Expression of DSG1 and DSC1 are prognostic markers in anal carcinoma patients.

BACKGROUND: Our purpose was to investigate if dysregulation of cell adhesion molecules could be linked to prognosis in squamous cell carcinomas (SCCs) of the anal region. METHODS: Protein expression of desmoglein-1 (DSG1), desmocollin-1 (DSC1) and E-cadherin was studied by immunohistochemistry in a cohort of 53 anal carcinoma patients treated by radiation alone or combined with 5-fluorouracil and mitomycin C. RESULTS: Univariate analyses identified, among others, negative membranous DSG1 staining (P=0.009), negative cytoplasmic DSC1 staining (P=0.012) and negative DSG1 (membranous)+negative DSC1 (cytoplasmic) staining (P=0.004) to be associated with improved cancer-specific survival (CSS). On multivariate analyses positive DSG1 (membranous)+DSC1 (cytoplasmic) staining (HR 6.95, P=0.044), large tumour size and lymph node metastases (HR 6.44, P=0.004) and radiation without chemotherapy (HR 6.73 P=0.004) were associated with worse CSS. On univariate analysis, improved disease-free survival was associated with negative membranous staining of DSG1 (P=0.047), and negative DSG1 (membranous)+negative DSC1 (cytoplasmic) staining (P=0.025), among others. CONCLUSION: Membrane negativity for DSG1 and cytoplasmic negativity for DSC1 are favourable markers for CSS in SCCs of the anal region.

MicroRNA-15b is induced with E2F-controlled genes in HPV-related cancer.

BACKGROUND: MicroRNAs (miRNAs) are important regulators of cellular processes and are found to be deregulated in many cancers. We here analysed the miRNA expression in anal carcinomas. In a previous study, we found that our anal carcinoma tumours were divided into two groups based on the expression of E2F-regulated genes. Therefore, we searched for miRNAs that could reproduce this grouping. METHODS: A global screen of the miRNA population was performed using real-time quantitative PCR (RT-qPCR) array methods and differentially expressed miRNAs were identified. Real-time-qPCR was used to verify the expression levels of selected miRNAs and genes in a larger collection of biopsies. A siRNA-mediated knockdown of human papilloma virus (HPV)16 E7 in a cervical cell line was performed to assess the effect of E7 on miR-15b. RESULTS: The grouping of tumours into two groups based on the expression of E2F-controlled genes was confirmed in a larger collection of anal carcinoma tumours. The expression of miR-15b was shown to be highly correlated with that of five selected E2F-induced genes (CCNA2, CCNB1, CCNB2, MSH6 and MCM7). A knockdown of HPV16 E7 resulted in decreased levels of miR-15b in Ca Ski cells. CONCLUSION: MiR-15b expression correlates with E2F-regulated genes in anal carcinoma and appears to be part of the E2F-regulatory network.

Rectal cancer with macroscopic peritoneal involvement--clinical challenges and consequences.

OBJECTIVE: In gastrointestinal cancer, serosal involvement indicates advanced disease. We looked at the possible role of clinical peritoneal involvement (CPI) in local recurrences (LRs) and the overall survival of patients with rectal cancer (RC). METHOD: Between 1993 and 2002, 6404 patients were diagnosed with RC. Based on macroscopic findings at surgery and corresponding histological findings, 166 patients (3%) had CPI. Surgery was stratified according to type and extent of operation: as resective or nonresective surgery and as curative (R0) or noncurative (R1 or R2) resection. RESULTS: The presence of CPI was a negative factor for survival with a median of 15 months (95% CI, 12-19) in the presence of CPI compared with 65 months (95% CI, 61-70) without it (P < 0.001). In R0 resections, the median survival was 97 months (95% CI, 90-102) in patients without CPI compared with 48 months (95% CI, 22-74) in patients with CPI (P < 0.001). In R1 or R2 resections, the median survival was 16 months (95% CI, 15-17) in the absence of CPI and 9 months (95% CI, 8-10) in the presence of CPI. The LR rate in patients without CPI was 10.2% compared with 15.7% in patients with CPI (P = 0.022). CONCLUSIONS: Clinical peritoneal involvement is a significant detrimental prognostic factor for the LR of RC and survival in the absence of metastases. Observations from this large national cohort add to what is known about peritoneal involvement. Diagnosed CPI should be taken into consideration when adjuvant treatment strategies are addressed.

Palliative surgery for rectal cancer in a national cohort.

