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Yellinek S, Krizzuk D, Gilshtein H, Freund MR, Wexner SD, Berho M. Distal Tumor Spread in Rectal Cancer-How Low Should We Go? Am Surg 2023; 89:5553-5558. [PMID: 36855994 DOI: 10.1177/00031348231157408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Distal tumor spread (DTS) is an adverse prognostic factor in rectal cancer correlating with advanced stage disease. We aimed to assess prevalence and location of distal tumor spread and impact of neoadjuvant chemoradiotherapy (NACRT) in patients who underwent proctectomy for rectal cancer. METHODS The pathology database at our institution was queried for all patients who underwent proctectomy with curative intent for rectal cancer from 1/2008 to 12/2016. Specimen slides were re-evaluated by a single expert rectal cancer pathologist to verify diagnosis and measure the distance to the distal resection margin. Main outcome measures were 3-year overall and disease-free survival. RESULTS 275 consecutive patients were identified. 109/111 patients with clinical stage 3 disease received preoperative neoadjuvant chemoradiotherapy. DTS was found in 13 (4.7%) specimens, 6 with intra-mural and 7 with extra-mural distal tumor spread. DTS was found only in patients with clinical stage 3 disease. Length of DTS from the distal end of the tumor ranged from 0 to 30 mm; in only 4 specimens DTS was >10 mm. A positive distal resection margin was found in 5/275 (1.8%) specimens. CONCLUSION A macroscopically tumor-free margin may suffice in patients with pre-treatment stage 1 or 2 disease. Furthermore, a 1 cm margin is adequate in most patients with stage 3 disease.
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Affiliation(s)
- Shlomo Yellinek
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dimitri Krizzuk
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General and Minimally-Invasive surgery, Aurelia Hospital, Rome, Italy
| | - Hayim Gilshtein
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
| | - Mariana Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA
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Sylla P, Sands D, Ricardo A, Bonaccorso A, Polydorides A, Berho M, Marks J, Maykel J, Alavi K, Zaghiyan K, Whiteford M, Mclemore E, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Moshier E, Wexner SD. Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results. Surg Endosc 2023; 37:9483-9508. [PMID: 37700015 PMCID: PMC10709232 DOI: 10.1007/s00464-023-10266-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/27/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765). METHODS 100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications. RESULTS Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003). CONCLUSION When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL, USA
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, The Oregon Clinic, Providence Cancer Center, Portland, OR, USA
| | - Elisabeth Mclemore
- Division of Colorectal Surgery, Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Sami Chadi
- Division of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre and University Health Network, Toronto, ON, Canada
| | - Sherief F Shawki
- Department of Colorectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alessio Pigazzi
- Division of Colorectal Surgery, Department of Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL, USA
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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Sylla P, Berho M, Sands D, Ricardo A, Bonaccorso A, Moshier E, Hain E, Letchinger R, Marks J, Whiteford M, Mclemore E, Maykel J, Alavi K, Zaghiyan K, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Polydorides A, Wexner S. Discordance in Total Mesorectal Excision Specimen Grading in a Prospective Phase 2 Multicenter Rectal Cancer Trial: Are We Overestimating the Quality of Our Resections? Ann Surg 2023; 278:452-463. [PMID: 37450694 DOI: 10.1097/sla.0000000000005948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVES To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase 2 trial of transanal TME. BACKGROUND Grading of TME specimens is based on the macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described. METHODS A phase 2 prospective transanal TME trial was conducted from 2017 to 2022 across 11 North American centers with TME quality as the primary study endpoint. QC measures included (1) training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance before trial reporting. Cohen Kappa statistic was used to assess agreement in grading. RESULTS Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ = 0.35; 95% CI: 0.10-0.61; P < 0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases, respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre versus postreconciliation rates of complete or NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC-NC; N = 1) or major downgrade (NC/C-IC, N = 4) in 5 cases overall (5%). CONCLUSIONS A 14% rate of major discordance was observed in TME grading between the site and central reviewers. The resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through a central review of TME photographs and reconciliation of major discordances is strongly recommended.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Elisabeth Hain
- Department of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | - Riva Letchinger
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, the Oregon Clinic Providence Cancer Center, Portland, OR
| | - Elisabeth Mclemore
- Department of Surgery, Division of Colorectal Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sami Chadi
- Department of Surgery, Division of Surgical Oncology, Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada
| | | | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH
| | - Alessio Pigazzi
- Department of Surgery, Division of Colorectal Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL
| | | | | | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
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Gefen R, Garoufalia Z, Horesh N, Freund MR, Emile SH, Parlade A, Berho M, Allende D, DaSilva G, Wexner SD. How reliable is restaging MRI after neoadjuvant therapy in rectal cancer? Colorectal Dis 2023; 25:1631-1637. [PMID: 37376824 DOI: 10.1111/codi.16641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 01/07/2023] [Accepted: 04/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Despite the pivotal role of magnetic resonance imaging (MRI) in rectal cancer staging and evaluation, the reliability of restaging MRI after neoadjuvant therapy is still debatable. This study aimed to assess the accuracy of restaging MRI by comparing post-neoadjuvant MRI findings with those of the final pathology. METHODS This study was a retrospective review of the medical records of adult rectal cancer patients who had restaging MRI following neoadjuvant therapy and prior to rectal cancer resection in a NAPRC-certified rectal cancer centre between 2016 and 2021. The study compared findings of preoperative, post-neoadjuvant MRI with final pathology relative to T stage, N stage, tumour size, and circumferential resection margin (CRM) status. RESULTS A total of 126 patients were included in the study. We found fair concordance (kappa -0.316) for T stage between restaging MRI and pathology report, and slight concordance for N stage and CRM status (kappa -0.11, kappa = 0.089, respectively). Concordance rates were lower for patients following total neoadjuvant treatment (TNT) or with a low rectal tumour. In total, 73% of patients with positive N pathology status had negative N status in the restaging MRI. Sensitivity and specificity regarding positive CRM in post-neoadjuvant treatment MRI were 45.45% and 70.4%, respectively. CONCLUSION We found low concordance levels between restaging MRI and pathology regarding TN stage and CRM status. Concordance levels were even lower for patients after TNT regimen and with a low rectal tumour. In the era of TNT and watch-and-wait approach, we should not rely solely on restaging MRI to make post-neoadjuvant treatment decisions.
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Affiliation(s)
- Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of Surgery and Transplantations, Sheba Medical Centre, Affiliated with the Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Faculty of Medicine, Shaare Zedek Medical Centre, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Albert Parlade
- Lang Family Department of Imaging, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | - Daniela Allende
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Ohio, Cleveland, Ohio, USA
| | - Giovanna DaSilva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
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Jabbal IS, Nagarajan A, Rivera C, Yaghi M, Liang H, Nahleh Z, Bejarano P, Berho M, Wexner S. Medullary carcinoma of the colon: A comprehensive analysis of the National Cancer Database. Surg Oncol 2022; 45:101856. [PMID: 36446307 DOI: 10.1016/j.suronc.2022.101856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Medullary carcinomas (MC) of the colon are uncommon tumors. In this study, we analyzed demographic and disease characteristics as well as survival outcomes of MC versus undifferentiated (UDA) and poorly differentiated (PDA) adenocarcinomas (AC) of the colon. MATERIALS AND METHODS The National Cancer Database (2004-2018) was utilized to identify patients with colon cancer. Patient demographics (including age, gender, race), disease characteristics (including grade, TNM stage, carcinoembryonic levels, perineural and lymphovascular invasion, lymph node status, microsatellite stability, KRAS mutation, and primary tumor site), and facility type and location were evaluated. Chi-square tests were used to compare descriptive data. Cox Regression and Kaplan Meier analyses were used to analyze survival characteristics. RESULTS 1,041,753 patients with colon cancer were identified of whom 2709 patients had MC and 897,902 had AC (136,597 PDA and 18,042 UDA). MC was seen in older patients (mean age 74 ± 13 years) and women (72.5% vs. 27.5% males). Most MCs were poorly differentiated (63.3%), and 82.4% of patients with MC had microsatellite instability. Fewer patients with MC had perineural invasion (15.6% vs. 22.0% in PDA and 22.4% in UDA, p < 0.001) and positive lymph nodes (38.4% versus 59.9% with PDA and 59.7% with UDA, p < 0.0001). MC diagnosis increased by year (Cochran-Armitage trend test, p < 0.0001). Kaplan Meir analysis revealed a better prognosis for patients with MC when compared to PDA or UDA (p < 0.001). CONCLUSION Given the rarity, pathologists should maintain a high suspicion for MC when encountering poorly differentiated or undifferentiated right-sided colon cancer with associated MSI-H.
