Prognostic role of APC and RASSF1A promoter methylation status in cell free circulating DNA of operable gastric cancer patients.

Gastric carcinogenesis is a multistep process including not only genetic mutations but also epigenetic alterations. The best known and more frequent epigenetic alteration is DNA methylation affecting tumor suppressor genes that may be involved in various carcinogenetic pathways. The aim of the present study was to investigate the methylation status of APC promoter 1A and RASSF1A promoter in cell free DNA of operable gastric cancer patients. Using methylation specific PCR, we examined the methylation status of APC promoter 1A and RASSF1A promoter in 73 blood samples obtained from patients with gastric cancer. APC and RASSF1A promoters were found to be methylated in 61 (83.6%) and 50 (68.5%) of the 73 gastric cancer samples examined, but in none of the healthy control samples (p < 0.001). A significant association between methylated RASSF1A promoter status and lymph node positivity was observed (p = 0.005). Additionally, a significant correlation between a methylated APC promoter and elevated CEA (p = 0.033) as well as CA-19.9 (p = 0.032) levels, was noticed. The Kaplan-Meier estimates of survival, significantly favored patients with a non-methylated APC promoter status (p = 0.008). No other significant correlations between APC and RASSF1A methylation status and different tumor variables examined was observed. Serum RASSF1A and APC promoter hypermethylation is a frequent epigenetic event in patients with early operable gastric cancer. The observed correlations between APC promoter methylation status and survival as well as between a hypermethylated RASSF1A promoter and nodal positivity may be indicative of a prognostic role for those genes in early operable gastric cancer. Additional studies, in a larger cohort of patients are required to further explore whether these findings could serve as potential molecular biomarkers of survival and/or response to specific treatments.

Docetaxel plus oxaliplatin in combination with capecitabine as first-line treatment for advanced gastric cancer.

OBJECTIVE: In the present phase II study, we evaluated the efficacy and safety of a docetaxel-oxaliplatin-capecitabine combination as a first-line treatment in patients with advanced gastric cancer. PATIENTS AND METHODS: A total of 27 patients (18 males) with histologically confirmed inoperable gastric adenocarcinoma were recruited. Docetaxel was given (50 mg/m(2) i.v.) on day 1 followed by oxaliplatin (75 mg/m(2) i.v.) also on day 1. Capecitabine (2,750 mg/m(2)) was given orally as two daily divided doses from days 1 to 7. Cycles were repeated every 2 weeks. All patients had measurable disease and 18 of them had a performance status (WHO) of 0. RESULTS: A total of 240 treatment cycles were administered. All patients were evaluable for toxicity. Four patients who discontinued treatment early (having received only 3 chemotherapy cycles) were included as non-responders in an intention-to-treat response analysis. Complete response, partial response, stable disease and progressive disease were observed in 4 (15%), 12 (44%), 3 (11%) and 8 (30%) patients, respectively. The observed response rate was 59%, and the disease control rate (complete response + partial response + stable disease) was 70%. At the time of analysis, 6 patients were still alive and the median survival was 18.0 months. The most common grade III/IV toxicities observed were neutropenia (5%), diarrhea (2%), palmar-plantar erythrodysesthesia (2%) and neurotoxicity (1%). All other toxicities were mostly of grade I/II and easily manageable. CONCLUSION: The combination of docetaxel, oxaliplatin and capecitabine in the described mode of administration represents a relatively active and well-tolerated regimen in patients with advanced gastric cancer and warrants further evaluation.

Recombinant leptin administration improves early angiogenesis in full-thickness skin flaps: an experimental study.

