The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM

Colorectal cancer migration and invasion initiated by microRNA-106a

MicroRNAs have been implicated in the regulation of several cellular signaling pathways of colorectal cancer (CRC) cells. Although emerging evidence proves that microRNA (miR)-106a is expressed highly in primary tumor and stool samples of CRC patients; whether or not miR-106a mediates cancer metastasis is unknown. We show here that miR-106a is highly expressed in metastatic CRC cells, and regulates cancer cell migration and invasion positively in vitro and in vivo. These phenotypes do not involve confounding influences on cancer cell proliferation. MiR-106a inhibits the expression of transforming growth factor-β receptor 2 (TGFBR2), leading to increased CRC cell migration and invasion. Importantly, miR-106a expression levels in primary CRCs are correlated with clinical cancer progression. These observations indicate that miR-106a inhibits the anti-metastatic target directly and results in CRC cell migration and invasion.

Incidental gallbladder cancer during laparoscopic cholecystectomy: Managing an unexpected finding

AIM: To evaluate the impact of incidental gallbladder cancer on surgical experience.

METHODS: Between 1998 and 2008 all cases of cholecystectomy at two divisions of general surgery, one university based and one at a public hospital, were retrospectively reviewed. Gallbladder pathology was diagnosed by history, physical examination, and laboratory and imaging studies [ultrasonography and computed tomography (CT)]. Patients with gallbladder cancer (GBC) were further analyzed for demographic data, and type of operation, surgical morbidity and mortality, histopathological classification, and survival. Incidental GBC was compared with suspected or preoperatively diagnosed GBC. The primary endpoint was disease-free survival (DFS). The secondary endpoint was the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention.

RESULTS: Nineteen patients (11 women and eight men) were found to have GBC. The male to female ratio was 1:1.4 and the mean age was 68 years (range: 45-82 years). Preoperative diagnosis was made in 10 cases, and eight were diagnosed postoperatively. One was suspected intraoperatively and confirmed by frozen sections. The ratio between incidental and nonincidental cases was 9/19. The tumor node metastasis stage was: pTis (1), pT1a (2), pT1b (4), pT2 (6), pT3 (4), pT4 (2); five cases with stage Ia (T1 a-b); two with stage Ib (T2 N0); one with stage IIa (T3 N0); six with stage IIb (T1-T3 N1); two with stage III (T4 Nx Nx); and one with stage IV (Tx Nx Mx). Eighty-eight percent of the incidental cases were discovered at an early stage (≤ II). Preoperative diagnosis of the 19 patients with GBC was: GBC with liver invasion diagnosed by preoperative CT (nine cases), gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum (one case), porcelain gallbladder (one case), gallbladder adenoma (one case), and chronic cholelithiasis (eight cases). Every case, except one, with a T1b or more advanced invasion underwent IVb + V wedge liver resection and pericholedochic/hepatoduodenal lymphadenectomy. One patient with stage T1b GBC refused further surgery. Cases with Tis and T1a involvement were treated with cholecystectomy alone. One incidental case was diagnosed by intraoperative frozen section and treated with cholecystectomy alone. Six of the nine patients with incidental diagnosis reached 5-year DFS. One patient reached 38 mo survival despite a port-site recurrence 2 years after original surgery. Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5-year DFS.

CONCLUSION: Laparoscopic cholecystectomy does not affect survival if implemented properly. Reoperation should have two objectives: R0 resection and clearance of the lymph nodes.

Lessons from cancer immunoediting in cutaneous melanoma

We will revisit the dual role of the immune system in controlling and enabling tumor progression, known as cancer immunoediting. We will go through the different phases of this phenomenon, exposing the most relevant evidences obtained from experimental models and human clinical data, with special focus on Cutaneous Melanoma, an immunogenic tumor per excellence. We will describe the different immunotherapeutic strategies employed and consider current models accounting for tumor heterogeneity. And finally, we will propose a rational discussion of the progress made and the future challenges in the therapeutics of Cutaneous Melanoma, taking into consideration that tumor evolution is the resulting from a continuous feedback between tumor cells and their environment, and that different combinatorial therapeutic approaches can be implemented according to the tumor stage.

First experiences of photoacoustic imaging for detection of melanoma metastases in resected human lymph nodes

BACKGROUND AND OBJECTIVE

Excision and histological assessment of the first draining node (sentinel lymph node) is a frequently used method to assess metastatic lymph node involvement related to cutaneous melanoma. Due to the time required for accurate histological assessment, nodal status is not immediately available to the surgeon. Hence, in case histological examination shows metastases, the patient has to be recalled to perform additional lymphadenectomy. To overcome these drawbacks we studied the applicability of photoacoustic tomographic imaging as an intra-operative modality for examining the status of resected lymph nodes.

MATERIALS AND METHODS

In melanoma patients undergoing lymphadectomy for metastatic disease, six suspect lymph nodes were photoacoustically (PA) imaged using multiple wavelengths. Histopathologal examination showed three nodes without tumor cells (benign nodes) and three nodes with melanoma cells (malignant nodes). PA images were compared with histology and anatomical features were analyzed. In addition, PA spectral analysis was performed on areas of increased signal intensity.

RESULTS

After correlation with histopathology, multiple areas containing melanoma cells could be identified in the PA images due to their increased response. Malignant nodes showed a higher PA response and responded differently to an increase in excitation wavelength than benign nodes. In addition, differences in anatomical features between the two groups were detected.

CONCLUSIONS

Photoacoustic detection of melanoma metastases based on their melanin content proves to be possible in resected human lymph nodes. The amount of PA signal and several specific anatomical features seem to provide additional characteristics for nodal analysis. However, it is as yet preliminary to designate a highly accurate parameter to distinguish between malignant and benign nodes. We expect to improve the specificity of the technique with a future implementation of an adjusted illumination scheme and depth correction for photon fluence.

Two lymph nodes draining the mouse liver are the preferential site of DC migration and T cell activation

BACKGROUND & AIMS

Lymph nodes (LNs) play a critical role in host defence against pathogens. In rodents, lymphatic anatomy and drainage have been characterized for many different organs. Surprisingly, the LNs draining the mouse liver have not been clearly identified. This knowledge is of central importance to allow accurate characterization of immune responses to pathogens infecting the liver. It is also important for exploring immune responses in hepatic tumour models, and mechanisms underlying the relative tolerogenic properties of the liver. In this study, we used both anatomical and immunological approaches to identify the LN(s) draining the mouse liver.

METHODS

Evans Blue and purified dendritic cells were directly injected into the hepatic parenchyma.

RESULTS

Using Evans Blue, we identified three LNs adjacent to the liver that stained with the dye within the first 5 min, which we termed portal, coeliac, and first mesenteric LNs. We also provide evidence that dendritic cells (DCs) injected under the liver capsule preferentially migrate to the coeliac and portal nodes, leading to local activation of antigen-specific naïve CD8 and CD4 T cells, suggesting this is a route of lymphatic drainage from the liver. Consistent with this result, cell-associated antigen injected under the liver capsule was also cross-presented to CD8 T cells in these nodes.

CONCLUSIONS

These results suggest for the first time that the coeliac and portal nodes are the main LNs draining the liver, and that DCs exiting the liver can elicit primary T cell activation within these lymph nodes; first mesenteric nodes play a secondary role. We propose this nomenclature to be used as common designations for the observed structures.

Endoscopic and clinicopathologic characteristics of early gastric cancer with high microsatellite instability

AIM: To investigate endoscopic and clinicopathologic characteristics of early gastric cancer (EGC) according to microsatellite instability phenotype.

METHODS: Data were retrospectively collected from a single tertiary referral center. Of 981 EGC patients surgically treated between December 2003 and October 2007, 73 consecutive EGC patients with two or more microsatellite instability (MSI) mutation [high MSI (MSI-H)] and 146 consecutive EGC patients with one or no MSI mutation (non-MSI-H) were selected. The endoscopic and clinicopathologic features were compared between the MSI-H and non-MSI-H EGC groups.

