Stroma AReactive Invasion Front Areas (SARIFA): a novel histopathologic biomarker in colorectal cancer patients and its association with the luminal tumour proportion

BACKGROUND

Stroma AReactive Invasion Front Areas (SARIFA) is a novel prognostic histopathologic biomarker measured at the invasive front in haematoxylin & eosin (H&E) stained colon and gastric cancer resection specimens. The aim of the current study was to validate the prognostic relevance of SARIFA-status in colorectal cancer (CRC) patients and investigate its association with the luminal proportion of tumour (PoT).

METHODS

We established the SARIFA-status in 164 CRC resection specimens. The relationship between SARIFA-status, clinicopathological characteristics, recurrence-free survival (RFS), cancer-specific survival (CSS), and PoT was investigated.

RESULTS

SARIFA-status was positive in 22.6% of all CRCs. SARIFA-positivity was related to higher pT, pN, pTNM stage and high grade of differentiation. SARIFA-positivity was associated with shorter RFS independent of known prognostic factors analysing all CRCs (RFS: hazard ratio (HR) 2.6, p = 0.032, CSS: HR 2.4, p = 0.05) and shorter RFS and CSS analysing only rectal cancers. SARIFA-positivity, which was measured at the invasive front, was associated with PoT-low (p = 0.009), e.g., higher stroma content, and lower vessel density (p = 0.0059) measured at the luminal tumour surface.

CONCLUSION

Here, we validated the relationship between SARIFA-status and prognosis in CRC patients and provided first evidence for a potential prognostic relevance in the subgroup of rectal cancer patients. Interestingly, CRCs with different SARIFA-status also showed histological differences measurable at the luminal tumour surface. Further studies to better understand the relationship between high luminal intratumoural stroma content and absence of a stroma reaction at the invasive front (SARIFA-positivity) are warranted and may inform future treatment decisions in CRC patients.

Predictive preoperative clinical score for patients with liver-only oligometastatic colorectal cancer

Background

Resection of liver metastases from colorectal cancer (CRC) in the oligometastatic stage improves survival and is a potentially curative treatment. Thus, predictive scores that reliably identify those patients who especially benefit from surgery are essential.

Patients and methods

In this multicenter analysis, 512 patients had undergone surgery for liver metastases from CRC. We investigated distinct cancer-specific risk factors that are routinely available in clinical practice and developed a predictive preoperative score using a training cohort (TC), which was thereafter tested in a validation cohort (VC).

Results

Inflammatory response to the tumor, a right-sided primary tumor, multiple liver metastases, and node-positive primary tumor were significant adverse variables for overall survival (OS). Patients were stratified in five groups according to the cumulative score given by the presence of these risk factors. Median OS for patients without risk factors was 133.8 months [95% confidence interval (CI) 81.2-not reached (nr)] in the TC and was not reached in the VC. OS decreased significantly for each subsequent group with increasing number of risk factors. Median OS was significantly shorter (P < 0.0001) for patients presenting all four risk factors: 14.3 months (95% CI 10.5 months-nr) in the TC and 16.6 months (95% CI 14.6 months-nr) in the VC.

Conclusions

Including easily obtainable variables, this preoperative score identifies oligometastatic CRC patients with prolonged survival rates that may be cured, and harbors potential to be implemented in daily clinical practice.

•

We identified four variables of adverse outcome for patients treated with surgical resection of liver metastases from CRC.

•

Adverse variables were inflammatory response to the tumor, multiple metastases, right-sided primary tumor, node-positive primary tumor.

•

We developed a preoperative clinical score according to the number of risk factors present.

•

Using easily obtainable variables, this score identified patients with oligometastatic CRC with good prognosis.

•

Patients without risk factors should strongly be considered for surgical resection of their metastases.

[Update on collaborative autopsy-based research in German pathology, neuropathology, and forensic medicine]

BACKGROUND

Autopsies are a valuable tool for understanding disease, including COVID-19.

MATERIALS AND METHODS

The German Registry of COVID-19 Autopsies (DeRegCOVID), established in April 2020, serves as the electronic backbone of the National Autopsy Network (NATON), launched in early 2022 following DEFEAT PANDEMIcs.

