High CD142 Level Marks Tumor-Promoting Fibroblasts with Targeting Potential in Colorectal Cancer.

Colorectal cancer (CRC) has a high incidence and is one of the leading causes of cancer-related death. The accumulation of cancer-associated fibroblasts (CAF) induces an aggressive, stem-like phenotype in tumor cells, and it indicates a poor prognosis. However, cellular heterogeneity among CAFs and the targeting of both stromal and CRC cells are not yet well resolved. Here, we identified CD142high fibroblasts with a higher stimulating effect on CRC cell proliferation via secreting more hepatocyte growth factor (HGF) compared to CD142low CAFs. We also found that combinations of inhibitors that had either a promising effect in other cancer types or are more active in CRC compared to normal colonic epithelium acted synergistically in CRC cells. Importantly, heat shock protein 90 (HSP90) inhibitor selected against CD142high fibroblasts, and both CRC cells and CAFs were sensitive to a BCL-xL inhibitor. However, targeting mitogen-activated protein kinase kinase (MEK) was ineffective in fibroblasts, and an epigenetic inhibitor selected for a tumor cell population with markers of aggressive behavior. Thus, we suggest BCL-xL and HSP90 inhibitors to eliminate cancer cells and decrease the tumor-promoting CD142high CAF population. This may be the basis of a strategy to target both CRC cells and stromal fibroblasts, resulting in the inhibition of tumor relapse.

Improved Accuracy of Lymph Node Staging and Long-Term Survival Benefit in Colorectal Cancer With Ex Vivo Arterial Methylene Blue Infiltration.

Introduction: Ex vivo methylene blue (MB) injection into the main supplying arteries of the colorectal specimen after surgical removal is an uncomplicated technique to support lymph node harvest during pathological evaluation. The primary aim of this randomized, interventional, bicentric trial was to evaluate the impact of MB injection on lymph node yield, with secondary aims assessing the accuracy of lymph node staging and the effect on 5-year overall survival for patients undergoing resection of colorectal cancer. Methods: In the study period between December 2013 and August 2015, 200 colorectal resections were performed at two independent onco-surgery centers of Hungary. Following surgical resection, each specimen was randomly assigned either to the control (standard pathological work-up) or to the MB staining group before formaldehyde fixation. Patient-level surgical and clinical data were retrieved from routinely collected clinical datasets. Survival status data were obtained from the National Health Insurance Fund of Hungary. Results: A total of 162 specimens, 82 in the control and 80 in the MB groups, were included for analysis. Baseline characteristics were equally distributed among study groups, except for specimen length. Both the median of total number of lymph nodes retrieved (control 11 ± 8 [0-33] nodes vs. MB 14 ± 6 [0-42] nodes; p < 0.01), and the ratio of cases with at least 12 removed lymph nodes (36/82, 43.9% vs. 53/80, 66.3%; p < 0.01) were higher in the MB group. The rate of accurate lymph node staging was non-significantly improved. As for rectal cancer, nodal staging accuracy (16/31, 51.6% vs. 23/30, 76.7%; p = 0.04) and the proportion with minimum 12 lymph node retrieval (7/31, 22.6%, vs. 18/30, 60%; p < 0.01) was improved by MB injection. In Mantel-Cox regression, a statistically significant survival benefit with methylene blue injection at 5 years post-surgery was proven (51.2% vs. 68.8%; p = 0.04). Conclusion: In our experience, postoperative ex vivo arterial methylene blue injection appears to be an uncomplicated technique, improving lymph node yield and decreasing the chance of insufficient nodal staging. The technique might also associate with a 5-year overall survival benefit.

CD44 Expression Intensity Marks Colorectal Cancer Cell Subpopulations with Different Extracellular Vesicle Release Capacity.

