Pilot study of oral anthocyanins for colorectal cancer chemoprevention

Naturally occurring anthocyanins possess colorectal cancer chemopreventive properties in rodent models. We investigated whether mirtocyan, an anthocyanin-rich standardized bilberry extract, causes pharmacodynamic changes consistent with chemopreventive efficacy and generates measurable levels of anthocyanins in blood, urine, and target tissue. Twenty-five colorectal cancer patients scheduled to undergo resection of primary tumor or liver metastases received mirtocyan 1.4, 2.8, or 5.6 grams (containing 0.5-2.0 grams anthocyanins) daily for 7 days before surgery. Bilberry anthocyanins were analyzed by high performance liquid chromatography (HPLC) with visible or mass spectrometric detection. Proliferation was determined by immunohistochemistry of Ki-67 in colorectal tumor. Concentrations of insulin-like growth factor (IGF)-I were measured in plasma. Mirtocyan anthocyanins and methyl and glucuronide metabolites were identified in plasma, colorectal tissue, and urine, but not in liver. Anthocyanin concentrations in plasma and urine were roughly dose-dependent, reaching approximately 179 ng/gram in tumor tissue at the highest dose. In tumor tissue from all patients on mirtocyan, proliferation was decreased by 7% compared with preintervention values. The low dose caused a small but nonsignificant reduction in circulating IGF-I concentrations. In conclusion, repeated administration of bilberry anthocyanins exerts pharmacodynamic effects and generates concentrations of anthocyanins in humans resembling those seen in Apc(Min) mice, a model of FAP adenomas sensitive to the chemopreventive properties of anthocyanins. Studies of doses containing <0.5 gram bilberry anthocyanins are necessary to adjudge whether they may be appropriate for development as colorectal cancer chemopreventive agents.

A fuller understanding of pancreatic neuroendocrine tumours combined with aggressive management improves outcome

BACKGROUND

Neuroendocrine tumours of the pancreas (PNETs) represent 1-2% of all pancreatic tumours. The terms 'islet cell tumours' and 'carcinoids' of the pancreas should be avoided. The aim of this review is to offer an overview of the history and diagnosis of PNETs followed by a discussion of the available treatment options.

METHODS

A search on PubMed using the keywords 'neuroendocrine', 'pancreas' and 'carcinoid' was performed to identify relevant literature over the last 30 years.

RESULTS

The introduction of a revised classification of neuroendocrine tumours by the World Health Organisation (WHO) in 2000 significantly changed our understanding of and approach to the management of these tumours. Advances in laboratory and radiological techniques have also led to an increased detection of PNETs. Surgery remains the only treatment that offers a chance of cure with increasing number of non-surgical options serving as beneficial adjuncts. The better understanding of the behaviours of PNETs together with improvements in tumour localisation has resulted in a more aggressive management strategy with a concomitant improvement in symptom palliation and a prolongation of survival.

CONCLUSION

Due to their complex nature and the wide range of therapeutic options, the involvement of specialists from all necessary disciplines in a multidisciplinary team setting is vital to provide optimal treatment of this disease.

Prediction of mortality in acute pancreatitis: a systematic review of the published evidence

OBJECTIVE

In this review, we focus on studies that examined such prognostic indices in relation to predicting a fatal outcome from pancreatitis.

SUMMARY BACKGROUND DATA

Acute pancreatitis (AP) is a common emergency, and early identification of high-risk patients can be difficult. For this reason, a plethora of different prognostic variables and scoring systems have been assessed to see if they can reliably predict the severity of pancreatitis and/or subsequent mortality.

METHODS

All studies that focused on AP, including retrospective series and prospective trials, were retrieved and analysed for factors that could influence mortality. Articles that analysed factors influencing the severity of the disease or the manifestation of disease-related complications were excluded.

RESULTS

58 articles meeting the inclusion criteria were identified. Among the various factors investigated, APACHE II seemed to have the highest positive predictive value (69%). However, most prognostic variables and scores showed high negative predictive values but suboptimal values for positive predictive power.

CONCLUSIONS

Despite the proliferation of scoring systems for grading AP, none are ideal for the prediction of mortality. With the exception of the APACHE II, the other scores and indexes do not have a high degree of sensitivity, specificity and predictive values.

