A retrospective observational study of the relationship between family history and survival from colorectal cancer

BACKGROUND

Although family history is well established to be a risk factor for developing colorectal cancer (CRC), much less is known about its impact on patient survival. This study aimed to link CRC patient data from the National Study of Colorectal Cancer Genetics (NSCCG) to the National Cancer Data Repository (NCDR) to examine the relationship between family history and the characteristics and outcomes of CRC.

METHODS

All eligible NSCCG patients underwent a matching process to the NCDR using combinations of their personal identifiers. The characteristics and survival of CRC patients with and without a family history of CRC were compared.

RESULTS

Of the 10 937 NSCCG patients eligible to be matched into the NCDR, 10 782 (98.6%) could be fully linked. There were no significant differences between those with and without a family history of CRC (defined as having at least one affected first-degree relative) in terms of age, sex, tumour stage at diagnosis, presence of multiple cancers, mode of presentation to hospital and surgical management, although patients with familial CRC were more likely to have right-sided tumours (P<0.01). The survival of patients with familial CRC was significantly better than those with sporadic CRC (HR 0.89, 95%CI: 0.81-0.98, P=0.02).

CONCLUSION

We have demonstrated that it is possible to robustly match patients recruited into the NSCCG into the NCDR and, by using this record linkage, enable genetic data to be related to CRC phenotype, clinical management and outcome. This study provides evidence that a family history of CRC is associated with better survival after a diagnosis of CRC.

Defunctioning stomas prior to chemoradiation for anal cancer are usually permanent

AIM

A few patients with anal cancer will require a defunctioning stoma prior to chemoradiotherapy (CRT). The purpose of this retrospective review was to determine the frequency with which a pretreatment stoma was subsequently reversed.

METHOD

Between 1997 and 2007, 46/344 patients who were treated for anal cancer underwent a defunctioning stoma prior to CRT. Thirty-five of these were treated with curative intent.

RESULTS

Of the 35 patients, 16 patients had T4, 17 T3 and 2 T2 disease. Sixteen were node positive. The average tumour size was 7 cm. The median interval between stoma formation and CRT was 6 (4-20) weeks. The median follow up was 26 (2-80) months. A defunctioning stoma was performed for rectovaginal fistula or risk of fistula in 18 and severe local symptoms in 17. Seven (20%) patients had the stoma reversed subsequently. The reasons for nonreversal were progressive disease (n = 9), persistent fistula (n = 3), predicted poor function (n = 4), cavity formation (n = 1), fibrosis (n = 3), death from another cause (n = 2), patient choice (n = 3) and salvage surgery (n = 2). The overall 3-year survival was only 48%, explained by the advanced stage of disease at presentation.

CONCLUSION

Most patients who undergo a defunctioning stoma before CRT will not undergo subsequent reversal. The patient should therefore be informed that the stoma is likely to be permanent and this should be taken into account when considering the type and site of stoma to be formed.

Successful treatment of a large Buschke–Lowenstein tumour with chemo-radiotherapy

We report the case of a patient with a large Buschke–Lowenstein tumour which had previously recurred following local excision. A preferred treatment modality for this rare variant of human papillomavirus has not been clearly defined. Treatment with chemo-radiotherapy in this case resulted in complete resolution of the disease without the need for further surgical intervention.

Human gamma-aminobutyric acid A receptor alpha2 gene moderates the acute effects of alcohol and brain mRNA expression

Gamma-aminobutyric acid A (GABA(A)) receptors moderate several of the behavioral effects of alcohol. In fact, recent studies have shown an association between the gene for the alpha2-subunit of the GABA(A) receptor (GABRA2) and alcoholism. In the present study, we examined the functional relevance of the GABRA2 gene in alcohol dependence by assessing brain GABRA2 mRNA and GABA(A)alpha2-subunit protein levels in post-mortem prefrontal cortical tissue collected from control and alcohol-dependent individuals. In addition, using an endophenotype approach, we tested whether the GABRA2 gene moderates sensitivity to the acute effects of alcohol in two independent samples from distinct human alcohol challenge studies. Results indicated that GABRA2 mRNA levels significantly differed by GABRA2 genotype. GABRA2 single nucleotide polymorphisms (rs573400, rs279871 and rs279858) were significantly associated with sensitivity to the acute effects of alcohol. Specifically, there was a significant main effect of GABRA2 x breath alcohol concentration on several measures of subjective responses to alcohol, including the hedonic value of alcohol. Importantly, reanalysis of a previous intravenous alcohol administration study confirmed the results of the oral alcohol challenge study. In summary, these results extend previous findings and provide new insights into the putative biobehavioral mechanisms that may moderate the association between the GABRA2 gene, sensitivity to the acute effects of alcohol and ultimately alcohol dependence.

