Therapeutic approach of human peritoneal carcinomatosis with Dbait in combination with capnoperitoneum: proof of concept

Background

Peritoneal carcinomatosis is an unmet medical need. Laparoscopy offers a unique opportunity to control and to steer the operating environment during surgery by loading carbon dioxide with a therapeutic substance and creating the so-called therapeutic capnoperitoneum. We have treated a human sample of peritoneal carcinomatosis from an endometrial adenocarcinoma ex vivo just after surgery.

Methods

A nontoxic therapeutic agent (Dbait) was aerosolized into a box containing diseased human peritoneum under a pressure of 12 mmHg CO₂. Dbait (noncoding DNA fragments) acts through jamming DNA damage sensing and signaling, ultimately inhibiting DNA repair system of cancer cells. Dbait were coupled to cholesterol molecules to facilitate intracellular uptake, and to Cyanine (Cy5) to allow detection by fluorescence. In a control experiment, the same solution was applied to the other half of the sample using conventional lavage.

Results

Physical results revealed fluorescence within the tumor up to 1 mm depth in the therapeutic capnoperitoneum sample and no uptake in the lavage sample. Biological results showed intranuclear phosphorylation of H2AX in the nebulized sample and no activity in the lavage sample. Importantly, tumor nodules showed more activity than the neighbor, normal peritoneum. Detection of histone gamma-H2AX (phosphorylated H2AX) reveals activation of DNA-dependent protein kinase (DNA-PK) by Dbait, which has been shown to be the key step for sensitization to genotoxic therapy.

Conclusions

Dbait are taken up by cancer cells and have a biological activity up to 1 mm depth. Nebulization of the molecule is significantly more effective than conventional lavage. This proof of principle supports the need for clinical studies applying therapeutic capnoperitoneum together with Dbait for treating peritoneal carcinomatosis.

Large cell neuroendocrine carcinoma of the head and neck

Large cell neuroendocrine carcinoma is a poorly differentiated neuroendocrine carcinoma that usually occurs in the lung. Although rare in the head and neck, salivary and mucosal subtypes are recognized. This article describes their characteristic light microscopic and immunohistochemical features and highlights the importance of accurate diagnosis, management and prognostic implications.

Selection criteria for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer

Peritoneal carcinomatosis in gastric cancer is associated with a dismal prognosis. Systemic chemotherapy is not effective because of the existence of a blood-peritoneal barrier. Cytoreductive surgery and intraperitoneal chemotherapy can improve survival and quality of life in selected patients. Patient selection for this multimodal approach is one of the most critical issues, and calls for interdisciplinary evaluation by radiologists, medical and surgical oncologists, and anaesthetists. This article sets forth criteria for selection of gastric cancer patients suffering from peritoneal carcinomatosis.

Maspin is a deoxycholate-inducible, anti-apoptotic stress-response protein differentially expressed during colon carcinogenesis

Increased maspin expression in the colon is related to colon cancer risk and patient survival. Maspin is induced by the hydrophobic bile acid, deoxycholate (DOC), which is an endogenous carcinogen and inducer of oxidative stress and DNA damage in the colon. Persistent exposure of colon epithelial cells, in vitro, to high physiologic levels of DOC results in increased constitutive levels of maspin protein expression associated with the development of apoptosis resistance. When an apoptosis-resistant colon epithelial cell line (HCT-116RC) developed in the authors' laboratory was treated with a maspin-specific siRNA probe, there was a statistically significant increase in apoptosis compared to treatment with an siRNA control probe. These results indicate, for the first time, that maspin is an anti-apoptotic protein in the colon. Immunohistochemical evaluation of maspin expression in human colonic epithelial cells during sporadic colon carcinogenesis (131 human tissues evaluated) indicated a statistically significant increase in maspin protein expression beginning at the polyp stage of carcinogenesis. There was no statistically significant difference in maspin expression between hyperplastic/adenomatous polyps and colonic adenocarcinomas. The absence of "field defects" in the non-neoplastic colonic mucosa of patients with colonic neoplasia indicates that maspin may drive the growth of tumors, in part, through its anti-apoptotic function.

Melatonin exerts by an autocrine loop antiproliferative effects in cholangiocarcinoma: its synthesis is reduced favoring cholangiocarcinoma growth

Cholangiocarcinoma (CCA) is a devastating biliary cancer. Melatonin is synthesized in the pineal gland and peripheral organs from serotonin by two enzymes, serotonin N-acetyltransferase (AANAT) and acetylserotonin O-methyltransferase (ASMT). Cholangiocytes secrete neuroendocrine factors, including serotonin-regulating CCA growth by autocrine mechanisms. Melatonin exerts its effects by interaction with melatonin receptor type 1A/1B (MT1/MT2) receptors. We propose that 1) in CCA, there is decreased expression of AANAT and ASMT and secretion of melatonin, changes that stimulate CCA growth; and 2) in vitro overexpression of AANAT decreases CCA growth. We evaluated the 1) expression of AANAT, ASMT, melatonin, and MT1/MT2 in human nonmalignant and CCA lines and control and CCA biopsy samples; 2) melatonin levels in nonmalignant and CCA lines, and bile and serum from controls and patients with intrahepatic CCA; 3) effect of melatonin on the growth and expression of AANAT/ASMT and MT1/MT2 in CCA lines implanted into nude mice; and 4) effect of AANAT overexpression on the proliferation, apoptosis, and expression of MT1/MT2 in Mz-ChA-1 cells. The expression of AANAT, ASMT, and melatonin decreased, whereas MT1/MT2 expression increased in CCA lines and biopsy samples. Melatonin secretion decreased in the supernatant of CCA lines and bile of CCA patients. Melatonin decreased xenograft CCA tumor growth in nude mice by increased AANAT/ASMT and melatonin, along with reduced MT1/MT2 expression. Overexpression of AANAT in Mz-ChA-1 cells inhibited proliferation and MT1/MT2 expression and increased apoptosis. There is dysregulation of the AANAT/ASMT/melatonin → melatonin receptor axis in CCA, which inhibited melatonin secretion and subsequently enhanced CCA growth.

Gastric malignancy: surgical management

PURPOSE OF REVIEW

To highlight the recent changes and development in the surgical management of gastric adenocarcinoma. There is significant development in the field. However, issues like extent of resection, lymphadenectomy, and minimal access approach are still to be refined for clinical and oncological effectiveness and safety.

RECENT FINDINGS

The outcomes of surgical treatment of gastric adenocarcinoma are improving due to several factors, including specialist unit settings, refinement of the surgical techniques, improved adequacy of lymphadenectomy and some other minor factors such as multidisciplinary team approach and the use of perioperative chemotherapy or radiotherapy. The most hot issue in the past year's literatures is the use of minimal access surgery for resection and lymphadenectomy. The trend of studies is supporting minimal access approach for limited, subtotal and even total gastrectomy.

