Clinical Aspects and Management of Hereditary Non-Polyposis Colorectal Cancer (HNPCC)

Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomical dominant trasmitted disease phenotypically defined according to the “Amsterdam criteria” as follows: at least 3 affected relatives, one of whom first degree relative of other two, at least two successive generations affected. Important cardinal features are:

1 prevalent proximal location of cancers (above splenic flexure);

2 multiple synchronous or methachronous large bowel cancers;

3 early age of onset (<50 years);

4 presence of extracolonic cancers (endometrium, stomach, urinary tract, skin).

The treatment is essentially surgical and total colectomy with ileo-rectum anastomosis is already proposed as standard procedure with annual endoscopic examination of retained rectum. The screening of individuals at risk, so determined by the analysis of pedigree or the results of molecular tests, must be performed every 1-2 years by colonoscopy starting around the age of 25 years. In this review are described and analysed the spectrum of the disease with particular attention to the frequency and characteristics of extracolonic cancers. Moreover, the guidelines of the surveillance and screening are reported following the data of the literature and as proposed by the International Collaborative Group (ICG-HNPCC).

Cancer of the Pancreas: Clinical Outcome in 76 Cases

A final diagnosis of pancreatic cancer was established in 76 consecutive patients during 4 years. The clinical outcome was evaluated retrospectively, as well as clinical presentation and its impact on the rate of resectability. Even though the diagnostic techniques showed a high sensitivity, only 18.4% of patients had a radical resection performed. In 77.6% of the cases a tissue diagnosis had been obtained. However, in only 1/5 of them was the tissue proof obtained preoperatively. This review confirms that the survival of patients with pancreatic cancer is poor, with slight advantages in the few resectable cases. Therefore, an earlier diagnosis should be attempted in high-risk symptomatic patients, selected by means of nonaggressive tests and evaluated by means of more accurate diagnostic techniques, when suitable.

Outcome of Follow-Up Programs in Patients Previously Resected for Colorectal Cancer

The survival of a group of 115 patients (group A) who entered a follow-up program after apparently « curative » surgery for colorectal cancer was compared with that of 62 similar patients (group B) who did not join such a program. No significant difference was found. Clinical benefits to single patients in group A, in terms of anticipated diagnosis and effective treatment of recurrences and of metachronous neoplasias, appeared to be, if any, extremely limited. In light of the high costs of intensive follow-up programs, it is concluded that their use can be justified only within controlled perspective trials aimed to evaluate their usefulness.

Value of Multiple Forceps Biopsies in Assessing the Malignant Potential of Colonic Polyps

Fifty-nine colo-rectal polyps were detected at endoscopy and repeatedly biopsied before removal by endoscopic snare polypectomy. The aim of the present paper was to evaluate the reliability of multiple forceps biopsies in assessing both the malignant potential and the presence or absence of invasive cancers (IC) in colo-rectal adenomas (CRA). In order to achieve the first objective, the histologic types and the degree of dysplasia have been defined. The data obtained by means of multiple biopsies examination, compared with those of polyp in toto study, show that fractional biopsies were of value in the histologic classification of only the smallest 41 polyps (agreement 88.09 %), whilst no reliability of biopsies was demonstrated in the 18 largest polyps (agreement 27.68 %). In the field of dysplasia grading, the agreement was 55 % and 61 % for the smallest and the largest CRA respectively. These last figures are hardly acceptable. Biopsies examination gave also under- and overestimation of the histologic severity and of dysplasia as well as a significant incidence of false negative results in IC detection. It is concluded that polypectomy is the only method which provides adequate material for precise diagnosis, no matter how large a polyp. Therefore it should be performed whenever possible. Finally the authors discuss the management of small sessile adenomas.

Ca 19-9 Assay in Patients with Extrahepatic Cholestatic Jaundice

Serum concentrations of the CA 19-9 tumour marker were determined in 35 patients with histologically proven bilio-pancreatic malignancies associated with obstructive jaundice and in 35 patients with benign extrahepatic jaundice due to choledocholithiasis.

At a cut-off level of 37 U/ml the sensitivity of this assay was 82.8%, but the specificity was very low (45.7%). Thus CA 19-9 can not be employed to differentiate between malignant and benign extrahepatic jaundice.

Serial samples of CA 19-9 were achieved in 7 patients with benign and in 6 patients with malignant biliary obstruction, before and after the disappearance of jaundice. Serum concentrations of this tumour-antigen returned to normal concurrently with the bilirubin values only in patients with benign obstruction, remaining unchanged in all cases of malignancies.

The data suggest that patients with extrahepatic jaundice should be evaluated by other examinations or by collecting serial samples for this assay.

Esophageal Involvement in Breast Cancer. Report of Six Cases

Six case reports are described which illustrate a uniform syndrome characterized by progressive dysphagia developing in postmenopausal breast cancer patients after a long disease-free interval following mastectomy. Literature cases are reviewed and treatment strategies are discussed. The authors recommend that, when possible, radiotherapy to the mediastinum and/or chemotherapy with dilation or positioning of an endoprothesis should be considered as the treatment of choice, whereas surgical intervention should be limited.

