Activation of extracellular regulated kinases (ERK1/2) but not AKT predicts poor prognosis in colorectal carcinoma and is associated with k-ras mutations.

Signal transduction and modulation represent central mechanisms in cellular processes such as cell-cycle regulation, oncogenesis, and apoptosis. The aim of this study was to determine the prognostic relevance of two kinases important in the regulation of cell proliferation and apoptosis in 135 colorectal cancer cases: AKT and extracellular regulated kinases (ERK1/2). We investigated the relationship of phospho-ERK1/2 (pERK1/2) and phospho-AKT (pAKT) with associated parameters (EGFR, COX-2, cyclin-D1), proliferative activity (Ki-67), and apoptosis (TUNEL) using immunohistochemistry. Additionally, the k-ras gene was screened for mutations to determine its putative association with ERK1/2 activation. Activation of ERK1/2 but not AKT correlated statistically with the presence of k-ras mutations (P = 0.015). Survival analysis of phospho-ERK1/2 immunoexpression showed a significant correlation with decreased overall survival (OS). The multivariate Cox regression analysis identified pERK1/2 as an independent prognostic parameter (P = 0.005). Activation of ERK1/2 in colorectal cancer may indicate aggressive tumor behavior and may constitute an independent prognostic factor. Furthermore, our data suggest that mutations of the k-ras oncogene may induce activation of ERK1/2. We propose immunohistochemical determination of pERK1/2 status as a promising candidate for the identification of high-risk patients who would benefit from new anticancer drugs targeting the ERK pathway.

Sulindac sulfide inhibits Ras signaling.

The non-steroidal anti-inflammatory drug sulindac is used in cancer prevention and therapy, but the molecular aspects of its anti-tumor effect remain unresolved. In vivo the prodrug sulindac, is converted into the metabolite sulindac sulfide. We found that sulindac sulfide strongly inhibits Ras induced malignant transformation and Ras/Raf dependent transactivation. Sulindac sulfide decreases the Ras induced activation of its main effector, the c-Raf-1 kinase. In vitro sulindac sulfide directly binds to the Ras gene product p21ras in a non-covalent manner. Moreover, we can show that sulindac sulfide inhibits the interaction of p21ras with the p21ras binding domain of the Raf protein. In addition, sulindac sulfide can impair the nucleotide exchange on p21ras by CDC25 as well as the acceleration of the p21ras GTPase reaction by p120GAP. Due to its action at the most critical site in Ras signaling we propose sulindac sulfide as a lead compound in the search for novel anti-cancer drugs which directly inhibit Ras mediated cell proliferation and malignant transformation.

[Spincter preservation after selective chemoradiotherapy of rectal cancer. Interim results of the OCUM study]. / Spinktererhalt nach selektiver Radiochemotherapie des Rektumkarzinoms. Zwischenergebnisse der OCUM-Studie.

BACKGROUND: In a prospective multicenter observational study (OCUM) neoadjuvant chemoradiotherapy (nRCT) was selectively administered depending on the risk of local recurrence and based on the distance between tumor and mesorectal fascia in pretherapeutic high-resolution magnetic resonance imaging (MRI). OBJECTIVE: Frequency and quality of abdominoperineal excision (APE) and sphincter preserving operations. PATIENTS AND METHODS: Of 642 patients treated in 13 hospitals 389 received surgery alone and 253 nRCT followed by surgery. By univariate and multivariate analysis risk factors for APE were determined. Quality parameters were the quality grade of mesorectal excision, the pathohistological involvement of the circumferential resection margin and intraoperative local dissemination of tumor cells. RESULTS AND DISCUSSION: In 12.8 % of the patients APE was performed. Independent risk factors for APE were tumor location in the lower third of the rectum and the individual hospitals, where APE varied between 0 and 32 %. This variation was chiefly caused by the different case mix. Hospitals with a high APE rate (> 30 %) treated significantly more patients with very low lying carcinomas (< 3 cm above the anal verge) and more advanced tumors. The median height of the tumor in cases of APE was nearly equal in all participating hospitals. Independent on the number of cases the quality of rectal surgery was high. Within the patient groups of primary surgery and nRCT the oncological quality parameter did not significantly differ between sphincter preservation and APE. As far as sphincter preservation is concerned the results justify a selective application of nRCT in patients with rectal carcinoma. The long-term results still have to be awaited.

