Core outcome set for surgical trials in gastric cancer (GASTROS study): international patient and healthcare professional consensus.

BACKGROUND: Surgery is the primary treatment that can offer potential cure for gastric cancer, but is associated with significant risks. Identifying optimal surgical approaches should be based on comparing outcomes from well designed trials. Currently, trials report different outcomes, making synthesis of evidence difficult. To address this, the aim of this study was to develop a core outcome set (COS)-a standardized group of outcomes important to key international stakeholders-that should be reported by future trials in this field. METHODS: Stage 1 of the study involved identifying potentially important outcomes from previous trials and a series of patient interviews. Stage 2 involved patients and healthcare professionals prioritizing outcomes using a multilanguage international Delphi survey that informed an international consensus meeting at which the COS was finalized. RESULTS: Some 498 outcomes were identified from previously reported trials and patient interviews, and rationalized into 56 items presented in the Delphi survey. A total of 952 patients, surgeons, and nurses enrolled in round 1 of the survey, and 662 (70 per cent) completed round 2. Following the consensus meeting, eight outcomes were included in the COS: disease-free survival, disease-specific survival, surgery-related death, recurrence, completeness of tumour removal, overall quality of life, nutritional effects, and 'serious' adverse events. CONCLUSION: A COS for surgical trials in gastric cancer has been developed with international patients and healthcare professionals. This is a minimum set of outcomes that is recommended to be used in all future trials in this field to improve trial design and synthesis of evidence.

Selective decontamination of the digestive tract in upper gastrointestinal surgery: systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Infectious complications are common after gastrointestinal surgery. Selective decontamination of the digestive tract (SDD) might reduce their incidence. SDD is used widely in colorectal resections, but its role in upper gastrointestinal resection is less clear. The aim of this study was to investigate the impact of SDD on postoperative outcome in upper gastrointestinal surgery. METHODS: Studies investigating SDD in upper gastrointestinal surgery were included after search of medical databases (PubMed, Ovid, Cochrane Library and Google Scholar). Results were analysed according to predefined criteria. The incidence of perioperative overall complications and death was pooled. Risk of bias was assessed using the revised Cochrane risk-of-bias tool. RESULTS: Some 1384 studies were identified, of which four RCTs were included in the final analysis. These studies included 415 patients, of whom 213 (51·3 per cent) received standard treatment/placebo and 202 (48·7 per cent) had SDD. The incidence of anastomotic leakage (odds ratio (OR) 0·39, 95 per cent c.i. 0·19 to 0·80; P = 0·010) and pneumonia (OR 0·42, 0·23 to 0·78; P = 0·006) was reduced in patients receiving SDD. Rates of surgical-site infection (P = 0·750) and mortality (P = 0·130) were not affected by SDD. CONCLUSION: SDD seems to be associated with reduction of anastomotic leakage and pneumonia following upper gastrointestinal resection, without affecting postoperative mortality.

ANTECEDENTES: Las complicaciones infecciosas son frecuentes tras la cirugía gastrointestinal. La descontaminación selectiva del tracto digestivo (Selective Decontamination of the Digestive tract, SDD) podría reducir su incidencia. Mientras que la SDD es ampliamente utilizada en las resecciones colorrectales, su papel en las resecciones del tracto gastrointestinal superior está menos definido. El objetivo de este estudio fue investigar el impacto de la SDD en el resultado postoperatorio en cirugía del tracto gastrointestinal superior. MÉTODOS: Se incluyeron estudios que investigasen la SDD en cirugía del tracto gastrointestinal superior después de una búsqueda de bases de datos médicas (Pubmed, Ovid, Cochrane-Library y Google/Scholar). Los resultados se analizaron de acuerdo con criterios predefinidos. Se agrupó la incidencia de complicaciones perioperatorias globales y mortalidad. El riesgo de sesgo se analizó utilizando la herramienta de la colaboración Cochrane revisada para la evaluación del riesgo de sesgo. RESULTADOS: Se identificaron 1.380 estudios, de los cuales cuatro ensayos controlados aleatorizados fueron incluidos en el análisis final. Estos estudios incluían a 415 pacientes de los cuales 213 (51,3%) recibieron tratamiento estándar/placebo y 202 (48,7%) recibieron SDD. La incidencia de fugas anastomóticas (razón de oportunidades, odds ratio, OR: 0,39 (0,19-0,80); P = 0,010)) y neumonía (OR: 0,42 (0,23-0,78); P = 0,006)) se redujo en pacientes que recibieron SDD. Infecciones del sitio quirúrgico (P = 0,750) y la mortalidad (P = 0,130) no se relacionaron con la SDD. CONCLUSIÓN: SDD parece asociarse con reducción de fuga anastomótica y neumonía tras resecciones del tracto gastrointestinal superior, sin afectar a la mortalidad postoperatoria.