RESULTS

The NATON consortium's interconnected, collaborative autopsy research is enabled by an unprecedented collaboration of 138 individuals at more than 35 German university and non-university autopsy centers through which pathology, neuropathology, and forensic medicine autopsy data including data on biomaterials are collected in DeRegCOVID and tissue-based research and methods development are conducted. More than 145 publications have now emerged from participating autopsy centers, highlighting various basic science and clinical aspects of COVID-19, such as thromboembolic events, organ tropism, SARS-CoV‑2 detection methods, and infectivity of SARS-CoV-2 at autopsy.

CONCLUSIONS

Participating centers have demonstrated the high value of autopsy and autopsy-derived data and biomaterials to modern medicine. The planned long-term continuation and further development of the registry and network, as well as the open and participatory design, will allow the involvement of all interested partners.

Metastases of Cutaneous Squamous Cell Carcinoma Seem to be the Most Frequent Malignancies in the Parotid Gland: A Hospital-Based Study From a Salivary Gland Center

Malignant parotid tumors account for approximately 20% of all parotid lesions. In addition to the various primary parotid lesions there are secondary parotid malignancies, such as metastases or lymphomas. Data on histopathological distribution of all malignancies-including secondary parotid lesions-is limited. Recent evidence indicated a rising surgical incidence of secondary parotid malignancies. This study aims to review the distribution of malignancies in parotid resections from a salivary gland center. A retrospective review of prospectively collected data for all patients who had received parotidectomy between 2014 and 2019 was performed. Histopathological distribution was displayed separately for all parotid malignancies and for primary parotid malignancies. Further, patients` characteristics were compared between benign and malignant parotid lesions and between the two most common malignant parotid lesions. Out of 777 patients, 614 (78.9%) patients had a benign and 164 (21.1%) patients had a malignant parotid lesion. The most common parotid malignancy was metastatic cutaneous squamous cell carcinoma (cSCC) accounting for 35.4% of all parotid malignancies. 71.5% of all malignant lesions were secondary malignancies. Patients with metastatic cSCC were significantly older (p < 0.001) and significantly more likely to be male (p < 0.001) than patients with primary parotid malignancies. No significant difference was found when the lesion size of metastatic cSCC was compared to primary parotid malignancies (p = 0.216). The present study shows the high prevalence of secondary parotid malignancies in patients who had received parotidectomy. Furthermore, it confirms a rising surgical incidence of metastatic cSCC to the parotid gland in a series from a salivary gland center. At this time, parotid surgery for malignant lesions is more likely to be performed for metastases than for primary parotid malignancies.

[Increased risk of deep vein thrombosis in intensive care unit patients with CoViD-19 infections?-Preliminary data]

Hintergrund

Die Inzidenz tiefer Beinvenenthrombosen (TVT) bei intensivpflichtigen CoViD-19-Patienten wurde bisher nur in wenigen Studien untersucht. Prospektive vergleichende Studien mit Non-CoViD-19-Intensivpatienten fehlen gänzlich.

Fragestellung

Die Inzidenz TVT bei an CoViD-19 erkrankten Intensivpatienten verglichen mit Non-CoViD-19-Patienten, die im selben Zeitraum auf den Intensivstationen des Universitätsklinikums Augsburg behandelt wurden, wurden erhoben. Zudem soll untersucht werden, welche Art der Antikoagulation zum Zeitpunkt des Auftretens der TVT bei CoViD-19-Patienten vorlag und inwiefern eine TVT bei diesem Patientengut mit einer erhöhten Letalität vergesellschaftet ist.

Material und Methoden

In der prospektiven Single-Center Studie wurden im Zeitraum vom 18.04.2020 bis 30.04.2020 20 SARS-CoV2-positive Patienten mit 20 Non-CoViD-Patienten auf Intensivstation bezüglich des Auftretens tiefer Beinvenenthrombosen verglichen. Hierzu wurden demographische Daten, Laborparameter und klinische Verläufe erfasst und ausgewertet.

Ergebnisse

Die Rate an TVT war im untersuchten Kollektiv bei Patienten mit SARS-CoV2 deutlich erhöht (CoViD-19-Patienten: 20 % vs. Non-CoViD-19-Patienten: 5 %). Sowohl das Vorliegen einer TVT sowie deutlich erhöhte D‑Dimer-Werte waren in der vorliegenden Studie mit erhöhter Letalität vergesellschaftet.

