Colorectal cancer stem cells

Colorectal cancer (CRC) is one of the most commonly diagnosed and lethal cancers worldwide. It is a multistep process that requires the accumulation of genetic/epigenetic aberrations. There are several issues concerning colorectal carcinogenesis that remain unanswered, such as the cell of origin and the type of cells that propagate the tumor after its initiation. There are two models of carcinogenesis: the stochastic and the cancer stem cell (CSC) model. According to the stochastic model, any kind of cell is capable of initiating and promoting cancer development, whereas the CSC model suggests that tumors are hierarchically organized and only CSCs possess cancer-promoting potential. Moreover, various molecular pathways, such as Wingless/Int (Wnt) and Notch, as well as the complex crosstalk network between microenvironment and CSCs, are involved in CRC. Identification of CSCs remains controversial due to the lack of widely accepted specific molecular markers. CSCs are responsible for tumor relapse, because conventional drugs fail to eliminate the CSC reservoir. Therefore, the design of CSC-targeted interventions is a rational target, which will enhance responsiveness to traditional therapeutic strategies and reduce local recurrence and metastasis. This review discusses the implications of the newly introduced CSC model in CRC, the markers used up to now for CSC identification, and its potential implications in the design of novel therapeutic approaches.

Canagliflozin attenuates the progression of atherosclerosis and inflammation process in APOE knockout mice

Background

Sodium glucose co-transporter2 inhibitors reduce the incidence of cardiovascular events in patients with type 2 diabetes mellitus based on the results of recent cardiovascular outcome studies. Herein, we investigated the effects of long-term treatment with canagliflozin on biochemical and immunohistochemical markers related to atherosclerosis and atherosclerosis development in the aorta of apolipoprotein E knockout (Apo-E^(−/−)) mice.

Methods

At the age of 5 weeks, mice were switched from normal to a high-fat diet. After 5 weeks, Apo-E^(−/−) mice were divided into control-group (6 mice) treated with 0.5% hydroxypropyl methylcellulose and Cana-group (7 mice) treated with canagliflozin (10 mg/kg per day) per os. After 5 weeks of intervention, animals were sacrificed, and heart and aorta were removed. Sections stained with hematoxylin–eosin (H&E) were used for histomorphometry whereas Masson’s stained tissues were used to quantify the collagen content. Immunohistochemistry to assess MCP-1, CD68, a-smooth muscle actin, MMP-2, MMP-9, TIMP-1 and TIMP-2 expression was carried out and q-PCR experiments were performed to quantify mRNA expression.

Results

Canagliflozin-group mice had lower total-cholesterol, triglycerides and glucose levels (P < 0.01), while heart rate was significantly lower (P < 0.05). Histomorphometry revealed that one in seven Cana-group mice versus four in six control mice developed atheromatosis, while aortic root plaque was significantly less, and collagen was 1.6 times more intense in canagliflozin-group suggesting increased plaque stability. Immunohistochemistry revealed that MCP-1 was significantly less expressed (P < 0.05) in the aortic root of canagliflozin-group while reduced expression of a-actin and CD68 was not reaching significance (P = 0.15). VCAM-1 and MCP-1 mRNA levels were lower (P = 0.02 and P = 0.07, respectively), while TIMP-1/MMP-2 ratio expression was higher in canagliflozin-group approaching statistical significance (P = 0.07).

Conclusions

Canagliflozin attenuates the progression of atherosclerosis, reducing (1) hyperlipidemia and hyperglycemia, and (2) inflammatory process, by lowering the expression of inflammatory molecules such as MCP-1 and VCAM-1. Moreover, canagliflozin was found to increase the atherosclerotic plaque stability via increasing TIMP-1/MMP-2 ratio expression.

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0749-1) contains supplementary material, which is available to authorized users.

Anatomic versus non-anatomic resection for hepatocellular carcinoma: A systematic review and meta-analysis

OBJECTIVE

The relative benefit of anatomic resection (AR) versus non-anatomic resection (NAR) of HCC remains poorly defined. We sought to evaluate the available evidence on oncologic outcomes, as well as the clinical efficacy and safety of AR versus NAR performed as the primary treatment for HCC patients.

MATERIAL AND METHODS

A systematic review and meta-analysis was conducted using Medline, ClinicalTrials.gov and Cochrane library through April 15th, 2017. Only clinical studies comparing AR versus NAR were deemed eligible.

