Paraoxonase-1: Characteristics and Role in Atherosclerosis and Carotid Artery Disease

Paraoxonase-1 (PON-1) is a calcium-dependent enzyme that is synthesized in the liver and then secreted in blood where it is bound to high density lipoprotein (HDL). PON-1 is a hydrolase with a wide range of substrates, including lipid peroxides. It is considered responsible for many of the antiatherogenic properties of HDL. PON-1 prevents low density lipoprotein (LDL) oxidation, a process that is considered to contribute to the initiation and development of atherosclerosis. PON-1 activity and levels are influenced by gene polymorphisms; of the 2 common variants, one is in position 192 (Q192R) and one in position 55 (M55L). Also, many drugs affect PON-1 activity. The role of PON-1 in carotid atherosclerosis is inconsistent. Some studies show an association of PON-1 polymorphisms with carotid plaque formation, whereas others do not. The aim of this review is to summarize the characteristics of PON-1, its interactions with drugs and its role in atherosclerosis and especially its relationship with carotid artery disease.

Minimally invasive management of hepatic cysts: indications and complications

OBJECTIVE

Liver cysts are divided into congenital and acquired. Congenital cystic lesions include polycystic liver disease, simple cysts, duct related and ciliated hepatic foregut cysts. Acquired cystic lesions are divided into infectious and non-infectious. The infectious cysts are the hydatid cyst, the amoebic abscess, and the pyogenic abscess, whereas the non-infectious cysts are neoplastic cysts and false cysts. While modern medicine provides a lot of minimally invasive therapeutic modalities, there has emerged a pressing need for understanding the various types of liver cysts, the possible minimal therapeutic options along with their indications and complications. We aim is to clarify the role of minimally invasive techniques in the management of hepatic cysts.

MATERIALS AND METHODS

A literature review was performed using the MEDLINE database. The search terms were: liver cyst, minimally invasive, laparoscopic, percutaneous, drainage and fenestration. We reviewed 82 English language publications articles, published until October 2017.

RESULTS

Minimally invasive management of liver LC is an emerging field including many therapeutic modalities ranging from the percutaneous aspiration of pyogenic abscesses to laparoscopic hepatectomy for hepatic cystadenomas. The most used techniques are percutaneous drainage, laparoscopic fenestration, and laparoscopic hepatectomy.

CONCLUSIONS

The application of the various minimally invasive approaches, as well as their indication and complications, depend on the type of the cystic lesion, its size and its position in the liver. Percutaneous drainage is mostly used in simple cysts, hydatid cysts, pyogenic abscesses and bilomas. Laparoscopic fenestration is mostly used in simple cysts and polycystic liver disease. Finally, laparoscopic hepatectomy is mostly used in polycystic liver disease, hydatid cysts, and cystadenomas.

Iodine intake and chronic autoimmune thyroiditis: a comparative study between coastal and mainland regions in Greece

INTRODUCTION

The purpose of this study was to evaluate the relationship between iodine intake and autoimmune thyroiditis in Chios, an island located in the North East Aegean Sea, in comparison to mainland regions in South Western Greece (SWG).

MATERIALS AND METHODS

Urine iodine concentration (UIC), thyroid function (serum TSH, thyroid autoantibodies: anti-TPO and anti-Tg), and thyroid U/S were assessed in 200 subjects (150 females and 50 males) from Chios and 322 subjects (255 females and 67 males) from several mainland regions in SWG. All participants were recruited from outpatient clinics and were diagnosed as euthyroid.

RESULTS

Median UIC in Chios was significantly higher compared to SWG (136.1 vs. 104.5 μg/L, p < 0.001), indicating that both regions are iodine sufficient according to World Health Organization (WHO) criteria. The prevalence of thyroid autoimmunity was 66.5% in Chios and 27% in SWG, significantly higher in females (46.7%) than in males (26.5%). Furthermore, individuals with increased levels of thyroid autoantibodies either anti-TPO or anti-Tg (TAbs) showed increased median UIC levels compared to those / subjects / patients with normal levels (126.7 vs. 108.95 μg/L, p < 0.001). Serum TSH mean values (mIU/L) were greater in females (mean = 2.1 ± 1.41) compared to males (mean = 1.82 ± 1.26) (p = 0.04) and decreased with age.

CONCLUSIONS

In conclusion, in the present study, we clearly indicate that increased thyroid autoimmunity is positively associated with increased iodine intake, as well as with the female gender. Moreover, iodine intake and thyroid autoimmunity appear to be significantly higher in a coastal region (Chios) than in mainland Greece (SWG). Additional environmental factors, apart from iodine, should be investigated in future studies. Mean TSH values were increased in females and decreased with age. The latter is probably due to the presence of autonomous goiter in older Greek populations, as a result of long-term status of iodine deficiency in the past.

Current clostridium difficile treatments: Lessons that need to be learned from the clinical trials

Clostridium difficile infection (CDI) is the most common infectious disease cause of nosocomial diarrhea in adults in developed countries. Judging from the clinical trials on drugs used in CDIs, no approved treatment for recurrences exists, possibly indicating that a combination of treatment approaches are mandatory especially in severe infections, with current studies not being fully representative. Among the new strategies researched intensively fidaxomicin is presented, which demonstrates reduced CDI recurrences. Moreover, biotherapeutic strategies, mainly fecal microbiota transplantation but also competitive inhibition with non-toxigenic strains of C. difficile, and finally monoclonal antibodies against C. difficile toxins which offer protection against recurrences. Careful interpretation of the results based on lessons learned from previous trials conducted seems crucial. Questions are raised regarding how the results of future studies regarding new strategies researched will be managed and interpreted especially with regard to recurrence management as relevant data must be monitored for at least 30 days after end of treatment.

Postoperative deep wound dehiscence of thoracotomy with isolation of Corynebacterium tuberculostearicum: surgical site infection or colonization?

OBJECTIVE

Infections with Corynebacterium tuberculostearicum are very rare as in most of the cases its isolation is associated with tissue colonization rather than infection.

CASE REPORT

An 80-year old female patient was sent to the consultation hour of thoracic surgery for evaluation of a symptomatic persistent unilateral pleural effusion of her right lung. The differential diagnosis included either the presence of a chronic pleural empyema or the presence of malignancy. After excluding a malignancy, a decortication of the middle and lower lobe was performed, as the two lobes could not significantly re-expand. The course was further complicated by the presence of two-times deep wound dehiscence, which made necessary a rethoracotomy. The microbiologic results of the biopsies revealed the presence of only Corynebacterium tuberculostearicum with an initially questionable clinical relevance. As soon as the antibiotic treatment for Corynebacterium tuberculostearicum began, together with the use of vacuum-assisted therapy (VAC), the closure of the thoracotomy was accelerated.

CONCLUSIONS

Clinically relevant surgical site infections with Corynebacterium species in thoracic surgery are difficult to distinguish. Nevertheless, its combined surgical and antibiotic treatment is warranted when its relevance is questionable due to its resistance to broad-spectrum antibiotics as well as to its potential for the complicated clinical course.