Gastric Carcinoma: Preliminary Data of a Cooperative Program for Early Diagnosis

The results of a program of early gastric cancer detection, carried out in the Oncologic Institutes of Genoa, Forlì and Florence, are evaluated. General practitioners screened subjects, according to possible anamnestic and clinical risk indicators (age, family history, previous gastric lesions, digestive complaints, etc.). The diagnostic procedure consisted of medical examinations, endoscopy with cytology and/or directed biopsy, and possibly air contrast barium X-ray. Of 3,180 subjects examined, 224 had gastric cancers (7 %), 29 of which were early cancers, and 688 had high risk lesions; 1,478 cases of other pathology were detected. The authors stress that the proportion of early cancer is clearly higher than that found in routine diagnosis, yet still lower compared to the results of screening programs carried on the general population. Moreover, the high diagnostic sensitivity of each method in early gastric cancer detection and, on the other hand, the difficulties in the detection of high risk lesions, which require systematic multiple biopsies, are emphasized.

Pancreatic intraductal sampling during ERCP in patients with chronic pancreatitis and pancreatic cancer: cytologic studies and k-ras-2 codon 12 molecular analysis in 47 cases

BACKGROUND

A preoperative tissue diagnosis of pancreatic cancer is desirable but difficult to obtain.

METHODS

Pancreatic brush cytology, salvage cytology, and collection of pancreatic juice were attempted prospectively during ERCP in 34 patients with pancreatic cancer and 11 with chronic pancreatitis. K-ras-2 codon 12 was analyzed for presence and type of point mutations.

RESULTS

Brush cytology coupled with salvage cytology had a sensitivity of 74%. The addition of cytologic analysis of pancreatic juice did not substantially improve sensitivity (76%). K-ras-2 was mutated in both cancer (87%) and pancreatitis (40%). The specificity for cytology was 100% and for K-ras-2 mutations 60%. Combining cytology with mutation analysis increased sensitivity to 93% but reduced the positive predictive value. The negative predictive value never exceeded 75%. None of the patients with chronic pancreatitis had cancer develop (median follow-up 60 months).

CONCLUSIONS

Pancreatic ductal brushing with salvage cytology is useful in the diagnosis of cancer, whereas cytologic analysis of pancreatic juice can be abandoned. At present, K-ras-2 mutation is not useful for differentiating pancreatic cancer from chronic pancreatitis or the identification of patients with chronic pancreatitis at risk for malignant transformation.

Gastroesophageal reflux disease: relationship between clinical and histological features. GOSPE. Gruppo Operativo per lo Studio delle Precancerosi dell'Esofago

Our purpose was to evaluate the relationship between the clinical and histological features in a cohort of patients who had gastroesophageal reflux-related lesions diagnosed after upper digestive endoscopy. In all, 589 patients scheduled for elective endoscopy in a multicentric prospective study were evaluated. Multiple biopsies from the distal esophagus showing aspects of esophagitis or metaplastic epithelium were taken. Esophagitis was histologically detected in 25.6%, gastric-type Barrett's esophagus in 36.2%, and specialized columnar epithelium in 33.1%. The frequency of esophagitis was constant across age decades. Patients with specialized columnar epithelium were significantly older (P = 0.01) and had a greater extent of metaplastic epithelium (P<0.0001). Specialized columnar epithelium was observed in 15% of patients with only distal esophagitis. In conclusion, endoscopic esophagitis was constant across age strata. The presence of specialized columnar epithelium was associated with older age and with longer segments of Barrett's esophagus. Short areas of esophagitis should be biopsied in view of their potential for holding areas of specialized columnar epithelium.

Do patients with rectosigmoid adenomas 5 mm or less in diameter need total colonoscopy?

BACKGROUND

The need for colonoscopy in the care of patients with rectosigmoid adenoma 5 mm or less in diameter is still debatable.

METHODS

We estimated the prevalence of proximal adenomas among 3052 consecutive subjects undergoing total colonoscopy. Rectosigmoid adenoma was classified as diminutive (5 mm), small (6 to 10 mm), or large (>/=11 mm). Advanced proximal adenoma was 10 mm in diameter or larger, or with a villous component, severe dysplasia, or infiltrating adenocarcinoma.

RESULTS

Proximal adenoma was found in 212 of 2483 patients (8.5%, 95% CI [7.5, 9.7]) without distal neoplastic polyps, 49 of 214 (22.9%, 95% CI [17.6, 29.2]) with diminutive, 44 of 174 (25.3%, 95% CI [19.1, 32.5] with small, and 70 of 181 (38.7%, 95% CI [31.6, 46.2]) with large distal adenoma. Advanced proximal adenoma was found in 49 (2.0%, 95% CI [1.5, 2.6]), 8 (3.7%, 95% CI [1.7, 7.5]), 17 (9.8%, 95% CI [6.0, 15.4]), and 29 patients (16.0%, 95% [11.2, 22.4]), respectively. In patients with distal adenoma risk for proximal lesions increased with increasing age, size, and number of distal adenomas (p = 0.01). Size of distal adenoma was the strongest predictor of the presence of proximal advanced adenoma (multivariate analyses).

