Early detection of colorectal adenocarcinoma: a clinical decision support tool based on plasma porphyrin accumulation and risk factors.

BACKGROUND: An increase in naturally-occurring porphyrins has been described in the blood of subjects bearing different kinds of tumors, including colorectal, and this is probably related to a systemic alteration of heme metabolism induced by tumor cells. The aim of our study was to develop an artificial neural network (ANN) classifier for early detection of colorectal adenocarcinoma based on plasma porphyrin accumulation and risk factors. METHODS: We measured the endogenous fluorescence of blood plasma in 100 colorectal adenocarcinoma patients and 112 controls using a conventional spectrofluorometer. Height, weight, personal and family medical history, use of alcohol, red meat, vegetables and tobacco were all recorded. An ANN model was built up from demographic data and from the integral of the fluorescence emission peak in the range 610-650 nm. We used the Receiver Operating Characteristic (ROC) curve to assess performance in distinguishing colorectal adenocarcinoma patients and controls. A liquid chromatography-high resolution mass spectrometry (LC-HRMS) analytical method was employed to identify the agents responsible for native fluorescence. RESULTS: The fluorescence analysis indicated that the integral of the fluorescence emission peak in the range 610-650 nm was significantly higher in colorectal adenocarcinoma patients than controls (p < 0.0001) and was weakly correlated with the TNM staging (Spearman's rho = 0.224, p = 0.011). LC-HRMS measurements showed that the agents responsible for the fluorescence emission were mainly protoporphyrin-IX (PpIX) and coproporphyrin-I (CpI). The overall accuracy of our ANN model was 88% (87% sensitivity and 90% specificity) with an area under the ROC curve of 0.83. CONCLUSIONS: These results confirm that tumor cells accumulate a diagnostic level of endogenous porphyrin compounds and suggest that plasma porphyrin concentrations, indirectly measured through fluorescence analysis, may be useful, together with risk factors, as a clinical decision support tool for the early detection of colorectal adenocarcinoma. Our future efforts will be aimed at examining how plasma porphyrin accumulation correlates with survival and response to therapy.

MIF/CD74 axis is a target for novel therapies in colon carcinomatosis.

