Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer.

BACKGROUND: Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long-term outcomes, particularly those related to rectal cancer, are limited. The results of long-term follow-up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented. METHODS: A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long-term follow-up data were analysed to determine differences in survival outcomes and recurrences for intention-to-treat and actual treatment groups. RESULTS: Median follow-up of all patients was 62·9 (interquartile range 22·9 - 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease-free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019). CONCLUSION: Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer.

Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer.

INTRODUCTION: The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented. METHODS: Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve. RESULTS: No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results. CONCLUSION: The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results. REGISTRATION NUMBER: ISRCTN74883561 (http://www.controlled-trials.com).

Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial.

BACKGROUND: This study investigated adhesive intestinal obstruction (AIO) and incisional hernia (IH) in patients undergoing laparoscopically assisted and open surgery for colorectal cancer. METHODS: In a case-note review of patients randomized to the Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial, primary and key secondary endpoints were AIO and IH admission rates respectively. RESULTS: Of 411 patients, 11 were admitted for AIO: four (3.1 per cent) of 131 patients in the open arm of the trial versus seven (2.5 per cent) of 280 in the laparoscopic arm (difference 0.6 (95 per cent confidence interval (c.i.) - 2.9 to 4.0) per cent). Thirty-six patients developed IH: 12 (9.2 per cent) after open versus 24 (8.6 per cent) after laparoscopic surgery (difference 0.6 (95 per cent c.i. - 5.3 to 6.5) per cent). Results by actual procedure showed higher AIO and IH rates in the 24.5 per cent of patients who converted from laparoscopic to open surgery (AIO: 2.3, 2.0 and 6 per cent; IH: 8.6, 7.4 and 11 per cent-for open, laparoscopic and converted operations respectively). CONCLUSION: Although this study has not confirmed that laparoscopic surgery reduces rates of AIO and IH after colorectal cancer surgery, trends suggest that a reduction in conversion to open surgery and elimination of port-site hernias may produce such an effect. Registration number for CLASICC trial: ISRCTN74883561 (http://www.controlled-trials.com).

Expression of cyclin D2 is an independent predictor of the development of hepatic metastasis in colorectal cancer.

INTRODUCTION: Cyclin D1 has been implicated in the progression of several cancers by virtue of its influence on progression of the G1/S phase of the cell cycle. However, little is known about the possible roles of cyclin D2 and D3 in colorectal cancers (CRCs). METHOD: We investigated the expression levels of cyclin D2 and D3 in 84 CRC specimens. Antigen expression was determined by immunohistochemical analysis of cyclin D1, D2, D3, p16INK4A and Ki67 on tissue microarrays constructed using core samples from tumour centres and margins. RESULTS: For the whole cohort, expression of cyclin D2 at the margin was associated with vascular invasion (P = 0.039), lymph node metastasis (P = 0.020) and liver metastasis (P < 0.001). In patients with stage I and II tumours (n = 84), elevated cyclin D2 and D3 were associated with vascular invasion (P = 0.014 and 0.028 respectively), liver metastasis (P = 0.001 and 0.007 respectively) and reduced disease specific survival (Cyclin D2, P < 0.022). No association was noted between the proliferative marker Ki-67 and the D-type cyclins. CONCLUSION: These findings suggest that cyclin D2 expression at the invasive margin of CRCs is associated with liver metastasis and may serve as a useful prognostic marker and indicator of the need for adjuvant therapy.

Laser microdissection expression profiling of marginal edges of colorectal tumours reveals evidence of increased lactate metabolism in the aggressive phenotype.