Influence of the surgical technique on survival in the treatment of carcinomas of the true cardia (Siewert Type II) - Right thoracoabdominal vs. transhiatal-abdominal approach.

INTRODUCTION: It is still a matter of debate whether subtotal esophagectomy via a right thoracoabdominal approach (RTA) or extended gastrectomy using a transhiatal-abdominal approach (TH) is the favorable technique in the treatment of Siewert type II esophago-gastric junction adenocarcinoma (EJA). MATERIALS AND METHODS: Patients undergoing RTA or TH for EJA at our institution between 2000 and 2013 were extracted from a prospective database. Of 270 patients 91 (33.7%) underwent RTA and 179 (66.3%) were treated by TH. Differences in baseline characteristics, 30d mortality and complications were investigated using the χ2-test or exact testing. Survival analysis was performed using the Kaplan-Meier method and log rank testing. Median survival and hazard ratios were calculated and multivariable analysis of predictors was performed using a Cox model. Confounders were balanced using propensity score matching (PSM). RESULTS: No significant difference between the two procedures was detected regarding overall-survival (OS) and disease-free survival (DFS). 30d mortality rates were 1.1% in the RTA group and 4.5% in the TH group (p = 0.134). Morbidity was 34.1% in the RTA and 24.6% in the TH group (p = 0.006). Cox regression analysis identified age, ASA class and UICC stage as independent prognostic factors for OS. After PSM survival curves (OS + PFS) showed no significant difference. CONCLUSION: The present study could not detect a difference between RTA and TH from the oncologic point of view; RTA was not associated with higher 30d mortality. RTA for Siewert Type II EJA is justified whenever the oral tumor margin cannot be safely reached via a transhiatal approach.

Alpha-fetoprotein is a significant prognostic factor for gastric cancer: Results from a propensity score matching analysis after curative resection.

BACKGROUND: Prognosis of alpha-fetoprotein positive gastric cancer (AFPP-GC) remains elusive so far due to disparities in cohort size and baseline characteristics in previous studies. A propensity score matching (PSM) analysis as well as multivariable model was performed for unbiased evaluation of the outcome in AFPGC. METHODS: Among 3034 gastric cancer patients who underwent curative gastric cancer surgery (R0, M0) at the National Cancer Center, Korea between 2002 and 2007, we identified 97 patients being positive for AFP either by elevation of serum-AFP levels >10 µg/L or by immunohistochemical staining. Due to marked disparities in baseline characteristics and cohort size, propensity-score-matching was performed which matched 87 AFPP-GC patients to the same number of AFP-negative gastric cancer (AFPN-GC) patients. Baseline characteristics were compared using χ2-test. Survival curves were compared using the Kaplan-Meier-method and multivariable regression analysis was performed to evaluate the effect of AFP-positivity while adjusting the effects of confounding variables. RESULTS: AFPP-GC and AFPN-GC patients revealed marked disparities in patient cohorts. After PSM, groups were balanced for age, sex, tumor size, BMI, tumor location, grade of differentiation, presence of lymphatic vessel infiltration (LVI), Lauren histologic type and stage distribution. In multivariable regression analysis of the PSM-groups, only AFP-positivity and pathologic stage were predictive for overall survival (HR 2.98, CI 95% {1.7-5.1}, p < 0.0001). Five-year-survival rates were significantly worse for AFPP-GC patients (57.9% vs. 76.1%, p = 0.014). Recurrence was significantly more frequent in AFPP-GC patients (p = 0.003). CONCLUSION: AFP can be considered as an independent negative predictor of overall and recurrence-free survival in patients with gastric cancer.

