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Background Taiwan is an area with moderate to high incidence of Mycobacterium tuberculosis infection. The risk of M tuberculosis infection in transplantation recipients is considered to be significant. Our aim in this study was to investigate the clinical spectrums of M tuberculosis–infected transplantation recipients in a southeast Asian country, Taiwan. Methods We retrospectively analyzed the demographic data, clinical features, treatment, and outcome of M tuberculosis infection in kidney, heart, and liver transplant recipients from May 1996 to April 2005 at the National Taiwan University Hospital. Results Fifteen patients who had received solid organ transplantation developed tuberculosis (kidney = 6, heart = 7, liver = 2). The median duration from transplantation to diagnosis of tuberculosis was 31 months. The cumulative incidence of posttransplantation tuberculosis was 2.0% (15/760), ie, ~ 3 times that of the general population. Ten patients (66.7%) had pulmonary tuberculosis, 1 (6.7%) had extrapulmonary tuberculosis, and 4 (26.7%) had disseminated tuberculosis. Nine patients completed the anti-tuberculosis treatment; the median treatment duration was 12 months (pulmonary: 9 months; extrapulmonary: 13.5 months). No treatment failure was noted in patients receiving the complete treatment course. The graft failure and mortality rates of post-transplantation tuberculosis were 13.3% each (2/15). The tuberculosis-associated mortality rate was 6.7% (1/15). Conclusions Cumulative incidence of tuberculosis was slightly higher in transplant recipients than in the general population in Taiwan. Conventional 4-combined anti-tuberculosis regimen for 12 months can treat the potentially fatal infection successfully in posttransplantation tuberculosis patients without recurrence.

A 47-year-old man with chronic hepatitis B had progressive elevated alpha-fetoprotein of 2 years' duration. A pancreatic tail tumor, instead of liver tumor, was detected. He underwent elective distal pancreatectomy and splenectomy and the pathology turned out to be acinar cell carcinoma of the pancreas. Serum level of alpha-fetoprotein returned to normal soon after surgery. No cancer recurrence was noted after 3 years of follow-up. Alpha-fetoprotein is commonly used as a tumor marker to screen for hepatocellular carcinoma in high-risk patients. However, elevated alpha-fetoprotein could occur in a much rarer disease, acinar cell carcinoma of the pancreas.

To evaluate whether the tumour suppressor gene, PPP2R1B, is involved in pathogenesis of hepatocellular carcinoma (HCC), reverse transcription-polymerase chain reaction (RT-PCR) and cDNA sequencing were performed. Eleven of 38 (29%) tumours and 1 of 34 (3%) corresponding non-tumour tissues showed coexpression of wild-type and aberrant mRNA. Various deletions were found in aberrant transcripts. Southern blot analysis did not show gene deletion in tumours, suggesting abnormal RNA splicing may be involved. These data suggest the possibility that aberrant transcripts of PPP2R1B might be associated with the development of HCC.

Connective tissue growth factor (CTGF) expression is elevated in advanced stages of breast cancer, but the regulatory role of CTGF in invasive breast cancer cell phenotypes is unclear. Presently, overexpression of CTGF in MCF-7 cells (MCF-7/CTGF cells) enhanced cellular migratory ability and spindle-like morphological alterations, as evidenced by actin polymerization and focal-adhesion-complex aggregation. Reducing the CTGF level in MDA-MB-231 (MDA231) cells by antisense CTGF cDNA (MDA231/AS cells) impaired cellular migration and promoted a change to an epithelial-like morphology. A neutralizing antibody against integrin alphavbeta3 significantly attenuated CTGF-mediated ERK1/2 activation and cellular migration, indicating that the integrin-alphavbeta3-ERK1/2 signaling pathway is crucial in mediating CTGF function. Moreover, the cDNA microarray analysis revealed CTGF-mediated regulation of the prometastatic gene S100A4. Transfection of MCF-7/CTGF cells with AS-S100A4 reversed the CTGF-induced cellular migratory ability, whereas overexpression of S100A4 in MDA231/AS cells restored their high migratory ability. Genetic and pharmacological manipulations suggested that the CTGF-mediated S100A4 upregulation was dependent on ERK1/2 activation, with expression levels of CTGF and S100A4 being closely correlated with human breast tumors. We conclude that CTGF plays a crucial role in migratory/invasive processes in human breast cancer by a mechanism involving activation of the integrin-alphavbeta3-ERK1/2-S100A4 pathway.

The purpose of this study was to evaluate the relationship between the expression of PlGF in tumor tissue and clinical outcomes in HCC patients. Tumor PlGF and vascular endothelial growth factor (VEGF)-A and VEGF-C mRNA were analyzed. Results demonstrated that patients with PlGF expression levels higher than median tended to have early recurrence compared to patients with PlGF expression lower than median ( P = .031). In patients with AJCC stage II–III disease, this difference was even more significant ( P = .002). In contrast, VEGF-A and VEGF-C could not predict early recurrence-free survival. Since PlGF expression correlated with early recurrence of HCC, PlGF may be an important prognostic indicator in HCC.

Many Japanese surgeons routinely perform extended D3 lymph node dissection for the treatment of advanced rectosigmoid cancer with a view to achieving better tumor control. However, the application of a laparoscopic approach to perform D3 lymphadenectomy has been challenging. This phase 2 prospective study aimed to explore the oncologic results of this surgical approach.The study was conducted during a 6-year period, in consideration of median follow-up time being3 years. The study subjects were tumor, node, metastasis system stage III rectosigmoid cancer staged by clinical images. The extent of D3 dissection and the postoperative lymph node mapping were according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Patients were stratified according to the histopathologically proved highest level of involved lymph nodes and placed into N0, N1, N2, and N3 groups. The primary end points of the study were the estimated time to recurrence and 5-year recurrence rate of cancer after laparoscopic D3 dissection.The estimated 5-year recurrence rate (20% in the N0 group [n = 10]; 25% in N1 [n = 44]; 33.3% in N2 [n = 30]; and 42.8% in N3 [n = 14]), time to recurrence (mean [95% confidence interval] 59.8 [42.6-76.9] months in the N0 group; 56.8 [48.3-65.2] months in N1; 46.8 [37.5-56.1] months in N2; and 43.9 [28.3-59.4] months in N3), and recurrence patterns were without significant difference (all P values.05) among N0, N1, N2, and N3 groups. Therefore, by laparoscopic wide anatomic dissection, patients with lymph node involvement could be treated as well as those without lymph node metastasis. Laparoscopic D3 dissection facilitated the collection of more lymph nodes (mean +/- standard deviation, 27.4 +/- 4.2) for histopathologic examination. Mapping of dissected lymph nodes showed that 18.2% (16 of 88) patients had skip lymph node metastasis. D3 dissection facilitated upstaging of cancer (from N0 to N3) in five patients (5.1%). However, this procedure resulted in transient voiding dysfunction in 77.5% patients and loss of ejaculatory function in 91.7%. By laparoscopic approach, the D3 lymph node dissection was safely performed through small wounds, resulting in quick functional recovery and only moderate blood loss (324.8 +/- 44.5 mL), but at the expense of a long operation time (294.4 +/- 34.8 minutes).The good short-term oncologic results and quick convalescence mean that the laparoscopic D3 dissection may be recommended for patients with stage III rectosigmoid cancer who could accept the genitourinary dysfunction.

Preoperative diagnosis of hepatic angiomyolipoma is difficult, and the treatment for it remains controversial. The aim of this study is to review our experience in the treatment of hepatic angiomyolipoma and to propose a treatment strategy for this disease. We retrospectively collected the clinical, imaging, and pathological features of patients with hepatic angiomyolipoma. Immunohistochemical studies with antibodies for HMB-45, actin, S-100, cytokeratin, vimentin, and c-kit were performed. Treatment experience and long-term follow-up results are summarized. During a period of 9 years, 10 patients with hepatic angiomyolipoma were treated at our hospital. There was marked female predominance (nine patients). Nine patients received surgical resection without complications. One patient received nonoperative management with biopsy and follow-up. One patient died 11 months after surgery because of recurrent disease. We propose all symptomatic patients should receive surgical resection for hepatic angiomyolipoma. Conservative management with close follow-up is suggested in patients with asymptomatic tumors and meet the following criteria: (1) tumor size smaller than 5 cm, (2) angiomyolipoma proved through fine needle aspiration biopsy, (3) patients with good compliance, and (4) not a hepatitis virus carrier.