OBJECTIVE: Whether resection of the primary tumour is of benefit to patients with incurable rectal cancer (RC) remains a matter of debate. In this study we analyse prospectively recorded data from a national cohort. METHOD: Among 4831 patients diagnosed with RC between 1997 and 2001, 838 (17%) patients were treated with palliative surgery. Patients were stratified according to disease stage, age and type of surgery. RESULTS: A significantly longer median survival, 12 (range 10-13) months, was observed in patients treated with resection of the primary tumour compared with 5 (range 4-6) months in patients treated with nonresective procedures (P < 0.001). Median survival in months was significantly (P < 0.001) related to age (13; < 60 years of age, 10; 60 to 69 years, 7; 70 to 79 years, 6; >/= 80 years of age). In patients over 80 years, survival was similar regardless of the treatment. Thirty-day mortality varied from 2.5% to 20%, according to age groups. CONCLUSION: The longer survival observed in patients with resection of the primary tumour may partly be explained by patient selection. Elderly patients (>/= 80 years) had a similar survival, irrespective of resection of the primary tumour or not. Careful consideration of the individual patient, extent of disease and treatment-related factors are important in decision-taking for palliative treatment for patients with advanced RC.

Androgen receptors in operable breast cancer: relation to other steroid hormone receptors, correlations to prognostic factors and predictive value for effect of adjuvant tamoxifen treatment.

Steroid hormone receptors have been evaluated as independent prognostic factors as well as predictive factors for endocrine manipulation in the clinical management of breast cancer. The contribution of each receptor or combinations of different receptors remains controversial. In cytosols from 224 patients with operable breast cancer (stages I & II), estrogen receptor (ER), progesterone receptor (PgR) and androgen receptor (AR) content have been measured. An improved AR-assay has been used in order to circumvent some of the problems inherent in other methods. In this study, 91.1% of the patients were classified as AR 'positive' (i.e. greater than or equal to 10 pmol/g). The steroid hormone receptors were significantly correlated (P less than 0.001). Taking the median value of AR as cut-off (50.5 pmol/g), a significantly higher incidence (P = 0.004) of node negative patients was found in the group with a lower AR content. In a multivariate analysis the AR category (median value used as cut-off) was shown to be an independent predictor of the likelihood of axillary metastases (P = 0.001). AR category, however, did not reveal any significant prognostic information concerning relapse free survival. A subpopulation of node positive patients with ER positive tumors, have been included in a randomized trial on the role of tamoxifen as an adjuvant treatment compared with no endocrine treatment. In a multivariate analysis, PgR status was shown to be a single independent prognostic factor (P = 0.016) for relapse free survival in patients with a lower AR content (less than median value). The improved AR assay used in the present study may provide a basis for more correct estimation of the AR content in an individual tumor. The present study suggests that AR analysis and the use of a well-chosen cut-off level may add information about tumor biology to increase our understanding of breast cancer biology and treatment.

Progesterone binding cyst protein in hormone receptor positive breast cancer; a predictive factor for effect of adjuvant tamoxifen treatment.

Progesterone binding cyst protein (PBCP) was measured in breast cancer cytosols from 128 pre- and post-menopausal women with operable node positive (pN+) breast cancer Stage II. All patients were included in a national multicenter study on the effect of adjuvant tamoxifen treatment in hormone sensitive breast cancer, i.e. estrogen receptor content of at least 10 pmol/g cytosol protein. Patients were randomised to receive adjuvant tamoxifen 20 mg once daily for two years or no endocrine treatment. At a median follow-up of 60 months, we found PBCP content in the primary tumor to be an important factor with regard to the effect of adjuvant tamoxifen treatment. The benefit of adjuvant tamoxifen treatment on relapse-free survival and overall survival was confined to the subpopulation of patients with PBCP negative tumors. PBCP should be further evaluated as a predictive factor for the effect of tamoxifen treatment.

Progesterone-binding cyst protein (PBCP) in operable breast cancer: correlations with prognostic factors and predictive value for effect of adjuvant tamoxifen treatment.

Progesterone-binding cyst protein (PBCP) is a secretory protein which has been found in varying concentrations and incidence in cytosols from benign breast tumors, primary breast cancer and metastasis. In order to evaluate its correlation to other prognostic factors, PBCP was analysed in tumor cytosols from 386 women with stage I and stage II breast cancer. The incidence of PBCP negative (i.e. PBCP = 0) tumors was significantly decreased in node negative patients as compared to node positive (p = 0.012). An inverse correlation between estrogen receptor content and PBCP was found (p = 0.001). In a multivariate analysis PBCP category was found to be an independent predictor of the likelihood of axillary nodal involvement (p = 0.015). In spite of this association, PBCP did not reach statistical significance as an independent prognostic factor with regard to relapse-free survival. To evaluate PBCP category as a possible predictive factor for response to adjuvant endocrine treatment, a subpopulation of node positive patients with ER positive tumors was analysed; in patients with PBCP negative tumors, adjuvant treatment with tamoxifen proved to increase the relapse-free survival significantly (p = 0.011). We suggest that PBCP may have a place among other biochemical parameters in breast cancer, to provide an extended basis for understanding of tumor biology and a better selection of patients for endocrine treatment.