CONCLUSIONS

In a clinical setting, the decision to perform colonoscopy should take into account proximal lesions of clinical interest, life expectancy, costs, and risks associated with the procedure. When detection of advanced proximal adenoma is the goal, presence of distal diminutive adenoma alone might not be an indication for total colonoscopy.

Endoscopic Nd:YAG laser therapy for villous adenomas of the right colon

BACKGROUND

Endoscopic laser therapy is considered an acceptable treatment of benign colorectal adenomas. The aim of our study was to evaluate the efficacy of Nd:YAG laser to ablate right-sided colonic sessile adenomas.

METHODS

Between January 1990 and February 1996, 56 patients underwent laser therapy because of high operative risk or refusal of surgery. Lesions were located as follows: cecum (23), ascending, (15), and hepatic flexure (18). Six patients (10.7%) had multiple polyps in the ascending colon. Histologic examination showed a tubulovillous pattern in 20 (35.7%) and a villous pattern in 36 (64.3%). Low-grade dysplasia was detected in 44 patients (78. 5%) and high-grade dysplasia in 12 (21.4%).

RESULTS

The number of laser sessions ranged between 1 and 6 (median 3) and complete ablation, histologically confirmed, was achieved in 49 cases (87.5%). Seven patients (12.5%) underwent surgery: 2 for incomplete tumor destruction, 3 because of invasive carcinoma on repeated biopsies. Two patients (3.6%) had complications (one perforation of the cecum and one hemorrhage). Follow-up ranged from 6 to 60 months and no recurrences were observed.

CONCLUSION

Laser therapy is an effective method for the destruction of sessile adenomas of the right colon in selected patients.

Novel germline APC variants in patients with multiple adenomas

Chain-terminating germline APC mutations are responsible for adenomatous polyposis coli (APC). In the present work, we tested the hypothesis that germline APC mutations may be present in some patients with a milder phenotype, i.e., multiple synchronous colorectal adenomas. Eighteen patients with 3 or more colorectal adenomas at endoscopy (within a 6-month period) were ascertained from a series of subjects undergoing endoscopic examination. Their blood DNAs were analysed for the presence of germline mutations in the APC coding region by single-strand polymorphism analysis. Ten unrelated polyp-free subjects and 101 unrelated APC patients were used as controls in the molecular analyses. Five of the eighteen patients carried novel germline APC variants or rare polymorphisms. These were various in site (from the splice acceptor site of intron 7 to the end of exon 15) and type (splice-site, missense, and chain-terminating mutations). Only one of ten polyp-free individuals carried a silent APC variant and none of these variants was found in the 101 APC controls. A first- or second-degree family history of colorectal cancer was reported by 4 of the 5 patients carrying a germline APC variant. In conclusion, novel APC germline variants were detected in patients with multiple synchronous adenomas. This suggests that the development of sporadic adenomas, in some instances, is associated with the presence of minor germline variants of the APC gene and that the spectrum of germline APC functional mutations may be larger than previously thought.

Incidence of Barrett's adenocarcinoma in an Italian population: an endoscopic surveillance programme. Gruppo Operativo per lo Studio delle Precancerosi Esofagee (GOSPE)

BACKGROUND

Barrett's oesophagus is a premalignant condition leading to adenocarcinoma. The incidence of adenocarcinoma of the oesophagus and the gastrooesophageal junction is rapidly increasing in the USA, northern and central Europe. Data from southern Europe are still unavailable.

OBJECTIVE

To evaluate the incidence of oesophageal adenocarcinoma in a large cohort of Italian patients with Barrett's oesophagus.

METHODS

A total of 344 patients (253 males and 91 females, age range 19-75 years) with histologically proven Barrett's oesophagus (length of metaplasia > or = 3 cm) were enrolled from November 1987 to June 1995. Endoscopic and histological examinations were scheduled at yearly intervals.

RESULTS

One hundred and eighty-seven patients complied with the follow-up. The mean duration of the follow-up period was 36 months (total follow-up 562 patient-years; range 12-90 months). Low grade dysplasia was found in five patients at the initial examination. During the surveillance period, dysplasia increased in frequency as well as in severity and was found exclusively in the intestinal type of Barrett's oesophagus. In all, dysplastic changes were found in seven patients (five low grade and two high grade) and adenocarcinoma developed in three patients during the follow-up. In a single case, both adenocarcinoma and specialized columnar epithelium developed without any evidence of dysplasia or intestinal metaplasia at the previous follow-up examination. This prospective study shows an incidence of adenocarcinoma in Barrett's oesophagus of 1/187 patient-years. When only patients with specialized columnar epithelium were considered, the risk of adenocarcinoma was 1/88 patient-years.

CONCLUSION

The present report shows that the incidence of adenocarcinoma in Italian Barrett's oesophagus patients is in the range of that reported from other Western countries.

Distal hyperplastic polyps do not predict proximal adenomas: results from a multicentric study of colorectal adenomas

BACKGROUND

The association between distal hyperplastic polyps and proximal adenomas is still a matter of debate. We investigated this association while taking into account patient characteristics.

