Kyushu University Academic Staff Educational and Research Activities Database
List of Papers
Ohtsuka Takao Last modified date:2019.06.26

Associate Professor / Department of Surgery and Oncology / Department of Clinical Medicine / Faculty of Medical Sciences


Papers
1. Ohtsuka T, Chijiiwa K, Yamaguchi K, Akashi Y, Matsunaga H, Miyoshi A, Posterior hepatic duct injury during laparoscopic cholecystectomy finally necessitating hepatic resection:Case report., JSLS, 3, 4, 323-326, 1999.04, A case of bile duct injury during laparoscopic cholecystectomy finally necessitating right hepatic lobectomy is reported to re-emphasize the importance of preoperative and intraoperative assessment of the biliary tree. A 47-year-old Japanese woman underwent laparoscopic cholecystectomy for cholecystolithiasis. On postoperative day 5, fever and right hypochondralgia developed, and CT revealed fluid collection at the right hypochondrium. Percutaneous drainage was performed, and subsequent fistulography revealed a communication of the cystic cavity with the right posterior bile duct, which suggested injury of the aberrant hepatic duct. Conservative therapy, including the adaptation of fibrin glue, was performed, but closure of the fistula and cavity was not obtainable. Finally, a right hepatic lobectomy was performed four months after cholecystectomy. In this case, endoscopic retrograde cholangiopancreatography was unsuccessful preoperatively, and intraoperative cholangiography was not done. This case report re-emphasizes that the preoperative and intraoperative examination of the biliary tree is mandatory to avoid bile duct injury. ".
2. Ohtsuka T, Kodama K, Nishikata F, Okada K, Nakano R, Iwata Y, Mucosa-associated lymphoid tissue lymphoma of the duodenum forming multiple polypoid lesions., Jpn. J. Surg., 29, 6, 557-559, 1999.04, We report herein the case of a patient found to have mucosa-associated lymphoid tissue (MALT) lymphoma of the duodenum forming multiple polypoid lesions. Endoscopic examination revealed multiple small nodules with a yellow-white, rough surface in the duodenal bulb. Histopathological and immunological findings subsequently suggested low-grade B-cell MALT lymphoma. Cytologically, MALT lymphoma is similar to multiple lymphomatous polyposis (MLP); however, this case, which involved multiple polypoid lesions, was confirmed not to be MLP. ".
3. Maosheng D, Ohtsuka T, Ohuchida J, Inoue K, Yokohata K, Yamaguchi K, Chijiiwa K, Tanaka M, Surgical bypass versus metallic stent for unresectable pancreatic cancer, J. Hepatobiliary Pancreat. Surg., 8, 4, 367-373, 2001.04, With the development of interventional radiology and endoscopy, the practice of inserting expandable metallic stents for malignant jaundice has become widespread. Many studies have compared surgical bypass with polyethylene stents, or metallic stents with polyethylene stents. However, few data are available on the comparison of surgical bypass and metallic stents. The aim of this study was to compare the patient's postprocedure course and the cost performance of surgical bypass and metallic stents in patients with unresectable pancreatic cancer. The parameters analyzed were the rates of procedural and therapeutic success, duration of hospital stay, prevalence of early and late complications, cost performance, and prognosis. The rates of procedural and therapeutic success were excellent with both palliative treatments. With surgical bypass, there was a low prevalence of late complications, but duodenal obstruction sometimes occurred in patients without gastric bypass. With metallic stents, there was shorter hospitalization and lower cost, but a higher prevalence of late complications. Stent occlusion tended to occur in patients with uncovered metallic stents. There was no difference in the prognosis between the two palliative treatments. Thus, in consideration of the poor prognosis of pancreatic cancer, in patients with unresectable pancreatic cancer, insertion of covered metallic stents would be preferable to surgical bypass, because of the subsequent short hospitalization and the low cost. On the other hand, in patients with a relatively long expected prognosis, or in those with existing duodenal obstruction, biliary bypass with gastrojejunostomy may provide an advantage..
4. Ohtsuka T, Yamaguchi K, Chijiiwa K, Kinukawa N, Tanaka M, Quality of life after pylorus-preserving pancreatoduodenectomy, Am. J. Surg., 182, 3, 230-236, 2001.04, BACKGROUND: With increasing numbers of long-term survivors after pylorus-preserving pancreatoduodenectomy (PPPD), postoperative quality of life (QOL) has become a great concern. However, few reports are available on data of the postoperative changes in QOL after PPPD. METHODS:A total of 20 patients were studied regarding QOL before and at short term (within 2 months), intermediate term (6 months), and long term (1 year) after PPPD, using a questionnaire. The questionnaire consisted of 13 physical and 10 psychosocial items. The medical records were also reviewed to evaluate objective nutritional status. Factors predicting delayed recovery of QOL were examined at intermediate term by univariate and multivariate analyses. RESULTS: Overall and physical QOL scores returned to the preoperative level at intermediate term after PPPD, showing parallel changes with the objective nutritional status. However, the scores of psychosocial condition, which reflected the patient's mental health, remained low even at long term. QOL scores at intermediate term in patients with pancreatic carcinoma were significantly lower than those with other diseases. Univariate analysis showed that preoperative body weight loss, impaired preoperative pancreatic exocrine function, long operative time, intraoperative radiotherapy, pancreatic carcinoma, and postoperative diarrhea were factors predicting the delayed recovery of QOL. Multivariate analysis revealed that preoperative pancreatic exocrine function significantly affected the delayed recovery of QOL. CONCLUSIONS: Preoperative supplement of pancreatic enzymes together with perioperative mental care would improve QOL at long term after PPPD..
5. Ohtsuka T, Yamaguchi K, Chijiiwa K, Tanaka M, Postoperative pancreatic exocrine function influences body weight maintenance after pylorus-preserving pancreatoduodenectomy, Am. J. Surg., 182, 5, 524-529, 2001.04, BACKGROUND: Most patients who undergo pylorus-preserving pancreatoduodenectomy (PPPD) are able to gain their weight postoperatively. However, sometimes patients experience a lack of weight gain even at long term after PPPD. The aim of this study was to examine factors influencing a body weight change after PPPD. METHODS: In 34 Japanese patients with PPPD, 28 clinical parameters were assessed as possible factors affecting body weight maintenance at long term (1 year) after the operation by univariate and multivariate analyses. RESULTS: Univariate analysis showed that long operation time (P = 0.02), extended retroperitoneal lymph node dissection (P = 0.0005), intraoperative radiotherapy (P = 0.02), adjuvant postoperative chemotherapy (P = 0.02), histopathological diagnosis of pancreatic cancer (P = 0.02), postoperative ulceration (P = 0.007), and insufficient postoperative pancreatic exocrine function (P = 0.002) were significantly related with the lack of weight gain at long term after PPPD. Multivariate analysis regarding the seven profound factors revealed that the insufficient postoperative pancreatic exocrine function significantly affected the lack of weight gain after PPPD. The use of ordinary amount of pancreatic exocrine enzymes did not influence the weight gain after PPPD (P = 0.23). CONCLUSIONS: In patients refractory to an ordinary amount of medicine, a large dosage of enzymes may be necessary to gain weight after PPPD..
6. Yamaguchi K, Kishinaka M, Nagai E, Nakano K, Ohtsuka T, Chijiiwa K, Tanaka M, Pancreatoduodenectomy for pancreatic head carcinoma with or without pylorus preservation , Hepatogastroenterology., 48, 41, 1479-1485, 2001.04, BACKGROUND/AIMS: With the concept of less invasive surgery, PpPD (pylorus-preserving pancreatoduodenectomy) has taken the place of conventional Whipple pancreatoduodenectomy (Whipple) as a standard operation for pancreatic head carcinoma. The aim of this paper is to compare early and late postoperative results of PpPD and Whipple for pancreatic head carcinoma. METHODOLOGY: Postoperative clinical follow-up data and outcome of 50 Japanese patients with pancreatic head carcinoma who underwent pancreatoduodenectomy with or without pylorus preservation were reviewed to scrutinize the demerits and merits of the pylorus preservation. RESULTS: Preoperative and postoperative serum chemistry was not different between the two groups. Mean operation time of the Whipple group was 517 minutes, which was significantly shorter than 624 minutes of the PpPD group (P = 0.0006). Cumulative stage was not different between the two groups. Cumulative curability of the PpPD group was superior to the Whipple group; of the 27 patients with Whipple, A in 4, B in 5 and C in 18, while of the 23 patients with PpPD, A in 12, B in 2 and C in 9 (P = 0.0182). Gastric tube was removed on POD 6.0 in the Whipple group, while on POD 39 in the PpPD group (P < 0.0001). Oral intake was started on POD 14.0 in the Whipple group, while on POD 28.3 in the PpPD group (P = 0.0018). Discharge was on POD 57.8 in the Whipple group, while POD 86.9 in the PpPD group (P = 0.0023). At the time of discharge and postoperative 6, 12, and 18 months, body weight loss from the preoperative level was 1kg smaller in the PpPD group than in the Whipple group. 1-year and 3-year survival rates of the Whipple group was 53.8% and 15.8%, while 62.8% and 19.6% of the PpPD group, showing no significant difference. CONCLUSIONS: These data show that delayed gastric emptying is evident in the PpPD group, resulting in longer hospital stay, while long-term body weight loss is smaller in this group. The clinical outcome is similar between the two groups. PpPD can be accepted as a standard operation for pancreatic head carcinoma..
7. Ohtsuka T, Tanaka M, Inoue K, Nabae T, Takahata S, Yokohata K, Yamaguchi K, Chijiiwa K, Ideda S, Is peripapillary choledochoduodenal fistula an indication for endoscopic sphincterotomy?, Gastrointest. Endosc., 53, 3, 313-317, 2001.04, BACKGROUND: Most patients with a peripapillary choledochoduodenal fistula undergo fistulotomy by endoscopic sphincterotomy for the treatment of bile duct stones. However, whether sphincterotomy should be performed in patients with the fistula but without stones is controversial. METHODS: Among 165 patients in whom a benign peripapillary choledochoduodenal fistula was diagnosed at ERCP, the clinical outcome was retrospectively analyzed and compared between those who underwent fistulotomy by endoscopic sphincterotomy (group 1) and those whose fistula was left untreated (group 2). All patients with hepatolithiasis, residual stones, biliary diversion, or transduodenal papilloplasty were excluded (32, leaving 133). Fistulas were divided into types I and II according to the location of the fistula (Ikeda classification). RESULTS: Follow-up data collected during a median period of 124 months were available for 127 of 133 patients (95%), 76 in group 1 and 53 in group 2. Late complications were bile duct stone recurrence (17 patients), acute cholangitis (7 patients), and biliary carcinoma (2 patients). The incidence of stone recurrence was not significantly different between the 2 groups (p = 0.1). In group 2, 4 patients (8%) with an untreated type II fistula had 1 to 3 episodes of presumed reflux cholangitis, which resolved quickly with conservative treatment. CONCLUSIONS: Endoscopic sphincterotomy is not always necessary for peripapillary choledochoduodenal fistulas if bile duct stones are absent because reflux cholangitis is a relatively rare complication that can be easily managed. ".
8. Ohtsuka T, Inoue K, Ohuchida J, Nabae T, Takahata S, Niiyama H, Yokohata K, Ogawa Y, Yamaguchi K, Chijiiwa K, Tanaka M, Carcinoma arising in choledochocele, Endoscopy, 33, 7, 614-619, 2001.04, BACKGROUND AND STUDY AIMS: Choledochocele has a potential for carcinogenesis, but no report has described malignant changes of the choledochocele in relation to pancreaticobiliary reflux because its anatomic form does not fit the criteria of pancreaticobiliary malunion (PBM). The aims of this study were to analyze the amylase level in bile in patients with choledochocele and to clarify whether the presence of a choledochocele predisposed to carcinoma. PATIENTS AND METHODS: Records of 2826 patients who had undergone endoscopic retrograde cholangiopancreatography between 1995 and 1999 were reviewed for the presence of choledochocele and/or periampullary carcinoma. As an evidence of pancreaticobiliary reflux, amylase activity was examined in common duct bile obtained at surgery or by endoscopy. The prevalence of periampullary carcinoma was compared between patients with and without choledochocele. RESULTS: A total of 11 patients were diagnosed as having a choledochocele. The amylase level in bile was higher in patients with choledochocele (120,922 +/- 62,269 IU/l; n = 4) than in previously examined patients with functioning gallbladders (15 +/- 24 IU/l; n = 10, P = 0.005). The prevalence of periampullary carcinoma in patients with choledochocele (27%, 3/11) was significantly higher than that in those without choledochocele (0.9%, 26/2815; P<0.0002). CONCLUSION: The bile analysis of the present study presents one possible explanation for the predisposition to carcinoma in choledochocele as bile containing amylase may stagnate in the choledochocele and then carcinoma may develop in the inner epithelium of the choledochocele by the same mechanism as that leading to carcinogenesis in patients with PBM..
9. Yamaguchi K, Ohuchida J, Ohtsuka T, Nakano K, Tanaka M, Intraductal papillary-mucinous tumor of the pancreas concomitant with ductal carcinoma of the pancreas, Pancreatology, 2, 5, 484-490, 2002.04, BACKGROUND: Despite the recent progress of diagnostic and therapeutic modalities, the clinical course of patients with ductal carcinoma (DC) of the pancreas remains dismal. Intraductal papillary-mucinous tumor of the pancreas (IPMT) is sometimes accompanied by malignant diseases of the other organs and pancreatic adenocarcinoma. Thus, IPMT may be a potential diagnostic clue to DC of the pancreas at early phase. METHODS: Clinicopathologic findings of 7 Japanese patients with IPMT of the pancreas concomitant with independent DC were examined and compared with those of 69 patients with IPMT alone and of 70 with DC alone. RESULTS: The seven patients corresponded to 9.2% of 76 patients with IPMT and 9.1% of 77 patients with DC. The seven male patients ranged from 55 to 75 years with a mean of 64.3. DC was synchronous with IPMT in five patients, metachronous to IPMT (4 years after IPMT) in one, and synchronous with IPMT and metachronous to IPMT and DC (7 years after IPMT) in the other. In 4 patients, the presence of IPMT led to the diagnosis of DC. All the 7 IPMTs were of branch type with a mean diameter of 3.0 cm. The IPMT was located in the head of the pancreas in 3, body in 2 and tail in the other 2. All the 7 IPMTs were adenoma with mild dysplasia. Two of the 7 patients with DC had in situ carcinoma, 1 minimally invasive carcinoma and the remaining 4 invasive carcinoma. The mean diameter of seven DCs (3.0 cm) with IPMT were smaller than that of 70 DCs (3.6 cm) (8P = 0.0295). Stage (stage I/II/III/IV = 3/0/3/1) of the seven DCs concomitant with IPMT were significantly earlier than that (stage I/II/III/IV = 5/6/28/31) of the other 70 (p = 0.0203). The survival curve of the 7 patients with IPMT and DC was significantly better than that of the 70 with DC alone (p = 0.0460). CONCLUSIONS: Clinicians should pay attention to the possible presence of DC of the pancreas in male patients with intraductal papillary-mucinous adenoma of the pancreas of branch type in their 6th to 8th decades. Copyright 2002 S. Karger AG, Basel and IAP.
10. Ohtsuka T, Takahata S, Ohuchida J, Takeda T, Matsunaga H, Yokohata K, Yamaguchi K, Chijiiwa K, Tanaka M, Gastric phase 3 motility after pylorus-preserving pancreatoduodenectomy, Ann. Surg., 235, 3, 417-423, 2002.04, OBJECTIVE: To analyze factors affecting the recovery course of phase 3 activity of the gastric migrating motor complex after pylorus-preserving pancreatoduodenectomy (PPPD) and investigate effects of the recovery of gastric phase 3 on gastric emptying after feeding. SUMMARY BACKGROUND DATA: Whether early recovery of gastric phase 3 during fasting would predict early recovery of the fed-state gastric emptying function after PPPD has not been well documented. METHODS: Manometric recording from the gastric antrum was repeated at a weekly interval until the first appearance of gastric phase 3 in 57 patients after PPPD. Twenty-three clinical parameters were assessed as possible factors affecting the recovery course of gastric phase 3 by simple and multiple regression analyses. A gastric emptying study after feeding of a test meal was performed by the acetaminophen method and the values were compared between patients with and without gastric phase 3 after PPPD. RESULTS: The mean period before the first appearance of gastric phase 3 was 38 days. Among 23 parameters, only lymph node dissection along the hepatoduodenal ligament significantly delayed recovery of gastric phase 3 after PPPD by univariate and multivariate analyses. The presence or absence of gastric phase 3 in the early postoperative period did not influence gastric emptying after feeding in the intermediate period after PPPD. CONCLUSIONS: Avoiding lymph node dissection along the hepatoduodenal ligament, if applicable, may contribute to early recovery of gastric phase 3 after PPPD. The recovery state of gastric phase 3 during fasting, however, is not necessarily consistent with the degree of improvement of gastric emptying after feeding..
11. Ohtsuka T, Yamaguchi K, Chijiiwa K, Tanaka M, Effect of gastrointestinal reconstruction on quality of life and nutritional status after pylorus-preserving pancreatoduodenectomy., Dig. Dis. Sci., 47, 6, 1241-1247, 2002.04, A total of 31 Japanese patients who underwent pylorus-preserving pancreatoduodenectomy from January 1998 through September 2000 were studied regarding quality of life and nutritional status before and within two months (short term) and six months to one year (long term) after surgery. Quality of life was estimated using a questionnaire consisting of 23 items (13 physical and 10 psychosocial domains). Nutritional status was assessed by body weight, hemoglobin concentration, serum concentration of albumin and cholesterol, and pancreatic function. These data were compared between 18 patients with end-to-end (Imanaga) and 13 with end-to-side (Traverso) gastrointestinal reconstruction. In both groups, physical quality of life scores dropped at short term, and then returned to the normal level at long term after operation, showing mostly parallel changes with the parameters of nutritional status. However, the scores of psychosocial conditions, which reflected the patient's mental health, remained low even at long term in both groups. The values of these parameters showed no statistical difference between the two groups at each time point. Postoperative quality of life and nutritional status were not different between Imanaga and Traverso reconstructions after pylorus-preserving pancreatoduodenectomy and mental health care would be necessary for at least one year after operation in both groups..
12. Takahata S, Ohtsuka T, Nabae T, Matsunaga H, Yokohata K, Yamaguchi K, Chijiiwa K, Tanaka M, Comparison of recovery of gastric phase III motility and gastric juice output after different types of gastrointestinal reconstruction following pylorus-preserving pancreatoduodenectomy., J Gastroenterol. , 37, 8, 596-603, 2002.04, BACKGROUND: Early gastric stasis is a frequent complication of pylorus-preserving pancreatoduodenectomy (PPPD). However, few reports have addressed this phenomenon in relation to the type of gastrointestinal reconstruction. We compared gastrointestinal motility and gastric juice output after two different types of gastrointestinal reconstruction following PPPD, end-to-side duodenojejunostomy after pancreaticojejunostomy and hepaticojejunostomy (group 1) and end-to-end duodenojejunostomy before pancreaticojejunostomy and hepaticojejunostomy (group 2). METHOD: In a total of 25 patients, 10 in group 1 and 15 in group 2, who underwent PPPD, manometry was repeated to assess gastric and jejunal motility until the first occurrence of phase III activity of gastric cyclic motor activity (CMA). The plasma level of motilin was measured in each phase of the gastric CMA and compared between the two groups. The daily volume of gastric juice output through a gastrostomy tube was also recorded for comparison. RESULT: There was no significant difference in the time period for recovery of gastric phase III activity and gastric juice output between the two groups. However, abnormal contractions with an increased basal pressure appeared frequently in the afferent jejunal loop only in group 1. The plasma motilin level after PPPD showed no apparent cyclic change even after the recovery of gastric phase III in either group. CONCLUSION: Gastrointestinal reconstructive procedures have almost no effect on the recovery of gastric CMA. The plasma motilin concentration does not play a major role in the recovery of gastric CMA in the early postoperative period after PPPD.

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13. Ohtsuka T, Yokohata K, Inoue K, Nabae T, Takahata S, Tanabe Y, Sugitani A, Tanaka M, Biliary sphincter motility after neural isolation of the pancreatoduodenal region in conscious dogs
, Surgery, 131, 2, 139-148, 2002.04, BACKGROUND: Several neural and hormonal factors are known to affect the motility of the sphincter of Oddi. However, the precise mechanisms of the control of sphincter motility have not been completely explored. We investigated the relationship of canine biliary sphincter motility when it is extrinsically denervated by neural isolation of the pancreatoduodenal region. METHODS: Interdigestive and postprandial sphincter motility in a denervated pancreatoduodenal segment and effects of cholecystokinin-octapeptide were studied in 7 conscious dogs. Data were compared with those of 7 neurally intact control dogs. RESULTS: After extrinsic denervation of the pancreatoduodenal region, sphincter motility exerted a cyclic change in concert with the duodenal myoelectric cycles; this change involved short cyclic bursts of motor activity, which gradually increased in intensity. The increase in the cyclic bursts of motor activity was also cyclic and associated with an increase in the plasma motilin concentration. Neural isolation of the pancreatoduodenal region increased sphincter basal pressure and motility index (integral per minute). In the denervated biliary sphincter, the feeding pattern and temporary inhibitory effect of feeding, as seen in controls, were absent, which suggests the role of extrinsic nerves in delivering bile into the duodenum after feeding. In the denervated dogs, cholecystokinin-octapeptide caused excitation of the sphincter activity, instead of relaxation observed in controls. CONCLUSIONS: Extrinsic innervation to the pancreatoduodenal region has an inhibitory effect on biliary sphincter motility. Abnormalities in extrinsic innervation to the biliary sphincter might increase the resistance of the sphincter to the bile flow and induce bile stagnation.
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14. Inoue K, Ohuchida J, Ohtsuka T, Nabae T, Yokohata K, Ogawa Y, Yamaguchi K, Tanaka M, Severe localized stenosis and marked dilatation of the main pancreatic duct are indicators of pancreatic cancer instead of chronic pancreatitis on endoscopic retrograde balloon pancreatography, Gastrointest Endosc., 58, 4, 510-515, 2003.04, BACKGROUND: Differentiation between benign and malignant localized stenoses of the main pancreatic duct is difficult by pancreatography. METHODS: A total of 48 patients with such localized stenosis who underwent endoscopic retrograde balloon pancreatography with abdominal compression were retrospectively studied. The following were examined: (1) diameter of the stenotic, prestenotic, and poststenotic ductal segments; (2) ratios of prestenotic/poststenotic, stenotic/prestenotic, and stenotic/poststenotic ductal segments; (3) length of stenosis and steepness of transition to the stenosis (proximal angle, distal angle); and (4) main duct and branch findings for peristenotic segments. RESULTS: The stenosis was diagnosed as caused by chronic pancreatitis in 27 patients and pancreatic cancer in 21 by histopathology, cytology, or clinical follow-up. The prestenotic/poststenotic ductal segments ratio and proximal angle were greater in pancreatic cancer compared with chronic pancreatitis. Severe stenosis (stenotic ductal segments less than 20% of prestenotic or poststenotic ductal segments); moderate (prestenotic ductal segments 2.5 to 3.5 times larger than poststenotic ductal segments), and severe (prestenotic ductal segments more than 3.5 times larger than poststenotic ductal segments) dilatation of the proximal duct were more frequent in pancreatic cancer than in chronic pancreatitis. Multivariate regression analyses showed that severe stenosis and dilatation were independently significant parameters that indicated a diagnosis of pancreatic cancer. Various combinations of severe stenosis, proximal dilatation, and double duct sign gave high predictive values. CONCLUSIONS: Severe stenosis, marked proximal dilatation, double duct sign, and combinations of these findings are useful indicators of malignant localized stenosis of the pancreatic duct.
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15. Ohtsuka T, Ryu H, Minamishima YA, Ryo A, Lee SW, Modulation of p53 and p73 levels by cyclin G: implication of a negative feedback regulation, Oncogene, 22, 11, 1678-1687, 2003.04, Cyclin G is a transcriptional target gene of tumor suppressor p53. Recent studies present evidence that cyclin G may play a central role in the p53-Mdm2 autoregulated module, but the precise function of cyclin G remains elusive. Here, we show a negative effect of cyclin G on the stability of p53 and p73. Cyclin G expression resulted in a dramatic decrease of p53 protein levels in response to DNA damage and abrogated irradiation-mediated G1 arrest along with an increase of S phase in MCF7 cells containing wild-type p53. In p53-null Saos2 cells, cyclin G inhibited p73 induction in response to genotoxic stress and delayed the camptothecin-mediated cell cycle arrest. Cyclin G interacts with p53 as well as p73, and its binding to p53 or p73 presumably mediates downregulation of p53 and p73. We also found that cyclin G-mediated reduction of p53 but not of p73 is Mdm2-dependent. Moreover, inhibition of cyclin G by small interfering RNA (siRNA) caused the accumulation of p53 and p73 protein levels in response to DNA damage. Therefore, our results imply that cyclin G is transcriptionally activated by p53 or p73, and, in turn, cyclin G negatively regulates the stabilization of p53 family proteins through an unknown mechanism different from ubiquitination or transcriptional control.
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16. Ohtsuka T, Yamaguchi K, Ohuchida J, Inoue K, Nagai E, Chijiiwa K, Tanaka M, Comparison of quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection.

, Hepatogastroenterology, 50, 51, 846-850, 2003.04, BACKGROUND/AIMS: There have been many supportive data that the postoperative changes in nutritional status are more favorable after pylorus-preserving pancreatoduodenectomy than after Whipple resection; however, few reports are available on the postoperative changes in subjective quality of life after pancreatoduodenectomy. The aim of this study was to compare the postoperative change in quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection. METHODOLOGY: A total of 36 patients (31 with pylorus-preserving pancreatoduodenectomy and five with Whipple resection) were studied regarding quality of life before and at short term (within two months) and at long term (six months to one year) after surgery, using a questionnaire. The questionnaire consisted of 13 physical and 10 psychosocial items. The medical records were also reviewed to evaluate their objective nutritional status. Postoperative changes in quality of life and nutritional status were compared between the pylorus-preserving pancreatoduodenectomy and Whipple groups. RESULTS: Overall and physical quality of life scores dropped at short term and then recovered at long term in the pylorus-preserving pancreatoduodenectomy group, but showed a persistently low value even at long term in the Whipple group. The change in physical quality of life showed almost parallel changes with the nutritional status in both groups. However, the scores of psychosocial quality of life, which reflected the patient's mental status, remained low even at long term in both pylorus-preserving pancreatoduodenectomy and Whipple groups. CONCLUSIONS: Quality of life is more favorable after pylorus-preserving pancreatoduodenectomy than after Whipple resection, but long-standing mental health care is necessary in patients with pyloruspreserving pancreatoduodenectomy and Whipple resection..
17. Aglipay JA, Lee SW, Okada S, Fujiuchi N, Ohtsuka T, Kwak JC, Wang Y, Johnstone RW, Deng C, Qin J, Ouchi T, A member of the Pyrin family, IFI16, is a novel BRCA1-associated protein involved in the p53-mediated apoptosis pathway, Oncogene, 22, 55, 8931-8938, 2003.04, We identified IFI16 as a BRCA1-associated protein involved in p53-mediated apoptosis. IFI16 contains the Pyrin/PAAD/DAPIN domain, commonly found in cell death-associated proteins. BRCA1 (aa 502-802) interacted with the IFI16 Pyrin domain (aa 1-130). We found that IFI16 was localized in the nucleoplasm and nucleoli. Clear nucleolar IFI16 localization was not observed in HCC1937 BRCA1 mutant cells, but reintroduction of wild-type BRCA1 restored IFI16 nuclear relocalization following IR (ionizing radiation). Coexpression of IFI16 and BRCA1 enhanced DNA damage-induced apoptosis in mouse embryonic fibroblasts from BRCA1 mutant mice expressing wild-type p53, although mutant IFI16 deficient in binding to BRCA1 did not induce apoptosis. Furthermore, tetracycline-induced IFI16 collaborated in inducing apoptosis when adenovirus p53 was expressed in DNA-damaged p53-deficient EJ cells. These results indicate a BRCA1-IFI16 role in p53-mediated transmission of DNA damage signals and apoptosis.
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18. Ohtsuka T, Jensen MR, Kim HG, Kim KT, Lee SW, The negative role of cyclin G in ATM-dependent p53 activation, Oncogene, 23, 31, 5405-5408, 2004.04, Cyclin G is one of the earliest p53 target genes to be identified, but its function in the p53 pathway has been elusive. Although the precise mechanisms of cyclin G in this novel network have not been explored, recent studies have demonstrated that cyclin G is a key regulator of the p53-Mdm2 network. Here we present evidence that cyclin G-mediated p53 regulation is dependent upon the status of ataxia-telangiectasia mutated (ATM) protein, which activates p53 in response to DNA damage. Abrogation of cyclin G enhances p53 accumulation and phosphorylation of p53 at the Ser-15 residue, resulting in cell cycle arrest. Ectopically expressed cyclin G significantly reduces the steady-state levels of p53 as well as that of phosphorylated p53 at Ser-15 after DNA damage in normal human dermal fibroblasts containing normal ATM. However, cyclin G does not cause similar reductions in p53 levels in ATM-mutated cells. We also show that translocation of cyclin G to the nucleus requires functional ATM. Thus, our findings identify a new role of cyclin G in ATM-dependent p53 regulation and in cell cycle regulation during DNA damage.

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19. Fujiuchi N, Aglipay JA, Ohtsuka T, Maehara N, Sahin F, Su GH, Lee SW, Ouchi T, Requirement of IFI16 for the maximal activation of p53 induced by ionizing radiation, J Biol Chem, 279, 17, 20339-20344, 2004.04, IFI16 is a member of the PYRIN superfamily that has been implicated in BRCA1-mediated apoptosis and inflammation signaling pathways. Here we report that most breast cancer cell lines examined expressed decreased mRNA and protein levels of IFI16, although IFI16 is expressed in human primary normal mammary epithelial cells. Significantly, immunohistochemical analysis of tissues from 25 breast cancer patients demonstrated that carcinoma cells showed negative or weaker staining of IFI16 compared with positive nuclear staining in normal mammary duct epithelium. si-RNA-mediated reduction of IFI16 resulted in perturbation of p53 activation when treated with ionizing radiation (IR). Expression of IFI16 enhanced p53 transcriptional activity in cells exposed to IR. Adenovirus expression of IFI16 in IFI16-deficient MCF7 induced apoptosis, which was enhanced by radiomimetic neocarcinostatin treatment. Tetracycline-regulated IFI16 also induced apoptosis when coexpressed with p53 in p53-deficient EJ cells subjected to IR, suggesting that IFI16 is involved in p53-mediated transmission of apoptosis signaling. Consistent with these results, expression of IFI16 enhanced activation of the known p53 target genes, including p21, Hdm2, and bax in MCF7 cells. These results suggest that loss of IFI16 results in deregulation of p53-mediated apoptosis, leading to cancer development.

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20. Ohtsuka T, Ryu H, Minamishima YA, Macip S, Sagara J, Nakayama KI, Aaronson SA, Lee SW, ASC is a Bax adaptor and regulates the p53-Bax mitochondrial apoptosis pathway, Nat Cell Biol , 6, 2, 121-128, 2004.04, The apoptosis-associated speck-like protein (ASC) is an unusual adaptor protein that contains the Pyrin/PAAD death domain in addition to the CARD protein-protein interaction domain. Here, we present evidence that ASC can function as an adaptor molecule for Bax and regulate a p53-Bax mitochondrial pathway of apoptosis. When ectopically expressed, ASC interacted directly with Bax, colocalized with Bax to the mitochondria, induced cytochrome c release with a significant reduction of mitochondrial membrane potential and resulted in the activation of caspase-9, -2 and -3. The rapid induction of apoptosis by ASC was not observed in Bax-deficient cells. We also show that induction of ASC after exposure to genotoxic stress is dependent on p53. Blocking of endogenous ASC expression by small-interfering RNA (siRNA) reduced the apoptotic response and inhibited translocation of Bax to mitochondria in response to p53 or genotoxic insult, suggesting that ASC is required to translocate Bax to the mitochondria. Our findings demonstrate that ASC has an essential role in the intrinsic mitochondrial pathway of apoptosis through a p53-Bax network.
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21. Ide T, Kitajima Y, Miyoshi A, Ohtsuka T, Mitsuno M, Ohtaka K, Koga Y, Miyazaki K, Tumor-stromal cell interaction under hypoxia increases the invasiveness of pancreatic cancer cells through the hepatocyte growth factor c-Met pathway, Int J Cancer, 119, 12, 2750-2759, 2006.04, The hypoxic environment in tumor is reported to play an important role in pancreatic cancer progression. The interaction between stromal and cancer cells also contributes to the malignant behavior of pancreatic cancer. In the present study, we investigated whether hypoxic stimulation affects stromal as well as pancreatic cancer cells. Our findings demonstrated that hypoxia remarkably elevated the HIF-1alpha expression in both pancreatic cancer (PK8) and fibroblast cells (MRC5). Hypoxic stimulation accelerated the invasive activity of PK8 cells, and invasiveness was thus further accelerated when the hypoxic PK8 cells were cultured with conditioned medium prepared from hypoxic MRC5 cells (hypoxic conditioned medium). MMP-2, MMP-7, MT1-MMP and c-Met expressions were increased in PK8 cells under hypoxia. Hypoxic stimulation also increased the hepatocyte growth factor (HGF) secretion from MRC5 cells, which led to an elevation of c-Met phosphorylation in PK8 cells. Conversely, the elevated cancer invasion, MMP activity and c-Met phosphorylation of PK8 cells were reduced by the removal of HGF from hypoxic conditioned medium. In immunohistochemical study, the HIF-1alpha expression was observed in surrounding stromal as well as pancreatic cancer cells, thus indicating hypoxia exists in both of cancer and stromal cells. Moreover, the stromal HGF expression was found to significantly correlate with not only the stromal HIF-1alpha expression but also the c-Met expression in cancer cells. These results indicate that the hypoxic environment within stromal as well as cancer cells activates the HGF/c-Met system, thereby contributing to the aggressive invasive features of pancreatic cancer. Copyright 2006 Wiley-Liss, Inc.

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22. Ohtsuka T, Kitahara K, Matsuyama S, Shimonishi T, Nakafusa Y, Miyazaki K, Significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy, Hepatogastroenterology, 53, 71, 788-791, 2006.04, BACKGROUND/AIMS: The significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy (PD) has not been well understood. The aim of this study was to clarify this issue. METHODOLOGY: Clinical records of 60 Japanese patients who underwent PD were reviewed retrospectively. Patients were divided into two groups, normal (n=33) and low (n=27) pancreatic exocrine function, according to the preoperative value of N-benzoyl-L-tyrosyl-p-aminobenzoic acid excretion test (normal value >70%). We compared the perioperative events and nutritional status between the two groups. RESULTS: The preoperative and operative characteristics between the two groups were not significantly different. Postoperative pancreatic juice output from the remnant pancreas during the initial 7 days after PD was greater (1145 +/- 618 vs. 741 +/-612mL, P=0.02), and the prevalence of pancreatic anastomotic leakage was higher (10/23, 30% vs. 1/27, 4%, P=0.008) in the group with normal pancreatic exocrine function than that in the insufficient group. Perioperative body mass index and serum albumin concentration, which reflect the nutritional status of patients, were significantly lower in the group with low pancreatic exocrine function (P=0.007 and 0.04, respectively). CONCLUSIONS: Surgeons should pay more attention to pancreatic anastomotic leakage in patients with normal pancreatic exocrine function after PD. On the other hand, in patients with insufficient exocrine function, perioperative nutritional support should be considered.

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23. Ohtsuka T, Liu XF, Koga Y, Kitajima Y, Nakafusa Y, Ha CW, Lee SW, Miyazaki K, Methylation-induced silencing of ASC and the effect of expressed ASC on p53-mediated chemosensitivity in colorectal cancer., Oncogene , 25 , 12, 1807-1811, 2006.04, Tumor suppressor p53 is known to play a crucial role in chemosensitivity in colorectal cancer. We previously demonstrated that an apoptosis-associated speck-like protein, ASC, is a p53-target gene which regulates p53-Bax mitochondrial apoptotic pathway. ASC is also known to be a target of methylation-induced gene silencing. An inactivation of ASC might thus cause resistance to chemotherapy, and if this is the case, then the expression of ASC would restore the chemosensitivity. The aim of this study was to clarify this hypothesis. ASC was methylated in 25% of all resected specimens in patients with colorectal cancer; however, ASC methylation did not always correspond to a lack of ASC protein. When expressed in colon cancer cells, in which ASC is absent due to methylation, ASC was found to enhance the chemosensitivity in a p53-dependent manner. In p53-null cells, ASC increased the p53-mediated cell death induced by p53-expressing adenovirus infection. Our data suggest that the methylation-induced silencing of ASC might cause resistance to p53-mediated chemosensitivity in colorectal cancer. The gene introduction of ASC may thus restore such chemosensitivity, and this modality may therefore be a useful new treatment strategy for colorectal cancer.

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24. Ide T, Kitajima Y, Miyoshi A, Ohtsuka T, Mitsuno M, Ohtaka K, Miyazaki K, The hypoxic environment in tumor-stromal cells accelerates pancreatic cancer progression via the activation of paracrine hepatocyte growth factor/c-Met signaling., Ann Surg Oncol. , 14, 9, 2600-7, 2007.04, BACKGROUND: Pancreatic cancer is one of the representative solid tumors, in which the hypoxic microenvironment plays a crucial role in malignant progression. We previously demonstrated that tumor-stromal interaction under hypoxia enhances the invasiveness of pancreatic cancer cells through hepatocyte growth factor (HGF)/c-Met signaling. METHODS: We investigated the immunohistochemical expression of hypoxia inducible factor-1alpha (HIF-1alpha) c-Met, and HGF in both cancer and stromal cells using 41 pancreatic cancer tissue specimens, and tried to identify any correlations with the clinical features and survival. RESULTS: Positive staining for HIF-1alpha was observed in both pancreatic cancer and the surrounding stromal cells in more than 30% of the cases, and it significantly correlated with lymph node metastasis (P < .05). A significant correlation was observed between the expression of HIF-1alpha and HGF in stromal cells (P < .05). In addition, the c-Met expression in cancer cells was found to significantly correlate with the HGF expression in not only cancer but also stromal cells. The disease-free survival rates of the patients with HIF-1alpha in cancer, stromal, c-Met in cancer, and an HGF expression in stromal cells was significantly worse than those without such expressions (P < .05). CONCLUSIONS: These data suggest that the HGF/c-Met signaling via HIF-1alpha ?may therefore negatively affect the prognosis in patients with pancreatic cancer, and targeting tumor stroma under hypoxia might thus be potentially useful as a novel therapy for this cancer.


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25. Ohuchida J, Chijiiwa K, Ohtsuka T, Konomi H, Tanaka M, Pylorus-preserving pancreatoduodenectomy: preoperative pancreatic function and outcome., Hepatogastroenterology. , 54, 75, 913-916, 2007.04, BACKGROUND/AIMS: To investigate the effects of preoperative pancreatic function on gastric emptying, body weight, and quality of life after pylorus-preserving pancreatoduodenectomy. METHODOLOGY: Thirty-one patients who underwent pylorus-preserving pancreatoduodenectomy were divided into 2 groups according to preoperative pancreatic exocrine and endocrine function (normal vs. abnormal). Gastric emptying, body weight, and quality of life were evaluated before surgery, 1-2 months after surgery (short-term), and 6-12 months after surgery (long-term). RESULTS: Short-term body weight was significantly decreased in comparison to preoperative body weight regardless of preoperative exocrine and endocrine pancreatic function. Body weight returned to the preoperative level by 12 months after surgery in patients with normal preoperative pancreatic function but not in patients with abnormal pancreatic function. In both groups, gastric emptying was delayed at 1-2 months after surgery and then returned to the preoperative value by 12 months. Short-term quality of life did not differ from preoperative quality of life in either group, but long-term quality of life improved to beyond the preoperative level in both groups. CONCLUSIONS: Preoperative pancreatic function appears to significantly influence long-term body weight after pylorus-preserving pancreatoduodenectomy.

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26. Ide T, Kitajima Y, Miyoshi A, Ohtsuka T, Mitsuno M, Ohtaka K, Miyazaki K, HIF-1a-HGF signaling in stroma accelerates the pancreatic cancer progression via paracrine regulation., Ann Surg Oncol, 14, 9, 2600-2607, 2007.04.
27. Ohtsuka T, Kitahara K, Matsuyama S, Shimonishi T, Nakafusa Y, Miyazaki K, Comparison of the postoperative outcome after a pancreatoduodenectomy using the Billroth I and II type of reconstruction., Hepatogastroenterology , 54, 77, 1570-1574, 2007.04, BACKGROUND/AIMS: Several types of gastrointestinal reconstruction have been employed after a pancreatoduodenectomy (PD), however, it remains controversial as to which type is the most beneficial. The aim of this study was to investigate the effects of a gastrointestinal reconstruction on the postoperative outcome after PD. METHODOLOGY: The medical records of 68 patients who underwent a PD between 1994 and 2004 were retrospectively reviewed. A total of 28 patients underwent a Billroth I reconstruction while 40 had the Billroth II reconstruction. Both the occurrence of postoperative complications and the nutritional status were compared between the two groups. RESULTS: The patient age, gender, preoperative symptoms, and operation profiles were the same between the two groups. The morbidity and mortality did not differ between the two groups; however, the prevalence of leakage after a hepaticojejunostomy was higher in the Billroth II group than that in the Billroth I group (23% vs. 0%, P = 0.007). All cases of bile leakage were successfully treated by conservative therapy. The day that oral intake was resumed and the length of the hospital stay also did not differ between the two groups. Both groups showed a similar postoperative nutritional status after a PD, as assessed by body weight, the serum albumin and cholesterol concentrations, and the number of lymphocytes. CONCLUSIONS: Bile leakage tends to occur after a PD using a Billroth II reconstruction, however, this can be easily managed by conservative therapy, and it does not influence morbidity, the resumption of oral intake, or the length of hospital stay. Therefore, we could not clearly identify any advantages of one group or another in terms of postoperative complications and the nutrition status after PD. Further investigations from other points of view are therefore necessary to clarify the effect of a gastrointestinal reconstruction after PD.


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28. Ohtsuka T, Mitsuno M, Kitajima Y, Ide T, Lee SW, Miyazaki K, Role of ASC in hypoxia-mediated cell death in pancreatic cancer., Mol Med Rep , 1, 3, 827-831, 2008.04.
29. Nakafusa Y, Tanaka M, Ohtsuka T, Miyoshi A, Kohya N, Kitajima Y, Sato S, Mochinaga S, Dohi S, Miyazaki K, Phase I/II study of combination therapy with S-1 and CPT-11 for metastatic colon cancer., Mol Med Rep , 1, 3, 925-930, 2008.04.
30. Ohtsuka T, Sato S, Kitajima Y, Tanaka M, Nakafusa Y, Miyazaki K, False positive of tumor marker after curative gastrectomy for gastric cancer., Dig Dis Sci, 53, 1, 73-79, 2008.04, The objective of this study was to assess the frequency and characteristics of false-positive results for tumor markers after curative gastrectomy for gastric cancer. Carcinoembryonic antigen and/or carbohydrate antigen 19-9 were periodically assessed for 168 patients who underwent curative gastrectomy. Cancer recurrence was observed for 17 (10.1%) patients and 151 (89.9%) were disease-free during the mean follow-up period of 23.1 months after the operation. The frequency of false-positive findings for tumor markers after gastrectomy was 14.3% (24/168) for all followed-up patients. Three different patterns of marker elevation were observed in the false-positive group. A false-positive finding for these markers was observed for patients with early-stage cancer and for those with chronic benign diseases, for example bronchitis, liver dysfunction, diabetes mellitus, and renal dysfunction. For most patients with false-positive findings for a marker a spontaneous decrease in the tumor marker was observed 1-2 months after the marker was first observed at a high level after the operation. Surgeons and oncologists should therefore keep in mind the high frequency of false-positive findings for tumor markers after curative gastrectomy for gastric cancer.


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31. Ohtsuka T, Nakafusa Y, Sato S, Kitajima Y, Tanaka M, Miyazaki K, Different roles of tumor marker monitoring after curative resections of gastric and colorectal cancers., Dig Dis Sci, 53, 6, 1537-1543, 2008.04, We previously demonstrated that false-positive findings for tumor markers are frequently observed, and that the sensitivity of marker monitoring for early detection of the recurrence is low after curative resection of gastric cancer. The aim of this study was to investigate whether such characters are specific to gastric cancer. Serum carcinoembryonic antigen and/or carbohydrate antigen 19-9 were periodically assessed in 258 patients who underwent curative gastrectomy for gastric cancer (n = 161) or curative resection for colorectal cancer (n = 97). The frequency of false-positive findings for the tumor markers, the sensitivity of the marker monitoring for detection of the recurrence, and the characteristics of such cases were compared between these two cancer groups. During the median follow-up period of 30 months, recurrence developed in 14% of gastric cancer and 23% of colorectal cancer patients. A false positive with the tumor marker was frequently observed in patients after gastrectomy compared with after colorectal surgery. The sensitivity of the marker monitoring regarding early detection of recurrence was higher in patients with colorectal cancer than those with gastric cancer, especially in cases of advanced stage. As a result, the accuracy of marker monitoring for the detection of recurrence was higher in patients after the resection of colorectal cancer than that of gastric cancer. Surgeons and oncologists should thus be aware that the role of the tumor marker monitoring after a curative operation differs between patients with gastric and colorectal cancers.


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32. Ohtsuka T, Kitajima Y, Takahashi T, Sato S, Miyoshi A, Kohya N, Kitahara K, Nakafusa Y, Miyazaki K, Infectious complications after gastric cancer surgery accelerate a rapid hepatic recurrence, Hepatogastroenterology , 56, 94-95, 1277-1280, 2009.04, BACKGROUND/AIMS: Rapid hepatic recurrence is sometimes experienced after gastric or pancreatobiliary cancer surgery. The aim of this study was to investigate the risk factors for the timing of hepatic recurrence. METHODOLOGY: The medical records of 20 patients who had hepatic recurrence after either a gastrectomy for gastric cancer (11 patients) or a pancreatoduodenectomy for pancreatobiliary cancer (9 patients) between 2002 and 2007 were retrospectively reviewed. The cumulative recurrence rate of liver metastasis was calculated using the Kaplan-Meier method, and 14 possible factors affecting the rapid hepatic recurrence were analyzed by univariate and multivariate analyses. RESULTS: The median time for the hepatic recurrence after the operation was 4.9 months (range 1 to 20.4 months). Among 14 factors, only postoperative infectious complications significantly accelerated the hepatic recurrence based on a univariate analysis (p = 0.049). Two more factors, gastric cancer and preoperative tumor marker elevation, had a tendency to affect the rapid recurrence, but did not show statistical significance (both p = 0.06). A multivariate analysis revealed that postoperative infectious complications (p = 0.005) and gastric cancer (p = 0.04) were significant and independent factors. Five of 11 patients with gastric cancer suffered from postoperative infectious complications, 4 of which were associated with pancreatic leakage after a pancreatosplenectomy, and all 5 patients had hepatic recurrence within 3 months after the operation. CONCLUSIONS: Postoperative infectious complications are thus considered to accelerate a rapid hepatic recurrence after a gastrectomy for gastric cancer.

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33. Ohtsuka T, Kitahara K, Kohya N, Miyoshi A, Miyazaki K, Improvement of the glucose metabolism after a pancreatoduodenectomy, Pancreas, 38, 6, 700-705, 2009.04, OBJECTIVES: The aim of this study was to investigate the mechanisms of the change in glucose metabolism after a pancreatoduodenectomy (PD). METHODS: Oral glucose tolerance tests were performed in 17 patients before and 1 month after a PD. The changes in plasma glucose and insulin concentrations, homeostasis model of insulin resistance, and insulinogenic index (beta-cell function) were analyzed. Two additional factors, gastric emptying function and plasma glucagon-like peptide-1 (GLP-1) concentration, that possibly affect perioperative glucose metabolism were also assessed. RESULTS: The plasma glucose and insulin concentrations were significantly lower after the operation, especially in preoperative diabetic patients. beta-Cell function did not change after the operation. On the other hand, insulin resistance became normal 1 month after the operation. The value of gastric emptying function after the operation was not statistically different in comparison with that before the operation. Postoperative plasma GLP-1 concentration was significantly higher than the preoperative value. CONCLUSIONS: beta-Cell function is maintained after a PD, whereas the improvement of insulin resistance may cause a short-term transient improvement of the glucose metabolism after the operation. The significance of increased postoperative GLP-1 concentration remains an unsolved issue..
34. Ide T, Brown-Endres L, Chu K, Ongusaha PP, Ohtsuka T, El-Deiry WS, Aaronson SA, Lee SW , GAMT, a p53-inducible modulator of apoptosis, is critical for the adaptive response to nutrient stress
, Mol Cell , 36, 3, 379-392, 2009.04, The p53 tumor suppressor protein has a well-established role in cell-fate decision-making processes. However, recent discoveries indicate that p53 has a non-tumor-suppressive role. Here we identify guanidinoacetate methyltransferase (GAMT), an enzyme involved in creatine synthesis, as a p53 target gene and a key downstream effector of adaptive response to nutrient stress. We show that GAMT is not only involved in p53-dependent apoptosis in response to genotoxic stress but is important for apoptosis induced by glucose deprivation. Additionally, p53-->GAMT upregulates fatty acid oxidation (FAO) induced by glucose starvation, utilizing this pathway as an alternate ATP-generating energy source. These results highlight that p53-dependent regulation of GAMT allows cells to maintain energy levels sufficient to undergo apoptosis or survival under conditions of nutrient stress. The p53-->GAMT pathway represents a new link between cellular stress responses and processes of creatine synthesis and FAO, demonstrating a further role of p53 in cellular metabolism.