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Affiliation(s)
- Iktej S Jabbal
- Department of Hematology/Oncology, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Arun Nagarajan
- Department of Hematology/Oncology, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
| | - Carlos Rivera
- Department of Hematology/Oncology, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Marita Yaghi
- Department of Hematology/Oncology, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Hong Liang
- Department of Clinical Research, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Zeina Nahleh
- Department of Hematology/Oncology, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Pablo Bejarano
- Department of Pathology, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Mariana Berho
- Department of Pathology, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Steven Wexner
- Department of Colon and Rectal Surgery, Cleveland Clinic, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
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Jabbal IS, Nagarajan A, Rivera C, Yaghi M, Liang H, Nahleh ZA, Bejarano P, Berho M, Wexner S. Medullary carcinoma of the colon: A comprehensive analysis of a large cancer database. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
180 Background: Medullary carcinoma (MC) of the colon was described first in 1999 and is characterized by undifferentiated sheets of epithelial cells in a solid growth pattern with pushing borders and prominent lymphoplasmacytic infiltrates. It frequently shows microsatellite instability (MSI). However, the clinicopathological and survival outcomes between MC and the more common adenocarcinoma of the colon (AC) are not well defined in a large database. Therefore, we used a large national registry to explore the association of survival characteristics with sociodemographic, geographic, and disease variables in this cohort of patients. Methods: We sampled the National Cancer Database (NCDB) for colon cancer patients diagnosed with MC from 2004-2018. Multivariate cox regression models were used to compare hazard ratios for demographic, geographic, and disease characteristics. In addition, Kaplan-Meier survival plots were utilized to assess survival rate differences between MC and AC tumors located in the ascending, transverse, or descending colon. A p-value<0.05 was considered statistically significant. Results: Only 2,709 (0.29%) of the 922,667 patients with AC had MC. MC was seen in older patients than AC (76 vs. 69 years). MC was also more common in females than AC (72.5 vs. 49%). The most striking finding in our analysis was the predominance of poorly differentiated (63%) and undifferentiated (21.7%) pathologies in MC. This was in sharp contrast to AC, where 15.8% of patients were poorly differentiated, and only 2% were undifferentiated. Furthermore, undifferentiated and poorly differentiated MC tumors had a poor prognosis (HR 1.45, 95% CI 1.26-1.68, p<0.001 and HR 1.44, 95% CI 1.29-1.62, p<0.001 respectively) as compared to the other histological grades. Another notable finding in our analysis was the high prevalence of MSI in MC vs. AC (82.4% vs. 25.9%). Cecal MC (HR 1) had the worst prognosis of any colonic site. Left-sided MC tumors also had an inferior prognosis compared to AC (63.21 vs. 87.72 months), although not statistically significant (p=0.217). Conclusions: Colon cancer presenting as undifferentiated or poorly differentiated with associated MSI should raise the possibility of a medullary carcinoma diagnosis. However, given the rarity and difficulty in its pathological delineation, MC may remain underdiagnosed. In the modern treatment era, with the approval of immunotherapy for metastatic MSI colon cancer patients, survival and outcomes for metastatic MC may be improved.
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Rivard SJ, Vu JV, Kanters AE, Park J, Berho M, Hendren S. Interactive Training Program Improves Surgeon and Pathologist Comfort Level With Total Mesorectal Excision Grading for Rectal Cancer. Dis Colon Rectum 2022; 65:238-245. [PMID: 34759249 DOI: 10.1097/dcr.0000000000002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total mesorectal excision for rectal cancer has been shown to decrease local recurrence and improve survival, and specimen grading is recommended as a best practice. However, specimen grading remains underutilized in the United States potentially because of the lack of surgeon and pathologist training in the technique. OBJECTIVE This study aimed to determine whether an interactive webinar improves physician comfort with mesorectal grading. DESIGN To test the effect of the program, participants completed a survey before and after participating. SETTINGS Twelve Michigan Surgical Quality Collaborative hospitals volunteered to participate in a Total Mesorectal Excision Project. PARTICIPANTS Total mesorectal excision grading training program participants were surgeons, surgery residents, pathologists, and pathology assistants from 12 hospitals. MAIN OUTCOME MEASURES Comfort with grading total mesorectal excision specimens was our main outcome measure. Prewebinar surveys also measured familiarity, previous experience, and training in grade assignment, as well as interest in the training program. Postwebinar surveys measured webinar relevance and effectiveness as well as participant intention to use content in practice. RESULTS A total of 34 participants completed the prewebinar survey and 28 participants completed the postwebinar survey. The postwebinar overall median comfort level with specimen grading of 3.64 was significantly higher than the prewebinar overall median comfort level of 2.94 (95% CI, 3.32-3.96 versus 95% CI 2.56-3.32; p = 0.007). When evaluated separately, both surgeons and pathologists reported significantly higher comfort levels with total mesorectal excision grading after the webinar. LIMITATIONS Six participants did not complete the postwebinar survey. Surgery residents and pathology assistants were analyzed with practicing surgeons and pathologists. The pre- and postwebinar surveys were deidentified, so paired analysis was not possible. CONCLUSIONS Our total mesorectal excision grading training program improved the comfort level of both surgeons and pathologists with specimen grading. Survey results also demonstrate that providers are interested in receiving training in rectal cancer specimen grading. See Video Abstract at http://links.lww.com/DCR/B766.PROGRAMA DE ENTRENAMIENTO INTERACTIVO MEJORA EL NIVEL DE COMODIDAD DEL CIRUJANO Y DEL PATÓLOGO CON LA CLASIFICACIÓN DE LA ESCISIÓN TOTAL DEL MESORRECTO PARA EL CÁNCER DE RECTO. ANTECEDENTES Se ha demostrado que la escisión total del mesorrecto para el cáncer de recto disminuye la recurrencia local y mejora la supervivencia, y se recomienda la clasificación de la muestra como buena práctica de rutina. Sin embargo, sigue siendo poco utilizado en los Estados Unidos debido principalmente a la falta de formación en la técnica de cirujanos y patólogos. OBJETIVO Determinar si un seminario interactivo en línea mejora la comodidad del médico con la clasificación mesorrectal. DISEO Para probar el efecto del programa, los participantes completaron una encuesta antes y después de haber participado de la misma. MARCO Doce hospitales en cooperación sobre la calidad quirúrgica de Michigan se ofrecieron como voluntarios para participar en el proyecto de Escisión Total de Mesorrecto. PARTICIPANTES Los participantes del programa de entrenamiento en la clasificación de escisión total de mesorrecto fueron cirujanos, residentes de cirugía, patólogos y asistentes de patología de doce hospitales. PRINCIPALES RESULTADOS MEDIDOS La comodidad con la clasificación de las muestras de escisión total de mesorrecto fue nuestro principal resultado de medición. Las encuestas previas al seminario en línea también midieron la familiaridad, la experiencia y entrenamiento previo en la clasificación, así como el interés en el programa de entrenamiento. Las encuestas posteriores midieron la relevancia y la eficacia del seminario web, así como la intención de los participantes de utilizar en la practica el contenido. RESULTADOS Un total de 34 participantes completaron la encuesta previa, y 28 de ellos la completaron con posterioridad al seminario en línea.La mediana del nivel de comodidad general, posterior al seminario en línea, con respecto a la clasificación de la pieza de 3,64 fue significativamente mayor con respecto al valor de 2,94 previo al seminario (IC del 95%: 3,32 - 3,96 versus IC 2,56 - 3,32, respectivamente; valor de p = 0,007).Cuando fueron evaluados de manera separada, tanto los cirujanos como los patólogos reportaron niveles de comodidad significativamente más altos con la clasificación de escisión total de mesorrecto (TME) después del seminario en línea. LIMITACIONES Seis participantes no completaron la encuesta posterior al seminario en línea. Los residentes de cirugía y los asistentes de patología fueron analizados conjuntamente con los cirujanos y patólogos en ejercicio, respectivamente. Las encuestas previas y posteriores al seminario en línea fueron anónimas, anulándose la identificación, por lo que no fue posible realizar un análisis por pares. CONCLUSIONES Nuestro programa de entrenamiento en la clasificación de escisión total de mesorrecto mejoró el nivel de comodidad tanto de los cirujanos como de los patólogos con la clasificación de las muestras. Los resultados de la encuesta también demuestran que el personal involucrado está interesado en recibir capacitación en la clasificación de muestras de cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B766. (Traducción-Dr Osvaldo Gauto).
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Affiliation(s)
| | | | | | | | - Mariana Berho
- Department of Pathology and Laboratory Medicine Institute, Cleveland Clinic Florida, Weston, Florida
| | - Samantha Hendren
- Department of Colorectal Surgery, Michigan Medicine, Ann Arbor, Michigan
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Keller DS, Berho M, Brown G, Hull T, Moeslein G, Wexner SD. A narrative celebrating the recent contributions of women to colorectal surgery. Surgery 2020; 168:355-362. [PMID: 32741622 DOI: 10.1016/j.surg.2020.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND To interview extraordinary women who have made recent significant contributions to the field of colorectal surgery. DESIGN The authors asked some of the many extraordinary women who have made significant contributions to the field of colorectal surgery to answer several questions. These women were selected from many potential candidates based upon their extraordinary recent contributions to the field of colorectal surgery. These thought leaders were asked about their contributions to colorectal surgery, their mentors, whether they had any women as role models, and, lastly, what they would tell their younger selves. The study was structured to recognize these women for their remarkable recent contributions to colorectal surgery, and we wished to encourage women to pursue leadership in colorectal surgery including the allied fields of colorectal pathology and colorectal imaging. Furthermore, the authors hoped to inspire male colorectal surgeons to actively mentor and help the career development of women colorectal surgeons. The potential limitations of the study include the fact that there are many more well-deserving women who could have been included in the sample survey but, because of space constraints, were not invited. CONCLUSION Women in colorectal surgery and in the allied specialties of colorectal pathology and colorectal radiology have made many recent major significant contributions to colorectal surgery. The expectation is that the volume and frequency of such contributions as well as the number of women making these contributions should further significantly increase with time.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY
| | - Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, FL
| | - Gina Brown
- Department of Radiology and Gastrointestinal Imaging, Imperial College London, Royal Marsden NHS Foundation Trust, London
| | - Tracy Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Gabriela Moeslein
- Surgical Center for Hereditary Tumors, Ev. BETHESDA Khs, Academic Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL.
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9
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Abstract
Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, New York-Presbyterian, Columbia University Medical Centre, New York, NY, USA
| | - Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS); University College London, London, UK.
