Ahmet Ziya Balta

Pretreatment Neutrophil/Lymphocyte Ratio as a Prognostic Aid in Colorectal Cancer

BACKGROUND Colorectal cancers(CRC) are the third most common cancer in the western world, with surgery preferred for management of non-metastatic disease and post surgical treatment usually arranged according to the TNM staging system. However, there is still prognostic variation between patients who have the same stage. It is increasingly recognized that variations within disease course and clinical outcome in colorectal cancer patients are influenced by not only oncological characteristics of the tumor itself but also host response factors. Recent studies have shown correlation between the inflammatory response and clinical outcomes in various cancers. The neutrophil/lymphocyte ratio (NLR) has been described as a marker for immune response to various stimuli including cancer. MATERIAL-METHODS Two hundred eighty-one CRC patients were included in our retrospective analysis, separated into two groups according to a cut-off value for the NLR. Patient data including age, gender, vertical penetration, anatomic location, and differentiation of the tumor, TNM stage, survival rate, and disease-free survival were analyzed for correlations with the NLR. RESULTS Using ROC curve analysis, we determined a cut-off value of 2.2 for NLR to be best to discriminate between patient survival in the whole group. In univariate analysis, high pretreatment NLR (p=0.001, 95%CI 1.483-4.846), pathologic nodal stage (p<0.001, 95%CI 1.082- 3.289) and advanced pathologic TNM stage (p<0.001, 95%CI 1.462-4.213) were predictive of shorter survival. In multivariate analysis, advanced pathologic TNM stage (p=0.001, 95%CI 1.303-26.542) and high pretreatment NLR (p=0.005, 95%CI 1.713-6.378) remained independently associated with poor survival. CONCLUSIONS High pre-treatment NLR is a significant independent predictor of shorter survival in patients with colorectal cancer. This parameter is a simple, easily accessible laboratory value for identifying patients with poorer prognosis.

Prognostic value of oncoprotein expressions in thyroid papillary carcinoma

The aim of this study was to evaluate the expressions of oncoproteins and to correlate the results with clinicopathologic parameters in papillary thyroid carcinoma (PTC). Papillary thyroid cancer (PTC) is the most common form and accounts for about 80% of all thyroid cancers. Although PTC generally has a good prognosis, some patients suffer from local recurrence and/or distant metastasis. Oncogenes have reported to be related not only in carcinogenesis but also in tumor prognosis, tumor type, differentiation and site of tumor in epithelial malignant tumors such as thyroid, breast, ovarian, and stomach cancer. This study was planned retrospectively and was performed in 87 patients (47 PTC, 40 benign lesions). The data of clinicopathologic parameters and tissue samples were collected from the archives. Sections stained with H&E were evaluated for each case and after confirming the diagnosis of PTC, oncoprotein expressions were determined by immunohistochemical analysis. The differences of oncoprotein expressions in PTC compared with control group were statistically significant. Cyclin D1 and p53 expressions were significantly increased in PTC. The expressions of bcl-2 and c-erbB-2 in PTC were found as increased, but the correlation between these proteins and poor prognostic parameters were not significant. We suggest that increased expressions of cyclin D1 and p53 could be used as prognostic factors in patients with PTC.

Primary retroperitoneal mucinous cystadenoma with a sarcoma-like mural nodule: an immunohistochemical study with histogenetic considerations and literature review.

Primary retroperitoneal mucinous cystadenomas (PRMCs) are extremely rare tumors and their association with sarcoma-like mural nodules (SLMNs) has not been described thoroughly. The aim of this study is to characterize the gross and microscopic features and the immunohistochemical profile of the first case of PRMC with SLMN and to discuss the differential diagnosis of SLMNs. The literature related to primary retroperitoneal mucinous tumors is reviewed in an attempt to clarify the histogenesis of the epithelial and sarcomatoid components of the associated mural nodules. A 34-yr-old woman presented with a 14-cm retroperitoneal cystic lesion with a 6-cm mural nodule. An immunohistochemical study with a panel of 19 antibodies and a histochemical study for mucin stains were performed. The epithelial component of the PRMC showed positive staining for cytokeratin (CK) 7, CK AE1/3, epithelial membrane antigen, carcinoembryonic antigen, and calretinin. The neoplasm was not immunoreactive for CK 20, CK 5/6, and the other antibodies used in this study. In addition, it stained positively for mucin by mucicarmine, periodic acid-Schiff, and Alcian blue. The stromal cells of the cyst showed estrogen receptor positivity. SLMN cells were negative for all CKs and other epithelial markers used in the study, but they showed diffuse positive staining for vimentin and CD68, and positive staining for Ki-67 was demonstrated in 25% of these cells. The immunohistochemical and histochemical profiles of PRMC were similar to those of ovarian mucinous neoplasms and the mesothelium. The formation of SLMNs seems to be related to subepithelial hemorrhage and some reactive epithelial changes near the mural nodules. The specific immunohistochemical and morphologic features of SLMNs are helpful in differentiating them from malignant mural nodules, including true sarcomas, osteoclast-rich undifferentiated carcinomas, and carcinosarcomas. Such a differentiation is critical in view of its significant impact on the management of these neoplasms, particularly in young patients who desire to preserve their fertility.

