Kurume University

Small synthetic molecules called growth hormone secretagogues (GHSs) stimulate the release of growth hormone (GH) from the pituitary. They act through the GHS-R, a G protein-coupled receptor whose ligand has only been discovered recently. Using a reverse pharmacology paradigm with a stable cell line expressing GHS-R, we purified an endogenous ligand for GHS-R from rat stomach and named it "ghrelin," after a word root ("ghre") in Proto-Indo-European languages meaning "grow." Ghrelin is a peptide hormone in which the third amino acid, usually a serine but in some species a threonine, is modified by a fatty acid; this modification is essential for ghrelin's activity. The discovery of ghrelin indicates that the release of GH from the pituitary might be regulated not only by hypothalamic GH-releasing hormone, but also by ghrelin derived from the stomach. In addition, ghrelin stimulates appetite by acting on the hypothalamic arcuate nucleus, a region known to control food intake. Ghrelin is orexigenic; it is secreted from the stomach and circulates in the bloodstream under fasting conditions, indicating that it transmits a hunger signal from the periphery to the central nervous system. Taking into account all these activities, ghrelin plays important roles for maintaining GH release and energy homeostasis in vertebrates.

Japanese mortality due to colorectal cancer is on the rise, surpassing 49,000 in 2015. Many new treatment methods have been developed during recent decades. The Japanese Society for Cancer of the Colon and Rectum Guidelines 2016 for the treatment of colorectal cancer (JSCCR Guidelines 2016) were prepared to show standard treatment strategies for colorectal cancer, to eliminate disparities among institutions in terms of treatment, to eliminate unnecessary treatment and insufficient treatment, and to deepen mutual understanding between health-care professionals and patients by making these Guidelines available to the general public. These Guidelines were prepared by consensus reached by the JSCCR Guideline Committee, based on a careful review of the evidence retrieved by literature searches, and in view of the medical health insurance system and actual clinical practice settings in Japan. Therefore, these Guidelines can be used as a tool for treating colorectal cancer in actual clinical practice settings. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. As a result of the discussions held by the Guideline Committee, controversial issues were selected as Clinical Questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories based on the consensus reached by the Guideline Committee members. Here we present the English version of the JSCCR Guidelines 2016.

Keys, A. (84060 Pioppi (SA), Italy), A. Menotti, M. J. Karvonen, C. Aravanis, H. Blackburn, R. Buzina, B. S. Djordjevlc, A. S. Dontas, F. Fldanza, M. H. Keys, D. Kromhout, S. Nedeljkovic, S. Punsar, F. Seccareccia, and H. Toshima. The diet and 15-year death rate In the Seven Countries Study. Am J Epidemiol 1986; 124:903–15 In 15 cohorts of the Seven Countries Study, comprising 11,579 men aged 40-years and “healthy” at entry, 2,288 died In 15 years. Death rates differed among cohorts. Differences In mean age, blood pressure, serum cholesterol, and smoking habits “explained” 46% of variance in death rate from all causes, 80% from coronary heart dIsease, 35% from cancer, and 45% from stroke. Death rate differences were unrelated to cohort differences in mean relative body weIght. fatness, and physical activity. The cohorts differed in average dIets. Death rates were related positively to average percentage of dIetary energy from saturated fatty acids, negatively to dietary energy percentage from monounsaturated fatty acids, and were unrelated to dietary energy percentage from polyunsaturated fatty acids, proteins, carbohydrates, and alcohol. All death rates were negatively related to the ratio of monounsaturated to saturated fatty acids. Inclusion of that ratio with age, blood pressure, serum cholesterol, and smokIng habits as inde pendent variables accounted for 85% of variance In rates of deaths from all causes, 96% coronary heart dIsease, 55% cancer, and 66% stroke. Oleic acid accounted for almost all dIfferences In monounsaturates among cohorts. All- cause and coronary heart disease death rates were low In cohorts with olive oil the main fat Causal relationshIps are not claimed but consideration of characteristics of populations as well as of Individuals withIn populations is urged evaluating risks.

New growth in the vascular network is important since the proliferation, as well as metastatic spread, of cancer cells depends on an adequate supply of oxygen and nutrients and the removal of waste products. New blood and lymphatic vessels form through processes called angiogenesis and lymphangiogenesis, respectively. Angiogenesis is regulated by both activator and inhibitor molecules. More than a dozen different proteins have been identified as angiogenic activators and inhibitors. Levels of expression of angiogenic factors reflect the aggressiveness of tumor cells. The discovery of angiogenic inhibitors should help to reduce both morbidity and mortality from carcinomas. Thousands of patients have received antiangiogenic therapy to date. Despite their theoretical efficacy, antiangiogeic treatments have not proved beneficial in terms of long-term survival. There is an urgent need for a new comprehensive treatment strategy combining antiangiogenic agents with conventional cytoreductive treatments in the control of cancer.

