Pancreatic cancer is one of the most aggressive gastrointestinal cancer with less than 10% long-term survivors. The apoptotic pathway deregulation is a postulated mechanism of carcinogenesis of this ...tumour. The present study investigated the prognostic role of apoptosis and apoptosis-involved proteins in a series of surgically resected pancreatic cancer patients. All patients affected by pancreatic adenocarcinoma and treated with surgical resection from 1988 to 2003 were considered for the study. Patients' clinical data and pathological tumour features were recorded. Survivin and Cox-2 expression were evaluated by immunohistochemical staining. Apoptotic cells were identified using the TUNEL method. Tumour specimen of 67 resected patients was included in the study. By univariate analysis, survival was influenced by Survivin overexpression. The nuclear Survivin overexpression was associated with better prognosis (P = 0.0009), while its cytoplasmic overexpression resulted a negative prognostic factor (P = 0.0127). Also, the apoptotic index was a statistically significant prognostic factor in a univariate model (P = 0.0142). By a multivariate Cox regression analysis, both the nuclear (P = 0.002) and cytoplasmic (P = 0.040) Survivin overexpression maintained the prognostic statistical value. This is the first study reporting a statistical significant prognostic relevance of nuclear and cytoplasmic Survivin overexpression in pancreatic cancer. In particular, patients with high nuclear Survivin staining showed a longer survival, whereas patients with high cytoplasmic Survivin staining had a shorter overall survival.
The aim of this study was to prospectively define and measure evacuation and continence disorders after preoperative radiochemotherapy and total mesorectal excision (TME) for rectal cancer 1 year ...after surgery.
We submitted 100 patients, who underwent neoadjuvant treatment and anterior resection with TME from 1996 to 2003, to a questionnaire on postoperative continence and evacuation. Anal sphincter function was further assessed by the Memorial Sloan-Kettering score. Factors influencing anorectal function were examined in univariate and multivariate analysis.
Median evacuation score was 16.12 +/- 5.12 (range 0-28). Sensation of incomplete evacuation was reported in 58% of cases, necessity to return to the bathroom <15 min in 37% and inability to evacuate completely <15 min in 35%. Median continence score was 13.7 +/- 4.79 (range 0-20). Incontinence to flatus was reported in 46% of cases. Colonic J-pouch allows better evacuation and continence. Continence was also better in absence of postoperative complications. Sphincter function resulted excellent or good in 75% of patients according to the Memorial Sloan-Kettering score.
The most frequent symptoms in our series are the sensation of incomplete evacuation, the incontinence to flatus, and the necessity to return to the bathroom <15 min. Colonic J-pouch warrants a better function. Postoperative complications compromise good functional results.
Biotin synthase, encoded by the bio2 gene in Arabidopsis, catalyzes the final step in the biotin biosynthetic pathway. The development of radiochemical and biological detection methods allowed the ...first detection and accurate quantification of a plant biotin synthase activity, using protein extracts from bacteria overexpressing the Arabidopsis Bio2 protein. Under optimized conditions, the turnover number of the reaction was >2 h-1 with this in vitro system. Purified Bio2 protein was not efficient by itself in supporting biotin synthesis. However, heterologous interactions between the plant Bio2 protein and bacterial accessory proteins yielded a functional biotin synthase complex. Biotin synthase in this heterologous system obeyed Michaelis-Menten kinetics with respect to dethiobiotin (Km = 30 μM) and exhibited a kinetic cooperativity with respect to S-adenosyl-methionine (Hill coefficient = 1.9; K0.5 = 39 μM), an obligatory cofactor of the reaction. In vitro inhibition of biotin synthase activity by acidomycin, a structural analog of biotin, showed that biotin synthase reaction was the specific target of this inhibitor of biotin synthesis. It is important that combination experiments using purified Bio2 protein and extracts from pea (Pisum sativum) leaf or potato (Solanum tuberosum) organelles showed that only mitochondrial fractions could elicit biotin formation in the plant-reconstituted system. Our data demonstrated that one or more unidentified factors from mitochondrial matrix (pea and potato) and from mitochondrial membranes (pea), in addition to the Bio2 protein, are obligatory for the conversion of dethiobiotin to biotin, highlighting the importance of mitochondria in plant biotin synthesis.
