Long-Term Total Neoadjuvant Therapy Leads to Impressive Response Rates in Rectal Cancer: Results of a German Single-Center Cohort

Intensified preoperative chemotherapy after (chemo)radiotherapy, (Total Neoadjuvant Therapy-TNT), increases pathological complete response (pCR) rates and local control. In cases of clinically complete response (cCR) and close follow-up, non-operative management (NOM) is feasible. We report early outcomes and toxicities of a long-term TNT regime in a single-center cohort. Fifteen consecutive patients with distal or middle-third locally advanced rectal cancer (UICC stage II-III) were investigated, who received neoadjuvant chemoradiotherapy (total adsorbed dose: 50.4 Gy in 28 fractions and two concomitant courses 5-fluorouracil (250 mg/m²/d)/oxaliplatin (50 mg/m²), followed by consolidating chemotherapy (nine courses of FOLFOX4). NOM was offered if staging revealed cCR 2 months after TNT, with resection performed otherwise. The primary endpoint was complete response (pCR + cCR). Treatment-related side effects were quantified for up two years after TNT. Ten patients achieved cCR, of whom five opted for NOM. Ten patients (five cCR and five non-cCR) underwent surgery, with pCR confirmed in the five patients with cCR. The main toxicities comprised leukocytopenia (13/15), fatigue (12/15) and polyneuropathy (11/15). The most relevant CTC °III + IV events were leukocytopenia (4/15), neutropenia (2/15) and diarrhea (1/15). The long-term TNT regime resulted in promising response rates that are higher than the response rates of short TNT regimes. Overall tolerability and toxicity were comparable with the results of prospective trials.

Planning adaptive treatment by longitudinal response assessment implementing MR imaging, liquid biopsy and analysis of microenvironment during neoadjuvant treatment of rectal cancer (PRIMO)

INTRODUCTION

Conducting neoadjuvant chemoradiotherapy (CRT) and additional preoperative consolidating chemotherapy (CTx), that is, total neoadjuvant therapy (TNT), improves local control and complete response (CR) rates in locally advanced rectal cancer (LARC), putting the focus on organ preservation concepts. Therefore, assessing response before surgery is crucial. Some LARC patients would either not benefit from intensification by TNT or may reach CR, making resection not mandatory. Treatment of LARC should therefore be based on patient individual risk and response to avoid overtreatment.The "PRIMO" pilot study aims to determine early response assessment to form a basis for development and validation of a noninvasive response prediction model by a subsequent prospective multicenter trial, which is highly needed for individual, response-driven therapy adaptions.

METHODS

PRIMO is a prospective observational cohort study including adult patients with LARC receiving neoadjuvant CRT. At least 4 multiparametric magnetic resonance imaging (MRI) scans (diffusion-weighted imaging [DWI] and hypoxia-sensitive sequences) as well as repeated blood samples in order to analyze circulating tumor cells (CTC) and cell-free tumor DNA (ctDNA) are scheduled. Pelvic radiotherapy (RT, 50.4 Gy) will be performed in combination with a 5-fluorouracil/oxaliplatin regimen in all patients (planned: N = 50), succeeded by consolidation CTx (FOLFOX4) if feasible. Additional (immuno)histochemical markers, such as tumor-infiltrating lymphocytes (TIL) and programmed death ligand 1 (PD-L1) status will be analyzed before and after CRT. Routine resection is scheduled subsequently, nonoperative management is offered alternatively in case of clinical CR (cCR).The primary endpoint is pathological response; secondary endpoints comprise longitudinal changes in MRI as well as in CTCs and TIL. These are evaluated for early response prediction during neoadjuvant therapy, in order to develop a noninvasive response prediction model for subsequent analyses.

DISCUSSION

Early response assessment is the key in differentiating "good" and "bad" responders during neoadjuvant CRT, allowing adaption of subsequent therapies (additional consolidating CTx, organ preservation). This study will contribute in this regard, by advancing MR imaging and substantiating new surrogate markers. Adaptive treatment strategies might build on these results in further studies.

Non-mucinous adenocarcinomas and squamous cell carcinomas of the anal region masquerading as abscess or fistula: a retrospective analysis and systematic review of literature

PURPOSE

Abscess or fistula of the anal region is an uncommon presentation of malignancy. Under the assumption of a benign condition, diagnostics is often delayed, resulting in advanced tumour stages at first diagnosis. Due to the case rarity, treatment guidelines for cancers of anorectal region masquerading as abscess or fistula are missing.

METHODS

We analysed all patients presenting with an abscess or fistula of the anal region in our department between January 2004 and August 2020. The malignancies were included to our study to acquire data on clinical presentation, treatment and outcome. Furthermore, a systematic review to present adenocarcinomas and squamous cell carcinomas associated to an abscess or fistula was performed.