Pharmacological enhancement of mGlu5 receptors rescues behavioral deficits in SHANK3 knock-out mice.

SHANK3 (also called PROSAP2) genetic haploinsufficiency is thought to be the major cause of neuropsychiatric symptoms in Phelan-McDermid syndrome (PMS). PMS is a rare genetic disorder that causes a severe form of intellectual disability (ID), expressive language delays and other autistic features. Furthermore, a significant number of SHANK3 mutations have been identified in patients with autism spectrum disorders (ASD), and SHANK3 truncating mutations are associated with moderate to profound ID. The Shank3 protein is a scaffold protein that is located in the postsynaptic density (PSD) of excitatory synapses and is crucial for synapse development and plasticity. In this study, we investigated the molecular mechanisms associated with the ASD-like behaviors observed in Shank3Δ11-/- mice, in which exon 11 has been deleted. Our results indicate that Shank3 is essential to mediating metabotropic glutamate receptor 5 (mGlu5)-receptor signaling by recruiting Homer1b/c to the PSD, specifically in the striatum and cortex. Moreover, augmenting mGlu5-receptor activity by administering 3-Cyano-N-(1,3-diphenyl-1H-pyrazol-5-yl)benzamide ameliorated the functional and behavioral defects that were observed in Shank3Δ11-/- mice, suggesting that pharmaceutical treatments that increase mGlu5 activity may represent a new approach for treating patients that are affected by PMS and SHANK3 mutations.

Influence of an elevated nutrition risk score (NRS) on survival in patients following gastrectomy for gastric cancer.

In the last years, the impact of weight loss in patients with malignant tumors has come more and more into the focus of clinical research, as the occurrence of weight loss is often associated with a reduced survival. Weight loss can be a hint for metastases in patients suffering from malignant tumors; furthermore, these patients are usually not able to be treated with chemotherapy. The aim of the study was to show the influence of weight loss and an elevated nutrition risk score on survival following tumor resection in patients suffering from gastric cancer. In 99 patients in whom a gastrectomy due to gastric cancer was performed, the nutrition risk score was calculated and its influence on mortality, morbidity and survival was analyzed. Of the included patients, 45 % of the patients gave a history of weight loss; they had significantly more often a NRS ≥ 3. In UICC stage 1a/b, a NRS ≥ 3 was associated with a significantly reduced survival compared to patients with a NRS < 3. In early tumor stages (UICC 1a/b), a NRS ≥ 3 was associated with a significantly reduced survival, while in progressed tumor stage, the influence of a poor NRS was not significant. This seems to show that in progressed stages in patients with gastric cancer, the influence of a reduced NRS is negligible.

Occurrence of multinucleated hepatocytes in cynomolgus monkeys (Macaca fascicularis) from different geographical regions.