Background & Aims: This study was undertaken to prospectively compare the clinical outcomes of small bowel radiographs with the wireless capsule endoscopy. Methods: Twenty-two patients were selected ...consecutively because of suspected small bowel disease. Two patients were excluded owing to ileal stenosis. Thus, the results of barium follow-through and the Given M2A wireless video capsule (Given Imaging Ltd., Yoqneam, Israel) endoscopy were compared in 20 patients (13 men; mean age, 52.5 yr; range, 29–78 yr). Results: Barium follow-through was normal in 17 patients and showed ileal nodularity in 3 patients. Capsule endoscopy was normal in 3 patients and showed positive findings in the remaining 17 patients. The barium study was considered diagnostic in 4 (20%) patients. The capsule endoscopy was considered diagnostic in 9 (45%) patients, suspicious in 8 (40%) patients, and failed in 3 (15%) patients. For obscure gastrointestinal (GI) bleeding, the diagnostic potential of barium follow-through was much worse as compared with the capsule endoscopy (5% vs. 31%, P < 0.05). Capsule endoscopy was well tolerated and better accepted by patients when compared with the most recently performed endoscopic procedure. Conclusions: The video capsule endoscope was found to be superior to small bowel radiograph for evaluation of small bowel diseases. However, this novel wireless endoscope system needs further assessment because of limitations such as difficulties in interpretation of potentially nonspecific findings.
GASTROENTEROLOGY 2002;123:999-1005
Background: There is a lack of data in the literature concerning the identification of potential prognostic factors in ampullary adenocarcinoma. Aims: To examine the prognostic significance of Bax, ...Bcl-2, and p53 protein expression and the apoptotic index in a large cohort of uniformly treated patients with radically resected ampullary cancer. Methods: All patients with a pathological diagnosis of ampullary cancer and radical resection were evaluated. Expression analysis for p53, Bax, and Bcl-2 was performed by immunohistochemistry. Apoptotic cells were identified by terminal deoxynucleotidyl transferase mediated dUTP nick end labelling (TUNEL). Results: Thirty nine tumour specimens from patients with radically resected ampullary adenocarcinoma were studied. A positive significant correlation between Bax and p53 expression was found by rank correlation matrix (p < 0.001). A trend towards a positive correlation was found between the apoptotic index and p53 expression (p = 0.059). By univariate analysis, overall survival was influenced by Bax expression, p53 expression, and TUNEL staining (p = 0.001, p = 0.01, and p = 0.03, respectively). Bcl-2 expression did not influence overall survival in these patients (p = 0.55). By multivariate Cox regression analysis, the only immunohistochemical parameter that influenced overall survival was Bax expression (p = 0.020). Conclusions: These results provide evidence that apoptosis may be an important prognostic factor in patients with radically resected ampullary cancer. This study is the first to assess the clinical usefulness of Bax expression in radically resected ampullary cancer.
The present study is a prospective evaluation of immediate preoperative laparoscopy compared to ultrasound/computed tomography (US/CT) staging for gastric cancer in a series of 100 patients observed ...at two major Italian hospitals from April 1995 through September 1996.
After a complete preoperative work-up all c-M0 patients underwent laparoscopy immediately prior to an eventual surgical exploration. pTNM was considered as the gold standard for the evaluation of the results.
Laparoscopy detected 21 unsuspected M+ cases out of 100. As regards locally advanced tumors, laparoscopy showed a sensibility of 69.7% for T3 and 89.6% for T4, significantly higher than US/CT staging (23.2% and 48.3%, respectively; p < 0.02). In this series laparoscopic staging altered clinical staging in 58% of cases.
This procedure plays two crucial roles in the preoperative evaluation of advanced gastric cancer: It makes it possible to avoid unnecessary surgical exploration in M+ cases and, to date, it represents the most reliable and economic tool for the selection of locally advanced tumors in the light of neoadjuvant treatment.
The aim of this study was to show that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography.