RESULTS

0.5% of the patients treated for an abscess or fistula of the anal region met the selection criteria. Mean time from the onset of symptoms to diagnosis of malignancy was 100 days. Histology revealed adenocarcinoma and squamous cell carcinoma each in two patients. All patients had locally advanced tumours without distant metastases, in two cases with regional lymph-node metastases. Neoadjuvant chemoradiation was applied in two patients. All patients underwent abdomino-perineal resection of the rectum. The overall outcome reveals a recurrence-free survival of 4.5 and 3 years for two patients. Further two patients died within 5 months after the primary resection.

CONCLUSION

Advanced carcinomas of the anorectal region may masquerade as abscess or fistula, cause diagnostic problems and delay oncologic treatment. However, even in these very advanced situations, surgical therapy with curative intent should be attempted.

Monitoring of the Progression of the Perioperative Serum Lactate Concentration Improves the Accuracy of the Prediction of Acute Mesenteric Ischemia Development After Cardiovascular Surgery

OBJECTIVES

To examine the sensitivity and specificity of perioperative lactate gradients for the prediction of subsequent acute mesenteric ischemia development in patients undergoing cardiovascular surgery.

DESIGN

Retrospective, single-center, case-control study.

SETTING

University hospital.

PARTICIPANTS

The study comprised 108 (1.15%) patients with acute mesenteric ischemia who were selected from 9,385 patients who underwent cardiovascular surgery and were matched to 324 control patients by age and surgery type.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Univariate and logistic regression analyses were used to examine intraoperative and early postoperative lactate levels in patients with and without mesenteric ischemia after cardiac surgery. Late intraoperative lactate concentrations were significantly greater in patients who subsequently developed mesenteric ischemia (p < 0.001). Patients with lactate levels >3 mmol/L had a four-fold increased risk of mesenteric ischemia development (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.4-7.5; area under the curve [AUC] 0.597; p < 0.002). Patients whose lactate levels remained >3 mmol/L on the first postoperative day had a nearly eight-fold increased risk (OR 7.8, 95% CI 4.6-13.3; AUC 0.68; p < 0.001), indicating that mesenteric ischemia developed at an early stage in almost every second patient (p < 0.001). For patients with normal or less elevated lactate levels, similar results were obtained for a >200% increase between the intraoperative and early postoperative periods (OR 4.1, 95% CI 2.4-6.8; AUC 0.62; p < 0.001).

CONCLUSION

Late intraoperative and early postoperative lactate levels >3 mmol/L and increases >200%, even when remaining within the normal range, should raise the suspicion of subsequent mesenteric ischemia development.

The role of computed tomography in the diagnostic pathway of acute mesenteric ischemia: a nested case-control study

BACKGROUND

Computed tomography (CT) can be used as the primary screening modality for the evaluation of patients suspected of having acute mesenteric ischemia known to show high sensitivity and specificity rates.

PURPOSE

To prove the value of CT in patients with pathological abdominal findings following cardiac surgery.

MATERIAL AND METHODS

In a retrospective case-control study, 12 different CT scan parameters of patients with or without mesenteric ischemia following cardiac surgery were compared using univariate and logistic regression analyses.

RESULTS

Of 14,176 patients, 133 (0.9%) received an abdominal CT scan during postoperative care due to pathological abdominal findings. Sixty-eight patients were diagnosed with acute mesenteric ischemia. In-hospital mortality was 73.5% for this group. CT parameters with the highest specificity for indicating colonic ischemia were intestinal (99%) or porto-venous (96%) pneumatosis, abnormal contrast medium enhancement (89%), and occlusion of the proximal inferior mesenteric artery (81%). All of those parameters showed low sensitivity levels in the range of 15%-23%. A statistically significant association between acute mesenteric ischemia and CT appearance was obtained for contrast medium enhancement (odds ratio [OR] 12.2, 95% confidence interval [CI] 1.5-99.2) and intestinal pneumatosis (OR 21.0, 95% CI 2.7-165.2) only.

CONCLUSION

The typical CT criteria indicating mesenteric ischemia lose their accuracy in patients under critical clinical conditions. As CT remains the first-line diagnostic imaging modality for abnormal abdominal findings following cardiac surgery, negative signs should not prevent early laparotomy if clinical suspicion remains high.

[Global Health Care]

Global health data are changing rapidly and they show large regional differences. The incidence and mortality of infectious diseases can be reduced by successes in medical research, national health plans and large financial expenditure. In contrast, illnesses that are caused by unhealthy and changing environmental and living conditions are on the rise. The Global Health Care concept is a cross-sectoral master plan taking into account that worldwide health cannot be established by healthcare workers alone. It was designed to have a lasting impact on the cause of disease through global health programs, of which improved medical services, including essential surgical treatment need to play a key role.