RESULTS

A total of 43 studies were considered eligible (total 12,429 patients: AR, n = 6839 (55%) versus NAR, n = 5590 (45%)). Blood loss was higher among patients undergoing AR (mean difference: +229.74 ml, 95% CI: 97.09-362.38, p = 0.0007), whereas resection margin was slightly wider following AR versus NAR (mean difference: +0.29 cm, 95% CI: 0.15-0.44, p < 0.0001). No difference was noted for perioperative complications (RR: 0.95, 95% CI: 0.81-1.11, p = 0.49) and perioperative mortality (RR: 0.91, 95% CI: 0.43-1.95, p = 0.82). AR was associated with a disease-free survival (DFS) benefit at 1- (HR: 0.79, 95% CI: 0.68-0.92, p = 0.002), 3- (HR: 0.87, 95% CI: 0.78-0.95, p = 0.004) and 5-years (HR: 0.87, 95% CI: 0.82-0.93, p < 0.0001). AR also was associated with a decreased risk of death at 5-years (HR: 0.88, 95% CI: 0.79-0.97, p = 0.01).

CONCLUSION

Despite the high heterogeneity among studies, the data demonstrated that AR had comparable perioperative morbidity and mortality versus NAR. AR seemed to offer an advantage versus NAR in terms of DFS and OS among patients undergoing resection of HCC - especially among patients without cirrhosis. Thus, AR should be considered the preferred surgical option for patients with HCC when feasible.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

Laparoscopic liver resections (LLR) are widely accepted as safe and effective procedures for the management of hepatocellular carcinoma (HCC) in the hands of experienced surgeons. The efficacy and extent of benefits of pure as well as hand-assisted laparoscopic and laparoscopy-assisted liver resection over open liver resection (OLR) have been investigated by numerous studies during the last 10 years. The aim of our meta-analysis is to investigate the effect of LLR in short- and long-term outcomes compared to OLR in patients operated for HCC. A total of 5203 patients from forty-four studies were included in our meta-analysis reporting for short- and long-term results for both LLR and OLR for HCC. Among them, 1830 underwent pure laparoscopic hepatectomy, 282 underwent pure laparoscopic or hand-assisted laparoscopic or laparoscopy-assisted hepatectomy, and 3091 were operated through open approach. LLRs were found to be significantly associated with lower blood loss, need for blood transfusion, successful achievement of R0 resection as well as wider resection margin, shorter hospital stay, lower morbidity and 30-day mortality rates. Operative time, tumor recurrence, 1-, 3-, and 5-year overall survival as well as 1-, 3-, and 5-year disease-free survival were not found different between the groups. This meta-analysis clearly demonstrates the superiority of laparoscopic resection over the open approach for patients with small HCC.

Operative Results and Oncologic Outcomes of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Versus Two-Stage Hepatectomy (TSH) in Patients with Unresectable Colorectal Liver Metastases: A Systematic Review and Meta-Analysis

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently emerged as a treatment choice for patients with colorectal liver metastases (CLM) and inadequate future liver remnant (FLR). The aim of this study was to define the results of ALPPS compared with two-stage hepatectomy (TSH) for patients with CLM.

MATERIALS AND METHODS

A meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Identification of eligible studies was performed using three distinct databases through February 2017; Medline, ClinicalTrials.gov and Cochrane library-Cochrane Central Register of Controlled Trials using a syntax including medical subject headings terms "portal vein ligation," "PVE," "staged hepatectomy," "staged liver resection," "liver resection," "two-stage hepatectomy," "TSH," "in situ liver transection with portal vein ligation," "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS".

RESULTS

Among the 634 records identified, 9 studies comparing ALPPS with TSH met the inclusion criteria. These studies included 657 patients with unresectable CLM (ALPPS, n = 186 vs TSH, n = 471). There was no difference in final postoperative FLR between ALPPS versus TSH (mean difference: 31.72, 95% CI: -27.33 to 90.77, p = 0.29). The kinetic growth rate was faster with the ALPPS versus TSH (mean difference 19.07 ml/day, 95% CI 8.12-30.02, p = 0.0006). TSH had a lower overall and major morbidity versus ALPPS (overall morbidity: RR: 1.39, 95% CI: 1.07-1.8, p = 0.01; I 2: 58%, p = 0.01; major morbidity: RR: 1.57, 95% CI: 1.18-2.08, p = 0.002; I 2: 0%, p = 0.44). Overall survival was comparable following ALPPS versus TSH.

CONCLUSION

While ALPPS may be a suitable approach for patients, the higher morbidity and mortality should be considered when determining the operative approach for patients with extensive CLM.