Extracellular vesicles (EV) are released by virtually all cells and they transport biologically important molecules from the release site to target cells. Colorectal cancer (CRC) is a leading cause of cancer-related death cases, thus, it represents a major health issue. Although the EV cargo may reflect the molecular composition of the releasing cells and thus, EVs may hold a great promise for tumor diagnostics, the impact of intratumoral heterogeneity on the intensity of EV release is still largely unknown. By using CRC patient-derived organoids that maintain the cellular and molecular heterogeneity of the original epithelial tumor tissue, we proved that CD44high cells produce more organoids with a higher proliferation intensity, as compared to CD44low cells. Interestingly, we detected an increased EV release by CD44high CRC cells. In addition, we found that the miRNA cargos of CD44high and CD44low cell derived EVs largely overlapped and only four miRNAs were specific for one of the above subpopulations. We observed that EVs released by CD44high cells induced the proliferation and activation of colon fibroblasts more strongly than CD44low cells. However, this effect was due to the higher EV number rather than to the miRNA cargo of EVs. Collectively, we identified CRC subpopulations with different EV releasing capabilities and we proved that CRC cell-released EVs have a miRNA-independent effect on fibroblast proliferation and activation.

The role of liver-specific contrast-enhanced MRI before resection of colorectal liver metastases / Májsejtspecifikus kontrasztanyaggal végzett MR-vizsgálat alkalmazása colorectalis eredetu májáttétek reszekciója elott.

Összefoglaló. Bevezetés: A colorectalis eredetu májáttétek (CRCLM-ek) kuratív célú kezelésében elsodleges a sebészi reszekció. A mutét elott különbözo képalkotó vizsgálatok végezhetok, az egyik ilyen speciális vizsgálat a májsejtspecifikus kontrasztanyaggal végzett MR-vizsgálat. Célkituzés: Tanulmányunkban a májsejtspecifikus kontrasztanyaggal végzett MR-vizsgálat helyét és szerepét vizsgáltuk a májsebészeti gyakorlatban colorectalis áttétes betegek esetében. Módszer: Az Uzsoki Utcai Kórház Sebészeti-Onkosebészeti Osztályán 2017. 01. 01. és 2019. 12. 31. között CRCLM miatt májreszekcióra kerülo betegek adatait elemeztük. Retrospektív módon vizsgáltuk a betegek általános sebészeti és onkosebészeti paramétereit, a képalkotó diagnosztikai eredményeket, a mutéti adatokat és a patológiai leleteket. Eredmények: 132, CRCLM miatt operált betegbol 73 szoliter áttét (55%), míg 59 beteg (45%) többszörös áttét miatt került mutétre. 94 betegnél (71%) történt májsejtspecifikus MR-vizsgálat. Szoliter áttét esetén 60%-ban, multiplex áttétek esetén 85%-ban történt májsejtspecifikus MR-vizsgálat (p = 0,02). A szoliter áttétes betegek 8%-ában, míg a multiplex áttétes betegek 39%-ában mutatott további áttétet a májspecifikus kontrasztanyaggal végzett MR-vizsgálat (p = 0,001). A betegek 5%-ában igazolódott fals pozitivitás és 6%-ában fals negativitás a májsejtspecifikus MR-vizsgálat során. 264 góc vizsgálata alapján a májspecifikus kontrasztanyaggal végzett MR-vizsgálat szenzitivitása CRCLM esetén 95%-os, míg pozitív prediktív értéke 93%-os volt vizsgálatunkban. Következtetés: A májsejtspecifikus kontrasztanyaggal végzett MR-vizsgálat hasznos diagnosztikai módszer a CRCLM-ek sebészi reszekciója elott. Leginkább többszörös áttétek esetén, preoperatív szisztémás onkológiai kezelést követoen, illetve más képalkotó vizsgálaton igazolt eltunt áttét esetén javasolható az alkalmazása. Orv Hetil. 2021; 162(50): 2010-2016. INTRODUCTION: Liver resection is the only curtive treatment option of colorectal cancer liver metastases (CRCLMs). While different diagnostic modalities are available before surgery, a specific diagnostic tool is the liver-specific contrast-enhanced MRI. OBJECTIVE: The purpose of this study was to evaluate the role of liver-specific contrast-enhanced MRI before resection of colorectal liver metastases. METHOD: Patients with CRCLM, resected at the Department of Surgical Oncology, Uzsoki Teaching Hospital, between 01. 01. 2017 and 31. 12. 2019 were enrolled in our study. Clinical data, diagnostic, intraoperative and pathological findings were analyzed in a retrospective setting. RESULTS: 132 CRCLM patients were resected in this period, 73 patients had solitary (55%), and 59 patients (45%) had multiple metastases. Liver-specific contrast-enhanced MRI was performed in 94 patients (71%). 60% of the patients with solitary and 85% of the patients with multiple CRCLM had liver-specific contrast-enhanced MRI (p = 0.02). Compared to other modalities, liver-specific contrast-enhanced MRI showed additional metastases in 8% of the patients with solitary, and in 39% of the patients with multiple metastases (p = 0.001). Liver-specific contrast-enhanced MRI had a 5% false-positivity and a 6% false-negativity rate. 264 leasions were analyzed, and the sensitivity of the liver-specific contrast-enhanced MRI was 95% with a predictive positive value of 93%. CONCLUSION: Liver-specific contrast-enhanced MRI is a useful diagnostic tool in CRCLM patients before liver resection. It is highly recommended in the case of multiple metastases, after preoperative chemotherapy and in the case of disappearing metastases. Orv Hetil. 2021; 162(50): 2010-2016.