Hypertension associated with multiple renal arteries may be renin-dependent.

OBJECTIVE: Subjects with multiple renal arteries have been shown to suffer more frequently from hypertension and to have higher blood pressures than subjects whose kidneys are supplied by single renal arteries. This study was carried out to determine whether subjects with multiple renal arteries also have higher renin activity. METHODS: We studied 62 consecutive patients who had undergone angiography for various reasons. They were divided into two groups. Group A comprised 29 patients whose kidneys were supplied by single arteries (male :female ratio 1.63, mean age 51.8 +/- 1.9 years) while Group B comprised 33 patients with multiple renal arteries (male:female ratio 2, mean age 47.3 +/- 2.3 years). RESULTS: Before stimulation with frusemide, the plasma renin in Group A was 0.79 +/- 0.13 ng angiotensin l/ml per h, while in Group B the corresponding figure was 1.73 +/- 0.38 ng angiotensin l/ml per h. This difference was statistically significant (P= 0.0127). Thirty minutes later the plasma renin level in Group A was 2.43 +/- 0.37 ng angiotensin l/ml per h versus a level of 3.86 +/- 0.53 ng angiotensin l/ml per h in Group B (P= 0.0169). Again, 30 minutes later the level was 2.59 +/- 0.4 ng angiotensin l/ ml per h in Group A, versus 3.79 +/- 0.59 ng angiotensin l/ ml per h in Group B (P= 0.0495). CONCLUSIONS: We conclude that patients with multiple renal arteries constitute a group who have high plasma renin activity and may therefore be prone to develop arterial hypertension.

Decreased HER-2 tyrosine kinase expression in rectal mucosa of FAP patients following low-dose sulindac chemoprevention.

As a part of the mechanisms of action in reversing FAP adenomas by the low-dose sulindac maintenance therapy (2 x 25 mg/patient per day), the extent of HER-2 proto-oncogene expression in the rectal mucosa seems to be of interest. Immunocytochemical analyses were performed in plasma and in rectal tissue of sulindac-treated FAP patients during an 18 months follow-up and compared with rectal tissue of patients with FAP, Crohn's disease, or rectal cancer or with healthy volunteers. HER-2 was significantly reduced and maintained in tissue under sulindac chemoprevention below base line levels of healthy individuals, but not in plasma. Therefore, a direct or indirect effect of sulindac as a tyrosine kinase inhibitor may be implicated. During NSAID treatment HER-2 protein expression as a prognostic tool seems to be of little clinical relevance.

DNA alterations in sporadic colorectal tumors do not correlate with tumor staging diagnosed by the TNM system.

Blood normal and tumor tissue samples of 23 patients with sporadic colorectal tumors were screened for DNA alterations in the tumor relevant genes APC, K-ras, DCC and p53. Six different microsatellite regions were analyzed for instability by a new developed non-radioactive method. Somatic DNA alterations were found in 17 tumor samples: 13 carried single or multiple changes in single genes; six carried alterations in microsatellites; two tumors showed tumor suppressor gene mutations in addition to microsatellite changes. We found no indications of correlations between current genetic models of colorectal tumor progression and the established TNM system for histopathological tumor classification.

Immunohistochemical demonstration of the calcium-binding proteins MRP8 and MRP14 and their heterodimer (27E10 antigen) in Crohn's disease.

Monospecific antibodies against the calcium-binding proteins MRP8 and MRP14 and their heterodimer MRP8/14 (epitope 27E10) were used to investigate immunohistochemically the distribution of these proteins in routinely processed small and large bowel tissues from patients with Crohn's disease. MRP8, MRP14, and complex MRP8/14 were demonstrated in most granulocytes and macrophages in active Crohn's disease. Additionally, a strong complex MRP8/14 immunoreactivity was present in epithelial cells of the terminal ileum adjacent to ulcerative and fissuring lesions, whereas epithelial cells in large bowel tissues were consistently negative. Our results morphologically confirm the clinical finding of increased MRP8/14 serum levels in patients with active Crohn's disease; there is evidence that the serum MRP8/14 increase is caused by active secretion from granulocytes, monocytes, and epithelial cells.

