Tomoki Makino

Role of multidrug resistance protein 2 (MRP2) in chemoresistance and clinical outcome in oesophageal squamous cell carcinoma.

Background:Although multidrug resistance protein 2 (MRP2) confers chemoresistance in some cancer types, its implication on oesophageal squamous cell carcinoma (ESCC) remains unclear.Methods:We evaluated MRP2 expression by immunohistochemistry and RT–PCR using 81 resected specimens from ESCC patients who did or did not receive neo-adjuvant chemotherapy (NACT), including 5-fluorouracil, doxorubicin, and cisplatin (CDDP). Correlation between MRP2 expression and response to chemotherapy was also examined in 42 pre-therapeutic biopsy samples and eight ESCC cell lines.Results:MRP2-positive immunostaining was more frequently observed in ESCCs with NACT than in those without NACT (27.3 vs 5.4%). The MRP2-positive patients showed poorer prognosis than MRP2-negative patients (5-year survival rate, 25.6 vs 55.7%). Concordantly, ESCC with NACT showed 2.1-fold higher mRNA expression of MRP2 than those without NACT (P=0.0350). In pre-therapeutic biopsy samples of patients with NACT, non-responders showed 2.9-fold higher mRNA expression of MRP2 than responders (P=0.0035). Among the panel of ESCC cell lines, TE14 showed the highest MRP2 mRNA expression along with the strongest resistance to CDDP. Inhibition of MRP2 expression by small-interfering RNA reduced chemoresistance to CDDP.Conclusion:Our data suggested that MRP2 is one of molecules, which regulate the sensitivity to chemotherapy including CDDP in advanced ESCC patients.

Cytokeratins 18 and 8 are poor prognostic markers in patients with squamous cell carcinoma of the oesophagus

Background:Cytokeratins (CKs) are structural marker proteins specific for epithelial cells. However, recent studies indicate their involvement in cancer progression.Methods:We evaluated CK18 and its filament partner, CK8 expression, by immunohistochemistry in 210 resected specimens from patients with oesophageal squamous cell carcinoma (OSCC). We also analysed the relationship between their expression and various clinicopathological parameters including prognosis.Results:Neither CK18 nor CK8 was expressed in non-cancerous squamous epithelium whereas proper oesophageal glands expressed both CKs. Ninety (42.9%) tumours were CK18 positive and 85 (40.5%) CK8 positive, and the concordance rate for immunohistochemical classification for CK18 and CK8 was 82.4%. CK18 expression correlated with poorly differentiated tumours, use of neo-adjuvant chemotherapy, and advanced stage. Prognosis of patients with CK18-positive tumours was poorer than that of patients with negative OSCC (P<0.001). A similar trend was noted for CK8 expression. Multivariate analysis identified pT (P=0.020), pN number (P=0.001), and CK18 expression (P=0.004) as independent prognostic factors. CK18 expression in 83 pretreatment biopsy specimens was detected in 47 cases (56.6%) and also correlated with prognosis (P=0.045).Conclusion:CK18/CK8 expression correlated with progression of OSCC. The significant correlation with prognosis and stable expression in biopsy specimen suggest usefulness of CK18 in selection of treatment strategies for OSCC.

Preoperative T staging of gastric cancer by multi-detector row computed tomography

BACKGROUND AND PURPOSE Preoperative T staging demands high accuracy, because it greatly influences subsequent therapies in advanced gastric cancer. PATIENTS AND METHODS 616 patients with gastric cancer underwent multi-detector row computed tomography (MDCT) before operation. The results were compared with operative and pathologic findings. Especially, we evaluated the correlations among the diagnostic accuracy of T staging and various clinicopathologic parameters by focusing on 276 patients who had detectable lesions by MDCT. RESULTS The overall diagnostic accuracy of preoperative T staging by MDCT was 90.9% (560/616). For each pathologic T stage, the accuracy was 95% for pT1, 76% for pT2-3, 92% for pT4a, and 75% for pT4b, respectively. Among the 276 patients, 239 (87%) were correctly staged by MDCT whereas 29 (11%) and 8 (3%) were over- or under-staged, respectively. Antral tumors (P = .045), and Borrmann type 1 tumors (P = .0001) were incorrectly T staged by MDCT, whereas differentiated type tumors tended to be over-staged. All patients with positive cytology (n = 12 cases) and peritoneal metastasis (n = 7 cases) diagnosed at laparotomy had been diagnosed as T4a or deeper by MDCT. The 5-year overall survival rates classified by preoperative T staging by MDCT (T1/T2-3/T4a/T4b) were 100%, 89%, 59%, and 31%, respectively, whereas those for each pT stage were 100%, 84%, 59%, and 19%. CONCLUSION Preoperative T staging of gastric cancer by MDCT is highly accurate and could contribute to treatment strategies, particularly in advanced disease.