The American Joint Committee on Cancer/Union Internationale Contre le Cancer (AJCC/UICC) TNM staging system provides the most reliable guidelines for the routine prognostication and treatment of colorectal carcinoma. This traditional tumour staging summarizes data on tumour burden (T), the presence of cancer cells in draining and regional lymph nodes (N) and evidence for distant metastases (M). However, it is now recognized that the clinical outcome can vary significantly among patients within the same stage. The current classification provides limited prognostic information and does not predict response to therapy. Multiple ways to classify cancer and to distinguish different subtypes of colorectal cancer have been proposed, including morphology, cell origin, molecular pathways, mutation status and gene expression-based stratification. These parameters rely on tumour-cell characteristics. Extensive literature has investigated the host immune response against cancer and demonstrated the prognostic impact of the in situ immune cell infiltrate in tumours. A methodology named 'Immunoscore' has been defined to quantify the in situ immune infiltrate. In colorectal cancer, the Immunoscore may add to the significance of the current AJCC/UICC TNM classification, since it has been demonstrated to be a prognostic factor superior to the AJCC/UICC TNM classification. An international consortium has been initiated to validate and promote the Immunoscore in routine clinical settings. The results of this international consortium may result in the implementation of the Immunoscore as a new component for the classification of cancer, designated TNM-I (TNM-Immune).

BACKGROUND: The long-term consequences of the cardiovascular sequelae in Kawasaki disease remain uncertain. METHODS AND RESULTS: We identified 594 consecutive children with acute Kawasaki disease between 1973 and 1983, and this cohort was followed up for 10 to 21 years (mean, 13.6 years). In all patients, we evaluated coronary lesions by coronary angiography just after the acute stage. One hundred and forty-six patients (24.6%) were diagnosed as having coronary aneurysms. A second angiogram was performed 1 to 2 years later in all 146 patients who previously had coronary aneurysms, which demonstrated that 72 (49.3%) of these 146 had regression in the coronary aneurysm. A third angiogram was performed for 62 patients, a fourth for 29, and a fifth for 17. By 10 to 21 years after the onset of the illness, stenosis in the coronary aneurysm had developed in 28 patients. Myocardial infarction occurred in 11 patients, 5 of whom died. In the 26 patients with giant coronary aneurysms, stenotic lesions developed in 12, and no regression occurred. The 448 patients with normal findings at the first angiogram subsequently never developed any abnormal cardiac findings. Systemic artery aneurysms developed in 13 patients (2.2%), and valvular heart disease appeared in 7 (1.2%). CONCLUSIONS: The incidence of coronary aneurysm in acute Kawasaki disease was 25%, 55% of which showed regression. During follow-up, ischemic heart disease developed in 4.7% and myocardial infarction in 1.9%. Death occurred in 0.8%.

Inflammatory bowel disease (IBD) is an intestinal inflammatory condition that affects more than 2 million people in the United States. Although the etiology and pathogenesis of IBD are still largely unknown, dysregulated host/enteric microbial interactions are requisite for the development of IBD. So far, many researchers have tried to identify a precise relationship between IBD and an imbalance of the intestinal microbiota, termed "dysbiosis." Despite extensive efforts, it is still largely unknown about the interplay among microbes, their hosts, and their environments, and whether dysbiosis is a causal factor or an effect of IBD. Recently, deep-sequencing analyses of the microbiota in patients with IBD patients have been instrumental in characterizing the strong association between dysbiosis and IBD development, although it is still unable to identify specific-associated species level changes in most cases. Based on many recent reports, dysbiosis of the commensal microbiota is implicated in the pathogenesis of several diseases, including IBD, obesity, and allergic disorders, in both human and animal models. In this review article, the authors have focused on explaining the multiple types of dysbiosis, as well as dysbiosis-related diseases and potential treatments to apply this knowledge to understand a possible cause and potentially find therapeutic strategies for IBD as well as the other dysbiosis-related diseases.

Abstract The genetic make-up of an individual contributes to the susceptibility and response to viral infection. Although environmental, clinical and social factors have a role in the chance of exposure to SARS-CoV-2 and the severity of COVID-19 1,2 , host genetics may also be important. Identifying host-specific genetic factors may reveal biological mechanisms of therapeutic relevance and clarify causal relationships of modifiable environmental risk factors for SARS-CoV-2 infection and outcomes. We formed a global network of researchers to investigate the role of human genetics in SARS-CoV-2 infection and COVID-19 severity. Here we describe the results of three genome-wide association meta-analyses that consist of up to 49,562 patients with COVID-19 from 46 studies across 19 countries. We report 13 genome-wide significant loci that are associated with SARS-CoV-2 infection or severe manifestations of COVID-19. Several of these loci correspond to previously documented associations to lung or autoimmune and inflammatory diseases 3–7 . They also represent potentially actionable mechanisms in response to infection. Mendelian randomization analyses support a causal role for smoking and body-mass index for severe COVID-19 although not for type II diabetes. The identification of novel host genetic factors associated with COVID-19 was made possible by the community of human genetics researchers coming together to prioritize the sharing of data, results, resources and analytical frameworks. This working model of international collaboration underscores what is possible for future genetic discoveries in emerging pandemics, or indeed for any complex human disease.