Diskussion

Wir empfehlen bei der stationären Aufnahme von Patienten mit SARS-CoV2-Verdacht oder Nachweis die Bestimmung der D‑Dimere und im Falle erhöhter Werte die großzügige Indikationsstellung zur Kompressionssonographie der tiefen Beinvenen. So können TVT früh erkannt und eine therapeutische Antikoagulation begonnen werden. Alle stationären CoViD-19-Patienten sollten eine Thromboseprophylaxe mit NMH erhalten. Weitere Studien zu Point-of-care-Methoden (TEG®, ROTEM®) zur Erkennung einer Hyperkoagulabilität bei SARS-CoV2 sind notwendig.

[Periodic fever and pancytopenia in a 35-year-old patient]

MEDICAL HISTORY AND INITIAL PRESENTATION

A 35-year-old patient with a previous history of persistent episodic fever, sore throat, myalgia, and cephalgia presented for evaluation of pancytopenia. He had no recent travel history, except for a stay in Italy 1 year prior to admission and in Spain several years in the past.

DIAGNOSTIC WORKUP

Laboratory evaluation confirmed pancytopenia, agranulocytosis, and elevated infection parameters without indicative serological results en par with lymphadenitis colli. Computed tomography scanning revealed cervical lymphadenopathy, hepatosplenomegaly, and colitis with occult perforation of the sigmoid colon. Bone marrow biopsy showed an infiltration of polyclonal plasma cells. Lymph node biopsy was compatible with necrotizing lymphadenitis.

DIAGNOSIS

Polymerase chain reaction analysis of a lymph node specimen confirmed the presence of Leishmania species, thereby enabling the diagnosis of visceral Leishmania.

THERAPY COURSE

Treatment with liposomal amphotericin B was initiated. Both fever and lymphadenopathy quickly resolved.

CONCLUSION

VL is a clinically pleiotropic, severe disease with fatal outcome if left untreated. It often presents with distinct similarities to hematologic malignancies. Exacerbation can occasionally occur as fulminant macrophage activation syndrome. Disease incidence is globally increasing and has not peaked as yet. A complex interplay between pathogen and the immune system is the key pathophysiological mechanism.

[Pathology of early stage cancer of the gastrointestinal tract : Definition, principles and diagnosis]

BACKGROUND

Early stage cancers of the gastrointestinal tract are malignant tumors that are eligible for local therapy regimens and show an excellent prognosis.

OBJECTIVE

This article explains the histopathological aspects of the various diseases that are covered by this topic.

METHODS

Organ-preserving therapies are discussed according to their locations and under consideration of the current guidelines and the relevant literature.

RESULTS

The exact histopathological evaluation of early cancers of the gastrointestinal tract is of crucial importance. It is the essential basis for all further therapy decisions. In most cases, an option for a local resection is given. In comparison to partial or complete organ resections, local resection is associated with a significantly decreased morbidity and reduced length of hospital stays; however, it must be ensured that local therapies do not become responsible for increased rates of tumor recurrence and progression. Therefore, an optimal risk estimation based on a sophisticated histopathological classification is mandatory. This includes the evaluation of the infiltration depth, grading, lymphovascular invasion and resection margins.

CONCLUSION

Molecular analyses have not yet entered clinical practice. The only exceptions are investigations to detect hereditary diseases. The exact histopathological diagnostic of early gastrointestinal cancers is the basis of an effective and organ-preserving therapy.

Antithrombogenic Coating of Stents Using a Biodegradable Drug Delivery Technology

To reduce the thrombogenic properties of coronary artery stents, a biodegradable polylactic acid (PLA) stent coating with an incorporated thrombin inhibitor and a platelet aggregation inhibitor has been developed. In an ex vivo human stasis model, its effect on platelets, plasmatic coagulation and its release characteristics were studied using whole blood. Bare steel and bare gold-surface stents were compared to steel and gold-surface stents coated with PLA (30 kDa) containing 5% polyethyleneglycol (PEG)-hirudin and 1% iloprost, with an empty tube as control. Markers of activated coagulation (prothrombin fragment F1-2 and thrombin-antithrombin III complex, TAT), were assayed and the release of drugs from the coating was assessed by aPTT and collagen-induced platelet aggregation. Bare steel and gold stents were completely covered by a blood clot, and high levels of coagulation markers (F1-2 fragment and TAT) were detected. No differences in the thrombogenic properties were found between bare gold or steel stents. Coated stents were free of blood clots and only minor elevations of markers were detected. Release data from in-vitro studies over 90 days showed a gradual release of the drugs with an initial exponential release characteristic for PEG-hirudin, slow release of iloprost and a 10% degradation of the PLA carrier. This drug releasing biodegradable coating effectively reduced thrombus formation independent of the metallic surface.