Multinucleated hepatocytes (MNHs) have been occasionally reported in macaques, as well as chimpanzees and gorillas, as an incidental finding. However, information is sparse on variations in incidence in the cynomolgus macaque (Macaca fascicularis). A survey was conducted to assess the occurrence of MNHs in the liver of stock (nonstudy) animals from SNBL SRC (Alice, TX) and SNBL USA (Everett, WA) submitted for diagnostic purposes. A total of 215 cynomolgus monkeys originally from Cambodia (61), China (5), Indonesia (125), and Mauritius (24) were used for this investigation. From each animal, usually 2 liver samples were processed for histopathology with 2 sections in each slide. An MNH was defined as a hepatocyte with 3 or more nuclei. A threshold of 3 MNHs was selected for the Multinucleated Hepatocyte Grading System: 0 = not remarkable (≤3 MNHs counted from 2-4 liver sections), minimal = 4 to 15 MNHs, mild = 16 to 30 MNHs, moderate = 31 to 59 MNHs, and severe ≥60 MNHs. The incidence of MNHs was 60 of 86 (70%) in males and 72 of 129 (56%) in females for a total overall incidence of 132 of 215 animals (61%). Affected hepatocytes were frequently observed close to the capsule and generally had 3 to 8 nuclei per hepatocyte but as many as 15 occurred in a single cell. Awareness of the incidence of MNHs in cynomolgus monkeys is important for potential use as background data in preclinical safety and toxicity evaluation studies.

[Lymphadenectomy for malignancies of the upper gastrointestinal tract]. / Lymphadenektomie bei Malignomen des oberen Gastrointestinaltraktes.

Studies from specialized and high volume centers revealed an improved overall survival for patients subjected to extended lymphadenectomy. The drawbacks of radical lymph node dissection seem to be represented in higher rates of morbidity and mortality and thus are correlated to the surgical expertise of the respective institution. Especially patients in the early stages of metastatic lymph node spread benefit from extended and more radical lymphadenectomy. In a retrospective analysis of this institution's own patients, a pN0 category pT stage and the amount of retrieved lymph nodes have been found to be independent prognostic factors. In patients with up to six positive nodes (pN1) pT stage, the number of retrieved nodes, the number of positive nodes and R stage are correlated to survival prognosis. If more than six nodes are invaded only the amount of metastatic nodes and R stage are relevant prognostic factors. It will be of upmost interest to compare these data with analyses from regional and national cancer registers for gastric and esophageal cancer. As so far no reliable procedure for preoperative determination of lymphatic spread exists, the recommendations by the respective research organizations will have to be adopted until further notice, which is D2 lymphadenectomy for locally advanced gastric cancer and 2-field lymphadenectomy for patients with advanced esophageal cancer.Due to higher complication rates for patients subjected to radical lymphadenectomy, it is recommended that these procedures be performed in specialized high volume centers with corresponding surgical experience.

[Diagnosis and surgical treatment of pancreatic cancer].

Despite sustained efforts, intensive research has not been proven successful to reveal risk factors, which relevantly influence early diagnostics or effective treatment of pancreatic carcinoma. Principally, it must be noted, that currently no ideal tumor marker exists for the (early) detection of pancreatic carcinoma. The most important imaging modalities are high-resolution computed tomography, abdominal ultrasound, and endosonography. Surgical procedures in therapy have become more and more standardised and lead to a decrease in morbidity and mortality on the one hand and to an increase in resectability on the other hand. Pylorus-preserving partial pancreaticoduodenectomy is the treatment of choice for a tumor of the pancreatic head, whereas resection of the left pancreas (including splenectomy) is the standard therapy for carcinomas of the pancreatic tail. In all cases, a local systematic lymphadenectomy is mandatory; hence the prognostic gain of an extended lymphadenectomy remains indeterminate. An infiltration of mesenteric and portal veins does not prevent respectability, as long as by venous resection an R0 status can be achieved. However arterial involvement in general excludes resection. Patients with marginally resectable or locally non-resectable tumors should be recruited into neoadjuvant radiochemotherapy trials since one third of these patients could be considered for potentially curative resection. However the majority of pancreatic cancer patients show locally unresectable or metastasized disease and therefore palliative treatment concepts are needed. Both, endoscopic or percutaneous stenting procedures and operative bypass surgery, are safe and reach high success rates.

N-terminal sequence analysis of proteins and peptides.

