Deoxycholic acid promotes development of gastroesophageal reflux disease and Barrett's oesophagus by modulating integrin-αv trafficking

The fundamental mechanisms underlying erosive oesophagitis and subsequent development of Barrett's oesophagus (BO) are poorly understood. Here, we investigated the contribution of specific components of the gastric refluxate on adhesion molecules involved in epithelial barrier maintenance. Cell line models of squamous epithelium (HET‐1A) and BO (QH) were used to examine the effects of bile acids on cell adhesion to extracellular matrix proteins (Collagen, laminin, vitronectin, fibronectin) and expression of integrin ligands (α₃, α_4, α₅, α₆ and α_ν). Experimental findings were validated in human explant oesophageal biopsies, a rat model of gastroesophageal reflux disease (GORD) and in patient tissue microarrays. The bile acid deoxycholic acid (DCA) specifically reduced adhesion of HET‐1A cells to vitronectin and reduced cell‐surface expression of integrin‐α_νvia effects on endocytic recycling processes. Increased expression of integrin‐α_v was observed in ulcerated tissue in a rat model of GORD and in oesophagitis and Barrett's intestinal metaplasia patient tissue compared to normal squamous epithelium. Increased expression of integrin‐α_ν was observed in QH BO cells compared to HET‐1A cells. QH cells were resistant to DCA‐mediated loss of adhesion and reduction in cell‐surface expression of integrin‐α_ν. We demonstrated that a specific component of the gastric refluxate, DCA, affects the epithelial barrier through modulation of integrin α_ν expression, providing a novel mechanism for bile acid‐mediated erosion of oesophageal squamous epithelium and promotion of BO. Strategies aimed at preventing bile acid‐mediated erosion should be considered in the clinical management of patients with GORD.

Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland

INTRODUCTION

There is variation in margin policy for breast conserving therapy (BCT) in the UK and Ireland. In response to the Society of Surgical Oncology and American Society for Radiation Oncology (SSO-ASTRO) margin consensus ('no ink on tumour' for invasive and 2 mm for ductal carcinoma in situ [DCIS]) and the Association of Breast Surgery (ABS) consensus (1 mm for invasive and DCIS), we report on current margin practice and unit infrastructure in the UK and Ireland and describe how these factors impact on re-excision rates.

METHODS

A trainee collaborative-led multicentre prospective study was conducted in the UK and Ireland between 1st February and 31st May 2016. Data were collected on consecutive BCT patients and on local infrastructure and policies.

RESULTS

A total of 79 sites participated in the data collection (75% screening units; average 372 cancers annually, range 70-900). For DCIS, 53.2% of units accept 1 mm and 38% accept 2-mm margins. For invasive disease 77.2% accept 1 mm and 13.9% accept 'no ink on tumour'. A total of 2858 patients underwent BCT with a mean re-excision rate of 17.2% across units (range 0-41%). The re-excision rate would be reduced to 15% if all units applied SSO-ASTRO guidelines and to 14.8% if all units followed ABS guidelines. Of those who required re-operation, 65% had disease present at margin.

CONCLUSION

There continues to be large variation in margin policy and re-excision rates across units. Altering margin policies to follow either SSO-ASTRO or ABS guidelines would result in a modest reduction in the national re-excision rate. Most re-excisions are for involved margins rather than close margins.

Estimating the OncotypeDX score: validation of an inexpensive estimation tool

BACKGROUND

OncotypeDX, a multi-gene expression assay, has been incorporated into clinical practice as a prognostic and predictive tool. However, its use in resource-constrained international healthcare systems is limited. Here we develop and validate a simplified model using clinicopathologic criteria to predict OncotypeDX score.

METHODS

Patients with estrogen receptor (ER) and/or progesterone receptor (PR)-positive and HER2-negative invasive ductal carcinoma for whom the OncotypeDX test was successfully performed between 09/2008 and 12/2011 were retrospectively identified. Tumor size, nuclear and histologic grade, lymphovascular invasion, and ER and PR status were extracted from pathology reports. Data were split into a training dataset comprising women tested 09/2008-04/2011, and a validation dataset comprising women tested 04/2011-12/2011. Using the training dataset, linear regression analysis was used to identify factors associated with OncotypeDX score, and to create a simplified risk score and identify risk cutoffs.