BACKGROUND: Previous studies on the effect of interferon therapy on the incidence of hepatocellular carcinoma have not sufficiently assessed degree of liver fibrosis, a major risk factor for hepatocellular carcinoma. OBJECTIVE: To evaluate the effect of interferon therapy on incidence of hepatocellular carcinoma, adjusting for risk factors, including the degree of liver fibrosis. DESIGN: Retrospective cohort study. SETTING: Seven university hospitals and one regional core hospital in Japan. PATIENTS: 2890 patients with chronic hepatitis C who had undergone liver biopsy since 1986. Of these patients, 2400 received interferon and 490 were untreated. MEASUREMENTS: The degree of liver fibrosis was assessed from stage F0 (no fibrosis) to stage F4 (cirrhosis). Response to interferon was determined virologically and biochemically. Screening for development of hepatocellular carcinoma was performed periodically during an average follow-up of 4.3 years. Effect of interferon therapy on the risk for hepatocellular carcinoma was analyzed by using Cox proportional hazards regression. RESULTS: Hepatocellular carcinoma developed in 89 interferon-treated patients and in 59 untreated patients. Among untreated patients, the annual incidence of hepatocellular carcinoma increased with the degree of liver fibrosis, from 0.5% among patients with stage F0 or F1 fibrosis to 7.9% among patients with stage F4 fibrosis. The cumulative incidence in treated and untreated patients differed significantly for patients with stage F2 fibrosis (P = 0.0128) and for those with stage F3 fibrosis (P = 0.0011). In multivariate analysis, interferon therapy was associated with a reduced risk for hepatocellular carcinoma (adjusted risk ratio, 0.516 [95% CI, 0.358 to 0.742]; P < 0.001), especially among patients with sustained virologic response (risk ratio, 0.197 [CI, 0.099 to 0.392]), among those with persistently normal serum alanine aminotransferase levels (risk ratio, 0.197 [CI, 0.104 to 0.375]), and among those with alanine aminotransferase levels less than two times the upper limit of normal (risk ratio, 0.358 [CI, 0.206 to 0.622]). CONCLUSIONS: Interferon therapy significantly reducesthe risk for hepatocellular carcinoma, especially among virologic or biochemical responders.

BACKGROUND: The gastrointestinal peptide hormone ghrelin was discovered in 1999 as the endogenous ligand of the growth hormone secretagogue receptor. Increasing evidence supports more complicated and nuanced roles for the hormone, which go beyond the regulation of systemic energy metabolism. SCOPE OF REVIEW: In this review, we discuss the diverse biological functions of ghrelin, the regulation of its secretion, and address questions that still remain 15 years after its discovery. MAJOR CONCLUSIONS: In recent years, ghrelin has been found to have a plethora of central and peripheral actions in distinct areas including learning and memory, gut motility and gastric acid secretion, sleep/wake rhythm, reward seeking behavior, taste sensation and glucose metabolism.

BACKGROUND: Bone marrow implantation (BMI) was shown to enhance angiogenesis in a rat ischemic heart model. This preclinical study using a swine model was designed to test the safety and therapeutic effectiveness of BMI. METHODS AND RESULTS: BM-derived mononuclear cells (BM-MNCs) were injected into a zone made ischemic by coronary artery ligation. Three weeks after BMI, regional blood flow and capillary densities were significantly higher (4.6- and 2.8-fold, respectively), and cardiac function was improved. Angiography revealed that there was a marked increase (5.7-fold) in number of visible collateral vessels. Implantation of porcine coronary microvascular endothelial cells (CMECs) did not cause any significant increase in capillary densities. Labeled BM-MNCs were incorporated into approximately 31% of neocapillaries and corresponded to approximately 8.7% of macrophages but did not actively survive as myoblasts or fibroblasts. There was no bone formation by osteoblasts or malignant ventricular arrhythmia. Time-dependent changes in plasma levels for cardiac enzymes (troponin I and creatine kinase-MB) did not differ between the BMI, CMEC, and medium-alone implantation groups. BM-MNCs contained 16% of endothelial-lineage cells and expressed basic fibroblast growth factor>>vascular endothelial growth factor>angiopoietin 1 mRNAs, and their cardiac levels were significantly upregulated by BMI. Cardiac interleukin-1beta and tumor necrosis factor-alpha mRNA expression were also induced by BMI but not by CMEC implantation. BM-MNCs were actively differentiated to endothelial cells in vitro and formed network structure with human umbilical vein endothelial cells. CONCLUSIONS: BMI may constitute a novel safety strategy for achieving optimal therapeutic angiogenesis by the natural ability of the BM cells to secrete potent angiogenic ligands and cytokines as well as to be incorporated into foci of neovascularization.

Endothelial precursor cells (EPCs) have been identified in adult peripheral blood. We examined whether EPCs could be isolated from umbilical cord blood, a rich source for hematopoietic progenitors, and whether in vivo transplantation of EPCs could modulate postnatal neovascularization. Numerous cell clusters, spindle-shaped and attaching (AT) cells, and cord-like structures developed from culture of cord blood mononuclear cells (MNCs). Fluorescence-trace experiments revealed that cell clusters, AT cells, and cord-like structures predominantly were derived from CD34-positive MNCs (MNC(CD34+)). AT cells and cell clusters could be generated more efficiently from cord blood MNCs than from adult peripheral blood MNCs. AT cells incorporated acetylated-LDL, released nitric oxide, and expressed KDR, VE-cadherin, CD31, and von Willebrand factor but not CD45. Locally transplanted AT cells survived and participated in capillary networks in the ischemic tissues of immunodeficient nude rats in vivo. AT cells thus had multiple endothelial phenotypes and were defined as a major population of EPCs. Furthermore, laser Doppler and immunohistochemical analyses revealed that EPC transplantation quantitatively augmented neovascularization and blood flow in the ischemic hindlimb. In conclusion, umbilical cord blood is a valuable source of EPCs, and transplantation of cord blood-derived EPCs represents a promising strategy for modulating postnatal neovascularization.