[Surgery of pancreatic cancer]. / A hasnyálmirigyrák sebészi kezelése.

The pancreatic ductal adenocarcinoma (PDAC) is responsible for 95% of pancreatic malignancies. It is the 12th most common cancer and is the 7th leading cause of cancer deaths worldwide. The incidence of PDAC is increasing in the USA and in Europe (including Hungary), while mortality rate is not changing too much. The only curative therapeutic possibility is R0 surgical resection. The mortality of pancreatic resections has been decreasing in recent years and can be kept below 5% in HPB centers. The limits of surgical radicality have been extended and the en bloc resection of greater veins around the pancreas is now accepted. The survival could be improved by R0 resection of early cancers without lymph node spread and results can be augmented by combined oncologic therapies.

IFITM1 expression determines extracellular vesicle uptake in colorectal cancer.

The majority of colorectal cancer (CRC) patients carry mutations in the APC gene, which lead to the unregulated activation of the Wnt pathway. Extracellular vesicles (EV) are considered potential therapeutic tools. Although CRC is a genetically heterogeneous disease, the significance of the intra-tumor heterogeneity in EV uptake of CRC cells is not yet known. By using mouse and patient-derived organoids, the currently available best model of capturing cellular heterogeneity, we found that Apc mutation induced the expression of interferon-induced transmembrane protein 1 (Ifitm1), a membrane protein that plays a major role in cellular antiviral responses. Importantly, organoids derived from IFITM1high CRC cells contained more proliferating cells and they had a markedly reduced uptake of fibroblast EVs as compared to IFITM1low/- cells. In contrast, there was no difference in the intensity of EV release between CRC subpopulations with high and low IFITM1 levels. Importantly, the difference in cell proliferation between these two subpopulations disappeared in the presence of fibroblast-derived EVs, proving the functional relevance of the enhanced EV uptake by IFITM1low CRC cells. Furthermore, inactivating IFITM1 resulted in an enhanced EV uptake, highlighting the importance of this molecule in establishing the cellular difference for EV effects. Collectively, we identified CRC cells with functional difference in their EV uptake ability that must be taken into consideration when using EVs as therapeutic tools for targeting cancer cells.

Wnt Activity and Cell Proliferation Are Coupled to Extracellular Vesicle Release in Multiple Organoid Models.

Extracellular vesicles (EV) are considered as a potential tool for early disease diagnosis; however, factors modifying EV release remain partially unknown. By using patient-derived organoids that capture the cellular heterogeneity of epithelial tissues, here we studied the connection between the Wnt-producing microniche and EV secretion in multiple tissues. Although nearly all cells in pancreatic ductal (PD) and pancreatic ductal adenocarcinoma (PDAC) samples expressed porcupine (PORCN), an enzyme critical for Wnt secretion, only a subpopulation of lung bronchiolar (NL) and lung adenocarcinoma (LUAD) organoid cells produced active Wnt. The microniche for proliferating cells was shaped not only by PORCN + cells in NL and LUAD organoids but also by fibroblast-derived EVs. This effect could be blocked by using Wnt secretion inhibitors. Whereas inhibiting Wnt secretion in PD NL or LUAD organoids critically changed both cell proliferation and EV release, these were uncoupled from each other in PDAC. Sorting for CD133 identified a cell population in the LUAD microniche that produced organoids with a high percentage of PORCN + and proliferating cells and an elevated EV secretion, which may explain that CD133 marks LUAD cells with malignant behavior. Collectively, we show here that high cell proliferation rate, induced by Wnt pathway activation, is coupled to a higher EV release, a critical finding that may be considered when developing EV-based diagnostic tools.

