Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study.

INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Fashioning enterotomy closure after totally laparoscopic ileocolic anastomosis for right colon cancer: a multicenter experience.

BACKGROUND: Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis. METHOD: A multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures' materials, interrupted versus running suture and the presence of deep corner suture has been investigated. RESULTS: We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (p = 0.455) and anastomotic leak (p = 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (p = 0.02). About double-layer characteristics, we found a significant reduction of bleedings (p = 0.008) and leaks (p = 0.017) with a running suture; similarly, a reduction of bleedings (p = 0.001) and leaks (p = 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (p = 0.001) and leaks (p = 0.001). We found no significant differences in terms of bleedings (p = 0.245) and anastomotic leak (p = 0.660) comparing sewn versus stapled anastomosis. CONCLUSIONS: Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.

Cost-effectiveness analysis of the temporary percutaneous ileostomy for faecal diversion after colorectal resection in elderly.

BACKGROUND: Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery. AIMS: We analyse the outcomes and the costs of the TPI in protecting low colorectal anastomosis in elderly, compared to the CLI. METHODS: Data of patients underwent elective anterior rectal resection for rectal cancer with extra-peritoneal colorectal anastomosis protected by ileostomy from January 2011 to December 2015 were reviewed. Sixty-one out of 132 patients were older than 70; 35 underwent faecal diversion by TPI and 26 by CLI. RESULTS: The two groups resulted homogenous about age, sex, operative time, short-term post-operative complications. None of the patients reported anastomotic leakage. The hospital stay and the cost for the first surgical procedure did not show statistically significant differences between TPI and CLI. When comparing the overall hospital stay and costs the differences are statistically significant: the TPI showed a shorter hospital stay (12.4 vs 19.3 days, -35.7%) and a lower cost of hospitalization (7954.0 vs 14,372.1€, -44.7%), compared to CLI. DISCUSSION: The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of TPI, especially in elderly. CONCLUSION: The TPI not only improved the post-operative outcome of the patients, but also allowed a remarkable saving for the National Health System.

Myoblastoma of the breast: Our experience and review of literature.

INTRODUCTION: Breast myoblastoma or granular cell tumor involving the breast parenchyma has been described in detail for the first time since Abrikossoff in 1931. The location of this injury to the breast is very rare, accounting for between 5% and 15% of all cases of cancer of the granular cells. We present our experience regarding the identification of two cases because of the relative rarity of this tumor. It is often confused with breast cancer on clinical and radiological, and its diagnosis can then be difficult for physicians, radiologists and pathologists. PRESENTATION OF CASES: We report the cases of two young women who came to our attention because of the presence of mass shoveled breast, mobile and accompanied by pain cycle independent. In both cases, mammography and ultrasound revealed the presence of heterogeneous mass and irregular, but in one of two such mass located at the Union of external quadrants of the left breast and was in contact with his serratus anterior and suspicion for malignancy. In both cases the 'histology combined with immunohistochemical study proved to be a granular cell tumor. CONCLUSION: Although a granular cell tumor of the breast is a rare tumor breast, should be considered in the differential diagnosis of benign and malignant lesions. Surgeons and pathologists should keep in mind when considering a granular cell tumor cells with abundant granular cytoplasm containing materials to avoid misdiagnosing breast cancer, which could lead to unnecessary surgery.

Male breast cancer, clinical presentation, diagnosis and treatment: Twenty years of experience in our Breast Unit.

BACKGROUND: The male breast cancer (MBC) is a rare and represents less than 1% of all malignancies in men and only 1% of all breast cancers incident. We illustrate the experience of our team about the clinico-pathological characteristics, treatment and prognostic factors of patients treated over a period of twenty years . RESULTS: Forty-seven patients were collected 1995-2014 at the Breast Unit of the Hospital of Terni, Italy. The average age was 67 years and the median time to diagnosis from the onset of symptoms was 16 months. The main clinical complaint was sub areolar swelling in 36, 76% of cases. Most patients have come to our attention with advanced disease. The histology of about ninety percent of the tumors were invasive ductal carcinoma. Management consisted mainly of radical mastectomy; followed by adjuvant radiotherapy and hormonal therapy with or without chemotherapy. The median follow-up was 38 months. The evolution has been characterized by local recurrences; in eight cases (17% of all patients). Metastasis occurred in 15 cases (32% of all patients). The site of bone metastases was in eight cases; lung in four cases; liver in three cases; liver and skin in one case and pleura and skin in one case. CONCLUSION: The male breast cancer has many similarities to breast cancer in women, but there are distinct functions that need to be appreciated. Future research for a better understanding of the disease should provide a better account of genetic and epigenetic characteristics of these forms; but, above all, epidemiological and biological cohorts numerically more consistent.

