[Clinicopathological features and prognosis of anorectal melanoma: A report of 68 cases]

OBJECTIVE

To investigate the clinicopathological characteristics of anorectal mucosal melanoma (ARMM), and to evaluate the prognostic factors.

METHODS

A total of 68 primary ARMM surgical specimens from 2010 to 2018 were retrospectively studied. Slides were reviewed to evaluate pathological features. Slingluff staging method was used for staging.

RESULTS

(1) Clinical features: The median age at diagnosis in this group was 61.5 years, with a male-to-female ratio 1 ∶1.62. The most common complaint was blooding (49 cases). For anatomic site, anorectum was the prevalent (66.2%), followed by rectum (20.6%). At the time of diagnosis, 28 cases were stage Ⅰ (localized stage, 41.2%), 25 cases were stage Ⅱ (regional lymph node metastasis, 36.8%), and 15 cases were stage Ⅲ (distant metastasis, 22.1%). Five patients underwent wide local excision, the rest abdominoperineal resection, and 48 patients received adjuvant therapy after surgery. (2) Pathological features: Grossly 88.2% of the tumors were exophytic polypoid masses, with the median tumor size 3.5 cm and the median tumor thickness 1.25 cm. Depth of invasion below lamina muscularis mucosae ranged from 0-5.00 cm (median 1.00 cm). The deepest site of tumor invasion reached muscular layer in 27 cases, and perirectal tissue in 16 cases. Melanin pigmentation was absent or not obvious in 67.6% of the cases. The predominant cytology was epithelioid (45 cases, 66.2%). The rate for ulceration, necrosis, lymphovascular invasion, and perineural invasion was 89.7%, 35.3%, 55.9%, and 30.9%, respectively. The median mitotic count was 18/mm². The positive rate of S100, HMB-45 and Melan-A were 92.0%, 92.6% and 98.0%, respectively. The median of Ki-67 was 50%. The incidences of mutations within CKIT, BRAF and NRAS genes were 17.0% (9 cases), 3.8% (2 cases) and 9.4% (5 cases), respectively. (3) Prognosis: Survival data were available in 66 patients, with a median follow-up of 17 months and a median survival time of 17.4 months. The 1-year, 2-year and 5-year overall survival rate was 76.8%, 36.8% and 17.2%, respectively. The rate of lymphatic metastasis at diagnosis was 56.3%. Forty-nine patients (84.5%) suffered from distant metastasis, and the most frequent metastatic site was liver. Univariate analysis revealed that tumor size (>3.5 cm), depth of invasion below lamina muscularis mucosae (>1.0 cm), necrosis, lymphovascular invasion, BRAF gene mutation, lack of adjuvant therapy after surgery, deep site of tumor invasion, and high stage at diagnosis were all poor prognostic factors for overall survival. Multivariate model showed that lymphovascular invasion and BRAF gene mutation were independent risk factors for lower overall survival, and high stage at diagnosis showed borderline negative correlation with overall survival.

CONCLUSION

The overall prognosis of ARMM is poor, and lymphovascular invasion and BRAF gene mutation are independent factors of poor prognosis. Slingluff staging suggests prognosis effectively, and detailed assessment of pathological features, clear staging and genetic testing should be carried out when possible. Depth of invasion below lamina muscularis mucosae of the tumor might be a better prognostic indicator than tumor thickness.

Toripalimab (anti-PD-1) versus High-Dose Interferon-α2b as Adjuvant Therapy in Resected Mucosal Melanoma: A Phase II Randomized Trial

BACKGROUND

No standard of care for mucosal melanoma (MM) in the adjuvant setting has been established. Meanwhile, relapse-free survival (RFS) is only about five months after surgery alone. This phase II trial aimed to compare toripalimab vs. high-dose interferon-α2b (HDI) as an adjuvant therapy for resected MM.

PATIENTS AND METHODS

From July 2017 to May 2019, 145 patients with resected MM were randomized (1:1) to receive HDI (N = 72) or toripalimab (N = 73) for one year until disease relapse/distant metastasis, unacceptable toxicity, or withdrawal of consent. The primary endpoint was RFS. The secondary endpoints included distant metastasis-free survival (DMFS), overall survival (OS), and safety.