Recto-urethral fistula following brachytherapy for localized prostate cancer

OBJECTIVE

The use of prostate brachytherapy (BT) in the management of prostate cancer is increasing. BT is often chosen because of its perceived lower toxicity when compared with other radical therapy options. Rarely however serious complications can occur. One such complication is recto-urethral fistula (RUF). We report the incidence of RUF following BT at our centre and review the potential factors in fistula development.

METHOD

A prospectively collected database was used to identify cases of RUF among 1455 patients treated with prostate BT at a single UK centre with at least 2 years of follow up. This included patients treated with BT monotherapy, as well as those treated with BT combined with external beam radiotherapy and BT used as salvage as all these groups have a higher incidence of RUF. Implant dose and volume characteristics for those patients, their co-morbidities and history of endoscopic procedures were recorded.

RESULTS

Recto-urethral fistula was identified in three (0.2%) patients, occurring at 19-27 months following BT. All these patients had BT monotherapy. All three patients had rectal symptoms after their BT and had been investigated with endoscopy and low rectal biopsy. Subsequent surgical management with faecal and/or urinary diversion was required. On review of patients' BT details, radiation dose and volume parameters were higher on the postprocedure CT calculations than had been suggested by the preimplant plan. No other predisposing risk factors for RUF were identified.

CONCLUSION

The incidence of RUF in our population is low. RUF following BT has been associated with rectal biopsy in previous series and this is confirmed in our report. Gastrointestinal specialists should not perform biopsy of the anterior rectum in patients who have had BT unless there is a very high clinical suspicion of malignancy.

Dysbiosis and pouchitis

BACKGROUND AND METHODS

The exact aetiology of pouchitis is unknown, but an association with dysbiosis has been suggested. This is a retrospective review of 17 studies published between 1985 and 2005, identified by a search of the Medline, Pubmed and Embase databases.

RESULTS

The methodology of the studies varied widely. Many were performed at a time when the distinction between a healthy and an inflamed pouch was vague; misclassification of patients makes the analysis of data difficult and conclusions uncertain.

CONCLUSION

The evidence that dysbiosis is a cause of pouchitis is poor. Nevertheless, available data allow the construction of an algorithm to aid management and suggest a structured approach for future research.

Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer

OBJECTIVE

To study circumferential margin involvement (CMI) in patients undergoing restorative, compared with nonrestorative, surgery for rectal cancer.

DATA SOURCE

Descriptive multicentre study, using routinely collected clinical data from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) Bowel Cancer Audit database. The study encompassed 1403 newly diagnosed patients with rectal cancer undergoing either restorative (anterior resection (AR)), or nonrestorative (abdominoperineal excision of rectum (APER) or Hartmann's procedure), surgery. Operations were carried out in 39 hospitals during a variable period between April 1999 to March 2002. A logistic regression analysis was used to control for variables associated with circumferential margin involvement.

RESULTS

One thousand and thirty-six patients satisfied the inclusion criteria. The average CMI was 12.5% (range 0-33.3% between hospitals). CMI for anterior resection was 7.5% (n = 629) compared with a CMI of 16.7% for APER (n = 306) and a CMI of 31.7% for Hartmann's procedure (n = 101); P < or = 0.001. CMI for patients undergoing curative surgery was 7.1% (423 anterior resections, CMI 3.8% (n = 16); 181 APER, CMI 13.3% (n = 24); 29 Hartmann's procedure, CMI 17.2%). On multivariate analysis, having controlled for Dukes' stage and operative intent, the CMI was significantly different between APER and AR (odds ratio 3.3, 95%CI 2.0-5.4), but less so between Hartmann's procedure and AR (odds ratio 2.2, 95%CI 1.1-4.2).

CONCLUSIONS

APER is associated with a significantly higher CMI than anterior resection. Attention to surgical technique, with a wide perineal dissection and the use of pre-operative adjuvant therapy, may reduce CMI in patients undergoing APER.