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10
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Dossa F, Acuna SA, Rickles AS, Berho M, Wexner SD, Quereshy FA, Baxter NN, Chadi SA. Association Between Adjuvant Chemotherapy and Overall Survival in Patients With Rectal Cancer and Pathological Complete Response After Neoadjuvant Chemotherapy and Resection. JAMA Oncol 2019; 4:930-937. [PMID: 29710274 DOI: 10.1001/jamaoncol.2017.5597] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Although American guidelines recommend use of adjuvant chemotherapy in patients with locally advanced rectal cancer, individuals who achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy are less likely to receive adjuvant treatment than incomplete responders. The association and resection of adjuvant chemotherapy with survival in patients with pCR is unclear. Objective To determine whether patients with locally advanced rectal cancer who achieve pCR after neoadjuvant chemoradiation therapy and resection benefit from the administration of adjuvant chemotherapy. Design, Setting, and Participants This retrospective propensity score-matched cohort study identified patients with locally advanced rectal cancer from the National Cancer Database from 2006 through 2012. We selected patients with nonmetastatic invasive rectal cancer who achieved pCR after neoadjuvant chemoradiation therapy and resection. Exposures We matched patients who received adjuvant chemotherapy to patients who did not receive adjuvant treatment in a 1:1 ratio. We separately matched subgroups of patients with node-positive disease before treatment and node-negative disease before treatment to investigate for effect modification by pretreatment nodal status. Main Outcome and Measures We compared overall survival between groups using Kaplan-Meier survival methods and Cox proportional hazards models. Results We identified 2455 patients (mean age, 59.5 years; 59.8% men) with rectal cancer with pCR after neoadjuvant chemoradiation therapy and resection. We matched 667 patients with pCR who received adjuvant chemotherapy and at least 8 weeks of follow-up after surgery to patients with pCR who did not receive adjuvant treatment. Over a median follow-up of 3.1 years (interquartile range, 1.94-4.40 years), patients treated with adjuvant chemotherapy demonstrated better overall survival than those who did not receive adjuvant treatment (hazard ratio, 0.44; 95% CI, 0.28-0.70). When stratified by pretreatment nodal status, only those patients with pretreatment node-positive disease exhibited improved overall survival with administration of adjuvant chemotherapy (hazard ratio, 0.24; 95% CI, 0.10-0.58). Conclusions and Relevance The administration of adjuvant chemotherapy in patients with rectal cancer with pCR is associated with improved overall survival, particularly in patients with pretreatment node-positive disease. Although this study suggests a beneficial effect of adjuvant treatment on survival in patients with pCR, these results are limited by the presence of potential unmeasured confounding in this nonrandomized study.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sergio A Acuna
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Aaron S Rickles
- Department of Colorectal Surgery, Digestive Disease Centre, Cleveland Clinic Florida, Weston
| | - Mariana Berho
- Department of Pathology, Cleveland Clinic Florida, Weston
| | - Steven D Wexner
- Department of Colorectal Surgery, Digestive Disease Centre, Cleveland Clinic Florida, Weston
| | - Fayez A Quereshy
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sami A Chadi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
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11
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Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, Wolthuis A, Daniels IR, Hompes R, Penna M, Fürst A, Papamichael D, Desai AM, Cascinu S, Gèrard JP, Myint AS, Lemmens VE, Berho M, Lawler M, De Liguori Carino N, Potenti F, Nanni O, Altini M, Beets G, Rutten H, Winchester D, Wexner SD, Audisio RA. Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol 2018; 44:1685-1702. [DOI: 10.1016/j.ejso.2018.08.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
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12
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Zheng M, Ma J, Fingerhut A, Adamina MP, Atroschenko A, Bergamaschi R, Berho M, Boni L, Chadi SA, Chen WTL, Delaney CP, Dapri G, Khatkov IE, Kim NK, Kim SH, Karachun A, Lomanto D, MacRae H, Milone M, Morino M, Remzi FH, Uranues S, Watanabe M, Wexner S. Complete mesocolic excision for colonic cancer: Society for Translational Medicine expert consensus statement. Ann Laparosc Endosc Surg 2018. [DOI: 10.21037/ales.2018.08.02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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13
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Chand M, Keller DS, Mirnezami R, Bullock M, Bhangu A, Moran B, Tekkis PP, Brown G, Mirnezami A, Berho M. Novel biomarkers for patient stratification in colorectal cancer: A review of definitions, emerging concepts, and data. World J Gastrointest Oncol 2018; 10:145-158. [PMID: 30079141 PMCID: PMC6068858 DOI: 10.4251/wjgo.v10.i7.145] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/22/2018] [Accepted: 06/08/2018] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer (CRC) treatment has become more personalised, incorporating a combination of the individual patient risk assessment, gene testing, and chemotherapy with surgery for optimal care. The improvement of staging with high-resolution imaging has allowed more selective treatments, optimising survival outcomes. The next step is to identify biomarkers that can inform clinicians of expected prognosis and offer the most beneficial treatment, while reducing unnecessary morbidity for the patient. The search for biomarkers in CRC has been of significant interest, with questions remaining on their impact and applicability. The study of biomarkers can be broadly divided into metabolic, molecular, microRNA, epithelial-to-mesenchymal-transition (EMT), and imaging classes. Although numerous molecules have claimed to impact prognosis and treatment, their clinical application has been limited. Furthermore, routine testing of prognostic markers with no demonstrable influence on response to treatment is a questionable practice, as it increases cost and can adversely affect expectations of treatment. In this review we focus on recent developments and emerging biomarkers with potential utility for clinical translation in CRC. We examine and critically appraise novel imaging and molecular-based approaches; evaluate the promising array of microRNAs, analyze metabolic profiles, and highlight key findings for biomarker potential in the EMT pathway.
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Affiliation(s)
- Manish Chand
- GENIE Centre, University College London, London W1W 7TS, United Kingdom
| | - Deborah S Keller
- Department of Surgery, Columbia University Medical Centre, New York, NY 10032, United States
| | - Reza Mirnezami
- Department of Surgery, Imperial College London, London SW7 2AZ, United Kingdom
| | - Marc Bullock
- Department of Surgery, University of Southampton, Southampton SO17 1BJ, United Kingdom
| | - Aneel Bhangu
- Department of Surgery, University of Birmingham, Birmingham B15 2QU, United Kingdom
| | - Brendan Moran
- Department of Colorectal Surgery, North Hampshire Hospital, Basingstoke RG24 7AL, United Kingdom
| | - Paris P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital and Imperial College London, London SW3 6JJ, United Kingdom
| | - Gina Brown
- Department of Radiology, Royal Marsden Hospital and Imperial College London, London SW3 6JJ, United Kingdom
| | - Alexander Mirnezami
- Department of Surgical Oncology, University of Southampton and NIHR, Southampton SO17 1BJ, United Kingdom
| | - Mariana Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, FL 33331, United States
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14
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Siddiqui M, Nagtegaal I, Santiago I, Knijn N, Berho M, Mirnezami A, Rao S, Brown G. Session 2: What causes liver metastases - lymph nodes or is it something else? Colorectal Dis 2018; 20 Suppl 1:39-42. [PMID: 29878686 DOI: 10.1111/codi.14077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The traditional view of progression of disease in cancer is the sequential spread of tumour to locoregional lymph nodes and then to distant metastases. However, this view may need to be challenged and modern pathology techniques such as immunohistochemistry and tumour profiling can provide us with a greater insight into the pathways and mechanisms of distant spread. Professor Nagtegaal discusses the evidence for reconsidering the current paradigm and reflects on the need for further investigation into mechanisms of distant metastatic spread.
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Affiliation(s)
- M Siddiqui
- Royal Marsden NHS Foundation Trust, London, UK.,Croydon University Hospital, Croydon, UK
| | - I Nagtegaal
- Radboud University Medical Care Academy, Nijmegen, The Netherlands
| | - I Santiago
- Champalimaud Foundation, Lisbon, Portugal
| | - N Knijn
- Radboud University Medical Care Academy, Nijmegen, The Netherlands
| | - M Berho
- Pathology and Laboratory Medicine, Cleveland Clinic, Weston, Florida, USA
| | | | - S Rao
- Royal Marsden NHS Foundation Trust, London, UK
| | - G Brown
- Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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15
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Balyasnikova S, Haboubi N, Wale A, Santiago I, Morgan M, Cunningham D, Mason M, Berho M, Brown G. Session 2: Extramural vascular invasion and extranodal deposits: should they be treated the same? Colorectal Dis 2018; 20 Suppl 1:43-48. [PMID: 29878681 DOI: 10.1111/codi.14078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Professor Nagtegaal has already highlighted that lymph nodes are probably not responsible for the development of liver metastases. If they are not, then is there another mechanism? Professor Haboubi addresses the question of extranodal deposits - their frequency and their importance in the development of metastatic disease. The experts review the evidence and discuss whether this information will alter treatment decisions and staging systems in the future.