Use of 18F-fluorodeoxyglucose-positron emission tomography to evaluate responses to neo-adjuvant chemotherapy for primary tumor and lymph node metastasis in esophageal squamous cell carcinoma

BACKGROUND Neoadjuvant chemotherapy (NACT) targets lymph node metastasis (LN), as well as the primary tumor (PT) in esophageal squamous cell carcinomas (ESCC). (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) reflects viable tumor volume and may be more useful for evaluating NACT responses than conventional radiography. Moreover, FDG-PET may elucidate the clinical significance of NACT responses for LN, which is not always identical to those for PT. PATIENTS AND METHODS We retrospectively investigated prognostic factors in 38 node-positive ESCC patients who had undergone NACT (5-fluorouracil, adriamycin, and cisplatin) and surgical resection. The NACT response was evaluated separately by both PET and computed tomography (CT) for each PT and LN. RESULTS Although NACT effect for PT and LN was similar by PET evaluation (SUVmax reduction; average 70.58% vs 71.57%), they did not show significant correlation, revealing discordance for 13 (34.2%) patients when SUVmax reduction of more than 70% was classified as a PET responder. An opposite relationship existed in that the pre-NACT SUVmax of PT was significantly lower in PET responders than in PET non-responders (9.92 +/- 4.3 vs 12.96 +/- 3.8, P = .032), while that of LN tended to be higher in responders than in non-responders (5.70 +/- 3.2 vs 3.77 +/- 0.9, P = .072). Multivariate analysis identified the number of PET-positive LN (P = .018, HR = 5.464) and PET response for PT (P = .015, HR = 4.620) and for LN (P = .028, HR = 3.854) as independent prognostic predictors. The NACT response for PT or LN on CT evaluation was not a significant prognostic predictor. CONCLUSION PET is superior to CT for evaluating the NACT response from the viewpoint of survival analysis. The NACT response should be evaluated for both LN and PT because of their different behaviors during chemotherapy. Further studies of larger sample number should be conducted in the future.

Utility of response evaluation to neo-adjuvant chemotherapy by 18F-fluorodeoxyglucose-positron emission tomography in locally advanced esophageal squamous cell carcinoma

BACKGROUND Neoadjuvant chemotherapy (NACT) has been frequently used for locally advanced esophageal squamous cell cancer (ESCC). It is therefore important to establish criteria for evaluating the response to NACT based on survival analysis. METHODS This study analyzed 100 patients with ESCC (cT1, 2/3/4:25/57/18, cN0/1/M1lym: 5/59/36) who received NACT (5-fluorouracil, adriamycin, and cisplatin) followed by surgical resection. NACT response was monitored using (18)F-fluorodeoxyglucose-positron emission tomography (PET) and computed tomography by measuring pre- and post-NACT maximal standardized uptake value (SUVmax) and area of primary tumor, respectively. The associations between NACT and clinicopathological factors including prognosis were analyzed. RESULTS The mean ± SEM values of pre- and post-NACT SUVmax were 12.23 ± 4.62 and 6.31 ± 5.41, respectively, and the mean/median SUVmax reduction was 59.50%/73.45%. The most significant difference in survival between responders and non-responders was at 70% of cutoff value based on every 10% stepwise cutoff analysis (2-year progression-free survival [PFS]: 57.7% vs 25.1%; hazard ratio [HR] = 2.864; P = .0004). Univariate analysis indicated a correlation between PFS and number of cN before NACT, SUVmax reduction, decrease in tumor area, pT, and number of pN, while cT before NACT and pathological response to NACT showed no association. Multivariate analysis identified number of cN before NACT (HR = 2.537; P = .0092), SUVmax reduction (HR = 3.202; P = .0072), and number of pN (HR = 2.226; P = .0146) as independent prognostic predictors. CONCLUSION By determining the optimal cutoff value based on survival analysis, we evaluated patient responses to NACT using PET. Such evaluation could be valuable in formulating treatment strategies for ESCC.