Phosphoinositide 3-kinase gamma: a key modulator in inflammation and allergy

Chronic inflammation and allergy involve the activation of tissue-resident cells and, later on, the invasion of effector cells. We have previously shown that the loss of phosphoinositide 3-kinase (PI3K) gamma impairs chemokine-dependent migration of neutrophils and macrophages both in vitro and in vivo. On the other hand, PI3K gamma is not required either during phagocytic processes or in the activation of bactericidal activities like granule secretion and particle-mediated respiratory burst in neutrophils. Tissue mast cells are key regulators in allergy and inflammation and release histamine upon clustering of their IgE receptors. We have demonstrated that murine mast cell responses are exacerbated in vitro and in vivo by autocrine signals, and require functional PI3K gamma. Adenosine, acting through the A(3) adenosine receptor, as well as other agonists of G(alpha i)-coupled receptors, transiently increased PtdIns(3,4,5) P (3) exclusively via PI3K gamma. PI3K gamma-derived PtdIns(3,4,5) P (3) was instrumental for initiation of a sustained influx of external Ca(2+) and degranulation. Mice that lacked PI3K gamma did not form oedema when challenged by passive systemic anaphylaxis. PI3K gamma thus relays inflammatory signals through various GPCRs, and is thus central to mast cell function. Taken together, this suggests that pharmaceutical targeting of PI3K gamma might alleviate inflammation at both early and late stages of the allergic response.

SH3 domain-mediated interactions involving the phox components of the NADPH oxidase

OBJECTIVE AND DESIGN

To derive a model describing the SH3 domain-mediated assembly of the activated NADPH oxidase.

MATERIALS

Recombinant SH3 domain and Pro-rich fusion proteins were used to investigate potential co-associations.

METHODS

Interactions were assessed using biotinylated overlay assays and the yeast two hybrid system. Association with p47phox from cell lysates was examined by immunoblot analysis.

RESULTS

The association between p47- and p22phox involves the SH3 domains of p47phox functioning in tandem. The Prorich motif in p47phox interacts with both p40phox and the COOH-terminal SH3 domain of p67phox.

CONCLUSIONS

In the resting cell, the Pro-rich motif of p47phox interacts with the SH3 domain of p40phox, which in turn associates with p67phox. Upon activation, the p47-p40phox regulatory complex dissociates, permitting the association of p47phox with the COOH-terminal SH3 domain of p67phox. This complex translocates to the plasma membrane and associates with cytochrome b558, via interaction of the tandem SH3 domains of p47phox with the p22phox Pro-rich motif.

Imaging appearances of ileouterine fistula complicating recurrent adenocarcinoma of the rectum

Enterouterine fistulae are rare and nowadays are most commonly due to pelvic tumours. We review the literature and present the case of a woman who presented with an ileouterine fistula following surgery and radiotherapy for recurrent rectal adenocarcinoma. The presence of tumour within the fistula track may also have been a significant aetiological factor. Magnetic resonance imaging (MRI) is an excellent method to demonstrate the site and size of the track and has not, to date, been used to identify such a fistula.

The C-terminal SH3 domain of p67phox binds its natural ligand in a reverse orientation

Src-homology 3 (SH3) domains are small protein modules that bind to proline-rich motifs and mediate the formation of signalling complexes. SH3 domains have been implicated in the assembly of the phagocyte NADPH oxidase complex, a multicomponent enzyme responsible for the production of antimicrobial oxidants. Two components of the NADPH oxidase, p67phox and p47phox, each contain two SH3 domains and we have previously shown that the SH3 domain near the carboxyl terminus of p67phox interacts with a proline-rich region of p47phox. In order to gain an insight into the specificity of this interaction, a structural model of the p67phox SH3 domain has been produced using the known structure of the c-abl SH3 domain as a template. The model suggests that the proline-rich ligand of p47phox can bind to the SH3 domain in either of two orientations. In each orientation, the key residues of the SH3 domain that contact the ligand have been identified and altered by site-directed mutagenesis. The ability of the mutated SH3 domains to associate with p47phox from cell lysates was tested and the results provide the first evidence for the binding of a full-length protein to an SH3 domain in a reversed orientation.

The immunomodulatory effect of levamisole is influenced by postoperative changes and type of lymphocyte stimulant

The results of both laboratory and clinical research into the immunomodulatory activity of levamisole have shown a considerable degree of inconsistency and sometimes contradiction. This is probably a reflection of the lack of understanding of the mechanism(s) of action of levamisole and it is therefore necessary to base conclusions about its immunomodulatory efficacy in the treatment of disease on experimental assays that take into consideration the in vivo conditions. This investigation was designed to compare the immunomodulatory activity of levamisole under clinically achievable and non-achievable conditions as judged by changes in the perioperative proliferative response of lymphocytes from 30 patients with colorectal cancer. The results obtained showed that proliferation in antigen (purified protein derivative, PPD)-stimulated, but not phytohaemagglutinin(PHA)- or staphylococcal-enterotoxin-B(SEB)-stimulated, lymphocyte cultures was consistently and significantly augmented by levamisole in concentrations of 25 ng-25 micrograms/ml. High concentrations of levamisole (25 micrograms/ml and 100 micrograms/ml) were inhibitory to PHA- and SEB-stimulated, but not PPD-stimulated, lymphocyte cultures, especially in the postoperative period. Of particular interest was the observation that, although levamisole temporarily lost its stimulatory activity in the postoperative period (third postoperative day), it did enhance antigen-stimulated lymphocytes at the time of the nadir of the postoperative suppression of lymphocyte proliferation (first postoperative day). Clinically achievable concentrations of levamisole are therefore effective both before and after operation in enhancing the response of lymphocytes to antigens.