BACKGROUND: The morphology of the invasive margin in colorectal cancer can be described as either pushing or infiltrative. These phenotypes carry prognostic significance, particularly in node negative disease, and provide an excellent model for the study of invasive behaviour in vivo. METHODS: The marginal edges of 16 stage-matched tumours exhibiting these contrasting growth patterns were microdissected. The extracted mRNA was amplified and hybridised to a 9546 feature oligonucleotide array. Selected differentials were validated using real-time polymerase chain reaction and the protein product was interrogated by using immunohistochemistry. RESULTS: After stringent quality control and filtering of data generated, 39 genes were identified as being significantly differentially expressed between the two types of marginal edge. Several genes involved in cellular metabolism were identified as differentials including lactate dehydrogenase B (LDHB) and modulators of glucose transport. CONCLUSIONS: The LDH expression profile differs between the invasive phenotypes. A hypothesis is proposed in which altered metabolism is a cause of contrasting invasive behaviour independent of the hypoxia-inducible factor mediated hypoxic response, consistent with the Warburg phenomenon.

Enhanced hot-electron localization and heating in high-contrast ultraintense laser irradiation of microcone targets.

We report experiments demonstrating enhanced coupling efficiencies of high-contrast laser irradiation to nanofabricated conical targets. Peak temperatures near 200 eV are observed with modest laser energy (10 J), revealing similar hot-electron localization and material heating to reduced mass targets (RMTs), despite having a significantly larger mass. Collisional particle-in-cell simulations attribute the enhancement to self-generated resistive (approximately 10 MG) magnetic fields forming within the curvature of the cone wall, which confine energetic electrons to heat a reduced volume at the tip. This represents a different electron confinement mechanism (magnetic, as opposed to electrostatic sheath confinement in RMTs) controllable by target shape.

Patient factors influencing conversion from laparoscopically assisted to open surgery for colorectal cancer.

BACKGROUND: Intraoperative conversion from laparoscopically assisted to open surgery for colorectal cancer is thought to be influenced by several patient factors. Analysis of the Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) Trial data aimed to identify these risk factors. METHODS: Of 488 laparoscopically assisted procedures attempted, 143 (29.3 per cent) were converted to open operation. Patient factors considered in multivariable analyses were age, sex, previous abdominal incisions, body mass index (BMI), tumour site, tumour diameter, pathological tumour (pT) and pathological node (pN) stage, extent of tumour spread from the muscularis propria, liver and peritoneal metastases, and American Society of Anesthesiologists (ASA) grade. As BMI was missing for 30.7 per cent of patients, two approaches were employed: one considered BMI as a possible risk factor and one did not. RESULTS: When BMI was taken into consideration, male sex (odds ratio (OR) 2.07; P = 0.020), BMI (OR 1.10; P = 0.006) and extent of tumour spread from the muscularis propria (OR 1.08; P < 0.001) were independent predictors of conversion. When BMI was not considered, extent of tumour spread (OR 1.07; P < 0.001) and male sex (OR 2.05; P = 0.004) were again identified, as were tumour site (OR 2.11; P = 0.005) and ASA grade (II versus I, OR 0.92; III versus I, OR 2.74; P = 0.012). CONCLUSION: Intraoperative conversion is more likely with larger BMI, in men, patients with rectal cancer, those graded ASA III or when there is greater local tumour spread.

Successful outcome following resection of a pancreatic liposarcoma with solitary metastasis.

Liposarcomas are rare soft tissue tumors, commonly affecting the lower limbs and less commonly the retroperitoneum. Although other organs can be affected, the pancreas is one of the rarest, and metastasis at presentation has never been reported. We describe the case of a 76-year-old gentleman presenting with abdominal pain and an abdominal mass. Imaging confirmed a primary tumor in the body and tail of the pancreas, with a metastatic deposit in the mesentery adjacent to the second part of the duodenum. Biopsy confirmed a liposarcoma, and subsequently a complete surgical excision was achieved. He then received adjuvant radiotherapy and has remained disease free for the next 26 mo.

Assessing the relative costs of standard open surgery and laparoscopic surgery in colorectal cancer in a randomised controlled trial in the United Kingdom.

