Acute intermittent porphyria in pregnancy: a common misdiagnosis

Acute intermittent porphyria (AIP) is inherited in an autosomal dominant fashion. Only 10% to 15% of the gene carriers have the clinical syndrome. The prevalence of AIP in Europe is 1/20,000. Pregnancy represents an essential risk factor in patients suffering from AIP. The clinical syndrome in AIP presents mainly with acute attacks, especially during the first trimester. Misdiagnosis of AIP unfortunately is very common. Pregnancy in women with AIP is associated with higher rates of spontaneous abortion, hypertension, low birth weight infants and considerable mortality (2-42%). Pregnancy, despite the major hormonal alterations it causes, is seldom associated with porphyric symptoms. There are only limited reports supporting the use of hemin during pregnancy, but experience indicates that it can be safely administered in pregnant women. Until clinical improvement is achieved, symptomatic treatment is recommended. Despite the fact that pregnancy in women suffering from AIP is related to higher rates of morbidity and complications, close management throughout the pregnancy could ensure a good outcome.

The value of proliferation indexes in breast cancer

INTRODUCTION

During the past several years, the Ki-67 antigen has gathered great interest in its role as a prognostic marker. Nevertheless, despite the large number of published papers, the role of Ki-67 in clinical practice remains controversial.

AIM

To evaluate the association between Ki-67 immunoreactivity and other clinicohistopathological parameters.

METHODS

We retrospectively analyzed the archival pathology tissues of 356 patients, diagnosed and treated in our department, from 2002 to 2006. Statistical analysis was used to examine the association between Ki-67 expression and other clinicopathological factors.

RESULTS

The expression of Ki-67 was correlated with the mitotic count, tumor grade and size and p53, HER2 and EGFR expression. Furthermore Ki-67 expression was significantly related with nodal status and inversely associated with hormonal expression. Moreover, invasive carcinomas appeared to have greater proliferation values than in situ carcinomas, while invasive ductal carcinomas were correlated with higher Ki-67 expression compared to lobular cancers.

CONCLUSION

The expression of Ki-67 appears to be a valuable method of proliferation measurement that could prove helpful in clinical practice. Further research is warranted in order to standardize the methodology and to reach uniformity in regard with the optimal cut-off value.

Cytolytic and Cytotoxic Activity of a Human Natural Killer Cell Line Genetically Modified to Specifically Recognize HER-2/neu Overexpressing Tumor Cells

NK92 cells genetically engineered to recognize the HER-2/neu oncoprotein have been previously reported to lyse HER-2/neu positive tumor cell lines through direct cell to cell contact. In the present study we have transduced NK92 cells with a chimeric receptor gene composed of the HER-/neu specific scFv (FRP5) antibody fragment, joined to the peptide CD8 hinge region and the signaling CD3 zeta chain. NK92 cells expressing this chimeric receptor (NK92.HER-2/neu/zeta) specifically recognized and lysed HER-2/neu overexpressing tumor cell lines both in vitro and in preclinical tumor models in vivo. More important we demonstrate that NK92.HER-2/neu/zeta cells constitutively secrete high levels of soluble scFv which mediate strong tumor cytostatic effects by directly binding on cell surface HER-2/neu. Our data uncover an additional mechanism through which NK92.HER-2/neu/zeta cells mediate antitumor effects and further support their use in cell based therapeutics for the treatment of HER-2/neu expressing cancers.

Newly established tumourigenic primary human colon cancer cell lines are sensitive to TRAIL-induced apoptosis in vitro and in vivo

Most data on the therapeutic potential of tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) as well as resistance to FAS ligand (FASL) in colorectal cancer have come from in vitro studies using cell lines. To gain a clearer understanding about the susceptibility of patient tumours to TRAIL and FASL, we derived primary human cancer epithelial cells from colon cancer patients. Characterisation of primary cultures PAP60 and MIH55 determined their highly proliferating advantage, transforming capability and tumorigenicity in vitro and in vivo. Although FASL treatment appeared to cause little apoptosis only in the PAP60 primary culture, increased apoptosis independent of p53 was observed in both primary PAP60 and MIH55 and control cell lines Caco-2, HT29 and DLD-1 after treatment with SuperKiller TRAIL. Expression analysis of death receptors (DR) in the original parental tumours, the primary cultures before and after engraftment as well as the mouse xenografts, revealed a significant upregulation of both DR4 and DR5, which correlated to differences in sensitivity of the cells to TRAIL-induced apoptosis. Treating patient tumour xenograft/SCID mouse models with Killer TRAIL in vivo suppressed tumour growth. This is the first demonstration of TRAIL-induced apoptosis in characterised tumorigenic primary human cultures (in vitro) and antitumour activity in xenograft models (in vivo).