Clinical significance of AGE-RAGE axis in colorectal cancer: associations with glyoxalase-I, adiponectin receptor expression and prognosis

Background

Advanced glycation end products (AGEs) and their receptor RAGE emerge as important pathogenic contributors in colorectal carcinogenesis. However, their relationship to the detoxification enzyme Glyoxalase (GLO)-I and Adiponectin receptors (AdipoR1, AdipoR2) in colorectal carcinoma (CRC) is currently understudied. In the present study, we investigated the expression levels of the above molecules in CRC compared to adjacent non-tumoral tissue and their potential correlation with clinicopathological characteristics and patients’ survival.

Methods

We analyzed the immunohistochemical expression of AGE, RAGE, GLO-1, AdipoR1 and AdipoR2 in 133 primary CRC cases, focusing on GLO-I. The tumour MSI status was further assessed in mucinous carcinomas. Western immunoblotting was employed for validation of immunohistochemical data in normal and tumoral tissues as well in three CRC cell lines. An independent set of 55 patients was also used to validate the results of univariate survival analysis regarding GLO-I.

Results

CRC tissue showed higher intensity of both AGE and RAGE expression compared with normal colonic mucosa which was negative for GLO-I in most cases (78 %). Western immunoblotting confirmed AGE, RAGE and GLO-I overexpression in tumoral tissue. GLO-I expression was directly related to RAGE and inversely related to AGE immunolabeling. There was a trend towards higher expression of all markers (except for RAGE) in the subgroup of mucinous carcinomas which, although of borderline significance, seemed to be more prominent for AdipoR1 and AGE. Additionally, AGE, AdipoR1 and Adipo R2 expression was related to tumor grade, whereas GLO-1 and AdipoR1 to T-category. In survival analysis, AdipoR2 and GLO-I overexpression predicted shortened survival in the entire cohort and in early stage cases, an effect which for GLO-I was reproduced in the validation cohort. Moreover, GLO-I emerged as an independent prognosticator of adverse significance in the patients’ cohort.

Conclusions

We herein provide novel evidence regarding the possible interactions between the components of AGE-RAGE axis, GLO-I and adiponectin receptors in CRC. AGE and AdipoR1 are possibly involved in colorectal carcinogenesis, whereas AdipoR2 and GLO-I emerged as novel independent prognostic biomarkers of adverse significance for patients with early disease stage. Further studies are warranted to extend our observations and investigate their potential therapeutic significance.

Epithelial-Mesenchymal Transition in Non Small-cell Lung Cancer

BACKGROUND/AIM

Lung cancer is the first cause of cancer related deaths in both males and females. Epithelial-mesenchymal transition (EMT) is a reversible process by which epithelial cells transform to mesenchymal stem cells by losing their cell polarity and cell-to-cell adhesion, gaining migratory and invasive properties. High levels of E-cadherin are expressed in epithelial cells, whereas mesenchymal cells express high levels of N-cadherin, fibronectin and vimentin. The aim of this study was to evaluate the correlation between E-cadherin and vimentin expression and their clinical significance in non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

The immunohistochemical expression of E-cadherin, vimentin and Ki-67 was performed on tissue microarrays from NSCLC specimens obtained from 112 newly- diagnosed cases and were studied using classical pathological evaluation. Associations between E-cadherin, vimentin and Ki-67 expression, clinicopathological variables and survival were analyzed. In all cases, a value of p≤0.05 was considered significant.

RESULTS

Low E-cadherin expression was significantly correlated with tumor necrosis (p=0.019). Moreover, there was a trend for correlation between high E-cadherin expression and better overall survival (hazard ratio=1.02, and 95% confidence interval=0.45-1.87, p=0.091). There was also a significant negative correlation between vimentin expression and overall survival (hazard ratio=1.13, and 95% confidence interval=0.78-1.65, p=0.026). Additionally, there was a significant negative correlation between vimentin expression and grade I tumors (p=0.031). Finally, a positive correlation trend between vimentin expression and Ki-67 was found (p=0.073).

CONCLUSION

High E-cadherin and low vimentin expression correlate with better prognosis and overall survival.

Comparison between liver transplantation and resection for hilar cholangiocarcinoma: A systematic review and meta-analysis

BACKGROUND

Hilar cholangiocarcinoma (hCCA) is a rare and aggressive malignancy with R0 resection being currently the only option for long-term survival. With the improvement in the outcomes of liver transplantation (LT), the indications for LT have expanded to include other malignant tumors, such as hCCA. The aim of the present analysis is to demonstrate and critically evaluate the outcomes of LT compared to resection with curative intent in patients with hCCA.

