Increased insufflation pressure enhances the development of liver metastasis in a mouse laparoscopy model: possible mechanisms

Rapid exacerbation featuring acute leukemoid reaction after retrolaparoscopic nephrectomy: a rare case report of renal cell carcinoma with postoperative comprehensive genomic profiling

Background

Rapid lethal exacerbation and recurrence featuring acute leukemoid reaction (ALR) after retrolaparoscopic radical nephrectomy (RN) is a relatively rare clinical incident. Performing the reoperation for the patient and analyzing the tissue-based genetic mutation information postoperatively are a skill-demanding and meaningful task, which have been even more rarely reported.

Case presentation

We present a case with a large right renal mass (13.0 × 10.0 × 8.0 cm). This 71-year-old male patient underwent the retrolaparoscopic RN in our department. The operation was technically precise and successful with final pathological diagnosis of hybrid (clear cell and papillary type) renal cell carcinoma (RCC). However, 10 days after the patient was discharged, he was readmitted with the chief complaint of high fever with severe right flank pain. CT scanning revealed that right retroperitoneal hematoma and the blood routine showed the dramatic elevation of white blood cell count (WBC). Even though the immediate broad-spectrum antibiotics were administered without delay and subsequent percutaneous puncturing and drainage was performed, the patient’s condition still exacerbated rapidly. In spite of the reoperation of hematoma evacuation, the patient died of multiple organ failure 10 days after the reoperation. The pathological result of reoperation showed the necrotic and hematoma tissue blended with RCC tumor cells (nuclear grading III), and both of the postoperative tissue-originated comprehensive genomic profiling by using the specimens from the RN and reoperation respectively indicated significant mutations of some oncogenes which might have potential relevance with ALR. Besides, both of the immunohistochemical (IHC) staining results from primary surgical renal mass and reoperative resected tissue revealed the positive expressions of granulocyte colony-stimulating factor (G-CSF).

Conclusions

ALR may be a predictor of poor prognosis in patients with RCC, and comprehensive genomic profiling as well as the alterative expression of G-CSF can help to provide potential valuable genetic etiological information and evidence for guiding the potential effective molecular-targeting therapy.

Long-Term Results of Laparoscopic Retroperitoneal Lymph Node Dissection (RPLND) in Low-Stage Nonseminomatous Germ-Cell Testicular Tumors (NSGCTT) Performed by a Senior Surgeon: 1999–2003

Background

Laparoscopic RPLND for low-stages NSGCTT is controversial: it is performed and recommended by excellent laparoscopic surgeons, but it is not widely used. The aim of this paper is to evaluate the results achieved by a senior surgeon, expert in open RPLND, who was introduced to laparoscopic surgery by excellent laparoscopists (LN, CU, GJ).

Patients and Methods

of the 48 operated patients, 36 had primary RPLND for clinical stage I disease (22 TINO, 7 TxNO, 5 T2–3 NO and 2 TIS1 NO) and 12 had post-chemotherapy surgery for IIA and IIB retroperitoneal nodes with normalized AFP and HCG. L-RPLND was performed with 4 ports and the en bloc removal of unilateral retroperitoneal nodes with the spermatic vessels. No post-operative adjuvant chemotherapy was planned for patients with documented nodal metastases as for open RPLND since 1985.

Results

Average operative time was 3.30'for the 36 clinical stage I patients and 4 hours for post-chemotherapy surgery. Blood loss was minimal in all cases, because of early conversion to open surgery in all patients with no immediate hemostasis at L-RPLND. Metastases were found in 6 (17%) out of the 36 clinical stage I patients: none in the 22 pTI, 1 in the 7 Tx, 3 in the 5 pT2–3 and in 2 of the 2 pT1S1 patients. Residual teratoma was found in 6 of the 12 patients who received neo-adjuvant chemotherapy for clinical stage IIA or IIB disease. The other 6 had fibrosis-necrosis. Further metastases developed in 2 of the 30 patients with negative nodes: 1 in the lung in a pT1, and 1 in a pT2 patient with increasing markers. Surprisingly, the first two pT2–3 patients with positive nodes developed liver metastases in a few months after L-RPLND. Consequently, all following patients with active metastases at L-RPLND received 2 courses of adjuvant PEB. All 4 patients who relapsed were cured, are alive and disease-free.

Conclusions

L-RPLND is a very demanding operation, which appears to be more a staging procedure than a curative operation. It is ideal for pT1 clinical stage I and for post-chemotherapy stages IIA& B with residual teratoma and normalized markers, but wait & see in good risk and open RPLND in high risk patients are very competing. Only few reports compared laparoscopic versus open RPLND, but not in a randomized study.