METHODS

After exclusion of patients with inflammatory bowel diseases, familial adenomatous polyposis, or any cancer, 3088 eligible consecutive subjects aged 18 to 69 years underwent total colonoscopy in four gastroenterology units. The odds ratios (OR) of having proximal adenomas according to patient characteristics (age, sex, medical center, year of endoscopy, reasons for referral, and distal findings) were estimated in univariate and multivariate analyses.

RESULTS

Patients with distal polyps of any type showed an adjusted OR of 2.5 (95% CI [1.9, 3.1] p < .001) of having proximal adenomas as compared with those without distal polyps. When distal adenomas and distal hyperplastic polyps were included in the multivariate model as independent factors, the presence of adenomas significantly increased the risk of proximal adenomas (OR = 2.8: 95% CI [2.2, 3.6] p < .001), whereas the presence of hyperplastic polyps did not (OR = 1.1: 95% CI [0.8, 1.5] p = .64). No association with number, size, or location of distal hyperplastic polyps was seen.

CONCLUSIONS

Our data show that the presence of hyperplastic polyps should not be the sole indication for total colonoscopy because they are not associated with proximal adenomas when adjusting for patient characteristics and presence of distal adenomas.

Combined treatment with lasertherapy (Nd:YAG) and endocavitary radiation in the palliation of rectal cancer

BACKGROUND/AIMS

The ideal treatment for patients with advanced rectal cancer and who cannot undergo a radical therapy is still undefined. The association between lasertherapy (LT) and internal radiotherapy (IRT) could affect both technical results and quality of life. This study was aimed at evaluating the association of LT and IRT in the palliative treatment of rectal cancer.

MATERIAL AND METHODS

Between January and April 1994, 9 patients (2 males, 7 females) with rectal cancer underwent a combined treatment modality in order to control their symptoms. All patients were unfit for surgery and EUS showed an invasion of the whole muscular layer. After laser recanalization, brachytherapy was applied at a one week interval from last laser session. Two fractions of 10 Gy were administered at one week intervals.

RESULTS

The mean number of laser sessions to obtain a complete recanalization was 3 (range:2-5) and no complications occurred. After IRT, we obtained a good result in 7/9 patients (79%) and 2 patients required further LT. The mean follow-up was 146 days (range:74-240): during this period no laser treatment was performed. Four patients complained of acute perineal pain and tenesmus after brachytherapy: in one patient, a colostomy was performed.

CONCLUSION

We deem that the administration of two fractions of 10 Gy is not advisable, particularly for the treatment of non-circumferential lesions, due to the severe side effects we observed.

p53 is frequently mutated in Barrett's metaplasia of the intestinal type

Barrett's Esophagus (BE) is a complication of gastroesophageal reflux in which the normal squamous epithelium of the lower esophagus is replaced by metaplastic tissue. The clinical significance of this condition is the associated predisposition to adenocarcinomas (ADCs). Three types of BE have been characterized: the gastric fundic (F) type, the gastric cardial (C) type, and the intestinal (I) type. The latter is the most closely associated with the development of ADCs; the causes of this bias remain unknown. To determine whether p53 and/or K-ras gene alterations (a) are present in preneoplastic lesions and (b) are associated with a specific histotype, we performed PCR-based denaturing gradient gel electrophoresis (DGGE) analysis of exon 1 (codons 12-13) of K-ras gene and of exons 5-8 of the p53 gene in biopsies obtained from 30 patients with BE of the I type (9 patients), combined I type (I + C +/- F; 10 patients) and non-I type (C, F, or C + F; 11 patients). None of the cases under study revealed K-ras mutations, whereas biopsies from 12 patients showed at least one p53 DGGE variant. Four patients showed the exact same variants in leukocytes also (polymorphisms), whereas eight cases revealed specific DGGE variants only in biopsies. The molecular characterization of these variants revealed that four of them showed a single base pair substitution, and four showed multiple mutations. Of 17 somatic mutations, all but 1 were base pair substitutions located mainly in exons 7 and 8. The majority of these mutations were GC targeted (13 of 16; 81%), 54% (7 of 13) of which were transitions occurring at CpG sites. All somatic mutations were found in BE with at least one I component. The association with the histotype was statistically significant (P < 0.03; pure I type versus non-I type; P < 0.04, combined I type versus non-I type; Fisher's exact test). Loss of heterozygosity in the vicinity of the p53 locus was evaluated by PCR using a highly polymorphic variable number of tandem repeats marker on 25 out of 30 cases. Ninety-two % of the cases analyzed were informative, and none of them showed LOH. In conclusion, we showed that p53 mutations are frequently observed in specimens from BE patients of the I-type, whereas no involvement of K-ras (exon 1) mutational activation was observed. In light of the key roles that the p53 protein plays in controlling cell cycle and cell diploidy, this result may suggest why this type of metaplasia is the most closely associated to the development of ADCs.

Effect of sulglycotide in the prevention of duodenal ulcer relapse

OBJECTIVE

To evaluate the effectiveness of sulglycotide, a gastroprotective drug, as maintenance treatment for patients with duodenal ulcer.

DESIGN

A randomized double-blind study.