RESULTS: In terms of endoscopic characteristics, MSI-H EGCs more frequently presented with elevated pattern (OR 4.38, 95% CI: 2.40-8.01, P < 0.001), moderate-to-severe atrophy in the surrounding mucosa (OR 1.91, 95% CI: 1.05-3.47, P = 0.033), antral location (OR 3.99, 95% CI: 2.12-7.52, P < 0.001) and synchronous lesions, compared to non-MSI-H EGCs (OR 2.65, 95% CI: 1.16-6.07, P = 0.021). Other significant clinicopathologic characteristics of MSI-H EGC included predominance of female sex (OR 2.77, 95% CI: 1.53-4.99, P < 0.001), older age (> 70 years) (OR 3.30, 95% CI: 1.57-6.92, P = 0.002), better histologic differentiation (OR 2.35, 95% CI: 1.27-4.34, P = 0.007), intestinal type by Lauren classification (OR 2.34, 95% CI: 1.15-4.76, P = 0.019), absence of a signet ring cell component (OR 2.44, 95% CI: 1.02-5.86, P = 0.046), presence of mucinous component (OR 5.06, 95% CI: 1.27-20.17, P = 0.022), moderate-to-severe lymphoid stromal reaction (OR 3.95, 95% CI: 1.59-9.80, P = 0.003), and co-existing underlying adenoma (OR 2.66, 95% CI: 1.43-4.95, P = 0.002).

CONCLUSION: MSI-H EGC is associated with unique endoscopic and clinicopathologic characteristics including frequent presentation in protruded type, co-existing underlying adenoma, and synchronous lesions.

Randomised controlled trial comparing laparoscopic and robot-assisted radical prostatectomy

BACKGROUND

The advantages of robot-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) have rarely been investigated in randomised controlled trials.

OBJECTIVE

To compare RARP and LRP in terms of the functional, perioperative, and oncologic outcomes. The main end point of the study was changes in continence 3 mo after surgery.

DESIGN, SETTING, AND PARTICIPANTS

From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned (using a randomisation plan) to one of two groups based on surgical approach: the RARP group and the LRP group.

INTERVENTION

All RARP and LRP interventions were performed with the same technique by the same single surgeon.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The demographic, perioperative, and pathologic results, such as the complications and prostate-specific antigen (PSA) measurements, were recorded and compared. Continence was evaluated at the time of catheter removal and 48 h later, and continence and potency were evaluated after 1, 3, 6, and 12 mo. The student t test, Mann-Whitney test, χ(2) test, Pearson χ(2) test, and multiple regression analysis were used for statistics.

RESULTS AND LIMITATIONS

The two groups (RARP: n=60; LRP: n=60) were comparable in terms of demographic data. No differences were recorded in terms of perioperative and pathologic results, complication rate, or PSA measurements. The continence rate was higher in the RARP group at every time point: Continence after 3 mo was 80% in the RARP group and 61.6% in the LRP group (p=0.044), and after 1 yr, the continence rate was 95.0% and 83.3%, respectively (p=0.042). Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% and 54.2%, respectively (p=0.020). The limitations included the small number of patients.

CONCLUSIONS

RARP provided better functional results in terms of the recovery of continence and potency. Further studies are needed to confirm our results.

In oral squamous cell carcinoma, high FAK expression is correlated with low P53 expression

Focal adhesion kinase (FAK) and p53 have been associated with metastatic activity and a poor prognosis in oral squamous cell carcinoma (OSCC). Recently, a feedback mechanism in which FAK regulates p53 has been proposed. The present study aims to determine the role of p53 in FAK regulation in these tumors. FAK and p53 expression was examined by immunohistochemistry in normal oral mucosa and in 67 oral squamous cell carcinomas. p16(INK4a) was also studied in view of its association with human papillomavirus infection. The association between FAK and p53 was subsequently analyzed. FAK expression in OSCCs was heterogeneous: 22 (33 %) cases showed weak expression, 16 (24 %) showed moderate expression, and 22 (33 %) cases showed high expression. Regarding p53, 31 of 67 (46 %) available tumor specimens showed negative staining, and 36 of 67 (54 %) showed positive nuclear staining for p53. FAK expression was inversely correlated with p53 expression (Fisher's exact test, p = 0.005). There was no association between p16(INK4a) and p53 or FAK expression. In conclusion, our results support the hypothesis that FAK activity might be involved in the down-regulation of p53 expression in OSCC.

Serum peptidome patterns for early screening of esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers in the world. Early diagnosis is critical for guiding the therapeutic management of ESCC. The present study aims to determine serum peptidome patterns for diagnosing ESCC. To identify novel peptidome patterns for diagnosing ESCC, sera from 31 healthy volunteers and 32 ESCC patients were subjected to a comparative proteomic analysis using a ClinProt™ Kit combined with mass spectrometry (MS). This approach enables the determination of peptidome patterns that can differentiate between ESCC sera and sera from healthy volunteers. For further validation, the diagnostic and differential diagnostic capabilities of the peptidome patterns were verified blindly by using an independent group of sera, consisting of sera from 31 ESCC patients, 33 healthy volunteers, 38 colorectal patients, and 36 gastric cancer patients. A Quick Classifier Algorithm was used to construct the peptidome patterns for the identification of ESCC from the control samples. Five of the identified peaks at mass to charge ratios 759, 786, 1,866, 3,316, and 6,634 were used to construct the peptidome patterns with almost 100% accuracy. Furthermore, the peptidome patterns could also differentiate the validation group with high accuracy. These results suggest that the ClinProt™ Kit combined with MS achieves significantly high accuracy for ESCC diagnosis and differential diagnosis.

Does t3 subdivision correlate with nodal or distant metastasis in colorectal cancer?

Purpose

We analyzed the clinical data of T3 colorectal cancer patients to assess whether T3 subdivision correlates with node (N) or metastasis (M) staging and stage-independent factors.

Methods

Five hundred fifty-five patients who underwent surgery for primary colorectal cancer from January 2003 to December 2009 were analyzed for T3 subdivision. T3 subdivision was determined by the depth of invasion beyond the outer border of the proper muscle (T3a, <1 mm; T3b, 1 to 5 mm; T3c, >5 to 15 mm; T3d, >15 mm). We investigated the correlation between T3 subdivision and N, M staging and stage-independent prognostic factors including angiolymphatic invasion (ALI), venous invasion (VI) and perineural invasion (PNI).

Results

The tumors of the 555 patients were subclassified as T3a in 86 patients (15.5%), T3b in 209 patients (37.7%), T3c in 210 patients (37.8%) and T3d in 50 patients (9.0%). The nodal metastasis rates were 39.5% for T3a, 56.5% for T3b, 75.7% for T3c and 74.0% for T3d. The distant metastasis rates were 7.0% for T3a 9.1% for T3b, 27.1% for T3c and 40.0% for T3d. Both N and M staging correlated with T3 subdivision (Spearman's rho = 0.288, 0.276, respectively; P < 0.001). Other stage-independent prognostic factors correlated well with T3 subdivision (Spearman's rho = 0.250, P < 0.001 for ALI; rho = 0.146, P < 0.001 for VI; rho = 0.271, P < 0.001 for PNI).

Conclusion

Subdivision of T3 colorectal cancer correlates with nodal and metastasis staging. Moreover, it correlates with other prognostic factors for colorectal cancer.

Epidermal growth factor receptor expression in esophageal adenocarcinoma: relationship with tumor stage and survival after esophagectomy

Background and Aims. Esophageal adenocarcinoma (EA) is an aggressive tumor with increasing incidence in occidental countries. Several prognostic biomarkers have been proposed, including epidermal growth factor receptor (EGFR). The aim of this study was to assess whether EGFR expression predicts EA staging and patient survival. Methods. In this historical cohort, consecutive patients with EA managed between 2000 and 2010 were considered eligible for the study. Surgical specimens of patients treated with transhiatal esophagectomy were evaluated to establish EGFR expression and tumor differentiation. Staging was classified according with tumor-node-metastasis (TNM) system. Survival was determined according to either medical register or patient's family contact. Results. Thirty-seven patients who underwent esophagectomy without presurgical chemotherapy or radiotherapy were studied. EGFR expression was found in 16 patients (43%). EGFR expression was more frequent as higher was the TNM (I and II = 0% versus III = 47% versus IV = 100%; P < 0.001). Average survival in months was significantly shorter in the group of patients with EGFR expression (10.5 versus 21.7; P = 0.001). Conclusions. In patients with esophageal adenocarcinoma treated with transhiatal esophagectomy, EGFR expression was related to higher TNM staging and shorter survival. EGFR expression might be assumed as a prognostic marker for esophageal adenocarcinoma.