BACKGROUND: Strategies aimed at obtaining a complete cytoreduction are needed to improve long-term survival for patients with colorectal cancer peritoneal carcinomatosis (CRC-pc). METHODS: We established organoid models from peritoneal metastases of two naïve CRC patients. A standard paraffin inclusion was conducted to compare their 3D structure and immunohistochemical profile with that of the corresponding surgical samples. RNA expression levels of the CRC stem cell marker LGR5 was measured by in situ hybridization. The secretome of organoids was profiled by mass spectrometry. Energy homeostasis of organoids was interfered with 4-IPP and metformin. Biochemical and metabolic changes after drug treatments were investigated by western blot and mass spectrometry. Mitochondria impairment was evaluated by electron microscopy and mitotraker staining. RESULTS: The two organoids recapitulated their corresponding clinical samples in terms of 3D structure and immmunoistochemical profile and were positive for the cancer stem cells marker LGR5. Proteomic analyses of organoids highlighted their strong dependence on energy producing pathways, which suggest that their targeting could be an effective therapeutic approach. To test this hypothesis, we treated organoids with two drugs that target metabolism acting on AMP-activated protein kinase (AMPK), the main regulator of cellular energy homeostasis, which may act as metabolic tumour suppressor in CRC. Organoids were treated with 4-IPP, an inhibitor of MIF/CD74 signalling axis which activates AMPK function, or metformin that inhibits mitochondrial respiratory chain complex I. As a new finding we observed that treatment with 4-IPP downregulated AMPK signalling activity, reduced AKT phosphorylation and activated a JNK-mediated stress-signalling response, thus generating mitochondrial impairment and cell death. Metformin treatment enhanced AMPK activation, decreasing the activity of the anabolic factors ribosomal protein S6 and p4EBP-1 and inducing mitochondrial depolarization. CONCLUSION: We provide evidence that the modulation of AMPK activity may be a strategy for targeting metabolism of CRC-pc organoids.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) at the Time of Primary Curative Surgery in Patients with Colorectal Cancer at High Risk for Metachronous Peritoneal Metastases.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) are maximally effective in early-stage colorectal cancer peritoneal metastases (CRC-PM); however, the use of HIPEC to treat subclinical-stage PM remains controversial. This prospective two-center study assessed adjuvant HIPEC in CRC patients at high risk for metachronous PM ( www.clinicaltrials.gov NCT02575859). METHODS: During 2006-2012, a total of 22 patients without systemic metastases were prospectively enrolled to receive HIPEC simultaneously with curative surgery, plus adjuvant systemic chemotherapy (oxaliplatin/irinotecan-containing ± biologics), based on primary tumor-associated criteria: resected synchronous ovarian (n = 2) or minimal peritoneal (n = 6) metastases, primaries directly invading other organs (n = 4) or penetrating the visceral peritoneum (n = 10). A control group retrospectively included 44 matched (1:2) patients undergoing standard treatments and no HIPEC during the same period. The cumulative PM incidence was calculated in a competing-risks framework. RESULTS: Patient characteristics were comparable for all groups. Median follow-up was 65.2 months [95 % confidence interval (CI) 50.9-79.5] in the HIPEC group and 34.5 months (95 % CI 21.1-47.9) in the control group. The 5-year cumulative PM incidence was 9.3 % in the HIPEC group and 42.5 % in the control group (p = 0.004). Kaplan-Meier estimated 5-year overall survival (OS) was 81.3 % in the HIPEC group versus 70.0 % in the control group (p = 0.047). No operative death occurred. Grade 3-4 [National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4] morbidity rates were 18.2 % in the HIPEC group and 25 % in controls (p = 0.75). At multivariate analysis, HIPEC correlated to lower PM cumulative incidence [hazard ratio (HR) 0.04, 95 % CI 0.01-0.31; p = 0.002], and better OS (HR 0.25, 95 % CI 0.07-0.89; p = 0.039) and progression-free survival (HR 0.31, 95 % CI 0.11-0.85; p = 0.028). CONCLUSION: Adjuvant HIPEC may benefit CRC patients at high-risk for peritoneal failure. These results warrant confirmation in phase III trials.

Abdominosacral resection for locally recurring rectal cancer.

AIM: To investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma. METHODS: A population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences. RESULTS: At the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic. CONCLUSION: Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Epidural analgesia does not influence anastomotic leakage incidence after open colorectal surgery for cancer: A retrospective study on 1,474 patients.

BACKGROUND: Anastomotic leakage is a major cause of morbidity after colorectal surgery. Epidural analgesia is the most effective method for postoperative pain relief after major abdominal surgery. Anyhow, its effect on anastomotic leakage rate is still controversial. This study aimed to compare epidural versus intravenous analgesia as risk factor for anastomotic leakage requiring reoperation in patients undergoing open colorectal surgery for cancer. METHODS: A retrospective study on 1,474 patients was performed. The Cox proportional hazards model was used to study the relation between primary and secondary factors of risk and anastomotic leakage occurrence within 30 days after elective operation. RESULTS: Overall 30-day anastomotic leakage requiring reoperation was 4.9% (95%CI: 3.8-6.0%). No difference in anastomotic leakage occurrence was observed between the epidural analgesia group and the intravenous analgesia group (Hazard ratio: 0.94; 95%CI: 0.53-1.67%; P = 0.8338). Females had a rate of anastomotic leakage 43% lower than males (P = 0.0301). The diverting stoma resulted to be protective for anastomotic leakage occurrence (P = 0.0052). AL significantly increased postoperative median length of stay but not in-hospital mortality. CONCLUSIONS: Epidural analgesia does not influence the AL risk after open colorectal surgery for cancer.

Circulating free DNA in a screening program for early colorectal cancer detection.