SUMMARY

The outcomes of surgical treatment of gastric adenocarcinoma are improving. Minimal access approach to treat gastric adenocarcinoma is evolving and continuing to have a substantial role in current surgical practice. The potential role of minimal access surgery, surgical resectional techniques, extent of lymphadenectomy and setting of specialized units and multidisciplinary team approach have stimulated an active research.

Second-line chemotherapy with paclitaxel and doxifluridine after failure of S-1 in elderly patients with unresectable advanced or recurrent gastric cancer

PURPOSE

There is no standard second-line treatment for patients with unresectable advanced or recurrent gastric cancer (URGC) in the event that first-line treatment fails. Moreover, the benefits of second-line chemotherapy in elderly patients remain uncertain. The aim of this study was to identify the benefits of the second-line paclitaxel (PTX) plus doxifluridine (5'-DFUR) regimen for URGC in elderly patients in comparison to nonelderly patients.

METHODS

We retrospectively examined the clinical outcomes of the second-line PTX plus 5'-DFUR regimen in patients with URGC, who had previously been treated with S-1-based first-line chemotherapy.

RESULTS

A total of 27 patients (10 elderly, ≥70 years old; 17 nonelderly, <70 years old) were enrolled in the study. The clinical benefit rate (complete response, partial response, and stable disease) in the elderly group was 6 of 10 (60%), and that of the nonelderly group was 9 of 17 (53%). Age had no statistically significant influence on the response rate, and no grade 4 adverse events were observed in either group. In addition, the median survival time was 12.2 months in both groups.

CONCLUSION

Although it remains unclear whether second-line chemotherapy contributes to survival in patients with URGC, the combination of PTX plus 5'-DFUR might be the treatment of choice for second-line chemotherapy in both elderly and nonelderly patients who have already received an S-1-based first-line treatment.

Current advance in small bowel tumors

Small intestinal tumors are difficult challenge to gastroenterologists. The difficulty in making a diagnosis of small intestinal tumor lies in the relative inaccessibility and absence of typical presentation. New endoscopic and radiologic technologies provide clear and fine anatomical visualization of the small bowel and are approved to improve the diagnostic sensitivity and accuracy. Patients at risk of small intestinal tumors might gain a benefit from proper surveillance with this new technology. Minimally invasive therapy is now available with advance of balloon assisted enteroscopy. This review describes the general aspect of the small intestinal tumors, focusing on the new modalities for diagnosis.

Serum galectin-2, -4, and -8 are greatly increased in colon and breast cancer patients and promote cancer cell adhesion to blood vascular endothelium

PURPOSE

Adhesion of disseminating tumor cells to the blood vascular endothelium is a pivotal step in metastasis. Previous investigations have shown that galectin-3 concentrations are increased in the bloodstream of patients with cancer and that galectin-3 promotes adhesion of disseminating tumor cells to vascular endothelium in vitro and experimental metastasis in vivo. This study determined the levels of galectin-1, -2, -3, -4, -8, and -9 in the sera of healthy people and patients with colon and breast cancer and assessed the influence of these galectins on cancer-endothelium adhesion.

EXPERIMENTAL DESIGN

Serum galectins and auto-anti-MUC1 antibodies were assessed using ELISA and mucin protein (MUC1) glycan microarrays, and cancer-endothelium adhesion was determined using monolayers of human microvascular lung endothelial cells.

RESULTS

The levels of serum galectin-2, -3, -4, and -8 were significantly increased up to 31-fold in patients with cancer and, in particular, those with metastases. As previously shown for galectin-3, the presence of these galectins enhances cancer-endothelium adhesion by interaction with the Thomsen-Friedenreich (TF; Galβ1,3GalNAcα-) disaccharide on cancer-associated MUC1. This causes MUC1 cell surface polarization, thus exposing underlying adhesion molecules that promote cancer-endothelium adhesion. Elevated circulating galectin-2 levels were associated with increased mortality in patients with colorectal cancer, but this association was suppressed when anti-MUC1 antibodies with specificity for the TF epitope of MUC1 were also present in the circulation.

CONCLUSIONS

Increased circulation of several members of the galectin family is common in patients with cancer and these may, like circulating galectin-3, also be involved in metastasis promotion.

Successful treatment of a patient with HER2-positive metastatic gastric cancer with third-line combination therapy with irinotecan, 5-fluorouracil, leucovorin and trastuzumab (FOLFIRI-T)

BACKGROUND

For patients with HER2-overexpressing gastric cancer, there is an improved prognosis with additional trastuzumab to chemotherapy with a platinum compound and a fluoropyrimidin in first-line therapy. Second-line combinations are currently evaluated in various studies.

CASE REPORT

We report the case of a 43-year-old male patient who came to our hospital with recurrent metastatic gastric cancer after curative surgery 18 months before. His disease responded well to several therapeutic regimens. Firstline chemotherapy with a combination of epirubicin, oxaliplatin and capecitabine (EOX) and the following therapies -- peritonectomy, multivisceral resection, hyperthermic intraperitoneal chemotherapy (HIPEC), and secondline chemotherapy with oxaliplatin, 5-fluorouracil and leucovorin (FLO) - induced a complete remission. At the time of the subsequent progression, HER2 overexpression was detected. We administered the combination of irinotecan, 5-fluorouracil, leucovorin (FOLFIRI) and trastuzumab, which to our knowledge was used for the first time in a patient with metastatic gastric cancer in third-line therapy. This regimen again induced a complete remission of the disease, which has been sustained now for at least 8 months.

CONCLUSION

This is the first time in the literature that a combination of FOLFIRI and trastuzumab (FOLFIRIT) was used successfully in a patient with recurrent metastatic gastric cancer.

Outcomes in unresectable and locally advanced resected cholangiocarcinoma

Patients with cholangiocarcinomas often present with unresectable disease, which is associated with a poor clinical outcome and survival. A number of palliative options are available to patients; the evaluated article presented experience from a single institution of treating cholangiocarcinoma, either unresectable or locally advanced, with conformal radiotherapy and concurrent chemotherapy. Patients who had received biliary radiation for cholangiocarcinoma were identified from the hospital database, and information on the patients sourced from notes and reports. In total, 20 patients with a diagnosis of biliary tract cancer were included and received radical conformal radiotherapy with concurrent cisplatin/5-fluorouracil and sequential gemcitabine. The median overall survival was 20.4 months and the relapse-free survival was 9.6 months. Treatment failure within the radiotherapy field was recorded in 45% of patients; adverse events were minimal. This study adds to the retrospective data available regarding the management of patients with biliary tract carcinomas, and we have found in our own cohort of 45 patients that gemcitabine/platinum was a more effective combination than monotherapy.

