Tim3 and PD-1 as a therapeutic and prognostic targets in colorectal cancer: Relationship with sidedness, clinicopathological parameters, and survival.

Background: Colorectal cancer (CRC) is a heterogeneous disease that complicates predicting patients' prognosis and their response to treatment. CRC prognosis is influenced by the tumor microenvironment (TME). The immune system is a critical component of the TME. Programmed cell death receptor 1 (PD-1) and T-cell immunoglobulin and mucin-domain containing-3 (Tim3) are inhibitory immune checkpoints that regulate immune response and may provide prognostic power. However, the effect of their expressions and co-expressions on the CRC prognosis remains unclear. Accordingly, this study aimed to investigate the prognostic value of the CD8, CD3, PD-1, Tim3 expression, and PD-1/Tim3 co-expression in patients with CRC. Materials and Methods: One hundred and thirty six patients with CRC who underwent curative surgery were enrolled in the study. Immunohistochemical staining was performed for PD-1, Tim3, CD8, and CD3, and the expression of each marker was evaluated in the center of the tumor (CT), invasive margin (IM), and adjacent normal-like tissue. Result: Our results indicated that high expression of PD-1 in IM was significantly associated with lower TNM stage, T-stage, M-stage, lack of metastasis, the presence of tertiary lymphoid structure (TLS), lack of recurrence (in the left-sided tumors), and larger tumor size (in right-sided tumors) (P<0.05). High expression of PD-1 in IM was also associated with improved overall survival (OS) in a subgroup of patients with high CD8 expression. High Tim3 expression in CT was associated with higher M-stage (M1) (in left-sided CRCs) (P<0.05). It was also associated with decreased OS in total cohort and left-sided CRCs and represented an independent prognostic factor for CRC patients in multivariate analysis. PD-1 and Tim3 co-expression had no synergistic effects on predicting OS. Conclusion: Our findings suggest that the clinicopathological and prognostic significance of immune system-related markers such as CD8, PD-1, and Tim3 depends on the primary tumor sides. We also showed that Tim3 could act as a prognostic factor and therapeutic target in CRC. This marker is probably a more preferred target for immunotherapy than PD-1, especially in left-sided CRCs.

Clinicopathological significance and prognostic role of LAG3 + tumor-infiltrating lymphocytes in colorectal cancer; relationship with sidedness.

BACKGROUND: It is well-documented that the interplay between tumor-infiltrating lymphocytes (TILs) and tumor cells is a major determining factor in cancer progression. CD45RO seems to be a reliable indicator for predicting prognosis and disease outcome, along with CD3 and CD8 markers. LAG-3 is another important marker that overexpresses on TILs in a variety of cancers and is associated with disease prognosis; however, its prognostic impact is controversial. Hence, in the present study, we aimed to investigate the presence of CD45RO + , LAG3 + , CD3 + , and CD8 + lymphocytes in CRC tumor tissues and their association with clinicopathological parameters of the disease as well as patients' survival, according to primary tumor locations. METHODS: Expression of CD45RO, LAG3, CD3, and CD8 was immunohistochemically assessed in tissue sections of 136 patients with CRC. The percentages of TILs expressing these markers were then separately determined in both invasive margin (IM) and center of tumor (CT). Their associations with clinicopathological factors and patients' survival were analyzed in the entire cohort and the subgroups of patients with right- and left- rectum tumors. RESULTS: Based on our observation, CD45RO + and CD3 + cells were the most frequent infiltrated lymphocytes in both CT and IM regions of colon tumor tissue. Whilst, LAG3 + lymphocytes were the least frequent subset in both areas. Statistical analysis indicated that the frequency of CD45RO + TILs was positively associated with advanced TNM stages (III/IV), in the entire cohort and right-sided tumors (P < 0.05). LAG3 + TILs in IM were also increased in tumor tissues with higher T-stages in the entire cohort (P = 0.027). In univariate analysis, high score of CD45RO + TILs in IM was associated with better overall survival in the entire cohort. High score of CD8 + and CD45RO + lymphocytes in IM were also associated with improved survival in patients with right-sided tumors. CONCLUSIONS: Our findings generally suggest that the clinicopathological and prognostic significance of immune system-related markers such as CD45RO and LAG3 depends on the primary tumor sides. Our results collectively demonstrated that infiltration of CD45RO + lymphocytes in IM could be an independent prognostic factor in a site-dependent manner.

