The proportion of tumor-stroma as a strong prognosticator for stage II and III colon cancer patients: validation in the VICTOR trial.

BACKGROUND: The intra-tumor stroma percentage in colon cancer (CC) patients has previously been reported by our group as a strong independent prognostic parameter. Patients with a high stroma percentage within the primary tumor have a poor prognosis. PATIENTS AND METHODS: Tissue samples from the most invasive part of the primary tumor of 710 patients (52% Stage II, 48% Stage III) participating in the VICTOR trial were analyzed for their tumor-stroma percentage. Stroma-high (>50%) and stroma-low (≤50%) groups were evaluated with respect to survival times. RESULTS: Overall and disease-free survival times (OS and DFS) were significantly lower in the stroma-high group (OS P<0.0001, hazard ratio (HR)=1.96; DFS P<0.0001, HR=2.15). The 5-year OS was 69.0% versus 83.4% and DFS 58.6% versus 77.3% for stroma-high versus stroma-low patients. CONCLUSION: This study confirms the intra-tumor stroma ratio as a prognostic factor. This parameter could be a valuable and low cost addition to the TNM status and next to current high-risk parameters such as microsatellite instability status used in routine pathology reporting. When adding the stroma-parameter to the ASCO criteria, the rate of 'undertreated' patients dropped from 5.9% to 4.3%, the 'overtreated' increased with 6.8% but the correctly classified increased with an additional 14%.

Are we reporting ileal pouch biopsies correctly?

AIM: The accuracy of ileo-anal pouch biopsy reporting was assessed. METHOD: The pathology reports of 100 consecutive pouch biopsies were reviewed to assess the accuracy and consistency with which the St Mark's histological scoring criteria were applied. The quality of pouch biopsy sampling and provision of clinical and endoscopic information on pathology request forms was also assessed. RESULTS: In 27% of cases no relevant endoscopic or clinical information was provided with the pathology request form. Separately labelled biopsies from the prepouch ileum, pouch and columnar cuff were submitted in only 4% of cases. In 32% of pathology reports, no acute or chronic St Mark's score was included. In 2% of cases the St Mark's scoring criteria were applied inappropriately. Twenty per cent of cases histologically diagnosed as pouchitis did not include a numerical score. In 30% of cases diagnosed histologically as pouchitis, an acute inflammatory score of < 4 (i.e. insufficient for this diagnosis) was included in the report. CONCLUSION: Pouchitis is a combined clinical, endoscopic and histological diagnosis. The correct interpretation and application of the St Mark's histological scoring criteria for pouch biopsies is an important part of this diagnostic process.

Quality control in upper gastrointestinal endoscopy: detection rates of gastric cancer in Oxford 2005-2008.

BACKGROUND: Gastric cancer (GC) represents the sum of advanced gastric cancer (AGC) and early gastric cancer (EGC). Endoscopy (with biopsies) is the gold standard for detection of GC, but a false-negative rate of up to 19% is reported. AIM: To determine whether patients with GC had had an oesophagogastroduodenoscopy (OGD) in the year preceding diagnosis that might reasonably have been expected to detect the cancer, as a measure of quality assurance of endoscopic practice. METHODS: Patients with histologically proven GC were identified from pathology records. Endoscopy reports and case notes were examined to identify any OGD before diagnosis, the interval and endoscopic findings. A false-negative OGD was defined as one where GC was neither suspected nor shown at pathology, but where a diagnosis of GC was made within 12 months. RESULTS: Between January 2005 and February 2008, 9764 OGDs were performed. GC was diagnosed in 74 patients (male/female ratio 2.89; median age 76, range 38-95). Nine (12%) patients had EGC. There were no differences in age, sex or symptoms between the EGC and AGC group. Sixty-eight of the 74 patients with GC (92%) presented with alarm symptoms. Ten of the 74 had had an OGD within 12 months before definitive diagnosis; all these were planned because of suspicious lesions. Significantly fewer biopsies were performed at OGDs preceding definitive diagnosis (median 2 (0-10) vs 6 (2-12); p=0.002). CONCLUSION: False-negative rates of 0% (within 12 months) and 8% (within 3 years) for diagnosis of GC are reassuring, but an inadequate number of biopsies compromises the quality assurance of endoscopy. GC presents without alarm symptoms in <10%.