METHODS

A total of 119 patients with recently healed duodenal ulcers were randomly allocated, in a double-blind fashion, to receive sulglycotide 200 mg twice daily (60 patients) or placebo (59 patients) for 1 year. Patients underwent clinical assessment every third month and endoscopy at 6 and 12 months, or earlier if relapse was suspected.

RESULTS

The cumulative endoscopic relapse rates, compared using the log rank test, were 37 and 52% after 6 and 12 months, respectively, in the sulglycotide group and 62 and 71% (P = 0.03), respectively, in the placebo group.

CONCLUSIONS

Sulglycotide is moderately effective as a maintenance treatment for duodenal ulcer disease.

Genomic PCR-SSCP analysis of the metastasis associated NM23-H1 (NME1) gene: a study on colorectal cancer

To facilitate further mutational analysis of NM13-H1, a human metastasis suppressor gene, we have established its genomic organization. NM23-H1 is composed of five exons, spanning a genomic DNA fragment of 10 kb. Using oligonucleotide primers flanking each exon, PCR-SSCP analysis was performed on genomic DNAs of healthy individuals. A common polymorphism, a C to T transition, was detected 30 nucleotides upstream from the 5' splice site flanking exon 1. As NM23-H1 allele loss and altered expression have been reported in colorectal cancer, genomic DNAs of 20 colorectal tumors were analyzed for the presence of gene-specific mutations by PCR-SSCP: no abnormal sequences were detected within the coding and splice site regions of the NM23-H1 gene. This finding suggests that NM23-H1 mutations are rare events in human colorectal cancer.

Primary gastric lymphoma

The records of 30 patients with primary gastric lymphoma and a minimum of 5 years of follow-up were reviewed and clinical and pathologic prognostic factors analyzed. The overall 5-year survival was 40% (median 23 months). No significant relationship between surgical and patient age, sex, duration of symptoms, macroscopic appearance, or size of the primary lesion or degree of serosal infiltration was demonstrated. Stage of disease and site of primary had an impact on prognosis. Survival was improved in patients with stage I-II disease (P < 0.05) and in patients with primary located in the distal third of the stomach (P < 0.05). Although histology in all three classifications did not correlate well with survival, patients with low-grade lymphoma according to Kiel showed improved outcome (P < 0.05). Five-year survival of 11 patients with positive lymph nodes, 6 of whom were treated with cytotoxic therapy, was 54% and comparable to that of 7 patients (56%) with no nodal involvement who did not receive chemotherapy after surgery.

[Colorectal adenocarcinoma in patients with familial anamnesis positive for malignant neoplasms of the large intestine]

Familial aggregation of colorectal cancer occurs also among sporadic cases that are not part of defined genetic syndromes. First degree relatives of patients with "sporadic" colorectal cancer have a 3-4 fold increased risk of the same cancer. The aim of the present study is to investigate the relationship between a first degree family history of colorectal cancer and pathological and clinical features of the tumor (site, Dukes' stage, age at diagnosis, sex and survival of patients). 461 patients with colorectal cancer were evaluated (250 males and 211 females) after obtaining informations about their family history of cancer. 52 (11.25%) of them reported to have at least one close relative affected by intestinal cancer. Sex, age and stage of the disease are the only parameters that significantly affect survival. No relationship between family history of colorectal cancer and prognostic variables was observed.

Cytosolic and nuclear androgen receptors in colorectal adenomas

The aim of this study was to verify the presence of androgen receptors (AR) in human colorectal adenomas and in normal adjacent mucosa, and to determine whether there is any difference in AR tissue content between females and males. Our data show higher levels of nuclear AR in normal mucosa than in adenomas (p less than 0.001). A significant difference was also present in males between normal and pathological tissue both in cytosolic (p less than 0.05) and nuclear receptors (p less than 0.01). In female subjects this difference was also evident, but not significant. Our results seem to support the hypothesis of protective effects of androgens in colonic mucosa.

Flow cytometric DNA index in the prognosis of colorectal cancer

The authors investigated the relationship between flow cytometric DNA index (DI, defined as the ratio of the DNA content of malignant cells to that of normal cells) and other prognostic factors (grade and stage, anatomical site, age and sex) with the survival of 115 patients with colorectal cancer. Multiple biopsy specimens from 62 patients were taken during colonoscopy before surgery. Additional samples from 53 patients were obtained from paraffin-embedded material. All patients were treated with surgery only. Fresh-frozen material gave higher incidence of DNA aneuploidy than paraffin-embedded material (79% versus 41%). The patients with DNA diploid tumors (DI = 1) had a better overall survival than those with DNA aneuploid tumors (DI = 1). Among DNA aneuploid tumors, those with DI greater than 1.2 (excluding DI = 2) were worse than those with DI = 1.2 (excluding DI = 1) and DI = 2. Cox's regression analysis showed that pathologic stage was more important for prognosis than DNA index, whereas age, sex, histologic grade, and anatomic site were removed from the analysis as not relevant for prognosis. Relative risk of death (RR), in reference to patients with DI = 1 and Stages A + B (RR = 1), were RR = 1.8 for patients with carcinomas with Stage C. RR = 2.7 for patients with carcinomas with DNA near-diploid and DNA tetraploid tumors. RR = 3.5 for those with DI greater than 1.2 (excluding DI = 2), and RR = 8.0 for those with Stage D. These data indicate that flow cytometrically evaluated DI values have a relevant independent power for predicting the clinical outcome of colorectal cancer patients.

