Mario Ferri

Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study.

BackgroundThis study aimed to evaluate the long-term risk of local and distant recurrence as well as the survival of patients with early rectal cancer treated using transanal endoscopic microsurgery (TEM).MethodsThe study reviewed 69 patients with Tis/T1/T2 rectal cancer treated using full-thickness excision between 1991 and 1999. The pathology T-stages included 25 Tis, 23 T1, and 21 T2. The median follow-up period was 6.5 years (range 5–10.2 years).ResultsThe overall local recurrence rate was 8.7%. The 5-year local recurrence rate was 8% for Tis, 8.6% for T1, and 9.5% for T2. All six patients with recurrence were managed surgically. The 5-year disease-specific survival rate was 100% for Tis, 100% for T1, and 70% for T2. The overall cancer-related mortality rate was 7.2%.ConclusionsAfter local excision of early rectal cancer, a substantial local recurrence rate is observed. Patients with recurrent Tis/T1 cancers who undergo a salvage operation may achieve good long-term outcome. Local treatment without adjuvant therapy for T2 rectal cancers appears inadequate.

Role of the Lymph node ratio in pancreatic ductal adenocarcinoma. Impact on patient stratification and prognosis

Survival after resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumor grading have been identified. Aim of the study was to evaluate the prognostic significance of the lymph node ratio (LNR) for resected pancreatic ductal adenocarcinoma.

Local staging of rectal cancer with MRI using a phased array body coil

Surgery is the method of choice for the treatment of rectal cancer. Optimization of therapeutic strategies (i.e., preor postoperative radiotherapy and chemotherapy) is fundamental to prevent local recurrence and increase survival rates of patients. Local recurrence varies from 3% to 32% of cases depending on the study [1] and is related mostly to incomplete removal of lateral spread of the tumor [2, 3]. Moreover, local recurrence is reduced when the histologic specimen shows a tumor-free circumferential resection margin larger than 1 mm. Thus, total mesorectal excision, with resection of the tumor and the surrounding mesorectal fat, is the surgically accepted treatment of choice; this procedure is associated with a recurrence rate of less than 10% without radiotherapy. Therefore, the use of preor postoperative radiotherapy may be limited to cases in which involvement of mesorectal fascia is diagnosed. This therapeutic approach demands accurate preoperative tumor staging. Goals of an imaging method are represented by (a) accurate staging of rectal wall infiltration, (b) evaluation of spreading into mesorectal fat and involvement of mesorectal fascia, and (c) nodal involvement. Endorectal ultrasonography is considered as the most accurate imaging modality for T-staging of rectal cancers, with accuracies ranging between 64% and 94% [4, 5]. However, it is limited in the evaluation of stenosing lesions and tumors located at the rectosigmoid junction; moreover, it does not identify mesorectal fascia and lymph nodes far from the rectal wall due to its limited field of view. Computed tomography, even with the use of spiral scanners, cannot demonstrate rectal wall layers. Moreover, it has limitations in the assessment of tumor infiltration in surrounding structures for locally advanced primary and recurrent rectal cancers, with a sensitivity approaching 70% and a specificity of approximately 85%. However, it remains an useful imaging modality for identification of distant metastases (i.e., liver lesions and mesenteric lymph nodes) [6–9]. The use of magnetic resonance imaging (MRI) has been advocated in recent years. Initial results were disappointing due to technical limitations. Advancements in terms of MR equipment, coils, and sequences have progressively optimized the technique, with a parallel increase in accuracy. Thanks to the high-contrast spatial resolution and large field of view, MRI has the potential to fulfill the requirements for the ideal imaging technique for the preoperative staging of rectal cancer.