Spontaneous regression of rectal polyps following abdominal colectomy and ileorectal anastomosis for familial adenomatous polyposis, without sulindac treatment: report of four cases

The only curative treatment for familial adenomatous polyposis (FAP) is prophylactic surgery and the two most popular options are total colectomy with ileorectal anastomosis and restorative proctocolectomy with ileal pouch-anal anastomosis. Today, ileal pouch-anal anastomosis has gained wider acceptance as a safer procedure, but ileorectal anastomosis still remains an option, especially for young patients with a moderate phenotype of the disease and limited polyps in the rectum. Partial or complete regression of rectal polyps after total colectomy with ileorectal anastomosis and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) such as sulindac is reported in up to 80 % of patients. However, in some cases such regression can be spontaneous and long-lasting following total colectomy and ileorectal anastomosis, without further treatment with NSAIDs. We present the cases of four patients with FAP treated by colectomy and ileorectal anastomosis, who had immediate, complete spontaneous regression of multiple polyps in the rectal stump, with no further need for sulindac treatment.

Leucovorin and 5-fluorouracil versus levamisole and 5-fluorouracil as adjuvant chemotherapy in rectal cancer

PURPOSE

To evaluate the effectiveness of 6-month therapy with leucovorin (LV)+5-fluorouracil (5-FU) versus 12-month therapy with levamisole (LVS)+5-FU, as adjuvant chemotherapy in patients with completely resected Aster-Coller stage B(2) or C(1)/C(2) rectal cancer (RC).

PATIENTS AND METHODS

One hundred and fifty patients with surgically resected RC were enrolled. Seventy patients with stage B(2) and 80 with stage C were randomly assigned to adjuvant chemotherapy with 5-FU+LXx6 months or 5-FU+LVSx12 months. Patient characteristics were equally balanced between the examined groups. Adjuvant chemotherapy consisted of LV 20 mg/m(2) intravenously (i.v.) plus 5-FU 450 mg/m(2) i.v. bolus every week plus LVS tablets 50 mg t.i.dx3 days every 2 weeks for 1 year.

RESULTS

After a median follow up for survivors of 8.7 years (range 1.8-10.5), all of the patients were evaluable. There were no significant differences between the two treatment groups with respect to the recurrence rates (p=0.821). Moreover, there were no significant differences between the two tratment groups in disease-free survival (DFS) (p=0.84) [B(2)(p=0.805) and C (p=0.978)] and overall survival (OS) rates for patients of either stage B(2) or C (p=0.78). Toxicities were more frequent in the 5-FU+LVS versus 5-FU+LV group: myelosuppression (grade 3 leucopenia, 12 versus 4%, p<0.04), diarrhea (grade 0, 60 versus 76%, p<0.02), and liver toxicity (increase of transaminases >3-fold, 12 patients versus 2, p<0.03.). No patient stopped chemotherapy because of toxicity, and there were no treatment-related deaths.

CONCLUSION

Adjuvant chemotherapy in RC with LV+5-FU for 6 months is equally effective and less toxic than LVS+5-FU for 12 months.

The use of isobutylcyanoacrylate as a tissue adhesive in abdominal surgery

BACKGROUND

The use of cyanoacrylate substances as tissue adhesives is of valuable aid in surgery, especially in cases of injuries of the intraabdominal organs, where the haemorrhage is very difficult to control.

MATERIALS AND METHODS

We investigated the efficiency of isobutyl-2-cyanoacrylate as a tissue adhesive in the haemostasis and adhesion of different types of wounds in solid and hollow organs. Forty-six dogs underwent single-organ (26 dogs) and combined-organ (20 dogs) procedures; cuneiform excisions of the liver and the spleen, as well as incisions of the small intestine were carried out. The wound surfaces were coated with isobutyl-2-cyanoacrylate and approximated.

RESULTS

The majority (91.3%) of the surgical operations were uncomplicated, in which a very good macroscopical and histological result was achieved. Histological examination of the surgical injuries, performed 4 months later, confirmed complete wound healing.

