Alterations in colonic transit time after laparoscopic versus open cholecystectomy: a clinical study.

PURPOSE: Postoperative enteral paresis constitutes a common problem for surgeons around the world. Evidence by many authors suggests that colonic inertia constitutes a major component of postoperative enteral paresis. This study aims at comparing the effect of laparoscopic versus open cholecystectomy on colonic transit time in humans. MATERIALS AND METHODS: In this study, were included a total of 29 patients suffering from cholelithiasis, divided into two groups, a laparoscopic cholecystectomy and an open cholecystectomy group. All patients ingested one capsule containing 24 radiopaque markers on the day of the operation, and plain abdominal films were obtained on the 3rd postoperative day. The number of remaining markers was counted, and the percentage of rejected markers was calculated. For the statistical analysis, SPSS for windows version 12 was used. RESULTS AND DISCUSSION: The study's results show a significant difference in postoperative colonic motility, in favor of the laparoscopic cholecystectomy group (P = 0,001). Causative interpretation of these results is difficult, mainly due to the multifactorial nature of postoperative colonic hypomotility. CONCLUSION: The present study suggests an advantage of laparoscopic cholecystectomy, as far as the duration of postoperative colonic paresis is concerned.

Evaluation of predictive and prognostic significance of serum TGF-beta1 levels in breast cancer according to HER-2 codon 655 polymorphism.

The present study was conducted to clarify the predictive and prognostic significance of serum TGF-I(2)1 in breast cancer in relation to Ile655Val single nucleotide polymorphism (SNP) of human epidermal growth factor receptor-2 (HER-2). In a case-control study, 56 consecutive patients with primary breast cancer were prospectively included and evaluated. The control group consisted of 45 healthy women. Serum concentrations of TGF-I(2)1 were measured by quantitative sandwich enzyme immunoassay (ELISA). HER-2 SNP was genotyped using PCR-RFLP method. Serum levels of TGF-I(2)1 were significantly increased in breast cancer patients compared to healthy controls (p<0.001). For the evaluation of the diagnostic significance of serum TGF-I(2)1 the area under the receiver operating characteristic (ROC) curve (AUC) was 0.804, while the optimal cut-off point of 30.86 ng/ml was determined to classify breast cancer patients, which yielded sensitivity of 77%, specificity of 78% and accuracy of 77%. Significantly elevated serum TGF-I(2)1 levels were associated with advanced stages (p=0.023), positive lymph nodes (p=0.019) and postmenopausal status (p=0.031). A marginal trend towards higher TGF-I(2)1 levels was found among patients with Val-containing genotypes compared to homozygous Ile-Ile (p=0.094). In multivariate analysis lymph node metastases (p=0.009) remained the only significant independent determinant of high TGF-I(2)1 levels. With regard to prognostic significance for advanced stages (AUC, 0.704) and lymph node metastasis (AUC, 0.683), when the optimal cut-off value was set at 65.15 pg/ml, the sensitivity was 86% and 67%, the specificity was 60% and 62% and accuracy was 66% and 64%, respectively. Survival was shorter in patients with increased serum TGF-I(2)1 (36 months vs 46 months, p=0.022). Multivariate analysis demonstrated a marginal prognostic significance of serum TGF-I(2)1 for survival (p=0.072). The combination of high TGF-I(2)1 and Val-Val genotype predicts a worse prognosis than high serum TGF-I(2)1 alone. Our findings suggest that serum TGF-I(2)1 is involved in tumor malignancy and lymph node metastasis and could be used clinically as a useful tumor marker for evaluation, the extension and the outcome of the disease. They also provide clinical evidence for a significant association between HER-2 Ile655Val SNP and serum TGF-I(2)1, resulting to more aggressive phenotype of the tumor and poor prognosis.

The influence of serum HER-2 levels and HER-2 codon 655 polymorphism on breast cancer outcome.