Preliminary Evaluation of the Potential Prognostic Value of Serum Levels of Immunoglobulins (IgA, IgM, IgG, IgE) in Patients with Gastric Cancer

Sixty patients with advanced gastric carcinoma who refused to receive cytotoxic chemotherapy were examined for serum immunoglobulin levels (IgG, IgM, IgA, IgE). Three samples were obtained every two months thereafter. The group of patients who had above-normal values of one or more of the examined immunoglobulins had a longer survival than the other (p<0.024). Immunoglobulin values were independent of the Helicobacter pylori antibody titer and of acute phase reactants. It is concluded that survival potentially correlates with serum immunoglobulin levels. Further studies including larger numbers of patients and correlating serum immunoglobulin levels with specific clinical parameters are needed to establish the prognostic role of serum immunoglobulins in patients with gastric carcinoma.

Serum Tissue Inhibitor of Metalloproteinase 1 and 2 (TIMP-1 and TIMP-2) Levels in Colorectal Cancer Patients: Associations with Clinicopathological Variables and Patient Survival

Tissue inhibitors of metalloproteinases (TIMPs) appear to affect many aspects of cancer biology, playing a crucial role in cell signaling by regulating cell growth, apoptosis, invasion, metastasis, angiogenesis, and genomic instability. The aim of the present study was to elucidate the diagnostic and prognostic utility of TIMP-1 and TIMP-2 in patients with colon cancer. Serum TIMP-1 and TIMP-2 concentrations were quantified using an enzyme-linked immunosorbent assay in 97 colon cancer patients. Elevated serum TIMP-1 levels were found in patients with advanced disease stage (p=0.0512) and poorly differentiated histopathological tumor grade (p=0.0059). Patients with increased TIMP-1 levels had shorter overall survival times (log-rank test, p=0.0143). Multivariate analysis also identified TIMP-1 as an independent prognostic factor (Cox regression analysis, p=0.0149). Serum TIMP-2 levels were not significantly associated with disease stage, histopathological grade or survival. In the subgroup of patients with well and moderately differentiated tumors, TIMP-1 and TIMP-2 were identified as independent prognostic factors (Cox regression analysis, p=0.0379 and p=0.0451, respectively). In conclusion, assessment of serum TIMP-1 can be considered a useful biomarker in colon cancer, whereas TIMP-2 appears to be of limited value.

HIV patient with pseudomyxoma peritonei of extra-appendiceal origin is disease-free and alive 9 years after complete cytoreductive surgery

OBJECTIVE

Pseudomyxoma peritonei (PMP) is a clinical syndrome that is mainly characterized by the presence of mucinous ascites that results from the rupture of a mucin-producing neoplasm. No reports exist so far regarding the management of this syndrome in HIV patients.

CASE REPORT

A 54-year old male patient with a diagnosed atypical colitis developed additionally over time a complicated diverticulitis which was initially treated conservatively with antibiotics. Due to septic complication, the patient received a Hartmann resection. Six months after the first surgery a Hartmann reversal was tried; it, however, revealed peritoneal implants and a significant stenosis of the colon stump. Resection of these lesions confirmed histopathologically the presence of a low-grade pseudomyxoma peritonei. Five months later, a second try for a Hartmann reversal was performed. In the view of the slightly enlarged paracolic lymph nodes, a low anterior resection was performed with a primary descendorectostomy. Histopathological examination revealed no more signs of the tumor, which confirmed the completeness of the cytoreductive surgery by the first try for a Hartmann reversal.

CONCLUSIONS

Completeness of cytoreductive surgery and low grade histology seem to be the most important factors for the prognosis in pseudomyxoma peritonei in immunocompromised patients as suggested by the long overall and progression free survival of the present patient.

Nestin and CD146 expression in metaplastic breast cancer: stem-cell therapy in need? Lessons reported from a male patient

OBJECTIVE

Metaplastic breast carcinomas represent a rare subtype of breast cancer exhibiting aggressive clinical features. They appear as highly chemoresistant tumors, therefore showing poor outcome and high rates of local recurrence or distant metastasis.

CASE REPORT

A 37-year-old greek man was referred to our hospital for evaluation of a locally advanced, ulcerated, fixed, irregular and hard in consistency mass covering his left breast and chest wall. Further work out with CT and biopsy of the tumor revealed a triple negative metaplastic breast cancer classified as cT4cN3cM1. The patient received first line chemotherapy and afterward a palliative resection of the tumor. The histology revealed the presence of a combined triple negative adenocarcinoma with a predominant metaplastic squamous carcinoma and a spindle cell (sarcomatoid) carcinoma of the breast. In the tissue sample stem cell markers, nestin and CD146 (MCAM) were expressed, enhancing the theory that cancer cells of this tumor could possibly harbor stem cell properties. The patient received several chemotherapy regimens but died 6 months after the initiation of treatment.

CONCLUSIONS

Metaplastic breast cancer consists of cells with stem cell properties. New targeted therapies are warranted in the view of the tumor's high resistance to conventional chemotherapy. Targeting nestin and CD146 might be a promising therapy as they seem to be implicated in the EMT pathway.

Thyroid hormone receptor alpha (TRa) tissue expression in ductal invasive breast cancer: A study combining quantitative immunohistochemistry with digital slide image analysis

BACKGROUND

In breast cancer, hormonal receptors hold promise for developing novel targeted therapies. The thyroid exerts its actions via the thyroid hormone receptors alpha and beta. The clinical significance of the expression of thyroid hormone receptors in breast cancer is unclear.

MATERIAL AND METHODS

We studied thyroid hormone receptor alpha (TRa) expression in 82 samples from 41 women with ductal invasive breast cancer and no thyroid disease. We performed quantitative immunohistochemistry with digital image analysis and correlated TRa expression with clinicopathological parameters.

RESULTS

TRa was expressed in both normal breast epithelium and breast cancer, but expression in breast cancer was significantly lower. TRa was expressed significantly less in larger and grade III tumors. Conversely, breast cancers with lymphovascular invasion showed increased TRa expression compared to cancers without lymphovascular invasion. TRa expression was not significantly different between node-positive and node-negative breast cancers, or among different hormonal profiles and intrinsic subtypes.

DISCUSSION

This is the first-in-human study to combine quantitative immunohistochemistry with image analysis to study TRa expression in women with ductal invasive breast cancer and no clinical or biochemical evidence of thyroid dysfunction. We confirm that TRa is expressed in both normal and malignant breast epithelium and suggest that TRa expression is downregulated during breast carcinogenesis. Larger and higher grade breast cancers demonstrate partial loss in TRa expression. Alterations in TRa expression take place even in the absence of clinical or biochemical thyroid disease. The underlying mechanism of these findings and their potential significance in survival and relapse mandate further research.