Palliative bipolar electrocoagulation treatment of malignant gastroesophageal strictures

Seventeen patients with non-resectable circumferential malignant strictures of the esophagus (n = 13) or the gastroesophageal junction (n = 4) were treated with a bipolar electrocoagulation tumor probe (BICAP). None had received prior radiotherapy or chemotherapy. The mean tumor length was 7.2 cm. After treatment swallowing was improved in 86.7% of the patients. The mean duration of response to the first treatment was 18 days. Three major complications (1 fatal hemorrhage, 2 tracheoesophageal fistulae) and two minor complications (chest pain) were observed. The overall actuarial survival rate after 13 months of follow-up was 20%. The BICAP tumor probe can be considered an efficacious and safe device in selected patients with long, circumferential esophageal cancers.

DNA flow cytometry of endoscopically examined colorectal adenocarcinomas

The purpose of the study was to evaluate the correlation of DNA-ploidy of colorectal adenocarcinomas (adk) with histological and clinical parameters including the survival of the patients. Multiple biopsies from 95 adk were taken during colonoscopy prior to surgery. The samples were used to obtain nuclei suspensions for specific staining of DNA content and high resolution flow cytometry. DNA-aneuploidy, i.e. the presence of more than one G0/G1 peak, was detected in 67/95 cases (71%). The individual-specific control mucosa was DNA-diploid in all cases. The mean fraction of S-phase cells was 7.2% in control mucosa and 13.6% in adk. DNA-ploidy did neither correlate with Dukes' stage nor with differentiation degree. Among the patients studied for the correlation of DNA ploidy with survival for a period extending to 30 months (n = 51), the DNA aneuploid group was estimated to be about 5 times as risky as the DNA diploid group with respect to the odds of dying. We conclude that DNA flow cytometry of colorectal adk may predict clinical outcome and be helpful in addition to histopathology.

Long-term postoperative results in 54 cases of early gastric cancer: the choice of surgical procedure

Surgical experience on the management of early gastric carcinoma (EGC) related to a series of 54 subjects was observed from 1974 to 1984. Thirty-four patients were male, 20 were female; median age was 61.84 (range 22-79) years. Malignancy always occurred in the middle or distal third of the stomach. A partial subtotal gastrectomy (two-thirds of the stomach) with Roux en Y or Billroth II reconstruction was performed. Omentectomy and lymph node dissection of the primary and secondary groups of nodes, according to General Rules, was always performed. Age-corrected 5- and 10-year survival rates were 95.7% and 84.3%, respectively. Based on their experience, the authors discuss the surgical approach to EGC stressing the need for an accurate lymph node dissection and pointing out that results of subtotal gastrectomy are similar to that reported in the literature for total gastrectomy. The only absolute need for a total gastrectomy may be the presence of an EGC in the proximal third of the stomach. To this end the authors compare their results with 5- and 10-year series from Japanese and western countries reported in the literature.

Growth of cells from esophageal squamous cell carcinoma biopsies in a reconstituted basement membrane

Cells from esophageal carcinoma biopsies were cultured on or inside a three-dimensional basement membrane matrix (matrigel). Their growth was compared to cells derived from control esophageal biopsies. Cells from both normal and neoplastic tissue attached poorly to tissue culture plastic. Matrigel coating improved adhesion and growth. When cells were grown inside a matrigel matrix, a striking difference was noticed between carcinoma cells and controls. Carcinoma cells grew invasively in the three-dimensional substrate and digested the matrix after a few weeks; control cells did not grow and only a few necrotic cells were visible with time. Matrigel provided a better growth substrate than plastic for esophageal derived cells and discriminated between carcinoma-derived and control cells when used as a three-dimensional growth substrate. Our studies suggest a possible use of matrigel for the selective growth of tumor cells derived directly from tissue biopsies.

CA 19-9 and CA 50 in benign and malignant pancreatic and biliary diseases

Serum concentrations of the CA 19-9 and CA 50 antigens were determined in 129 patients with malignant and benign biliary and pancreatic diseases. Values for the two markers were highly correlated (P less than 0.001). The concentrations of CA 19-9 and CA 50 were positive in 84.6% and 80.7% of patients with pancreatic cancer, respectively. The overall specificity of CA 19-9 (92.4%) was slightly higher than that of CA 50 (88.5%). The sensitivity of CA 50 (91.3%) was greater than that of CA 19-9 (73.9%) in patients with diseases of the biliary tract. Elevated concentrations of CA 19-9 (12.9%) and CA 50 (35.2%) were also found in a number of cases with benign disease, especially in patients with obstructive jaundice. These data suggest that both CA 19-9 and CA 50 can be useful markers of pancreatic cancer in nonjaundiced patients. The joint use of the two markers does not yield a better diagnostic resolution than the use of either one alone.

