Significance of biological resource collection and tumor tissue bank creation

Progress in the molecular oncology of gastrointestinal carcinomas depends on high quality cancer tissues for research. Recent acceleration on new technological platforms as well as the “omics” revolution increases the demands on tissues and peripheral blood for research at the DNA, mRNA and protein levels. Tissue bank creation emerges as a priority. Tumor tissue banks are facilities that are organized to collect, store and distribute samples of tumor and normal tissue for further use in basic and translational cancer research. The samples are generally obtained immediately after excision, prior to fixation, to ensure optimal preservation of proteins and nucleic acids. It is possible for surgeons or pathologists to collect fresh tissue prospectively during their routine dissection procedures. Most tissue banks are “project-driven” tumor banks, which are specialized collections of tumor samples on which their research is based. Systematic collection of all available tumor tissue is much rarer. High quality tissue banks need the collaboration of clinicians and basic scientists, but also the informed consent of patients and ethical approval. Through the standard operation procedure, snap frozen fresh tissue collection, storage and quality control for cryopreserved tissues are the pivotal factors on tissue bank construction and maintaining. The purpose of the tissue bank creation is enhancing the quality and speed on both the basic and translational research on gastrointestinal cancer. The quality assurance and quality control are handled based on reviewing HE staining slides or touch imprint cytology by pathologists.

Early and long-term postoperative management following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Peritoneal surface malignancies have been traditionally regarded as end-stage conditions amenable to merely palliative options. The combination of aggressive cytoreductive surgery (CRS), involving peritonectomy procedures and multivisceral resections, with intra-operative hyperthermic intra-peritoneal chemotherapy (HIPEC) and/or early postoperative intra-peritoneal chemotherapy (EPIC) to treat the microscopic residual tumor is a new concept. In recent years, promising results have been reported for peritoneal mesothelioma and carcinomatosis of gastrointestinal and gynaecologic origin treated by this combined protocol. However, CRS with HIPEC and/or EPIC is a complex procedure associated with high rates of potentially life-threatening complications. Furthermore, disease progression following comprehensive treatment is not uncommon and represents a relevant cause of treatment failure. The present paper reviews the available information on early postoperative management and long-term follow-up in patients treated with CRS and intraperitoneal chemotherapy. The peculiar clinical and biological alterations that can be expected during an uncomplicated postoperative course, as compared to standard digestive surgery, are discussed. Early recognition and appropriate management of the most common adverse events are addressed, in order to minimize the impact of treatment-related morbidity on survival and quality of life results. Since re-operative surgery with additional HIPEC, has proven to be useful in selected patients with recurrent disease, long-term surveillance aiming at early detection of postoperative disease progression has become a relevant issue. Current results on follow-up investigations are presented.

New approach to peritoneal surface malignancies

Peritoneal surface malignancies (PSM) are a clinical entity with an unfavourable prognosis. They comprise peritoneal carcinomatosis, pseudomyxoma peritonei, and primitive tumors of the peritoneum. Because the treatment of PSM presents unique and challenging problems to the cancer clinician, many new approaches have been attempted in recent years. In the current and next issues of World Journal of Gastrointestinal Oncology, some international groups of researchers discuss the most important and innovative aspects of PSM treatment, with particular accuracy for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. In conclusion, because this new approach to PSM has a reputation for being based more on common sense than on experimental data, I hope that highlighting this topic can make a contribution to the treatment of this group of diseases.