Augmenting the Ablative Effect of Liver Electrolysis: Using Two Electrodes and the Pringle Maneuver

Several methods of liver tumor ablation have been investigated, and these include the novel technique of electrolysis. Electrolysis is slower than other forms of ablative therapy. This study determined methods of increasing the ablative effect of electrolysis. Domestic white pigs were divided. One group received electrolysis using two electrode catheters, and in the other group a concurrent intermittent Pringle maneuver was performed to induce intermittent ischemia. The effect of two electrode catheters versus a single electrode catheter was compared, and the effect of the Pringle maneuver versus no Pringle was examined with two electrode catheters. The livers were harvested, and the volume of each lesion was calculated. There was a linear relationship between the volume of hepatic necrosis and the electrolytic dose in (p <.005) in both the single-electrode-catheter and two-electrode-catheter groups. Comparison between the single- and multiple-electrode groups showed a highly significant difference in the dose response (p <.0000002) when more than one electrode was used. Use of the Pringle maneuver during electrolysis produced larger volumes of hepatic necrosis over all doses when using two electrode catheters. Rates of necrosis were 3.8 cm(3)/100 C for a single electrode catheter, 5.46 cm(3)/100 C for two electrode catheters without Pringle, and 6.17 cm(3)/100 C for electrolysis with two electrode catheters coupled with intermittent Pringle maneuver. Thus, electrolysis was both reliable and predictable in producing hepatic necrosis in a dose-dependent manner. The time delay in achieving tumor ablation via electrolysis can be overcome by using two electrodes combined with the Pringle maneuver to increase the volume of the lesion produced.

Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma

BACKGROUND

The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass.

METHODS

This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma.

RESULTS

We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05).

CONCLUSIONS

On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.

Inaccuracy of fine-needle biopsy in the diagnosis of solitary fibrous tumour of the liver

Solitary fibrous tumour (SFT) is an uncommon neoplasm of mesenchymal origin that primarily affects the pleura and mediastinum. SFTs may occur elsewhere in the body including the liver, peritoneum, orbit and other soft tissues. Recent advances in immunohistochemical analysis have allowed greater identification of SFTs. Nevertheless, radiologically it remains difficult to distinguish SFTs of the liver from other solitary tumours as they have many common features. We report a case of SFT of the liver and highlight the potential inaccuracy of percutaneous biopsy in the diagnosis of large solitary liver tumours.

The inguinal release procedure for groin pain: initial experience in 73 sportsmen/women

OBJECTIVE

To assess the impact of the laparoscopic inguinal release procedure with mesh reinforcement on athletes with groin pain.

DESIGN

Prospective cohort study.

SETTING

Private sector.

PATIENTS

Professional and amateur sportsmen/women undergoing the inguinal release for groin pain.

MAIN OUTCOME MEASUREMENTS

Change in patient's symptoms, functional limitation and time to resuming sporting activity following surgery.

RESULTS

73 sportsmen/women underwent laparoscopic inguinal release in the study period, 37 (51%) of whom were professionals. 95% were male with a median age of 30 years. Following operation, patients returned to light training at a median of 1 week, full training at 3 weeks (professionals-2 weeks) and playing competitively at 4 weeks (professionals-3 weeks). 74% considered themselves match-fit by 4 weeks (84% of professionals). Following surgery, there was a highly significant improvement in frequency of pain, severity of pain and functional limitation in both the whole cohort and professional group. 88% reported a return to full fitness at follow-up, with 73% reporting complete absence of symptoms. 97% of the cohort thought the operation had improved their symptoms.

CONCLUSIONS

This study shows that the laparoscopic inguinal release procedure may be effective in the treatment of a subgroup of athletes with groin pain.

Ten-year experience in the management of gallbladder cancer from a single hepatobiliary and pancreatic centre with review of the literature

BACKGROUND

There is no consensus regarding the optimum surgical approach to gallbladder cancer. This study reviews the management of gallbladder cancer in a single unit.

METHODS

Retrospective study of 73 consecutive patients diagnosed with gallbladder cancer. Twenty-three patients underwent surgery with curative intent (surgical group), 28 patients underwent exploratory surgery but had inoperable disease (surgically inoperable group) and 22 patients had inoperable disease radiologically (radiologically inoperable group). Within the surgical group, nine patients (cholecystectomy group) were diagnosed with gallbladder cancer after routine cholecystectomy.

