Tomokazu Fuji

Risk factors for acute renal injury in living donor liver transplantation: evaluation of the RIFLE criteria.

Acute renal injury (ARI) is a serious complication after liver transplantation. This study investigated the usefulness of the RIFLE criteria in living donor liver transplantation (LDLT) and the prognostic impact of ARI after LDLT. We analyzed 200 consecutive adult LDLT patients, categorized as risk (R), injury (I), or failure (F), according to the RIFLE criteria. ARI occurred in 60.5% of patients: R‐class, 23.5%; I‐class, 21%; and F‐class, 16%. Four patients in Group‐A (normal renal function and R‐class) and 26 patients in Group‐B (severe ARI: I‐ and F‐class) required renal replacement therapy (P < 0.001). Mild ARI did not affect postoperative prognosis regarding hospital mortality rate in Group A (3.2%), which was superior to that in Group B (15.8%; P = 0.0015). Fourteen patients in Group B developed chronic kidney disease (KDIGO stage 3/4). The 1‐, 5‐ and 10‐year survival rates were 96.7%, 90.6%, and 88.1% for Group A and 71.1%, 65.9%, and 59.3% for Group B, respectively (P < 0.0001). Multivariate analysis revealed risk factors for severe ARI as MELD ≥20 [odds ratio (OR) 2.9], small‐for‐size graft (GW/RBW <0.7%; OR 3.1), blood loss/body weight >55 ml/kg (OR 3.7), overexposure to calcineurin inhibitor (OR 2.5), and preoperative diabetes mellitus (OR 3.2). The RIFLE criteria offer a useful predictive tool after LDLT. Severe ARI, defined beyond class‐I, could have negative prognostic impact in the acute and late postoperative phases. Perioperative treatment strategies should be designed and balanced based on the risk factors for the further improvement of transplant prognosis.

First successful case of simultaneous liver and kidney transplantation for patients with chronic liver and renal failure in Japan.

Establishment of a preferential liver allocation rule for simultaneous liver and kidney transplantation (SLK) and revisions of laws regarding organ transplants from deceased donors have paved the way for SLK in Japan. Very few cases of SLK have been attempted in Japan, and no such recipients have survived for longer than 40 days. The present report describes a case of a 50‐year‐old woman who had undergone living donor liver transplantation at the age of 38 years for management of post‐partum liver failure. After the first transplant surgery, she developed hepatic vein stenosis and severe hypersplenism requiring splenectomy. She was then initiated on hemodialysis (HD) due to the deterioration of renal function after insertion of a hepatic vein stent. She was listed as a candidate for SLK in 2011 because she required frequent plasma exchange for hepatic coma. When her Model for End‐stage Liver Disease score reached 46, the new liver was donated 46 days after registration. The reduced trisegment liver and the kidney grafts were simultaneously transplanted under veno‐venous bypass and intraoperative HD. The hepatic artery was reconstructed prior to portal reconstruction in order to shorten anhepatic time. Although she developed subcapsular bleeding caused by hepatic contusion on the next day, subsequent hemostasis was obtained by transcatheter embolization. Thereafter, her recovery was uneventful, except for mild rejection and renal tubular acidosis of the kidney graft. This case highlights the need to establish Japanese criteria for SLK.

Abstract 2317: PD-1 and PD-L1 expression patterns and DNA mismatch repair status for precision management of patients with gastric cancer