CONCLUSION

Isobutyl-2-cyanoacrylate proved to be a very effective tissue adhesive for both solid and hollow organs, even for high risk surgical operations.

Identification of germline BRCA1 and BRCA2 genetic alterations in Greek breast cancer moderate-risk and low-risk individuals--correlation with clinicopathological data

The current study was designed to evaluate the prevalence of BRCA1 and BRCA2 germline mutations in Greek moderate- and low-risk individuals with respect to clinicopathological phenotype and clinical outcome of breast cancer. Ninety-four consecutive individuals were prospectively recruited from two University Breast Cancer Clinics (Hippokrateion Hospitan and Laikon Hospital) between 1989 and 1999 and were categorized as moderate-risk and low-risk individuals for carrying BRCA1/2 germline mutations. To identify the underlying mutations, protein-truncation test and single-strand conformation polymorphism methods were used, followed by direct sequencing. Three novel BRCA1 missense mutations, one novel BRCA1 intronic deletion, three novel (previously reported) BRCA2 truncating mutations, and one novel BRCA2 missense mutation were identified in the moderate-risk group of individuals studied. The BRCA1/2 missense mutations as well as the single intronic variant identified were designated as unclassified genetic variants. Two BRCA1 unclassified genetic variants (missense mutations) were detected in two of the three (66.7%) male breast cancer patients analyzed, while the third one was identified in a sporadic (low-risk) breast cancer patient. Clinicopathological characteristics of breast carcinomas originating from BRCA1/2 heterozygotes were consistent with those already reported and not different from those observed in BRCA1/2 mutation (-) breast cancer patients. Furthermore, BRCA1/2 mutation carriers presented an excellent 4.5-year overall survival (100%). Our results reveal the unique characteristics of BRCA1/2 mutation status, genotype-phenotype correlations, and prognosis, in moderate- and low-risk individuals of Greek ancestry. Breast cancer due to mutations in BRCA1 and BRCA2 genes appears to be a heterogeneous syndrome in the Greek population.

Leucovorin and fluorouracil vs levamisole and fluorouracil as adjuvant chemotherapy in rectal cancer

The aim of this study was to evaluate the effectiveness of 6-month therapy with leucovorin (LV) + 5-fluorouracil (5-FU) vs 12 months of therapy with levamisole (LVZ) + 5-FU, as adjuvant chemotherapy in patients with completely resected Dukes' stage B2 or C rectal cancer. One hundred and fifty patients with surgically resected rectal carcinoma, were enrolled in the present study; Dukes' stage B2 (n=70) or C (n=80), were randomly assigned to chemotherapy with 5-FU + LV x 6 months or 5-FU + LVZ x 12 months. Patient characteristics were equally balanced between the examined groups. Adjuvant CT consisted of LV 20 mg/m(2) intravenously (i.v.) plus 5-FU 450 mg/m(2) i.v., on days 1-5 every 4 weeks for 6 cycles or 5-FU 450 mg/m(2) i.v. every week plus LVZ 50 mg t.i.d x 3 days for 1 year. All patients received radiotherapy with a three-field technique to a total dose of 45 Gy, over 5 weeks. After a median follow-up of 7.4 years there were no significant differences between the two treatment groups with respect to the recurrence rates (P=0.821). Moreover, there was no difference in disease-free survival for patients stage Dukes' B2 (log-rank p=0.73); median for LV group 90 (8-131) months, and for LVZ group 86.5 (3-129) months. No difference was noted in disease-free survival for patients stage Dukes' C (log-rank p=0.73); median for LV group 60 (17-128) months, and for LVZ group 64 (2-123) months. There was no difference in overall survival for patients stage Dukes' B2 (log-rank p=0.75); median for LV group 90 (22-131) months, and for LVZ group 86 (10-129) months. For stage Dukes' C (log-rank p=0.73); median for LV group 67 (17-128) months, and for LVZ group 64 (5-123) months. Toxicities were as follows in the 5-FU + LVZ vs 5-FU + LV group; myelosuppression (leucopenia grade 3, 12% vs 4%, p<0.04), diarrhea (grade 0, 60% vs 76%, p<0.02), and liver toxicity (increase of transaminases >3-fold, 12 patients vs 2, p<0.03), were more frequent in LVZ group. None of the patients stopped chemotherapy because of the toxicity, and there were no toxicity-related deaths. In conclusion, adjuvant chemotherapy in RC with LV + 5-FU for 6 months is equally effective and less toxic than LVZ + 5-FU for 12 months.