Incidence of inactive allele CYP2D6*4 among Greek women suffering from hormone-sensitive breast cancer

BACKGROUND

The incidence of CYP2D6*4 among Caucasians is estimated up to 27%, while it is present in up to 90% of all poor metabolizers within the Caucasian population. The hypothesis under question is whether the presence of one or two non-functioning (null) alleles predicts an inferior outcome in postmenopausal women with breast cancer receiving adjuvant treatment with tamoxifen. The aim of the present study is to estimate the incidence of CYP2D6*4, in the Greek population and more precisely among females suffering from breast cancer.

MATERIALS AND METHODS

Eighty unrelated mainland Greek female volunteers suffering from hormone-sensitive breast cancer were recruited during their primary handling or follow-up examination in order to provide samples for purification and polymerase chain reaction/restriction fragment length polymorphism (PCR-RFLP) of genomic DNA derived from buccal swabs.

RESULTS

The incidence of individuals with at least one present allele*4 within the Hellenic population was estimated to be as high as 30% (n = 24/80), with a 95% confidence interval of 20% to 40%. From the statistical point of view, it can be securely stated that incidence of *4 among Greek women is over 20%. The incidence of homozygous carriers of *4 in the present sample occurred in 8.75%, while the incidence of allele*4 haplo-type occurred in 19.4% (n=160).

CONCLUSION

Although the outcoming results for Greek women are actually in line with existing data for other European nations, it should be noted, that a routine CYP2D6 testing of women suffering from breast cancer is formally not recommended, as the clinical significance of CYP2D6 phenotype in treatment and outcome of breast cancer remains unclear.

Comparison Between Minimally Invasive and Open Gastrectomy for Gastric Cancer in Europe: A Systematic Review and Meta-analysis

AIMS

We compared laparoscopic and robotic gastrectomies with open gastrectomies and with each other that were held for gastric cancer in Europe.

METHODS

We searched for studies conducted in Europe and published up to 20 February 2015 in the PubMed database that compared laparoscopic or robotic with open gastrectomies for gastric cancer and with each other.

RESULTS

We found 18 original studies (laparoscopic vs open: 13; robotic vs open: 3; laparoscopic vs robotic: 2). Of these, 17 were non-randomized trials and only 1 was a randomized controlled trial. Only four studies had more than 50 patients in each arm. No significant differences were detected between minimally invasive and open approaches regarding the number of retrieved lymph nodes, anastomotic leakage, duodenal stump leakage, anastomotic stenosis, postoperative bleeding, reoperation rates, and intraoperative/postoperative mortality. Nevertheless, laparoscopic procedures provided higher overall morbidity rates when compared with open ones, but robotic approaches did not differ from open ones. On the contrary, blood loss was less and hospital stay was shorter in minimally invasive than in open approaches. However, the results were controversial concerning the duration of operations when comparing minimally invasive with open gastrectomies. Additionally, laparoscopic and robotic procedures provided equivalent results regarding resection margins, duodenal stump leakage, postoperative bleeding, intraoperative/postoperative mortality, and length of hospital stay. On the contrary, robotic operations had less blood loss, but lasted longer than laparoscopic ones. Finally, there were relatively low conversion rates in laparoscopic (0%-6.7%) and robotic gastrectomies (0%-5.6%) in most studies.

CONCLUSION

Laparoscopic and robotic gastrectomies may be considered alternative approaches to open gastrectomies for treating gastric cancer. Minimally invasive operations are characterized by less blood loss and shorter hospital stay than open ones. In addition, robotic procedures have less blood loss, but last longer than laparoscopic ones.

Platelet indices and netrophil to lymphocyte ratio in adults with acute appendicitis

BACKGROUND

A study was performed in adults with acute appendicitis and matched controls to assess the utility of the platelet indices and neutrophil to lymphocyte ratio, as a diagnostic adjunct.

METHOD

Data were retrospectively collected from a complete blood count test of 155 adult patients (72 men and 83 women) with histologically proven acute appendicitis upon admission, and of 50 healthy adults (20 men and 30 women). The parameters for white blood cells and platelets were compared between the two groups, and for each gender separately.

RESULTS

A higher white blood cell count, neutrophil count, neutrophil percentage, neutrophil to lymphocyte ratio and lower lymphocyte percentage was reported in patients with acute appendicitis than that in the healthy controls, with high areas under the curve (AUC), sensitivities, specifi cities, positive predictive values (PPVs) and moderate negative predictive values (NPVs). The lymphocyte count was lower in patients than it was in the healthy controls. The platletcrit was lower in the female patients than that in the female controls, whereas a difference was not detected in the male participants. Differences were not detected with regard to platelet count, mean platelet volume and platelet distribution width for both genders.

CONCLUSION

The neutrophil to lymphocyte ratio increases and lymphocyte percentage decreases in acute appendicitis, and can be used as an additional diagnostic marker. Plateletcrit, and therefore total platelet mass, is reduced in women with acute appendicitis, indicating the involvement of platelets in its pathophysiology. However, it is neither a reliable predictor or excluder of the disease.

Histone deacetylase (HDAC)-1, -2, -4 and -6 expression in human pancreatic adenocarcinoma: associations with clinicopathological parameters, tumor proliferative capacity and patients' survival

Background

Histone deacetylases (HDACs) have been associated with malignant tumor development and progression in humans. HDAC inhibitors (HDACIs) are currently being explored as anti-cancer agents in clinical trials. The present study aimed to evaluate the clinical significance of HDAC-1, −2, −4 and −6 protein expression in pancreatic adenocarcinoma.

Methods

HDAC-1, −2, −4 and −6 protein expression was assessed immunohistochemically on 70 pancreatic adenocarcinoma tissue specimens and was statistically analyzed with clinicopathological characteristics and patients’ survival.

Results

Enhanced HDAC-1 expression was significantly associated with increased tumor proliferative capacity (p = 0.0238) and borderline with the absence of lymph node metastases (p = 0.0632). Elevated HDAC-4 expression was significantly associated with the absence of organ metastases (p = 0.0453) and borderline with the absence of lymph node metastases (p = 0.0571) and tumor proliferative capacity (p = 0.0576). Enhanced HDAC-6 expression was significantly associated with earlier histopathological stage (p = 0.0115) and borderline with smaller tumor size (p = 0.0864). Pancreatic adenocarcinoma patients with enhanced HDAC-1 and −6 expression showed significantly longer survival times compared to those with low expression (p = 0.0022 and p = 0.0113, respectively), while a borderline association concerning HDAC-2 expression was noted (p = 0.0634).

Conclusions

The present study suggested that HDACs may be implicated in pancreatic malignant disease progression, being considered of clinical utility with potential use as therapeutic targets.

Pregnane X Receptor Expression in Human Pancreatic Adenocarcinoma: Associations With Clinicopathologic Parameters, Tumor Proliferative Capacity, Patients' Survival, and Retinoid X Receptor Expression

OBJECTIVES

Pregnane X receptor (PXR) has been involved in human malignancy, either by directly affecting carcinogenesis or by inducing drug-drug interactions and chemotherapy resistance. The present study aimed to assess the clinical significance of PXR in pancreatic adenocarcinoma.

