[Influence of mucinous and signet-ring cell differentiation on epidemiological, histological, molecular biological features, and outcome in patients with colorectal carcinoma]

BACKGROUND

Colorectal cancer (CRC) is one of the most common malignancies in the Western world. Histopathologically, adenocarcinomas are mostly diagnosed. Mucinous and signet-ring cell subtypes occur with a very low incidence. However, these subtypes differ remarkably in terms of clinical, histological and molecular biological characteristics. The aim of this review is to present a detailed analysis of current knowledge regarding differences between classical adenocarcinoma and mucinous, and signet-ring cell CRC along with potential consequences for daily practice.

METHODS

For this report all articles with relevant information on differences between classical adenocarcinoma and mucinous, and signet-ring cell CRC found via Pubmed searches were analysed. Furthermore, findings of our previous study were included.

RESULTS

Mucinous CRC occur with a reported incidence of 10 - 20 % in Western countries and are predominantly found in younger patients and females. They are more often diagnosed in the proximal colon and present with a higher stage at diagnosis. Furthermore, there is a higher rate of lymph node-positive tumours and peritoneal carcinomatosis. Results of molecular biological studies confirm that they may represent a different tumour entity. The response to well established chemotherapy regimens is poorer which may be attributed to the higher rate of microsatellite-instable tumours and an increased mucin secretion. The poorer outcome is likely related to the higher stage at the time of diagnosis. Signet-ring cell type CRC are rare with an incidence ranging between 0,9 % to 4 %. They are also more common in the right colon and are associated with a poorer outcome compared to adenocarcinoma and mucinous CRC.

CONCLUSIONS

However, it should be noted that most of the results come from studies with a very low number of patients which can be attributed to the low incidence of mucinous and signet-ring cell CRC. Based on the findings of the present analysis, a more radical surgical approach should be considered providing that the exact preoperative histology is available. Furthermore, the histological subtype should be taken into account in future chemotherapy trials to avoid unnecessary therapy. A closer follow-up, especially for patients with signet-ring cell CRC should be discussed. In the near future, a more tailored therapy in patients with colorectal cancer would be highly desirable.

Run performance of middle-aged and young adult runners in the heat

The aging process may impair exercise tolerance in the heat. It is not clear whether this impairment is partly due to a reduction in aerobic capacity. To compare the exercise performance and thermoregulatory responses of middle-aged and young adults with similar aerobic capacities and training statuses, 7 middle-aged (54±2 years; 58±4 ml·kg - 1·min - 1) and 7 young (28±1 years; 61±5 ml·kg - 1·min - 1) male competitive endurance runners underwent 2 10-km self-paced and 2 fixed-workload (90% of race speed) runs until fatigue on a treadmill in hot (40°C) and moderate (20°C) environments on separate days. The runners' total time, average speed, rectal temperature, heat storage rate, physiological strain index, sweat rate, sweat sensitivity, number of heat-activated sweat glands and sweat rate per sweat gland were measured or calculated. Body fat, body surface area, body surface area per body mass, training volume and VO2max were similar between the 2 groups. No differences were observed in total time (59±3; 49±3; 27±2; 54±5 min in the middle-aged and 60±2; 49±3; 27±2; 51±4 min in the young group), average speed, rectal temperature, heat storage rate, physiological strain index, sweat rate (17±7; 15±3; 23±7; 13±2 g.m - 2.min - 1 in the middle-aged and 20±5; 14±4; 22±5; 15±4 g.m - 2.min - 1 in the young group) or sweat sensitivity between age groups (p>0.05) in any trial. The number of heat-activated sweat glands (88±14; 80±18; 90±16; 66±14 cm - 2 in the middle-aged and 43±10; 32±10; 37±11; 31±11 cm - 2 in the young group) was higher, and the sweat rate per sweat gland was smaller, in the middle-aged than the young group (p<0.05) in all of the trials. We conclude that running performance and body thermoregulation are similar between young and middle-aged runners with similar aerobic capacities and training statuses under hot and moderate conditions in self-paced and fixed-intensity runs. The decrease observed in the sweat rate per sweat gland in middle-aged men was compensated for by a higher number of heat-activated sweat glands.