Telomere shortening limits the proliferative capacity of human cells, restrains the regenerative capacity of organ systems during chronic diseases and aging and also induces chromosomal instability as well as initiation of cancer. Previous studies demonstrated that telomeres are often significantly shorter in tumor tissue, including hepatocellular carcinoma (HCC), compared to the surrounding tissue, but telomere length in HCC tissues was not correlated with several clinical parameters, such as age, sex, HBV or HCV infections and tumor size. In the present study, the telomere length ratio of 36 paired HCC, and their adjacent non-tumor tissues was measured by quantitative PCR (Q-PCR). The mean telomere lengths (SD) for HCC and adjacent non-tumor tissues were 0.26 (0.10) and 0.47 (0.20) respectively (t = 6.22, P < 0.0001). There was a large difference in the distribution of subjects based on telomere length in tumor and adjacent non-tumor tissues. The number of tumors with telomere length shorter than 0.50 was much higher than that of adjacent non-tumor tissues; more than 90% of the tissues with telomere length ≥ 0.50 were adjacent non-tumor tissues. The correlations between telomere length and aflatoxin B1- and polycyclic aromatic hydrocarbon-DNA adducts level, p53 mutations and p16 hypermethylation status were also tested, but no significant associations were found. The relationship between telomere length shortening, chemical carcinogen exposure, and genetic and epigenetic changes in hepatocarcinogenesis needs further investigation.

Clinical and pathogenic differences exist between hepatitis B viral (HBV) genotypes B and C, and genotype C has a higher risk of hepatocellular carcinoma (HCC) development than genotype B. The aim of this study was to investigate whether HBV genotypes B and C influence the clinicopathological features of patients with resectable HCC. Stored serum samples from 193 patients with resectable HBV-related HCC were tested for HBV genotypes by a molecular method. Of 193 patients undergoing resection of HCC, 107 (55%) and 86 (45%) were infected with genotypes B and C, respectively. Compared with genotype C patients, genotype B patients were less likely to be associated with liver cirrhosis (33%vs 51%, P = 0.01). Pathologically, genotype B patients had a higher rate of solitary tumour (94%vs 86%, P = 0.048) and more satellite nodules (22%vs 12%, P = 0.05) than genotype C patients. Our results indicate that genotype B-related HCC is less associated with liver cirrhosis and has a higher frequency of solitary tumour as well as more satellite nodules than genotype C-related HCC. These characteristics may contribute to the recurrence patterns and prognosis of HBV-related HCC in patients with genotype B or C infection.

Background/purpose Gene expression profiles of liver regeneration are well explored in rat models. However, there are limited relative data in humans. This study aimed to show that mRNA expression profiles change immediately after right hepatectomy in living-related donors and correlate with mechanisms of liver regeneration reported in the literature. Methods Prospective study was conducted from March 2003 to August 2004. Living-related donors who donated right lobe of liver were included. Liver biopsies were performed at the beginning and, 5 hours later, at the end of liver resection. RNAs were isolated to synthesize cRNA. Oligo DNA microarray experiments were conducted and paired signal intensity ratios (Cy3/Cy5) were normalized with rank-invariant global Lowess regression analysis by taking base two logarithms. Genes whose average residuals more than 2.5-fold increased or less than −2.5-fold decreased were selected to get the most pronounced expression changes during this period. Results Five of 34 donors were included with qualified samples. The expression patterns of paired DNA microarray experiments were similar in five donors. A total of 28 upregulated and 14 downregulated genes were collected. Acute-phase proteins (serum amyloid A, complement-reactive protein, heme oxygenase-1) were up-regulated. Genes related to growth signal transduction (G-protein coupled receptor-30) were downregulated. Conclusion Gene expression profiles immediately after partial hepatectomy were reported first in humans with the techniques of oligo DNA microarray, which were compatible with the initial gene expression patterns of liver regeneration in rats. [ J Formos Med Assoc 2007;106(4):288-294]

Gastrointestinal bypass changes the gut microbiota and decreases systemic endotoxemia in obese subjects. Epithelial barrier integrity is crucial for confining enteric bacteria in the lumen and preventing gut-derived endotoxemia. The effect of bypass surgery on intestinal barrier functions remains poorly understood. This study aimed to evaluate the changes in intestinal permeability and gut barrier between rats receiving Roux-en-Y duodenojejunal bypass (DJB) or sham operation (SO).Eighteen Sprague-Dawley rats were assigned to DJB or SO groups. Tissues of the alimentary, biliopancreatic, and common limbs in the small intestine, and the colon, were collected 2 weeks after operation. Mucosa-associated bacteria were quantified by colony forming units. Intestinal permeability was determined by mucosal-to-serosal dextran flux measured in Ussing chambers. Expression of occludin and proliferating cell nuclear antigen (PCNA) in the intestinal mucosa was examined by western blots.Enteric bacterial numbers were increased in the alimentary and common limbs after DJB. Reduced dextran permeability was found in the alimentary limb, common limb, and colon after DJB. Moreover, increased villus height and crypt depth were found to be associated with higher mucosal levels of occludin and PCNA levels in the alimentary and common limbs after DJB.DJB in rats altered gut microbiota and reduced intestinal permeability due to increased epithelial proliferation and tight junctional protein expression. Our results show that bypass surgery led to fortification of the intestinal barrier functions, which may provide an explanation for the decreased risk of systemic endotoxemia in postoperative patients.

Liver fibrosis represents the end stage of chronic liver inflammatory diseases and is defined by the abnormal accumulation of extracellular matrix in the liver. Advanced liver fibrosis results in cirrhosis, liver failure, and portal hypertension. Liver transplantation has been the most effective treatment for these diseases, but the procedure is limited by the shortage of suitable donors. Mesenchymal stromal cells (MSCs) have shown great potential in the treatment of chronic inflammatory diseases associated with fibrosis. This study aimed to evaluate the therapeutic effect of MSC-based cell transplantation as an alternative treatment for liver fibrosis. A CD34-positive subpopulation of human placental amnion membrane-derived stem/progenitor cells (CD34+ AMSPCs) was isolated through the depletion of CD34-negative stromal fibroblasts (CD34− AMSFCs) facilitated by CD34 fluorescence-activated cell sorting, enriched and expanded ex vivo. These cells express pluripotency markers and demonstrate multidirectional differentiation potentials. Comparative analysis was made between CD34+ AMSPCs and CD34− AMSFCs in terms of the expressions of stemness surface markers, embryonic surface antigens, and multilineage differentiation potentials. A mouse model of liver fibrosis was established by thioacetamide (TAA) administration. When injected into the spleen of TAA-injured mice, human placental amnion membrane-derived MSCs (hAM-MSCs) can engraft into the injury site, ameliorate liver fibrosis, and restore liver function, as shown by pathological and blood biochemical analysis and downregulated gene expressions associated with liver damage. CD34+ AMSPCs represent a more primitive subset of hAM-MSCs and could be a suitable candidate with a potentially better safety profile for cell-based therapy in treatment of liver diseases associated with fibrosis. Significance In this study, a CD34+ subpopulation of stem/progenitor cells derived from neonatal placental amnion membrane, denoted as CD34+ AMSPCs, were identified, enriched, and characterized. These cells are highly proliferative, express mesenchymal stromal cells and pluripotent stem cell markers, and demonstrate multidirectional differentiation potentials, indicating their promising application in clinical regenerative therapies. CD34+ AMSPC transplantation ameliorated liver fibrosis in mice with drug-induced liver injury. These cells represent a potential therapeutic agent for treating liver diseases associated with fibrosis.

The deregulation of autophagy is involved in liver regeneration. Here, we investigated the role of autophagy in the regulation of liver regeneration after partial hepatectomy (PHx) and the development of pharmacological interventions for improved liver regeneration after PHx. We show that autophagy was activated in the early stages of liver regeneration following 70% PHx in vivo. Moreover, amiodarone was associated with a significant enhancement of autophagy, liver growth and hepatocyte proliferation, along with reduced liver injury and the termination of liver regeneration due to decreased transforming growth factor-β1 expression after 70% PHx. The promotion of autophagy appeared to selectively increase the removal of damaged mitochondria. We also found that Atg7 knockdown or pretreatment with chloroquine aggravated the liver injury associated with 70% PHx and reduced liver growth and hepatocyte proliferation. Finally, amiodarone improved liver regeneration, survival and liver injury after 90% PHx. In conclusion, our results indicate that autophagy plays an important role in mouse liver regeneration and that modulating autophagy with amiodarone may be an effective method of improving liver regeneration, increasing survival and ameliorating liver injury following PHx.