EPIYA Motif Genetic Characterization from Helicobacter pylori Isolates in Distinct Geographical Regions of Iran.

Background: This study aimed to determine the current EPIYA motifs of the cagA gene in Helicobacter pylori isolates from patients with gastric disorders, and evaluate the association between these patterns and the clinical outcome of H. pylori infection in different geographical regions of Iran. Materials and Methods: We examined 150 patients with gastrointestinal disorders from the central and eastern regions of Iran. The detection of H. pylori and screening of cagA was performed by polymerase chain reaction (PCR). The pattern of the motifs was determined by PCR followed by sequencing. Results: The overall prevalence of H. pylori was 66.3% in eastern (Mashad) and 50.6% in the central (Isfahan) part of Iran. The frequency of cagA-positive strains in Mashad and Isfahan were 63.4% and 56.7%, respectively. The pattern of EPIYA motif was as follows: 43 (79.6%) ABC, 7 (12.9%) AB, 4 (7.4%) ABCC, and one (1.9%) ABCCC. We also identified a novel EPIYA C sequence motif which showed association with gastric cancer (GC). The relationship between the frequency of specific EPIYA motifs and GC was statistically significant (P < 0.05). Conclusions: This is the first report for the determination of the cagA EPIYA motif of H. pylori in the Northeast and center of Iran. The prevalence of cagA positive H. pylori between the two regions was significant (P ≤ 0.05). All isolates of the H. pylori cagA were western type (ABC). The increase in the number of EPIYA-C repeats was associated with GC (P ≤ 0.01).

Epstein-barr virus/Helicobacter pylori coinfection and gastric cancer: the possible role of viral gene expression and shp1 methylation.

Background and Objectives: Among the various factors involved in the development of gastric cancer (GC), infectious agents are one of the most important causative inducers. This study aimed to investigate the possible role of EBV gene expression on SHP1 methylation in co-infection with Helicobacter pylori in patients with GC. Materials and Methods: Formalin-fixed paraffin-embedded samples were obtained from 150 patients with gastrointestinal disorders. The presence of the H. pylori and EBV genome were examined by PCR. The expression level of viral gene transcripts and methylation status of the SHP1 cellular gene was assessed by quantitative real-time PCR and methyl-specific PCR. Results: EBV and H. pylori coinfection were reported in 5.6% of patients. The mean DNA viral load was significant in patients coinfected with cagA-positive H. pylori (P= 0.02). The expression of BZLF1 and EBER was associated with GC. Also, the expression level of BZLF1in GC tissues was significantly higher in coinfection (P = 0.01). SHP1 methylation frequency was higher in the GC group than in the control group (P = 0.04). The correlation between the methylation rate and the H. pylori infection was highly significant (P<0.0001). The strongest positive correlation was observed in GC specimens between SHP1 methylation and H. pylori cagA-positive strains (p= 0.003). Conclusion: Our results suggested that cagA might involve in the elevation of EBV lytic gene expression and SHP1 methylation, and the development of gastric cancer. Understanding the mechanism of EBV H. pylori - cagA + coinfection, as well as host epigenetic changes, can play an important role in diagnosing and preventing gastric cancer.

5-Year Survival in Gastric Adenocarcinoma with Epithelial and Stromal Versican Expression.

BACKGROUND & OBJECTIVE: Gastric cancer is the second most frequent cause of cancer death worldwide, despite dif- ferences in incidence around the world. The majority of gastric cancer cases concern gastric adenocarcinoma, which has a fairly high 5-year survival rate when coupled with early-stage diagnosis. Versican, a member of the aggregating chondroitin sulfate proteoglycans family, is accumulated predominantly in the tumor stroma. The aim of our study was to investigate versican expression in gastric adenocarcinoma. METHODS: In this study we investigated 80 patients with gastric adenocarcinoma who underwent gastrectomy. Each sample was obtained from paraffin-embedded resected specimens of the stomach after histopathological diagnosis. Patient follow-up was performed every 3 months after the beginning of data collection. Survival analysis was calcu- lated using the Kaplan-Meier method for univariate analysis. RESULTS: Out of 80 patients with gastric adenocarcinoma, 76 cases (76.3%males and 23.7% females) completed the follow-up period. Positive versican expression in tumor epithelial and stromal cells was found in 39.5% and 22.4% of tumors, respectively. Shorter survival was observed among patients whose gastric adenocarcinoma expressed epithelial or stromal versican. CONCLUSION: In summary, the present study suggests that versican is likely a prognostic biomarker that predicts a poor outcome in patients with gastric adenocarcinoma. Comprehensive studies with larger sample sizes are needed.