RESULTS

The inoperable groups had significantly higher bilirubin and alkaline phosphatase (ALP) than the surgical group (p=0.02 and p<0.01, respectively). Age>68, white cell count (WCC)>7.6 x 109/L, platelet>345 x 109/L, bilirubin>16 mol/L, ALP >124 iu/L and sodium < or = 137 mmol/L were markers of inoperability. Age, haemoglobin and neutrophil:lymphocyte ratio (NLR) were predictors for survival following surgery (p=0.04, p=0.01 and p<0.01, respectively). The surgical and cholecystectomy groups had significantly higher median survivals than the surgically and radiologically inoperable groups (18.97 and 26.17 months versus 5.03 and 12.20 months, p=0.04).

CONCLUSION

Curative surgical resection of gallbladder cancer improved survival. Exploratory laparotomy which revealed inoperable disease reduced survival. Preoperative WCC, platelet, bilirubin and ALP may be used as additional discriminators during the investigation and work up prior to surgery.

Elevation of carbohydrate antigen 19.9 in benign hepatobiliary conditions and its correlation with serum bilirubin concentration

BACKGROUND

Carbohydrate antigen 19.9 (CA19.9), a tumor marker for malignancies of the hepatobiliary tract and pancreas, has frequently been shown to be deranged in a number of non-malignant conditions that are associated with jaundice. This study aims to demonstrate the correlation between CA19.9 and serum bilirubin concentration in patients with benign conditions and to determine the frequency of a false-positive increase in CA19.9 in patients being investigated for potential HPB malignancies.

METHODS

This is a retrospective review of 83 consecutive patients presenting with an abnormal CA19.9 and radiological or clinical features suggestive of HPB malignancy subsequently shown to have benign disease. All patients were thoroughly investigated and followed up until the diagnosis of malignancy could be safely excluded.

RESULTS

Serum bilirubin, sodium, lymphocyte count, neutrophil:lymphocyte ratio (NLR), beta-human chorionic gonadotrophin (HCG), and age were found to correlate with CA19.9 by Pearson's correlation (P = 0.001, P = 0.006, P = 0.006, P < 0.001, P = 0.012, and P = 0.049, respectively). In multivariate regression analysis, bilirubin was identified as an independent variable that may predict CA19.9 level (P = 0.028).

CONCLUSION

CA19.9 level is significantly influenced by serum bilirubin and elevated levels have been observed in patients with non-malignant HPB conditions. Adjusting CA19.9 according to bilirubin levels is likely to improve the specificity of this antigen in the differential diagnosis of benign and malignant HPB diseases and its reliability in the monitoring of disease response to chemotherapy.

An unusual case of concurrent insulinoma and nesidioblastosis

CONTEXT

Endogenous hyperinsulinaemic hypoglycaemia in adults is most commonly caused by an insulinoma. Adult nesidioblastosis is rarely reported. To the best of our knowledge the presence of both insulinoma and nesidioblastosis has not been reported before.

CASE REPORT

We report a case of a 35-year-old female presenting with neuroglycaemic symptoms. A supervised 72-hour fast confirmed hypoglycaemia in the presence of hyperinsulinaemia. Thorough pre-operative biochemical and radiological investigations, including selective splenic, superior mesenteric and portal venous sampling inferred a tentative diagnosis of adult nesidioblastosis. However, a grossly elevated insulin level within the splenic vein on a second set of venous sampling produced a high index of suspicion for the presence of an insulinoma. At surgical exploration both an insulinoma and nesidioblastosis were identified and confirmed by histological examination.

CONCLUSION

We report an even rarer entity of concurrent insulinoma and nesidioblastosis.

Inoperable colorectal liver metastases: a declining entity?

BACKGROUND

Untreated colorectal liver metastases (CLMs) have a dismal prognosis. Surgery remains the gold standard of treatment, but many patients will have inoperable disease at presentation. Until recently, the outlook for such patients was bleak. The purpose of this review was to report on available options in the treatment CLMs, which would be considered unresectable by conventional evaluation.

METHODS

Inclusion criteria were articles published in English-language journals reporting on either retrospective or prospective cohorts of patients undergoing treatment for conventionally inoperable CLM. Main outcome measures were survival, resectability rates, morbidity and mortality following treatment of the patients' disease.

RESULTS

Improved chemotherapy regimes and other innovative treatments have opened up new options for such patients and may even render conventionally inoperable disease resectable. The aim of treatment should be down-staging of metastases to achieve resectability, however, other treatments such as ablation may be also be used (either alone or in conjunction with resection).

CONCLUSION

A nihilistic attitude to the patient with seemingly inoperable liver metastases should be discouraged. Discussion of such patients at multi-disciplinary meetings is essential in order to plan and monitor treatments.

Cystic lesions of the pancreas. A diagnostic and management dilemma

BACKGROUND/AIMS

Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management.