Pharmacologic rationale for treatments of peritoneal surface malignancy from colorectal cancer

The peritoneal surfaces of the abdomen and pelvis are important sites for the dissemination of gastrointestinal and gynecologic malignancy. Transcoelomic dissemination of cancer cells gives rise to carcinomatosis, which, without special treatment, is a fatal manifestation of these diseases. To treat peritoneal carcinomatosis, cytoreductive surgery removes gross disease plus perioperative intraperitoneal and perioperative intravenous chemotherapy eradicates microscopic residual disease and chemical compatibilities. Chemotherapy agents are administered either by the intraperitoneal or intravenous route, based on their pharmacologic properties. A peritoneal-plasma barrier, which retards the clearance of high molecular weight chemotherapy from the peritoneal cavity, results in a large exposure of small cancer nodules on abdominal and pelvic surfaces. Tissue penetration of the intraperitoneal chemotherapy is facilitated by moderate hyperthermia (41-42°C). Targeting of intravenous chemotherapy to the peritoneal surface is facilitated by the intraperitoneal heat. A constant dose of chemotherapy agent and volume of carrier solution, based on body surface area, allows prediction of systemic drug exposure and systemic toxicity. Timing of the hyperthermic chemotherapy as a scheduled part of the surgical procedure to uniformly expose all peritoneal surfaces is crucial to success.

Selenium as a chemopreventive agent in experimentally induced colon carcinogenesis

AIM: To elucidate the chemopreventive efficacy of selenium during experimentally induced colon carcinogenesis.

METHODS: Thirty-two male wistar rats were divided into four groups: group I (normal control); group II [1,2-dimethylhydrazine (DMH) treated]; group III (selenium treated); and group IV (DMH + selenium treated). Groups II and IV were given subcutaneous injections of DMH (30 mg/kg body weight) every week for 20 wk. Selenium, in the form of sodium selenite, was given to groups III and IV at 1 ppm in drinking water ad libitum for 20 wk. At the end of the study, rats were sacrificed and their colons were analyzed for the development of tumors, antioxidant enzyme levels and histological changes.

RESULTS: 100% of the DMH treated rats developed tumors, which was reduced to 60% upon simultaneous selenium supplementation. Similarly, tumor multiplicity decreased to 1.1 following selenium supplementation to DMH treated rats. Levels of lipid peroxidation, glutathione-S-transferase, superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPx) decreased following DMH treatment, whereas levels of glutathione (GSH) and glutathione reductase (GR) significantly increased in DMH treated rats. Selenium administration to DMH treated rats led to an increase in the levels of lipid peroxidation, SOD, catalase, glutathione-S-transferase and GPx, but decreased the levels of GSH and GR. Histopathological studies on DMH treated rats revealed dysplasia of the colonic histoarchitecture, which showed signs of improvement following selenium treatment.

CONCLUSION: The study suggests the antioxidative potential of selenium is a major factor in providing protection from development of experimentally induced colon carcinogenesis.

Undefined familial colorectal cancer

Colorectal cancer (CRC), one of the most common cancers of the world, is actually a spectrum of several subtypes, with different molecular profiles, clinico-pathological characteristics and possibly separate pathways of progression. It is estimated that in approximately 25%-35% of cases, a familial component exists, so they are classified as familial CRC (fCRC). However the known hereditary CRC syndromes justify only up to 5%. The rest are attributed to some inherited genetic predisposition passed to offspring through low-penetrance genes, which in the proper environmental setting can bring on tumorigenesis. Furthermore, part of the familial clustering may be attributed to chance. Because of the complexity regarding the etiology of CRC, the clinician is sometimes faced with obscure patient data, and cannot be sure if they are dealing with fCRC or sporadic CRC. The elucidation of what is going on with the as yet “undefined” portion of CRC will aid not only in the diagnosis, classification and treatment of CRC, but more importantly in the proper adjustment of the screening guidelines and in genetic counselling of patients.

Hypermethylation of tumor suppressor and tumor-related genes in neoplastic and non-neoplastic gastric epithelia

A number of tumor suppressor and tumor-related genes exhibit promoter hypermethylation with resultant gene silencing in human cancers. The frequencies of methylation differ among genes and genomic regions within CpG islands in different tissue types. Hypermethylation initially occurs at the edge of CpG islands and spreads to the transcription start site before ultimately shutting down gene expression. When the degree of methylation was quantitatively evaluated in neoplastic and non-neoplastic gastric epithelia using DNA microarray analysis, high-level methylation around the transcription start site appeared to be a tumor-specific phenomenon, although multiple tumor suppressor genes became increasingly methylated with patient age in non-neoplastic gastric epithelia. Quantitative analysis of DNA methylation is a promising method for both cancer diagnosis and risk assessment.