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35. Fujita H, Ohuchida K, Mizumoto K, Nakata K, Yu J, Kayashima T, Cui L, Manabe T, Ohtsuka T, Tanaka M, α-Smooth Muscle Actin Expressing Stroma Promotes an Aggressive Tumor Biology in Pancreatic Ductal Adenocarcinoma, Pancreas, 39, 8, 1254-1262, 2010.04, OBJECTIVES:: Pancreatic ductal adenocarcinoma (PDAC) is often characterized by a prominent desmoplastic stroma that is induced partially by alpha-smooth muscle actin (SMA)-expressing activated pancreatic stellate cells (PSCs). This study aimed to investigate the significance of alpha-SMA expression in PDAC and the correlation between alpha-SMA mRNA levels and the patient prognosis. METHODS:: We obtained formalin-fixed, paraffin-embedded tissue samples from 109 patients with PDAC, who underwent pancreatectomy at our institution from 1992 to 2007. We measured alpha-SMA mRNA levels by quantitative real-time reverse transcription-polymerase chain reaction and investigated the association of alpha-SMA mRNA expression with clinicopathologic parameters and survival time. We also assessed the influence of activated PSCs on malignant behaviors of pancreatic cancer cells using in vitro experiments. RESULTS:: alpha-SMA immunoreactivity was detected exclusively in the stroma of PDAC. The group with high alpha-SMA expression showed a significantly shorter survival, as shown by univariate analysis (P = 0.005) and multivariate analysis (P < 0.0001). alpha-SMA-expressing activated PSCs enhanced the invasiveness, proliferation, and colony formation of pancreatic cancer cells. CONCLUSIONS:: Quantitative analysis of alpha-SMA mRNA expression using formalin-fixed, paraffin-embedded tissue samples was useful to predict the prognosis of patients with PDAC. Activated PSCs may regulate the malignant behavior of pancreatic cancer cells..
36. Sadakari Y, Ohuchida K, Nakata K, Ohtsuka T, Aishima S, Takahata S, Nakamura M, Mizumoto K, Tanaka M, Invasive carcinoma derived from the nonintestinal type intraductal papillary mucinous neoplasm of the pancreas has a poorer prognosis than that derived from the intestinal type, Surgery , 147, 6, 812-817, 2010.04, BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is divided into 4 subtypes: an intestinal type, a gastric type, a pancreatobiliary type, and an oncocytic type. The purposes of this study were to clarify the outcomes and the characteristics of invasive carcinoma derived from IPMN (invasive IPMC) by focusing on these subtypes with a comparison to conventional invasive ductal carcinoma (IDC) of the pancreas. METHODS: A total of 30 patients with invasive IPMC were reviewed, and the tumors were divided into 2 pathologic subtypes, intestinal and nonintestinal type. The prognosis and characteristics of the 2 subtypes were evaluated. Furthermore, the prognosis of 119 patients with conventional IDC was compared with that of patients with invasive carcinoma derived from the intestinal or nonintestinal type IPMN. RESULTS: The 5-year survival rate of patients with the nonintestinal type (0.0%) was as poor as that of patients with conventional IDC (19.9%; P = .67). The patients with the intestinal type (66.7%) had a more favorable prognosis than patients with conventional IDC (P < .001). The nonintestinal type was characterized by positive lymphatic invasion and tubular invasive pattern. CONCLUSION: Invasive carcinoma derived from the nonintestinal type IPMN characterized by lymphatic invasion and tubular invasive pattern is associated with a poor prognosis. Copyright 2010 Mosby, Inc. All rights reserved.

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37. Fujita H, Ohuchida K, Mizumoto K, Itaba S, Ito T, Nakata K, Yu J, Kayashima T, Souzaki R, Tajiri T, Manabe T, Ohtsuka T, Tanaka M, Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy, NEOPLASIA, 12, 10, 807-817, 2010.04, Abstract
BACKGROUND AND AIMS: The standard palliative chemotherapy for pancreatic ductal adenocarcinoma (PDAC) is gemcitabine-based chemotherapy; however, PDAC still presents a major therapeutic challenge. The aims of this study were to investigate the expression pattern of genes involved in gemcitabine sensitivity in resected PDAC tissues and to determine correlations of gene expression with treatment outcome.

MATERIALS AND METHODS: We obtained formalin-fixed paraffin-embedded (FFPE) tissue samples from 70 patients with PDAC. Of the 70 patients, 40 received gemcitabine-based adjuvant chemotherapy (AC). We measured hENT1, dCK, CDA, RRM1, and RRM2 messenger RNA (mRNA) levels by quantitative real-time reverse transcription-polymerase chain reaction and determined the combined score (GEM score), based on the expression levels of hENT1, dCK, RRM1, and RRM2, to investigate the association with survival time. By determining the expression levels of these genes in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytologic specimens, we investigated the feasibility of individualized chemotherapy.

RESULTS: High dCK (P = .0067), low RRM2 (P = .003), and high GEM score (P = .0003) groups had a significantly longer disease-free survival in the gemcitabine-treated group. A low GEM score (<2) was an independent predictive marker for poor outcome to gemcitabine-based AC as shown by multivariate analysis (P = .0081). Altered expression levels of these genes were distinguishable in microdissected neoplastic cells from EUS-FNA cytologic specimens.

CONCLUSIONS: Quantitative analyses of hENT1, dCK, RRM1, and RRM2 mRNA levels using FFPE tissue samples and microdissected neoplastic cells from EUS-FNA cytologic specimens may be useful in predicting the gemcitabine sensitivity of patients with PDAC.

PMID: 20927319 [PubMed - in process]PMCID: PMC2950330Free PMC Article



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Figure 1
Quantitative analyses of mRNA associated with cellular uptake and metabolism of gemcitabine in gemcitabine-resistant cells. Quantitative analyses of hENT1 (A), dCK (B), RRM1 (C), RRM2 (D), and CDA (E) mRNA in gemcitabine-resistant cell lines (SUIT-2-GR and Capan-1-GR) and parental cells. SUIT-2-GR cells expressed sign...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 2
Correlation between gemcitabine-based AC and survival time. The patients who received gemcitabine-based AC (GEMgroup) showed a significantly prolongedOStime compared with the non-AC group (P = .0017). *P < .05.
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 3
Correlation between the expression of each mRNA and DFS. Low dCK (P= .0067) and high RRM2 (P=.003) levels, normalized to β-actin, were associated with a shorter DFS in the GEM group (A, C, E, G). In contrast, there was no significant correlation between these gene expression levels and DFS in the non-AC group (B, D...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 4
Correlation between the expression of each mRNA and OS. Low hENT1 (P = .011), low dCK (P = .0095), high RRM1 (P = .041), and high RRM2 (P = .030) levels, normalized to β-actin, were associated with a shorterOSin theGEMgroup (A, C, E, G). In contrast, there was no significant correlation between these gene expression levels an...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 5
Correlation between GEM score and survival time. DFS time (A) and OS time (B) after resection of PDAC categorized by combined GEM score (hENT1 score x dCK score x RRM1 score x RRM2 score) in GEM group patients. High GEM scores were well correlated with prolonged DFS time (A) and OS time (B). *P < .05.
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 6
Quantitative analyses of mRNA associated with gemcitabine sensitivity in EUS-FNA cytologic specimens. Representative micrographs of cytologic specimens obtained from patients with PDAC who underwent EUS-FNA cytologic examination (A, B). Most samples consisted of a large amount of blood and inflammat...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
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38. Kobayashi K, Sadakari Y, Ohtsuka T, Takahata S, Nakamura M, Mizumoto K, Tanaka M , Factors in Intraductal Papillary Mucinous Neoplasms of the Pancreas Predictive of Lymph Node Metastasis
, Pancreatology, 10, 6, 720-725, 2010.04, Background: Little is known about the frequency of lymph node metastasis (LNM) in intraductal papillary mucinous neoplasms (IPMNs), and we have not been able to determine how much lymph node dissection is necessary in individual cases. The aim of this study was to investigate the predictive factors for the LNM in IPMNs. Methods: Medical records of 120 patients pathologically diagnosed as having IPMN were reviewed, and 16 possible predictive factors regarding the LNM were analyzed. Results: LNM was observed in 7 patients (6%), all of whom were diagnosed as having mural nodules preoperatively. Sensitivity, specificity, and accuracy of preoperative imaging for detecting mural nodules of IPMNs in this study were 84, 97, and 90%, respectively. Univariate analysis using 61 patients having mural nodules preoperatively revealed that the size of mural nodules ≥10 mm and positive imaging findings for invasive tumor and possible LNM were significant predictive factors for the LNM. Multivariate analysis demonstrated that only an imaging finding for invasive tumor was an independent significant predictive factor. Positive and negative predictive values of the imaging finding of invasive IPMNs for LNM were 50 and 98%, respectively. Conclusions: Standard lymph node dissection would be recommended in patients with IPMNs with mural nodules demonstrating preoperative imaging findings for invasive carcinomas. and IAP.

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39. Tsutsumi K, Ohtsuka T, Oda Y, Sadakari Y, Mori Y, Aishima S, Takahata S, Nakamura M, Mizumoto K, Tanaka M, A History of Acute Pancreatitis in Intraductal Papillary Mucinous Neoplasms of the Pancreas Is a Potential Predictive Factor for Malignant Papillary Subtype
, Pancreatology, 10, 6, 707-712, 2010.04, Background/Aims: There are several reports regarding intraductal papillary mucinous neoplasms (IPMNs) detected after the occurrence of acute pancreatitis. Although the presence of symptoms is regarded as a factor for predicting malignant IPMNs, there have been few reports demonstrating whether a history of acute pancreatitis is a predictor of malignancy. The aim of this study was to evaluate the relationship between a history of acute pancreatitis and clinicopathological features of IPMNs including the papillary subtype. Methods: The data of 150 IPMNs resected between 1990 and 2009 were retrospectively reviewed. They were classified into IPMNs with or without history of acute pancreatitis, and then the clinicopathological features were compared between the 2 groups. Results: Nineteen (13%) of the 150 patients had a history of acute pancreatitis. Nine of them had repeated episodes of pancreatitis; however, severe pancreatitis was uncommon. The diameter of the main pancreatic duct of the pancreatitis group was significantly larger than that of the nonpancreatitis group (p = 0.04). The pancreatitis group had a significantly higher frequency of carcinoma derived from IPMNs than the nonpancreatitis group (p = 0.03). The incidence of intestinal-type IPMNs in the pancreatitis group was significantly higher than that in the nonpancreatitis group (p < 0.001). Conclusion: Acute pancreatitis associated with IPMNs could predict malignant intestinal-type tumor. and IAP.

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40. Yasui T, Ohuchida K, Zhao M, Onimaru M, Egami T, Fujita H, Ohtsuka T, Mizumoto K, Tanaka M , Tumor-stroma interactions reduce the efficacy of adenoviral therapy through the HGF-MET pathway.
, Cancer science , 102, 2, 484-491, 2011.04, Many preclinical studies have shown the potential of adenovirus-based cancer gene therapy. However, successful translation of these promising results into the clinic has not yet been achieved. Pancreatic ductal adenocarcinoma (PDAC) is characterized by abundant desmoplastic stroma, and tumor-stromal cell interactions play a critical role in tumor progression. Therefore, we hypothesized that tumor-stroma interactions reduce the efficacy of adenoviral therapy. We investigated the effect of fibroblasts on adenovirus-based gene therapy using SUIT-2 and PANC-1 pancreatic cancer cells cultured with or without fibroblast-conditioned culture supernatant then infected with Ad-LacZ. After 48 h, the cells were stained for β-galactosidase. The results showed that the number of β-galactosidase-positive cells was significantly reduced after culture with fibroblast-conditioned supernatant (P < 0.05). Because the hepatocyte growth factor (HGF)/MET pathway plays an important role in tumor-stroma interactions we next investigated the involvement of this pathway in tumor-stroma interactions leading to the decreased efficacy of adenoviral therapy. SUIT-2 cells were cultured with or without SU11274 (a MET inhibitor) and/or fibroblast-conditioned culture supernatant, then infected with Ad-GFP. After 48 h, GFP-positive cells were counted. The number of GFP-positive cells in cultures containing fibroblast-conditioned supernatant plus SU11274 was significantly greater than in cultures without SU11274. In conclusion, our results suggest that stromal cells in PDAC reduce the efficacy of adenoviral therapy through a mechanism involving the HGF/MET pathway. Control of such tumor-stroma interactions may lead to improvements in adenoviral gene therapy for PDAC.

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41. Kurata N, Fujita H, Ohuchida K, Mizumoto K, Mahawithitwong P, Sakai H, Onimaru M, Manabe T, Ohtsuka T, Tanaka M, Predicting the chemosensitivity of pancreatic cancer cells by quantifying the expression levels of genes associated with the metabolism of gemcitabine and 5-fluorouracil
, international journal of oncology, 39, 2, 473-482, 2011.04, Abstract
Gemcitabine (GEM) is the standard treatment for advanced/metastatic pancreatic cancer. However, there is a substantial subset of patients in whom the efficacy of GEM, when used as a single agent, is inadequate. Recently, the 5-fluorouracil (5-FU) prodrugs capecitabine and S-1 have been used as an alternative, either alone or in combination with GEM. The aim of the present study was to investigate the expression pattern of genes that render pancreatic cancer cells sensitive to GEM and 5-FU, and to identify markers for individualized chemotherapy, even in patients who have developed resistance. We investigated the correlation between the expression of genes associated with the metabolism of GEM and 5-FU, and sensitivity to these drugs in 15 human pancreatic cancer cell lines. We also established GEM- and 5-FU-resistant pancreatic cancer cell lines to investigate changes in the expression levels of these genes and the effects of one drug on cells resistant to the other. We found no correlation between pancreatic cancer cell sensitivity to either GEM- or 5-FU. GEM-resistant cells did not become resistant to 5-FU and vice versa. High expression of RRM1 (P=0.048) and TS x DPD (P=0.035) correlated significantly with sensitivity to GEM and 5-FU, respectively. 5-FU-resistant cells expressed significantly higher levels of TP than parental cells (P<0.05). In conclusion, pancreatic cancer cells showed no cross-resistance to GEM and 5-FU. Quantitative analyses of RRM1, TP, DPD and TS mRNA levels in pancreatic cancer cells may be useful for predicting their sensitivity to GEM and 5-FU.

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42. Fujita H, Ohuchida K, Mizumoto K, Itaba S, Ito T, Nakata K, Yu J, Kayashima T, Hayashi A, Souzaki R, Tajiri T, Onimaru M, Manabe T, Ohtsuka T, Tanaka M , High EGFR mRNA expression is a prognostic factor for reduced survival in pancreatic cancer after gemcitabine-based adjuvant chemotherapy.
, International journal of oncology , 38, 3, 629-641, 2011.04, Pancreatic ductal adenocarcinoma (PDAC) still presents a major therapeutic challenge and a phase III clinical trial has revealed that the combination of gemcitabine and a human epidermal growth factor receptor type I (HER1/EGFR) targeting agent presented a significant benefit compared to treatment with gemcitabine alone. The aim of this study was to investigate EGFR mRNA expression in resected PDAC tissues and its correlation with patient prognosis. We obtained formalin-fixed paraffin-embedded (FFPE) tissue samples from 88 patients with PDAC who underwent pancreatectomy, and measured EGFR mRNA levels by quantitative real-time reverse transcription-polymerase chain reaction. The high-level EGFR group had significantly shorter disease-free-survival (p=0.029) and overall-survival (p=0.014) as shown by univariate analyses, although these did not reach statistical significance, as shown by multivariate analyses. However, we found that high EGFR expression was an independent prognostic factor in patients receiving gemcitabine-based adjuvant chemotherapy (p=0.023). Furthermore, we measured EGFR mRNA levels in 20 endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytological specimens. Altered EGFR levels were distinguishable in microdissected neoplastic cells from EUS-FNA cytological specimens compared to those in whole cell pellets. In conclusion, quantitative analysis of EGFR mRNA expression using FFPE tissue samples and microdissected neoplastic cells from EUS-FNA cytological specimens could be useful in predicting prognosis and sensitivity to gemcitabine in PDAC patients.

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43. Tsutsumi K, Sato N, Cui L, Mizumoto K, Sadakari Y, Fujita H, Ohuchida K, Ohtsuka T, Takahata S, Tanaka M , Expression of claudin-4 (CLDN4) mRNA in intraductal papillary mucinous neoplasms of the pancreas
, Mod Pathol, 24, 4, 533-541, 2011.04, Claudin-4, encoding a protein for tight junction formation and function, is highly overexpressed in pancreatic ductal adenocarcinoma and is also associated with invasive adenocarcinomas arising in intraductal papillary mucinous neoplasms of the pancreas. However, the expression pattern of claudin-4 during neoplastic progression of intraductal papillary mucinous neoplasms remains unknown. Using quantitative real-time reverse transcription-PCR, we analyzed claudin-4 mRNA in a panel of 14 pancreatic cancer cell lines and in formalin-fixed paraffin-embedded tissues from 80 patients with intraductal papillary mucinous neoplasms of different histological grades and papillary subtypes. Increased expression of claudin-4 was confirmed in all the pancreatic cancer cell lines tested as compared with normal ductal epithelial cells and fibroblast cultures. The claudin-4 expression was significantly higher in high-grade intraductal papillary mucinous neoplasms (borderline neoplasm and carcinoma) than in low-grade intraductal papillary mucinous neoplasms (adenoma) (P<0.0001). In addition, claudin-4 mRNA levels were significantly higher in intestinal-type intraductal papillary mucinous neoplasms than in non-intestinal-type intraductal papillary mucinous neoplasms based on papillary subclassification (P<0.0001). Our findings suggest that claudin-4 expression is associated with neoplastic progression of intraductal papillary mucinous neoplasms and, especially, with a distinct pathway to intestinal differentiation.

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44. Tsutsumi K, Sato N, Tanabe R, Mizumoto K, Morimatsu K, Kayashima T, Fujita H, Ohuchida K, Ohtsuka T, Takahata S, Nakamura M, Tanaka M, Claudin-4 Expression Predicts Survival in Pancreatic Ductal Adenocarcinoma
, Ann Surg Oncol. , 19, Suppl3, S491-499, 2011.04, Abstract
BACKGROUND: Identification of prognostic markers would be useful in the clinical management of patients with pancreatic ductal adenocarcinoma (PDAC). The clinical relevance of claudin-4 (CLDN4), recently identified as overexpressed in PDAC, is unknown.

METHODS: Using quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR), we analyzed CLDN4 mRNA expression in a panel of 9 pancreatic cancer cell lines and formalin-fixed paraffin-embedded (FFPE) tissues from 100 patients with PDAC. The CLDN4 expression levels were then correlated with clinicopathological variables and patient outcome. We also performed immunohistochemical analysis in 20 FFPE samples of PDAC to investigate the expression of CLDN4 protein.

RESULTS: Increased expression of CLDN4 was confirmed in all the pancreatic cancer cell lines tested compared with normal ductal epithelial cells and fibroblasts. We found that low expression of CLDN4 was significantly associated with shorter survival in patients with PDAC (hazard ratio; 1.362, 95% confidence interval; 1.011-1.873, P = 0.0419). Patients with high CLDN4 expression survived longer for a median of 63.0 months, compared with 14.7 months in patients with low CLDN4 expression (P = 0.0067). In immunohistochemical analysis, the level of CLDN4 mRNA expression was significantly correlated with the expression of CLDN4 protein (P = 0.0168).

CONCLUSION: Increased expression of CLDN4 mRNA predicts better prognosis in PDAC.

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45. Yasui T, Ohuchida K, Zhao M, Cui L, Onimaru M, Egami T, Fujita H, Ohtsuka T, Mizumoto M, Matsumoto K, Tanaka M, Adenoviral therapy is more effective in gemcitabine-resistant pancreatic cancer than in gemcitabine-sensitive cells.
, Anticancer Res. , 31, 4, 1279-1288, 2011.04, BACKGROUND: Although gemcitabine is the standard treatment for pancreatic cancer, this particular type of cancer develops rapidly and has intrinsic chemoresistance. Chemoresistance plays a critical role in tumor progression, invasion and migration. Nevertheless, the effect of adenoviral therapy on chemoresistant cancer cells has not been studied. In this study, we compared the efficacy of adenoviral therapy in parental and chemoresistant pancreatic cancer cells.

MATERIALS AND METHODS: To establish gemcitabine-resistant cells, pancreatic cancer SUIT2 cells were exposed to increasing concentrations of gemcitabine. Both parental and chemoresistant cells were infected with adenoviruses expressing either green fluorescent protein (Ad-GFP) or the hepatocyte growth factor antagonist, NK4 (Ad-NK4). To investigate the transduction efficacy, GFP expression and NK4 concentrations were measured and an invasion assay was used to investigate the efficacy of the adenoviral therapy.

RESULTS: The 50% inhibitory concentration of gemcitabine was <10 nM in the parental SUIT-2 cells, while it was >1 μM in gemcitabine-resistant cells. A large number of gemcitabine-resistant cells were GFP-positive compared with only a small number of parental cells (p<0.05). The NK4 expression level was significantly higher in gemcitabine-resistant cells than in parental cells (p<0.05). The supernatant from Ad-NK4-infected gemcitabine-resistant cells significantly inhibited the invasion of cancer cells compared with that from Ad-NK4-infected parental cells (p<0.05).

CONCLUSION: Both the efficiency of transduction and the therapeutic efficacy of adenoviral therapy were higher in gemcitabine-resistant cells than in parental cells, suggesting that adenoviral gene therapy is more effective in patients with gemcitabine-resistant pancreatic cancer.

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46. Ikenaga N, Ohuchida K, Mizumoto K, Akagawa S, Fujiwara K, Eguchi D, Kozono S, Ohtsuka T, Takahata S, Tanaka M, Pancreatic cancer cells enhance the ability of collagen internalization during epithelial-mesenchymal transition., PLoS One, 7, 7, e40434, 2012.04, Abstract


BACKGROUND:

Extracellular matrix (ECM) remodeling is predominantly mediated by fibroblasts using intracellular and extracellular pathways. Although it is well known that extracellular degradation of the ECM by proteases derived from cancer cells facilitates cellular invasion, the intracellular degradation of ECM components by cancer cells has not been clarified. The aim of this study was to characterize collagen internalization, which is the initial step of the intracellular degradation pathway in pancreatic cancer cells, in light of epithelial-mesenchymal transition (EMT).

METHODOLOGY/PRINCIPAL FINDINGS:

We analyzed the function of collagen internalization in two pancreatic cancer cell lines, SUIT-2 and KP-2, and pancreatic stellate cells (PSCs) using Oregon Green 488-gelatin. PSCs had a strong ability for collagen uptake, and the pancreatic cancer cells also internalized collagen although less efficiently. The collagen internalization abilities of SUIT-2 and KP-2 cells were promoted by EMT induced by human recombinant transforming growth factor β1 (P<0.05). Expression of Endo180, a collagen uptake receptor, was high in mesenchymal pancreatic cancer cell lines, as determined by EMT marker expression (P<0.01). Quantitative RT-PCR and western blot analyses showed that Endo180 expression was also increased by EMT induction in SUIT-2 and KP-2 cells. Endo180 knockdown by RNA interference attenuated the collagen uptake (P<0.01) and invasive abilities (P<0.05) of SUIT-2 and KP-2 cells.

CONCLUSIONS/SIGNIFICANCE:

Pancreatic cancer cells are capable of collagen internalization, which is enhanced by EMT. This ECM clearance system may be a novel mechanism for cellular invasion and a potential therapeutic target in pancreatic cancer.
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47. Ohuchida K, Mizumoto K, Lin C, Yamaguchi H, Ohtsuka T, Sato N, Toma H, Nakamura M, Nagai E, Hashizume M, Tanaka M, MicroRNA-10a is overexpressed in human pancreatic cancer and involved in its invasiveness partially via suppression of the HOXA1 gene, Ann Surg Oncol., 19, 7, 2394-2402, 2012.04, Abstract
BACKGROUND:
There is increasing evidence that microRNAs are differentially expressed in many types of cancers. Despite progress in analyses of microRNAs in several types of cancers, the functional contributions of microRNAs to pancreatic cancer remain unclear.
METHODS:
In the present study, the expression levels of specific microRNAs identified by microarray analyses were examined in a panel of 15 pancreatic cancer cell lines. We then investigated the functional roles of these microRNAs in the proliferation and invasion of pancreatic cancer cells.
RESULTS:
Based on the microarray data, we found frequent and marked overexpression of miR-10a, miR-92, and miR-17-5p in pancreatic cancer cell lines. Microdissection analyses revealed that miR-10a was overexpressed in pancreatic cancer cells isolated from a subset of primary tumors (12 of 20, 60%) compared with precursor lesions and normal ducts (P<.01). In vitro experiments revealed that miR-10a inhibitors decreased the invasiveness of pancreatic cancer cells (P<.01), but had no effect on their proliferation. Inhibition of HOXA1, a target of miR-10a, promoted the invasiveness of pancreatic cancer cells (P<.01).
CONCLUSIONS:
The present data suggest that miR-10a is overexpressed in a subset of pancreatic cancers and is involved in the invasive potential of pancreatic cancer cells partially via suppression of HOXA1..
48. Aso T, Ohtsuka T, Ideno N, Kono H, Nagayoshi Y, Mori Y, Ohuchida K, Ueda J, Takahata S, Morimatsu K, Aishima S, Igarashi H, Ito T, Ishigami K, Mizumoto K, Tanaka M, Diagnostic significance of a dilated orifice of the duodenal papilla in intraductal papillary mucinous neoplasm of the pancreas, Gastrointest Endosc, 76, 2, 313-320, 2012.04,
BACKGROUND:

A dilated orifice of the duodenal papilla found during screening endoscopy or ERCP is well-known as one of the specific findings of intraductal papillary mucinous neoplasm (IPMN). However, its clinical significance is still unclear.

OBJECTIVE:

To assess the diagnostic significance of a dilated orifice of the duodenal papilla and evaluate whether this could be a factor predictive of malignancy or a subtype of IPMN.

DESIGN:

Retrospective study.

SETTING:

University hospital.

PATIENTS:

This study involved 149 patients who underwent pancreatectomy for IPMN between January 1987 and June 2011.

INTERVENTION:

ERCP.

MAIN OUTCOME MEASUREMENTS:

The rate of malignant and intestinal type IPMNs in patients with and without papillary dilation.

RESULTS:

A dilated orifice of the duodenal papilla was significantly associated with intestinal type IPMN (P < .001), but this finding could not predict the malignant grade of IPMN (P = .13). Multivariate analysis revealed that a dilated orifice was a significant factor for predicting intestinal type in both main duct (P = .01) and branch duct IPMNs (P < .001).

LIMITATIONS:

The validity of the definition of papillary dilation, selection bias, and a retrospective study.

CONCLUSION:

A dilated orifice of the duodenal papilla could be a significant factor for predicting intestinal type IPMN. This may lead to better clinical management of patients with IPMN.

Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.


Comment in
Pancreatic cancer: Dilated orifice of the duodenal papilla predicts intestinal type IPMN. [Nat Rev Gastroenterol Hepatol. 2012]
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49. Fujiwara K, Ohuchida K, Mizumoto K, Shindo K, Eguchi D, Kozono S, Ikenaga N, Ohtsuka T, Takahata S, Aishima S, Tanaka M, CD271⁺ subpopulation of pancreatic stellate cells correlates with prognosis of pancreatic cancer and is regulated by interaction with cancer cells., PLOS one, 0.1371/journal.pone.0052682, 7, 12, e52682, 2012.04, Abstract
Pancreatic stellate cells (PSCs) play a crucial role in the aggressive behavior of pancreatic cancer. Although heterogeneity of PSCs has been identified, the functional differences remain unclear. We characterized CD271⁺ PSCs in human pancreatic cancer. Immunohistochemistry for CD271 was performed for 31 normal pancreatic tissues and 105 pancreatic ductal adenocarcinomas (PDACs). We performed flow cytometry and quantitative RT-PCR, and assessed CD271 expression in PSCs isolated from pancreatic tissues and the changes in CD271 expression in PSCs cocultured with cancer cells. We also investigated the pattern of CD271 expression in a SCID mouse xenograft model. In the immunohistochemical analyses, the CD271-high staining rates in pancreatic stroma in normal pancreatic tissues and PDACs were 2/31 (6.5%) and 29/105 (27.6%), respectively (p = 0.0069). In PDACs, CD271⁺ stromal cells were frequently observed on the edge rather than the center of the tumors. Stromal CD271 high expression was associated with a good prognosis (p = 0.0040). Flow cytometric analyses demonstrated CD271-positive rates in PSCs were 0-2.1%. Quantitative RT-PCR analyses revealed that CD271 mRNA expression was increased in PSCs after coculture with pancreatic cancer cells. However, the level of CD271 mRNA expression subsequently decreased after the transient increase. Furthermore, CD271 mRNA expression was decreased in PSCs migrating toward pancreatic cancer cells through Matrigel. In the xenograft model, CD271⁺ PSCs were present at tumor margins/periphery and were absent in the tumor core. In conclusion, CD271 was expressed in PSCs around pancreatic tumors, but not in the center of the tumors, and expression decreased after long coculture with pancreatic cancer cells or after movement toward pancreatic cancer cells. These findings suggest that CD271⁺ PSCs appear at the early stage of pancreatic carcinogenesis and that CD271 expression is significantly correlated with a better prognosis in patients with PDAC..
50. Kozono S, Ohuchida K, Ohtsuka T, Cui L, Eguchi D, Fujiwara K, Zhao M, Mizumoto K, Tanaka M, S100A4 mRNA expression level is a predictor of radioresistance of pancreatic cancer cells, Oncol Rep. , 30, 4, 1601-1608, 2013.04, Improving poor outcomes in patients with pancreatic cancer requires a greater understanding of the biological mechanisms contributing to radioresistance. We, therefore, sought to identify genes involved in the radioresistance of pancreatic cancer cells. Two pancreatic cancer cell lines, CFPAC-1 and Capan-1, were repeatedly exposed to radiation, establishing two radioresistant cell lines. Gene expression profiling using cDNA microarrays was performed to identify genes responsible for radioresistance. The levels of expression of mRNAs encoded by selected genes and their correlation with radiation dose resulting in 50% survival rate were analyzed in pancreatic cancer cell lines. The radiation dose resulting in a 50% survival rate was significantly higher in irradiated (IR) compared to parental CFPAC-1 cells (8.31 ± 0.85 Gy vs. 2.14 ± 0.04 Gy, P<0.0001), but was lower in IR compared with parental Capan-1 cells (2.66 ± 0.24 Gy vs. 2.25 ± 0.03 Gy, P=0.04). cDNA microarray analysis identified 4 genes, including S100 calcium binding protein A4 (S100A4), overexpressed and 23 genes underexpressed in the IR compared with the parental cell lines. The levels of S100A4 mRNA expression were correlated with radiation dose resulting in a 50% survival rate (Pearson's test, R2=0.81, P=0.0025). S100A4 mRNA expression may predict radioresistance of pancreatic cancer cells and may play an important role in the poor response of pancreatic cancer cells to radiation therapy..
51. Fujiwara K, Ohuchida K, Ohtsuka T, Mizumoto K, Shindo K, Ikenaga N, Cui L, Takahata S, Aishima S, Tanaka M, Migratory Activity of CD105+ Pancreatic Cancer Cells Is Strongly Enhanced by Pancreatic Stellate Cells
, Pancreas, 42, 8, 1283-1290, 2013.04, OBJECTIVES: CD105 expression correlates with prognosis for several cancers. However, its significance in pancreatic cancer is unclear.METHODS: We analyzed CD105 expression in resected pancreatic cancer tissue and pancreatic cancer cell lines, compared the properties of CD105 and CD105 cells using quantitative RT-PCR and migration assays, and evaluated the relationship between CD105 cells and pancreatic stellate cells (PSCs).RESULTS: Immunohistochemistry showed that the frequency of CD105 expression was higher in pancreatic cancer than that in normal tissue (8% vs 0%, respectively). In flow cytometry, CD105 was expressed in pancreatic cancer cells, whereas weak CD105 expression was detected in normal pancreatic ductal epithelial cells. Quantitative RT-PCR showed that E-cadherin mRNA expression was suppressed and vimentin mRNA was overexpressed in CD105 cells (P < 0.05). Migration of CD105 cancer cells was strongly enhanced (more than that of CD105 c
ells) in coculture with PSCs (P < 0.05). CD105 expression did not correlate to clinicopathologic characteristics or the Kaplan-Meier survival analysis.CONCLUSIONS: Suppression of an epithelial marker and overexpression of a mesenchymal marker suggest that epithelial-mesenchymal transition is induced in CD105 pancreatic cancer cells. CD105 pancreatic cancer cell migration is strongly enhanced by PSCs, suggesting that these cells play a role in the pancreatic cancer microenvironment..
52. Eguchi D, Ohuchida K, Kozono S, Ikenaga N, Shindo K, Cui L, Fujiwara K, Akagawa S, Ohtsuka T, Takahata S, Tokunaga S, Mizumoto K, Tanaka M, MAL2 expression predicts distant metastasis and short survival in pancreatic cancer, Surgery. , 154, 3, 573-582, 2013.04, BACKGROUND:

Pancreatic cancer is associated with a devastating prognosis, partially because of its aggressive metastatic ability. Identification of prognostic markers of metastasis would be useful in the clinical management of postoperative patients with pancreatic cancer. Mal, T-cell differentiation protein 2 (MAL2) has been identified as a molecule predictive of metastases; the clinical relevance of MAL2 in pancreatic cancer is unknown.

METHODS:

Orthotopic human pancreatic cancer xenografts from the pancreatic cancer cell line SUIT-2 were established in nude mice. Only liver metastasis was harvested and cultured. These metastatic cycles were repeated 5 times to establish a highly metastatic cell line, termed metastatic SUIT-2 (MS). We investigated proliferation and motility of MS cells compared with those of the parent SUIT-2. Microarray analysis was performed to investigate differences in gene expression. We also performed immunohistochemical analysis of 89 formalin-fixed, paraffin-embedded human pancreatic cancer tissue samples to investigate the clinical significance of MAL2 expression.

RESULTS:

MS cells showed a greater metastatic rate after orthotopic implantation than parental SUIT-2. MS cells had increased motility but decreased proliferation compared with parental SUIT-2. Microarray analyses showed that 26 genes were significantly upregulated (>10-fold) in MS cells compared with parental SUIT-2, particularly MAL2 expression. Immunohistochemical analysis showed that high expression of MAL2 was associated with a lesser survival of postoperative patients (P = .03) and a high rate of distant metastasis (P = .008).

CONCLUSION:

We characterized a newly established pancreatic cancer cell line with highly metastatic potential. MAL2 is a promising predictive marker for distant metastasis and short survival in patients with resected pancreatic cancer.

Copyright © 2013 Mosby, Inc. All rights reserved.
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53. Mahawithitwong P, Ouchida K, Ikenaga N, Fujita H, Zhao M, Kozono S, Shindo K, Ohtsuka T, Mizumoto K, Tanaka M, Kindlin-2 expression in peritumoral stroma is associated with poor prognosis in pancreatic ductal adenocarcinoma., Pancreas, 42, 4, 663-669, 2013.04, OBJECTIVES:

Kindlin-2 is a novel focal adhesion protein reported to be expressed in breast, lung, and gastric cancers. This study aimed to investigate the significance of kindlin-2 expression in pancreatic ductal adenocarcinomas (PDACs).

METHODS:

We performed immunohistochemical analysis on kindlin-2 on PDAC samples from 95 patients. We investigated the association between kindlin-2 expression and clinicopathological parameters of PDAC and the survival time of patients with PDAC who underwent pancreatectomy.

RESULTS:

Kindlin-2 was highly expressed in the peritumoral stroma of PDACs. Stromal kindlin-2 expression was related to nodal metastasis (P = 0.03). Univariate analysis showed that patients with positive kindlin-2 expression had significantly shorter survival times than those with negative kindlin-2 expression (P = 0.01). In addition, multivariate analysis revealed that kindlin-2 expression was an independent factor of poor prognosis in patients with PDAC after R0 resection (RR = 2.15; P = 0.04).

CONCLUSIONS:

Kindlin-2 expression in stromal components is significantly associated with poor prognosis of patients with PDAC, suggesting that kindlin-2 is a prognostic marker for patients with PDAC.
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54. Mahawithitwong P, Ohuchida K, Ikenaga N, Fujita H, Zhao M, Kozono S, Shindo K, Ohtsuka T, Aishima S, Mizumoto K, Tanaka M, Kindlin-1 expression is involved in migration and invasion of pancreatic cancer , International journal of oncology, 42, 4, 1360-1366, 2013.04, Abstract
Kindlin-1 is a novel focal adhesion protein that belongs to the kindlin family. Expression of kindlin-1 has recently been reported in lung and colon cancers, but there have been no studies on its expression in pancreatic cancer. This study aimed to investigate the expression and function of kindlin-1 in pancreatic cancer. Quantitative RT-PCR of Kindlin-1 mRNA was performed in various pancreatic cancer cell lines as well as normal pancreatic epithelial cells and fibroblasts. Immunohistochemical analysis of kindlin-1 was performed for pancreatic cancer tissues. The effects of kindlin-1 on the proliferation, migration and invasion of pancreatic cancer cells were investigated using an RNA interference technique. Kindlin-1 mRNA was highly expressed in the pancreatic cancer cell lines, but only slightly expressed in normal pancreatic epithelial cells and fibroblasts. The Kindlin-1 protein was heterogeneously expressed in the cytoplasm and membrane of pancreatic cancer cells, while normal ductal epithelial cells and stromal cells showed no expression. In vitro experiments involving knockdown of kindlin-1 in AsPC-1 and KP-2 cells revealed that the migratory and invasive abilities of the cells were significantly decreased (P<0.001), while the proliferation abilities were not affected. The present findings suggest that kindlin-1 expression is involved in the progression of pancreatic cancer via enhancement of cell migration and invasion..
55. Ideno N, Ohtsuka T, Kono H, Fujiwara K, Oda Y, Aishima S, Ito T, Tokunaga S, Ohuchida K, Takahata S, Nakamura M, Mizumoto K, Tanaka M, Intraductal Papillary Mucinous Neoplasms of the Pancreas with Distinct Pancreatic Ductal Adenocarcinoma Are Frequently of Gastric Subtype, Ann Surg., 258, 1, 141-151, 2013.04, OBJECTIVE:: To identify a high-risk group of patients with pancreatic ductal adenocarcinoma (PDAC), independently arising in the pancreas with intraductal papillary mucinous neoplasm (IPMN), using histopathologic subtypes. BACKGROUND:: Pathologic features of IPMN with distinct PDAC, including histopathologic subtypes of IPMN and PDAC phenotypes, have not been well characterized. Mucin expression patterns and the mutational status of GNAS and KRAS are useful to explore the relationship between these 2 lesion types. METHODS:: Clinicopathologic data of 179 resected IPMNs and 180 resected PDACs without IPMNs as a control group were reviewed. IPMNs were classified into 4 grades (low-grade, intermediate-grade, high-grade dysplasia, and an associated invasive carcinoma) and 4 subtypes (gastric, intestinal, pancreatobiliary, and oncocytic). The expression of MUC1, MUC2, MUC5AC, MUC6, and CDX2 was investigated by immunohistochemistry in IPMNs and PDACs with an
d without IPMNs. The mutational status of GNAS and KRAS was evaluated by cycle sequencing in PDACs and pre-/coexisting IPMNs. RESULTS:: Twenty-six synchronous or metachronous PDACs were identified in 20 patients (11.2%) with IPMNs. Occurrence of concomitant PDACs was more frequently observed in gastric-type IPMNs (18/110, 16.4%) compared with intestinal (1/49, 2.0%), pancreatobiliary (1/17, 5.9%), or oncocytic-type (0/3, 0%) (P = 0.047). Both PDACs with and without IPMNs were frequently positive for MUC1, MUC5AC, and MUC6 expression, as assessed by immunohistochemistry, but were negative for MUC2 and CDX2. The mucin-staining patterns were similar to those of invasive tubular adenocarcinoma arising from gastric-type IPMNs. Mutation of GNAS within codon 201 was not detected in PDACs and gastric-type IPMNs, whereas most of these exhibited KRAS mutations. However, the R201H GNAS mutation was detected in 1 intestinal-type IPMN with distinct PDAC. CONCLUSIONS:: Mucin expression pa
tterns demonstrate that PDAC without GNAS mutations of an aggressive phenotype frequently arise in the pancreas with benign gastric-type IPMN in the absence of GNAS mutations..
56. Eguchi D, Ikenaga N, Ohuchida K, Kozono S, Cui L, Fujiwara K, Fujino M, Ohtsuka T, Mizumoto K, Tanaka M, Hypoxia enhances the interaction between pancreatic stellate cells and cancer cells via increased secretion of connective tissue growth factor, Journal of surgical research, 181, 2, 225-233, 2013.04, Abstract

BACKGROUND:

Pancreatic cancer (PC), a hypovascular tumor, thrives under hypoxic conditions. Pancreatic stellate cells (PSCs) promote PC progression by secreting soluble factors, but their functions in hypoxia are poorly understood. This study aimed to clarify the effects of hypoxic conditions on the interaction between PC cells and PSCs.

METHODS:

We isolated human PSCs from fresh pancreatic ductal adenocarcinomas and analyzed functional differences in PSCs between normoxia (21% O(2)) and hypoxia (1% O(2)), including expression of various factors related to tumor-stromal interactions. We particularly analyzed effects on PC invasiveness of an overexpressed molecule-connective tissue growth factor (CTGF)-in PSCs under hypoxic conditions, using RNA interference techniques.

RESULTS:

Conditioned media from hypoxic PSCs enhanced PC cell invasiveness more intensely than that from normoxic PSCs (P < 0.01). When co-cultured with PSCs, PC cell invasion was more enhanced under hypoxia than under normoxia (P < 0.05). Among various soluble factors, which were related to invasiveness, CTGF was one of the overexpressed molecules in hypoxic PSCs. A higher level of CTGF expression was also found in supernatant of hypoxic PSCs than in supernatant of normoxic PSCs. PC cell invasiveness was reduced by CTGF knockdown in hypoxic PSCs co-cultured with PC cells (P < 0.05).

CONCLUSION:

Hypoxia induces PSCs' secretion of CTGF, leading to enhancement of PC invasiveness. CTGF derived from hypoxia-stimulated PSCs may be a new therapeutic target for pancreatic cancer.
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57. Kono H, Nakamura M, Ohtsuka T, Nagayoshi Y, Mori Y, Takahata S, Aishima S, Tanaka M, High expression of microRNA-155 is associated with the aggressive malignant behavior of gallbladder carcinoma., Oncol Rep., 30, 1, 17-24, 2013.04, The prognosis of gallbladder cancer (GBC) remains poor despite recent advances in diagnostics and therapeutic strategies. Although the role of microRNAs (miRs) in GBC have not been well documented, miR-155 is known to be associated with inflammation-associated carcinogenesis in various types of cancers. The aim of this study was to investigate the clinical significance of miR-155 expression and the biological functions of miR-155 in GBC. The expression levels of miR-155 in surgically resected GBCs and gallbladders with pancreaticobiliary maljunction (PBM) were assessed by quantitative reverse transcription-polymerase chain reaction. The relationship between the expression levels of miR-155 and clinicopathological features of GBCs was analyzed. Human GBC cell lines were transfected with miR-155 inhibitors or mimics, and the effects on proliferation and invasion were assessed. miR-155 was significantly overexpressed in GBCs when compared with that in gallbladders with PBM (p=0.007) and normal gallbladders (p=0.04). The high expression level of miR-155 in GBCs was significantly associated with the presence of lymph node metastasis (p=0.01) and a poor prognosis (p=0.02). In vitro assays showed that aberrant expression of miR-155 significantly enhanced GBC cell proliferation and invasion. In conclusion, high miR-155 expression correlates with the aggressive behavior of GBCs, and miR-155 may become a prognostic marker and therapeutic target for GBC..
58. Nakamura M, Ohtsuka T, Nakashima H, Nagayoshi Y, Kono H, Tsutsumi K, Takahata S, Tanaka M, Extensive distal pancreatectomy for pancreatic tumor., Anticancer Res, 33, 1, 267-270, 2013.04, Aim: The purpose of this study was to evaluate the feasibility and advantages of extensive distal pancreatectomy (ExDP).

PATIENTS AND METHODS:

We retrospectively analyzed our experience in 24 patients, who underwent ExDP or total pancreatectomy (TP) for the treatment of pancreatic cancer (22 patients) or benign tumor (two patients).

RESULTS:

ExDP was associated with less blood loss (p=0.0189), shorter operative times (p=0.024), lower rates of worsening of diabetes mellitus (p<0.0001), and shorter hospital stays (p=0.0009) than TP. ExDP also had a lower complication rate than TP (1/11 cases versus 4/13 cases), but this was not a significant difference. There was no difference in the curative resection rate for pancreatic cancer between the two procedures (p=0.685).

CONCLUSION:

ExDP is a feasible and function-preserving operation for the treatment of pancreatic tumors in the body of the pancreas near the portal vein.
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59. Nakamura M, Kayashima T, Fujiwara K, Nagayoshi Y, Kono H, Ohtsuka T, Takahata S, Mizumoto K, Tanaka M, Combination therapy of portal vein resection and adjuvant gemcitabine improved prognosis of advanced pancreatic cancer, Hepato-Gastroenterology, 60, 122, 354-357, 2013.04, Abstract


Background/Aims: Although adjuvant chemotherapy (AC) using gemcitabine improves the prognosis of patients with resectable pancreatic cancer, the effect of gemcitabine AC on the prognosis of patients with borderline resectable pancreatic cancer is not clear. Methodology: We analyzed the prognosis of patients with pancreatic cancer who underwent curative pancreatoduodenectomy or total pancreatectomy in combination with portal/superior mesenteric vein resection (PVR) [PVR (+) group] or without PVR [PVR(-) group]. Results: MST of the PVR (+) group was significantly shorter than that of the PVR(-) group (p=0.017). In contrast, when we focused on the patients with gemcitabine AC, there was no significant difference in MST between the PVR (+) and the PVR (-) groups (p=0.247). Furthermore, we compared MST of two subgroups in the PVR (+) group depending on gemcitabine AC status. In the PVR (+) group, MST of the patients with gemcitabine AC was significantly longer than that without gemcitabine AC (p=0.003). This was also true for the patients with pancreatic cancer which had histologically proven invasion to portal/superior mesenteric vein (PV/SMV) (p=0.001). Conclusions: The prognosis of patients with pancreatic cancer invading PV/SMV can be improved by combination therapy with PVR and gemcitabine adjuvant chemotherapy.
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60. Tamura K, Ohtsuka T, Ideno N, Aso T, Shindo K, Aishima S, Ohuchida K, Takahata S, Ushijima Y, Ito T, Oda Y, Mizumoto K, Tanaka M, Treatment Strategy for Main Duct Intraductal PapillaryMucinous Neoplasms of the Pancreas Based on the Assessmentof Recurrence in the Remnant Pancreas After ResectionA Retrospective Review, Annals of Surgery, 259, 2, 360-368, 2014.04, OBJECTIVES:

To clarify the recurrence pattern after resection of main duct intraductal papillary mucinous neoplasms (MD-IPMNs) using molecular analyses and determine the most adequate treatment strategy.

BACKGROUND:

The most appropriate resection line for MD-IPMNs remains an unresolved issue.

METHODS:

Medical records of 56 patients with pancreatectomy were retrospectively reviewed. Histological subtypes and Kras/GNAS mutations were assessed in patients with recurrence in the remnant pancreas.

RESULTS:

Forty-nine patients underwent partial pancreatectomy and 7 underwent total pancreatectomy. Thirty-six patients (64%) had malignant MD-IPMNs. Recurrence was observed in 7 of 49 patients (14%), including 6 with malignant IPMNs and 1 with pancreatic ductal adenocarcinoma, all of whom underwent remnant pancreatectomy. The cumulative disease-specific survival rate of patients with pancreatic recurrence was greater than that of patients with extrapancreatic recurrence (P < 0.001). Although the pancreatic margin status at the initial operation did not affect the pancreatic recurrence rate, all 4 recurrent IPMNs examined had histological subtypes and Kras/GNAS mutations identical to those of the initial lesions. Four patients experienced recurrence in the remnant pancreas or systemic recurrence after resection of high-grade dysplasia of MD-IPMN. Three of the 56 patients had concomitant pancreatic ductal adenocarcinomas and MD-IPMNs.

CONCLUSIONS:

One-step total pancreatectomy can be avoided, and remnant total pancreatectomy would lead to favorable outcomes even in patients with pancreatic recurrence, some cases of which seem to involve residual lesions. Postoperative surveillance of high-grade dysplasia should be performed as if malignant, and close attention should be paid to the occurrence of concomitant pancreatic ductal adenocarcinomas in patients with MD-IPMNs.
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61. Ohtsuka T, Tamura K, Ideno N, Aso T, Nagayoshi Y, Kono H, Ueda J, Takahata S, Aso A, Igarashi H, Ushijima Y, Ookubo F, Oda Y, Mizumoto K, Tanaka M, The role of ERCP in the era of EUS-FNA for preoperative cytological confirmation of resectable pancreatic ductal adenocarcinoma, Surg Today., 44, 10, 1887-1892, 2014.04, PURPOSE:

In patients with pancreatic ductal carcinoma (PDAC), EUS-FNA carries a risk of cancer seeding. To avoid this risk, we attempted to obtain preoperative cytological confirmation of adenocarcinoma by ERCP. The aim of this study was to assess the validity of our diagnostic strategy.

METHODS:

The medical records of 124 consecutive patients who were investigated for potentially resectable PDAC were retrospectively reviewed, and the ability to detect adenocarcinoma by ERCP was evaluated.

RESULTS:

ERCP was performed in 115 patients, 69 of whom had positive cytology results. Thirty-four patients underwent EUS-FNA, 29 of whom had positive cytology results. A total of 98 patients (79 %), therefore, had preoperative cytological confirmation of adenocarcinoma, which was more frequent in patients with lesions of the head of the pancreas than in those with lesions of the body or tail of the pancreas. The postoperative pathological diagnosis demonstrated malignant pancreatic neoplasms in 122 patients (98 %), including 111 with PDAC. EUS-FNA did not affect the rate of postoperative peritoneal dissemination.

