Tn as a potential predictor for regional lymph node metastasis in T1 colorectal cancer

BACKGROUND

Approximately 10 percent of T1 colorectal cancer (CRC) has lymph node metastasis. In this study, we aimed to determine possible predictors for nodal involvement in order to aid selection of appropriate patients for organ-preserving strategies.

METHODS

We retrospectively reviewed CRC patients underwent radical surgery from January 2009 to December 2016, with final pathology report disclosed as T1 lesion. The paraffin-embedded samples were achieved for glycosylated proteins expression analysis by immunohistochemistry.

RESULTS

Totally, 111 CRC patients with T1 lesion were enrolled in this study. Of these patients, seventeen patients had nodal metastases, with the lymph node positive rate of 15.3%. Semiquantitative analysis of immunohistochemical results indicated that mean value of Tn protein expression in T1 CRC specimens was significantly different between patients with and without lymph node metastasis (63.6 vs. 27.4; p = 0.018).

CONCLUSIONS

Our data shown that Tn expression may be applied as a molecular predictor for regional lymph node metastasis in T1 CRC. Moreover, the organ-preserving strategy could be improved by proper classification of patients. The mechanism involved in expression of Tn glycosylation protein and CRC metastasis need further investigation.

Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B

People with hemophilia (PWH), especially severe hemophilia, often experience bleeding episodes, which occur mostly at major joints. Intramural hematoma of the gastrointestinal (GI) tract is a rare, potentially life-threatening clinical bleeding manifestation in PWH. Prompt identification and timely administration of clotting factor concentrates are of utmost importance for effective management and optimal patient outcomes. In this report, we present the case of a 48-year-old male with severe hemophilia A. The patient developed a spontaneous intramural hematoma of the jejunum, leading to signs of acute abdomen, bloody stool, and paralytic ileus. Conservative management with factor VIII (FVIII) infusion was successfully administered. However, within a span of three months, the patient suffered from a recurrent episode of intramural hematoma, which was again effectively treated with conservative therapy. Subsequently, prophylactic FVIII therapy was administered to the patient, resulting in the absence of recurrence for over three years. Inspired by this case, we conducted a comprehensive review of the relevant literature and gathered data from 79 reported cases of intramural hematoma that were documented between the years 1956 and 2022. We classified these cases based on the site affected within the gastrointestinal (GI) tract (spread across five different locations) and proceeded to conduct a simple pooling analysis on the data collected, which subsequently revealed that the overall mortality rate of intramural hematoma in people with hemophilia (PWH) was found to be 12.2%, while children have a higher mortality rate (23.3%) than adults (4.9%). We hope this case report and literature review increase awareness of this rare bleeding manifestation in PWH, the effectiveness of conservative treatment, and the possibility of prophylaxis against recurrence.

Phase 1b/ 2 study of a radio-enhancer, PEP503 (NBTXR3), in combination with concurrent chemo-radiation in locally advanced or unresectable rectal cancer

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Background: PEP503 (aka NBTXR3) is a novel radio-enhancer composed of functionalized hafnium oxide nanoparticles that increases the energy deposition of radiotherapy. A phase 3 study in soft tissue sarcoma patients has significantly increased pCR and R0 when PEP503 was added to preop radiotherapy. This phase 1b/2 study was conducted with the aim to identify a recommended phase 2 dose (RP2D), and evaluate the efficacy of PEP503 intratumoral injection in combination with concurrent chemoradiation (CCRT) in patients with locally advanced rectal cancer (LARC). Methods: Patients with stage T3-T4 LARC (or with unresectable disease) suitable for neoadjuvant CCRT were enrolled. An intratumoral single administration of PEP503 (multiple punctures) was done 24 to 72 hours prior to IMRT of 50 Gy in 25 fractions of 2 Gy per fraction over 5-6 weeks with concurrent capecitabine or 5-FU. Traditional 3 + 3 design with 4 levels, 5%, 10%, 15%, and 22%, of the baseline GTV as measured by MRI, of PEP503 were assessed in Phase Ib. PEP503 nanoparticles intratumoral dispersion was analyzed by CT-scan. Surgery was performed 8 to 12 weeks after the completion of CCRT for patients with resectable tumors. Body kinetics was evaluated in Phase Ib. (ClinicalTrials.gov, NCT02465593) Results: Thirty-two (32) patients (male/female: 20/12; median age 62 years, range 38 to 76) were enrolled (1 dropped out before starting CCRT). In Phase 1b, 20 patients were treated and dose was escalated to 22%. RP2D was then determined as 22% with 6 patients treated at this dose level without DLT. Twelve (12) patients were included in the Phase 2. One (1) (3.2%) and 19 (61.3%) of evaluable patients (n = 31) had CR and PR, respectively, as the best tumor response across dose levels. No patient progressed as all evaluable patients (n = 31) achieved disease control for a DCR of 100%. Furthermore, twenty-five patients underwent surgery, of which 24 (96%) had microscopically clear resection margins and 5 of them (20%) had pathological complete response (pCR). The G3 AEs were diarrhea, ileus, thrombocytopenia, urosepsis, procedural haemorrhage, wound complication, hypokalaemia, and myalgia (all in 3.1%). No G4 AE were observed. The results of CT scans for nanoparticles dispersion demonstrated PEP503 remained within the tumor without leakage to the surrounding healthy tissues, before and after CCRT. In most patients, hafnium was not detected or below the Lower Limit of Quantification (LLOQ) in the circulation 60 minutes after PEP503 injection and was not found in urine. Conclusions: A single intratumoral injection of PEP503 in locally advanced or unresectable rectal adenocarcinoma undergoing capecitabine or 5-FU based CCRT is feasible and safe. The preliminary observed efficacy results may warrant further examination in larger clinical studies. Clinical trial information: NCT02465593.