Human leukocyte antigens as genetic markers in Greek patients with sporadic pancreatic cancer

PURPOSE

In this study we investigated the relationship between specific HLA antigens and sporadic pancreatic cancer in Greek population.

METHODS

The allele frequencies of serologically and molecular defined class I and II HLA antigens were studied in 60 unrelated patients with pancreatic cancer histologically confirmed. The results obtained for HLA frequencies were compared with those of 105 healthy control subjects (control group).

RESULTS

Increased frequencies of HLA-A30 (16.7 vs. 3.8%; P < 0.01; OR = 5.05), A31 (9.5 vs. 1.9%; P < 0.05; OR = 5.72), B18 (31.7 vs. 14.3%; P < 0.05; OR = 2.78) and Cw7 (53.3 vs. 21.9%; P < 0.01; OR = 4.07) were observed in patients with pancreatic cancer in comparison to the control subjects.

CONCLUSIONS

This study demonstrates the association between specific HLA antigens and pancreatic cancer development in whites and suggests a genetic susceptibility factor for the disease.

Incidental finding of gallbladder carcinoma detected during or after laparoscopic cholecystectomy

AIM

Carcinoma of the gallbladder is a rare neoplasm with a dismal prognosis. With the increase of cholecystectomies due to the wide acceptance of laparoscopic cholecystectomy, the incidental diagnosis of gallbladder carcinoma is more frequent. We report our experience with gallbladder cancer diagnosed during or after the performance of laparoscopic cholecystectomy.

METHODS

We evaluated 11 patients with gallbladder cancer out of 5539 patients who underwent laparoscopic cholecystectomy. Patient clinical and demographic characteristics were reviewed.

RESULTS

Intraoperatively in 297 patients there was the suspicion of adenocarcinoma and frozen sections were performed. In four of them the diagnosis of adenocarcinoma was confirmed. In two of them the procedure was converted to open with gallbladder liver bed resection and regional lymph node dissection while the other two were considered inoperable. Of the remaining 5242 patients, seven were diagnosed postoperatively at the pathologic examination. Of these, five patients refused to undergo a repeat operation. We did not observe port site metastasis in any of our patients. Survival was low and ranged from 3-14 months.

CONCLUSION

Gallbladder cancer runs a short course, with a poor prognosis. The use of a meticulous laparoscopic technique seems to be important for the diagnosis and the avoidance of early complications of the disease.

Etoposide, leucovorin (LV) and 5-fluorouracil (5-FU) in 5-FU+LV pre-treated patients with advanced colorectal cancer

In the present study, we evaluated the efficacy and safety of the weekly combination of etoposide, leucovorin (LV) and 5-fluorouracil (5-FU) when administered as second-line chemotherapy in patients with relapsed/refractory advanced colorectal cancer (ACC), previously treated with weekly LV+5-FU. Etoposide was administered at 3 different dose levels (DLs), in 3 groups of 20 patients each (total: 60); DL-I: etoposide 80 mg/m2, DL-II: etoposide 120 mg/m2, and DL-III: etoposide 180 mg/m2, in 45 min i.v. infusion, and followed in all levels by LV 100 mg/m2 i.v. over 1 hour and 5-FU 500 mg/m2 i.v. bolus. Treatment was administered weekly until disease progression or unacceptable toxicity. No patients at DL-I responded, while 2 patients at DL-II and 3 at DL-III had a partial response (PR). Stable disease (SD) rates were as follows; at DL-I: 2, DL-II: 8 and DL-III: 9. More patients in DL-I progressed (n = 19) compared to DL-II (n=10) and DL-II (n = 8) (p < 0.0007). Time to progression was for DL-I, -II, -III: 17, 15, and 14 weeks, respectively. Median survival was DL-I, -II, -III: 30, 30, and 32.5 weeks, respectively. Toxicity consisted mainly of neutropenia, diarrhea and mucositis at all DLs, and was significantly more severe in DL-III. No difference was noted in responses between DL-II and DL-III. The authors conclude that the combination of etoposide with LV+5-FU has limited activity when administered after failure of weekly LV+5-FU in patients with ACC and should not be recommended for further evaluation.