Because the molecular mechanisms of morphogenesis of the hepatic cord and sinus are unclear, we investigated the involvement of bone morphogenetic protein (BMP4) in hepatic sinusoid morphogenesis.We used embryonic chicken livers, which develop rapidly, as our model, and investigated expression of BMP-related genes. BMP4 activity was manipulated by overexpressing BMP4 and its antagonist, noggin.During hepatic cord morphogenesis, BMP4 and its receptors are expressed in both peri-sinusoidal cells and hepatoblasts as the sinusoids form, whereas noggin is expressed transiently in peri-sinusoidal cells at early stages. Suppression of BMP activity with noggin overexpression disrupted normal hepatic sinusoid structure, leading to liver congestion, failure of fibronectin deposition, and markedly reduced numbers of peri-sinusoidal cells. However, overexpression of BMP did not change sinusoidal morphology but increased endothelial cell number. Noggin overexpression resulted in disrupted cord organization, and dilated sinusoidal space, eventually leading to increased apoptosis and failed hepatocyte differentiation.Our results show that proper BMP signaling mediates peri-sinusoidal cell-hepatoblast interactions during development; this is essential for hepatic cord organization among hepatoblasts, endothelium, and presumptive hepatic stellate cells.

Hepatic artery thrombosis is a serious complication after liver transplantation which often results in biliary complications, early graft loss, and patient death. It is generally thought that early hepatic artery thrombosis without urgent re-vascularization or re-transplantation almost always leads to mortality, especially if the hepatic artery thrombosis occurs within a few days after transplantation. This series presents 3 cases of early hepatic artery thrombosis after living donor liver transplantation, in which surgical or endovascular attempts at arterial re-vascularization failed. Unexpectedly, these 3 patients survived with acceptable graft function after 32 mo, 11 mo, and 4 mo follow-up, respectively. The literatures on factors affecting this devastating complication were reviewed from an anatomical perspective. The collective evidence from survivors indicated that modified nonsurgical management after liver transplantation with failed revascularization may be sufficient to prevent mortality from early hepatic artery occlusion. Re-transplantation may be reserved for selected patients with unrecovered graft function.

Dopamine (DA) is commonly used to maintain the hemodynamic stability of brain-dead donors despite its controversial effects on organ functions. This study aimed at examining the hemodynamic effect of DA in a rat brain-dead model in vivo, alteration of hepatocyte integrity in liver grafts after ex vivo preservation, and changes in cultured clone-9 hepatocytes including cellular viability, cell cycle, apoptotic regulators, and lipopolysaccharide (LPS)-stimulated nuclear factor kappa B (NF-κB) signaling machinery. Although in vivo findings demonstrated enhanced portal venous blood flow and hepatic microcirculatory perfusion after DA infusion, no apparent advantage was noted in preserving hepatocyte integrity ex vivo. In vitro, prolonged exposure to high-dose DA reduced proliferation and induced G1 growth arrest of clone-9 hepatocytes with concomitant decreases in B cell lymphoma 2 (BCL2)/B cell lymphoma 2-associated X protein (BAX) and heat shock protein 70/BAX protein ratios and intracellular NF-κB p65. Moreover, DA pretreatment suppressed LPS-elicited inhibitor of κBα phosphorylation and subsequent NF-κB nuclear translocation, suggesting that DA may down-regulate NF-κB signaling, thereby reducing expression of antiapoptotic regulators, such as BCL2. In conclusion, despite augmentation of hepatic perfusion, DA infusion failed to preserve hepatocyte integrity both in vivo and ex vivo. In vitro findings demonstrated that high-dose DA may hamper the function of NF-κB signaling machinery and eventually undermine functional integrity of hepatocytes in liver grafts.

Purpose To identify the prognostic factors for pulmonary metastasectomy (PM-ectomy) in hepatocellular carcinoma (HCC). Patients and methods We conducted a retrospective review of patients with pulmonary metastases (PM) from HCC who had undergone curative PM-ectomy at National Taiwan University Hospital between 1990 and 2004. Univariate (log-rank) and multivariate (Cox’s model) analyses of survival were used to identify the significant prognostic factors. Results In total, 34 patients were eligible for curative PM-ectomy. The overall survival rates (Kaplan-Meier) after PM-ectomy were 65.2% and 27.5% at 2 and 5 years, respectively. High alpha-fetoprotein level, positive hepatic resection margin, and short disease-free interval (DFI) were unfavorable factors for overall survival from univariate analysis, however, only DFI (P = 0.028) was identified as an independently prognostic factor by multivariate analysis. Bilateral distribution and more PMs were unfavorable factors for PM-free survival from univariate analysis, with only PM number identified as an independent prognostic factor by multivariate analysis (P = 0.017). Conclusion Patients with longer DFIs and fewer PMs can benefit from PM-ectomy in HCC.

The stomach is an uncommon site for metastasis, and most of the reported examples would appear to have been caused by direct invasion from primary malignancies. Metastases to the stomach are extremely rare, and few cases have been reported in the literature. This study was intended to evaluate the character of and the prognosis for metastasized tumors of the stomach. We evaluated the medical records of patients who had presented at the National Taiwan University Hospital over a period of 10 years prior to writing who had malignancies and had developed metastasis to the stomach. We evaluated the histology, initial presentations, imaging findings, lesion locations, treatment courses, and overall patient survival. From October 1995 to October 2004 inclusively, only 18 patients featuring known malignancies with metastases to the stomach were found. The male to female ratio was 10:8. The initial symptom for 13 study patients was bleeding from the metastasis tumors, and the remaining 5 experienced a variety of other symptoms. The site of the metastasis was the gastric body for 9 patients, the gastric antrum for 6, the cardia or fundus for 2, and the entire stomach for 1. The time period elapsing between the emergence of the primary malignancy and the gastric metastasis was less than 2 years for 3 patients and about 5–6 years for another 2 patients. The mean time elapsing from the diagnosis of gastric metastasis to patient death was quite short, namely, about 6 months. Carcinomas featuring gastric metastasis are typically very rare and reveal a rather poor prognosis. The results of this preliminary study suggest that most treatment for these patients seemed to provide only symptomatic relief but did not prove helpful for long-term survival.

Hepatic resection may offer long-term survival for patients with colorectal metastases. However, controversies exist regarding the prognostic factors. Herein, the impact of synchronicity of liver metastasis on patient clinicopathological features and prognosis was evaluated. One hundred and fifty-five patients who underwent hepatectomy for colon cancer metastasis, from 1995 to 2004, were enrolled in this study. Patients were divided into two groups: synchronous and metachronous colorectal liver metastasis. Patient demographics, the nature of the primary and metastatic tumors, surgery-related complications, and long-term outcome were analyzed. Patients included in the synchronous group tended to be younger than those in the metachronous group. Compared to the metachronous group, patients in the synchronous group showed more metastases (P = 0.008) and bilobarly distributed metastases (P = 0.016). Bile leakage was the most common surgical complication. The estimated 5-year disease-free and overall survival rates were 16.8 and 41.1%, respectively. Univariate analysis indicated that synchronous metastases, advanced stage of the primary tumor, bilobar distribution of the metastases, more than three metastases, and colonic versus rectal location of the primary tumor were prognostic factors of shorter disease-free survival, but not overall survival. Multivariate analysis revealed that synchronous metastases and the advanced stage of the primary tumor were indicators for a worse disease-free survival. The synchronous presence of primary colon cancer and liver metastasis may indicate a more disseminated disease status and is associated with a shorter disease-free survival than metachronous metastasis. These patients may need more careful monitoring and aggressive chemotherapy following curative resection.