Influence of gastric banding on stomach blood supply with or without concurrent splenectomy.

A lethal gastric perforation occurred after a gastric banding procedure, which was complicated with splenectomy. Prompted by this incident, an experimental study was undertaken in which regional blood flow in the stomach was measured in anesthetized cats after gastric banding or splenectomy or both. A fatal course with an extensive ischemic lesion of the stomach near the banding area was seen in all the cats with the combined procedure after 5 to 12 days. Banding alone reduced gastric blood flow within 24 hours, particularly on the greater curvature. Splenectomy also reduced blood flow along the greater curvature within 2 weeks. The combined procedure showed similar flow changes within 24 hours. The implication of these experimental results is that, if the spleen must be removed, the performance of gastric partitioning for morbid obesity should be reconsidered.

Partial gastrectomy for peptic ulcer by the Krønlein method. Long term results 12 years later with particular reference to general health condition and working capacity.

A one-year material of 97 patients was studied 12 years after partial gastrectomy for peptic ulcer. These patients had all been subjected to a standard Billroth II type operation as described by Krønlein, with emphasis laid upon a transverse position of the gastrojejunostomy. Of the seventy-six patients who were available for evaluation, 15 patients (20%) had some symptoms. The overall grading of results according to Visick was: I in 80 per cent, II in 9 per cent, IIIs in 7 per cent, IIIu + IV in 4 per cent. Three patients had retired and one had changed work partly because of postoperative symptoms.

Partial gastrectomy for peptic ulcer by the Krønlein method. An outpatient follow-up study 12 years later with particular reference to endoscopy with biopsy and brush cytology and to clinical-chemical and radiological results.

Forty-six patients were studied 12 years after partial gastrectomy for peptic ulcer. They had all been subjected to a standard Billroth II type operation as described by Krønlein, with emphasis laid upon the transverse position of the gastrojejunostomy. The clinical examination was supplemented by an outpatient gastroscopy with photography, biopsy and brush cytology, and by a series of blood analyses and X-ray of the gastric remnant. The general finding on gastroscopy was a slightly injected mucosa with flattened folds near the anastomosis, no or slight reflux of bile. The cytological examination revealed metaplasia in 7.5-15 per cent of the specimens, no sign of dysplasia or carcinoma. Biopsy showed severe atrophic gastritis in 0-13 per cent of the specimens, slight to moderate in 58-96 per cent, no signs of cellular atypia or irregular arrangements. Judged by the results of blood analyses a deficiency in iron, Vitamin B12 or both, was demonstrated in about 25 per cent of patients and of these more than 50 per cent were anaemic. X-ray examination showed that 70 per cent of the patients had an emptying time of the gastric remnant of 10-20 minutes. A transverse position of the anastomosis could be demonstrated in about 67 per cent. The necessity of a close follow-up of these patients is stressed.

Gene expression reveals two distinct groups of anal carcinomas with clinical implications.

Human papillomavirus (HPV) is a major aetiological agent in anal carcinomas. We here present a study of global gene expression using microarray hybridisation in a collection of anal carcinoma biopsies. Quantitative PCR was used to verify expression of selected genes. All biopsies contained integrated DNA of human papillomavirus subtype 16 (HPV16) and expressed HPV16 E7 mRNA. No other subspecies of HPV were detected in these 13 biopsies as assessed by PCR amplification and DNA sequencing. Unsupervised cluster analysis, based on global mRNA expression, divided the tumour biopsies into two distinct groups. Cluster analysis based on a number of high-risk HPV and/or E2F-regulated genes reproduced this biopsy grouping, suggesting that integrated HPV16 substantially influenced global gene expression in approximately half the biopsies studied. The levels of HPV16 E7 mRNA were significantly different between the two groups, but with considerable overlap. Thus, influence on global gene expression could not be absolutely ascribed to the expression level of HPV16. To investigate whether this distinction in gene expression had prognostic impact, we studied protein expression in an independent cohort of 55 anal carcinomas not included in the microarray study of two differentially expressed candidate genes, minichromosome maintenance complex component 7 (MCM7) and cyclin-dependent kinase inhibitor 2A (CDKN2A or p16). HPV status was assessed by in situ hybridisation. There was a significant association between in situ staining for HPV E7 mRNA and immunostaining for CDKN2A (p16) and MCM7 protein. CDKN2A (p16) mRNA was found significantly differentially expressed between the two tumour groups. However, cluster analysis on genes directly regulated by CDKN2A (p16) could not reproduce this split of biopsies into two groups, suggesting that the transcriptional regulatory activity of CDKN2A in these biopsies is inhibited. Furthermore, protein expression of CDKN2A (p16) could not be associated with survival. MCM7 is directly regulated by E2F and induced by HPV, and its mRNA was found differentially expressed between the two tumour groups. High level of MCM7 protein was found to be associated with both improved relapse-free survival (RFS, P=0.02) and cancer-specific survival (CSS, P=0.03) in anal cancer patients treated with radiation with or without additional chemotherapy.

