The ACTIV study: acupuncture treatment in provoked vestibulodynia.

INTRODUCTION: Provoked vestibulodynia (PVD) is a distressing genital pain condition affecting 12% of women. Treatment modalities vary and although vestibulectomy has the highest efficacy rates, it is usually not a first-line option. Acupuncture has a long history in the traditional Chinese medicine (TCM) system and operates on the premise that pain results from the blockage or imbalance of important channels. The main principle of treatment is to move Qi and blood to cease genital pain. AIM: To explore effect sizes and feasibility in a pilot study of acupuncture for women with PVD. METHODS: Eight women with PVD (mean age 30 years) underwent 10 1-hour acupuncture sessions. Specific placement of the needles depended on the woman's individual TCM diagnosis. TCM practitioners made qualitative notes on participants' feedback after each session. Main Outcome Measures. Self-reported pain (investigator-developed), pain-associated cognitions (Pain Catastrophizing Scale [PCS], Pain Vigilance and Awareness Questionnaire), and sexual response (Female Sexual Function Index) were measured before and after treatment sessions 5 and 10. Qualitative analyses of TCM practitioner notes were performed along with one in-depth case report on the experience of a participant. RESULTS: A repeated measures analysis of variance revealed significant decreases in pain with manual genital stimulation and helplessness on the PCS. An examination of effect sizes also revealed strong (though nonsignificant) effects for improved ability to have intercourse and sexual desire. Qualitative analyses were overall more positive and revealed an improvement in perceived sexual health, reduced pain, and improved mental well-being in the majority of participants. CONCLUSIONS: Effect sizes and qualitative analyses of practitioner-initiated interviews showed overall positive effects of acupuncture, but there were statistically significant improvements only in pain with manual genital stimulation and helplessness. These findings require replication in a larger, controlled trial before any definitive conclusions on the efficacy of acupuncture for PVD can be made.

Non-functioning retroperitoneal abdominal schwannoma.

There are less than 150 cases of non-functioning retroperitoneal abdominal schwannoma (NRS) reported. Hormonal assay is crucial in confirming the diagnosis of NRS, as manipulation of a functional retroperitoneal paraganglioma will instigate an abrupt liberation of catecholamines, resulting in devastating consequences. We report the case of 42-year-old woman who presented with headache, night sweats and abdominal discomfort. Cross-sectional imaging demonstrated a retroperitoneal mass adherent to the aorta and inferior vena cava but biochemical testing of blood and urine was negative for metanephrines and normetanephrines. She underwent successful tumour resection via laparotomy, as location increased the complexity and risk of laparoscopic resection.

Profiling markers of prognosis in colorectal cancer.

PURPOSE: Colorectal cancer is one of the most common forms of cancer in developed nations and the incidence of this disease is increasing. There is a need to further stratify prognostically distinct groups of colorectal cancer, and the purpose of this study was to identify prognostically significant immunohistochemical marker profiles in colorectal cancer. EXPERIMENTAL DESIGN: In this study, a range (n = 23) of markers [pRb, p16, p21, p27, p53, proliferating cell nuclear antigen, cyclin D1, bcl-2, epidermal growth factor receptor, C-erb-B2, topoisomerase-I, liver fatty acid-binding protein, matrix metalloproteinases (MMP) 1-3, 7, 9, and 13, MT1-MMP, MT2-MMP, and tissue inhibitors of MMP 1-3] of putative prognostic significance have been investigated by immunohistochemistry on formalin-fixed, wax-embedded sections in a series (n = 90) of stage III (Dukes C) colorectal cancers. An immunohistochemical score based on the intensity of immunoreactivity and, where relevant, the proportion of immunoreactive cells was established for each marker. RESULTS: Unsupervised two-dimensional hierarchical cluster analysis identified three distinct cluster groups (designated groups 1-3) with different marker profiles. There were significant survival differences between groups 1 and 2 (log rank = 11.48; P = 0.0007) and between groups 1 and 3 (log rank = 8.32; P = 0.0039). Multivariate analysis showed that the complete marker profile was independently the most significant prognostic factor (hazard ratio, 2.27; 95% confidence interval, 1.15-4.48; P = 0.004). CONCLUSIONS: This study has identified an immunohistochemical marker profile of colorectal cancer and showed that it is an independent indicator of prognosis in this type of cancer.