METHODS

Pregnane X receptor and its heterodimers' PXR/retinoid X receptor α (RXR-α), RXR-β, and RXR-γ expression were assessed immunohistochemically on tumoral samples from 55 pancreatic adenocarcinoma patients and were associated with clinicopathologic parameters, tumor proliferative capacity, and patients' survival.

RESULTS

Enhanced PXR expression was noted in 24 (43.6%) of 55 pancreatic adenocarcinoma cases. Pancreatic adenocarcinoma patients presenting increased histological grade of tumor differentiation showed a significant increased incidence of elevated PXR expression (P = 0.023). Enhanced PXR/RXR-β expression was significantly associated with smaller tumor size and earlier clinical stage (P = 0.005 and P = 0.003, respectively). Elevated PXR/RXR-γ expression was significantly associated with smaller tumor size and earlier clinical stage (P = 0.012 and P = 0.014, respectively) and borderline with the absence of lymph node metastases (P = 0.056). In addition, pancreatic adenocarcinoma patients presenting enhanced PXR/RXR-γ expression showed marginally longer survival times compared with those with decreased expression (log-rank test, P = 0.053).

CONCLUSIONS

This study supported evidence that PXR and its copartners' overexpression may be associated with favorable clinicopathologic parameters and better outcome in pancreatic adenocarcinoma.

Expression and promoter methylation status of hMLH1, MGMT, APC, and CDH1 genes in patients with colon adenocarcinoma

Colorectal cancer (CRC) is the third most common cancer in men and the second in women worldwide. CRC development is the result of genetic and epigenetic alterations accumulation in the epithelial cells of colon mucosa. In the present study, DNA methylation, an epigenetic event, was evaluated in tumoral and matching normal epithelium in a cohort of 61 CRC patients. The results confirmed and expanded knowledge for the tumor suppressor genes hMLH1, MGMT, APC, and CDH1. Promoter methylation was observed for all the examined genes in different percentage. A total of 71% and 10% of the examined cases were found to be methylated in two or more and in all genes, respectively. mRNA and protein levels were also evaluated. Promoter methylation of hMLH1, MGMT, APC, and CDH1 genes was present at the early stages of tumor's formation and it could also be detected in the normal mucosa. Correlations of the methylated genes with patient's age and tumor's clinicopathological characteristics were also observed. Our findings suggest that DNA methylation is a useful marker for tumor progression monitoring and that promoter methylation in certain genes is associated with more advanced tumor stage, poor differentiation, and metastasis.

The role of serum total ghrelin level elevation in colon cancer patients

PURPOSE

Many studies have pointed out a possible role of ghrelin, in the pathogenesis and natural history of gastrointestinal tract malignancies. The objective of this study was to estimate serum total ghrelin levels (STGL) in patients with colon cancer (CC) and to evaluate the value of this assay in research and clinical practice.

METHODS

STGL were measured pre-operatively in 95 CC patients and in 39 healthy controls, and were correlated with patients' age, gender, body mass index (BMI), tumor location, Dukes stage, grade of differentiation and patients' survival.

RESULTS

STGL were significantly elevated in patients with CC (127.6±34.5 pmol/L) vs healthy controls (89.3±19 pmol/L, p<0.05). STGL were significantly higher in endstage (180±10 pmol/L) vs initial-stage CC (94.2±22.6 pmol/L; p<0.05). Furthermore, patients with poorly differentiated tumors had statistically significantly higher STGL (144.5±30.7 pmol/L) compared to those with well (91.8±23.6 pmol/L) or moderately well (126±34 pmol/L) differentiated CC cases (p<0.05). No statistically significant differences in the patients' STGL were noticed with respect to their demographic/ clinical characteristics, tumor location and survival (p>0.05).

CONCLUSIONS

The obtained results showed a link between elevated STGL and CC, suggesting that colon tumors contribute to ghrelin's production.

Individual patient data systematic review and meta-analysis of optic nerve sheath diameter ultrasonography for detecting raised intracranial pressure: protocol of the ONSD research group

BACKGROUND

The purpose of the optic nerve sheath diameter (ONSD) research group project is to establish an individual patient-level database from high quality studies of ONSD ultrasonography for the detection of raised intracranial pressure (ICP), and to perform a systematic review and an individual patient data meta-analysis (IPDMA), which will provide a cutoff value to help physicians making decisions and encourage further research. Previous meta-analyses were able to assess the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP but failed to determine a precise cutoff value. Thus, the ONSD research group was founded to synthesize data from several recent studies on the subject and to provide evidence on the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP.

METHODS

This IPDMA will be conducted in different phases. First, we will systematically search for eligible studies. To be eligible, studies must have compared ONSD ultrasonography to invasive intracranial devices, the current reference standard for diagnosing raised ICP. Subsequently, we will assess the quality of studies included based on the QUADAS-2 tool, and then collect and validate individual patient data. The objectives of the primary analyses will be to assess the diagnostic accuracy of ONSD ultrasonography and to determine a precise cutoff value for detecting raised ICP. Secondly, we will construct a logistic regression model to assess whether patient and study characteristics influence diagnostic accuracy.

DISCUSSION

We believe that this IPD MA will provide the most reliable basis for the assessment of diagnostic accuracy of ONSD ultrasonography for detecting raised ICP and to provide a cutoff value. We also hope that the creation of the ONSD research group will encourage further study.

TRIAL REGISTRATION

PROSPERO registration number: CRD42012003072.

Full Dose Paclitaxel Plus Vinorelbine as Salvage Chemotherapy in Anthracycline-Resistant Advanced Breast Cancer: A Phase II Study

This phase II trial studied the efficacy and toxicity of full dose paclitaxel plus vinorelbine, as salvage chemotherapy in patients with metastatic breast cancer resistant to anthracyclines. Patients received vinorelbine (30 mg/m2) followed 1 hour later by full dose paclitaxel (175 mg/m2) every 3 weeks for a maximum of 8 cycles or until disease progression. Because of the heavy pretreatment of the patients, prophylactic granulocyte-colony stimulating factor (5 microg/kg) was administered daily for 5-10 days. To minimize potentially cumulative neurotoxicity due to both agents, amifostine was given prior to chemotherapy. Thirty-four patients: 8 with tumors primary resistant and 26 with tumors recurring within 3-6 months after anthracycline treatment, were evaluable for efficacy and toxicity. Objective responses occurred in 11 patients [32%; 95% confidence interval (CI): 16.3-47.7%), all partial responses. Responses were observed in lung and liver. The median response duration was 4 months (range 3-7), median time to progression was 5 months (range 3-9) and median overall survival was 8 months (range 4-24). Neutropenia was dose limiting (35% grade 3-4 toxicity). The left ventricular ejection fraction, measured and followed in 18 patients, fell less than 20% below baseline level in 9 patients (50%), but only one patient developed congestive cardiac failure. The paclitaxel-vinorelbine regimen was moderately tolerated and moderately effective in poor prognosis breast cancer patients with visceral metastases and tumors resistant to anthracyclines. The combination at these doses and schedules should be considered in the design of regimens for advanced breast cancer.