Short-term advantages of ELAPE over APR.

INTRODUCTION: Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of intraoperative tumour perforation (IOTP) and can provide wider circumferential resection margins (CRM) but at the price of higher perineal complication rate. The aim of our study was to compare the short term results of conventional APR to ELAPE. MATERIALS AND METHODS: Thirty-five consecutively operated APRs compared to 38 also consecutively operated ELAPEs. Prospectively collected short-term outcome data were analysed retrospectively. RESULTS: There was no difference in demographics, disease stage or tumour location between groups. IOTP rate and CRM positivity rates were similar between the two groups (p = .608). No difference was found in major (Clavien-Dindo III-V) complications, but we found statistically significant difference in minor (Clavien-Dindo I-II) complications (p = .01) in favour of the ELAPE group. Frequency of perineal SSI was lower in ELAPE group, but the difference was not significant (p = .320). Intraoperative iatrogenic complications occurred at significantly lower rate in ELAPE group (p = .035). Also, postoperative morbidity connected with the dissection in the perineal phase (e.g. urine incontinence, urinary retention) was significantly lower (p = .018) after ELAPE. DISCUSSION AND CONCLUSIONS: In our experience ELAPE operations may diminish the rate of Clavien-Dindo I-II complications compared to conventional APR. This effect is ensuing from the decrease of intraoperative iatrogenic complications and from the decrease of minor postoperative complications.

Shared extracellular vesicle miRNA profiles of matched ductal pancreatic adenocarcinoma organoids and blood plasma samples show the power of organoid technology.

Extracellular vesicles (EV) are considered as a promising diagnostic tool for pancreatic ductal adenocarcinoma (PDAC), a disease with a poor 5-year survival that has not improved in the past years. PDAC patient-derived 3D organoids maintain the intratumoral cellular heterogeneity, characteristic for the tumor in vivo.Thus, they represent an ideal in vitro model system to study human cancers. Here we show that the miRNA cargo of EVs from PDAC organoids largely differs among patients. However, we detected a common set of EV miRNAs that were present in matched organoids and blood plasma samples of individual patients. Importantly, the levels of EV miR-21 and miR-195 were higher in PDAC blood EV preparations than in healthy controls, albeit we found no difference compared to chronic pancreatitis (CP) samples. In addition, here we report that the accumulation of collagen I, a characteristic change in the extracellular matrix (ECM) in both CP and PDAC, largely increases EV release from pancreatic ductal organoids. This provides a possible explanation why both CP and PDAC patient-derived plasma samples have an elevated amount of CD63 + EVs. Collectively, we show that PDAC patient-derived organoids represent a highly relevant model to analyze the cargo of tumor cell-derived EVs. Furthermore, we provide evidence that not only driver mutations, but also changes in the ECM may critically modify EV release from pancreatic ductal cells.

Fibroblast-Derived Extracellular Vesicles Induce Colorectal Cancer Progression by Transmitting Amphiregulin.

Extracellular vesicles (EV), structures surrounded by a biological membrane, transport biologically active molecules, and represent a recently identified way of intercellular communication. Colorectal cancer (CRC), one of the most common cancer types in the Western countries, is composed of both tumor and stromal cells and the amount of stromal fibroblasts negatively correlates with patient survival. Here we show that normal colon fibroblasts (NCF) release EVs with a characteristic miRNA cargo profile when stimulated with TGFß, one of the most important activating factors of fibroblasts, without a significant increase in the amount of secreted EVs. Importantly, fibroblast-derived EVs induce cell proliferation in epidermal growth factor (EGF)-dependent patient-derived organoids, one of the best current systems to model the intra-tumoral heterogeneity of human cancers. In contrast, fibroblast-derived EVs have no effect in 3D models where EGF is dispensible. This EV-induced cell proliferation did not depend on whether NCFs or cancer-associated fibroblasts were studied or on the pre-activation by TGFß, suggesting that TGFß-induced sorting of specific miRNAs into EVs does not play a major role in enhancing CRC proliferation. Mechanistically, we provide evidence that amphiregulin, transported by EVs, is a major factor in inducing CRC cell proliferation. We found that neutralization of EV-bound amphiregulin blocked the effects of the fibroblast-derived EVs. Collectively, our data suggest a novel mechanism for fibroblast-induced CRC cell proliferation, coupled to EV-associated amphiregulin.