A Leiomyosarcoma of Inferior Vena Cava Presenting as a Liver Metastasis Mass in a Patient with History of Transitional Cell Carcinoma.

The most probable diagnosis for a newly detected mass in the cancer patients is secondary metastasis. However, the multiple primary tumors should not be off the table of diagnoses. In this study, a 70-year-old man with the history of transitional cell carcinoma (TCC) was reported who had been referred due to a newly detected mass in the hepatic segment one which adhered to the inferior vena cava (IVC). Although the most probable diagnosis according to the patient's medical history was secondary metastasis, the biopsy revealed a leiomyosarcoma (LMS) tumor. Therefore, a mass biopsy can be determinative for confirming the diagnosis and further management of cancer patients with a newly detected mass.

Undifferentiated Pleomorphic Sarcoma of Pancreas: A Case Report and Review of the Literature for the Last Updates.

The most prevalent type of soft tissue sarcoma is undifferentiated pleomorphic sarcoma (UPS) or previously known as malignant fibrous histiocytoma. It accounts over 20% of all soft tissue sarcomas and occurs most frequently in the extremities, trunk, and retroperitoneum. However, it has been rarely observed in the digestive system. Pancreas sarcoma represents less than 1% of all pancreatic tumors, and primary UPS of the pancreas is even rarer. It exhibits high recurrence and poor prognosis. In this case, a 72-year-old woman with a UPS tumor which was located in the pancreas head and neck without adhesion to the retroperitoneum will be discussed.

Gastric Schwannoma: A Case Report and Review of the Literature for Gastric Submucosal Masses Distinction.

Schwannomas origin from Schwann cells sheath and generally are benign, slow-growing, and asymptomatic neoplasms which frequently appear in the head and neck. Although gastrointestinal schwannoma is really rare, the most affected organ in GI system is the stomach. Gastric schwannoma forms 0.2% of all gastric tumors. This neoplasm is always detected as a submucosal mass, the same as other gastrointestinal stromal tumors. Although these tumors have almost the same presentations, they are completely different at therapeutic options and prognoses. Hence, it is important to distinguish them apart and make an accurate diagnosis to optimize treatment outcomes. Herein, we report a case of 28-year-old woman with frequent vomiting and abdominal pain caused by 5 × 6 cm schwannoma in the antrum of the stomach. This is a rare case of gastric outlet obstruction due to a massive schwannoma. In addition, all other probable submucosal masses will be discussed at different aspects.

The Impacts of Gastroileostomy Rat Model on Glucagon-like Peptide-1: a Promising Model to Control Type 2 Diabetes Mellitus.

BACKGROUND: One of the new current treatment options for Diabetes Mellitus is about increasing glucagon-like peptide-1 (GLP-1) activity. GLP-1 with its incretin effect showed major role in glucose homeostasis. Gastroileostomy can increase GLP-1 secretion by rapid delivery of undigested food to the terminal ileum. We studied the early effects of a gastroileostomy on serum levels of GLP-1, glucose, and insulin in rats. METHODS: Gastroileostomies with side-to-side anastomosis were performed on 15 male New Zealand rats. Blood samples were obtained before and 1 week after the gastroileostomy. RESULTS: Our results showed that the rats lost a lot of weight from start (330 ± 15 g) to the end (240 ± 25 g) of the experiment (p = 0.048). The data analysis showed that the gastroileostomy surgery elevates the level of GLP-1in plasma significantly (89.1852 vs. 177.440 respectively; p < 0.001) and caused a significant decrease in plasma glucose as well (92.00 and 66.29 mg/dL respectively; p < 0.001). However, the insulin state elevated after the surgery significantly (8.03 vs. 9.89; p < 0.001). CONCLUSION: In this study, we showed the effectiveness of gastroileostomy treatment to decrease body weight and plasma glucose with increased GLP-1 in rats. This small rat model suggests the potential of this surgery to treat type 2 diabetes mellitus.