We performed a retrospective analysis of 1139 consecutive ...patients (376 men and 763 women with an average age of 51.4 years) who underwent laparoscopic cholecystectomy between 1991 and 1999. In all, 227 patients (20%) were selected to undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) on the basis of four criteria for risk of stones.
ERCP allowed us to make a diagnosis of biliary stones in 53.3% of the selected patients. Extraction of the stones was successful in 97% of the cases. In 14% of cases, ERCP was normal; in 32.7%, some useful diagnostic information was obtained. There were three complications (pancreatitis) following endoscopy (complication rate, 1.3%). Laparoscopic cholecystectomy was successful in 92% of patients. The postoperative morbidity rate was 3.2% (major complications, 0.5%). There were no deaths. During a follow-up period ranging from 3 to 97 months, six patients (0.6%) were found to have residual biliary stones.
This study confirms the hypothesis that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography.
Purpose
: To evaluate the impact of tumor response; tumor and nodal downstaging; and cTNM, yTNM (clinical stage after chemoradiation, based on preoperative imaging), and pTNM classifications on ...long-term outcome in patients with rectal cancer treated with preoperative 5-fluorouracil (5-FU)-based concurrent chemoradiation.
Methods and Materials
: Between January 1990 and March 1998, 165 consecutive patients with locally advanced extraperitoneal cancer of the rectum were treated with preoperative chemoradiation. Four patients had a cT2 lesion (2.5%), 120 had a cT3 lesion (74.5%), and 41 had a cT4 lesion (23%). The nodal involvement at combined imaging was cN0 in 21%, cN1 in 41%, cN2 in 34%, and cN3 in 4%. Preoperative chemoradiation was delivered according to 1 of 3 schedules: (
1) FUMIR-T3 (from 1990 to 1995) for patients with cT3N0-2 or cT2N1-2 rectal carcinoma (82 patients): 37.8 Gy (1.8 Gy/fraction) plus 5-FU, 1 g/m
2/d on Days 1–4, continuous infusion, and mitomycin-C, 10 mg/m
2/d on Day 1; (
2) FUMIR-T4 (from 1990 to 1999) for patients with cT4N0-3 or cT3-4N3 rectal carcinoma (40 patients): 45 Gy (1.8 Gy/fraction) plus 5-FU, 1 g/m
2/d on Days 1–4 and 29–32, continuous infusion, and mitomycin-C, 10 mg/m
2/d on Days 1 and 29; and (
3) PLAFUR-4 (from 1995 to 1998) for patients with cT3N0-2 or cT2N1-2 rectal carcinoma (42 patients): 50.4 Gy (1.8 Gy/fraction) plus 5-FU, 1 g/m
2/d on Days 1–4 and 29–32, continuous infusion, and cisplatin, 60 mg/m
2/d on Days 1 and 29. Four to five weeks after chemoradiation, patients were reevaluated for clinical response by imaging studies (CT scan, transrectal ultrasonography, barium enema, liver ultrasonography, chest X-rays) and restaged (yTNM). Surgery was performed 6–8 weeks after chemoradiation. Adjuvant chemotherapy (5-FU + l-folinic acid) was delivered to 26 patients in the FUMIR-T4 protocol group. Local control (LC), freedom from distant metastases (FDM), disease-free survival, and overall survival (OS) were evaluated according to the clinical response and cTNM, yTNM, and pTNM classification. The median follow-up was 67 months.
Results
: The 5-year survival rate was 100% for cT2, 77% for cT3, and 62% for cT4 (
p = 0.0497); after chemoradiation, it ranged between 81% and 91% for pT0-pT2 and dropped to 66% for pT3 and 47% for pT4 (
p = 0.014). The 5-year local control rate was, at the first staging, 84% for cT3 and 72% for cT4; after chemoradiation, the pT stage correlated significantly with LC (
p = 0.0012): 100% for pT0, 83% for pT1, 88% for pT2, 79% for pT3, and 46% for pT4. N stage was statistically significant in predicting FDM and OS at any staging step. A significant impact of tumor response, tumor downstaging, and nodal downstaging on LC, FDM, disease-free survival, and OS was also recorded. If the residual tumor, before surgery, had a tumor index <30 (i.e., width less than one-quarter of rectal circumference and length in its caudocranial axis ≤30 mm), the 5-year LC, FDM, disease-free survival, and OS rates were significantly higher at both the univariate and the multivariate analyses. The surgical procedure was tailored according to tumor downstaging, and thus the choice of sphincter-preserving surgery was based on the distance between the lower pole of the tumor and the anorectal ring “after” chemoradiation. In 36 patients with the lower pole of the lesion in the range of 0–30 mm from the anorectal ring, 16 patients (44%) underwent a sphincter-saving procedure. All clinical outcomes were similar compared with 20 patients with tumor located at the same rectum level who received an abdominoperineal resection.