BACKGROUND: Programmed cell death protein 1 (PD-1) and its ligand (PD-L1) downregulate T cell activation and are related to immune tolerance. Recently, microsatellite unstable (MSI) colorectal cancers have been shown to have good therapeutic response to PD-1 antibody immunotherapy, possibly due to release exhaustion of their ability to recognize high number of tumor neo-antigens. The aim of this study was to clarify the significance of PD-1 and PD-L1 expression, and to analyze the relationship between MSI status and MLH1 hypermethylation status in gastric cancer. METHODS: A total of 105 patients who underwent curative gastrectomy for gastric cancer were included in this study. The PD-1, PD-L1, HER2, and mismatch repair proteins (MLH1/PMS2/MSH2/MSH6) expression were examined by immunohistochemistry. MSI status were examined by analyzing three mononucleotide repeat markers. MLH1 methylation was evaluated using a highly sensitive fluorescence-based PCR assay, as we reported previously (JNCI 2009). KRAS/BRAF/PIK3CA mutations were determined by conventional Sanger sequencing. Infection of Helicobacter Pylori (H. Pylori) and EB virus (EBV) were determined by amplifying H. Pylori and EBV specific sequence by PCR, followed by conventional Sanger sequencing. RESULTS: PD-1 and PD-L1 were expressed in 40% (38/95) and 33% (31/95) gastric cancers, respectively. HER2 was expressed in 15% (14/96) gastric cancers. Infection of H.Pylori and EBV were observed in 71% (70/98) and 8% (8/98) gastric cancers, respectively. MSI was observed in 13% (13/98) gastric cancers. Among 13 MSI cancers, 11 cases (85%) showed extensive methylation in the MLH1 promoter region, suggesting their sporadic manifestation. KRAS (exon 2), BRAF (exon 15) and PIK3CA (exon 9 & 20) mutations were observed in 5% (5/98), 0% (0/98), and 4% (4/98), respectively. Among these, one case harbored simultaneous KRAS and PIK3CA mutation. Gastric cancers with KRAS/PIK3CA were more frequently MSI-positive (5/8, p = 0.003). Among eight EBV infected cancers, only one case showed MSI and MLH1 methylation. PD-1 expression was significantly correlated with PD-L1 expression (p = 0.04). Although both PD-1 and PD-L1 expression were associated with MSI (p = 0.007 and p = 0.008, respectively), only PD-L1 expression was significantly correlated with gastric cancers with MLH1 methylation (p = 0.01). While expression of immune checkpoint molecules were specific for tumors with MMR deficiency, HER2 expression was exclusively observed in MMR-proficient tumors. CONCLUSIONS: PD-1/PD-L1 expression is associated with MMR-deficient gastric cancers. In contrast, HER2 expression is observed exclusively in gastric cancers with MMR-proficiency. Our result highlight that expression analysis of genetic markers could lead the precision management of patients with gastric cancer. Citation Format: Keisuke Kimura, Takeshi Nagasaka, Yoshiko Mori, Takashi Kawai, Tomokazu Fuji, Fumitaka Taniguchi, Kazuya Yasui, Toshiaki Toshima, Yuzo Umeda, Hiroshi Tazawa, Ajay Goel, Toshiyoshi Fujiwara. PD-1 and PD-L1 expression patterns and DNA mismatch repair status for precision management of patients with gastric cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2317.

Surgical education using a multi‐viewpoint and multi‐layer three‐dimensional atlas of surgical anatomy (with video)

Trainee surgeons must have a good understanding of surgical anatomy. Especially in the hepatobiliary‐pancreatic field, beginning surgeons often find it difficult to recognize the three‐dimensional structure of the target organ and its complex anatomical correlation with surrounding organs. Conventional anatomy textbooks are not written with the aim of teaching these three‐dimensional structures and complex correlations. We developed a novel teaching atlas of surgical anatomy using a multi‐viewpoint and multi‐layer three‐dimensional camera system.

Risk Analysis for Invasive Fungal Infection after Living Donor Liver Transplantation: Which Patient Needs Potent Prophylaxis?

Background: Invasive fungal infection (IFI) is associated with high mortality after living donor liver transplant (LDLT). The aim of this study was to identify the risk factors for post-LDLT IFI for early diagnosis and improvement of antifungal treatment outcome. Methods: Risk analysis data were available for all 153 patients who underwent LDLT between January 2005 and April 2012. Results: During the follow-up period (1,553 ± 73 days, range 20–2,946 days), 15 patients (9.8%) developed IFI classified as “proven” (n = 8) and “probable” (n = 7) with fungal pathogens including Candida spp. (n = 10), Aspergillus spp. (n = 4), and Trichosporon (n = 2). Of these patients, 7 patients with IFI died despite treatment. The 1-, 3-, and 5-year survival rates were lower in patients with IFI than those without IFI (66.7/59.3/44.4 vs. 90.4/85.7/81.8%, respectively; p = 0.0026). Multivariate analysis identified model for end-stage liver disease score of ≥26 (OR 16.0, p = 0.0012) and post-transplant acute kidney injury (RIFLE criteria I- or F-class; OR 4.87, p = 0.047) as independent risk factors for IFI. Conclusion: Preoperative recipients’ status and postoperative kidney dysfunction can affect an occurrence of post-transplant IFI. These risk factors would be taken into consideration for designation of proper antifungal therapy.

Abstract 510: A novel circulating cell free DNA-based assay in colorectal cancer patients during treatment with systematic chemotherapy