METHODS

We systematically searched the literature for articles published up to May 2018. The following algorithm was applied ((hilar cholangiocarcinoma) OR (perihilar cholangiocarcinoma) OR klatskin$ OR (bile duct neoplasm) OR cholangiocarcinoma) AND (transplant$ OR graft$).

RESULTS

Neoadjuvant treatment with chemotherapy and radiation therapy was far more common in the LT group, with very few patients having received preoperative therapy in the resection group (p = 0.0005). Moreover, length of hospital stay was shorter after LT than after resection (p<0.00001). In contrast, no difference was found between the two treatment methods concerning postoperative mortality (p = 0.57). There was a trend towards longer overall survival after LT in comparison with resection. This was not obvious in the first year postoperatively, however, the advantage of LT over resection became obvious at 3 years after the operation (p = 0.02).

CONCLUSIONS

In non-disseminated unresectable tumors, LT seems to have a non-inferior survival. In the same patients, neoadjuvant chemoradiotherapy and/or strict selection criteria may contribute to superior survival outcomes compared to curative-intent resection. Due to the scarcity of level 1 evidence, it remains unclear whether LT should be increasingly considered for technically resectable early stage hCCA.

Empagliflozin improves primary haemodynamic parameters and attenuates the development of atherosclerosis in high fat diet fed APOE knockout mice

The effects of long-term treatment with empagliflozin on biochemical and immunohistochemical markers related to atherosclerosis and atherosclerosis development in the aorta of apolipoprotein E knockout [Apo-E ^(-/-)] mice were evaluated in this study. Empagliflozin-treated mice had lower total cholesterol (P < 0.05), fasting glucose (P < 0.01), heart rate (P < 0.01) and diastolic blood pressure (DBP) (P < 0.05) compared to controls. Histomorphometry revealed reduced atherosclerotic lesion progress approaching statistical significance (P = 0.06) and approximately 50% wider lumen area for the Empagliflozin treated mice group. Although empagliflozin significantly reduced Vcam-1 and Mcp-1 (P < 0.05, P < 0.01, respectively) and marginally induced Timp-1 and Timp-2 mRNA expression (P < 0.08, P = 0.1 respectively), immunohistochemistry revealed a marginal reduction in VCAM-1 and MMP-9 (P = 0.1) without affecting the expression of TIMP-2 and MCP-1 in atherosclerotic lesions. Empagliflozin improves primary haemodynamic parameters and attenuates the progression of atherosclerosis by reducing hyperlipidemia and hyperglycemia, while direct actions in aorta vessel mediated via SGLT-1 are strongly hypothesized.

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.

Meta-analysis of laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is a rare and aggressive hepatic malignancy. An up-to-date systematic review and meta-analysis was conducted aiming to compare outcomes between laparoscopic (LLR) and open liver resection (OLR) for patients with iCCA. A systematic literature search of Medline, Scopus, Google Scholar, and Cochrane databases was performed. A total of 8 studies comprising 2872 patients, who underwent LLR or OLR for iCCA, were included in our meta-analysis. LLR patients had smaller tumors [mean difference (MD): - 1.17 cm, 95% confidence intervals (CI) - 1.77 to - 0.57, p = 0.0001], underwent major resections less frequently [risk ratio (RR): 0.75, 95% CI 0.67-0.83, p < 0.00001] and R0 resections more frequently (RR: 1.05, 95% CI 1.01-1.09, p = 0.01), while lymphadenectomy was less common in the laparoscopic group (RR: 0.73, 95% CI 0.58-0.92, p = 0.007). The LLR group presented reduced blood loss (MD: - 270.16 ml, 95% CI - 381.53 to - 32.79, p = 0.002), need for transfusion (RR: 0.39, 95% CI 0.21-0.73, p = 0.003), overall morbidity (RR: 0.58, 95% CI 0.4-0.83, p = 0.003) and hospital stay (MD: - 3.48 days, 95% CI: - 6.94 to - 0.02, p = 0.05) compared to the OLR group. No differences were shown in operative time (MD: 1.6 min, 95% CI - 34.17-37.37, p = 0.93), major morbidity (RR: 0.65, 95% CI 0.38-1.11, p = 0.12), mortality (RR: 1.42, 95% CI 0.13-15.07, p = 0.77), overall (HR: 0.9, 95% CI 0.59-1.38, p = 0.63) and relapse-free survival (HR: 0.77, 95% CI 0.5-1.16, p = 0.21) between the two groups. LLR seems to benefit patients with iCCA in terms of short-term outcomes, whilst long-term outcomes are comparable among the two approaches.

Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis

OBJECTIVES

Acute appendicitis is the most prevalent cause of non-obstetrical surgical disease during pregnancy. There is no consensus on the optimal surgical management of acute appendicitis in pregnancy. Our aim is to identify surgical and obstetrical outcomes of laparoscopic (LA) and open approach (OA) in pregnant patients with acute appendicitis.

STUDY DESIGN

Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases were searched for articles published up to May 2017, along with the references of all articles. Prospective and retrospective trials reporting outcomes among pregnant women undergoing laparoscopic and open appendectomy were included. Of the 493 records screened, 20 were eligible for meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Statistical meta-analysis was performed using the RevMan 5.3 software.

RESULTS

A total of 6210 pregnant women from twenty studies were included in meta-analysis. Laparoscopic appendectomy was associated with significantly lower overall complication rates and shorter hospital stays (1835 patients OR 0.48 95% CI 0.29, 0.80 p = 0.005). While the open appendectomy group showed prolongation of gestational age for term deliveries, laparoscopic appendectomy patients had higher rates of fetal loss (543 patients MD -0.46 weeks 95% CI-0.87 to -0.04, p = 0.03 and 4867 patients OR 1.82 95% CI 1.30 to 2.57, p = 0.0006, respectively).

CONCLUSIONS

Current literature remains inconclusive on the optimal approach of appendectomy in pregnant women. Further larger-volume studies are needed in order to elucidate the critical effect of laparoscopic appendectomy on fetal loss rates.

Is Resection of Primary Midgut Neuroendocrine Tumors in Patients with Unresectable Metastatic Liver Disease Justified? A Systematic Review and Meta-Analysis

INTRODUCTION

Patients with midgut neuroendocrine tumors (MNETs) frequently present with metastatic disease at the time of diagnosis. Although combined resection of the primary MNET and liver metastases (NELM) is usually recommended for appropriate surgical candidates, primary tumor resection (PTR) in the setting of extensive, inoperable metastatic disease remains controversial.

METHODS

A systematic review was performed according to PRISMA guidelines utilizing Medline (PubMed), Embase, and Cochrane library-Cochrane Central Register of Controlled Trials (CENTRAL) databases until September 30, 2018.

RESULTS

Among patients with MNET and NELM, 1226 (68.4%; range, 35.5-85.1% per study) underwent PTR, whereas 567 (31.6%; range, 14.9-64.5%) patients did not. Median follow-up ranged from 55 to 90 months. Cytoreductive liver surgery was performed in approximately 15.7% (range, 0-34.8%) of patients. Pooled 5-year overall survival (OS) among the resected group was approximately 73.1% (range, 57-81%) versus 36.6% (range, 21-46%) for the non-resection group. For patients without liver debulking surgery, PTR remained associated with a decreased risk of death at 5 years compared with patients who did not have the primary tumor resected (HR 0.36, 95% CI 0.16 to 0.79, p = 0.01; I2 58%, p = 0.12). For patients undergoing PTR, 30-day postoperative mortality ranged from 1.43 to 2%.

CONCLUSION

PTR was safe with a low peri-operative risk of mortality and was associated with an improved OS for patients with MNET and unresectable NELM. Given the poor quality of evidence, however, strong evidenced-based recommendations cannot be made based on these retrospective single center-derived data. Future well-design randomized controlled trials will be critical in elucidating the optimal treatment strategies for patients with MNET and advanced metastatic disease.

Comparison between robotic and open liver resection: a systematic review and meta-analysis of short-term outcomes

Minimally invasive liver surgery has evolved significantly during the last 2 decades. A growing number of published studies report outcomes from robotic liver resections (RLR). The aim of our meta-analysis was to evaluate short-term outcomes after RLR vs. open liver resection (OLR). A systematic search of Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases for articles published from January 2000 until November 2018 was performed. Ten non-randomized retrospective clinical studies comprising a total of 1248 patients were included in our meta-analysis. Four hundred and fifty-eight patients underwent RLR and 790 underwent OLR. RLRs were associated with lower overall morbidity rates (p =0.006) and shorter hospital stay (p <0.00001), whereas OLRs were associated with shorter operative time (p =0.003). No differences were shown between the two groups with regard to blood loss, blood transfusion requirements, R0 resection and mortality rates. Cumulative conversion rate was 4.6% in the RLR group. Due to limited available data, further prospective randomized studies are needed to better determine the potential beneficial role of the robotic approach in the treatment of malignant and benign hepatic tumors.

Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

The role of calprotectin in obstetrics and gynecology

The purpose of this article is to create the first complete review concerning the role of calprotectin, a calcium- and zinc-binding protein of the S100/calgranulins family, in obstetrics and gynecology. A Medline search was conducted between 6 and 8 June 2009 using the term calprotectin and its synonyms combined with the following ones: calprotectin, obstetrics and gynecology, breast cancer, ovarian cancer, endometrial cancer, cervical cancer, menstrual cycle, pregnancy, fetal implantation, labor, intra-amniotic inflammation, preeclampsia, HELLP syndrome, Rh(-) incompatibility. We found 46 studies which referred to obstetrics and gynecology. We excluded 11 studies which referred to obstetrics and gynecology but did not include enough information about calprotectin, and another two which referred to calprotectin but were not related to subjects of obstetrics and gynecology. Thus, we ended up with 33 studies which contained sufficient information to extract data for this review. All the articles were written in English. It was found that calprotectin is associated with many physiologic and pathologic processes in obstetrics and gynecology, such as: breast cancer, ovarian cancer, endometrial cancer, cervical cancer, cervical and vaginal physiology, menstrual cycle, pregnancy and labor. The role of calprotectin in these conditions is significant. In conclusion, the role of calprotectin seems to be important in several issues of obstetrics and gynecology. For example, calprotectin could be used as a diagnostic, prognostic or metastatic marker in several types of cancer, as a marker of inflammation and as a pharmaceutical target in many conditions. Further studies must be conducted to elucidate this role.

Liver Transplantation for Giant Hepatic Hemangioma: A Systematic Review

INTRODUCTION

Despite their benign nature, liver hemangiomas (LH) are lesions that can cause major complications requiring intervention. Liver transplantation (LT) has been suggested as an effective treatment option in selected patients with giant LHs causing severe symptoms and cannot be treated otherwise. The aim of our study was to investigate the indications, aspects and post-operative outcomes of patients with a LH who underwent LT.

MATERIALS AND METHODS

A meticulous search of the literature was performed. Studies presenting cases of LT due to LH were evaluated. Studies presenting patients characteristics and symptoms, aspects of the disease, transplantation indications and details were selected.

RESULTS

Fifteen studies were included in the present review that involved 16 patients. Among them, 4 were male while the remaining 12 were female with a mean age of 39.9 ± 8.7 years. The main indications for LT included respiratory distress, massive hemorrhage, Kasabach-Merritt syndrome, and unsuccessful previous treatment strategies. Four patients were transplanted from living donors and the remaining 12 from cadaveric donors. No post-operative deaths were reported and all patients returned to normal activity. No deaths during the long-term follow-up were reported.

CONCLUSIONS

LH is an extremely rare indication for LT. Nevertheless, the currently available data suggest that LT is a safe and efficient treatment in the management of symptomatic or complicated LH in selected patients.

Erythropoietin and sildenafil protect against ischemia/reperfusion injury following testicular torsion in adult rats

Testicular torsion/detorsion causes severe tissue damage due to ischemia/reperfusion injury. The present study investigated the protective effect of erythropoietin and sildenafil against ischemia/reperfusion injury following unilateral testicular torsion/detorsion in adult rats. A total of 28 adult male rats were included, and were divided into the following groups: Group A (n=5), sham operated; groups B (n=5), C (n=5), D (n=5) and E (n=8), undergoing right testis torsion and detorsion after 90 min. Group B received no drug treatment. Rats in the groups C and D received low-dose (1,000 IU/kg) or high-dose (3,000 IU/kg) erythropoietin, while those in group E received sildenafil (0.7 mg/kg), through intraperitoneal injection after 60 min of torsion. The right testis was extracted 24 h after detorsion, and the tissue was subjected to histopathological examination and immunohistochemical assessment of cleaved caspase-3 expression. Histological alterations and the quality of spermatogenesis were scored according to the Cosentino and the Johnsen scoring systems, respectively. The results demonstrated normal testicular architecture in group A, while the other groups showed ischemic cellular damages, with the worst scores observed in group B. Groups D and E presented better scores compared with group C. Regarding the quality of spermatogenesis, the best scores were observed in group A, and the worst in group B. Groups C, D and E presented similar results, which were improved in comparison to group B, however, not compared to group A. Furthermore, cleaved caspase-3 levels were lower in groups A, D and E, with equal results observed. Group C had higher levels of cleaved caspase-3 compared with these groups, but lower than group B, which presented the highest cleaved caspase-3 levels. In conclusion, erythropoietin and sildenafil protect testis from ischemia/reperfusion injury by decreasing cellular damage and attenuating apoptosis.