Abstract Common single-nucleotide polymorphisms (SNPs) are predicted to collectively explain 40–50% of phenotypic variation in human height, but identifying the specific variants and associated regions requires huge sample sizes 1 . Here, using data from a genome-wide association study of 5.4 million individuals of diverse ancestries, we show that 12,111 independent SNPs that are significantly associated with height account for nearly all of the common SNP-based heritability. These SNPs are clustered within 7,209 non-overlapping genomic segments with a mean size of around 90 kb, covering about 21% of the genome. The density of independent associations varies across the genome and the regions of increased density are enriched for biologically relevant genes. In out-of-sample estimation and prediction, the 12,111 SNPs (or all SNPs in the HapMap 3 panel 2 ) account for 40% (45%) of phenotypic variance in populations of European ancestry but only around 10–20% (14–24%) in populations of other ancestries. Effect sizes, associated regions and gene prioritization are similar across ancestries, indicating that reduced prediction accuracy is likely to be explained by linkage disequilibrium and differences in allele frequency within associated regions. Finally, we show that the relevant biological pathways are detectable with smaller sample sizes than are needed to implicate causal genes and variants. Overall, this study provides a comprehensive map of specific genomic regions that contain the vast majority of common height-associated variants. Although this map is saturated for populations of European ancestry, further research is needed to achieve equivalent saturation in other ancestries.