Cyclooxygenase-2 expression and its prognostic significance in clear cell renal cell carcinoma

Background

The prognostic value of cyclooxygenase-2 (COX-2) in human renal cell carcinoma (RCC) remains unclear. The purposes of this study are to elucidate the clinical significance of COX-2 in clear cell RCC (CCRCC) and to assess the treatment effect of COX-2 inhibition on CCRCC cell lines.

Methods

Using tumor samples obtained from 137 patients who had undergone nephrectomy at Seoul National University Hospital, we evaluated COX-2 expression on immunohistochemistry. Moreover, we performed the cell proliferation assay using 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl-2H tetrazolium bromide (MTT) and cell invasion assay. Thus, we evaluated the effect of meloxicam, an inhibitor of COX-2, in two human CCRCC cell lines.

Results

Cancer-specific survival (p=0.038) and progression-free survival (p=0.031) were shorter in the COX-2 high expression group. A multivariate logistic regression model showed that COX-2 expression was an independent risk factor for pTNM stage and Fuhrman nuclear grade. The MTT assay revealed that COX-2 inhibition led to the suppression of the proliferation of CCRCC cell lines. Moreover, it also reduced their invasion capacity.

Conclusions

This study postulates that COX-2 is a poor prognostic indicator in human CCRCC, suggesting that COX-2 inhibition can be a potential therapy in CCRCC.

Foxo3a drives proliferation in anaplastic thyroid carcinoma through transcriptional regulation of cyclin A1: a paradigm shift that impacts current therapeutic strategies

The Forkhead transcription factor, FoxO3a, is a known suppressor of primary tumor growth through transcriptional regulation of key genes regulating cell cycle arrest and apoptosis. In many types of cancer, in response to growth factor signaling, FoxO3a is phosphorylated by Akt, resulting in its exclusion from the nucleus. Here we show that FoxO3a remains nuclear in anaplastic thyroid carcinoma (ATC). This correlates with lack of Akt phosphorylation at serine473 in ATC cell lines and tissues of ATC patients, providing a potential explanation for nuclear FoxO3a. Mechanistically, nuclear FoxO3a promotes cell cycle progression by transcriptional upregulation of cyclin A1, promoting proliferation of human ATC cells. Silencing FoxO3a with a reverse genetics approach leads to downregulation of CCNA1 mRNA and protein. These combined data suggest an entirely novel function for FoxO3a in ATC promotion by enhancing cell cycle progression and tumor growth through transcriptional upregulation of cyclin A1. This is clinically relevant since we detected highly elevated CCNA1 mRNA and protein levels in tumor tissues of ATC patients. Our data indicate therapeutic inactivation of FoxO3a may lead to attenuation of tumor expansion in ATC. This new paradigm also suggests caution in relation to current dogma focused upon reactivation of FoxO3a as a therapeutic strategy against cancers harboring active PI3-K and Akt signaling pathways.

Early clinical outcomes of anal squamous cell carcinoma treated with concurrent chemoradiotherapy with 5-Fluorouracil plus mitomycin C in Japanese patients: experience at a single institution

Concurrent chemoradiotherapy with 5-fluorouracil plus mitomycin C has been established as a standard therapy for non-metastatic anal squamous cell carcinoma in the West. However, there have been few reports of chemoradiotherapy for anal squamous cell carcinoma in Japan. We retrospectively investigated seven consecutive anal squamous cell carcinoma patients who were treated with concurrent chemoradiotherapy consisting of 5-fluorouracil plus mitomycin C with a total irradiation of 59.4 Gy. The patients consisted of two males and five females. Clinical stages II/IIIA/IIIB accounted for four, one and two patients, respectively. Full-dose irradiation was completed in all patients. Median relative dose intensities of 5-fluorouracil and mitomycin C were both 99%. All patients achieved complete response. At a median follow-up of 37.5 months, one patient experienced local recurrence. The most common grade 3/4 acute toxicities were dermatitis in 100% and anal pain in 71%. There was no treatment-related death. Concurrent chemoradiotherapy appears to be tolerable and effective in Japanese patients with anal squamous cell carcinoma.

Malignant mucosal melanoma in the olfactory cleft of a 10-year-old child

Mucosal malignant melanoma is a rare but aggressive neoplasm with high rates of recurrence and death. It is known that two-thirds of mucosal melanoma cases arise in the nasal cavity and paranasal sinuses in adults. However, there have been few studies until now on children with mucosal malignant melanoma and the related treatment. We report on a 10-year-old girl with mucosal malignant melanoma presented as a nasal polyp, which was removed via endoscopic sinus surgery and adjuvant chemotherapy without recurrence.

Locally advanced cancer of the esophagus, current treatment strategies, and future directions

For patients with locally advanced esophageal cancer no clear standard of care exists. Notwithstanding several negative phase III studies the data provide support for so-called trimodality treatment and this is probably the most common approach. Even the role of surgery has been questioned. These alternative approaches are set against a changing epidemiological background whereby adenocarcinoma has become the predominant tumor type, at least in the western world. In recent times an emphasis has been placed on the better selection of patients, predominantly based on data that shows a markedly improved survival in those who exhibit a response to neo-adjuvant therapy. In this article we review the major studies and discuss new approaches to the management of patients with locally advanced cancer of the esophagus.

Late recurrence of renal cell carcinoma >5 years after surgery: clinicopathological characteristics and prognosis

What's known on the subject? and What does the study add? Late recurrence more than five years after the initial treatment is one of the biological behaviours specific for RCC. In our study, late recurrence was observed in 8.8% of the patients. Also, patients with late recurrence had more favorable clinicopathological features and better prognosis with long cancer-specific survival after recurrence. Age and preoperative hs-CRP levels may be independent predictive factors for late recurrence of RCC.

OBJECTIVE

• To evaluate the clinicopathological features and prognosis of late recurrence of renal cell carcinoma (RCC).

PATIENTS AND METHODS

• A total of 747 patients who had undergone curative surgery for RCC with follow-up of >5 years or recurrence within 5 years were included in the study. • The patients were stratified into four groups based on cancer-free intervals: no recurrence (no recurrence >5 years after surgery, n= 425), synchronous metastasis (n= 138), early recurrence (recurrence within 5 years, n= 143), and late recurrence (recurrence after 5 years, n= 41). • Multivariate analysis was performed to identify the clinicopathological factors affecting late recurrence and its clinical outcome.

RESULTS

• The subgroups were significantly different in clinicopathological variables, including age, preoperative haemoglobin, platelet count, high-sensitivity C-reactive protein (hs-CRP) levels, pT stage and nuclear grade. • In multiple logistic regression analysis, age (odds ratio [OR] 1.085, 95% confidence interval [CI] 1.012-1.163, P= 0.022), and preoperative hs-CRP levels (OR 6.211, 95% CI 1.590-24.270, P= 0.009) were independent predictive factors for late recurrence. • In patients with synchronous metastasis, early recurrence and late recurrence, 5-year cancer-specific survival rates after recurrence were 27.0%, 41.1% and 73.7%, respectively (P < 0.001). • Multivariate Cox analysis indicated that cancer-free interval, as well as body mass index, initial symptoms, Fuhrman's nuclear grade, sarcomatoid differentiation, lymphovascular invasion and metastasectomy, were independent predictive factors for cancer-related death.

CONCLUSIONS

• Late recurrence of RCC is not a rare event. • Patients with late recurrence had more favourable clinicopathological features and better prognosis with long cancer-specific survival after recurrence. • Age and preoperative hs-CRP levels may be independent predictive factors for late recurrence of RCC.