[True thymic hyperplasia : Differential diagnosis of thymic mass lesions in neonates and children]

Reactive and neoplastic thymic pathologies are the main considerations in the case of masses in the anterior and middle part of the mediastinum, while neurogenic tumors are predominant in the posterior mediastinum (which are not dealt with here). In neonates and infants, the commonest pathologies in the anterior mediastinum comprise germ cell tumors (mainly teratomas), congenital thymic cysts and true thymic hyperplasia (TTH). In toddlers, teratomas, yolk sac tumors and cysts predominate. In children over 5 years of age, lymphomas are the commonest mass lesions whereas thymomas and thymic carcinomas are rare. In addition, inflammation-linked hyperplasia in myasthenia gravis and rebound thymic hyperplasia after chemotherapy must be considered. Although rare at all ages, sarcomas must be considered in the differential diagnosis from birth onwards and throughout adolescence. Based on the report of a rare case of recurrent TTH, the differential diagnosis of this benign but potentially life-threatening condition is discussed.

[Percutaneous Phil™-Embolization for Preoperative Therapy of Carotid Body Paragangliomas]

Introduction: Paragangliomas are rare tumors representing a therapeutic challenge. In particular, the surgical removal may lead to life-threatening bleeding. The preoperative percutaneous embolization is an alternative that allows a high closure rate of tumor-feeding vessels in a short intervention time and thus significantly reduces intraoperative bleeding probability. Complete tumor resection is facilitated thereby. The use of a new non-adhesive liquid embolic agent is presented here. Methods: A 50-year old patient presented with 4 cm large paraganglioma of the carotid body (Shamblin II). A percutaneous embolization with 7 ml PHIL™ (injectable precipitating hydrophobic liquid) was performed preoperatively. 24 h later the complete surgical resection of the tumor was performed. Results: A good distribution of the liquid embolic agent could be achieved over the entire tumor. Intraoperative resection of the tumor was much easier and faster due to low bleeding tendency over the entire surface of the tumor. Total blood loss was less than 50 ml. All adjacent nerve and arterial structures could be spared. Postoperative nerve function was normal and the patient was discharged on the 4^th postoperative day. Conclusion: The combination of percutaneous embolization and surgical resection provides a safe combination in the treatment of advanced carotid body paragangliomas. The use of a novel liquid embolic agent may possibly further optimize the therapy.

[Laparoscopic rectal resection technique]

The quality of radical oncological operations for patients with rectal cancer determines the rate of local recurrence and long-term survival. Neoadjuvant chemoradiotherapy for locally advanced tumors, a standardized surgical procedure for rectal tumors less than 12 cm from the anus with total mesorectal excision (TME) and preservation of the autonomous nerve system for sexual and bladder function have significantly improved the oncological results and quality of life of patients. The TME procedure for rectal resection has been performed laparoscopically in Germany for almost 20 years; however, no reliable data are available on the frequency of laparoscopic procedures in rectal cancer patients in Germany. The rate of minimally invasive procedures is estimated to be less than 20 %. A prerequisite for using the laparoscopic approach is implicit adherence to the described standards of open surgery. Available data from prospective randomized trials, systematic reviews and meta-analyses indicate that in the early postoperative phase the generally well-known positive effects of the minimally invasive approach to the benefit of patients can be realized without any long-term negative impact on the oncological results; however, the results of many of these studies are difficult to interpret because it could not be confirmed whether the hospitals and surgeons involved had successfully completed the learning curve. In this article we would like to present our technique, which we have developed over the past 17 years in more than 1000 patients. Based on our experiences the laparoscopic approach can be highly recommended as a suitable alternative to the open procedure.