Advances in imaging techniques and establishment of surveillance protocols for high-risk populations have led to the detection of small hepatic nodules in patients with chronic liver diseases, particularly those with cirrhosis or chronic hepatitis caused by hepatitis B or C viruses. These nodules, comprising a broad range of diagnostic entities—some benign and some with malignant potential—are currently defined histologically, and their clinical management often depends on the ability to make a reliable histologic diagnosis. Evidence accumulated in the last two decades strongly favors the existence of a sequence of events in hepatic nodules that precedes the emergence of hepatocellular carcinoma (HCC),1-10 and these lesions are recognized as precursors of HCC. However, from the beginning of their recognition, there has been considerable confusion concerning nomenclature and diagnostic approaches to these hepatic nodules. To clarify these issues, an International Working Party (IWP) of the World Congresses of Gastroenterology proposed a consensus nomenclature and diagnostic criteria for hepatocellular nodular lesions in 1995.11 The IWP classified nodular lesions found in chronic liver disease into large regenerative nodule, low-grade dysplastic nodule (L-DN), high-grade dysplastic nodule (H-DN), and HCC; this nomenclature has been widely adopted. In addition, the IWP introduced the concept of dysplastic focus as a cluster of hepatocytes with features of early neoplasia (in particular small cell change or iron-free foci in a siderotic background) measuring less than 0.1 cm, and defined small HCC as a tumor measuring less than 2 cm. More recent studies support the division of small HCC into two clinico-pathological groups that have been termed early HCC and progressed HCC. Early HCC has a vaguely nodular appearance and is well differentiated. Progressed HCC has a distinctly nodular pattern and is mostly moderately differentiated, often with evidence of microvascular invasion.12 Early HCC has a longer time to recurrence and a higher 5-year survival rate compared with progressed HCC.13 Small lesions with malignant potential have only subtle differences from the surrounding parenchyma, making them difficult to assess reproducibly. Differences in the application of diagnostic criteria between Western and Eastern pathologists has been a persistent difficulty in research and clinical management of these lesions.14 In order to obtain a refined and up-to-date international consensus on the histopathologic diagnosis of nodular lesions, such as dysplastic nodules and early HCC, the International Consensus Group for Hepatocellular Neoplasia (ICGHN) was convened in April 2002 in Kurume, Japan. The group has met several times up to July 2007 under the auspices of the Laennec Liver Pathology Society. The ICGHN is currently comprised of 34 pathologists and two clinicians from 13 countries. It includes most members of the original IWP who are still active and all the participants from the first ICGHN meeting. This consensus document summarizes the results of our meetings. GPC3, glypican-3; GS, Glutamine synthetase; HCC, hepatocellular carcinoma; H-DN, high-grade dysplastic nodule; HSP70, heat shock protein 70; ICGHN, The International Consensus Group for Hepatocellular Neoplasia; IWP, International Working Party; L-DN, low-grade dysplastic nodule. Twenty-six resected cases of nodules from 23 patients with chronic hepatitis or cirrhosis caused by hepatitis B or C virus were selected from one Korean and two Japanese medical centers. All the lesions measured less than 2 cm in diameter. One hematoxylin and eosin–stained slide comprising the entire width of each lesion, a gross picture, and brief clinical data were reviewed by each pathologist individually, and the lesions were classified according to the IWP criteria. The group met at Kurume University Medical School, Kurume, Japan, in April 2002 to review all the lesions with photographs and by group review of relevant slides with a projecting microscope. The histologic diagnostic criteria were discussed, focusing on cases with marked discrepancies in initial, premeeting diagnosis. The second meeting was held at the University of Leuven, Belgium, in May 2004. The members discussed the diagnosis of an additional set of 22 resected small nodules. The third meeting was held at the Aristotle University of Thessaloniki, Greece in May 2006, and histopathologic consensus on both dysplastic nodules and early HCC was obtained. Kappa statistics were obtained from the comparative diagnostic panels of the first two of these meetings using SAS software version 8.2 (SAS Institute Inc., Cary, NC). There was little difficulty in agreeing on the diagnosis of well-differentiated, small HCC of the distinctly nodular type or when the tumor was moderately differentiated HCC (Fig. 1A). The overwhelming diagnostic challenge was the differentiation of H-DNs from well-differentiated, small HCC of the vaguely nodular type (early HCC) (Fig. 1B). These lesions showed the lowest kappa value at the first conference with wide interobserver variation on initial review; the variation was diminished, but not totally resolved after the first conference. Initially, Asia-trained pathologists generally diagnosed HCC more frequently than Western pathologists. After the first conference, this discrepancy decreased, and kappa values for HCC rose from 0.30 to 0.49 (though with different slide sets), with most Western pathologists ultimately agreeing with the diagnosis of HCC. The improvement of diagnostic agreement after the initial conference was due to the recognition of stromal invasion as a criterion for diagnosis of well-differentiated HCC. Stromal invasion is defined as tumor cell invasion into the portal tracts or fibrous septa within vaguely nodular lesions15, 16 (Fig. 2). (A) HCC of distinctly nodular type (progressed HCC), 12 mm in diameter. There was no discrepancy in the diagnosis of HCC with this growth pattern despite the small tumor size. (B) Small HCC of vaguely nodular type (early HCC) (arrows). These lesions were often a diagnostic problem, solved in part by recognition of the histologic features of stromal invasion. (A) Stromal invasion in early HCC. The tumor cells (arrows) are invading an intratumoral portal tract. (B) CK19 immunostaining of another lesion. The ductular reaction (arrows) is mimicking stromal invasion and is prominent at the stroma–parenchymal interface. Well-differentiated HCC with fatty change is located at the bottom half of the image. It is often possible to make a presumptive diagnosis of HCC when a small lesion is distinctly nodular and is hypervascular on contrast-enhanced imaging in the setting of cirrhosis.17, 18 However, errors will occur occasionally with this approach. It has been reported that a small but significant proportion of explant livers was misdiagnosed as HCC.19 Any focal lesion containing a large arterio-venous shunt may be hypervascular (for example, focal nodular hyperplasia20 or similar lesions21). A hypovascular lesion less than 2 cm having a vaguely nodular appearance cannot be accurately diagnosed by gross examination or imaging. Such lesions should undergo guided needle core biopsy. Some small nodules have a “nodule-in-nodule” appearance either radiologically or on gross examination.22 In this situation, the subnodule usually represents de-differentiation of the “parent” nodule. The parent nodule may be a dysplastic nodule or well-differentiated HCC, and the subnodule is invariably a less-differentiated lesion. In these situations, the entire nodule is classified by the worst component. Typically, the less-differentiated component is more vascular than the parent component.23-27 However, if the parent nodule is a dysplastic nodule and the subnodule is well-differentiated HCC, the subnodule may not be hypervascular, because unpaired arteries have not yet developed. Such unpaired arteries are small arteries (unaccompanied by bile duct) occurring outside the original portal tracts, and are indicative of neovascularization. They have a thin muscular wall that can be recognized in more detail via immunostaining for α-smooth muscle actin. Regardless of vascularity, a nodule-in-nodule appearance suggests the presence of HCC. L-DNs are sometimes vaguely nodular but are often distinct from the surrounding cirrhotic liver because of the presence of peripheral fibrous scar. This is not a true capsule, but rather condensation of scarring as is seen around all cirrhotic nodules. L-DNs show mild increase in cell density with a monotonous pattern, and they have no cytologic atypia, though they may have large cell change (formerly referred to as large cell dysplasia28). Architectural changes beyond clearly regenerative features are not present; these lesions do not contain pseudoglands or markedly thickened trabeculae (Fig. 3). Unpaired arteries are sometimes present in small numbers.29 Nodule-in-nodule lesions are not present in L-DNs. L-DNs may have diffuse siderosis or diffusely increased copper retention. (A) Low-grade dysplastic nodule (right two-thirds) shows mild increase in cell density with a clearer trabecular arrangement than the adjacent parenchyma. (B) High-grade dysplastic nodule. The cell density in this example is more than 1.5 times higher than that in the surrounding tissue (upper left). Irregularity of the trabecular pattern is remarkable, but there is no obvious infiltrative growth. (C, D) Small, well-differentiated HCC of vaguely nodular type (early HCC). The tumor shows replacing growth at the boundary (arrows), and the cell density is more than 2 times higher than that in the surrounding tissue. The tumor cells show an irregular thin-trabecular pattern with occasional pseudoglands. Stromal invasion was present elsewhere in the tumor. Among members of the consensus panels, there was no serious difficulty in differentiating L-DNs from early HCC. At the opposite end of the spectrum, distinction between L-DNs and large regenerative nodules was often found to be difficult or impossible. Therefore, there is currently consensus that distinction between these two diagnostic categories cannot be made confidently by morphology alone and remains a task for the future. Fortunately, this distinction does not appear to have significant practical consequences at present. H-DNs may be distinctly or vaguely nodular in the background of cirrhosis, although they also lack a true capsule, similar to