RESULTS

Estrogen and progesterone receptors, tumor size, nuclear and histologic grades, and lymphovascular involvement were independently associated with OncotypeDX. The full model explained 39% of the variation in the test data, and the simplified risk score and cutoffs assigned 57% of patients in the test data to the correct risk category (OncotypeDX score <18, 18-30, >30). 41% of patients were predicted to have OncotypeDX score <18, of these 83, 16, and 2% had true scores of <18, 18-30, and >30, respectively.

CONCLUSIONS

Awaiting an inexpensive test that is prognostic and predictive, our simplified tool allows clinicians to identify a fairly large group of patients (41%) with very low chance of having high-risk disease (2%).

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Local approaches to hereditary breast cancer

The diagnostic and local treatment modalities of hereditary breast cancer (HBC) are evolving based on emerging evidence from new imaging, radiotherapy and surgical studies. The optimal selection of diagnostic and therapeutic strategies for the individual HBC patient remains an area of active research in this relatively new patient population. In this context, some rational pathways of intervention are currently available to both reduce cancer risk in mutation carriers without a cancer diagnosis, as well as to reduce the risk of recurrence or new cancers among the carriers already diagnosed with a malignancy. It is encouraging to notice to what degree certain interventions have successfully reduced both the risk of malignancy and the anxiety associated with this genetic diagnosis. This updated report aims at summarizing the most recent findings, while it identifies the areas of uncertainty that remain, and continue to present difficult challenges, particularly among younger HBC patients.

Radioactive seed localization compared to wire localization in breast-conserving surgery: initial 6-month experience

BACKGROUND

Wire localization (WL) of nonpalpable breast cancers on the day of surgery is uncomfortable for patients and impacts operating room efficiency. Radioactive seed localization (RSL) before the day of surgery avoids these disadvantages. In this study we compare outcomes of our initial 6-month experience with RSL to those with WL in the preceding 6 months.

METHODS

Lumpectomies for invasive or intraductal cancers localized with a single (125)iodine seed (January-June 2012) were compared with those using 1 wire (July-December 2011). Surgeons and radiologists did not change. Positive and close margins were defined as tumor on ink and tumor ≤1 mm from ink, respectively. Demographic and clinical characteristics and outcomes were compared between RSL and WL patients.

RESULTS

There were 431 RSL and 256 WL lumpectomies performed. Clinicopathologic characteristics did not differ between groups. Most seeds (90 %) were placed before the day of surgery. Positive margins were present in 7.7 % of RSL versus 5.5 % of WL patients, and 16.9 % of RSL versus 19.9 % of WL had close margins (p = 0.38). The median operative time was longer for lumpectomy and sentinel lymph node biopsy (SLNB) in the RSL group (55 vs. 48 min, p < 0.0001). There was no significant difference in the volume of tissue excised between groups.

CONCLUSIONS

In the first 6 months of RSL, operative scheduling was simplified, while rates of positive and close margins were similar to those seen after many years of experience with WL. Operative time was slightly longer for RSL lumpectomy and SLNB; we anticipate this will decrease with experience.

New innovative techniques in radiotherapy for breast cancer

Breast-conserving surgery (BCS) followed by adjuvant whole breast radiotherapy (WBRT) is an established treatment for early-stage breast cancer. Long-term follow-up has demonstrated equivalent survival to mastectomy. However, standard WBRT to the conserved breast requires daily radiation treatment, 5 days per week, for 5-7 weeks. This schedule imposes a considerable burden on breast cancer patients and healthcare systems alike. For the last decade, there has been considerable interest in lessening the volume of breast treated with radiotherapy and reducing the number of fractions of radiation treatment. Accelerated partial breast irradiation (APBI), including intraoperative radiotherapy (IORT), delivers high-dose radiation immediately surrounding the lumpectomy cavity, with relative sparing of the majority of the ipsilateral breast. Hypofractionated WBRT delivers radiation to the entire ipsilateral breast; however, this is achieved using a smaller number of fractions and total dose of radiotherapy. The attraction of less invasive or demanding radiotherapy schedules has led to the widespread introduction of APBI before its long-term results have been established. In the past 5 years, data from prospective trials of hypofractionated WBRT and IORT compared to standard WBRT have become available. Additionally, a large, prospective randomized study of APBI versus WBRT is nearing accrual. In this review article, we will discuss these new innovative techniques in radiotherapy for breast cancer. We will also discuss the recently completed and ongoing prospective studies that will provide a robust evaluation of the safety and efficacy of these techniques.