HER-2 (human epidermal growth factor receptor-2) proto-oncogene is a member of the EGFR family and plays an important role in the regulation of cell growth, differentiation and survival and is involved in the regulation of normal breast growth and development. Alterations of HER-2 have been associated with carcinogenesis and poor prognosis of breast cancer. The present case-control study was conducted to clarify the predictive and prognostic significance of serum HER-2 protein in breast cancer patients in relation to Ile655Val single nucleotide polymorphism (SNP) of this gene. Fifty-six consecutive patients with primary breast cancer and 45 healthy women were prospectively included and evaluated. Serum levels of HER-2 were significantly increased in breast cancer patients compared to healthy controls (p=0.035). The optimal cut-off point of 1.98 ng/ml, which was determined to classify breast cancer patients, yielded sensitivity of 54%, specificity of 73% and accuracy of 62%. Significantly elevated serum HER-2 levels were associated with lymphovascular invasion (p=0.022), poor differentiation (p=0.011), advanced clinical stages (p=0.001), lymph node metastasis (p=0.011), higher number of positive lymph nodes (p=0.007) and the immunohistochemical overexpression of HER-2 protein (p=0.016). Regarding to HER-2 Ile655Val SNP, Ile-Val and Val-Val genotypes exhibited highly significant serum HER-2 elevation compared to homozygous Ile-Ile (both p<0.001). In multivariate analysis advanced stages (p=0.003) and Val-containing genotypes (p=0.009) remained the two significant independent determinants of high HER-2 levels. Survival analysis demonstrated an independent prognostic significance of homozygous Val-Val genotype for reduced survival (p=0.045), but not of serum HER-2 (p=0.181). Our findings confirm that serum HER-2 could be used clinically as a useful tumor marker for the diagnosis and the progression of breast cancer. Furthermore, they provide clinical evidence that HER-2 Ile655Val SNP does affect serum HER-2 levels and it can be regarded as a predictive biomarker for breast cancer patients with poor prognosis.

Allelic imbalance of HER-2 codon 655 polymorphism among different religious/ethnic populations of northern Greece and its association with the development and the malignant phenotype of breast cancer.

Alterations of c-erbB-2 (neu or HER-2) proto-oncogene have been associated with carcinogenesis and poor prognosis of breast cancer. A single nucleotide polymorphism (SNP) at codon 655 resulting in a G to A transition (Ile655Val) in the transmembrane domain-coding region of this gene has been associated with an increased risk of breast cancer. This study aims to determine the prevalence of the HER-2 genotype and its association with breast cancer in the Greek Christian and Greek Muslim population of Thrace, Greece. In this case-control study, we genotyped 56 patients (43 Christians and 13 Muslims) with primary breast cancer and 45 healthy women (32 Christians and 13 Muslims) for the Ile655Val polymorphism, with the PCR-RFLP method. The Val allele and the Val-containing genotypes were significantly more frequent in Muslims than in Christians (p=0.020 and p=0.008, respectively). Among the Greek Christian population, a 5-fold and a 3.1-fold increase in risk of breast cancer was associated with the Val-Val genotype and the Ile-Val or Val-Val genotypes (95% CI, 1.3-18.4; p=0.017 and aOR, 3.1; 95% CI, 1.2-8.3; p=0.025; respectively) compared to homozygous Ile-Ile. No significant association was found in the Muslim population. Among the entire cohort, the Val allele confers a modest increase in breast cancer risk (OR, 2.6; 95% CI, 0.9-7.6; p=0.076, for Val-Val and OR, 2.2; 95% CI, 0.9-5.2; p=0.079 for Ile-Val or Val-Val). This effect was even more pronounced in younger women. Among breast cancer patients, invasive carcinomas, low differentiation tumors, advanced stages, positive lymph nodes, high number of lymph nodes and HER-2 overexpression were more frequent in patients with allele Val than those with allele Ile. Our study proposes the allelic imbalance of Ile655Val polymorphism between Greek Christian and Greek Muslim populations of Thrace contributes to the inconsistent association between this SNP and breast cancer risk across these two different ethnic groups. The association of the HER-2 genotype with clinicopathologic characteristics and HER-2 expression may indicate its possible implication on the more aggressive phenotype.

Endoscopic transgastric procedures in anesthetized pigs: technical challenges, complications, and survival.