Delayed surgery for acute severe colitis is associated with increased risk of postoperative complications.

BACKGROUND: This study determined the long-term outcome after colectomy for acute severe ulcerative colitis (ASUC) and assessed whether the duration of in-hospital medical therapy is related to postoperative outcome. METHODS: All patients who underwent urgent colectomy and ileostomy for ASUC between 1994 and 2000 were identified from a prospective database. Patient details, preoperative therapy and complications to last follow-up were recorded. RESULTS: Eighty patients were identified, who were treated with intravenous steroids for a median of 6 (range 1-22) days before surgery. Twenty-three (29 per cent) also received intravenous ciclosporin. There were 23 complications in 22 patients in the initial postoperative period. Sixty-eight patients underwent further planned surgery, including restorative ileal pouch-anal anastomosis in 57. During a median follow-up of 5.4 (range 0.5-9.0) years, 48 patients (60 per cent) developed at least one complication. Patients with a major complication at any time during follow-up had a significantly longer duration of medical therapy before colectomy than patients with no major complications (median 8 versus 5 days; P = 0.036). CONCLUSION: Delayed surgery for patients with ASUC who do not respond to medical therapy is associated with an increased risk of postoperative complications.

Management of early rectal cancer.

BACKGROUND: Early rectal cancer (ERC) is adenocarcinoma that has invaded into, but not extended beyond, the submucosa of the rectum (that is a T1 tumour). Local excision is curative for low-risk ERCs but for high-risk cancers such management is controversial. METHODS: This review is based on published literature obtained by searching the PubMed and Cochrane databases, and the bibliographies of extracted articles. RESULTS AND CONCLUSION: ERC presents as a focus of malignancy within an adenoma, as a polyp, or as a small ulcerating adenocarcinoma. Preoperative staging relies on endorectal ultrasonography and magnetic resonance imaging. Pathological staging uses the Haggitt and Kikuchi classifications for adenocarcinoma in pedunculated and sessile polyps respectively. Lymph node metastases increase with the Kikuchi level, with a 1-3 per cent risk for submucosal layer (Sm) 1, 8 per cent for Sm2 and 23 per cent for Sm3 lesions. Low-risk ERCs may be treated endoscopically or by a transanal procedure. Transanal excision or transanal endoscopic microsurgery may be inadequate for high-risk ERCs and adjuvant chemoradiotherapy may be appropriate. There is a low rate of recurrence after local surgery for low-risk ERCs but this increases to up to 29 per cent for high-risk cancers.

Effect of neoadjuvant chemotherapy on circumferential margin positivity and its impact on prognosis in patients with resectable oesophageal cancer.

BACKGROUND: The significance of circumferential resection margin (CRM) involvement in oesophageal cancer surgery is controversial. This study investigated the relationship between CRM involvement, locoregional recurrence and survival, after surgery alone or with neoadjuvant chemotherapy. METHODS: Patients operated on by one surgeon at a tertiary referral centre between October 1997 and May 2004 were identified from a prospective database. RESULTS: Some 242 patients underwent oesophagectomy; 91 had surgery alone, 142 had neoadjuvant chemotherapy and nine neoadjuvant chemoradiotherapy. Among patients with histologically confirmed T3 tumours, 26 (55 per cent) of 47 who underwent surgery alone had CRM involvement, compared with 27 (31 per cent) of 88 patients who completed two cycles of neoadjuvant chemotherapy (P = 0.005). Thirty-seven (42 per cent) of 89 patients with a negative CRM developed locoregional recurrence, compared with 33 (59 per cent) of 56 with a positive margin (P = 0.032); median survival was 28 and 12 months respectively (P < 0.001). Cox multivariable regression analysis identified CRM involvement as an independent prognostic factor (P = 0.006). CONCLUSION: A positive CRM is an independent predictor of overall survival after oesophageal cancer resection. There has been a significant decrease in CRM involvement with the introduction of neoadjuvant chemotherapy.