BACKGROUND: Leptin is a potent direct angiogenic factor that stimulates endothelial cell migration and activation in vitro, and angiogenesis in vivo. In addition, leptin seems to play an important role in angiogenesis as it promotes the formation of new blood vessels. OBJECTIVE: To determine the effect of local application of exogenous leptin on the survival of full thickness skin flaps in an experimental animal model. MATERIALS AND METHODS: Ninety Sprague-Dawley rats were used in this study. A full thickness dorsal flap (10 cm x 2 cm) with the pedicle located at the level of the iliac crest was designed. Animals were divided into ten groups of nine animals each. In the distal two thirds of the flap and by means of subdermal injection at 8 different locations, rats were injected with 100 ng/ml leptin, 250 ng/ml leptin, 500 ng/ml leptin, 1000 ng/ml leptin (groups A, B, C and D), 1 microg/ml VEGF (group E), or 1 ml saline (control group), respectively. For each of the four leptin doses used, another animal group was injected with a combination of leptin/antileptin: 100 ng/ml leptin with 150 ng/ml antileptin, 250 ng/ml leptin with 375 ng/ml antileptin, 500 ng/ml leptin with 750 ng/ml antileptin or 1000 ng/ml leptin with 1500 ng/ml antileptin (groups A1, B1, C1 and D1, respectively), in order to study the inhibition of the leptin factor. Nine rats served as controls and were injected with 1 ml saline solution. Rats were sacrificed 3, 7 and 9 days postoperatively. After sacrifice of the animals, the skin was grossly arranged on its appearance, colour and texture. Full thickness skin flaps were dissected for histological examination. A qualitative analysis of angiogenesis in the flap was conducted following a standard hematoxylin and eosin stain. The wound tissue samples from each experimental group underwent immunohistochemical evaluation of microvessel density by endothelial cell staining with mouse anti-rat CD 34 monoclonal antibody. RESULTS: Immunohistochemical staining revealed that more granulation tissue and improved angiogenesis were observed in group D (1000 ng/ml leptin) flaps compared to those in the VEGF, leptin/antileptin and saline groups. In addition, skin flap survival rate in group D (1000 ng/ml leptin) and group E (1 microg/ml VEGF) were significantly better than those of the other groups. The most impressive formation of new blood vessels was noted in the groups with the higher leptin doses. Surgical wounds in the control, as well as in the leptin/antileptin groups, did not demonstrate any new vessels. CONCLUSION: Exogenous administration of recombinant leptin increases early skin flap angiogenesis in an experimental animal model. Local application of leptin could efficiently improve survival of ischemic skin flaps.

Subcutaneous metastasis from a gastrointestinal stromal tumor of the stomach: a case report.

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the stomach, which account for approximately 3.6% of all gastric tumors. They may or may not be malignant. Malignant GIST rarely metastasizes to distant organs. We report a case of a gastric GIST diagnosed in a 69- year-old woman presented with a synchronous subcutaneous paraumbilical metastasis. Computed tomography (CT) scan demonstrated a space-occupying lesion arising from the gastric wall with a second well-circumscribed lesion in the subcutaneous tissue which infiltrated the aponeurosis of the right rectus abdominis. The patient underwent total gastrectomy and resection of the subcutaneous mass. Pathologic examination of the gastric tumor and subcutaneous mass showed histological and immunohistochemical characteristics of a GIST. The patient succumbed on the 4th postoperative day. Gastric stromal tumor metastasis must be taken into consideration in the differential diagnosis of a palpable paraumbilical mass in a patient diagnosed with malignant GIST.

Exogenously-administered leptin increases early incisional wound angiogenesis in an experimental animal model.

BACKGROUND: Leptin is a potent direct angiogenic factor that stimulates endothelial cell migration and activation in vitro, as well as angiogenesis in vivo. In addition, leptin seems to play an important role in clinical angiogenesis by promoting the development of new blood vessels. OBJECTIVE: To determine the effect of exogenously administered leptin on incisional wound healing in an experimental animal model. MATERIALS AND METHODS: Sixty-three Sprague-Dawley male mice were used for the study. Full thickness incisional wound was considered as the wound model. The mice were divided into seven groups of nine animals each. Surgical wounds were injected with murine recombinant leptin. Three different leptin doses of 100 pg/ml, 200 pg/ml and 500 pg/ml were used in different animal groups (A, B and C). For each of the three leptin doses used, another animal group was evaluated with a combined injection of leptin and antileptin: 100 pg/ml leptin with 50 pg antileptin, 200 pg/ml leptin with 100 pg antileptin, 500 pg/ml leptin with 250 pg antileptin (A1, B1, and C1), in order to study the inhibitory effect on the leptin factor. Nine mice served as controls. These were injected with 0.3 ml water for injection solution. Mice were sacrificed 3, 7 and 9 days postoperatively. After sacrifice of the animals, the skin was grossly assessed for appearance, colour and texture. Full thickness incisional wounds were dissected for histological examination. A qualitative analysis of angiogenesis in the surgical wound was conducted following a standard hematoxylin and eosin stain. The wound tissue samples from each experimental group underwent immunohistochemical evaluation of microvessel density by endothelial cell staining with mouse anti-rat CD34 monoclonal antibody. RESULTS: The most impressive growth of new blood vessels appeared seven and nine days after treatment with the highest leptin doses. There were no significant differences in microvessel density at seven or nine postoperative days among different groups treated with leptin. None of the wounds from the control group, or those from animal groups treated with the combined injection of leptin and antileptin developed any new vessels. CONCLUSION: Exogenous administration of leptin may increase early tissue angiogenesis in the incisional wound of an experimental animal model.