METHODS

A search was undertaken with a Pubmed database to identify all English articles using the keywords 'pancreatic cysts', 'serous cystadenoma', 'intraductal papillary mucinous tumour', 'pseudocysts', 'mucinous cystic neoplasm' and 'solid pseudopapillary tumour'.

RESULTS

The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones.

CONCLUSION

In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested. and IAP.

Major resection of hepatic colorectal liver metastases in elderly patients – An aggressive approach is justified

AIMS

With a progressively ageing population, increasing numbers of elderly patients will present with colorectal metastases and be referred for surgical resection. The aim of this study was to assess the safety of hepatic resection in patients over 70 years of age by comparing outcomes with those of a younger cohort of patients.

METHODS

Forty-nine patients over 70 years of age who underwent hepatic resection of colorectal liver metastases were compared to 142 patients less than 70 years of age in terms of pre-, peri- and post-operative results, as well as long-term survival.

RESULTS

Major resections were performed in 61% of the elderly group and 68% of the younger group. The two groups were comparable in terms of operative duration, transfusion rate, length of HDU stay and post-operative hospital stay. The elderly group had a non-significant increase in post-operative morbidity. The 30-day and 60-day/inpatient mortality rates were similar between the two groups (elderly 0% and 4%; younger 2% and 3%). Long-term disease-free survival was similar between elderly and younger patients.

CONCLUSION

This study confirms that an aggressive surgical policy towards colorectal metastases in elderly patients is associated with low peri-operative morbidity and mortality, as well as good long-term outcomes.

Survival following curative resection for pancreatic ductal adenocarcinoma. A systematic review of the literature

CONTEXT

Patients with resectable pancreatic cancer comprise a small subgroup of the overall population with the disease from around 15 to 20%, with nearly all patients dying from their disease within 7 years of surgery. In the light of such bleak statistics, data regarding what factors may influence outcome, following attempted curative resection is essential in order to optimise the treatment options for patients.

METHODS

This review analysed all English-language publications using PubMed and Web of Science databases for studies detailing outcomes following resection for pancreatic ductal adenocarcinoma from 1980 to the present day.

MAIN OUTCOME MEASURES

The data examined from papers were post-operative mortality rates, median survival, yearly survival rates and other factors which may have influenced long-term survival; such as patient demographics, operative details and tumour characteristics (such as example tumour size, lymph node metastases and tumour differentiation).

RESULTS

There has been significant improvement in post-operative mortality over the last decades with a modest improvement in long-term survival. With the exception of post-operative blood transfusion, tumour characteristics remain the only significant features influencing survival after pancreatic cancer surgery. Favourable prognostic factors include tumour size less than 2 cm, negative resection margin, lymph node negative tumours, well-differentiated tumours and absence of perineural or blood vessel invasion.

CONCLUSION

In light of these data, it could be reasoned that tumour size, on cross-sectional imaging, might be employed as means of selecting the most appropriate candidates for surgery, in cases where the risks of resection are high.

Oesophageal metastasis from colorectal cancer

Metastasis to the oesophagus is most frequently described in association with lung or breast cancer. Diagnosis is frequently complicated as often only normal tissue is present in endoscopic biopsy specimens. Although oesophagectomy for metastasis has been described, few patients are suitable for curative resection. We report the case of a 62-year-old man who developed an oesophageal metastasis from colorectal cancer and review the available literature.

Glycogen synthase kinase-3 beta; a new target in pancreatic cancer?

Glycogen synthase kinase (GSK) was initially described as a key enzyme involved in glycogen metabolism. However, since that time it has been found to regulate a diverse range of cell functions. In addition to having a major role in the regulation of the important onco-protein beta-catenin, GSK is also a critical regulator of NF-kappaB. NF-kappaB comprises a family of transcription factors which activate the expression of a wide array of genes involved in inflammation, tumourigenesis, metastasis, differentiation, embryonic development, apoptosis. Inflammation mediated by the NF-kappaB family has been implicated in the initiation of pancreatic cancer, resistance to chemotherapy and the development of the debilitating cancer cachexia seen with advanced disease. Hence, GSK has potential as an important new target both in the treatment of resectable pancreatic cancer as an adjuvant to surgery, and in the palliation of inoperable tumours.