BACKGROUND AND STUDY AIMS: An incisionless endoscopic peroral transgastric approach to the peritoneal cavity has shown promise in animals as a potentially less invasive form of surgery. We present our experience with various endoscopic peroral transgastric procedures, reporting on the technical aspects and challenges that arose. MATERIALS AND METHODS: The following procedures were performed in 10 anesthetized pigs using a double-channel endoscope: peritoneoscopy (10 pigs), liver biopsy (one pig), cholecystectomy (six pigs), fallopian tube excision (one pig), and hysterectomy (one pig). RESULTS: All the procedures were accomplished successfully. There were six minor intraoperative complications. Complete gastric cleansing and elimination of all bacteria was found to be impossible to achieve in the porcine model. Overinflation was a common problem. The lack of adequate endoscope support was a major limitation. Safe closure of the gastrotomy incision was difficult using the available clipping devices. Six pigs made an uncomplicated recovery after a follow-up period of 4-6 weeks. Subsequent pathological examination revealed deep gastric ulceration in one animal and a gastric wall abscess in another. CONCLUSIONS: Peroral transgastric surgery is technically feasible and safe in a porcine model. Although all the procedures were performed successfully, the study highlights some technical difficulties and illustrates the need for major technical innovations and extensive animal studies in order to evaluate the merits of incisionless surgery.

Intussusception of the small bowel due to Peutz-Jeghers syndrome: a case report.

The Peutz-Jeghers syndrome is an autosomal dominant disorder characterized by hamartomatous polyposis of the gastrointestinal tract, melanin pigmentation of the skin and mucous membranes, and an increased risk for cancer. The incidence of surgical complications in these patients is relatively rare, and correlates with the size and location of the polyps. Herein we report the case of a 27-year-old woman presented with episodes of abdominal pain, abdominal distention and intermittent vomiting. Moreover, multiple pigmentation of the mouth was also noted. A preoperative diagnosis of a double jejunal intussusception and jejunal occlusion was based on the findings of small bowel enema and computed tomography. The diagnosis was confirmed at laparotomy.

Proliferative breast disease: epidemiologic aspects, and cytologic diagnosis.

PURPOSE: The aim of the present study is to describe the prevalence of proliferative breast lesions in cases of benign and malignant tumors of the breast as well as to assess the contribution of rapid intraoperative imprint cytology in the diagnosis of proliferative breast disease. METHODS: Frozen section and intraoperative imprint cytology were performed on breast tissue biopsies from 486 breast cancer patients who underwent primary surgical treatment. Imprints were stained either by the Papanicolaou (Pap) or the May Grünwald-Giemsa (MGG) or the Hematoxylin eosin (HE) technique. Cytologic diagnoses were compared to the histopathologic ones from paraffin sections. RESULTS: Sclerosing adenosis was the most common finding in benign breast biopsies while in breast cancer the prevalence of the lesion was reduced by half. On the other hand, atypical hyperplasias in malignant biopsies were almost twice as many as in benign ones. Imprint cytology presented high sensitivity and specificity (99% and 96% respectively) in distinguishing benign proliferative from malignant lesions as a whole, but regarding atypical hyperplasias the specificity was significantly reduced (76% vs 96%). CONCLUSION: Clarification of cytologic diagnostic criteria and expertise in cytologic interpretation could show off intraoperative imprint cytology as a useful and inexpensive diagnostic tool providing the surgeon with prompt and accurate information regarding the nature of breast lesions.

Relationship between nosocomial Acinetobacter species occurring in two geographical areas (Greece and the UK).

Fifty-two isolates of Acinetobacter spp. obtained from three Greek and one UK hospital, were studied using partial 16 S ribosomal DNA sequence analysis, repetitive extragenic palindromic sequence-based polymerase chain reaction (REP-PCR) mediated fingerprinting and DNA macro-restriction analysis. The aim was twofold: first, to discern the major differences in the population of Acinetobacter spp. between the two countries. Second, to compare a simple PCR-based typing scheme with pulsed-field gel electrophoresis (PFGE). The multi-resistant Greek isolates were within DNA groups 2 and TU13, and clustered into three types both by REP-PCR and PFGE. By contrast, the more susceptible Oxford isolates were heterogeneous on 16 S RNA sequence analysis and distinguishable on typing. The need for studies that elucidate the phylogeny of Acinetobacter spp. inside and outside hospitals are important, as this will help clarify the relationship between organisms that are increasingly recognized as causes of severe infections.