Value of ultrasound (US)-guided percutaneous needle biopsy of detected pathological gastrointestinal (GI) tract lesions but negative or incomplete endoscopy

PURPOSE

The study aim was to investigate the diagnostic value of US-guided percutaneous needle biopsy in the case of suspicious tumor lesion of the GI tract revealed by abdominal US but without detection with endoscopy or with incomplete or no possible endoscopy.

PATIENTS AND METHODS

Over a defined time period, all consecutive patients with no appropriate endoscopic diagnostic specimen or finding were registered. The patient, diagnostic, and periinterventional characteristics were documented.

RESULTS

In total, 16 patients (7 males; mean age, 63.2 [range, 43 - 90] years) were enrolled in this study representing a rare but possible constellation from endoscopic practice characterized by no detectable intraluminal tumor growth and a suspicious tumor lesion revealed with abdominal US as found in each case (n = 16) from 01 / 01 / 2003 - 12 / 31 / 2006. The main indications for needle biopsy were pathological colonic cockades (n = 7) and tumor lesions of the stomach and small intestine (n = 9). The first needle biopsy attempt was successful in all subjects (technical success rate: 100 %) using the color-coded US mode in each case (100 %). There were no postinterventional complications (rate: 0 %).

CONCLUSION

Percutaneous US-guided needle biopsy can be considered a safe diagnostic tool for clarifying the differential diagnosis of suspicious tumor lesions of the GI tract (revealed originally only by abdominal US) as the next favorable diagnostic step in the rare situation that endoscopy cannot provide appropriate information, in order to shorten the diagnostic course, to achieve a therapeutic decision and to decrease effort and costs.

[Interims analysis of a prospective observational study on the use of cilostazol (Pletal®) in daily clinical vascularsurgical practice]

BACKGROUND AND AIMS

Peripheral arterial occlusion disease (PAOD) has undergone a systematic classification of findings and stage-adapted sequential therapy. After the former limited otions of a conservative, rather medication-based approach, Cilostazol has led to more flexibility in the non-interventional therapeutic profile in angiologically clearly defined indications. The aim of this first interims analysis was to evaluate the preliminary results of the prospective observational study on the effect of Cilostazol (Pletal®, 2 × 100 mg; UCB Pharma Deutschland GmbH, Monheim, Germany - primary / secondary end points: increase of walking distance / quality of life including side effects) used according to its appropriate indication in daily clinical practice (effectiveness), which were obtained in a representative group of exclusively vascular surgical patients in a centre for vascular medicine.

PATIENTS AND METHODS

Through a defined study period, all consecutive patients were enrolled in whom a Cilostazol medication was initiated after official approval of the pharmakon in the Division of Vascular Surgery or outpatient clinic because of PAOD, stage  II b, indicated by a subjective walking distance of < 200 m with a minimal observational study period of 6  months, a 12-week study-appointment interval (as recommended to each) and a reliable compliance with regard to patient data and medication. Primary study end point was the absolute increase of pain-free walking distance (as measured on the treadmill under standardised conditions, statistically tested by ANOVA for repeated measurements as well as pairwise t tests); secondary end point was the change of quality of life (determined semiquantitatively by the requested assessments "worse - equal - better"). In addition, the side effect profile and the spectrum of accompanying diseases with its possible alterations of impact on the Cilostazol effect were registered.

RESULTS

Over 1.5  years, 40  patients were documented (male / female = 23 : 17 [67.5 / 32.5 %]) with a mean age of 65.7 ± 9.1 (range: 41-88; median: 47.1) years. In the spectrum of accompanying diseases (registration rate, 95 %; n = 38), arterial hypertension (n = 25; 62 %), hyperlipoproteinaemia (58 %; n = 23), diabetes (28 %; n = 11), obesity (25 %; n = 10) and nicotine misuse (23 %; n = 9) predominated. On average, treatments lasted 235 (range: 3-566) days. Overall, there was a continuous prolongation of the walking distance up to 12 months after initiation of Cilostazol. The objective walking distance (treadmill) was 250 m at time "0", after 3 and 6  months + 114 m (P = 0.009) and + 157 m (P = 0.001), respectively - all statistics are based on completely documented data of the single study patients over the observational time period). Quality of life reached a statistically detectable improvement after 6  months. In smokers, there was no detectable significant increase of walking distance under Cilostazol. In 11 / 38 individuals (registration rate, 95 %), side effects were reported: Hyperglycaemia and tachycardia was found in 2  cases (5.3 % each); diarrhoea, anxiousness, headache, changing blood pressure, jaundice, nausea, n = 1. The AB index was not a feasible parameter (not shown).