MicroRNA-93 inhibits tumor growth and early relapse of human colorectal cancer by affecting genes involved in the cell cycle

PURPOSE

Colorectal cancer (CRC) is associated with high recurrence and mortality. Because deregulation of microRNAs is associated with CRC development and recurrence, the expression levels of microRNAs can be a simple and reliable biomarker to detect postoperative early relapse, thereby helping physicians to treat high-risk patients more efficiently.

EXPERIMENTAL DESIGN

We used microRNA arrays and observed that microRNA-93 had substantially different expression levels in early (recurrence within 12 months after surgery) and non-early relapse CRC patients. The replication study, which included 35 early relapse and 42 non-early relapse subjects, further confirmed overexpression of microRNA-93 in non-early relapse samples. The in vitro and in vivo effects of microRNA-93 were investigated by examining cell proliferation, migration and invasion, as well as cell cycles, target-gene expression and xenograft in null mice.

RESULTS

Cellular studies showed that the overexpression of microRNA-93 inhibited colon cancer cell proliferation and migration but not invasion. The cell cycle studies also revealed that microRNA-93 caused an accumulation of the G2 population. However, microRNA-93 could not induce cell apoptosis or necrosis. Functional studies showed that microRNA-93 could suppress CCNB1 protein expression leading to cell cycle arrest in the G2 phase. Moreover, microRNA-93 repressed expression of ERBB2, p21 and VEGF, all of which are involved in cell proliferation. MicroRNA-93 also suppressed tumor growth in null mice.

CONCLUSIONS

This study showed that microRNA-93 can inhibit tumorigenesis and reduce the recurrence of CRC; these findings may have potential clinical applications for predicting the recurrence of CRC.

Analysis of the seventh edition of American Joint Committee on colon cancer staging

PURPOSE

The seventh edition of the American Joint Committee on Cancer (AJCC) staging system has new substages for colon cancer. We used survival data from a single medical center to analyze this new AJCC edition.

METHODS

The colon cancer database of Taipei Veterans General Hospital provided 1,865 patient records covering from 1999 to 2005. Survival rates were evaluated using the Kaplan-Meier method.

RESULTS

There were 268, 607, 561, and 421 patients in stages I, II, III, and IV disease with 5-year observed survival rates of 86.3%, 79.2%, 65.4%, and 12.8%, respectively. Survival rates were not significantly different between those with T4a and T4b disease (P = 0.806). The outcome of N1c disease was similar to N1a and N1b but worse than N0 (P = 0.004). Survival rates for M1a and M1b disease became different after reclassifying solely peritoneal seeding as M1a (P < 0.001). No discrepancy of outcomes between stage IIIA and stage IIB/IIC remained in the seventh edition.

CONCLUSIONS

Evolution from the fifth to seventh edition of the AJCC staging system is successful in separating prognostic groups by substaging. But some issues remain unresolved, including the subdivision of T4, N1, and M1.

Clinical features and prognostic factors in papillary thyroid microcarcinoma depends on age

Purpose

Clinical outcomes of papillary thyroid microcarcinoma (PTMC) vary. In general, age at diagnosis is an independent prognostic factor in conventional papillary thyroid carcinoma. However, it is unclear in patients of PTMC. The purpose of this study was to identify clinicopathologic features and prognostic factors of PTMC according to patients' age.

Methods

Five hundred twenty-seven patients who received thyroid surgery and diagnosed as having PTC between January 2001 and December 2009 were included. The clinical data were retrospectively analyzed.

Results

We divided the patients into two groups; group I who were younger than 45 years, and group II who were 45 years old or older. The mean tumor size and incidences of neck lymph nodes involvement of group I was larger than group II. In group II, however, there were more patients who had multiple cancer foci and were body mass index ≥ 25 kg/m². The overall incidence of recurrent disease was 3.2%. The incidence of recurrence was higher in group II (2.0% vs. 4.0%), without a statistical difference. In multivariate analysis, the significant risk factors of recurrence were male gender and multifocality in group I, and lymph node metastasis and multifocality in group II. In particular, the male gender and multifocality showed the highest odds ratio (OR) on each group (OR, 4.721 and 6.177).

Conclusion

The patients with PTMCs had different clinical features and prognostic factors according to age. Hence, clinicians should consider a different strategy for therapy and plan for follow-up according to age.

Lymph-node ratio is an independent prognostic factor in patients with stage III colorectal cancer: a retrospective study from the Middle East

Background

In this retrospective study, we evaluated the prognostic effect of positive lymph-node ratio (pLNR) on patients with stage III colorectal cancer (CRC). Our paper is the first analysis, to our knowledge, to deal with such data from the Middle East.

Methods

We analyzed the clinicopathological data of 535 patients diagnosed with colorectal cancer at our institution between 1983 and 2003. The 164 patients diagnosed with stage III disease were divided into two categories based on lymph-node ratio (LNR) being the ratio of positive lymph nodes over total lymph nodes dissected: LNR ≤0.4 and LNR >0.4. We used Kaplan-Meier and Cox proportional hazard models to evaluate the prognostic effect of pLNR.

Results

The 10-year survival rate for the patients with stage IIIA, IIIB and IIIC cancers were 76%, 56% and 0% respectively (P = 0.014). Using pLNR of 0.4 as the cutoff point was found to yield clinically and significant results, with a significant difference in the outcomes of patients with pLNR ≤0.4 compared to those with pLNR >0.4 (hazard ratio = 5.25, 95% confidence interval = 1.2 to 22.1, P = 0.02).

Conclusion

The ratio-based staging (pLNR) of CRC is a more accurate and clinically useful prognostic method than the number of positive LNs resected or the total number of LNs retrieved for predicting the course of patients with stage III CRC.

Clinical significance of free-to-total prostate-specific antigen (PSA) ratio in advanced prostate cancer patients with PSA less than 0.1 ng/ml after hormone treatment

PURPOSE

We analyzed the pattern of change in the free-to-total prostate-specific antigen (f/t PSA) ratio and the progression to castration-resistant prostate cancer (CRPC) in patients with advanced prostate cancer who received hormone treatment and whose PSA nadir was below 0.1 ng/ml.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of 52 patients with advanced prostate cancer. All patients were treated with maximum androgen blockade (gonadotrophin-releasing hormone agonist and anti-androgen agents). The patients were divided into two groups: those with a nadir f/t PSA ratio above 60% and those with a nadir f/t PSA ratio of 60% or below. Age, initial PSA, clinical stage, lymph node metastasis, bone metastasis, and follow-up data, including PSA, free PSA, and f/t PSA ratio, were collected. The Mann-Whitney U-test, Fisher exact test, chi-square test, Kaplan-Meier survival analysis, and log rank test were used.

RESULTS

There were 24 patients in the group with a nadir f/t PSA ratio above 60% and 28 patients in the group with a nadir f/t PSA ratio of 60% or below. After hormone therapy, the median f/t PSA ratio in each group increased from 37% and 34% at 3 months to 75% and 60% at 6 months, respectively. At 9 months, however, the f/t PSA ratio increased to 80% in the group with a nadir f/t PSA ratio above 60%, whereas it decreased to 31% in the group with a nadir f/t PSA ratio of 60% or below. From 9 to 15 months, the f/t PSA ratio showed a tendency to decrease (75 to 37% and 27 to 20%, respectively). The progression to CRPC was significantly different between the two groups (10 vs. 24).

CONCLUSIONS

Progression to CRPC was significantly higher in the group with a lower f/t PSA ratio. Additionally, the pattern of change in the f/t PSA ratio was significantly different after 9 months. Collectively, the f/t PSA ratio can be used as an additional marker for prognosis of hormone treatment.

15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas

BACKGROUND

The aim of our study was to compare the outcomes of periampullary and extra-ampullary duodenal adenocarcinomas and segmental duodenal resection versus pancreatoduodenectomy and to evaluate prognostic factors.

METHODS

We performed a retrospective review of all adults treated for duodenal adenocarcinoma by operative resection at a large tertiary referral center from 1994 to 2009.