The contribution of rapid intraoperative cytology to the improvement of ovarian cancer staging.

OBJECTIVE: The goal of this work was to evaluate the use of intraoperative cytology in the improvement of ovarian cancer staging. METHODS: Fifty-two patients with clinical stage IA-IIB ovarian cancer underwent peritoneal washing (PW) cytology and imprint cytology performed on retroperitoneal lymph node samples, during primary surgical treatment. Cytologic specimens were stained by the May-Grünwald-Giemsa (MGG) and hematoxylin-eosin (HE) techniques. Pertinent histologic sections of the ovarian lesions, cell blocks prepared from PW sediments, and lymph node samples were studied and compared with the cytologic findings. RESULTS: Our study reveals that, when malignant cells are present in the peritoneal cavity, PW cytology has 84.6% sensitivity and 94.7% specificity in detecting them. Imprint cytology performed on lymph node samples presented 94.1% sensitivity and 94.1% specificity in the diagnosis of retroperitoneal metastasis of ovarian cancer. Only 7 patients (13.4%) were upstaged with either cytologic method. PW cytology alone upstaged 6 more patients, while imprint cytology alone upstaged 11 more patients. This corresponds to a total of 17 patients (32.6%) who benefit from the combined performance of both cytologic methods. HE stain presents lower values of sensitivity and specificity compared with MGG. CONCLUSION: Cytologic evaluation of intraperitoneal and retroperitoneal spread of ovarian cancer by use of PW cytology and imprint cytology performed on lymph node samples contributes to the improvement of ovarian cancer staging.

Hypoxia-regulated carbonic anhydrase-9 (CA9) relates to poor vascularization and resistance of squamous cell head and neck cancer to chemoradiotherapy.

PURPOSE: Carbonic anhydrases are proteins involved in the catalytic hydration of carbon dioxide to carbonic acid. Recent studies show that carbonic anhydrase 9 (CA9) is up-regulated by hypoxia and that its immunohistochemical tissue distribution follows the distribution of the radiosensitizer pimonidazole (C. C. Wykoff et al., Cancer Res. 60: 7075-7083, 2001). Therefore, CA9 expression may show hypoxia levels of clinical importance. EXPERIMENTAL DESIGN: We assessed the expression of CA9 and the microvessel density (MVD; CD31-positive) in 75 locally advanced squamous cell head and neck cancers treated with concurrent chemoradiotherapy with carboplatin. RESULTS: Strong membrane/cytoplasmic CA9 expression, noted in 20/75 (26.6%) tumors, mainly occurred in tumors with very poor vascularization (expression in 63% versus 14%; P < 0.0001), was located around areas of focal necrosis, and was related to poor complete response rate (40% versus 70%; P = 0.02). These observations suggested that CA9 might be a marker of clinically important hypoxia. Combining the CA9 staining and the tumor angiogenicity (MVD), we identified three groups of patients: (a) hypoxic tumors; (b) euoxic highly angiogenic tumors; and (c) euoxic non-highly angiogenic tumors. Groups (a) and (b) had a very poor local relapse-free survival (P < 0.0001). CONCLUSIONS: Stratification of patients undergoing radical radiotherapy using the CA9/MVD model may be useful for the individualization of therapeutic strategies combining antiangiogenesis and hypoxia targeting with radiotherapy.

The immunophenotypic profile of hepatic hemopoiesis in fetuses with Down's syndrome during the second trimester of development.