Synthesis and cytotoxic activity of 2-dialkylaminoethylamino substituted xanthenone and thioxanthenone derivatives

The synthesis and biological evaluation of some new pyranoxanthenones and pyranothioxanthenones, substituted with flexible amino side-chains, and their evaluation as potential antitumor agents is described. The cytotoxic activity of the compounds and their eventual selective effect on a phase of the cell cycle were evaluated in vitro, using the murine lymphocytic L1210 leukemia cell line. The new aminoderivatives exhibited highly potent cytotoxicity against the leukemia L1210 cell line when compared to acronycine. All the compounds induced a partial accumulation of cells in the G2 + M phase of the cell cycle.

The Emerging Role of Laparoscopic Liver Resection in the Treatment of Recurrent Hepatocellular Carcinoma: A Systematic Review

BACKGROUND/AIM

Tumor recurrence complicates more than half of patients at 5 years after primary hepatocellular carcinoma (HCC) resection. Repeat open liver resection (ROLR) is the standard procedure for patients eligible for repeat resection, whereas laparoscopic repeat liver resection (RLLR) has been proposed as an alternative approach. The aim of this systematic review is to evaluate studies reporting on outcomes of RLLR for recurrent HCC (rHCC).

MATERIALS AND METHODS

A comprehensive search of the literature was undertaken.

RESULTS

A total of 11 studies, 6 non-comparative and 5 comparative (RLLR versus ROLR), which reported outcomes for 165 patients who underwent RLLR, were included in our review. RLLRs were associated with reduced blood loss, shorter hospital stay, lower conversion to ROLR and lower morbidity rates.

CONCLUSION

Selected patients with rHCC who undergo RLLR, benefit in terms of short-term outcomes. Larger prospective trials will elucidate the impact of RLLR on long-term outcomes and establish treatment guidelines.

Management of liver metastases from gastrointestinal stromal tumors: where do we stand?

The recommended management of liver metastases (LM) from gastrointestinal stromal tumors (GISTs) disease consists of perioperative administration of tyrosine kinase inhibitors (TKIs) and surgical resection. The aim of our study was to investigate the efficacy of this therapeutic approach. Studies reporting outcomes for patients underwent liver resection from metastatic gastrointestinal stromal tumor (GIST) were overviewed. Eleven studies were included, which enrolled 240 patients with liver metastasis from GISTs. A median overall survival (OS) interval of 41.8 months was calculated while a median disease free interval of 17.9 [17-43] months following resection was also measured. Recurrences were recorded in 63 patients. Prognostic factors identified by the studies included surgical resection, R0 resection, age <55 years, clinical response to TKIs, pre- and postoperative administration of TKIs. The included studies highlight the importance of complete resection and the timing of resection, as well underline the importance of pre- and post-operative administration of TKIs.

Identifying prognostic risk factors for poor outcome following COVID-19 disease among in-centre haemodialysis patients: role of inflammation and frailty

INTRODUCTION

The pandemic of coronavirus disease (COVID-19) has highly affected patients with comorbidities and frailty who cannot self-isolate, such as individuals undergoing haemodialysis. The aim of the study was to identify risk factors for mortality and hospitalisation, which may be useful in future disease spikes.

METHODS

We collected data retrospectively from the electronic medical records of all patients receiving a diagnosis of COVID-19 between 11th March and 10th May 2020 undergoing maintenance haemodialysis at four satellite dialysis units from the Royal Free London NHS Foundation Trust, London, UK. Mortality was the primary outcome, and the need for hospitalization was the secondary one.

RESULTS

Out of 746 patients undergoing regular haemodialysis, 148 symptomatic patients tested positive for SARS-CoV-2 by RT-PCR and were included in the analysis. The overall mortality rate was 24.3%. By univariate analysis, older age, ischaemic heart disease, lower systolic blood pressure, lower body mass index (BMI) and higher frailty scores were associated with higher rates of mortality (all p value < 0.05). The laboratory factors associated with mortality were higher values of WBC, neutrophil counts, neutrophil to lymphocyte ratios (NLR), C-reactive protein (CRP), bilirubin, ferritin, troponin, and lower serum albumin level (all p value < 0.05). In the logistic regression, mortality was associated with older age and higher CRP, while high levels of NLR and CRP were associated with the need for hospitalization.

DISCUSSION

Haemodialysis patients are susceptible to COVID-19 and have a high mortality rate. Our study identifies prognostic risk factors associated with poor outcome including age, frailty and markers of inflammation, which may support more informed clinical decision-making.

Prognostic and predictive factors in patients with metastatic or recurrent cervical cancer treated with platinum-based chemotherapy

BACKGROUND

Recognizing resistance or susceptibility to the current standard cisplatin and paclitaxel treatment could improve therapeutic outcomes of metastatic or recurrent cervical cancer.