Cytochrome p450 profile of colorectal cancer: identification of markers of prognosis.

PURPOSE: The cytochromes P450 (P450) are a multigene family of enzymes with a central role in the oxidative metabolism of a wide range of xenobiotics, including anticancer drugs, carcinogens, and endogenous compounds. The purpose of this study was to define the P450 profile of colorectal cancer and establish the prognostic significance of expression of individual P450s in colorectal cancer. EXPERIMENTAL DESIGN: Immunohistochemistry for a panel of 23 P450s was done on a colorectal cancer tissue microarray consisting of 264 primary colorectal cancers, 91 lymph node metastasis, and 10 normal colorectal samples. The intensity of immunoreactivity in each sample was established by light microscopy. RESULTS: The most frequently expressed form of P450 in normal colon was CYP3A4. In primary colorectal cancer, several P450s (CYP1B1, CYP2S1, CYP2U1, CYP3A5, and CYP51) were present at a significantly higher level of intensity compared with normal colon. P450 expression was also detected in lymph node metastasis and the presence of several P450s (CYP1B1, CYP2A/2B, CYP2F1, CYP4V2, and CYP39) in the lymph node metastasis strongly correlated with their presence in corresponding primary tumors. The presence of strong CYP51 (log-rank = 12.11, P = 0.0005) or strong CYP2S1 (log-rank = 6.72, P = 0.0095) immunoreactivity were associated with poor prognosis. CYP51 was also an independent marker of prognosis (P = 0.009). CONCLUSIONS: The expression of individual P450s has been established in colorectal cancer. Several P450s show increased expression in colorectal cancer. High expression of CYP51 or CYP2S1 were associated with poor prognosis and CYP51 is an independent marker of prognosis.

An introduction to laser-based tissue microdissection techniques.

The development and application of laser-based tissue microdissection techniques has provided a major impetus to the sensitive and specific molecular analysis of solid tissues and tumors. This chapter provides an overview of the different laser-based microdissection systems and an introduction to the principles involved in the function and applications of these individual systems.

Laser capture microdissection and colorectal cancer proteomics.

The ability to define protein profiles of normal and diseased cells is important in understanding cell function. Laser capture microdissection permits the isolation of specific cell types for subsequent molecular analysis. In this study we have established conditions for obtaining proteomic information from laser capture microdissected colorectal cancer cells. Laser capture microdissection was performed on toluidine blue-stained frozen sections of colorectal cancer. Proteins were solubilized from microdissected cells and the solubilized proteins were separated by two-dimensional gel electrophoresis: protein spots were characterized by peptide mass mapping using matrix assisted laser desorption ionization-time of flight mass spectrometry. Proteins isolated from laser capture microdissected tissue retained their expected electrophoretic mobility and peptide mass mapping was also unaffected. The ability to study the protein expression profile of specific cell types will allow for the identification of novel disease markers and therapeutic targets and also provide for the enhanced understanding of pathogenetic mechanisms.

Matrix metalloproteinase/tissue inhibitors of matrix metalloproteinase phenotype identifies poor prognosis colorectal cancers.

PURPOSE: The matrix metalloproteinases (MMPs) are a family of proteolytic enzymes involved in tumor invasion; several individual members of which have been implicated in tumor prognosis. These enzymes and their physiologic inhibitors, the tissue inhibitors of matrix metalloproteinases (TIMPs), act in a coordinated manner to form an integrated system. Therefore, to understand their role in tumor invasion, it is necessary to evaluate them collectively. EXPERIMENTAL DESIGN: In this study all of the major members of the matrix metalloproteinase (MMP-1, MMP-2, MMP-3, MMP-7, MMP-9, MMP-13, MT1-MMP and MT2-MMP)/tissue inhibitor of matrix metalloproteinase (TIMP-1, TIMP-2, and TIMP-3) system have been investigated by immunohistochemistry in a series (n = 90) of stage III (Dukes' C) colorectal cancers. An immunohistochemical score based on the intensity of immunoreactivity and proportion of immunoreactive cells was established for each MMP and TIMP. RESULTS: The MMP/TIMP profile defined by hierarchical cluster analysis of the immunohistochemical score identifies a distinct group of colorectal cancers with poor prognosis (log-rank test, 12.22, P = 0.0005). The median survival time of patients in this survival group was 18 months compared with a median survival of 49 months in the "good" survival group. Multivariate analysis showed that this profile was independently the most significant prognostic factor (P = 0.001). CONCLUSIONS: This study has identified that the MMP/TIMP profile is an independent indicator of poor prognosis in colorectal cancer.