L-DNs; however, they are more likely to show a vaguely nodular pattern than L-DNs. An H-DN is defined as having architectural and/or cytologic atypia, but the atypia is insufficient for a diagnosis of HCC. These lesions most often show increased cell density, sometimes more than 2 times higher than the surrounding nontumoral liver, often with an irregular trabecular pattern (Fig. 3). Small cell change (also known as small cell dysplasia30) is the most frequently seen form of cytologic atypia in H-DNs. This form of atypia may also occur in small hepatocellular foci outside of H-DNs; the term dysplastic focus11 may be appropriately used for such lesions. Large cell change may or may not be present in H-DNs. Unpaired arteries are found in most lesions, but usually not in great numbers. A nodule-in-nodule appearance is occasionally found in H-DNs, and subnodules often have a higher labeling index of Ki-67 or proliferating cell nuclear antigen than that of H-DN parenchyma. When a nodule with largely H-DN features contains a subnodule of HCC, the subnodule of HCC is usually well-differentiated with a well-defined margin. The diagnostic discrepancy between H-DN and early HCC was frequent at the first consensus meeting, but was remarkably improved at the second meeting due to the recognition of stromal invasion as a diagnostic criterion for the differentiation of H-DN from early HCC. If areas of questionable invasion are present, immunostaining for keratins 7 or 19 may be useful; if such staining demonstrates a ductular reaction, the focus is considered a pseudoinvasion and does not warrant a diagnosis of HCC31 (Fig. 2B). increased cell density more than 2 times that of the surrounding tissue, with an increased nuclear/cytoplasm ratio and irregular thin-trabecular pattern; varying numbers of portal tracts within the nodule (intratumoral portal tracts); pseudoglandular pattern; diffuse fatty change; and varying numbers of unpaired arteries. Among these features, diffuse fatty change is observed in approximately 40% of cases.33 The characteristic features of early HCC are sometimes seen in larger tumors as well—that is, well-differentiated tumors that measure over 2 cm and thus do not qualify for the designation of small HCC set forth by the IWP. The prevalence of fatty change decreases along with increasing tumor size; therefore, fatty change is uncommon in tumors larger than 3 cm. Fatty change is also uncommon in moderately differentiated HCCs. Any of the features listed above may be diffuse throughout the lesion or may be restricted to an expansile subnodule (nodule-in-nodule). Most importantly, because all of these features may also be found in H-DNs, it is important to note that stromal invasion remains most helpful in differentiating early HCC from H-DNs. Alpha-fetoprotein is a well-established serum marker for HCC. However, elevated levels are rarely found in early HCCs. Alpha-fetoprotein is not useful as a tissue marker because of low sensitivity (25% to 30%), even with moderately differentiated HCC. Glypican-3 (GPC3), a cell-surface heparan sulfate proteoglycans that is secreted into the plasma, has recently become established as a serum and tissue marker for HCC.34-39 GPC3 immunoreactivity has a reported sensitivity of 77% and specificity of 96% in the diagnosis of small HCC; therefore, GPC3 positivity is a strong argument for malignancy.40, 41 The staining pattern is usually cytoplasmic but may be membranous or canalicular (Fig. 4). The monoclonal antibody from Biomosaics (IG12 clone) at a dilution of 1/50 to 1/100 as amplified with the new short polymer systems (Advance [Dako], Novolink [Novocastra], and Super-picture + [Zymed]) yields reliable results. Because GPC3 staining may be only focal, additional markers or a panel of markers may be necessary. GPC3 staining must be interpreted in context, because it may also be seen in regenerating hepatocytes in a setting of hepatitis42 and in melanocytic lesions.43 GPC3 expression in small, well-differentiated HCC of vaguely nodular type (early HCC). (A) Hematoxylin-eosin stain. (B) Immunostaining for GPC3 shows expression in the cytoplasm of tumor cells. Heat shock protein 70 (HSP70) belongs to a class of genes (heat shock proteins) implicated in the regulation of cell cycle progression, in apoptosis, and in tumorigenesis.44-46 Most HCCs are associated with chronic inflammation and fibrosis acting as stressful conditions that lead to heat shock protein synthesis. HSP70 is, in particular, a potent antiapoptotic survival factor. Chuma et al.47 reported HSP70 as the most abundantly up-regulated gene among a set of 12,600 genes in early HCC. Furthermore, it was significantly overexpressed in progressed HCC as compared with early HCC, and in the latter as compared with precancerous lesions. HSP70 immunoreactivity was recently reported in the majority of HCCs, including early and well-differentiated forms, but not in nonmalignant nodules,48 thus suggesting its use as a marker of malignancy. HSP70 immunoreactivity (SC-24, dilution 1:250 to 1:500 amplified with short polymer systems; Santa Cruz Biotechnology, Santa Cruz, CA) is nucleo-cytoplasmic and mostly focal with 70% sensitivity for HCC detection in surgically resected specimens.49 Glutamine synthetase (GS) catalyzes the synthesis of glutamine from glutamate and ammonia in the mammalian liver49 where it has been shown to be restricted to hepatocytes surrounding the terminal hepatic venules.50 It is known that glutamine, the end product of GS activity, is the major energy source of tumor cells.51 Most importantly, GS is a target gene of β-catenin so that its overexpression is associated with mutations of β-catenin or with activation of this pathway.52-54 Up-regulation of GS messenger RNA, protein, and activity were shown by Christa et al.52 in human HCC, while Osada et al.55 reported the stepwise increase in GS immunoreactivity from precancerous lesions to early HCC to progressed HCC. The monoclonal antibody from Chemicon International (clone MB302) at a dilution of 1/500 to 1/1000 and amplified with a new short polymer system yields reliable results. In order to increase its specificity as a marker of malignancy, GS immunostaining should be diffuse and of strong intensity, a pattern that can be seen in 50% of HCCs, including early forms.49 The combination of more than one putative marker of malignancy raises the overall accuracy. When applying a panel of these three markers (GPC3, HSP70, and GS) to resected small lesions, the finding of any two positive markers had a sensitivity of 72% and a specificity of 100% to detect malignancy.48 The diagnostic accuracy of this panel of markers in liver biopsies of hepatocellular nodules has not been yet tested. The IWP criteria of 1995 have led to remarkable progress in global standardization of nomenclature of liver nodules.11 However, although these criteria have been widely adopted, their application is challenging in equivocal lesions. Perhaps the most significant problem is that most histologic criteria are arrayed on a gradual spectrum and cannot be easily summarized as present or absent. Additionally, the number of criteria suggested in the literature are too numerous to achieve interobserver consensus, and the diagnostic weight carried by each of these criteria is uncertain. Frequently used criteria for malignancy in other tissues, such as mitotic activity and cellular atypia, are not represented to a significant degree in well-differentiated HCC. In addition, because the liver lacks a layered structure as seen in the gastrointestinal tract, it is difficult to determine the presence of destructive growth in early HCCs. Despite these difficulties, current histologic criteria for these nodules clearly yield reliable diagnoses at both ends of the spectrum; most pathologists will correctly identify nodules up to L-DN as benign, whereas even small well-differentiated nodules with distinct nodular pattern or small moderately differentiated HCCs will be correctly identified as The includes H-DN and early HCC. In of these lesions, the presence of stromal invasion is a useful criterion of 16 pathologists can the equivocal tumor is HCC or H-DN by the presence or of tumor cell invasion into the intratumoral portal When obvious stromal invasion is not found in an equivocal the lesion may be diagnosed as either H-DN or early HCC invasion. The diagnosis of stromal invasion is and may the of or and 7 or for differentiation from and markers are still under and are likely to the application of for small nodules, the for the of Liver that should be for nodules less than 2 cm if their are not characteristic of HCC, whereas is not for lesions characteristic This has been by diagnosis of equivocal nodules remains a because may not contain intratumoral portal tracts, thus the detection of stromal invasion. the detection of unpaired and markers are to liver is to needle because the obtained is for the of both architectural and cytologic Furthermore, the tissue obtained for marker needle is usually for the of large lesions that are likely to be moderately to differentiated, where diagnostic criteria are to and features of early hepatocellular neoplasia are summarized in The characteristic imaging appearance of HCC is a hypervascular lesion that shows in the portal This appearance is also in small HCC of the distinctly nodular type and most moderately differentiated small HCCs. nodules and most early HCCs are hypovascular lesions. These are by the features of the lesions. the and imaging features three in the of neoplasia in cirrhotic liver, where dysplastic nodules the well-differentiated HCC of the vaguely nodular type represents early and small HCCs of the distinctly nodular type and moderately differentiated HCCs progressed In the liver, however, the of HCC in has not been clinical and The in the show the changes that are found with the of malignant HCC. Because early HCCs in a replacing pattern at the with tumor cells replacing the surrounding liver cell they show a vaguely nodular When the tumors 1.5 to 2 cm in they to moderately differentiated and in an expansile with of a fibrous and are to the in the of contrast-enhanced imaging to the is to the of unpaired the of portal and the distinctly nodular growth. The diagnosis must the of the lesion, the presence of cirrhosis, the imaging and the growth In the context, a lesion with portal is of early HCC. The for kappa The is not for the or of any by the Any than should be to the for the