Management of acute gastrointestinal bleeding. Multidisciplinary guideline proposal. / Heveny gastrointestinalis vérzések ellátása. Multidiszciplináris útmutató javaslat.

Gastrointestinal bleeding has a profound impact on public health due to its high prevalence and severity. With the elderly population taking more anticoagulants/antiaggregants/non-steroid anti-inflammatory drugs, the digestive bleeding will certainly raise more and more challenges in quantity as well as in severity for the public healthcare system. The emergency medicine specialists and gastroenterologists have a central role in the management of patients presenting with gastrointestinal bleeding. In certain cases, radiologists, invasive radiologists, intensive care specialists and surgeons should also be involved in the decision making process and management of patients. Therefore, Hungarian experts felt the need to elaborate a comprehensive, multidisciplinary, practical local guideline reflecting the frequently arisen aspects based on current international guidelines. This guideline proposal covers topics of basic requirements, initial assessment of patients, risk evaluation, laboratory tests, hemodynamic resuscitation in the case of gastrointestinal bleeding followed by its consecutive steps of diagnosis and therapy sorted by location of the source of the hemorrhage. The authors give practical instructions for unsuccessful hemostasis or rebleeding. Finally, the role of surgery is also summarized in the management of gastrointestinal bleeding. Orv Hetil. 2020; 161(30): 1231-1242.

Extracellular vesicles transmit epithelial growth factor activity in the intestinal stem cell niche.

Extracellular vesicles (EV) are membrane-surrounded vesicles that represent a novel way of intercellular communication by carrying biologically important molecules in a concentrated and protected form. The intestinal epithelium is continuously renewed by a small proliferating intestinal stem cell (ISC) population, residing at the bottom of the intestinal crypts in a specific microenvironment, the stem cell niche. By using 3D mouse and human intestinal organoids, we show that intestinal fibroblast-derived EVs are involved in forming the ISC niche by transmitting Wnt and epidermal growth factor (EGF) activity. With a mouse model that expresses EGFP in the Lgr5+ ISCs, we prove that loss in ISC number in the absence of EGF is prevented by fibroblast-derived EVs. Furthermore, we demonstrate that intestinal fibroblast-derived EVs carry EGF family members, such as amphiregulin. Mechanistically, blocking EV-bound amphiregulin inhibited the EV-induced survival of organoids. In contrast, EVs have no role in transporting R-Spondin, a critical niche factor amplifying Wnt signaling. Collectively, we prove the important role of fibroblast-derived EVs as a novel transmission mechanism of factors in the normal ISC niche.

[Guidance for transanal operations]. / Transzanális mutéti útmutató.

We summarized diagnostic, surgical treatment and follow-up principles of benign and early malignant lesions of the rectum. Our aim is to provide a nationwide practical synopsis of transanal minimally invasive surgical techniques which might be the basis of a Hungarian national audit of rectal polyp management.

Extracellular vesicle release from intestinal organoids is modulated by Apc mutation and other colorectal cancer progression factors.

Extracellular vesicles (EVs) are membrane-surrounded structures that transmit biologically important molecules from the releasing to target cells, thus providing a novel intercellular communication mechanism. Since EVs carry their cargo in a protected form and their secretion is generally increased in tumorigenesis, EVs hold a great potential for early cancer diagnosis. By 3D culturing, we provide evidence that colorectal cancer (CRC) patient-derived organoids, representing a state-of-the-art established and essential approach for studying human CRC, is a suitable model for EV analysis. When testing the effects of major factors promoting CRC progression on EV release in the organoid model, we observed that Apc mutation, leading to uncontrolled Wnt activation and thus to tumorigenesis in the vast majority in CRC patients, critically induces EV release by activating the Wnt pathway. Furthermore, the extracellular matrix component collagen, known to accumulate in tumorigenesis, enhances EV secretion as well. Importantly, we show that fibroblast-derived EVs induce colony formation of CRC organoid cells under hypoxia. In contrast, there was no major effect of tumor cell-derived EVs on the activation of fibroblasts. Collectively, our results with CRC and Apc-mutant adenoma organoids identify Apc mutation and collagen deposition as critical factors for increasing EV release from tumors. Furthermore, we provide evidence that stromal fibroblast-derived EVs contribute to tumorigenesis under unfavorable conditions in CRC.