Immunohistochemical metallothionein expression in colorectal adenocarcinoma: correlation with tumour stage and patient survival.

Metallothioneins (MTs), a set of ubiquitous low-molecular-weight proteins essential for the protection of cells against heavy metal ion toxicity, were demonstrated immunohistochemically using a monoclonal antibody (E9) against a conserved epitope of I and II isoforms in a series of 109 colorectal adenocarcinomas. In a semiquantitative analysis strong MT expression in the majority of tumour cells was observed in 34 (31%) cases, 24 (22%) tumours showed a focal MT positivity, and 51 (47%) almost completely lacked MT expression. These differences in MT expression were statistically significantly (P < 0.05) associated with the tumour stage (Dukes classification) and the lymph node involvement at the time of operation (pN stages). However, in contrast to previous findings obtained on a variety of tumours, MT positivity was associated with a favourable clinical outcome in colonic carcinoma, which may indicate their different biological behaviour. Survival curves of cases with MT-positive and MT-negative status differed from each other in a univariate analysis (Mantel-Haenszel: 8.9, P < 0.05) but lost significance when a multivariate analysis was carried out by means of the Cox proportional regression model with Dukes' stages as a stratification factor. It is concluded that immunohistochemically demonstrated MT expression is significantly associated with tumour stages but does not represent an independent prognostic variable in colorectal cancer. However, it may provide important information about some of the biological mechanisms underlying progression in colorectal cancer.

Immunohistochemical distribution of chromogranins A and B and secretogranin II in neuroendocrine tumours of the gastrointestinal tract.

The aim of the present study was to investigate immunohistochemically the distribution of chromogranin A, chromogranin B, and secretogranin II in a series of 152 neuroendocrine tumours of the gastrointestinal tract. Tumour tissues from 25 argyrophil gastric carcinoids, 18 gastrin and 5 somatostatin-producing tumours, 4 'gangliocytic paragangliomas', 49 classical argentaffin and 2 L cell appendiceal carcinoids, 27 classical ileal carcinoids, 17 rectal carcinoids, and 5 poorly differentiated neuroendocrine tumours of the stomach and rectum were immunostained with antibodies against chromogranin A, chromogranin B, and secretogranin II. Chromogranin A was the major granin expressed in gastric carcinoids and in serotonin-producing carcinoids of the appendix and the ileum. In contrast, strong chromogranin B and secretogranin II immunoreactivity was found in rectal carcinoids, in which chromogranin A was rarely expressed. Since chromogranin A is a widely used marker for neuroendocrine differentiation, it is of diagnostic importance that some gastrin-producing tumours, 'gangliocytic paragangliomas', poorly differentiated neuroendocrine carcinomas, and appendiceal L cell carcinoids completely lacked chromogranin A positivity. It is concluded that the various neuroendocrine tumours of the gastrointestinal tract show distinctly different patterns of granin expression, probably reflecting their histogenetical origin.

Differential ventilation with low-flow CPAP and CPPV in the treatment of unilateral chest trauma.

A case of severe unilateral chest trauma with bronchopleural fistula is presented. Ventilatory therapy consisted of asynchronous independent lung ventilation (AILV). The injured lung was ventilated with intermittent positive pressure ventilation (IPPV) [tidal volume (TV) = 200 ml, f = 25/min, I:E = 0.5, minute volume (MV) = 5.0 l/min, FiO2 = 0.4], and the unaffected lung was ventilated with continuous positive pressure ventilation (CPPV) (TV = 600 ml, f = 12/min, I:E = 0.5, MV = 7.2 l/min, PEEP = 0.5 kPa, FiO2 = 0.4). Adequate gas exchange was obtained (PaO2 = 14.5 +/- 2.3 kPa, PaCO2 = 5.5 +/- 0.7 kPa), but high air leakage volumes persisted. Thus, differential low-flow CPAP (V = 5.0-7.5 l/min, PEEP = 0.5 kPa, FiO2 = 0.4) of the injured lung and CPPV (TV = 600 ml, f = 12/min, MV = 7.2 l/min, I:E = 0.5, PEEP = 0.5 kPa, FiO2 = 0.4) of the unaffected lung was applied for 36 hours. Further deterioration of pulmonary function was prevented, and the bronchopleural fistula closed after several hours. After another period of AILV the patient was treated with conventional mechanical ventilation, and finally weaned with high-flow CPAP.