Local resection of rectal tumors by transanal endoscopic microsurgery: experience with the first 70 cases.

BACKGROUND: Transanal endoscopic microsurgery (TEM) can access the whole rectum up to 20 cm from the anal verge. Due to its excellent view and accurate dissection, TEM is useful for the removal of adenoma and selected low risk cancers of the rectum. We report our experience with the first 70 patients presenting. METHODS: A prospective descriptive study of 70 patients treated for rectal tumor with TEM from December 99 until October 2002 at Haukeland University Hospital. RESULTS: TEM was performed in 37 men and 33 women, median age 70.5 (19-90) years, for anticipated adenoma (n = 64), adenocarcinoma (n = 3), rectal ulcer (n = 1), and re-resection after snare resection of rectal polyp with adenocarcinoma (n = 1) and carcinoid tumor (n = 1). The median observation time was 12 (1-33) months. The distance from the anal verge to the lower tumor border was 5.5 (2.5-14) cm. The median resected area was 15.4 (1.5-132) cm(2). 56 of the 64 anticipated adenomas were true adenoma, resected without recurrences; 8 (12.5%) were unexpected adenocarcinoma. Three of these underwent a secondary rectal resection and 5 patients have been observed without recurrence. Of the 3 patients with known adenocarcinoma, there was one recurrence which was treated with a secondary curative rectal resection. CONCLUSIONS: TEM can access tumors in the whole rectum. Large tumors may be removed with low frequency of per- and postoperative complications and short hospital stay. TEM is highly useful for removal of rectal adenoma. A role for primary treatment of selected low-risk rectal cancers may emerge.

Effect of vasopressin on blood flow distribution in the stomach of cats with gastric ulcer.

An ulcer was induced in the anterior wall of the antrum by local injection of acetic acid solution. Carbonized microspheres 15 +/- 5 micrometer in diameter, labeled with 85Sr and 141Ce, were used to measure blood flow in different regions and layers of the stomach wall, and in each sample the mucosa was separated from the muscularis. The radioactivity of a blood reference sample and the tissue sample was determined, and the blood flow was calculated for each tissue sample. Two groups of anesthetized animals were used: animals with normal stomachs given vasopressin and animals with a 1-week ulcer given vasopressin. The vasopressin was administered intravenously over a 20-min period. In animals with normal stomachs and in animals with a gastric ulcer vasopressin was found to decrease the blood flow to the stomach in all areas examined. The presence of a 1-week ulcer in the cat did not seem to influence the effect of vasopressin.

Effect of indomethacin on blood flow distribution in the stomach of cats with acute gastric ulcer.

An ulcer was induced in the anterior wall of the antrum of cats by local injection of acetic acid solution. Carbonized microspheres, 15 +/- microns in diameter, labelled with 141Ce, 46Sc, and 85Sr, were used to measure blood flow in different regions and layers of the stomach wall. The radioactivity of a blood reference sample and of tissue samples was determined, and the blood flow was calculated for each tissue sample. The blood flow distribution was determined before, 1/2 h, and 1 h after an intravenous infusion of indomethacin in a dose of 3 mg/kg. Two groups of anaesthetized animals were used: animals with a 24-h gastric ulcer and control animals 24 h after laparotomy. In the control animals indomethacin caused a mean reduction in gastric mucosal blood flow of approximately 50%. The flow reduction was about the same in different regions of the stomach. In the muscularis there was no change in blood flow after indomethacin. The blood flow was reduced in the duodenum and jejunum but not in the other intestinal organs studied. The blood pressure and cardiac output remained unchanged. In the ulcer group indomethacin caused about the same reduction in mucosal blood flow. However, the blood flow was reduced less in the ulcer region and tended to increase in the mucosa around the ulcer 1 h after indomethacin infusion.