Galectin-3--a jack-of-all-trades in cancer

Galectin-3 is a mammalian β-galactoside-binding protein that is expressed by various types of human cells. Changes in galectin-3 expression and subcellular and intercellular localizations are commonly seen in cancer and pre-cancerous conditions. It is increasingly recognized that galectin-3 is an important regulator of a broad range of cancer cell activities and plays important roles in cancer cell growth, transformation, apoptosis, angiogenesis, adhesion, invasion and metastasis. Such a divergent influence of galectin-3 on cancer cell activities derives from its multiple inter- and sub-cellular localizations where it interacts with a range of different binding partners. This mini-review summaries the diverse influences of galectin-3 on cancer cell behaviours with particular emphasis on its role in tumorigenesis and metastasis.

Middle-preserving pancreatectomy for synchronous ampullary carcinoma and solid-pseudopapillary tumor of distal pancreas

INTRODUCTION

Total pancreatectomy is the treatment of choice for multicentric diseases involving the pancreas. Middle-preserving pancreatectomy is a recently reported alternative procedure when the pancreatic body is spared from disease.

PRESENTATION OF CASE

We report a 63-year old lady who underwent a combined Whipple's operation and distal splenopancreatectomy for her synchronous ampullary carcinoma and solid-pseudopapillary tumor of the distal pancreas.

DISCUSSION

For multiple tumors of the pancreas, the choice of surgery should be based on the nature of pathology and follow the principle of oncological resection.

CONCLUSION

Middle-preserving pancreatectomy is a safe and feasible option for patient with multicentric or synchronous pancreatic pathologies.

Management and outcome of gastric carcinoma in Zaria, Nigeria

INTRODUCTION

Gastric cancer is the second leading cause of cancer death in the world. The objective of this study was to present the clinical evaluation, treatment and outcome of 179 patients with gastric carcinoma in Zaria, Nigeria.

METHODS

Patients managed for histologically diagnosed gastric carcinoma were reviewed. The extent of surgical intervention was based on pre-operative and intra-operative staging balanced against the age and overall fitness of the patient. Mortality, morbidity and patient's survival were monitored.

RESULTS

There were 179 patients, with a male to female ratio of 1.4:1. Their mean age was 51 ± 6.3. Ten (5.6%) patients presented with early gastric cancer. Overall, 155(86.6%) patients had surgical intervention including gastric resection in 87 (56.1%). Of the gastrectomies , 28.7% were curative (R0). Postoperative complications were seen in 43(27.7%) patients. Postoperative mortality in 25(16.1%) patients was significantly associated with peritoneal metastasis (p<0.001), preoperative comorbidity (p<0.01) and age more than 60 years (p<0.03). The overall median survival was 13.6 months while 70.1% and 21.8% of patients that underwent gastrectomy survived for 1 and 5 years respectively.

CONCLUSION

Treatment of gastric cancer should be based on a reasonable choice of operation that must consider not only the survival benefits but also the surgical risks and postoperative quality of life.

Pulmonary histoplasmosis producing a spindle cell "pseudotumor"

Pulmonary spindle cell proliferations have been reported in association with a limited group of infectious agents. These lesions are rare and identified most often in the setting of immunosuppression. Because their appearance can simulate a spindle cell neoplasm, they are diagnostically treacherous, sometimes delaying antimicrobial therapy or resulting in unnecessary surgery. We report a case of a spindle pseudotumor of the lung resulting from Histoplasma capsulatum infection, a previously unreported cause of a spindle cell lesion in the lung. The patient was a 67-year-old woman in whom positron emission tomography-positive nodules developed in the left lung and left mediastinum. The patient had undergone renal transplantation and was receiving immunosuppressive therapy with mycophenolate, tacrolimus, and low-dose prednisone. Infection with H capsulatum was confirmed by culture of pleural effusion fluid, DNA probe analysis of the pleural fluid culture isolate, urinary Histoplasma antigen detection, and Grocott methenamine silver stains of tissue sections. To our knowledge, this is the first case of a spindle cell "pseudotumor" of the lung resulting from histoplasmosis. It highlights the importance of performing special stains for organisms when evaluating pulmonary spindle cell lesions in an immunocompromised host.

Chemotherapy outcomes for the treatment of unresectable intrahepatic and hilar cholangiocarcinoma: a retrospective analysis

BACKGROUND

Recent clinical trials for "biliary cancers" include a heterogenous group of patients with cholangiocarcinoma, gallbladder, and ampullary cancers. Limited data exist regarding the relative effectiveness of known chemotherapeutic regimens specifically in intrahepatic or hilar cholangiocarcinoma.

METHODS

Records of M D Anderson Cancer Center patients with unresectable intrahepatic and hilar cholangiocarcinoma who received first-line chemotherapy from January 1, 2005, to October 31, 2009, were retrospectively reviewed. The primary objective of this research was to determine overall tumor control rates with chemotherapeutic regimens used for first-line treatment of unresectable intrahepatic and hilar cholangiocarcinoma. Secondary objectives included duration of response, overall survival, and prognostic factors.

RESULTS

Eighty-five patients met inclusion criteria and were eligible for analysis. The most commonly used regimen was gemcitabine/cisplatin (62%), followed by oxaliplatin and capecitabine (16%). There was no significant difference between tumor control rates with gemcitabine/cisplatin (72% PR + SD) and other regimens (69% PR + SD). There was no significant difference between overall survival with the use of gemcitabine/cisplatin (15.2 months) or alternative regimens (13.9 months). A decrease in overall survival was seen with elevated baseline CA 19-9 (p < .0001), an initial diagnosis of unknown primary tumor (p = .0001), and prior treatment with chemoradiation (p = .0018).

CONCLUSION

In this retrospective review, both gemcitabine/cisplatin and alternative doublets (including capecitabine/oxaliplatin, gemcitabine/capecitabine, and gemcitabine/oxaliplatin) were effective regimens in maintaining disease control in intrahepatic and hilar cholangiocarcinoma.

Epidemiological trends in incidence and mortality of hepatobiliary cancers in Germany

OBJECTIVE

While marked changes in the frequency of hepatobiliary malignancies, most notably hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), have been observed in different populations, no such data have been reported for Germany. We aimed to provide epidemiological data on recent trends in liver-related mortality, specifically mortality from hepatobiliary malignancies, in Germany.

MATERIAL AND METHODS

We used incidence and mortality data to determine changes in the frequency of malignant and non-malignant liver disease in Germany over the past 30 years.

RESULTS

While overall liver disease mortality has slightly declined in Germany, deaths from hepatobiliary malignancies have declined in women, but remained constant in men. Among hepatobiliary malignancies, ICC stands out, because mortality has more than tripled both in men and women between 1998 and 2008. This is mirrored by a marked increase in new cases reported to local cancer registries, that is, incidence. Over the same time period, HCC and extrahepatic cholangiocarcinoma (ECC) have remained largely constant while gall bladder cancers (GBC) have declined twofold. The rapid rise in ICC is in line with finding from different regions worldwide, but in contrast to recent data from Denmark and France, two of Germany's direct neighbors.

CONCLUSIONS

The incidence of and mortality from ICC are rising markedly in Germany. The risk factors underlying this trend are as yet unclear.

