Impact of age-related comorbidity on results of colorectal cancer surgery

AIM: To analyze the correlation between preexisting comorbidity and other clinicopathological features, short-term surgical outcome and long-term survival in elderly patients with colorectal cancer (CRC). METHODS: According to age, 403 patients operated on for CRC in our department were divided into group A (< 70 years old) and group B (≥ 70 years old) and analyzed statistically. RESULTS: Rectal localization prevailed in group A (31.6% vs 19.7%, P = 0.027), whereas the percentage of R0 resections was 77% in the two groups. Comorbidity rate was 46.2% and 69.1% for group A and B, respectively (P < 0.001), with a huge difference as regards cardiovascular diseases. Overall, postoperative morbidity was 16.9% and 20.8% in group A and B, respectively (P = 0.367), whereas mortality was limited to group B (4.5%, P = 0.001). In both groups, patients who suffered from postoperative complications had a higher overall comorbidity rate, with preexisting cardiovascular diseases prevailing in group B (P = 0.003). Overall 5-year survival rate was significantly betterfor group A (75.2% vs 55%, P = 0.006), whereas no signif icant difference was observed considering disease-specif ic survival (76.3% vs 76.9%, P = 0.674). CONCLUSION: In spite of an increase in postoperative mortality and a lower overall long-term survival for patients aged ≥ 70 years old, it should be considered that, even in the elderly group, a signif icant number of patients is alive 5 years after CRC resection.

Follow-up after gastrectomy for cancer:results of an international web round table

Oncological follow-up after radical gastrectomy for cancer still represents a discrepancy in the field,with many retrospective series demonstrating that early diagnosis of recurrence does not result in an improvement in patient survival;yet,many centers with high quality of care still provide routine patient follow-up after surgery by clinical and instrumental controls.This was the topic for a web round table entitled"Rationale and limits of oncological follow-up after gastrectomy for cancer"that was launched one year before the 10th International Gastric Cancer Congress.Authors having specific expertise were invited to comment on their previous publications to provide the subject for an open debate.During a three-month-long discussion,32 authors from 12 countries participated,and 2299people visited the dedicated web page.Substantial differences emerged between the participants:authors from Japan,South Korea,Italy,Brazil,Germany and France currently engage in instrumental follow-up,whereas authors from Eastern Europe,Peru and India do not,and British and American surgeons practice it in a rather limited manner or in the context of experimental studies.Although endoscopy is still considered useful by most authors,all the authors recognized that computed tomography scanning is the method of choice to detect recurrence;however,many limit follow-up to clinical and biochemical examinations,and acknowledge the lack of improved survival with early detection.

Recurrence in node-negative advanced gastric cancer:Novel findings from an in-depth pathological analysis of prognostic factors from a multicentric series

AIM To analyze the clinicopathological characteristics of patients with both node-negative gastric carcinoma and diagnosis of recurrence during follow-up. METHODS We enrolled 41 patients treated with curative gastrectomy for p T2-4 a N0 gastric carcinoma between 1992 and 2010,who developed recurrence(Group 1). We retrospectively selected this group from the prospectively collected database of 4 centers belonging to the Italian Research Group for Gastric Cancer,and compared them with 437 p T2-4 a N0 patients without recurrence(Group 2). We analyzed lymphatic embolization,microvascular infiltration,perineural infiltration,and immunohistochemical determination of p53,Ki67,and HER2 in Group 1 and in a subgroup of Group 2(Group 2 bis) of 41 cases matched with Group 1 according to demographic and pathological characteristics. RESULTS T4 a stage and diffuse histotype were associated with recurrence in the group of p N0 patients. In-depth pathological analysis of two homogenous groups of p N0 patients,with and without recurrence during longterm follow-up(groups 1 and 2 bis),revealed two striking patterns: lymphatic embolization and perineural infiltration(two parameters that pathologists can easily report),and p53 and Ki67,represent significant factors for recurrence.CONCLUSION The reported pathological features should be considered predictive factors for recurrence and could be useful to stratify node-negative gastric cancer patients for adjuvant treatment and tailored follow-up.

Optimized management of advanced hepatocellular carcinoma:Four long-lasting responses to sorafenib

The therapeutic options for hepatocellular carcinoma (HCC) have been so far rather inadequate.Sorafenib has shown an overall survival benefit and has become the new standard of care for advanced HCC.Nevertheless,in clinical practice,some patients are discontinuing this drug because of side effects,and misinterpretation of radiographic response may contribute to this.We highlight the importance of prolonged sorafenib ad-ministration,even at reduced dose,and of qualitative and careful radiographic evaluation.We observed two partial and two complete responses,one histologically confirmed,with progression-free survival ranging from 12 to 62 mo.Three of the responses were achieved following substantial dose reductions,and a gradual change in lesion density preceded or paralleled tumor shrinkage,as seen by computed tomography.This report supports the feasibility of dose adjustments to allow prolonged administration of sorafenib,and highlights the need for new imaging criteria for a more appropriate characterization of response in HCC.

Magnetic resonance imaging:Is there a role in clinical management for acute ischemic colitis?