Comparison between colorectal low- and high-grade mucinous adenocarcinoma with MUC1 and MUC5AC

AIM: To explore useful prognostic factors for mucinous adenocarcinoma (MAC) in the colon and rectum.

METHODS: MAC was divided into low- and high-grade types based on the degree of structural differentiation; low-grade MAC arisen from well to moderately differentiated adenocarcinoma and papillary carcinoma, and high-grade MAC from poorly differentiated adenocarcinoma and signet ring cell carcinoma. Immunohistochemically, the expression of 2 types of MUC1 (MUC1/DF and MUC1/CORE), MUC2, 2 types of MUC5AC (MUC5AC/CHL2 and HGM), MUC6, CDX2, and CD10 was examined in 16 cases of MAC consisting of 6 low- and 10 high-grade types.

RESULTS: MUC1/DF3 was expressed in 3 of 6 low-grade MAC (50%) and 10 of 10 high-grade MAC (100%). MUC1/CORE was expressed in 1 of 6 low-grade MAC (16.7%) and 7 of 10 high-grade MAC (70%). MUC2 was expressed in all MAC regardless of the grade. MUC5AC was expressed in 6 of 6 low-grade MAC (100%) and 4 of 10 high-grade MAC (40%). HGM was expressed in 5 of 6 low-grade MAC (83.3%) and 6 of 10 high-grade MAC (60%). Expression of MUC6 and CD10 was undetected in all MAC regardless of the grade. CDX2 was expressed in 5 of 6 low-grade MAC (83.3%) and 7 of 10 high-grade MAC (70%). Taken together, MUC1/DF3 was expressed significantly more frequently in high-grade MAC than in low-grade, and MUC5AC/CHL2 was expressed significantly more frequently in low-grade MAC than in high-grade.

CONCLUSION: It is proposed that MUC1/DF3 and MUC5AC/CHL2 immunostaining is useful to discriminate high-grade MAC from low-grade MAC.

Concept of chemoprevention in colorectal cancer

Colorectal cancer remains a significant cause of morbidity and mortality throughout the world. The incidence of colorectal cancer is nearly four-fold higher in more-developed as compared with less-developed regions of the world. At present an early detection of colorectal cancer remains a crucial step in determining the therapeutic outcomes. Screening programmes have been introduced in an effort to detect colorectal cancer at an early stage or at a precancerous colonic polyp stage. These programmes should be used by the health professionals as an opportunity to educate the public regarding the use of chemoprevention in colorectal cancer, which is the main focus of this review and an attractive concept needing further evaluation.

Potential of casein kinase I in digestive cancer screening

Casein kinase I is a group of ubiquitous Serine/Threonine kinases that have been implicated in both normal cellular functions and several pathological conditions including Alzheimer’s disease and cancer. Recent findings in colon and pancreatic cancer have brought tremendous attention to these molecules as potential therapeutic targets in treatment of digestive cancers. In this review, we summarize up to date what is known about this family of kinases and their involvement in carcinogenesis and other pathological conditions. Our emphasis is on their implications in digestive cancers and their potential for cancer screening and therapy.

Studies on activity of various extracts of Mentha arvensis Linn against drug induced gastric ulcer in mammals

AIM: To examine the antiulcerogenic effects of various extracts of Mentha arvensis Linn on acid, ethanol and pylorus ligated ulcer models in rats and mice.

METHODS: Various crude extracts of petroleum ether, chloroform, or aqueous at a dose of 2 g/kg po did not produce any signs or symptoms of toxicity in treated animals. In the pyloric ligation model oral administration of different extracts such as petroleum ether, chloroform and aqueous at 375 mg/kg po, standard drug ranitidine 60 mg/kg po and control group 1% Tween 80, 5 mL/kg po to separate groups of Wister rats of either sex (n = 6) was performed. Total acidity, ulcer number, scoring, incidence, area, and ulcer index were assessed.