RESULTS

After a median follow-up of 26.3 months, the numbers of RFS, OS, and DMFS events were 51 vs. 46, 33 vs. 29, and 49 vs. 44 in the toripalimab arm and the HDI arm, respectively. The median RFS were 13.6 (95%CI: 8.31-19.02) months and 13.9 (95%CI: 8.28-19.61) months in the toripalimab arm and HDI arm, respectively. The DMFS was not significantly different between the two arms (HR: 1.00, 95%CI: 0.65-1.54). The median OS was 35.1 months (95%CI: 27.93-NR) in the toripalimab arm, with no significant difference in all-cause death (HR: 1.11, 95% CI: 0.66-1.84) for the two arms. The median sums of the patients' actual infusion doses were 3672 mg and 1054.5 MIU in the toripalimab arm and HDI arm, respectively. The incidence of treatment-emergent adverse events with a grade ≥ 3 was much higher in the HDI arm than in the toripalimab arm (87.5% vs. 27.4%).

CONCLUSION

Toripalimab showed a similar RFS and a more favorable safety profile than HDI, both better than historical data, suggesting that toripalimab might be the better treatment option. However, additional translational studies and better treatment regimens are still warranted to improve the clinical outcome of MM.

Cost Effectiveness of Watch and Wait Versus Resection in Rectal Cancer Patients with Complete Clinical Response to Neoadjuvant Chemoradiation

BACKGROUND

Watch and wait (WW) protocols have gained increasing popularity for patients diagnosed with locally advanced rectal cancer and presumed complete clinical response after neoadjuvant chemoradiation. While studies have demonstrated comparable survival and recurrence rates between WW and radical surgery, the decision to undergo surgery has significant effects on patient quality of life. We sought to conduct a cost-effectiveness analysis comparing WW with abdominoperineal resection (APR) and low anterior resection (LAR) among patients with stage II/III rectal cancer.

METHODS

In this comparative-effectiveness study, we built Markov microsimulation models to simulate disease progression, death, costs, and quality-adjusted life-years (QALYs) for WW or APR/LAR. We assessed cost effectiveness using the incremental cost-effectiveness ratio (ICER), with ICERs under $100,000/QALY considered cost effective. Probabilities of disease progression, death, and health utilities were extracted from published, peer-reviewed literature. We assessed costs from the payer perspective.

RESULTS

WW dominated both LAR and APR at a willingness to pay (WTP) threshold of $100,000. Our model was most sensitive to rates of distant recurrence and regrowth after WW. Probabilistic sensitivity analysis demonstrated that WW was the dominant strategy over both APR and LAR over 100% of iterations across a range of WTP thresholds from $0-250,000.

CONCLUSIONS

Our study suggests WW could reduce overall costs and increase effectiveness compared with either LAR or APR. Additional clinical research is needed to confirm the clinical efficacy and cost effectiveness of WW compared with surgery in rectal cancer.

BRAF inhibitors: efficacious and tolerable in BRAF-mutant acral and mucosal melanoma

BRAF inhibitors substantially have impressive clinical efficacy in cutaneous melanoma. However, their role in acral and mucosal melanoma remains unclear. Records were reviewed of patients with metastatic or unresectable BRAF-mutant acral and mucosal melanoma hospitalized and administrated BRAF inhibitors during January 2011 and March 2016. Clinical data were collected to determine PFS, ORR, DCR, OS, and safety. Among 28 acral and 12 mucosal melanoma patients treated with BRAF inhibitors, median PFS were 3.6 (95%CI 3.0-6.4) and 4.4 (95%CI 0.8-12.7) months, median OS were 6.2 (95%CI 6.1-12.1) and 8.2 (95%CI 6.6-19.9) months; ORRs were 38.1% and 20.0%, DCRs were 81.0% and 70.0% in acral and mucosal melanoma, respectively. BRAF inhibitors were well tolerated. The most common adverse effects (AEs) were cutaneous and hematological. Grade 3/4 AEs were relatively rare. In conclusion, BRAF inhibitors have acceptable efficacy and good tolerance in BRAF mutant acral and mucosal melanoma.