Chloroma of the testis in a patient with a history of acute myeloid leukemia.

Chloroma, or granulocytic sarcoma, is a rare extramedullary solid hematologic cancer, found concomitant with acute myeloid leukemia. It is infrequently associated with other myeloproliferative disorders or chronic myelogenous leukemia. Chloroma of the testis after allogeneic bone marrow transplantation is particularly sparsely represented in the literature. It is suggested that an appropriate panel of marker studies be performed along with clinical correlation and circumspection to avoid misleading conclusions. We report an interesting case of a 32-year-old male with a clinical history of acute myelogenous leukemia, postallogeneic peripheral blood stem cell transplantation that was found to have chloroma of the right testis.

Evaluation of Urokinase Plasminogen Activator Receptor, Soluble Urokinase Plasminogen Activator Receptor, and ß1 Integrin in Patients with Hodgkin's Lymphoma.

BACKGROUND: The objective of this study is to indicate the role of urokinase plasminogen activator receptor (uPAR), soluble uPAR (suPAR), and ß1 integrin in tumor growth and invasion of lymph nodes from Hodgkin's lymphoma (HL) patients. MATERIALS AND METHODS: In this study, 25 lymph nodes from HL patients were analyzed for the expression of ß1 integrin and uPAR on mononuclear cells using two-color flow cytometry and immunohistochemical analysis. Moreover, the levels of suPAR in the serum samples of HL patients were measured and compared with 32 healthy controls. RESULTS: Flowcytometry and immunohistochemical results indicated no significant association of uPAR expression with tumor size, different stages, or different histological subtypes of HL; however, an increased expression of ß1 integrin was detected in the advanced stages of HL. Higher expression of ß1 integrin was detected in nodular sclerosis compared to lymphocyte predominant. No significant difference was observed between the serum levels of suPAR in patients with different stages of HL and healthy controls. Moreover, the levels of suPAR were significantly higher in nodular sclerosis in comparison with other subtypes. CONCLUSIONS: This study showed that the levels of suPAR and ß1 integrin varied between different histological subtypes of HL. Although uPAR may play only a minor role in the growth and metastasis of lymphoma, ß1 integrin may be important in predicting prognosis and metastasis in HL.

Associating liver partition and portal vein ligation for staged hepatectomy: A surgical technique for liver resections.

BACKGROUND: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel surgical technique liver resection in traditionally nonresectable primary intrahepatic tumors or colorectal liver metastases. MATERIALS AND METHODS: From June 2013 to March 2014, patients with primary tumor of liver or colorectal tumors with liver metastasis were selected to evaluate whether they met the initial criteria for ALPPS procedure. RESULTS: Nine patients enrolled in the study with primary diagnoses of colon and rectosigmoid cancer, carcinoid tumor, gastrointestinal stromal tumor of small intestine, hepatocellular carcinoma, and pancreatic neuroendocrine tumor (PNET). Four candidates excluded from the study prior or during the first step operation due to fatty liver, hepatic fibrosis, peritoneal seeding, and multiple small intestine metastases. Five patients underwent two stages of ALPPS with the interval of about 1 week. Liver hypertrophy was 100% among our candidates after the initial step. One postoperative death happened because of massive pulmonary thromboembolism Recurrence of liver metastasis was seen in one patient. Hepatic failure Class B and A were observed in two patients which did not progress during follow-up period. One patient developed an enterocutaneous fistula. DISCUSSION: We recommend to use 2 organ bags, one for wrapping right lobe and the other one for covering visceral organs and also do liver biopsy in suspicious cases of damaged liver parenchyma and laparoscopic exploration of abdomen for seeding and multiple metastases prior to laparotomy. CONCLUSION: As the procedure has not been well established and verified by oncologists yet, further studies are required to define the exact indications of ALPPS.

Upper Gastrointestinal Bleeding as the First Manifestation of Wegener's Granulomatosis.

