Metastatic lymph node ratio as a better prognostic tool than the TNM system in colorectal cancer.

Background: The minimum number of lymph nodes that should be evaluated in colon cancer to adequately categorize lymph node status is still controversial. The lymph node ratio (LNR) may be a better prognostic indicator. Materials & methods: We studied 1065 patients treated from 1 January 2000 to 31 August 2012. Results: Significant differences in survival were detected according to regional lymph nodes (pN) (p < 0.001) and LNR (p < 0.001). LRN and pN are independent prognostic factors. Spearman correlation analysis showed a significant correlation between the total number of dissected lymph nodes and pN (rs = 0.167; p < 0.001), but the total number of dissected lymph nodes is not significantly correlated with LNR (rs = -0.019; p = 0.550). Interpretation: In this study, LNR seems to demonstrate a superior prognostic value compared with the pN categories, in part due to its greater independence regarding the extent of lymphadenectomy.

Lay abstract The prognosis of colon cancer is determined by tumor dimensions, number of metastatic lymph nodes and the presence of distant metastasis. Altogether, these criteria comprise the TNM (tumor-node-metastasis) staging system. Some societies consider a minimum of 12 lymph nodes to access the prognosis, but it is not always possible to resect this number of lymph nodes during the surgery. The lymph node ratio, calculated as the division between the number of metastatic lymph nodes and the number of resected lymph nodes, seems to demonstrate a superior prognostic value because it is independent from the extent of lymphadenectomy.

Antimicrobial therapy in palliative care: an overview.

In the advanced stages of illness, patients often face challenging decisions regarding their treatment and overall medical care. Terminal ill patients are commonly affected by infections. However, in palliative care, the use of antimicrobials can be an ethical dilemma. Deciding whether to treat, withhold, or withdraw the antimicrobial treatment for an infection can be difficult. Antimicrobial administration can lead to adverse outcomes but the two main benefits, longer survival and symptom relief, are the main reasons why physicians prescribe antimicrobial when treating terminally ill patients. For the patient who has an irreversible advanced heart or lung disease, or an advanced dementia, or a metastatic cancer, it is easier the decision of withholding mechanical ventilation, tube feeding, and dialysis than antibiotherapy. To characterize infections, agents, and their treatments in palliative care, we conducted a review of the literature. We also included some tips to help health professionals to guide their clinical approach.

Angiogenic factors: role in esophageal cancer, a brief review.

Esophageal cancer has an aggressive behavior with rapid tumor mass growth and frequently poor prognosis; it is known as one of the most fatal types of cancer worldwide. The identification of potential molecular markers that can predict the response to treatment and the prognosis of this cancer has been subject of a vast investigation in the recent years. Among several molecules, various angiogenic factors that are linked to the tumor development, growth, and invasion, such as VEGF, HGF, angiopoietin-2, IL-6, and TGF-B1, were investigated. In this paper, the authors sought to review the role of these angiogenic factors in prognosis and hypothesize how they can be used as a treatment target.

Squamous Cell Carcinoma of the Conjunctiva in a Patient With Previous Squamous Cell Carcinoma of the Lower Lip.

Squamous cell carcinoma (SCC) of the conjunctiva is a rare malignancy that is part of the spectrum of ocular surface squamous neoplasia (OSSN). Numerous non-modifiable and modifiable risk factors, such as male sex, age, cigarette smoking, and immunosuppression, have been identified. Any lesion of the conjunctiva requires a differential diagnosis between benign and malignant diseases, and all suspicious lesions should be biopsied. We present a case of SCC of the conjunctiva in a former smoker with multiple risk factors, including a previous SCC of the lower lip. Metastatic tumors rarely occur in the conjunctiva, but due to our patient's medical history, the exclusion of metastasis from the previous primary tumor was performed through whole-body imaging restaging.  The patient underwent a no-touch wide resection, followed by adjuvant topical chemotherapy with 5-fluorouracil (5-FU). After finishing treatment, the patient continues to attend regular ophthalmology and oncology appointments. Increasing population awareness of modifiable risk factors for OSSN is essential. Misdiagnosis can lead to a loss of time in treatment and progression of the disease.

Gastric Cancer and Angiogenesis: Is VEGF a Useful Biomarker to Assess Progression and Remission?