The yolk sac and aorto-gonad-mesonephros region are well recognized as the principal sites of hematopoiesis in the developing embryo, and the liver is the principal site of hematopoiesis in the fetus. In the present study, we investigated the immunohistochemical expression of Glycophorin C (erythrocytes), Neutrophilic elastase (granulocytes), and CD34 (progenitor hematopoietic stem cells, progenitor stromal cells, and vascular endothelial cells) in hepatic parenchyma from fetuses with Down's syndrome (DS) (16th, 20th, and 24th week of gestational age), and correlated the findings with the equivalent of the hepatic parenchyma from fetuses after spontaneous abortion. Our results did not demonstrate a quantitative difference at the level of erythropoiesis in all three periods examined. In contrast, an important numerical difference was shown in the expression of CD34 positive cells in liver parenchyma from fetuses with DS, in comparison with those found in liver parenchyma from fetuses after spontaneous abortion (p < 0.02). Furthermore, a modest but significant difference was demonstrated at the level of granulopoiesis between the 20th and 24th week (p < 0.01). Given that, the living newborns with Down's syndrome manifest diverse haematological abnormalities, including a transient leukemoid reaction that usually disappears after some weeks or months, a significantly increased number of CD34 positive and a less significantly increased number of neutrophilic elastase positive cells between the 20th and 24th gestational week could explain this phenomenon in combination with the respective results, if any, in the bone marrow. Regarding our finding of increased stromal CD34 positive cells in the hepatic portal triads, it raises the possibility that a process similar to fibrosis of the bone marrow may contribute to the hepatic fibrosis in DS.

Differential expression of Bcl-2 proto-oncogene in the trophoblast from embryos with Down's syndrome and those after spontaneous abortion.

Down's syndrome (trisomy 21) was the first human chromosomal syndrome to be recognized (in 1959 by Lejeune and colleagues). It is also the most frequent chromosomal aberration occurring in one out of 700 live newborns. In the present study we investigated the immunohistochemical expression of the apoptosis-suppressing protein Bcl-2 in placental trophoblastic cells from embryos with Down's syndrome (gestational age 12th, 15th and 22nd week) and correlated the findings with equivalent trophoblastic cells from embryos after spontaneous abortion. In our cases with Down's syndrome a weak Bcl-2 expression was noted in the cytotrophoblast and syncytiotrophoblast of chorionic villi in contrast to strong Bcl-2 staining of the same cells in the cases of spontaneous abortions (p < 0.0001). Although there are no specific findings that truly characterize a placenta with trisomy, obtaining a small piece of chorionic villus tissue (chorionic villus biopsy) and immunohistochemical control for Bcl-2 protein could be an additional prenatal examination available to the perinatologist to detect chromosomal abnormalities.

Serum levels of tumor necrosis factor-alpha and nutritional status in pancreatic cancer patients.

BACKGROUND: Tumour necrosis factor-alpha (TNF-alpha) is a multifunctional cytokine associated with cancer-related cachexia. In this study we evaluated serum levels of TNF-alpha in pancreatic cancer patients and investigated their relationships to cachexia. PATIENTS AND METHODS: Serum TNF-alpha levels were determined in 63 patients with pancreatic cancer using an enzyme immunoassay specific for human TNF-alpha. RESULTS: Serum TNF-alpha levels were detected in 36.5% of patients. Patients with metastatic disease showed significantly higher positive serum TNF-alpha rate compared to those with non-metastatic disease. Patients with detectable serum TNF-alpha levels had significantly lower body weight and body mass index, lower haematocrit and haemoglobin values, and lower serum total protein and albumin levels compared to those with undetectable TNF-alpha levels. Serum TNF-alpha levels were inversely correlated with body weight, body mass index, haematocrit, haemoglobin, and serum protein and albumin levels. CONCLUSIONS: TNF-alpha levels are detectable in the serum of pancreatic cancer patients, particularly in those with advanced disease, and these levels correlate with poor nutritional status.

Bax protein expression in colorectal cancer: association with p53, bcl-2 and patterns of relapse.