microRNA Expression Profile in Patients with Stage II Colorectal Cancer: A Turkish Referral Center Study

BACKGROUND There are increasing data about microRNAs (miRNA) in the literature, providing abundant evidence that they play important roles in pathogenesis and development of colorectal cancer. In this study, we aimed to investigate the miRNA expression profiles in surgically resected specimens of patients with recurrent and non-recurrent colorectal cancer. MATERIALS AND METHODS The study population included 40 patients with stage II colorectal cancer (20 patients with recurrent tumors, and 20 sex and age matched patients without recurrence), who underwent curative colectomy between 2004 and 2011 without adjuvant therapy. Expression of 16 miRNAs (miRNA-9, 21, 30d, 31, 106a, 127, 133a, 133b, 135b, 143, 145, 155, 182, 200a, 200c, 362) was verified by quantitative real-time polymerase chain reaction (qRT-PCR) in all resected colon cancer tissue samples and in corresponding normal colonic tissues. Data analyses were carried out using SPSS 15 software. Values were statistically significantly changed in 40 cancer tissues when compared to the corresponding 40 normal colonic tissues (p<0.001). MiR-30d, miR-133a, miR-143, miR-145 and miR-362 expression was statistically significantly downregulated in 40 resected colorectal cancer tissue samples (p<0.001). When we compared subgroups, miRNA expression profiles of 20 recurrent cancer tissues were similar to all 40 cancer tissues. However in 20 non-recurrent cancer tissues, miR-133a expression was not significantly downregulated, moreover miR-133b expression was significantly upregulated (p<0.05). CONCLUSIONS Our study revealed dysregulation of expression of ten miRNAs in Turkish colon cancer patients. These miRNAs may be used as potential biomarkers for early detection, screening and surveillance of colorectal cancer, with functional effects on tumor cell behavior.

Early Detection of Potentially Severe Acute Pancreatitis

4. Donati M, Stavrou GA, Basile F, et al. Combination of in situ split and portal ligation: lights and shadows of a new surgical procedure. Ann Surg 2012;256:e11ee12. 5. Oldhafer KJ, Donati M, Maghsoudi T, et al. Integration of 3D volumetry, portal vein transection and in situ split procedure: a new surgical strategy for inoperable liver metastasis. J Gastrointest Surg 2012;16:415e416. 6. Machado MA, Makdissi FF, Surjan RC. ALPPS procedure with the use of pneumoperitoneum. Ann Surg Oncol 2013;20: 1491e1493.

Comparison of modified Limberg flap transposition and lateral advancement flap transposition with Burow’s triangle in the treatment of pilonidal sinus disease

BACKGROUND Although many options exist for surgical treatment of pilonidal sinus disease (PSD), consensus has not yet been achieved, as all surgical methods have various rates of complications, postoperative infection, and recurrence. METHODS This study was a prospective, randomized, clinical trial, and was conducted with consecutive 100 patients admitted to Ankara Military Hospital General Surgery Service for treatment of PSD from May 2013 to August 2013. This study compared two surgical treatments for PSD: modified Limberg flap transposition and lateral advancement flap transposition with Burows triangle. The patients received surgical treatment with either modified Limberg flap transposition (n = 50) or lateral advancement flap transposition with Burows triangle (n = 50). Clinical healing period, length of hospital stay, operative time, postoperative complications including recurrence, wound dehiscence, and surgical site infection, as noted during postoperative follow-up period; Visual Analog Scale scores for pain. RESULTS The mean follow-up period was 12 months. No significant differences were observed between the 2 groups in length of hospital stay (P = .515), operative time (P = .175), wound dehiscence (P = .645), and Visual Analog Scale pain scores (P = .112). The mean operative times were 42.5 minutes in the modified Limberg group and 40.0 minutes in the lateral advancement group. CONCLUSIONS Although lateral advancement flap transposition with Burows triangle is used less often than modified Limberg flap transposition, we could not determine a parameter that was statistically different such as operative time, postoperative complication, or the length of hospital stay. Hence, the lateral advancement flap is as viable an option as other more preferable techniques in the treatment of PSD, which particularly settled on the upper segment without a deep natal cleft.

Horizontal tumor diameter as a prognostic factor.

We read the recent article about the relation between tumor size and the survival in colon cancer by Saha et al with great interest. We conducted similar study from our clinical database about 1 year ago, and we reached almost the same results like Saha et al. We believe that horizontal tumor diameter (tumor size), which calculated widest diameter of the tumor at the final pathologic examination, has a negative effect to the tumor behavior and lymph node involvement in the colorectal cancer as in the gastric, breast, and lung cancer, etc. According to our data, we found that there was a significant statistical relation between the size of horizontal diameter prognostic factors especially lymph node invasion; large tumors were associated with a greater number of the positive lymph nodes. The current management of nonmetastatic colon cancer is the removal of the tumor and the surrounding lymph nodes. The postsurgical treatment is closely related with the tumor–node–metastasis staging system. Although the lymph node involvement is the most important prognostic factor for adjuvant therapy, sometimes, the number of the harvested lymph node may be less than 12. Thus, we need additional prognostic factors such as lymphovascular invasion, tumor differentiation, molecular, and genetic markers. But, analyzing these factors may cause the time consumption or have no cost effectivity, whereas measurement of the tumor size is simple and rapid. Saha et al have been perfectly demonstrated that if the tumor size increases, the colon cancer may have more aggressive behavior as the previous studies showed. According to our thought, it is possible that they could have studied the relation between the tumor size and the prognosis because of the insufficient harvested lymph node situation. In conclusion, we look forward the study that has similar results like ours because we believe that tumor size should be inserted to The American Joint Committee on Cancer new tumor–node–metastasis staging system edition as a prognostic factor.