Neither Antioxidants nor COX-2 Inhibition Protect Against Esophageal Inflammation in an Experimental Model of Severe Reflux

BACKGROUND

Reflux-induced injury and oxidative stress result in esophageal inflammation and the potential for progression to intestinal metaplasia and adenocarcinoma. Proton-pump inhibitors represent the standard medical approach, but anti-inflammatories and antioxidants offer novel therapeutic possibilities.

MATERIALS AND METHODS

Six weeks after an esophagojejunostomy reflux procedure, female Wistar rats (n = 100) were randomized to receive either an antioxidant (vitamin C, 8 mg or 28 mg/day), a cyclooxygenase-2 (COX-2) inhibitor (rofecoxib, 1 mg/day), or no therapy. After sacrifice 16 weeks later, esophageal injury was scored using pathologic and image analysis scoring.

RESULTS

Esophagitis was present in all 63 animals completing the study and was severe in 27 (43%). No animal developed metaplasia or tumor. The extent of inflammation and esophageal ulceration were not significantly different between experimental groups.

CONCLUSIONS

In this model of reflux injury, antioxidants and COX-2 inhibitors failed to ameliorate the severe inflammation induced. Further experimental designs should evaluate these novel approaches in less severe experimental models.

Neither Antioxidants nor COX-2 Inhibition Protect Against Esophageal Inflammation in an Experimental Model of Severe Reflux

BACKGROUND

Reflux-induced injury and oxidative stress result in esophageal inflammation and the potential for progression to intestinal metaplasia and adenocarcinoma. Proton-pump inhibitors represent the standard medical approach, but anti-inflammatories and antioxidants offer novel therapeutic possibilities.

MATERIALS AND METHODS

Six weeks after an esophagojejunostomy reflux procedure, female Wistar rats (n = 100) were randomized to receive either an antioxidant (vitamin C, 8 mg or 28 mg/day), a cyclooxygenase-2 (COX-2) inhibitor (rofecoxib, 1 mg/day), or no therapy. After sacrifice 16 weeks later, esophageal injury was scored using pathologic and image analysis scoring.

RESULTS

Esophagitis was present in all 63 animals completing the study and severe in 27 (43%). No animal developed metaplasia or tumor. The extent of inflammation and esophageal ulceration were not significantly different between experimental groups.

CONCLUSIONS

In this model of reflux injury, antioxidants and COX-2 inhibitors failed to ameliorate the severe inflammation induced. Further experimental designs should evaluate these novel approaches in less severe experimental models.

Impact of solitary involved lymph node on outcome in localized cancer of the esophagus and esophagogastric junction

Node-positive esophageal cancer is associated with a dismal prognosis. The impact of a solitary involved node, however, is unclear, and this study examined the implications of a solitary node compared with greater nodal involvement and node-negative disease. The clinical and pathologic details of 604 patients were entered prospectively into a database from1993 and 2005. Four pathologic groups were analyzed: node-negative, one lymph node positive, two or three lymph nodes positive, and greater than three lymph nodes positive. Three hundred and fifteen patients (52%) were node-positive and 289 were node-negative. The median survival was 26 months in the node-negative group. Patients (n=84) who had one node positive had a median survival of 16 months (p=0.03 vs node-negative). Eighty-four patients who had two or three nodes positive had a median survival of 11 months compared with a median survival of 8 months in the 146 patients who had greater than three nodes positive (p=0.01). The survival of patients with one node positive [number of nodes (N)=1] was also significantly greater than the survival of patients with 2-3 nodes positive (N=2-3) (p=0.049) and greater than three nodes positive (p<0001). The presence of a solitary involved lymph node has a negative impact on survival compared with node-negative disease, but it is associated with significantly improved overall survival compared with all other nodal groups.