Recurrence after hepatocellular carcinoma (HCC) resection is the major obstacle to improved survival. The presence of vascular invasion (VI) in pathology specimens is a well-known unfavorable prognostic factor for HCC recurrence. Though some VI-related genes have been reported, their association with recurrence-free survival is not known. We hypothesized that a gene expression profile for VI can predict the recurrence of HCC after liver resection. Eighteen patients receiving complete HCC resection were included as a “training group”. Genome-wide gene expression profile was obtained for each tumor using a microarray technique. Datasets were subjected to clustering analysis supervised by the presence or absence of VI to obtain 14 discriminative genes. We then applied those genes to execute pattern recognition using the k-Nearest Neighbor (KNN) classification method, and the best model for this VI gene signature to predict recurrence-free survival in the training group was obtained. The resulting model was then tested in an independent “test group” of 35 patients. A 14-gene profile was extracted which could accurately separate ten patients with VI and eight patients without VI in the “training group”. In the “test group”, significant difference in disease-free survival was found between patients predicted to have and not to have recurrence (P = .02823). In patients with stage_I disease, this model can also predict outcomes (P = .000205). Using the 14-gene expression profile extracted from microarrays based on the presence of VI can effectively predict recurrence after HCC resection. This approach might facilitate “personalized medicine” for HCC patients after surgical resection.

Our objectives were to assess the characteristics of donors for living-donor liver transplantation (LDLT) and to examine the impact of donation on LDLT donor quality of life (QOL) regarding physical and psychological distress. Methods Data were collected from a mailed survey or an interview using a cross-sectional prospective study design. We used the abbreviated version of the World Health Organization Quality of Life (WHOQOL-BREF), Physical Symptom Disturbance Scale, and Psychological Distress Scale. LDLT donors were recruited from a teaching hospital located in a metropolitan area of northern Taiwan. Results The 35 LDLT donors have a mean age 34.0 ± 8.6 years and were recruited at a median of 25.9 months after donation (range, 0.6–92 months). The average scores in the four domains of the WHOQOL-BREF scale ranged from 13.5 to 14.9. LDLT Donors reported higher QOL scores in social and environment domains but lower scores in physical and psychological domains than healthy adults. Numbers of physical symptoms experienced by each donor ranged from one ( n = 4) to 27 ( n = 2). Feeling throbbing, itching or numbness around the wound was the most common physical symptom disturbance reported by donors ( n = 26, 74%). Approximately 40% of the donors reported having one to three metrics of psychological distresses. “Easily feel distress and angry” was the most common psychological distress reported by 57% ( n = 20) of donors. Conclusions This study indicated that liver donation had a mild negative impact on donors physical and psychological facets of QOL. These results may assist professionals to provide appropriate clinical management.

Purpose Molecular, cellular, and animal studies have established that overexpressed proline-directed protein kinase FA (PDPK FA) is essential for the development of tumorigenesis, invasion, and metastasis of human cancer cells. However, the prognostic role of PDPK FA in cancer patients remains largely unknown. In this study, association of PDPK FA expression with poor prognosis of hepatocellular carcinoma (HCC) patients was examined. Patients and Methods PDPK FA expression in the resected tumors of 134 HCC patients (112 men and 22 women) with ages ranging from 33 to 83 years (mean, 55 years) was analyzed by immunohistochemistry. Highly condensed cytoplasmic and nuclear PDPK FA associated with tumor cells was used as the major scoring parameter for positive PDPK FA expression. Results Approximately 68% of the patients (91 of 134) exhibited positive PDPK FA expression. Patients with positive PDPK FA showed poorer disease-free survival and overall survival (P < .001). Cox multivariate regression analysis further established PDPK FA as the strongest independent prognosticator for progression and patient survival of HCC (hazard ratio [HR], 2.878; 95% CI, 1.634 to 5.067 for disease-free survival; and HR, 5.035; 95% CI, 2.137 to 11.866 for overall survival; P < .001). Conclusion Consistent with PDPK FA’s essential role in the development of highly malignant phenotypes, the present study establishes the potential prognostic role of PDPK FA in progression and patient survival of surgically resected primary HCC. Taken together, PDPK FA represents a new modifiable signal-transducing target for prognostic prediction and adjuvant treatment of patients with aggressive HCC after hepatic resection.

Stathmin, a major microtubule-depolymerizing protein, is involved in cell cycle progression and cell motility. This study aimed to elucidate its role in the progression, early tumour recurrence (ETR), and prognosis of hepatocellular carcinoma (HCC). Stathmin mRNA was overexpressed in 88/156 (56%) resected, unifocal, primary HCCs, while p53 mutation was present in 72 (46%) and osteopontin mRNA overexpression in 79 (51%). Stathmin mRNA expression exhibited high concordance (93%) with protein expression in 107 cases examined by immunohistochemistry. Stathmin overexpression correlated with high alpha-fetoprotein (>200 ng/ml, p = 0.02), larger tumour size (>5 cm, p = 0.012), high tumour grade (p < 0.0002), high tumour stage (stage IIIA-IV) with vascular invasion and various degrees of intrahepatic metastasis (p < 1 x 10(-8)), ETR (p = 0.003), and lower 5-year survival (p = 0.0007). Stathmin protein expression was often more intense in the peripheral regions of tumour trabeculae, tumour borders, and portal vein tumour thrombi. Stathmin overexpression correlated with p53 mutation (p = 0.017) and osteopontin overexpression (p = 1 x 10(-8)), both of which were associated with vascular invasion (both p < 0.0001) and poorer prognosis (p < 0.0004 and p = 0.0004, respectively). Regardless of the status of p53 mutation or osteopontin expression, stathmin overexpression was associated with higher vascular invasion (all p < 0.0001). Approximately 90% of HCCs harbouring stathmin overexpression with concomitant p53 mutation or osteopontin overexpression exhibited vascular invasion, and hence the lowest 5-year survival, p = 0.00018 and p = 0.0009, respectively. However, we did not find that stathmin overexpression exerted prognostic impact independent of tumour stage. In conclusion, stathmin expression correlates with metastatic potential, is an important prognostic factor for HCC, and may serve as a useful marker to predict ETR.

This study aims to examine the incidence and risk factors of bilateral breast cancer in area with low incidence rate. A total of 120 and 1902 women with bilateral and unilateral breast cancers were enrolled; various factors, including those concerning their medical history and life style, were extracted. Using Kaplan-Meier method, we calculate the cumulative incidence of contralateral breast cancer. The results show as follows. The cumulative incidences of contralateral breast cancer at 1, 3, 5 years after diagnosis of first breast cancer were 1.15, 1.94, and 2.97%, respectively. The statistically significant risk factors included menopause (Hazard Ratio (HR) =1.56, (1.00-2.42)), invasive lobular carcinoma (HR=2.98, (1.35-6.56)), receiving chemotherapy (HR=2.21, (1.43-3.42)) and/or radiotherapy (HR=3.32, (2.19-5.05) and a protective factor was tamoxifen therapy (HR=0.5 (0.34-0.74). Size of the second occurred tumour (2.97 cm) tended to be smaller than the first one (3.58 cm) with borderline statistical significance (p=0.0731). Comparing to the existing data on Western countries, we find a higher risk for developing contralateral breast cancer in Taiwan where a low incidence of first breast cancer rate with early age diagnosis is noted. It suggests that first primary breast tumour with early age of onset and lobular carcinoma are found more likely to develop bilateral breast cancers.

Nothing by mouth (NPO) is the standard treatment for small-bowel obstruction. Whether oral medications should be prohibited during treatment of adhesive, partial small-bowel obstruction is unclear. The goal of this study was to determine whether a combination of specific oral medications in adhesive, partial small-bowel obstruction will decrease the need for operative intervention.Of 266 consecutive adult patients with partial small-bowel obstruction admitted at a tertiary medical center, 236 were randomized into 2 groups. Group I patients were treated with intravenous hydration, nasogastric tube decompression, and NPO. Group II patients were placed on intravenous hydration, nasogastric tube decompression, and oral fluids incorporating an oral laxative, a digestant, and a defoaming agent. We compared differences between the groups in (1) the number of patients having a successful nonoperative treatment, (2) complications, and (3) recurrence of symptoms.A total of 116 and 120 patients comprised groups I and II, respectively. The number of patients treated successfully by a nonoperative approach was less in group I than in group II (77% vs 90%, P.01). The complications and recurrence rate for groups I and II did not differ (4% vs 5% and 5% vs 4%, respectively).The NPO status for patients with adhesive, partial small-bowel obstruction may not be necessary. This cocktail of oral medications can decrease the need for operative intervention in patients with presumed adhesive, partial small-bowel obstruction.