CA 19-9 and CA 50 in benign and malignant pancreatic and biliary diseases

Serum concentrations of the CA 19-9 and CA 50 antigens were determined in 129 patients with malignant and benign biliary and pancreatic diseases. Values for the two markers were highly correlated (P less than 0.001). The concentrations of CA 19-9 and CA 50 were positive in 84.6% and 80.7% of patients with pancreatic cancer, respectively. The overall specificity of CA 19-9 (92.4%) was slightly higher than that of CA 50 (88.5%). The sensitivity of CA 50 (91.3%) was greater than that of CA 19-9 (73.9%) in patients with diseases of the biliary tract. Elevated concentrations of CA 19-9 (12.9%) and CA 50 (35.2%) were also found in a number of cases with benign disease, especially in patients with obstructive jaundice. These data suggest that both CA 19-9 and CA 50 can be useful markers of pancreatic cancer in nonjaundiced patients. The joint use of the two markers does not yield a better diagnostic resolution than the use of either one alone.

DNA flow cytometry of endoscopically examined colorectal adenomas and adenocarcinomas

DNA ploidy of 64 colorectal adenomas and 49 adenocarcinomas, examined endoscopically, was studied by flow cytometry. We found DNA aneuploidy in none of the 105 normal mucosa samples (0%), in 20 adenomas (31%), and in 36 adenocarcinomas (74%). DNA ploidy of adenomas correlated with size (P = 0.02) and degree of dysplasia (P less than 0.01) but not with histologic type. Adenomas had a 45% incidence of DNA aneuploid stem lines in the DNA index range of 0.80-1.20, compared with 8% in the case of adenocarcinomas. The distribution of the DNA index values of adenocarcinomas was approximately normal, with a mean value 1.63 +/- 0.28. The mean DNA index for the three cases of "carcinoma in adenoma" with invasion of the stalk of the adenoma was 1.52 +/- 0.18. These results, using DNA flow cytometry, provide evidence for the progression of colorectal adenoma to adenocarcinoma. The classification of adenomas according to DNA ploidy may be information of considerable practical value to the clinician in predicting risk of further adenomas and/or risk of cancer.

Family history of colorectal cancer as a risk factor for benign and malignant tumours of the large bowel. A case-control study

The relationship between first degree family history of colorectal cancer and the risk of benign or malignant tumours of the large bowel was investigated in a case-control study. Two groups of cases (283 patients with adenomatous polyps and 414 patients with adenocarcinoma of the large bowel) and 2 groups of controls (399 polyp-free subjects and 456 hospitalized patients) were interviewed. Since no difference in the frequency of family history between the 2 control groups was detected, these were lumped together. A 3-fold increase in risk of adenomatous polyps in relatives of patients with colon cancer was observed (OR = 3.18, 95% CI 2.06-4.89). The relative risk of colorectal cancer among relatives of patients with adenocarcinoma was 2.36 (95% CI 1.54-3.60). No significant difference in the frequency of first degree relatives with a history of cancer of the large bowel was detected between patients with colorectal cancer and those with adenomatous polyps. When only history of colorectal cancer among parents was considered, the results closely paralleled those of the previous analysis.

Flow cytometric DNA ploidy in colorectal adenomas and family history of colorectal cancer

Flow cytometric DNA ploidy of colorectal adenomas resected from 34 patients and the corresponding patient family history in first-degree relatives were evaluated. The samples with at least two separate G0-G1 peaks were defined as DNA aneuploid. The correlation between DNA ploidy and family history was evaluated using two-by-two contingency tables. This correlation was highly statistically significant: seven of nine patients (78%) with positive family histories, and five of 25 (20%) with negative family history had adenomas with DNA aneuploid stemlines (P = 0.0068). The overall DNA aneuploidy incidence was 12 in 34 cases (35.2%). The combined information of DNA aneuploidy and positive family history of colorectal cancer in patients with colorectal adenomas may help to better understand the process of colon carcinogenesis and to identify patients who have a higher risk for developing a malignancy.

Colorectal cancer in patients with family history

The relationship between first degree family history of colorectal cancer and some pathological and clinical features was investigated in 302 patients affected by large bowel carcinoma. Patients with inherited forms of polyposis of the large bowel were excluded. Thirty-six (11.9%) had at least one close relative affected by intestinal cancer. No relationship between family history and pathological features (anatomic distribution, stage and grading) was found. Moreover no difference in prognosis between patients with a family history and those without was shown. These results suggest no relationship between a first degree family history and the natural history of the disease.

Association between breast and colorectal cancer in a sample of surgical patients

The frequency of adenomatous polyps and adenocarcinomas of the large bowel in 95 patients mastectomized for breast cancer, and the prevalence of breast cancer in 77 women previously operated on for colorectal cancer were evaluated by means of a case-control study. The mastectomized patients as well as the control group, underwent a left-sided colonoscopy. The latter had been selected among women spontaneously referring to our gastroenterological out-patients clinic. The choice of this self selected control group could produce a under-estimation of the relative for colon cancer in mastectomized patients. Among mastectomized patients the frequency of adenomatous polyps and colorectal cancer was 10.5% and 5.3% respectively; while the control group showed 8.5% frequency for adenomatous polyps and 3.9% frequency for cancer. These figures are not statistically different. Patients operated on for colorectal cancer and the control group underwent clinical and mammographic examination. The prevalence of breast cancer among colorectal cancer patients and the control group women was 5.2% and 0.3% respectively (10 times higher): the difference was statistically significant (P less than 0.006). In spite of the relatively small number of studied cases, our finding are consistent with the hypothesis of a correlation between breast cancer and colorectal cancer.