Results and prognostic factors of splenectomy in idiopathic thrombocytopenic purpura.

BACKGROUND: Splenectomy is the therapy of choice after relapse following different immunosuppressive treatments for idiopathic thrombocytopenic purpura, which is still the most frequent cause of thrombocytopenia. STUDY DESIGN: A prospective clinical study was undertaken to evaluate the rate of complete remission in idiopathic thrombocytopenic purpura after splenectomy, to reveal the influence of preoperative immunosuppression on the postoperative course in groups of patients with different responses to treatment, and to describe possible prognostic factors predicting the postoperative course of idiopathic thrombocytopenic purpura. Difino's classification of remission was used. After fulfilling criteria for admission into the study, 72 patients who had undergone splenectomy (male to female ratio, 1:1.4) were examined. RESULTS: Early postoperative mortality and morbidity rates were 3 percent each. The following degrees of remission were achieved: complete remission, 72 percent; partial remission, 15 percent; partial remission affording further medical support, 6 percent; and no remission, 4 percent. Platelet counts differed significantly between complete and partial remission, but not between patients who did or did not experience a response to different preoperative medical strategies (Tukey-Kramer test, p < .05; t test, not significant). The correlation of megakaryocytopoiesis and the site of thrombocytolysis to the stages of remission was significant (Fisher's exact test). Patients with hyperplasia of splenic follicles had significantly higher platelet counts 2 years after operation than did those without hyperplastic splenic follicles (Student-Newman-Keuls test). CONCLUSIONS: Splenectomy is a low morbidity and low mortality procedure. It is, therefore, a treatment of choice after relapse following immunosuppressive courses. Isolated splenic thrombocytolysis and hyperplasia of megakaryocytopoiesis and of splenic follicles correlated with better postoperative outcome (ie, stable remission and platelet counts) and could serve as possible prognostic factors for the postoperative course in idiopathic thrombocytopenic purpura.

Cost containment through L-alanyl-L-glutamine supplemented total parenteral nutrition after major abdominal surgery: a prospective randomized double-blind controlled study.

BACKGROUND & AIMS: Glutamine is recognized as a conditionally essential amino acid. Recent studies indicate that glutamine-containing total parenteral nutrition improves nitrogen economy, enhances gastrointestinal and immune functions and shortens hospital stay. METHODS: Thirty-seven patients (19 w and 18 m; age 61. 4+/-10.4 years; BMI 23.7+/-2.8 kg/m(2)) following major abdominal surgery receiving an isonitrogenous isoenergetic TPN with or without alanyl-glutamine supplementation (0.5 g/kg BW/day), were evaluated in a double-blind, randomized, controlled trial over a five-day period by measuring nitrogen balance, selected biochemical parameters and length of hospital stay. RESULTS: Supplemental alanyl-glutamine improved the overall mean (-3.5+/-1.6 vs. -5.5+/-1. 4 g N;P<0.05) and cumulative nitrogen balance (-14.1+/-9.1 vs. -21.7+/-11.4 g N;P<0.05) compared with the isonitrogenous, isoenergetic standard regimen. Alanyl-glutamine normalized plasma glutamine concentration and reduced the length of hospital stay (12.8+/-2.6 vs. 17.5+/-6.4 days;P<0.05). CONCLUSIONS: The results of the study confirm that supplementation with synthetic alanyl-glutamine dipeptide is associated with cost containment due to shortened hospitalization and improved nitrogen economy.

Monoclonal antibody 1F10 immunoreactivity in inflammatory bowel disease: a new marker specific only for continuous endothelial cells.