Background Coagulopathy caused by cirrhosis may contribute to excessive bleeding during hepatectomy. We evaluated the hemostatic effect and safety of recombinant factor VIIa (rFVIIa) in cirrhotic patients undergoing partial hepatectomy. Methods Patients were randomized to rFVIIa 50 or 100 μg/kg or placebo, administered intravenously 10 minutes before surgery and every second hour during surgery. The primary efficacy end points were the proportion of patients receiving red blood cell (RBC) transfusions and the amount of RBCs transfused. The RBC transfusion trigger was blood loss of 500 mL. Safety end points included thromboembolic and adverse events. Results No statistically significant effect of rFVIIa treatment on efficacy end points was observed. Serious and thromboembolic adverse events occurred at similar incidences in the study groups. Conclusions Using blood loss as a transfusion trigger, the efficacy of rFVIIa in reducing the requirement for RBC transfusion was not established in this study. No safety concerns were identified.

Background/PurposeConventional training in bronchoscopy may increase patient's discomfort and procedure-related morbidity. Computer-based bronchoscopy simulator (CBBS) permits the acquisition and evaluation of the necessary skills through a realistic bronchoscopic experience. This study was conducted to validate the use of a CBBS system developed in Taiwan as a learning and assessment tool.MethodsTwenty novice bronchoscopists and 10 expert bronchoscopists were enrolled as subjects in this prospective study. The 20 novice bronchoscopists were randomized into two groups, which received conventional bronchoscopic training or CBBS training and then completed a satisfaction survey. Subsequently, the novices who received CBBS training underwent an observational performance trial and the results were compared with those of expert bronchoscopists. All 10 expert bronchoscopists completed a realism survey and observational trial after CBBS performance.ResultsThe satisfaction survey showed that the CBBS training program significantly increased participants' satisfaction (p = 0.002) and interest in learning (p < 0.001). The realism survey by the 10 expert broncho-scopists indicated that CBBS provides a favorable degree of realism with regard to the mechanical and visual parameters examined. Analysis of the performance results showed that the following parameters were capable of differentiating the participants by level of expertise: total procedure time (p = 0.002), percentage of bronchial segments entered (p = 0.012), percentage of bronchial segments identified (p

Background and Objectives It has been recognized that inducible nitric oxide synthase (iNOS) and cyclooxygenase (COX-2) produce important endogenous factors of human tumors such as nitric oxide (NO) and prostaglandins, which is involved in the process of carcinogenesis and tumor progression. This study aimed to evaluate the association of clinicopathologic factors, microvessel density, and patient survival with the expression of iNOS and COX-2 in patients with gastric adenocarcinoma. Materials and Methods Seventy-nine specimens, resected from patients with gastric adenocarcinoma, were investigated by immunohistochemical stain against iNOS and COX-2. Microvessels were stained using anti-CD34 antibody and counted as microvessel density. Results Positive iNOS and COX-2 expressions were significantly correlated with microvessel density by multivariate analysis, respectively (P = 0.0127 vs. P = 0.0214). There was significant difference among the four groups (both iNOS and COX-2 positive, iNOS positive only, COX-2 positive only, and both negative) in serosal invasion (P = 0.038), lymph node metastasis (P = 0.038), Helicobacter pylori infection (P = 0.025), vascular invasion (P = 0.035), and microvessel density (P = 0.019). In patients with gastric cancer that co-expressed iNOS and COX-2, prognosis was significantly poorer than in those that expressed either iNOS or COX-2, or did not express both of them (P = 0.01738). The Cox proportional hazard regression analysis indicated that iNOS expression, vascular invasion, serosal invasion, and microvessel density are independent prognostic factors for patients with gastric cancer. Conclusions iNOS and COX-2 expression of gastric cancer are related to tumor angiogenesis, tumor progression, and patient survival in human gastric cancer. J. Surg. Oncol. 2006;94:226–233. © 2006 Wiley-Liss, Inc.

Nodular goiter is a common disease in Taiwan, and substernal or intrathoracic goiters are not infrequent. However, intrathoracic goiters are mainly of the secondary type and primary intrathoracic goiters are rarely seen. We report a 55-year-old woman who was incidentally found to have an ectopic goiter located in the anterior upper mediastinum with the initial presenting symptom of productive cough. Imaging studies including chest X-ray and computed tomography identified the lesion, and 131I-uptake scan showed weak uptake in the thorax. Surgical removal via thoracotomy was performed and the diagnosis was confirmed by pathology. A primary intrathoracic goiter, although rare, should also be considered in the differential diagnosis of mediastinal tumor.

This study investigated the effect of n-3 fatty acid (FA)-containing parenteral nutrition on the circulatory lymphocyte subpopulation, intracellular cytokine and leukocyte adhesion molecule expression, and phagocytic activity in rats undergoing total gastrectomy. Normal rats with internal jugular catheters were assigned to normal control (NC) and two experimental groups and received total parenteral nutrition (TPN). At the same time, a total gastrectomy was performed in the experimental groups, whereas the NC group underwent a sham operation. The TPN solutions were isonitrogenous and identical in nutrient compositions except for differences in fat emulsion contents. The NC and one of the experimental groups received a soybean oil emulsion (SO), and the other experimental group received 50% soybean oil and 50% fish oil emulsion (FO). Half of the rats in each respective group were sacrificed 1 or 3 days after surgery or the sham operation to examine their immune response. The results showed that the FO group had a higher CD4+ proportion and CD4+/CD8+ ratio than those of the SO and NC groups postoperatively. The phagocytic activity of peritoneal macrophages was higher in the FO group than in the NC group, but no difference was found between the SO and NC groups 3 days after surgery. The intracellular interferon (IFN)-γ distribution in the FO group was higher than that of the SO group on postoperative days. Leukocyte adhesion molecule expressions and peritoneal monocyte chemotactic protein-1 levels were lower in the FO group than in the SO group on postoperative day 3. These results suggest that parenterally infused FO did not result in immunosuppression. In addition, FO administration promotes lymphocyte Th1 cytokine production, enhances peritoneal macrophage phagocytic activity, and reduces leukocyte adhesion molecule expression in rats with total gastrectomy.

The morbidity and mortality that accompany fatty liver may occur as a result of increased apoptosis of hepatocytes and decreased liver regeneration. We determined the effects of a high-fiber diet on hepatocyte apoptosis and liver regeneration after partial hepatectomy in rats with fatty liver.Fatty liver was induced in male Wistar rats weighing around 200 g through feeding of a high-fat diet for 4 weeks. The rats were then randomly assigned to 3 groups that received a high-fat diet, a normal diet, or a high-fiber diet for another 4 weeks. Partial hepatectomy (around 70%) was performed, and rats were killed 6, 24, 48, or 72 hours after hepatectomy. We then measured (1) the ratio of remnant liver weight to body weight and assessed the histology of the remnant liver as indicators of fatty liver, (2) caspase-3 activity and in situ cell death detection of DNA fragmentation as indicators of apoptosis, and (3) 5-bromo-2-deoxyuridine (BrdU) activity and (4) ornithine decarboxylase (ODC) contents in remnant livers as markers of regeneration.We found that (1) a high-fat diet for 4 weeks can markedly induce fatty liver, (2) apoptosis of hepatocytes is greater in fatty liver than in normal liver (98 +/- 19 vs 36 +/- 7) at 6 hours after partial hepatectomy (p.05), (3) the capacity of liver regeneration decreases significantly (BrdU index: 30 +/- 5 vs 12 +/- 3, and ODC contents: 604 +/- 48 vs 390 +/- 42 mg/dL) in fatty liver 24 hours after partial hepatectomy (p.05), (4) a normal diet can partially reverse the effects of fatty liver; (5) a high-fiber diet can significantly reverse the effects of fatty liver (p.05).A high-fiber diet can reverse the negative effects of fatty liver on apoptosis and regenerative capacity after partial hepatectomy.

