Julia Rudno-Rudzińska

HER-2 Expression in Immunohistochemistry Has No Prognostic Significance in Gastric Cancer Patients

The role of HER-2 expression as a prognostic factor in gastric cancer (GC) is still controversial. The aim of the study was to asses HER-2 status, its correlations with clinicopathological parameters, and prognostic impact in GC patients. Tumor samples were collected from 78 patients who had undergone curative surgery. In order to evaluate the intensity of immunohistochemical (IHC) reactions two scales were applied: the immunoreactive score according to Remmele modified by the authors and standardised Hercep test score modified for GC by Hofmann et al. The HER-2 overexpression was detected by IHC in 23 (29.5%) tumors in Hercep test (score 2+/3+) and in 24 (30.7%) in IRS scale (IRS 4–12). The overexpression of HER-2 was associated with poorly differentiated tumors, but this correlation was not significant (P = 0.064). No relationship was found between HER-2 expression and primary tumor size and degree of spread to regional lymph nodes. Both univariate and multivariate analyses revealed that TNM stage and patients age were the crucial negative prognostic factors. No correlation was observed between patient survival and expression of HER-2 estimated using both scales. This research did not confirm HER-2 expression (evaluated with immunohistochemistry) value as a prognostic tool in GC.

Control of active B and L cathepsins in tissues of colorectal cancer using cystatins isolated from chicken egg proteins: in vitro studies

The activity of cysteine peptidases (cathepsins B and L) was estimated in homogenates of tissues sampled during surgery from 60 patients operated due to colorectal tumors. The results were compared to those obtained using tissues in which histopathology disclosed no tumorous cells, obtained from 20 patients of the same group, treated as a control. Activity of the enzymes was inhibited using cysteine peptidase inhibitors isolated from chicken egg proteins. Application of the inhibitors was found to inhibit activity of the enzymes which play a key role in tumor development. It is suggested that in future the inhibitors may provide a component of new generation drugs in the so-called inhibitor therapy.

Pilonidal sinus: finding the righttrack for treatment

Pilonidal cyst is a troublesome condition affecting usually young people. It significantly influences quality of life and causes low self-esteem. Despite its known pathophysiology and numerous therapeutic methods available, pilonidal cysts still constitute a significant problem in general surgery. A large number of surgical techniques indicates the lack of a single method that ensures therapeutic success, and frequent complications cause both patients dissatisfaction and frustration of the operator. In many cases, therapy is based on methods developed in a given healthcare center and their efficacy is usually not scientifically verified. Search for optimal strategy is also impeded by lack of an unambiguous clinical classification. In this article, we reviewed publications on various methods of managing pilonidal cyst, and we also presented surgical treatment used in our department. However, we did not manage to point out a surgical method with efficacy high enough to become standard treatment. It indicates the need for further search for new techniques that will give chances for successful treatment of pilonidal cyst.

Disrupted Balance of MMPs/TIMPs in Gastric Carcinogenesis-Paradoxical Low MMP-2 Expression in Tumor and Stromal Compartments as a Potential Marker of Unfavorable Outcome.

The aim of the study was to find correlations between MMP/TIMP reactivity and the expression of angiogenic factors, and relationships between these parameters and clinicopathological features of gastric cancer patients. Receiver Operating Characteristic curve analysis was used to find cut-off points that enabled fair decision-making in survival analysis. Low levels of MMP-2 expression in tumor and stromal compartments were significantly associated with poor prognosis–the probability that a patient would die within 60 months of surgery if their MMP-2 was low, and was about 0.8 in both neoplastic and stromal compartments.