CONCLUSIONS:

Our strategy using ERCP as the initial diagnostic modality for obtaining cytological confirmation of potentially resectable PDAC seems to be adequate, yielding a high rate of positive cytology, especially in cases with tumors of the head of the pancreas.
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62. Ohtsuka T, Matsunaga T, KImura H, Watanabe Y, Tamura K, ideno N, Aso T, Miyasaka Y, Ueda J, Takahata S, Osoegawa T, Igarashi H, Ito T, Ushijima Y, Ookubo F, Oda Y, Mizumoto K, Tanaka M, Role of pancreatic juice cytology in the preoperative management of intraductal papillary mucinous neoplasm of the pancreas in the era of international consensus guidelines 2012, World J Surg., 38, 11, 2994-3001, 2014.04, BACKGROUND:

Routine endoscopic retrograde pancreatography (ERP) for pancreatic juice cytology (PJC) during management of intraductal papillary mucinous neoplasm (IPMN) is not recommended in the international consensus guidelines 2012. The aim of the present study was to investigate the roles of PJC in relation to the new stratification of clinical findings in the consensus guidelines 2012.

METHODS:

Medical records of 70 consecutive patients who underwent preoperative PJC, subsequent pancreatectomy, and a pathological diagnosis of IPMN were reviewed. Diagnostic ability of PJC to detect malignant lesions was calculated by the stratification of clinical findings.

RESULTS:

Forty patients had malignant lesions, including 29 with malignant IPMN, 10 with concomitant pancreatic adenocarcinoma, and one with both. Accuracies of PJC in all 70 patients and in 59 patients with IPMN alone were 77 and 80 %, respectively. The sensitivity and accuracy of PJC in patients with "worrisome features" were 100 and 94 %, respectively. Eight of 11 patients with concomitant pancreatic adenocarcinoma had non-malignant IPMN without risk factors, and 3 significant lesions could be diagnosed only by ERP/PJC. In addition, the management plan based on imaging study changed from observation to resection in two patients who had the single "worrisome feature" of branch duct IPMN and positive PJC results. As a result, PJC altered the management plan in 5 patients.

CONCLUSIONS:

Pancreatic juice cytology potentially has important roles to determine the adequate treatment choice in patients with IPMNs with "worrisome features," and to detect significant lesions that could not be detected by other imaging modalities.
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63. Nagayoshi Y, Nakamura M, Matsuoka K, Ohtsuka T, Mori Y, Kono H, Aso T, Takahata S, Ryo A, Takeda H, Ito T, Oda Y, Endo Y, Sawasaki T, Tanaka M, Profiling of autoantibodies in sera of pancreatic cancer patients, Ann Surg Oncol, 10.1245/s10434-014-3574-0, 21, Suppl3, S459-S465, 2014.04, BACKGROUND:

Although autoantibodies to cancer antigens are candidates for biomarkers, no comprehensive studies to detect cancer-specific antibodies have been performed. This study identified autoantibodies in the sera of pancreatic cancer (PC) patients using proteomics based on a wheat germ cell-free protein production system.

METHODS:

We constructed a biotinylated protein library of 2,183 genes. Interactions between biotinylated proteins and serum antibodies were detected by AlphaScreen® assay. Relative luminescence signals of each protein in 37 PC patients and 20 healthy controls were measured, and their sensitivity and specificity for PC were calculated.

RESULTS:

Luminescence signals of nine proteins were significantly higher than those of healthy controls, with calcium and integrin binding 1 (CIB1) protein showing the greatest significance (p = 0.002). Sensitivity, specificity, positive predictive value and negative predictive value of CIB1 autoantibody alone for PC were 76, 70, 82, and 61 %, respectively, and 97, 35, 74, and 88 %, respectively, when the four most significant proteins were combined. Presence of these autoantibodies did not vary significantly with other clinicopathological characteristics.

CONCLUSION:

Several autoantibodies, including CIB1, are potential biomarkers for PC.
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64. Nakamura M, Shindo K, Ideno N, Ueda J, Takahata S, Nakashima H, Ohtsuka T, Shimizu S, Oda Y, Tanaka M, Prediction of Pancreatic Fistula by Preoperatively Assessable Factors; Retrospective Review of Unified Operations by Single Surgeon, Hepato-Gastroenterology, 2014, 61, 834-837, 2014.04, Abstract
BACKGROUND/AIMS: This retrospective study was conducted to find preoperatively assessable risk factors for postoperative pancreatic fistula (POPF) in patients undergoing laparoscopic distal pancreatectomy (LDP) using a slow compression method with a stapler, which we call pen-firing compression (PFC).
METHODOLOGY: Fifty-two patients underwent LDP, of whom 42 underwent PFC for pancreatic division using a stapler. The relationship between preoperatively assessable factors and the incidence of clinical POPF was statistically analyzed.
RESULTS: Overall rate of POPF was 7.1% in 42 patients. Univariate analysis showed that greater BMI (p = 0.004) and thicker pancreatic stump (0.0022) were significant risk factors for POPF. BMI and stump thickness remained significant (P < 0.0001, P < 0.0001) by multivariate analysis. Cutoff points estimated by ROC curve were 27 kg/m2 for BMI and 27 mm for stump thickness.
CONCLUSIONS: High BMI value and thick pancreatic stump are significant risk factors for POPF after LDP. Alternative treatment of the pancreatic stump may prevent POPF in high-risk patients.
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65. Nagayoshi Y, Aso T, Ohtsuka T, Kono H, Ideno N, Igarashi H, Takahata S, Oda Y, Ito T, Tanaka M, Peroral pancreatoscopy using the SpyGlass system for the assessment of intraductal papillary mucinous neoplasm of the pancreas, J Hepatobiliary Pancreat Sci., 21, 6, 410-417, 2014.04, BACKGROUND:

Peroral pancreatoscopy (POPS) using a mother-baby endoscope system is often useful for assessment of intraductal papillary mucinous neoplasm (IPMN) of the pancreas with main pancreatic duct (MPD) involvement, but is not widely used for several reasons. The aim of this study was to evaluate the usefulness of the SpyGlass Direct Visualization System for assessment of IPMN.

METHODS:

Seventeen patients diagnosed with possible IPMN with MPD dilation underwent peroral pancreatoscopy using the SpyGlass system at our institution. The quality of visualization and the sensitivities of cytological and pathological investigations for diagnosing malignant lesions were evaluated.

RESULTS:

Peroral pancreatoscopy was performed using the SpyScope in 12 patients and an endoscopic retrograde cholangiopancreatography (ERCP) catheter in five patients. Sufficient visualization was achieved in 92% of cases using the SpyScope and 40% of cases using the ERCP catheter. Biopsy under direct visualization was successful in seven patients. Biopsy specimens showed adenocarcinoma in one patient, benign neoplastic epithelium in five patients, and regenerative changes in one patient; and had 25% sensitivity and 100% specificity for detecting malignancy. SpyGlass pancreatoscopy with irrigation cytology had 100% sensitivity and 100% specificity for detecting malignancy. SpyGlass pancreatoscopy was useful for determining the operative excision line in three patients. There were no severe procedure-related adverse events.

CONCLUSIONS:

Peroral pancreatoscopy using the SpyGlass system seems to be feasible and useful for assessment of IPMN with a dilated MPD.
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66. Akagawa S, Ohuchida K, Torata N, Hattori M, Eguchi D, Fujiwara K, Kozono S, Cui L, Ikenaga N, Ohtsuka T, Aishima S, Mizumoto K, Oda Y, Tanaka M, Peritoneal myofibroblasts at metastatic foci promote dissemination of pancreatic cancer, Int J Oncol. , 45, 1, 113-120, 2014.04, Myofibroblasts in the stroma of pancreatic cancers promote tumor proliferation, invasion and metastasis by increasing extracellular matrix and secretion of several growth factors. In contrast, the role of myofibroblasts at peritoneally disseminated sites of pancreatic cancer has not yet been determined. This study was designed to assess the role of myofibroblasts at peritoneally disseminated sites of pancreatic cancer. Three primary cultures of human peritoneal myofibroblasts (hPMFs) were established from disseminated sites of pancreatic cancer and their interactions with the SUIT-2 and CAPAN-1 human pancreatic cancer cell lines were analyzed in vitro. Using a model in BALB/c nu/nu mice, we compared the dissemination ability of intraperitoneally implanted pancreatic cancer cells, with and without hPMFs, and examined the presence of green fluorescent protein (GFP)-labeled hPMFs at peritoneally disseminated sites in mice. hPMFs significantly promoted the migration and invasion of pancreatic cancer cells (P<0.05), while the cancer cells significantly promoted the migration and invasion of hPMFs (P<0.05). In vivo, the number of peritoneally disseminated nodules, more than 3 mm in size, was significantly greater in mice implanted with cancer cells plus hPMFs compared to mice implanted with cancer cells alone, with GFP-labeled hPMFs surviving in the peritoneal cavity of the former. hPMFs promote the peritoneal dissemination of pancreatic cancer. The cancer-stromal cell interaction in the peritoneal cavity may be a new therapeutic target to prevent the dissemination of pancreatic cancer. .
67. Ohtsuka T, Takahata S, Takanami H, Ueda J, Mizumoto K, Shimizu S, Tanaka M, Laparoscopic surgery is applicable for larger mucinous cystic neoplasms of the pancreas, J Hepatobiliary Pancreat Sci. , 21, 5, 343-348, 2014.04, BACKGROUND:

Mucinous cystic neoplasms (MCN) of the pancreas frequently develop in the distal pancreases of young women. Laparoscopic surgery can enhance cosmetic benefits and ease of surgery. This study assessed the feasibility of laparoscopic surgery for MCN.

METHODS:

The medical records of 21 patients pathologically diagnosed with benign MCN after laparoscopic resection were reviewed. Clinical data were compared in the 11 patients with tumors ≥45 mm (large tumor group) and the 10 patients with tumors <45 mm (small tumor group).

RESULTS:

Laparoscopic resection was completed in all patients, including distal pancreatectomy with (n = 9) and without (n = 11) spleen preservation and enucleation for pancreatic head lesion (n = 1). Operation time, blood loss, postoperative morbidity, and hospital stay were similar in the two groups. Spleen-preserving pancreatectomy could be more frequently completed in the small MCN group (P = 0.02). No recurrence was observed during a median follow-up period of 12 months.

CONCLUSIONS:

Laparoscopic surgery can be completed in all patients with benign MCN, even those with large tumors, and patients with small MCN can get the additional benefit of spleen preservation.
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68. Mori Y, Ohtsuka T, Tamura K, Ideno N, Aso T, Kono H, Nagayoshi Y, Ueda J, Takahata S, Aishima S, Ookubo F, Oda Y, Tanaka M, Intraoperative irrigation cytology of the remnant pancreas to detect remnant distinct pancreatic ductal adenocarcinoma in patients with intraductal papillary mucinous neoplasm undergoing partial pancreatectomy, Surgery, 155, 1, 67-73, 2014.04, Abstract
BACKGROUND:
Patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas may have concomitant distinct pancreatic ductal adenocarcinoma (PDAC). We evaluated the safety and usefulness of intraoperative irrigation cytology of the remnant pancreas (IICP) during pancreatectomy to detect remnant distinct PDAC in patients with IPMN.
METHODS:
The records of all 48 patients with IPMN who underwent IICP during partial pancreatectomy at our institution from April 2007 to March 2012 were reviewed retrospectively. After division of the pancreas, a 4-French tube was inserted into the main pancreatic duct of the remnant pancreas from the cut edge, and fluid for cytologic examination was obtained by saline irrigation through the tube. If the third IICP was positive, patients underwent additional pancreatic resection. Clinical and pathologic outcomes were evaluated.
RESULTS:
The third IICP was positive in 5 patients. Postoperative pathologic examination showed that these patients all had remnant distinct PDAC in the additionally resected specimen, which was not detectable on preoperative imaging examination or on intraoperative macroscopic examination, ultrasonography, or palpation. This PDAC was stage 0 in 4 patients and stage III in 1 patient. No procedure-related complications were observed. One patient developed peritoneal metastasis after 10 months, 1 developed liver metastasis after 20 months, and 1 developed PDAC in the remnant pancreas after 24 months.
CONCLUSION:
IICP seems to be a safe and useful method for detection of early stage PDAC concomitant with IPMN that cannot be detected by preoperative imaging or intraoperative examination.
Copyright © 2014 Mosby, Inc. All rights reserved..
69. Aso T, Ohtsuka T, Matsunaga T, Kimura H, Watanabe Y, Tamura K, Ideno N, Osoegawa T, Takahata S, Shindo K, Ushijima Y, Aishima S, Oda Y, Ito T, Mizumoto K, Tanaka M, High-risk stigmata of the 2012 international consensus guidelines correlate with the malignant grade of branch duct intraductal papillary mucinous neoplasms of the pancreas, Pancreas, 43, 8, 1239-1243, 2014.04, Objectives: The 2012 international consensus guidelines for themanagementof intraductal papillary mucinous neoplasm (IPMN) of the pancreasstratified patients into 2 clinical categories, “high-risk stigmata” and “worrisomefeatures,” and recommended different therapeutic strategies forthese groups. The aim of this study was to elucidate the significance ofthese categories in terms of predicting malignant IPMNs.Methods: The medical records of 100 consecutive patients whounderwent pancreatectomy for IPMNs were retrospectively reviewed. Seventypatients with branch duct IPMNs (BD-IPMNs) were stratified into 3groups. The relationships between the number of predictive factors and histopathologicgrade were investigated.Results: The prevalence rates of malignant IPMN, invasive carcinoma,and lymph node metastasis in the high-risk group were 80%, 55%, and20%, respectively, with these percentages significantly increasing in a stepwisemanner acc
ording to the number of predictive factors. In contrast,there was no significant correlation between the number of worrisome featuresand grade of malignancy in patients stratified as having worrisomeBD-IPMNs.Conclusions: The number of high-risk stigmata correlated significantlywith the grade of malignancy of BD-IPMNs. The presence of at least 1high-risk stigma in patients with BD-IPMNs indicates a need for pancreatectomywith lymphadenectomy..
70. Ueda J, Kayashima T, Mori Y, Ohtsuka T, Takahata S, Nakamura M, Tanaka M, Hepaticocholecystojejunostomy as effective palliative biliary bypass for unresectable pancreatic cancer, Hepatogastroenterology, 61, 129, 197-202, 2014.04, Abstract
BACKGROUND/AIMS:
The majority of patients with pancreatic cancer present with far advanced disease and jaundice. With the advancement of endoscopic interventional techniques, the role of surgical bypass has declined. However, surgical bypass is still considered to be appropriate in patients who are able to tolerate surgery. We performed hepaticocholecystojejunostomy consecutively as a palliative surgical biliary bypass for the purpose of long-term palliation. The aim of this study was to analyze the results of our palliative surgical biliary bypass, hepaticocholecystojejunostomy.
METHODOLOGY:
Between January 2001 through December 2009, 69 patients received palliative surgical biliary bypass (bypass group) and 33 patients received endoscopic biliary stenting (stent group) for unresectable pancreatic cancers. Mortality, morbidity and survival between the two groups were compared.
RESULTS:
There was no in-hospital death in the bypass group, but 2 patients (6%) in the stent group died in the hospital (p = 0.04). The surgical morbidity rate was 15% in the bypass group, while 20 patients (61%) in the stent group developed complications, mainly due to stent blockage. There was no significant difference in overall survival between the two groups. Among patients who underwent systemic chemotherapy but did not present with jaundice at the time of diagnosis, those who underwent prophylactic surgical biliary bypass before chemotherapy showed better survival than those who underwent systemic chemotherapy preceding biliary bypass or biliary stenting after occurrence of jaundice (p = 0.01).
CONCLUSIONS:
Hepaticocholecystojejunostomy resulted in negligible mortality, low morbidity and effective long-term palliation. Prophylactic surgical biliary bypass with gastrointestinal bypass might be a good treatment option for non-jaundiced patients undergoing chemotherapy for unresectable pancreatic cancer..
71. Cases AI, Ohtsuka T, Fujino M, Ideno N, Kozono S, Zhao M, Ohuchida K, Aishima S< Nomura M, Oda Y, Mizumoto K, Tanaka M, Expression of glucagon-like Peptide 1 receptor and its effects on biologic behavior in pancreatic neuroendocrine tumors., Pancreas, 43, 1, 1-6, 2014.04, OBJECTIVES:

Glucagon-like peptide 1 (GLP-1) interacts with its specific high-affinity receptor, glucagon-like peptide 1 receptor (GLP-1R), and induces cellular growth and inhibition of apoptosis in pancreatic β cells. The aim of this study was to investigate the significance of GLP-1R expression in pancreatic neuroendocrine tumors (PNETs).

METHODS:

Glucagon-like peptide 1 receptor expression was semiquantitatively evaluated by immunohistochemical staining in 50 resected PNETs, and the correlation between the GLP-1R expression and clinicopathologic features was investigated.

RESULTS:

There were 23 PNETs with positive expression and 27 PNETs with negative expression of GLP-1R. Positive expression of GLP-1R was more frequently observed in insulinoma than in gastrinoma and nonfunctioning tumor (P < 0.05). Although expression status of GLP-1R did not affect the prognosis of the patients with PNETs (P = 0.82), most of the metastatic sites such as lymph node and liver showed positive staining for GLP-1R (8 of 11 PNETs, 73%).

CONCLUSIONS:

Glucagon-like peptide 1 receptor would be a diagnostic marker of insulinoma and might become a molecular target for treatment of metastatic PNETs and hormonal regulation of insulin.
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72. Aso T, Ohtsuka T, Tamura K, Ideno N, Kono H, Nagayoshi Y, Ohuchida K, Ueda J, Takahata S, Shindo K, Aishima S, Oda Y, Mizumoto K, Tanaka M, Elevated Expression Level of MicroRNA-196a Is Predictive of Intestinal-Type Intraductal Papillary Mucinous Neoplasm of the Pancreas, Pancreas, 43, 3, 361-366, 2014.04, AbstractOBJECTIVES: Aberrant expression of several microRNAs (miRs) has been reported in various neoplasms including intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. MicroRNA-196a (miR-196a) is up-regulated in Barrett esophagus (characterized by intestinal metaplasia) and in colorectal cancer; this relationship between intestinal characteristics and miR-196a might also be applicable to intestinal-type IPMNs. The aim of this study was to evaluate whether intestinal-type IPMNs can be discriminated from non-intestinal-type IPMNs by the expression level of miR-196a in tissue and pancreatic juice samples.METHODS: Thirty-seven formalin-fixed paraffin-embedded tissue samples (including 3 of normal pancreatic ducts) and 36 pancreatic juice samples were obtained. The expression level of miR-196a measured by quantitative reverse transcription-polymerase chain reaction assays was compared between intestinal-type and non-intestinal-type IPMNs.RESULTS: Mi
croRNA-196a expression in intestinal-type IPMN tissue samples (n = 18) was significantly higher than that of non-intestinal-type IPMNs (n = 16) (P < 0.001). Similarly, miR-196a expression in pancreatic juice samples of intestinal-type IPMNs (n = 6) was significantly higher than that of non-intestinal-type IPMNs (n = 30) (P = 0.008), and the sensitivity and specificity for prediction of intestinal-type IPMNs using pancreatic juice samples were both 83%.CONCLUSIONS: Elevated expression of miR-196a in pancreatic juice samples is predictive of intestinal-type IPMNs..
73. Fujiwara K, Ohuchida K, Sada M, Horioka K, Ulrich CD 3rd, Shindo K, Ohtsuka T, Takahata S, Mizumoto K, Oda Y, Tanaka M, CD166/ALCAM expression is characteristic of tumorigenicity and invasive and migratory activities of pancreatic cancer cells, PLoS One., 9, 9, e107247, 2014.04, BACKGROUND:

CD166, also known as activated leukocyte cell adhesion molecule (ALCAM), is expressed by various cells in several tissues including cancer. However, the role of CD166 in malignant tumors is controversial, especially in pancreatic cancer. This study aimed to clarify the role and significance of CD166 expression in pancreatic cancer.

METHODS:

We performed immunohistochemistry and flow cytometry to analyze the expression of CD166 in surgical pancreatic tissues and pancreatic cancer cell lines. The differences between isolated CD166+ and CD166- pancreatic cancer cells were analyzed by invasion and migration assays, and in mouse xenograft models. We also performed quantitative RT-PCR and microarray analyses to evaluate the expression levels of CD166 and related genes in cultured cells.

RESULTS:

Immunohistochemistry revealed high expression of CD166 in pancreatic cancer tissues (12.2%; 12/98) compared with that in normal pancreas controls (0%; 0/17) (p = 0.0435). Flow cytometry indicated that CD166 was expressed in 33.8-70.2% of cells in surgical pancreatic tissues and 0-99.5% of pancreatic cancer cell lines. Invasion and migration assays demonstrated that CD166- pancreatic cancer cells showed stronger invasive and migratory activities than those of CD166+ cancer cells (p<0.05). On the other hand, CD166+ Panc-1 cells showed a significantly stronger colony formation activity than that of CD166- Panc-1 cells (p<0.05). In vivo analysis revealed that CD166+ cells elicited significantly greater tumor growth than that of CD166- cells (p<0.05) in both subcutaneous and orthotopic mouse tumor models. mRNA expression of the epithelial-mesenchymal transition activator Zeb1 was over-expressed in CD166- cells (p<0.001). Microarray analysis showed that TSPAN8 and BST2 were over-expressed in CD166+ cells, while BMP7 and Col6A1 were over-expressed in CD166- cells.

CONCLUSIONS:

CD166+ pancreatic cancer cells are strongly tumorigenic, while CD166- pancreatic cancer cells exhibit comparatively stronger invasive and migratory activities. These findings suggest that CD166 expression is related to different functions in pancreatic cancer cells.
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74. Tsutsumi K, Ohtsuka T, Fujino M, Nakashima H, Aishima S, Ueda J, Takahata S, Nakamura M, Oda Y, Tanaka M, Analysis of risk factors for recurrence after curative resection of well-differentiated pancreatic neuroendocrine tumors based on the new grading classification, J Hepatobiliary Pancreat Sci., 21, 6, 418-425, 2014.04,

BACKGROUND:

It is difficult to predict the malignant potential of pancreatic neuroendocrine tumors (PNETs) precisely. This study investigated the validity of a new grading system adopted by the World Health Organization 2010 classification to determine risk factors for recurrence of PNETs.

METHODS:

Data of 70 patients with PNETs who underwent curative resection were retrospectively examined by uni- and multivariate analyses. Histopathological findings were re-reviewed by experienced pathologists. NET G1 was defined as mitotic count <2 per 10 high power fields (HPF) and/or ≤2% Ki67 index, and NET G2 as 2-20 mitosis per 10 HPF and/or 3-20% Ki67 index.

RESULTS:

There were 58 patients with NET G1 and 12 with NET G2. Incidence of recurrence was 11.4%. Univariate analysis demonstrated significant risk factors for recurrence including NET G2 of histological grade (P = 0.0089), male gender (P = 0.0333), tumor size ≥ 20 mm (P = 0.0117), lymph node metastasis (P = 0.0004), liver metastasis (P < 0.0001), lymphatic invasion (P = 0.046), and neural invasion (P = 0.0002). By multivariate analysis, histological grade (hazard ratio; 59.76, P = 0.0022) and neural invasion (hazard ratio; 147.49, P = 0.0016) were significantly associated with recurrence of PNETs.

CONCLUSIONS:

This study confirmed the prognostic relevance of the new grading classification and that evaluation of perineural invasion and histological grade should be considered as prognostic predictors in well-differentiated PNETs (NET G1 and G2).

© 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery.


KEYWORDS:

Grading classification; Neural invasion; Pancreatic neuroendocrine tumor; Predictors of recurrence; WHO 2010 classification
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75. Zheng B, Ohuchida K, Cui L, Zhao M, Shindo K, Fujiwara K, Manabe T, Torata N, Moriyama T, Miyasaka Y, Ohtsuka T, Takahata S, Mizumoto K, Oda Y, Tanaka M, TM4SF1 as a prognostic marker of pancreatic ductal adenocarcinoma is involved in migration and invasion of cancer cells, Int J Oncol, 47, 2, 490-498, 2015.04, The cell surface protein Transmembrane 4 L6 family member 1 (TM4SF1) has been detected in various tumors, and its expression on tumor cells is implicated in cancer cell metastasis and patient prognosis. The role of TM4SF1 in malignant tumors remains poorly understood, particularly in pancreatic cancer. We performed immunohistochemical staining to analyze the expression of TM4SF1 in resected pancreatic tissues and investigated the correlation between TM4SF1 expression and prognosis. The function of TM4SF1 in the invasion and migration of pancreatic cancer cells was analyzed in vitro using an RNA interference technique. In pancreatic cancer tissues, TM4SF1 expression was detected in cancer cells, and patients with high tumor levels of TM4SF1 showed longer survival times than those with low TM4SF1 levels (P=0.0332). In vitro, reduced TM4SF1 expression enhanced the migration (P<0.05) and invasion (P<0.05) of pancreatic cancer cells partially via decreased E-cadherin expression. TM4SF1 protein levels were also reduced after TGF-β1-induced epithelial-mesenchymal transition (EMT).TM4SF1 expression is associated with better prognosis in pancreatic cancer. Loss of TM4SF1 contributes to the invasion and migration of pancreatic cancer cells..
76. Cases AI, Ohtsuka T, Kimura H, Zheng B, Shindo K, Oda Y, Mizumoto K, Nakamura M, Tanaka M, Significance of expression of glucagon-like peptide 1 receptor in pancreatic cancer, Oncol Rep, 10.3892/or.2015.4138, 34, 4, 1717-1725, 2015.04, Abstract
Glucagon-like peptide 1 (GLP-1) induces insulin secretion and proliferation of pancreatic β-cells, and inhibits their apoptosis through the GLP-1 receptor (GLP-1R), thus providing a foundation for using GLP-1-based therapies for the treatment of type 2 diabetes. However, doubts have emerged regarding the drug safety of these therapies. We investigated the potential role of GLP-1R in pancreatic ductal adenocarcinoma (PDAC). GLP-1R expression was semi-quantitatively evaluated by immunohistochemistry in 48 PDAC samples, and its correlations with clinicopathological features were investigated. CFPAC-1 cells were used for GLP-1R knockdown to evaluate its effects on cell proliferation, migration and invasion. GLP-1R expression was positive in 23 tumors and negative in 25 tumors. No correlations were found between GLP-1R expression status and clinicopathological characteristics. Furthermore, GLP-1R expression status did not affect the patient prognosis (P=0.74). The majority of lymph node metastases (11 of 15 samples examined; 73%) were positive for GLP-1R expression. Immunoreactivity for GLP-1R was also noted in sites of perineural and lymphovascular invasion. GLP-1R knockdown significantly reduced the proliferation, migration and invasion of CFPAC-1 cells (P<0.05). In conclusion, although GLP-1R is not an independent prognostic factor in PDAC patients, it appears to have some implications for PDAC metastatic ability.
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77. Ueda J, Miyasaka Y, Ohtsuka T, Takahata S, Tanaka M, Short- and long-term results of the Frey procedure for chronic pancreatitis, J Hepatobiliary Pancreat Sci, 22, 3, 211-216, 2015.04, BACKGROUND:

The aim of this study was to determine the short- and long-term results of the Frey procedure for chronic pancreatitis.

METHODS:

From November 1998 to December 2013, 41 patients underwent the Frey procedure for painful chronic pancreatitis at Kyushu University Hospital. The short- and long-term results of the Frey procedure including mortality, morbidity, pain relief, weight gain and pancreatic endocrine function were analyzed. The long-term results were analyzed in 29 patients who had been followed-up for more than 12 months. The long-term follow-up rate was 85%.

RESULTS:

There was no mortality. Early postoperative complications occurred in seven patients (17%), including pancreatic fistula in four (10%, International Study Group of Pancreatic Fistula ISGPF grade B) and hemorrhage in three (7%). Long-term relief of abdominal pain was achieved in 90% (26/29) of cases. One patient developed relapse of inflammation of the head of pancreas during the follow-up period, necessitating pylorus-resecting pancreatoduodenectomy. Only two patients (7%) developed new-onset diabetes mellitus after the Frey procedure during the follow-up period.

CONCLUSIONS:

The Frey procedure for painful chronic pancreatitis may be safe and pancreatic endocrine function is preserved. Complete decompression of the pancreatic ducts in the head of pancreas and full length drainage of the main pancreatic duct from the head of pancreas to the tail may be important in the Frey procedure to prevent recurrence of acute inflammation.
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78. Shimizu S, Ohtsuka T, Takahata S, Nagai E, Nakashima N, Tanaka M, Remote transmission of live endoscopy over the Internet:Report from the 87th Congress of the Japan Gastroenterological Endoscopy Society, Digestive Endoscopy, 28, 1, 92-97, 2015.04, Abstract
Live demonstration of endoscopy is one of the most attractive and useful methods for education and is often organized locally in hospitals. However, problems have been apparent in terms of cost, preparation, and potential risks to patients. Our aim was to evaluate a new approach to live endoscopy whereby remote hospitals are connected by the Internet for live endoscopic demonstrations. Live endoscopy was transmitted to the Congress of the Japan Gastroenterological Endoscopic Society by 13 domestic and international hospitals. Patients with upper and lower gastrointestinal diseases and with pancreatobiliary disorders were the subjects of a live demonstration. Questionnaires were distributed to the audience and were sent to the demonstrators. Questions concerned the quality of transmitted images and sound, cost, preparations, programs, preference of style, and adverse events. Of the audience, 91.2% (249/273) answered favorably regarding the transmitted image quality and 93.8% (259/276) regarding the sound quality. All demonstrators answered favorably regarding image quality and 93% (13/14) regarding sound quality. Preparations were completed without any outsourcing at 11 sites (79%) and were evaluated as 'very easy' or 'easy' at all but one site (92.3%). Preparation cost was judged as 'very cheap' or 'cheap' at 12 sites (86%). Live endoscopy connecting multiple international centers was satisfactory in image and sound quality for both audience and demonstrators, with easy and inexpensive preparation. The remote transmission of live endoscopy from demonstrators' own hospitals was preferred to the conventional style of locally organized live endoscopy.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society.
KEYWORDS:
education; international; internet; live demonstration; telemedicine.
79. Kimura H, Ohtsuka T, Matsunaga T, Watanabe Y, Tamura K, Ideno N, Aso T, Miyazaki T, Osoegawa T, Aishima S, Miyasaka Y, Ueda J, Ushijima Y, Igarashi H, Ito T, Takahata S, Oda Y, Mizumoto K, Tanaka M, Predictors and Diagnostic Strategies for Early-Stage Pancreatic Ductal Adenocarcinoma: A Retrospective Study, Pancreas , 44, 7, 1148-1154, 2015.04, OBJECTIVES:

As a strategy to diagnose early-stage pancreatic ductal adenocarcinoma (PDAC) is urgently needed, we aimed to clarify characteristics of early-stage PDAC.

METHODS:

We retrospectively reviewed medical records of 299 consecutive patients who underwent R0 or R1 surgical resection for PDAC between 1994 and 2013 and compared clinical characteristics between patients with early-stage (stages 0-I by Japanese General Rules for Pancreatic Cancer) and advanced-stage (stages II-IV) disease. Diagnostic processes were also analyzed.

RESULTS:

Twenty-four patients (8%) had early-stage PDAC (stage 0: 11; stage I: 13). Univariate and multivariate analyses showed that presence or history of intraductal papillary mucinous neoplasm (P < 0.01), history of pancreatitis (P < 0.01), and presence or history of extrapancreatic malignancies (P = 0.01) independently predicted detection of early-stage PDAC. Cytological examination during endoscopic retrograde pancreatography cytology was ∼65% sensitive in preoperative diagnosis of early-stage PDAC, whereas other imaging modalities were only 29% to 38% sensitive; 9 of 24 early-stage PDACs were diagnosed by endoscopic retrograde pancreatography cytology alone.

CONCLUSIONS:

Endoscopic retrograde pancreatography cytology for patients with intraductal papillary mucinous neoplasm or pancreatitis may help diagnose early-stage PDAC. Surveillance of extrapancreatic malignancies might also provide opportunities to detect early-stage PDAC as a second malignancy.
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80. Watanabe Y, Ohtsuka T, Matsunaga T, Kimura H, Tamura K, Ideno N, Aso T, Miyasaka Y, Ueda J, Takahata S, Igarashi H, Inoguchi T, Ito T, Tanaka M, Long-term outcomes after total pancreatectomy: special reference to survivors' living conditions and quality of life, World J Surg, 39, 5, 1231-1239, 2015.04, Abstract
BACKGROUND:
Although recent studies have confirmed the safety of total pancreatectomy (TP), appropriate selection of patients for TP has not been well documented. Because patients require lifelong medical treatment and self-management of pancreatic insufficiency after TP, indications for TP should be determined carefully according not only to disease factors but also to the social background of patients. We aimed to clarify long-term outcomes after TP, including the living conditions and quality of life (QoL), of surviving patients.
METHODS:
Medical records of 44 consecutive patients who underwent TP between 1990 and 2013 were reviewed retrospectively; 25 survivors completed cross-sectional clinical surveys and responded to a questionnaire about QoL using Short Form 36v2.
RESULTS:
Prevalence of morbidity and mortality after TP was 32 and 5 %, respectively. Postoperative complications occurred more frequently in elderly patients than in young patients (48 vs. 14 %; P = 0.02); however, there was no significant difference in mortality, postoperative hospital stay, or survival. Twenty-four of 25 survivors (96 %) could manage pancreatogenic diabetes by themselves, and the median level of glycosylated hemoglobin was 7.4 %. Although one-third of patients after TP complained of diarrhea and the QoL scores of patients with diarrhea were lower than those of patients without diarrhea, QoL scores after TP were virtually comparable with those of the national population, even in elderly patients.
CONCLUSIONS:
TP can be performed safely, even in elderly patients. QoL after TP seems to be acceptable if patients are capable of self-management..
81. Ideno N, Ohtsuka T, Matsunaga T, Kimura H, Watanabe Y, Tamura K, Aso T, Aishima S, Miyasaka Y, Ohuchida K, Ueda J, Takahata S, Oda Y, Mizumoto K, Tanaka M, Clinical Significance of GNAS Mutation in Intraductal Papillary Mucinous Neoplasm of the Pancreas With Concomitant Pancreatic Ductal Adenocarcinoma, Pancreas, 44, 2, 311-320, 2015.04, OBJECTIVE:

The aims of this study were to investigate the GNAS mutational status in pancreatic intraductal papillary mucinous neoplasm (IPMN) with and without distinct pancreatic ductal adenocarcinoma (PDAC) and to evaluate the significance of GNAS analysis using duodenal fluid (DF) in patients with IPMN.

METHODS:

The clinicopathologic features of 110 patients with IPMN including 16 with distinct PDAC were reviewed. The GNAS status in the IPMN tissue and 23 DF specimens was assessed by sensitive mutation scanning methods.

RESULTS:

The GNAS mutation rate in IPMN with distinct PDAC was significantly lower than that in IPMN without PDAC (4/16, 25%, vs 61/94, 65%; P = 0.0047). By multivariate analysis, GNAS wild-type and gastric type IPMNs were significantly associated with distinct PDAC. Of 45 GNAS wild-type IPMNs, 10 (43%) of 23 gastric type IPMNs had distinct PDAC, whereas only 2 (9%) of 22 non-gastric type IPMNs had distinct PDAC (P = 0.017). The GNAS status in DF was consistent with that in tissue in 21 (91%) of 23 patients.

CONCLUSIONS:

Distinct PDACs frequently develop in the pancreas with gastric type IPMN without GNAS mutations. Duodenal fluid DNA test would predict the GNAS status of IPMN, whereas the detection of the gastric subtype using noninvasive test remains to be determined.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0.
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82. Watanabe Y, Ohtsuka T, Kimura H, Matsunaga T, Tamura K, Ideno N, Aso T, Miyasaka Y, Ueda J, Takahata S, Tanaka M, Braun enteroenterostomy reduces delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: a retrospective review, Am J Surg, 209, 2, 369-377, 2015.04, BACKGROUND: Several recent studies have suggested that Braun enteroenterostomy (BEE) during conventional pancreatoduodenectomy might decrease delayed gastric emptying (DGE). However, the advantages and disadvantages of performing BEE during pylorus-preserving pancreatoduodenectomy (PPPD) remain controversial.METHODS: The medical records of 185 patients who underwent PPPD either with or without BEE between January 2008 and June 2013 were retrospectively reviewed, and the postoperative course of the 2 groups was compared.RESULTS: Ninety-eight patients underwent PPPD with BEE and 87 without BEE. DGE occurred in 4% of patients with BEE and in 21% of those without BEE (P < .01). The addition of BEE did not affect postoperative complications other than DGE. By multivariate analysis, the omission of BEE was the only independent factor associated with DGE (odds ratio 5.04, 95% confidence interval: 1.59 to 19.66; P < .01).CONCLUSIONS: BEE during PPPD reduced the
incidence of DGE..
83. Tamura K, Ohtsuka T, Matsunaga T, Kimura H, Watanabe Y, Ideno N, Aso T, Miyazaki T, Ohuchida K, Takahata S, Ito T, Ushijima Y, Oda Y, Mizumoto K, Tanaka M, Assessment of Clonality of Multisegmental Main Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas Based on GNAS Mutation Analysis, Surgery, 157, 2, 277-284, 2015.04, Background: Main duct intraductal papillary mucinous neoplasms (MD-IPMNs) may occur in one or multiple segments of the pancreatic duct. Unlike multifocal branch duct (BD)-IPMNs, the clonality of multisegmental MD-IPMNs remains unclear. GNAS mutations are common and specific for IPMNs, and mutational assessment might be useful to determine the clonality of IPMNs as well as to detect high-risk IPMN with distinct ductal adenocarcinoma (PDAC). Our aim was to clarify clonality using GNAS status in multisegmental MD-IPMNs.Methods: Medical records of 70 patients with MD-IPMN were retrospectively reviewed. Histological subtypes and KRAS/GNAS mutations were investigated, and the clonal relationships among multisegmental MD-IPMNs were assessed. Mutational analysis was performed using high-resolution melting analysis and subsequent Sanger/pyrosequencing.Results: Thirteen patients had multiple synchronous and/or metachronous lesions. Seven of these 13 patients had multip
le MD-IPMNs; three had multiple MD-IPMNs and distinct BD-IPMNs; one had multiple MD-IPMNs and a distinct PDAC; one had a solitary MD-IPMN, BD-IPMN, and PDAC; and one had a solitary MD-IPMN and PDAC. KRAS/GNAS mutations were consistent in 10 of 11 multisegmental MD-IPMNs, while MD-IPMNs, BD-IPMNs, and PDACs tended to show different mutational patterns. The frequency of malignant IPMNs was significantly higher in the multisegment cohort; malignant IPMNs constituted 90% (9/10) of the multiple cohort and 56% (32/57) of the solitary cohort (P=0.04). Mutant GNAS was more frequently observed in the intestinal subtype (94%) than the others.Conclusions: MD-IPMNs can be characterized by monoclonal skip progression. Close attention should be paid to the possible presence of skip areas during/after partial pancreatectomy..
84. Horioka K, Ohuchida K, Sada M, Zheng B, Moriyama T, Fujita H, Manabe T, Ohtsuka T, Shimamoto M, Miyazaki T, Mizumoto K, Oda Y, Nakamura M, Suppression of CD51 in pancreatic stellate cells inhibits tumor growth by reducing stroma and altering tumor-stromal interaction in pancreatic cancer, Int J Oncol, 48, 4, 1499-1508, 2016.04, Pancreatic stellate cells (PSCs) enhance the malignant behavior of pancreatic cancer by interacting with cancer cells and producing extracellular matrix (ECM). To date, several stroma-targeted therapies for pancreatic cancer have been attempted, but these therapies are still not in practical use. Integrins expressed in stromal cells are involved in fibrosis of several organs, as well as promoting tumor malignancy. We investigated whether CD51, also known as integrin αV, expressed in PSCs was associated with stromal formation of pancreatic cancer and enhancement of tumor malignancy. We also assessed the effects of suppression of CD51 in PSCs on pancreatic cancer. Immunohistochemistry for CD51 in resected pancreatic cancer tissues showed that high expression of CD51 in the tumor stroma was associated with lymph node metastasis (P=0.025), positive pathologic margin (P=0.025), and shorter patient survival times (P=0.043). Lentivirus-mediated short hairpin RNA knockdown of CD51 decreased the proliferation and migration of PSCs. Quantitative real-time polymerase chain reaction showed that expression levels of genes related with ECM and tumor-stromal interactions were decreased by CD51 knockdown in PSCs. In a co-implantation model of pancreatic cancer cells and PSCs, tumor growth in vivo was inhibited by CD51 knockdown in PSCs (P<0.05). We also found reduced tumor stroma and decreased proliferation of cancer cells in implanted cancer tissues with CD51-silenced PSCs (P<0.05). Our results showed that CD51 expression in pancreatic cancer stroma is associated with enhanced tumor malignancy and that CD51 may be a potential therapeutic target for pancreatic cancer. .
85. Miyasaka Y, Ohtsuka T, Tamura K, Mori Y, Shindo K, Yamada D, Takahata S, Ishigami K, Ito T, Tokunaga S, Oda Y, Mizumoto K, Nakamura M, Tanaka M, Predictive factors for the metachronous development of high-risk lesions in the remnant pancreas after partial pancreatectomy for intraductal papillary mucinous neoplasm, Ann Surg, 263, 6, 1180-1187, 2016.04, Abstract
OBJECTIVE:
To identify factors predicting the development of high-risk lesions in the remnant pancreas after surgery for intraductal papillary mucinous neoplasm (IPMN).
BACKGROUND:
IPMN has unique features, including multifocality, adenoma-carcinoma sequence, and the development of distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. Careful attention should, therefore, be paid to the metachronous occurrence of high-risk lesions, including high-grade dysplasia or invasive carcinoma (HGD/INV) of IPMN and concomitant PDAC in the remnant pancreas after partial pancreatectomy for IPMN.
METHODS:
Clinicopathologic and surveillance data for 195 patients who underwent partial pancreatectomy for IPMN were reviewed retrospectively.
RESULTS:
Thirteen patients exhibited metachronous development of high-risk lesions including 6 HGD/INV and 7 concomitant PDACs in the remnant pancreas. The 5- and 10-year cumulative incidences of metachronous high-risk lesions in the remnant pancreas were 7.8% and 11.8%, respectively. Twelve of 13 patients had high-risk lesions at the time of initial surgery, and 10 of the 13 IPMNs were located in the distal pancreas. The IPMN subtypes initially resected were gastric in 6 patients, intestinal in 5, and pancreatobililary in the remaining 2. Univariate and multiple regression analyses identified pathologic results of HGD/INV and IPMN located in the distal pancreas as independent predictive factors for metachronous HGD/INV of IPMN, and the pancreatobiliary subtype of IPMN and presence of concomitant PDAC for metachronous PDAC.
CONCLUSIONS:
Patients undergoing partial pancreatectomy for IPMN are at high risk of developing lesions requiring surgery in the remnant pancreas, and close, long-term surveillance should be considered in these patients..
86. Chijiiwa Y, Moriyama T, Ohuchida K, Nabae T, Ohtsuka T, Miyasaka Y, Fujita H, Maeyama R, Manabe T, Abe A, Mizuuchi Y, Oda Y, Mizumoto K, Nakamura M, Overexpression of microRNA-5100 decreases the aggressive phenotype of pancreatic cancer cells by targeting PODXL, Int J Oncol, 48, 4, 1688-1700, 2016.04, Abstract

Metastasis is the main cause of cancer-associated death, and metastasis of pancreatic cancer remains difficult to treat because of its aggressiveness. MicroRNAs (miRNAs) play crucial roles in the regulation of various human transcripts, and many miRNAs have been reported to correlate with cancer metastasis. We identified an anti-metastatic miRNA, miR-5100, by investigating differences in miRNA profiling between highly metastatic pancreatic cancer cells and their parental cells. Overexpression of miR-5100 inhibited colony formation (P<0.05), cell migration (P<0.0001) and invasion (P<0.0001) of pancreatic cancer cells. In addition, we identified a possible target of miR-5100, podocalyxin-like 1 (PODXL), and demonstrated miR-5100 directly binds to the 3' untranslated region of PODXL and post-transcriptionally regulates its expression in pancreatic cancer cells. Silencing PODXL resulted in diminished cell migration (P<0.0001) and invasion (P<0.05). We also clarified the close relationship between expression of PODXL in human pancreatic cancer specimens and liver metastasis (P=0.0003), and determined that post-operative survival was longer in the low-PODXL expression group than in the high-PODXL expression group (P<0.05). These results indicate that miR-5100 and PODXL have considerable therapeutic potential for anti-metastatic therapy and could be potential indicators for cancer metastases in patients with pancreatic cancer.
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87. Sada M, Ohuchida K, Horioka K, Okumura T, Moriyama T, Miyasaka Y, Ohtsuka T, Mizumoto K, Oda Y, Nakamura M, Hypoxic stellate cells of pancreatic cancer stroma regulate extracellular matrix fiber organization and cancer cell motility, Cancer Letters, 372, 2, 210-218, 2016.04, Desmoplasia and hypoxia in pancreatic cancer mutually affect each other and create a tumor-supportive microenvironment. Here, we show that microenvironment remodeling by hypoxic pancreatic stellate cells (PSCs) promotes cancer cell motility through alteration of extracellular matrix (ECM) fiber architecture. Three-dimensional (3-D) matrices derived from PSCs under hypoxia exhibited highly organized parallel-patterned matrix fibers compared with 3-D matrices derived from PSCs under normoxia, and promoted cancer cell motility by inducing directional migration of cancer cells due to the parallel fiber architecture. Microarray analysis revealed that procollagen-lysine, 2-oxoglutarate 5-dioxygenase 2 (PLOD2) in PSCs was the gene that potentially regulates ECM fiber architecture under hypoxia. Stromal PLOD2 expression in surgical specimens of pancreatic cancer was confirmed by immunohistochemistry. RNA interference-mediated knockdown of PLOD2 in PSCs abrogated para
llel fiber architecture of 3-D matrices, leading to decreased directional migration of cancer cells within the matrices. In conclusion, these findings indicate that hypoxia-induced PLOD2 in PSCs creates a permissive microenvironment for migration of cancer cells through architectural regulation of stromal ECM in pancreatic cancer..
88. Fujimoto T, Ohtsuka T, Date K, Kimura H, Matsunaga T, Mori Y, Miyasaka Y, Mochidome N, Oda Y, Nakamura M, Expression of Bcl-2 19-kDa interacting protein 3 predicts prognosis after ampullary carcinoma resection, J Hepatobiliary Pancreat Sci, 23, 8, 489-496, 2016.04, Abstract
BACKGROUND:
An adequate management strategy for ampullary carcinoma (AC), a rare neoplasm, has yet to be determined. The aim of this study was to identify specific molecular markers allowing for the adequate management of AC.
METHODS:
The clinicopathological data of 41 patients who underwent curative resection of AC were reviewed retrospectively. The expression of thymidylate synthase (TS) and Bcl-2 19-kDa interacting protein 3 (BNIP3), two sensitive markers for S-1 and gemcitabine, respectively, was evaluated immunohistochemically. The relationship between the expression levels of these markers and the clinicopathological data were then investigated.
RESULTS:
The 5-year overall survival rate in the study population was 62%. In univariate and multivariate analyses, lymph node metastasis, neural invasion, lymphatic invasion, and the high-level BNIP3 expression were significant predictive factors for a poor postoperative prognosis. Neither TS nor BNIP3 expression were able to predict survival or the disease recurrence rate in patients who received postoperative adjuvant chemotherapy for AC.
CONCLUSIONS:
BNIP3 expression may serve as a prognostic marker for patients with AC, but neither TS nor BNIP3 contributes to the selection criteria for adjuvant chemotherapy for AC, at least with respect to current drug regimens.
© 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
KEYWORDS:
Ampulla of Vater; BNIP3; Carcinoma; Chemotherapy; Thymidylate synthase.
89. Tamura K, Ohtsuka T, Date K, Fujimoto T, Matsunaga T, Kimura H, Watanabe Y, Miyazaki T, Ohuchida K, Takahata S, Ishigami K, Oda Y, Mizumoto K, Nakamura M, Tanaka M, Distinction of Invasive Carcinoma Derived From Intraductal Papillary Mucinous Neoplasms From Concomitant Ductal Adenocarcinoma of the Pancreas Using Molecular Biomarkers, Pancreas, 45, 6, 826-835, 2016.04, OBJECTIVES:To clarify the usefulness of molecular biomarkers for distinguishing invasive carcinoma derived from intraductal papillary mucinous neoplasms (IPMNs [Inv-IPMN]) from concomitant pancreatic ductal adenocarcinoma (PDAC).METHODS:Data from 19 patients with resected concomitant PDAC were retrospectively reviewed. KRAS/GNAS mutations and immunohistochemical (IHC) expression of p53 and p16/CDKN2A were assessed in both IPMN and distinct PDAC. As controls, KRAS/GNAS mutations and IHC labeling were assessed between invasive and noninvasive components in 1 lesion of 22 independent patients.RESULTS:KRAS/GNAS mutation status of invasive and noninvasive components in Inv-IPMN was consistent in 18 (86%) of 21 patients. Conversely, mutational patterns in IPMN and distinct PDAC in the same pancreas differed from each other in 17 (89%) of 19. There were 10 (53%) and 8 (42%) of 19 patients who showed the same p53 and p16/CDKN2A staining between concomitant PDAC and d
istinct IPMN. In the Inv-IPMN cohort, 19 (86%) of 22 patients showed the same IHC expression pattern between the noninvasive and invasive components.CONCLUSIONS:It may be possible to distinguish Inv-IPMN from concomitant PDAC by assessing these molecular biomarkers. More precise distinction of Inv-IPMN and concomitant PDAC will lead to adequate recognition of the natural history of IPMNs and hence optimal management..
90. Kimura H, Ohtsuka T, Fujimoto T, Date K, Matsunaga T, Cases AI, Abe A, Mizuuchi Y, Miyasaka Y, Ito T, Oda Y, Nakamura M, Tanaka M, Different hormonal expression patterns between primary pancreatic neuroendocrine tumors and metastatic sites, Pancreas, 45, 7, 947-952, 2016.04, OBJECTIVES: Pancreatic neuroendocrine tumors (PNETs) are known to have heterogeneity in terms of their ability to produce multiple hormones. The aim of this study was to evaluate the heterogeneity of PNETs from the viewpoint of hormonal expression. METHODS: The expressions of 4 representative hormones, gastrin, insulin, glucagon, and somatostatin, in both primary and metastatic lesions, were analyzed by immunohistochemical staining in 20 patients with metastatic PNETs (6 gastrinomas, 1 insulinoma, 1 glucagonoma, and 12 nonfunctioning PNETs [NF-PNETs]). Metastatic sites included lymph nodes in all 20 patients and liver metastasis in 7 patients (2 gastrinomas and 5 NF-PNETs). RESULTS: There were 6 PNETs with multiple hormone secretion (30%), and positive expression of 1 or more hormones was found in 9 of 12 patients whose primary tumors were diagnosed as NF-PNETs. The positive concordance rate of the hormonal expression pattern between primary tumors and metast
atic lymph nodes and between primary tumors and hepatic metastasis were 50% and 11%, respectively. Three patients had metastatic lesions with positive hormonal expression, whereas their primary tumors were negative. CONCLUSIONS: Hormonal expressions are often different between the primary tumors and metastatic sites of PNETs..
91. Abe T, Ohuchida K, Miyasaka Y, Ohtsuka T, Oda Y, Nakamura M, Comparison of Surgical Outcomes Between Radical Antegrade Modular Pancreatosplenectomy (RAMPS) and Standard Retrograde Pancreatosplenectomy (SPRS) for Left-Sided Pancreatic Cancer, World J Surg, 40, 9, 2267-75, 2016.04, BACKGROUND: Radical antegrade modular pancreatosplenectomy (RAMPS) is a modification of standard retrograde pancreatosplenectomy (SRPS) used to achieve the dissection of N1 lymph nodes, early vascular control, and negative posterior margins. However, there have been few comparative studies regarding the clinical outcomes of the RAMPS and SRPS procedures.METHODS: Ninety-three patients underwent distal pancreatectomy for the treatment of pancreas body and tail adenocarcinoma between 2000 and 2014. Clinicopathologic data were retrospectively analyzed in this study. We compared short- and long-term outcomes between RAMPS and SRPS. In addition, we investigated the significance of clinicopathologic factors in left-sided pancreatic cancers.RESULTS: Fifty-three patients underwent RAMPS and 40 patients underwent SRPS. RAMPS revealed a larger number of retrieved lymph nodes [28.4 ± 11.6 vs 20.7 ± 10.1; P = 0.0016], more frequent R0 resection [90.5 vs 67.5
%; P = 0.0053], less intraoperative bleeding than SRPS [485.4 ± 63.3 vs 682.3 ± 72.8 ml; P = 0.0444], and shorter operating time (267.3 ± 11.5 vs 339.4 ± 13.2 min; P < 0.0001) as compared with SRPS. In comparing RAMPS and SRPS, RAMPS showed a tendency for improvement of the median survival times than SRPS (47 vs 34 months) (P = 0.1920). In the multivariate analysis, R1 resection, histologic grade, and vascular invasion for overall survival (OS) were found to be independent factors.CONCLUSIONS: There were a decrease of intraoperative bleeding and an increase in the number of retrieved lymph nodes and the R0 resection rate using RAMPS as compared with SRPS..
92. Zheng B, Ohuchida K, Chijiiwa Y, Zhao M, Mizuuchi Y, Cui L, Horioka K, Ohtsuka T, Mizumoto K, Oda Y, Hashizume M, Nakamura M, Tanaka M, CD146 Attenuation in Cancer-Associated Fibroblasts Promotes Pancreatic Cancer Progression, Molecular Carcinogenesis, 55, 1560-1572, 2016.04.
93. Yoshida M, Miyasaka Y, Ohuchida K, Okumura T, Zheng B, Torata N, Fujita H, Nabae T, Manabe T, Shimamoto M, Ohtsuka T, Mizumoto K, Nakamura M, Calpain inhibitor calpeptin suppresses pancreatic cancer by disrupting cancer-stromal interactions in a mouse xenograft model., Cancer Sci, 107, 10, 1443-1452, 2016.04, Desmoplasia contributes to the aggressive behavior of pancreatic cancer. However, recent clinical trials testing several antifibrotic agents on pancreatic cancer have not shown clear efficacy. Therefore, further investigation of desmoplasia-targeting antifibrotic agents by another mechanism is needed. Calpeptin, an inhibitor of calpains, suppressed fibroblast function and inhibited fibrosis. In this study, we investigated the anticancer effects of calpeptin on pancreatic cancer. We investigated whether calpeptin inhibited tumor progression using a mouse xenograft model. We used quantitative RT-PCR to evaluate the expression of calpain-1 and calpain-2 mRNA in pancreatic cancer cells (PCCs) and pancreatic stellate cells (PSCs). We also undertook functional assays, including proliferation, migration, and invasion, to evaluate the inhibitory effects of calpeptin on PCCs and PSCs. Quantitative RT-PCR indicated that PCCs and PSCs expressed calpain-2 mRNA. C
alpeptin reduced tumor volume (P = 0.0473) and tumor weight (P = 0.0471) and inhibited the tumor desmoplastic reaction (P < 0.001) in xenograft tumors in nude mice. Calpeptin also inhibited the biologic functions of PCCs and PSCs including proliferation (P = 0.017), migration (P = 0.027), and invasion (P = 0.035) in vitro. Furthermore, calpeptin reduced the migration of PCCs and PSCs by disrupting the cancer-stromal interaction (P = 0.0002). Our findings indicate that calpeptin is a promising antitumor agent for pancreatic cancer, due not only to its suppressive effect on PCCs and PSCs but also its disruption of the cancer-stromal interaction..
94. Matsunaga T, Ohtsuka T, Asano K, Kimura H, Ohuchida K, Kitada H, Ideno N, Mori Y, Tokunaga S, Oda Y, Guha S, Raimondo M, Nakamura M, Tanaka M, S100P in Duodenal Fluid Is a Useful Diagnostic Marker for Pancreatic Ductal Adenocarcinoma, Pancreas, 10.1097/MPA.0000000000000940, 46, 10, 1288-1295, 2017.04, Abstract
OBJECTIVES:
The development of an effective screening method for pancreatic ductal adenocarcinoma (PDAC) is of paramount importance. This study assessed the diagnostic utility in pancreatic diseases of duodenal markers during upper gastrointestinal endoscopy (GIE) or endoscopic ultrasonography.