Robotic transanal minimally invasive surgery for rectal cancer after clinical complete response to neoadjuvant chemoradiation

BACKGROUND

Full-thickness local excision (FTLE) for rectal cancer showing clinical complete remission (cCR) after neoadjuvant chemoradiation therapy (NCRT) is associated with good oncological results. The purpose of this study was to report the results of robotic transanal minimally invasive surgery for such patients.

METHODS

Patients were treated with a 5-fluorouracil-based NCRT regimen. The determination of cCR was based on digital rectal examination, colonoscopy, and magnetic resonance imaging.

RESULTS

Six patients underwent transanal FTLE using the da Vinci Xi surgical system. The median operative time was 106.5 minutes, and the estimated blood loss was minimal. The mean length of hospital stay was 4.2 days. After 18.2 months of follow-up, none of the patients developed local recurrences or distant disease.

CONCLUSIONS

With the use of robotic technology, FTLE can be performed with relative ease and can be considered as a viable alternative to radical resection or a "Watch and Wait" strategy.

Can we predict pathologic complete response before surgery for locally advanced rectal cancer treated with preoperative chemoradiation therapy?

BACKGROUND

Pathologic complete response has been proven to have oncological benefits for locally advanced rectal cancer treated with chemoradiation therapy. The aims of this study are to analyze and determine the factors to predict pathologic complete response for patients treated with preoperative neoadjuvant therapy.

METHODS

Patients with biopsy-proven, locally advanced rectal cancer were treated neoadjuvantly followed by radical surgical resection. Tumors were re-assessed after completing chemoradiation, including pelvic magnetic resonance images, colonoscopic examination, and re-biopsy. The results of examination were compared with the final pathologic status.

RESULTS

A retrospective chart review of 166 patients was conducted. Twenty-five patients (15.1%) had pathologic complete response after chemoradiation. The 5-year overall survival rates were better in the complete response group than the residual tumor group (91.1% vs. 70.8%; P = 0.047), and there were also significant differences in the 5-year disease-free survival rates between these two groups (91.1% vs. 70.2%; P = 0.027). The prediction rates for pathologic complete response by re-biopsy, magnetic resonance images, and colonoscopy were 21.4%, 33.3%, and 53.8%, respectively. In addition, when we further combine the results of colonoscopic findings and re-biopsy, the prediction rate for pathologic complete response reached 77.8% (P = 0.009).

CONCLUSIONS

Combining the results of the re-biopsy and post-treatment colonoscopic findings, we can achieve a good prediction rate for pathologic complete response. Post-treatment magnetic resonance images are not useful tools in predicting tumor clearance following chemoradiation.