The utility of pre-operative peritoneal lavage examination in serosa-invading gastric cancer patients

BACKGROUND Peritoneal dissemination is frequently found during laparotomy in patients with serosa-invading gastric cancer. Detection of exfoliated cancer cells in abdominal lavage cytology is indicative of stage IV because of its strong association with peritoneal dissemination. Herein we have described peritoneal lavage cytology using a bedside procedure under local anesthesia. METHODS A prospective study of 113 patients with serosa-invading gastric cancer but without peritoneal metastases was performed. A drainage tube was inserted into the abdominal cavity for peritoneal lavage. Patients with negative cytology (CY0) were scheduled for curative gastrectomy. RESULTS The bedside procedure was performed safely without any complications. Lavage cytology identified CY1 in 35 (31.0%) patients and CY0 in 78 (69.0%) patients. Patients with CY0 underwent laparotomy and peritoneal lavage cytology, and 9 were found to have peritoneal disease (3 with operative CY1, 4 with peritoneal dissemination, and 2 with both operative CY1 and peritoneal dissemination). Two other patients had small, distant metastases. Finally, curative gastrectomy was achieved in 67 (59.3%) patients, but not in 46 (40.7%) patients. Thus, our bedside, pre-operative peritoneal lavage detected 76.1% (35/46) of noncurative disease before operative with a false-negative rate for detecting peritoneal disease of 20.5% (9/44). Patients with pre-operative CY1 had a poorer prognosis than pre-operative CY0 (2-year cause-specific survival 26.6% vs 82.6%). CONCLUSION Pre-operative bedside peritoneal lavage under local anesthesia followed by cytology is a simple and safe method for the pre-operative diagnosis of peritoneal dissemination and may help to reduce unexpected, noncurative surgery.

An icteric type hepatocellular carcinoma with no detectable tumor in the liver: report of a case.

A 70-year-old man was admitted to our hospital with obstructive jaundice. Computed tomography revealed a tumor in the left intrahepatic bile duct extending to the common bile duct without any significant lesions in the liver. Cholangiography showed a filling defect due to an intraductal tumor. Cytology of the bile juice was negative and tumor markers were carcinoembryonic antigen 5.7 ng/ml, carbohydrate antigen 19-9 49 U/ml, α-fetoprotein 9 ng/dl, and PIVKA-II 19 200 AU/ml. With a preoperative diagnosis of hilar bile duct carcinoma, a laparotomy was performed. The common bile duct was filled with a tumor and it extended into the bilateral intrahepatic bile ducts. The intraductal tumor was removed together with the extrahepatic bile ducts. An intraoperative histological examination of the tumor showed a well-differentiated hepatocellular carcinoma. No lesions were detected in the liver by ultrasonography, palpation during the operation, or a computed tomography scan after the operation. At 1 year postoperatively, no recurrence has been seen in this patient.

Detecting Secondary C-KIT Mutations in the Peripheral Blood of Patients with Imatinib-Resistant Gastrointestinal Stromal Tumor

Objective: Imatinib is a standard treatment for metastatic gastrointestinal stromal tumor (GIST). Imatinib resistance is mostly caused by secondary mutations in C-KIT. The antitumor effect of second-line agents is correlated with the type of secondary mutation: indeed, sunitinib is effective against tumors with C-KIT exon 13 or 14 mutations. We investigated whether secondary C-KIT mutations can be detected in circulating tumor DNA (ctDNA) from peripheral blood. Methods: This study included 4 patients who underwent resection of imatinib-resistant GIST. Tumor-specific mutations in each tumor were determined by Sanger sequencing. ctDNA was extracted from peripheral blood obtained before and after the treatment of imatinib-resistant lesions. Each of the secondary target mutations in ctDNA was investigated, using a next-generation sequencer. Results: Imatinib-resistant lesions had single-nucleotide substitutions in C-KIT exon 13 in 3 patients and exon 18 in 1 patient. Identical secondary C-KIT mutations could be detected in ctDNA with a mutant fraction range of 0.010-9.385%. One patient had growth of an imatinib-resistant tumor containing a C-KIT exon 13 mutation, and the fraction of ctDNA decreased after initiation of sunitinib. Conclusion: Detection of secondary C-KIT mutations in ctDNA could be useful for the selection of targeted agents and prediction of antitumor effects.