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death not only in Japan but also worldwide. Clinical practice guidelines for HCC were first published in 2001 by the European Society of Study of the Liver (EASL) followed by the American Association for the Study of Liver Disease (AASLD) published in 2005 and updated in 2010. However, these guidelines have proven to be somewhat unsuitable for Japanese patients. In 2005, supported by the Japanese Ministry of Health, Labour and Welfare, evidence-based clinical practice guidelines for HCC were compiled in Japan. In 2009, a revised version of evidence-based guidelines was published. Based on both 'evidence-based' guidelines and the consensus of an expert panel on HCC, the Japan Society of Hepatology (JSH) published the Consensus-Based Clinical Practice Manual in 2007 and updated in 2010. In this article, the 2010 updated version of this manual, especially issues on prevention, surveillance, pathology, diagnosis, staging, and treatment algorithm are summarized.

Prediction of clinical outcome in cancer is usually achieved by histopathological evaluation of tissue samples obtained during surgical resection of the primary tumor. Traditional tumor staging (AJCC/UICC-TNM classification) summarizes data on tumor burden (T), presence of cancer cells in draining and regional lymph nodes (N) and evidence for metastases (M). However, it is now recognized that clinical outcome can significantly vary among patients within the same stage. The current classification provides limited prognostic information, and does not predict response to therapy. Recent literature has alluded to the importance of the host immune system in controlling tumor progression. Thus, evidence supports the notion to include immunological biomarkers, implemented as a tool for the prediction of prognosis and response to therapy. Accumulating data, collected from large cohorts of human cancers, has demonstrated the impact of immune-classification, which has a prognostic value that may add to the significance of the AJCC/UICC TNM-classification. It is therefore imperative to begin to incorporate the 'Immunoscore' into traditional classification, thus providing an essential prognostic and potentially predictive tool. Introduction of this parameter as a biomarker to classify cancers, as part of routine diagnostic and prognostic assessment of tumors, will facilitate clinical decision-making including rational stratification of patient treatment. Equally, the inherent complexity of quantitative immunohistochemistry, in conjunction with protocol variation across laboratories, analysis of different immune cell types, inconsistent region selection criteria, and variable ways to quantify immune infiltration, all underline the urgent requirement to reach assay harmonization. In an effort to promote the Immunoscore in routine clinical settings, an international task force was initiated. This review represents a follow-up of the announcement of this initiative, and of the J Transl Med. editorial from January 2012. Immunophenotyping of tumors may provide crucial novel prognostic information. The results of this international validation may result in the implementation of the Immunoscore as a new component for the classification of cancer, designated TNM-I (TNM-Immune).