RESULTS: There was a decrease in gastric secretion and ulcer index among the treated groups i.e. petroleum ether (53.4%), chloroform (59.2%), aqueous (67.0%) and in standard drug (68.7%) when compared to the negative control. In the 0.6 mol/L HCl induced ulcer model in rats (n = 6) there was a reduction in ulcerative score in animals receiving petroleum ether (50.5%), chloroform (57.4%), aqueous (67.5%) and standard. drug (71.2%) when compared to the negative control. In the case of the 90% ethanol-induced ulceration model (n = 6) in mice, there was a decrease in ulcer score in test groups of petroleum ether (53.11%), chloroform (62.9%), aqueous (65.4%) and standard drug ranitidine (69.7%) when compared to the negative control. It was found that pre-treatment with various extracts of Mentha arvensis Linn in three rat/mice ulcer models ie ibuprofen plus pyloric ligation, 0.6 mol/L HCl and 90% ethanol produced significant action against acid secretion (49.3 ± 0.49 vs 12.0 ± 0.57, P < 0.001). Pre-treatment with various extracts of Mentha arvensis Linn showed highly -significant activity against gastric ulcers (37.1 ± 0.87 vs 12.0 ± 0.57, P < 0.001).

CONCLUSION: Various extracts of Mentha arvensis Linn. 375 mg/kg body weight clearly shows a protective effect against acid secretion and gastric ulcers in ibuprofen plus pyloric ligation, 0.6 mol/L HCl induced and 90% ethanol-induced ulcer models.

Newly emerging standard chemotherapies for gastric cancer and clinical potential in elderly patients

With the increase in average life expectancy, the rate of occurrence of gastric cancer in elderly patients is also rising. While many clinical trials have been conducted to examine the effect of chemotherapy treatment on gastric cancer, age limits for eligible subjects have prevented the establishment of standards for chemotherapy in elderly patients with gastric cancer. As of March 2009, evidence-based standard chemotherapy regimens were established. In the Western world, debates centered on the ECF (Epirubicin/cisplatin/5-FU) or DCF (Docetaxel/cisplatin/5-FU) regimens based on the phase III randomized controlled trial at the Royal Marsden Hospital (RMH) or the V325 study, respectively. The JCOG9912 and SPIRITS trials emerged from Japan indicating attractive regimens that include S-1 for advanced gastric cancer patients. Using these active anticancer drugs, the trials that studied the efficacy of adjuvant therapies or surgical approaches, such as the Int-116/MAGIC/ACTS-GC trials, have actually succeeded in demonstrating the benefits of adjuvant therapies in gastric cancer patients. For cases of gastric cancer in elderly patients, treatment policies should consider these studies while analyzing not only the therapeutic effects but also drug toxicity, individual general health conditions, and social factors to select treatments that emphasize quality of life.

Vascular endothelial growth factor, p53, and the H-ras oncogene in Egyptian patients with bladder cancer

AIM: To evaluate the relationship between vascular endothelial growth factor (VEGF), p53, and the H-ras oncogene and different clinicopathological parameters in Egyptian patients with Schistosoma-associated transitional cell carcinoma of the bladder.

METHODS: The study included 50 patients with transitional cell carcinoma for whom radical cystectomy and urinary diversions were carried out. VEGF and p53 protein expressions were evaluated with an immunohistochemical staining method, and H-ras oncogene mutations were analyzed with a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique.

RESULTS: High grade tumors revealed higher p53 immunostaining than low grade tumors (P = 0.016). p53 and VEGF protein expressions, as well as H-ras oncogene mutations, had an insignificant impact on patient outcomes (P = 0.962, P = 0.791, and P = 967, respectively). Cancer extension to regional lymph nodes was associated with poor outcomes (P = 0.008).