Proposals for the management of gastrointestinal stromal tumours of the stomach.

BACKGROUND AND AIMS: It has been reported that gastric gastrointestinal stromal tumours (GIST) are aggressive, rare and difficult to treat. Some have advocated radical resection as the only potential cure. We present data to support treatment of gastric GISTs with a limited surgical approach and minimal morbidity. Furthermore, we propose that surveillance for recurrence is unnecessary based upon the follow-up of a cohort of patients with gastric GISTs. METHODS: Database and case notes analysis of 20 patients diagnosed with gastric GIST (1998-2004) and managed by one surgeon in a single centre over seven years. Main outcome measures were inpatient adverse events, positive resection margins and symptom free survival. OUTCOMES: Three cases have been managed with surveillance only. Successful resection was performed in 17 patients without mortality. No patient had positive margins on histological assessment. Fifteen out of seventeen samples were positive for the c-Kit proto-oncogene (CD117) and 14117 positive for CD34. Only two patients required en-bloc resections due to the tumour size and involvement of adjacent structures. One patient developed metastatic disease during follow-up of 19-86 months. CONCLUSIONS: We recommend local excision of gastric GISTs to allow macroscopically clear margins. This policy then allows symptomatic follow-up due to the indolent nature of the majority of the tumours resected. A tailored follow-up with endoscopy and radiological imaging has been advocated by others but appears unnecessary in most cases. Imatinib (anti c-Kit) can now be offered to patients presenting with recurrent GIST, if further surgery is deemed inappropriate.

EpCAM and gpA33 are markers of Barrett's metaplasia.

AIMS: To characterise a specific and sensitive marker of Barrett's metaplasia (BM). METHODS: Cases of normal oesophageal squamous mucosa (11 fresh endoscopic biopsies and 10 formalin fixed, paraffin embedded tissue blocks), BM (11 biopsies and 11 tissue blocks), and normal gastric body mucosa (five biopsies and five tissue blocks) were analysed using reverse transcriptase PCR, Western blotting, and immunohistochemistry for EpCAM, and reverse transcriptase PCR for gpA33. RESULTS: Strong EpCAM mRNA expression was detected in all the BM cases, in contrast to weak expression in all the normal gastric mucosal samples and no expression in any of the normal oesophageal mucosal samples tested. Strong gpA33 mRNA expression was detected in all the BM cases, in contrast to weak expression in a quarter of the normal gastric mucosal samples and no expression in any of the normal oesophageal mucosal samples tested. Western blotting showed EpCAM protein expression in all the BM cases and in none of the normal gastric or oesophageal mucosal samples tested. Immunohistochemistry showed strong EpCAM protein expression in BM and complete absence of expression in normal oesophageal squamous epithelium. Scattered EpCAM expressing cells were found in the gland bases of normal gastric body mucosa. CONCLUSIONS: EpCAM protein and gpA33 mRNA expressions are specific and sensitive markers of BM.

Abnormal retention of intron 9 in CD44 gene transcripts in human gastrointestinal tumors.

We have recently identified a new exon of the CD44 gene and demonstrated abnormal retention of a noncoding section, intron 9, in mRNA from bladder carcinomas. To analyze this further, the present study examined CD44 gene expression in cell lines from 14 esophageal, 3 colonic, and 4 breast carcinomas and in fresh samples from 20 colorectal carcinomas and corresponding normal colonic mucosa, using reverse transcriptase followed by the polymerase chain reaction (RT-PCR). This confirmed that there was abnormal assembly of several exons of the gene in cell lines and in tumor tissues from these organs. However, the most striking new finding was that intron 9 was present in RNA from 11 esophageal, 3 colon, and 1 breast carcinoma cell line, respectively. This was confirmed by RNase and DNase digestion analysis. Moreover, it was detected both in nuclear and cytoplasmic mRNA fractions, indicating that abnormal splicing of pre-mRNA occurs in cancer cells. The abnormal retention of intron 9 in CD44 gene transcripts was also demonstrated in tumor tissues from 16 (80%) of 20 patients with colon carcinoma, but there was no correlation with Dukes' stage. The biological significance of these observations is not yet understood. However, it is clear that, as with the abnormal expression pattern of CD44 variant exons, intron 9 retention is a good-candidate molecular diagnostic tool for colorectal carcinomas.