BACKGROUND: A retrospective review of treatment results comparing women with clear cell carcinoma of the ovary (CCC) with a group with serous adenocarcinoma of the ovary (SAC) was conducted. METHODS: Between 1988-1998, 662 patients with epithelial ovarian carcinoma were identified through the medical records department and the tumor registry at 4 institutions. After the central pathologic review, 101 patients with pure or dominant (>/= 90%) CCC (15.3%) were entered into the current study. Two hundred thirty five patients with pure SAC were selected as a group for comparison. All patients underwent staging laparotomy followed by platinum-based chemotherapy. Distribution of the International Federation of Gynecology and Obstetrics (FIGO) disease stage, response to chemotherapy, and prognosis for patients with CCC were compared with the same values in patients with SAC. RESULTS: Patients with CCC were significantly more likely to have FIGO Stage I disease than were patients with SAC (48.5% vs. 16.6%). A high recurrence rate was noted in those patients with Stage IC CCC (37%). In those patients with Stage IC disease, the survival rates for patients with CCC were lower than those for patients with SAC. The 3-year and 5-year survival rates for Stage III CCC patients were significantly lower compared with Stage III SAC patients. The response rate to platinum-based chemotherapy in patients with CCC was significantly lower than that in patients with SAC. CONCLUSIONS: CCC is an intriguing histologic type of epithelial ovarian cancer that demonstrates a clinical behavior distinctly different from that of SAC.

OBJECTIVE: We aimed to develop consensus-based recommendations for streamlining medical communication among various health care professionals, to improve accuracy of diagnosis and treatment, and to facilitate future investigations for mucous membrane pemphigoid. PARTICIPANTS: Because of the highly specific nature of this group of diseases, the 26 invited participants included either international scholars in the field of mucous membrane pemphigoid or experts in cutaneous pharmacology representing the 3 medical disciplines ophthalmology, oral medicine, and dermatology. EVIDENCE: The first author (L.S.C.) conducted a literature search. Based on the information obtained, international experts who had contributed to the literature in the clinical care, diagnosis, and laboratory investigation for mucous membrane pemphigoid were invited to participate in a consensus meeting aimed at developing a consensus statement. CONSENSUS PROCESS: A consensus meeting was convened and conducted on May 10, 1999, in Chicago, Ill, to discuss the relevant issues. The first author drafted the statement based on the consensus developed at the meeting and the participants' written comments. The draft was submitted to all participants for 3 separate rounds of review, and disagreements were reconciled based on literature evidence. The third and final statement incorporated all relevant evidence obtained in the literature search and the consensus developed by the participants. The final statement was approved and endorsed by all 26 participants. CONCLUSIONS: Specific consensus-based recommendations were made regarding the definition, diagnostic criteria, pathogenic factors, medical treatment, and prognostic indicators for mucous membrane pemphigoid. A system of standard reporting for these patients was proposed to facilitate a uniform data collection.

BACKGROUND: Exposure to risk factors such as hypertension or hypercholesterolemia decreases the bioavailability of endothelium-derived nitric oxide (NO) and impairs endothelium-dependent vasodilation. Recently, a circulating endogenous NO synthase inhibitor, asymmetric dimethylarginine (ADMA), has been detected in human plasma. The purpose of this study was to examine the relationship between plasma ADMA and atherosclerosis in humans. METHODS AND RESULTS: Subjects (n=116; age, 52+/-1 years; male:female ratio, 100:16) underwent a complete history and physical examination, determination of serum chemistries and ADMA levels, and duplex scanning of the carotid arteries. These individuals had no symptoms of coronary or peripheral artery disease and were taking no medications. Univariate and multivariate analyses revealed that plasma levels of ADMA were positively correlated with age (P<0.0001), mean arterial pressure (P<0.0001), and Sigma glucose (an index of glucose tolerance) (P=0.0006). Most intriguingly, stepwise regression analysis revealed that plasma ADMA levels were significantly correlated to the intima-media thickness of the carotid artery (as measured by high-resolution ultrasonography). CONCLUSIONS: This study reveals that plasma ADMA levels are positively correlated with risk factors for atherosclerosis. Furthermore, plasma ADMA level is significantly correlated with carotid intima-media thickness. Our results suggest that this endogenous antagonist of NO synthase may be a marker of atherosclerosis.

Non-alcoholic fatty liver disease (NAFLD) is a potentially serious liver disease that affects approximately one-quarter of the global adult population, causing a substantial burden of ill health with wide-ranging social and economic implications. It is a multisystem disease and is considered the hepatic component of metabolic syndrome. Unlike other highly prevalent conditions, NAFLD has received little attention from the global public health community. Health system and public health responses to NAFLD have been weak and fragmented, and, despite its pervasiveness, NAFLD is largely unknown outside hepatology and gastroenterology. There is only a nascent global public health movement addressing NAFLD, and the disease is absent from nearly all national and international strategies and policies for non-communicable diseases, including obesity. In this global Delphi study, a multidisciplinary group of experts developed consensus statements and recommendations, which a larger group of collaborators reviewed over three rounds until consensus was achieved. The resulting consensus statements and recommendations address a broad range of topics - from epidemiology, awareness, care and treatment to public health policies and leadership - that have general relevance for policy-makers, health-care practitioners, civil society groups, research institutions and affected populations. These recommendations should provide a strong foundation for a comprehensive public health response to NAFLD.