METHODS:
This study prospectively enrolled 299 consecutive participants, including 94 patients with PDACs, 144 patients with other pancreatic diseases, and 61 normal individuals as control subjects. All subjects underwent upper GIE or endoscopic ultrasonography either at Kyushu University Hospital (Fukuoka, Japan) or the Mayo Clinic (Jacksonville, Fla) from October 2011 to July 2014. Duodenal fluid (DF) was collected without secretin stimulation and of carcinoembryonic antigen and S100 calcium-binding protein P (S100P) concentrations were measured.

RESULTS:
Concentrations of S100P in DF were significantly higher in patients with PDAC and chronic pancreatitis than in control subjects (P < 0.01). A logistic regression model that included age found that the sensitivity and specificity of S100P concentration in diagnosing stages 0/IA/IB/IIA PDAC were 85% and 77%, respectively, with an area under the receiver operating characteristic curve of 0.82. Carcinoembryonic antigen concentrations in DF of patients with pancreatic disease did not differ significantly from control subjects.

CONCLUSIONS:
Analysis of S100P concentration in DF, in combination with routine screening upper GIE, may facilitate the detection of PDAC..
95. Miyasaka Y, Mori Y, Nakata K, Ohtsuka T, Nakamura M, Prophylactic biliary and gastrointestinal bypass for unresectable pancreatic head cancer: A retrospective case series, Journal of the Pancreas, 18, 6, 470-474, 2017.04.
96. Date S, Noguchi H, Kaku K, Kurihara K, Miyasaka Y, Okabe Y, Nakamura U, Ohtsuka T, Nakamura M, Laparoscopy-Assisted Spleen-Preserving Distal Pancreatectomy for Living-Donor Pancreas Transplantation, Transplant Proc. , 10.1016/j.transproceed.2017.03.037, 49, 5, 1133-1137, 2017.04, BACKGROUND:Living pancreas transplantation plays an important role in the treatment of patients with severe type 1 diabetes. However, pancreatectomy is very invasive for the donor, and less-invasive surgical procedures are needed. Although some reports have described hand-assisted laparoscopic surgery for distal pancreatectomy in living-donor operations, less-invasive laparoscopy-assisted (LA) procedures are expected to increase the donor pool. We herein report the outcomes of four cases of LA spleen-preserving distal pancreatectomy (Warshaw technique [WT]) in living pancreas donors.PATIENTS AND METHODS:Four living pancreas donors underwent LA-WT at our institution from September 2010 to January 2013. All donors fulfilled the donor criteria established by the Japan Society for Pancreas and Islet Transplantation.RESULTS:The median donor age was 54 years. Two donors underwent left nephrectomy in addition to LA-WT for simultaneous pancreas-kidney transpl
antation. The median donor operation time for pancreatectomy was 340.5 minutes. The median pancreas warm ischemic time was 3 minutes. The median donor blood loss was 246 g. All recipients immediately achieved insulin independence. One donor required reoperation because of obstructive ileus resulting from a port-site hernia. Another donor developed a pancreatic fistula (International Study Group of Pancreatic Fistula grade B), which was controlled with conservative management. After a maximum follow-up of 73 months, no clinically relevant adverse events had occurred. These results were comparable with those of previous studies concerning living-donor pancreas transplantation.CONCLUSION:The LA-WT is a safe and acceptable operation for living-donor pancreas transplantation..
97. Ohuchida K, Nagai E, Moriyama T, Shindo K, Manabe T, Ohtsuka T, Shimizu S, Nakamura M, Feasibility and safety of modified inverted T-shaped method using linear stapler with movable cartridge fork for esophagojejunostomy following laparoscopic total gastrectomy, Transl Gastroenterol Hepatol., 23, 2, 50, 2017.04, Abstract
BACKGROUND:
We previously reported the use of an inverted T-shaped method to obtain a suitable view for hand sewing to close the common entry hole when the linear stapler was fired for esophagojejunostomy after laparoscopic total gastrectomy (LTG). This conventional method involved insertion of the fixed cartridge fork to the Roux limb and the fine movable anvil fork to the esophagus to avoid perforation of the jejunum. However, insertion of the movable anvil fork to the esophagus during this procedure often requires us to strongly push down the main body of the stapler with the fixed cartridge fork to bring the direction of the anvil fork in line with the direction of the long axis of the esophagus while controlling the opening of the movable anvil fork. We therefore modified this complicated inverted T-shaped method using a linear stapler with a movable cartridge fork. This modified method involved insertion of the movable cartridge fork into the Roux limb followed by natural, easy insertion of the fixed anvil fork into the esophagus without controlling the opening of the movable cartridge fork.
METHODS:
We performed LTG in a total of 155 consecutive patients with gastric cancer from November 2007 to December 2015 in Kyushu University Hospital. After LTG, we performed the conventional inverted T-shaped method using a linear stapler with a fixed cartridge fork in 61 patients from November 2007 to July 2011 (fixed cartridge group). From August 2011, we used a linear stapler with a movable cartridge fork and performed the modified inverted T-shaped method in 94 patients (movable cartridge group). We herein compare the short-term outcomes in 94 cases of LTG using the modified method (movable cartridge fork) with those in 61 cases using the conventional method (fixed cartridge fork).
RESULTS:
We found no significant differences in the perioperative or postoperative events between the movable and fixed cartridge groups. One case of anastomotic leakage occurred in the fixed cartridge group, but no anastomotic leakage occurred in the movable cartridge group.
CONCLUSIONS:
Although there were no remarkable differences in the short-term outcomes between the movable and fixed cartridge groups, we believe that the modified inverted T-shaped method is technically more feasible and reliable than the conventional method and will contribute to the improved safety of LTG..
98. Okumura T, Ohuchida K, Sada M, Abe T, Endo S, Koikawa K, Iwamoto C, Miura D, Mizuuchi Y, Moriyama T, Nakata K, Miyasaka Y, Manabe T, Ohtsuka T, Nagai E, Mizumoto K, Oda Y, Hashizume M, Nakamura M, Extra-pancreatic invasion induces lipolytic and fibrotic changes in the adipose microenvironment, with released fatty acids enhancing the invasiveness of pancreatic cancer cells, Oncotarget, 10.18632/oncotarget.15430., 8, 11, 18280-18295, 2017.04, Abstract
Pancreatic cancer progression involves components of the tumor microenvironment, including stellate cells, immune cells, endothelial cells, and the extracellular matrix. Although peripancreatic fat is the main stromal component involved in extra-pancreatic invasion, its roles in local invasion and metastasis of pancreatic cancer remain unclear. This study investigated the role of adipose tissue in pancreatic cancer progression using genetically engineered mice (Pdx1-Cre; LSL-KrasG12D; Trp53R172H/+) and an in vitro model of organotypic fat invasion. Mice fed a high fat diet had significantly larger primary pancreatic tumors and a significantly higher rate of distant organ metastasis than mice fed a standard diet. In the organotypic fat invasion model, pancreatic cancer cell clusters were smaller and more elongated in shape and showed increased fibrosis. Adipose tissue-derived conditioned medium enhanced pancreatic cancer cell invasiveness and gemcitabine resistance, as well as inducing morphologic changes in cancer cells and increasing the numbers of lipid droplets in their cytoplasm. The concentrations of oleic, palmitoleic, and linoleic acids were higher in adipose tissue-derived conditioned medium than in normal medium, with these fatty acids significantly enhancing the migration of cancer cells. Mature adipocytes were smaller and the concentration of fatty acids in the medium higher when these cells were co-cultured with cancer cells. These findings indicate that lipolytic and fibrotic changes in peripancreatic adipose tissue enhance local invasiveness and metastasis via adipocyte-released fatty acids. Inhibition of fatty acid uptake by cancer cells may be a novel therapy targeting interactions between cancer and stromal cells.
KEYWORDS:
adipose microenvironment; extra-pancreatic invasion; fatty acids; lipolysis; pancreatic cancer.
99. Fujimoto T, Ohtsuka T, Nakashima Y, Gotoh Y, Date K, Mori Y, Sadakari Y, Takahata S, Oda Y, Nakamura M, Elevated bile amylase level without pancreaticobiliary maljunction is a risk factor for gallbladder carcinoma, J Hepatobiliary Pancreat Sci., 24, 2, 103-108, 2017.04, Background: Elevated bile amylase level in patients with pancreaticobiliary maljunction (PBM) or high confluence of pancreaticobiliary ducts (HCPBD) is well known as a risk factor for gallbladder carcinoma (GBC) development. However, the effects of occult pancreaticobiliary reflux (OPR), a condition characterized by high bile amylase level in the presence of an anatomically normal pancreaticobiliary junction, on GBC development remain unclear. The aim of this study was to assess the relationship between OPR and GBC.Methods: Clinicopathological data of 52 patients who were preoperatively diagnosed with gallbladder (GB) tumor (22 malignant, 30 benign) were retrospectively reviewed. All of the patients underwent preoperative endoscopic retrograde cholangiopancreatography to evaluate pancreaticobiliary junction morphology and bile amylase level. The relationship between the histological diagnosis of GB lesions, and pancreaticobiliary junction morphology a
nd bile amylase level were investigated.Results: PBM, HCPBD, and normal pancreaticobiliary junction (NPJ) were identified in 12, 9, and 31 patients, respectively. The rates of GBC in patients with PBM, HCPBD, and NPJ were 58% (7/12), 67% (6/9), and 29% (9/31), respectively. Of the 31 patients with NPJ, 22 had OPR and 9 of these had GBC. None of the patients with NPJ and normal bile amylase level had GBC. Additionally, among patients with NPJ, bile amylase level was significantly higher in patients with GBC than in patients with benign tumors.Conclusions: OPR, like PBM and HCPBD, is a risk factor for GBC development..
100. Nakayama H, Ohuchida K, Yoshida M, Miyazaki T, Takesue S, Abe T, Endo S, Koikawa K, Okumura T, Moriyama T, Nakata K, Miyasaka Y, Shirahane K, Manabe T, Ohtsuka T, Toma H, Tominaga Y, Nagai E, Mizumoto K, Oda Y, Nakamura M, Degree of desmoplasia in metastatic lymph node lesions is associated with lesion size and poor prognosis in pancreatic cancer patients, Oncol Lett, 10.3892/ol.2017.6549, 14, 3, 3141-3147, 2017.04, Abstract
Pancreatic cancer is characterized by increased hyperplasia of fibrotic tissue, termed desmoplasia, and lymph node metastasis is an independent prognostic factor in this disease. However, there are no reports focused on desmoplasia in pancreatic cancer lymph node metastases. The present study evaluated a range of factors and investigated their association with poor prognosis in pancreatic cancer cases with lymph node metastasis, including the degree of desmoplasia in lesions. To identify the poor prognostic factors associated with lymph node metastasis, the present study retrospectively reviewed the clinical data of 65 patients with lymph node metastases that underwent surgical pancreatic cancer resection between 2007 and 2012 at a single institution. The investigation focused on the degree of fibrosis in metastatic lesions in 216 lymph nodes, and investigated associations with prognosis or clinicopathological findings. The ratios of the fibrotic area in metastatic lymph node lesions were evaluated and classified into three categories, high (≥70%), moderate (10-70%) and low (<10%). Desmoplasia was not observed in cancer-free lymph nodes. The size of metastatic lymph node lesions was additionally measured, and a significant association between metastatic lesion size and the degree of desmoplasia was observed (P<0.001). The degree of desmoplasia was additionally associated with local extranodal invasion. In the analysis of 65 pancreatic cancer patients with metastatic lymph nodes, the presence of multiple metastatic lymph nodes with moderate or high desmoplasia was significantly associated with poor survival (high, P=0.0048; moderate/high, P=0.0075). Of several clinicopathological factors, the presence of multiple metastatic lymph nodes with high or moderate desmoplasia was associated with overall survival in univariate (P=0.0098) and multivariate (P=0.0466) analyses. The degree of desmoplasia in metastatic lymph nodes is associated with lesion size, and the presence of multiple metastatic lymph nodes with desmoplasia is an independent poor prognostic factor, suggesting that the desmoplasia may have an important role in the malignant progression of lymph node metastases.
KEYWORDS:
desmoplasia; locally extranodal invasion; lymph node metastasis; pancreatic cancer; prognostic factor.
101. Ohtsuka T, Mori Y, Ishigami K, Fujimoto T, Miyasaka Y, Nakata K, Ohuchida K, Nagai E, Oda Y, Shimizu S, Nakamura M, Clinical significance of circumportal pancreas, a rare congenital anomaly, in pancreatectomy, Am J Surg, 214, 2, 267-272, 2017.04, Abstract
BACKGROUND:
Circumportal pancreas is a rare congenital pancreatic anomaly. The aim of this study was to clarify the clinical characteristics of patients with circumportal pancreases undergoing pancreatectomy.
METHODS:
The medical records of 508 patients who underwent pancreatectomy were retrospectively reviewed. The prevalence of circumportal pancreas and related anatomical variations were assessed. Surgical procedures and postoperative outcomes were compared in patients with and without circumportal pancreas.
RESULTS:
Circumportal pancreas was observed in 9 of the 508 patients (1.7%). In all nine patients, the portal vein was completely encircled by the pancreatic parenchyma above the level of the splenoportal junction, and the main pancreatic duct ran dorsal to the portal vein. The rate of variant hepatic artery did not differ significantly in patients with and without circumportal pancreas. Pancreatic fistula developed more frequently in patients with than without circumportal pancreas (44% vs. 14%, p = 0.03), but other clinical parameters did not differ significantly in these two groups.
CONCLUSIONS:
Despite being rare, circumportal pancreas may increase the risk of postoperative pancreatic fistula in patients undergoing pancreatectomy. However, a prospective, large-cohort study is necessary to determine the real incidence of relevant anatomical variations and the definitive clinical significance of this rare anomaly..
102. Abe T, Ohuchida K, Endo S, Ookubo F, Mori Y, Nakata K, Miyasaka Y, Manabe T, Ohtsuka T, Nagai E, Oda Y, Nakamura M, Clinical importance of intraoperative peritoneal cytology in patients with pancreatic cancer, Surgery, 161, 4, 951-958, 2017.04, BACKGROUND:The clinical importance of intraoperative peritoneal cytology in patients with pancreatic cancer remains incompletely understood.METHODS:Peritoneal washing samples were collected from 411 consecutive patients with pancreatic ductal adenocarcinoma from 1996 to 2014. Of the 411 patients, 335 underwent macroscopically curative resection and 76 with noncurative factors did not undergo resection. We compared long-term outcomes between patients with positive cytology (cytology+) and those with negative cytology (cytology-) and investigated the importance of clinicopathologic factors.RESULTS:Of 335 patients with curative resection, 300 (89.6%) were cytology- and 35 (10.4%) were cytology+. The median overall survival of cytology+ patients was less than that of cytology- patients (16 vs 31 months, respectively; P < .0001). The median overall survival of cytology+ patients with noncurative factors was significantly worse than that of cytology+ pat
ients with curative resection (6.9 vs 16.0 months, respectively; P = .0023). The median disease-free survival of cytology+ patients was less than that of cytology- patients (6.5 vs 16 months, respectively; P < .0001). In the multivariate analysis, cytology+ was an independent prognostic factor for overall survival and disease-free survival.CONCLUSION:Cytology+ without noncurative factors was a predictive factor for a poor prognosis. Therefore, it is important to regard patients with pancreatic cancer characterized by cytology+ as a special group that may warrant more aggressive adjuvant therapy..
103. Abe T, Ohuchida K, Koikawa K, Endo S, Okumura T, Sada M, Horioka K, Zheng B, Moriyama T, Nakata K, Miyasaka Y, Manabe T, Ohtsuka T, Nagai E, Mizumoto K, Hashizume M, Nakamura M, Cancer-associated peritoneal mesothelial cells lead the formation of pancreatic cancer peritoneal dissemination, Int J Oncol, 50, 2, 457-467, 2017.04, The interaction between the cancer cells and the peritoneal mesothelial cells (PMCs) plays an important role in the peritoneal dissemination in several types of cancer. However, the role of PMCs in the peritoneal dissemination of pancreatic cancer remains unclear. In the present study, we investigated the interaction between the pancreatic cancer cells (PCCs) and the PMCs in the formation of peritoneal dissemination in vitro and in vivo. The tumor-stromal interaction of PCCs and PMCs significantly enhanced their mobility and invasiveness and enhanced the proliferation and anoikis resistance of PCCs. In a 3D organotypic culture model of peritoneal dissemination, co-culture of PCCs and PMCs significantly increased the cells invading into the collagen gel layer compared with mono-culture of PCCs. PMCs pre-invaded into the collagen gel, remodeled collagen fibers, and increased parallel fiber orientation along the direction of cell invasion. In the tissues
of peritoneal dissemination of the KPC (LSL-KrasG12D/+; LSL-Trp53R172H/+;Pdx-1-Cre) transgenic mouse, the monolayer of PMCs was preserved in tumor-free areas, whereas PMCs around the invasive front of peritoneal dissemination proliferated and invaded into the muscle layer. In vivo, intraperitoneal injection of PCCs with PMCs significantly promoted peritoneal dissemination compared with PCCs alone. The present data suggest that the cancer-associated PMCs have important promoting roles in the peritoneal dissemination of PCCs. Therapy targeting cancer-associated PMCs may improve the prognosis of patients with pancreatic cancer..
104. Endo S, Nakata K, Ohuchida K, Takesue S, Nakayama H, Abe T, Koikawa K, Okumura T, Sada M, Horioka K, Zheng B, Mizuuchi Y, Iwamoto C, Murata M, Moriyama T, Miyasaka Y, Ohtsuka T, Mizumoto K, Oda Y, Hashizume M, Nakamura M, Autophagy Is Required for Activation of Pancreatic Stellate Cells, Associated With Pancreatic Cancer Progression and Promotes Growth of Pancreatic Tumors in Mice, Gastroenterology, 10.1053/j.gastro.2017.01.010, 152, 6, 1492-1506, 2017.04, BACKGROUND & AIMS: Pancreatic stellate cells (PSCs) changefrom a quiescent to activated state in the tumor environmentand secrete extracellular matrix (ECM) molecules and cytokinesto increase the aggressiveness of tumors. However, it is notclear how PSCs are activated to produce these factors, orwhether this process can be inhibited. PSCs have morphologicand functional similarities to hepatic stellate cells, whichundergo autophagy to promote fibrosis and tumor growth. Weinvestigated whether autophagy activates PSCs, which promotesdevelopment of the tumor stroma and growth ofpancreatic tumors in mice. METHODS: We used immunofluorescencemicroscopy and immunohistochemistry to analyzepancreatic tumor specimens from 133 patients who underwentpancreatectomy in Japan from 2000 to 2009. PSCs werecultured from pancreatic tumor tissues or tissues of patientswith chronic pancreatitis; these were analyzed by immunofluorescencemicroscopy, immunoblots, quantitative
reversetranscription polymerase chain reaction, and in assays forinvasiveness, proliferation, and lipid droplets. Autophagy wasinhibited in PSCs by administration of chloroquine or transfectionwith small interfering RNAs. Proteins were knockeddown in immortalized PSCs by expression of small hairpinRNAs. Cells were transplanted into pancreatic tails of nudemice, and tumor growth and metastasis were quantified. RESULTS:Based on immunohistochemical analyses, autophagywas significantly associated with tumor T category (P シ .018),histologic grade (P シ .001), lymph node metastases (P < .001),stage (P シ .009), perilymphatic invasion (P シ .001), and perivascularinvasion (P シ .003). Autophagy of PSCs was associatedwith shorter survival times of patients with pancreatic cancer.PSC expression of microtubule-associated protein 1 lightchain 3, a marker of autophagosomes, was associated with pooroutcomes (shorter survival time, disease recurrence) forpati
ents with pancreatic cancer (relative risk of shorter survivaltime, 1.56). Immunoblots showed that PSCs from pancreatictumor samples expressed higher levels of markers of autophagythan PSCs from chronic pancreatitis samples. Inhibitorsof autophagy increased the number of lipid droplets of PSCs,indicating a quiescent state of PSCs, and reduced their productionof ECM molecules and interleukin 6, as well as theirproliferation and invasiveness in culture. PSCs exposedto autophagy inhibitors formed smaller tumors in nude mice(P シ .001) and fewer liver metastases (P シ .018) with lessperitoneal dissemination (P シ .018) compared to PSCs notexposed to autophagy inhibitors. CONCLUSIONS: AutophagicPSCs produce ECM molecules and interleukin 6 and areassociated with shorter survival times and disease recurrencein patients with pancreatic cancer. Inhibitors of PSC autophagymight reduce pancreatic tumor invasiveness by altering thetumor stroma..
105. Endo S, Nakata K, Sagara A, Koikawa K, Ando Y, Kibe S, Takesue S, Nakayama H, Abe T, Okumura T, Moriyama T, Miyasaka Y, Ohuchida K, Ohtsuka T, Mizumoto K, Nakamura M, Autophagy inhibition enhances antiproliferative effect of salinomycin in pancreatic cancer cells, Pancreatology, 10.1016/j.pan.2017.08.009, 17, 6, 990-996, 2017.04, Background: Salinomycin has cytotoxic effects on various types of malignancy and induces autophagy.However, it has not been clarified whether autophagy induced by salinomycin treatment has a protectiveor cytotoxic role. We investigated whether salinomycin affects autophagy in pancreatic cancer cells andwhether autophagy induced by salinomycin treatment has a protective or cytotoxic role in these cells.Methods: We investigated the effect of salinomycin using three pancreatic cancer cell lines. We investigatedeffect on proliferation and the CD133 positive fraction using flow cytometry. In addition, wemonitored the change in autophagic activity after salinomycin treatment using fluorescent immunostaining,western blotting, and flow cytometry. Finally, knockdown of ATG5 or ATG7 by siRNA was usedto investigate the impact of autophagy inhibition on sensitivity to salinomycin.Results: Salinomycin suppressed the proliferation of pancreatic cancer cells in a co
ncentration dependentmanner, and reduced the CD133 positive fraction. Salinomycin enhanced autophagy activity in these cellsin a concentration dependent manner. Autophagy inhibition made pancreatic cancer cells more sensitiveto salinomycin.Conclusions: Our data provide the first evidence indicating that autophagy induced by salinomycin havea protective role in pancreatic cancer cells. A new therapeutic strategy of combining salinomycin,autophagy inhibitors, and anticancer drugs could hold promise for pancreatic cancer treatment..
106. Nakamura M, Nakata K, Matsumoto H, Ohtsuka T, Yoshida K, Tokunaga S, Hino K, Acyl/free carnitine ratio is a risk factor for hepatic steatosis after pancreatoduodenectomy and total pancreatectomy, Pancreatology, 17, 1, 135-138, 2017.04, Abstract
OBJECTIVES:
Hepatic steatosis, one of the most frequent long-term complications of pancreatectomy, influences not only hepatic function but also survival rate. However, its risk factors and pathogenesis have not been established. The purpose of this study was to clarify the risk factors for hepatic steatosis after pancreatectomy.
METHODS:
In this retrospective study of 21 patients who had undergone pancreatectomy (19 cases of pancreatoduodenectomy and 2 cases of total pancreatectomy), serum carnitine concentrations, fractions of carnitine, and hepatic attenuation on computed tomography images were analyzed with the aim of identifying risk factors for hepatic steatosis.
RESULTS:
Thirteen (61.9%) of the 21 patients were diagnosed as having hypocarnitinemia after pancreatectomy. Average hepatic attenuation was as low as 42.2HU (±21.3 SD). A high ratio of acyl/free carnitine was associated with less pronounced hepatic attenuation according to both univariate (P < 0.001) and multivariate (P = 0.020) regression analyses.
CONCLUSIONS:
The serum carnitine concentrations were low after pancreatectomy in some patients. The statistical analyses suggest that a high ratio of acyl/free carnitine is an independent risk factor for hepatic steatosis after pancreatectomy..
107. Date K, Ohtsuka T, Nakamura S, Mochidome N, Mori Y, Miyasaka Y, Oda Y, Nakamura M, Surveillance of patients with intraductal papillary mucinous neoplasm with and without pancreatectomy with special reference to the incidence of concomitant pancreatic ductal adenocarcinoma, Surgery, 10.1016/j.surg.2017.09.040, 163, 2, 291-299, 2018.04, Abstract
BACKGROUND:
The presence of an intraductal papillary mucinous neoplasm is important in the detection of concomitant pancreatic ductal adenocarcinoma. The aim of this study was to elucidate the incidence and timing of development of concomitant pancreatic ductal adenocarcinoma in patients with and without pancreatectomy for intraductal papillary mucinous neoplasm.

METHODS:
We reviewed retrospectively the surveillance data for 22 patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm (pancreatic ductal adenocarcinoma-resection group), 180 who underwent pancreatectomy for intraductal papillary mucinous neoplasm (intraductal papillary mucinous neoplasm-resection group), and 263 whose intraductal papillary mucinous neoplasms were left untreated (nonresection group). The incidence and timing of the development of a concomitant pancreatic ductal adenocarcinoma during the surveillance of patients with and without partial pancreatectomy for intraductal papillary mucinous neoplasm were investigated using the Kaplan-Meier method.

RESULTS:
During a median surveillance period of 40 months (range 6-262 months), 5 patients in the pancreatic ductal adenocarcinoma-resection group, 6 in the intraductal papillary mucinous neoplasm-resection group, and 8 in the nonresection group developed concomitant pancreatic ductal adenocarcinoma. The estimated 5-year (17%) and 10-year (56%) cumulative incidences of secondary pancreatic ductal adenocarcinoma in the pancreatic ductal adenocarcinoma-resection group were significantly greater than those in the other two groups (P < .01). Conversely, the difference in the estimated cumulative incidence of concomitant pancreatic ductal adenocarcinoma between the intraductal papillary mucinous neoplasm-resection and nonresection groups was not significant (5-year, 5.0% vs 2.2%; 10-year, 5.0% vs 8.7%; P = .87).

CONCLUSION:
Long-term (≥5-year) surveillance in patients with intraductal papillary mucinous neoplasm is necessary and important because of the potential for development of concomitant pancreatic ductal adenocarcinoma. Those with a history of resection of concomitant pancreatic ductal adenocarcinoma at the time of the initial operation are at quite high risk for the development of secondary pancreatic ductal adenocarcinoma..
108. Ohtsuka T, Gotoh Y, Nakashima Y, Okayama Y, Nakamura S, Morita M, Aly MYF, Velasquez VVDM, Mori Y, Sadakari Y, Nakata K, Miyasaka Y, Ishigami K, Fujimori N, Mochidome N, Oda Y, Shimizu S, Nakamura M, Role of SpyGlass-DStm in the preoperative assessment of pancreatic intraductal papillary mucinous neoplasm involving the main pancreatic duct, Pancreatology, 10.1016/j.pan.2018.04.012, 18, 5, 566-571, 2018.04, Abstract
BACKGROUND/OBJECTIVES:
It is often difficult to determine an adequate resection line during pancreatectomy for intraductal papillary mucinous neoplasm involving the main pancreatic duct during partial pancreatectomy. The aim of this study was to evaluate the usefulness of improved peroral pancreatoscopy using SpyGlass-DStm in the preoperative assessment of intraductal papillary mucinous neoplasm involving the main pancreatic duct.
METHODS:
We collected and retrospectively analyzed clinicopathological data from seven consecutive patients who underwent preoperative assessment of intraductal papillary mucinous neoplasm involving the main duct using SpyGlass-DStm.
RESULTS:
Good imaging quality of the intraductal protruding lesion was obtained in all seven patients, and only one adverse event was noted wherein a patient had mild pancreatitis. Six patients underwent pancreatectomy. In one patient, masked-type concomitant pancreatic ductal adenocarcinoma and low-length dysplastic lesion was found near the surgical margin, which was not detected by preoperative imaging modalities including SpyGlass-DStm. The sensitivity of targeting biopsy during SpyGlass-DStm to diagnose high-grade dysplasia was 0%.
CONCLUSIONS:
SpyGlass-DStm can be safely performed in patients with intraductal papillary mucinous neoplasm involving the main duct, and has excellent visualization of the target lesion. However, challenges include poor diagnostic ability of targeting biopsy, and, therefore, intraoperative frozen section is still needed to obtain negative surgical margins
.
109. Abe T, Nakata K, Kibe S, Mori Y, Miyasaka Y, Ohuchida K, Ohtsuka T, Oda Y, Nakamura M, Prognostic Value of Preoperative Nutritional and Immunological Factors in Patients with Pancreatic Ductal Adenocarcinoma, Ann Surg Oncol., 10.1245/s10434-018-6761-6, 25, 13, 3996-4003, 2018.04.
110. Noguchi H, Miyasaka Y, Kaku K, Nakamura U, Okabe Y, Ohtsuka T, Ishigami K, Nakamura M, Preoperative Muscle Volume Predicts Graft Survival after Pancreas Transplantation: A Retrospective Observational Cohort Study, Transplantation Proceedings, 10.1016/j.transproceed.2018.03.018, 50, 5, 1482-1488, 2018.04, Abstract
Background
Several studies have suggested that decreased muscle volume is associated with attenuation of immune function. The recipient’s immune system is responsible for rejection of transplanted organs, which is a major cause of graft loss after transplantation. We aimed to determine whether muscle volume is correlated with graft survival after pancreas transplantation (PT).

Methods
Forty-three patients underwent PT for type 1 diabetes mellitus at our institution from August 2001 to May 2016. The quantity of skeletal muscle was evaluated using the psoas muscle mass index (PMI). The correlation between the PMI and outcome after PT was assessed.

Results
A total of 32 and 11 recipients underwent simultaneous pancreas–kidney transplantation (SPK) and PT alone/pancreas after kidney transplantation, respectively. Patients with a surviving graft showed a significantly lower PMI than those with graft loss (P = 0.0451). We divided the recipients into two groups according to the PMI cutoff values which were established using receiver operating characteristic curves. The cumulative graft survival rate was significantly higher in patients with a low than normal PMI (P = 0.0206). A multivariate Cox regression analysis revealed that a low PMI (P= 0.0075) is an independent predictive factor for better graft survival. A low PMI was not a significant predictive factor for acute rejection, but was an independent predictive factor for graft survival after the first acute rejection (P= 0.0025).

Conclusions

Our data suggest that muscle volume could be a predictor of graft survival after PT.

Key words
pancreas transplantation; sarcopenia; graft rejection; graft survival

Abbreviations
AR, acute rejection; ATG, rabbit antithymocyte globulin; BMI, body mass index; CI, confidence interval; CT, computed tomography; DM, diabetes mellitus; HR, hazard ratio; IL, interleukin; ND, not done; PAK, pancreas-after-kidney transplantation; PMI, psoas muscle mass index; PT, pancreas transplantation; PTA, pancreas transplantation alone; SPK, simultaneous pancreas–kidney transplantation; TNF-α, tumor necrosis factor-alpha; Tregs, regulatory T cells.
111. Koikawa K, Ohuchida K, Takesue S, Ando Y, Kibe S, Nakayama H, Endo S, Abe T, Okumura T, Horioka H, Sada M, Iwamoto C, Moriyama T, Nakata K, Miyasaka Y, Ohuchida R, Manabe T, Ohtsuka T, Nagai E, Mizumoto K, Hashizume M, Nakamura M, Pancreatic stellate cells reorganize matrix components and lead pancreatic cancer invasion via the function of Endo180, Cancer letters, 10.1016/j.canlet.2017.10.010, 1, 412, 143-154, 2018.04, Specific cell populations leading the local invasion of cancer are called “leading cells”. However, the underlying mechanisms are unclear. Here, we identified leading cells in pancreatic cancer and deter- mined how these cells lead and promote cancer cell invasion in the extracellular matrix (ECM). Using three-dimensional matrix remodeling assay, we found that pancreatic stellate cells (PSCs) frequently invaded the collagen matrix with pancreatic cancer cells (PCCs), which invaded behind the invading PSCs. In addition, invading PSCs changed the alignment of collagen fibers, resulting in ECM remodeling and an increase in the parallel fibers along the direction of invading PSCs. Endo180 expression was higher in PSCs than in PCCs, Endo180 knockdown in PSCs attenuated the invasive abilities of PSCs and co- cultured PCCs, and decreased the expression level of phosphorylated myosin light chain 2 (MLC2). In mouse models, Endo180-knockdown PSCs
suppressed tumor growth and changes in collagen fiber orientation in co-transplantation with PCCs. Our findings suggest that PSCs lead the local invasion of PCCs by physically remodeling the ECM, possibly via the function of Endo180, which reconstructs the actin cell skeleton by phosphorylation of MLC2..
112. Kanno A, Masamune A, Hanada K, Maguchi H, Shimizu Y, Ueki T, Hasebe O, Ohtsuka T, Nakamura M, Takenaka M, Kitano M, Kikuyama M, Gabata T, Yoshida K, Sasaki T, Serikawa M, Furukawa T, Yanagisawa A, Shimosegawa T, Multicenter study of early pancreatic cancer in Japan, Pancreatology, 10.1016/j.pan.2017.11.007, 18, 1, 61-67, 2018.04, Abstract
BACKGROUND/OBJECTIVES:
The diagnosis of early-stage pancreatic ductal adenocarcinoma (PDAC) is still challenging. We conducted a multicenter study to clarify the clinical features of early-stage PDAC in Japan.

METHODS:
We collected patients with stage 0 and stage I PDAC according to the sixth edition of the Japanese Classification of Pancreatic Carcinoma. We retrospectively analyzed the clinical profiles including opportunities for medical examination, imaging modalities and findings, methods of cytological diagnosis, and prognosis according to the stages at diagnosis.

RESULTS:
Two hundred cases with Stage 0 and stage I PDAC were reported from 14 institutions, which accounted for approximately 0.7% and 3% of all PDAC cases, respectively. Overall, 20% of the early-stage PDAC cases were symptomatic. Indirect imaging findings such as dilatation of the main pancreatic duct were useful to detect early-stage PDAC. In particular, local fatty changes may be specific to early-stage PDAC. For preoperative pathologic diagnosis, cytology during endoscopic retrograde cholangiopancreatography was more commonly applied than endoscopic ultrasound fine-needle aspiration. Although the overall prognosis was favorable, new PDAC lesions developed in the remnant pancreas in 11.5% cases.

CONCLUSIONS:
This multicenter study revealed several key points concerning the diagnosis and management of early-stage PDAC, including screening of asymptomatic cases, importance of indirect imaging findings, application of cytology during endoscopic retrograde cholangiopancreatography, and the risk of carcinogenesis in the remnant pancreas..
113. Nagakawa Y, Nakamura Y, Honda G, Gotoh Y, Ohtsuka T, Ban D, Nakata K, Sahara Y, Velasquez VVDM, Takaori K, Misawa T, Kuroki T, Kawai M, Morikawa T, Yamaue H, Tanabe M, Mou Y, Lee WJ, Shrikhande SV, Conrad C, Han HS, Tang CN, Palanivelu C, Kooby DA, Asbun HJ, Wakabayashi G, Tsuchida A, Takada T, Yamamoto M, Nakamura M, Learning curve and surgical factors influencing the surgical outcomes during the initial experience with laparoscopic pancreaticoduodenectomy, J HepatoBiliary Pancreat Sci., 10.1002/jhbp.586 , 25, 11, 498-507, 2018.04, Abstract
BACKGROUND:
Laparoscopic pancreaticoduodenectomy (LPD) requires sufficient laparoscopic training for optimal outcomes. Our aim is to determine the learning curve and investigate the factors influencing surgical outcomes during the learning curve.
METHODS:
We analyzed surgical results of 150 consecutive cases of LPD performed by three hepatopancreatobiliary surgeons during their 50 first cases. Learning curves were constructed by cumulative sum (CUSUM) analysis. Preoperative factors influencing resection time and blood loss were investigated in the introductory and stable periods. RESULTS : The learning curve could be divided into three phases: initial (1-20 cases), plateau (21-30), and stable (31-50). Resection time with lymph node dissection was significantly longer during the introductory period (initial and plateau periods) (P < 0.01) but not the stable phase (P = 0.51). Multivariate analysis revealed that patients with pancreatitis had longer resection times and massive blood loss in both the introductory and stable periods (stable phase). High visceral fat area was also significantly related to massive blood loss in the introductory period (P = 0.04).
CONCLUSIONS:
Hepatopancreatobiliary surgeons need more than 30 cases until LPD becomes stable. Lymph node dissection and patients with high visceral fat area and concomitant pancreatitis should be avoided during the introductory period of the learning curve..
114. Aly MYF, Mori Y, Miyasaka Y, Ohtsuka T, Sadakari Y, Nakata K, Oda Y, Shimizu S, Nakamura M, Laparoscopic surgery for congenital biliary dilatation: a single-institution experience, Surg Today, 10.1007/s00595-017-1545-3, 48, 1, 44-50, 2018.04, Abstract
PURPOSE:
Laparoscopic surgery as a treatment for congenital biliary dilatation is uncommon. We herein present a series of laparoscopic surgeries for congenital biliary dilatation performed in our institution and review our experience with this approach over a long period of time.

METHODS:
Medical records of 36 consecutive patients who underwent laparoscopic surgery for congenital biliary dilatation from 1996 to 2015 were retrospectively reviewed. Data on patient demographics, operative time, blood loss, hospital stay, and complications were evaluated. A comparison between the former period (Group A, 1996-2005) and the latter period (Group B, 2006-2015) was performed.

RESULTS:
The patients comprised 23 females and 13 males with a median age of 34 years. The median operative time, blood loss, and hospital stay was 493 min, 154 g, and 11 days, respectively. Total early and late complications occurred in 7 (19%) and 2 (5%) patients, respectively. A comparison between Groups A and B revealed no significant difference in operative time or complications, but operative blood loss, open conversion, and hospital stay were significantly lower in Group B than in Group A (P < 0.05).