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Affiliation(s)
| | - N Haboubi
- Surgical Pathology, Salford University, Manchester, UK
| | - A Wale
- The Royal Marsden NHS Foundation Trust, London, UK
| | - I Santiago
- The Champalimaud Foundation, Lisbon, Portugal
| | - M Morgan
- University Hospital of Wales, Cardiff, UK
| | - D Cunningham
- Clinical Research and Development, NIHR Biomedical Research Centre, The Royal Marsden NHS Foundation Trust, London, UK
| | - M Mason
- Institute of Cancer and Genetics, Cardiff University, Cardiff, UK
| | - M Berho
- Pathology and Laboratory Medicine, Cleveland Clinic, Weston, FL, USA
| | - G Brown
- The Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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16
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Abstract
Examination of the rectum by pathologists is instrumental in the management of patients affected by rectal carcinoma. That role includes evaluation of multiple gross and microscopic features that convey prognostic implications. The analysis is based on the authors' experience handling rectal specimens along with review of the pertinent literature in these areas: margins of excision, quality of the mesorectum, diligence and techniques to sample lymph nodes, tumor budding, grading of residual amount of carcinoma after preoperative therapy, vascular/perineural invasion, and staging the tumor. Pathologists must communicate the findings in a clear manner. Evaluation of margins and completeness of mesorectum are markers of the quality of surgical excision. The number of lymph nodes obtained and examined is dependent in great part on the diligence of the pathologist finding them in the mesenteric adipose tissue. There are grades for budding and response to prior chemoradiation therapy. The location of vascular invasion (extramural vs. intramural) may predict aggressive behavior. Pathologists proactively are to choose sections of tumor for molecular testing. Meticulous macro- and microscopic evaluation of specimens for rectal carcinoma by pathologist is needed to determine an accurate assessment of staging and other prognostic factors. The modern pathologists play a pivotal part in the care and management of patients suffering from rectal adenocarcinoma. That role goes from the initial histological diagnosis to the gross and microscopic examination of the excised specimens. Based on that examination pathologists issue statements that not only evaluate the quality of the surgical procedure, but also through the application of molecular tests they give light on prognostic factors and information for therapeutic purposes.
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Affiliation(s)
- Mariana Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA -
| | - Pablo A Bejarano
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA
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17
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Affiliation(s)
- Steven D Wexner
- Cleveland Clinic Florida, Department of Colorectal Surgery, USA.
| | - Mariana Berho
- Cleveland Clinic Florida, Department of Pathology, USA
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18
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Keller DS, Berho M, Wexner SD, Chand M. Can surgical technology better guide oncological resections in colon cancer? Colorectal Dis 2018; 20:77-78. [PMID: 29166554 DOI: 10.1111/codi.13970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/06/2017] [Indexed: 02/08/2023]
Affiliation(s)
- D S Keller
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, GENIE Centre, University College London, London, UK
| | - M Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - S D Wexner
- Division of Colorectal Surgery, Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - M Chand
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, GENIE Centre, University College London, London, UK
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19
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Becerra AZ, Aquina CT, Berho M, Boscoe FP, Schymura MJ, Noyes K, Monson JR, Fleming FJ. Surgeon-, pathologist-, and hospital-level variation in suboptimal lymph node examination after colectomy: Compartmentalizing quality improvement strategies. Surgery 2017; 161:1299-1306. [PMID: 28088321 DOI: 10.1016/j.surg.2016.11.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/05/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The goals of this study were to characterize the variation in suboptimal lymph node examination for patients with colon cancer across individual surgeons, pathologists, and hospitals and to examine if this variation affects 5-year, disease-specific survival. METHODS A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System, Medicaid, and Medicare claims to identify resections for stages I-III colon cancer from 2004-2011. Multilevel logistic regression models characterized variation in suboptimal lymph node examination (<12 lymph nodes). Multilevel competing-risks Cox models were used for survival analyses. RESULTS The overall rate of suboptimal lymph node examination was 32% in 12,332 patients treated by 1,503 surgeons and 814 pathologists at 187 hospitals. Patient-level predictors of suboptimal lymph node examination were older age, male sex, nonscheduled admission, lesser stage, and left colectomy procedure. Hospital-level predictors of suboptimal lymph node examination were a nonacademic status, a rural setting, and a low annual number of resections for colon cancer. The percent of the total clustering variance attributed to surgeons, pathologists, and hospitals was 8%, 23%, and 70%, respectively. Increasing the pathologist and hospital-specific rates of suboptimal lymph node examination were associated with worse 5-year, disease-specific survival. CONCLUSION There was a large variation in suboptimal lymph node examination between surgeons, pathologists, and hospitals. Collaborative efforts that promote optimal examination of lymph nodes may improve prognosis for colon cancer patients. Given that 93% of the variation was attributable to pathologists and hospitals, endeavors in quality improvement should focus on these 2 settings.
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Affiliation(s)
- Adan Z Becerra
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY; Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mariana Berho
- Department of Laboratory Medicine, Cleveland Clinic Florida, Weston, FL
| | - Francis P Boscoe
- New York State Cancer Registry, Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
| | - Maria J Schymura
- New York State Cancer Registry, Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, Division of Health Services Policy and Practice, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - John R Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, Florida Hospital, Orlando, FL
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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20
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Vallance A, Wexner S, Berho M, Cahill R, Coleman M, Haboubi N, Heald RJ, Kennedy RH, Moran B, Mortensen N, Motson RW, Novell R, O'Connell PR, Ris F, Rockall T, Senapati A, Windsor A, Jayne DG. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis 2017; 19:O1-O12. [PMID: 27671222 DOI: 10.1111/codi.13534] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.
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Affiliation(s)
- A Vallance
- Royal College of Surgeons of England, London, UK
| | - S Wexner
- Cleveland Clinic Florida, Weston, Florida, USA
| | - M Berho
- Cleveland Clinic Florida, Weston, Florida, USA
| | - R Cahill
- University College Dublin, Dublin, Ireland
| | | | - N Haboubi
- University Hospital of South Manchester, Manchester, UK
| | - R J Heald
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - B Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - R W Motson
- The ICENI Centre, Colchester University Hospital, Colchester, UK
| | - R Novell
- The Royal Free Hospital, London, UK
| | | | - F Ris
- Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - T Rockall
- Royal Surrey County Hospital, Guildford, UK
| | | | - A Windsor
- University College Hospital, London, UK
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21
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Severino NP, Chadi SA, Rosen L, Coiro S, Choman E, Berho M, Wexner SD. Survival following salvage abdominoperineal resection for persistent and recurrent squamous cell carcinoma of the anus: do these disease categories affect survival? Colorectal Dis 2016; 18:959-966. [PMID: 26850085 DOI: 10.1111/codi.13288] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 12/01/2015] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to investigate the results of salvage abdominoperineal excision (APR) in patients with persistent or recurrent squamous cell carcinoma of the anus (SCCA). METHOD Patients with anal neoplasia were identified from a prospective database. Patients with invasive SCCA with demonstrated failure of chemoradiation therapy (CRT) who underwent salvage APR for one of three disease categories (persistent, < 6 months post-CRT; early recurrent, 6-24 months post-CRT; late recurrent, > 24 months post-CRT) were included. The primary outcome was overall survival after salvage APR. Tumour size, metastatic lymph nodes (LN), circumferential resection margin positivity (CRM) and neurolymphovascular invasion (NLVI) were correlated with the outcome. RESULTS Thirty-six patients with a median 3-year overall survival of 46% (median follow-up 24 months) underwent salvage APR due to persistent or recurrent SCCA (14 men, mean age 59 years). Eleven (31%) patients were diagnosed with persistent disease, 17 (47%) with early and 8 (22%) with late recurrence. Two-year overall survival of Stage 0/I/II and III/IV disease was 81.5% and 33.74%, respectively (P = 0.022). Overall disease stage was associated with disease categorization (P = 0.009): patients with persistent disease or early recurrence had a significantly higher disease stage than patients with late recurrence (OR = 20.9 and 17.2). Despite apparently improved survival in patients with late disease recurrence on live table analysis, no significant difference was identified in overall survival when stratified by disease category on log-rank test analysis. CONCLUSION Persistent and recurrent disease does not show any significant difference in survival, but patients with late recurrence may have a better prognosis.
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Affiliation(s)
- N P Severino
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S A Chadi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - L Rosen
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S Coiro
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - E Choman
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - M Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, Florida, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.
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22
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Abstract
CONTEXT Esophageal cancer continues to be one of the most lethal of all gastrointestinal malignancies. Its prognostic parameters are based on the gross and histopathologic examination of resected specimens by pathologists. OBJECTIVE To describe the implications of appropriate handling and examination of endomucosal resection and esophagectomy specimens from patients with esophageal carcinoma while considering the implications of the surgical techniques used to obtain such specimens. Parameters include histopathologic findings necessary for accurate staging, differences in the assessment of margins, residual malignancy, and criteria to evaluate for tumor regression after chemoradiation therapy as well as the role of immunohistochemistry and the judicious use of frozen sections. DATA SOURCES Sources were a review of the literature and the authors' experience handling these types of specimens. CONCLUSIONS Examining surgical specimens of the esophagus is critical in the management of patients with esophageal carcinoma, and it requires careful consideration of the diagnostic pitfalls, staging-related parameters, and results of molecular tests.
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Affiliation(s)
| | - Mariana Berho
- From the Department of Pathology, Cleveland Clinic Florida, Weston
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23
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Abstract
Biomarkers in the field of pathology and oncology may allow for the detection of disease, assessment of prognosis or to predict response to certain therapy. Molecular abnormalities in colorectal cancer genesis may occur due to chromosome instability, microsatellite instability and DNA methylation (CpG island methylator phenotype). These alterations are associated in some cases to sporadic carcinomas whereas in others are seen in syndrome-related tumors and are the basis for the use of different biomarkers in the clinical setting. These may include mismatched repair gene/proteins, RAS, BRAF, PIK3CA, which help to determine tumor prognosis and predict response to certain drugs.