Human papillomavirus and colorectal cancer: evidences and pitfalls of published literature

PurposeThe aim of this study is to review published literature regarding a possible role of human papillomavirus (HPV) infection in colorectal cancer in order to understand if HPV infection plays an active role in colorectal carcinogenesis and to highlight evidences and pitfalls of published studies.MethodsWe reviewed literature by searching PubMed, Ovid, and the Cochrane databases for published series investigating HPV and colorectal cancer from 1988 to date.ResultsTwenty-one studies investigating a possible correlation between HPV infection and colon cancer have been published. We reviewed 15 case–control studies and six studies investigating a possible role for HPV virus in colorectal carcinogenesis. HPV was detected in the majority of reported series with a significant difference in HPV infection between tumors and disease-free controls or tumor-adjacent tissue; the HPV mean detection rate within carcinomas was 41.7%, comparing to a mean detection rate of 32.8% in adjacent colic mucosae, and 5.8% in disease-free controls (Chi-square test, p = 0.001). The correlation between HPV infection and c-myc amplification, k-ras mutation, and p53 polymorphism or mutations has been investigated; however, the possible role of HPV in colorectal carcinogenesis was not defined.ConclusionsHPV has been detected in the majority of reported series, but published literature lacks in definitive data regarding standard methods of investigation and stratification of groups and population. These data encourage further studies with the aim to investigate the presence of the virus in larger series, its possible role in oncogenesis, the integration in host genome, the expression of viral oncoproteins, the mutations in HPV positive cancers and routes of colon infection (hematologic/lymphatic spreading or perineal diffusion).

Circulating tumor cells count predicts survival in colorectal cancer patients

Background & Aims: Respiratory complications represent an important adverse event of endoscopic procedures. We screened for respiratory complications aer endoscopic procedures using a questionnaire and followed-up patients suggestive of respiratory infection. Method: In this prospective observational, multicenter study performed in Outpatient practices of gastroenterology we investigated 15,690 patients by questionnaires administered 24 hours aer the endoscopic procedure. Results: 832 of the 15,690 patients stated at least one respiratory symptom aer the endoscopic procedure: 829 patients reported coughing (5.28%), 23 fever (0.15%) and 116 shortness of breath (SOB, 0.74%); 130 of the 832 patients showed at least two concomitant respiratory symptoms (107 coughing + SOB, 17 coughing + fever, 6 coughing + coexisting fever + SOB) and 126 patients were followed-up to assess their respiratory complaints. Twenty-nine patients (follow-up: 22.31%, whole sample: 0.18%) reported signs of clinically evident respiratory infection and 15 patients (follow-up: 11.54%; whole sample: 0.1%) received therefore antibiotic treatment. Coughing or vomiting during the endoscopic procedure resulted in a 156.12-fold increased risk of respiratory complications (95% CI: 67.44 - 361.40) and 520.87-fold increased risk of requiring antibiotic treatment (95% CI: 178.01 - 1524.05). All patients of the follow-up sample who coughed or vomited during endoscopy developed clinically evident signs of respiratory infection and required antibiotic treatment while this occurred in a signicantly lower proportion of patients without these symptoms (17.1% and 5.1%, respectively). Conclusions: We demonstrated that respiratory complications following endoscopic sedation are of comparably high incidence and we identied major predictors of aspiration pneumonia which could inuence future surveillance strategies aer endoscopic procedures.

The importance of lymph node retrieval and lymph node ratio following preoperative chemoradiation of rectal cancer

Preoperative chemoradiation (CRT) for rectal cancer decreases the number of examined lymph nodes (NELN) found in the resected specimen. However, the prognostic role of lymph node evaluation including overall numbers and the lymph node ratio (LNR) in patients having preoperative CRT have not yet been defined. The study has assessed the influence of CRT on the NELN and on lymph node number and LNR on the survival of patients with rectal cancer.

Number of harvested lymph nodes is the main prognostic factor in Stage IIa colorectal cancer patients

Current international guidelines on colorectal cancer (CRC) treatment suggest performing adjuvant chemotherapy only in Stage II patients presenting with high‐risk prognostic factors. Aim of the study was to a the impact of these parameters on the survival of Stage IIa CRC patients, focusing on the prognostic value of the number of harvested lymph nodes (NHLN).