Amino-terminal (N-terminal) sequence analysis is used to identify the order of amino acids of proteins or peptides, starting at their N-terminal end. This unit describes the sequence analysis of protein or peptide samples in solution or bound to PVDF membranes using a Perkin-Elmer Procise Sequencer. Sequence analysis of protein or peptide samples in solution or bound to PVDF membranes using a Hewlett-Packard Model G1005A sequencer is also described. Methods are provided for optimizing separation of PTH amino acid derivatives on Perkin-Elmer instruments and for increasing the proportion of sample injected onto the PTH analyzer on older Perkin-Elmer instruments by installing a modified sample loop. The amount of data obtained from a single sequencer run is substantial, and careful interpretation of this data by an experienced scientist familiar with the current operation performance of the instrument used for this analysis is critically important. A discussion of data interpretation is therefore provided. Finally, discussion of optimization of sequencer performance as well as possible solutions to frequently encountered problems is included.

Condyloma acuminatum in a cynomolgus monkey (Macaca fascicularis).

Condyloma acuminatum was found on the penile shaft and glans of a wild-caught cynomolgus monkey. The characteristic cauliflower-like, digitated lesions corresponded histopathologically with epidermal hyperplasia, hyperkeratosis, hypergranulosis, pallor of the mid-spinous zone, and crowding of keratinocytes. Electron microscopy revealed 10 intranuclear viral particles. In situ hybridization studies using human DNA probes (pan-Human Papillomavirus [HPV] 6/11, HPV 16/18, and HPV 31/33) all failed to hybridize. Polymerase chain reaction using papillomavirus probes MY09, MY11, GP5, and GP6 failed to amplify HPV DNA. We conclude that this lesion likely is a viral-induced condyloma but that the virus is not detectable by using presently available human or monkey papillomavirus probes.

Identification of a survival-promoting peptide in medium conditioned by oxidatively stressed cell lines of nervous system origin.

A survival-promoting peptide has been purified from medium conditioned by Y79 human retinoblastoma cells and a mouse hippocampal cell line (HN 33.1) exposed to H2O2. A 30 residue synthetic peptide was made on the basis of N-terminal sequences obtained during purification, and it was found to exhibit gel mobility and staining properties similar to the purified molecules. The peptide maintains cells and their processes in vitro for the HN 33.1 cell line treated with H2O2, and in vivo for cortical neurons after lesions of the cerebral cortex. It has weak homology with a fragment of a putative bacterial antigen and, like that molecule, binds IgG. The peptide also contains a motif reminiscent of a critical sequence in the catalytic region of calcineurin-type phosphatases; surprisingly, like several members of this family, the peptide catalyzes the hydrolysis of para-nitrophenylphosphate in the presence of Mn2+. Application of the peptide to one side of bilateral cerebral cortex lesions centered on area 2 in rats results in an increase in IgG immunoreactivity in the vicinity of the lesions 7 d after surgery. Microglia immunopositive for IgG and ED-1 are, however, dramatically reduced around the lesions in the treated hemisphere. Furthermore, pyramidal neurons that would normally shrink, die, or disintegrate were maintained, as determined by MAP2 immunocytochemistry and Nissl staining. These survival effects were often found in both hemispheres. The results suggest that this peptide operates by diffusion to regulate the immune response and thereby rescue neurons that would usually degenerate after cortical lesions. The phosphatase activity of this molecule also suggests the potential for direct neuron survival-promoting effects.

Histologic changes of doxycycline pleurodesis in rabbits. Effect of concentration and pH.