Robot-assisted or conventional laparoscoic rectopexy for rectal prolapse? Systematic review and meta-analysis.

AIM: The use of robotic technology has proved to be safe and effective, arising as a helpful alternative to standard laparoscopy in a variety of surgical procedures. However the role of robotic assistance in laparoscopic rectopexy is still not demonstrated. METHODS: A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE, the Cochrane Library, and Google Scholar up to 30th June 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the data currently available regarding the incidence of recurrence rate of rectal prolapse, conversion rate, operative time, intra-operative blood loss, post-operative complications, re-operation rate and hospital stay in robot-assisted rectopexy (RC) compared to conventional laparoscopic rectopexy (LR). RESULTS: Six studies were included resulting in 340 patients. The meta-analysis showed that the RR does not influence the recurrence rate of rectal prolapse, the conversion rate and the re-operation rate, whereas it decreases the intra-operative blood loss, the post-operative complications and the hospital stay. Yet, the RR resulted to be longer than the LR. Post-operative ano-rectal and the sexual functionality and procedural costs could not meta-analyzed because the data from included studies about these issues were heterogeneous and incomplete. CONCLUSION: The meta-analysis showed that the RR may ensure limited improvements in post-operative outcomes if compared to the LR. However, RCTs are needed to compare RR to LR in terms of short-term and long-term outcomes, specially investigating the functional outcomes that may confirm the cost-effectiveness of the robotic assisted rectopexy.

Temporary percutaneous ileostomy for faecal diversion after intestinal resection for acute abdomen in elderly: how to avoid the conventional loop ileostomy.

Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colocolic or colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery, as faecal diversion in low colorectal anastomosis. Now we report our experience with the TPI in protecting colocolic and colorectal anastomosis in urgency in elderly. From January 2012 to June 2014, 45 patients underwent urgent surgical procedures for acute abdomen with colonic and/or rectal resections and colocolic or colorectal anastomosis with faecal diversion by TPI. Nineteen out of 45 patients were older than 70. Four low colorectal anastomoses, 10 intra-peritoneal colorectal anastomosis and 4 colocolic anastomosis were performed. Neither intra-operative complications nor post-operative deaths were observed. None of the 19 patients treated had evidence of clinical or radiological leakage of the anastomosis. Post-operative complications occurred in 7 patients and nobody required re-intervention. No intestinal obstruction was reported in the early (30 days) post-operative period. The TPI seems to be a valid alternative to standard ileostomy, ensuring an optimal faecal diversion both in elective surgery and in urgency. The TPI also ensures less patient discomfort and it can be easily removed without surgery, unlike the CLI. The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of this new technique, especially in elderly.

Traditional lateral ileostomy versus percutaneous ileostomy by exclusion probe for the protection of extraperitoneal colo-rectal anastomosis: the ALPPI (Anastomotic Leak Prevention by Probe Ileostomy) trial. A randomized controlled trial.

BACKGROUND: Low colo-rectal anastomoses have a relevant risk of leakage. The protective stomas (ileostomy or colostomy) have always been utilized to reduce the complications due to anastomotic leakage. The stoma not only causes relevant morbidity but also needs a second operation to be closed, with an added risk of complications. PURPOSE: For this reason we planed and carried out a temporary percutaneous ileostomy by a jejunal probe introduced in the distal ileum, that can be removed without a surgical procedure and with negligible complications. METHODS: The ALPPI trial is a randomized controlled, open, parallel, equivalence multicenter study. Patients undergoing elective laparoscopic or laparotomic surgery for rectal cancer with extraperitoneal anastomosis, will be randomly allocated to undergo either lateral ileostomy or percutaneous ileostomy by exclusion probe. RESULTS: The primary endpoint is the protection of the extraperitoneal colo-rectal anastomosis in terms of incidence of symptomatic and asymptomatic anastomotic leakages. The secondary endpoints are the evaluation of complications due to the placement and the removal of the exclusion probe for percutaneous ileostomy. CONCLUSIONS: The ALPPI trial is designed to provide the surgical community with an evidence based new technique in the protection of low colo-rectal anastomosis, alternative to the conventional stomas. TRIAL REGISTRATION: The ALPPI trial was approved by the Ethical Committee of Regional Public Health System of Umbria, Italy, (Protocol Number 28657/11/AV, study code RO-MA 01) and it is registered in the International Standard Randomised Controlled Trial Number (ISRCTN) Register with identification number ISRCTN99356919.