The retroperitoneal surface in distal caecal and proximal ascending colon carcinoma: the Cinderella surgical margin?

BACKGROUND: Mesorectal margin tumour involvement is a predictor of local recurrence in rectal carcinoma and an indication for postoperative radiotherapy in suitable patients. However, the prevalence of non-peritonealised surgical margin involvement in ascending colon carcinoma is unknown. AIMS: To test the hypothesis that retroperitoneal surgical margin (RSM) tumour involvement occurs in distal caecal and proximal ascending colon carcinoma. METHODS/RESULTS: One hundred right hemicolectomy specimens, removed for adenocarcinoma of the caecum or proximal ascending colon, were studied. During routine specimen dissection, at least one additional tissue block was taken to include the tumour and the RSM. The tumour distance from the RSM was recorded. RSM tumour involvement was present in seven cases (7%). Direct (non-nodal) RSM tumour involvement (five cases) only occurred in posterior or circumferential tumours. CONCLUSIONS: RSM tumour involvement occurs within a considerable number of distal caecal and proximal ascending colon carcinomas. The rate of RSM tumour involvement identified here is similar to a previously published local recurrence rate of 10% in caecal carcinoma, suggesting that RSM tumour involvement may be a predictor of recurrence in these tumours. Therefore, patients with distal caecal or proximal ascending colon carcinoma and RSM tumour involvement may benefit from postoperative radiotherapy.

Cytokines in the cotton top tamarin model of human ulcerative colitis.

The cotton top tamarin is a unique model of human ulcerative colitis. This disease is clinically and histologically similar. It is also complicated in some cases by colon cancer. The cotton top tamarin provides an appropriate animal model for assessing new treatments in inflammatory bowel disease.

Reduplication cyst of appendix with mucinous carcinoma and Müllerian metaplasia: a case report.

This report describes a case of mucinous carcinoma and Müllerian metaplasia arising within an appendiceal duplication cyst found incidentally during an emergency Caesarian section. Intestinal duplication cysts are rare and although there are occasional reports of malignant transformation, this is the first case where Müllerian metaplasia was found concurrently with a malignancy. There was no previous history of endometriosis and no other abnormalities were found at surgery. Treatment included surgical excision. The patient is alive and well two years after removal of the cyst.

Apparent deficiency of mucosal vascular collagen type IV associated with angiodysplasia of the colon.

AIMS: To investigate the presence and distribution of vascular collagen type IV in colonic tissue in cases of angiodysplasia and age and sex matched controls. METHODS: Sections of colon from seven cases of colonic angiodysplasia and eight age and sex matched controls were examined for the presence of collagen type IV in vessels of the mucosa and submucosa. Immunohistochemical staining was performed on paraffin wax embedded sections, and the degree of vascular staining for each marker compared between mucosa and submucosa and between cases and controls. Staining for endothelial markers P-selection and factor VIII was used to control for non-specific differences in immunostaining. RESULTS: In both the angiodysplastic tissues and approximately half the control tissues, staining for collagen type IV was considerably weaker in vessels in the mucosa than in the submucosa. In angiodysplasia, ectatic vessels in the mucosa appeared to contain less collagen type IV than similarly sized vessels in the submucosa, and perforating vessels appeared in many cases to lose staining at the level of the muscularis mucosae. No differences were found in staining intensity for the control endothelial markers between cases and controls. CONCLUSIONS: The apparent relative deficiency of collagen type IV in the mucosal vessels in angiodysplasia may be related to their susceptibility to ectasia and haemorrhage. The finding of a similar deficiency in half of the control cases may reflect a population at risk of this relatively common condition.

Colour perception in pathologists: the Farnsworth-Munsell 100-hue test.