Detection of HPV16 in Esophageal Cancer in a High-Incidence Region of Malawi

This study was designed to explore the role of human papillomavirus (HPV) in esophageal squamous cell carcinoma (ESCC). Fifty-five patients receiving diagnostic upper gastrointestinal endoscopy at Zomba Central Hospital or Queen Elizabeth Hospital in Blantyre (Malawi) in 2010, were included in our study. Formalin-fixed paraffin-embedded biopsies were collected for histopathological diagnosis. HPV DNA was detected using multiplex Quantitative PCR (qPCR) and in situ hybridization (ISH). p16INK4a staining served as a surrogate marker for HPV oncogene activity. Cell proliferation was determined by Ki-67 staining. Human immunodeficiency virus (HIV) status was evaluated by serology. Data on the consumption of alcohol and tobacco, and history of tuberculosis (TBC), oral thrush, and Herpes zoster, were obtained by questionnaire. Forty patients displayed ESCC, three displayed dysplastic epithelium, and 12 displayed normal epithelium. HPV16 was detected in six ESCC specimens and in one dysplastic lesion. Among HPV-positive patients, viral load varied from 0.001 to 2.5 copies per tumor cell. HPV DNA presence could not be confirmed by ISH. p16INK4a positivity correlated with the presence of HPV DNA (p = 0.03). Of particular note is that the Ki-67 proliferation index, in areas with diffuse nuclear or cytoplasmatic p16INK4a staining ≥50%, was significantly higher in HPV-positive tumors compared to the corresponding p16INK4a stained areas of HPV-negative tumors (p = 0.004). HPV infection in ESCC was not associated with the consumption of tobacco or alcohol, but there were significantly more patients drinking locally brewed alcohol among HPV-positive tumor patients compared to non-tumor patients (p = 0.02) and compared to HPV-negative tumor patients (p = 0.047). There was no association between HIV infection, history of TBC, Herpes zoster, oral thrush, or HPV infection, in ESCC patients. Our indirect evidence for viral oncogene activity is restricted to single tumor cell areas, indicative of the role of HPV16 in the development of ESCC. The inhomogeneous presence of the virus within the tumor is reminiscent of the "hit and run" mechanism discussed for β-HPV types, such as HPV38.

Task-shifting of orthopaedic surgery to non-physician clinicians in Malawi: effective and safe?

There is a shortage of orthopaedic surgeons in Malawi. Orthopaedic clinical officers (OCOs) treat trauma patients and occasionally perform major orthopaedic surgery. No studies have assessed the efficacy and safety of their work. The aim of this study was to evaluate their contribution to major orthopaedic surgery at Zomba Central Hospital. Data about orthopaedic procedures during 2006-2010 were collected from theatre books. We selected major amputations and open reductions and plating for outcome analysis and collected details from files. We compared patients operated by OCOs alone ('OCOs alone' group) and by surgeons or OCOs assisted by surgeons ('Surgeon present' group). OCOs performed 463/1010 major (45.8%) and 1600/1765 minor operations (90.7%) alone. There was no difference in perioperative outcome between both groups. OCOs carry out a large proportion of orthopaedic procedures with good clinical results. Shifting of clinical tasks including major orthopaedic surgery can be safe. Further prospective studies are recommended.

Surgery for colorectal cancer in elderly patients: how can we improve outcome?

PURPOSE

Patients over 70 years of age are characterised by diminished long-term survival rates following resection of colorectal cancer (CRC) compared to younger patients. The aim of this study was to clarify whether reduced survival is a result of malignancy, comorbidities or the treatment received.

METHODS

All patients with CRC, who were admitted to our institution over a period of 10 years, were selected from a prospectively maintained database. Disease-specific, disease-free and overall survival rates were calculated dependent on variables considered potentially relevant for the patients' prognosis.

RESULTS

915 patients were included in the study. Observed 5- and 10-year survival rates for the whole group were 48 ± 2% and 40 ± 2%, respectively, but 10-year survival rates dropped to 14 ± 4% for patients aged 80 and older. Resection of the primary tumour was attempted in all cases independent of age. Emergency admission, Charlson index ≥2, ECOG ≥2, old age, second malignancies, distant metastases, high grading and non-resective surgery were identified as independent prognostic parameters associated with decreased overall survival. In contrast, disease-specific and disease-free survival rates for patients after elective radical resection in UICC-stage I-III did not show significant differences related to age. Tumour site, UICC-stage and resection status were independent statistically significant predictors of disease-specific survival.