Targeting the tumor microenvironment: focus on angiogenesis

Tumorigenesis is a complex multistep process involving not only genetic and epigenetic changes in the tumor cell but also selective supportive conditions of the deregulated tumor microenvironment. One key compartment of the microenvironment is the vascular niche. The role of angiogenesis in solid tumors but also in hematologic malignancies is now well established. Research on angiogenesis in general, and vascular endothelial growth factor in particular, is a major focus in biomedicine and has led to the clinical approval of several antiangiogenic agents including thalidomide, bevacizumab, sorafenib, sunitinib, pazopanib, temesirolimus, and everolimus. Indeed, antiangiogenic agents have significantly changed treatment strategies in solid tumors (colorectal cancer, renal cell carcinoma, and breast cancer) and multiple myeloma. Here we illustrate important aspects in the interrelationship between tumor cells and the microenvironment leading to tumor progression, with focus on angiogenesis, and summarize derived targeted therapies.

Lack of association between gene polymorphisms of Angiotensin converting enzyme, Nod-like receptor 1, Toll-like receptor 4, FAS/FASL and the presence of Helicobacter pylori-induced premalignant gastric lesions and gastric cancer in Caucasians

BACKGROUND

Several polymorphisms of genes involved in the immunological recognition of Helicobacter pylori and regulating apoptosis and proliferation have been linked to gastric carcinogenesis, however reported data are partially conflicting. The aim of our study was to evaluate potential associations between the presence of gastric cancer (GC) and high risk atrophic gastritis (HRAG) and polymorphisms of genes encoding Angiotensin converting enzyme (ACE), Nod-like receptor 1 (NOD1), Toll-like receptor 4 (TLR4) and FAS/FASL.

METHODS

Gene polymorphisms were analyzed in 574 subjects (GC: n = 114; HRAG: n = 222, controls: n = 238) of Caucasian origin. ACE I/D (rs4646994), NOD1 796G>A (rs5743336), TLR4 3725G>C (rs11536889), FAS 1377G>A (rs2234767), FAS 670A>G (rs1800682) and FASL 844T>C (rs763110) were genotyped by different PCR approaches and restriction fragment length polymorphism analysis.

RESULTS

Frequencies of genotypes in our study are similar to the data reported on subjects of Caucasian ethnicity. There was a tendency for NOD1 796G/G genotype to be associated with increased risk of HRAG (62.4% vs. 54.5% in controls, p = 0.082). FAS 670G/G genotype was more frequent in HRAG when compared to controls, 23.9% and 17.2% respectively, however it failed to reach significance level (p = 0.077). We did not find any significant associations for all polymorphisms in relation to GC or HRAG. NOD1 796G>A and TLR4 3725G>C gene polymorphisms were also not associated with Helicobacter pylori infection.

CONCLUSIONS

ACE, NOD1, TRL4 and FAS/FASL gene polymorphisms are not linked with gastric carcinogenesis in Caucasians, and therefore they should not be considered as potential biomarkers for identifying individuals with higher risk for GC.

Optimal primary surgical treatment for advanced epithelial ovarian cancer

BACKGROUND

Ovarian cancer is the sixth most common cancer among women. In addition to diagnosis and staging, primary surgery is performed to achieve optimal cytoreduction (surgical efforts aimed at removing the bulk of the tumour) as the amount of residual tumour is one of the most important prognostic factors for survival of women with epithelial ovarian cancer. An optimal outcome of cytoreductive surgery remains a subject of controversy to many practising gynae-oncologists. The Gynaecologic Oncology group (GOG) currently defines 'optimal' as having residual tumour nodules each measuring 1 cm or less in maximum diameter, with complete cytoreduction (microscopic disease) being the ideal surgical outcome. Although the size of residual tumour masses after surgery has been shown to be an important prognostic factor for advanced ovarian cancer, it is unclear whether it is the surgical procedure that is directly responsible for the superior outcome that is associated with less residual disease.

OBJECTIVES

To evaluate the effectiveness and safety of optimal primary cytoreductive surgery for women with surgically staged advanced epithelial ovarian cancer (stages III and IV).To assess the impact of various residual tumour sizes, over a range between zero and 2 cm, on overall survival.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3) and the Cochrane Gynaecological Cancer Review Group Trials Register, MEDLINE and EMBASE (up to August 2010). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Retrospective data on residual disease from randomised controlled trials (RCTs) or prospective and retrospective observational studies which included a multivariate analysis of 100 or more adult women with surgically staged advanced epithelial ovarian cancer and who underwent primary cytoreductive surgery followed by adjuvant platinum-based chemotherapy. We only included studies that defined optimal cytoreduction as surgery leading to residual tumours with a maximum diameter of any threshold up to 2 cm.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis.

MAIN RESULTS

There were no RCTs or prospective non-RCTs identified that were designed to evaluate the effectiveness of surgery when performed as a primary procedure in advanced stage ovarian cancer.We found 11 retrospective studies that included a multivariate analysis that met our inclusion criteria. Analyses showed the prognostic importance of complete cytoreduction, where the residual disease was microscopic that is no visible disease, as overall (OS) and progression-free survival (PFS) were significantly prolonged in these groups of women. PFS was not reported in all of the studies but was sufficiently documented to allow firm conclusions to be drawn.When we compared suboptimal (> 1 cm) versus optimal (< 1 cm) cytoreduction the survival estimates were attenuated but remained statistically significant in favour of the lower volume disease group There was no significant difference in OS and only a borderline difference in PFS when residual disease of > 2 cm and < 2 cm were compared (hazard ratio (HR) 1.65, 95% CI 0.82 to 3.31; and HR 1.27, 95% CI 1.00 to 1.61, P = 0.05 for OS and PFS respectively).There was a high risk of bias due to the retrospective nature of these studies where, despite statistical adjustment for important prognostic factors, selection bias was still likely to be of particular concern.Adverse events, quality of life (QoL) and cost-effectiveness were not reported by treatment arm or to a satisfactory level in any of the studies.

AUTHORS' CONCLUSIONS

During primary surgery for advanced stage epithelial ovarian cancer all attempts should be made to achieve complete cytoreduction. When this is not achievable, the surgical goal should be optimal (< 1 cm) residual disease. Due to the high risk of bias in the current evidence, randomised controlled trials should be performed to determine whether it is the surgical intervention or patient-related and disease-related factors that are associated with the improved survival in these groups of women. The findings of this review that women with residual disease < 1 cm still do better than women with residual disease > 1 cm should prompt the surgical community to retain this category and consider re-defining it as 'near optimal' cytoreduction, reserving the term 'suboptimal' cytoreduction to cases where the residual disease is > 1 cm (optimal/near optimal/suboptimal instead of complete/optimal/suboptimal).

Can the intestinal dysmotility of critical illness be differentiated from postoperative ileus?