DISCUSSION

Use of Cilostazol in daily clinical practice is safe, effective and causes an early increase of the walking distance (after 3  months) and, but delayed, an improvement of the quality of life also in vascular surgical patients.

CONCLUSION

Cilostazol medication can be considered a suitable tool as: (i) an initial step in the sequential therapeutic algorithm in stage II b of PAOD, (ii) a therapeutic alternative in exhausted vascular surgical (interventional) options. Further study-based clinical observations on the use of Cilostazol appear to be indicated.

[What must the (abdominal) surgeon know about paediatric surgery - paediatric surgical aspects in general (abdominal) surgery]

Due to the advances in neonatal intensive care medicine, prenatal ultrasound-guided diagnostic measures and paediatric surgical options, conditions have been established to achieve long-term survival in newborns with severe diseases. In addition, this means that the "non-paediatric" physician can be increasingly confronted with patients who would not have survived childhood some decades ago. Therefore, the article summarises concisely selected diseases of premature infants and newborns, e. g., congenital abdominal wall defects, and outlines possible long-term consequences based on the surgical interventions and their basic diseases, respectively, which need to be adequately cared for in the case of a surgical disease of the former patient of paediatric surgery. The overview cannot be considered as a complete revision course; however, it might constitute a basic outline for thought-provoking impulses for personal professional skills and expertise in managing such patients in later age from a surgical perspective.

[Gastric stump carcinoma--a surgical and oncological challenge]

Gastric stump carcinoma after gastric surgery for benign disease is now widely recognized as a distinct clinical entity. An electronic literature search was performed in the MEDLINE database to identify relevant studies concerning epidemiology, prognosis, treatment, aetiology and pathology of gastric stump carcinoma. The references reported in these studies were used to complete the literature search. It can be assumed that approximately 10 % of patients who had undergone a distal gastric resection for benign disease will develop a carcinoma in the gastric remnant about 15 to 20 years after the primary procedure. The incidence is reported to be higher in males and following Billroth II resection. The site of tumour growth is predominantly in the anastomotic area, but may occur anywhere in the stump. Enterogastric reflux, achlorhydria, bacterial overgrowth, and genetic factors appear to be the major factors involved in the aetiopathogenesis of the gastric stump cancer. Unfortunately, a significant proportion of patients presents with synchronous metastases. Clinical symptoms are mainly attributed to locally advanced tumour growth. Surgical therapy comprises total removal of the gastric remnant and the jejunal segment including modified lymphadenectomy (D2 lymphadenectomy and jejunal mesentery). Surveillance of patients with endoscopy and multiple biopsies should be initiated from the tenth postoperative year and may provide the means to diagnose tumours at an early stage.

[Ischemic lesions in kidneys after extracorporeal shock wave lithotripsy demonstrated by Proton NMR spectroscopy of urine samples]

PURPOSE

The aim of this prospective study was to investigate the effect of extracorporeal shock wave lithotripsy (SWL) on kidneys of patients with pyelic stone disease. The effects of SWL were assessed by high-resolution proton nuclear magnetic resonance (HNMR) spectroscopy of urine samples.

METHODS

Twenty-three patients, aged 31-80years (mean: 55years), with pyelic stone disease were investigated before and after SWL. Multiparameter analysis was performed by HNMR spectroscopy of urine samples collected before and 5h after SWL (second miction post-SWL).

RESULTS

The most relevant resonances determined by HNMR spectroscopy were acetate, lactate, trimethylamine N-oxide and amino acids. Excretion of these markers increased significantly in comparison with pre-SWL urinary samples.

CONCLUSION

These results show that early ischemic damage occurs after SWL. Post-SWL. HNMR spectroscopy is an effective tool for noninvasive follow-up of renal damage.

[Narrow band imaging: description of the technique and initial experience with upper urinary tract carcinomas]

PURPOSE

Endoscopic treatment of upper urinary tract carcinomas (UUTC) is becoming more and more prevalent compared to non-conservative surgery. Our goal was to determine if NBI technology could improve tumour detection.