CONCLUSION:
Laparoscopic surgery for congenital biliary dilatation is feasible and provides acceptable results. Further prospective studies of larger numbers of patients are needed..
115. Gotoh Y, Ohtsuka T, Nakamura S, Shindo K, Ohuchida K, Miyasaka Y, Mori Y, Mochidome N, Oda Y, Nakamura M, Genetic assessment of recurrent pancreatic high-risk lesions in the remnant pancreas: Metachronous multifocal lesion or local recurrence?, Surgery, 10.1016/j.surg.2018.10.025 , 165, 4, 767-774, 2018.04, Abstract
BACKGROUND: It is difficult to determine whether a second high-risk lesion, including pancreatic ductal adenocarcinoma or high-grade pancreatic intraepithelial neoplasm, is a metachronous multifocal lesion or represents local recurrence after resection of the first high-risk lesion. This study attempts to clarify the characteristics of second high-risk lesions in the remnant pancreas using genetic analyses.
METHODS: Clinicopathologic data were collected from 12 patients who underwent pancreatectomy for a second high-risk lesion in the remnant pancreas. We performed mutational and immunohistochemical analyses of 4 major genes-KRAS, TP53, CDKN2A, and SMAD4-associated with pancreatic ductal adenocarcinoma progression, as well as targeted next-generation sequencing.
RESULTS: Mutations in the four genes in the second high-risk lesion were consistent with the first lesion in four patients but were inconsistent in the remaining eight patients, and thus we considered that the latter eight patients likely had metachronous multifocal high-risk lesions and the other four patients had local recurrence. The estimated cumulative recurrence rate after resection of the second high-risk lesion was greater in the local recurrence group compared with the metachronous multifocal group, and the estimated cumulative disease-specific survival rate was greater in the metachronous multifocal group. Targeted next-generation sequencing demonstrated that the second lesions in the metachronous multifocal high-risk lesion group showed differences in founder mutations compared with the first lesion. In the local recurrence group, the founder mutations in the second lesion were common with those in the first lesion.
CONCLUSION: Genetic assessment might help discriminate metachronous multifocal high-risk lesions from local recurrence.
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116. Ohtsuka T, Mori Y, Fujimoto T, Miyasaka Y, Nakata K, Ohuchida K, Nagai E, Oda Y, Shimizu S, Nakamura M, Feasibility of Prophylactic Pancreatojejunostomy in Possible High-Risk Patients for Prevention of Pancreatic Fistula during Enucleation or Limited Pancreatic Resection, Am Surg, 84, 1, 149-153, 2018.04, Abstract
The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with (n = 10) and without (n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer (P < 0.01) and blood loss significantly greater (P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent (P = 0.02) and postoperative hospital stay was significantly longer (P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study..
117. Ohtsuka T, Ban D, Nakamura Y, Nagakawa Y, Tanabe M, Gotoh Y, Velasquez VVDM, Nakata K, Sahara Y, Takaori K, Honda G, Misawa T, Kawai M, Yamaue H, Morikawa T, Kuroki T, Mou Y, Lee WJ, Shrikhande SV, Tang CN, Conrad C, Han HS, Palanivelu C, Asbun HJ, Kooby DA, Wakabayashi G, Takada T, Yamamoto M, Nakamura M, Difficulty scoring system in laparoscopic distal pancreatectomy, J HepatoBiliary Pancreat Sci., 10.1002/jhbp.578, 25, 11, 489-497, 2018.04, Abstract
BACKGROUND:
Several factors affect the level of difficulty of laparoscopic distal pancreatectomy (LDP). The purpose of this study was to develop a difficulty scoring (DS) system to quantify the degree of difficulty in LDP.
METHODS:
We collected clinical data for 80 patients who underwent LDP. A 10-level difficulty index was developed and subcategorized into a three-level difficulty index; 1-3 as low, 4-6 as intermediate, and 7-10 as high index. The automatic linear modeling (LINEAR) statistical tool was used to identify factors that significantly increase level of difficulty in LDP.
RESULTS:
The operator's 10-level DS concordance between the 10-level DS by the reviewers, LINEAR index DS, and clinical index DS systems were analyzed, and the weighted Cohen's kappa statistic were at 0.869, 0.729, and 0.648, respectively, showing good to excellent inter-rater agreement. We identified five factors significantly affecting level of difficulty in LDP; type of operation, resection line, proximity of tumor to major vessel, tumor extension to peripancreatic tissue, and left-sided portal hypertension/splenomegaly.
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118. Matsuda R, Miyasaka Y, Ohishi Y, Yamamoto T, Saeki K, Mochidome N, Abe A, Ozono K, Shindo K, Ohtsuka T, Kikutake C, Nakamura M, Oda Y, Concomitant Intraductal Papillary Mucinous Neoplasm in Pancreatic Ductal Adenocarcinoma Is an Independent Predictive Factor for the Occurrence of New Cancer in the Remnant Pancreas, Ann Surg., 10.1097/SLA.0000000000003060, 2018.04, Abstract
OBJECTIVE:
To determine the factors predicting the subsequent development of pancreatic ductal adenocarcinoma in remnant pancreas (PDAC-RP) after partial pancreatectomy for PDAC.
SUMMARY BACKGROUND DATA:
PDAC-RP after partial pancreatectomy for PDAC is currently not so rare because of improved prognosis of PDAC patients due to recent advances in surgical techniques and adjuvant therapy. However, the predictive factors related to PDAC-RP remain unknown.
METHODS:
We retrospectively reviewed the clinicopathological data of a consecutive series of 379 patients with PDAC treated by partial pancreatectomy between 1992 and 2015; 14 patients (3.69%) had PDAC-RP. Clinicopathological variables were compared between PDAC-RP and non-PDAC-RP.
RESULTS:
In univariate analysis, concomitant intraductal papillary mucinous neoplasm (IPMN) (P = 0.0005), cancer location (body/tail) (P = 0.0060), and lower T factor in UICC (P = 0.0039) were correlated with PDAC-RP development. Multivariate analysis revealed concomitant IPMN (P = 0.0135) to be an independent predictive factor for PDAC-RP. PDAC concomitant with IPMN had higher cumulative incidence of PDAC-RP (47.5%/10 yrs) than PDAC without IPMN (9.96%/10 yrs) (P = 0.0071). Moreover, the density of pancreatic intraepithelial neoplasia lesions in the background pancreas of cases of PDAC concomitant with IPMN (1.86/cm) was higher than that of cases of PDAC without IPMN (0.91/cm) (P = 0.0007).
CONCLUSIONS:
Concomitant IPMN in PDAC is an independent predictive factor for the development of new PDAC in remnant pancreas. Cancer susceptibility of remnant pancreas after resection for PDAC concomitant with IPMN is probably due to an increased density of pancreatic intraepithelial neoplasia lesions.
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119. Koikawa K, Ohuchida K, Ando Y, Kibe S, Nakayama H, Takesue S, Endo S, Abe T, Okumura T, Iwamoto C, Moriyama T, Nakata K, Miyasaka Y, Ohtsuka T, Nagai E, Mizumoto K, Hashizume M, Nakamura M, Basement membrane destruction by pancreatic stellate cells leads to local invasion in pancreatic ductal adenocarcinoma, Cancer Letters, 10.1016/j.canlet.2018.03.031 , 1, 425, 65-77, 2018.04, Stroma invasion is an important step in pancreatic cancer progression. However, how pancreatic ductal adenocarcinoma (PDAC) with ductal structure invades the surrounding stroma has not been clear. Here, we elucidated the mechanism of stromal invasion of PDAC, using organoids. From resected PDAC specimens, we established human PDAC organoids, which developed ductal and basement membrane (BM) structures. When the organoids were co-cultured with pancreatic stellate cells (PSCs) in a collagen matrix, organoids lost their BM and ductal structures, and invaded collagen matrix more frequently than did mono-cultured organoids. Interestingly, direct contact by PSCs to PDAC organoids was observed before BM destruction. Matrix metalloproteinase (MMP) 2 or membrane type-1 MMP (MT1MMP) knockdown in PSCs significantly attenuated BM destruction by PSCs, and retained the ductal structures in organoids. Our results imply that direct contact by PSCs induces BM destruct
ion and stromal invasion of PDAC via MMP2 which binds to MT1MMP on PSCs..
120. Sadakari Y, Nagai S, Velasquez VV, Nagayoshi K, Fujita H, Ohuchida K, Manabe T, Ohtsuka T, Nakamura M, Application of ultrasonography to high-tie and low-tie vascular ligation of the inferior mesenteric artery in laparoscopic colorectal cancer surgery: technical notes., Surgical Endoscopy, 10.1007/s00464-018-6302-1, 33, 1, 309-314, 2018.04, Abstract
BACKGROUND:
Two ligation techniques can be applied in laparoscopy for left-sided colorectal cancer: (1) high-tie (HT), transection at the level of the inferior mesenteric artery (IMA); and (2) low-tie (LT), transection below the IMA, at the level of superior rectal artery (SRA), preserving the left colic artery (LCA). However, even with preoperative images, it can still be a challenge to identify these structures due to intraoperative individual conditions. In this study, we assess the use intraoperative ultrasonography (IOUS) to aid us in identifying the IMA and its branches to the SRA, LCA, and sigmoid artery.
METHODS:
We performed IOUS in 18 patients diagnosed with left-sided colorectal cancer. Preoperatively, a three-dimensional computed tomography (3D-CT) angiography was obtained in majority of the patients, to visualize the IMA and its branches. Two patients were contraindicated to receive a contrast study, hence, was unable to undergo 3D-CT angiography. The resected specimen was grossly examined for the study. The bifurcation types were identified and compared using different modalities: preoperative 3D-CT, IOUS, and gross examination of the resected specimen.
RESULTS:
The branching of the IMA revealed by IOUS was consistent to the findings preoperatively by the 3D-CT and postoperatively by the resected specimen. The IOUS result of the two patients without preoperative 3D-CT evaluation was also consistent with the post-operative bifurcation type.
CONCLUSIONS:
IOUS is an easy and feasible modality which aids in detecting the branching of the IMA during LT and HT ligation in laparoscopic left-sided colorectal surgery. It can serve as an adjunct modality for 3D-CT angiography and can also be considered a safe alternative option for cases wherein 3D-CT angiography is unavailable
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121. Okumura T, Ohuchida K, Kibe S, Iwamoto C, Ando Y, Takesue S, Nakayama H, Abe T, Endo S, Koikawa K, Sada M, Horioka K, Mochidome N, Arita M, Moriyama T, Nakata K, Miyasaka Y, Ohtsuka T, Mizumoto K, Oda Y, Hashizume M, Nakamura M, Adipose tissue-derived stromal cells are sources of cancer-associated fibroblasts and enhance tumor progression by dense collagen matrix, Int J Cancer., 10.1002/ijc.31775 , 144, 6, 1401-1413, 2018.04, Abstract
Although recent studies revealed that adipose tissue accelerates pancreatic tumor progression with excessive extracellular matrix, key players for desmoplasia in the adipose microenvironment remains unknown. Here, we investigated the roles of adipose tissue-derived stromal cells (ASCs) in desmoplastic lesions and tumor progression by in vitro and in vivo experiments. In a three-dimensional (3-D) organotypic fat invasion model using visceral fat from CAG-EGFP mice, GFP-positive fibroblastic cells infiltrated toward cancer cells. When tumor cells were inoculated into transplanted visceral fat pads in vivo, tumor weights and stromal components were enhanced compared to subcutaneous and orthotopic tumor cells inoculated without fat pads. Expression of αSMA in established human ASCs was lower compared to cancer associated fibroblasts, and the 3-D collagen matrices produced by ASCs cultured in cancer cell-conditioned medium changed from loose to dense structures that affected the motility of cancer cells. Microarray analyses revealed upregulation of S100A4 in ASCs, while S100A4-positive stromal cells were observed at extrapancreatic invasion sites of human pancreatic cancer. The present findings indicate that ASCs are recruited to extrapancreatic invasion sites and produce dense collagen matrices that lead to enhanced tumor progression. Both inhibition of ASCs recruitment and activation could lead to a novel antistromal therapy.
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122. Hiroshi Kurahara, Hiroyuki Shinchi, Takao Ohtsuka, Yoshihiro Miyasaka, Taketo Matsunaga, Hirokazu Noshiro, Tomohiko Adachi, Susumu Eguchi, Naoya Imamura, Atsushi Nanashima, Kazuhiko Sakamoto, Hiroaki Nagano, Masayuki Ohta, Masafumi Inomata, Akira Chikamoto, Hideo Baba, Yusuke Watanabe, Kazuyoshi Nishihara, Masafumi Yasunaga, Koji Okuda, Shoji Natsugoe, Masafumi Nakamura, Significance of neoadjuvant therapy for borderline resectable pancreatic cancer: a multicenter retrospective study, Langenbecks Arch Surg, 10.1007/s00423-019-01754-5, 404, 2, 167-174, 2019.04, Abstract
PURPOSE:
Neoadjuvant therapy (NAT) is increasingly used to improve the prognosis of patients with borderline resectable pancreatic cancer (BRPC) albeit with little evidence of its advantage over upfront surgical resection. We analyzed the prognostic impact of NAT on patients with BRPC in a multicenter retrospective study.
METHODS:
Medical data of 165 consecutive patients who underwent treatment for BRPC between January 2010 and December 2014 were collected from ten institutions. We defined BRPC according to the National Comprehensive Cancer Network guidelines, and subclassified patients according to venous invasion alone (BR-PV) and arterial invasion (BR-A).
RESULTS:
The rates of NAT administration and resection were 35% and 79%, respectively. There were no significant differences in resection rates and prognoses between patients in the BR-PV and BR-A subgroups. NAT did not have a significant impact on prognosis according to intention-to-treat analysis. However, in patients who underwent surgical resection, NAT was independently associated with longer overall survival (OS). The median OS of patients who underwent resection after NAT (53.7 months) was significantly longer than that of patients who underwent upfront (17.8 months) or no resection (14.9 months). The rates of superior mesenteric or portal vein invasion, lymphatic invasion, venous invasion, and lymph node metastasis were significantly lower in patients who underwent resection after NAT than in those who underwent upfront resection despite similar baseline clinical profiles.
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123. Nakamura S, Sadakari Y, Ohtsuka T, Okayama T, Nakashima Y, Gotoh Y, Saeki K, Mori Y, Nakata K, Miyasaka Y, Onishi H, Oda Y, Goggins M, Nakamura M, Pancreatic Juice Exosomal MicroRNAs as Biomarkers for Detection of Pancreatic Ductal Adenocarcinoma, Annals Surgical Oncology, 10.1245/s10434-019-07269-z, 2019.04, Abstract
BACKGROUND:
Pancreatic ductal adenocarcinoma (PDAC) is a lethal neoplasm because of difficulties in early detection. Several studies have recently suggested that exosomes may have potential as novel biomarkers. This study aimed to isolate exosomes from pancreatic juice and to investigate whether exosomal microRNAs (ex-miRs) could be used as biomarkers for PDAC.
METHODS:
Pancreatic juice was collected from patients with PDAC and chronic pancreatitis (CP) by endoscopic retrograde pancreatography. Exosomes were extracted by ultracentrifugation. The presence of exosomes was confirmed by electron microscopy and Western blotting using anti-CD63, -CD81, and -TSG101 antibodies. Relative levels of ex-miR-21 and ex-miR-155 were quantified and compared between PDAC and CP patients.
RESULTS:
A total of 35 pancreatic juice samples (27 PDAC and 8 CP) were collected. Relative levels of both ex-miR-21 and ex-miR-155 were significantly higher in PDAC patients compared with CP patients (p < 0.001 and p = 0.008, respectively). By contrast, no significant difference was apparent in relative levels of miR-21 and miR-155 in whole pancreatic juice from PDAC patients compared with CP patients (p = 0.08 and p = 0.61, respectively). Ex-miR-21 and ex-miR-155 levels discriminated PDAC patients from CP patients with area under the curve values of 0.90 and 0.89, respectively. The accuracies of ex-miR-21 levels, ex-miR-155 levels, and pancreatic juice cytology were 83%, 89%, and 74%, respectively. When combining the results of ex-miR profiling with pancreatic juice cytology, the accuracy was improved to 91%.
CONCLUSIONS:
We successfully extracted exosomes from pancreatic juice. Ex-miRs, including ex-miR-21 and ex-miR-155, in pancreatic juice may be developed as biomarkers for PDAC
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124. Yoshihiro Miyasaka, Takao Ohtsuka, Ryuichiro Kimura, Ryota Matsuda, Yasuhisa Mori, Kohei Nakata, Daisuke Kakihara, Nao Fujimori, Takamasa Ohno, Yoshinao Oda, Masafumi Nakamura, Neoadjuvant Chemotherapy with Gemcitabine Plus Nab-Paclitaxel for Borderline Resectable Pancreatic Cancer Potentially Improves Survival and Facilitates Surgery, Ann Surg Oncol, 26, 5, 1528-1534, 2019.04.
125. Nakashima Y, Ohtsuka T, Nakamura S, Mori Y, Nakata K, Miyasaka Y, Ishigami K, Matsuda R, Oda Y, Nakamura M, Clinicopathological characteristics of non-functioning cystic pancreatic neuroendocrine tumors, Pancreatology, 10.1016/j.pan.2018.11.010, 19, 1, 50-56, 2019.04, Abstract
BACKGROUND/OBJECTIVES:
The biological features of cystic pancreatic neuroendocrine tumors (PNETs) remain unclear. The aim of this study was to clarify the clinicopathological characteristics of non-functioning PNETs (NF-PNETs) with a cystic component.
METHODS:
The medical records of 75 patients with NF-PNETs who had undergone resection in our institution were retrospectively reviewed. Clinicopathological factors were compared between PNETs with and without a cystic component. Expression of somatostatin 2 receptor (SSTR-2) was also analyzed.
RESULTS:
Cystic PNETs were diagnosed in 14 patients (19%). The proportion of men was significantly higher for cystic than solid PNETs (79% vs. 44%, P < 0.05) and cystic PNETs were significantly larger than solid PNETs (25 mm vs. 17 mm, P < 0.01). However, there were no significant differences in the prevalence of lymph node metastases (14% vs. 10%, P = 0.64), hepatic metastasis (7% vs. 3%, P = 0.54), or disease-free survival rate (both 86%, P = 0.29) between PNETs with and without a cystic component. SSTR-2 expression was more frequently observed in PNETs with a cystic component than in those without (100% vs. 70%, P < 0.01).
CONCLUSIONS:
Although cystic PNETs were larger upon diagnosis than solid PNETs in this study, prognosis after surgical resection did not differ significantly between these types of PNET. Somatostatin receptor scintigraphy and somatostatin analogues may be more useful for diagnosing and treating cystic PNETs, respectively.
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126. Ohtsuka T, Chijiiwa K, Yamaguchi K, Akashi Y, Matsunaga H, Miyoshi A, Posterior hepatic duct injury during laparoscopic cholecystectomy finally necessitating hepatic resection:Case report., JSLS, 3, 4, 323-326, 1999.04, A case of bile duct injury during laparoscopic cholecystectomy finally necessitating right hepatic lobectomy is reported to re-emphasize the importance of preoperative and intraoperative assessment of the biliary tree. A 47-year-old Japanese woman underwent laparoscopic cholecystectomy for cholecystolithiasis. On postoperative day 5, fever and right hypochondralgia developed, and CT revealed fluid collection at the right hypochondrium. Percutaneous drainage was performed, and subsequent fistulography revealed a communication of the cystic cavity with the right posterior bile duct, which suggested injury of the aberrant hepatic duct. Conservative therapy, including the adaptation of fibrin glue, was performed, but closure of the fistula and cavity was not obtainable. Finally, a right hepatic lobectomy was performed four months after cholecystectomy. In this case, endoscopic retrograde cholangiopancreatography was unsuccessful preoperatively, and intraoperative cholangiography was not done. This case report re-emphasizes that the preoperative and intraoperative examination of the biliary tree is mandatory to avoid bile duct injury. ".
127. Ohtsuka T, Kodama K, Nishikata F, Okada K, Nakano R, Iwata Y, Mucosa-associated lymphoid tissue lymphoma of the duodenum forming multiple polypoid lesions., Jpn. J. Surg., 29, 6, 557-559, 1999.04, We report herein the case of a patient found to have mucosa-associated lymphoid tissue (MALT) lymphoma of the duodenum forming multiple polypoid lesions. Endoscopic examination revealed multiple small nodules with a yellow-white, rough surface in the duodenal bulb. Histopathological and immunological findings subsequently suggested low-grade B-cell MALT lymphoma. Cytologically, MALT lymphoma is similar to multiple lymphomatous polyposis (MLP); however, this case, which involved multiple polypoid lesions, was confirmed not to be MLP. ".
128. Maosheng D, Ohtsuka T, Ohuchida J, Inoue K, Yokohata K, Yamaguchi K, Chijiiwa K, Tanaka M, Surgical bypass versus metallic stent for unresectable pancreatic cancer, J. Hepatobiliary Pancreat. Surg., 8, 4, 367-373, 2001.04, With the development of interventional radiology and endoscopy, the practice of inserting expandable metallic stents for malignant jaundice has become widespread. Many studies have compared surgical bypass with polyethylene stents, or metallic stents with polyethylene stents. However, few data are available on the comparison of surgical bypass and metallic stents. The aim of this study was to compare the patient's postprocedure course and the cost performance of surgical bypass and metallic stents in patients with unresectable pancreatic cancer. The parameters analyzed were the rates of procedural and therapeutic success, duration of hospital stay, prevalence of early and late complications, cost performance, and prognosis. The rates of procedural and therapeutic success were excellent with both palliative treatments. With surgical bypass, there was a low prevalence of late complications, but duodenal obstruction sometimes occurred in patients without gastric bypass. With metallic stents, there was shorter hospitalization and lower cost, but a higher prevalence of late complications. Stent occlusion tended to occur in patients with uncovered metallic stents. There was no difference in the prognosis between the two palliative treatments. Thus, in consideration of the poor prognosis of pancreatic cancer, in patients with unresectable pancreatic cancer, insertion of covered metallic stents would be preferable to surgical bypass, because of the subsequent short hospitalization and the low cost. On the other hand, in patients with a relatively long expected prognosis, or in those with existing duodenal obstruction, biliary bypass with gastrojejunostomy may provide an advantage..
129. Ohtsuka T, Yamaguchi K, Chijiiwa K, Kinukawa N, Tanaka M, Quality of life after pylorus-preserving pancreatoduodenectomy, Am. J. Surg., 182, 3, 230-236, 2001.04, BACKGROUND: With increasing numbers of long-term survivors after pylorus-preserving pancreatoduodenectomy (PPPD), postoperative quality of life (QOL) has become a great concern. However, few reports are available on data of the postoperative changes in QOL after PPPD. METHODS:A total of 20 patients were studied regarding QOL before and at short term (within 2 months), intermediate term (6 months), and long term (1 year) after PPPD, using a questionnaire. The questionnaire consisted of 13 physical and 10 psychosocial items. The medical records were also reviewed to evaluate objective nutritional status. Factors predicting delayed recovery of QOL were examined at intermediate term by univariate and multivariate analyses. RESULTS: Overall and physical QOL scores returned to the preoperative level at intermediate term after PPPD, showing parallel changes with the objective nutritional status. However, the scores of psychosocial condition, which reflected the patient's mental health, remained low even at long term. QOL scores at intermediate term in patients with pancreatic carcinoma were significantly lower than those with other diseases. Univariate analysis showed that preoperative body weight loss, impaired preoperative pancreatic exocrine function, long operative time, intraoperative radiotherapy, pancreatic carcinoma, and postoperative diarrhea were factors predicting the delayed recovery of QOL. Multivariate analysis revealed that preoperative pancreatic exocrine function significantly affected the delayed recovery of QOL. CONCLUSIONS: Preoperative supplement of pancreatic enzymes together with perioperative mental care would improve QOL at long term after PPPD..
130. Ohtsuka T, Yamaguchi K, Chijiiwa K, Tanaka M, Postoperative pancreatic exocrine function influences body weight maintenance after pylorus-preserving pancreatoduodenectomy, Am. J. Surg., 182, 5, 524-529, 2001.04, BACKGROUND: Most patients who undergo pylorus-preserving pancreatoduodenectomy (PPPD) are able to gain their weight postoperatively. However, sometimes patients experience a lack of weight gain even at long term after PPPD. The aim of this study was to examine factors influencing a body weight change after PPPD. METHODS: In 34 Japanese patients with PPPD, 28 clinical parameters were assessed as possible factors affecting body weight maintenance at long term (1 year) after the operation by univariate and multivariate analyses. RESULTS: Univariate analysis showed that long operation time (P = 0.02), extended retroperitoneal lymph node dissection (P = 0.0005), intraoperative radiotherapy (P = 0.02), adjuvant postoperative chemotherapy (P = 0.02), histopathological diagnosis of pancreatic cancer (P = 0.02), postoperative ulceration (P = 0.007), and insufficient postoperative pancreatic exocrine function (P = 0.002) were significantly related with the lack of weight gain at long term after PPPD. Multivariate analysis regarding the seven profound factors revealed that the insufficient postoperative pancreatic exocrine function significantly affected the lack of weight gain after PPPD. The use of ordinary amount of pancreatic exocrine enzymes did not influence the weight gain after PPPD (P = 0.23). CONCLUSIONS: In patients refractory to an ordinary amount of medicine, a large dosage of enzymes may be necessary to gain weight after PPPD..
131. Yamaguchi K, Kishinaka M, Nagai E, Nakano K, Ohtsuka T, Chijiiwa K, Tanaka M, Pancreatoduodenectomy for pancreatic head carcinoma with or without pylorus preservation , Hepatogastroenterology., 48, 41, 1479-1485, 2001.04, BACKGROUND/AIMS: With the concept of less invasive surgery, PpPD (pylorus-preserving pancreatoduodenectomy) has taken the place of conventional Whipple pancreatoduodenectomy (Whipple) as a standard operation for pancreatic head carcinoma. The aim of this paper is to compare early and late postoperative results of PpPD and Whipple for pancreatic head carcinoma. METHODOLOGY: Postoperative clinical follow-up data and outcome of 50 Japanese patients with pancreatic head carcinoma who underwent pancreatoduodenectomy with or without pylorus preservation were reviewed to scrutinize the demerits and merits of the pylorus preservation. RESULTS: Preoperative and postoperative serum chemistry was not different between the two groups. Mean operation time of the Whipple group was 517 minutes, which was significantly shorter than 624 minutes of the PpPD group (P = 0.0006). Cumulative stage was not different between the two groups. Cumulative curability of the PpPD group was superior to the Whipple group; of the 27 patients with Whipple, A in 4, B in 5 and C in 18, while of the 23 patients with PpPD, A in 12, B in 2 and C in 9 (P = 0.0182). Gastric tube was removed on POD 6.0 in the Whipple group, while on POD 39 in the PpPD group (P < 0.0001). Oral intake was started on POD 14.0 in the Whipple group, while on POD 28.3 in the PpPD group (P = 0.0018). Discharge was on POD 57.8 in the Whipple group, while POD 86.9 in the PpPD group (P = 0.0023). At the time of discharge and postoperative 6, 12, and 18 months, body weight loss from the preoperative level was 1kg smaller in the PpPD group than in the Whipple group. 1-year and 3-year survival rates of the Whipple group was 53.8% and 15.8%, while 62.8% and 19.6% of the PpPD group, showing no significant difference. CONCLUSIONS: These data show that delayed gastric emptying is evident in the PpPD group, resulting in longer hospital stay, while long-term body weight loss is smaller in this group. The clinical outcome is similar between the two groups. PpPD can be accepted as a standard operation for pancreatic head carcinoma..
132. Ohtsuka T, Tanaka M, Inoue K, Nabae T, Takahata S, Yokohata K, Yamaguchi K, Chijiiwa K, Ideda S, Is peripapillary choledochoduodenal fistula an indication for endoscopic sphincterotomy?, Gastrointest. Endosc., 53, 3, 313-317, 2001.04, BACKGROUND: Most patients with a peripapillary choledochoduodenal fistula undergo fistulotomy by endoscopic sphincterotomy for the treatment of bile duct stones. However, whether sphincterotomy should be performed in patients with the fistula but without stones is controversial. METHODS: Among 165 patients in whom a benign peripapillary choledochoduodenal fistula was diagnosed at ERCP, the clinical outcome was retrospectively analyzed and compared between those who underwent fistulotomy by endoscopic sphincterotomy (group 1) and those whose fistula was left untreated (group 2). All patients with hepatolithiasis, residual stones, biliary diversion, or transduodenal papilloplasty were excluded (32, leaving 133). Fistulas were divided into types I and II according to the location of the fistula (Ikeda classification). RESULTS: Follow-up data collected during a median period of 124 months were available for 127 of 133 patients (95%), 76 in group 1 and 53 in group 2. Late complications were bile duct stone recurrence (17 patients), acute cholangitis (7 patients), and biliary carcinoma (2 patients). The incidence of stone recurrence was not significantly different between the 2 groups (p = 0.1). In group 2, 4 patients (8%) with an untreated type II fistula had 1 to 3 episodes of presumed reflux cholangitis, which resolved quickly with conservative treatment. CONCLUSIONS: Endoscopic sphincterotomy is not always necessary for peripapillary choledochoduodenal fistulas if bile duct stones are absent because reflux cholangitis is a relatively rare complication that can be easily managed. ".
133. Ohtsuka T, Inoue K, Ohuchida J, Nabae T, Takahata S, Niiyama H, Yokohata K, Ogawa Y, Yamaguchi K, Chijiiwa K, Tanaka M, Carcinoma arising in choledochocele, Endoscopy, 33, 7, 614-619, 2001.04, BACKGROUND AND STUDY AIMS: Choledochocele has a potential for carcinogenesis, but no report has described malignant changes of the choledochocele in relation to pancreaticobiliary reflux because its anatomic form does not fit the criteria of pancreaticobiliary malunion (PBM). The aims of this study were to analyze the amylase level in bile in patients with choledochocele and to clarify whether the presence of a choledochocele predisposed to carcinoma. PATIENTS AND METHODS: Records of 2826 patients who had undergone endoscopic retrograde cholangiopancreatography between 1995 and 1999 were reviewed for the presence of choledochocele and/or periampullary carcinoma. As an evidence of pancreaticobiliary reflux, amylase activity was examined in common duct bile obtained at surgery or by endoscopy. The prevalence of periampullary carcinoma was compared between patients with and without choledochocele. RESULTS: A total of 11 patients were diagnosed as having a choledochocele. The amylase level in bile was higher in patients with choledochocele (120,922 +/- 62,269 IU/l; n = 4) than in previously examined patients with functioning gallbladders (15 +/- 24 IU/l; n = 10, P = 0.005). The prevalence of periampullary carcinoma in patients with choledochocele (27%, 3/11) was significantly higher than that in those without choledochocele (0.9%, 26/2815; P<0.0002). CONCLUSION: The bile analysis of the present study presents one possible explanation for the predisposition to carcinoma in choledochocele as bile containing amylase may stagnate in the choledochocele and then carcinoma may develop in the inner epithelium of the choledochocele by the same mechanism as that leading to carcinogenesis in patients with PBM..
134. Yamaguchi K, Ohuchida J, Ohtsuka T, Nakano K, Tanaka M, Intraductal papillary-mucinous tumor of the pancreas concomitant with ductal carcinoma of the pancreas, Pancreatology, 2, 5, 484-490, 2002.04, BACKGROUND: Despite the recent progress of diagnostic and therapeutic modalities, the clinical course of patients with ductal carcinoma (DC) of the pancreas remains dismal. Intraductal papillary-mucinous tumor of the pancreas (IPMT) is sometimes accompanied by malignant diseases of the other organs and pancreatic adenocarcinoma. Thus, IPMT may be a potential diagnostic clue to DC of the pancreas at early phase. METHODS: Clinicopathologic findings of 7 Japanese patients with IPMT of the pancreas concomitant with independent DC were examined and compared with those of 69 patients with IPMT alone and of 70 with DC alone. RESULTS: The seven patients corresponded to 9.2% of 76 patients with IPMT and 9.1% of 77 patients with DC. The seven male patients ranged from 55 to 75 years with a mean of 64.3. DC was synchronous with IPMT in five patients, metachronous to IPMT (4 years after IPMT) in one, and synchronous with IPMT and metachronous to IPMT and DC (7 years after IPMT) in the other. In 4 patients, the presence of IPMT led to the diagnosis of DC. All the 7 IPMTs were of branch type with a mean diameter of 3.0 cm. The IPMT was located in the head of the pancreas in 3, body in 2 and tail in the other 2. All the 7 IPMTs were adenoma with mild dysplasia. Two of the 7 patients with DC had in situ carcinoma, 1 minimally invasive carcinoma and the remaining 4 invasive carcinoma. The mean diameter of seven DCs (3.0 cm) with IPMT were smaller than that of 70 DCs (3.6 cm) (8P = 0.0295). Stage (stage I/II/III/IV = 3/0/3/1) of the seven DCs concomitant with IPMT were significantly earlier than that (stage I/II/III/IV = 5/6/28/31) of the other 70 (p = 0.0203). The survival curve of the 7 patients with IPMT and DC was significantly better than that of the 70 with DC alone (p = 0.0460). CONCLUSIONS: Clinicians should pay attention to the possible presence of DC of the pancreas in male patients with intraductal papillary-mucinous adenoma of the pancreas of branch type in their 6th to 8th decades. Copyright 2002 S. Karger AG, Basel and IAP.
135. Ohtsuka T, Takahata S, Ohuchida J, Takeda T, Matsunaga H, Yokohata K, Yamaguchi K, Chijiiwa K, Tanaka M, Gastric phase 3 motility after pylorus-preserving pancreatoduodenectomy, Ann. Surg., 235, 3, 417-423, 2002.04, OBJECTIVE: To analyze factors affecting the recovery course of phase 3 activity of the gastric migrating motor complex after pylorus-preserving pancreatoduodenectomy (PPPD) and investigate effects of the recovery of gastric phase 3 on gastric emptying after feeding. SUMMARY BACKGROUND DATA: Whether early recovery of gastric phase 3 during fasting would predict early recovery of the fed-state gastric emptying function after PPPD has not been well documented. METHODS: Manometric recording from the gastric antrum was repeated at a weekly interval until the first appearance of gastric phase 3 in 57 patients after PPPD. Twenty-three clinical parameters were assessed as possible factors affecting the recovery course of gastric phase 3 by simple and multiple regression analyses. A gastric emptying study after feeding of a test meal was performed by the acetaminophen method and the values were compared between patients with and without gastric phase 3 after PPPD. RESULTS: The mean period before the first appearance of gastric phase 3 was 38 days. Among 23 parameters, only lymph node dissection along the hepatoduodenal ligament significantly delayed recovery of gastric phase 3 after PPPD by univariate and multivariate analyses. The presence or absence of gastric phase 3 in the early postoperative period did not influence gastric emptying after feeding in the intermediate period after PPPD. CONCLUSIONS: Avoiding lymph node dissection along the hepatoduodenal ligament, if applicable, may contribute to early recovery of gastric phase 3 after PPPD. The recovery state of gastric phase 3 during fasting, however, is not necessarily consistent with the degree of improvement of gastric emptying after feeding..
136. Ohtsuka T, Yamaguchi K, Chijiiwa K, Tanaka M, Effect of gastrointestinal reconstruction on quality of life and nutritional status after pylorus-preserving pancreatoduodenectomy., Dig. Dis. Sci., 47, 6, 1241-1247, 2002.04, A total of 31 Japanese patients who underwent pylorus-preserving pancreatoduodenectomy from January 1998 through September 2000 were studied regarding quality of life and nutritional status before and within two months (short term) and six months to one year (long term) after surgery. Quality of life was estimated using a questionnaire consisting of 23 items (13 physical and 10 psychosocial domains). Nutritional status was assessed by body weight, hemoglobin concentration, serum concentration of albumin and cholesterol, and pancreatic function. These data were compared between 18 patients with end-to-end (Imanaga) and 13 with end-to-side (Traverso) gastrointestinal reconstruction. In both groups, physical quality of life scores dropped at short term, and then returned to the normal level at long term after operation, showing mostly parallel changes with the parameters of nutritional status. However, the scores of psychosocial conditions, which reflected the patient's mental health, remained low even at long term in both groups. The values of these parameters showed no statistical difference between the two groups at each time point. Postoperative quality of life and nutritional status were not different between Imanaga and Traverso reconstructions after pylorus-preserving pancreatoduodenectomy and mental health care would be necessary for at least one year after operation in both groups..
137. Takahata S, Ohtsuka T, Nabae T, Matsunaga H, Yokohata K, Yamaguchi K, Chijiiwa K, Tanaka M, Comparison of recovery of gastric phase III motility and gastric juice output after different types of gastrointestinal reconstruction following pylorus-preserving pancreatoduodenectomy., J Gastroenterol. , 37, 8, 596-603, 2002.04, BACKGROUND: Early gastric stasis is a frequent complication of pylorus-preserving pancreatoduodenectomy (PPPD). However, few reports have addressed this phenomenon in relation to the type of gastrointestinal reconstruction. We compared gastrointestinal motility and gastric juice output after two different types of gastrointestinal reconstruction following PPPD, end-to-side duodenojejunostomy after pancreaticojejunostomy and hepaticojejunostomy (group 1) and end-to-end duodenojejunostomy before pancreaticojejunostomy and hepaticojejunostomy (group 2). METHOD: In a total of 25 patients, 10 in group 1 and 15 in group 2, who underwent PPPD, manometry was repeated to assess gastric and jejunal motility until the first occurrence of phase III activity of gastric cyclic motor activity (CMA). The plasma level of motilin was measured in each phase of the gastric CMA and compared between the two groups. The daily volume of gastric juice output through a gastrostomy tube was also recorded for comparison. RESULT: There was no significant difference in the time period for recovery of gastric phase III activity and gastric juice output between the two groups. However, abnormal contractions with an increased basal pressure appeared frequently in the afferent jejunal loop only in group 1. The plasma motilin level after PPPD showed no apparent cyclic change even after the recovery of gastric phase III in either group. CONCLUSION: Gastrointestinal reconstructive procedures have almost no effect on the recovery of gastric CMA. The plasma motilin concentration does not play a major role in the recovery of gastric CMA in the early postoperative period after PPPD.

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138. Ohtsuka T, Yokohata K, Inoue K, Nabae T, Takahata S, Tanabe Y, Sugitani A, Tanaka M, Biliary sphincter motility after neural isolation of the pancreatoduodenal region in conscious dogs
, Surgery, 131, 2, 139-148, 2002.04, BACKGROUND: Several neural and hormonal factors are known to affect the motility of the sphincter of Oddi. However, the precise mechanisms of the control of sphincter motility have not been completely explored. We investigated the relationship of canine biliary sphincter motility when it is extrinsically denervated by neural isolation of the pancreatoduodenal region. METHODS: Interdigestive and postprandial sphincter motility in a denervated pancreatoduodenal segment and effects of cholecystokinin-octapeptide were studied in 7 conscious dogs. Data were compared with those of 7 neurally intact control dogs. RESULTS: After extrinsic denervation of the pancreatoduodenal region, sphincter motility exerted a cyclic change in concert with the duodenal myoelectric cycles; this change involved short cyclic bursts of motor activity, which gradually increased in intensity. The increase in the cyclic bursts of motor activity was also cyclic and associated with an increase in the plasma motilin concentration. Neural isolation of the pancreatoduodenal region increased sphincter basal pressure and motility index (integral per minute). In the denervated biliary sphincter, the feeding pattern and temporary inhibitory effect of feeding, as seen in controls, were absent, which suggests the role of extrinsic nerves in delivering bile into the duodenum after feeding. In the denervated dogs, cholecystokinin-octapeptide caused excitation of the sphincter activity, instead of relaxation observed in controls. CONCLUSIONS: Extrinsic innervation to the pancreatoduodenal region has an inhibitory effect on biliary sphincter motility. Abnormalities in extrinsic innervation to the biliary sphincter might increase the resistance of the sphincter to the bile flow and induce bile stagnation.
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139. Inoue K, Ohuchida J, Ohtsuka T, Nabae T, Yokohata K, Ogawa Y, Yamaguchi K, Tanaka M, Severe localized stenosis and marked dilatation of the main pancreatic duct are indicators of pancreatic cancer instead of chronic pancreatitis on endoscopic retrograde balloon pancreatography, Gastrointest Endosc., 58, 4, 510-515, 2003.04, BACKGROUND: Differentiation between benign and malignant localized stenoses of the main pancreatic duct is difficult by pancreatography. METHODS: A total of 48 patients with such localized stenosis who underwent endoscopic retrograde balloon pancreatography with abdominal compression were retrospectively studied. The following were examined: (1) diameter of the stenotic, prestenotic, and poststenotic ductal segments; (2) ratios of prestenotic/poststenotic, stenotic/prestenotic, and stenotic/poststenotic ductal segments; (3) length of stenosis and steepness of transition to the stenosis (proximal angle, distal angle); and (4) main duct and branch findings for peristenotic segments. RESULTS: The stenosis was diagnosed as caused by chronic pancreatitis in 27 patients and pancreatic cancer in 21 by histopathology, cytology, or clinical follow-up. The prestenotic/poststenotic ductal segments ratio and proximal angle were greater in pancreatic cancer compared with chronic pancreatitis. Severe stenosis (stenotic ductal segments less than 20% of prestenotic or poststenotic ductal segments); moderate (prestenotic ductal segments 2.5 to 3.5 times larger than poststenotic ductal segments), and severe (prestenotic ductal segments more than 3.5 times larger than poststenotic ductal segments) dilatation of the proximal duct were more frequent in pancreatic cancer than in chronic pancreatitis. Multivariate regression analyses showed that severe stenosis and dilatation were independently significant parameters that indicated a diagnosis of pancreatic cancer. Various combinations of severe stenosis, proximal dilatation, and double duct sign gave high predictive values. CONCLUSIONS: Severe stenosis, marked proximal dilatation, double duct sign, and combinations of these findings are useful indicators of malignant localized stenosis of the pancreatic duct.
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140. Ohtsuka T, Ryu H, Minamishima YA, Ryo A, Lee SW, Modulation of p53 and p73 levels by cyclin G: implication of a negative feedback regulation, Oncogene, 22, 11, 1678-1687, 2003.04, Cyclin G is a transcriptional target gene of tumor suppressor p53. Recent studies present evidence that cyclin G may play a central role in the p53-Mdm2 autoregulated module, but the precise function of cyclin G remains elusive. Here, we show a negative effect of cyclin G on the stability of p53 and p73. Cyclin G expression resulted in a dramatic decrease of p53 protein levels in response to DNA damage and abrogated irradiation-mediated G1 arrest along with an increase of S phase in MCF7 cells containing wild-type p53. In p53-null Saos2 cells, cyclin G inhibited p73 induction in response to genotoxic stress and delayed the camptothecin-mediated cell cycle arrest. Cyclin G interacts with p53 as well as p73, and its binding to p53 or p73 presumably mediates downregulation of p53 and p73. We also found that cyclin G-mediated reduction of p53 but not of p73 is Mdm2-dependent. Moreover, inhibition of cyclin G by small interfering RNA (siRNA) caused the accumulation of p53 and p73 protein levels in response to DNA damage. Therefore, our results imply that cyclin G is transcriptionally activated by p53 or p73, and, in turn, cyclin G negatively regulates the stabilization of p53 family proteins through an unknown mechanism different from ubiquitination or transcriptional control.
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141. Ohtsuka T, Yamaguchi K, Ohuchida J, Inoue K, Nagai E, Chijiiwa K, Tanaka M, Comparison of quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection.

, Hepatogastroenterology, 50, 51, 846-850, 2003.04, BACKGROUND/AIMS: There have been many supportive data that the postoperative changes in nutritional status are more favorable after pylorus-preserving pancreatoduodenectomy than after Whipple resection; however, few reports are available on the postoperative changes in subjective quality of life after pancreatoduodenectomy. The aim of this study was to compare the postoperative change in quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection. METHODOLOGY: A total of 36 patients (31 with pylorus-preserving pancreatoduodenectomy and five with Whipple resection) were studied regarding quality of life before and at short term (within two months) and at long term (six months to one year) after surgery, using a questionnaire. The questionnaire consisted of 13 physical and 10 psychosocial items. The medical records were also reviewed to evaluate their objective nutritional status. Postoperative changes in quality of life and nutritional status were compared between the pylorus-preserving pancreatoduodenectomy and Whipple groups. RESULTS: Overall and physical quality of life scores dropped at short term and then recovered at long term in the pylorus-preserving pancreatoduodenectomy group, but showed a persistently low value even at long term in the Whipple group. The change in physical quality of life showed almost parallel changes with the nutritional status in both groups. However, the scores of psychosocial quality of life, which reflected the patient's mental status, remained low even at long term in both pylorus-preserving pancreatoduodenectomy and Whipple groups. CONCLUSIONS: Quality of life is more favorable after pylorus-preserving pancreatoduodenectomy than after Whipple resection, but long-standing mental health care is necessary in patients with pyloruspreserving pancreatoduodenectomy and Whipple resection..
142. Aglipay JA, Lee SW, Okada S, Fujiuchi N, Ohtsuka T, Kwak JC, Wang Y, Johnstone RW, Deng C, Qin J, Ouchi T, A member of the Pyrin family, IFI16, is a novel BRCA1-associated protein involved in the p53-mediated apoptosis pathway, Oncogene, 22, 55, 8931-8938, 2003.04, We identified IFI16 as a BRCA1-associated protein involved in p53-mediated apoptosis. IFI16 contains the Pyrin/PAAD/DAPIN domain, commonly found in cell death-associated proteins. BRCA1 (aa 502-802) interacted with the IFI16 Pyrin domain (aa 1-130). We found that IFI16 was localized in the nucleoplasm and nucleoli. Clear nucleolar IFI16 localization was not observed in HCC1937 BRCA1 mutant cells, but reintroduction of wild-type BRCA1 restored IFI16 nuclear relocalization following IR (ionizing radiation). Coexpression of IFI16 and BRCA1 enhanced DNA damage-induced apoptosis in mouse embryonic fibroblasts from BRCA1 mutant mice expressing wild-type p53, although mutant IFI16 deficient in binding to BRCA1 did not induce apoptosis. Furthermore, tetracycline-induced IFI16 collaborated in inducing apoptosis when adenovirus p53 was expressed in DNA-damaged p53-deficient EJ cells. These results indicate a BRCA1-IFI16 role in p53-mediated transmission of DNA damage signals and apoptosis.
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143. Ohtsuka T, Jensen MR, Kim HG, Kim KT, Lee SW, The negative role of cyclin G in ATM-dependent p53 activation, Oncogene, 23, 31, 5405-5408, 2004.04, Cyclin G is one of the earliest p53 target genes to be identified, but its function in the p53 pathway has been elusive. Although the precise mechanisms of cyclin G in this novel network have not been explored, recent studies have demonstrated that cyclin G is a key regulator of the p53-Mdm2 network. Here we present evidence that cyclin G-mediated p53 regulation is dependent upon the status of ataxia-telangiectasia mutated (ATM) protein, which activates p53 in response to DNA damage. Abrogation of cyclin G enhances p53 accumulation and phosphorylation of p53 at the Ser-15 residue, resulting in cell cycle arrest. Ectopically expressed cyclin G significantly reduces the steady-state levels of p53 as well as that of phosphorylated p53 at Ser-15 after DNA damage in normal human dermal fibroblasts containing normal ATM. However, cyclin G does not cause similar reductions in p53 levels in ATM-mutated cells. We also show that translocation of cyclin G to the nucleus requires functional ATM. Thus, our findings identify a new role of cyclin G in ATM-dependent p53 regulation and in cell cycle regulation during DNA damage.

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144. Fujiuchi N, Aglipay JA, Ohtsuka T, Maehara N, Sahin F, Su GH, Lee SW, Ouchi T, Requirement of IFI16 for the maximal activation of p53 induced by ionizing radiation, J Biol Chem, 279, 17, 20339-20344, 2004.04, IFI16 is a member of the PYRIN superfamily that has been implicated in BRCA1-mediated apoptosis and inflammation signaling pathways. Here we report that most breast cancer cell lines examined expressed decreased mRNA and protein levels of IFI16, although IFI16 is expressed in human primary normal mammary epithelial cells. Significantly, immunohistochemical analysis of tissues from 25 breast cancer patients demonstrated that carcinoma cells showed negative or weaker staining of IFI16 compared with positive nuclear staining in normal mammary duct epithelium. si-RNA-mediated reduction of IFI16 resulted in perturbation of p53 activation when treated with ionizing radiation (IR). Expression of IFI16 enhanced p53 transcriptional activity in cells exposed to IR. Adenovirus expression of IFI16 in IFI16-deficient MCF7 induced apoptosis, which was enhanced by radiomimetic neocarcinostatin treatment. Tetracycline-regulated IFI16 also induced apoptosis when coexpressed with p53 in p53-deficient EJ cells subjected to IR, suggesting that IFI16 is involved in p53-mediated transmission of apoptosis signaling. Consistent with these results, expression of IFI16 enhanced activation of the known p53 target genes, including p21, Hdm2, and bax in MCF7 cells. These results suggest that loss of IFI16 results in deregulation of p53-mediated apoptosis, leading to cancer development.

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145. Ohtsuka T, Ryu H, Minamishima YA, Macip S, Sagara J, Nakayama KI, Aaronson SA, Lee SW, ASC is a Bax adaptor and regulates the p53-Bax mitochondrial apoptosis pathway, Nat Cell Biol , 6, 2, 121-128, 2004.04, The apoptosis-associated speck-like protein (ASC) is an unusual adaptor protein that contains the Pyrin/PAAD death domain in addition to the CARD protein-protein interaction domain. Here, we present evidence that ASC can function as an adaptor molecule for Bax and regulate a p53-Bax mitochondrial pathway of apoptosis. When ectopically expressed, ASC interacted directly with Bax, colocalized with Bax to the mitochondria, induced cytochrome c release with a significant reduction of mitochondrial membrane potential and resulted in the activation of caspase-9, -2 and -3. The rapid induction of apoptosis by ASC was not observed in Bax-deficient cells. We also show that induction of ASC after exposure to genotoxic stress is dependent on p53. Blocking of endogenous ASC expression by small-interfering RNA (siRNA) reduced the apoptotic response and inhibited translocation of Bax to mitochondria in response to p53 or genotoxic insult, suggesting that ASC is required to translocate Bax to the mitochondria. Our findings demonstrate that ASC has an essential role in the intrinsic mitochondrial pathway of apoptosis through a p53-Bax network.
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146. Ide T, Kitajima Y, Miyoshi A, Ohtsuka T, Mitsuno M, Ohtaka K, Koga Y, Miyazaki K, Tumor-stromal cell interaction under hypoxia increases the invasiveness of pancreatic cancer cells through the hepatocyte growth factor c-Met pathway, Int J Cancer, 119, 12, 2750-2759, 2006.04, The hypoxic environment in tumor is reported to play an important role in pancreatic cancer progression. The interaction between stromal and cancer cells also contributes to the malignant behavior of pancreatic cancer. In the present study, we investigated whether hypoxic stimulation affects stromal as well as pancreatic cancer cells. Our findings demonstrated that hypoxia remarkably elevated the HIF-1alpha expression in both pancreatic cancer (PK8) and fibroblast cells (MRC5). Hypoxic stimulation accelerated the invasive activity of PK8 cells, and invasiveness was thus further accelerated when the hypoxic PK8 cells were cultured with conditioned medium prepared from hypoxic MRC5 cells (hypoxic conditioned medium). MMP-2, MMP-7, MT1-MMP and c-Met expressions were increased in PK8 cells under hypoxia. Hypoxic stimulation also increased the hepatocyte growth factor (HGF) secretion from MRC5 cells, which led to an elevation of c-Met phosphorylation in PK8 cells. Conversely, the elevated cancer invasion, MMP activity and c-Met phosphorylation of PK8 cells were reduced by the removal of HGF from hypoxic conditioned medium. In immunohistochemical study, the HIF-1alpha expression was observed in surrounding stromal as well as pancreatic cancer cells, thus indicating hypoxia exists in both of cancer and stromal cells. Moreover, the stromal HGF expression was found to significantly correlate with not only the stromal HIF-1alpha expression but also the c-Met expression in cancer cells. These results indicate that the hypoxic environment within stromal as well as cancer cells activates the HGF/c-Met system, thereby contributing to the aggressive invasive features of pancreatic cancer. Copyright 2006 Wiley-Liss, Inc.

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147. Ohtsuka T, Kitahara K, Matsuyama S, Shimonishi T, Nakafusa Y, Miyazaki K, Significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy, Hepatogastroenterology, 53, 71, 788-791, 2006.04, BACKGROUND/AIMS: The significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy (PD) has not been well understood. The aim of this study was to clarify this issue. METHODOLOGY: Clinical records of 60 Japanese patients who underwent PD were reviewed retrospectively. Patients were divided into two groups, normal (n=33) and low (n=27) pancreatic exocrine function, according to the preoperative value of N-benzoyl-L-tyrosyl-p-aminobenzoic acid excretion test (normal value >70%). We compared the perioperative events and nutritional status between the two groups. RESULTS: The preoperative and operative characteristics between the two groups were not significantly different. Postoperative pancreatic juice output from the remnant pancreas during the initial 7 days after PD was greater (1145 +/- 618 vs. 741 +/-612mL, P=0.02), and the prevalence of pancreatic anastomotic leakage was higher (10/23, 30% vs. 1/27, 4%, P=0.008) in the group with normal pancreatic exocrine function than that in the insufficient group. Perioperative body mass index and serum albumin concentration, which reflect the nutritional status of patients, were significantly lower in the group with low pancreatic exocrine function (P=0.007 and 0.04, respectively). CONCLUSIONS: Surgeons should pay more attention to pancreatic anastomotic leakage in patients with normal pancreatic exocrine function after PD. On the other hand, in patients with insufficient exocrine function, perioperative nutritional support should be considered.

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148. Ohtsuka T, Liu XF, Koga Y, Kitajima Y, Nakafusa Y, Ha CW, Lee SW, Miyazaki K, Methylation-induced silencing of ASC and the effect of expressed ASC on p53-mediated chemosensitivity in colorectal cancer., Oncogene , 25 , 12, 1807-1811, 2006.04, Tumor suppressor p53 is known to play a crucial role in chemosensitivity in colorectal cancer. We previously demonstrated that an apoptosis-associated speck-like protein, ASC, is a p53-target gene which regulates p53-Bax mitochondrial apoptotic pathway. ASC is also known to be a target of methylation-induced gene silencing. An inactivation of ASC might thus cause resistance to chemotherapy, and if this is the case, then the expression of ASC would restore the chemosensitivity. The aim of this study was to clarify this hypothesis. ASC was methylated in 25% of all resected specimens in patients with colorectal cancer; however, ASC methylation did not always correspond to a lack of ASC protein. When expressed in colon cancer cells, in which ASC is absent due to methylation, ASC was found to enhance the chemosensitivity in a p53-dependent manner. In p53-null cells, ASC increased the p53-mediated cell death induced by p53-expressing adenovirus infection. Our data suggest that the methylation-induced silencing of ASC might cause resistance to p53-mediated chemosensitivity in colorectal cancer. The gene introduction of ASC may thus restore such chemosensitivity, and this modality may therefore be a useful new treatment strategy for colorectal cancer.