Wegener's granulomatosis is an uncommon inflammatory disease that manifests as vasculitis, granulomatosis, and necrosis. It usually involves the upper and lower respiratory tracts and kidneys. Although it may essentially involve any organ, gastrointestinal (GI) involvement is notably uncommon. A 20-year-old male patient presented with epigastric pain, vomiting, hematemesis, and melena. On physical examination, he was pale. There was no abdominal tenderness or organomegaly. Upper GI endoscopy revealed dark blue-colored infiltrative lesions in prepyloric area. Evaluation of the biopsy sample showed mononuclear cell infiltration in the submucosal area, hyperplastic polyp, and chronic gastritis. High dose proton pump inhibitor and adjunctive supportive measures were given but no change in the follow-up endoscopy was detected. During hospital course, he developed intermittent fever and serum creatinine elevation. 12 days after admission, he developed dyspnea, tachypnea, and painful swelling of metacarpophalangeal joints, and maculopapular rash in extensor surface of the right forearm. Chest radiography showed pulmonary infiltration. Serum c-ANCA titer was strongly positive and skin biopsy revealed leukocytoclastic vasculitis. The patient received methylprednisolone pulse, which resulted in complete recovery of symptoms and gastric lesion. The present case indicates that GI bleeding may be the first manifestation of Wegener's granulomatosis. Moreover, it should be emphasized that gastric biopsy is not characteristic or diagnostic in such patients.

Comparing the efficacy of routine H&E staining and cytokeratin immunohistochemical staining in detection of micro-metastasis on serial sections of dye-mapped sentinel lymph nodes in colorectal carcinoma.

BACKGROUND: The significance of techniques used for detecting micro-metastasis (MM) or isolated tumor cells (ITCs) is a controversial issue among investigators. We evaluated the different techniques used on sentinel lymph node (SLN) to detect MM/ITCs. MATERIALS AND METHODS: Ninety-one SLNs of 15 patients underwent serial section with 100 µm interval. In each level, two sections were prepared. One section was stained with H&E and another with anti-cytokeratin antibody (immunohistochemistry). Then the sections were evaluated for detecting MM/ITCs. Results were analyzed by chi-square test. RESULTS: 1656 sections of 91 SLNs of 15 patients were evaluated by a pathologist; MM was found in 1 and ITCs in 1 case. Overall, 2 out of 15 cases (13.3% of the patients) showed MM/ITCs by IHC staining. So, serial section along with using IHC was superior than serial section and routine H&E staining. But it did not affect the 5-year survival of the patients (P = 0.47). CONCLUSION: Using the combined techniques of serial section and IHC staining could up-stage 13.3% of colon cancer patients who were lymph node negative. In other studies with different combination of serial section, IHC staining, and PCR, investigators were able to find MM/ITCs in 3-39% of the cases. In our study, although serial section and IHC staining could up-stage 13.3% of patients, it could not affect the 5-year survival of the patients.

Frequency of virulence factors in Helicobacter pylori-infected patients with gastritis.

UNLABELLED: The outcome of Helicobacter pylori infection has been related to specific virulence-associated bacterial genotypes. The vacuolating cytotoxin (vacA), cagA gene, oipA and babA2 gene are important virulence factor involving gastric diseases. The objective of this study was to assess the relationship between virulence factors of H. pylori and histopathological findings. MATERIAL AND METHODS: Gastroduodenoscopy was performed in 436 dyspeptic patients. Antrum biopsy was obtained for detection of H. pylori, virulence factors and for histopathological assessment. The polymerase chain reaction was used to detect virulence factors of H. pylori using specific primers. RESULTS: vacA genotypes in patients infected with H. pylori were associated with cagA, iceA1 and iceA2. In the patients with H. pylori infection there was a significant relationship between cagA positivity and neutrophil activity (P = 0.004) and chronic inflammation (P = 0.013) and with H. pylori density (P = 0.034). Neutrophil infiltration was found to be more severe in the s1 group than in the s2 group (P = 0.042). Also was a significant relationship between oipA positivity and neutrophil activity (P = 0.004) and with H. pylori density (P = 0.018). No significant relationships were observed between other vacA genotypes and histopathological parameters. CONCLUSION: H. pylori strains showing cagA, vacA s1 and oipA positivity are associated with more severe gastritis in some histological features but virulence factors of H. pylori do not appear to determine the overall pattern of gastritis.