Galectin-3 and Cyclin D3 Immunohistochemistry and Tumor Dimensions Are Useful in Distinguishing Follicular Oncocytic Carcinomas from Oncocytic Adenomas of the Thyroid

Aims. Oncocytic (Hurthle) follicular cell tumors (OTs) of the thyroid are both adenomas (OAs) and follicular carcinomas (OCs). The routine diagnosis of these tumors can be problematic even after an accurate sampling and histological examination. Beside preoperative evaluation due to the tumor's dimension several studies have been performed to find markers able to distinguish malignant from benign follicular tumors in the thyroid, with Galectin-3 being one of the most effective. Recently, some authors suggested cyclin D3 as adjunct to the diagnosis of the oncocytic lesions of the thyroid. Methods and Results. In this paper we assess the role of Galectin-3 and cyclin D3 in a well-selected group of follicular oncocytic tumors (14 OCs and 26 OAs). The diameter of each lesion was also evaluated. The combination of Galectin-3 and cyclin D3 has a good specificity (81%) and sensitivity (100%). Moreover, the maximum diameter (in cm) of OCs is greater than OAs (4.1 versus 2.3). Conclusions. We believe that the use of Galectin-3 and cyclin D3 in OTs of the thyroid can be a helpful panel in daily practice when histology is doubtful.

[Case report of granulomatous necrotizing sialadenitis. Rarity of first manifestation in submandibular gland]

This article presents the case of a 43-year-old male patient with recurrent painful swelling of the right submandibular gland. Submandibulectomy was performed. Histological investigations showed an intense granulomatous inflammation with severe destruction of the parenchyma. The inflammatory infiltrate consisted of abscesses with neutrophilic and eosinophilic granulocytes and ill-defined granulomas with multinucleated giant cells. Some of the blood vessels showed evidence of vasculitis. After further clinical and serological investigations with highly elevated levels of cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) and antiproteinase-3 antibodies, a rare limited disease of granulomatous polyangiitis (Wegener granulomatosis) was finally diagnosed. Such a manifestation of the disease is exceedingly rare; therefore, only single case reports have so far been described. The certain establishment of the diagnosis seems to be challenging because of the lack of involvement of the respiratory tract and the kidneys. In this case a histological assessment and clinical findings are mandatory for the correct diagnosis.

[Lymph node staging in gastrointestinal cancer. Combination of methylene blue-assisted lymph node dissection and ex vivo sentinel lymph node mapping]

The histopathological lymph node staging is of crucial importance for the prognosis estimation and therapy stratification in gastrointestinal cancer. However, the recommended numbers of lymph nodes that should be evaluated are often not reached in routine practice. Methylene blue assisted lymph node dissection was introduced as a new, simple and efficient technique to improve lymph node harvest in gastrointestinal cancer. This method is inexpensive, causes no delay and needs no toxic substances. All studies performed revealed a highly significantly improved lymph node harvest in comparison to the conventional technique. Moreover, this technique can be combined with a new ex vivo sentinel lymph node mapping that for the first time is based on histological sentinel lymph node detection. The success rate of this method is similar to conventional techniques and it enables an efficient application of extended investigation methods, such as immunohistochemistry or the polymerase chain reaction.

Endoscopic submucosal dissection in large sessile lesions of the rectosigmoid: learning curve in a European center

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) in the colorectum is not currently a standard procedure. Few data are available from the Western world. The aim of the present study was to report on the first experiences and the learning curve of colorectal ESD in a European center.

PATIENTS AND METHODS

A total of 82 rectosigmoid lesions were referred for ESD. Lesion characteristics, resection rates, procedure times, complications, and recurrences were recorded prospectively. Results were compared between three consecutive study periods in order to determine the learning curve.

RESULTS

Lesions were located in the rectum (86.6 %) and the sigmoid colon (13.4 %). Median diameter was 45.5 mm. Lesions were of Paris type 0-Is with pit pattern type V (n = 8), 0-IIa (n = 33), 0-IIa + Is (n = 36), and 0-IIa + IIc (n = 5). The malignancy rate in these groups was 100 %, 0 %, 14 %, and 20 %, respectively. ESD was possible in 76 lesions (92.7 %). En bloc resection rate and R0 resection rate were 81.6 % and 69.7 %, respectively. Median procedure time was 176 minutes. Between the three consecutive study periods, en bloc resection rate increased (60.0 %, 88.0 %, 96.2 %), R0 resection rate increased (48.0 %, 76.0 %, 84.5 %; P < 0.001), and procedure time decreased (200, 193, 136 minutes; P = 0.027). The perforation and bleeding rates were 1.3 % and 7.9 %, respectively. Recurrence risk was 0 % after R0 en bloc resection and 41.7 % after piecemeal resection (P < 0.05). Median follow-up was 23.6 months.