CONCLUSION: VEGF, p53 and the H-ras oncogene have no relation to patient survival and outcome in Schistosoma-associated transitional cell carcinoma.

Ileal inflammatory fibroid polyp causing chronic ileocolic intussusception and mimicking cecal carcinoma

Inflammatory fibroid polyp (IFP) is a rare, idiopathic pseudotumorous lesion of the gastrointestinal tract. While mostly reported as solitary gastric lesions, multiple cases of small bowel IFPs are also reported. It is a documented cause of intussusception in adults. In the case reports of ileal inflammatory fibroid polyps with intussusception, an emergent presentation with small bowel obstruction has been most often described. Here we depict a case of ileal inflammatory fibroid polyp presenting with chronic intermittent ileocolic intussusception, anemia and weight loss with an endoscopic appearance mimicking necrotic cecal carcinoma.

Positron emission tomography’s changing significance in the treatment of esophageal cancer

Incidence of esophageal cancer has been rising, and Positron Emission Tomography (PET) is one tool that has shown utility and promise as a tool for staging, treatment response, and prognosis. PET delivery has evolved over time and is now frequently registered with a CT scan at the time of acquisition. However, resolution and confounders such as post-treatment radiation changes may limit clinical utility. PET has been shown to be helpful in staging, especially in evaluating for distant metastases. PET acquired after chemoradiation may give important prognostic information that can guide additional treatment decisions. Studies have had substantial variability in recommendations for the timing and manner of using PET for this purpose, and additional study is needed.

What is the purpose of launching World Journal of Gastrointestinal Oncology?

The first issue of World Journal of Gastrointestinal Oncology (WJGO), whose preparatory work was initiated on September 27, 2008, will be published on October 15, 2009. The WJGO Editorial Board has now been established and consists of 210 distinguished experts from 32 countries. Our purpose of launching WJGO is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.

Gastric amyloidoma in patient after remission of Non-Hodgkin’s Lymphoma

Amyloidosis is commonly systemic, occasionally organ-limited, and rarely a solitary localized mass. The latter, commonly referred to as tumoral amyloidosis, is described as occurring in nearly every organ/tissue. Only a few reports of gastric amyloidosis exist today. We describe a 72 year-old black male from Barbados presenting with 3 d of diffuse abdominal pain. His medical history included Non-Hodgkin’s Lymphoma diagnosed five years ago, status-post six rounds of cyclophosphamide, adriamycin, vincristine, prednisone chemotherapy, and currently was in remission. On computed tomography scan of the abdomen, thickening and calcification of the gastric wall was noted along with pneumatosis. On esophagogastroduodenoscopy, a large circumferential friable mass was seen from the gastroesophageal junction to the body. A large non-bleeding 3 cm polyp was also seen in post bulbar area of duodenum. Biopsies were stained with Congo red and gave green birefringence under polarized light, consistent with tumoral amyloidosis. Positron emission tomography scan revealed diffuse gastric mucosa uptake compatible with gastric malignancy without metastatic foci. Treatment for gastric amyloidomas has presently been one of observation or, at most, resection of the amyloid mass. It is not known if our patient required the same approach or if this warranted the re-institution of chemotherapy for Non-Hodgkin’s Lymphoma. Until more reports of tumoral amyloidosis are made known, treatment as well as prognosis remain uncertain.

Telomere function in colorectal cancer

Colorectal cancer is the third most common form of cancer and the second leading cause of cancer-related death in the western world. Tumour cells acquire the hallmarks of cancer during the carcinogenic selection process. Cell immortality is one of the principal features acquired during this process which involves the stabilization of telomere length. It is achieved mainly, by telomerase activation. Thus, the discovery of telomeres and telomerase allowed an understanding of the mechanisms by which cells can become immortalized. Different studies have shown that tumour cells have shorter telomeres than nontumour cells and have detected telomerase activity in the majority of tumours. Survival studies have determined that telomere maintenance and telomerase activity are associated with poor prognosis. Taking into account all the results achieved by different groups, quantification and evaluation of telomerase activity and measurement of telomere length may be useful methods for additional biologic and prognostic staging of colorectal carcinoma.