Topoisomerase I protein expression in primary colorectal cancer and lymph node metastases.

Topoisomerase I (topo I) is an important target for the treatment of malignant disease, especially colorectal cancer. Because there is little information on the expression of topo I in colorectal tumors, this study evaluated and characterized topo I protein expression in primary colorectal cancer and lymph node metastases and studied the association between topo I protein expression and clinicopathologic data, p53 status, and proliferating cell nuclear antigen (PCNA) status. Immunohistochemistry assay was performed for topo I protein expression in 249 primary human colorectal cancer and 42 paired lymph node metastasis samples. Topo I expression was described as the percentage of cells staining positive for topo I, along with the intensity and localization of the staining. Clinicopathologic data (sex, age, Dukes' stage, differentiation grade, survival status), p53 status, and PCNA status were statistically analyzed for association with topo I protein expression. Topo I expression in paired primary lymph node metastases were studied for concordance. Topo I protein expression was detected in 127 (51%) samples, including 24.4% with >50% positive tumor cells. The majority had nuclear (70.1%) or nuclear and cytoplasmic staining (17.3%). A higher percentage of cells expressing topo I in primary colorectal cancer was significantly associated with advanced age (P =.040). Patients with rectal cancer had greater topo I expression than those with colon tumors (P =.029). No significant correlation was found between topo I protein expression and sex, Dukes' stage, differentiation grade, survival status, p53 status, and PCNA status. Concordance in topo I staining between primary and lymph node metastases was observed in 33 of 42 cases (P =.029). This suggests that the activity of topo I inhibitors will not differ across various tumor stages, pathology, and patient gender. p53 and PCNA status do not appear to influence topo I expression, and topo I has no apparent association with the acquisition of a metastatic phenotype. Topo I expression now needs to be evaluated in patients undergoing topo I-inhibitor therapy, to better define the role of this protein as a predictive marker.

Primary colorectal tumour is not an accurate predictor of thymidylate synthase in lymph node metastasis.

Analysis of tumour markers is helping to predict individual patient response to chemotherapy. However, the difficulties in obtaining metastatic disease samples has led to a reliance on assessment of primary tumour, with little data on its predictive ability. This study assessed thymidylate synthase (TS), a target for the commonly used drug 5FU, in 42 paired primary colorectal tumour and lymph node metastasis. High TS staining was seen in 63% of primary colon tumour cells and 81% of the secondary lymph node. Primary tumour did not have significant predictive power for secondary tumour samples (kappa=0.125; p=0.38). There was no significant relationship between TS staining and expression of G1/S cell cycle proteins p21, p27, p53, cyclin D1, proliferating cell nuclear antigen (PCNA) and retinoblastoma protein (Rb) (p>0.05 in all cases). Discordance in TS protein levels between primary and secondary tumours demonstrates the danger of predicting outcome after chemotherapy in metastatic colorectal cancer from the primary tumour.

Heterotopic ossification of the abdominal wall.

INTRODUCTION: Heterotopic ossification is a rare, benign condition which occurs when bone develops in tissues that do not normally ossify. PRESENTATION OF CASE: We herein report the case of a 73-year-old gentleman who underwent a laparotomy for a large splenic flexure tumour considered unresectable at initial intervention. Following delivery of chemotherapy, he was referred for a second opinion and the tumour with adjacent structures was removed at a subsequent laparotomy. A segment of abnormal hard tissue present in the abdominal wall was also excised. Histopathology revealed metaplastic bone deposition. DISCUSSION: Heterotopic ossification may occur at various sites and is a recognised but exceedingly infrequent sequela of abdominal surgery. CONCLUSION: This case highlights clinical, aetiological and histopathological features of this rare finding.

The structure, regulation, and function of human matrix metalloproteinase-13.

Matrix metalloproteinase-13 (MMP-13) is a proteolytic enzyme that belongs to a large family of extracellular matrix-degrading endopeptidases that are characterized by a zinc-binding motif at their catalytic sites. MMP-13 has a key role in the MMP activation cascade and appears to be critical in bone metabolism and homeostasis. It also has an important role in tumor invasion and metastasis. This commentary provides a detailed overview of the regulatory mechanisms, structure, and function of human MMP-13 and highlights the key factors involved in the biology of this important molecule.