Irinotecan as Salvage Chemotherapy for Advanced Small Bowel Adenocarcinoma: A Series of Three Patients

Small bowel adenocarcinoma (SBA) is a relatively rare disease. Because of its rarity the role of chemotherapy either as adjuvant or for advanced disease has not been clearly defined. Therefore any information, including case reports, is warranted. We report on three patients with adenocarcinoma of the jejunum and ileum. Two patients with positive lymph nodes received postoperative adjuvant chemotherapy with 5-fluorouracil-folinic acid (5FU-FA) for 12 months but they developed metastatic disease 3 and 8 months later, respectively. The third patient was initially treated with the same agents but for metastatic disease. All patients were subsequently treated for tumor recurrence with irinotecan 350 mg/m2 i.v. every 3 weeks as salvage chemotherapy supported by Granulocyte Colony Stimulating Factor (GCSF) for 5 days. Two patients achieved a minor response and had a dramatic improvement of their symptoms. Their survival times after irinotecan administration were 14 and 6 months with an overall survival after primary diagnosis of 29 and 27 months, respectively. The third patient who had a tumor refractory to 5FU-FA progressed also on irinotecan and had an 8-month overall survival. Although conclusions cannot be drawn regarding the role of adjuvant chemotherapy in SBA, it seems reasonable to extrapolate from large bowel carcinoma experience. Irinotecan seems to have some degree of activity in the treatment of SBA but further studies are warranted.

Focal nodular hyperplasia and hepatocellular adenoma: current views

Focal Nodular Hyperplasia (FNH) is a rare benign hepatic lesion believed to generate upon a hyperplastic response of the hepatocyte. Hepatocellular Adenoma (HA) occurs predominantly in young women receiving oral contraceptive medication. These two lesions have drawn significant attention throughout the recent years due to their specific clinical and pathological features as well as their challenging management. Although Focal Nodular Hyperplasia is managed conservatively in the majority of cases, it can albeit pose a difficult diagnostic dilemma. On the other hand, Hepatocellular Adenoma can be complicated with catastrophic hemorrhage or malignant transformation and therefore mandates surgical excision in many cases. The aim of this work is to review the current literature pertaining to these two clinical entities regarding their pathogenesis, diagnostic approach and genetics, as well as to shed light on specific differential diagnostic issues arising in many cases these lesions are encountered.

The role of ThinPrep cytology in the investigation of ki-67 index, p53 and HER-2 detection in fine-needle aspirates of breast tumors

PURPOSE

The aim of the current study was to compare the immunocytochemical expression of ki-67, HER-2 and p53 on ThinPrep (TP)-processed smears, obtained by preoperative fine-needle aspiration (FNA) biopsies from primary breast carcinoma with the immunohistochemical results obtained on the corresponding surgical samples.

METHODS

FNA biopsies were collected from 119 female patients during a 31-month period. Subsequently, these patients underwent surgical resection of the tumors.

RESULTS

The overall accuracy (OA) of the TP cytology for ki-67, p53 and HER-2 expression was 96, 99 and 97%, respectively. There was a strong positive correlation between immunohistochemistry and immunocytochemistry results for ki-67 (Spearman's test 0.875) for p53 (Cramer's phi test 0.965) and HER-2 (Kendall's tau test 0.891).

CONCLUSION

This pilot study demonstrates that it is possible to monitor multiple molecular markers by using the TP cytology. Sample collection and storage is simple and permits the assortment of the FNA sample for both morphologic diagnosis and ancillary studies. The accuracy of TP technique in the evaluation of ki-67, p53 and HER-2 expression is comparable to those of the histological evaluation, and could be of paramount importance for the preoperative planning of treatment.

Management of cystic and solid pancreatic incidentalomas: a review analysis

Incidentally discovered pancreatic lesions that are asymptomatic have become much more common in recent years. It is important to characterize these lesions and to determine which patients can be safely observed and which should undergo an operation, as a substantial proportion of them might be malignant or premalignant. This review focus on the diagnostic approach and management of the different types of cystic and solid incidental pancreatic lesions based on appropriate clinical input, imaging screening and histological criteria. The task of developing guidelines to deal with an incidentally found pancreatic lesion, however, is much more complex and controversial than with other organs incidentalomas. In most series, pancreatic incidentalomas (PIs) <2 cm and of cystic appearance are likely to be benign, whereas those >2 cm are usually premalignant or malignant. Serous cystadenomas can reach very large size and are usually benign lesions. The presence of a solid mass or a mural nodule in a cystic lesion along with main pancreatic duct dilatation, thick septations and biliary obstruction are considered features suspicious of malignancy. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms are malignant or lesions of malignant potential and need surgical exploration. Solid lesions are much more likely to be premalignant or malignant and most of patients will undergo resection. The decision to operate rather than follow a solid lesion is a matter of tumor size and of clinical judgment based on the age and patient comorbidities. The present study should serve as a general guide and not applied as strict principles. Key words: cystic pancreatic incidentalomas, diagnostic approach, management, solid pancreatic incidentalomas.

Dysfunction of the E-cadherin/catenin cell adhesion cascade in epithelial cancers (Review)

The E-cadherin/catenin complex is the major adhesion system that maintains the intercellular contacts in all epithelial cells. E-cadherin mediates Ca++-dependent, homotypic cell-cell adhesion and associates with the cytoskeleton through the interaction with three cytoplasmic proteins, called catenins. Dysfunction of the E-cadherin/catenin complex occurs frequently in the epithelial cancers and is correlated with dedifferentiation, advanced stage and poor prognosis. Additionally, loss of E-cadherin and alpha-catenin expression in epithelial cells in vitro, is associated with fibroblastic morphology and increased invasiveness. E-cadherin and alpha-catenin might be regarded as tumor suppressor molecules with potential diagnostic and prognostic value in epithelial cancers.

Correlation of Peroxisome Proliferator-Activated Receptor-gamma (PPAR-gamma) and Retinoid X Receptor-alpha (RXR-alpha) expression with clinical risk factors in patients with advanced carotid atherosclerosis

Background

Peroxisome proliferator-activated Receptor-γ (PPAR-γ) and its nuclear partners, the Retinoid X Receptors (RXRs), have been recognized as crucial players in the pathogenesis of atherosclerosis. The present study aimed to assess the clinical significance of PPAR-γ and RXR-α expression in different cellular populations localized within advanced carotid atherosclerosis lesions.

Material/Methods

PPAR-γ and RXR-α expression was assessed by immunohistochemistry ïn 134 carotid atherosclerotic plaques obtained from an equal number of patients that underwent endarterectomy procedure for vascular repair, and was correlated with patients’ medical history, risk factors and medication intake.