The effects of doxycycline hyclate (DOXY) pleurodesis were compared with those of tetracycline hydrochloride (TCN) in 25 healthy New Zealand White rabbits. One group of rabbits received TCN (pH 2.0) in the left pleural space at a concentration of 35 mg/kg in 3.0 ml of saline solution. Four other groups of rabbits received DOXY in two concentrations (35 mg/kg or 10 mg/kg) and at two pHs (an acid of 2.0 and a NaOH neutralized pH of 7.6). No attempt was made to drain the pleural space after pleurodesis. At autopsy 2 weeks later, bloody fluid filled the pleural cavity and extensive intrapleural adhesions compressed the underlying lung. Microscopically, fibrin and collagen were diffusely deposited in the pleural connective tissue and in the intrapleural adhesions. The visceral pleural thickness increased from its normal value of 0.01 mm to values of 0.5 to 0.9 mm in the TCN and DOXY groups. Fibroblasts were the predominant inflammatory cell in the pleural connective tissue with few neutrophils or lymphocytes. No significant differences of histologic characteristics were observed between the TCN and DOXY groups. Alterations in pH or concentration in the DOXY groups produced similar changes in the gross and microscopic appearance of the pleural space. We conclude that DOXY is as effective as TCN in producing chemical pleurodesis. Doxycycline concentrations of 10 mg/kg were sufficient to substantially sclerose the pleural space in these healthy rabbits. Doxycycline pleurodesis was effective at neutral pH suggesting a mechanism of action independent of acid injury to the mesothelium.

A method for high-performance sequence analysis using polyvinylidene difluoride membranes with a biphasic reaction column sequencer.

Methods have been developed for high-sensitivity sequence analysis of proteins electroblotted onto polyvinylidene difluoride (PVDF) membranes using a Hewlett-Packard G1005A protein sequencer. This sequencer normally uses a biphasic (hydrophobic/hydrophilic) reaction column which was designed to accommodate loading and cleanup of samples from diverse solutions. However, the standard column, programs, and chemistry were not designed to accommodate PVDF, which has become a common sequencing support. In this study, a systematic evaluation of the suitability of this sequencer for analysis using PVDF bound samples was performed and included evaluation of: different wash and extraction solvents, multiple programming changes, two alternative formulations of coupling reagents, and the effect of direction for solvent and reagent deliveries. High-performance analysis of PVDF bound samples was achieved by: using a modified reaction column with an empty hydrophobic (top) half of the column module, program modifications for the reaction column and converter, substitution of ethyl acetate for the standard S2/3 extraction solvent and using prototype Version 2.0 formulations of the coupling reagents, R1 and R2. High-performance sequence analyses of experimental samples electroblotted from either 1D or 2D gels onto high-retention PVDF membranes were obtained with a 41-min cycle time, including experimental samples with initial coupling yields < 2 pmol. Routine sequencer performance was comparable to, or slightly better than, a conventional gas-phase sequencer which had been previously optimized by us for high-performance sequence analysis of electroblotted samples in the low pmol range.

High-sensitivity gas phase sequence analysis of proteins and peptides on PVDF membranes using short cycle times.

An optimized sequencer program with a cycle time of 38 min which is specifically tailored for analysis using polyvinylidene difluoride (PVDF) membranes has been developed. The program was developed using a pulsed liquid-phase instrument which was converted to gas-phase acid delivery. Gas-phase acid delivery minimized sample extraction from PVDF membranes and improved tryptophan yields in at least some cases. Other modifications which contributed to reliable high sensitivity sequencer performance included use of a Blott cartridge, substitution of ethyl acetate:heptane (1:1, v/v) instead of butyl chloride as the extraction solvent, use of a modified 100-microliters injection loop with an internal restrictor to reliably inject nearly 90% of the sample, and an HPLC gradient which resolved tryptophan from diphenylurea. These shortened cycle times were achieved at the conventional gas-phase reaction temperature. A slight increase in lag or carryover at prolines was compensated by reduced background from nonspecific acid cleavage which facilitated extended and/or high sensitivity sequencing of large proteins. Reproducible high initial and repetitive cycle yields were obtained with a wide range of experimental peptides which were electroblotted from either 1D or 2D polyacrylamide gels onto high retention PVDF membranes. Initial yields of the majority of the experimental samples analyzed with this program were less than 5 pmol. In addition, most samples with initial yields below 1-2 pmol yielded sufficient sequence information to identify the protein by comparison to protein sequence data-bases or to design oligonucleotide probes.