[Is preoperative systemic chemotherapy recommended for resectable colorectal liver metastases? Oncosurgical aspects]. / Reszekábilis colorectalis eredetu májáttét esetén javasolt-e a preoperatív szisztémás kezelés? Onkosebészeti nézopont.

Surgical resection is still the only curative treatment for colorectal liver metastases, but this is one part of a complex therapy. Nowadays a patient with colorectal liver metastasis is not treated only by a surgeon or by an oncologist or even only by an invasive radiologist. Collective decisions, complement treatments give the only chance to treat these patients for longer time. Patients with colorectal liver metastases could be regarded as patients with chronic disease. Specially interesting are the various treatment options of resectable colorectal liver metastases. The efficiency and necessity of preoperative chemotherapy are still a hot spot in the treatment of resectable liver metastases. In this study, we try to summarize the international and local experiences and the current evidence of the use of preoperative chemotherapy in the treatment of colorectal liver metastases. Orv Hetil. 2018; 159(21): 823-830.

[New perspectives in rectal cancer surgery: Transanal total mesorectal excision. Initial experiences]. / Új távlatok a végbélrák sebészetében: Transanalis teljes mesorectum excisio. Kezdeti eredményeink.

INTRODUCTION: Colorectal cancer is the second most frequent cause of oncologic mortality. Its key prognostic factors are operability and surgical quality. Total mesorectal excision is the gold standard of rectal cancer surgery, however, it is hardly achievable with the laparoscopic technique in a number of cases due to anatomical issues. Transanal total mesorectal excision (TaTME) is a new operative concept, which may address this technical problem. AIM: We aimed to present the initial Hungarian experiences with the new technique. METHOD: Retrospective analysis of clinical data of the first year case series at two Hungarian centers initiating the technique. RESULTS: A total of 17 transanal total mesorectal excision (TaTME) operations were performed at two centers. Major perioperative complications happened in two cases. There was no 30-day mortality. CONCLUSIONS: Early Hungarian experiences with transanal total mesorectal excision (TaTME) give hope of a brand new era of rectal cancer surgery. Orv Hetil. 2018; 159(1): 16-22.

[Advantages of transanal approach in low rectal cancer resections]. / A transanalis megközelítés elonye a mély rectumdaganatok mutéteinél.

Laparoscopic surgery is proven equal technique to open rectal surgery. Despite advantages, some problems in case of low rectal surgery are existing: visualization of the pelvis, securing safe distal resection margin, preparing single stapled rectal stump with safe conjunction to the colorectal anastomosis. Approximately 500 procedures have been performed worldwide until today by applying Transanal Total Mesorectal Excision (TaTME) technique, which evolved from a combination of laparoscopy and transanal approach. TaTME presents a solution to the low and mid-level rectal cases. The transanal path provides a better opportunity for preparing safe distal resection margin, an easier way for making a secure distal stump closure, and also offers perfect visualization even in the most difficult area, supporting the aim of nerve-sparing. We present a case, where we performed a synchronous laparoscopic and transanal TaTME resection of a down-sized low rectal tumor at 5 cm, after neoadjuvant radio-chemotherapy. To the best of our knowledge, this was the first case in Hungary, when TaTME was administered in a synchronous way.

[Modern surgical treatment of breast cancer. 3rd Breast Cancer Consensus Conference]. / Az emlorák korszeru sebészi kezelése. III. Emlorák-konszenzuskonferencia.

Therapy for breast cancer today is characterised by ever more precise diagnostic methods and ever more effective oncological treatments, a trend which will certainly continue into the future. Breast preservation and the application of oncoplastic principles are increasingly popular. A sentinel lymph node biopsy in the surgical treatment of the axilla is primary, with the indication for axillary block dissection (ABD) narrowing and radiation therapy becoming an alternative to ABD in certain cases. This publication summarises our recommendations on the surgical treatment of breast cancer based on the content of the 3rd Breast Cancer Consensus Conference and considering the latest international studies and professional recommendations.