OBJECTIVE: To investigate in detail the immunohistochemical properties of the two endothelial-specific markers 1F10 (continuous endothelia) and MS-1 (discontinuous endothelia) in bowel tissues of patients suffering from chronic inflammatory bowel disease (IBD). METHOD: Immunohistochemical techniques were employed to study the morphology and phenotypic expression of these two proteins in routinely processed bowel tissues from 27 patients with Crohn's disease, 18 patients with ulcerative colitis, and 20 normal controls. RESULTS: All patients with IBD and controls showed a low to moderate 1F10 immunohistochemical staining restricted to the lamina propria and submucosa. In contrast to ulcerative colitis patients and healthy controls, 1F10 immunoreactivity was strongly upregulated in the muscularis propria of the small and large bowel in Crohn's disease patients regardless of the histological severity of the inflammatory process. We did not observe immunoreactivity for MS-1 on endothelial surfaces in either Crohn's disease or ulcerative colitis. CONCLUSIONS: We conclude that endothelia in patients with IBD do not undergo metaplasia. The high immunoreactivity of 1F10 antigen in the muscularis propria in Crohn's disease indicates a state of tropical immunological activation and may be important in the maintenance of chronic inflammation by facilitating leukocyte migration into sites of Crohn's disease involvement. Further studies of the factors controlling endothelial cell differentiation in the bowel of Crohn's disease patients may help to explain the features observed in this study.

Cytology and image cytometry after colonic lavage: a complementary diagnostic tool in patients with ulcerative colitis.

BACKGROUND: Patients with extensive, long-standing ulcerative colitis have increased risk of colorectal cancer. AIMS: To improve the detection of high-risk patients, using a combination of colonic cytology, histology, and DNA image cytometry after segmental colonic lavage. PATIENTS: A series of 16 patients (8 high-risk patients) with ulcerative colitis were investigated. METHODS: After segmental lavage step, biopsies were obtained. Gradient centrifugation of the colonic fluid was performed for isolation and purification of epithelial cells. The smears and biopsy specimens obtained were stained for routine interpretation and for DNA image cytometry. RESULTS: Segmental lavage could be performed in all patients. Specimens from two high-risk patients showed low grade dysplasia and atypia by means of histology and cytology, respectively. In one patient, without increased colorectal cancer risk, atypia was detected. Three patients in the high-risk group, two of those diagnosed as positive for dysplasia and atypia, showed aneuploidy histologically and cytologically. DNA aneuploidy, in cytological material, was found exclusively in three low-risk patients, one of those had atypia cytologically. CONCLUSIONS: Isolation and purification of epithelial cells after segmental colonic lavage using density gradient centrifugation can be performed as part of routine endoscopy. It provides information about atypical cells and DNA aneuploidy as additional markers of malignant transformation. The combination of cytologic examination and DNA image cytometry might improve the detection of high-risk ulcerative colitis patients.

Immunohistochemical double labeling of macrophages, smooth muscle cells, and apolipoprotein E in the atherosclerotic plaque.

To find out which cell types in the atherosclerotic plaque are actively involved in apolipoprotein-secretion, we stained tissue samples from the ascending aorta of patients undergoing coronary bypass surgery. We used monoclonal antibodies against macrophages, smooth muscle cells and apolipoprotein E. The present in situ-study of the atherosclerotic plaque has shown that apolipoprotein synthesis is predominantly secreted by macrophages transformed into foam cells. Besides this, there are obviously some smooth muscle cells equally transformed to foam cells, which also carry apolipoprotein E in their cytoplasm. Our data suggest that both cell types in the atherosclerotic plaque are actively involved in apolipoprotein secretion.

A possible explanation for the frequent concomitance of arterial hypertension and multiple renal arteries.