CONCLUSIONS

Similar disease-specific survival rates in all age groups speak in favour of tumour resection in curative intent even in old patients. Better outcome may be achieved, if regular screening for colorectal cancer is considered even in the elderly to avoid late presentation requiring emergency surgery.

Systematic classification of uterine cervical elongation in patients with pelvic organ prolapse

OBJECTIVE

To define and classify cervical elongation, to compare uterine measurements after prolapse hysterectomy with a non-prolapse control group, and to associate stage of prolapse and degree of cervical elongation.

STUDY DESIGN

This was a single-centre retrospective case-control study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. Data were collected from patients with and without pelvic organ prolapse (POP) who underwent laparoscopically assisted vaginal hysterectomy. Post-hysterectomy uterine cervical elongation was examined using the corpus/cervix ratio (CCR), calculated from measurements taken on photographs. Cervical elongation was classified as physiological (grade 0, CCR>1.5) grade I (CCR>1 and ≤1.5) grade II (CCR>0.5 and ≤1), and grade III (CCR≤0.5).

RESULTS

Cervical elongation was detected in 288/295 (97.6%) patients in the prolapse group (grade I, 44/288 [15.2%]; grade II, 212 [73.6%]; grade III, 32 [11.1%]). Mean CCR was greater among those with stage II/III than among those with stage IV prolapse (1.0±0.4 vs. 0.8±0.2; p<0.001). Grades of cervical elongation and prolapse stages were associated (p<0.001). Grade I cervical elongation was detected in 26/69 (37.6%), grade II in 5/69, and grade III in 0/69 patients of the control group. Cervical elongation was found more often in the prolapse group compared to the control group (p<0.001). Mean total uterine length did not differ between the prolapse and control groups (8.0±1.6 vs. 8.2±1.3cm), but mean calculated cervical length was greater in the prolapse group than in the control group (4.4±1.1 vs. 3.1+0.8cm; p<0.001).

CONCLUSIONS

Uterine cervical elongation is found in patients undergoing hysterectomy for pelvic organ prolapse. Cervical elongation grades and prolapse stages are correlated. Defining uterine cervical elongation based on corpus/cervix ratio with grades I-III could be a valuable basic tool for further research.

Partial liver resection results in a significantly better long-term survival than locally ablative procedures even in elderly patients

PURPOSE

The number of elderly patients with HCC will increase worldwide in the next years. Therefore, surgeons need to reassess clinical algorithms for the treatment of patients with HCC. We reevaluated a cohort of patients treated in the last 10 years at our hospital, with emphasis on long-term results and age.

METHOD

A prospectively recorded consecutive series of all patients treated in between January 1995 and December 2014 with curative intent either by partial liver resection or by ablative therapy was analysed.

RESULTS

At the time of diagnosis, 232 patients were younger than 70 years and 127 patients were aged 70 years and over. In the latter group, solitary tumours, absence of liver cirrhosis and resection therapy were more frequent compared to younger patients. Charlson index, AFP-negative tumours and CLIP score were equally distributed in both groups. Observed survival of older and younger patients was similar but after partial liver resection, younger patients had a better survival than elderly patients, whereas survival in patients treated with ablation was similar in both groups. In the univariate analysis, long-term survival of patients aged 70 years and over was influenced by treatment procedure, number of lesions, liver cirrhosis, Child's stage and CLIP score. In the multivariate analysis, only treatment procedure and CLIP score were identified as independent predictors of observed survival, and comorbidity was not.

CONCLUSION

In patients aged 70 years and over, long-term prognosis is independently influenced by CLIP score and treatment procedure and other findings have only minor influence on long-term survival.

Butyrate modulates antioxidant enzyme expression in malignant and non-malignant human colon tissues

The induction of antioxidant enzymes is an important mechanism in colon cancer chemoprevention, but the response of human colon tissue to butyrate, a gut fermentation product derived from dietary fiber, remains largely unknown. Therefore, our study investigated the effect of a butyrate treatment on catalase (CAT) and superoxide dismutase (SOD2) in matched human colon tissues of different transformation stages (n = 3-15 in each group) ex vivo. By performing quantitative real-time PCR, Western blot, and spectrophotometric measurements, we found an increase in SOD2 at expression and activity level in colonic adenocarcinomas (mRNA: 1.96-fold; protein: 1.41-fold, activity: 1.8-fold; P < 0.05). No difference was detectable for CAT between normal, adenoma, and carcinoma colon tissues. Treatment of normal colon epithelium (12 h) with a physiologically relevant concentration of butyrate (10 mM) resulted in a significant increase (P < 0.05) in CAT mRNA (1.24-fold) and protein (1.39-fold), without affecting the enzymatic activity. Consequently, preliminary experiments failed to show any protective effect of butyrate against H2 O2 -mediated DNA damage. Despite a significantly lowered SOD2 transcript (0.51-fold, P < 0.01) and, to a lesser extent, protein level (0.86-fold) after butyrate exposure of normal colon cells, the catalytic activity was significantly enhanced (1.19-fold, P < 0.05), suggesting an increased protection against tissue superoxide radicals. In malignant tissues, greater variations in response to butyrate were observed. Furthermore, both enzymes showed an age-dependent decrease in activity in normal colon epithelium (CAT: r = -0.49, P = 0.09; SOD2: r = -0.58, P = 0.049). In conclusion, butyrate exhibited potential antioxidant features ex vivo but cellular consequences need to be investigated more in depth.