Purpose This study was conducted to characterize gene expression profile of survival in patients with surgically curable gastric cancer by using an in-house membrane microarray and developing a survival prediction model. Materials and Methods Data of cDNA microarrays were obtained from 18 pairs of cancerous and noncancerous gastric tissues. Nine patients who survived > 30 months were identified as good survival, and the other nine, who survived < 12 months, were identified as poor survival. Supervised analysis was performed to identify a gene expression profile by good and poor survival. Semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR) was used to confirm the microarray data in 10 patients with sufficient RNA. Using these 10 patients and another 10 patients selected randomly from 40 newly enrolled patients as the training group, the RT-PCR status of the confirmed genes was used for predicting good versus poor survival. Finally, the prediction model was tested in the remaining 30 newly enrolled gastric cancer patients. Results A survival prediction model consisting of three genes (CD36, SLAM, PIM-1) was developed. This model could correctly predict poor or good survival in 23 (76.7%) of 30 newly enrolled patients, and yielded a specificity of 80% and a sensitivity of 73.3%. The survival rate of the patients predicted to have good survival was significantly higher than that of those predicted to have poor survival in the test group as a whole (N = 30; P = .00531) and in stage III patients (n = 16; P = .04467). Conclusion The semiquantitative RT-PCR gene expression profiling of three genes extracted from microarray study can accurately predict surgery-related outcome in gastric cancer patients.

Background Most pancreatic leaks after pancreaticoduodenectomy were initially treated conservatively, and for the most part, they were self-limiting and closed spontaneously. But in a few patients, hemorrhage occurred 1 to 3weeks postoperatively and remained a fatal complication after pancreaticoduodenectomy. Study design To identify possible risk factors for massive bleeding, the medical records of 402 patients who had pancreaticoduodenectomies were reviewed for leak complications and analyzed for associations between the occurrence of massive bleeding and preoperative, intraoperative, postoperative, and pathologic parameters. Results In univariate logistic regression analysis, infectious clinical signs (p=0.021, odds ratio [OR]=7.06, 95% CI=1.34, 37.12) and bile in the drainage fluid (p=0.036, OR=5.89, 95% CI=1.13, 30.86) were associated with the risk of developing massive hemorrhage. This combination provided the highest estimate of massive bleeding after pancreatic leak (p=0.005, OR=8.57, 95% CI=1.92, 38.35). Conclusions Both infectious clinical signs and bile content in the drainage fluid considerably increase the risk of massive bleeding after pancreatic leak. Close observation of patients with these ominous signs is warranted.

The aim of this study was to determine whether progressive increase of bowel wall thickness during nonoperative treatment is a reliable indicator for surgery in patients with adhesive small bowel obstruction. The study consisted of a prospective case series of 121 patients with adhesive small bowel obstruction who underwent an abdominal ultrasonographic examination. The results of ultrasonographic examinations were classified into two groups according to the presence (Group I) or absence (Group II) of bowel wall thickening. Bowel wall thickening was recognized as a visible small bowel wall ≥3 mm in width as seen by ultrasonographic examination. The findings of subsequent ultrasonographic examinations taken 24 hours later were compared with those taken at admission. Surgery was determined based on the presence of any toxic signs or the failure of nonoperative treatment. The number of patients who had successful nonoperative treatment, the number of patients who underwent surgeries, and the number of complications in each group were calculated to correlate with the ultrasonographic findings. There are 49 and 72 patients in Groups I and II, respectively. The number of patients who had successful nonoperative treatment and number of patients who underwent surgeries in Group I are 40 (81.6 percent) and 9 (18.4 percent) and in Group II the numbers are 68 (94.4 percent) and four (5.6 percent), respectively (P = 0.036). All 12 (100 percent) patients with progressive increase of bowel wall thickness underwent surgery. Progressive increase of bowel wall thickness as an indicator for surgery has a sensitivity of 92.3 percent (95 percent confidence interval, 62.1–99.6 percent) and a specificity of 100 percent (95 percent confidence interval, 95.7–100 percent). Patients with initial bowel wall thickening have a higher incidence of surgery, and progressive increase of bowel wall thickness that appears 24 hours later is a reliable indicator for surgery in patients with adhesive small bowel obstruction.

Purpose: Cysteine-rich 61 (Cyr61/CCN1) is involved in many different types of tumor development and progression. Nonetheless, the role of Cyr61 in human gastric cancer has not yet been fully characterized. Experimental design: We addressed the issue by immunohistochemical staining of 81 gastric adenocarcinoma specimens. Liposome-mediated transfection was used to introduce a Cyr61 expression vector into gastric cancer AGS cell lines. Transfectants were tested in invasion assay by a Boyden chamber. Furthermore, a cyclooxygenase-2 (COX-2) reporter assay and gel mobility shift assay were done to investigate the potential signal pathway of Cyr61. Results: Patients with gastric adenocarcinoma whose tumor displayed high expression of Cyr61 correlated well with aggressive lymph node metastasis, more advanced tumor stage, histologic diffuse type, and early recurrence. Stable transfection of Cyr61 into the AGS cell line strongly enhanced its invasive activity. The overexpression of Cyr61 into AGS cells significantly increased the expression of COX-2 mRNA, protein, and enzymatic activity. Gel mobility shift assays further showed that the nuclear factor-κB (NF-κB) pathway was evidently activated in Cyr61-expressing AGS cells. Function-neutralizing antibody to αvβ3 but not αvβ5 effectively suppressed Cyr61-mediated NF-κB activation, COX-2 gene expression, and cell invasiveness. Conclusions: Cyr61 may contribute to the malignant progression of gastric cancer by promoting tumor cell motility/invasion through up-regulation of the functional COX-2 via an integrin αvβ3/NF-κB-dependent pathway.

In response to organ shortage, we used the renal grafts from non-heart-beating donors (NHBDs). Extracorporeal membrane oxygenation (ECMO) was used to maintain NHBDs before organ procurement. We compared the results of renal transplantation from different donors, including heart-beating donors (HBDs), living-related donors (LDs), and NHBDs supported with ECMO. From February 1998 to June 2003, we recruited 219 patients receiving renal transplantation at National Taiwan University Hospital. Among them, 31 received kidneys from NHBDs supported with ECMO, 120 from HBDs, and 68 from LDs. Multiple organ transplant recipients were not included in this study. We compared the graft survival, serum creatinine levels, and estimated glomerular filtration rates of the three groups. The rate of delayed graft function was higher in NHBD recipients (41.9%) than in HBD recipients (27.0%) and LD recipients (10.9%) (p = 0.003). In the NHBD group, the recipients of grafts with delayed function had significantly longer ECMO runs (63.1 ± 3.0 min) than those without delayed function (53.7 ± 2.5 min) (p = 0.024). Estimated glomerular filtration rate (p = 0.472) and mean serum creatinine level (p = 0.286) were not significantly different between the three groups using a longitudinal approach. The 5-yr graft survival rates for NHBD (88.4%, 95% CI: 0.680–0.962), HBD (83.2%, 95% CI: 0.728–0.899), and LD transplant recipients (89.3%, 95% CI: 0.619–0.974) were not significantly different (p = 0.239). The 5-yr patient survival rates for NHBD, HBD, and LD transplant recipients were 100, 93.0 (95% CI: 0.859–0.966) and 100% respectively. The long-term allograft survival and function of kidneys from NHBDs supported by ECMO, HBD, and LD did not differ significantly. Long ECMO running time tended to delay graft function.

Study Objective. To compare the effects of different calcineurin inhibitors on sirolimus pharmacokinetics during long-term, staggered administration in kidney transplant recipients. Design. Randomized, open-label, parallel-group trial. Setting. A medical center and one of its teaching hospitals in Taiwan. Patients. Twenty-two de novo kidney transplant recipients. Intervention. Patients received cyclosporine microemulsion or tacrolimus capsules twice/day in combination with once-daily sirolimus solution and corticosteroids. Sirolimus was administered 6 hours after the morning dose of cyclosporine or tacrolimus. After receiving a 6-mg loading dose of sirolimus, participants received sirolimus 2 mg/day for at least 7 days. Neither the cyclosporine nor the tacrolimus dosage was adjusted for at least 3 days before and during blood sampling for pharmacokinetic profiling. Measurements and Main Results. One patient dropped out because of trimethoprim-sulfamethoxazole–related hepatotoxicity. We observed no differences between the two patient groups in terms of their demographic data, renal and liver function, or dosage of sirolimus during the study. During multiple-dose administration, the area under the whole-blood concentration–time curve and the peak and trough concentrations of sirolimus in the cyclosporine group were, respectively, 1.46 (95% confidence interval [CI] 1.21–1.71), 1.42 (95% CI 1.08–1.76), and 1.42 (95% CI 1.09–1.76) times higher than those of the tacrolimus group, even though sirolimus was administered 6 hours after the other agents. Conclusion. Sirolimus pharmacokinetics may change significantly when calcineurin inhibitors are switched, even with staggered administration, which may not completely prevent a drug interaction between cyclosporine and sirolimus solution.