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149. Ide T, Kitajima Y, Miyoshi A, Ohtsuka T, Mitsuno M, Ohtaka K, Miyazaki K, The hypoxic environment in tumor-stromal cells accelerates pancreatic cancer progression via the activation of paracrine hepatocyte growth factor/c-Met signaling., Ann Surg Oncol. , 14, 9, 2600-7, 2007.04, BACKGROUND: Pancreatic cancer is one of the representative solid tumors, in which the hypoxic microenvironment plays a crucial role in malignant progression. We previously demonstrated that tumor-stromal interaction under hypoxia enhances the invasiveness of pancreatic cancer cells through hepatocyte growth factor (HGF)/c-Met signaling. METHODS: We investigated the immunohistochemical expression of hypoxia inducible factor-1alpha (HIF-1alpha) c-Met, and HGF in both cancer and stromal cells using 41 pancreatic cancer tissue specimens, and tried to identify any correlations with the clinical features and survival. RESULTS: Positive staining for HIF-1alpha was observed in both pancreatic cancer and the surrounding stromal cells in more than 30% of the cases, and it significantly correlated with lymph node metastasis (P < .05). A significant correlation was observed between the expression of HIF-1alpha and HGF in stromal cells (P < .05). In addition, the c-Met expression in cancer cells was found to significantly correlate with the HGF expression in not only cancer but also stromal cells. The disease-free survival rates of the patients with HIF-1alpha in cancer, stromal, c-Met in cancer, and an HGF expression in stromal cells was significantly worse than those without such expressions (P < .05). CONCLUSIONS: These data suggest that the HGF/c-Met signaling via HIF-1alpha ?may therefore negatively affect the prognosis in patients with pancreatic cancer, and targeting tumor stroma under hypoxia might thus be potentially useful as a novel therapy for this cancer.


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150. Ohuchida J, Chijiiwa K, Ohtsuka T, Konomi H, Tanaka M, Pylorus-preserving pancreatoduodenectomy: preoperative pancreatic function and outcome., Hepatogastroenterology. , 54, 75, 913-916, 2007.04, BACKGROUND/AIMS: To investigate the effects of preoperative pancreatic function on gastric emptying, body weight, and quality of life after pylorus-preserving pancreatoduodenectomy. METHODOLOGY: Thirty-one patients who underwent pylorus-preserving pancreatoduodenectomy were divided into 2 groups according to preoperative pancreatic exocrine and endocrine function (normal vs. abnormal). Gastric emptying, body weight, and quality of life were evaluated before surgery, 1-2 months after surgery (short-term), and 6-12 months after surgery (long-term). RESULTS: Short-term body weight was significantly decreased in comparison to preoperative body weight regardless of preoperative exocrine and endocrine pancreatic function. Body weight returned to the preoperative level by 12 months after surgery in patients with normal preoperative pancreatic function but not in patients with abnormal pancreatic function. In both groups, gastric emptying was delayed at 1-2 months after surgery and then returned to the preoperative value by 12 months. Short-term quality of life did not differ from preoperative quality of life in either group, but long-term quality of life improved to beyond the preoperative level in both groups. CONCLUSIONS: Preoperative pancreatic function appears to significantly influence long-term body weight after pylorus-preserving pancreatoduodenectomy.

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151. Ide T, Kitajima Y, Miyoshi A, Ohtsuka T, Mitsuno M, Ohtaka K, Miyazaki K, HIF-1a-HGF signaling in stroma accelerates the pancreatic cancer progression via paracrine regulation., Ann Surg Oncol, 14, 9, 2600-2607, 2007.04.
152. Ohtsuka T, Kitahara K, Matsuyama S, Shimonishi T, Nakafusa Y, Miyazaki K, Comparison of the postoperative outcome after a pancreatoduodenectomy using the Billroth I and II type of reconstruction., Hepatogastroenterology , 54, 77, 1570-1574, 2007.04, BACKGROUND/AIMS: Several types of gastrointestinal reconstruction have been employed after a pancreatoduodenectomy (PD), however, it remains controversial as to which type is the most beneficial. The aim of this study was to investigate the effects of a gastrointestinal reconstruction on the postoperative outcome after PD. METHODOLOGY: The medical records of 68 patients who underwent a PD between 1994 and 2004 were retrospectively reviewed. A total of 28 patients underwent a Billroth I reconstruction while 40 had the Billroth II reconstruction. Both the occurrence of postoperative complications and the nutritional status were compared between the two groups. RESULTS: The patient age, gender, preoperative symptoms, and operation profiles were the same between the two groups. The morbidity and mortality did not differ between the two groups; however, the prevalence of leakage after a hepaticojejunostomy was higher in the Billroth II group than that in the Billroth I group (23% vs. 0%, P = 0.007). All cases of bile leakage were successfully treated by conservative therapy. The day that oral intake was resumed and the length of the hospital stay also did not differ between the two groups. Both groups showed a similar postoperative nutritional status after a PD, as assessed by body weight, the serum albumin and cholesterol concentrations, and the number of lymphocytes. CONCLUSIONS: Bile leakage tends to occur after a PD using a Billroth II reconstruction, however, this can be easily managed by conservative therapy, and it does not influence morbidity, the resumption of oral intake, or the length of hospital stay. Therefore, we could not clearly identify any advantages of one group or another in terms of postoperative complications and the nutrition status after PD. Further investigations from other points of view are therefore necessary to clarify the effect of a gastrointestinal reconstruction after PD.


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153. Ohtsuka T, Mitsuno M, Kitajima Y, Ide T, Lee SW, Miyazaki K, Role of ASC in hypoxia-mediated cell death in pancreatic cancer., Mol Med Rep , 1, 3, 827-831, 2008.04.
154. Nakafusa Y, Tanaka M, Ohtsuka T, Miyoshi A, Kohya N, Kitajima Y, Sato S, Mochinaga S, Dohi S, Miyazaki K, Phase I/II study of combination therapy with S-1 and CPT-11 for metastatic colon cancer., Mol Med Rep , 1, 3, 925-930, 2008.04.
155. Ohtsuka T, Sato S, Kitajima Y, Tanaka M, Nakafusa Y, Miyazaki K, False positive of tumor marker after curative gastrectomy for gastric cancer., Dig Dis Sci, 53, 1, 73-79, 2008.04, The objective of this study was to assess the frequency and characteristics of false-positive results for tumor markers after curative gastrectomy for gastric cancer. Carcinoembryonic antigen and/or carbohydrate antigen 19-9 were periodically assessed for 168 patients who underwent curative gastrectomy. Cancer recurrence was observed for 17 (10.1%) patients and 151 (89.9%) were disease-free during the mean follow-up period of 23.1 months after the operation. The frequency of false-positive findings for tumor markers after gastrectomy was 14.3% (24/168) for all followed-up patients. Three different patterns of marker elevation were observed in the false-positive group. A false-positive finding for these markers was observed for patients with early-stage cancer and for those with chronic benign diseases, for example bronchitis, liver dysfunction, diabetes mellitus, and renal dysfunction. For most patients with false-positive findings for a marker a spontaneous decrease in the tumor marker was observed 1-2 months after the marker was first observed at a high level after the operation. Surgeons and oncologists should therefore keep in mind the high frequency of false-positive findings for tumor markers after curative gastrectomy for gastric cancer.


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156. Ohtsuka T, Nakafusa Y, Sato S, Kitajima Y, Tanaka M, Miyazaki K, Different roles of tumor marker monitoring after curative resections of gastric and colorectal cancers., Dig Dis Sci, 53, 6, 1537-1543, 2008.04, We previously demonstrated that false-positive findings for tumor markers are frequently observed, and that the sensitivity of marker monitoring for early detection of the recurrence is low after curative resection of gastric cancer. The aim of this study was to investigate whether such characters are specific to gastric cancer. Serum carcinoembryonic antigen and/or carbohydrate antigen 19-9 were periodically assessed in 258 patients who underwent curative gastrectomy for gastric cancer (n = 161) or curative resection for colorectal cancer (n = 97). The frequency of false-positive findings for the tumor markers, the sensitivity of the marker monitoring for detection of the recurrence, and the characteristics of such cases were compared between these two cancer groups. During the median follow-up period of 30 months, recurrence developed in 14% of gastric cancer and 23% of colorectal cancer patients. A false positive with the tumor marker was frequently observed in patients after gastrectomy compared with after colorectal surgery. The sensitivity of the marker monitoring regarding early detection of recurrence was higher in patients with colorectal cancer than those with gastric cancer, especially in cases of advanced stage. As a result, the accuracy of marker monitoring for the detection of recurrence was higher in patients after the resection of colorectal cancer than that of gastric cancer. Surgeons and oncologists should thus be aware that the role of the tumor marker monitoring after a curative operation differs between patients with gastric and colorectal cancers.


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157. Ohtsuka T, Kitajima Y, Takahashi T, Sato S, Miyoshi A, Kohya N, Kitahara K, Nakafusa Y, Miyazaki K, Infectious complications after gastric cancer surgery accelerate a rapid hepatic recurrence, Hepatogastroenterology , 56, 94-95, 1277-1280, 2009.04, BACKGROUND/AIMS: Rapid hepatic recurrence is sometimes experienced after gastric or pancreatobiliary cancer surgery. The aim of this study was to investigate the risk factors for the timing of hepatic recurrence. METHODOLOGY: The medical records of 20 patients who had hepatic recurrence after either a gastrectomy for gastric cancer (11 patients) or a pancreatoduodenectomy for pancreatobiliary cancer (9 patients) between 2002 and 2007 were retrospectively reviewed. The cumulative recurrence rate of liver metastasis was calculated using the Kaplan-Meier method, and 14 possible factors affecting the rapid hepatic recurrence were analyzed by univariate and multivariate analyses. RESULTS: The median time for the hepatic recurrence after the operation was 4.9 months (range 1 to 20.4 months). Among 14 factors, only postoperative infectious complications significantly accelerated the hepatic recurrence based on a univariate analysis (p = 0.049). Two more factors, gastric cancer and preoperative tumor marker elevation, had a tendency to affect the rapid recurrence, but did not show statistical significance (both p = 0.06). A multivariate analysis revealed that postoperative infectious complications (p = 0.005) and gastric cancer (p = 0.04) were significant and independent factors. Five of 11 patients with gastric cancer suffered from postoperative infectious complications, 4 of which were associated with pancreatic leakage after a pancreatosplenectomy, and all 5 patients had hepatic recurrence within 3 months after the operation. CONCLUSIONS: Postoperative infectious complications are thus considered to accelerate a rapid hepatic recurrence after a gastrectomy for gastric cancer.

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158. Ohtsuka T, Kitahara K, Kohya N, Miyoshi A, Miyazaki K, Improvement of the glucose metabolism after a pancreatoduodenectomy, Pancreas, 38, 6, 700-705, 2009.04, OBJECTIVES: The aim of this study was to investigate the mechanisms of the change in glucose metabolism after a pancreatoduodenectomy (PD). METHODS: Oral glucose tolerance tests were performed in 17 patients before and 1 month after a PD. The changes in plasma glucose and insulin concentrations, homeostasis model of insulin resistance, and insulinogenic index (beta-cell function) were analyzed. Two additional factors, gastric emptying function and plasma glucagon-like peptide-1 (GLP-1) concentration, that possibly affect perioperative glucose metabolism were also assessed. RESULTS: The plasma glucose and insulin concentrations were significantly lower after the operation, especially in preoperative diabetic patients. beta-Cell function did not change after the operation. On the other hand, insulin resistance became normal 1 month after the operation. The value of gastric emptying function after the operation was not statistically different in comparison with that before the operation. Postoperative plasma GLP-1 concentration was significantly higher than the preoperative value. CONCLUSIONS: beta-Cell function is maintained after a PD, whereas the improvement of insulin resistance may cause a short-term transient improvement of the glucose metabolism after the operation. The significance of increased postoperative GLP-1 concentration remains an unsolved issue..
159. Ide T, Brown-Endres L, Chu K, Ongusaha PP, Ohtsuka T, El-Deiry WS, Aaronson SA, Lee SW , GAMT, a p53-inducible modulator of apoptosis, is critical for the adaptive response to nutrient stress
, Mol Cell , 36, 3, 379-392, 2009.04, The p53 tumor suppressor protein has a well-established role in cell-fate decision-making processes. However, recent discoveries indicate that p53 has a non-tumor-suppressive role. Here we identify guanidinoacetate methyltransferase (GAMT), an enzyme involved in creatine synthesis, as a p53 target gene and a key downstream effector of adaptive response to nutrient stress. We show that GAMT is not only involved in p53-dependent apoptosis in response to genotoxic stress but is important for apoptosis induced by glucose deprivation. Additionally, p53-->GAMT upregulates fatty acid oxidation (FAO) induced by glucose starvation, utilizing this pathway as an alternate ATP-generating energy source. These results highlight that p53-dependent regulation of GAMT allows cells to maintain energy levels sufficient to undergo apoptosis or survival under conditions of nutrient stress. The p53-->GAMT pathway represents a new link between cellular stress responses and processes of creatine synthesis and FAO, demonstrating a further role of p53 in cellular metabolism.

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160. Fujita H, Ohuchida K, Mizumoto K, Nakata K, Yu J, Kayashima T, Cui L, Manabe T, Ohtsuka T, Tanaka M, α-Smooth Muscle Actin Expressing Stroma Promotes an Aggressive Tumor Biology in Pancreatic Ductal Adenocarcinoma, Pancreas, 39, 8, 1254-1262, 2010.04, OBJECTIVES:: Pancreatic ductal adenocarcinoma (PDAC) is often characterized by a prominent desmoplastic stroma that is induced partially by alpha-smooth muscle actin (SMA)-expressing activated pancreatic stellate cells (PSCs). This study aimed to investigate the significance of alpha-SMA expression in PDAC and the correlation between alpha-SMA mRNA levels and the patient prognosis. METHODS:: We obtained formalin-fixed, paraffin-embedded tissue samples from 109 patients with PDAC, who underwent pancreatectomy at our institution from 1992 to 2007. We measured alpha-SMA mRNA levels by quantitative real-time reverse transcription-polymerase chain reaction and investigated the association of alpha-SMA mRNA expression with clinicopathologic parameters and survival time. We also assessed the influence of activated PSCs on malignant behaviors of pancreatic cancer cells using in vitro experiments. RESULTS:: alpha-SMA immunoreactivity was detected exclusively in the stroma of PDAC. The group with high alpha-SMA expression showed a significantly shorter survival, as shown by univariate analysis (P = 0.005) and multivariate analysis (P < 0.0001). alpha-SMA-expressing activated PSCs enhanced the invasiveness, proliferation, and colony formation of pancreatic cancer cells. CONCLUSIONS:: Quantitative analysis of alpha-SMA mRNA expression using formalin-fixed, paraffin-embedded tissue samples was useful to predict the prognosis of patients with PDAC. Activated PSCs may regulate the malignant behavior of pancreatic cancer cells..
161. Sadakari Y, Ohuchida K, Nakata K, Ohtsuka T, Aishima S, Takahata S, Nakamura M, Mizumoto K, Tanaka M, Invasive carcinoma derived from the nonintestinal type intraductal papillary mucinous neoplasm of the pancreas has a poorer prognosis than that derived from the intestinal type, Surgery , 147, 6, 812-817, 2010.04, BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is divided into 4 subtypes: an intestinal type, a gastric type, a pancreatobiliary type, and an oncocytic type. The purposes of this study were to clarify the outcomes and the characteristics of invasive carcinoma derived from IPMN (invasive IPMC) by focusing on these subtypes with a comparison to conventional invasive ductal carcinoma (IDC) of the pancreas. METHODS: A total of 30 patients with invasive IPMC were reviewed, and the tumors were divided into 2 pathologic subtypes, intestinal and nonintestinal type. The prognosis and characteristics of the 2 subtypes were evaluated. Furthermore, the prognosis of 119 patients with conventional IDC was compared with that of patients with invasive carcinoma derived from the intestinal or nonintestinal type IPMN. RESULTS: The 5-year survival rate of patients with the nonintestinal type (0.0%) was as poor as that of patients with conventional IDC (19.9%; P = .67). The patients with the intestinal type (66.7%) had a more favorable prognosis than patients with conventional IDC (P < .001). The nonintestinal type was characterized by positive lymphatic invasion and tubular invasive pattern. CONCLUSION: Invasive carcinoma derived from the nonintestinal type IPMN characterized by lymphatic invasion and tubular invasive pattern is associated with a poor prognosis. Copyright 2010 Mosby, Inc. All rights reserved.

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162. Fujita H, Ohuchida K, Mizumoto K, Itaba S, Ito T, Nakata K, Yu J, Kayashima T, Souzaki R, Tajiri T, Manabe T, Ohtsuka T, Tanaka M, Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy, NEOPLASIA, 12, 10, 807-817, 2010.04, Abstract
BACKGROUND AND AIMS: The standard palliative chemotherapy for pancreatic ductal adenocarcinoma (PDAC) is gemcitabine-based chemotherapy; however, PDAC still presents a major therapeutic challenge. The aims of this study were to investigate the expression pattern of genes involved in gemcitabine sensitivity in resected PDAC tissues and to determine correlations of gene expression with treatment outcome.

MATERIALS AND METHODS: We obtained formalin-fixed paraffin-embedded (FFPE) tissue samples from 70 patients with PDAC. Of the 70 patients, 40 received gemcitabine-based adjuvant chemotherapy (AC). We measured hENT1, dCK, CDA, RRM1, and RRM2 messenger RNA (mRNA) levels by quantitative real-time reverse transcription-polymerase chain reaction and determined the combined score (GEM score), based on the expression levels of hENT1, dCK, RRM1, and RRM2, to investigate the association with survival time. By determining the expression levels of these genes in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytologic specimens, we investigated the feasibility of individualized chemotherapy.

RESULTS: High dCK (P = .0067), low RRM2 (P = .003), and high GEM score (P = .0003) groups had a significantly longer disease-free survival in the gemcitabine-treated group. A low GEM score (<2) was an independent predictive marker for poor outcome to gemcitabine-based AC as shown by multivariate analysis (P = .0081). Altered expression levels of these genes were distinguishable in microdissected neoplastic cells from EUS-FNA cytologic specimens.

CONCLUSIONS: Quantitative analyses of hENT1, dCK, RRM1, and RRM2 mRNA levels using FFPE tissue samples and microdissected neoplastic cells from EUS-FNA cytologic specimens may be useful in predicting the gemcitabine sensitivity of patients with PDAC.

PMID: 20927319 [PubMed - in process]PMCID: PMC2950330Free PMC Article



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Figure 1
Quantitative analyses of mRNA associated with cellular uptake and metabolism of gemcitabine in gemcitabine-resistant cells. Quantitative analyses of hENT1 (A), dCK (B), RRM1 (C), RRM2 (D), and CDA (E) mRNA in gemcitabine-resistant cell lines (SUIT-2-GR and Capan-1-GR) and parental cells. SUIT-2-GR cells expressed sign...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 2
Correlation between gemcitabine-based AC and survival time. The patients who received gemcitabine-based AC (GEMgroup) showed a significantly prolongedOStime compared with the non-AC group (P = .0017). *P < .05.
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 3
Correlation between the expression of each mRNA and DFS. Low dCK (P= .0067) and high RRM2 (P=.003) levels, normalized to β-actin, were associated with a shorter DFS in the GEM group (A, C, E, G). In contrast, there was no significant correlation between these gene expression levels and DFS in the non-AC group (B, D...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 4
Correlation between the expression of each mRNA and OS. Low hENT1 (P = .011), low dCK (P = .0095), high RRM1 (P = .041), and high RRM2 (P = .030) levels, normalized to β-actin, were associated with a shorterOSin theGEMgroup (A, C, E, G). In contrast, there was no significant correlation between these gene expression levels an...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 5
Correlation between GEM score and survival time. DFS time (A) and OS time (B) after resection of PDAC categorized by combined GEM score (hENT1 score x dCK score x RRM1 score x RRM2 score) in GEM group patients. High GEM scores were well correlated with prolonged DFS time (A) and OS time (B). *P < .05.
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
Neoplasia. 2010 October;12(10):807-817.Figure 6
Quantitative analyses of mRNA associated with gemcitabine sensitivity in EUS-FNA cytologic specimens. Representative micrographs of cytologic specimens obtained from patients with PDAC who underwent EUS-FNA cytologic examination (A, B). Most samples consisted of a large amount of blood and inflammat...
Gene Expression Levels as Predictive Markers of Outcome in Pancreatic Cancer after Gemcitabine-Based Adjuvant Chemotherapy12
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163. Kobayashi K, Sadakari Y, Ohtsuka T, Takahata S, Nakamura M, Mizumoto K, Tanaka M , Factors in Intraductal Papillary Mucinous Neoplasms of the Pancreas Predictive of Lymph Node Metastasis
, Pancreatology, 10, 6, 720-725, 2010.04, Background: Little is known about the frequency of lymph node metastasis (LNM) in intraductal papillary mucinous neoplasms (IPMNs), and we have not been able to determine how much lymph node dissection is necessary in individual cases. The aim of this study was to investigate the predictive factors for the LNM in IPMNs. Methods: Medical records of 120 patients pathologically diagnosed as having IPMN were reviewed, and 16 possible predictive factors regarding the LNM were analyzed. Results: LNM was observed in 7 patients (6%), all of whom were diagnosed as having mural nodules preoperatively. Sensitivity, specificity, and accuracy of preoperative imaging for detecting mural nodules of IPMNs in this study were 84, 97, and 90%, respectively. Univariate analysis using 61 patients having mural nodules preoperatively revealed that the size of mural nodules ≥10 mm and positive imaging findings for invasive tumor and possible LNM were significant predictive factors for the LNM. Multivariate analysis demonstrated that only an imaging finding for invasive tumor was an independent significant predictive factor. Positive and negative predictive values of the imaging finding of invasive IPMNs for LNM were 50 and 98%, respectively. Conclusions: Standard lymph node dissection would be recommended in patients with IPMNs with mural nodules demonstrating preoperative imaging findings for invasive carcinomas. and IAP.

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164. Tsutsumi K, Ohtsuka T, Oda Y, Sadakari Y, Mori Y, Aishima S, Takahata S, Nakamura M, Mizumoto K, Tanaka M, A History of Acute Pancreatitis in Intraductal Papillary Mucinous Neoplasms of the Pancreas Is a Potential Predictive Factor for Malignant Papillary Subtype
, Pancreatology, 10, 6, 707-712, 2010.04, Background/Aims: There are several reports regarding intraductal papillary mucinous neoplasms (IPMNs) detected after the occurrence of acute pancreatitis. Although the presence of symptoms is regarded as a factor for predicting malignant IPMNs, there have been few reports demonstrating whether a history of acute pancreatitis is a predictor of malignancy. The aim of this study was to evaluate the relationship between a history of acute pancreatitis and clinicopathological features of IPMNs including the papillary subtype. Methods: The data of 150 IPMNs resected between 1990 and 2009 were retrospectively reviewed. They were classified into IPMNs with or without history of acute pancreatitis, and then the clinicopathological features were compared between the 2 groups. Results: Nineteen (13%) of the 150 patients had a history of acute pancreatitis. Nine of them had repeated episodes of pancreatitis; however, severe pancreatitis was uncommon. The diameter of the main pancreatic duct of the pancreatitis group was significantly larger than that of the nonpancreatitis group (p = 0.04). The pancreatitis group had a significantly higher frequency of carcinoma derived from IPMNs than the nonpancreatitis group (p = 0.03). The incidence of intestinal-type IPMNs in the pancreatitis group was significantly higher than that in the nonpancreatitis group (p < 0.001). Conclusion: Acute pancreatitis associated with IPMNs could predict malignant intestinal-type tumor. and IAP.

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165. Yasui T, Ohuchida K, Zhao M, Onimaru M, Egami T, Fujita H, Ohtsuka T, Mizumoto K, Tanaka M , Tumor-stroma interactions reduce the efficacy of adenoviral therapy through the HGF-MET pathway.
, Cancer science , 102, 2, 484-491, 2011.04, Many preclinical studies have shown the potential of adenovirus-based cancer gene therapy. However, successful translation of these promising results into the clinic has not yet been achieved. Pancreatic ductal adenocarcinoma (PDAC) is characterized by abundant desmoplastic stroma, and tumor-stromal cell interactions play a critical role in tumor progression. Therefore, we hypothesized that tumor-stroma interactions reduce the efficacy of adenoviral therapy. We investigated the effect of fibroblasts on adenovirus-based gene therapy using SUIT-2 and PANC-1 pancreatic cancer cells cultured with or without fibroblast-conditioned culture supernatant then infected with Ad-LacZ. After 48 h, the cells were stained for β-galactosidase. The results showed that the number of β-galactosidase-positive cells was significantly reduced after culture with fibroblast-conditioned supernatant (P < 0.05). Because the hepatocyte growth factor (HGF)/MET pathway plays an important role in tumor-stroma interactions we next investigated the involvement of this pathway in tumor-stroma interactions leading to the decreased efficacy of adenoviral therapy. SUIT-2 cells were cultured with or without SU11274 (a MET inhibitor) and/or fibroblast-conditioned culture supernatant, then infected with Ad-GFP. After 48 h, GFP-positive cells were counted. The number of GFP-positive cells in cultures containing fibroblast-conditioned supernatant plus SU11274 was significantly greater than in cultures without SU11274. In conclusion, our results suggest that stromal cells in PDAC reduce the efficacy of adenoviral therapy through a mechanism involving the HGF/MET pathway. Control of such tumor-stroma interactions may lead to improvements in adenoviral gene therapy for PDAC.

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166. Kurata N, Fujita H, Ohuchida K, Mizumoto K, Mahawithitwong P, Sakai H, Onimaru M, Manabe T, Ohtsuka T, Tanaka M, Predicting the chemosensitivity of pancreatic cancer cells by quantifying the expression levels of genes associated with the metabolism of gemcitabine and 5-fluorouracil
, international journal of oncology, 39, 2, 473-482, 2011.04, Abstract
Gemcitabine (GEM) is the standard treatment for advanced/metastatic pancreatic cancer. However, there is a substantial subset of patients in whom the efficacy of GEM, when used as a single agent, is inadequate. Recently, the 5-fluorouracil (5-FU) prodrugs capecitabine and S-1 have been used as an alternative, either alone or in combination with GEM. The aim of the present study was to investigate the expression pattern of genes that render pancreatic cancer cells sensitive to GEM and 5-FU, and to identify markers for individualized chemotherapy, even in patients who have developed resistance. We investigated the correlation between the expression of genes associated with the metabolism of GEM and 5-FU, and sensitivity to these drugs in 15 human pancreatic cancer cell lines. We also established GEM- and 5-FU-resistant pancreatic cancer cell lines to investigate changes in the expression levels of these genes and the effects of one drug on cells resistant to the other. We found no correlation between pancreatic cancer cell sensitivity to either GEM- or 5-FU. GEM-resistant cells did not become resistant to 5-FU and vice versa. High expression of RRM1 (P=0.048) and TS x DPD (P=0.035) correlated significantly with sensitivity to GEM and 5-FU, respectively. 5-FU-resistant cells expressed significantly higher levels of TP than parental cells (P<0.05). In conclusion, pancreatic cancer cells showed no cross-resistance to GEM and 5-FU. Quantitative analyses of RRM1, TP, DPD and TS mRNA levels in pancreatic cancer cells may be useful for predicting their sensitivity to GEM and 5-FU.

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167. Nakata K, Ohuchida K, Kayashima T, Ikenaga N, Sakai H, Lin C, Fujita H, Ohtsuka T, Aishima S, Nagai E, Oda Y, Tanaka M, MicroRNA-10b is overexpressed in pancreatic cancer, promotes its invasiveness, and correlates with a poor prognosis., Surgery. , 150, 5, 916-922, 2011.04, BACKGROUND:

MicroRNAs (miRNAs) have been gaining attention as new, key molecules that contribute to carcinogenesis. In pancreatic cancer, previous profiling analyses of miRNA expression have shown that several miRNAs are differently expressed in normal and cancerous tissues. Several pancreatic cancer-specific miRNAs differed, however, in each analysis.

METHODS:

We investigated the miRNA expression profiles of the pancreatic cancer cell lines CAPAN-1 and CFPAC1 and an immortalized human normal pancreatic ductal epithelial cell line (HPDE) using a high-throughput, TaqMan, qRT-PCR array analysis. We also analyzed the expression levels of this miRNA in microdissected (n = 15) and formalin-fixed, paraffin-embedded (FFPE) (n = 115) samples from pancreatic cancers by quantitative RT-PCR. Finally, we investigated the effects of this miRNA on the invasiveness of pancreatic cancer cells.

RESULTS:

Based on the microarray analysis, miR-372, miR-146a, miR-204, miR-10a, and miR-10b showed particularly large differences (>10-fold changes) between both pancreatic cell lines and HPDE cells. Thirteen of the 15 pancreatic cancer cell lines showed 2.1- to 36.4-fold (median, 15.3-fold) greater levels of miR-10b than HPDE cells. Microdissection analysis revealed that miR-10b exhibited greater expression levels in pancreatic cancer cells (n = 5) than in normal pancreatic ductal cells (n = 10) (P < .020). Analysis of FFPE samples showed that high miR-10b expression was associated with a lesser overall survival (P = .014). Furthermore, miR-10b correlated with the invasiveness of pancreatic cancer cells (P < .01).

CONCLUSION:

miR-10b is overexpressed in pancreatic cancer and may be involved in the invasiveness in pancreatic cancer cells, thereby leading to a poor prognosis.
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168. Fujita H, Ohuchida K, Mizumoto K, Itaba S, Ito T, Nakata K, Yu J, Kayashima T, Hayashi A, Souzaki R, Tajiri T, Onimaru M, Manabe T, Ohtsuka T, Tanaka M , High EGFR mRNA expression is a prognostic factor for reduced survival in pancreatic cancer after gemcitabine-based adjuvant chemotherapy.
, International journal of oncology , 38, 3, 629-641, 2011.04, Pancreatic ductal adenocarcinoma (PDAC) still presents a major therapeutic challenge and a phase III clinical trial has revealed that the combination of gemcitabine and a human epidermal growth factor receptor type I (HER1/EGFR) targeting agent presented a significant benefit compared to treatment with gemcitabine alone. The aim of this study was to investigate EGFR mRNA expression in resected PDAC tissues and its correlation with patient prognosis. We obtained formalin-fixed paraffin-embedded (FFPE) tissue samples from 88 patients with PDAC who underwent pancreatectomy, and measured EGFR mRNA levels by quantitative real-time reverse transcription-polymerase chain reaction. The high-level EGFR group had significantly shorter disease-free-survival (p=0.029) and overall-survival (p=0.014) as shown by univariate analyses, although these did not reach statistical significance, as shown by multivariate analyses. However, we found that high EGFR expression was an independent prognostic factor in patients receiving gemcitabine-based adjuvant chemotherapy (p=0.023). Furthermore, we measured EGFR mRNA levels in 20 endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytological specimens. Altered EGFR levels were distinguishable in microdissected neoplastic cells from EUS-FNA cytological specimens compared to those in whole cell pellets. In conclusion, quantitative analysis of EGFR mRNA expression using FFPE tissue samples and microdissected neoplastic cells from EUS-FNA cytological specimens could be useful in predicting prognosis and sensitivity to gemcitabine in PDAC patients.

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169. Tsutsumi K, Sato N, Cui L, Mizumoto K, Sadakari Y, Fujita H, Ohuchida K, Ohtsuka T, Takahata S, Tanaka M , Expression of claudin-4 (CLDN4) mRNA in intraductal papillary mucinous neoplasms of the pancreas
, Mod Pathol, 24, 4, 533-541, 2011.04, Claudin-4, encoding a protein for tight junction formation and function, is highly overexpressed in pancreatic ductal adenocarcinoma and is also associated with invasive adenocarcinomas arising in intraductal papillary mucinous neoplasms of the pancreas. However, the expression pattern of claudin-4 during neoplastic progression of intraductal papillary mucinous neoplasms remains unknown. Using quantitative real-time reverse transcription-PCR, we analyzed claudin-4 mRNA in a panel of 14 pancreatic cancer cell lines and in formalin-fixed paraffin-embedded tissues from 80 patients with intraductal papillary mucinous neoplasms of different histological grades and papillary subtypes. Increased expression of claudin-4 was confirmed in all the pancreatic cancer cell lines tested as compared with normal ductal epithelial cells and fibroblast cultures. The claudin-4 expression was significantly higher in high-grade intraductal papillary mucinous neoplasms (borderline neoplasm and carcinoma) than in low-grade intraductal papillary mucinous neoplasms (adenoma) (P<0.0001). In addition, claudin-4 mRNA levels were significantly higher in intestinal-type intraductal papillary mucinous neoplasms than in non-intestinal-type intraductal papillary mucinous neoplasms based on papillary subclassification (P<0.0001). Our findings suggest that claudin-4 expression is associated with neoplastic progression of intraductal papillary mucinous neoplasms and, especially, with a distinct pathway to intestinal differentiation.

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170. Tsutsumi K, Sato N, Tanabe R, Mizumoto K, Morimatsu K, Kayashima T, Fujita H, Ohuchida K, Ohtsuka T, Takahata S, Nakamura M, Tanaka M, Claudin-4 Expression Predicts Survival in Pancreatic Ductal Adenocarcinoma
, Ann Surg Oncol. , 19, Suppl3, S491-499, 2011.04, Abstract
BACKGROUND: Identification of prognostic markers would be useful in the clinical management of patients with pancreatic ductal adenocarcinoma (PDAC). The clinical relevance of claudin-4 (CLDN4), recently identified as overexpressed in PDAC, is unknown.

METHODS: Using quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR), we analyzed CLDN4 mRNA expression in a panel of 9 pancreatic cancer cell lines and formalin-fixed paraffin-embedded (FFPE) tissues from 100 patients with PDAC. The CLDN4 expression levels were then correlated with clinicopathological variables and patient outcome. We also performed immunohistochemical analysis in 20 FFPE samples of PDAC to investigate the expression of CLDN4 protein.

RESULTS: Increased expression of CLDN4 was confirmed in all the pancreatic cancer cell lines tested compared with normal ductal epithelial cells and fibroblasts. We found that low expression of CLDN4 was significantly associated with shorter survival in patients with PDAC (hazard ratio; 1.362, 95% confidence interval; 1.011-1.873, P = 0.0419). Patients with high CLDN4 expression survived longer for a median of 63.0 months, compared with 14.7 months in patients with low CLDN4 expression (P = 0.0067). In immunohistochemical analysis, the level of CLDN4 mRNA expression was significantly correlated with the expression of CLDN4 protein (P = 0.0168).

CONCLUSION: Increased expression of CLDN4 mRNA predicts better prognosis in PDAC.

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171. Yasui T, Ohuchida K, Zhao M, Cui L, Onimaru M, Egami T, Fujita H, Ohtsuka T, Mizumoto M, Matsumoto K, Tanaka M, Adenoviral therapy is more effective in gemcitabine-resistant pancreatic cancer than in gemcitabine-sensitive cells.
, Anticancer Res. , 31, 4, 1279-1288, 2011.04, BACKGROUND: Although gemcitabine is the standard treatment for pancreatic cancer, this particular type of cancer develops rapidly and has intrinsic chemoresistance. Chemoresistance plays a critical role in tumor progression, invasion and migration. Nevertheless, the effect of adenoviral therapy on chemoresistant cancer cells has not been studied. In this study, we compared the efficacy of adenoviral therapy in parental and chemoresistant pancreatic cancer cells.

MATERIALS AND METHODS: To establish gemcitabine-resistant cells, pancreatic cancer SUIT2 cells were exposed to increasing concentrations of gemcitabine. Both parental and chemoresistant cells were infected with adenoviruses expressing either green fluorescent protein (Ad-GFP) or the hepatocyte growth factor antagonist, NK4 (Ad-NK4). To investigate the transduction efficacy, GFP expression and NK4 concentrations were measured and an invasion assay was used to investigate the efficacy of the adenoviral therapy.

RESULTS: The 50% inhibitory concentration of gemcitabine was <10 nM in the parental SUIT-2 cells, while it was >1 μM in gemcitabine-resistant cells. A large number of gemcitabine-resistant cells were GFP-positive compared with only a small number of parental cells (p<0.05). The NK4 expression level was significantly higher in gemcitabine-resistant cells than in parental cells (p<0.05). The supernatant from Ad-NK4-infected gemcitabine-resistant cells significantly inhibited the invasion of cancer cells compared with that from Ad-NK4-infected parental cells (p<0.05).

CONCLUSION: Both the efficiency of transduction and the therapeutic efficacy of adenoviral therapy were higher in gemcitabine-resistant cells than in parental cells, suggesting that adenoviral gene therapy is more effective in patients with gemcitabine-resistant pancreatic cancer.

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172. Ikenaga N, Ohuchida K, Mizumoto K, Akagawa S, Fujiwara K, Eguchi D, Kozono S, Ohtsuka T, Takahata S, Tanaka M, Pancreatic cancer cells enhance the ability of collagen internalization during epithelial-mesenchymal transition., PLoS One, 7, 7, e40434, 2012.04, Abstract


BACKGROUND:

Extracellular matrix (ECM) remodeling is predominantly mediated by fibroblasts using intracellular and extracellular pathways. Although it is well known that extracellular degradation of the ECM by proteases derived from cancer cells facilitates cellular invasion, the intracellular degradation of ECM components by cancer cells has not been clarified. The aim of this study was to characterize collagen internalization, which is the initial step of the intracellular degradation pathway in pancreatic cancer cells, in light of epithelial-mesenchymal transition (EMT).

METHODOLOGY/PRINCIPAL FINDINGS:

We analyzed the function of collagen internalization in two pancreatic cancer cell lines, SUIT-2 and KP-2, and pancreatic stellate cells (PSCs) using Oregon Green 488-gelatin. PSCs had a strong ability for collagen uptake, and the pancreatic cancer cells also internalized collagen although less efficiently. The collagen internalization abilities of SUIT-2 and KP-2 cells were promoted by EMT induced by human recombinant transforming growth factor β1 (P<0.05). Expression of Endo180, a collagen uptake receptor, was high in mesenchymal pancreatic cancer cell lines, as determined by EMT marker expression (P<0.01). Quantitative RT-PCR and western blot analyses showed that Endo180 expression was also increased by EMT induction in SUIT-2 and KP-2 cells. Endo180 knockdown by RNA interference attenuated the collagen uptake (P<0.01) and invasive abilities (P<0.05) of SUIT-2 and KP-2 cells.

CONCLUSIONS/SIGNIFICANCE:

Pancreatic cancer cells are capable of collagen internalization, which is enhanced by EMT. This ECM clearance system may be a novel mechanism for cellular invasion and a potential therapeutic target in pancreatic cancer.
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173. Ohuchida K, Mizumoto K, Lin C, Yamaguchi H, Ohtsuka T, Sato N, Toma H, Nakamura M, Nagai E, Hashizume M, Tanaka M, MicroRNA-10a is overexpressed in human pancreatic cancer and involved in its invasiveness partially via suppression of the HOXA1 gene, Ann Surg Oncol., 19, 7, 2394-2402, 2012.04, Abstract
BACKGROUND:
There is increasing evidence that microRNAs are differentially expressed in many types of cancers. Despite progress in analyses of microRNAs in several types of cancers, the functional contributions of microRNAs to pancreatic cancer remain unclear.
METHODS:
In the present study, the expression levels of specific microRNAs identified by microarray analyses were examined in a panel of 15 pancreatic cancer cell lines. We then investigated the functional roles of these microRNAs in the proliferation and invasion of pancreatic cancer cells.
RESULTS:
Based on the microarray data, we found frequent and marked overexpression of miR-10a, miR-92, and miR-17-5p in pancreatic cancer cell lines. Microdissection analyses revealed that miR-10a was overexpressed in pancreatic cancer cells isolated from a subset of primary tumors (12 of 20, 60%) compared with precursor lesions and normal ducts (P<.01). In vitro experiments revealed that miR-10a inhibitors decreased the invasiveness of pancreatic cancer cells (P<.01), but had no effect on their proliferation. Inhibition of HOXA1, a target of miR-10a, promoted the invasiveness of pancreatic cancer cells (P<.01).
CONCLUSIONS:
The present data suggest that miR-10a is overexpressed in a subset of pancreatic cancers and is involved in the invasive potential of pancreatic cancer cells partially via suppression of HOXA1..
174. Aso T, Ohtsuka T, Ideno N, Kono H, Nagayoshi Y, Mori Y, Ohuchida K, Ueda J, Takahata S, Morimatsu K, Aishima S, Igarashi H, Ito T, Ishigami K, Mizumoto K, Tanaka M, Diagnostic significance of a dilated orifice of the duodenal papilla in intraductal papillary mucinous neoplasm of the pancreas, Gastrointest Endosc, 76, 2, 313-320, 2012.04,
BACKGROUND:

A dilated orifice of the duodenal papilla found during screening endoscopy or ERCP is well-known as one of the specific findings of intraductal papillary mucinous neoplasm (IPMN). However, its clinical significance is still unclear.

OBJECTIVE:

To assess the diagnostic significance of a dilated orifice of the duodenal papilla and evaluate whether this could be a factor predictive of malignancy or a subtype of IPMN.

DESIGN:

Retrospective study.

SETTING:

University hospital.

PATIENTS:

This study involved 149 patients who underwent pancreatectomy for IPMN between January 1987 and June 2011.

INTERVENTION:

ERCP.

MAIN OUTCOME MEASUREMENTS:

The rate of malignant and intestinal type IPMNs in patients with and without papillary dilation.

RESULTS:

A dilated orifice of the duodenal papilla was significantly associated with intestinal type IPMN (P < .001), but this finding could not predict the malignant grade of IPMN (P = .13). Multivariate analysis revealed that a dilated orifice was a significant factor for predicting intestinal type in both main duct (P = .01) and branch duct IPMNs (P < .001).

LIMITATIONS:

The validity of the definition of papillary dilation, selection bias, and a retrospective study.

CONCLUSION:

A dilated orifice of the duodenal papilla could be a significant factor for predicting intestinal type IPMN. This may lead to better clinical management of patients with IPMN.

Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.


Comment in
Pancreatic cancer: Dilated orifice of the duodenal papilla predicts intestinal type IPMN. [Nat Rev Gastroenterol Hepatol. 2012]
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175. Fujiwara K, Ohuchida K, Mizumoto K, Eguchi D, Kozono S, Ikenaga N, Ohtsuka T, Takahata S, Aishima S, Tanaka M, CD271⁺Subpopulation of Pancreatic Stellate Cells Correlates with Prognosis of Pancreatic Cancer and Is Regulated by Interaction with Cancer Cells, PLoS One., 7, 12, e52682, 2012.04, Pancreatic stellate cells (PSCs) play a crucial role in the aggressive behavior of pancreatic cancer. Although heterogeneity of PSCs has been identified, the functional differences remain unclear. We characterized CD271⁺ PSCs in human pancreatic cancer. Immunohistochemistry for CD271 was performed for 31 normal pancreatic tissues and 105 pancreatic ductal adenocarcinomas (PDACs). We performed flow cytometry and quantitative RT-PCR, and assessed CD271 expression in PSCs isolated from pancreatic tissues and the changes in CD271 expression in PSCs cocultured with cancer cells. We also investigated the pattern of CD271 expression in a SCID mouse xenograft model. In the immunohistochemical analyses, the CD271-high staining rates in pancreatic stroma in normal pancreatic tissues and PDACs were 2/31 (6.5%) and 29/105 (27.6%), respectively (p = 0.0069). In PDACs, CD271⁺ stromal cells were frequently observed on the edge rather than the center of the tumors. Stromal CD271 high expression was associated with a good prognosis (p = 0.0040). Flow cytometric analyses demonstrated CD271-positive rates in PSCs were 0-2.1%. Quantitative RT-PCR analyses revealed that CD271 mRNA expression was increased in PSCs after coculture with pancreatic cancer cells. However, the level of CD271 mRNA expression subsequently decreased after the transient increase. Furthermore, CD271 mRNA expression was decreased in PSCs migrating toward pancreatic cancer cells through Matrigel. In the xenograft model, CD271⁺ PSCs were present at tumor margins/periphery and were absent in the tumor core. In conclusion, CD271 was expressed in PSCs around pancreatic tumors, but not in the center of the tumors, and expression decreased after long coculture with pancreatic cancer cells or after movement toward pancreatic cancer cells. These findings suggest that CD271⁺ PSCs appear at the early stage of pancreatic carcinogenesis and that CD271 expression is significantly correlated with a better prognosis in patients with PDAC..
176. Fujiwara K, Ohuchida K, Mizumoto K, Shindo K, Eguchi D, Kozono S, Ikenaga N, Ohtsuka T, Takahata S, Aishima S, Tanaka M, CD271+ Subpopulation of Pancreatic Stellate CellsCorrelates with Prognosis of Pancreatic Cancer and IsRegulated by Interaction with Cancer Cells, PLOS one, 7, 12, e52682, 2012.04, Abstract
Pancreatic stellate cells (PSCs) play a crucial role in the aggressive behavior of pancreatic cancer. Although heterogeneity of PSCs has been identified, the functional differences remain unclear. We characterized CD271⁺ PSCs in human pancreatic cancer. Immunohistochemistry for CD271 was performed for 31 normal pancreatic tissues and 105 pancreatic ductal adenocarcinomas (PDACs). We performed flow cytometry and quantitative RT-PCR, and assessed CD271 expression in PSCs isolated from pancreatic tissues and the changes in CD271 expression in PSCs cocultured with cancer cells. We also investigated the pattern of CD271 expression in a SCID mouse xenograft model. In the immunohistochemical analyses, the CD271-high staining rates in pancreatic stroma in normal pancreatic tissues and PDACs were 2/31 (6.5%) and 29/105 (27.6%), respectively (p = 0.0069). In PDACs, CD271⁺ stromal cells were frequently observed on the edge rather than the center of the tumors. Stromal CD271 high expression was associated with a good prognosis (p = 0.0040). Flow cytometric analyses demonstrated CD271-positive rates in PSCs were 0-2.1%. Quantitative RT-PCR analyses revealed that CD271 mRNA expression was increased in PSCs after coculture with pancreatic cancer cells. However, the level of CD271 mRNA expression subsequently decreased after the transient increase. Furthermore, CD271 mRNA expression was decreased in PSCs migrating toward pancreatic cancer cells through Matrigel. In the xenograft model, CD271⁺ PSCs were present at tumor margins/periphery and were absent in the tumor core. In conclusion, CD271 was expressed in PSCs around pancreatic tumors, but not in the center of the tumors, and expression decreased after long coculture with pancreatic cancer cells or after movement toward pancreatic cancer cells. These findings suggest that CD271⁺ PSCs appear at the early stage of pancreatic carcinogenesis and that CD271 expression is significantly correlated with a better prognosis in patients with PDAC..
177. Kozono S, Ohuchida K, Ohtsuka T, Cui L, Eguchi D, Fujiwara K, Zhao M, Mizumoto K, Tanaka M, S100A4 mRNA expression level is a predictor of radioresistance of pancreatic cancer cells, Oncol Rep. , 30, 4, 1601-1608, 2013.04, Improving poor outcomes in patients with pancreatic cancer requires a greater understanding of the biological mechanisms contributing to radioresistance. We, therefore, sought to identify genes involved in the radioresistance of pancreatic cancer cells. Two pancreatic cancer cell lines, CFPAC-1 and Capan-1, were repeatedly exposed to radiation, establishing two radioresistant cell lines. Gene expression profiling using cDNA microarrays was performed to identify genes responsible for radioresistance. The levels of expression of mRNAs encoded by selected genes and their correlation with radiation dose resulting in 50% survival rate were analyzed in pancreatic cancer cell lines. The radiation dose resulting in a 50% survival rate was significantly higher in irradiated (IR) compared to parental CFPAC-1 cells (8.31 ± 0.85 Gy vs. 2.14 ± 0.04 Gy, P<0.0001), but was lower in IR compared with parental Capan-1 cells (2.66 ± 0.24 Gy vs. 2.25 ± 0.03 Gy, P=0.04). cDNA microarray analysis identified 4 genes, including S100 calcium binding protein A4 (S100A4), overexpressed and 23 genes underexpressed in the IR compared with the parental cell lines. The levels of S100A4 mRNA expression were correlated with radiation dose resulting in a 50% survival rate (Pearson's test, R2=0.81, P=0.0025). S100A4 mRNA expression may predict radioresistance of pancreatic cancer cells and may play an important role in the poor response of pancreatic cancer cells to radiation therapy..
178. Fujiwara K, Ohuchida K, Ohtsuka T, Mizumoto K, Shindo K, Ikenaga N, Cui L, Takahata S, Aishima S, Tanaka M, Migratory Activity of CD105+ Pancreatic Cancer Cells Is Strongly Enhanced by Pancreatic Stellate Cells
, Pancreas, 42, 8, 1283-1290, 2013.04, OBJECTIVES: CD105 expression correlates with prognosis for several cancers. However, its significance in pancreatic cancer is unclear.METHODS: We analyzed CD105 expression in resected pancreatic cancer tissue and pancreatic cancer cell lines, compared the properties of CD105 and CD105 cells using quantitative RT-PCR and migration assays, and evaluated the relationship between CD105 cells and pancreatic stellate cells (PSCs).RESULTS: Immunohistochemistry showed that the frequency of CD105 expression was higher in pancreatic cancer than that in normal tissue (8% vs 0%, respectively). In flow cytometry, CD105 was expressed in pancreatic cancer cells, whereas weak CD105 expression was detected in normal pancreatic ductal epithelial cells. Quantitative RT-PCR showed that E-cadherin mRNA expression was suppressed and vimentin mRNA was overexpressed in CD105 cells (P < 0.05). Migration of CD105 cancer cells was strongly enhanced (more than that of CD105 c
ells) in coculture with PSCs (P < 0.05). CD105 expression did not correlate to clinicopathologic characteristics or the Kaplan-Meier survival analysis.CONCLUSIONS: Suppression of an epithelial marker and overexpression of a mesenchymal marker suggest that epithelial-mesenchymal transition is induced in CD105 pancreatic cancer cells. CD105 pancreatic cancer cell migration is strongly enhanced by PSCs, suggesting that these cells play a role in the pancreatic cancer microenvironment..
179. Eguchi D, Ohuchida K, Kozono S, Ikenaga N, Shindo K, Cui L, Fujiwara K, Akagawa S, Ohtsuka T, Takahata S, Tokunaga S, Mizumoto K, Tanaka M, MAL2 expression predicts distant metastasis and short survival in pancreatic cancer, Surgery. , 154, 3, 573-582, 2013.04, BACKGROUND:

Pancreatic cancer is associated with a devastating prognosis, partially because of its aggressive metastatic ability. Identification of prognostic markers of metastasis would be useful in the clinical management of postoperative patients with pancreatic cancer. Mal, T-cell differentiation protein 2 (MAL2) has been identified as a molecule predictive of metastases; the clinical relevance of MAL2 in pancreatic cancer is unknown.