Results

Increased incidence of low PPAR-γ expression in both macrophages and smooth muscle cells was noted in patients presenting coronary artery disease (p=0.032 and p=0.046, respectively). PPAR-γ expression in smooth muscle cells was borderline down-regulated in symptomatic compared to asymptomatic patients (p=0.061), reaching statistical significance when analyzing groups of patients with specific cerebrovascular events; amaurosis fugax (p=0.008), amaurosis fugax/stroke (p=0.020) or amaurosis fugax/transient ischemic attack patients (p=0.028) compared to asymptomatic patients. Low RXR-α expression in macrophages was more frequently observed in hypertensive (p=0.048) and hyperlipidemic patients (p=0.049). Increased incidence of low RXR-α expression in smooth muscle cells was also noted in patients presenting advanced carotid stenosis grade (p=0.015).

Conclusions

PPAR-γ and RXR-α expression down-regulation in macrophages and smooth muscle cells was associated with a more pronounced disease progression in patients with advanced carotid atherosclerotic lesions.

MCM-2 and MCM-5 expression in gastric adenocarcinoma: clinical significance and comparison with Ki-67 proliferative marker

BACKGROUND

Minichromosome maintenance (MCM) proteins are essential components of DNA replication, being related to cell proliferation, and serve as useful biomarkers for cancer screening, surveillance and prognosis. The aim of the present study was to evaluate the clinical significance of MCM-2 and MCM-5 expression in gastric adenocarcinoma in comparison with Ki-67 proliferative marker.

METHODS

MCM-2, MCM-5 and Ki-67 expression was assessed immunohistochemically in 66 tumoral samples of gastric adenocarcinoma patients and was statistically analyzed in relation to clinicopathological characteristics and patient survival.

RESULTS

MCM-2 expression did not show significant associations with any clinicopathological parameters, while Ki-67 expression was merely significantly associated with tumor size (P = 0.0150). MCM-2 and Ki-67 expression were more frequently in intestinal (median values: 67.5 and 60%) compared to diffuse-type (median values: 60 and 45%) gastric adenocarcinoma cases without though reaching statistical significance (P > 0.05). MCM-5 expression was significantly associated with tumor size (P = 0.0295), presence of lymph node metastases (P = 0.0216) and tumor histopathological stage (P = 0.0098). Patients presenting high MCM-5 expression had significantly shorter survival times (log-rank test, P = 0.0042), whereas neither MCM-2 nor Ki-67 expression showed significant prognostic value (log-rank test, P = 0.9618 and P = 0.7174, respectively). In multivariate analysis, patient age, histopathological stage and grade of differentiation, but not MCM-5 expression, were identified as independent prognostic factors (Cox regression analysis, P = 0.0097, P = 0.0195, P = 0.0035 and P = 0.3245, respectively).

CONCLUSIONS

The present study showed that MCM-5 expression was associated with clinicopathological parameters in gastric adenocarcinoma. However, further studies highlighting the distinct impact of the two histopathological types, intestinal and diffuse, are warranted to delineate whether MCMs could be used as diagnostic and prognostic markers in gastric neoplasia.

Platelet-activating factor involvement in thioacetamide-induced experimental liver fibrosis and cirrhosis

Platelet-activating factor (PAF) is a potent lipid inflammatory mediator acting on cells through its specific receptor. Plasma PAF-acetylhydrolase (PAF-AH) is the main enzyme that inactivates PAF in blood, participating in its homeostasis. The objective of this study was to investigate the involvement of PAF in the liver fibrotic process using an experimental animal model. Liver fibrosis was induced in adult male Wistar rats by administration of thioacetamide (TAA) in drinking water (300 mg/l) for three months. The animals were sacrificed at time 0 (control group) and after 1, 2, and 3 months. PAF levels in liver and blood and PAF-AH activity in plasma were determined. Liver histopathological examination was also performed. TAA administration resulted in progressively increased liver fibrosis, leading finally to the formation of cirrhotic nodules in the liver. Throughout the experiment PAF levels in liver tissue remained stable. "Total" ("free" plus "bound") PAF levels in blood decreased, reaching statistically significant differences in the first and third months compared with the control group (P < 0.05). "Free" PAF levels in blood were higher at one month (P < 0.05) and decreased gradually thereafter. In all treated groups, "bound" PAF levels in blood decreased whereas plasma PAF-AH activity increased (P < 0.05) compared with the control group. Our data indicated alterations of PAF levels in blood and PAF-AH activity during fibrosis induction, implicating participation of PAF in the liver fibrotic process.

Does Helicobacter pylori identification in the mucosa of the gallbladder correlate with cholesterol gallstone formation?

OBJECTIVE

Helicobacter pylori (H pylori) represents a potential initiator of cholesterol crystallization and it has been proposed that it is related to gallstone formation. In this study, any possible association between the H pylori identification in the mucosa of gallbladder and cholesterol gallstone formation was evaluated

METHODS

Gallbladders containing pure or mixed cholesterol gallstones (cholelithiasis group, n = 89) and gallbladders without gallstones (control group, n = 42) were submitted to standard histopathological examination for H pylori detection, as well as to nested polymerase chain reaction amplification for H pylori DNA detection.

RESULTS

Helicobacter pylori was identified in the gallbladder's epithelium in four patients with cholelithiasis and in two patients in the control group by histology. In all the cases which were found to be H pylori positive by histological examination, H pylori DNA were also detected. No correlation between gallstone formation and H pylori detection in the biliary epithelium was found. A higher incidence of acute inflammation in the cholelithiasis (22.5% vs 9.5%, p = not significant [ns]) and in the H pylori positive groups (33% vs 17.6%, p = ns) were histologically detected. A higher incidence (10% vs 0%), p = ns) of H pylori in gallbladders with gallstones and acute inflammation, compared to gallbladders with acute inflammation but without gallstones, was noticed

CONCLUSION

Helicobacter pylori is detectable in low frequency in the mucosa of the gallbladder and it does not seem to act as a lithogenic component for cholesterol gallstone formation. Its higher incidence in gallbladders with gallstones and acute inflammation, suggests a possible accessory role in a subset of patients with cholelithiasis.

Peroxisome proliferator-activated receptor-gamma and retinoid X receptor-alpha expression in pancreatic ductal adenocarcinoma: association with clinicopathological parameters, tumor proliferative capacity, and patients' survival

BACKGROUND

Peroxisome proliferator-activated receptor-gamma (PPAR-gamma), a ligand-activated transcription factor that forms heterodimers with the retinoid X receptors (RXRs), is overexpressed in various tumors, regulating many aspects of cancer biology. The aim of the present study was to evaluate the clinical significance of PPAR-gamma and RXR-alpha expression in pancreatic adenocarcinoma.

MATERIAL/METHODS

PPAR-gamma and RXR-alpha protein expression was assessed immunohistochemically in tumoral samples of 65 pancreatic adenocarcinoma patients and statistically analyzed in relation to clinicopathological characteristics, tumor proliferative capacity, and patients' survival.