Purpose: Pancreatitis-associated protein (PAP) and regenerating protein 1 α (Reg1A) are up-regulated during the pancreas regeneration. This study is to investigate the clinicopathologic denotation of their expression in hepatocellular carcinoma (HCC). Experimental Design: PAP and REG1A mRNA levels were measured in 265 surgically removed unifocal primary HCCs using reverse transcription-PCR. Results: PAP and REG1A mRNAs were detected in 97 (36.6%) and 55 (20.8%) HCCs, respectively, including 46 with coexpression but in none of the 219 nontumorous livers. HCCs with PAP expression correlated with low-stage tumors without evidence of vascular invasion (P = 0.013) but the REG1A expression did not. By a combination analysis, HCCs with PAP expression alone showed the lowest frequency of p53 mutation (P < 0.036), the highest rates of grade 1 and low-stage tumors (P < 0.007 and P < 0.001, respectively), less frequent early tumor recurrence (P = 0.051), and hence a better 5-year survival (P = 0.044) than groups expressing PAP and REG1A, REG1A alone, and neither PAP or REG1A. Besides, PAP expressing HCCs had significantly frequent β-catenin mutation, regardless of REG1A expression, P < 0.00001. In the subset of HCCs that has no mutations of p53 and β-catenin but showed PAP expression, coexpression of REG1A and PAP was associated with more frequent vascular invasion than PAP expression alone (P < 0.005). Conclusions: These data suggest that PAP expression designate a subset of low-grade, low-stage HCC with frequent β-catenin mutation and hence more favorable prognosis, whereas further genetic or epigenetic alterations, such as p53 mutation and REG1A expression, lead to more advanced HCCs.

Background and Aim: Loss of heterozygosity (LOH) on chromosomes 16q and 13q, associated with tumor development, is frequently found in hepatocellular carcinoma (HCC). In light of this, an attempt was made to use the LOH pattern determined by microsatellite markers on 16q and 13q to discriminate clonality. Methods: In an effort to locate the LOH region more precisely and select the appropriate markers, LOH studies on 88 HCC using a panel of 35 microsatellite markers on 16q were carried out. Nine independent regions of frequent LOH were defined. In combination with a previous study of deletion mapping of 13q by the same authors, 12 markers on 16q and 13q were selected and polymerase chain reaction amplification, from microdissection-extracted DNA, was used to allelotype microsatellite polymorphism as an indication of clonality. Results: Two patterns of LOH were observed. In pattern A, in 8 of 16 (50%) patients, the LOH pattern of the first tumor was preserved in the second sample, with some tumors also showing additional LOH. In these patients, the original and second tumors are presumed to arise from the same original clone with or without progressive accumulation of LOH. In pattern B (8 of 16, 50%), LOH seen in the first tumor was not preserved in the second or recurrent tumors, as evidenced by retention of heterozygosity compared with the first tumor. Conclusion: The data suggest that the second tumor might have arisen from another independent clone. Moreover, this approach also provides a more sensitive and specific strategy to determine whether multiple or recurrent tumors are derived from the same or a different clone.

Glutathione S -transferases (GSTs) are a family of isoenzymes that play an important role in protecting cells from cytotoxic and carcinogenic agents. GSTπ is encoded by the GSTP1 gene. GSTP1 null mice show an increased risk of skin tumorigenesis induced by carcinogens. GSTP1 is transcriptionally silenced by promoter hypermethylation in several human cancers including hepatocellular carcinoma (HCC). Methylation-specific PCR (MSP) was used to analyze the GSTP1 promoter hypermethylation status of 83 hepatocellular carcinoma tissues from Taiwan. Hypermethylation was detected in 38 of 83 (46%) tumors. GSTP1 expression by immunohistochemical staining of HCC tissue samples was significantly associated with methylation status. The relationship between methylation status and clinical parameters and tumor markers including environmental exposure to aflatoxin B 1 (AFB 1 ) and polycyclic aromatic hydrocarbons (PAH), measured as DNA adducts, was also investigated. A statistically significant association was found between GSTP1 promoter hypermethylation and the level of AFB 1 –DNA adducts in tumor tissue (OR 2.81, 95% CI 1.03–7.70); a marginally significant association was found for adjacent non-tumor tissue (OR 2.57, 95% CI 0.97–6.80). There was no association between GSTP1 hypermethylation and PAH–DNA adducts in tumor or adjacent non-tumor tissues. These results suggest that epigenetic inactivation of GSTP1 plays an important role in the development of HCC and exposure to environmental carcinogens may be related to altered methylation of genes involved in hepatocarcinogenesis. The mechanism by which environmental exposures induce epigenetic changes in HCC needs further analysis.

Background & Aims: Connective tissue growth factor (CTGF) has been shown to be implicated in tumor development and progression. The aim of this study was to investigate the role of CTGF in progression of colorectal cancer (CRC). Methods: Immunohistochemical staining of specimens from 119 patients with CRC was performed. Liposome-mediated transfection was used to introduce a CTGF expression vector into CRC cell lines. Transfectants were tested in invasive ability and experimental hepatic metastasis in BALB/c mice. Furthermore, a FOPflash/TOPflash reporter assay was performed to investigate CTGF on the β-catenin/T-cell factor signaling pathway. Results: Patients with stage II and stage III CRC whose tumors displayed high CTGF expression had a significantly higher overall survival and a disease-free advantage over patients with CRC with low CTGF expression. Alterations in the CTGF level in CRC cell lines modulated their invasive ability with an inverse correlation. In addition, a reduction in the CTGF level of CT26 cells after stable transfection with antisense CTGF resulted in increased liver metastasis in BALB/c mice. The activity of the β-catenin/T-cell factor signaling pathway and its downstream effector gene matrix metalloproteinase 7 in these CTGF-transfected cells was strongly attenuated. Blockage of matrix metalloproteinase 7 with its neutralizing antibodies inhibited increased invasiveness in antisense CTGF-transfected CT26 cells. Conclusions: Our results implicate CTGF as a key regulator of CRC invasion and metastasis, and it appears to be a useful and better prognosis factor for patients with stage II and stage III CRC.

Placenta growth factor (PlGF) is a member of the vascular endothelial growth factor (VEGF) family of proangiogenic factors and its overexpression has been linked to pathological angiogenesis. We studied the relationship between the expression of PlGF and VEGF in human gastric cancer tissues and microvessel density (MVD), as well as clinical outcome in 79 patients with gastric cancer by using an enzyme immunoassay for PlGF and VEGF expression levels in gastric cancers and surrounding non-cancerous mucosa. PlGF protein levels were significantly higher in tumor than in the corresponding non-tumorous mucosa (median value 48.5 vs 9.8 pg/mg, P < 0.001). In contrast, VEGF protein levels were not (66.7 vs 80.7 pg/mg, P = 0.522). VEGF expression level was not significantly correlated with MVD, patient survival, and clinicopathological factors except Lauren classification in this study. PlGF may be an important angiogenic factor in human gastric cancer, and PlGF expression level was significantly correlated with serosal invasion, positive lymph node metastases, tumor stages, and patient survival.

Background Tumour angiogenesis, cyclo-oxygenase (COX) 2 expression, K-ras mutation and p53 overexpression are commonly involved in colorectal tumorigenesis, but their interrelationship and clinicopathological effects remain inconclusive. Methods Clinicopathological data from 114 consecutive patients with primary stage III colorectal cancer were evaluated prospectively. Microvessel density (MVD) of the tumour was defined by counting the number of microvessels in hotspots, visualized by immunocytochemical staining of endothelial CD34. K-ras mutation was analysed by the restriction enzyme cleavage method. COX-2 expression and p53 overexpression were determined by immunocytochemistry. Results Increased MVD in hotspots was significantly associated with COX-2 expression (P < 0·001), K-ras mutation (P = 0·007) and p53 overexpression (P = 0·006). COX-2 expression was not associated with either K-ras mutation or p53 overexpression. Clinicopathologically, greater MVD and COX-2 expression were significantly associated with vascular invasion of cancer cells (MVD, P = 0·027 and COX-2 expression, P = 0·006), but p53 overexpression and K-ras mutation were not. Multivariate analysis indicated that greater MVD (P = 0·002) and p53 overexpression (P = 0·016) were significant independent predictors of tumour recurrence, whereas COX-2 expression (P = 0·634) and K-ras mutation (P = 0·356) were not. Conclusion Tumour angiogenesis may be associated with tumour metastasis and is significantly influenced by K-ras mutation, p53 overexpression and COX-2 expression in patients with colonic cancer.