RESULTS

One hundred twenty-four patients had an operation for duodenal adenocarcinoma over a 15-year period (periampullary, n = 25, and extra-ampullary, n = 99). Ninety-nine patients (80%) underwent curative resection, including 24 (96%) with periampullary and 75 (76%) with extra-ampullary carcinomas. The average number of lymph nodes sampled was eight with segmental resection and 12 with pancreatoduodenectomy (p < 0.001). Five-year overall survivals were 37% for the entire cohort (n = 124), 37% in the extra-ampullary group, and 38% in the periampullary group. Tumor size (p = 0.20), positive nodes (p = 0.60), segmental resection versus pancreatoduodenectomy (p = 0.55), adjuvant therapy (p = 0.23), and R(1) versus R(0) resection (p = 0.21) were not associated with survival. In contrast, advanced T stage and pathologic grade were associated with poor survival.

CONCLUSION

Extra-ampullary and periampullary duodenal adenocarcinomas have similar survival after resection. For distal duodenal tumors, survival is improved by curative resection without being compromised by limited resection. The number of lymph nodes sampled was significantly less with segmental resection than pancreatoduodenectomy.

Functional characterization of glycine N-methyltransferase and its interactive protein DEPDC6/DEPTOR in hepatocellular carcinoma

Glycine N-methyltransferase (GNMT) is a tumor suppressor for hepatocellular carcinoma (HCC). High rates of Gnmt knockout mice developed HCC. Epigenetic alteration and dysregulation of several pathways including wingless-type MMTV integration site (Wnt), mitogen-activated protein kinase (MAPK) and Janus kinase and signal transducer and activator of transcription (JAK-STAT) are associated with HCC development in Gnmt knockout mice. We hypothesized that GNMT may regulate signal transduction through interacting with other proteins directly. In this report, we identified a mammalian target of rapamycin (mTOR) inhibitor (DEP domain containing MTOR-interacting protein [DEPDC6/DEPTOR]) as a GNMT-binding protein by using yeast two-hybrid screening. Fluorescence resonance energy transfer assay demonstrated that the C-terminal half of GNMT interact with the PSD-95/Dlg1/ZO-1 (PDZ) domain of DEPDC6/DEPTOR. Immunohistochemical staining showed that 27.5% (14/51) of HCC patients had higher expression levels of DEPDC6/DEPTOR in the tumorous tissues than in tumor-adjacent tissues, especially among HCC patients with hepatitis B viral infection (odds ratio 10.3, 95% confidence interval [CI] 1.05-11.3) or patients with poor prognosis (death hazard ratio 4.51, 95% CI 1.60-12.7). In terms of molecular mechanism, knockdown of DEPDC6/DEPTOR expression in HuH-7 cells caused S6K and 4E-BP activation, but suppressed Akt. Overexpression of DEPDC6/DEPTOR activated Akt and increased survival of HCC cells. Overexpression of GNMT caused activation of mTOR/raptor downstream signaling and delayed G2/M cell cycle progression, which altogether resulted in cellular senescence. Furthermore, GNMT reduced proliferation of HuH-7 cells and sensitized them to rapamycin treatment both in vitro and in vivo. In conclusion, GNMT regulates HCC growth in part through interacting with DEPDC6/DEPTOR and modulating mTOR/raptor signaling pathway. Both GNMT and DEPDC6/DEPTOR are potential targets for developing therapeutics for HCC.

Comparative effectiveness research for prostate cancer radiation therapy: current status and future directions

Comparative effectiveness research aims to help clinicians, patients and policymakers make informed treatment decisions under real-world conditions. Prostate cancer patients have multiple treatment options, including active surveillance, androgen deprivation therapy, surgery and multiple modalities of radiation therapy. Technological innovations in radiation therapy for prostate cancer have been rapidly adopted into clinical practice despite relatively limited evidence for effectiveness showing the benefit for one modality over another. Comparative effectiveness research has become an essential component of prostate cancer research to help define the benefits, risks and effectiveness of the different radiation therapy modalities currently in use for prostate cancer treatment.

Celiac node failure patterns after definitive chemoradiation for esophageal cancer in the modern era

PURPOSE

The celiac lymph node axis acts as a gateway for metastatic systemic spread. The need for prophylactic celiac nodal coverage in chemoradiation therapy for esophageal cancer is controversial. Given the improved ability to evaluate lymph node status before treatment via positron emission tomography (PET) and endoscopic ultrasound, we hypothesized that prophylactic celiac node irradiation may not be needed for patients with localized esophageal carcinoma.

METHODS AND MATERIALS

We reviewed the radiation treatment volumes for 131 patients who underwent definitive chemoradiation for esophageal cancer. Patients with celiac lymph node involvement at baseline were excluded. Median radiation dose was 50.4 Gy. The location of all celiac node failures was compared with the radiation treatment plan to determine whether the failures occurred within or outside the radiation treatment field.

RESULTS

At a median follow-up time of 52.6 months (95% CI 46.1-56.7 months), 6 of 60 patients (10%) without celiac node coverage had celiac nodal failure; in 5 of these patients, the failures represented the first site of recurrence. Of the 71 patients who had celiac coverage, only 5 patients (7%) had celiac region relapse. In multivariate analyses, having a pretreatment-to-post-treatment change in standardized uptake value on PET >52% (odds ratio [OR] 0.198, p = 0.0327) and having failure in the clinical target volume (OR 10.72, p = 0.001) were associated with risk of celiac region relapse. Of those without celiac coverage, the 6 patients that later developed celiac failure had a worse median overall survival time compared with the other 54 patients who did not fail (median overall survival time: 16.5 months vs. 31.5 months, p = 0.041). Acute and late toxicities were similar in both groups.

CONCLUSIONS

Although celiac lymph node failures occur in approximately 1 of 10 patients, the lack of effective salvage treatments and subsequent low morbidity may justify prophylactic treatment in distal esophageal cancer patients.

[The Comparison between 6th and 7th International Union Against Cancer/American Joint Committee on Cancer Classification for Survival Prognosis of Gastric Cancer]

BACKGROUND/AIMS

The tumor-node-metastasis (TNM) staging is an useful system to assess the prognosis of any solid cancer. As new TNM staging classification of 7th stomach cancer was revised in 2009, we evaluated the prognostic predictability of the 7th International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) TNM classification compared to 6th UICC/AJCC TNM classification in gastric cancer.

METHODS

From January 2000 to December 2009, 5-year survival rates of 266 patients with gastric cancer were calculated by the 6th and 7th UICC/AJCC TNM classification.

RESULTS

Using the 7th UICC/AJCC TNM classification, there was no significant difference in the 5-year cumulative survival rates (5 YSR) between stage IIA and IIB, IIB and IIIA, and IIIA and IIIB (70% vs. 71%, p=0.530; 71% vs. 80%, p=0.703; 80% vs. 75%, p=0.576, respectively) though significant differences of the survival rates were observed among stages of 6th edition. Using T stage of 7th edition, 5 YSR was not different between T2 and T3 (86% vs. 82%, p=0.655). Using N stage of 7th edition, 5 YSR were not different between N1 and N2, N3a and N3b (79% vs. 81%, p=0.506; 41% vs. 17%, p=0.895, respectively).

CONCLUSIONS

The 7th UICC/AJCC TNM classification had poor prognostic predictability in gastric cancer compared to the 6th edition.

Correlation between the proportion of breast volume involved by locally advanced tumors and invasion of the skin and posterior structures

AIM: To evaluate any differences between the percentages of involved breast volume, pathologic attributes, and tumor marker expression of T3 and T4a-c tumors in locally advanced breast cancers (BC).

METHODS: All patients with T3N > 0 and T4a-c BC without evidence of distant metastasis (M0), presenting to the Breast Clinic from 1980 to 2010, were examined to determine whether their BC’s involved ≥ 50% of their breast volumes, defined by gross replacement of at least one hemisphere. Core needle biopsy or post-mastectomy specimens from tumors involving a known percent of breast volume were evaluated for: (1) pathological grades and lympho-vascular invasion (LVI); (2) hormone receptor (ER/PR) expression > 0; and (3) epidermoid growth factor 2 (her2) over-expression (3+) by immune-histochemical staining or fluorescent in situ hybridization.