Gastrointestinal dysmotility is commonly noted in the intensive care unit and postoperative settings. Characterized by delayed passage of stool and flatus, nausea, vomiting, and abdominal distention, the condition is associated with nutritional deficiencies, risk of aspiration, and considerable allocation of health care resources. Knowledge of gastrointestinal function in health and illness continues to expand. While the factors that precipitate ileus differ between postoperative and critically ill patients, the two clinical scenarios seem to have similar mechanisms and share many of the same pathophysiologic patterns. By reviewing and comparing the literature on the respective mechanisms and contributing factors generated in these separate clinical settings, a common more comprehensive management strategy may be derived with the potential for newer innovative therapeutic options.

Management of peritoneal carcinomatosis from colorectal cancer

The management of peritoneal carcinomatosis from colorectal cancer is evolving. The introduction of new chemotherapeutic and biologic agents has certainly improved the outlook for many patients with metastatic colorectal cancer. Traditionally, patients with limited hepatic or pulmonary metastases were the only candidates for metastasectomy. However, patients with metastasis localized to the peritoneum have been shown to be candidates for metastasectomy with improved clinical outcomes. Cytoreductive surgery with the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) in this cohort of patients offers the only chance for long-term survival. Complete cytoreduction in combination with HIPEC for peritoneal surface disease has been demonstrated to produce survival outcomes similar to liver resection for hepatic metastases. This review will examine recent evidence pertaining to the evolving surgical oncology paradigm for management of colorectal peritoneal carcinomatosis.

Current perception of nutrition education in U.S. medical schools

Historically, physicians have perceived the quality of nutrition training during medical school as inadequate. A literature review suggests that this perception has not significantly changed since the 1950s. Many schools have worked to create clinical nutrition curricula for use during medical school. Interestingly, data suggest that medical students' perception of the importance of clinical nutrition can decrease during medical school. Recent data support the importance of targeted nutritional therapy to reduce morbidity and mortality, yet the number of physicians interested in nutrition appears to be declining, and fewer hours of nutrition training are occurring in medical school. One possible solution to improve both training and awareness of the problem is to implement a certification program for both students and preceptors modeled after the Cardiac Life Support training offered by the American Heart Association.

The NLRP3 inflammasome in health and disease: the good, the bad and the ugly

While interleukin (IL)-1β plays an important role in combating the invading pathogen as part of the innate immune response, its dysregulation is responsible for a number of autoinflammatory disorders. Large IL-1β activating platforms, known as inflammasomes, can assemble in response to the detection of endogenous host and pathogen-associated danger molecules. Formation of these protein complexes results in the autocatalysis and activation of caspase-1, which processes precursor IL-1β into its secreted biologically active form. Inflammasome and IL-1β activity is required to efficiently control viral, bacterial and fungal pathogen infections. Conversely, excess IL-1β activity contributes to human disease, and its inhibition has proved therapeutically beneficial in the treatment of a spectrum of serious, yet relatively rare, heritable inflammasomopathies. Recently, inflammasome function has been implicated in more common human conditions, such as gout, type II diabetes and cancer. This raises the possibility that anti-IL-1 therapeutics may have broader applications than anticipated previously, and may be utilized across diverse disease states that are linked insidiously through unwanted or heightened inflammasome activity.

Overexpression of PDGFA and its receptor during carcinogenesis of Opisthorchis viverrini-associated cholangiocarcinoma

Cholangiocarcinoma (CCA) is a crucial health problem in northeastern part of Thailand, which is caused by a combination of Opisthorchis viverrini infection and nitrosamine. A better understanding of its molecular mechanism is an important step to discover and develop the new diagnostics and therapies for CCA. To reveal the involvement of potential genes in the development of CCA, the present study investigated the expression kinetics of platelet-derived growth factor alpha (Pdgfa) and its receptor (Pdgfra) during the tumorigenesis of CCA induced by O. viverrini infection with quantitative RT-PCR, and confirmed the expression with immunohistological staining. The results showed that in the hamster model of opisthorchiasis-associated CCA, the expression of Pdgfa was increased after infection plus N-nitrosodimethylamine (NDMA) administration, reached its peak at 2 months post infection, and remained at the high level until 6 months. Similarly, the expression of Pdgfra was increased time-dependently. The positive immunostaining for PDGFA proteins was observed in the cytoplasm of epithelial tumor cells of hamster CCA. Moreover, the analysis of the expression of these genes in 10 cases of human opisthorchiasis-associated CCA showed that Pdgfa was overexpressed in 80%, and Pdgfra was overexpressed in 40% cases (>3.0 folds, compared with the expressions of adjacent normal tissues). This result suggests that PDGFA is likely involved in the tumorigenesis of opisthorchiasis-associated CCA, and may be a promising candidate biomarker for diagnosis and treatment strategies of CCA.

New approach to peritoneal surface malignancies

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

Anti-inflammatory activities of mogrosides from Momordica grosvenori in murine macrophages and a murine ear edema model

Momordica grosvenori (Luo Han Guo), grown primarily in Guangxi province in China, has been traditionally used for thousands of years by the Chinese to make hot drinks for the treatment of sore throat and the removal of phlegm. The natural noncaloric sweetening triterpenoid glycosides (mogrosides) contained in the M. grosvenori fruits are also antioxidative, anticarcinogenic, and helpful in preventing diabetic complications. The aim of this study was to assess the anti-inflammatory properties of mogrosides in both murine macrophage RAW 264.7 cells and a murine ear edema model. The results indicate that mogrosides can inhibit inflammation induced by lipopolysaccharides (LPS) in RAW 264.7 cells by down-regulating the expression of key inflammatory genes iNOS, COX-2, and IL-6 and up-regulating some inflammation protective genes such as PARP1, BCL2l1, TRP53, and MAPK9. Similarly, in the murine ear edema model, 12-O-tetradecanoylphorbol-13-acetate-induced inflammation was inhibited by mogrosides by down-regulating COX-2 and IL-6 and up-regulating PARP1, BCL2l1, TRP53, MAPK9, and PPARδ gene expression. This study shows that the anticancer and antidiabetic effects of M. grosvenori may result in part from its anti-inflammatory activity.

The role of galectins in colorectal cancer progression

Galectins constitute a family of 15 mammalian galactoside-binding proteins that share a consensus amino acid sequence in their carbohydrate binding sites. They are multi-functional molecules and are expressed widely in human tissues. Four galectins: galectin -1, -3, -4 and -8 are expressed in the human colon and rectum and their expressions show significant changes during colorectal cancer development and metastasis. These changes in galectin expression correlate with alterations in cancer cell growth, apoptosis, cell-cell and cell-matrix interactions and angiogenesis. This review summaries current knowledge of the expression and roles of these galectins in the progression of human colorectal cancer and discusses the relevance of galectins and their ligands as potential therapeutic targets for cancer treatment.