A review on Eph/ephrin, angiogenesis and lymphangiogenesis in gastric, colorectal and pancreatic cancers

Erythroprotein-producing human hepatocellular carcinoma receptors (Eph receptors) compose a subfamily of transmembrane protein-tyrosine kinases receptors that takes part in numerous physiological and pathological processes. Eph family receptor-interacting proteins (Ephrins) are ligands for those receptors. Eph/ephrin system is responsible for the cytoskeleton activity, cell adhesion, intercellular connection, cellular shape as well as cell motility. It affects neuron development and functioning, bone and glucose homeostasis, immune system and correct function of enterocytes. Moreover Eph/ephrin system is one of the crucial ones in angiogenesis and lymphangiogenesis. With such a wide range of impact it is clear that disturbed function of this system leads to pathology. Eph/ephrin system is involved in carcinogenesis and cancer progression. Although the idea of participation of ephrin in carcinogenesis is obvious, the exact way remains unclear because of complex bi-directional signaling and cross-talks with other pathways. Further studies are necessary to find a new target for treatment.

Lymphangiogenesis in early and advanced gastric cancer: is there any difference?

Gastric cancer (GC) in Poland is on the third place of mens mortality and on the fifth place of womens mortality in malignant neoplasms, and the percentage of diagnosed early GC is less than 20%.

The giant in the stomach - trichobezoar.