AIMS AND BACKGROUND: The quantification and molecular characterization of circulating free DNA (cfDNA) have attracted much interest as new and promising, noninvasive means of detecting and monitoring the presence of surgical resectable colorectal cancer (CRC). Instead, the role of cfDNA in the early detection of malignant and premalignant colorectal lesions is still unclear. The aim of this study was to evaluate the predictive power of the quantification and KRAS status of cfDNA in detecting early colorectal lesions in plasma from healthy high-risk subjects. METHODS: The study population consisted of 170 consecutive healthy high-risk subjects aged >50 years who participated in the screening program promoted by the Local Health Service (ASL-Milano) for early CRC detection and who underwent endoscopic examination after being found positive at fecal occult blood test (FOBT). Thirty-four participants had malignant lesions consisting of 12 adenocarcinomas (at an early stage in half of the cases) and 22 instances of high-grade intraepithelial neoplasia (HGIN) in adenomas; 73 participants had premalignant lesions (adenomas and hyperplasia), and 63 participants had no lesions. Plasma cfDNA was quantified by quantitative real-time PCR and analyzed for KRAS mutations by a mutant-enriched PCR. KRAS status was assessed also in matched adenocarcinoma and HGIN tissues. The distribution of cfDNA concentrations among FOBT-positive subjects with diagnosed lesion (cases) was compared with that of FOBT-positive subjects without lesions (controls) and its predictive capability (AUC) was assessed. RESULTS: The predictive capability of cfDNA levels was satisfactory in predicting adenocarcinomas (AUC 0.709; 95% CI, 0.508-0.909) but not HGIN and premalignant lesions. The rate of KRAS mutations in plasma was low (5/170 = 3%) compared with the rate observed in the matched adenocarcinoma and HGIN tissues (45%). CONCLUSIONS: The use of cfDNA quantification to predict adenocarcinoma at an early stage in high-risk (aged >50 years and FOBT positive) subjects seems to be promising but needs more sensitive methods to improve cfDNA detection.

miRNA profiling in colorectal cancer highlights miR-1 involvement in MET-dependent proliferation.

Altered expression of miRNAs is associated with development and progression of various human cancers by regulating the translation of oncogenes and tumor suppressor genes. In colorectal cancer, these regulators complement the Vogelstein multistep model of pathogenesis and have the potential of becoming a novel class of tumor biomarkers and therapeutic targets. Using quantitative real-time PCR, we measured the expression of 621 mature miRNAs in 40 colorectal cancers and their paired normal tissues and identified 23 significantly deregulated miRNAs. We subsequently evaluated their association with clinical characteristics of the samples and presence of alterations in the molecular markers of colorectal cancer progression. Expression levels of miR-31 were correlated with CA19-9 and miR-18a, miR-21, and miR-31 were associated with mutations in APC gene. To investigate the downstream regulation of the differentially expressed miRNAs identified, we integrated putative mRNA target predictions with the results of a meta-analysis of seven public gene expression datasets of normal and tumor samples of colorectal cancer patients. Many of the colorectal cancer deregulated miRNAs computationally mapped to targets involved in pathways related to progression. Here one promising candidate pair (miR-1 and MET) was studied and functionally validated. We show that miR-1 can have a tumor suppressor function in colorectal cancer by directly downregulating MET oncogene both at RNA and protein level and that reexpression of miR-1 leads to MET-driven reduction of cell proliferation and motility, identifying the miR-1 downmodulation as one of the events that could enhance colorectal cancer progression.

Wall defects after abdominoperineal resection: a modified tension-free technique.