New insights into the roles of matrix metalloproteinases in colorectal cancer development and progression.

This review outlines new concepts that are emerging for the functions of matrix metalloproteinases in colorectal cancer development and progression. The two main concepts that will be discussed are the role of matrix metalloproteinases in the early stages of colorectal tumour development and the functional mechanisms by which matrix metalloproteinases contribute to colorectal tumour invasion and metastasis. The matrix metalloproteinases are a group of enzymes, which have been best characterized for their ability to degrade extracellular matrix proteins and thus they have been extensively studied in tumour invasion. It is now becoming recognized that the matrix metalloproteinases have key roles in a variety of biological processes that are distinct from their well-defined role in matrix degradation. This group of enzymes has been shown to interact with a broad range of non-matrix proteins including growth factors and their receptors, mediators of apoptosis, and cell adhesion molecules. The elucidation of novel biological roles for the matrix metalloproteinases also challenges the current predominant concept of matrix metalloproteinases as enzymes only involved in matrix degradation. Recent studies have shown that several matrix metalloproteinases, especially matrilysin (MMP-7), interact with the specific molecular genetic and signalling pathways involved in colorectal cancer development. In particular, matrilysin is activated at an early stage of colorectal tumourigenesis by the beta-catenin signalling pathway. Furthermore, studies are now elucidating specific mechanisms by which individual matrix metalloproteinases, especially membrane-type matrix metalloproteinases, interact with specific cell adhesion molecules and cytoskeletal proteins and thus contribute dynamically to colorectal tumour invasion.

The candidate oncogene ZNF217 is frequently amplified in colon cancer.

In this study we have defined the changes in gene copy number of the candidate oncogene ZNF217 during colon cancer development and progression. This gene is mapped to chromosome 20q and lies within 20q13.2, a region which we have previously shown to be highly amplified in colorectal cancer by comparative genomic hybridization. The gene copy number of ZNF217 was assessed in 100 colon carcinomas (19 Dukes' A, 42 Dukes' B and 39 Dukes' C), 13 colonic adenomas and 10 normal colon samples. DNA extracted from laser microdissected cells was amplified by multiplex real-time PCR at two distinct gene loci--ZNF217 and beta-globin (control gene)--on an ABI7700 sequence detection system. Of the 100 colon cancers studied, 61 showed some level of amplification of ZNF217, 15 had loss of ZNF217, while 24 were diploid. All the adenomas except one were diploid. In this study we have found that ZNF217 amplification is a frequent event in colon cancer and that the extent of its amplification varies markedly between tumours (range 3-13 copies). There was a trend toward poorer survival in patients whose cancers had either gain or loss of ZNF217.

Analysis of key cell-cycle checkpoint proteins in colorectal tumours.

Aberrations in the components of cell-cycle checkpoints are a common feature of many tumours and several have been shown to have prognostic significance in colorectal cancer. In this study, seven components of cell-cycle control [cyclin D1, retinoblastoma (pRb), p21, p27, p16, p53, and proliferating cell nuclear antigen (PCNA)] were examined in a large series of well-characterized colorectal adenocarcinomas using immunohistochemistry to ascertain co-regulation and influence on survival. The majority (92%) of the tumours had abnormal staining of > or =2 cell-cycle control factors. Expression of cyclin D1 protein was correlated with both p21 (p<0.001) and p27 (p=0.033), suggesting co-regulation of these proteins in colorectal tumours. Only cyclin D1 (p=0.048) and p53 (p=0.025) were directly associated with PCNA levels, suggesting a more important role in the proliferative capacity of tumour cells. Significant associations between cell cycle-related proteins and clinicopathological data were observed: cyclin D1 and p53 proteins were correlated with patient age (p=0.042 and p<0.001, respectively) and p53 (p=0.01) and p21 (p=0.024) proteins were associated with tumour site. Expression of cyclin D1 protein was the only protein examined that was related to improved outcome in these patients (p=0.0266), but it was not an independent predictor of survival. These results suggest that loss of control of cell-cycle checkpoints is a common occurrence in colorectal tumours and may be an important therapeutic target.