METHODS:

Orthotopic human pancreatic cancer xenografts from the pancreatic cancer cell line SUIT-2 were established in nude mice. Only liver metastasis was harvested and cultured. These metastatic cycles were repeated 5 times to establish a highly metastatic cell line, termed metastatic SUIT-2 (MS). We investigated proliferation and motility of MS cells compared with those of the parent SUIT-2. Microarray analysis was performed to investigate differences in gene expression. We also performed immunohistochemical analysis of 89 formalin-fixed, paraffin-embedded human pancreatic cancer tissue samples to investigate the clinical significance of MAL2 expression.

RESULTS:

MS cells showed a greater metastatic rate after orthotopic implantation than parental SUIT-2. MS cells had increased motility but decreased proliferation compared with parental SUIT-2. Microarray analyses showed that 26 genes were significantly upregulated (>10-fold) in MS cells compared with parental SUIT-2, particularly MAL2 expression. Immunohistochemical analysis showed that high expression of MAL2 was associated with a lesser survival of postoperative patients (P = .03) and a high rate of distant metastasis (P = .008).

CONCLUSION:

We characterized a newly established pancreatic cancer cell line with highly metastatic potential. MAL2 is a promising predictive marker for distant metastasis and short survival in patients with resected pancreatic cancer.

Copyright © 2013 Mosby, Inc. All rights reserved.
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180. Mahawithitwong P, Ouchida K, Ikenaga N, Fujita H, Zhao M, Kozono S, Shindo K, Ohtsuka T, Mizumoto K, Tanaka M, Kindlin-2 expression in peritumoral stroma is associated with poor prognosis in pancreatic ductal adenocarcinoma., Pancreas, 42, 4, 663-669, 2013.04, OBJECTIVES:

Kindlin-2 is a novel focal adhesion protein reported to be expressed in breast, lung, and gastric cancers. This study aimed to investigate the significance of kindlin-2 expression in pancreatic ductal adenocarcinomas (PDACs).

METHODS:

We performed immunohistochemical analysis on kindlin-2 on PDAC samples from 95 patients. We investigated the association between kindlin-2 expression and clinicopathological parameters of PDAC and the survival time of patients with PDAC who underwent pancreatectomy.

RESULTS:

Kindlin-2 was highly expressed in the peritumoral stroma of PDACs. Stromal kindlin-2 expression was related to nodal metastasis (P = 0.03). Univariate analysis showed that patients with positive kindlin-2 expression had significantly shorter survival times than those with negative kindlin-2 expression (P = 0.01). In addition, multivariate analysis revealed that kindlin-2 expression was an independent factor of poor prognosis in patients with PDAC after R0 resection (RR = 2.15; P = 0.04).

CONCLUSIONS:

Kindlin-2 expression in stromal components is significantly associated with poor prognosis of patients with PDAC, suggesting that kindlin-2 is a prognostic marker for patients with PDAC.
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181. Mahawithitwong P, Ohuchida K, Ikenaga N, Fujita H, Zhao M, Kozono S, Shindo K, Ohtsuka T, Aishima S, Mizumoto K, Tanaka M, Kindlin-1 expression is involved in migration and invasion of pancreatic cancer , International journal of oncology, 42, 4, 1360-1366, 2013.04, Abstract
Kindlin-1 is a novel focal adhesion protein that belongs to the kindlin family. Expression of kindlin-1 has recently been reported in lung and colon cancers, but there have been no studies on its expression in pancreatic cancer. This study aimed to investigate the expression and function of kindlin-1 in pancreatic cancer. Quantitative RT-PCR of Kindlin-1 mRNA was performed in various pancreatic cancer cell lines as well as normal pancreatic epithelial cells and fibroblasts. Immunohistochemical analysis of kindlin-1 was performed for pancreatic cancer tissues. The effects of kindlin-1 on the proliferation, migration and invasion of pancreatic cancer cells were investigated using an RNA interference technique. Kindlin-1 mRNA was highly expressed in the pancreatic cancer cell lines, but only slightly expressed in normal pancreatic epithelial cells and fibroblasts. The Kindlin-1 protein was heterogeneously expressed in the cytoplasm and membrane of pancreatic cancer cells, while normal ductal epithelial cells and stromal cells showed no expression. In vitro experiments involving knockdown of kindlin-1 in AsPC-1 and KP-2 cells revealed that the migratory and invasive abilities of the cells were significantly decreased (P<0.001), while the proliferation abilities were not affected. The present findings suggest that kindlin-1 expression is involved in the progression of pancreatic cancer via enhancement of cell migration and invasion..
182. Ideno N, Ohtsuka T, Kono H, Fujiwara K, Oda Y, Aishima S, Ito T, Tokunaga S, Ohuchida K, Takahata S, Nakamura M, Mizumoto K, Tanaka M, Intraductal Papillary Mucinous Neoplasms of the Pancreas with Distinct Pancreatic Ductal Adenocarcinoma Are Frequently of Gastric Subtype, Ann Surg., 258, 1, 141-151, 2013.04, OBJECTIVE:: To identify a high-risk group of patients with pancreatic ductal adenocarcinoma (PDAC), independently arising in the pancreas with intraductal papillary mucinous neoplasm (IPMN), using histopathologic subtypes. BACKGROUND:: Pathologic features of IPMN with distinct PDAC, including histopathologic subtypes of IPMN and PDAC phenotypes, have not been well characterized. Mucin expression patterns and the mutational status of GNAS and KRAS are useful to explore the relationship between these 2 lesion types. METHODS:: Clinicopathologic data of 179 resected IPMNs and 180 resected PDACs without IPMNs as a control group were reviewed. IPMNs were classified into 4 grades (low-grade, intermediate-grade, high-grade dysplasia, and an associated invasive carcinoma) and 4 subtypes (gastric, intestinal, pancreatobiliary, and oncocytic). The expression of MUC1, MUC2, MUC5AC, MUC6, and CDX2 was investigated by immunohistochemistry in IPMNs and PDACs with an
d without IPMNs. The mutational status of GNAS and KRAS was evaluated by cycle sequencing in PDACs and pre-/coexisting IPMNs. RESULTS:: Twenty-six synchronous or metachronous PDACs were identified in 20 patients (11.2%) with IPMNs. Occurrence of concomitant PDACs was more frequently observed in gastric-type IPMNs (18/110, 16.4%) compared with intestinal (1/49, 2.0%), pancreatobiliary (1/17, 5.9%), or oncocytic-type (0/3, 0%) (P = 0.047). Both PDACs with and without IPMNs were frequently positive for MUC1, MUC5AC, and MUC6 expression, as assessed by immunohistochemistry, but were negative for MUC2 and CDX2. The mucin-staining patterns were similar to those of invasive tubular adenocarcinoma arising from gastric-type IPMNs. Mutation of GNAS within codon 201 was not detected in PDACs and gastric-type IPMNs, whereas most of these exhibited KRAS mutations. However, the R201H GNAS mutation was detected in 1 intestinal-type IPMN with distinct PDAC. CONCLUSIONS:: Mucin expression pa
tterns demonstrate that PDAC without GNAS mutations of an aggressive phenotype frequently arise in the pancreas with benign gastric-type IPMN in the absence of GNAS mutations..
183. Eguchi D, Ikenaga N, Ohuchida K, Kozono S, Cui L, Fujiwara K, Fujino M, Ohtsuka T, Mizumoto K, Tanaka M, Hypoxia enhances the interaction between pancreatic stellate cells and cancer cells via increased secretion of connective tissue growth factor, Journal of surgical research, 181, 2, 225-233, 2013.04, Abstract

BACKGROUND:

Pancreatic cancer (PC), a hypovascular tumor, thrives under hypoxic conditions. Pancreatic stellate cells (PSCs) promote PC progression by secreting soluble factors, but their functions in hypoxia are poorly understood. This study aimed to clarify the effects of hypoxic conditions on the interaction between PC cells and PSCs.

METHODS:

We isolated human PSCs from fresh pancreatic ductal adenocarcinomas and analyzed functional differences in PSCs between normoxia (21% O(2)) and hypoxia (1% O(2)), including expression of various factors related to tumor-stromal interactions. We particularly analyzed effects on PC invasiveness of an overexpressed molecule-connective tissue growth factor (CTGF)-in PSCs under hypoxic conditions, using RNA interference techniques.

RESULTS:

Conditioned media from hypoxic PSCs enhanced PC cell invasiveness more intensely than that from normoxic PSCs (P < 0.01). When co-cultured with PSCs, PC cell invasion was more enhanced under hypoxia than under normoxia (P < 0.05). Among various soluble factors, which were related to invasiveness, CTGF was one of the overexpressed molecules in hypoxic PSCs. A higher level of CTGF expression was also found in supernatant of hypoxic PSCs than in supernatant of normoxic PSCs. PC cell invasiveness was reduced by CTGF knockdown in hypoxic PSCs co-cultured with PC cells (P < 0.05).

CONCLUSION:

Hypoxia induces PSCs' secretion of CTGF, leading to enhancement of PC invasiveness. CTGF derived from hypoxia-stimulated PSCs may be a new therapeutic target for pancreatic cancer.
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184. Kono H, Nakamura M, Ohtsuka T, Nagayoshi Y, Mori Y, Takahata S, Aishima S, Tanaka M, High expression of microRNA-155 is associated with the aggressive malignant behavior of gallbladder carcinoma., Oncol Rep., 30, 1, 17-24, 2013.04, The prognosis of gallbladder cancer (GBC) remains poor despite recent advances in diagnostics and therapeutic strategies. Although the role of microRNAs (miRs) in GBC have not been well documented, miR-155 is known to be associated with inflammation-associated carcinogenesis in various types of cancers. The aim of this study was to investigate the clinical significance of miR-155 expression and the biological functions of miR-155 in GBC. The expression levels of miR-155 in surgically resected GBCs and gallbladders with pancreaticobiliary maljunction (PBM) were assessed by quantitative reverse transcription-polymerase chain reaction. The relationship between the expression levels of miR-155 and clinicopathological features of GBCs was analyzed. Human GBC cell lines were transfected with miR-155 inhibitors or mimics, and the effects on proliferation and invasion were assessed. miR-155 was significantly overexpressed in GBCs when compared with that in gallbladders with PBM (p=0.007) and normal gallbladders (p=0.04). The high expression level of miR-155 in GBCs was significantly associated with the presence of lymph node metastasis (p=0.01) and a poor prognosis (p=0.02). In vitro assays showed that aberrant expression of miR-155 significantly enhanced GBC cell proliferation and invasion. In conclusion, high miR-155 expression correlates with the aggressive behavior of GBCs, and miR-155 may become a prognostic marker and therapeutic target for GBC..
185. Nakamura M, Ohtsuka T, Nakashima H, Nagayoshi Y, Kono H, Tsutsumi K, Takahata S, Tanaka M, Extensive distal pancreatectomy for pancreatic tumor., Anticancer Res, 33, 1, 267-270, 2013.04, Aim: The purpose of this study was to evaluate the feasibility and advantages of extensive distal pancreatectomy (ExDP).

PATIENTS AND METHODS:

We retrospectively analyzed our experience in 24 patients, who underwent ExDP or total pancreatectomy (TP) for the treatment of pancreatic cancer (22 patients) or benign tumor (two patients).

RESULTS:

ExDP was associated with less blood loss (p=0.0189), shorter operative times (p=0.024), lower rates of worsening of diabetes mellitus (p<0.0001), and shorter hospital stays (p=0.0009) than TP. ExDP also had a lower complication rate than TP (1/11 cases versus 4/13 cases), but this was not a significant difference. There was no difference in the curative resection rate for pancreatic cancer between the two procedures (p=0.685).

CONCLUSION:

ExDP is a feasible and function-preserving operation for the treatment of pancreatic tumors in the body of the pancreas near the portal vein.
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186. Nakamura M, Kayashima T, Fujiwara K, Nagayoshi Y, Kono H, Ohtsuka T, Takahata S, Mizumoto K, Tanaka M, Combination therapy of portal vein resection and adjuvant gemcitabine improved prognosis of advanced pancreatic cancer, Hepato-Gastroenterology, 60, 122, 354-357, 2013.04, Abstract


Background/Aims: Although adjuvant chemotherapy (AC) using gemcitabine improves the prognosis of patients with resectable pancreatic cancer, the effect of gemcitabine AC on the prognosis of patients with borderline resectable pancreatic cancer is not clear. Methodology: We analyzed the prognosis of patients with pancreatic cancer who underwent curative pancreatoduodenectomy or total pancreatectomy in combination with portal/superior mesenteric vein resection (PVR) [PVR (+) group] or without PVR [PVR(-) group]. Results: MST of the PVR (+) group was significantly shorter than that of the PVR(-) group (p=0.017). In contrast, when we focused on the patients with gemcitabine AC, there was no significant difference in MST between the PVR (+) and the PVR (-) groups (p=0.247). Furthermore, we compared MST of two subgroups in the PVR (+) group depending on gemcitabine AC status. In the PVR (+) group, MST of the patients with gemcitabine AC was significantly longer than that without gemcitabine AC (p=0.003). This was also true for the patients with pancreatic cancer which had histologically proven invasion to portal/superior mesenteric vein (PV/SMV) (p=0.001). Conclusions: The prognosis of patients with pancreatic cancer invading PV/SMV can be improved by combination therapy with PVR and gemcitabine adjuvant chemotherapy.
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187. Tamura K, Ohtsuka T, Ideno N, Aso T, Shindo K, Aishima S, Ohuchida K, Takahata S, Ushijima Y, Ito T, Oda Y, Mizumoto K, Tanaka M, Treatment Strategy for Main Duct Intraductal PapillaryMucinous Neoplasms of the Pancreas Based on the Assessmentof Recurrence in the Remnant Pancreas After ResectionA Retrospective Review, Annals of Surgery, 259, 2, 360-368, 2014.04, OBJECTIVES:

To clarify the recurrence pattern after resection of main duct intraductal papillary mucinous neoplasms (MD-IPMNs) using molecular analyses and determine the most adequate treatment strategy.

BACKGROUND:

The most appropriate resection line for MD-IPMNs remains an unresolved issue.

METHODS:

Medical records of 56 patients with pancreatectomy were retrospectively reviewed. Histological subtypes and Kras/GNAS mutations were assessed in patients with recurrence in the remnant pancreas.

RESULTS:

Forty-nine patients underwent partial pancreatectomy and 7 underwent total pancreatectomy. Thirty-six patients (64%) had malignant MD-IPMNs. Recurrence was observed in 7 of 49 patients (14%), including 6 with malignant IPMNs and 1 with pancreatic ductal adenocarcinoma, all of whom underwent remnant pancreatectomy. The cumulative disease-specific survival rate of patients with pancreatic recurrence was greater than that of patients with extrapancreatic recurrence (P < 0.001). Although the pancreatic margin status at the initial operation did not affect the pancreatic recurrence rate, all 4 recurrent IPMNs examined had histological subtypes and Kras/GNAS mutations identical to those of the initial lesions. Four patients experienced recurrence in the remnant pancreas or systemic recurrence after resection of high-grade dysplasia of MD-IPMN. Three of the 56 patients had concomitant pancreatic ductal adenocarcinomas and MD-IPMNs.

CONCLUSIONS:

One-step total pancreatectomy can be avoided, and remnant total pancreatectomy would lead to favorable outcomes even in patients with pancreatic recurrence, some cases of which seem to involve residual lesions. Postoperative surveillance of high-grade dysplasia should be performed as if malignant, and close attention should be paid to the occurrence of concomitant pancreatic ductal adenocarcinomas in patients with MD-IPMNs.
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188. Ohtsuka T, Tamura K, Ideno N, Aso T, Nagayoshi Y, Kono H, Ueda J, Takahata S, Aso A, Igarashi H, Ushijima Y, Ookubo F, Oda Y, Mizumoto K, Tanaka M, The role of ERCP in the era of EUS-FNA for preoperative cytological confirmation of resectable pancreatic ductal adenocarcinoma, Surg Today., 44, 10, 1887-1892, 2014.04, PURPOSE:

In patients with pancreatic ductal carcinoma (PDAC), EUS-FNA carries a risk of cancer seeding. To avoid this risk, we attempted to obtain preoperative cytological confirmation of adenocarcinoma by ERCP. The aim of this study was to assess the validity of our diagnostic strategy.

METHODS:

The medical records of 124 consecutive patients who were investigated for potentially resectable PDAC were retrospectively reviewed, and the ability to detect adenocarcinoma by ERCP was evaluated.

RESULTS:

ERCP was performed in 115 patients, 69 of whom had positive cytology results. Thirty-four patients underwent EUS-FNA, 29 of whom had positive cytology results. A total of 98 patients (79 %), therefore, had preoperative cytological confirmation of adenocarcinoma, which was more frequent in patients with lesions of the head of the pancreas than in those with lesions of the body or tail of the pancreas. The postoperative pathological diagnosis demonstrated malignant pancreatic neoplasms in 122 patients (98 %), including 111 with PDAC. EUS-FNA did not affect the rate of postoperative peritoneal dissemination.

CONCLUSIONS:

Our strategy using ERCP as the initial diagnostic modality for obtaining cytological confirmation of potentially resectable PDAC seems to be adequate, yielding a high rate of positive cytology, especially in cases with tumors of the head of the pancreas.
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189. Ohtsuka T, Matsunaga T, KImura H, Watanabe Y, Tamura K, ideno N, Aso T, Miyasaka Y, Ueda J, Takahata S, Osoegawa T, Igarashi H, Ito T, Ushijima Y, Ookubo F, Oda Y, Mizumoto K, Tanaka M, Role of pancreatic juice cytology in the preoperative management of intraductal papillary mucinous neoplasm of the pancreas in the era of international consensus guidelines 2012, World J Surg., 38, 11, 2994-3001, 2014.04, BACKGROUND:

Routine endoscopic retrograde pancreatography (ERP) for pancreatic juice cytology (PJC) during management of intraductal papillary mucinous neoplasm (IPMN) is not recommended in the international consensus guidelines 2012. The aim of the present study was to investigate the roles of PJC in relation to the new stratification of clinical findings in the consensus guidelines 2012.

METHODS:

Medical records of 70 consecutive patients who underwent preoperative PJC, subsequent pancreatectomy, and a pathological diagnosis of IPMN were reviewed. Diagnostic ability of PJC to detect malignant lesions was calculated by the stratification of clinical findings.

RESULTS:

Forty patients had malignant lesions, including 29 with malignant IPMN, 10 with concomitant pancreatic adenocarcinoma, and one with both. Accuracies of PJC in all 70 patients and in 59 patients with IPMN alone were 77 and 80 %, respectively. The sensitivity and accuracy of PJC in patients with "worrisome features" were 100 and 94 %, respectively. Eight of 11 patients with concomitant pancreatic adenocarcinoma had non-malignant IPMN without risk factors, and 3 significant lesions could be diagnosed only by ERP/PJC. In addition, the management plan based on imaging study changed from observation to resection in two patients who had the single "worrisome feature" of branch duct IPMN and positive PJC results. As a result, PJC altered the management plan in 5 patients.

CONCLUSIONS:

Pancreatic juice cytology potentially has important roles to determine the adequate treatment choice in patients with IPMNs with "worrisome features," and to detect significant lesions that could not be detected by other imaging modalities.
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190. Nagayoshi Y, Nakamura M, Matsuoka K, Ohtsuka T, Mori Y, Kono H, Aso T, Takahata S, Ryo A, Takeda H, Ito T, Oda Y, Endo Y, Sawasaki T, Tanaka M, Profiling of autoantibodies in sera of pancreatic cancer patients, Ann Surg Oncol, 21, Suppl3, S459-S465, 2014.04, BACKGROUND:

Although autoantibodies to cancer antigens are candidates for biomarkers, no comprehensive studies to detect cancer-specific antibodies have been performed. This study identified autoantibodies in the sera of pancreatic cancer (PC) patients using proteomics based on a wheat germ cell-free protein production system.

METHODS:

We constructed a biotinylated protein library of 2,183 genes. Interactions between biotinylated proteins and serum antibodies were detected by AlphaScreen® assay. Relative luminescence signals of each protein in 37 PC patients and 20 healthy controls were measured, and their sensitivity and specificity for PC were calculated.

RESULTS:

Luminescence signals of nine proteins were significantly higher than those of healthy controls, with calcium and integrin binding 1 (CIB1) protein showing the greatest significance (p = 0.002). Sensitivity, specificity, positive predictive value and negative predictive value of CIB1 autoantibody alone for PC were 76, 70, 82, and 61 %, respectively, and 97, 35, 74, and 88 %, respectively, when the four most significant proteins were combined. Presence of these autoantibodies did not vary significantly with other clinicopathological characteristics.

CONCLUSION:

Several autoantibodies, including CIB1, are potential biomarkers for PC.
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191. Nakamura M, Shindo K, Ideno N, Ueda J, Takahata S, Nakashima H, Ohtsuka T, Shimizu S, Oda Y, Tanaka M, Prediction of Pancreatic Fistula by Preoperatively Assessable Factors; Retrospective Review of Unified Operations by Single Surgeon, Hepato-Gastroenterology, 2014, 61, 834-837, 2014.04.
192. Nagayoshi Y, Aso T, Ohtsuka T, Kono H, Ideno N, Igarashi H, Takahata S, Oda Y, Ito T, Tanaka M, Peroral pancreatoscopy using the SpyGlass system for the assessment of intraductal papillary mucinous neoplasm of the pancreas, J Hepatobiliary Pancreat Sci., 21, 6, 410-417, 2014.04, BACKGROUND:

Peroral pancreatoscopy (POPS) using a mother-baby endoscope system is often useful for assessment of intraductal papillary mucinous neoplasm (IPMN) of the pancreas with main pancreatic duct (MPD) involvement, but is not widely used for several reasons. The aim of this study was to evaluate the usefulness of the SpyGlass Direct Visualization System for assessment of IPMN.

METHODS:

Seventeen patients diagnosed with possible IPMN with MPD dilation underwent peroral pancreatoscopy using the SpyGlass system at our institution. The quality of visualization and the sensitivities of cytological and pathological investigations for diagnosing malignant lesions were evaluated.

RESULTS:

Peroral pancreatoscopy was performed using the SpyScope in 12 patients and an endoscopic retrograde cholangiopancreatography (ERCP) catheter in five patients. Sufficient visualization was achieved in 92% of cases using the SpyScope and 40% of cases using the ERCP catheter. Biopsy under direct visualization was successful in seven patients. Biopsy specimens showed adenocarcinoma in one patient, benign neoplastic epithelium in five patients, and regenerative changes in one patient; and had 25% sensitivity and 100% specificity for detecting malignancy. SpyGlass pancreatoscopy with irrigation cytology had 100% sensitivity and 100% specificity for detecting malignancy. SpyGlass pancreatoscopy was useful for determining the operative excision line in three patients. There were no severe procedure-related adverse events.

CONCLUSIONS:

Peroral pancreatoscopy using the SpyGlass system seems to be feasible and useful for assessment of IPMN with a dilated MPD.
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193. Akagawa S, Ohuchida K, Torata N, Hattori M, Eguchi D, Fujiwara K, Kozono S, Cui L, Ikenaga N, Ohtsuka T, Aishima S, Mizumoto K, Oda Y, Tanaka M, Peritoneal myofibroblasts at metastatic foci promote dissemination of pancreatic cancer, Int J Oncol. , 45, 1, 113-120, 2014.04, Myofibroblasts in the stroma of pancreatic cancers promote tumor proliferation, invasion and metastasis by increasing extracellular matrix and secretion of several growth factors. In contrast, the role of myofibroblasts at peritoneally disseminated sites of pancreatic cancer has not yet been determined. This study was designed to assess the role of myofibroblasts at peritoneally disseminated sites of pancreatic cancer. Three primary cultures of human peritoneal myofibroblasts (hPMFs) were established from disseminated sites of pancreatic cancer and their interactions with the SUIT-2 and CAPAN-1 human pancreatic cancer cell lines were analyzed in vitro. Using a model in BALB/c nu/nu mice, we compared the dissemination ability of intraperitoneally implanted pancreatic cancer cells, with and without hPMFs, and examined the presence of green fluorescent protein (GFP)-labeled hPMFs at peritoneally disseminated sites in mice. hPMFs significantly promoted the migration and invasion of pancreatic cancer cells (P<0.05), while the cancer cells significantly promoted the migration and invasion of hPMFs (P<0.05). In vivo, the number of peritoneally disseminated nodules, more than 3 mm in size, was significantly greater in mice implanted with cancer cells plus hPMFs compared to mice implanted with cancer cells alone, with GFP-labeled hPMFs surviving in the peritoneal cavity of the former. hPMFs promote the peritoneal dissemination of pancreatic cancer. The cancer-stromal cell interaction in the peritoneal cavity may be a new therapeutic target to prevent the dissemination of pancreatic cancer. .
194. Ohtsuka T, Takahata S, Takanami H, Ueda J, Mizumoto K, Shimizu S, Tanaka M, Laparoscopic surgery is applicable for larger mucinous cystic neoplasms of the pancreas, J Hepatobiliary Pancreat Sci. , 21, 5, 343-348, 2014.04, BACKGROUND:

Mucinous cystic neoplasms (MCN) of the pancreas frequently develop in the distal pancreases of young women. Laparoscopic surgery can enhance cosmetic benefits and ease of surgery. This study assessed the feasibility of laparoscopic surgery for MCN.

METHODS:

The medical records of 21 patients pathologically diagnosed with benign MCN after laparoscopic resection were reviewed. Clinical data were compared in the 11 patients with tumors ≥45 mm (large tumor group) and the 10 patients with tumors <45 mm (small tumor group).

RESULTS:

Laparoscopic resection was completed in all patients, including distal pancreatectomy with (n = 9) and without (n = 11) spleen preservation and enucleation for pancreatic head lesion (n = 1). Operation time, blood loss, postoperative morbidity, and hospital stay were similar in the two groups. Spleen-preserving pancreatectomy could be more frequently completed in the small MCN group (P = 0.02). No recurrence was observed during a median follow-up period of 12 months.

CONCLUSIONS:

Laparoscopic surgery can be completed in all patients with benign MCN, even those with large tumors, and patients with small MCN can get the additional benefit of spleen preservation.
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195. Mori Y, Ohtsuka T, Tamura K, Ideno N, Aso T, Kono H, Nagayoshi Y, Ueda J, Takahata S, Aishima S, Ookubo F, Oda Y, Tanaka M, Intraoperative irrigation cytology of the remnant pancreas to detect remnant distinct pancreatic ductal adenocarcinoma in patients with intraductal papillary mucinous neoplasm undergoing partial pancreatectomy, Surgery, 155, 1, 67-73, 2014.04, Abstract
BACKGROUND:
Patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas may have concomitant distinct pancreatic ductal adenocarcinoma (PDAC). We evaluated the safety and usefulness of intraoperative irrigation cytology of the remnant pancreas (IICP) during pancreatectomy to detect remnant distinct PDAC in patients with IPMN.
METHODS:
The records of all 48 patients with IPMN who underwent IICP during partial pancreatectomy at our institution from April 2007 to March 2012 were reviewed retrospectively. After division of the pancreas, a 4-French tube was inserted into the main pancreatic duct of the remnant pancreas from the cut edge, and fluid for cytologic examination was obtained by saline irrigation through the tube. If the third IICP was positive, patients underwent additional pancreatic resection. Clinical and pathologic outcomes were evaluated.
RESULTS:
The third IICP was positive in 5 patients. Postoperative pathologic examination showed that these patients all had remnant distinct PDAC in the additionally resected specimen, which was not detectable on preoperative imaging examination or on intraoperative macroscopic examination, ultrasonography, or palpation. This PDAC was stage 0 in 4 patients and stage III in 1 patient. No procedure-related complications were observed. One patient developed peritoneal metastasis after 10 months, 1 developed liver metastasis after 20 months, and 1 developed PDAC in the remnant pancreas after 24 months.
CONCLUSION:
IICP seems to be a safe and useful method for detection of early stage PDAC concomitant with IPMN that cannot be detected by preoperative imaging or intraoperative examination.
Copyright © 2014 Mosby, Inc. All rights reserved..
196. Aso T, Ohtsuka T, Matsunaga T, Kimura H, Watanabe Y, Tamura K, Ideno N, Osoegawa T, Takahata S, Shindo K, Ushijima Y, Aishima S, Oda Y, Ito T, Mizumoto K, Tanaka M, High-risk stigmata of the 2012 international consensus guidelines correlate with the malignant grade of branch duct intraductal papillary mucinous neoplasms of the pancreas, Pancreas, 43, 8, 1239-1243, 2014.04, Objectives: The 2012 international consensus guidelines for themanagementof intraductal papillary mucinous neoplasm (IPMN) of the pancreasstratified patients into 2 clinical categories, “high-risk stigmata” and “worrisomefeatures,” and recommended different therapeutic strategies forthese groups. The aim of this study was to elucidate the significance ofthese categories in terms of predicting malignant IPMNs.Methods: The medical records of 100 consecutive patients whounderwent pancreatectomy for IPMNs were retrospectively reviewed. Seventypatients with branch duct IPMNs (BD-IPMNs) were stratified into 3groups. The relationships between the number of predictive factors and histopathologicgrade were investigated.Results: The prevalence rates of malignant IPMN, invasive carcinoma,and lymph node metastasis in the high-risk group were 80%, 55%, and20%, respectively, with these percentages significantly increasing in a stepwisemanner acc
ording to the number of predictive factors. In contrast,there was no significant correlation between the number of worrisome featuresand grade of malignancy in patients stratified as having worrisomeBD-IPMNs.Conclusions: The number of high-risk stigmata correlated significantlywith the grade of malignancy of BD-IPMNs. The presence of at least 1high-risk stigma in patients with BD-IPMNs indicates a need for pancreatectomywith lymphadenectomy..
197. Ueda J, Kayashima T, Mori Y, Ohtsuka T, Takahata S, Nakamura M, Tanaka M, Hepaticocholecystojejunostomy as effective palliative biliary bypass for unresectable pancreatic cancer, Hepatogastroenterology, 61, 129, 197-202, 2014.04, Abstract
BACKGROUND/AIMS:
The majority of patients with pancreatic cancer present with far advanced disease and jaundice. With the advancement of endoscopic interventional techniques, the role of surgical bypass has declined. However, surgical bypass is still considered to be appropriate in patients who are able to tolerate surgery. We performed hepaticocholecystojejunostomy consecutively as a palliative surgical biliary bypass for the purpose of long-term palliation. The aim of this study was to analyze the results of our palliative surgical biliary bypass, hepaticocholecystojejunostomy.
METHODOLOGY:
Between January 2001 through December 2009, 69 patients received palliative surgical biliary bypass (bypass group) and 33 patients received endoscopic biliary stenting (stent group) for unresectable pancreatic cancers. Mortality, morbidity and survival between the two groups were compared.
RESULTS:
There was no in-hospital death in the bypass group, but 2 patients (6%) in the stent group died in the hospital (p = 0.04). The surgical morbidity rate was 15% in the bypass group, while 20 patients (61%) in the stent group developed complications, mainly due to stent blockage. There was no significant difference in overall survival between the two groups. Among patients who underwent systemic chemotherapy but did not present with jaundice at the time of diagnosis, those who underwent prophylactic surgical biliary bypass before chemotherapy showed better survival than those who underwent systemic chemotherapy preceding biliary bypass or biliary stenting after occurrence of jaundice (p = 0.01).
CONCLUSIONS:
Hepaticocholecystojejunostomy resulted in negligible mortality, low morbidity and effective long-term palliation. Prophylactic surgical biliary bypass with gastrointestinal bypass might be a good treatment option for non-jaundiced patients undergoing chemotherapy for unresectable pancreatic cancer..
198. Cases AI, Ohtsuka T, Fujino M, Ideno N, Kozono S, Zhao M, Ohuchida K, Aishima S< Nomura M, Oda Y, Mizumoto K, Tanaka M, Expression of glucagon-like Peptide 1 receptor and its effects on biologic behavior in pancreatic neuroendocrine tumors., Pancreas. , 43, 1, 1-6, 2014.04, OBJECTIVES:

Glucagon-like peptide 1 (GLP-1) interacts with its specific high-affinity receptor, glucagon-like peptide 1 receptor (GLP-1R), and induces cellular growth and inhibition of apoptosis in pancreatic β cells. The aim of this study was to investigate the significance of GLP-1R expression in pancreatic neuroendocrine tumors (PNETs).

METHODS:

Glucagon-like peptide 1 receptor expression was semiquantitatively evaluated by immunohistochemical staining in 50 resected PNETs, and the correlation between the GLP-1R expression and clinicopathologic features was investigated.

RESULTS:

There were 23 PNETs with positive expression and 27 PNETs with negative expression of GLP-1R. Positive expression of GLP-1R was more frequently observed in insulinoma than in gastrinoma and nonfunctioning tumor (P < 0.05). Although expression status of GLP-1R did not affect the prognosis of the patients with PNETs (P = 0.82), most of the metastatic sites such as lymph node and liver showed positive staining for GLP-1R (8 of 11 PNETs, 73%).

CONCLUSIONS:

Glucagon-like peptide 1 receptor would be a diagnostic marker of insulinoma and might become a molecular target for treatment of metastatic PNETs and hormonal regulation of insulin.
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199. Aso T, Ohtsuka T, Tamura K, Ideno N, Kono H, Nagayoshi Y, Ohuchida K, Ueda J, Takahata S, Shindo K, Aishima S, Oda Y, Mizumoto K, Tanaka M, Elevated Expression Level of MicroRNA-196a Is Predictive of Intestinal-Type Intraductal Papillary Mucinous Neoplasm of the Pancreas, Pancreas, 43, 3, 361-366, 2014.04, AbstractOBJECTIVES: Aberrant expression of several microRNAs (miRs) has been reported in various neoplasms including intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. MicroRNA-196a (miR-196a) is up-regulated in Barrett esophagus (characterized by intestinal metaplasia) and in colorectal cancer; this relationship between intestinal characteristics and miR-196a might also be applicable to intestinal-type IPMNs. The aim of this study was to evaluate whether intestinal-type IPMNs can be discriminated from non-intestinal-type IPMNs by the expression level of miR-196a in tissue and pancreatic juice samples.METHODS: Thirty-seven formalin-fixed paraffin-embedded tissue samples (including 3 of normal pancreatic ducts) and 36 pancreatic juice samples were obtained. The expression level of miR-196a measured by quantitative reverse transcription-polymerase chain reaction assays was compared between intestinal-type and non-intestinal-type IPMNs.RESULTS: Mi
croRNA-196a expression in intestinal-type IPMN tissue samples (n = 18) was significantly higher than that of non-intestinal-type IPMNs (n = 16) (P < 0.001). Similarly, miR-196a expression in pancreatic juice samples of intestinal-type IPMNs (n = 6) was significantly higher than that of non-intestinal-type IPMNs (n = 30) (P = 0.008), and the sensitivity and specificity for prediction of intestinal-type IPMNs using pancreatic juice samples were both 83%.CONCLUSIONS: Elevated expression of miR-196a in pancreatic juice samples is predictive of intestinal-type IPMNs..
200. Fujiwara K, Ohuchida K, Sada M, Horioka K, Ulrich CD 3rd, Shindo K, Ohtsuka T, Takahata S, Mizumoto K, Oda Y, Tanaka M, CD166/ALCAM expression is characteristic of tumorigenicity and invasive and migratory activities of pancreatic cancer cells, PLoS One., 9, 9, e107247, 2014.04, BACKGROUND:

CD166, also known as activated leukocyte cell adhesion molecule (ALCAM), is expressed by various cells in several tissues including cancer. However, the role of CD166 in malignant tumors is controversial, especially in pancreatic cancer. This study aimed to clarify the role and significance of CD166 expression in pancreatic cancer.

METHODS:

We performed immunohistochemistry and flow cytometry to analyze the expression of CD166 in surgical pancreatic tissues and pancreatic cancer cell lines. The differences between isolated CD166+ and CD166- pancreatic cancer cells were analyzed by invasion and migration assays, and in mouse xenograft models. We also performed quantitative RT-PCR and microarray analyses to evaluate the expression levels of CD166 and related genes in cultured cells.

RESULTS:

Immunohistochemistry revealed high expression of CD166 in pancreatic cancer tissues (12.2%; 12/98) compared with that in normal pancreas controls (0%; 0/17) (p = 0.0435). Flow cytometry indicated that CD166 was expressed in 33.8-70.2% of cells in surgical pancreatic tissues and 0-99.5% of pancreatic cancer cell lines. Invasion and migration assays demonstrated that CD166- pancreatic cancer cells showed stronger invasive and migratory activities than those of CD166+ cancer cells (p<0.05). On the other hand, CD166+ Panc-1 cells showed a significantly stronger colony formation activity than that of CD166- Panc-1 cells (p<0.05). In vivo analysis revealed that CD166+ cells elicited significantly greater tumor growth than that of CD166- cells (p<0.05) in both subcutaneous and orthotopic mouse tumor models. mRNA expression of the epithelial-mesenchymal transition activator Zeb1 was over-expressed in CD166- cells (p<0.001). Microarray analysis showed that TSPAN8 and BST2 were over-expressed in CD166+ cells, while BMP7 and Col6A1 were over-expressed in CD166- cells.

CONCLUSIONS:

CD166+ pancreatic cancer cells are strongly tumorigenic, while CD166- pancreatic cancer cells exhibit comparatively stronger invasive and migratory activities. These findings suggest that CD166 expression is related to different functions in pancreatic cancer cells.
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201. Tsutsumi K, Ohtsuka T, Fujino M, Nakashima H, Aishima S, Ueda J, Takahata S, Nakamura M, Oda Y, Tanaka M, Analysis of risk factors for recurrence after curative resection of well-differentiated pancreatic neuroendocrine tumors based on the new grading classification, J Hepatobiliary Pancreat Sci., 21, 6, 418-425, 2014.04,

BACKGROUND:

It is difficult to predict the malignant potential of pancreatic neuroendocrine tumors (PNETs) precisely. This study investigated the validity of a new grading system adopted by the World Health Organization 2010 classification to determine risk factors for recurrence of PNETs.

METHODS:

Data of 70 patients with PNETs who underwent curative resection were retrospectively examined by uni- and multivariate analyses. Histopathological findings were re-reviewed by experienced pathologists. NET G1 was defined as mitotic count <2 per 10 high power fields (HPF) and/or ≤2% Ki67 index, and NET G2 as 2-20 mitosis per 10 HPF and/or 3-20% Ki67 index.

RESULTS:

There were 58 patients with NET G1 and 12 with NET G2. Incidence of recurrence was 11.4%. Univariate analysis demonstrated significant risk factors for recurrence including NET G2 of histological grade (P = 0.0089), male gender (P = 0.0333), tumor size ≥ 20 mm (P = 0.0117), lymph node metastasis (P = 0.0004), liver metastasis (P < 0.0001), lymphatic invasion (P = 0.046), and neural invasion (P = 0.0002). By multivariate analysis, histological grade (hazard ratio; 59.76, P = 0.0022) and neural invasion (hazard ratio; 147.49, P = 0.0016) were significantly associated with recurrence of PNETs.

CONCLUSIONS:

This study confirmed the prognostic relevance of the new grading classification and that evaluation of perineural invasion and histological grade should be considered as prognostic predictors in well-differentiated PNETs (NET G1 and G2).

© 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery.


KEYWORDS:

Grading classification; Neural invasion; Pancreatic neuroendocrine tumor; Predictors of recurrence; WHO 2010 classification
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202. Zheng B, Ohuchida K, Cui L, Zhao M, Shindo K, Fujiwara K, Manabe T, Torata N, Moriyama T, Miyasaka Y, Ohtsuka T, Takahata S, Mizumoto K, Oda Y, Tanaka M, TM4SF1 as a prognostic marker of pancreatic ductal adenocarcinoma is involved in migration and invasion of cancer cells, Int J Oncol, 47, 2, 490-498, 2015.04, The cell surface protein Transmembrane 4 L6 family member 1 (TM4SF1) has been detected in various tumors, and its expression on tumor cells is implicated in cancer cell metastasis and patient prognosis. The role of TM4SF1 in malignant tumors remains poorly understood, particularly in pancreatic cancer. We performed immunohistochemical staining to analyze the expression of TM4SF1 in resected pancreatic tissues and investigated the correlation between TM4SF1 expression and prognosis. The function of TM4SF1 in the invasion and migration of pancreatic cancer cells was analyzed in vitro using an RNA interference technique. In pancreatic cancer tissues, TM4SF1 expression was detected in cancer cells, and patients with high tumor levels of TM4SF1 showed longer survival times than those with low TM4SF1 levels (P=0.0332). In vitro, reduced TM4SF1 expression enhanced the migration (P<0.05) and invasion (P<0.05) of pancreatic cancer cells partially via decreased E-cadherin expression. TM4SF1 protein levels were also reduced after TGF-β1-induced epithelial-mesenchymal transition (EMT).TM4SF1 expression is associated with better prognosis in pancreatic cancer. Loss of TM4SF1 contributes to the invasion and migration of pancreatic cancer cells..
203. Cases AI, Ohtsuka T, Kimura H, Zheng B, Shindo K, Oda Y, Mizumoto K, Nakamura M, Tanaka M, Significance of expression of glucagon-like peptide 1 receptor in pancreatic cancer, Oncol Rep, 34, 4, 1717-1725, 2015.04.
204. Ueda J, Miyasaka Y, Ohtsuka T, Takahata S, Tanaka M, Short- and long-term results of the Frey procedure for chronic pancreatitis, J Hepatobiliary Pancreat Sci, 22, 3, 211-216, 2015.04, BACKGROUND:

The aim of this study was to determine the short- and long-term results of the Frey procedure for chronic pancreatitis.

METHODS:

From November 1998 to December 2013, 41 patients underwent the Frey procedure for painful chronic pancreatitis at Kyushu University Hospital. The short- and long-term results of the Frey procedure including mortality, morbidity, pain relief, weight gain and pancreatic endocrine function were analyzed. The long-term results were analyzed in 29 patients who had been followed-up for more than 12 months. The long-term follow-up rate was 85%.

RESULTS:

There was no mortality. Early postoperative complications occurred in seven patients (17%), including pancreatic fistula in four (10%, International Study Group of Pancreatic Fistula ISGPF grade B) and hemorrhage in three (7%). Long-term relief of abdominal pain was achieved in 90% (26/29) of cases. One patient developed relapse of inflammation of the head of pancreas during the follow-up period, necessitating pylorus-resecting pancreatoduodenectomy. Only two patients (7%) developed new-onset diabetes mellitus after the Frey procedure during the follow-up period.

CONCLUSIONS:

The Frey procedure for painful chronic pancreatitis may be safe and pancreatic endocrine function is preserved. Complete decompression of the pancreatic ducts in the head of pancreas and full length drainage of the main pancreatic duct from the head of pancreas to the tail may be important in the Frey procedure to prevent recurrence of acute inflammation.
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205. Shimizu S, Ohtsuka T, Takahata S, Nagai E, Nakashima N, Tanaka M, Remote transmission of live endoscopy over the Internet:Report from the 87th Congress of the Japan Gastroenterological Endoscopy Society, Digestive Endoscopy, 28, 1, 92-97, 2015.04, Abstract
Live demonstration of endoscopy is one of the most attractive and useful methods for education and is often organized locally in hospitals. However, problems have been apparent in terms of cost, preparation, and potential risks to patients. Our aim was to evaluate a new approach to live endoscopy whereby remote hospitals are connected by the Internet for live endoscopic demonstrations. Live endoscopy was transmitted to the Congress of the Japan Gastroenterological Endoscopic Society by 13 domestic and international hospitals. Patients with upper and lower gastrointestinal diseases and with pancreatobiliary disorders were the subjects of a live demonstration. Questionnaires were distributed to the audience and were sent to the demonstrators. Questions concerned the quality of transmitted images and sound, cost, preparations, programs, preference of style, and adverse events. Of the audience, 91.2% (249/273) answered favorably regarding the transmitted image quality and 93.8% (259/276) regarding the sound quality. All demonstrators answered favorably regarding image quality and 93% (13/14) regarding sound quality. Preparations were completed without any outsourcing at 11 sites (79%) and were evaluated as 'very easy' or 'easy' at all but one site (92.3%). Preparation cost was judged as 'very cheap' or 'cheap' at 12 sites (86%). Live endoscopy connecting multiple international centers was satisfactory in image and sound quality for both audience and demonstrators, with easy and inexpensive preparation. The remote transmission of live endoscopy from demonstrators' own hospitals was preferred to the conventional style of locally organized live endoscopy.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society.
KEYWORDS:
education; international; internet; live demonstration; telemedicine.
206. Kimura H, Ohtsuka T, Matsunaga T, Watanabe Y, Tamura K, Ideno N, Aso T, Miyazaki T, Osoegawa T, Aishima S, Miyasaka Y, Ueda J, Ushijima Y, Igarashi H, Ito T, Takahata S, Oda Y, Mizumoto K, Tanaka M, Predictors and Diagnostic Strategies for Early-Stage Pancreatic Ductal Adenocarcinoma: A Retrospective Study, Pancreas. , 44, 7, 1148-1154, 2015.04, OBJECTIVES:

As a strategy to diagnose early-stage pancreatic ductal adenocarcinoma (PDAC) is urgently needed, we aimed to clarify characteristics of early-stage PDAC.

METHODS:

We retrospectively reviewed medical records of 299 consecutive patients who underwent R0 or R1 surgical resection for PDAC between 1994 and 2013 and compared clinical characteristics between patients with early-stage (stages 0-I by Japanese General Rules for Pancreatic Cancer) and advanced-stage (stages II-IV) disease. Diagnostic processes were also analyzed.

RESULTS:

Twenty-four patients (8%) had early-stage PDAC (stage 0: 11; stage I: 13). Univariate and multivariate analyses showed that presence or history of intraductal papillary mucinous neoplasm (P < 0.01), history of pancreatitis (P < 0.01), and presence or history of extrapancreatic malignancies (P = 0.01) independently predicted detection of early-stage PDAC. Cytological examination during endoscopic retrograde pancreatography cytology was ∼65% sensitive in preoperative diagnosis of early-stage PDAC, whereas other imaging modalities were only 29% to 38% sensitive; 9 of 24 early-stage PDACs were diagnosed by endoscopic retrograde pancreatography cytology alone.

CONCLUSIONS:

Endoscopic retrograde pancreatography cytology for patients with intraductal papillary mucinous neoplasm or pancreatitis may help diagnose early-stage PDAC. Surveillance of extrapancreatic malignancies might also provide opportunities to detect early-stage PDAC as a second malignancy.
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207. Watanabe Y, Ohtsuka T, Matsunaga T, Kimura H, Tamura K, Ideno N, Aso T, Miyasaka Y, Ueda J, Takahata S, Igarashi H, Inoguchi T, Ito T, Tanaka M, Long-term outcomes after total pancreatectomy: special reference to survivors' living conditions and quality of life, World J Surg, 39, 5, 1231-1239, 2015.04, Abstract
BACKGROUND:
Although recent studies have confirmed the safety of total pancreatectomy (TP), appropriate selection of patients for TP has not been well documented. Because patients require lifelong medical treatment and self-management of pancreatic insufficiency after TP, indications for TP should be determined carefully according not only to disease factors but also to the social background of patients. We aimed to clarify long-term outcomes after TP, including the living conditions and quality of life (QoL), of surviving patients.
METHODS:
Medical records of 44 consecutive patients who underwent TP between 1990 and 2013 were reviewed retrospectively; 25 survivors completed cross-sectional clinical surveys and responded to a questionnaire about QoL using Short Form 36v2.
RESULTS:
Prevalence of morbidity and mortality after TP was 32 and 5 %, respectively. Postoperative complications occurred more frequently in elderly patients than in young patients (48 vs. 14 %; P = 0.02); however, there was no significant difference in mortality, postoperative hospital stay, or survival. Twenty-four of 25 survivors (96 %) could manage pancreatogenic diabetes by themselves, and the median level of glycosylated hemoglobin was 7.4 %. Although one-third of patients after TP complained of diarrhea and the QoL scores of patients with diarrhea were lower than those of patients without diarrhea, QoL scores after TP were virtually comparable with those of the national population, even in elderly patients.
CONCLUSIONS:
TP can be performed safely, even in elderly patients. QoL after TP seems to be acceptable if patients are capable of self-management..
208. Ideno N, Ohtsuka T, Matsunaga T, Kimura H, Watanabe Y, Tamura K, Aso T, Aishima S, Miyasaka Y, Ohuchida K, Ueda J, Takahata S, Oda Y, Mizumoto K, Tanaka M, Clinical Significance of GNAS Mutation in Intraductal Papillary Mucinous Neoplasm of the Pancreas With Concomitant Pancreatic Ductal Adenocarcinoma, Pancreas, 44, 2, 311-320, 2015.04, OBJECTIVE:

The aims of this study were to investigate the GNAS mutational status in pancreatic intraductal papillary mucinous neoplasm (IPMN) with and without distinct pancreatic ductal adenocarcinoma (PDAC) and to evaluate the significance of GNAS analysis using duodenal fluid (DF) in patients with IPMN.

METHODS:

The clinicopathologic features of 110 patients with IPMN including 16 with distinct PDAC were reviewed. The GNAS status in the IPMN tissue and 23 DF specimens was assessed by sensitive mutation scanning methods.

RESULTS:

The GNAS mutation rate in IPMN with distinct PDAC was significantly lower than that in IPMN without PDAC (4/16, 25%, vs 61/94, 65%; P = 0.0047). By multivariate analysis, GNAS wild-type and gastric type IPMNs were significantly associated with distinct PDAC. Of 45 GNAS wild-type IPMNs, 10 (43%) of 23 gastric type IPMNs had distinct PDAC, whereas only 2 (9%) of 22 non-gastric type IPMNs had distinct PDAC (P = 0.017). The GNAS status in DF was consistent with that in tissue in 21 (91%) of 23 patients.