Testicular choriocarcinoma metastatic to the stomach: cytological, histological and immunocyto‐histochemical findings

Dear Editor, Choriocarcinoma metastatic to the stomach is an extremely uncommon tumour that was first reported by Aydiner et al. Although some cases metastatic to other sites such as the breast, lung and oesophagus have been previously reported with their cytological findings, this is the first such report of choriocarcinoma metastatic to the stomach. The patient was a 20-year-old male who presented to the emergency service with a 10-day history of fatigue, vomiting, nausea, abdominal pain and tarry stools. He was hospitalized with a preliminary diagnosis of upper gastrointestinal bleeding and an emergency gastroscopy was performed. It revealed a 2.5-cm, erythematous, bleeding polypoid and a fragile lesion covered with clot at the junction of the gastric corpus and fundus. Sclerotherapy in controlling a gastric haemorrhage and a partial wedge gastrectomy was performed. Intra-operative imprint cytology and a frozen section revealed a malignant neoplasm, and a total gastrectomy was performed. Histological examination of paraffin sections of the lesion established the diagnosis of choriocarcinoma. At this stage, the serum b-hCG level was found to reach 225 000 mIU/ ml. A left testicular mass suggestive of choriocarcinoma was found at ultrasonography, favouring the possibility of the gastric tumour being metastatic. A computed tomography scan revealed brain, liver and retroperitoneal metastases. Although chemotherapy was started at postoperative day 7, the patient died at day 10 as a result of cerebral herniation and intracranial pressure owing to the brain metastases. Intra-operative imprint preparations revealed a bloody background with cohesive sheets of reactive gastric cells. There were also cytotrophoblastic cells in small groups or as isolated cells (Figure 1a). These appeared as round to polygonal, mononucleated medium to large cells, showing large central vesicular nuclei with granular chromatin and small nucleoli. Some mitotic figures were seen. Additionally, there were some isolated multinucleated syncitiotrophoblastic cells (Figure 1b). Haematoxylin and eosin (H&E)-stained frozen and paraffin sections showed an ulcerated tumour infiltrating the entire thickness of the gastric wall and reaching the subserosa. The tumour, which showed extensive haemorrhage and necrosis, consisted of two cell populations, syncitiotrophoblastic cells and cytotrophoblastic cells, corresponding to those encountered in the cytology material (Figure 2a). Immunostains were performed on histological sections and Papanicolaou-stained cytology smears using ‘Cell Marque’ antibodies and an automated immunostainer (BenchMark XT; Ventana Medical Systems, Tucson, AZ, USA). Cytotrophoblastic cells in the histological sections were negative for

Incidental gastrointestinal stromal tumor at a gastroscopic polypectomy specimen: A case report and review of literature

Although gastrointestinal stromal tumors (GISTs) comprise less than 1% of all gastrointestinal (GI) tract tumors, they are the most common mesenchymal tumors of the GI tract. Gastrointestinal stromal tumors can occur anywhere along the GI tract, but the stomach and small intestine are the most frequently involved sites. Gastrointestinal stromal tumors are frequently asymptomatic, and one-third of all cases are found incidentally. Endoscopy, endoscopic ultrasonography, and computed tomography are useful tools in the diagnosis. Endoscopic mucosal resection, endoscopic submucosal dissection, laparoscopic endoscopic cooperative surgery, and surgery with either laparoscopic or open approaches are treatment modalities for GISTs. An R0 resection is the principle surgery. Imatinib is the main medical agent used in the adjuvant or neoadjuvant treatment of GIST. We present a 65-year-old woman with an asymptomatic GIST that arose from a gastric polyp treated via endoscopic polypectomy.

Intramuscular Lipoma Occurring Within the Pectoralis Major Muscle: Case Report

Lipomas are benign mesenchymal neoplasms that develop from adipose tissue and one of the most common soft tissue neoplasms. They may occur subcutaneously in the extremities and body. Also they occur intramuscular or intermuscular in large muscles. Intramuscular lipomas are rare and they were reported frequently in the extremities and body, or rarely in the head and neck region, but occurring in pectoralis major muscle is very rare. We presented thirty years old woman presenting with intramuscular lipoma occurring in pectoralis major muscle. Physicians must be kept in mind lipomas when evaluating breast mass. Intramuscular lipomas may be confused with breast malignancies or liposarcomas. Computerized Tomography and Magnetic Resonance Imaging are important imaging for differentiation from breast malignancies and liposarcomas.