Polyphenol rich botanicals used as food supplements interfere with EphA2-ephrinA1 system

The Eph tyrosine kinase receptors and their ephrin ligands play a central role in several human cancers and their deregulated expression or function promotes tumorigenesis, inducing aggressive tumor phenotypes. Green tea extracts (GTE) have been recently found to inhibit Eph-kinase phosphorylation. In order to evaluate the potential contribution of edible and medicinal plants on EphA2-ephrinA1 modulation, 133 commercially available plant extracts used as food supplements, essential and fixed oils were screened with an ELISA-based binding assay. Nine plant extracts, rich of polyphenols, reversibly inhibited binding in a dose-dependent manner (IC₅₀ 0.83-24 μg/ml). Functional studies on PC3 prostate adenocarcinoma cells revealed that active extracts antagonized ephrinA1-Fc-induced EphA2-phosphorylation at non-cytotoxic concentrations (IC₅₀ 0.31-11.3 μg/ml) without interfering with EGF-induced EGFR activation, suggesting a specific effect. These findings could furnish an interesting starting point regarding the potential relationship between diet, edible plant secondary metabolites and Eph-ephrin system, suggesting their possible involvement in cancer development modulation.

RON (MST1R) is a novel prognostic marker and therapeutic target for gastroesophageal adenocarcinoma

RON (MST1R) is one of two members of the MET receptor tyrosine kinase family, along with parent receptor MET. RON has a putative role in several cancers, but its expression and function is poorly characterized in gastroesophageal adenocarcinoma. A recognized functional role of MET tyrosine kinase in gastroesophageal cancer has led to early phase clinical trials using MET inhibitors, with unimpressive results. Therefore, the role of RON in gastroesophageal cancer, as well as its role in cooperative signaling with MET and as a mechanism of resistance to MET inhibition, was studied in gastroesophageal tissues and cell lines. By IHC, RON was highly over-expressed in 74% of gastroesophageal samples (n=94), and over-expression was prognostic of poor survival (p=0.008); RON and MET co-expression occurred in 43% of samples and was prognostic of worst survival (p=0.03). High MST1R gene copy number by quantitative polymerase chain reaction, and confirmed by fluorescence in situ hybridization and/or array comparative genomic hybridization, was seen in 35.5% (16/45) of cases. High MST1R gene copy number correlated with poor survival (p=0.01), and was associated with high MET and ERBB2 gene copy number. A novel somatic MST1R juxtamembrane mutation R1018G was found in 11% of samples. RON signaling was functional in cell lines, activating downstream effector STAT3, and resulted in increased viability over controls. RON and MET co-stimulation assays led to enhanced malignant phenotypes over stimulation of either receptor alone. Growth inhibition as evidenced by viability and apoptosis assays was optimal using novel blocking monoclonal antibodies to both RON and MET, versus either alone. SU11274, a classic MET small molecule tyrosine kinase inhibitor, blocked signaling of both receptors, and proved synergistic when combined with STAT3 inhibition (combination index < 1). These preclinical studies define RON as an important novel prognostic marker and therapeutic target for gastroesophageal cancer warranting further investigation.

Efficacy of hypocaloric parenteral nutrition for surgical patients: a systematic review and meta-analysis

BACKGROUND AND AIMS

Hypocaloric parenteral nutrition is an underfeeding strategy that lowers energy intake to around 20 kcal/kg/d. It is believed to achieve benefits by modulating metabolic responses and alleviating hyperglycemia. This study aims to systematically review the clinical efficacy of hypocaloric parenteral nutrition on surgical patients.

METHODS

Medline, SCI, Embase, Cochrane Library, Chinese Biomedicine Database (CBM) and China Knowledge Resource Integrated Database (CNKI) were searched for studies published before July 1, 2010. Randomized control trials (RCTs) that compared hypocaloric PN with standard or higher energy PN in surgical patients were identified and included. Methodological quality assessment was based on Cochrane Reviewers' Handbook and modified Jadad's Score Scale. Statistical software RevMan 5.0 was used for meta-analysis.

RESULTS

Five trials met all inclusion criteria and were included in the final meta-analysis. There were significant reductions in infectious complications (RR, 0.60; 95%CI 0.39-0.91, P = 0.02; I(2) = 38%) and length of hospitalization (LOS) associated with receiving hypocaloric PN (MD-2.49 days, 95%CI -3.88 to -1.11, P = 0.0004; I² = 48%). Stratified analysis of the smaller trials (<60) and larger trials demonstrated that the heterogeneity between trials was mainly associated with sample size. When smaller trials were excluded, hypocaloric PN was associated with reduction in infectious complications (RR, 0.21, 95%CI 0.06-0.72, P = 0.01, I2 = 0%) and shortening of LOS (MD, -2.32 days, 95%CI -3.72 to -0.93, P = 0.001, I² = 0%).

CONCLUSION

Hypocaloric parenteral nutrition may reduce infectious complications and the length of hospitalization in post-operative patients. However, this conclusion is tentative due to patient type and sample size. Furthermore, in terms of hypocaloric PN, the actual energy amount still varies a great deal (from 15 kcal/kg/d to 20 kcal/kg/d). This suggests that further research, including larger randomized clinical trials is required.

Association between methylation in mismatch repair genes, V600E BRAF mutation and microsatellite instability in colorectal cancer patients

Colorectal cancer (CRC) corresponds to the third most prevalent type of cancer. Its origins can either be sporadic or inherited, being Lynch syndrome the most common form of hereditary CRC. The activation of BRAF oncogene, inactivation of mismatch repair genes by methylation of CpG islands, and microsatellite instability (MSI) have been reported to be involved in CRC development. The goal of the study was to characterize CRC tumors using clinical and molecular criteria through association and cluster analysis. Amsterdam II and Bethesda guidelines and molecular variables were analyzed in 77 patients from Brazil. The replication error (RER) status, based in microsatellite instability, showed association with metachronous tumor, MLH1 gene methylation and inverse association with left-sided and synchronous tumors. The PMS2 gene was considered the best predictor for differentiating levels of methylation and the mononucleotide were considered the best markers to evaluate RER status. The cluster 1 was characterized of individuals over 60 years of age, female, right-sided tumor, high microsatellite instability, and metachronous or synchronous tumors. The individuals in cluster 2 were younger than 45 years of age, male and showed left sided or rectum tumors, and microsatellite stability. Even though it was not observed a significant association, a higher number of individuals with family history of cancer and tumors without promoter methylation were found in cluster 2. The V600E mutation did not show association with clinical or molecular characteristics. Evaluation of MSI and methylation of MLH1 and PMS2 genes should be considered in order to assist with clinical diagnosis.