Gastric cancer (GC) has high mortality owing to its aggressive nature. Tumor angiogenesis plays an essential role in the growth, invasion, and metastatic spread of GC. The aim of this work was to review the angiogenic biomarkers related to the behavior of GC, documented in the literature. A search of the PubMed database was conducted with the MeSH terms: "Stomach neoplasms/blood [MeSH] or stomach neoplasms/blood supply [MeSH] and angiogenic proteins/blood [Major]". A total of 30 articles were initially collected, and 4 were subsequently excluded. Among the 26 articles collected, 16 examined the role of vascular endothelial growth factor (VEGF), 4 studied endostatin, 3 investigated angiopoietin (Ang)-2, 2 studied the Ang-like protein 2 (ANGTPL2), and 1 each examined interleukin (IL)-12, IL-8, and hypoxia inducible factor. Regarding VEGF, 6 articles concluded that the protein was related to lymph node metastasis or distant metastases. Five articles concluded that VEGF levels were elevated in the presence of GC and decreased following tumor regression, suggesting that VEGF levels could be a predictor of recurrence. Four articles concluded that high VEGF levels were correlated with poor prognosis and lower survival rates. Ang-2 and ANGTPL2 were elevated in GC and associated with more aggressive disease. Endostatin was associated with intestinal GC. VEGF is the most extensively studied angiogenic factor. It is associated with the presence of neoplastic disease and lymph node metastasis. It appears to be a good biomarker for disease progression and remission, but not for diagnosis. The data regarding other biomarkers are inconclusive.

Bone Metastases: An Overview.

Bone is a frequent site of metastases and typically indicates a short-term prognosis in cancer patients. Once cancer has spread to the bones it can rarely be cured, but often it can still be treated to slow its growth. The majority of skeletal metastases are due to breast and prostate cancer. Bone metastasis is actually much more common than primary bone cancers, especially in adults. The diagnosis is based on signs, symptoms and imaging. New classes of drugs and new interventions are given a better quality of life to these patients and improved the expectancy of life. It is necessary a multidisciplinary approach to treat patients with bone metastasis. In this paper we review the types, clinical approach and treatment of bone metastases.

Prognostic impact of the number of resected lymph node on survival in Colorectal Cancer / Impacto prognóstico do número de linfonodos ressectados na sobrevida de pacientes com câncer colorretal

Abstract Introduction Colorectal Cancer (CRC) is the third most common cancer and the second leading cause of death in Western countries. In Portugal, in the North, emerges as the second most common cancer. The presence of lymph node metastasis is an important predictor of overall and disease-free survival and several studies recommend the evaluation of at least 12-14 regional lymph nodes, as it contributes to improve cancer staging and patient outcomes. Aims Epidemiological characterization of the studied population and identify a possible relationship between the number of lymph nodes evaluated in the surgical specimen and survival. Methods We preceded to the study of 1065 CCR patients, submitted to surgical resection between 1 January 2000 and 31 August 2012, in Braga Hospital. Discussion/Conclusion The results of the epidemiological characterization of this population are coincident with those described in the literature. It was observed a significant correlation between age, tumor size, serosal invasion, differentiation, tumor penetration, venous and lymphatic invasion, metastasis, TNM stage and the number of lymph nodes evaluated. However, we did not observe a statistically significant correlation between patient survival and number of lymph nodes evaluated (p > 0.05). A possible explanation is the practice of oncologists, addressing patients with less than 12 nodes identified in the surgical specimen as "N-positive" and undergoing adjuvant therapy. A better harvest and careful analysis of lymph nodes would lead to more accurate staging, avoiding overtreatment and side effects associated, and allow better economic management of hospital resources, in real N0 patients.

Resumo Introdução O câncer colorretal (CCR) ocupa o terceiro lugar em termos de frequência e, além disso, é a segunda causa principal de morte nos países ocidentais. Em Portugal, no norte, CCR surge como o segundo câncer mais comum. A presença de metástase aos linfonodos é preditor importante de sobrevida em geral e de sobrevida livre da doença; vários estudos recomendam a avaliação de pelo menos 12-14 linfonodos regionais, pois tal procedimento contribui para aprimorar o estadiamento do câncer e os desfechos para os pacientes. Objetivos Caracterização epidemiológica da população estudada e identificação de possível relação entre o número de linfonodos avaliados no espécime cirúrgico e sobrevida. Métodos Estudo de 1065 pacientes com CCR, submetidos à ressecção cirúrgica entre 1 de janeiro de 2000 e 31 de agosto de 2012 em um hospital em Braga. Discussão/Conclusão Os resultados da caracterização epidemiológica dessa população coincidem com os resultados descritos na literatura. Foi observada uma correlação significativa entre idade, tamanho do tumor, invasão da serosa, diferenciação, penetração tumoral, invasão venosa e linfática, metástase, estágio TNM e número de linfonodos avaliados. Mas não observamos uma correlação estatisticamente significativa entre sobrevida do paciente e número de linfonodos avaliados (p > 0,05). Uma explicação possível é a prática dos oncologistas, que tratam pacientes com menos de 12 nodos identificados no espécime cirúrgico como "N-positivos", prosseguindo com terapia adjuvante. Uma coleta mais apropriada e uma análise cuidadosa dos linfonodos resultaria em um estadiamento mais preciso, evitando o tratamento excessivo e os efeitos colaterais associados, além de permitir um tratamento com melhor custo-benefício para os recursos hospitalares em pacientes realmente N0.