Laparoscopic repair of direct inguinal hernia: a new technique that reduces the development of postoperative seroma

BACKGROUND

Seroma are common early postoperative complications encountered in laparoscopic inguinal hernia repair. Previous anecdotal evidence from our surgical practice suggested a lower incidence of postoperative seroma formation with direct hernia repairs when the lax transversalis fascia (TF) is inverted by tacking to the pubic ramus. We undertook a study to investigate whether TF inversion in this way reduces the incidence of postoperative seroma.

METHOD

A total of 216 patients undergoing transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs from August 2003 to December 2005 were included in this prospective non-randomised controlled study. Surgeon 1 would routinely invert the TF whereas surgeon 2 would not. At follow-up the presence of postoperative seroma and pain was recorded.

RESULTS

Mann-Whitney U test demonstrated no significant difference in terms of age, sex and time to follow-up between the surgeons' patient groups (P > 0.05), and Chi-square test demonstrated significantly that inversion of the TF is associated with a lower incidence of postoperative seroma (P < 0.05). There was no significant difference in terms of postoperative pain at follow-up.

CONCLUSION

Inversion of the TF is associated with a statistically lower incidence of postoperative seroma, without increasing postoperative pain despite the use of one or two additional tacks.

Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas

AIMS

We have maintained a highly conservative policy in selecting patients with carcinoma of the head of pancreas for resection. This has been based on tumour size, evidence of lymph node involvement or local invasion outside of the gland at laparotomy, laparoscopy or CT imaging. This study investigated our survival rates following pancreatic resection and examined clinicopathological predictors of survival.

METHODS

Sixty-two consecutive patients undergoing pancreatic resections for malignancy were identified from 1999 onwards. Thirty-three underwent resection for pancreatic ductal adenocarcinoma and were included in our analysis, the remainder included resections for ampullary adenocarcinoma (n=20) or other malignancies (n=9). Patient, tumour and operative characteristics were analysed to assess predictors of survival following resection (Kaplan-Meier survival curves).

RESULTS

Median survival following resection for ductal pancreatic adenocarcinoma was 54 months (ampullary adenocarcinomas achieved a median survival of 62 months) and thirty-day mortality was 2.7% (n=1). Survival was not associated with any demographic or intraoperative factors, such as blood loss, operative duration or anaesthetic technique. Survival curves were significantly worse when perineural or vascular invasion was evident histologically (p=0.023 and 0.0023 respectively). Patients with positive lymph nodes had a significantly shorter survival (p=0.0030) especially when lymph node status was expressed as a percentage of total lymph node yield. If more than 20% of retrieved lymph nodes were positive for tumour, this was a clear predictor of survival (p<0.0001). A positive resection margin was also associated with shortened survival (p=0.0291).

CONCLUSION

Despite the advances made in the management of pancreatic cancer, tumour biology still dictates long-term survival. A highly selective surgical approach to the management of these patients results in good long-term survival.

Hypoxia and angiogenesis in pancreatic cancer

BACKGROUND

Pancreatic cancer remains one of the most lethal of all solid tumours of the gastrointestinal tract. It is characterized by late diagnosis, aggressive local invasion, early metastasis and resistance to chemoradiotherapy. Increasing knowledge regarding the molecular events behind the growth and invasion of pancreatic cancer may lead to new targets for intervention.

METHODS

A search of Pubmed and Medline databases was undertaken using the keywords pancreatic cancer, gastrointestinal cancer, hypoxia, angiogenesis and anti-angiogenesis therapy.

RESULTS

Hypoxia is the driving force behind angiogenesis in pancreatic cancers. Research into angiogenesis has shown many different sites that can be targeted by agents such as tyrosine kinase inhibitors.

CONCLUSION

Anti-angiogenic therapy could be an important adjunct to conventional chemotherapy treatment of gastrointestinal neoplasia.

Prognostic molecular markers in hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is the fifth commonest malignancy worldwide and its incidence is rising. Surgery, including transplantation, remains the only potentially curative modality for HCC, yet recurrence rates are high and long-term survival poor. The ability to predict individual recurrence risk and subsequently prognosis would help guide surgical and chemotherapeutic treatment. As understanding of hepatocarcinogenesis has increased, the myriad of genetic and molecular events that drive the hepatocarcinogenic disease process, including angiogenesis, invasion and metastasis, have been identified. This systematic review examines the evidence from published manuscripts reporting the prognostic potential of molecular biomarkers in hepatocellular carcinoma. In summary, a number of molecular biomarkers with prognostic significance have been identified in hepatocellular carcinoma. Not only might these molecules allow more accurate prediction of prognosis for patients with HCC, but they may also provide targets for potential therapeutic agents.