RESULTS

Of the 65 adenocarcinoma patients, 49 (75%) tested positive for PPAR-gamma and 55 (85%) stained positive for RXR-alpha. RXR-alpha positivity was significantly associated with tumor proliferative capacity and PPAR-gamma positivity (p=0.022 and p=0.043, respectively). PPAR-gamma and RXR-alpha staining intensity were associated with the histopathological tumor grade (p=0.003 and p=0.038, respectively). Significant associations of PPAR-gamma staining intensity and RXR-alpha expression with tumor size were also noted (p=0.041 and p=0.038, respectively). Moderate and intense PPAR-gamma staining intensity was associated with shorter overall survival in univariate analysis (log-rank test, p=0.023) and proved to be an independent prognostic factor in multivariate analysis (p=0.045), whereas RXR-alpha failed to predict patients' survival.

CONCLUSIONS

These data revealed that both PPAR-gamma and RXR-alpha were associated with pancreatic cancer characteristics. PPAR-gamma, but not RXR-alpha, was found to be an independent prognostic indicator. However, further molecular and clinical studies are required to delineate the potential clinical application of PPAR-gamma and RXR-alpha in the prognosis and management of pancreatic adenocarcinoma patients.

Heat Shock Protein-27, -60 and -90 expression in gastric cancer: association with clinicopathological variables and patient survival

BACKGROUND

Heat shock proteins (HSPs) are ubiquitous, highly conserved proteins across all the species and play essential roles in maintaining protein stability within the cells under normal conditions, while preventing stress-induced cellular damage. HSPs were also overexpressed in various types of cancer, being associated with tumor cell proliferation, differentiation and apoptosis. The aim of the present study was to evaluate the clinical significance of HSP -27, -60, and -90 expression in gastric carcinoma.

METHODS

HSP -27, -60, and -90 proteins expression was assessed immunohistochemically in tumoral samples of 66 gastric adenocarcinoma patients and was statistically analyzed in relation to various clinicopathological characteristics, tumor proliferative capacity and patients' survival.

RESULTS

HSP-27, -60, -90 proteins were abundantly expressed in gastric adenocarcinoma cases examined. HSP-27 expression was significantly associated with tumor size (pT, P = 0.026), the presence of organ metastases (pM, P = 0.046) and pStage (P = 0.041), while HSP-27 staining intensity with nodal status (pN, P = 0.042). HSP-60 expression was significantly associated with patients' sex (P = 0.011), while HSP-60 staining intensity with patients' age (P = 0.027) and tumor histopathological grade (P = 0.031). HSP-90 expression was not associated with any of the clinicopathological parameters examined; however, HSP-90 staining intensity was significantly associated with tumor size (pT, P = 0.020). High HSP-90 expression was significantly associated with longer overall survival times in univariate analysis (log-rank test, P = 0.033), being also identified as an independent prognostic factor in multivariate analysis (P = 0.026).

CONCLUSION

HSP-27, -60, and -90 were associated with certain clinicopathological parameters which are crucial for the management of gastric adenocarcinoma patient. HSP-90 expression may also be an independent prognostic indicator in gastric adenocarcinoma patients.

Clinical significance of MCM-2 and MCM-5 expression in colon cancer: association with clinicopathological parameters and tumor proliferative capacity

Minichromosome maintenance (MCM) proteins are essential components of DNA replication, being related to cell proliferation, and serve as useful markers for cancer screening, surveillance, and prognosis. Our aim was to examine the clinical significance of MCM-2 and MCM-5 protein expression in colon cancer and to evaluate the association with various clinicopathological characteristics and tumor proliferative capacity. Immunohistochemical expression of MCM-2 and MCM-5 was performed on paraffin-embedded malignant tissue sections obtained from 96 patients with colon cancer. MCM-2 and MCM-5 expression was correlated with different clinicopathological characteristics, proliferative capacity (Ki-67 labeling index), and p53 cell-cycle regulator expression. MCM-2 and Ki-67 expression was significantly associated with the tumors' histological grade (P = 0.003), existence of nodular metastases (N) (P = 0.003 and P = 0.030, respectively), malignancy on adenoma (P = 0.029 and P = 0.024, respectively), and vascular invasion (P = 0.010 and P = 0.011, respectively). MCM-2 expression was additionally associated with Dukes' stage (P = 0.005). Significant positive relationships were found between the expression of MCM-2 or MCM-5 proteins and that of Ki-67 protein (r = 0.963, P-value < 0.001, and r = 0.738, P-value < 0.001, respectively), as well as between MCM-2 and MCM-5 proteins (r = 0.745, P-value < 0.001). Significant positive relationships were also observed between the expression of MCM-2 or MCM-5 proteins and that of p53 protein; however, they were consistently lower than the corresponding with Ki-67 protein. No significant association was observed between MCM-5 protein expression and the clinicopathological characteristics examined. The current data suggest that MCM-2 protein expression is significantly associated with important clinicopathological characteristics for patients' management, being correlated with the cell proliferation state in colon cancer.

Clinical significance of tumor-associated antigen RCAS1 expression in human pancreatic ductal adenocarcinoma

Receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is a human tumor-associated antigen that induces cell cycle arrest and/or apoptosis in RCAS1 receptor-expressing immune cells. The aim of the present study was to evaluate the clinical significance of RCAS1 expression in human pancreatic adenocarcinoma. Immunohistochemical analysis of RCAS1 expression was performed on paraffin-embedded tissue sections obtained from 76 pancreatic adenocarcinoma patients. RCAS1 positivity and overexpression and intensity of the staining were correlated with clinicopathological parameters, proliferative capacity and patient survival. Of the 76 adenocarcinoma patients, 65 (86%) tested positive for RCAS1; of these 65 RCAS1-positive cases, 36 (55%) showed RCAS1 overexpression. RCAS1 positivity was statistically significantly correlated with the histopathological grade of the tumor (P = 0.026), and it showed a trend to be correlated with tumor size (P = 0.071). RCAS1 intensity and overexpression of staining showed a trend to be correlated with the histopathological grade of the tumor (P = 0.061 and P = 0.089, respectively), whereas RCAS1 positivity and the overexpression and intensity of staining were not statistically significantly correlated with the proliferative capacity of the tumor or any other clinicopathological parameter examined nor with patients' survival. Our data provide evidence for the implication of RCAS1 in pancreatic neoplasia. However, the prediction of survival using RCAS1 expression as a marker seems uncertain for this type of cancer.

New concepts in the therapeutic options of liver metastases from colorectal cancer

Colorectal cancer is one of the most frequent malignant neoplasms causing approximately 10% of cancer deaths. Up to 30% of patients with primary colorectal cancer have already liver metastatic disease at the time of diagnosis. Untreated patients with liver metastases share a poor prognosis with an average survival of 12 months. In contrast, patients whose metastatic lesions are surgically treated have an average 5-year survival rate of 40%. Only 10-15% of initial colorectal liver metastases are considered as being resectable. In the remaining patients, the current trend is to downstage initially unresectable metastases by neoadjuvant therapy (systemic or regional chemotherapy, portal vein embolization - PVE - or hepatic artery chemoembolization), tumor ablation and two-stage hepatectomy, alone or in combinations. This study reviews the current therapeutic options for colorectal liver metastases and their contribution to improve survival rates.