[Impact of first-line chemotherapy on renal function in patients with advanced upper tract urothelial carcinoma]

Objective: To observe the impact of first-line chemotherapy on renal function in patients with unresectable/metastatic upper tract urothelial carcinoma(UTUC). Methods: A total of 222 (130 males and 92 females) unresectable/metastatic upper tract urothelial carcinoma patients were included in the study between January 2005 and May 2017, with age of 29 to 87 (62.4±10.1) years old. The serum creatinine level and estimated glomerular filtration rate (eGFR) were compared before and after first-line chemotherapy. And predictive factors for decreased renal function were analyzed in logistic regression model. Results: After the first-line chemotherapy, the average serum creatinine level increased, with a median changing value of 1.5 μmol/L. Howerver, the eGFR improved, with a median changing value of 0.5 ml·min^-1· (1.73 m²)^-1, but the differences were not statistically significant (all P>0.05). In 149 patients who were treated with cisplatin-based chemotherapy, the average serum creatinine level increased by 1.31 μmol/L and eGFR improved by 0.14 ml·min^-1·(1.73 m²)^-1, but the differences were not statistically significant (P>0.05). In multivariate logistic regression model, age more than and equal to 60 years old (OR=0.88, P=0.745) and cisplatin-based chemotherapy (OR=0.95, P=0.893) did not increase the risk of renal dysfunction after first-line chemotherapy. If the time interval between surgery and first-line chemotherapy was more than 1 year, the risk of renal dysfunction due to chemotherapy decreased (OR=0.54, P=0.196). Eastern Cooperative Oncology Group Performance Status (ECOG PS) Scale≥1 (OR=1.81, P=0.131), anemia before treatment (OR=1.14, P=0.764), the cycles of first-line chemotherapy (OR=1.41, P=0.398) may lead to increase the risk of renal dysfunction, but the differences were not statistically significant. However in the patients who accepted nephrectomy, the risk of renal dysfunction after chemotherapy increased, but the difference was still not statistically significant (OR=3.06, P=0.089). Conclusions: First-line chemotherapy, especially the cisplatin-based regimen, had no significant impact on renal function in the patients with UTUC. Nephrectomy maybe a predictive risk factor for decreased renal function after chemotherapy. Adequate assessment of renal function before treatment, hydration and close monitoring during chemotherapy can effectively protect renal function of the patients.

[The invasive fungal rhino-sinusitis cased by aspergillus nidulans: one case report]

This report described a case of the invasive fungal sinusitis cased by asperigillus. A 51 years old women patient complained a sense of welling on right facial, mild pain. No complain of facial numbness and toothache. During the 2 months the symptom repeatedly occurrence. A combined treatment including endoscopic sinus surgery (ESS) and anti fungal therapy was performed in a patient with invasive fungal rhino sinusitis. After 3 months of operation, the patient recovered well. No recurrence, no jaw facial pain and swelling, no eye movement disorder.

Impact of Protein Nutritional Status on Plasma BNP in Elderly Patients

BACKGROUND

Previous studies have demonstrated that the levels of B-type natriuretic peptide (BNP) in plasma are negatively correlated with Body Mass Index (BMI) whereas lean body mass is also closely related to plasma BNP. The purpose of this study is to determine the effect of protein nutritional status on plasma BNP in aged patients.

METHODS AND RESULTS

The cross-sectional study was applied and the anthropometric measurement and nutritional biochemical test was performed in 1118 elderly inpatients in a stable condition were enrolled in the study (mean age, 75 years; 54% women). The partial correlation and multivariate regression analysis were conducted to analyze the relation of plasma BNP with covariates. After adjustment for confounding factors such as age, smoking and coexisting diseases, we found that the concentrations of BNP were independently associated with serum albumin (β=-0.065, P<0.001), serum total cholesterol (β=-0.097, P<0.012) and calf circumference (β=-0.032, P<0.014) in female patients, and associated with the serum albumin (β=-0.051, P<0.001), prealbumin (β=-2.177, P<0.026), mid-arm circumference (β=-0.062, P<0.001) and grip strength (β=-0.100, P<0.048) in male patients. Every 1 gram per liter of increased serum albumin corresponded to the reduced plasma BNP in male patients by 13.9% (OR 0.861, 95% CI 0.817, 0.909) and in female patients by 13.4% (OR 0.866, 95% CI 0.819, 0.916).

CONCLUSIONS

Our study suggests that plasma BNP is negatively correlated with muscle mass, and it is also related to muscle force in male patients. The serum albumin is an independent determinant factor of BNP in both men and women. These findings suggest that good protein nutritional status could be beneficial in maintaining the cardiac function in elder population.