The value of many histological stains depends on the ability of the observer to differentiate colour. This ability was assessed in 30 histopathologists and cytopathologists of varying experience using the Farnsworth-Munsell 100-hue test. As a group, the pathologists performed better than a reference population. Twenty eight subjects showed a wide ranging ability to differentiate colour: none was colour blind. Three of the 30 pathologists, however, fell below the twentieth centile for normal subjects and only one was aware of this deficiency! They may unknowingly misinterpret subtle stains. Two of these three had specific and major defects which could affect their ability to interpret a wide range of less subtle stains. Those with the poorest colour discrimination were not those with the least experience of microscopy. Pathologists should be apprised of the importance of their ability to discriminate colour, and that formal colour vision testing of prospective histopathologists may be appropriate.

An unusual case of colonic angiodysplasia.

An unusual case of a colonic vascular anomaly resembling angiodysplasia associated with right sided diverticular disease is presented. The patient, a 74 year old man, presented with a four day history of rectal bleeding and subsequently underwent hemicolectomy. The resected specimen was flushed out with heparin-saline solution and injected with a barium-gelatine mixture. Preoperative barium enema revealed right sided diverticula, whereas post-resection angioradiography revealed the "coral reef" vascular anomaly consistent with angiodysplasia. Histology confirmed the presence of both diverticular disease and angiodysplasia. This case report highlights the importance of considering a vascular anomaly in patients presenting with rectal bleeding despite the presence of another radiologically demonstrable anatomical lesion.

Unacceptably high site variability in postmortem blood alcohol analysis.

Blood alcohol concentration is a frequently requested test in forensic pathology. The variability of this value was studied by measuring the blood alcohol concentration from six sites in nine subjects at necropsy in whom alcohol was the implicated cause of death. There were small consistent differences in the blood alcohol concentrations between the sites in the nine subjects (p < 0.04). Calculation of the mean blood:vitreous humour alcohol concentration ratio (B:V ratio) showed that vitreous humour alcohol concentration most closely reflected the concentration at the femoral vein (B:V ratio = 0.94, r = 0.98), which is considered the optimal site for blood alcohol measurement. The correlation of left heart blood with femoral blood was lower compared with the other sites. There is a potential for an unacceptably large variation in the postmortem measurement of blood alcohol within each subject.

How many lymph nodes to stage colorectal carcinoma?

This study aimed to establish the number of cassettes that should be filled with lymph nodes to stage a colorectal carcinoma as Dukes's stage C. The records from the Oxford Colorectal Cancer database of all patients diagnosed with Dukes's stage C cancer from late 1988 to early 1993 were reviewed. Each slide of lymph nodes was examined to determine how many slides needed to be looked at to find the first positive lymph node. The resected specimens were not fat cleared but dissected manually in a routine fashion. One hundred and eight slides were retrieved. The mean total lymph node harvest was 8.44 for each patient. Ninety eight patients (90.7%) had positive lymph nodes on the first slide with an average of 3.42 lymph nodes on each slide, of which a mean of 1.82 were positive. For nine patients, two slides were required to make a diagnosis of lymph node involvement, and for one patient the first three slides needed inspection to establish Dukes's stage C. In conclusion, using a routine technique to obtain lymph nodes from colorectal cancer specimens 99% of Dukes's stage C colorectal carcinoma can be found by filling two cassettes with lymph nodes.

Lack of mucin MUC5AC field change expression associated with tubulovillous and villous colorectal adenomas.