A dose escalation study of pegylated liposomal Doxorubicin (caelyx) in combination with capecitabine (xeloda) in patients with refractory solid tumors.

OBJECTIVE: Pegylated liposomal doxorubicin (PLD) and capecitabine (CAP) have separately shown significant antitumor activity in a wide range of solid tumors. A phase I study was conducted in order to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of their combination in patients with refractory solid tumors. PATIENTS AND METHODS: Fifteen patients with histologically confirmed inoperable solid neoplasms were enrolled. The patients' median age was 65 years, 10 were male, and 12 had a performance status score (WHO) of 0-1. PLD was administered on day 1 as a 1-hour intravenous infusion at escalated doses ranging from 35 to 40 mg/m(2). CAP was administered on days 1-14 per os, at escalated doses ranging from 1,600 to 1,800 mg/m(2), given as two daily divided doses. Treatment was repeated every 3 weeks. RESULTS: At the dose of PLD 40 mg/m(2) and CAP 1,800 mg/m(2), all 3 enrolled patients presented DLTs [2 patients grade 3 palmar-plantar erythrodysesthesia (PPE) and 1 patient grade 3 asthenia] and thus, the recommended MTD for future phase II studies is PLD 40 mg/m(2) and CAP 1,700 mg/m(2). A total of 57 treatment cycles were administered. Grade 2/3 neutropenia complicated 9 (17%) cycles and 1 patient was hospitalized for febrile neutropenia. There was no septic death. The main nonhematologic toxicity was PPE grade 2 in 3 (19%) patients and grade 3 in 4 (27%). PPE was the reason of treatment interruption for 3 patients. Other toxicities were mild and easily manageable. Two patients (16%) with partial response suffering from gastric cancer and 5 patients with (42%) stable disease were observed among 12 evaluable patients. CONCLUSIONS: The results of this phase I study demonstrate that PLD and CAP can be combined at clinically effective and relevant doses. However, PPE is a common side effect and further investigation is warranted to define its precise role in the treatment of solid malignancies.

Delayed perforation of the large bowel due to thermal injury during laparoscopic cholecystectomy.

We report a case of delayed perforation of the large bowel because of thermal injury during a laparoscopic cholecystectomy. A 78-year-old male with symptomatic cholelithiasis underwent a difficult laparoscopic cholecystectomy because of multiple adhesions resulting from two previous cholecystitis episodes. The patient recovered well after surgery and was discharged on post-operative day 2. On postoperative day 10, the patient returned to the hospital with peritonitis. An exploratory laparotomy revealed perforation of the wall of the hepatic flexure of the large bowel, which was centred in a necrotic area 1 cm in diameter. The perforation was sutured and a temporary ileostomy performed, which was closed at a later date. The patient was doing well at a 10-month follow-up review. A delayed rupture of any part of the bowel after laparoscopic surgery can be potentially fatal if not treated during an emergency exploratory laparotomy, even if the clinical signs are not severe.

Penetration of clarithromycin in experimental pleural empyema model fluid.

BACKGROUND: The degree of penetration of clarithromycin into the pleural fluid has not been studied. OBJECTIVE: To determine the degree to which clarithromycin penetrates into empyemic pleural fluid using a new rabbit model of empyema. METHODS: An empyema was created via the intrapleural injection of 1 ml turpentine followed 24 h later by instillation of 5 ml (10(10)) Escherichia coli bacteria (ATCC 35218) into the pleural space of New Zealand white rabbits. After an empyema was verified by thoracentesis and pleural fluid analysis, clarithromycin 30 mg/kg was administered intravenously. Antibiotic levels were determined on samples of pleural fluid and blood samples collected serially over 12 h. Antibiotic levels were estimated using HPLC. RESULTS: The antibiotic penetrated well into the empyemic pleural fluid (AUC(PF)/AUC(serum) ratio of 1.57). The time to equilibration between the pleural fluid and blood antibiotic levels was 8 h. The peak pleural fluid level (Cmax(PF) of 2.88 microg/ml) occurred 1 h (Tmax(PF) of 1 h) after infusion and decreased thereafter. The Cmax(serum) was 3.53 microg/ml at 1 h after administration. CONCLUSION: The levels of clarithromycin in the pleural fluid after intravenous administration are inhibitory for most of the usual pathogens causing empyema. The degree of penetration of clarithromycin should be considered when macrolides are selected for the treatment of patients with empyema.

Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy.

BACKGROUND: Conversion to open cholecystectomy is still required in some patients. The aim of this study was to evaluate preoperative factors associated with conversion to open cholecystectomy in elective cholecystectomy and acute cholecystitis. METHODS: The records of 1,804 patients who underwent cholecystectomy from May 1992 to January 2004 were reviewed retrospectively. The demographics and preoperative data of patients who required conversion to laparotomy were compared to those with successful laparoscopic cholecystectomy. RESULTS: Conversion to open cholecystectomy was needed in 94 patients (5.2%),of which 44 (2.8%) had no inflammation and 50 (18.4%) had acute inflammation of the gallbladder. Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. Also, the conversion from laparoscopic to open cholecystectomy in acute cholecystitis patients was associated with greater white blood cell count, fever, elevated total bilirubin, aspartate transaminase, and alanine transaminase levels, and the various types of inflammation. CONCLUSIONS: None of these risk factors were contraindications to laparoscopic cholecystectomy. This may help predict the difficulty of the procedure and permit the surgeon to better inform patients about the risk of conversion from laparoscopic to open cholecystectomy.

Extramedullary plasmacytoma: report of two cases with uncommon presentation.

Lymph node infiltration by monoclonal plasma cells can occur either in aggressive forms of myeloma or may represent regional extension of extramedullary plasmacytomas, whereas lymph node plasmacytoma presenting as a solitary extramedullary plasmacytoma is very unusual. We report two cases of lymph node plasmacytomas without systemic disease diagnosed after surgical excision. Clinical remission was achieved after local radiotherapy although one patient relapsed with multifocal extramedullary plasmacytomas 20 months after radiotherapy.

Predictive value of risk factors in patients with obstructive jaundice.

Clinical and laboratory parameters that may affect post-operative mortality and morbidity were studied in 215 patients operated on for obstructive jaundice. The cause of the bile duct obstruction was benign disease in 56.7% of patients and malignant disease in 43.3%. Overall postoperative mortality and morbidity rates were 21.9% and 33.5%, respectively. Eight risk factors were shown to be associated with increased mortality: age > 70 years; malignancy; leucocytosis > 15 000 cells/microl and fever > 38.5 degrees C; haematocrit < or = 30%; creatinine > 1.3 mg/dl; albumin < or = 3 g/dl; bilirubin > 20 mg/dl; and serum alkaline phosphatase > 100 IU/l. The simultaneous presence of less than three risk factors was always associated with post-operative survival, but concomitant existence of seven or more risk factors indicated 100% mortality. Understanding the factors related to post-operative morbidity and mortality in patients with obstructive jaundice will better guide appropriate surgical or non-surgical management and lead to improved survival.

Circulating soluble E-cadherin levels are of prognostic significance in patients with multiple myeloma.

BACKGROUND: The epithelial transmembrane molecule E-cadherin (E-Cad) is the prime mediator of epithelial cell-cell adhesion, through homotypic interactions. It also participates in the maintenance of cytoskeletal structure and cell-cell signalling, while there are no published reports of expression of E-Cad in non-epithelial tissues. We examined whether the circulating levels of soluble E-Cad in newly diagnosed patients with multiple myeloma (MM) are of prognostic significance. PATIENTS AND METHODS: We used an ELISA method to determine the levels of circulating soluble E-cadherin (sE-Cad) in 21 newly diagnosed patients with MM and in 29 healthy volunteers, as a control group. RESULTS: MM patients demonstrated increased circulating levels of sE-Cad, compared with controls (p<0.0001). Increased circulating sE-Cad levels correlated with LDH levels at diagnosis (p<0.001) and poor prognosis. Multivariate analysis demonstrated that sE-Cad levels are an independent prognostic factor of survival (p<0.0207). CONCLUSION: Our data suggest that adhesion molecules play a role in the pathogenesis of MM, establish sE-Cad as an independent marker of survival and, finally, provide evidence of non-epithelial production of E-Cad in MM patients.

Prognostic significance of soluble adhesion molecules in Hodgkin's disease.