Conclusion
: After preoperative chemoradiation, clinical response and tumor/nodal pathologic downstaging showed a close correlation with improved outcomes. The better 5-year survival and local control in pT0-2 patients regardless of their initial stage seems to confirm a heterogeneity in rectal cancer patients. The responder population showed a behavior similar to rectal cancer diagnosed at Stage cT1-2 and treated with conservative surgery alone. Additional studies aimed at improving local tumor response seem justified. Trials of sphincter-saving surgery after a major response are warranted.
The prognosis in T3-T4 or N+ gastric cancer is dismal, and the role of adjuvant therapy remains uncertain. Neoadjuvant chemotherapy could improve both resectability and survival. Here, we report the ...results of the long-term follow-up of a pilot study aimed at evaluating a neoadjuvant treatment in a group of patients carefully staged by computed tomography (CT), endoscopic ultrasound and laparoscopy.
Twenty-five stage II-III patients with histologically proven gastric adenocarcinoma were enrolled in the study. All patients gave informed consent and were thoroughly staged. Patients were treated with epidoxorubicin (40 mg/m2 i.v.) on days 1 and 4, etoposide (VP-16; 100 mg/m2) on days 1, 3 and 4 and cisplatinum (80 mg/m2) on day 2, every 21-28 days for 3 pre-operative cycles before CT clinical restaging followed by laparotomy and D2 gastrectomy. Three further cycles of chemotherapy were planned after radical surgery.
Twenty-four patients received the planned pre-operative chemotherapy and underwent surgical resection; total (13 patients) or subtotal (7 patients) R0 D2 gastrectomy was possible in 20 patients. One patient died as a result of gastric bleeding. Perioperative complications occurred in 5 patients (failure of anastomosis in 1 patient and wound infection in the other 4). The pathologic response rate included 7 partial responses (29.1%) and 10 patients with stable disease (41.7%). The main toxicity was grade 3/4 neutropenia (68%), which occurred more frequently during the postoperative chemotherapy, and fatigue (68%). Fever or infection, however, were never observed. The median disease-free survival was 37 months, and median survival has not been reached after 40 months of median follow-up. One-, 2- and 3-year survival rates were 80, 64 and 60%, respectively.
The notable long-term survival in the present study suggests a comparison between the neoadjuvant approach, including new drug combinations, and adjuvant chemo- or chemoradio-therapy in locally advanced gastric cancer.
In plants, the last step of the biotin biosynthetic pathway is localized in mitochondria. This chemically complex reaction is catalyzed by the biotin synthase protein, encoded by the bio2 gene in ...Arabidopsis thaliana. Unidentified mitochondrial proteins in addition to the bio2 gene product are obligatory for the reaction to occur. In order to identify these additional proteins, potato mitochondrial matrix was fractionated onto different successive chromatographic columns. Combination experiments using purified Bio2 protein and the resulting mitochondrial matrix subfractions together with a genomic based research allowed us to identify mitochondrial adrenodoxin, adrenodoxin reductase, and cysteine desulfurase (Nfs1) proteins as essential components for the plant biotin synthase reaction. Arabidopsis cDNAs encoding these proteins were cloned, and the corresponding proteins were expressed in Escherichia coli cells and purified. Purified recombinant adrenodoxin and adrenodoxin reductase proteins formed in vitro an efficient low potential electron transfer chain that interacted with the bio2 gene product to reconstitute a functional plant biotin synthase complex. Bio2 from Arabidopsis is the first identified protein partner for this specific plant mitochondrial redox chain.
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