Recurrent Incisional Hernia due to Pseudomyxoma Peritonei

Pseudomyxoma peritonei is a rare but challenging neoplastic disease which is characterized with intraperitoneal mucinous-gelatinous fluid accumulation. It rarely presents as a mass mimicking abdominal wall hernias A recurrent incisional hernia due to pseudomyxoma peritonei is presented here. A 60-year-old female patient had been operated on for a left mucinous ovarian cyst 20 cm in diameter in 1998. Mucinous material had disseminated into interloop spaces through the right subdiaphragmatic region. Total abdominal hysterectomy + bilateral salpingooophorectomy and peritoneal toilet had been performed. She was rehospitalized for abdominal distention and a 4 cm defect over the incision and underwent a hernia repair using polypropylene mesh in 2001. Abdominal distention recurred to give a rise to an incisional hernia in 2006. She was reoperated for decompression and repair, but nothing could be done because of sticky adhesions and the incision were simply closed. The patient was referred to our department for operation. A prosthetic hernia repair with 30 × 30 cm polypropylene mesh was performed. The patient was discharged on the postoperative 5th day following an uneventful recovery. However, she died of disseminated disease after 18 months.

Systematic review of outcome of downstaging hepatocellular cancer before liver transplantation in patients outside the Milan criteria

BACKGROUND

The aim of this systematic review was to assess the evidence on tumour downstaging before liver transplantation in patients with hepatocellular carcinoma (HCC) initially staged beyond the Milan criteria.

METHODS

MEDLINE (from 1952), Embase (from 1980) and the Cochrane Library were searched. The review included cohort studies that reported the outcomes of patients with HCC outside the Milan criteria who underwent downstaging before transplantation.

RESULTS

Eight studies met the inclusion criteria and included a total of 720 patients who underwent transplantation following downstaging after initial presentation with disease outside the Milan criteria. The rate of successful downstaging varied from 24 to 69 per cent of patients. Reported survival rates ranged from 82 to 100 per cent, 79 to 100 per cent and 54·6 to 94 per cent at 1, 3 and 5 years respectively. These were comparable with results for patients presenting within the Milan criteria.

CONCLUSION

Successful downstaging of HCC to within the Milan criteria is feasible in a proportion of patients. Absolute and disease-free survival rates in patients transplanted following downstaging are comparable to those in patients within the Milan criteria.

Laparoscopic resection of the uncinate process of the pancreas: the inframesocolic approach and hanging maneuver of the mesenteric root

BACKGROUND

Laparoscopic pancreatic procedures have increased in recent years. However, only a single case of laparoscopic uncinatectomy has been reported to date, performed through an anterior approach. This video presents a hitherto undescribed laparoscopic inframesocolic approach and also an undescribed maneuver to expose the uncinate process.

METHODS

A 39-year-old women had a 16-mm insulinoma in the uncinate pancreas. The patient was placed in the supine position with legs apart. A 30º, 5-mm optic was used, and only a 12-mm trocar was needed. The first maneuver moved the major omentum and transverse colon upward to expose the mesenteric root. The duodenum was identified through the peritoneal sheath and mobilized. The superior mesenteric vein was identified and carefully exposed in the vicinity of the uncinate pancreas. To improve the exposure for the uncinatectomy, a hanging maneuver of the mesenteric root was performed with cotton tape. Intraoperative ultrasound identified the tumor and defined the limits of the resection. An inferior pancreaticoduodenal vein was sectioned between clips, and the uncinate process was dissected from the retropancreatic fascia. The transection was performed with a reinforced endostapler. The specimen was dragged into a bag and removed through the 12-mm orifice, which did not have to be enlarged. No drain was left.

RESULTS

The patient was discharged on postoperative day 3. No early or late surgical complications were observed. At this writing 1 year after the procedure, the patient has lost 35 kg and shows a normal body mass index. She remains asymptomatic with normal blood sugar levels.

CONCLUSION

Laparoscopic resection of the uncinate process of the pancreas is feasible and safe. The inframesocolic approach is easy to perform and achieves an optimal exposure that is improved with a hanging maneuver of the mesenteric root.

Lymph node metastasis of gastric cancer is associated with the interaction between poly (ADP-ribose) polymerase 1 and matrix metallopeptidase 2

Poly (ADP-ribose) polymerase 1 (PARP1), which plays a critical role in the base excision DNA repair mechanism, and matrix metallopeptidase 2 (MMP2), a member of the matrix metalloprotease family, are involved in tumor formation and metastasis, respectively. In the present study, the possible association of single nucleotide polymorphisms (SNPs) and gene-gene interaction between PARP1 and MMP2 with the increased incidence of gastric cancer (GC) development and lymph node metastasis (LNM) was investigated in a Korean population. Samples were obtained from 326 patients with chronic gastritis and 153 patients with GC and genotyped using the GoldenGate® method. The PARP1 rs1136410 genotype showed a significant association with the frequency of LNM of GC (odds ratio [OR] = 2.19, p = 0.02), LNM stage (p = 0.035), and tumor invasion (p = 0.035). The allele frequency of MMP2 rs243865 was not associated with the development of GC or with the development of LNM of GC. Epistasis between the PARP1 SNP and the MMP2 SNP was associated with the development of LNM of GC. The combination of the MMP2 rs243865 CC genotype and the PARP1 rs1136410 CC or CC+CT genotypes showed a high risk of LNM of GC (OR = 2.47, p = 0.01; OR = 2.28, p = 0.01, respectively). In summary, PARP1 is associated with the risk of LNM of GC and the stage of LNM and tumor invasion. Epistasis between PARP1 rs1136410 and MMP2 rs243865 increased the risk of LNM of GC.

Baseline ¹⁸F-FDG PET image-derived parameters for therapy response prediction in oesophageal cancer

PURPOSE

The objectives of this study were to investigate the predictive value of tumour measurements on 2-deoxy-2-[(18)F]fluoro-D-glucose ((18)F-FDG) positron emission tomography (PET) pretreatment scan regarding therapy response in oesophageal cancer and to evaluate the impact of tumour delineation strategies.

METHODS

Fifty patients with oesophageal cancer treated with concomitant radiochemotherapy between 2004 and 2008 were retrospectively considered and classified as complete, partial or non-responders (including stable and progressive disease) according to Response Evaluation Criteria in Solid Tumors (RECIST). The classification of partial and complete responders was confirmed by biopsy. Tumours were delineated on the (18)F-FDG pretreatment scan using an adaptive threshold and the automatic fuzzy locally adaptive Bayesian (FLAB) methodologies. Several parameters were then extracted: maximum and peak standardized uptake value (SUV), tumour longitudinal length (TL) and volume (TV), SUV(mean), and total lesion glycolysis (TLG = TV × SUV(mean)). The correlation between each parameter and response was investigated using Kruskal-Wallis tests, and receiver-operating characteristic methodology was used to assess performance of the parameters to differentiate patients.

RESULTS

Whereas commonly used parameters such as SUV measurements were not significant predictive factors of the response, parameters related to tumour functional spatial extent (TL, TV, TLG) allowed significant differentiation of all three groups of patients, independently of the delineation strategy, and could identify complete and non-responders with sensitivity above 75% and specificity above 85%. A systematic although not statistically significant trend was observed regarding the hierarchy of the delineation methodologies and the parameters considered, with slightly higher predictive value obtained with FLAB over adaptive thresholding, and TLG over TV and TL.

