 per cent. On 4p, 7q, 14q, 17p, and 21q, LOH was detected at a similar frequency in both early and advanced carcinomas, while LOH on 2q, 5q, 6p, 11q, and 18q was observed more than twice as frequently in advanced than in early lesions. Mean fractional allelic losses (FALs) were 0·221 in early and 0·413 in advanced carcinomas, representing a significant difference (P<0·05). These results suggest that LOH on 4p, 7q, 14q, 17p, and 21q is a relatively early event, while LOH on 2q, 5q, 6p, 11q, and 18q typically accumulates during the progression of gastric carcinogenesis.

Tailored laparoscopic resection for suspected gastric gastrointestinal stromal tumors

BACKGROUND The aim of the present study was to evaluate the long-term outcomes of tailored laparoscopic resections for suspected gastric gastrointestinal stromal tumors (GISTs) based on the tumor size, location, and growth morphology. METHODS Between February 1994 and April 2009, 64 patients undergoing gastric resections of suspected gastric GISTs were identified in a prospectively collected database. Medical records were reviewed for patient demographics, perioperative outcomes, and follow-up. RESULTS Forty-five patients underwent attempted laparoscopic resections, with 44 completed laparoscopically. Twenty-eight neoplasms were located in the upper third of the stomach (including 6 neoplasms at the esophagogastric junction), 9 in the middle third, and 8 in the lower third (including 4 prepyloric neoplasms). Laparoscopic approaches included 35 exogastric (3 single incision access) and 10 transgastric approaches. Median operating time was 100min (range, 30-240), and blood loss was 5ml (range, 1-80). Median tumor size and operative margin were 32mm (range, 16-74) and 7mm (range, 1-20), respectively. One patient was converted to an open, pylorus-preserving gastrectomy. One patient developed a complication. The histopathologic risk assessment classifications of 37 GISTs were 2 very low, 26 low, 7 intermediate, and 2 high risk. Although 1 patient developed a local recurrence after intragastric resection, all 45 patients were disease free at a median follow-up of 74 months (range, 1-181). CONCLUSION Although technically demanding, tailored laparoscopic resection based on tumor characteristics in most patients with suspected gastric GIST is safe and feasible and resultis in good both surgical and oncologic outcomes.

RASSF2, a potential tumour suppressor, is silenced by CpG island hypermethylation in gastric cancer

RASSF2, a member of the RASSF1 family, has recently been identified as a potential tumour suppressor. We examined methylation status in multiple regions which included the CpG island and spanned the transcription start site of RASSF2 in 10 gastric cancer cell lines, as well as 78 primary gastric cancers and corresponding non-neoplastic gastric epithelia. Hypermethylation of RASSF2 in at least one of the regions examined was detected in seven (70%) of the 10 cell lines; two (20%) exhibited hypermethylation in all the regions examined including the transcription start site and lost expression of RASSF2 mRNA, which could, however, be restored by 5-aza-2′ deoxycytidine treatment, while the other five (50%) cell lines exhibited hypermethylation at the 5′- and/or 3′- edge, with four of them expressing RASSF2 mRNA. In primary gastric cancers and corresponding non-neoplastic gastric epithelia, frequencies of RASSF2 methylation ranged from 29% (23 out of 78) to 79% (62 out of 78) and 3% (two out of 78) to 60% (47 out of 78), respectively, at different CpG sites examined. Methylation was frequently observed at the 5′- and 3′- edges, and became less frequent near the transcription start site in both the primary gastric cancers and corresponding non-neoplastic gastric epithelia. Hypermethylation near the transcription start site was mostly cancer-specific. We thus showed that RASSF2 is silenced by hypermethylation near the transcription start site in gastric cancer. Hypermethylation was found initially to occur at the 5′- and 3′- furthest regions of the CpG island in non-neoplastic gastric epithelia, to gradually spreads near the transcription start site to shut down RASSF2 expression, and ultimately to constitute a field-defect placing tissue increased risk for development of gastric cancer.

Demethylation of MAGE promoters during gastric cancer progression

Melanoma antigen (MAGE)-encoding genes are expressed in various tumour types via demethylation of their promoter CpG islands, which are silent in all non-neoplastic tissues except for the testis and placenta. The clinicopathological significance of demethylation of MAGE genes in gastric carcinoma is not known. We investigated the promoter methylation status of MAGE-A1 and -A3 in 10 gastric cancer cell lines and in surgical specimens from 84 gastric cancer patients by methylation-specific PCR (MSP). Expression of MAGE-A1 and -A3 in the 10 gastric cancer cell lines was also investigated by RT–PCR. Any correlation between the methylation status of the MAGE promoters and clinicopathological characteristics of the gastric cancer patients was then assessed. Eight of the 10 gastric cancer cell lines showed demethylation of both MAGE-A1 and -A3, and the remaining two cell lines did either of MAGE-A1 or -A3. Expression of MAGE-A1 and -A3 was confirmed in seven and nine of the 10 gastric cancer cell lines, respectively. The MAGE-A1 and -A3 promoters were demethylated in 29% (25 out of 84) and 66% (56 out of 84) of the gastric tumour specimens, respectively. Demethylation of both MAGE-A1 and -A3 promoters (n=22) was found more frequently in gastric cancer patients in advanced clinical stages (P=0.0035), and these patients also exhibited a higher incidence of lymph node metastasis (P=0.0007) compared to those patients without demethylation (n=25). Furthermore, demethylation patients tended to have a worse prognosis, although this difference was not statistically significant (P=0.183). Demethylation of MAGE-A1 and -A3 occurs during progressive stages of gastric cancer, and may be associated with aggressive biological behaviour of gastric cancer.