Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.     

Beta 2-microglobulin is not required for cell surface expression of the murine class I histocompatibility antigen H-2Db or of a truncated H-2Db.

beta 2-Microglobulin (beta 2m) has been thought essential for transport of all major histocompatibility complex class I antigens to the cell surface. Here, we show that the mouse class I antigen H-2Db is expressed at the cell surface even when there is no beta 2m present within the cell. This was established by transfecting the H-2Db gene into the R1E cell line, which lacks beta 2m. The conformation of the Db antigen expressed by the R1E transfectant is very different from that of the native molecule. This Db antigen is not recognized by Db-allospecific and Db-restricted cytotoxic T lymphocytes or by most monoclonal antibodies to the native Db. We show further that a deletion construct of the Db gene, which consists of exon 1 linked to exons 4-8, expresses a truncated Db antigen lacking domains 1 and 2 [Db-(1 + 2)] at the cell surface after transfection into the R1E line. Previous biochemical and crystallographic data have indicated that domain 3 is associated with beta 2m; unexpectedly, Db-(1 + 2) does not associate with beta 2m when the mouse beta 2mb gene is transfected into the R1E transfectant expressing the truncated Db. This suggests that interactions with domains 1 and 2 are important for the paired association of domain 3 and beta 2m in the native Db antigen.     

Oral administration of PEGylated TLR7 ligand ameliorates alcohol-associated liver disease via the induction of IL-22

Effective therapies for alcohol-associated liver disease (ALD) are limited; therefore, the discovery of new therapeutic agents is greatly warranted. Toll-like receptor 7 (TLR7) is a pattern recognition receptor for single-stranded RNA, and its activation prevents liver fibrosis. We examined liver and intestinal damage in Tlr7^−/− mice to determine the role of TLR7 in ALD pathogenesis. In an alcoholic hepatitis (AH) mouse model, hepatic steatosis, injury, and inflammation were induced by chronic binge ethanol feeding in mice, and Tlr7 deficiency exacerbated these effects. Because these results demonstrated that endogenous TLR7 signaling activation is protective in the AH mouse model, we hypothesized that TLR7 activation may be an effective therapeutic strategy for ALD. Therefore, we investigated the therapeutic effect of TLR7 agonistic agent, 1Z1, in the AH mouse model. Oral administration of 1Z1 was well tolerated and prevented intestinal barrier disruption and bacterial translocation, which thus suppressed ethanol-induced hepatic injury, steatosis, and inflammation. Furthermore, 1Z1 treatment up-regulated the expression of antimicrobial peptides, Reg3b and Reg3g, in the intestinal epithelium, which modulated the microbiome by decreasing and increasing the amount of Bacteroides and Lactobacillus, respectively. Additionally, 1Z1 up-regulated intestinal interleukin (IL)-22 expression. IL-22 deficiency abolished the protective effects of 1Z1 in ethanol-induced liver and intestinal damage, suggesting intestinal IL-22 as a crucial mediator for 1Z1-mediated protection in the AH mouse model. Collectively, our results indicate that TLR7 signaling exerts protective effects in the AH mouse model and that a TLR7 ligand, 1Z1, holds therapeutic potential for the treatment of AH.