Gastrointestinal endoscopy in a low budget context: delegating EGD to non-physician clinicians in Malawi can be feasible and safe

Gastrointestinal endoscopy is rarely performed in low-income countries in sub-Saharan Africa. One reason is the lack of available medical doctors and specialists in these countries. At Zomba Central Hospital in Malawi, clinical officers (non-physician clinicians with 4 years of formal training) were trained in upper gastrointestinal endoscopy. Prospectively recorded details of 1732 consecutive esophagogastroduodenoscopies (EGDs) performed between September 2001 and August 2010 were analyzed to evaluate whether upper gastrointestinal endoscopy can be performed safely and accurately by clinical officers. A total of 1059 (61.1%) EGDs were performed by clinical officers alone and 673 (38.9%) were carried out with a medical doctor present who performed or assisted in the procedure. Failure and complication rates were similar in both groups (P=0.105). Endoscopic diagnoses for frequent indications were generally evenly distributed across the two groups. The main difference was a higher proportion of normal findings and a lower proportion of esophagitis in the group with a doctor present, although this was significant only in patients who had presented with epigastric/abdominal pain (P<0.001). In conclusion, delegating upper gastrointestinal endoscopy to clinical officers can be feasible and safe in a setting with a shortage of medical doctors when adequate training and supervision are provided.

Impact of butyrate on PKM2 and HSP90β expression in human colon tissues of different transformation stages: a comparison of gene and protein data

Due to protection of oncogenic proteins from degradation and enhancement of glycolytic phosphometabolites for synthetic processes, respectively, heat shock protein 90 (HSP90) and pyruvate kinase type M2 (PKM2) are important proteins for tumor growth. The present study was undertaken to investigate the susceptibility of both proteins and their encoding genes to the chemopreventive agent butyrate in human colon cells. Matched tissue of different transformation stages derived from 20 individual colon cancer patients was used for the experiments. The results of quantitative real-time PCR revealed a moderate increase of HSP90β and PKM2 mRNA in colon tumors (P < 0.01) compared to normal tissues without relation to clinical parameters. The expression pattern could be confirmed for PKM2 protein by Western blot but not for HSP90β. During culturing with butyrate, the amount of PKM2 transcripts decreased in all three tissue types with the strongest effects observed in tumors (median fold decrease 45%, P < 0.05). The protein data have not reflected this influence supposing a more gradual degradation rate due to a longer half-life of PKM2. In contrast, the mRNA expression of HSP90β in normal tissue was found 1.38-fold increased by butyrate (P < 0.05), but not the corresponding protein level. HSP90β expression in adenomas and tumors remained generally insensitive. Only in malignant tissue, however, a significant correlation was found between the individual effects observed on gene and protein expression level. In conclusion, the present study identified PKM2 as a potential direct target of butyrate in neoplastic colon tissue, whereas HSP90β is none of it.

Butyrate suppresses mRNA increase of osteopontin and cyclooxygenase-2 in human colon tumor tissue

The short chain fatty acid (SCFA) butyrate, a product of fermentation of dietary fiber in the human colon, is found to exert multiple regulatory processes in colon carcinogenesis. The aim of this study was to find out whether butyrate affects the tumor-promoting genes osteopontin (OPN) and cyclooxygenase (COX)-2, their respective proteins and/or their functional activity in matched normal, adenoma and tumor colon tissues obtained from 20 individuals at colon cancer surgery. Quantitative real-time polymerase chain reaction experiments showed increased levels of OPN and COX-2 messenger RNA in tumor tissues when compared with the adjacent normal samples (P < 0.001). The addition of butyrate reduced OPN and COX-2 mRNA expression in all tissue types compared with the related medium controls (tumor: P < 0.05). In tumor samples, a downregulation of up to median 35% (COX-2) and 50% (OPN) was observed, respectively. Thereby, tumors with lower levels of OPN basal expression were more sensitive to inhibition and vice versa for COX-2 in normal tissue. At the protein and enzyme level, which were determined by using western blot and enzyme immunometric assays, the impact of the SCFA was not clearly visible anymore. The active proteins of OPN and COX-2 (determined by prostaglandin E(2)) were found to correlate with their respective mRNA expression only in 50-63% of analyzed donors. For the first time, our data reveal new insights into the chemoprotective potential of butyrate by showing the suppression of OPN and COX-2 mRNA in primary human colon tissue with the strongest effects observed in tumors.