The role of laparoscopic surgery for the treatment of colorectal cancer is being explored in a multi-centre, randomised clinical trial in the UK, the MRC CLASICC Trial (Conventional versus Laparoscopic-assisted Surgery in Colorectal Cancer). An important end-point of the trial is the cost-effectiveness of laparoscopic surgery compared with that of conventional open surgery. The economic evaluation of this trial has been modelled on that in a similar trial being conducted in the USA in colon cancer. The aim of this paper is to discuss the rationale for modelling the UK trial on the US trial, and to describe the adaptations necessary for the UK trial. The parallel design of the economic evaluation in both trials will provide a unique opportunity to compare the cost implications of incorporating laparoscopic surgery in the UK and the USA, and to determine any cross-cultural differences. The UK trial will also provide information about the cost-effectiveness of laparoscopic surgery in rectal cancer.

A three-dimensional in-vitro model for the study of peritoneal tumour metastasis.

Peritoneal metastasis is a frequent complication of gastrointestinal malignancy. We have developed a three-dimensional model of the human peritoneum that simulates the metastatic process in vitro. Peritoneal fibroblasts were incorporated into collagen lattices, allowed to contract, then overlaid with mesothelial cells. Scanning and transmission electron microscopy showed the model to have similar physical properties to human peritoneum. Mesothelial expression of the beta1 integrin family, the basement membrane proteins fibronectin, laminin, collagen types III and IV, and the cell adhesion molecules ICAM-1, VCAM-1 and PECAM were assessed and showed similar results to in vivo tissue. Gastrointestinal tumour cells seeded onto the model exhibited mesothelial adhesion, cell spreading and vesicle formation, and invasion of the mesothelial monolayer on scanning electron microscopy. Two distinct patterns of tumour cell growth were observed using light microscopy: a superficial spreading layer, and discrete invasive deposits. Invasion was accompanied by disruption of the mesothelial monolayer, degradation and re-orientation of the matrix, and rudimentary tumour cell differentiation. We believe the use of this in vitro peritoneal model will facilitate the study of the molecular mechanisms involved in the metastatic process.

The candidate tumour suppressor gene, ING1, is retained in colorectal carcinomas.

ING1 plays a critical role in regulating cell cycle progression and susceptibility to apoptosis. The present study aimed to investigate allelic deletion of, and mutations within, the ING1 gene in colorectal carcinomas. Genomic DNA was extracted from 29 sporadic colorectal carcinomas and samples of adjacent normal mucosa. Losses of heterozygosity of two polymorphic dinucleotide repeat markers close to the ING1 locus at chromosome 13q32-34 were analysed. Single-stranded conformational polymorphisms of polymerase chain reaction amplified regions within the coding sequence of ING1 were examined. Microsatellite instability was noted in 5 (17%) colorectal carcinomas; this confirms selection of a subject sample representative of the population. Neither losses of heterozygosity nor changes in electrophoretic mobility of single-stranded polymerase chain reaction products were detected in any colorectal carcinoma. Thus, in common with tumour suppressor genes such as RB and BRCA2 on chromosome 13q, ING1 appears to be retained intact in colorectal carcinomas.

Differential responses to chemoimmunotherapy in patients with metastatic malignant melanoma.

An open, multicentre non-randomised study was performed to evaluate the activity and toxicity of combination chemoimmunotherapy, consisting of cisplatin, interleukin-2 and interferon-alpha, in metastatic malignant melanoma. Between March 1992 and September 1993, 28 patients with pathologically proven metastatic malignant melanoma, bidimensionally measurable disease and an Eastern Co-operative Oncology Group score < or = 1 were treated with the combination chemoimmunotherapy. The regimen consisted of cisplatin (100 mg/m2 on day 0), interleukin-2 (Proleukin, Chiron, Middlesex, U.K.) 18 x 10(6)IU/m2/d continuous intravenous infusion on days 3-7 and 17-22, with interferon-alpha (Roferon-A, Roche, Hertfordshire, U.K.) 9 x 10(6) U/d subcutaneously on days 3, 5, 7, 17, 19, 21 during the interleukin-2 infusions. The treatment cycle lasted 28 days. Among 27 assessable patients, 5 patients achieved partial responses, for an overall response rate of 18% (95% CI 6-37%). Median progression-free survival was 44 days (range 8-279) and median overall survival was 264 days (range 41-1432). Differential responses were noted in 41% of patients and responses were more frequent in non-visceral disease (skin, lymph node and soft tissue disease) (P = 0.04). These results indicate that differential responses to chemoimmunotherapy are common in patients with metastatic melanoma. This may account for the broad range of response rates reported in the literature.