Multicenter randomized phase II study of cisplatin and fluorouracil plus docetaxel (DCF) compared with cisplatin and fluorouracil plus Adriamycin (ACF) as preoperative chemotherapy for resectable esophageal squamous cell carcinoma (OGSG1003)

BACKGROUND This phase II trial evaluated the efficacy of cisplatin and fluorouracil (CF)-based combination neoadjuvant chemotherapy on the outcome of patients with resectable locally advanced esophageal squamous cell carcinoma (ESCC). We compared the recurrence-free survival (RFS) associated with CF plus Adriamycin (ACF) with that associated with CF plus docetaxel (DCF) to select an alternative regimen in a new phase III trial investigating the optimal neoadjuvant treatment of patients with ESCC. PATIENTS AND METHODS Patients with resectable advanced ESCC were randomly assigned to either ACF (Adriamycin 35 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 7 days) every 4 weeks or DCF (docetaxel 70 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 5 days) every 3 weeks. Surgery was scheduled after completion of two cycles of chemotherapy. The primary end point was RFS, analyzed by the intention-to-treat. RESULTS Between October 2011 and October 2013, 162 patients at 10 institutions were enrolled in the study, all of whom were eligible and randomly assigned to the two groups (81 to the ACF group and 81 to the DCF group). The R0 resection rates for the ACF and DCF groups were equivalent (95.9% versus 96.2%, P = 0.93). The 2-year RFS and overall survival rates for DCF versus ACF were 64.1% versus 42.9% (hazard ratio 0.53, 95% confidence interval 0.33-0.83, P = 0.0057) and 78.6% versus 65.4% (P = 0.08), respectively. CONCLUSION Compared with ACF, DCF chemotherapy was associated with prolonged RFS for patients with resectable advanced ESCC. Thus, DCF chemotherapy has potential as a standard neoadjuvant therapy for resectable ESCC. CLINICAL TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trials Registry of Japan (identification number UMIN000004555/000004616).Background This phase II trial evaluated the efficacy of cisplatin and fluorouracil (CF)-based combination neoadjuvant chemotherapy on the outcome of patients with resectable locally advanced esophageal squamous cell carcinoma (ESCC). We compared the recurrence-free survival (RFS) associated with CF plus Adriamycin (ACF) with that associated with CF plus docetaxel (DCF) to select an alternative regimen in a new phase III trial investigating the optimal neoadjuvant treatment of patients with ESCC. Patients and methods Patients with resectable advanced ESCC were randomly assigned to either ACF (Adriamycin 35 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 7 days) every 4 weeks or DCF (docetaxel 70 mg/m2, cisplatin 70 mg/m2 i.v. on day 1, fluorouracil 700 mg/m2 continuous infusion for 5 days) every 3 weeks. Surgery was scheduled after completion of two cycles of chemotherapy. The primary end point was RFS, analyzed by the intention-to-treat. Results Between October 2011 and October 2013, 162 patients at 10 institutions were enrolled in the study, all of whom were eligible and randomly assigned to the two groups (81 to the ACF group and 81 to the DCF group). The R0 resection rates for the ACF and DCF groups were equivalent (95.9% versus 96.2%, P = 0.93). The 2-year RFS and overall survival rates for DCF versus ACF were 64.1% versus 42.9% (hazard ratio 0.53, 95% confidence interval 0.33-0.83, P = 0.0057) and 78.6% versus 65.4% (P = 0.08), respectively. Conclusion Compared with ACF, DCF chemotherapy was associated with prolonged RFS for patients with resectable advanced ESCC. Thus, DCF chemotherapy has potential as a standard neoadjuvant therapy for resectable ESCC. Clinical Trial Registration University Hospital Medical Information Network Clinical Trials Registry of Japan (identification number UMIN000004555/000004616).

Which is a more reliable indicator of survival after gastric cancer surgery: Postoperative complication occurrence or C-reactive protein elevation?

The impact of postoperative complications on long‐term outcome has been reported in several types of malignancies. However, it is unclear why postoperative complications affect long‐term outcome. The aim of this study is evaluating whether postoperative complication occurrence or C‐reactive protein (CRP) elevation better reflects long‐term outcome in gastric cancer patients.