BACKGROUND: MUC5AC is a secreted mucin aberrantly expressed by polypoid colorectal adenomas. It has been hypothesised that the "normal" surrounding colorectal mucosa expresses MUC5AC as a field change phenomenon that can be used to predict adenoma recurrence following resection. AIM: To determine if there is a field change of de novo MUC5AC expression in histologically normal rectal mucosa adjacent to villous and tubulovillous adenomas, and thus whether MUC5AC expression can be used as a marker of early tumour recurrence. METHODS: In a prospective cohort study paired mucosal biopsies of adenomatous and macroscopically "normal" mucosa were obtained from 11 patients with villous and 11 patients with tubulovillous adenomas who underwent primary resection for purpose of cure. The tissues were studied to determine MUC5AC gene expression by immunohistochemistry and in situ hybridisation. Patients were followed up by flexible sigmoidoscopy to detect the presence of early local recurrence. RESULTS: 10 villous adenomas showed mature MUC5AC glycoprotein and all 11 expressed MUC5AC mRNA. Five tubulovillous adenomas showed mature MUC5AC glycoprotein and 10 expressed MUC5AC mRNA. Neoexpression of the MUC5AC mucin gene was not detected in any of the mucosal biopsies taken adjacent to either villous or tubulovillous adenomas, even in three patients with early, locally recurrent disease. CONCLUSIONS: Aberrant MUC5AC gene expression is not a "field change" in the colorectal mucosa in patients with rectal adenomas and therefore cannot be used to predict local recurrence of villous and tubulovillous adenomas.

Detection of exfoliated carcinoma cells in colonic luminal washings by identification of deranged patterns of expression of the CD44 gene.

AIMS: To investigate whether colonic cancer cells exfoliated into the lumen of the organ can be detected by identification of their abnormal CD44 gene products. METHODS: Exfoliated cells were obtained by centrifugation of saline wash-outs of 27 surgically resected colon specimens obtained from 15 patients with carcinoma, seven with ulcerative colitis and five with Crohn's disease. After extracting cellular mRNA, amplification by the reverse transcription-polymerase chain reaction (RT-PCR) technique and analysis by Southern blot hybridisation was carried out to examine the levels and patterns of transcription of exons 11(v6), and 12(v7) and intron 9 of the CD44 gene. The transcription of these CD44 components was also examined by RT-PCR of snap-frozen solid tissue specimens from 11 of the above patients with colorectal carcinoma, seven with ulcerative colitis and five with Crohn's disease. RESULTS: Abnormal expression of exons 11(v6) and 12(v7) was detected in exfoliated cells from 11 (73%) of 15 patients with carcinoma, but not in any patients with inflammatory bowel disease (IBD). The retention of intron 9 in CD44 mRNA transcripts was detected in washings from four (27%) carcinoma specimens but not in washings from non-malignant specimens. It was confirmed that in solid tissue samples from the same carcinomas there was abnormal over-expression of numerous alternatively spliced CD44 species containing transcripts of exons 11 and 12 and retention of intron 9. Low level expression of these exons was detected in tissue from inflammatory lesions from five of seven patients with ulcerative colitis and four of five with Crohn's disease. The retention of intron 9 was not seen in normal mucosa nor IBD. CONCLUSION: Abnormal expression of the variant exons and of intron 9 of the CD44 gene in tumour cells exfoliated into the colonic lumen may be helpful markers for the early, non-invasive, diagnosis of colorectal cancer.

Dukes' staging is poorly understood by doctors managing colorectal cancer.

OBJECTIVE: This study set out to investigate the current understanding of Dukes' staging for colorectal cancer. DESIGN: A questionnaire was distributed to surgeons and general practitioners attending colorectal meetings asking for a definition of Dukes' stages A, B and C. Results were analysed blind by two authors jointly to assess accuracy as correct, within definition, or incorrect. Within definition was defined as a description fitting within but not covering all tumours within that stage. RESULTS: 128 answers were received from 48 GPs, 7 final year medical students, 38 house officers and SHOs, 19 higher surgical trainees and 16 consultants. Overall, 3.9% defined all three stages correctly and 13.3% got all three definitions incorrect. Correct stages were Dukes' A 7.8%, Dukes' B 16.4% and Dukes' C 29.7%. Two consultants (12.5%) achieved three correct definitions, as did two HSTs (10.5%). No GPs had all three stages correct and 10 (20.8%) were wrong in all three. If those said to be within definition were considered right, 35.1% were correct for all three stages with 76.6% getting Dukes' A correct, 46.9% Dukes' B and 56.6% Dukes' C. CONCLUSIONS: Dukes' staging is, therefore, still poorly understood by doctors managing patients with colorectal cancer. The introduction of proformas will reduce the reliability upon memory for this and more complex staging classifications.