Gastric histomorphology and secretory biochemistry after biliopancreatic diversion

When paired data are considered and unpaired results are compared with controls, it appears that no significant changes of gastric histomorphology occur following biliopancreatic diversion.

Tissue sampling from the common bile duct through endoscopic retrograde cholangiopancreatography, endoscopic papillo(sphinctero)tomy and drainage in juxtapapillary malignancies

In 22 patients with radiological evidence of a malignant stricture or an obstruction of the common bile duct, endobiliary tissue specimens were obtained through endoscopic retrograde cholangiopancreatography. An endoscopic papillo(sphinctero)tomy was necessary in 9 of the 22 patients. The following techniques were employed: (1) forceps biopsy of the papillary infundibulum and/or of the common bile duct; (2) brush cytology in the same sites as above; (3) biliary juice cytology obtained by a nasobiliary drainage tube. In 8 patients, two different sampling techniques were used. The final diagnosis was established by means of pathological evaluation of surgical or necroscopic material. The diagnostic adequacy was 100% for biopsy, 88% for brush cytology, and 62% for bile cytology. The sensitivity was 100%, 66%, and 25%, respectively, for the above techniques. From 6 cases without biliary cancer, the specificity was 100%. These data show that biopsy specimens alone provide a definitive preoperative diagnosis in most cases, provided adequate samples are obtained.

The clinical significance of gastric epithelial dysplasia

Six-hundred-and-ninety-four patients with localized gastric lesions (ulcers, polyps, enlarged or irregular folds, erosions and tumors) underwent endoscopic examination and multiple biopsies. Twenty-nine proved to have severe or moderate gastric epithelial dysplasia. Another group of 123 patients were submitted to endoscopic examination and multiple biopsies, but showed no evidence of localized gastric lesions. Only one case of mild dysplasia was observed in this group. Of the 29 patients with dysplasia, 8 (27.5%) had a carcinoma in the surgical specimen. The endoscopic follow-up carried out in non-operated patients with dysplasia did not show any development of malignancy. This study shows dysplastic changes significantly associated with prominent or depressed lesions of the gastric mucosa at endoscopy. In operated patients a synchronous carcinoma is often detected in the surgical specimen.

Primary signet-ring carcinoma of the large bowel. Report of nine cases

Nine cases of signet-ring carcinoma have been observed from among 800 consecutive histologic cases diagnosed as adenocarcinoma of the colon during a period of 10 years (0.9%). This group of nine patients (Group A) has been matched for sex, age, and stage with a group of 45 patients affected by ordinary carcinoma of the colon (Group B). Clinical and histologic parameters, including symptoms, primary tumor site, free interval from primary surgery, histochemical investigation of intracytoplasmic mucins, and survival, were evaluated. The results of this investigation showed no clinical differences between signet-ring carcinoma and ordinary carcinoma, and no statistically significant results were observed regarding the frequency of local recurrence and actuarial survival.

Primary signet-ring carcinoma of the large bowel. Report of nine cases

Nine cases of signet-ring carcinoma have been observed from among 800 consecutive histologic cases diagnosed as adenocarcinoma of the colon during a period of 10 years (0.9%). This group of nine patients (Group A) has been matched for sex, age, and stage with a group of 45 patients affected by ordinary carcinoma of the colon (Group B). Clinical and histologic parameters, including symptoms, primary tumor site, free interval from primary surgery, histochemical investigation of intracytoplasmic mucins, and survival, were evaluated. The results of this investigation showed no clinical differences between signet-ring carcinoma and ordinary carcinoma, and no statistically significant results were observed regarding the frequency of local recurrence and actuarial survival.

Esophageal dilation in malignant dysphagia

Esophageal dilation by means of guided Neoplex (Medoc) tubes in 38 patients with malignant obstruction of the esophagus was analyzed. Peroral dilation proved to be a simple, well-tolerated primary procedure in the management of malignant strictures. Most patients have a temporary improvement of dysphagic symptoms, but the benefit appears to decrease progressively in successive dilatatory sessions. Dilations were more difficult, with a 10% perforation rate, in previously radiated patients. Esophageal dilations may play a complementary role in addition to other palliative techniques in the management of malignant dysphagia.

[Use of vasopressin in the treatment of acute hemorrhagic lesions of the stomach. Our experience]

Since bleeding from acute lesions of the gastric mucosa can cease spontaneously and the mortality rate of emergency surgery is high, conservative treatment is always preferable. Satisfactory results were obtained with continuous infusions of vasopressin in low doses (0.2 U/kg/hr for 8 hours) so that this treatment appears a valid alternative to more recent techniques (somatostatin).