Impact of circulating tumor cells in colorectal cancer patients undergoing laparoscopic surgery

Laparoscopic surgery has recently been widely used for various benign colorectal diseases as well as colorectal cancer. Although laparoscopic surgery has been shown to be with similar prognostic results for certain groups of colorectal cancer patients. The influence of laparoscopic procedures on the oncologist results, especially free tumor cell spreading is still a concern for some surgeons. Tumor cells found in the peripheral blood of patients with cancer are termed circulating tumor cells (CTCs). Presence of CTCs in the peripheral blood of patients with colorectal cancer has been reported to be associated with disease stage, poor prognosis, tumor progression, response to therapy, and drug resistance. Whether laparoscopic procedure enhances tumor spreading during operation remains unknown. Significantly less CTC detected during laparoscopic surgery than open surgery for colorectal cancer has been reported. In our previous experience, no significant elevation in CTC level was found in most patients during laparoscopic resection of colorectal cancer. We have shown that laparoscopic surgery had no significantly deleterious effect on CTCs in colorectal cancer patients. In this review, we aim at the impact of CTCs in patients with colorectal cancer undergoing laparoscopic surgery. The prognostic significance of CTCs in patients with colorectal cancer will also be addressed.

Influence of surgical manipulation and surgical modality on the molecular detection of circulating tumor cells from colorectal cancer

Purpose

The aim of this study was to evaluate the relationship between the detection of circulating tumor cell molecular markers from localized colorectal cancer and the time-course of a surgical manipulation or surgical modality.

Methods

From January 2010 to June 2010, samples from the peripheral blood and the inferior mesenteric vein were collected from 42 patients with cancer of the sigmoid colon or rectum. Pre-operative, intra-operative (both pre-mobilization and post-mobilization), and post-operative samples were collected. We examined carcinoembryonic antigen (CEA) mRNA and cytokeratin-20 (CK20) mRNA by real-time reverse-transcriptase polymerase chain reaction. Changes in mRNA detection rates were analyzed according to the time of blood sample collection, the surgical modality, and patient clinicopathological features.

Results

mRNA expression rates before surgical resection did not differ between blood samples from the peripheral and inferior mesenteric veins. The detection rate for CEA and CK20 mRNA showed a tendency to increase after operative mobilization of the cancer-bearing bowel segment. Furthermore, the cumulative detection rates for CEA and CK20 mRNA increased significantly over the course of surgery (pre-mobilization vs. post-mobilization). The cumulative detection rate decreased significantly after surgical resection compared with the pre-operative rates. However, no significant difference was observed in the detection rates between different surgical modalities (laparoscopy vs. open surgery).

Conclusion

The results of this study suggest that surgical manipulation has a negative influence on the dissemination of circulating tumor cells during operations on localized colorectal cancer. However, the type of surgical technique did not affect circulating tumor cells.

Higher CO2-insufflation pressure inhibits the expression of adhesion molecules and the invasion potential of colon cancer cells

AIM: To investigate the influence of CO₂-insufflation pressure on adhesion, invasion and metastatic potential of colon cancer cells based on adhesion molecules expression.

METHODS: With an in vitro artificial pneumoperitoneum model, SW1116 human colon carcinoma cells were exposed to CO₂-insufflation in 5 different pressure groups: 6 mmHg, 9 mmHg, 12 mmHg, 15 mmHg and control group, respectively for 1 h. Expression of E-cadherin, ICAM-1, CD44 and E-selectin was measured at 0, 12, 24, 48 and 72 h after CO₂-insufflation using flow cytometry. The adhesion and invasion capacity of SW1116 cells before and after exposure to CO₂-insufflation was detected by cell adhesion/invasion assay in vitro. Each group of cells was injected intraperitoneally into 16 BALB/C mice. The number of visible abdominal cavity tumor nodules, visceral metastases and survival of the mice were recorded in each group.

RESULTS: The expression of E-cadherin, ICAM-1, CD44 and E-selectin in SW1116 cells were changed significantly following exposure to CO₂ insufflation at different pressures (P < 0.05). The expression of E-cadherin, CD44 and ICAM-1 decreased with increasing CO₂-insufflation pressure. The adhesive/invasive cells also decreased gradually with increasing pressure as determined by the adhesion/invasion assay. In animal experiments, the number of abdominal cavity tumor nodules in the 15 mmHg group was also significantly lower than that in the 6 mmHg group (29.7 ± 9.91 vs 41.7 ± 14.90, P = 0.046). However, the survival in each group was not statistically different.