Common prognostic factors for stage III melanoma patients and for stage I and II melanoma patients with recurrence to their regional lymph nodes

This study was undertaken in order to identify the prognostic factors for stage III malignant melanoma patients. In addition we compared the survival data of these patients with data from patients presenting with stage I and II disease who subsequently developed a regional nodal recurrence, in order to identify common prognostic factors and to compare the biological behaviour of the two groups. We retrospectively examined two groups of patients. The first consisted of 116 patients with stage III malignant melanoma and the second consisted of 57 patients with stage I and II malignant melanoma that were found to have regional lymph node metastases diagnosed at least 6 months after surgical treatment of their primary lesion. The age of the patients, the number of disease-involved lymph nodes, the site of the primary lesion and the presence or not of palpable lymph nodes proved to be significant prognostic factors of the first group. We also analysed the survival data of the second group and compared it with data from the stage III patients. The 5 year survival starting from the time after diagnosis of the primary lesion was 47.37% compared with 25.86% in stage III patients; however, this difference was not statistically significant. Patients who present with stage III malignant melanoma seem to have a more aggressive phenotype than stage I and II malignant melanoma patients who present with recurrent disease in their regional lymph nodes. Disease behaviour is dictated by the number of disease-involved lymph nodes, the site of the primary lesion and the type of surgical procedure performed (elective or therapeutic lymph node dissection).

The effect of various types of splenectomy on the development of B-16 melanoma in mice

Two hundred and sixty CB57BL/J6 mice were used in an experimental protocol designed to investigate the effects of four different varieties of splenectomy on the growth rate of subcutaneously implanted GB-16 melanoma. In addition, the mean and absolute survival of the mice, the histopathology of the tumour and the effects of the same procedures on the immunological status of the tumour-bearing animals as assessed by serum IgG levels and immunoelectrophoresis were determined. The effects of timing of splenectomy and the removal of the primary tumour after splenectomy on the above parameters were also annotated. The following were found: 1. Splenectomy performed 8 days after B-16 melanoma tumour implantation in mice i.e. in the early period of oncogenesis, lengthened the survival of the grafted experiments, delayed tumour growth, reduced the "activity" of the tumour and caused pseudoencapsulation of the tumour by fibrous tissue. It increased, but not by a statistically significant degree (p > 0.05), the circulating levels of the IgG immunoglobulin. 2. Splenectomy performed 28 days prior to grafting of the same tumour did not affect the circulating IgG levels nor did it prolong survival; however it reduced the rate of tumour growth and pseudoencapsulation of the tumour was observed. 3. Splenectomy at the early stages of oncogenesis in combination with surgical removal of the primary tumour increased absolute and mean survival, delayed the tumour growth rate, increased the time to relapse and reduced the "activity" of the pseudoencapsulated tumour.

Prognostic factors in malignant melanoma patients with solitary or multiple brain metastases. Is there a role for surgery?

BACKGROUND

The aim of this study is to evaluate the prognostic parameters and treatment modalities of malignant melanoma patients with brain metastases.

METHODS

EXPERIMENTAL DESIGN

a retrospective study with a mean follow-up of 46 months.

SETTING

specialized Cancer Center.

PATIENTS

the charts of 136 patients, treated in Roswell Park Cancer Institute, for melanoma brain metastases, were analyzed.

INTERVENTIONS

all patients were treated surgically and in the majority adjuvant therapy was applied.

MEASURES

survival and time of recurrence of patients and possible prognostic factors.

RESULTS

PATIENTS who were treated surgically had a better one-year survival rate (28.3%), than patients who received radiotherapy and/or chemotherapy (6.67%) or patients who refused any kind of treatment (3.45%), (p=0.006). Prolonged survival after surgical treatment was found in patients with single metastatic lesions and in patients with multiple metastatic lesions.

CONCLUSIONS

Melanoma patients with single metastatic lesions to the brain seem to do better after surgical treatment. The role of surgical intervention in patients with multiple brain metastases needs re-evaluation from a big multicenter, prospective trial.

An adult patient with a mixed germ cell tumor of the spermatic cord

Tumors of the spermatic cord are very rare, and approximately one half of all primary spermatic cord tumors are malignant. We report the presentation and treatment of an adult (36-year-old) patient with a mixed germ cell tumor that originated in the spermatic cord. No similar cases of mixed tumors of the spermatic cord in adults have been reported.