AIM:To validate the utility of magnetic resonance imaging(MRI) for the clinical management of acute ischemic colitis(IC).METHODS:This is a magnetic resonance(MR) prospective evaluation of 7 patients who were proved to have acute IC on the basis of clinical,endoscopic and computed tomography(CT) findings and who were imaged in our institution between February 2011 and July 2012.The mean age of the patients was 72.28 years.Abdominal CTs were obtained using a 64-detector row configuration for all patients with un-enhanced and contrast-enhanced scans,in the late arterial phase(start delay 45-50 s) and in the portal venous phase(start delay 70-80 s).The MR examinations were performed using a 1.5T superconducting magnet,using Fast Imaging Employing Steady State Acquisition and T2-weighted fast-recovery fast-spin echo sequences in axial and coronal plane.CT and MRI examinations were analysed for the presence of colonic abnormalities and associated findings.RESULTS:Segmental involvement was seen in 6 patients(85.71%),with a mean length of involvement of 412 mm(range 145.5-1000 mm).Wall thickness varied between 6 mm and 17.5 mm(mean 10.52 mm) upon CT examinations and from 5 to 15 mm(mean 8.8 mm) upon MR examinations.The MRI appearance of the colonic wall varied over the time:TypeⅠappearance with a 3 layer sandwich sign was seen in 5 out of 12 examinations(41.66%),patients underwent MR within a mean of 36 h(ranging from 1 to 54 h) after the CT examination.Type Ⅱ and Ⅲ appearance with a 2 layer sign,was seen in 4 examinations(33.33%),patients underwent MR within a mean of 420.5 h(ranging from 121 to 720 h) after the CT examination.In the remaining three MRI examinations,performed within a mean of 410 h(ranging from 99.5 to 720 h) the colonic wall appeared normal.CONCLUSION:MRI,only using precontrast images,may be used as a substitute for invasive procedures in diagnosis and follow-up of acute IC.

Hepatic metastases from gastric cancer:A surgical perspective

Management of patients with hepatic metastases as the sole metastatic site at diagnosis of gastric cancer(synchronous setting) or detected during follow-up(metachronous) is controversial. The prevailing attitude in these cases is passive, leading to surgical palliation and, possibly, to chemotherapy. Authors focused this editorial in order to promote a more pragmatic attitude. They stress the importance of recognizing the good candidates to curative surgery of both gastric cancer and hepatic metastases(synchronous setting) or hepatic disease alone(metachronous disease) from those who will not benefit from surgical therapy. In fact, in adequately selected subgroup of patients surgery, especially if integrated in multimodal therapeutic strategies, may achieve unexpected 5-year survival rates, ranging from 10% to 40%. The critical revision of the literature suggests that some simple clinical criteria exist that may be effectively employed in patients selection. These are mainly related to the gastric cancer(factors T, N, G) and to the extent of hepatic involvement(factor H). Upon these criteria it is possible to adequately select about 50% of cases. In the remaining 50% of cases a critical discussion on a case-by-case basis is recommended, considering that among these patients some potential long-survivors exist, that survival is strictly influenced by the ablation of the tumor bulk and by multimodality treatments including chemotherapy and that in expert institutions this kind of surgery is performed with very low mortality and morbidity rates.

Hepato-splenic lymphoma:a rare entity mimicking acute hepatitis:A case report

We reported a case of non-Hodgkin's lymphoma where liver involvement was the predominant clinical manifestation. A 27-year old man presented wiht markedly elevated serum aspartate aminotrasferase, alanine aminotransferase and lactate dehydrogenase, reduced prothrombin activity, thrombocytopenic purpura and hepato-splenomegaly without adenopathy. Viral, toxic,autoimmune and metabolic liver diseases were excluded.Bone marrow biopsy showed an intracapillary infiltration of T-lymphocytes with no evidence of lipid storage disease.Because of a progressive spleen enlargement, splenectomy was performed. Histological examination showed lymphomatous intrasinuses invasion of the spleen.Immunohistochemical investigation revealed the T phenotype of the neoplastic cells: CD45+, CD45RO+,CD3+, CD4-, CD8-, TIA1-. About 50 % of the lymphoid cells expressed CD56 antigen. The diagnosis of hepatosplenic T cell lymphoma was done. The patient was treated with chemotherapy, which induced a complete remission. Eighteen months later, he had a first relapse with increased aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase,thrombocytopenic purpura and blast in the peripheral blood.In spite of autologous bone marrow transplantation, he died twenty months after the diagnosis. Even in the absence of a mass lesion or lymphoadenopathy, hepatosplenic Tcell lymphoma should be considered in the differential diagnosis of a patient whose clinical course is atypical for acute hepatic dysfunction.

基质金属蛋白酶-2与基质金属蛋白酶-9在持续性卵巢囊肿患者中的差异性表达

Matrix metalloproteinase-1 (MMP-1), MMP-2, and MMP-9 expression with real-time quantitative polymerase chain reaction were analyzed in endometriotic and nonendometriotic ovarian cysts. Although MMP-1 was not detected, MMP-9 and MMP-2 were expressed in all of the cysts. In particular, in five of six nonendometriotic cysts (83.3%) MMP-2 expression was higher than in endometriotic cysts. These data may represent new molecular elements helpful in differential diagnosis of endometriotic lesions.