Accuracy of High-Resolution MRI with Lumen Distention in Rectal Cancer Staging and Circumferential Margin Involvement Prediction

Objective To evaluate the accuracy of magnetic resonance imaging (MRI) with lumen distention for rectal cancer staging and circumferential resection margin (CRM) involvement prediction. Materials and Methods Seventy-three patients with primary rectal cancer underwent high-resolution MRI with a phased-array coil performed using 60-80 mL room air rectal distention, 1-3 weeks before surgery. MRI results were compared to postoperative histopathological findings. The overall MRI T staging accuracy was calculated. CRM involvement prediction and the N staging, the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were assessed for each T stage. The agreement between MRI and histological results was assessed using weighted-kappa statistics. Results The overall MRI accuracy for T staging was 93.6% (k = 0.85). The accuracy, sensitivity, specificity, PPV and NPV for each T stage were as follows: 91.8%, 86.2%, 95.5%, 92.6% and 91.3% for the group ≤ T2; 90.4%, 94.6%, 86.1%, 87.5% and 94% for T3; 98,6%, 85.7%, 100%, 100% and 98.5% for T4, respectively. The predictive CRM accuracy was 94.5% (k = 0.86); the sensitivity, specificity, PPV and NPV were 89.5%, 96.3%, 89.5%, and 96.3% respectively. The N staging accuracy was 68.49% (k = 0.4). Conclusion MRI performed with rectal lumen distention has proved to be an effective technique both for rectal cancer staging and involved CRM predicting.

Is EUS-FNA of solid-pseudopapillary neoplasms of the pancreas as a preoperative procedure really necessary and free of acceptable risks?

BACKGROUND Solid-pseudopapillary neoplasms (SPNs) of the pancreas are infrequent tumors since, as of 2014, only 2744 patients have been described. Its rarity, unclear histogenesis, pleomorphic aspect on radiology (cystic, solid or mixed) and unpredictable biological behavior with an insidious high-grade malignant potential make SPN difficult to recognize preoperatively even in its target patient population which is predominantly composed of young women (about 87% of cases). METHODS Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed to improve the preoperative diagnostic yield for this tumor and obviate the risks formerly given by percutaneous biopsy. RESULTS In light of our experience, such a procedure could not be so innocuous as generally acknowledged. CONCLUSION We report the first case of rupture of pancreatic SPN following EUS-FNA and entertain both the actual and potential complications ensuing from this type of mishap.

Recovery of immunological homeostasis positively correlates both with early stages of right-colorectal cancer and laparoscopic surgery.

Differences in postoperative outcome and recovery between patients subjected to laparoscopic-assisted versus open surgery for colorectal cancer (CRC) resection have been widely documented, though not specifically for right-sided tumors. We investigated the immunological responses to the different surgical approaches, by comparing postoperative data simultaneously obtained at systemic, local and cellular levels. A total of 25 right-sided CRC patients and controls were managed, assessing -in the immediate followup- the conventional perioperative parameters and a large panel of cytokines on plasma, peritoneal fluids and lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMC) tissue cultures. A general better recovery for patients operated with laparoscopy compared to conventional procedure, as indicated by the analysis of typical pre- and post-surgical parameters, was observed. The synchronous evaluation of 12 cytokines showed that preoperative plasma levels of the proinflammatory cytokines IL-6, IL-8, IL-1β, TNFα were significantly lower in healthy donors versus CRC patients and that such differences progressively increase with tumor stage. After surgery, the IL-6 and IL-8 increases were significantly higher in open compared to laparoscopic approach only in CRC at early stages. The postsurgical whole panel of cytokine levels were significantly higher in peritoneal fluids compared to corresponding plasma, but with no significant differences depending on kind of surgery or stage of disease. Then we observed that, pre- compared to the corresponding post-surgery derived LPS-stimulated PBMC cultures, produced higher supernatant levels of the whole cytokine panel. In particular IL-6 in vitro production was significantly higher in PBMC derived from patients subjected to laparoscopic versus open intervention, but -again- only in CRC at early stages of disease. Our results thus show that laparoscopy compared to open right resection is associated with a shorter compromission of the immunological homeostasis, mainly in early stages of right-CRC patients.