BACKGROUND: The treatment of wall defects after abdominoperineal resection has yet to be defined. In this study we report the outcome of a modified prosthetic technique for the treatment of combined large incisional and parastomal hernia performed after abdominoperineal resection. MATERIAL AND METHODS: Between January 2005 and July 2008, 21 consecutive patients who underwent abdominoperineal resection for low rectal cancer received surgical repair for large incisional hernias with a modified mesh technique consisting of a tension-free attachment of the prosthetic material to the posterior sheath of the rectus abdominis muscle. The surgical outcome was assessed mainly as the recurrence rate of abdominal hernia and postoperative complications. RESULTS: Among the 21 patients we reported two minor complications: partial necrosis of the skin flap (4.8%) and a seroma (4.8%). One major complication occurred: extensive necrosis of the skin flap (4.8%). We reported one death due to stroke 20 days after surgery. The mean postoperative hospital stay was 6.1 days (SD, 2.3). CONCLUSIONS: This study encourages the use of a tension-free modified prosthetic technique for the repair of combined wall defects after abdominoperineal resection. The technique does not lead to an increase in the incidence of complications, offering a considerable advantage to the patient.

Primary ileus after total hip arthroplasty: rare complication or sentinel event?

The incidence of hip dislocation after primary total hip arthroplasty (THA) has been reported to range from 1 to 25% in THA revision. Here, we explore the hypothesis that there is a correlation between postoperative ileus (POI) and THA dislocation, with POI after THA possibly representing a sentinel event. We retrospectively identified a cohort of 529 consecutive patients who underwent hip arthroplasty from 2008 to 2010. Of them, 251 were male and 278 were female, and a mean average for age of 71.5 (range 65-76). In particular, 19 THA patients showed signs of gastrointestinal complications, and therapeutic consultation was performed with the onset of the first intestinal symptom. Of these 19 patients, 3 THA patients developed POI within 1 week after surgical treatment. A conservative treatment was practised and it seemed to improve the condition: canalization returned and all patients were discharged from the hospital. Unfortunately, two of these patients were readmitted after 2 weeks due to THA dislocation and they underwent THA revision and were discharged from the hospital 7 days later. Follow-up revealed no further problems at 6 months. Our clinical experience with these post-THA primary ileus patients raises the possibility that intra-abdominal symptoms represent a sentinel event in THA dislocation. THA dislocation using neuronal pathway of immunomodulation may modulate POI. Since the risk of THA dislocation is the greatest in the first 3 months after hip arthroplasty, the surgeon should be familiar with the relationship between THA and various pelvic and visceral complications to ensure that POI remains only a rare complication.

Giant condyloma acuminatum of the anorectum: successful radical surgery with anal reconstruction.

Buschke-Löwenstein tumor, or giant condyloma acuminatum, is a relatively uncommon lesion of the anus with aggressive local invasive behavior which may present as a large warty tumor of the genital region with expansive and destructive growth. Many sporadic reports have been published suggesting various therapeutic strategies. We report a case of Buschke-Löwenstein tumor treated with conservative surgery followed by reconstructive procedures without a loop colostomy

Hospital bodies: the genesis of Italian National Health Service.

Hospital public bodies were instituted in Italy in 1968. Their creation represents a fundamental step forward in the evolution of the national healthcare system and has allowed improvements in social equity in hospitals. The lack of independent funding beyond the insurance-type healthcare system existing at the time, hindered its success. The hospital body has however left a trace in the modern national healthcare system with the introduction of the hospital corporation.

Diagnosis of rectal cancer by Tissue Resonance Interaction Method.

BACKGROUND: Since population screening has the potential to reduce mortality from rectal cancer (RC), novel methods with improved cost-effectiveness warrant consideration. In a previous pilot study, we found that the rapid, inexpensive and non-invasive electromagnetic detection of RC is a highly specific and sensitive technique. The aim of the present prospective study was to evaluate the prediction accuracy of electromagnetic detection of RC. METHODS: 304 eligible subjects were consecutively enrolled in our Institute and subjected to electromagnetic detection followed by colonoscopy and histopathologic analysis of biopsies. A putative RC carrier status was attributed to subjects showing an electromagnetic signal < 50 units (U). RESULTS: RC patients showed a significantly lower electromagnetic signal (40.9 +/- 0.9 U; mean +/- S.E.) than did non-RC subjects (79.2 +/- 1.4 U; P < 2.2e-16). At a threshold < 50 U, electromagnetic detection identified 103 putative patients, whereas colonoscopy detected 108 patients, with an overlap of 91 patients between the two methods. The 15.7% false-negative rate by electromagnetic detection was brought to zero by raising the threshold value to 70 U; on the other hand, such a threshold increased the false-positive rate to 30%. CONCLUSION: Electromagnetic detection of RC at a signal threshold < 70 U appears to eliminate false-negative results. Although colonoscopy would still be required in examining the false-positives associated with the < 70 U electromagnetic threshold, the need for this method would be reduced. Thus, electromagnetic detection represents a new accurate, rapid, simple, and inexpensive tool for early detection of RC that merits testing in large population-based programs.