Blood flow distribution in the stomach of cats with gastric ulcer.

Ulcer was induced in the anterior wall of the antrum by a subserous injection of 0.3 ml of a 20% acetic acid solution. Carbonized microspheres 15 plus or minus 5 mu in diameter and labelled with 169Yb were used to measure blood flow in different regions and layers of the stomach. Approximately 2-3 million microspheres were injected into the left ventricle of the heart. Simultaneously a blood sample was drawn from the distal aorta at a flow of 1 ml/min. Standardized tissue samples were punched from the lesser curvature and the anterior and posterior walls of the antrum, corpus, and fundus. In each sample the mucosa was separated from the muscularis. The radioactivity of the blood and tissue samples was determined, and the blood flow was calculated for each tissue sample. Three groups of animals were examined: 1) anaesthetized control animals, 2) animals laparotomized one week before examination, 3) animals with a one-week ulcer. In the control animals the blood flow was found to be the same in corresponding regions of the anterior and posterior walls of the stomach. The flow was slightly lower in the antrum than the fundus. The flow was similar in the different regions of the muscularis. The muscularis flow was markedly lower than the mucosa flow. In the laparotomized animals the blood flow was found to be increased in the muscularis of the corpus. In the ulcer animals the mucosa flow was increased in the anterior wall of the antrum, and the muscularis flow was increased in the antrum and the anterior wall of the corpus.

Perforated peptic ulcer: a comparison of long term results following partial gastric resection or simple closure.

The results of simple closure were compared with those of partial resection in the treatment of perforated peptic ulcer. The investigation was carried out 7-13 years after the primary operation on 126 patients who had been allotted to one of the two treatment methods on the basis of an almost randomized schedule. Better late results were obtained with partial resection than with simple closure in patients in the age range 50-59 years at operation, with short duration of perforation and with a long history of symptoms before perforation. None of the patients treated with partial resection later underwent surgical treatment for recurrence of symptoms. In the simple closure group 27.3 per cent needed further surgery at 3 months to 10 years after perforation.

Distribution of microspheres with different diameters in the small bowel wall of the cat.

The purpose of the present study was to investigate the distribution in the small bowel wall of intracardially injected microspheres with different diameters, and to find a sphere size that could be used for determination of blood flow to the different layers of the bowel wall. Microspheres were injected into the left ventricle of the hearts of cats in the following order of succession, 8--10, 15 +/- 5, 25 +/- 5 and 50 +/- 5 micrometer. Samples of the proximal part of the jejunum and the distal part of the ileum were examined microscopically, and the size and the location of the spheres recorded. The following distribution of the microspheres was found: villi 6--16 micrometer, crypt layer 6--20 micrometer, propria below the crypts and the muscularis mucosa 11--24 micrometer, submucosa 9--66 micrometer and muscularis 6--30 micrometer. Spheres between 8 and 13 micrometer appeared to be fairly uniformly distributed in the different layers of the intestinal wall.

Palpation of the axillary nodes in breast cancer: what does the surgeon feel?

The findings on routine pre-operative palpation of the axilla in patients with infiltrative breast carcinoma are compared to the results of histological quantitation of the nodal lymphoid tissue and its tumour deposits in 91 consecutive cases in which a standardized axillary dissection had been carried out. The study demonstrates that lymphoid tissue, even when present in large amounts (up to 6 cm2 on histology), is seldom palpable. What the clinician identifies in favourable cases is the tumour deposit itself. When little lymphoid tissue is present very small tumour deposits (0.2 cm2) may be found on palpation, but large deposits (1 cm2) may be missed when surrounded by sufficient lymphoid tissue. These findings go far to explain the well documented unreliability of the nodal findings on axillary palpation in breast cancer.

Changes in gastric mucosal morphology, capillary permeability and blood flow during the first 3 days of acute gastritis in cats.

In the present investigation gastric morphology, blood flow, vascular permeability and water content were studied in cat stomachs with acetic acid-induced gastritis at different time intervals up to 3 days after induction of gastritis. The morphological changes including mucosal erosions, edema and hemorrhage showed normalization within 3 days. The mucosa and muscularis blood flow remained essentially unchanged compared with pre-gastritis values and with the control group. Gastritis was associated with leakage of circulating albumin into the stomach wall most pronounced 4 h after the induction of gastritis. The water content was high at 4 and 24 h after induction of gastritis with almost normalization at 3 days. The morphologaical characteristics of our model are very similar to those observed in man. Leakage of circulating albumin into the gastric wall seems to be the best parameter for quantifaication of the inflammatory changes found in acute gastritis, while blood flow seems to be a less important parameter.