CONCLUSIONS

In the European setting, ESD in the distal colon is feasible with acceptable complication risks. Resection rates were not as high as those from Japanese studies; however, a clear learning curve could be shown. Colorectal ESD needs to be further evaluated, particularly in Europe where ESD experience is low.

Clinical significance of lymph vessel density in T3 colorectal carcinoma

PURPOSE

The purpose of the present study is to characterise the lymphatic vessel density (LVD) in the T3 colorectal carcinoma and to correlate it with N status, grading and presence of tumour budding.

METHODS

A total of 56 cases of T3 colorectal carcinoma were retrieved from the pathology's archive of Klinikum Augsburg. All slides were stained immunohistochemically with D2-40 (lymphatic endothelium) and with pancytokeratin to assess the tumour budding. Tumour budding and lymph vessel density were investigated independently by BM and CC. The highest density of lymphatic vessels was counted both in tumour centre (ILVD) and at the periphery of the tumour (PLVD) within an area of 0.24 mm(2).

RESULTS

Due to the strong intra-observer (BM and CC) difference in ILVD and PLVD, all cases were re-evaluated establishing a consensus that has been used for the further analyses. There was a significant difference between PLVD and ILVD (12 ± 4 versus 6 ± 3; P < 0.001). Moreover, we found a non-significant trend towards high PLVD in the cases with nodal metastasis versus the negative one, 13 ± 5/hpf versus 11 ± 4 (P = 0.072). There was no association between tumour budding and ILVD and PLVD (P = 0.249 and 0.38).

CONCLUSION

Colorectal carcinoma induces lymphangiogenesis. A higher PLVD could increase the capability of cancer cell to invade the lymphatic system. However, the obvious difficulties in immunohistochemical evaluation and the rather small differences between nodal positive and negative cases in T3 colorectal cancer seem to limit the clinical value of LVD evaluation.

Neoadjuvant chemotherapy affects staging of colorectal liver metastasis--a comparison of PET, CT and intraoperative ultrasound

PURPOSE

Surgery for colorectal liver metastasis facilitates long-term survival, and neoadjuvant chemotherapy improves resectability but may also alter staging accuracy. The aim of this study was to evaluate the effects of neoadjuvant chemotherapy on the efficacy of positron emission tomography (PET), PET-computed tomography (CT), CT and intraoperative ultrasound (IUS) in the detection of liver metastasis.

METHODS

Between January 2007 and January 2010, 34 patients with resectable colorectal liver metastasis were included in this retrospective analysis. Seventeen patients had received neoadjuvant chemotherapy. PET or PET-CT, CT or magnetic resonance imaging (MRI) and IUS were performed in all patients. Sensitivity, specificity, positive predictive value and negative predictive value were analysed. Histopathological examination of the resected specimens served as standard reference.

RESULTS

A total of 109 liver segments were resected, of which 50 showed no metastatic involvement (45.9%). For patients without systemic chemotherapy, sensitivities for PET, CT/MRI and IUS were 92%, 64% and 100% respectively as compared with 63%, 65% and 94% for patients after neoadjuvant chemotherapy in a segment-based analysis. For PET, standardised uptake values were decreased by 3.9 in 10 patients after chemotherapy whereas lesion diameters were similar (3.0 vs. 3.2 cm). Additional metastases were detected by IUS in seven patients resulting in a change of operative procedure in 20.6%.

CONCLUSION

Staging accuracy of colorectal liver metastasis is influenced by neoadjuvant chemotherapy. For PET, decreased tumour metabolism rather than downsizing may account for a drop in sensitivity after neoadjuvant chemotherapy. IUS is critical to avoid incomplete resections.

Tumour budding, uPA and PAI-1 are associated with aggressive behaviour in colon cancer

AIMS

The proteases PAI-1 and uPA play a major role in extracellular matrix degradation, which facilitates tumour progression. Tumour budding is a histomorphological expression of enhanced tumour cell migration.

MATERIALS AND METHODS

To investigate their prognostic value for and correlation with colon cancer, a prospective study was performed. We analysed tissue levels of uPA and PAI-1 of 55 colon cancer tumours employing a commercially available enzyme-linked immunosorbent assay (ELISA). Tumour budding was analysed on cytokeratin-stained slides.