Colorectal cancer detection by means of optical fluoroscopy. A study on 494 subjects.

In the present work we investigated the possible role of the native fluorescence of blood plasma in the management of colorectal cancer (CRC) and its feasibility as a new tumor marker. Sample of blood was collected from 248 asymptomatic blood donors and from 246 CRC patients. The native fluorescence of blood plasma was measured using a conventional spectrofluorimeter. The intensity of fluorescence of blood plasma at 623 nm (IF623), reasonably ascribed to endogenous porphyrins, was significantly higher in CRC patients than in healthy subjects. The diagnostic capability of IF623 in the discrimination between healthy subjects and CRC patients was tested by Receiving Operating Characteristic (ROC) curve analysis, which resulted in an Area Under the Curve (AUC) of 0.72+/-0.01. Fluorescence measurement of blood plasma might be considered diagnostically useful as a candidate for a new tumor marker for CRC management. The procedure is characterised by a great acceptability and by a very low cost, and might be used in a two-step screening wherein an IF623 positive result is followed by colonoscopy.

Health authority: the Italian experience.

The healthcare reform, introduced in Italy in 1992, has completely changed the structure of the national healthcare system (NHS) , including the introduction of the concept of "business firm" applied to public health service providers. The aim of this study was to outline the history of healthcare "firms" (azienda sanitaria) and evaluate the impact of this change on the NHS in terms of health expenditure, and corporate effectiveness and efficiency. Self regulation and correction are the abilities to which the success of healthcare companies can be attributed. The benefits of creating healthcare firms include preventing those problems associated with healthcare models based on the principles of the private insurance type model and preferring instead a cost-effectiveness approach.

Integrative approach for prioritizing cancer genes in sporadic colon cancer.

The current multistep carcinogenesis models of colon cancer do not fully capture the genetic heterogeneity of the disease, which is additionally complicated by the presence of passenger and driver genetic alterations. The aim of this study was to select in the context of this significant heterogeneity additional genes functionally related to colon cancer development. High-throughput copy number and gene expression data of 36 microsatellite stable sporadic colon cancers resected from patients of a single institution characterized for mutations in APC, KRAS, TP53 and loss of 18q were analyzed. Genes whose expression correlated with the underlying copy number pattern were selected, and their association with the above listed mutations and overall survival was evaluated. Gain of 20q was strongly associated with TP53 mutation, and overall survival with alterations on 7p, 8p, 13q, 18q, and 20q. An association with 18q loss and gain of 8q24 was also observed. New candidate genes with a potential role in colon cancer are PLCG1 on 20q, DBC1 on 8q21, and NDGR1 on 8p24. In addition, an unexpected pattern of loss and mutability was found in the region upstream of the KRAS gene. By integrating copy number alterations with gene expression and mutations in colon cancer associated genes, we have developed a strategy that identifies previously known molecular features and additional players in the molecular landscape of colon cancer.

Diagnosis of rectal cancer by electromagnetic interactions: preliminary results.