MATERIAL

Twenty-seven patients with known or suspected UUTC were prospectively enrolled and treated using the Olympus URF-V flexible ureteroscope. We report 13 new cases (48%) and 14 known cases as follow up (52%). White light and NBI were subsequently performed to examine the upper urinary tract. Visual aspect of the lesions could be compared using both types of light. Biopsies were taken for all apparent lesions prior to vaporization by Holmium laser.

RESULTS

Forty-three lesions were detected in 21 patients. Five lesions (14.2%) in four patients were detected through NBI light only among the 35 lesions containing UUTC. Two out of four of these patients were new cases and would not have been diagnosed with white light alone. Three UUTC-treated (8.5%) had extended margins in NBI. Thirteen biopsies (26%) were not valid. Altogether, the tumour detection rate improved by 22.7% in seven patients (25.9%) by using the NBI method.

CONCLUSION

Upper urinary tract endoscopy with NBI light is a new technology that improves visualization of UUCT and enables diagnosis of lesions non visible in white light. This procedure cannot yet be recommended for daily practice and further validation of the technique is required.

[Autoimmune haemolytic anemia: diagnosis strategy and new treatments]

The pattern of autoimmune hemolytic anemia has changed significantly these last 15 years. With regard to the diagnosis strategy, the use of gel filtration technique to perform the direct antiglobulin test (DAT) has decreased the number of autoimmune haemolytic anemias with negative tests results. In recent years, autoimmune haemolytic anemia increased in patients receiving purine nucleoside analogues, blood transfusions, solid organ transplantation or hematopoietic stem cells transplantation. These difficult autoimmune haemolytic anemia cases need to use new kinds of treatments. With regard to the treatment, very little progress was made this latter 50 years. The discovery of the efficacy of anti-CD20 antibody in this disease represents a breakthrough. Nowdays, the second-line treatment includes rituximab or splenectomy. Sometimes, the anti-CD20 treatment could be proposed in first-line but some clinical trials are needed.

[Molecular biological sepsis diagnostic using multiplex PCR in surgical intensive care as suitable alternative to conventional microbial culture - a representative overview]

INTRODUCTION

Sepsis causes a substantial rate of morbidity and mortality in intensive care patients, which is, in particular, triggered by an inadequate antimicrobial treatment from the beginning. Conventional microbiological standard procedures cannot provide valuable information on bacterial or fungal species of sepsis-relevant microbes within the first hours of a developing sepsis. However, multiplex PCR (PCR-M) focussing on the spectrum of the most relevant sepsis-associated microbes can considerably shorten the time period; the analytical tests have been standardised and, subsequently, inaugurated into clinical practice; they also have thus been available since 2005. Interestingly, in the surgical field an appropriate summary and concluding recommendation have been lacking so far. AIM, MATERIAL AND METHODS: A compact short overview based on a characteristic selection of relevant references from the literature is given on the commercially available sepsis-associated multiplex-PCR methods, reflecting critically the time point of inauguration, clinical value and future perspectives including our own experiences from clinical practice and medical studies.

RESULTS

Multiplex PCR in adult sepsis patients yielded in a range from 13.7 to 39.9 % of positive findings, whereas conventional blood cultures only range from 8 to 29.9 %. From 8 to 16.9 % of all investigations performed prompted us to a change of the antimicrobial treatment by using a positive PCR-M finding. A prospective study (end-point, reduction of sepsis-associated mortality) has not yet been initiated. Positive PCR-M findings correlate with an increased morbidity and mortality as well as clinical and laboratory sepsis parameters. Recent studies have aimed for a comparison of PCR-M on sepsis-associated microbes with regard to specificity and sensitivity with the current "gold standard", conventional blood culture. A few studies wrongly claimed to compare the methods because of the difference in the procedures; in addition, blood culture as gold standard has been increasingly considered as very problematic from a methodological point of view. Recent publications on multiplex-PCR studies in frequently heterogenic groups of patients have been mostly performed with the Lightcycler-Septifast® test (LC-SF) with great success. The procedure has provided evidence of an improved detection rate of sepsis-associated microbes, favourable concordance of positive PCR-M findings with clinical and laboratory sepsis parameters and substantial time-saving in the microbiological analysis of the specific microbial species, which is simultaneously associated with an earlier initiation of an adequate antimicrobial treatment regimen.

CONCLUSION

The available study data suggest that systrematic investigations on the molecular biological procedures should be rather related to a different standard based on the LC-SF. Positive PCR-M findings have been accepted as a sepsis marker in the mean time.