Efficacy of major general surgery performed by non-physician clinicians at a central hospital in Malawi

In some sub-Saharan African countries non-physician clinicians have to perform major general surgery without medical officers and surgeons. The safety of this practice has not been established. The aim of this study was to evaluate the contribution of clinical officers (COs) to major general surgery at Zomba Central Hospital. We performed a retrospective five-year period study during 2003-2007. The perioperative outcome for three procedures was analysed. During the study 2931 major general surgical procedures were performed: 1437 (49%) by surgeons; 366 (12.5%) by COs assisted by surgeons; and 1128 (38.5%) by COs alone. COs performed 50% of prostatectomies, ventriculo-peritoneal-shuntings and strangulated hernia repairs with bowel resection alone. Baseline parameters and perioperative outcomes of the patients who underwent operations with surgeons present (as operator or assistant, 'surgeon group') or patients operated by COs alone ('CO group') were similar. COs can safely perform major general surgery when adequate training and supervision are provided.

Defensin alpha 6 (DEFA 6) overexpression threshold of over 60 fold can distinguish between adenoma and fully blown colon carcinoma in individual patients

Background

It is known that alpha-defensin expression is enhanced in colon cancer. However, the expression of human alpha defensin 6 (DEFA 6) in earlier stages, such as adenoma, has so far not yet been studied in a patient resolved manner.

Methods

By using quantitative Real Time-PCR, the gene expression pattern of DEFA 1-3 and DEFA 6 was analyzed in tissue of different stages of carcinogenesis, derived from colorectal cancer patients. In addition to paired normal and tumor tissue, matched normal near tumor and adenoma tissue samples were examined.

Results

The median gene expression of human defensin alpha 6 (DEFA 6) has been found to be moderately increased (~ 5 fold) in tumor samples derived from individuals with colorectal cancer (CRC) when compared to their normal counterparts. However, when the data were analyzed in a patient-wise manner, a large expression variation among individual patients is found, making the use of DEFA 6 for individual diagnosis of fully blown colon carcinoma difficult. Surprisingly, in adenoma the gene expression analysis revealed a 100 fold increased median expression of DEFA 6 relative to normal colon tissue. 13/18 samples had an individual overexpression of more than 60 fold in adenoma but only 3/17 in carcinoma. In each of the individual patients, at least either the adenoma or the carcinoma showed strong DEFA 6 overexpression.

Conclusions

We suggest that the expression of DEFA 6 preferably can be used as a potential diagnostic marker for adenoma and not as a marker for fully blown carcinoma. This is supported by the fact that DEFA 6 is a downstream target of the Wnt pathway, which is mutational active during the earliest stage of cancer development.

Do patients in rural Malawi benefit from upper gastrointestinal endoscopy?

The aim of this study was to evaluate the benefits of upper gastrointestinal endoscopy at central hospital level in Malawi and to draw conclusions from its use in the treatment of patients presenting with dysphagia and dyspepsia to health institutions in rural Africa. This retrospective study was carried out in order to investigate the endoscopic findings in 455 patients who presented to Zomba Central Hospital, Malawi, with upper gastrointestinal symptoms. Fifty-six percent of patients presenting with dysphagia were found to have oesophageal carcinoma. In 50% of patients with epigastric pain and 44% with abdominal pain, an endoscopy did not reveal any pathological findings. The intended treatment was frequently altered as a result of performing the endoscopy. We were able to treat patients according to their specific diagnosis in a significantly higher number than before: 51% versus 18% of those presenting with dysphagia, 96% versus 24% of those with epigastric pain and 90% versus 39% of those with abdominal pain. Upper gastrointestinal endoscopy is a feasible diagnostic tool in developing countries which improves the detection and treatment of diseases of the gastrointestinal tract.

Outcome prediction in microsurgery by quantitative evaluation of perfusion using ICG fluorescence angiography

The purpose of this prospective study was to evaluate the clinical efficacy of laser-induced fluorescence angiography with indocyanine green (ICG-FA) for perioperative monitoring of tissue perfusion in hand surgery. Different quantitative parameters of the uptake, distribution and clearance of dye-marked blood were evaluated for their sensitivity and prognostic value in comparison to each other and to clinical parameters. One hundred and fifty-five measurements were performed prior to, or following, surgery for severe hand injuries. All quantitative parameters of ICG-FA detected intraoperatively were found to be of significant predictive value for outcome, but clinical parameters were not. For the dye uptake, a minimum slope value of 0.01 was significantly related to sufficient perfusion and good prognosis. There was no correlation between the quantitative ICG-FA results or any of the clinical parameters. Since clinical evaluation of perfusion in this surgery remains difficult, the additional use of ICG-FA may improve surgical decision making and, thereby, lead to better clinical results.