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Affiliation(s)
- Pablo A Bejarano
- Department of Pathology Cleveland Clinic Florida, 2900 Weston Road, Weston, FL 33331, USA
| | - Monica T Garcia-Buitrago
- Department of Pathology, University of Miami School of Medicine, 1611 NW 12 Ave. Holtz Bldg, Miami, FL 33136, USA
| | - Mariana Berho
- Department of Pathology Cleveland Clinic Florida, 2900 Weston Road, Weston, FL 33331, USA
| | - Daniela Allende
- Department of Pathology Cleveland Clinic, Cleveland, OH 9500 Euclid Avenue Cleveland, OH 44195, USA
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Herman RM, Berho M, Murawski M, Nowakowski M, Ryś J, Schwarz T, Wojtysiak D, Wexner SD. Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence--a blinded assessment in an animal model. Colorectal Dis 2015; 17:433-40. [PMID: 25524045 DOI: 10.1111/codi.12874] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/02/2014] [Indexed: 01/04/2023]
Abstract
AIM Nonablative radiofrequency (RF) sphincter remodelling has been used to treat gastro-oesophageal reflux disease (GERD) and faecal incontinence (FI). Its mechanism of action is unclear. We aimed to investigate the histomorphological and pathophysiological changes to the internal and external anal sphincter (IAS and EAS) following RF remodelling. METHOD An experimental FI model was created in 12 female pigs: eight underwent RF 6 weeks following induction of FI (FI+RF) and four were untreated (UFI). Four animals served as controls (CG). Two blinded pathologists examined all haematoxylin and eosin and trichrome stained slides. RESULTS Compared with the UFI group, histological examination of the IAS in the FI+RF group demonstrated an increased smooth muscle (SM)/connective tissue ratio (77.2 vs 68.1%, P < 0.05) and increased collagen I compared with collagen III content (67.2 vs 54.9%, P < 0.001). The RF+FI group exhibited greater SM bundle thickness compared with the UFI group (SM width 486.93 vs 338.59 μm, P < 0.01; height 4384.4 vs 3321.0 μm, P < 0.05). The EAS of the FI+RF animals showed a significantly higher type I/II fibre ratio (33.5 vs 25.2%, P = 0.023) and fibre type I diameter (67.2 vs 59.7 μm, P < 0.001) compared with the UFI group. Post-RF manometry showed higher basal (18.8 vs 0 mmHg, P < 0.001) and squeeze (76.8 vs 12.4 mmHg, P < 0.05) anal pressures. After RF treatment, the number of interstitial cells of Cajal was significantly reduced compared with the UFI and CG groups [0.9 (FI+RF) vs 6.7 (UFI) vs 0.7 (CG) per mm(2) , P < 0.001]. CONCLUSION In an animal model nonablative RF appeared to induce morphological changes in the IAS and EAS leading to an anatomical state reminiscent of normal sphincter structure.
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Affiliation(s)
- R M Herman
- Jagiellonian University Medical College, Krakow, Poland
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Affiliation(s)
- Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston
| | - Rahul Narang
- Digestive Disease Center, Cleveland Clinic Florida, Weston
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Nasseri YY, Krott E, Van Groningen KM, Berho M, Osborne MC, Wollman S, Weiss EG, Wexner SD. Abnormalities in collagen composition may contribute to the pathogenesis of hemorrhoids: morphometric analysis. Tech Coloproctol 2014; 19:83-7. [PMID: 25381456 PMCID: PMC4315876 DOI: 10.1007/s10151-014-1238-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 09/29/2014] [Indexed: 01/14/2023]
Abstract
Purpose While hemorrhoidal disease is common, its etiology remains unclear. It has been postulated that disturbances in collagen lead to reduced connective tissue stability, and in turn to the development of hemorrhoidal disease. We aimed to compare the quality and quantity of collagen in patients with hemorrhoidal disease versus normal controls. Methods Specimens from 57 patients with grade III or IV internal hemorrhoids undergoing hemorrhoidectomy between 2006 and 2011 were evaluated. Samples from 20 human cadavers without hemorrhoidal disease served as controls. Quality of collagen was analyzed by collagen I/III ratio, and quantity of collagen was determined by collagen/protein ratio. The study group was subdivided into gender and age subgroups. Results The male:female ratios in the study and control groups were 30:27 and 10:10, respectively. Median age was significantly less in the study group [46.9 years (range 20–69)] compared to the control group [76 years (range 46–90)] with P < 0.05. Tissues from patients in the study group had significantly lower collagen I/III ratio as compared to the control group (4.4 ± 1.1 vs. 5.5 ± 0.6; P < 0.0001). Nevertheless, despite a trend toward lower collagen/protein ratio in the study group, it did not reach statistical significance (57 ± 42.4 vs. 73 ± 32.5 g/mg; P = 0.167). There was no difference in collagen I/III or collagen/protein ratios among different age groups and genders. Conclusions Hemorrhoidal tissues from patients with hemorrhoidal disease appear to have reduced mechanical stability as compared to normal controls.
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Affiliation(s)
- Y. Y. Nasseri
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - E. Krott
- Klinik für Allgemein-, Visceral-und Transplantationschirurgie, Universitätsklinikum Aachen, Aachen, Germany
| | - K. M. Van Groningen
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - M. Berho
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - M. C. Osborne
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - S. Wollman
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - E. G. Weiss
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - S. D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
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Allende D, Elmessiry M, Hao W, DaSilva G, Wexner SD, Bejarano P, Berho M, Al-Qadasi M. Inter-observer and intra-observer variability in the diagnosis of dysplasia in patients with inflammatory bowel disease: correlation of pathological and endoscopic findings. Colorectal Dis 2014; 16:710-8; discussion 718. [PMID: 24836541 DOI: 10.1111/codi.12667] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 04/17/2014] [Indexed: 01/21/2023]
Abstract
AIM Colonic epithelial dysplasia is deemed the precursor lesion of cancer arising in inflammatory bowel disease (IBD). It has been suggested that many dysplastic lesions could be endoscopically detected to obtain target biopsies, leading to better yield. However, the clinical impact of a diagnosis of dysplasia may be hampered by a significant degree of histological and endoscopic intra-observer and inter-observer variability. This study aimed to evaluate intra-observer and inter-observer variability in the microscopic diagnosis of dysplasia in IBD and correlate endoscopic and histological findings. METHOD In total, 158 cases of ulcerative colitis and 14 of Crohn's disease with dysplasia were selected from a pathology database. Slides were blindly reviewed twice by two expert gastrointestinal pathologists. Results of endoscopic examinations were extracted from the reports. The degree of intra-observer and inter-observer variability was determined by kappa statistics. RESULTS Overall, there was an excellent degree of histopathological inter-observer agreement (κ = 0.786). The lowest level of agreement in the dysplasia group was for indefinite dysplasia (κ = 0.251). Negative and high grade dysplasia diagnosis reached the highest level of agreement with κ values of 0.822 [95% confidence interval (CI) 0.673-0.971] and 1.00 (95% CI 0.850-1.149), respectively. Intra-observer agreement was good and increased during the latter period of the study (κ = 0.734, 95% CI 0.642-0.826). Endoscopic-histological correlation was poor among the negative endoscopies, as up to 43% of cases were diagnosed with at least focal high grade dysplasia. The endoscopic-histological correlation improved when evaluating suspicious endoscopic lesions. CONCLUSION Dysplasia is reliably diagnosed by expert gastrointestinal pathologists but has poor correlation with an endoscopic diagnosis of dysplasia.
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Affiliation(s)
- D Allende
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
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Elmessiry MM, Van Koughnett JAM, Maya A, DaSilva G, Wexner SD, Bejarano P, Berho M. Local excision of T1 and T2 rectal cancer: proceed with caution. Colorectal Dis 2014; 16:703-9. [PMID: 24787457 DOI: 10.1111/codi.12657] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 03/16/2014] [Indexed: 12/13/2022]
Abstract
AIM This study aimed to compare the clinical outcome between local excision (LE) and total mesorectal excision (TME) for early rectal cancer. METHOD After Institutional Review Board approval, charts of patients with T1 or T2 N0M0 rectal adenocarcinoma treated by curative LE or TME without preoperative radiotherapy from 2004 to 2012 were reviewed. Categorical and continuous variables were compared using chi-square analysis and the ANOVA test. Kaplan-Meier analysis compared survival rates. RESULTS The study included 153 patients: 79 underwent TME and 74 LE. Postoperative infection was more common after TME (P = 0.009). There was tumour involvement of the margins in 13.5% after LE compared with 0% after TME (P = 0.001). Of the patients treated initially by LE, 13.5% had additional surgery for unfavourable histological findings and 4.1% had residual tumour. Median follow up was 35 (17-96) months. No deaths were recorded in 56 patients with a pT1 lesion. There was no significant difference in local recurrence (P = 0.332) or 3-year disease-free survival (DFS; P = 0.232) between patients having LE or TME. The 68 patients with a T2 lesion had higher local recurrence (P = 0.025) and lower DFS following LE compared with TME (P = 0.044). There was no difference in overall survival (P = 0.351). CONCLUSION LE of early rectal cancer is associated with higher local recurrence and decreased DFS. These disadvantages are significant for T2 lesions.
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Affiliation(s)
- M M Elmessiry
- Department of Surgery, University of Alexandria, Alexandria, Egypt
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Abstract
The pathologist plays a critical role in the multidisciplinary team in charge of treating cancer patients, as many of the therapeutic decisions rely on the information conveyed through the pathology reports. The task of the pathologist includes not only an accurate assessment of pathological T and N categories, but also the evaluation of other indicators of prognosis including quality of surgery, margins of resection, as well as additional histopathological and molecular markers that influence prognosis and could predict response to therapy.