Introduction: Although circulating cell-free DNA (cfDNA) in blood plasma is being touted as a frontier noninvasive approaches, its clinical utility still remains questionable. The purpose of this study was to compare the efficacy of cfDNA by comparing blood CEA levels and radiological evaluation in patients with unresectable metastatic colorectal cancer (mCRC) who received systemic chemotherapy. Experimental Procedures: In this study, we measured aberrant cancer-specific methylation in cfDNA and the concentration of cfDNA in plasma obtained following each treatment cycle of systemic chemotherapy in three patients with mCRC. To analyze aberrant cancer-specific methylation, we used a modified highly sensitive assay for bisulfite DNA followed by fluorescence-based PCR, as reported previously (JNCI 2009). This methodology can detect methylation status in eight regions, therefore both recovery score (RS) and methylation score (MS), ranged from 0-8 at a given time. We measured RS and MS two-times in each plasma specimen obtained before administration of systemic chemotherapies. Results: In this pilot study, we examined a series of blood plasma obtained from three patients who received oxaliplatin-based chemotherapy together with molecularly-targeted agents. Despite initial tumor shrinkage in the metastases, all patients ultimately developed progressive disease (PD). Patient1 had wild-type KRAS, but had developed a sigmoid colon cancer with synchronous multiple liver and lung metastases. In contrast, Patient2 had mutant KRAS with sigmoid colon cancer and synchronous multiple liver metastasis. Both patients 1 and 2, demonstrated decreasing levels of CEA after the first-line chemotherapy, along with low methylation scores and concentration of cfDNA. Interestingly, in both patients, MS and concentration level of cfDNA increased prior to radiographic documentation of PD. Patient3 harbored BRAF V600E mutation, and a cancer in the ascending colon with systemic lymph node metastasis. Although, in this case, the tumor development progressed rapidly, similar to patients 1 and 2, MS and the concentration levels of cfDNA also increased prior to radiographic documentation of rapid PD. Conclusions: Our novel DNA methylation and concentration-based monitoring assay is a novel methodology for capturing DNA methylation in circulating cell-free DNA in plasma, and is useful for the early identification of colorectal cancer patients who are at risk of developing PD prior to radiographic documentation. Citation Format: Toshiaki Toshima, Takeshi Nagasaka, Yoshiko Mori, Takashi Kawai, Tomokazu Fuji, Fumitaka Taniguchi, Keisuke Kimura, Kazuya Yasui, Hiroyuki Kishimoto, Yuzo Umeda, Hiroshi Tazawa, Ajay Goel, Toshiyoshi Fujiwara. A novel circulating cell free DNA-based assay in colorectal cancer patients during treatment with systematic chemotherapy. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 510.

Abstract 1078: Micro RNAs as promising therapeutic targets for anti-metastatic therapy in colorectal cancer

Background: Colorectal cancer (CRC) is the third most common cancer and is a leading cause of cancer related death worldwide and arises by accumulation of genetic and epigenetic alterations. Recently, it has been demonstrated that microRNAs (miRNAs) play critical roles in tumor progression in various cancers. In this study, we tried to find miRNAs associated with distant metastasis and poor outcome and evaluate those miRNAs as therapeutic target for advanced CRC. Methods: MiRNA array was done on CRC specimens derived from tumors with various gene status (KRAS/BRAF/microsatellite instability [MSI] status) with reference of their normal mucosal specimens. The array analysis revealed that a set of miRNAs was specifically down-regulated in CRC with BRAF V600E mutation without MSI, considered to be the poorer outcome. To examine whether the set of miRNAs causes distant metastasis or not, we investigated malignant potential of cell lines transfected and knock-downed the set of miRNAs by siRNA. Expression status of ZEB2 and Epithelial-Mesenchymal Transition (EMT) markers, E-cadherin, were evaluated. In addition, we analyzed expression level of the set of miRNAs in a cohort of 67 stage IV CRCs (TNM staging system by UICC 7th) by quantitative reverse transcription PCR using a comparative Ct method and examined association of target-miRNA fold change (tumor/normal tissue) and their clinocopathilogical findings. Patient survival analysis were performed by Cox proportional hazard model and Kaplan-Meier analysis. Results: In vitro, cell lines transfected the set of miRNAs significantly reduced their malignant potentials. In contrast cell lines knock-downed the set of miRNAs by siRNA obviously increased their malignant potentials. Finally, to confirm our results obtained from in vitro assays, we analyzed expression level of the set of miRNAs in a cohort of stage IV CRCs. Of 67 patients with stage IV CRCs, 15 patients showed KRAS mutation, 4 patients showed BRAF mutation. CRCs with the lower expression level of the set of miRNAs showed poor outcome compared with those with the higher expression level by Cox proportional hazard model and Kaplan-Meier analysis. Conclusions: Our data indicate that miRNAs associated with BRAF mutant CRCs is promising prognostic biomarkers and therapeutic targets for anti-metastatic therapy in CRC. Citation Format: Takashi Kawai, Takeshi Nagasaka, Yoshiko Mori, Tomokazu Fuji, Fumitaka Taniguchi, Keisuke Kimura, Toshiaki Toshima, Kazuya Yasui, Yuzo Umeda, Hiroshi Tazawa, Ajay Goel, Toshiyoshi Fujiwara. Micro RNAs as promising therapeutic targets for anti-metastatic therapy in colorectal cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1078.