The database dbEST correctly predicts gene expression in colon cancer patients

This study aims to test the predictive power of gene expression data derived from NIH's database dbEST, which collects gene expression results from a large number and variety of DNA array experiments. The motivation of this study is to make comparable experimental studies, which are usually performed only for one or a few tissues or organs, with a wide variety of other tissues. Confirmation of a good predictive power of dbEST would put a number of interesting and partially surprising recent findings, solely based on data mining, on a more solid basis than available so far. The expression of nine genes (eIF4E, DDX6, HAT1, USP28, HSP90(beta, PKM2, PLK1, COX2 and OPN) plus two calibration genes in paired normal and cancer colon tissues of eight individual patients was investigated by quantitative RT-PCR and compared with the predictions made by the data-base. GUS and beta-actin reveal only little variation among different patients, making them good internal calibration standards. In normal colon tissue, data mining correctly predicts the expression of all nine genes, which covers two orders of magnitude. In cancer, dbEST is somewhat less precise, but still valuable for the comparison with clinical results.

Different expression of calgizzarin (S100A11) in normal colonic epithelium, adenoma and colorectal carcinoma

The aim of the study was to detect proteomic markers usable to distinguish colorectal carcinoma from colon adenoma for a better understanding of the molecular mechanisms in the process of tumourigenesis. Therefore, we microdissected colon carcinoma tissue, epithelial colon adenoma tissue as well as normal adjacent colon epithelium and determined protein profiles by SELDI-TOF MS. A multitude of significantly different signals was detected. For their identification colon biopsis were lysed and subjected to a two-dimensional gel electrophoresis for separation. Subsequently, we identified nearly 100 proteins by tryptic digestion, peptide fingerprint mapping and database search. Calgizzarin (S100A11; S100C) identified by peptide fingerprint mapping correlated very well with a significantly differentially expressed signal found in prior protein profiling. Using an immunodepletion assay we confirmed the identity of this signal as calgizzarin. To localise calgizzarin in tissues we performed immunohistochemistry. For further confirmation of the identity of calgizzarin we re-analysed IHC-positive as well as IHC-negative tissue sections on ProteinChip arrays. This work demonstrates that biomarkers in colorectal cancer can be detected, identified and assessed by a proteomic approach comprising tissue-microdissection, protein profiling and immunological techniques.

Discovery and identification of alpha-defensins as low abundant, tumor-derived serum markers in colorectal cancer

BACKGROUND & AIMS

Although colorectal cancer is one of the best characterized tumors with regard to the multistep genetic progression, it remains one of the most frequent and deadly neoplasms in Western countries. This is mainly due to the fact that, up to now, no clinically relevant serum markers could be established in an early routine diagnostic procedure.

METHODS

We comparatively analyzed microdissected normal and tumorous colonic epithelium by ProteinChip technology to detect proteins specific for the tumor directly in the tissue. Immunohistochemistry (IHC) was used for the in situ localization of the discovered proteins, and an ELISA was performed to quantify these proteins in serum.

RESULTS

By this approach, we found and identified alpha-defensins 1-3 (HNP1-3) to be more highly expressed in the tumor than in normal epithelium. These findings could be confirmed by IHC. Detection of these peptides in the corresponding serum samples was subsequently performed with ELISA, resulting in an average sensitivity of 69% and specificity of 100% for the recognition of colorectal cancer when using the HNP1-3 level in the serum of the patients.

CONCLUSIONS

The direct analysis of microdissected tissue for the discovery of tumor-specific markers followed by the specific detection of these markers in serum by antibody-based methods proved to be a successful strategy in this study. Therefore, we can conclude that these promising markers would not have been found in serum without the information gained through the analysis of microdissected tissue by ProteinChip technology.

Indocyanine-green fluorescence video angiography used clinically to evaluate tissue perfusion in microsurgery

BACKGROUND

Laser-induced fluorescence angiography with indocyanine-green (ICG-FA) is a new diagnostic approach that allows quantitative evaluation of tissue perfusion in microsurgery as well as an analysis of the uptake, distribution, and clearance of dye-marked blood.

METHODS

The ICG-FA technique was evaluated for its sensitivity and prognostic value in comparison with clinical parameters (turgor, temperature, reperfusion time, bleeding after puncture) during and after different surgical procedures. Altogether, 91 measurements were made in cases of microvascular repair (n = 43) and free-flap surgery (n = 48).