To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis.

AIM: Anastomotic leakage is the one of the most serious complications in rectal cancer surgery and is associated with high mortality, morbidity and an increased incidence of local recurrence. Although many studies have compared drained and undrained colorectal anastomoses, to date the role of pelvic drainage in extraperitoneal colorectal anastomosis remains undefined. METHOD: We carried out a systematic review of the literature, performing an unrestricted search in MEDLINE and Embase up to 30 October 2012. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We performed a meta-analysis of the data currently available on the incidence of extraperitoneal anastomotic leakage, according to the presence or absence of pelvic drainage. RESULTS: Overall, eight studies - three randomized clinical trials (RCTs) and five non-RCTs, comprising a total of 2277 patients - were included in the meta-analysis. Pelvic drainage was demonstrated to reduce both the leak rate and the rate of reintervention in patients who underwent anterior rectal resection with extraperitoneal colorectal anastomosis (OR = 0.51, 95% CI: 0.36-0.73; and OR = 0.29, 95% CI: 0.18-0.46, respectively) compared with patients without drainage. Overall mortality and infection rates were also evaluated, but a nonsignificant correlation was found with the presence of drainage. CONCLUSION: The meta-analysis shows that the presence of a pelvic drain reduces the incidence of extraperitoneal colorectal anastomotic leakage and the rate of reintervention after anterior rectal resection.

Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study.

AIM: Loop ileostomy is a suitable procedure for transitory faecal diversion after low colorectal anastomosis, but it causes relevant morbidities (discomfort, peristomal infections, dehydration) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI) that can be removed without surgery. METHOD: The data of 143 consecutive patients, undergoing elective laparoscopic anterior resection of the rectum for adenocarcinoma and low mechanical colorectal anastomosis, 68 with conventional loop ileostomy (CLI) and 75 with TPI, were analyzed. RESULTS: Neither intra-operative complications nor deaths occurred during the follow-up period. Clinical anastomotic leakage occurred in 4 patients with CLI and in 1 with TPI (p = 0.191). The median time required for the emission of gases and faeces through the stoma was respectively 1 and 2.5 days in the CLI group, and 1 and 2 days in the TPI group (p = 0.259 and p = 0.126). The median post-operative stay was 8 days in the CLI group and 11 days in the TPI group (p < 0.001). PTIs were removed on the median of 9 days after surgery without major complications, whereas the CLIs were re-canalized in 79.4% of patients on an average of 106 days, with 2 major complications. CONCLUSION: The temporary percutaneous ileostomy seems to be a valid alternative to conventional ileostomy, ensuring optimal faecal diversion and less patient discomfort. It can be easily removed without surgery, allowing patients a better outcome.

Is laparoscopic right colectomy more effective than open resection? A meta-analysis of randomized and nonrandomized studies.

AIM: The aim of this systematic review was to compare laparoscopic and/or laparoscopic-assisted right colectomy (LRC) with open right colectomy (ORC). Many randomized clinical trial have shown that laparoscopic colectomy benefits patients with improved short-term outcomes and comparable overall survival in respect to the open approach. These results, however, could not be applied to right colectomy owing to its wide range of resection and more complicated vascular regional anatomy. METHOD: We performed a meta-analysis of the literature in order to compare LRC vs ORC by examining 21 end-points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing right colectomy for cancer was carried out. The meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement. The search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL until March 2011. We included randomized and non randomized studies that compared the LRC vs ORC for benign disease and malignant neoplasm irrespective of publication status. Only studies in English, French, German, Spanish and Italian languages were considered for inclusion. Emergency right colectomies were excluded. To perform the statistical analysis we used the odds ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. An intention-to-treat analysis was performed. RESULTS: Seventeen studies, 15 nonrandomized clinical trials and two randomized clinical trials, involving a total of 1489 patients, were identified. The mean operative time was longer in the group of patients undergoing LRC [weighted mean difference (WMD) = 37.94, 95% CI: 25.01 to 50.88; P < 0.00001]. Intra-operative blood loss (WMD = -96.61; 95% CI: -150.68 to -42.54; P = 0.0005), length of hospital stay (WMD = -2.29; 95% CI: -3.96 to -0.63; P = 0.007) and short-term postoperative morbidity (OR = 0.64; 95% CI: 0.49 to 0.83; P = 0.0009) were significantly in favour of LRC. CONCLUSION: Laparoscopic-assisted right colectomy results in less blood loss, a shorter length of hospital stay and lower postoperative short-term morbidity compared with ORC.