CONCLUSION: CO₂-insufflation induced a temporary change in the adhesion and invasion capacity of cancer cells in vitro. Higher CO₂-insufflation pressure inhibited adhesion, invasion and metastatic potential in vitro and in vivo, which was associated with reduced expression of adhesion molecules.

Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection

BACKGROUND

We experienced some technical difficulty in dividing the middle and lower rectum through the right-lower quadrant intracorporeally. The aim of this study was to determine whether multiple stapler firings during rectal division are associated with anastomotic leakage after laparoscopic rectal resection.

METHODS

Laparoscopic anterior resection with double-stapling technique anastomosis was performed in 180 consecutive rectal cancer patients. We often used vertical rectal division through a suprapubic site instead of the standard transverse rectal division for laparoscopic total mesorectal excision (LapTME). We attempted to determine whether there was an association between the number of stapler firings and procedures in rectal division. Moreover, we identified risk factors for anastomotic leakage after laparoscopic rectal resection by multivariate analysis.

RESULTS

Anastomotic leakage occurred in 5% of the subjects of this study. Vertical rectal division through the suprapubic site after Lap TME required fewer staples than transverse division through the right-lower port and a smaller percentage of patients required three or more staples for vertical rectal division than for transverse division (15% vs. 45%, p=0.03). In the multivariate analysis, TME and the number of staplers used for rectal division were the factors found to be associated with a significantly greater risk of subsequent leakage (odd's ratio=5.3; 95% CI 1.2-22.7 and odd's ratio=4.6; 95% CI 1.1-19.2).

CONCLUSION

TME and multiple stapler firings during distal rectal division were associated with anastomotic leakage after laparoscopic rectal resection. Vertical rectal division through a suprapubic site was a useful method of avoiding multiple stapler firings during laparoscopic TME.

The influence of different microenvironments on melanoma invasiveness and microcirculation patterns: an animal experiment study in the mouse model

OBJECT

To investigate the influence of different microenvironments on tumor microcirculation patterns and invasiveness capability.

METHODS

Melanoma B16 cells were injected into the abdominal cavity and skeletal muscle of C57 mice synchronously. CK-18 expression in melanoma was assessed to distinguish the malignant phenotype of tumors in the abdominal cavity from that in the skeletal muscle. HIF-1alpha, MMP-2 and MMP-9 expression and mRNA levels of MMP-2 and MMP-9 was detected to compare the mRNA levels of MMP-2 and MMP-9 from the two microenvironments. Cells positive for each immunohistochemical stain and the vessels representative of each type of microcirculation pattern were counted in two microenvironments.

RESULTS

CK-18 and HIF-1alpha expression of melanoma were significantly higher in the skeletal muscle than in the abdominal cavity (P<0.05). Compared with the abdominal cavity, melanoma cells in the skeletal muscle overexpressed MMP-2 and MMP-9 (P<0.05). Real time-PCR results also showed that MMP-2 and MMP-9 mRNA levels of melanoma were higher in the skeletal muscle than in the abdominal cavity (P<0.05). VM channels and endothelium-dependent vessels were the major microcirculation pattern in the skeletal muscle and in the abdominal cavity, respectively.

CONCLUSION

Different microenvironments affect invasiveness and blood supply patterns of melanoma.

Impact of circulating free tumor cells in the peripheral blood of colorectal cancer patients during laparoscopic surgery

Despite widespread use of laparoscopic surgery for colorectal operations, its application for curative resection of colorectal cancer is still controversial. One of the major concerns is the impact of the laparoscopic procedure on dissemination of tumor cells. The main purpose of this study was to investigate the impact of laparoscopic surgery on circulating tumor cells in colorectal cancer patients. Quantitation of circulating free tumor cells (FTCs) was performed preoperatively, during the operation, and 14 days later by means of real-time quantitative reverse transcriptasepolymerase chain reaction (RT-PCR) targeting guanylyl cyclase C (GCC) mRNA in 42 colorectal cancer patients undergoing laparoscopic resections. Despite an increasing trend of FTC detection in patients with advancing stage, there is no significant difference in the preoperative FTC level by disease stage. No elevation in FTC level was found during the laparoscopic procedure in most patients compared with their preoperative FTC value. Patients with a persistently high FTC load [per nucleated blood cells (NBCs)] (> 10(2) FTCs/10(6) NBCs) 2 weeks postoperatively portends a poor prognosis regarding disease recurrence and tumor-related mortality when compared to those with an undetectable or low FTC load (< or = 10(2) FTCs/10(6) NBCs). We concluded that the laparoscopic procedure itself had no significantly deleterious effect on circulating FTCs and that the detection of FTCs by real-time qRT-PCR might be of clinical importance during the postoperative follow-up for colorectal cancer patients.