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Affiliation(s)
- Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida
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Affiliation(s)
- S D Wexner
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA,
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Abstract
AIM Abdominoperineal excision (APR) has been associated with higher circumferential resection margin (CRM) involvement and local recurrence rates than extralevator APR for low rectal cancer. This study aimed to evaluate the CRMs in APR and low anterior resection (LAR) specimens and to identify factors influencing CRM involvement. METHOD All pathological specimens from consecutive patients with rectal cancer who underwent curative resection at the Cleveland Clinic Florida, from January 2000 to July 2010, were reviewed by two pathologists. Demographics, tumour characteristics, operative data, postoperative pathology and Dworak's tumour regression grade were compared between specimens with positive and negative CRMs. RESULTS One-hundred and fifty-four patients underwent curative APR (n = 65) or LAR (n = 69). Mean tumour size was 3.6 cm, and mean distance from the dentate line was 5.4 cm. Nine (6.8%) patients had a positive CRM (n = 6 APR, n = 3 LAR), which was associated with tumour size > 5.9 cm (P = 0.002), a distance of ≤ 2.6 cm from the dentate line (P = 0.013), microvascular invasion (P = 0.009), perineural invasion (P < 0.001), number of positive lymph nodes (P = 0.046) and incomplete total mesorectal excision (TME) (P < 0.001). APR specimens were three times more likely than LAR specimens to have an incomplete mesorectum (9.8%vs 2.9%, P = 0.322). CONCLUSIONS Factors associated with a positive CRM were tumour size > 5.9 cm, a distance of ≤ 2.6 cm from the dentate line, incomplete TME, number of positive nodes and microvascular and perineural invasion. The incidence of a positive CRM was not significantly different between LAR and APR (n = 3 LAR and n = 6 APR).
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Abstract
AIM The response to combined neoadjuvant therapy for advanced stage rectal adenocarcinoma is predictive of outcome. In addition to both clinical and pathological features, the expression of a variety of molecules may provide another method of identifying tumour responsiveness to pre-operative therapy. The aim of this study was to evaluate several markers in the apoptotic pathway as well as expression of Cox-2 and vascular endothelial growth factor (VEGF) to determine their ability to predict response to neoadjuvant therapy. METHOD In total, 152 patients with advanced rectal adenocarcinoma were treated with neoadjuvant therapy followed by resection. Paraffin-embedded sections obtained before and after therapy were assessed by immunohistochemical staining for Cox-2, VEGF, p53, p21, p27, Bax, BCL-2 and apoptosis protease-activating factor 1 (APAF-1). These stains were correlated with tumour regression grade, complete pathological response and T-downstaging of the surgical specimen. Clinical and pathological data were also collected. Data were analysed using the χ2 and Spearman's correlation tests. RESULTS Pathological complete response was seen in 24.5% of patients. Amongst the apoptosis-associated markers, only APAF-1 expression was found to be significantly associated with tumour regression grade (P<0.001), complete pathological response (P<0.031) and T-downstaging (P<0.004). On multivariate analysis, APAF-1 expression was found to be independently associated with good tumour regression grade. In contrast, overexpression of Cox-2 and VEGF in pretreatment biopsies was related to less tumour regression (P<0.003) and less likelihood of T-downstaging (P<0.03). CONCLUSION Immunohistochemical evaluation of initial biopsy specimens of rectal cancer with APAF-1, Cox-2 and VEGF may predict tumour response to neoadjuvant therapy in patients with advanced rectal adenocarcinoma. Those with an expected limited response may be considered for other investigational neoadjuvant protocols.
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Affiliation(s)
- Y Edden
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA
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Shaffer VO, Berho M, Rosen L. A case of intraluminal rectal aggressive angiomyxoma. Colorectal Dis 2012; 14:e78-9. [PMID: 21831173 DOI: 10.1111/j.1463-1318.2011.02757.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- V O Shaffer
- Department of Colorectal Surgery, Cleveland Clinic Florida, USA.
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Denoya P, Canedo J, Berho M, Allende DS, Bennett AE, Rosen L, Hull T, Wexner SD. Granulomas in Crohn's disease: does progression through the bowel layers affect presentation or predict recurrence? Colorectal Dis 2011; 13:1142-7. [PMID: 20860713 DOI: 10.1111/j.1463-1318.2010.02421.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM The aim of the study was to correlate the presence and pattern of distribution of granulomas in resected specimens to clinical characteristics and outcome in patients undergoing surgery for Crohn's disease. METHOD Patients with Crohn's disease who underwent surgical resection between 2001 and 2007 were identified. Pathology slides were reviewed for the presence, number and location of granulomas in four representative slides from each specimen. RESULTS Two-hundred and seven patients were identified. At a mean follow up of 14 months, 39 patients had a recurrence, 22 (57%) of whom underwent reoperation. Ninety-four (45%) patients had granulomas present in the surgical specimen. Patients with granulomas were younger (P<0.001), had a lower preoperative body mass index (P=0.037), were more likely to be female (P=0.017) and were more likely to have extra-intestinal manifestations (P=0.026) or perianal disease (P=0.012). Sites of disease and procedures performed were similar in both groups. Disease recurrence and reoperative rates were similar in both groups, as were length of stay and morbidity rates. The average number of granulomas present in each sampled pathology slide was 7.2, and there was no correlation between number of granulomas and disease severity. No link was found between the depth of involvement of the granulomas and fistulizing or stricturing disease. CONCLUSION Granulomas were associated with increased extra-intestinal manifestations and perianal disease, a lower body mass index and younger or female patients. There was no correlation between the presence of granulomas and disease progression or recurrence rates during the short follow-up period of this study.
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Affiliation(s)
- P Denoya
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA
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Doublier S, Lupia E, Catanuto P, Periera-Simon S, Xia X, Korach K, Berho M, Elliot SJ, Karl M. Testosterone and 17β-estradiol have opposite effects on podocyte apoptosis that precedes glomerulosclerosis in female estrogen receptor knockout mice. Kidney Int 2010; 79:404-13. [PMID: 20962747 DOI: 10.1038/ki.2010.398] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Podocyte damage and apoptosis are thought to be important if not essential in the development of glomerulosclerosis. Female estrogen receptor knockout mice develop glomerulosclerosis at 9 months of age due to excessive ovarian testosterone production and secretion. Here, we studied the pathogenesis of glomerulosclerosis in this mouse model to determine whether testosterone and/or 17β-estradiol directly affect the function and survival of podocytes. Glomerulosclerosis in these mice was associated with the expression of desmin and the loss of nephrin, markers of podocyte damage and apoptosis. Ovariectomy preserved the function and survival of podocytes by eliminating the source of endogenous testosterone production. In contrast, testosterone supplementation induced podocyte apoptosis in ovariectomized wild-type mice. Importantly, podocytes express functional androgen and estrogen receptors, which, upon stimulation by their respective ligands, have opposing effects. Testosterone induced podocyte apoptosis in vitro by androgen receptor activation, but independent of the TGF-β1 signaling pathway. Pretreatment with 17β-estradiol prevented testosterone-induced podocyte apoptosis, an estrogen receptor-dependent effect mediated by activation of the ERK signaling pathway, and protected podocytes from TGF-β1- or TNF-α-induced apoptosis. Thus, podocytes are target cells for testosterone and 17β-estradiol. These hormones modulate podocyte damage and apoptosis.
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Affiliation(s)
- Sophie Doublier
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
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Pincus DJ, Kassira N, Gombosh M, Berho M, Glassberg M, Karl M, Elliot SJ, Thaller S. 17β-estradiol modifies diabetic wound healing by decreasing matrix metalloproteinase activity . Wounds 2010; 22:171-178. [PMID: 25901496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
UNLABELLED Postmenopausal women are more susceptible to poor wound healing. This phenomenon can be reversed by estrogen replacement therapy in non-diabetic individuals. Postmenopausal women with type 2 diabetes are more susceptible to wound healing complications, potentially secondary to an estrogen deficiency. Few studies have examined the mechanism of action and effects of estrogens on diabetic wound healing in females. It appears that multiple factors influence delayed wound healing among individuals with diabetes including: an imbalance in cytokines, growth factors, extracellular matrix (ECM) turnover, and oxidant stress (OS). Estrogens have been shown to regulate the expression of genes important for extracellular matrix turnover, including collagen and matrix metalloproteinases (MMP). METHODS For this reason, the effects of 17β-estradiol (E2) on MMP-2, MMP-13, and MMP-14 and estrogen receptor alpha and beta (ER-α and -β) expression in the wound tissue of estrogen-deficient female mice with established type 2 diabetes mellitus (C57BL/6J-m Leprdb/2+) were studied. RESULTS Topical E2 upregulates ERα in wound tissue thereby improving and accelerating diabetic wound healing in estrogen deficient mice. CONCLUSION The mechanism appears to decrease MMP-2, MMP-13, and MMP-14 mediated tissue matrix destruction and increasing collagen content. .
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Abdemur A, Court I, Berho M, Bellorin O, Rivero HG, Li J, Szomstein S, Rosenthal RJ. P-72: Patterns of ghrelin producing cells distribution and number in a morbidly obese population. Surg Obes Relat Dis 2010. [DOI: 10.1016/j.soard.2010.03.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gonzalez G, Castro FP, Berho M, Petras R. Autoimmune enteropathy associated with cessation of interferon-alpha therapy in chronic hepatitis C. Dig Dis Sci 2010; 55:1490-3. [PMID: 19639409 DOI: 10.1007/s10620-009-0877-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Accepted: 06/08/2009] [Indexed: 12/09/2022]
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Berho M, Wexner SD. Advances in the relationship between lymph node status and prognosis: Comment on "Association Between a High Number of Isolated Lymph Nodes in T1 to T4 N0M0 Colorectal Cancer and the Microsatellite Instability". ACTA ACUST UNITED AC 2010; 145:17-8. [PMID: 20088097 DOI: 10.1001/archsurg.2009.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mariana Berho
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA.