OBJECTIVES: Although colonoscopy is effective in screening for colorectal cancer, its high cost and low compliance rates have encouraged a search for different methods. Our study was designed to evaluate the feasibility of rectal cancer detection using a nonlinear tuneable oscillator (TRIMprob), a recently developed device for detecting differences in electromagnetic properties of cancerous and normal tissues. METHODS: We tested 228 patients (115 male and 113 female) between March and September 2006: 114 patients with rectal cancer diagnosed on colonoscopy and 114 patients with negative colonoscopy results. The TRIMprob probe was moved over the surface of the pelvic area from the back and the front, with the patient standing, normally dressed, between the operator and the system receiver. The signal variation of three spectral lines, for 465-MHz, 930-MHz, and 1395-MHz frequencies was recorded for each of six probe positions. RESULTS: Analysis of resonance values showed that only the 465-MHz frequency differentiated patients with rectal cancer from those without cancer at all six probe positions (P < 0.001). With a cutoff value of 50 arbitrary units, the area under the receiver operating characteristic curve was 0.94 (specificity, 85 percent; sensitivity, 94 percent). CONCLUSIONS: The TRIMprob test discriminates well between patients with normal rectal tissue and those with malignant lesions. These preliminary results confirm that electromagnetic detection of rectal cancer is possible and suggest this method of extracorporeal scanning may be useful as a first-level screening tool.

Distal clearance margin of 1 cm or less: a safe distance in lower rectum cancer surgery.

PURPOSE: The purpose of this study was to investigate the prognostic role of distal clearance margin (DCM) in lower rectum cancer surgery. MATERIALS AND METHODS: Two-hundred-three cancer patients underwent total rectal resection, possibly followed by adjuvant chemoradiotherapy. DCM was classified as positive or negative (<1, > or =1 cm) and investigated with multivariable proportional hazard models. RESULTS: A total of 52 deaths, 19 local relapses, 40 distant metastases, and three second primaries were observed as first events. Five-year survival with positive, negative <1, or negative > or =1 cm DCM was 51%, 81%, and 69%, respectively (p = 0.018). The difference was significant between positive and negative DCM (p = 0.031), not between negative <1 and > or =1 cm (p = 0.106). Local and distant 5-year incidences according to DCM were 30%, 8%, and 8% (p = 0.006) and 38%, 26%, and 19% (p = 0.857), respectively. CONCLUSIONS: DCM, but not tumor size, is a prognostic factor after sphincter-saving surgery, which is safe whenever a negative margin is achieved.

Pelvic lymphedema: truth or fiction?

Pelvis is a functional shell-like unit consisting of the pelvic floor and perineum. The patients, who underwent a radical operation of the pelvis due to an oncological disease, often develop pelvic disorders. These disorders do not depend on the type of surgery or any presence of postoperative treatment (radio- and chemotherapy). The reason for this is still mostly unknown. These disorders without an appropriate treatment of rehabilitation always result in the following symptoms: fatty tissue hypertrophy and fibrosis as well as functional chronic disorders. Lymphedema is described as a progressive pathological condition with retention of protein-rich liquid in the interstitial space, fatty tissue hypertrophy and fibrosis. It is possible to assume that lymphadenectomy related to pelvic surgery results in a localized lymphedema in the pelvis developing disorders of perineum and pelvic floor: a pelvic lymphedema, or rather a blind lymphedema, i.e. with symptoms but with no signs. The clinical evidence shows that the lymphatic vessels play a relevant role in the pathology of the pelvic floor and perineum. The study of pelvic lymphedema could be the key when choosing the therapies for pelvic disorders resulting from surgery.

Simultaneous idiopathic segmental infarction of the great omentum and acute appendicitis: a rare association.

Idiopathic segmental infarction of the greater omentum is an uncommon cause of acute abdomen. The etiology is still unclear and the symptoms mimic acute appendicitis. Its presentation simultaneously with acute appendicitis is still more infrequent. We present a case of a 47-year old woman without significant previous medical history, admitted with an acute abdomen, in which the clinical diagnosis was acute appendicitis and in whom an infarcted segment of right side of the greater omentum was also found at laparotomy. As the etiology is unknown, we highlighted some of the possible theories, and emphasize the importance of omental infarction even in the presence of acute appendicitis as a coincident intraperitoneal pathological condition.