An SH3 domain and proline-rich sequence mediate an interaction between two components of the phagocyte NADPH oxidase complex

Neutrophils possess a multicomponent NADPH oxidase system capable of producing large quantities of superoxide in a process known as the respiratory burst (1). Upon stimulation of a phagocytic cell, two cytosolic components of the oxidase, p67phox and p47phox, associate with a membrane-bound flavocytochrome b and a small GTP-binding protein to form a functional enzyme complex. Each of the Phox proteins contains two src homology 3 (SH3) domains, which are of unknown function but are potential mediators of protein-protein interactions between components of the activated oxidase. We have isolated a 47-kDa protein from lysates of differentiated HL60 cells that specifically bound to the carboxyl-terminal SH3 domain of p67phox and not to any other SH3 domain tested. This protein was identified as p47phox, and the putative SH3 domain binding site was located to a carboxyl-terminal proline-rich region. Proline-rich synthetic peptides based on this carboxyl-terminal region specifically inhibited the binding of p47phox to the carboxyl-terminal SH3 domain of p67phox, and sequential truncation defined a unique minimal sequence, which, although similar, does not match the consensus sequence defined for other SH3-binding proteins.

Hepatic perfusion index: a multicentre trial

The reproducibility and accuracy of the hepatic perfusion index (HPI) was examined by consideration of in vitro and in vivo factors. A phantom was used to simulate liver blood flow and data acquired on nine gamma cameras. Dynamic hepatic scintigraphy was undertaken on 28 patients at two centres and values obtained for the HPI. Results from the phantom study showed good agreement between the nine cameras and also with the HPI values predicted from the measured phantom flow rates. The results of the patient study indicated a high degree of conformity between observers (r = 0.95, S.E = 0.03) but poorer correlation between the HPI values from the two centres (r = 0.67, S.E. = 0.09). These results imply that centres wishing to use HPI clinically should establish their own range of normality.

Stomas and appliances

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The selection of monoclonal antibodies for tumour localization in patients with colorectal carcinoma

We have investigated the ability of various predictive studies to assess which monoclonal antibody (MCA) will be most useful in the immunoscintigraphic localization of metastatic colorectal carcinoma. A set of MCAs was obtained by fusing splenic lymphocytes from rats immunized with membrane preparations from fresh human colorectal cancer. Supernatants from 17 cloned hybridomas were found to bind strongly to colon carcinoma lines by indirect radioimmunoassay. Immunofluorescence using these MCAs on sections of fresh frozen colon carcinoma and normal tissue revealed different staining patterns. Nine MCAs were purified and labelled with 131I. Groups of mice bearing human colorectal tumour xenografts were given radiolabelled MCA and scanned. Six out of the nine MCAs showed tumour localization as determined by rectilinear scanning. Three MCAs which gave good tumour images in mice were selected for clinical evaluation in patients with advanced colorectal cancer. One gave good tumour images, another targeted to bone marrow and the third bound almost exclusively to normal liver. Clinical evaluation is clearly essential in the selection of MCAs for tumour localization.

Localisation of metastatic carcinoma by a radiolabelled monoclonal antibody

Rat monoclonal antibodies were prepared by immunising rats with human colorectal carcinoma cell membranes and fusing splenic lymphocytes with a rat myeloma. Hybridoma supernatants were screened by binding assays on membranes prepared from colorectal carcinoma tissue. One hybridoma supernatant, containing a monoclonal antibody with high binding activity on malignant compared to normal colon sections, was grown in large quantities in serum-free medium. After ammonium sulphate precipitation the antibody was purified by ion-exchange chromatography and labelled with 131I. Radiolabelled antibody was administered i.v. to 27 patients with colonic and other tumours. Scintigrams were obtained at 48 h. Computerised subtraction of the blood pool image revealed localised areas of uptake corresponding with areas of known disease in 13/16 patients with colorectal carcinoma and 3/4 patients with breast cancer.

A problem with ear piercing

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