CONCLUSIONS:

Distinct PDACs frequently develop in the pancreas with gastric type IPMN without GNAS mutations. Duodenal fluid DNA test would predict the GNAS status of IPMN, whereas the detection of the gastric subtype using noninvasive test remains to be determined.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0.
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209. Watanabe Y, Ohtsuka T, Kimura H, Matsunaga T, Tamura K, Ideno N, Aso T, Miyasaka Y, Ueda J, Takahata S, Tanaka M, Braun enteroenterostomy reduces delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: a retrospective review, Am J Surg, 209, 2, 369-377, 2015.04, BACKGROUND: Several recent studies have suggested that Braun enteroenterostomy (BEE) during conventional pancreatoduodenectomy might decrease delayed gastric emptying (DGE). However, the advantages and disadvantages of performing BEE during pylorus-preserving pancreatoduodenectomy (PPPD) remain controversial.METHODS: The medical records of 185 patients who underwent PPPD either with or without BEE between January 2008 and June 2013 were retrospectively reviewed, and the postoperative course of the 2 groups was compared.RESULTS: Ninety-eight patients underwent PPPD with BEE and 87 without BEE. DGE occurred in 4% of patients with BEE and in 21% of those without BEE (P < .01). The addition of BEE did not affect postoperative complications other than DGE. By multivariate analysis, the omission of BEE was the only independent factor associated with DGE (odds ratio 5.04, 95% confidence interval: 1.59 to 19.66; P < .01).CONCLUSIONS: BEE during PPPD reduced the
incidence of DGE..
210. Tamura K, Ohtsuka T, Matsunaga T, Kimura H, Watanabe Y, Ideno N, Aso T, Miyazaki T, Ohuchida K, Takahata S, Ito T, Ushijima Y, Oda Y, Mizumoto K, Tanaka M, Assessment of Clonality of Multisegmental Main Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas Based on GNAS Mutation Analysis, Surgery, 157, 2, 277-284, 2015.04, Background: Main duct intraductal papillary mucinous neoplasms (MD-IPMNs) may occur in one or multiple segments of the pancreatic duct. Unlike multifocal branch duct (BD)-IPMNs, the clonality of multisegmental MD-IPMNs remains unclear. GNAS mutations are common and specific for IPMNs, and mutational assessment might be useful to determine the clonality of IPMNs as well as to detect high-risk IPMN with distinct ductal adenocarcinoma (PDAC). Our aim was to clarify clonality using GNAS status in multisegmental MD-IPMNs.Methods: Medical records of 70 patients with MD-IPMN were retrospectively reviewed. Histological subtypes and KRAS/GNAS mutations were investigated, and the clonal relationships among multisegmental MD-IPMNs were assessed. Mutational analysis was performed using high-resolution melting analysis and subsequent Sanger/pyrosequencing.Results: Thirteen patients had multiple synchronous and/or metachronous lesions. Seven of these 13 patients had multip
le MD-IPMNs; three had multiple MD-IPMNs and distinct BD-IPMNs; one had multiple MD-IPMNs and a distinct PDAC; one had a solitary MD-IPMN, BD-IPMN, and PDAC; and one had a solitary MD-IPMN and PDAC. KRAS/GNAS mutations were consistent in 10 of 11 multisegmental MD-IPMNs, while MD-IPMNs, BD-IPMNs, and PDACs tended to show different mutational patterns. The frequency of malignant IPMNs was significantly higher in the multisegment cohort; malignant IPMNs constituted 90% (9/10) of the multiple cohort and 56% (32/57) of the solitary cohort (P=0.04). Mutant GNAS was more frequently observed in the intestinal subtype (94%) than the others.Conclusions: MD-IPMNs can be characterized by monoclonal skip progression. Close attention should be paid to the possible presence of skip areas during/after partial pancreatectomy..
211. Horioka K, Ohuchida K, Sada M, Zheng B, Moriyama T, Fujita H, Manabe T, Ohtsuka T, Shimamoto M, Miyazaki T, Mizumoto K, Oda Y, Nakamura M, Suppression of CD51 in pancreatic stellate cells inhibits tumor growth by reducing stroma and altering tumor-stromal interaction in pancreatic cancer, Int J Oncol, 48, 4, 1499-1508, 2016.04, Pancreatic stellate cells (PSCs) enhance the malignant behavior of pancreatic cancer by interacting with cancer cells and producing extracellular matrix (ECM). To date, several stroma-targeted therapies for pancreatic cancer have been attempted, but these therapies are still not in practical use. Integrins expressed in stromal cells are involved in fibrosis of several organs, as well as promoting tumor malignancy. We investigated whether CD51, also known as integrin αV, expressed in PSCs was associated with stromal formation of pancreatic cancer and enhancement of tumor malignancy. We also assessed the effects of suppression of CD51 in PSCs on pancreatic cancer. Immunohistochemistry for CD51 in resected pancreatic cancer tissues showed that high expression of CD51 in the tumor stroma was associated with lymph node metastasis (P=0.025), positive pathologic margin (P=0.025), and shorter patient survival times (P=0.043). Lentivirus-mediated short hairpin RNA knockdown of CD51 decreased the proliferation and migration of PSCs. Quantitative real-time polymerase chain reaction showed that expression levels of genes related with ECM and tumor-stromal interactions were decreased by CD51 knockdown in PSCs. In a co-implantation model of pancreatic cancer cells and PSCs, tumor growth in vivo was inhibited by CD51 knockdown in PSCs (P<0.05). We also found reduced tumor stroma and decreased proliferation of cancer cells in implanted cancer tissues with CD51-silenced PSCs (P<0.05). Our results showed that CD51 expression in pancreatic cancer stroma is associated with enhanced tumor malignancy and that CD51 may be a potential therapeutic target for pancreatic cancer. .
212. Miyasaka Y, Ohtsuka T, Tamura K, Mori Y, Shindo K, Yamada D, Takahata S, Ishigami K, Ito T, Tokunaga S, Oda Y, Mizumoto K, Nakamura M, Tanaka M, Predictive factors for the metachronous development of high-risk lesions in the remnant pancreas after partial pancreatectomy for intraductal papillary mucinous neoplasm, Ann Surg, 263, 6, 1180-1187, 2016.04, Abstract
OBJECTIVE:
To identify factors predicting the development of high-risk lesions in the remnant pancreas after surgery for intraductal papillary mucinous neoplasm (IPMN).
BACKGROUND:
IPMN has unique features, including multifocality, adenoma-carcinoma sequence, and the development of distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. Careful attention should, therefore, be paid to the metachronous occurrence of high-risk lesions, including high-grade dysplasia or invasive carcinoma (HGD/INV) of IPMN and concomitant PDAC in the remnant pancreas after partial pancreatectomy for IPMN.
METHODS:
Clinicopathologic and surveillance data for 195 patients who underwent partial pancreatectomy for IPMN were reviewed retrospectively.
RESULTS:
Thirteen patients exhibited metachronous development of high-risk lesions including 6 HGD/INV and 7 concomitant PDACs in the remnant pancreas. The 5- and 10-year cumulative incidences of metachronous high-risk lesions in the remnant pancreas were 7.8% and 11.8%, respectively. Twelve of 13 patients had high-risk lesions at the time of initial surgery, and 10 of the 13 IPMNs were located in the distal pancreas. The IPMN subtypes initially resected were gastric in 6 patients, intestinal in 5, and pancreatobililary in the remaining 2. Univariate and multiple regression analyses identified pathologic results of HGD/INV and IPMN located in the distal pancreas as independent predictive factors for metachronous HGD/INV of IPMN, and the pancreatobiliary subtype of IPMN and presence of concomitant PDAC for metachronous PDAC.
CONCLUSIONS:
Patients undergoing partial pancreatectomy for IPMN are at high risk of developing lesions requiring surgery in the remnant pancreas, and close, long-term surveillance should be considered in these patients..
213. Chijiiwa Y, Moriyama T, Ohuchida K, Nabae T, Ohtsuka T, Miyasaka Y, Fujita H, Maeyama R, Manabe T, Abe A, Mizuuchi Y, Oda Y, Mizumoto K, Nakamura M, Overexpression of microRNA-5100 decreases the aggressive phenotype of pancreatic cancer cells by targeting PODXL, Int J Oncol, 48, 4, 1688-1700, 2016.04, Abstract

Metastasis is the main cause of cancer-associated death, and metastasis of pancreatic cancer remains difficult to treat because of its aggressiveness. MicroRNAs (miRNAs) play crucial roles in the regulation of various human transcripts, and many miRNAs have been reported to correlate with cancer metastasis. We identified an anti-metastatic miRNA, miR-5100, by investigating differences in miRNA profiling between highly metastatic pancreatic cancer cells and their parental cells. Overexpression of miR-5100 inhibited colony formation (P<0.05), cell migration (P<0.0001) and invasion (P<0.0001) of pancreatic cancer cells. In addition, we identified a possible target of miR-5100, podocalyxin-like 1 (PODXL), and demonstrated miR-5100 directly binds to the 3' untranslated region of PODXL and post-transcriptionally regulates its expression in pancreatic cancer cells. Silencing PODXL resulted in diminished cell migration (P<0.0001) and invasion (P<0.05). We also clarified the close relationship between expression of PODXL in human pancreatic cancer specimens and liver metastasis (P=0.0003), and determined that post-operative survival was longer in the low-PODXL expression group than in the high-PODXL expression group (P<0.05). These results indicate that miR-5100 and PODXL have considerable therapeutic potential for anti-metastatic therapy and could be potential indicators for cancer metastases in patients with pancreatic cancer.
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214. Sada M, Ohuchida K, Horioka K, Okumura T, Moriyama T, Miyasaka Y, Ohtsuka T, Mizumoto K, Oda Y, Nakamura M, Hypoxic stellate cells of pancreatic cancer stroma regulate extracellular matrix fiber organization and cancer cell motility, Cancer Letters, 372, 2, 210-218, 2016.04, Desmoplasia and hypoxia in pancreatic cancer mutually affect each other and create a tumor-supportive microenvironment. Here, we show that microenvironment remodeling by hypoxic pancreatic stellate cells (PSCs) promotes cancer cell motility through alteration of extracellular matrix (ECM) fiber architecture. Three-dimensional (3-D) matrices derived from PSCs under hypoxia exhibited highly organized parallel-patterned matrix fibers compared with 3-D matrices derived from PSCs under normoxia, and promoted cancer cell motility by inducing directional migration of cancer cells due to the parallel fiber architecture. Microarray analysis revealed that procollagen-lysine, 2-oxoglutarate 5-dioxygenase 2 (PLOD2) in PSCs was the gene that potentially regulates ECM fiber architecture under hypoxia. Stromal PLOD2 expression in surgical specimens of pancreatic cancer was confirmed by immunohistochemistry. RNA interference-mediated knockdown of PLOD2 in PSCs abrogated para
llel fiber architecture of 3-D matrices, leading to decreased directional migration of cancer cells within the matrices. In conclusion, these findings indicate that hypoxia-induced PLOD2 in PSCs creates a permissive microenvironment for migration of cancer cells through architectural regulation of stromal ECM in pancreatic cancer..
215. Fujimoto T, Ohtsuka T, Date K, Kimura H, Matsunaga T, Mori Y, Miyasaka Y, Mochidome N, Oda Y, Nakamura M, Expression of Bcl-2 19-kDa interacting protein 3 predicts prognosis after ampullary carcinoma resection, J Hepatobiliary Pancreat Sci, 23, 8, 489-496, 2016.04, Abstract
BACKGROUND:
An adequate management strategy for ampullary carcinoma (AC), a rare neoplasm, has yet to be determined. The aim of this study was to identify specific molecular markers allowing for the adequate management of AC.
METHODS:
The clinicopathological data of 41 patients who underwent curative resection of AC were reviewed retrospectively. The expression of thymidylate synthase (TS) and Bcl-2 19-kDa interacting protein 3 (BNIP3), two sensitive markers for S-1 and gemcitabine, respectively, was evaluated immunohistochemically. The relationship between the expression levels of these markers and the clinicopathological data were then investigated.
RESULTS:
The 5-year overall survival rate in the study population was 62%. In univariate and multivariate analyses, lymph node metastasis, neural invasion, lymphatic invasion, and the high-level BNIP3 expression were significant predictive factors for a poor postoperative prognosis. Neither TS nor BNIP3 expression were able to predict survival or the disease recurrence rate in patients who received postoperative adjuvant chemotherapy for AC.
CONCLUSIONS:
BNIP3 expression may serve as a prognostic marker for patients with AC, but neither TS nor BNIP3 contributes to the selection criteria for adjuvant chemotherapy for AC, at least with respect to current drug regimens.
© 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
KEYWORDS:
Ampulla of Vater; BNIP3; Carcinoma; Chemotherapy; Thymidylate synthase.
216. Tamura K, Ohtsuka T, Date K, Fujimoto T, Matsunaga T, Kimura H, Watanabe Y, Miyazaki T, Ohuchida K, Takahata S, Ishigami K, Oda Y, Mizumoto K, Nakamura M, Tanaka M, Distinction of Invasive Carcinoma Derived From Intraductal Papillary Mucinous Neoplasms From Concomitant Ductal Adenocarcinoma of the Pancreas Using Molecular Biomarkers, Pancreas, 45, 6, 826-835, 2016.04, OBJECTIVES:To clarify the usefulness of molecular biomarkers for distinguishing invasive carcinoma derived from intraductal papillary mucinous neoplasms (IPMNs [Inv-IPMN]) from concomitant pancreatic ductal adenocarcinoma (PDAC).METHODS:Data from 19 patients with resected concomitant PDAC were retrospectively reviewed. KRAS/GNAS mutations and immunohistochemical (IHC) expression of p53 and p16/CDKN2A were assessed in both IPMN and distinct PDAC. As controls, KRAS/GNAS mutations and IHC labeling were assessed between invasive and noninvasive components in 1 lesion of 22 independent patients.RESULTS:KRAS/GNAS mutation status of invasive and noninvasive components in Inv-IPMN was consistent in 18 (86%) of 21 patients. Conversely, mutational patterns in IPMN and distinct PDAC in the same pancreas differed from each other in 17 (89%) of 19. There were 10 (53%) and 8 (42%) of 19 patients who showed the same p53 and p16/CDKN2A staining between concomitant PDAC and d
istinct IPMN. In the Inv-IPMN cohort, 19 (86%) of 22 patients showed the same IHC expression pattern between the noninvasive and invasive components.CONCLUSIONS:It may be possible to distinguish Inv-IPMN from concomitant PDAC by assessing these molecular biomarkers. More precise distinction of Inv-IPMN and concomitant PDAC will lead to adequate recognition of the natural history of IPMNs and hence optimal management..
217. Kimura H, Ohtsuka T, Fujimoto T, Date K, Matsunaga T, Cases AI, Abe A, Mizuuchi Y, Miyasaka Y, Ito T, Oda Y, Nakamura M, Tanaka M, Different hormonal expression patterns between primary pancreatic neuroendocrine tumors and metastatic sites, Pancreas, 45, 7, 947-952, 2016.04, OBJECTIVES: Pancreatic neuroendocrine tumors (PNETs) are known to have heterogeneity in terms of their ability to produce multiple hormones. The aim of this study was to evaluate the heterogeneity of PNETs from the viewpoint of hormonal expression. METHODS: The expressions of 4 representative hormones, gastrin, insulin, glucagon, and somatostatin, in both primary and metastatic lesions, were analyzed by immunohistochemical staining in 20 patients with metastatic PNETs (6 gastrinomas, 1 insulinoma, 1 glucagonoma, and 12 nonfunctioning PNETs [NF-PNETs]). Metastatic sites included lymph nodes in all 20 patients and liver metastasis in 7 patients (2 gastrinomas and 5 NF-PNETs). RESULTS: There were 6 PNETs with multiple hormone secretion (30%), and positive expression of 1 or more hormones was found in 9 of 12 patients whose primary tumors were diagnosed as NF-PNETs. The positive concordance rate of the hormonal expression pattern between primary tumors and metast
atic lymph nodes and between primary tumors and hepatic metastasis were 50% and 11%, respectively. Three patients had metastatic lesions with positive hormonal expression, whereas their primary tumors were negative. CONCLUSIONS: Hormonal expressions are often different between the primary tumors and metastatic sites of PNETs..
218. Abe T, Ohuchida K, Miyasaka Y, Ohtsuka T, Oda Y, Nakamura M, Comparison of Surgical Outcomes Between Radical Antegrade Modular Pancreatosplenectomy (RAMPS) and Standard Retrograde Pancreatosplenectomy (SPRS) for Left-Sided Pancreatic Cancer, World J Surg, 40, 9, 2267-75, 2016.04, BACKGROUND: Radical antegrade modular pancreatosplenectomy (RAMPS) is a modification of standard retrograde pancreatosplenectomy (SRPS) used to achieve the dissection of N1 lymph nodes, early vascular control, and negative posterior margins. However, there have been few comparative studies regarding the clinical outcomes of the RAMPS and SRPS procedures.METHODS: Ninety-three patients underwent distal pancreatectomy for the treatment of pancreas body and tail adenocarcinoma between 2000 and 2014. Clinicopathologic data were retrospectively analyzed in this study. We compared short- and long-term outcomes between RAMPS and SRPS. In addition, we investigated the significance of clinicopathologic factors in left-sided pancreatic cancers.RESULTS: Fifty-three patients underwent RAMPS and 40 patients underwent SRPS. RAMPS revealed a larger number of retrieved lymph nodes [28.4 ± 11.6 vs 20.7 ± 10.1; P = 0.0016], more frequent R0 resection [90.5 vs 67.5
%; P = 0.0053], less intraoperative bleeding than SRPS [485.4 ± 63.3 vs 682.3 ± 72.8 ml; P = 0.0444], and shorter operating time (267.3 ± 11.5 vs 339.4 ± 13.2 min; P < 0.0001) as compared with SRPS. In comparing RAMPS and SRPS, RAMPS showed a tendency for improvement of the median survival times than SRPS (47 vs 34 months) (P = 0.1920). In the multivariate analysis, R1 resection, histologic grade, and vascular invasion for overall survival (OS) were found to be independent factors.CONCLUSIONS: There were a decrease of intraoperative bleeding and an increase in the number of retrieved lymph nodes and the R0 resection rate using RAMPS as compared with SRPS..
219. Zheng B, Ohuchida K, Chijiiwa Y, Zhao M, Mizuuchi Y, Cui L, Horioka K, Ohtsuka T, Mizumoto K, Oda Y, Hashizume M, Nakamura M, Tanaka M, CD146 Attenuation in Cancer-Associated Fibroblasts Promotes Pancreatic Cancer Progression, Molecular Carcinogenesis, 55, 1560-1572, 2016.04.
220. Yoshida M, Miyasaka Y, Ohuchida K, Okumura T, Zheng B, Torata N, Fujita H, Nabae T, Manabe T, Shimamoto M, Ohtsuka T, Mizumoto K, Nakamura M, Calpain inhibitor calpeptin suppresses pancreatic cancer by disrupting cancer-stromal interactions in a mouse xenograft model., Cancer Sci, 107, 10, 1443-1452, 2016.04, Desmoplasia contributes to the aggressive behavior of pancreatic cancer. However, recent clinical trials testing several antifibrotic agents on pancreatic cancer have not shown clear efficacy. Therefore, further investigation of desmoplasia-targeting antifibrotic agents by another mechanism is needed. Calpeptin, an inhibitor of calpains, suppressed fibroblast function and inhibited fibrosis. In this study, we investigated the anticancer effects of calpeptin on pancreatic cancer. We investigated whether calpeptin inhibited tumor progression using a mouse xenograft model. We used quantitative RT-PCR to evaluate the expression of calpain-1 and calpain-2 mRNA in pancreatic cancer cells (PCCs) and pancreatic stellate cells (PSCs). We also undertook functional assays, including proliferation, migration, and invasion, to evaluate the inhibitory effects of calpeptin on PCCs and PSCs. Quantitative RT-PCR indicated that PCCs and PSCs expressed calpain-2 mRNA. C
alpeptin reduced tumor volume (P = 0.0473) and tumor weight (P = 0.0471) and inhibited the tumor desmoplastic reaction (P < 0.001) in xenograft tumors in nude mice. Calpeptin also inhibited the biologic functions of PCCs and PSCs including proliferation (P = 0.017), migration (P = 0.027), and invasion (P = 0.035) in vitro. Furthermore, calpeptin reduced the migration of PCCs and PSCs by disrupting the cancer-stromal interaction (P = 0.0002). Our findings indicate that calpeptin is a promising antitumor agent for pancreatic cancer, due not only to its suppressive effect on PCCs and PSCs but also its disruption of the cancer-stromal interaction..
221. Matsunaga T, Ohtsuka T, Asano K, Kimura H, Ohuchida K, Kitada H, Ideno N, Mori Y, Tokunaga S, Oda Y, Guha S, Raimondo M, Nakamura M, Tanaka M, S100P in Duodenal Fluid Is a Useful Diagnostic Marker for Pancreatic Ductal Adenocarcinoma., Pancreas, 46, 10, 1288-1295, 2017.04, OBJECTIVES:

The development of an effective screening method for pancreatic ductal adenocarcinoma (PDAC) is of paramount importance. This study assessed the diagnostic utility in pancreatic diseases of duodenal markers during upper gastrointestinal endoscopy (GIE) or endoscopic ultrasonography.

METHODS:

This study prospectively enrolled 299 consecutive participants, including 94 patients with PDACs, 144 patients with other pancreatic diseases, and 61 normal individuals as control subjects. All subjects underwent upper GIE or endoscopic ultrasonography either at Kyushu University Hospital (Fukuoka, Japan) or the Mayo Clinic (Jacksonville, Fla) from October 2011 to July 2014. Duodenal fluid (DF) was collected without secretin stimulation and of carcinoembryonic antigen and S100 calcium-binding protein P (S100P) concentrations were measured.

RESULTS:

Concentrations of S100P in DF were significantly higher in patients with PDAC and chronic pancreatitis than in control subjects (P < 0.01). A logistic regression model that included age found that the sensitivity and specificity of S100P concentration in diagnosing stages 0/IA/IB/IIA PDAC were 85% and 77%, respectively, with an area under the receiver operating characteristic curve of 0.82. Carcinoembryonic antigen concentrations in DF of patients with pancreatic disease did not differ significantly from control subjects.

CONCLUSIONS:

Analysis of S100P concentration in DF, in combination with routine screening upper GIE, may facilitate the detection of PDAC.
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222. Miyasaka Y, Mori Y, Nakata K, Ohtsuka T, Nakamura M, Prophylactic biliary and gastrointestinal bypass for unresectable pancreatic head cancer: A retrospective case series, Journal of the Pancreas, 18, 6, 470-474, 2017.04.
223. Date S, Noguchi H, Kaku K, Kurihara K, Miyasaka Y, Okabe Y, Nakamura U, Ohtsuka T, Nakamura M, Laparoscopy-Assisted Spleen-Preserving Distal Pancreatectomy for Living-Donor Pancreas Transplantation., Transplant Proc. , 10.1016/j.transproceed.2017.03.037, 49, 5, 1133-1137, 2017.04, BACKGROUND:Living pancreas transplantation plays an important role in the treatment of patients with severe type 1 diabetes. However, pancreatectomy is very invasive for the donor, and less-invasive surgical procedures are needed. Although some reports have described hand-assisted laparoscopic surgery for distal pancreatectomy in living-donor operations, less-invasive laparoscopy-assisted (LA) procedures are expected to increase the donor pool. We herein report the outcomes of four cases of LA spleen-preserving distal pancreatectomy (Warshaw technique [WT]) in living pancreas donors.PATIENTS AND METHODS:Four living pancreas donors underwent LA-WT at our institution from September 2010 to January 2013. All donors fulfilled the donor criteria established by the Japan Society for Pancreas and Islet Transplantation.RESULTS:The median donor age was 54 years. Two donors underwent left nephrectomy in addition to LA-WT for simultaneous pancreas-kidney transpl
antation. The median donor operation time for pancreatectomy was 340.5 minutes. The median pancreas warm ischemic time was 3 minutes. The median donor blood loss was 246 g. All recipients immediately achieved insulin independence. One donor required reoperation because of obstructive ileus resulting from a port-site hernia. Another donor developed a pancreatic fistula (International Study Group of Pancreatic Fistula grade B), which was controlled with conservative management. After a maximum follow-up of 73 months, no clinically relevant adverse events had occurred. These results were comparable with those of previous studies concerning living-donor pancreas transplantation.CONCLUSION:The LA-WT is a safe and acceptable operation for living-donor pancreas transplantation..
224. Ohuchida K, Nagai E, Moriyama T, Shindo K, Manabe T, Ohtsuka T, Shimizu S, Nakamura M, Feasibility and safety of modified inverted T-shaped method using linear stapler with movable cartridge fork for esophagojejunostomy following laparoscopic total gastrectomy., Transl Gastroenterol Hepatol., 23, 2, 50, 2017.04, Abstract
BACKGROUND:
We previously reported the use of an inverted T-shaped method to obtain a suitable view for hand sewing to close the common entry hole when the linear stapler was fired for esophagojejunostomy after laparoscopic total gastrectomy (LTG). This conventional method involved insertion of the fixed cartridge fork to the Roux limb and the fine movable anvil fork to the esophagus to avoid perforation of the jejunum. However, insertion of the movable anvil fork to the esophagus during this procedure often requires us to strongly push down the main body of the stapler with the fixed cartridge fork to bring the direction of the anvil fork in line with the direction of the long axis of the esophagus while controlling the opening of the movable anvil fork. We therefore modified this complicated inverted T-shaped method using a linear stapler with a movable cartridge fork. This modified method involved insertion of the movable cartridge fork into the Roux limb followed by natural, easy insertion of the fixed anvil fork into the esophagus without controlling the opening of the movable cartridge fork.
METHODS:
We performed LTG in a total of 155 consecutive patients with gastric cancer from November 2007 to December 2015 in Kyushu University Hospital. After LTG, we performed the conventional inverted T-shaped method using a linear stapler with a fixed cartridge fork in 61 patients from November 2007 to July 2011 (fixed cartridge group). From August 2011, we used a linear stapler with a movable cartridge fork and performed the modified inverted T-shaped method in 94 patients (movable cartridge group). We herein compare the short-term outcomes in 94 cases of LTG using the modified method (movable cartridge fork) with those in 61 cases using the conventional method (fixed cartridge fork).
RESULTS:
We found no significant differences in the perioperative or postoperative events between the movable and fixed cartridge groups. One case of anastomotic leakage occurred in the fixed cartridge group, but no anastomotic leakage occurred in the movable cartridge group.
CONCLUSIONS:
Although there were no remarkable differences in the short-term outcomes between the movable and fixed cartridge groups, we believe that the modified inverted T-shaped method is technically more feasible and reliable than the conventional method and will contribute to the improved safety of LTG..
225. Okumura T, Ohuchida K, Sada M, Abe T, Endo S, Koikawa K, Iwamoto C, Miura D, Mizuuchi Y, Moriyama T, Nakata K, Miyasaka Y, Manabe T, Ohtsuka T, Nagai E, Mizumoto K, Oda Y, Hashizume M, Nakamura M, Extra-pancreatic invasion induces lipolytic and fibrotic changes in the adipose microenvironment, with released fatty acids enhancing the invasiveness of pancreatic cancer cells., Oncotarget, 8, 11, 18280-18295, 2017.04, Abstract
Pancreatic cancer progression involves components of the tumor microenvironment, including stellate cells, immune cells, endothelial cells, and the extracellular matrix. Although peripancreatic fat is the main stromal component involved in extra-pancreatic invasion, its roles in local invasion and metastasis of pancreatic cancer remain unclear. This study investigated the role of adipose tissue in pancreatic cancer progression using genetically engineered mice (Pdx1-Cre; LSL-KrasG12D; Trp53R172H/+) and an in vitro model of organotypic fat invasion. Mice fed a high fat diet had significantly larger primary pancreatic tumors and a significantly higher rate of distant organ metastasis than mice fed a standard diet. In the organotypic fat invasion model, pancreatic cancer cell clusters were smaller and more elongated in shape and showed increased fibrosis. Adipose tissue-derived conditioned medium enhanced pancreatic cancer cell invasiveness and gemcitabine resistance, as well as inducing morphologic changes in cancer cells and increasing the numbers of lipid droplets in their cytoplasm. The concentrations of oleic, palmitoleic, and linoleic acids were higher in adipose tissue-derived conditioned medium than in normal medium, with these fatty acids significantly enhancing the migration of cancer cells. Mature adipocytes were smaller and the concentration of fatty acids in the medium higher when these cells were co-cultured with cancer cells. These findings indicate that lipolytic and fibrotic changes in peripancreatic adipose tissue enhance local invasiveness and metastasis via adipocyte-released fatty acids. Inhibition of fatty acid uptake by cancer cells may be a novel therapy targeting interactions between cancer and stromal cells..
226. Ohtsuka T, Mori Y, Ishigami K, Fujimoto T, Miyasaka Y, Nakata K, Ohuchida K, Nagai E, Oda Y, Shimizu S, Nakamura M, Clinical significance of circumportal pancreas, a rare congenital anomaly, in pancreatectomy., Am J Surg, 214, 2, 267-272, 2017.04, Abstract
BACKGROUND:
Circumportal pancreas is a rare congenital pancreatic anomaly. The aim of this study was to clarify the clinical characteristics of patients with circumportal pancreases undergoing pancreatectomy.
METHODS:
The medical records of 508 patients who underwent pancreatectomy were retrospectively reviewed. The prevalence of circumportal pancreas and related anatomical variations were assessed. Surgical procedures and postoperative outcomes were compared in patients with and without circumportal pancreas.
RESULTS:
Circumportal pancreas was observed in 9 of the 508 patients (1.7%). In all nine patients, the portal vein was completely encircled by the pancreatic parenchyma above the level of the splenoportal junction, and the main pancreatic duct ran dorsal to the portal vein. The rate of variant hepatic artery did not differ significantly in patients with and without circumportal pancreas. Pancreatic fistula developed more frequently in patients with than without circumportal pancreas (44% vs. 14%, p = 0.03), but other clinical parameters did not differ significantly in these two groups.
CONCLUSIONS:
Despite being rare, circumportal pancreas may increase the risk of postoperative pancreatic fistula in patients undergoing pancreatectomy. However, a prospective, large-cohort study is necessary to determine the real incidence of relevant anatomical variations and the definitive clinical significance of this rare anomaly..
227. Abe T, Ohuchida K, Endo S, Ookubo F, Mori Y, Nakata K, Miyasaka Y, Manabe T, Ohtsuka T, Nagai E, Oda Y, Nakamura M, Clinical importance of intraoperative peritoneal cytology in patients with pancreatic cancer, Surgery, 161, 4, 951-958, 2017.04, BACKGROUND:The clinical importance of intraoperative peritoneal cytology in patients with pancreatic cancer remains incompletely understood.METHODS:Peritoneal washing samples were collected from 411 consecutive patients with pancreatic ductal adenocarcinoma from 1996 to 2014. Of the 411 patients, 335 underwent macroscopically curative resection and 76 with noncurative factors did not undergo resection. We compared long-term outcomes between patients with positive cytology (cytology+) and those with negative cytology (cytology-) and investigated the importance of clinicopathologic factors.RESULTS:Of 335 patients with curative resection, 300 (89.6%) were cytology- and 35 (10.4%) were cytology+. The median overall survival of cytology+ patients was less than that of cytology- patients (16 vs 31 months, respectively; P < .0001). The median overall survival of cytology+ patients with noncurative factors was significantly worse than that of cytology+ pat
ients with curative resection (6.9 vs 16.0 months, respectively; P = .0023). The median disease-free survival of cytology+ patients was less than that of cytology- patients (6.5 vs 16 months, respectively; P < .0001). In the multivariate analysis, cytology+ was an independent prognostic factor for overall survival and disease-free survival.CONCLUSION:Cytology+ without noncurative factors was a predictive factor for a poor prognosis. Therefore, it is important to regard patients with pancreatic cancer characterized by cytology+ as a special group that may warrant more aggressive adjuvant therapy..
228. Abe T, Ohuchida K, Koikawa K, Endo S, Okumura T, Sada M, Horioka K, Zheng B, Moriyama T, Nakata K, Miyasaka Y, Manabe T, Ohtsuka T, Nagai E, Mizumoto K, Hashizume M, Nakamura M, Cancer-associated peritoneal mesothelial cells lead the formation of pancreatic cancer peritoneal dissemination, Int J Oncol, 50, 2, 457-467, 2017.04, The interaction between the cancer cells and the peritoneal mesothelial cells (PMCs) plays an important role in the peritoneal dissemination in several types of cancer. However, the role of PMCs in the peritoneal dissemination of pancreatic cancer remains unclear. In the present study, we investigated the interaction between the pancreatic cancer cells (PCCs) and the PMCs in the formation of peritoneal dissemination in vitro and in vivo. The tumor-stromal interaction of PCCs and PMCs significantly enhanced their mobility and invasiveness and enhanced the proliferation and anoikis resistance of PCCs. In a 3D organotypic culture model of peritoneal dissemination, co-culture of PCCs and PMCs significantly increased the cells invading into the collagen gel layer compared with mono-culture of PCCs. PMCs pre-invaded into the collagen gel, remodeled collagen fibers, and increased parallel fiber orientation along the direction of cell invasion. In the tissues
of peritoneal dissemination of the KPC (LSL-KrasG12D/+; LSL-Trp53R172H/+;Pdx-1-Cre) transgenic mouse, the monolayer of PMCs was preserved in tumor-free areas, whereas PMCs around the invasive front of peritoneal dissemination proliferated and invaded into the muscle layer. In vivo, intraperitoneal injection of PCCs with PMCs significantly promoted peritoneal dissemination compared with PCCs alone. The present data suggest that the cancer-associated PMCs have important promoting roles in the peritoneal dissemination of PCCs. Therapy targeting cancer-associated PMCs may improve the prognosis of patients with pancreatic cancer..
229. Endo S, Nakata K, Ohuchida K, Takesue S, Nakayama H, Abe T, Koikawa K, Okumura T, Sada M, Horioka K, Zheng B, Mizuuchi Y, Iwamoto C, Murata M, Moriyama T, Miyasaka Y, Ohtsuka T, Mizumoto K, Oda Y, Hashizume M, Nakamura M, Autophagy Is Required for Activation of Pancreatic Stellate Cells, Associated With Pancreatic Cancer Progression and Promotes Growth of Pancreatic Tumors in Mice, Gastroenterology, 152, 6, 1492-1506, 2017.04, BACKGROUND & AIMS: Pancreatic stellate cells (PSCs) changefrom a quiescent to activated state in the tumor environmentand secrete extracellular matrix (ECM) molecules and cytokinesto increase the aggressiveness of tumors. However, it is notclear how PSCs are activated to produce these factors, orwhether this process can be inhibited. PSCs have morphologicand functional similarities to hepatic stellate cells, whichundergo autophagy to promote fibrosis and tumor growth. Weinvestigated whether autophagy activates PSCs, which promotesdevelopment of the tumor stroma and growth ofpancreatic tumors in mice. METHODS: We used immunofluorescencemicroscopy and immunohistochemistry to analyzepancreatic tumor specimens from 133 patients who underwentpancreatectomy in Japan from 2000 to 2009. PSCs werecultured from pancreatic tumor tissues or tissues of patientswith chronic pancreatitis; these were analyzed by immunofluorescencemicroscopy, immunoblots, quantitative
reversetranscription polymerase chain reaction, and in assays forinvasiveness, proliferation, and lipid droplets. Autophagy wasinhibited in PSCs by administration of chloroquine or transfectionwith small interfering RNAs. Proteins were knockeddown in immortalized PSCs by expression of small hairpinRNAs. Cells were transplanted into pancreatic tails of nudemice, and tumor growth and metastasis were quantified. RESULTS:Based on immunohistochemical analyses, autophagywas significantly associated with tumor T category (P シ .018),histologic grade (P シ .001), lymph node metastases (P < .001),stage (P シ .009), perilymphatic invasion (P シ .001), and perivascularinvasion (P シ .003). Autophagy of PSCs was associatedwith shorter survival times of patients with pancreatic cancer.PSC expression of microtubule-associated protein 1 lightchain 3, a marker of autophagosomes, was associated with pooroutcomes (shorter survival time, disease recurrence) forpati
ents with pancreatic cancer (relative risk of shorter survivaltime, 1.56). Immunoblots showed that PSCs from pancreatictumor samples expressed higher levels of markers of autophagythan PSCs from chronic pancreatitis samples. Inhibitorsof autophagy increased the number of lipid droplets of PSCs,indicating a quiescent state of PSCs, and reduced their productionof ECM molecules and interleukin 6, as well as theirproliferation and invasiveness in culture. PSCs exposedto autophagy inhibitors formed smaller tumors in nude mice(P シ .001) and fewer liver metastases (P シ .018) with lessperitoneal dissemination (P シ .018) compared to PSCs notexposed to autophagy inhibitors. CONCLUSIONS: AutophagicPSCs produce ECM molecules and interleukin 6 and areassociated with shorter survival times and disease recurrencein patients with pancreatic cancer. Inhibitors of PSC autophagymight reduce pancreatic tumor invasiveness by altering thetumor stroma..
230. Endo S, Nakata K, Sagara A, Koikawa K, Ando Y, Kibe S, Takesue S, Nakayama H, Abe T, Okumura T, Moriyama T, Miyasaka Y, Ohuchida K, Ohtsuka T, Mizumoto K, Nakamura M, Autophagy inhibition enhances antiproliferative effect of salinomycin in pancreatic cancer cells, Pancreatology, 10.1016/j.pan.2017.08.009, 17, 6, 990-996, 2017.04, Background: Salinomycin has cytotoxic effects on various types of malignancy and induces autophagy.However, it has not been clarified whether autophagy induced by salinomycin treatment has a protectiveor cytotoxic role. We investigated whether salinomycin affects autophagy in pancreatic cancer cells andwhether autophagy induced by salinomycin treatment has a protective or cytotoxic role in these cells.Methods: We investigated the effect of salinomycin using three pancreatic cancer cell lines. We investigatedeffect on proliferation and the CD133 positive fraction using flow cytometry. In addition, wemonitored the change in autophagic activity after salinomycin treatment using fluorescent immunostaining,western blotting, and flow cytometry. Finally, knockdown of ATG5 or ATG7 by siRNA was usedto investigate the impact of autophagy inhibition on sensitivity to salinomycin.Results: Salinomycin suppressed the proliferation of pancreatic cancer cells in a co
ncentration dependentmanner, and reduced the CD133 positive fraction. Salinomycin enhanced autophagy activity in these cellsin a concentration dependent manner. Autophagy inhibition made pancreatic cancer cells more sensitiveto salinomycin.Conclusions: Our data provide the first evidence indicating that autophagy induced by salinomycin havea protective role in pancreatic cancer cells. A new therapeutic strategy of combining salinomycin,autophagy inhibitors, and anticancer drugs could hold promise for pancreatic cancer treatment..
231. Nakamura M, Nakata K, Matsumoto H, Ohtsuka T, Yoshida K, Tokunaga S, Hino K, Acyl/free carnitine ratio is a risk factor for hepatic steatosis after pancreatoduodenectomy and total pancreatectomy., Pancreatology, 17, 1, 135-138, 2017.04, Abstract
OBJECTIVES:
Hepatic steatosis, one of the most frequent long-term complications of pancreatectomy, influences not only hepatic function but also survival rate. However, its risk factors and pathogenesis have not been established. The purpose of this study was to clarify the risk factors for hepatic steatosis after pancreatectomy.
METHODS:
In this retrospective study of 21 patients who had undergone pancreatectomy (19 cases of pancreatoduodenectomy and 2 cases of total pancreatectomy), serum carnitine concentrations, fractions of carnitine, and hepatic attenuation on computed tomography images were analyzed with the aim of identifying risk factors for hepatic steatosis.
RESULTS:
Thirteen (61.9%) of the 21 patients were diagnosed as having hypocarnitinemia after pancreatectomy. Average hepatic attenuation was as low as 42.2HU (±21.3 SD). A high ratio of acyl/free carnitine was associated with less pronounced hepatic attenuation according to both univariate (P < 0.001) and multivariate (P = 0.020) regression analyses.
CONCLUSIONS:
The serum carnitine concentrations were low after pancreatectomy in some patients. The statistical analyses suggest that a high ratio of acyl/free carnitine is an independent risk factor for hepatic steatosis after pancreatectomy..
232. Date K, Ohtsuka T, Nakamura S, Mochidome N, Mori Y, Miyasaka Y, Oda Y, Nakamura M, Surveillance of patients with intraductal papillary mucinous neoplasm with and without pancreatectomy with special reference to the incidence of concomitant pancreatic ductal adenocarcinoma, Surgery, 10.1016/j.surg.2017.09.040, 163, 2, 291-299, 2018.04, Abstract
BACKGROUND:
The presence of an intraductal papillary mucinous neoplasm is important in the detection of concomitant pancreatic ductal adenocarcinoma. The aim of this study was to elucidate the incidence and timing of development of concomitant pancreatic ductal adenocarcinoma in patients with and without pancreatectomy for intraductal papillary mucinous neoplasm.

METHODS:
We reviewed retrospectively the surveillance data for 22 patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm (pancreatic ductal adenocarcinoma-resection group), 180 who underwent pancreatectomy for intraductal papillary mucinous neoplasm (intraductal papillary mucinous neoplasm-resection group), and 263 whose intraductal papillary mucinous neoplasms were left untreated (nonresection group). The incidence and timing of the development of a concomitant pancreatic ductal adenocarcinoma during the surveillance of patients with and without partial pancreatectomy for intraductal papillary mucinous neoplasm were investigated using the Kaplan-Meier method.

RESULTS:
During a median surveillance period of 40 months (range 6-262 months), 5 patients in the pancreatic ductal adenocarcinoma-resection group, 6 in the intraductal papillary mucinous neoplasm-resection group, and 8 in the nonresection group developed concomitant pancreatic ductal adenocarcinoma. The estimated 5-year (17%) and 10-year (56%) cumulative incidences of secondary pancreatic ductal adenocarcinoma in the pancreatic ductal adenocarcinoma-resection group were significantly greater than those in the other two groups (P < .01). Conversely, the difference in the estimated cumulative incidence of concomitant pancreatic ductal adenocarcinoma between the intraductal papillary mucinous neoplasm-resection and nonresection groups was not significant (5-year, 5.0% vs 2.2%; 10-year, 5.0% vs 8.7%; P = .87).

CONCLUSION:
Long-term (≥5-year) surveillance in patients with intraductal papillary mucinous neoplasm is necessary and important because of the potential for development of concomitant pancreatic ductal adenocarcinoma. Those with a history of resection of concomitant pancreatic ductal adenocarcinoma at the time of the initial operation are at quite high risk for the development of secondary pancreatic ductal adenocarcinoma..
233. Koikawa K, Ohuchida K, Takesue S, Ando Y, Kibe S, Nakayama H, Endo S, Abe T, Okumura T, Horioka H, Sada M, Iwamoto C, Moriyama T, Nakata K, Miyasaka Y, Ohuchida R, Manabe T, Ohtsuka T, Nagai E, Mizumoto K, Hashizume M, Nakamura M, Pancreatic stellate cells reorganize matrix components and lead pancreatic cancer invasion via the function of Endo180, Cancer letters, 10.1016/j.canlet.2017.10.010, 1, 412, 143-154, 2018.04, Specific cell populations leading the local invasion of cancer are called “leading cells”. However, the underlying mechanisms are unclear. Here, we identified leading cells in pancreatic cancer and deter- mined how these cells lead and promote cancer cell invasion in the extracellular matrix (ECM). Using three-dimensional matrix remodeling assay, we found that pancreatic stellate cells (PSCs) frequently invaded the collagen matrix with pancreatic cancer cells (PCCs), which invaded behind the invading PSCs. In addition, invading PSCs changed the alignment of collagen fibers, resulting in ECM remodeling and an increase in the parallel fibers along the direction of invading PSCs. Endo180 expression was higher in PSCs than in PCCs, Endo180 knockdown in PSCs attenuated the invasive abilities of PSCs and co- cultured PCCs, and decreased the expression level of phosphorylated myosin light chain 2 (MLC2). In mouse models, Endo180-knockdown PSCs
suppressed tumor growth and changes in collagen fiber orientation in co-transplantation with PCCs. Our findings suggest that PSCs lead the local invasion of PCCs by physically remodeling the ECM, possibly via the function of Endo180, which reconstructs the actin cell skeleton by phosphorylation of MLC2..
234. Kanno A, Masamune A, Hanada K, Maguchi H, Shimizu Y, Ueki T, Hasebe O, Ohtsuka T, Nakamura M, Takenaka M, Kitano M, Kikuyama M, Gabata T, Yoshida K, Sasaki T, Serikawa M, Furukawa T, Yanagisawa A, Shimosegawa T, Multicenter study of early pancreatic cancer in Japan, Pancreatology, 10.1016/j.pan.2017.11.007, 18, 1, 61-67, 2018.04, Abstract
BACKGROUND/OBJECTIVES:
The diagnosis of early-stage pancreatic ductal adenocarcinoma (PDAC) is still challenging. We conducted a multicenter study to clarify the clinical features of early-stage PDAC in Japan.

METHODS:
We collected patients with stage 0 and stage I PDAC according to the sixth edition of the Japanese Classification of Pancreatic Carcinoma. We retrospectively analyzed the clinical profiles including opportunities for medical examination, imaging modalities and findings, methods of cytological diagnosis, and prognosis according to the stages at diagnosis.

RESULTS:
Two hundred cases with Stage 0 and stage I PDAC were reported from 14 institutions, which accounted for approximately 0.7% and 3% of all PDAC cases, respectively. Overall, 20% of the early-stage PDAC cases were symptomatic. Indirect imaging findings such as dilatation of the main pancreatic duct were useful to detect early-stage PDAC. In particular, local fatty changes may be specific to early-stage PDAC. For preoperative pathologic diagnosis, cytology during endoscopic retrograde cholangiopancreatography was more commonly applied than endoscopic ultrasound fine-needle aspiration. Although the overall prognosis was favorable, new PDAC lesions developed in the remnant pancreas in 11.5% cases.

CONCLUSIONS:
This multicenter study revealed several key points concerning the diagnosis and management of early-stage PDAC, including screening of asymptomatic cases, importance of indirect imaging findings, application of cytology during endoscopic retrograde cholangiopancreatography, and the risk of carcinogenesis in the remnant pancreas..
235. Aly MYF, Mori Y, Miyasaka Y, Ohtsuka T, Sadakari Y, Nakata K, Oda Y, Shimizu S, Nakamura M, Laparoscopic surgery for congenital biliary dilatation: a single-institution experience, Surg Today, 10.1007/s00595-017-1545-3, 48, 1, 44-50, 2018.04, Abstract
PURPOSE:
Laparoscopic surgery as a treatment for congenital biliary dilatation is uncommon. We herein present a series of laparoscopic surgeries for congenital biliary dilatation performed in our institution and review our experience with this approach over a long period of time.

METHODS:
Medical records of 36 consecutive patients who underwent laparoscopic surgery for congenital biliary dilatation from 1996 to 2015 were retrospectively reviewed. Data on patient demographics, operative time, blood loss, hospital stay, and complications were evaluated. A comparison between the former period (Group A, 1996-2005) and the latter period (Group B, 2006-2015) was performed.

RESULTS:
The patients comprised 23 females and 13 males with a median age of 34 years. The median operative time, blood loss, and hospital stay was 493 min, 154 g, and 11 days, respectively. Total early and late complications occurred in 7 (19%) and 2 (5%) patients, respectively. A comparison between Groups A and B revealed no significant difference in operative time or complications, but operative blood loss, open conversion, and hospital stay were significantly lower in Group B than in Group A (P < 0.05).

CONCLUSION:
Laparoscopic surgery for congenital biliary dilatation is feasible and provides acceptable results. Further prospective studies of larger numbers of patients are needed..
236. Ohtsuka T, Mori Y, Fujimoto T, Miyasaka Y, Nakata K, Ohuchida K, Nagai E, Oda Y, Shimizu S, Nakamura M, Feasibility of Prophylactic Pancreatojejunostomy in Possible High-Risk Patients for Prevention of Pancreatic Fistula during Enucleation or Limited Pancreatic Resection, Am Surg, 84, 1, 149-153, 2018.04, Abstract
The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with (n = 10) and without (n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer (P < 0.01) and blood loss significantly greater (P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent (P = 0.02) and postoperative hospital stay was significantly longer (P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study..
237. Koikawa K, Ohuchida K, Ando Y, Kibe S, Nakayama H, Takesue S, Endo S, Abe T, Okumura T, Iwamoto C, Moriyama T, Nakata K, Miyasaka Y, Ohtsuka T, Nagai E, Mizumoto K, Hashizume M, Nakamura M, Basement membrane destruction by pancreatic stellate cells leads to local invasion in pancreatic ductal adenocarcinoma, Cancer Letters, 10.1016/j.canlet.2018.03.031 , 1, 425, 65-77, 2018.04, Stroma invasion is an important step in pancreatic cancer progression. However, how pancreatic ductal adenocarcinoma (PDAC) with ductal structure invades the surrounding stroma has not been clear. Here, we elucidated the mechanism of stromal invasion of PDAC, using organoids. From resected PDAC specimens, we established human PDAC organoids, which developed ductal and basement membrane (BM) structures. When the organoids were co-cultured with pancreatic stellate cells (PSCs) in a collagen matrix, organoids lost their BM and ductal structures, and invaded collagen matrix more frequently than did mono-cultured organoids. Interestingly, direct contact by PSCs to PDAC organoids was observed before BM destruction. Matrix metalloproteinase (MMP) 2 or membrane type-1 MMP (MT1MMP) knockdown in PSCs significantly attenuated BM destruction by PSCs, and retained the ductal structures in organoids. Our results imply that direct contact by PSCs induces BM destruct
ion and stromal invasion of PDAC via MMP2 which binds to MT1MMP on PSCs..