This study evaluated the frequency and the prognostic significance of bax, bcl-2 and p53 proteins in stage B and C adenocarcinomas of the colon and rectum. Paraffin-embedded specimens from 268 patients with colorectal adenocarcinomas, treated with surgery, were assessed; of these 160 cases were Duke's stage B and 108 cases were Duke's stage C disease. Adjuvant chemotherapy was given to all stage C and to 108 out of 160 stage B cancer patients, while those having rectal malignancy also received pelvic radiotherapy. Duke's stage B patients were treated either with surgery alone or with surgery and radiotherapy. The follow-up period at the time of analysis ranged from 12-72 months (median 32 months). Immunohistochemical expression of bax, bcl-2 and mutant p53 proteins was detected with a frequency of 42%, 37% and 48%, respectively. However, the expression was strong only in 17% of tumours, on average. A strong bcl-2 expression was significantly associated with a strong bax expression (p < 0.0001) and with absence of p53 nuclear accumulation (p < 0.005). There was, however, no correlation between bax and p53 proteins. Furthermore, bcl-2 expression was significantly more frequent in grade I and 2 adenocarcinomas compared to grade 3 disease (p = 0.01). In stage B (but not C) adenocarcinomas, bax expression was directly associated with higher risk of local relapse (p = 0.04). By contrast, cases with p53 nuclear accumulation, when they had received adjuvant radiotherapy, were significantly associated with a lower incidence of local relapse (p = 0.01), but a higher rate of distant metastasis (p = 0.06). Multivariate analysis for disease free and overall survival showed that bax expression and high Duke's stage were independent prognostic parameters associated with an unfavourable outcome (p = 0.009 and p = 0.0001, respectively). It was concluded that the immunohistochemical expression of bax is a marker of poor prognosis and of a higher risk of local relapse in patients with colorectal adenocarcinomas. p53 nuclear accumulation is associated with a better local control, following radiotherapy and with a metastatic phenotype. The development of novel monoclonal antibodies recognising specifically the mutated versus the wild type form of proteins would apparently improve the prognostic and predictive value of the immunohistochemically detected apoptotic proteins.

Squamous cell head and neck cancer: evidence of angiogenic regeneration during radiotherapy.

BACKGROUND AND PURPOSE: Intra-tumoural neoangiogenesis is an essential process for tumour progression. Although intensification of angiogenic pathways during cytotoxic therapy has been reported by a few experimental studies, the role of angiogenesis in response to radiotherapy is unclear. We recently reported an adverse effect of intense angiogenesis in the radiotherapy outcome of squamous cell head and neck cancer (SCHNC). In the present study we investigated the radiotherapy-induced changes in the microvessel density (MVD) and in the expression of the angiogenic factor thymidine phosphorylase (TP) in SCHNC. PATIENTS AND METHODS: Twenty-four patients with SCHNC underwent a biopsy of the primary lesion immediately before and after delivery of 20Gy of conventionally fractionated radiotherapy. The MVD and the expression of TP was assessed with immunohistochemistry. RESULTS: The irradiated samples were composed of cancer cell islets or bands, immersed within avascular degenerated tissue. In tumours that did not reach complete response after the end of radiotherapy, these viable cancer tissue areas had a significantly higher MVD (p=0.006) and increased percentage of cancer cells with nuclear TP expression (p=0.0004) than the MVD and the TP expression noted in specimens before radiotherapy. TP expression in these islets was directly related to the MVD (p=0.004, r=0.56). CONCLUSION: The present study supports the idea that intensified angiogenic growth (angiogenic regeneration) during radiotherapy is associated with failure of radiotherapy.

Evaluation of kidney and liver subacute toxicity induced by Bezalip-Pravastatin-Lopid antihyperlipidaemic compounds in rats.

Renal and hepatic subacute toxicity induced by the antihyperlipidaemic drugs: Bezalip-Pravastatin and Lopid was investigated in rats using serum biochemical parameters. Toxicological evaluation was performed in serum samples following the administration of the therapeutic dose regimens of the compounds that were previously shown to be effective in inhibition of 3-hydroxy-methylglutaryl coenzyme A (HMG CoA) reductase, the enzyme controlling the rate-limiting step in the synthesis of cholesterol, and acyl-CoA cholesterol acyl transferase (ACAT) which converts intracellular free cholesterol to cholesterol ester. Renal and hepatic subacute toxicity was evaluated by measuring enzyme activity or concentrations of: alanine aminotransferace, alkaline phosphatase, aspartate aminotransferase, gamma-glutamyltransferase, glucose, potassium, sodium, blood urea nitrogen, uric acid and creatinine. The use of the above serum biochemical parameters indicated that the overall toxicity impact of antihyperlipidaemic drugs was Bezalip = Pravastatin < Lopid. We have found that the Pravastatin--in contrast to the above antihyperlipidaemic drugs--only transiently affects the biochemical parameters associated with toxicity, but, it affects some of the biochemical parameters associated with hepatic and renal toxicity, up to a significantly lower extent than the antihyperlipidaemic drugs.