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Wang H, Safar B, Wexner SD, Denoya P, Berho M. The clinical significance of fat clearance lymph node harvest for invasive rectal adenocarcinoma following neoadjuvant therapy. Dis Colon Rectum 2009; 52:1767-73. [PMID: 19966611 DOI: 10.1007/dcr.0b013e3181b14eaf] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study aimed to investigate the application of fat clearance in cases of rectal cancer after neoadjuvant chemoradiation. METHODS All patients who underwent proctectomy (R0 resection) from 1998 to 2007 were included. N1 and N2 stages were regarded as N+ stage. RESULTS Two hundred thirty-seven patients were identified, including 157 patients in the neoadjuvant group and 80 patients in the nonneoadjuvant group. In both groups, patients were assigned to receive the traditional method of harvesting lymph nodes, or the fat clearance method. Before July 2001, the patients received the traditional method, and after July 2001, they received exclusively the fat clearance method. In the nonneoadjuvant group, there was no significant difference in the number of positive lymph nodes (0.5 +/- 0.2 vs. 1.0 +/- 0.3, P = 0.235), N stage (P = 0.265), or patients with N+ stage (7/31 vs. 16/49, P = 0.332) between the two methods, even though the total lymph node harvest was significantly increased by use of the fat clearance method (9.6 +/- 1.3 vs. 27.6 +/- 2.5, P < 0.001). In contrast, the total lymph node retrieval (5.2 +/- 0.6 vs. 20.4 +/- 1.2, P < 0.001), number of positive lymph nodes (0.4 +/- 0.2 vs. 1.2 +/- 0.3, P = 0.007), N stage (P = 0.005), and patients with N+ stage (6/51 vs. 34/106, P = 0.006) were all increased by fat clearance in the neoadjuvant group. Moreover, the number of patients with N+ stage was stratified by T stage level (T0-T4) to eliminate the background bias, and the results were confirmed. CONCLUSIONS The utilization of the fat clearance technique significantly influences lymph node staging in patients with rectal cancer following neoadjuvant chemoradiation. These findings suggest that fat clearance may represent a useful tool in all patients receiving neoadjuvant therapy; a more generalized application in colorectal carcinoma specimens remains controversial and warrants further investigation.
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Affiliation(s)
- Hao Wang
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, Florida 3333, USA
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Abitbol CL, Chandar J, Rodríguez MM, Berho M, Seeherunvong W, Freundlich M, Zilleruelo G. Obesity and preterm birth: additive risks in the progression of kidney disease in children. Pediatr Nephrol 2009; 24:1363-70. [PMID: 19214591 DOI: 10.1007/s00467-009-1120-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2008] [Revised: 11/23/2008] [Accepted: 12/15/2008] [Indexed: 11/28/2022]
Abstract
Preterm birth is associated with decreased nephron mass and obesity that may impact on kidney disease progression in later life. Our objectives were to examine the relative risks of obesity and preterm birth on the progression of kidney disease in children. In a retrospective cohort study, 80 (44 obese and 36 non-obese) patients with proteinuric kidney disease were studied for disease progression and glomerular histomorphometry. Of the obese, 22 had been born at term (Obese-T) and 22 had been preterm (Obese-PT). Seventeen non-obese children with focal glomerular sclerosis, born at term (NO-FSGS), and 19 non-obese preterm (NO-PT) children, served as controls. Insulin resistance as measured by the homeostatic model assessment (HOMA-IR) was elevated in all obese children. Obese-PT patients had increased risk of renal demise during childhood when compared with Obese-T children [hazard ratio 2.4; 95% Confidence interval (95% CI) 1.1 to 7.1; P = 0.04]. In obese children, although proteinuria often exceeded nephrotic range, average levels of serum albumin remained normal. Preterm patients were more likely to have reduced renal mass (odds ratio 4.7; P = 0.006), but obesity was not a factor. Renal histomorphometry showed glomerulomegaly in obese patients, regardless of birth weight. Obesity and preterm birth appear to impose additive risks for progression of kidney disease in childhood.
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Affiliation(s)
- Carolyn L Abitbol
- Division of Pediatric Nephrology (M714), University of Miami/Holtz Children's Hospital, 1611 NW 12th Avenue, Annex 5, Miami, FL 33126, USA.
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Greidinger EL, Zang Y, Fernandez I, Berho M, Nassiri M, Martinez L, Hoffman RW. Tissue targeting of anti-RNP autoimmunity: effects of T cells and myeloid dendritic cells in a murine model. ACTA ACUST UNITED AC 2009; 60:534-42. [PMID: 19180485 DOI: 10.1002/art.24256] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To explore the role of immune cells in anti-RNP autoimmunity in a murine model of pneumonitis or glomerulonephritis, using adoptive transfer techniques. METHODS Donor mice were immunized with 50 mug of U1-70-kd small nuclear RNP fusion protein and 50 mug of U1 RNA adjuvant. Whole splenocytes as well as CD4+ cell and dendritic cell (DC) subsets from the immunized mice were infused into naive syngeneic recipients. Anti-RNP and T cell responses were assessed by immunoblotting, enzyme-linked immunosorbent assay, and flow cytometry. Development of renal or lung disease was assessed by histology and urinalysis. RESULTS Unfractionated splenocytes from donor mice without proteinuria induced predominantly lung disease in recipients (8 [57%] of 14 versus 2 [14%] of 14 developing renal disease; P = 0.046). However, infusion of CD4+ cells from donors without proteinuria induced renal disease more frequently than lung disease (7 [70%] of 10 versus 2 [20%] of 10; P = 0.01); adoptive transfer of RNP+CD4+ T cells from short-term culture yielded similar results (renal disease in 8 [73%] of 11 recipients versus lung disease in 3 [27%] of 11). Cotransfer of splenic myeloid DCs and CD4+ T cells from immunized donors prevented induction of renal disease in all 5 recipients (P = 0.026 versus recipients of fresh CD4+ cells alone), although lung disease was still observed in 1 of 5 mice. Transfer of myeloid DCs alone from immunized donors induced lung disease in 3 (60%) of 5 recipients, without evidence of nephritis. Cotransfer of splenocytes from mice with and those without nephritis led to renal disease in 4 of 5 recipients, without evidence of lung disease. CONCLUSION These findings indicate that RNP+CD4+ T cells are sufficient to induce anti-RNP autoimmunity, tissue targeting in anti-RNP autoimmunity can be deviated to either a renal or pulmonary phenotype depending on the presence of accessory cells such as myeloid DCs, and DC subsets can play a role in both propagation of autoimmunity and end-organ targeting.
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Affiliation(s)
- Eric L Greidinger
- Miami VA Medical Center, and University of Miami Miller School of Medicine, Miami, Florida, USA.
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Catanuto P, Doublier S, Lupia E, Fornoni A, Berho M, Karl M, Striker GE, Xia X, Elliot S. 17 beta-estradiol and tamoxifen upregulate estrogen receptor beta expression and control podocyte signaling pathways in a model of type 2 diabetes. Kidney Int 2009; 75:1194-1201. [PMID: 19279558 DOI: 10.1038/ki.2009.69] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Diabetic nephropathy remains one of the most important causes of end-stage renal disease. This is particularly true for women from racial/ethnic minorities. Although administration of 17beta-estradiol to diabetic animals has been shown to reduce extracellular matrix deposition in glomeruli and mesangial cells, effects on podocytes are lacking. Given that podocyte injury has been implicated as a factor leading to the progression of proteinuria and diabetic nephropathy, we treated db/db mice, a model of type 2 diabetic glomerulosclerosis, with 17beta-estradiol or tamoxifen to determine whether these treatments reduce podocyte injury and decrease glomerulosclerosis. We found that albumin excretion, glomerular volume, and extracellular matrix accumulation were decreased in these mice compared to placebo treatment. Podocytes isolated from all treatment groups were immortalized and these cell lines were found to express the podocyte markers WT-1, nephrin, and the TRPC6 cation channel. Tamoxifen and 17beta-estradiol treatment decreased podocyte transforming growth factor-beta mRNA expression but increased that of the estrogen receptor subtype beta protein. 17beta-estradiol, but not tamoxifen, treatment decreased extracellular-regulated kinase phosphorylation. These data, combined with improved albumin excretion, reduced glomerular size, and decreased matrix accumulation, suggest that both 17beta-estradiol and tamoxifen may protect podocytes against injury and therefore ameliorate diabetic nephropathy.
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Affiliation(s)
- Paola Catanuto
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, University of Miami, Miller School of Medicine, Miami, Florida, USA; Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Sophie Doublier
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, University of Miami, Miller School of Medicine, Miami, Florida, USA; Department of Genetics, Biology and Biochemistry, University of Turin, Turin, Italy
| | - Enrico Lupia
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, University of Miami, Miller School of Medicine, Miami, Florida, USA; Azienda Ospedaliera San Giovanni Battista, Turin, Italy
| | - Alessia Fornoni
- Division of Nephrology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Mariana Berho
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Michael Karl
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, University of Miami, Miller School of Medicine, Miami, Florida, USA; Division of Endocrinology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Gary E Striker
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Xiaomei Xia
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, University of Miami, Miller School of Medicine, Miami, Florida, USA; Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Sharon Elliot
- Study Group and Laboratory on Sex and Gender Differences in Health and Disease, University of Miami, Miller School of Medicine, Miami, Florida, USA; Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA.