Distribution of mediastinal ectopic thymic tissue in patients without thymic disease.

BACKGROUND: Different approaches to treat myasthenia gravis showed variable outcomes probably because of remained ectopic thymic tissue. The aim of this study is to determine incidence of thymic tissue in cases without any thymic disease. MATERIALS AND METHODS: Seventy-two patients scheduled for open heart surgery during 2000 and 2007 without thymic disease that were enrolled in the study at Chamran Hospital. Intraoperative biopsies were taken form aortopulmonary window, aortocaval groove and left and right pericardiophrenic regions. Finally, the distribution of ectopic thymic tissue was evaluated in above regions. RESULTS: Thymic tissue was found overall in 70.85% of patients. The most common sites for thymic tissue were left pericardiophrenic (50%) and right pericardiophrenic (31.9%) regions. Frequencies of ectopic thymus in aortopulmonary window and aortocaval groove were 19.4% and 12.5%, respectively. CONCLUSION: Because of high incidence of ectopic thymic tissue in mediastinum in patients without thymic disease, we recommend wide excision of thymus gland and all of adipose tissue in patients with myasthenia gravis.

Comparison of five staging systems of lymph node metastasis in the gastric carcinoma.

BACKGROUND: The presence of metastatic lymph nodes is the most important prognostic factor for gastric carcinoma; however, the optimal system for the accurate staging of lymph node metastasis for patients with gastric cancer remains controversial. This study was designed to compare five systems in relation to the N classification of gastric carcinoma. MATERIALS AND METHODS: This multicentric historical cohort study was conducted on 148 patients with M0 gastric adenocarcinoma who underwent gastrectomy in, five referral hospitals in Iran. Lymph nodes were sectioned, stained with hematoxyl in and eosin. The lymph node status was classified according to the five systems which are: The number of involved lymph nodes (TNM staging), metastatic lymph node ratio (N ratio), and the largest involved lymph node size, largest metastatic nest size and largest metastatic nest to lymph node size ratio. RESULTS: Patients were classified into significant prognostic groups by the five N classification method including the TNM method, N ratio (0, ≤0.15, 0.15-0.4, >0.4), largest involved lymph node size (0, ≤5, 5-11, >11 mm), Largest metastatic nest size (≤1, 1-7.5, >7.5 mm) and largest metastatic nest to lymph node size ratio (≤0.3, 0.3-0.9, >0.9). All of the above systems remained as independently significant prognostic factors in terms of overall and disease free survival time. CONCLUSION: Among the N staging systems we recommend the metastatic lymph node ratio and largest metastatic nest to lymph node size systems, since they are reproducible, simple, have good survival applicability, have prognostic value and include less stage migration especially in patients whom fewer than 15 lymph nodes are dissected.

Micrometastasis in non-small-cell lung cancer: Detection and staging.

BACKGROUND: The clinical relevance of bone marrow micrometastasis (BMM) in non-small-cell lung cancer is undetermined, and the value of such analyses in advanced stage patients has not been clearly assessed previously. This study was conducted to estimate the accuracy of both polymerase chain reaction (PCR) and immunohistochemistry (IHC) in micrometastases detection and determine the best site for bone marrow biopsy in order to find micrometastasis. METHODS: This prospective cross-sectional study was performed in the Department of Thoracic Surgery, Alzahra University Hospital from September 2008 to June 2009. To evaluate the bone marrow, a 3-cm rib segment and an aspirated specimen from the iliac bone prior to tumor resection were taken. PCR and IHC were performed for each specimen to find micrometastasis. RESULTS: Of 41 patients, 14 (34%) were positive for BMM by PCR compared with two positive IHC (4.8%). All BMMs were diagnosed in rib segments, and iliac specimens were all free from metastatic lesion. Our data showed no significant association between variables such as age, sex, histology, tumor location, side of tumor, involved lobe, smoking, or weight loss and presence of BMM. CONCLUSION: PCR could use as a promising method for BMM detection. BMM in a sanctuary site (rib) is not associated with advanced stages of lung cancer. In addition, when predictor variables such as age, sex, histology, tumor location, smoking, or weight loss are analyzed, no correlation can be found between micrometastasis prevalence and any of those variables.