RESULTS

Because of discrepancies between ICG-FA results and clinical findings, the planned postoperative management was changed 43 times (47.2%). In cases of microvascular repair that subsequently resulted in tissue necrosis, ICG fluorescence had a significantly higher prognostic value than any of the clinical parameters (p = 0.03). During free-flap surgery, intraoperative ICG-FA had better sensitivity for flap loss than clinical parameters, but postoperative ICG-FA did not.

CONCLUSIONS

Fluorescence angiography with ICG is a sensitive diagnostic tool for detecting compromised tissue perfusion in trauma surgery and microsurgery. Its use may improve perioperative management and thereby lead to better clinical results.

Association of p53 mutations, microvessel density and neoangiogenesis in pairs of colorectal cancers and corresponding liver metastases

p53 suppressor gene mutations are a well known step which occurs in the late stages of the complex tumourigenesis of colorectal cancer. A deregulation of p53 protein function may be associated with increased neovascularization and aggressive tumour growth. In vitro studies have shown that these genetic alterations cause a loss of wild-type p53-induced anti-angiogenetic control and could possibly induce expression of the neoangiogenic vascular endothelial growth factor (VEGF). Therefore, this in vivo study was performed to assess p53 mutations, i.e. hot spots in exons 4-9, in primary colorectal cancers and in corresponding liver metastases in order to test whether there is an association between p53 mutated tumours with increased microvessel density (MVD) and VEGF overexpression. Twenty-two tissue samples taken from primary colorectal cancers and the corresponding liver metastases were immediately snap-frozen in liquid nitrogen and fixed in formaldehyde. After DNA extraction exons 4-9 were amplified and directly sequenced. Cryostat sections were stained immunohistochemically using antibodies against VEGF, CD34, and p53 protein. A modified semiquantitative Weidner score and interactive computerized image analysis was used to assess MVD. Overexpression of immunohistochemically detected p53 protein was found in 7 of the 11 primary tumours and liver metastases (64%). Sequencing showed 3 out of 11 primary tumours (27%) and 5 out of 11 liver metastases (46%) to have p53 point or frameshift mutations; these samples tested immunohistochemically positive for p53 protein. Two p53 mutations in samples of liver metastases were not detectable in the corresponding primaries. We detected one frameshift mutation in exon 4 that has not yet been described in the literature. Tumour samples with p53 mutations and increased VEGF immunoreactivity were associated with higher MVD (p<0.01 and p<0.05, respectively). However, there was no association detected immunohistochemically between p53 and MVD as well as p53 mutations and VEGF overexpression. Our data demonstrate specific genetic alterations in the coding regions of p53 suppressor gene in both primary colorectal cancers and corresponding liver metastases, these alterations are associated with an increase in MVD, but not in VEGF overexpression. In addition, a novel frameshift mutation in both colorectal cancer and metastasis is described.

Alport syndrome associated with diffuse leiomyomatosis: COL4A5-COL4A6 deletion associated with a mild form of Alport nephropathy

BACKGROUND

The X-linked Alport syndrome (AS) is an inherited nephropathy due to mutations in the COL4A5 gene, encoding the alpha5 chain of type IV collagen, a major component of the glomerular basement membrane (GBM). Here, we report a new kindred with the rare association of X-linked AS and diffuse leiomyomatosis (DL), which is a tumourous process involving smooth muscle cells of the oesophagus, the tracheobronchial tree and, in females, the genital tract. For this syndrome, an almost constant association of large COL4A5 rearrangements with a severe juvenile form of nephropathy has been described for male patients.

METHODS

DNA rearrangement at the COL4A5-COL4A6 locus was studied in several members of this family using polymerase chain reaction and pulsed field gel electrophoresis. Furthermore, immunohistochemical staining of tumour and skin samples was performed.

RESULTS

The affected patients in this family carry a 120 kb deletion by which the COL4A5 exon 1 and COL4A6 exons 1, 1', and 2 are removed. Immunohistochemical investigation of a skin biopsy of an affected male patient confirmed the absence of both the alpha5 and the alpha6 chains of type IV collagen in the basement membrane of the skin. Surprisingly, both affected male patients had a rather mild renal phenotype.

CONCLUSIONS

This report shows that, contrary to what has been reported to date, patients suffering from AS associated with DL can be associated with a late onset renal failure (adult) form of nephropathy.

[Reversal of therapy of postoperative complications by measuring lung water]

Our data suggest that the indicator dilution technique allows differentiated and early prediction of cardiopulmonary complications during the postoperative period. This leads to significant changes in fluid therapy to prevent organ failure.