CONCLUSION

TLG is a promising predictive factor of concomitant radiochemotherapy response with statistically higher predictive value than SUV measurements in advanced oesophageal cancer.

Endoscopic Management of Gastric Polyp with Outlet Obstruction without Polypectomy

Although gastric polyp is usually an incidental endoscopic finding, large-sized polyps can cause symptoms ranging from epigastralgia to bleeding from ulcerated polyps and gastric outlet obstruction. Although the gold standard of treatment is removal of the polyp either through endoscopic polypectomy or surgical excision, complications associated with these procedures cannot be ignored. The risk becomes a major concern for patients at high risk for surgery when complications arise. We describe a debilitated 74-year-old woman who presented with early satiety, intermittent postprandial nausea and vomiting for three months. Upper endoscopy revealed a 2.5 cm pedunculated polyp over the gastric antrum causing intermittent obstruction. Considering her high risk for polypectomy, detachable snaring was performed without polypectomy in an outpatient setting. The patient was complication-free with complete relief of obstructive symptoms one week after the procedure. Subsequent follow-ups showed satisfactory healing without signs of mucosal disruption or recurrence. The results suggest that detachable snaring without polypectomy may be a therapeutic option for high-risk patients with benign symptomatic gastric polyps.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy associated toxicity in treatment of peritoneal carcinomatosis]

INTRODUCTION

Peritoneal carcinomatosis is a form of intra-abdominal dissemination of several tumours, which is associated with a poor prognosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is an alternative treatment. The aim of this study is to describe the toxicity associated with this procedure in patients with peritoneal carcinomatosis.

METHOD

We conducted a descriptive, retrospective, single-centre study, including all patients undergoing this procedure between December 2007 and January 2010. The following data were recorded: anthropometric data, personal and surgical events, indication, previous treatments, extent of carcinomatosis, intervention duration, hospital stay, and type of complications and/or adverse events following application of the multidisciplinary treatment.

RESULTS

We performed 46 interventions on 45 patients diagnosed with peritoneal carcinomatosis from different causes, mainly ovarian cancer (83%). Paclitaxel was the most-used drug (35 interventions). There was no associated mortality, the average intervention time was 6.4 hours and the average hospital stay 7 days. We recorded adverse effects for 42 procedures, being grade 3-4 in 28.3% of the patients. The severe adverse events were: 10.9% gastrointestinal, 10.9% infectious, 6.5% haemorrhage or bleeding, 6.5% medullary toxicity, 4.4% respiratory, 2.2% coagulation and 2.2% hepatobiliary disorders. One patient developed grade III neutropaenia, probably associated with cisplatin.

CONCLUSION

The morbidity and mortality is in line with the average of published studies, and has mainly been attributed to surgical complications. Toxicity data lower than other studies can be due to using more tolerable chemotherapy regimens, not including drug combinations and given that paclitaxel was the main drug.

Nutrition support in surgical patients with colorectal cancer

AIM: To review the application of nutrition support in patients after surgery for colorectal cancer, and to propose appropriate nutrition strategies.

METHODS: A total of 202 consecutive surgical patients admitted to our hospital with a diagnosis of colon cancer or rectal cancer from January 2010 to July 2010, meeting the requirements of Nutrition Risk Screening 2002, were enrolled in our study. Laboratory tests were performed to analyze the nutrition status of each patient, and the clinical outcome variables, including postoperative complications, hospital stay, cost of hospitalization and postoperative outcome, were analyzed.

RESULTS: The “non-risk” patients who did not receive postoperative nutrition support had a higher rate of postoperative complications than patients who received postoperative nutrition support (2.40 ± 1.51 vs 1.23 ± 0.60, P = 0.000), and had a longer postoperative hospital stay (23.00 ± 15.84 d vs 15.27 ± 5.89 d, P = 0.009). There was higher cost of hospitalization for patients who received preoperative total parenteral nutrition (TPN) than for patients who did not receive preoperative TPN (62 713.50 ± 5070.66 RMB Yuan vs 43178.00 ± 3596.68 RMB Yuan, P = 0.014). Applying postoperative enteral nutrition significantly shortened postoperative fasting time (5.16 ± 1.21 d vs 6.40 ± 1.84 d, P = 0.001) and postoperative hospital stay (11.92 ± 4.34 d vs 15.77 ± 6.03 d, P = 0.002). The patients who received postoperative TPN for no less than 7 d had increased serum glucose levels (7.59 ± 3.57 mmol/L vs 6.48 ± 1.32 mmol/L, P = 0.006) and cost of hospitalization (47 724.14 ± 16 945.17 Yuan vs 38 598.73 ± 8349.79 Yuan, P = 0.000). The patients who received postoperative omega-3 fatty acids had a higher rate of postoperative complications than the patients who did not (1.33 ± 0.64 vs 1.13 ± 0.49, P = 0.041). High level of serum glucose was associated with a high risk of postoperative complications of infection.

CONCLUSION: Appropriate and moderate nutritional intervention can improve the postoperative outcome of colorectal cancer patients.

Molecular pathways underlying IBD-associated colorectal neoplasia: therapeutic implications

Chronic inflammatory diseases, depending upon the duration and severity, are frequently associated with an increased risk of developing cancer. A classic paradigm is the enhanced risk of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD). Carcinogenesis is a multifactorial process that involves accumulation of genetic defects, protein modification, and cell-matrix interaction. In this review, we discuss aspects of chronic inflammation in IBD that influence the development of CRC and highlight the key molecular mediators involved in this process. Also, we identify potential targets that could facilitate earlier detection of dysplasia. The targeted manipulation of specific molecules or pathways could provide opportunities for the development of therapeutic and chemopreventive interventions, which may prove effective in arresting the progression of colitis-associated cancer (CAC), with clinical implications.

Granular cell tumour of the thyroid gland: a case report and review of the literature

Granular cell tumours of the thyroid gland are rare, with only six previously reported cases in the English literature. Current histological, immunohistochemical and electron microscopic evidence favours a neural/Schwannian relationship. A case of a granular cell tumour of the thyroid gland in a healthy 36-year-old woman is described. The tumour was found incidentally following a right thyroid lobectomy for symptoms from an asymmetric multinodular goitre. Macroscopically, the lesion resembled a papillary microcarcinoma. Microscopically, the tumour was composed of nests of epithelioid cells with abundant granular, eosinophilic cytoplasm. The nests were divided by fibrous septa and peripherally interdigitated with surrounding thyroid follicles. Immunohistochemistry helped to distinguish the lesion from other neoplasms such as Hurthle cell tumour, medullary carcinoma or metastasis, and also from a histiocytic reaction to previous fine needle aspiration. On the basis of this diagnosis, no further intervention was required, and the patient was discharged following post-operative review.