In more than 20% of subjects, at least one kidney is found to be supplied by more than one artery arising from the aorta. This aberrant renovascular anatomy has been reported in the literature to occur in up to 80% of patients who suffer from essential hypertension. Predominant numbers of the so-called 'accessory' vessels are longer and narrower than the segmental arteries arising in the main renal artery. As a result (in accordance with Poiseuille's law of fluid flow), the renal segments supplied by these 'accessory' vessels may have lower levels of blood pressure than the remainder of the parenchyma, thereby increasing the renin secretion. This hypothesis could be significant in terms of finding a causal treatment for a disorder induced by such a mechanism. We first review the literature in which the frequency of these vascular anomalies in normotensive and hypertensive patients is described, and then advance a hypothesis explaining the frequent incidence of essential hypertension in these subjects, as well as the ramifications of this phenomenon.

[Open pelvic fracture--an indication for laparotomy?]. / Die offene Beckenfraktur--eine Indikation zur Laparotomie?

Open pelvic fractures are rare and account for 1-5% of all pelvic fractures. Mortality rates of 50% and even more have been reported. Bleeding and septic complications are the major causes of death. In our retrospective study from 1974 to 1996 the data of 40 patients were analyzed. Five patients died (12.5%); 28 survivors could be investigated with a mean follow-up of 10 years. It is concluded that the comparably low mortality rate is due to a standardized treatment protocol. The main principles of management are emergency stabilization of the unstable pelvis and early laparotomy.

[Abdominal trauma and pelvic injury in the growth period]. / Bauchtrauma und Beckenverletzung im Wachstumsalter.

Children with pelvic fractures usually are polytraumatized. Concomitant abdominal and pelvic injuries are not uncommon. Medical records and X-rays of 54 children, in which a pelvic fracture was diagnosed at our institution from 1974-1993, were reviewed. Children ages < or = 16 years and treated as in-patients were included in this study. The fractures were classified according to the AO-Classification. 47 patients (87.0%) had concomitant injuries. The mean Polytrauma Score was 23.7 (mean Injury Severity Score 30.5). Nine Children sustained an open pelvic fracture with rectal and/or vaginal tear. 15 genitourinary lesions were found in 13 children. 18 patients underwent laparotomy. A large pelvic/retroperitoneal hematoma was found in 11 cases. There were 7 liver lacerations, 7 splenic injuries, 2 mesenteric tears, 2 kidney injuries and 1 small bowel lesion. Eight children (14.8%) died with 5 of them due to retroperitoneal or/and abdominal bleeding complications. A recent follow-up examination (81.8%) with a mean follow-up of 11.3 years showed that long-term morbidity usually was attributed to pelvic concomitant injuries.

[Bilhemia--a review of diagnosis and therapy]. / Die Bilhämie--ein Uberblick über Diagnostik und Therapie.

Bilhemia is a rare complication after liver injuries with high mortality. Clinical signs are rapid increase of direct and total bilirubin up to extreme values and increase of bile acids in serum. The reason is an intrahepatic connection between biliary and venous system. The bilio-venous fistula can be shown by ERCP and retrograde cholangiography via T-drainage. Localisation can be ensured by ultrasonography und computertomography. Treatment consists in resection of bilio-venous fistula, tamponade of intrahepatic cavities by use of a net of polyglactin-910 (Vicryl) or polyglycolic acid (Dexon) or sucking T-drainage.

[Fulminant necrotizing fasciitis secondary to Crohn's disease]. / Fulminante Fasciitis necroticans bei Morbus Crohn-assoziiertem Verlauf.

Necrotizing fasciitis is a life-threatening infection, commonly caused by group A streptococci, which has to be treated by surgical exploration and debridement during the first 24 h. Clinical clues are severe pain, in some cases followed by the appearance of bullous formations, and the detection of gas in the soft tissues by computed tomography or MRI. In addition to that, the infection is characterized by rapid inflammatory progression, producing a highly life-threatening situation. Diagnosis is finally based on surgical exploration obtaining specimens for culture and histopathologic examination. Debridement and exploration, in some cases amputation of the extremity, are indicated as soon as possible. Antibiotic therapy increases efficacy too, but there is no substitute for surgical treatment. Inflammatory bowel disease (Crohn's disease in this case) followed by necrotizing fasciitis is rarely mentioned in the literature. Therapeutic management in a situation of immunosuppression is discussed by illustration of an actual case.