Prognostic role of sentinel node biopsy in patients with thick melanoma: a meta-analysis.

OBJECTIVES: Sentinel lymph node (SLN) biopsy is a prognostic tool for patients with intermediate-thickness melanomas. However, controversies exist regarding its role in patients with thick melanomas (tumour thickness greater than 4.0 mm). We performed a meta-analysis to assess the prognostic role of SLN in thick melanoma in terms of disease-free survival (DFS) and overall survival (OS). METHODS: An electronic search in MEDLINE and EMBASE databases using the terms 'melanoma' and 'sentinel lymph node' was performed. Studies were considered if they reported data on thick melanoma and SLN biopsy results (positive and negative) and outcomes (DFS or OS). A proportion meta-analysis was used to calculate weighted means and an incidence rate ratio meta-analysis was used to compare outcomes according to SLN biopsy results. RESULTS: Nine studies were included. The weighted mean thickness of melanoma was 4.4 mm, 42% of patients had ulcerated melanoma. SLN was positive in 36% of the patients. Overall, DFS was 71% in patients with a negative SLN and 39% in patients with a positive SLN after a median follow-up of 33 months (IRR 1.83, 95% CI = 1.56-2.14). OS was 71% in patients with a negative SLN and 49% in patients with a positive SLN (IRR 1.44, 95% CI = 1.25-1.65). CONCLUSIONS: The results of this analysis showed that thick melanoma patients with a positive SLN had a significantly worse survival compared with SLN negative patients, thus supporting the routine adoption of SLN biopsy as a prognostic tool also for this subgroup of patients.

Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis.

AIM: The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer. METHOD: The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. RESULTS: Five nonrandomized studies including a total of 5012 patients were identified. Meta-analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43-0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39-0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42-0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39-0.98). CONCLUSION: Taking into account the limitations of the design of the included studies the meta-analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.

The sentinel node biopsy in patients with thick melanoma: outcome analysis from a single-institution database.

BACKGROUND: We examined the impact of sentinel lymph node (SLN) biopsy among patients with primary melanoma that exceeded 4.0 mm in Breslow thickness, treated in our Institution from 1998 until 2009. PATIENTS AND METHODS: According to Kaplan-Meier statistics, overall survival (OS) and disease-free survival (DFS) were assessed in patients with: i) disseminated disease at diagnosis with respect to patients undergoing SLN biopsy and ii) positive SLN and negative SLN. The effect of age, thickness and number of positive SLN on survival was also calculated. RESULTS: Forty-three patients with thick melanoma were included (29 men and 14 women; mean age 65 ± 17 years, tumor thickness ranging from 4 to 20 mm). Thirteen patients (30%) were not eligible for SLN biopsy due to metastatic disease or poor clinical condition. Biopsy was performed on 30 patients: 14 with positive SLN (46.7%, group A) and 16 with negative SLN (53.3%, group B). Seven patients (50%) died in group A and 2 patients (13%) in group B (mean follow-up 28 and 59 months, respectively); all 7 patients in group A and no patient in group B died because of melanoma. OS and DFS were both significantly higher in group B than group A. CONCLUSION: Our experience demonstrates a high rate of positive SLNs in patients with thick melanoma, and significant differences regarding the general outcomes between those with positive and negative SLNs, the latter group having a good prognosis despite the thick primary tumor. This observation stresses the importance of SLN biopsy as a staging tool in patients with thick melanoma.

Preliminary report of a new technique for temporary faecal diversion after extraperitoneal colorectal anastomosis.

AIM: Loop ileostomy is a suitable procedure for transitory faecal diversion after colorectal or coloanal anastomosis. We describe here an easy alternative technique for ileostomy construction that does not require reintervention for the closure. METHOD: In twenty patients undergoing anterior resection of the extraperitoneal rectum with colorectal and/or coloanal anastomosis, loop ileostomy was performed using a modified jejunotomy tube inflated with 10 ml of normal saline. The tube was deflated on the eighth post-operative day and removed on day 11 after a radiological contrast enema of the anastomosis. RESULTS: Radiological control carried out on day 11 evidenced a premature dislocation of the jejunostomy tube in 1 patient, thus the tube was correctly removed without any complications. In another patient a delayed closure of the ileo cutaneous fistula was recorded that required simple medication over 15 days in the out patient clinic. No signs of anastomotic leakage, either clinical or radiological were evidenced. CONCLUSION: We have described here a safe alternative technique for loop ileostomy with negligible complications related to construction as demonstrated in our results.

Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis.