RESULTS: The data base included 98 patients with T3N> 0 M0 and 120 with T4a-c, any N disease, M0 disease. T3 tumor masses involved 50% or more of the breast in 23/98 (24%), and T4a-c tumors 65/120 (54%) (P < 0.001). Only 1% of T3 tumors and 23% of T4a-c tumors presented with total breast replacement. There were no significant differences between the pathological attributes and marker expression of the T3 and T4a-c tumors.

CONCLUSION: These data suggest that erosion of the overlying skin or underlying chest wall by some BC may be due to neglect and delay, rather than inherent biological aggressiveness.

Endoscopic ultrasound-guided elastography in the nodal staging of oesophageal cancer

AIM: To assess quantitative endoscopic ultrasound (EUS)-guided elastography in the nodal staging of oesophago-gastric cancers.

METHODS: This was a single tertiary centre study assessing 50 patients with established oesophago-gastric cancer undergoing EUS-guided fine needle aspiration biopsy (FNAB) of lymph nodes between July 2007 and July 2009. EUS-guided elastography of lymph nodes was performed before EUS-FNAB. Standard EUS characteristics were also described. Cytological determination of whether a lymph node was malignant or benign was used as the gold standard for this study. Comparisons of elastography and standard EUS characteristics were made between the cytologically benign and malignant nodes. The main outcome measure was the accuracy of elastography in differentiating between benign and malignant lymph nodes in oesophageal cancers.

RESULTS: EUS elastography and FNAB were performed on 53 lymph nodes. Cytological malignancy was found in 23 nodes, one was indeterminate, one was found to be a gastrointestinal stromal tumor and 25 of the nodes were negative for malignancy. On 3 occasions insufficient material was obtained for analysis. The area under the curve for the receiver operating characteristic curve for elastography strain ratio was 0.87 (P < 0.0001). Elastography strain ratio had a sensitivity 83%, specificity 96%, positive predictive value 95%, and negative predictive value 86% for distinguishing between malignant and benign nodes. The overall accuracy of elastography strain ratio was 90%. Elastography was more sensitive and specific in determining malignant nodal disease than standard EUS criteria.

CONCLUSION: EUS elastography is a promising modality that may complement standard EUS and help guide EUS-FNAB during staging of upper gastrointestinal tract cancer.

Whole-body FDG PET/CT is more accurate than conventional imaging for staging primary breast cancer patients

PURPOSE

This retrospective study aimed (1) to compare the diagnostic accuracy of whole-body FDG PET/CT for initial breast cancer staging with the accuracy of a conventional, multimodal imaging algorithm, and (2) to assess potential alteration in patient management based on the FDG PET/CT findings.

METHODS

Patients with primary breast cancer (106 women, mean age 57 ± 13 years) underwent whole-body FDG PET/CT and conventional imaging (X-ray mammography, MR mammography, chest plain radiography, bone scintigraphy and breast, axillary and liver ultrasonography). The diagnostic accuracies of FDG PET/CT and a conventional algorithm were compared. Diagnostic accuracy was assessed in terms of primary tumour detection rate, correct assessment of primary lesion focality, T stage and the detection rates for lymph node and distant metastases. Histopathology, imaging or clinical follow-up served as the standards of reference.

RESULTS

FDG PET/CT was significantly more accurate for detecting axillary lymph node and distant metastases (p = 0.0125 and p < 0.005, respectively). No significant differences were detected for other parameters. Synchronous tumours or locoregional extraaxillary lymph node or distant metastases were detected in 14 patients (13%) solely by FDG PET/CT. Management of 15 patients (14%) was altered based on the FDG PET/CT findings, including 3 patients with axillary lymph node metastases, 5 patients with extraaxillary lymph node metastases, 4 patients with distant metastases and 3 patients with synchronous malignancies.

CONCLUSION

Full-dose, intravenous contrast-enhanced FDG PET/CT was more accurate than conventional imaging for initial breast cancer staging due to the higher detection rate of metastases and synchronous tumours, although the study had several limitations including a retrospective design, a possible selection bias and a relevant false-positive rate for the detection of axillary lymph node metastases. FDG PET/CT resulted in a change of treatment in a substantial proportion of patients.

Prognostic significance of diabetes mellitus in localized renal cell carcinoma

OBJECTIVE

We investigated whether diabetes mellitus is associated with the cancer-related outcomes in patients with localized clear cell renal cell carcinoma treated with radical or partial nephrectomy.

METHODS

We reviewed data from 950 patients who received radical or partial nephrectomy for localized clear cell renal cell carcinoma from 1988 to 2009. We analyzed potential association of patients' diabetic status and various clinicopathologic features. Univariate and multivariate analyses were performed to identify independent predictors of cancer-specific survival, overall survival and non-cancer-related survival.

RESULTS

Of 950 patients, 108 (11.4%) reported having diabetes mellitus pre-operatively. Patients with and without diabetes mellitus demonstrated no significant differences regarding various clinicopathologic features except for age (P < 0.001), pre-existing hypertension (P < 0.001), pre-existing cardiovascular disease (P < 0.001) and performance status (P = 0.019). In terms of cancer-specific, overall and non-cancer-related survival, the Kaplan-Meier curves showed that non-diabetic patients had superior survival rates than diabetics (P = 0.012, <0.001 and <0.001, respectively). Meanwhile, although diabetes mellitus was shown to be an independent predictor of overall survival (P = 0.022) and non-cancer-related survival (P = 0.034), it was not observed to be a significant predictor of cancer-specific survival (P = 0.234) in multivariate analyses.

CONCLUSIONS

Diabetes mellitus may not be directly associated with disease-specific outcome in patients who receive surgical management for localized renal cell carcinoma. However, since diabetes mellitus was observed to be associated with overall survival in such patients, diabetic patients undergoing surgery for localized renal cell carcinoma should be counseled on the potential impact of diabetes mellitus. Institutional review board (IRB) approval number H-1106-062-366.

Association of CTTN polymorphisms with the risk of colorectal cancer

Purpose

Various studies searching for biomarkers to predict tumor metastasis or prognosis in both esophageal squamous cell carcinoma (ESCC) and head and neck squamous cell carcinoma (HNSCC) are currently underway. However, few data have been reported on its association with colorectal cancer (CRC). Single nucleotide polymorphisms (SNPs) are the most common known form of human genetic variation and may contribute to an increased susceptibility to cancer including CRC. The present study aimed to investigate whether the polymorphisms in the CTTN gene are associated with susceptibility to CRC in the Korean population.

Methods

A case-control study was performed to examine the relationship between the CTTN g.-9101C>T, g.-8748C>T, and g.72C>T polymorphisms and the risk of CRC. Polymerase chain reaction-restriction fragment length polymorphism analysis of g.-8748C>T, g.-9101C>T and Taqman analysis of g.72C>T were performed on blood samples from 218 patients with CRC and 533 control individuals. The g.-9101C>T, g.-8748C>T, and g.72C>T SNPs in CTTN and their haplotypes were analyzed.

Results

The genotype and allele frequencies of g.-9101C>T, g.-8748C>T, and g.72C>T did not differ between the patient group and the control group. Further, the haplotype of CTTN g.-9101C>T, g.-8748C>T, and g.72C>T did not differ between patient group and the control group. However, the genotype and allele frequencies of CTTN g.-9101C>T were significantly increased in the lymph node positive CRC group compared to the control group.

Conclusion

The CTTN g.-9101C>T polymorphism may influence lymph node positive CRC.

Recurrence pattern in patients with locally advanced renal cell carcinoma: The implications of clinicopathological variables

Objectives

Recurrence rates for patients with locally advanced renal cell carcinoma (LARCC) remain high. To date the predictors of recurrence in those patients remain controversial. The aim of the present study was to assess the relapse pattern in those patients and identify predictors for recurrence.

Patients and methods

We evaluated retrospectively 112 consecutive patients who underwent surgery for LARCC (T3–T4N0M0) between January 2000 and December 2010. Clinical and pathological data were collected from hospital medical records and compiled into a computerized database. Studied variables were age, mode of presentation, Tumour-Node-Metastasis (TNM) stage, Fuhrman nuclear grade, histological subtype, tumour size, venous thrombus level, collecting-system invasion and sarcomatoid differentiation. Recurrence-free survival (RFS) was estimated using the Kaplan–Meier method. Univariate and multivariate analyses were conducted.