Spiral biphasic contrast-enhanced computerized tomography in the diagnosis of hepatocellular carcinoma

Advances in spiral computerized tomography (CT) have made rapid biphasic contrast-enhanced CT possible. This study evaluated the capability of biphasic contrast-enhanced spiral CT to detect hepatocellular carcinoma (HCC). A total of 125 patients (68 men and 57 women) with proven HCC underwent preliminary noncontrast (NC) scanning, followed by hepatic arterial phase (HAP) and portal venous phase (PVP) imaging. Contrast medium (80 mL, 300 mgI/mL) was administered routinely at a rate of 2 mL/second using an automated contrast injector under guidance software monitoring. Study of NC and PVP images without concurrent study of HAP images detected 131/171 (76.6%) cases of HCC. In contrast, combined study of NC, PVP, and HAP images detected 153/171 (89.5%) cases of HCC. Thus, combined study of NC and biphasic images was able to detect an additional 12.9% of HCC cases in comparison with conventional study of NC and PVP images only. All HCCs that were detectable only on HAP imaging were enhanced homogeneously with contrast medium during the arterial phase.

Computed tomography and magnetic resonance imaging of diffuse pigmented villonodular synovitis: report of a case

We describe the computed tomographic (CT) and magnetic resonance imaging (MRI) features of a surgically proven case of diffuse pigmented villonodular synovitis (PVNS) of the knee in a 34-year-old woman. A complex mass consisting of solid and multicystic components was clearly demonstrated by CT and MRI. The solid part showed homogeneous hypodense attenuation relative to adjacent muscles on CT scans, but it showed inhomogeneous signal intensity on spin echo T1- and T2-weighted images (WI). The solid component enhanced homogeneously on CT scans but heterogeneously on MR images. Multiseptated enhancement of the cystic component on both CT and MR images were displayed. All of the above features were better demonstrated on MRI. Multiple marked hypointense round and patchy areas, and also a few areas isointense to subcutaneous fat within the lesion were also found on T1WI, proton density WI and T2WI. These characteristic MRI features of PVNS correlated well with its histologic structures: depositions of hemosiderin and fat in the proliferative synovial villi and bloody cystic content. These features may help to distinguish PVNS from other disease entities arising from the synovium.

Magnetic resonance imaging of acoustic schwannomas

The magnetic resonance imaging (MRI) findings of 27 histologically proven acoustic schwannomas in 24 patients (13 men, 11 women, age 20-79 yr) are described in detail. Three patients had bilateral tumors. Twenty-two tumors (82%) had intra- and extracanalicular components, three tumors (11%) were limited to the internal auditory canal (IAC) and two tumors (7%) were limited to the cerebellopontine angle (CPA). The diameters of extracanalicular lesions in the CPA ranged from 12 to 50 mm, and most of them were round in shape. All IAC portions of CPA tumors had a funnel-shaped appearance on the axial images and short-club-shaped configuration on the coronal images. There was strong homogeneous contrast enhancement of the solid components in 12 tumors (44%) and heterogeneous enhancement in 15 tumors (56%). The cystic components of the tumors correlated well with the histologic features. All tumors could be demonstrated in their enterity by MRI. The "short-club sign", first described in this study, helped to confirm the intracanalicular component of acoustic schwannomas, which were usually found in the cerebellar cistern. The results of this study show that MRI is a sensitive imaging modality for the assessment of acoustic schwannomas located at the CPA or IAC, or in both regions. MRI is non-invasive and does not involve ionizing radiation. It should be considered the imaging examination of choice to evaluate patients with suspected acoustic schwannomas.

[Computed tomography of gastric carcinoma using water as a contrast agent]

To overcome the problem of poor mixing of gastrointestinal tract contents with a diluted iodinated contrast agent in abdominal computed tomography, pure water was adopted as an oral contrast agent. In 25 cases of clinically suspected gastric carcinoma, a subsequent pathological examination revealed six cases of early gastric cancer and 19 cases of advanced gastric cancer. We performed CT of the stomach using the following revised procedure: patients were given 600-1000 mL of water by mouth after an intramuscular dose of Buscopan to distend and immobilize the stomach. Gastric mucosal enhancement and the poorer enhanced submucosal layer were demonstrated by a bolus intravenous injection of iodine-containing contrast medium using an automatic injector synchronized with the CT machine. Based on abnormal gastric wall thickening and the abnormal mural enhancement patterns, an accuracy of 96% was attained in differentiating early gastric cancer from advanced gastric cancer, but the detection rates for extragastric invasion, gastric ulcers and lymphadenopathy were 67%, 43% and 63%, respectively. CT staging of gastric cancer was 72%, and was especially accurate for stages I and IV. Water as oral contrast agent for CT of the GI tract was readily accepted by patients and caused no side effects. Using water as an oral contrast for gastric CT is of great help in staging gastric cancer.