COX-2 overexpression in pretreatment biopsies predicts response of rectal cancers to neoadjuvant radiochemotherapy

PURPOSE

To determine the utility of COX-2 expression as a response predictor for patients with rectal cancer who are undergoing neoadjuvant radiochemotherapy (RCT).

METHODS AND MATERIALS

Pretreatment biopsies (PTB) from 49 patients who underwent RCT were included. COX-2 and proliferation in PTB were assessed by immunohistochemistry (IHC) and apoptosis was detected by TUNEL stain. Response to treatment was assessed by a 5-point tumor-regression grade (TRG) based on the ratio of residual tumor to fibrosis.

RESULTS

Good response (TRG 1+2), moderate response (TRG 3), and poor response (TRG 4+5) were seen in 21 patients (42%), 11 patients (22%), and 17 patients (34%), respectively. Patients with COX-2 overexpression in PTB were more likely to demonstrate moderate or poor response (TRG 3+4) to treatment than were those with normal COX-2 expression (p=0.026, chi-square test). Similarly, poor response was more likely if patients had low levels of spontaneous apoptosis in PTBs (p=0.0007, chi-square test).

CONCLUSIONS

COX-2 overexpression and reduced apoptosis in PTB can predict poor response of rectal cancer to RCT. As COX-2 inhibitors are commercially available, their administration to patients who overexpress COX-2 warrants assessment in clinical trials in an attempt to increase overall response rates.

Surgical informatics on the internet: any improvement?

PURPOSE

The Internet is a popular, but ungoverned, source of medical information. This study tracked the change in performance of commonly available search engines and the quality of medical data therein over a four-year period.

METHODS

We compared the accuracy of information on a commonly performed surgical procedure (vasectomy) using six standard search engines in a four-year period and with two recently developed search engines. The top 25 ranked sites cited by each search engine were scored for description of the procedure, post-operative instructions, complications and unproven associations.

RESULTS

There was no improvement in quality of individual sites over the study period. Additionally, the hit rate of search engines remained poor with 27 sites cited (40%) in 2002 either irrelevant or unavailable.

DISCUSSION

Few useful sites with accurate information on surgical procedures are available on the Internet and simple search strategies fail to identify site quality or relevancy.

CONCLUSION

At present, the Internet cannot be recommended as a reliable resource for many aspects of health information for patients. The onus is on health-care providers to provide high quality sites and direct patients to these sources of reliable information

Acute pancreatitis

Acute pancreatitis is an important and extremely common cause of acute hospital admission which may be associated with major morbidity and mortality. Modern treatment is largely supportive with a limited role for surgery.

The Combined Effect of Rotation and Magnetic Field on Finite-Amplitude Thermal Convection

The combined effect of an imposed rotation and magnetic field on convective transfer in a horizontal Boussinesq layer of fluid heated from below is studied in the mean field approximation. The basic equations are derived by a variational technique and their solutions are then found over a wide range of conditions, in the case of free boundaries, by numerical and analytic techniques, in particular by asymptotic and perturbation methods. The results obtained by the different techniques are shown to be in excellent agreement. As for the linear theory, the calculations predict that the simultaneous presence' of a magnetic field and rotation may produce conflicting tendencies.

On Magnetic Inhibition of Thermal Convection

The effect of an imposed vertical magnetic field on convective transfer in a horizontal Boussinesq layer of fluid heated from below is studied in the mean field approximation. Solutions are found over a wide range of conditions, for free boundaries, by a combination of numerical and analytic techniques. Quantitative estimates are made of the significant modifications to the heat transfer which are brought about by the presence of the magnetic field. It is found that the general properties of nonlinear steady cellular convection seem to persist in the face of magnetic inhibition.