BACKGROUND: Sphincter-saving surgery for the treatment of middle and low rectal cancer has spread considerably when total mesorectal excision became standard treatment. In order to reduce leakage-related complications, surgeons often perform a derivative stoma, a loop ileostomy (LI), or a loop colostomy (LC), but to date, there is no evidence on which is the better technique to adopt. METHODS: We performed a systematic review and meta-analysis of all randomized controlled trials until 2007 and observational studies comparing temporary LI and LC for temporary decompression of colorectal and/or coloanal anastomoses. Clinically relevant events were grouped into four study outcomes: general outcome measures: dehydratation and wound infection GOM construction of the stoma outcome measures: parastomal hernia, stenosis, sepsis, prolapse, retraction, necrosis, and hemorrhage closure of the stoma outcome measures: anastomotic leak or fistula, wound infection COM, occlusion and hernia functioning of the stoma outcome measures: occlusion and skin irritation. RESULTS: Twelve comparative studies were included in this analysis, five randomized controlled trials and seven observational studies. Overall, the included studies reported on 1,529 patients, 894 (58.5%) undergoing defunctioning LI. LI reduced the risk of construction of the stoma outcome measure (odds ratio, OR = 0.47). Specifically, patients undergoing LI had a lower risk of prolapse (OR = 0.21) and sepsis (OR = 0.54). LI was associated with an excess risk of occlusion after stoma closure (OR = 2.13) and dehydratation (OR = 4.61). No other significant difference was found for outcomes. CONCLUSION: Our overview shows that LI is associated with a lower risk of construction of the stoma outcome measures.

Endothelial progenitor cells are mobilized after major laparotomic surgery in patients with cancer.

The progression of cancer is largely dependent on neoangiogenesis. Circulating endothelial progenitor cells (EPC) have the ability to form complete vascular structures in vitro and play a crucial role in tumor vasculogenesis. Emerging evidence suggests that surgical injury may induce the mobilization of EPC in animal models, and this might have a negative effect on the prognosis of cancer patients. We studied 20 patients (10 men, 65+/-13 years) undergoing laparotomy for surgical treatment of various forms of abdominal cancer, and 20 age- and sex-matched healthy control subjects. The number of circulating EPC, defined as CD34+/KDR+ cells identified among mononuclear cells isolated from peripheral venous blood, was determined preoperatively and at days 1 and 2 after surgery. Surgery induced a significant increase in circulating EPC levels at day 1 (from 278/mL, interquartile range 171-334, to 558/mL, interquartile range 423-841, p<0.001) and day 2 (709/mL, interquartile range 355-834, p<0.001)compared with baseline values. EPC levels did not change in control subjects. Seven subjects who underwent laparotomic surgery for non-neoplastic disease also showed an increase in EPC levels after surgery (p=0.009 and p=0.028 at day 1 and day 2, respectively). We conclude that patients undergoing elective laparotomic surgery for cancer demonstrate an increase in EPC post-operatively. The potential adverse effects of surgical stress-induced EPC mobilization on tumor and metastasis growth in cancer patients need to be addressed in future studies.

Altered production of IFN-gamma? And other inflammation-related cytokines by mycobacteria- stimulated peripheral blood mononuclear cells from rheumatoid arthritis patients.

Peripheral blood mononuclear cells taken from 32 patients with Rheumatoid Arthritis (RA) receiving neither steroids nor methotrexate and 34 healthy controls were examined for lymphoproliferation in the presence of ultrasonic extracts of 14 different mycobacterial species or serotypes, of an extract of Candida albicans and of 2 mitogens. Additionally, cells were incubated for 96 hours alone, or with Mycobacterium tuberculosis (M.tb) sonicate or Concanavalin-A (Con-A), and supernatants were tested for a range of cytokines. Lymphocytes of rheumatoid patients were less reactive than controls to all the mycobacterial preparations, but no different in their responses to mitogens. Stimulation of patients' cells with M.tb sonicate induced significantly less interferon-gamma (IFN-gamma), tumour necrosis factor-alpha (TNF-alpha) and interleukin-10 (IL-10) but more transforming growth factor- beta (TGF-beta) than controls. Even stimulation with Con-A induced much less IFN-gamma in patient's cells than in those of controls. The combination of reduced responses to the mycobacterial reagents and reduced stimulation of type 1 cytokines by the sonicate of M.tb, suggests reduced responsiveness to group i, common mycobacterial antigens. Such findings need not indicate involvement of mycobacteria specifically in the disease aetiology, but provide novel information on the immunopathological abnormalities, which may explain the reported increased susceptibility to mycobacteria of RA patients.