RESULTS

There was a strong correlation between uPA and tumour budding (R = 0.440; P < 0.001). uPA levels were increased in high grade tumours, whereas PAI-1 was elevated in cases with venous invasion (P = 0.004 and P = 0.028). PAI-1 values and tumour budding are associated significantly with the occurrence of distant metastases (P < 0.001 and P = 0.034, respectively). Tumour budding was significantly associated with lymph node metastases (P = 0.034). Multivariate analysis revealed PAI-1 and lymph node metastases to be independently predictive of distant metastases (P = 0.007 and P = 0.004, respectively).

CONCLUSIONS

The results of our study show that tumour budding and the plasmin/plasminogen system are related. PAI-1 was independently predictive for the occurrence of distant metastasis.

Fulminant metastatic spread in a patient with an early gastric cancer

A patient with an early gastric cancer was treated initially by endoscopic submucosal dissection (ESD) at our hospital. The resected specimen showed a depth of submucosal infiltration of more than 500 microm. Therefore, in accordance with the extended criteria with regard to EMR, the patient underwent gastrectomy. The TNM stage was pT1 (sm3), pN0 (0 / 58), cM0, L0, V0, G2 after surgery (UICC stage Ia). At 3 months later ultrasound revealed a new mass in the liver, and biopsy showed a rapidly growing metastasis of the gastric adenocarcinoma. Finally, immunohistochemical analysis of all the lymph nodes of the resected stomach revealed a micrometastasis (3mm) directly under the ESD site. The patient died 6 months later. This clinical case highlights the risk of affected lymph nodes in early gastric cancer and the consequent risk of metastasis which increases with greater depth of infiltration to the submucosa.

[Lymph node preparation in colorectal cancer. Ex vivo methylene blue injection as a novel technique to improve lymph node visualization]

The UICC requires investigation of a minimum of 12 lymph nodes for adequate lymph node staging in colorectal cancer. Despite that, many authors recommend investigation of a larger number, and different techniques, such as fat clearance, have therefore been developed. In this study we introduce a novel technique involving ex vivo lymph node staining with intraarterial methylene blue injection in colon cancer. We compared 14 cases in which methylene injection was used with 14 cases from our records in which conventional investigation techniques were applied. The lymph node harvest differed highly significantly (p<0.001) between the two groups, with average numbers of 28+/-7 and 14+/-3 in the methylene blue group and the unstained group, respectively. The largest difference occurred in the size group 2-4 mm (191 vs 70 lymph nodes). In 6 cases in the unstained group additional embedding of fatty tissue was necessary to reach an adequate number of investigated lymph nodes. Methylene blue injection is a novel and highly effective method that will improve lymph node preparation in colorectal cancer.

Morphological and histopathological comparison of left and right internal thoracic artery with implications on their use for coronary surgery

Goal of this study was the morphological comparison of the left (LITA) and right internal thoracic artery (RITA). Both ITAs were taken out in 20 autopsy cases. Sections over the entire length of vessel were cut and histomorphological examination was performed. There were no significant differences between the LITA and RITA concerning length, diameter, wall thickness and structure. The occurrence rates of atherosclerosis were equal. Four vessels showed luminal narrowing of more than 50%. There was a good correlation between the length of the sternum and the ITA. According to our findings the morphology of LITA and RITA is similar.

Antithrombogenic coating of stents using a biodegradable drug delivery technology

To reduce the thrombogenic properties of coronary artery stents, a biodegradable polylactic acid (PLA) stent coating with an incorporated thrombin inhibitor and a platelet aggregation inhibitor has been developed. In an ex vivo human stasis model, its effect on platelets, plasmatic coagulation and its release characteristics were studied using whole blood. Bare steel and bare gold-surface stents were compared to steel and gold-surface stents coated with PLA (30 kDa) containing 5% polyethyleneglycol (PEG)-hirudin and 1% iloprost, with an empty tube as control. Markers of activated coagulation (prothrombin fragment F1-2 and thrombin-antithrombin III complex, TAT), were assayed and the release of drugs from the coating was assessed by aPTT and collagen-induced platelet aggregation. Bare steel and gold stents were completely covered by a blood clot, and high levels of coagulation markers (F1-2 fragment and TAT) were detected. No differences in the thrombogenic properties were found between bare gold or steel stents. Coated stents were free of blood clots and only minor elevations of markers were detected. Release data from in-vitro studies over 90 days showed a gradual release of the drugs with an initial exponential release characteristic for PEG-hirudin, slow release of iloprost and a 10% degradation of the PLA carrier. This drug releasing biodegradable coating effectively reduced thrombus formation independent of the metallic surface.