Results

Patients were followed for a mean and median follow-up of 33 and 24 months, respectively, after surgery. During the follow-up, recurrences (distant and/or local) were recorded in 58 patients, representing 52% of the cohort. The mean and median times to recurrence were 25 and 13 months, respectively. Sites of recurrence were multiple in 36 patients (62%), lung only in 14 (24%), and local in eight (14%). RFS rates at 1, 2, and 5 years were 50%, 43% and 34%, respectively, while the median RFS was 23.7 months. Using univariate analysis, RFS after nephrectomy was significantly shorter in patients aged <70 years, symptomatic at presentation, with larger tumours, higher nuclear grade, collecting-system invasion, and/or sarcomatoid differentiation. After multivariate analysis, T-stage, nuclear grade and sarcomatoid differentiation retained their power as independent predictors of RFS (P = 0.032, <0.001 and 0.003, respectively).

Conclusions

For patients with LARCC, T-stage, grade and sarcomatoid differentiation independently dictate the risk of tumour recurrence. Considering these variables in the postoperative surveillance protocols and in the need for a multimodal therapeutic approach is highly recommended.

The tumor-log odds of positive lymph nodes-metastasis staging system, a promising new staging system for gastric cancer after D2 resection in China

Background

In this study, we established a hypothetical tumor-lodds-metastasis (TLM) and tumor-ratio-metastasis (TRM) staging system. Moreover, we compared them with the 7^th edition of American Joint Committee on Cancer tumor-nodes-metastasis (AJCC TNM) staging system in gastric cancer patients after D2 resection.

Methods

A total of 1000 gastric carcinoma patients receiving treatment in our center were selected for the analysis. Finally, 730 patients who received D2 resection were retrospectively studied. Patients were staged using the TLM, TRM and the 7^th edition AJCC TNM system. Survival analysis was performed with a Cox regression model. We used two parameters to compare the TNM, TRM and TLM staging system, the −2log likelihood and the hazard ratio.

Results

The cut points of lymph node ratio (LNR) were set as 0, 0–0.3, 0.3–0.6, 0.6–1.0. And for the log odds of positive lymph nodes (LODDS), the cut points were established as≤−0.5, −0.5-0, 0-0.5, >0.5. There were significant differences in survival among patients in different LODDS classifications for each pN or LNR groups. When stratified by the LODDS classifications, the prognosis was highly homologous between those in the according pN or LNR classifications. Multivariate analysis showed that TLM staging system was better than the TRM or TNM system for the prognostic evaluation.

Conclusions

The TLM system was superior to the TRM or TNM system for prognostic assessment of gastric adenocarcinoma patients after D2 resection.

Capsular invasion in renal cell carcinoma: a meta-analysis

OBJECTIVES

Capsular invasion is frequently detected in localized renal cell carcinoma (RCCs) samples. Whether patients with localized RCCs and capsular invasion will suffer poorer clinical outcome than those without this pathologic finding is still at issue.

MATERIALS AND METHODS

We performed a systematic literature research of Central, Medline, Embase, and Chinese database CNKI and VIP. Cohort studies comparing the prognosis in patients with localized RCCs and with or without capsular invasion were included. Incidence of capsular invasion in different Fuhrman grade, primary TNM stage, and clinical outcome were analyzed.

RESULTS

Six cohort studies with 2,295 eligible patients were identified. Capsular invasion was presented in 500 specimens (21.79%). Lower grade (Fuhrman I/II vs. Fuhrman III/IV) and stage (pT1 vs. pT2) diseases were associated with lower incidence of capsular invasion, with OR = 0.56, 95% CI[0.37-0.85] and OR = 0.35, 95% CI[0.25-0.49], respectively. Our pooled analysis showed patients with capsular invasive had 1.80 times the risk of tumor recurrence than patients without these findings (HR = 1.8, 95% CI [1.21, 2.68]), and patients with localized RCCs and capsular invasion were detected at 4.93 times risk in developing cancer related death than those without its presence during follow up (HR = 4.93, 95% CI [2.14, 11.35]).

CONCLUSION

Patients with localized RCCs and capsular invasion are of poorer prognosis than those without this finding. Capsular invasion may serve as an additional factor in stratifying patient with localized RCCs.

Lymph node harvest in colon and rectal cancer: Current considerations

The prognostic significance of identifying lymph node (LN) metastases following surgical resection for colon and rectal cancer is well recognized and is reflected in accurate staging of the disease. An established body of evidence exists, demonstrating an association between a higher total LN count and improved survival, particularly for node negative colon cancer. In node positive disease, however, the lymph node ratios may represent a better prognostic indicator, although the impact of this on clinical treatment has yet to be universally established. By extension, strategies to increase surgical node harvest and/or laboratory methods to increase LN yield seem logical and might improve cancer staging. However, debate prevails as to whether or not these extrapolations are clinically relevant, particularly when very high LN counts are sought. Current guidelines recommend a minimum of 12 nodes harvested as the standard of care, yet the evidence for such is questionable as it is unclear whether an increasing the LN count results in improved survival. Findings from modern treatments, including down-staging in rectal cancer using pre-operative chemoradiotherapy, paradoxically suggest that lower LN count, or indeed complete absence of LNs, are associated with improved survival; implying that using a specific number of LNs harvested as a measure of surgical quality is not always appropriate. The pursuit of a sufficient LN harvest represents good clinical practice; however, recent evidence shows that the exhaustive searching for very high LN yields may be unnecessary and has little influence on modern approaches to treatment.

Clinical and histologic features of inverted papilloma-associated malignancy

The objectives of the study were to analyze the clinical features of inverted papillomas (IP) associated with malignancy and to evaluate the correlation of tumor stage, survival and histolologic features. We conducted a retrospective review of 18 IP associated with malignancy patients. In addition, we compared histopathologic characteristics (tumor differentiation and malignant cell proportion) with clinical outcomes. Eleven of the tumors were present on the nasal cavity and 7 on the maxillary sinus. The rates of synchronous and metachronous malignancy were 10.1 and 1.1%, respectively. The disease-free survival rate was 83.3%. The tumors were staged as T1 (5/18), T2 (2/18), T3 (8/18), and T4 (3/18). According to the percentage of the malignant cell in the entire tumor tissue, 4 patients (22%) were in grade I, 4 patients (22%) were in grade II, 3 patients (17%) were in grade III, and 7 patients (39%) were in grade IV. There was no relationship between recurrence- and/or disease-free survival and histologic findings including tumor differentiation and malignant proportion. IP-associated malignancy tends to occur synchronously and have more favorable prognosis compared to other sinonasal malignancy. Furthermore, the proportion of malignant cell to IP and tumor stage seems not to affect the clinical outcome of IP-associated malignancy.

Immunotherapeutic potential of anti-human endogenous retrovirus-K envelope protein antibodies in targeting breast tumors

BACKGROUND

The envelope (env) protein of the human endogenous retrovirus type K (HERV-K) family is commonly expressed on the surface of breast cancer cells. We assessed whether HERV-K env is a potential target for antibody-based immunotherapy of breast cancer.

METHODS

We examined the expression of HERV-K env protein in various malignant (MDA-MB-231, MCF-7, SKBR3, MDA-MB-453, T47D, and ZR-75-1) and nonmalignant (MCF-10A and MCF-10AT) human breast cell lines by immunoblot, enzyme-linked immunosorbent assay, immunofluorescence staining, and flow cytometry. Anti-HERV-K env monoclonal antibodies (mAbs; 6H5, 4D1, 4E11, 6E11, and 4E6) were used to target expression of HERV-K, and antitumor effects were assessed by quantifying growth and apoptosis of breast cancer cells in vitro, and tumor growth in vivo in mice (n = 5 per group) bearing xenograft tumors. The mechanisms responsible for 6H5 mAb-mediated effects were investigated by microarray assays, flow cytometry, immunoblot, and immunofluorescence staining. The expression of HERV-K env protein was assessed in primary breast tumors (n = 223) by immunohistochemistry. All statistical tests were two-sided.