Anatomical information for intercostobrachial nerve preservation in axillary lymph node dissection for breast cancer

This study aimed to provide additional anatomical information for axillary lymph node dissection (ALND) through in vivo anatomy studies of intercostobrachial nerve (ICBN) preservation in order to provide theoretical and practical experience for clinicians. A total of 156 patients with breast cancer underwent ALND at the Department of Gynecology of Baotou Tumor Hospital between June 2009 and March 2010. The origin, destination, main source, length, branch type, and direction of ICBN in axilla were observed, as well as its relationship with adjacent major blood vessels and nerves within the axilla. There were 120 cases of single trunk, 23 cases of double trunks, 9 cases of multiple trunks, and 4 cases without trunks in 156 patients with ICBN preservation. The transverse diameter at the origin of the ICBN was 1.89 ± 0.44 mm with a length of 94.45 ± 12.08 mm; the distances were 77.19 ± 21.04 mm, 29.34 ± 6.73 mm, 90.04 ± 13.13 mm, and 28.63 ± 13.01 mm from origin to the inferior margin at the midpoint of the clavicle, inferior margin of the axillary vein, the bottom of axilla, and branch point, respectively. The identification, dissection, and preservation of ICBN was simple and easy in a modified radical mastectomy for breast cancer and breast-conserving surgery, which only took 10-20 min, but effectively reduced the incidence of post-mastectomy pain syndrome and significantly improved the quality of life for patients after surgery.

[Correlation between motor paralysis and neurotoxicity induced by intrathecal dynorphin A (1-17) in rats]

Intrathecal(i.t.) injection of 10 microliters of dynorphin A(1-17) 20 nmol.L-1 per rat resulted in irreversible hind limb paralysis and suppression of the tail-flick reflex lasting for up to 40 h. The dual effects of dynorphin appeared 5-10 min after the i.t. administration. Histologic examination of the spinal cord in the rats demonstrated dead and/or dying and degenerated motor-neurons in the ventral horn located predominately in the lumbar segment(a 87.2% reduction of the number of motor neurons, P < 0.01) and also in a lesser degree in sacral segment(-69.6%, P < 0.05). The thoracic segment was essentially normal(-8.2%, P > 0.05).

Spinal kappa-opioid system plays an important role in suppressing morphine withdrawal syndrome in the rat

To explore the possible involvement of spinal kappa-opioid receptor in modulating morphine withdrawal syndrome, rats were made dependent on morphine by multiple injections of morphine HCl for 5 days. They were then given intrathecal administration (i.t.) of a kappa-opioid receptor agonist trans-3, 4-dichloro-N-methyl-N-[2-(1-pyrrolidinyl)-cyclohexyl]-benzenacetamide hydrochloride (U-50,488H, 2.5-10 microg) or its antagonist nor-binaltorphimine (nor-BNI, 1.25-5 microg), followed by intraperitoneal administration (i.p.) of naloxone (0.5 mg/kg), and the withdrawal syndrome was scored for 60 min. U-50,488H produced a dose-dependent suppression, whereas nor-BNI a dose-dependent potentiation in withdrawal syndrome. The latter result implies that an endogenous kappa receptor agonist, most probably dynorphin, exerts a tonic suppressive effect on morphine syndrome at spinal level.

Suppression of morphine withdrawal by electroacupuncture in rats: dynorphin and kappa-opioid receptor implicated

Our previous work has demonstrated that 100-Hz electroacupuncture (EA) or 100-Hz transcutaneous electrical nerve stimulation (TENS) was very effective in ameliorating the morphine withdrawal syndrome in rats and humans. The mechanism was obscure. (1) Rats were made dependent on morphine by repeated morphine injections (5-140 mg/kg, s.c., twice a day) for eight days. They were then given 100-Hz EA for 30 min 24 h after the last injection of morphine. A marked increase in tail flick latency (TFL) was observed. This effect of 100-Hz EA could be blocked by naloxone (NX) at 20 mg/kg, but not at 1 mg/kg, suggesting that 100-Hz EA-induced analgesia observed in morphine-dependent rats is mediated by kappa-opioid receptors. (2) A significant decrease of the concentration of dynorphin A (1-17) immunoreactivity (-ir) was observed in the spinal perfusate in morphine-dependent rats, that could be brought back to normal level by 100-Hz EA. (3) 100-Hz EA was very effective in suppressing NX-precipitated morphine withdrawal syndrome. This effect of EA could be prevented by intrathecal administration of nor-BNI (2.5 micrograms/20 microliters), a kappa-opioid receptor antagonist, or dynorphin A (1-13) antibodies (25 micrograms/20 microliters) administered 10 min prior to EA. In conclusion, while the steady-state spinal dynorphin release is low in morphine-dependent rats, it can be activated by 100-Hz EA stimulation, which may be responsible for eliciting an analgesic effect and ameliorating morphine withdrawal syndrome, most probably via interacting with kappa-opioid receptor at spinal level.