Expression of peroxisome proliferator-activated receptor-gamma in colon cancer: correlation with histopathological parameters, cell cycle-related molecules, and patients' survival

Peroxisome proliferator-activated receptor gamma (PPAR-gamma), a ligand-activated transcription factor, is a key regulator of adipogenic differentiation and glucose homeostasis. PPAR-gamma ligands have recently been demonstrated to affect proliferation and differentiation in cancer cells lines. The aim of the present work was to examine PPAR-gamma expression in colon cancer cases. PPAR-gamma expression was examined immunohistochemically in 86 colon cancer cases and was correlated with clinicopathological parameters, tumor proliferative capacity, cell cycle-related molecule expression, and patient survival. Positive PPAR-gamma immunostaining was prominent in 48 of 86 cases (56%). PPAR-gamma positivity was not correlated with Dukes' stage, histological grade of differentiation, lymph node and liver metastasis, venous invasion, tumor proliferative capacity, or patient survival. A statistically significant correlation was found between PPAR-gamma and the expression of cell cycle-related molecules pRb (P < 0.016), cyclin D1 (P <0.009), p16 (P<0.032), and p21 (P<0.033), while a positive trend for cyclin E was also noted (P<0.057). The pattern, intensity, and extent of PPAR-gamma expression in positive cases were not correlated with any of the examined variables. Our findings support evidence for participation of this protein in the biological mechanisms underlying carcinogenic evolution in the colon, also suggesting the importance of specific PPAR-gamma ligands as cell cycle modulators for a future therapeutic approach in colon cancer.

Emergency liver resection for combined biliary and vascular injury following laparoscopic cholecystectomy: case report and review of the literature

A 75-year-old woman suffering from symptomatic cholelithiasis was admitted to our hospital for elective laparoscopic cholecystectomy (LC). Intraoperatively, because of severe inflammation and dense adhesions in the region of the Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, the method was converted to a conventional open approach. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct or vascular injuries were recognized intraoperatively. Because of severe right upper quadrant abdominal pain and significant deterioration of the liver function tests (LFTs) on the first postoperative day, the patient underwent a Doppler ultrasound scan which showed absence of blood flow at the level of porta hepatis. Urgent relaparotomy revealed an ischemic liver on the right, a transected common bile duct at the level of its confluence, a divided and ligated right hepatic artery and thrombosed portal vein down to its confluence. Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver, and after restoration of blood flow to the left hemiliver, a right hemihepatectomy and a Roux-en-Y hepaticojejunostomy on the left were performed. Liver resection serves an important role in the case of parenchymal necrosis due to combined biliary, hepatic artery and portal vein injury following laparoscopic cholecystectomy and moreover, the operation can be safely performed in the acute setting.

The role of ThinPrep cytology in the evaluation of estrogen and progesterone receptor content of breast tumors

INTRODUCTION

The objective of the current study was to analyze the potential value of immunocytochemical analysis on ThinPrep (TP)-processed smears, from fine needle aspiration (FNA) biopsies, of breast tumors for the determination of ER and PR content as compared with the immunohistochemical analysis performed on paraffin-embedded breast tumor specimens.

PATIENTS AND METHODS

Percutaneous FNA biopsy of focal breast lesions in 119 female adult patients during a 31-month period was performed. Subsequently, these patients underwent surgical resection of the tumors. ER and PR status of the tumors was determined by immunocytochemical analysis on TP-processed smears and by immunohistochemical studies in paraffin-embedded sections.

RESULTS

With the use of TP technique adequate material was observed in all cases. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy (OA) of the TP technique for the ER were 98.95%, 100%, 100%, 95.84% and 99.15% respectively. In addition, sensitivity, specificity, PPV, NPV and OA of the TP technique for the PR were 100%, 87.5%, 95.60%, 100% and 96.64%, respectively.

CONCLUSIONS

ER and PR status can be evaluated in FNA material from breast carcinomas by using the TP technique. Sample collection and storage is simple and permits the assortment of the FNA sample for both morphologic diagnosis and ancillary studies. The accuracy of TP technique in the detection of ER and PR content is comparable to those of the histological evaluation, and could be of paramount importance for the preoperative planning of treatment.

Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients

Introduction

Central venous cannulation is crucial in the management of the critical care patient. This study was designed to evaluate whether real-time ultrasound-guided cannulation of the internal jugular vein is superior to the standard landmark method.

Methods

In this randomised study, 450 critical care patients who underwent real-time ultrasound-guided cannulation of the internal jugular vein were prospectively compared with 450 critical care patients in whom the landmark technique was used. Randomisation was performed by means of a computer-generated random-numbers table, and patients were stratified with regard to age, gender, and body mass index.

Results

There were no significant differences in gender, age, body mass index, or side of cannulation (left or right) or in the presence of risk factors for difficult venous cannulation such as prior catheterisation, limited sites for access attempts, previous difficulties during catheterisation, previous mechanical complication, known vascular abnormality, untreated coagulopathy, skeletal deformity, and cannulation during cardiac arrest between the two groups of patients. Furthermore, the physicians who performed the procedures had comparable experience in the placement of central venous catheters (p = non-significant). Cannulation of the internal jugular vein was achieved in all patients by using ultrasound and in 425 of the patients (94.4%) by using the landmark technique (p < 0.001). Average access time (skin to vein) and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < 0.001). In the landmark group, puncture of the carotid artery occurred in 10.6% of patients, haematoma in 8.4%, haemothorax in 1.7%, pneumothorax in 2.4%, and central venous catheter-associated blood stream infection in 16%, which were all significantly increased compared with the ultrasound group (p < 0.001).

Conclusion

The present data suggest that ultrasound-guided catheterisation of the internal jugular vein in critical care patients is superior to the landmark technique and therefore should be the method of choice in these patients.

An extended retroperitoneal abscess caused by duodenal diverticulum perforation: report of a case and short review of the literature

The authors report a case of an extended retroperitoneal abscess that developed secondarily after a duodenal diverticulum perforation. The diagnosis was established preoperatively endoscopically and by abdominal CT scan. The patient was treated surgically. The authors performed a subtotal gastrectomy and reconstruction with antecolic Billroth II anastomosis to bypass the inflamed region, as well as simultaneous drainage of the retroperitoneal abscess. The postoperative course of the patient was uncomplicated. The authors suggest that this method may be an acceptable approach in the management of similar cases, in which conservative or endoscopic means have failed.

An extended retroperitoneal abscess caused by duodenal diverticulum perforation: report of a case and short review of the literature

The authors report a case of an extended retroperitoneal abscess that developed secondarily after a duodenal diverticulum perforation. The diagnosis was established preoperatively endoscopically and by abdominal CT scan. The patient was treated surgically. The authors performed a subtotal gastrectomy and reconstruction with antecolic Billroth II anastomosis to bypass the inflamed region, as well as simultaneous drainage of the retroperitoneal abscess. The postoperative course of the patient was uncomplicated. The authors suggest that this method may be an acceptable approach in the management of similar cases, in which conservative or endoscopic means have failed.