METHODS

Forty-five tissue samples from patients participating in a phase II trial of cisplatin and ifosfamide, with or without paclitaxel were collected for retrograde analysis. Immunohistochemistry and genotyping was performed to test ERCC1, III β-tubulin, COX-2, CD4, CD8 and ERCC1 (C8092A and N118 N) and MDR1 (C3435T and G2677 T) gene polymorphisms, as possible predictive and prognostic markers. Results were statistically analyzed and correlated with patient characteristics and outcomes.

RESULTS

Patients with higher levels of ERCC1 expression had shorter PFS and OS than patients with low ERCC1 expression (mPFS:5.1 vs 10.2 months, p = 0.027; mOS:10.5 vs. 21.4 months, p = 0.006). Patients with TT in the site of ERCC1 N118 N and GT in the site of MDR1 G2677 T polymorphisms had significantly longer PFS (p = 0.006 and p = 0.027 respectively). ERCC1 expression and the ERCC1 N118 N polymorphism remained independent predictors of PFS. Interestingly, high III beta tubulin expression was associated with chemotherapy resistance and fewer responses [5/20 (25%)] compared to lower III β-tubulin expression [15/23 (65.2%)] (p = 0.008). Finally, ΙΙΙ β-tubulin levels and chemotherapy regimen were independent predictors of response to treatment.

CONCLUSIONS

ERCC1 expression proved to be a significant prognostic factor for survival in our metastatic or recurrent cervical cancer population treated with cisplatin based chemotherapy. ERCC1 N118 N and MDR1 G2677 T polymorphism also proved of prognostic significance for disease progression, while overexpression of III β-tubulin was positively correlated with chemotherapy resistance.

UK renal transplant outcomes in low and high BMI recipients: the need for a national policy

INTRODUCTION

We assessed the effect of recipient body mass index (BMI) on the outcomes of renal transplantation and the management of obese patients with end-stage renal disease across the UK.

METHODS

We analyzed data of 25539 adult renal transplants (2007-2016) from the UK Transplant Registry. Patients were divided in BMI groups [underweight: < 18.5, normal: 18.5-24.9 (reference group), overweight: 25-29.9, class I obese: 30-34.9, class II/III obese: ≥ 35]. We also conducted a national survey of all UK renal transplant centers on the influence of BMI on decisions regarding management of renal transplant candidates.

RESULTS

BMI ≥ 25 was an independent risk factor for delayed graft function and primary non-function (p ≤ 0.001). Underweight (p = 0.001), class I obese (p = 0.017) and class II/III obese recipients (p < 0.001) had poorer graft survival, however, 5- and 10-year graft survival rates were good. Patient survival was shorter for underweight recipients (p < 0.001) and longer for overweight (p = 0.028) and class I obese recipients (p = 0.013). The national survey revealed significant variability among transplant centers in BMI threshold for listing patients on transplant waiting list and limited support with conservative or surgical procedures for weight control.

CONCLUSIONS

Obesity alone should not be a barrier for renal transplantation. A national strategy is required to give all patients equal chances in transplantation.

Liver transplantation for hilar cholangiocarcinoma: A systematic review

Patients with hilar cholangiocarcinoma (hCCA) have advanced disease at presentation and therefore curative treatment options are limited. Liver transplantation (LT), in the case of unresectable disease, is theoretically an attractive option, as it offers the maximum resection margin and at the same time removes the underlying parenchymal liver disease. In the past years a number of studies have aimed to evaluate to potential beneficial role of neo adjuvant therapy followed by LT for treating patients with unresectable hCCA. The objective of our systematic review was to collect and evaluate long-term outcomes of patients with hCCA undergoing LT. A systematic search of 4 electronic databases (Medline, Scopus, Google Scholar and ClinicalTrails.gov databases) was performed for articles published between January 2000 and May 2019. A total of 13 studies with 698 patients were finally included in the present systematic review. A proportion of 74.4% of patients received combination of chemotherapy and radiation as a part of neoadjuvant therapy. One-, 3- and 5-year overall survival rates ranged greatly among the included studies from 58% to 92%, 31% to 80% and 20% to 74%, respectively. Recurrence rates ranged from 16% to 61%, whilst perioperative mortality ranged from 0% to 25.5%. LT could provide acceptable long-term outcomes in the setting of neoadjuvant chemoradiation and strict patient selection criteria. Taking into account organ shortage, combined with the lack of level I evidence, more prospective randomized trials are needed in order to establish certain indications, rigorous criteria and standardized protocols for LT in hCCA and provide the maximal potential benefits for these patients.