Simplified quantitation of cytotoxicity by integration of specific lysis against effector cell concentration at a constant target cell concentration and measuring the area under the curve.

Experience with the lytic unit (LU) as a measure of cytolytic efficiency has indicated that its accuracy is limited, even if expressed in a logarithmic format. A new method of quantifying cytotoxicity from effector dilution assays is proposed: the area under the curve (AUC) of the Ig (E/T) ratio vs. percentage cytotoxicity plot, gives an overall measure of lytic efficiency. The AUC derived from the Briggs-Haldane kinetic model is dependent on both the kinetic parameters that determine the efficiency of effector cells (the Michaelis constant KM and the catalytic constant kcat). AUC provides an index of inhibition or stimulation of lysis, independent of whether the modulation is kinetically competitive, uncompetitive or the same AUC value. In practice the method may be applied to interpret simple cytotoxicity assay data, where effector cells are being used in standardised screening for modifiers of the cytolytic response. Illustrative data of LAK cytotoxicity influenced by dose of the LAK response modifiers IL-2, TGF beta, TDSF and 5-FU, show different relationships between lytic units, KM and AUC. These data also show a wide range in the Hill coefficient and would be consistent with a cooperative effect dependent on the effector cell efficacy. This confirms that using LU as a simple measure of cytolytic efficiency could be erroneous and suggest that cytolytic response modifiers can produce a variety of kinetic changes. The AUC method, however, provides a comparative measure of efficiency in these situations, independent of mechanism.

Generation of mouse cytolytic T cells against human concanavalin A blasts. Involvement of non-MHC determinants in the antihuman response.

Normal human peripheral blood lymphocytes (PBL) are incapable of eliciting a significant murine cytotoxic T cell (CTL) response either in vivo or in vitro. However, using a primary in vivo and secondary in vitro stimulation with lectin-activated PBL, Thy-l-positive cytotoxic cells were produced. The antigens that these T-cells identified were independent of the serum source employed in the culture medium used for lectin activation. The cells always preferentially lysed cells from the immunizing individual but were also able to lyse target cells from unrelated individuals, regardless of HLA identity or disparity with the immunizing individual, suggesting the presence of both a private (possibly class II antigens) and public specificity. Using the lymphoblasts of different family members as immunogen and targets there was slight preference of the CTL for HLA-identical targets with no apparent difference between the lysis exhibited against semiidentical and nonidentical subjects. Monoclonal antibodies directed against HLA DR or beta 2-microglobulin failed to inhibit the cytotoxicity observed in these experiments. It is suggested that under these circumstances of xenogeneic education, non-MHC-restricted T cells may become cytotoxic, and this model may serve as a useful probe to investigate some of the less-well-defined aspects of the T cell repertoire.

The response to interferon of NK and K cells from conventionally immunosuppressed and cyclosporine-treated renal allograft recipients.

Interferon is a potent stimulator of natural killer (NK) and killer (K) cell activity in human beings, both these cytotoxic functions representing host defense mechanisms against viral infections and lymphoid malignancy. Both NK and K cell functions are markedly impaired in conventionally immunosuppressed allograft recipients but coincubation of lymphocytes from these patients with purified human lymphoblastoid interferon considerably augments both these activities. Cyclosporine immunosuppression causes only a moderate, but significant, impairment of NK activity--but K cell activity appears to be normal. Again IFN increases NK activity of the lymphocytes of these patients but produces a fall or only moderate increases in K cell activity. We conclude that these data support the functional distinction between NK and K cells and suggest that immunosuppressive agents act at the pre-NK/K cell stage of maturation, though possibly via different mechanisms.