Background The regulatory mechanism by which the B7 ligands (CD80 and CD86) direct the CD28/ CD152 costimulatory pathways is unclear. This study investigated the role of CD80 and CD86 in a CD152-mediated allograft tolerance model. Methods. A low-responding cardiac transplant model (BALB/c→B10.A) with possible long-term acceptance was used. Immunocytochemical and flow cytometric analyses of the graft-infiltrating cells were conducted to characterize this transplant model. The influence of anti-CD80 and anti-CD86 treatments on the proliferation and interleukin (IL)-2 productions of the tolerated splenocytes (SC) was analyzed. The role of CD80 and CD86 in the induction and maintenance of the graft acceptance in this transplant model were also tested. Results. B10.A mice could accept the BALA/c cardiac allografts (11/22), and an anti-CD152 antibody blocked the graft acceptance (10/10). Immunocytochemical and flow cytometric analyses showed that CD152 + cells were predominant among the CD4 + cells infiltrating the 100-day grafts of the B10A recipients (B10.A-100). Either anti-CD80 or anti-CD86 treatment significantly enhanced polyclonal proliferation and IL-2 production of the B10.A-100 SC. Blockade of either CD80 or CD86 prohibited the tolerance transmitted by adoptive transfer, and anti-CD80 or anti-CD86 plus skin grafting undermined the established allograft tolerance. Conclusions. Both CD80 and CD86 were essential for the induction and maintenance of the CD152-mediated allograft tolerance.

Background & Aims : Hepatitis B virus (HBV) genotype C is associated with the development of hepatocellular carcinoma (HCC), compared with genotype B. This study aims to investigate whether HBV genotypes influence the clinicopathologic features and long-term prognosis of patients after curative resection of HCC. Methods : Stored serum samples from 62 patients with HBV-related HCC were tested for HBV genotype using a molecular method. Results : Sixty of 62 patients (96.8%) undergoing curative resection of HCC were infected with genotype B or C. Concomitant cirrhosis was encountered more frequently in patients with genotype C. During a mean follow-up period of 26.3 ± 9.8 months, patients with genotype B had a lower overall tumor recurrence rate than those with genotype C (22% vs. 46%; P = 0.04). Stepwise multiple Cox proportional hazards regression analysis showed that multiplicity of tumor (hazard ratio, 6.84; 95% confidence interval [CI], 1.45–32.2; P = 0.02) was associated with tumor recurrence, whereas genotype C and age were associated with borderline significance (P = 0.06). Stratified analysis showed that genotype C was still associated with tumor recurrence in cirrhotic patients with borderline significance by univariate analysis (hazard ratio, 3.8; 95% CI, 0.84–17.6; P = 0.07). However, cumulative 2-year survival rates were similar between patients with genotype B and C (92% vs. 85%; P = 0.23). Conclusions : Our data suggest that patients with HCC with genotype C have a greater tumor recurrence rate after curative resection of HCC compared with those with genotype B. Prolonged follow-up is needed to clarify the impact of HBV genotype on postoperative outcome.

SUMMARY: The peritoneal mesothelial cell is a critical component of the peritoneal membrane. The intraperitoneal use of several antibiotics to treat bacterial peritonitis is current clinical practice. Our previous study showed that cephalothin (CPL) and cefotaxime (CFT) have cytotoxic effects on human peritoneal mesothelial cells (HPMC), however, the exact mechanism of cytotoxicity has not been elucidated. In the present study, flow cytometry, TdT-mediated dUTP nick-end labelling (TUNEL) staining and electron microscopy were used to detect the apoptosis of HPMCs. Immunofluorescent staining was used to evaluate the cytochrome c distribution pattern. Western blotting was used to assess apoptotic signalling proteins. We found that CPL (0.5 mg/mL) and CFT (1 mg/mL) induced apoptosis of HPMCs, whereas cefazolin (0.5 mg/mL) and ceftriaxone (0.5 mg/mL) failed to induce apoptosis of HPMCs. While the DNA content of CFT- or CPL-treated cells was reduced, as determined by flow cytometry, cefazolin and ceftriaxone had no such effect. The CFT- or CPL-treated cells displayed the features of apoptosis both under the electron microscope and by using TUNEL staining. However, cefazolin and ceftriaxone produced the same result as the medium controls. Furthermore, CFT and CPL increased the expression of Bax and p53, and caused the translocation of cytochrome c from the mitochondria to the cytoplasm. The HPMC treated by CFT but not by CPL induced the cleavage of procaspase-3 to form active caspase-3. In conclusion, cefotaxime and cephalothin induce apoptosis of HPMCs in vitro. Signal transduction may be through the mitochondrial pathway.

Objective: To analyze the efficacy of oral thalidomide in the treatment of advanced hepatocellular carcinoma (HCC). Methods: Sixty-eight patients with unresectable and nonembolizable HCC were consecutively enrolled in a compassionate treatment program of oral thalidomide. Tumor response and treatment-related toxicity were prospectively followed. Thalidomide was given at a starting dose of 200 mg per day. The dose was gradually escalated in 100-mg steps up to 600 mg per day if no limiting toxicities developed. Results: Sixty-three patients were evaluable for response. One complete and 3 partial responses, defined by World Health Organization criteria, were seen, with a response rate of 6.3% (95% CI 0–12.5). The duration of response was 50+, 24.6, 11.6+ and 8.7+ weeks, respectively. All 4 responders had a dramatic decrease in α-fetoprotein (α-FP) levels. Another 6 of the 42 patients with elevated α-FP levels before treatment had a more than 50% decrease in their α-FP levels after thalidomide treatment. Totally 10 patients had an objective response to thalidomide. The median overall survival for all of the 68 patients was 18.7 weeks (95% CI 11.8– 25.6) with a 1-year survival rate of 27.6%. The median overall survival of the 10 patients with an objective response to thalidomide was 62.4 weeks (95% CI 31.2–93.6 weeks). All responders responded at a dose equal to or less than 300 mg per day. Toxicities of thalidomide were generally manageable, and only 16, 6, and 0 patients developed grade 2, 3, and 4 toxicities, respectively. Conclusion: Low-dose thalidomide is safe and induces unequivocal tumor response in a minority of patients with advanced HCC.

Background There is a significant association between a positive family history of cancer and gastric cancer risk; however, the clinicopathologic characteristics and prognoses of gastric cancer patients with a positive family history of cancer are not clear. Goals To define the clinicopathologic characteristics and prognoses of gastric cancer patients with a positive family history of cancer. Study We reviewed 548 patients with pathologically confirmed primary gastric cancer who had undergone a gastrectomy between 1990 and 1996. The average age was 59.7 years, and the male-to-female ratio was 1.7. The familial cancer histories of these patients were reviewed, and the various clinicopathologic characteristics of those patients with a positive family history of cancer were compared with those with a negative history. Results Among this cohort, 74 (13.5%) patients had a positive family history of cancer in their primary or secondary relatives. The most common cancer was gastric cancer in 29 patients, followed by colorectal cancer in 10 and lung cancer in 7. Patients with a positive family history of cancer were associated with bigger tumors, and more patients received a total gastrectomy than did patients with a negative family history. Immunopathologic study disclosed a higher rate of p53 overexpression but not of neu or c-met in patients with a positive family history of cancer. There were no differences in the mean age, gender, site, depth of invasion, or TNM stage. The survival curve of patients with a positive family history of malignancy was similar to that of patients without a family cancer history. Conclusion Patients with gastric cancer with a positive family history of cancer appeared to have bigger tumors with a higher rate of p53 overexpression, and more patients required a total gastrectomy compared with those with a negative family history. This study suggests a genetic component in the aggressiveness of gastric cancer and indicates that higher caution should be exercised with people who have a positive family history of cancer.