Alcohol-associated liver disease (ALD) is caused by chronic and excessive consumption of alcohol. The disease ranges from alcohol-associated fatty liver to alcoholic hepatitis (AH), fibrosis, cirrhosis, and hepatocellular carcinoma (HCC) (1). Alcohol-associated fatty liver is considered reversible and nonprogressive. Nearly 35% of heavy alcohol drinkers develop AH, and up to 40% of severe AH patients die within 6 mo (2). AH patients who survive may progress to alcohol-associated cirrhosis. Treatment options for AH involve the use of corticosteroids and have remained largely unchanged since the early 1970s. Unfortunately, not all patients respond to corticosteroids, and the benefits are temporary in responders (1, 2). Early liver transplant has been shown to be superior to medical management for severe AH, but it still has limitations and can only be considered in a highly selective group of patients (1, 2). Thus, the identification of a better molecular therapeutic target for ALD is a significantly unmet medical need for the development of effective therapies for AH.Previous studies have demonstrated the involvement of Toll-like receptors (TLRs), including TLR2, TLR4, and TLR9, in the development of ALD (3–8). In addition to the direct effect of alcohol and its metabolite, acetaldehyde, in hepatocytes, ethanol intake affects the function of the intestinal epithelial barrier. Chronic alcohol consumption disrupts intestinal tight junction integrity and increases gut permeability, resulting in elevated bacterial lipopolysaccharide (LPS) concentrations in the portal and systemic circulation (4). Translocated LPS activates resident hepatic macrophages, known as Kupffer cells, via TLR4, thereby promoting ALD (1, 2, 7, 8). Other TLRs, such as TLR2 and TLR9, recognize gram-positive bacterial components and bacterial CpG-DNA, respectively (3, 4). Furthermore, TLR2, TLR9, and MyD88 are required for the development of the preclinical AH murine model (5), whereas TLR4 and TLR9 exert protective effects against intestinal inflammation (9, 10).TLR7 signaling has been shown to be protective against liver fibrosis in mice (11). Tlr7^−/− mice exhibit augmented cholestasis and carbon tetrachloride (CCl₄)-induced liver fibrosis (11). TLR7 signaling also induces IFN-α production in dendritic cells (DCs), followed by interleukin (IL)-1 receptor antagonist (IL-1Ra) induction in Kupffer cells. IL-1Ra suppresses IL-1-induced hepatic stellate cell (HSC) activation, resulting in inhibition of liver fibrosis (11). Among the TLRs, TLR3 and TLR7 activation has been reported to ameliorate some liver diseases (11, 12). However, a major disadvantage of the currently available synthetic ligands for TLR3 and TLR7, such as poly I:C, imiquimod, and R848, is the excessive induction of proinflammatory cytokines (3, 4). Thus, developing agents without undesirable adverse effects is of great clinical interest.IL-22 is a hepatoprotective cytokine produced by T helper (Th) 17 cells, Th22 cells, γδ T cells, natural killer (NK) T cells, and innate lymphoid cells (ILCs) (13). Exogenous administration of IL-22 has a profound effect on tissue repair following liver injury via the promotion of proliferation and inhibition of apoptosis in hepatocytes of mouse models of AH (14), liver fibrosis, and drug- and LPS-induced liver injury. Also, IL-22 promotes tissue repair in the intestines and is protective against intestinal epithelial damage and inflammation (13). These findings suggest that IL-22 may suppress ALD via the maintenance of intestinal barrier function, thereby preventing increased intestinal permeability and bacterial translocation due to intestine-derived microbial products that promote ethanol-induced liver injury (15, 16).Here, we have developed a synthetic TLR7 ligand, 1Z1, that possesses antiinflammatory effects via IL-22 induction and that is devoid of systemic toxicity after oral administration (17–19). Treatment with 1Z1 has already been reported to be effective for allergic encephalomyelitis, arthritis, dextran sodium sulfate (DSS)-induced colitis, and type I diabetes in mice (17–20). We hypothesize that targeting TLR7 activation may be an effective treatment strategy for ALD. Our experimental results demonstrate that 1Z1 oral administration inhibits ethanol-induced liver and intestinal damage and that these beneficial effects are due to intestinal IL-22 induction in an AH murine model.     

Photoinduced oxidation of a water-soluble manganese(III) porphyrin

The photoinduced oxidation of tetra(N-methyl-4-pyridyl)porphyrinmanganese(III) has been achieved in homogeneous solution. The manganese porphyrin was used as an electron donor in a three-component system with tris-(2,2′-bipyridine)ruthenium(II) as the photosensitizer and chloropentaamminecobalt(III) as the electron acceptor. The photooxidized manganese porphyrin is unstable in aqueous solution, reverting to the starting manganese(III) porphyrin. The oxidation of manganese(III) porphyrin and the subsequent reduction of the oxidized porphyrin can be cycled repeatedly.     

Photosensitized electron transport across lipid vesicle walls: Enhancement of quantum yield by ionophores and transmembrane potentials

The photosensitized reduction of heptylviologen in the bulk aqueous phase of phosphatidylcholine vesicles containing EDTA inside and a membrane-bound tris(2,2′-bipyridine)ruthenium(2+) derivative is enhanced by a factor of 6.5 by the addition of valinomycin in the presence of K⁺. A 3-fold stimulation by gramicidin and carbonyl cyanide m-chlorophenylhydrazone is observed. The results suggest that, under these conditions, the rate of photoinduced electron transfer across vesicle walls in the absence of ion carriers is limited by cotransport of cations. The rate of electron transfer across vesicle walls could be influenced further by generating transmembrane potentials with K⁺ gradients in the presence of valinomycin. When vesicles are made with transmembrane potentials, interior more negative, the quantum yield of heptylviologen reduction is doubled, and, conversely, when vesicles are made with transmembrane potentials, interior more positive, the quantum yield is decreased and approaches the value found in the absence of valinomycin.