Instructions to authors

Amyloidosis is commonly systemic, occasionally organ-limited, and rarely a solitary localized mass. The latter, commonly referred to as tumoral amyloidosis, is described as occurring in nearly every organ/tissue. Only a few reports of gastric amyloidosis exist today. We describe a 72 year-old black male from Barbados presenting with 3 d of diffuse abdominal pain. His medical history included Non-Hodgkin’s Lymphoma diagnosed five years ago, status-post six rounds of cyclophosphamide, adriamycin, vincristine, prednisone chemotherapy, and currently was in remission. On computed tomography scan of the abdomen, thickening and calcification of the gastric wall was noted along with pneumatosis. On esophagogastroduodenoscopy, a large circumferential friable mass was seen from the gastroesophageal junction to the body. A large non-bleeding 3 cm polyp was also seen in post bulbar area of duodenum. Biopsies were stained with Congo red and gave green birefringence under polarized light, consistent with tumoral amyloidosis. Positron emission tomography scan revealed diffuse gastric mucosa uptake compatible with gastric malignancy without metastatic foci. Treatment for gastric amyloidomas has presently been one of observation or, at most, resection of the amyloid mass. It is not known if our patient required the same approach or if this warranted the re-institution of chemotherapy for Non-Hodgkin’s Lymphoma. Until more reports of tumoral amyloidosis are made known, treatment as well as prognosis remain uncertain.

Pancreatic cancer: A model cancer for the study of the therapeutic effects of anticoagulants

Cancer-related thromboembolic disease is a well recognized syndrome since first described by Armand Trousseau in 1865. Preventing the morbidity and mortality related to thromboembolism in these patients is becoming a priority research area with the advent of new anti-coagulants. It is only recently that randomized trials of improved quality are been undertaken to study this question. Many of these trials however are still not accounting for the heterogeneity of “cancer” in terms of anatomical site, histology, stage and treatment. This editorial review highlights why pancreatic cancer may serve as a model malignancy to study this question.

Clinical value of 18F-FDG PET/CT in assessing suspicious relapse after rectal cancer resection

AIM: To evaluate the value of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the restaging of resected rectal cancer.

METHODS: From January 2007 to Sep 2008, 21 patients who had undergone curative surgery resection for rectal carcinoma with suspicious relapse in conventional imaging or clinical findings were retrospectively enrolled in our study. The patients underwent 28 PET/CT scans (two patients had two scans, one patient had three and one had four scans). Locoregional recurrences and/or distant metastases were confirmed by histological analysis or clinical and imaging follow-up.

RESULTS: Final diagnosis was confirmed by histopathological diagnosis in 12 patients (57.1%) and by clinical and imaging follow-up in nine patients (42.9%). Eight patients had extrapelvic metastases with no evidence of pelvic recurrence. Seven patients had both pelvic recurrence and extrapelvic metastases, and two patients had pelvic recurrence only. ¹⁸F-FDG PET/CT was negative in two patients and positive in 19 patients. ¹⁸F-FDG PET/CT was true positive in 17 patients and false positive in two. The accuracy of ¹⁸F-FDG PET/CT was 90.5%, negative predictive value was 100%, and positive predictive value was 89.5%. Five patients with perirectal recurrence underwent ¹⁸F-FDG PET/CT image guided tissue core biopsy. ¹⁸F-FDG PET/CT also guided surgical resection of pulmonary metastases in three patients and monitored the response to salvage chemotherapy and/or radiotherapy in four patients.

CONCLUSION: ¹⁸F-FDG PET/CT is useful for evaluating suspicious locoregional recurrence and distant metastases in the restaging of rectal cancer after curative resection.