Tu1386 Systematic Genomic Characterization of Normal Mucosa, Adenomatous Polyps, and Cancer in Patients With Familial Adenomatous Polyposis

Introduction: Serum tryptase measurement is part of the routine diagnostic work-up of anaphylaxis or suspected mastocytosis. Levels >20 ng/ml would be consistent with recent anaphylaxis and are associated with an elevated risk for mastocytosis. The clinical relevance of a basal elevated tryptase between 11.5 and 20 remains unclear, and autosomal dominant inheritance of such elevations has recently been reported. In this study, families with inherited basal elevations in serum tryptase levels were evaluated at the NIH. The patients (pts) shared similar features, such as atopic symptoms, connective tissue abnormalities, autonomic dysfunctions, neuropsychiatric disorders, and chronic gastrointestinal (GI) symptoms. Here we describe the GI findings from this unique cohort of pts. Methods: Pts were referred to the NIH for evaluation, and the index ptss family was also invited to undergo evaluation. Pts were evaluated by a gastroenterologist and/or completed the Bowel Disease Questionnaire (BDQ). The ptss basic demographic information was noted as well as their GI clinical symptoms, and diagnostic and treatment histories. Laboratory data, including tryptase level, were taken, and endoscopic procedures were performed when clinically indicated. Results: A total of 28 pts with confirmed elevated tryptase levels were seen and evaluated at the NIH. 13 pts were evaluated by a gastroenterologist and completed the BDQ, 9 pts completed the BDQ only, and 6 pts were evaluated by a gastroenterologist only. These pts represented 16 different families. There were 15 males and 13 females, and the median age was 39.1 years. The average BMI was 25.6 and the median tryptase level was 17.9. Of the pts who completed the questionnaire, 13 complained of abdominal pain while 9 did not. Of the pts who had abdominal pain, 11 fulfilled Rome III criteria for irritable bowel syndrome (IBS). 6 had IBS-Mixed, 2 had IBS-Constipation, and 3 had IBS-Diarrhea. Of the pts without abdominal pain, 6 fulfilled Rome III criteria for chronic constipation (CC). Evaluation of upper tract symptoms revealed that 23 of the 28 pts had gastroesophageal reflux disease (GERD) based on history and/or BDQ, and GERD was common in pts with and without abdominal pain (14/16, 9/12, respectively). Conclusions: In this cohort of families with basal elevated tryptase levels, functional GI disorders such as IBS and CC, as well as GERD, were more frequently seen in this cohort than in the general population. An autosomal dominant pattern of inheritance has been discovered. The percentage of functional GI pts with this genetic variation remains unknown, however eliciting personal and familial histories of the comorbid symptoms seen in these families, and, potentially, serum tryptase levels, may be warranted in the workup of patients with functional GI disease.

Sa2043 Inherent Single Nucleotide Variants in the TBX21 Gene As Novel Prognostic Markers in Patients With Pancreatic Ductal Adenocarcinoma

G A A b st ra ct s metastatic PC patients. SOMAmer® reagents are a unique class of DNA aptamers that bind their protein targets with high selectivity and a median limit of detection of 40fM. We have reported that a plasma SOMApanel can detect resectable PC in a multi-center case-control study. Methods: Chart reviews were performed for the 100 PC patients from our site used in the prior study to determine their time to disease progression (PFS) through September 2014. Pre-treatment plasma samples collected between 2008 and 2010 were analyzed for CA 19-9 and a SOMAscanTM assay consisting of 1045 known proteins. Univariate Cox models were used for identifying biomarkers related to time to progression compared to patients who have not progressed. Short PFS was defined as those with documented progression less than one year from PC diagnosis or unrecognized metastatic disease found at surgery. Long PFS was defined as progression greater than one year. The top 10 proteins identified in this analysis were then compared to 42 Stage IV patients. Statistical p-values were calculated with log likelihood ratio test of Cox regression and corrected for multiple comparisons using q-values calculated with the Benjamin and Hochberg method. Results: Nine of 43 patients who had resection for pancreatic cancer were excluded due to noncancer cause of death in the first year or loss to follow up. Thirty-four patients were eligible for progression analysis: 14 with short PFS including 2 individuals with unrecognized metastatic disease and 7 with no disease progression with a minimum 4 years follow-up. As shown in the Figure, two of the 10 top performing prognostic proteins that had higher levels correlating with shorter PFS times were present at similar levels in baseline samples from subjects presenting with Stage IV PC. CA 19-9 was not prognostic in these samples. Conclusions: This study demonstrates the potential utility of identifying biomarkers that predict the presence of unrecognized metastatic disease defined as the detection of metastases at or the rapid recurrence following attempted curative resection of a PC. Future studies are planned to validate the results. If successful, this could lead to a test that identifies a subset of PC patients who can avoid the morbidity and health care costs associated with a major pancreatic resection.