BACKGROUND: Cell adhesion may play a pivotal role in the development, progression and metastasis of solid malignancies. We evaluated the serum concentration of four adhesion molecules and their prognostic significance in patients with Hodgkin's Disease (HD). PATIENTS AND METHODS: Serum samples from 20 HD patients were collected at diagnosis, after 3 cycles of chemotherapy and at completion of treatment and compared with a control group of 29 apparently healthy subjects. Soluble forms of E-Selectin (sE-Selectin), ICAM-1 (sICAM-1), VCAM-1 (sVCAM-1) and E-Cadherin (sE-Cad) were measured by standard ELISA assays. RESULTS: Significantly increased serum levels of sICAM-1 and sE-Selectin were determined in HD patients at diagnosis compared to controls (p<0.0001), while sVCAM-1 at diagnosis correlated significantly with both sICAM-1 and sE-Selectin levels (r=0.5, p=0.03). Chemotherapy resulted in a significant decrease of sICAM-1 and sE-Selectin levels (p=0.02 and p=0.002, respectively). CONCLUSION: Serum levels of ICAM-1 and E-Selectin in newly diagnosed HD patients were found significantly increased, suggesting a possible involvement of these two molecules in the pathogenesis of the disease. Their rapid decrease following chemotherapy was found to be an independent predictor of response to treatment.

Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery.

BACKGROUND: Previous abdominal surgery has been reported as a relative contraindication to laparoscopic cholecystectomy. This study specifically examined the effect of previous intraabdominal surgery on the feasibility and safety of laparoscopic cholecystectomy. METHODS: Data from 1,638 consecutive patients who underwent laparoscopic cholecystectomy were reviewed and analyzed for open conversion rates, operative times, intra- and postoperative complications, and hospital stay. RESULTS: Of the 1,638 study patients 473 (28.9%) had undergone previous abdominal surgery: 58 upper and 415 lower abdominal operations. The 262 patients who had undergone only a previous appendectomy were excluded from further analysis. Adhesions were found in 70.7%, 58.8% and 2.1% of patients respectively, who had previous upper, lower or no previous abdominal surgery with adhesiolysis required, respectively, in 78%, 30% and 0% of these cases. There were no complications directly attributable to adhesiolysis. Patients with previous upper abdominal surgery had a longer operating time (66.4 +/- 34.2 min), a higher open conversion rate (19%), a higher incidence of postoperative wound infection (5.2%), and a longer postoperative stay (3.4 +/- 2.1 days) than those who had undergone previous lower abdominal surgery (50.8 +/- 24 min, 3.3%, 0.7%, and 2.6 +/- 1.4 days, respectively) and those without prior abdominal surgery (47.4 +/- 25.6 min, 5.4%, 1.2%, and 2.8 +/- 1.9 days, respectively). CONCLUSIONS: Previous abdominal operations, even in the upper abdomen, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with an increased need for adhesiolysis, a higher open conversion rate, a prolonged operating time, an increased incidence of postoperative wound infection, and a longer postoperative stay.

Catheter knots in the urinary tract.

The use of catheters in the urinary tract, both in children and adults, has not been without complications. Many procedures performed in the urinary tract, including urethral or suprapubic catheterization of the bladder, urethrography, and ureteral catheterization, have showed complications, one of which is the formation of catheter knots. This complication, although very rare, yet it is very annoying. In this study, we searched (in winter 2002, employing Medline) and reviewed published reports of urinary tract catheter knots, and present measures for prophylaxis, diagnosis and proper management of this rare complication.

Serum and drainage fluid vascular endothelial growth factor levels in early surgical wounds.

BACKGROUND: Wound healing relies on a coordinated expression and release of growth factors controlling angiogenesis. We measured vascular endothelial growth factor (VEGF) levels in serum and early wound fluid following primary sutured and mesh repair of abdominal hernias. MATERIALS AND METHODS: Thirty-seven patients were studied measuring serum and wound drainage fluid VEGF by enzyme-linked immunosorbent assay preoperatively and on the 1st, 3rd, 5th and 7th postoperative days. RESULTS: Serum and wound fluid VEGF levels increased significantly by the 3rd postoperative day and continued to rise during the conduct of the study with wound fluid concentrations always exceeding serum levels. The kinetics of VEGF increases were similar in both types of hernia repair; however, serum and wound levels rose slightly earlier in the mesh repair group. CONCLUSIONS: Steadily increasing levels of VEGF are detected during the early proliferative phase of wound healing in both serum and wound fluid. It is unknown whether either is predictive for delayed hernia recurrence.