Changes in human natural killer activity early and late ater renal transplantation using conventional immunosuppression.

The natural killer (NK) cell activity of human peripheral blood lymphocytes falls following major surgical procedures including renal transplantation but in non-immunosuppressed individuals returns to normal levels within the first 72 hr after operation. In renal allograft recipients, if this early postoperative fall is excluded from the analysis, NK cell function appears to follow changes in allograft function, suggesting that in vivo, as has been reported in vitro, NK activity is generated during activation of the alloreactive process. In an additional group of patients whose grafts were functioning for between 3 and 102 months after cadaveric renal transplantation using conventional immunosuppression, NK function was depressed in comparison with that of control subjects. However, some patients who were more than 48 months post-transplant had normal NK cell activity. Collectively, these results suggest that NK cell function may recover despite the continued administration of conventional immunosuppressive agents.

Clinical economics review: the health-care economic implications of minimal access gastrointestinal surgery.

This article reviews some of the health-care economic data that have been acquired in recent assessments of minimal access surgery of the digestive tract, with particular reference to laparoscopic cholecystectomy and laparoscopic surgery for gastro-oesophageal reflux disease.

Retrospective study of histological features of acute rejection in renal allografts and comparison with circulating T cell populations.

The histological severity of acute rejection in renal allografts was determined for 39 rejection episodes in 30 renal transplant recipients. Data were compared with the peripheral blood T cell subset ratios measured before and at the onset of the rejection episode. T cell subset ratios showed no correlation with the histological severity of rejection, nor with the reversibility of the rejection episode. The grade of histological rejection on biopsy was predictive of graft survival. We conclude that renal biopsy remains the best method for determining the severity and outcome of acute allograft rejection episodes.

Neutrophil activation, vascular leak toxicity, and cytolysis during interleukin-2 infusion in human cancer.

BACKGROUND: Recombinant interleukin-2 (rIL-2) therapy for advanced malignancy is usually associated with a vascular leak syndrome (VLS) similar to that seen in severe sepsis. We investigated the possibility that the IL-2-induced VLS may be associated with the presence of circulating activated polymorphonuclear (PMN) leukocytes as occurs in sepsis syndrome. METHODS: Estimation of phenotypic (CD11B/CD18) and functional (H2O2, HOCl) up-regulation of circulating neutrophil activity was made by fluorescence-activated cell sorter analysis and ultraviolet spectrophotometry. Associated systemic cytokine enhancement tumor necrosis factor-alpha by enzyme-linked immunosorbent assay for bioactivity and parallel estimation of clinical evidence of vascular leak syndrome were also studied in human subjects with advanced cancer receiving therapeutic doses of rIL-2. RESULTS: The present studies confirm previous reports that tumor necrosis factor-alpha is released into the circulation during infusional therapy with rIL-2. In addition, we have found that this is accompanied by both phenotypic (up-regulation of CD11b/CD18 adhesion receptor expression) and functional (hydrogen peroxide and hypochlorous acid production) evidence of potent PMN activation. Furthermore, patients showing disease response to treatment have significantly greater production of PMN oxidants. CONCLUSIONS: These data suggest that the VLS seen during rIL-2 infusion in human beings may be attributable to PMN mechanisms similar to those invoked during severe sepsis. Consequently, this study may provide further insights into the mechanism of rIL-2's therapeutic action in advanced malignant disease.

Primary adenocarcinoma in an ileostomy: a late complication of surgery for ulcerative colitis.

In the 1950s the treatment of ulcerative colitis was revolutionized by Brooke by way of a colectomy combined with an eversion ileostomy. This procedure is known to be associated with a number of complications that include skin excoriation, stenosis, intestinal obstruction, retraction or prolapse of the stoma, abscess and fistula formation, and ileitis. However, adenocarcinoma arising in the abnormally placed small intestinal mucosa 20 years or more after the initial operation is being increasingly recognized and reported. This article describes one such case and includes an extensive review of the current world literature on the subject of adenocarcinoma arising as a late complication of operation for ulcerative colitis.