RESULTS

The expression of HERV-K env protein in malignant breast cancer cell lines was substantially higher than nonmalignant breast cells. Anti-HERV-K-specific mAbs inhibited growth and induced apoptosis of breast cancer cells in vitro. Mice treated with 6H5 mAb showed statistically significantly reduced growth of xenograft tumors compared with mice treated with control immunoglobulin (control [mIgG] vs 6H5 mAb, for tumors originating from MDA-MB-231 cells, mean size = 1448.33 vs 475.44 mm(3); difference = 972.89 mm(3), 95% CI = 470.17 to 1475.61 mm(3); P < .001). Several proteins involved in the apoptotic signaling pathways were overexpressed in vitro in 6H5 mAb-treated malignant breast cells compared with mIgG-treated control. HERV-K expression was detected in 148 (66%) of 223 primary breast tumors, and a higher rate of lymph node metastasis was associated with HERV-K-positive compared with HERV-K-negative tumors (43% vs 23%, P = .003).

CONCLUSION

Monoclonal antibodies against HERV-K env protein show potential as novel immunotherapeutic agents for breast cancer therapy.

Accuracy of magnetic resonance imaging in diagnosing thyroid cartilage and thyroid gland invasion by squamous cell carcinoma in laryngectomy patients

OBJECTIVES

We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings.

STUDY DESIGN

A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998-2008 at University Hospital Aintree, Liverpool.

METHODS

Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings.

RESULTS

Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively.

CONCLUSION

Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

Circulating micro-RNAs as potential blood-based markers for early stage breast cancer detection

Introduction

MicroRNAs (miRNAs, miRs) are a class of small, non-coding RNA molecules with relevance as regulators of gene expression thereby affecting crucial processes in cancer development. MiRNAs offer great potential as biomarkers for cancer detection due to their remarkable stability in blood and their characteristic expression in many different diseases. We investigated whether microarray-based miRNA profiling on whole blood could discriminate between early stage breast cancer patients and healthy controls.

Methods

We performed microarray-based miRNA profiling on whole blood of 48 early stage breast cancer patients at diagnosis along with 57 healthy individuals as controls. This was followed by a real-time semi-quantitative Polymerase Chain Reaction (RT-qPCR) validation in a separate cohort of 24 early stage breast cancer patients from a breast cancer screening unit and 24 age matched controls using two differentially expressed miRNAs (miR-202, miR-718).

Results

Using the significance level of p<0.05, we found that 59 miRNAs were differentially expressed in whole blood of early stage breast cancer patients compared to healthy controls. 13 significantly up-regulated miRNAs and 46 significantly down-regulated miRNAs in our microarray panel of 1100 miRNAs and miRNA star sequences could be detected. A set of 240 miRNAs that was evaluated by radial basis function kernel support vector machines and 10-fold cross validation yielded a specificity of 78.8%, and a sensitivity of 92.5%, as well as an accuracy of 85.6%. Two miRNAs were validated by RT-qPCR in an independent cohort. The relative fold changes of the RT-qPCR validation were in line with the microarray data for both miRNAs, and statistically significant differences in miRNA-expression were found for miR-202.

Conclusions

MiRNA profiling in whole blood has potential as a novel method for early stage breast cancer detection, but there are still challenges that need to be addressed to establish these new biomarkers in clinical use.

The Feasibility of (18)F-Fluorothymidine PET for Prediction of Tumor Response after Induction Chemotherapy Followed by Chemoradiotherapy with S-1/Oxaliplatin in Patients with Resectable Esophageal Cancer

PURPOSE

The aim of this study was to determine whether (18)F-fluorothymidine (FLT) PET is feasible for the early prediction of tumor response to induction chemotherapy followed by concurrent chemoradiotherapy in patients with esophageal cancer.

METHODS

This study was prospectively performed as a collateral study of "randomized phase II study of preoperative concurrent chemoradiotherapy with or without induction chemotherapy with S-1/oxaliplatin in patients with resectable esophageal cancer". (18)F-FLT positron emission tomography (PET) images were obtained before and after two cycles of induction chemotherapy, and the percent change of maximum standardized uptake value (SUVmax) was calculated. All patients underwent esophagography, gastrofiberoscopy, endoscopic ultrasonography (EUS), computed tomography (CT) and (18)F-fluorodeoxyglucose (FDG) PET at baseline and 3-4 weeks after completion of concurrent chemoradiotherapy. Final tumor response was determined by both clinical and pathologic tumor responses after surgery.

RESULTS

The 13 patients for induction chemotherapy group were enrolled until interim analysis. In a primary tumor visual analysis, the tumor detection rates of baseline (18)F-FLT and (18)F-FDG PET were 85% and 100%, respectively. The tumor uptakes on (18)F-FLT PET were lower than those of (18)F-FDG PET. Among nine patients who completed second (18)F-FLT PET, eight patients were responders and one patient was a non-responder in the assessment of final tumor response. The percent change of SUVmax in responders ranged from 41.2% to 79.2% (median 57.1%), whereas it was 10.2% in one non-responder.

CONCLUSION

The percent change of tumor uptake in (18)F-FLT PET after induction chemotherapy might be feasible for early prediction of tumor response after induction chemotherapy and concurrent chemoradiotherapy in patients with esophageal cancer.

Clinicopathologic features of intraductal papillary neoplasm of the bile duct according to histologic subtype

OBJECTIVES

Despite an increase in the reports of intraductal papillary neoplasm of the bile duct (IPN-B), the clinical characteristics and long-term prognosis of this disease are not well known compared with those of intraductal papillary mucinous neoplasms of the pancreas. The objective of our study was to compare the clinical features, radiologic findings, and clinical outcomes of IPN-B according to histologic subtype.

METHODS

A retrospective analysis was performed on the medical records of 97 patients diagnosed with IPN-B by pathologic analysis of their surgical specimens between May 1995 and May 2010. We compared the clinical manifestations, radiological findings, pathologic grade, curative resection rate, recurrence, and overall survival according to four histologic subtypes: gastric (n=15), intestinal (n=46), pancreaticobiliary (n=33), and oncocytic (n=3), which were classified on the basis of hematoxylin and eosin staining and the immunohistochemical profile of mucin core proteins.

RESULTS

Mucin hypersecretion was significantly more frequent in patients with gastric and intestinal types than it was in those with oncocytic and pancreaticobiliary types (P=0.014). There were no significant differences between groups regarding the presence of bile duct stones or tumor location. The frequency of invasive carcinoma in the pancreaticobiliary type was significantly higher than those in the gastric and intestinal types (72.7 vs. 26.7 and 32.6%, P<0.001 and P<0.001). When comparing the survival curves according to histologic subtype, patients with pancreaticobiliary type demonstrated significantly worse survival compared to those with gastric and intestinal types (P=0.035).

CONCLUSIONS

Gastric and intestinal types of IPN-B have similar clinical characteristics compared with the pancreaticobiliary type, which has a worse prognosis.

Penile cancer: what's new?

PURPOSE OF REVIEW

This article reviews the epidemiology, diagnostic modalities and treatment of localized and advanced penile cancer, with special emphasis on most recent findings from the literature.

RECENT FINDINGS

Penile cancer is a rare disease and its treatment suffers from a paucity of evidence in the literature. Risk factors include phimosis with poor hygiene, human papilloma virus infections, chronic balanitis xerotica obliterans and smoking, among others. Surgical treatment for local disease remains the best option, but organ-preserving procedures provide good aesthetic and functional results with acceptable oncologic control. Regional disease, when present in the form of adenopathy, is best diagnosed with fine-needle aspiration, and treated with radical inguinal lymphadenectomy if resectable. Occult metastatic disease constitutes a challenge and is managed according to primary tumour risk factors. For nonresectable regional disease and metastases, neoadjuvant cisplatinum-based regimens are the best option, and provide a selection of patients who will be optimal candidates to consolidative surgical therapies.

SUMMARY

Penile cancer at its various stages constitutes a therapeutic challenge. Management should be increasingly confined to high volumes centres of excellence, allowing for clinical trials, which will hopefully provide a better understanding of the disease and the best treatment approach.