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Berho M, Oviedo M, Stone E, Chen C, Nogueras J, Weiss E, Sands D, Wexner S. The correlation between tumour regression grade and lymph node status after chemoradiation in rectal cancer. Colorectal Dis 2009; 11:254-8. [PMID: 18513188 DOI: 10.1111/j.1463-1318.2008.01597.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the correlation between tumour response to preoperative RCTX and lymph node status, an established parameter of clinical outcome. METHOD After IRB approval, 86 consecutive rectal cancer patients who received preoperative RCTX were identified. Fifty seven were males. Mean age 62 years. Preoperative staging by ultrasound was available in 60 patients. Radiotherapy consisted of (40-60 g) and chemotherapy of 5-FU infusion (1500 mg/m(2) week), assessed using Dworak's system. RESULTS Tumour response according to Tumor regression grade (TRG) were: TRG 0: 8 (9.3%); TRG 1: 15 (17.4%); TRG 2: 14 (16.2%); TRG 3: 31 (36%); TRG 4: 18 (20%). Eighteen patients had tumour stage 0 (20.9%); while 8 (9.2%), 28 (32.1%), 30 (34.5%) and three had tumours stages 1, 2, 3 and 4 respectively. Evaluation of nodal status revealed no involvement in 65 patients (N0), and positive nodes in 21 (14 N1, 7 N2). Response to RCTX was significantly associated with node stage, hence individuals without node involvement (N0) had 66% of positive tumour response (TRG 4), while individuals with node metastasis had less response to RCTX (TRG 0, 1 and 2) 35% N1 and 14% for N2 (P = 0.007). Node status was independently associated to poor response to preoperative RCTX, even after adjusting for tumour stage, age and gender (OR 0.02, 95% CI 0.0009-0.67). CONCLUSION Tumour shrinkage by preoperative RCTX appears to correlate with lymph node metastasis suggesting that neoadjuvant RCTX may have a positive impact in overall patient survival.
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Affiliation(s)
- M Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, Florida 33331, USA
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Kabirdas D, Afonso B, Avella H, Kanwar A, Berho M, Oliveira E. An elderly woman with asthma, eosinophilia, and septic shock. Cleve Clin J Med 2008; 74:877-81, 885-6. [PMID: 18183838 DOI: 10.3949/ccjm.74.12.877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Deepa Kabirdas
- Department of Internal Medicine, Cleveland Clinic Florida, Weston, FL 33331, USA.
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Elliot SJ, Berho M, Korach K, Doublier S, Lupia E, Striker GE, Karl M. Gender-specific effects of endogenous testosterone: female alpha-estrogen receptor-deficient C57Bl/6J mice develop glomerulosclerosis. Kidney Int 2007; 72:464-72. [PMID: 17495854 DOI: 10.1038/sj.ki.5002328] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Young female mice on a C57Bl/6J (B6) background are considered glomerulosclerosis (GS)-resistant but aging B6 mice develop mild GS. Estrogen deficiency accelerates while estrogen replacement retards GS in young sclerosis-prone oligosyndactyly mutant mice on an ROP background. To explore the effects of sex hormones on glomerular structure and function in the context of gender and genetic background, we studied mice in which the estrogen-receptor (ER) genes alpha- or -beta were deleted (alpha- or betaER knockout (KO)) and crossed into the B6 background. We also studied ovariectomized (Ovx) B6 mice given testosterone. Male and female betaERKO and male alphaERKO mice had no glomerular dysfunction at 9 months of age; however, alphaERKO female mice displayed albuminuria and GS. Ovx prevented glomerular dysfunction in alphaERKO female mice by eliminating endogenous testosterone production while exogenous testosterone induced GS in Ovx B6 mice. Androgen receptor (AR) expression and function was found in microdissected glomeruli and cultured mesangial cells. Testosterone compared to placebo increased both AR expression and TGF-beta1 mRNA levels in glomeruli isolated from female B6 mice. Estrogen deficiency had no deleterious effects on the glomeruli in B6 mice. Our study shows that genetic traits strongly influence the GS-promoting effects of estrogen deficiency while testosterone induces GS in a gender-specific manner.
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MESH Headings
- Albuminuria/genetics
- Albuminuria/metabolism
- Albuminuria/pathology
- Albuminuria/physiopathology
- Animals
- Body Weight
- Cells, Cultured
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Estradiol/metabolism
- Estrogen Receptor alpha/deficiency
- Estrogen Receptor alpha/genetics
- Estrogen Receptor alpha/metabolism
- Estrogen Receptor beta/deficiency
- Estrogen Receptor beta/genetics
- Estrogen Receptor beta/metabolism
- Extracellular Matrix Proteins/metabolism
- Female
- Genetic Predisposition to Disease
- Glomerulosclerosis, Focal Segmental/complications
- Glomerulosclerosis, Focal Segmental/genetics
- Glomerulosclerosis, Focal Segmental/metabolism
- Glomerulosclerosis, Focal Segmental/pathology
- Glomerulosclerosis, Focal Segmental/physiopathology
- Kidney Glomerulus/drug effects
- Kidney Glomerulus/metabolism
- Kidney Glomerulus/pathology
- Kidney Glomerulus/physiopathology
- Male
- Mesangial Cells/metabolism
- Mesangial Cells/pathology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Organ Size
- Ovariectomy
- Promoter Regions, Genetic
- RNA, Messenger/metabolism
- Receptors, Androgen/genetics
- Receptors, Androgen/metabolism
- Sex Factors
- Signal Transduction
- Testosterone/metabolism
- Testosterone/pharmacology
- Transfection
- Transforming Growth Factor beta1/genetics
- Transforming Growth Factor beta1/metabolism
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Affiliation(s)
- S J Elliot
- Department of Medicine, Study Group and Laboratory on Sex and Gender Differences in Health and Disease, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida 33136, USA
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Vaccaro CA, Carrozzo JE, Mocetti E, Berho M, Valdemoros P, Mullen E, Oviedo M, Redal MA. [Immunohistochemical expression and microsatellite instability in Lynch syndrome]. Medicina (B Aires) 2007; 67:274-8. [PMID: 17628916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Mutation of the mismatch repair genes MLH1 and MSH2 account for the majority of the genetic abnormalities in Lynch syndrome. Immunohistochemical detection of their protein products is becoming an increasingly common method to detect these mutations. The aim of this study was to compare the expression of MLH1 and MSH2 by immunohistochemistry and its relationship with a group of clinical and histological variables in patients with known Lynch syndrome (n=16) and in cohort of young patients (less than 50 years) who did not meet Amsterdam criteria (n=25). The mean age was 40.7 and 64% were women. Conclusive results were obtained in 40 cases (97.6%). Eighteen cases (45%) showed abnormal expression of either MLH1 (11 cases) or MSH2 (6 cases) and both stains (1 case). Alteration of the normal staining pattern was seen more commonly in patients with Lynch syndrome than in the sporadic group (68.7% vs 28%, p=0.01). A significant correlation was obtained between abnormal protein expression and microsatellite instability (MSI): normal expression: 5.9%, lack of expression: 92.3%, p<0.0001. The sensitivity and specificity of the immunohistochemical to predict MSI were 92.3% and 94.1% respectively. Immunohistochemistry and MSI results did not correlate with any histopathological parameter. In conclusion, in our experience abnormal staining of MLH and MSH correlates strongly with the presence of MSI. In addition it appears that in our population a significant proportion of young patients (< 50 years old) demonstrate alterations in the mismatch repair gene products suggesting an important role of these molecules in tumorigenesis.
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Affiliation(s)
- Carlos A Vaccaro
- Sección de Coloproctología, Hospital Italiano de Buenos Aires, Argentina.
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Carroll PB, Defaria W, Gandia C, Berho M, Misiakos E, Tzakis AG. Testing of a new prototype surgical stapler that automates the rollover sleeve technique for venous anastomoses. Biol Res 2006; 39:461-9. [PMID: 17106578 DOI: 10.4067/s0716-97602006000300008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The creation of successful vascular anastomoses is of primary importance in many surgical fields. Numerous attempts to automate this process have been made. These techniques have slowly gained acceptance, but their use is still limited. This report details feasibility testing of a new prototype stapler that automates the rollover sleeve technique for venous vascular anastomoses. Male and female mongrel dogs (n=7) (25-32 kg) were used. A segment of the right (n=5) or left (n=2) iliac vein was harvested for interposition grafts after the contra lateral side was transected. In each dog, two end-to-end venous anastomoses at the interposition grafts were performed. The standard anastomosis employed continuous mattress sutures. The experimental anastomosis was performed with a new prototype surgical stapler. The stapled anastomosis was proximal and the sutured was distal. In all experiments, it was possible to perform the experimental anastomosis with the stapler. Complications included two small leaks, one due to misfiring of a single pin in one experimental site. These leaks required suture reinforcement. One dog died of hemorrhage due to a slipped suture at the vein harvest site. One vein had thrombus seen at the sutured site although no technical abnormalities at either of the anastomoses could be found. After two weeks, grafts were inspected grossly and histologically. Healing appeared normal. There was a trend for less inflammatory cells infiltrating stapled sites; however, this was not statistically significant. The experiments demonstrate that this device can automate the rollover sleeve technique for venous anastomoses.
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Affiliation(s)
- Patricia B Carroll
- Department of Surgery, University of Miami School of Medicine, Florida 33136, USA.
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