Bezoar is an uncommon phenomenon which results from the accumulation of ingested foreign material such as hair, fur or fiber which can easily lead to formation of a large mass in the intestinal tract [1]. Bezoars were once prized as magical items with protective properties. The word “bezoar” comes from the Persian for “protection from poison”. People would place bezoars in their drinking glasses as an antidote to any potential poisons, and even set them into jewelry. There was a gold-framed bezoar in the Crown Jewels of Queen Elizabeth I as recently as 1962. During diagnostic gastrointestinal endoscopy it can be found in less than 1% of all patients complaining about nonspecific abdominal symptoms [2]. The first case was reported in the literature by Baudomant in 1779 [3] and the first surgical removal was performed in 1883 by Schonbern [3]. Depending on what it is made of we can distinguish different bezoars. The major types are phytobezoars (composed of vegetable fibers), trichobezoars (hair, fur), and pharmacobezoars (drugs). Medications reported to cause bezoars include aluminum hydroxide gel, enteric-coated aspirin, sucralfate, guar gum, cholestyramine, enteral feeding formulas, psyllium preparations, nifedipine, and meprobamate [4]. The structure grows because of continuous supply of food rich in cellulose, matted together by protein, mucus and pectin. Bezoars are rare in healthy people. It is believed that any previous operations or gastric dysfunction can lead to formation of a new mass. More recent studies have shown that 70% to 94% of patients with bezoars have a history of gastric surgery and 54% to 80% have undergone vagotomy, pyloroplasty, subtotal distal gastrectomy or antrectomy [5]. It is also statistically significant for patients with impaired gastric emptying to have a higher chance of getting a bezoar. Diabetics with autonomic neuropathy are also at risk. Trichotillomania (repeated action of pulling the hair for pleasure or decreasing tension) and trichophagia lead to formation of a trichobezoar in the stomach. Trichotillomania is considered as a psychiatric state caused by the bad perception that one has about one’s own hair, negative emotional experiences (tension, loneliness, fatigue) and recently identified factors such as studying, reading, and watching television [3]. The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) classifies it as an impulse control disorder. Criteria for diagnosis of this pathology are shown in Table I. Psychiatric follow-up is important although no conclusion has been reached with respect to whether the use of medication makes any difference in the progression of this condition. This follow-up care should be extended to family members, who should be vigilant with patients, since recurrences of the problem have been described [6]. Table I Criteria for diagnosing trichotillomania Only 1% of patients with trichophagia develop a trichobezoar [7]. Patients frequently have an underlying psychiatric condition. Hairs come down through the esophagus, get flushed by gastric acid, then they become black (regardless of their previous color), mixed with regular food and combine to form a bigger mass. When it gets colonized by different types of bacteria it can be a reason for an unpleasant smell from the mouth. Phytobezoars are mostly found in men in their 40s and 50s, while trichobezoars are typically diagnosed in young woman [8]. For many years symptoms may not even be recognized and they can develop very slowly. The most common ailments are abdominal pain, vomiting, nausea, anorexia and loss of weight, and early satiety. Those symptoms are rather nonspecific and can be caused by any other gastric disease. Bezoars can be a reason for some serious gastrointestinal complications such as perforation, ulceration, peritonitis, steatorrhea, pancreatitis, obstructive jaundice, appendicitis, and pneumatosis intestinalis [9]. Another uncommon issue is drug overdose from a pharmacobezoar. One patient presented with a theophylline overdose due to the presence of an unrecognized bezoar containing 29 g of theophylline, the residue of many sustained-release tablets [10]. Trichobezoars are mostly diagnosed as an incidental finding during abdominal X-ray in patients with nonspecific symptoms. Abdominal ultrasound or computed tomography (CT) can reveal a mass or filling defect in the stomach. The most valuable examination is upper gastrointestinal endoscopy. Direct visualizations can be achieved and some sample taking as well. There are different possibilities for medical treatment of a bezoar [11]. For this purpose chemical dissolution, endoscopy, and surgery can be performed. In one study, Coca-Cola alone achieved complete bezoar bubbles dissolution of 23.5% of patients. Coca-Cola appears to be more effective in dissolving bezoars in patients with phytobezoars and pharmacobezoars [12]. Endoscopic removal requires a water jet to cut the whole mass into smaller parts; a large channel endoscope (6 mm) is used in this procedure. Subsequently all fragments can be taken out by forceps via the esophagus. Surgical treatment is mostly considered in patients in whom previous chemical or endoscopic therapy failed or for those with complications such as obstruction or bleeding. Gastric trichobezoar with a duodenal or duodenojejunal tail is named Rapunzel syndrome after the 1812 German tale written by the Grimm brothers (also known as an animated musical film by Walt Disney Studios), where a girl with long-braided hair used it to help her lover climb the tower where she was imprisoned [13]. It is a rare form of trichobezoar. Until 2007, only 27 patients were reported to have Rapunzel syndrome and one of these concerned a man [14]. The case concerns a 22-year-old woman with a 9-month history of epigastric pain. She also noticed reduction of body mass by about 15 kg and a palpable tumor. After consultation in a provincial hospital, gastroscopy was performed. The examination revealed no pathology in the esophagus or the cardia and a giant bezoar in the stomach which filled its cavity leaving the fundus free. The bezoar entered the duodenal cap through the pylorus and it ended in the descending part of the duodenum. The size of the bezoar was estimated at about 25 cm × 15 cm. The patient was directed to our University Hospital of Wroclaw. On admission she confirmed eating her hair in childhood (trichotillomania). She also announced that she had undergone caesarean section twice, in 2009 and 2010, but a bezoar was not noticed. Blood tests revealed slight anemia (Hb 11.5 g/dl, MCV 71.8 fl, MCH 22.2 pg, MCHC 30.9 g/dl) which could be a result of iron deficiency. After overall examination and positive qualification for surgical treatment the operation was performed (Figure 1). In general anaesthesia the abdominal cavity was opened with an upper midline incision. Opening the stomach showed a giant trichobezoar filling 3/4 of its cavity. The bezoar was removed in one part. Gastritis was found. The stomach was stitched and a drain was placed. The whole removed finding was sent for pathological studies (Figure 2). Postoperative status was good. The patient did not report pain, and body temperature was normal. The drain was removed on the third day. The patient was discharged on the sixth day in a good condition. Pathomorphological studies confirmed bezoar diagnosis. The patient was advised to change her habits. Moreover, psychiatric consultation was recommended. Figure 1 Photograph from the middle of the operation Figure 2 Photograph of the whole bezoar after the operation Because bezoar is not a very common disorder it requires great alertness for a doctor, especially when a young woman describes unclear abdominal symptoms such as bloating or pain. They can be found in healthy patients without any gastrointestinal diseases but with some typical habits or psychiatric problems the diagnosis should be extended. It would be very beneficial for patients with those kinds of dysfunctions to have regular checkups. In such cases a psychiatric evaluation is recommended.