Michalis Fatouros

Impact of breast cancer surgery on angiogenesis circulating biomarkers: a prospective longitudinal study

BackgroundDebate about the potential effects that surgery might have on cancer cells dormancy and angiogenesis prompted us to investigate the impact of breast surgery on circulating angiogenesis modulating gene transcripts and proteins.MethodsBlood samples from 10 female patients diagnosed with breast cancer and 6 with fibroadenoma were collected before surgery and post-operatively on days 3 and 7 (breast cancer patients only). A set of 84 angiogenesis-associated transcripts were assessed using quantitative PCR arrays, and circulating protein levels (vascular endothelial growth factor A (VEGFA), IL8 and fibroblast growth factor 2 (FGF2) were measured using ELISA in the same samples. The results were investigated against clinicopathological data and patient outcome.ResultsPlasma levels of VEGFA and IL8 after surgery were significantly elevated in the breast cancer group compared to the control group (P = 0.038 and P = 0.021, respectively). In the cohort of breast cancer patients, VEGFA increased on day 3 (P = 0.038) and declined on day 7 (P= 0.017), while IL8 did not change on day 3 but showed a significant decline on day 7 (P = 0.02). FGF2 levels did not change significantly over time. Regarding gene transcripts, we detected upregulation of a significant number of angiogenesis-specific genes in patients with breast cancer versus controls: sphingosine kinase 1(SPHK1), epidermal growth factor (EGF), vascular endothelial growth factor C (VEGFC), neuropilin 1 (NRP1), fibroblast growth factor (FGF1), laminin alpha 5 (LAMA5), collagen type IV alpha 3 (COL4A3), IL8, ephrin B2 (EFNB2), ephrin A3 (EFNA3), tyrosine endothelial kinase (TEK), integrin beta 3 (ITGB3), AKT1, thrombospondin 1 (THBS1), chemokine (C-C motif) ligand 11 (CCL11) and TIMP metallopeptidase inhibitor 3 (TIMP3). Surgery induced an altered expression in several keygenes in breast cancer patients. We identified an upregulation of COL4A3 and downregulation of chemokine (C-X-C motif) ligand 9 (CXCL9), EGF, FGF1, Kinase insert domain receptor (KDR), Placental growth factor (PGF), TIMP3 and VEGFC.ConclusionBreast cancer patients have a different expression profile of circulating angiogenesis biomarkers compared to patients with fibroadenoma. Moreover, mastectomy promotes a transient increase of VEGFA and a shift in the expression patterns of a broad panel of angiogenesis-related circulating gene transcripts.

Protection of the gastroduodenal mucosa from the effects of diclofenac sodium: role of highly selective vagotomy and misoprostol.

Abstract. The aim of this study was to determine the effectiveness of highly selective vagotomy (HSV) or misoprostol, a prostaglandin E 1 (PGE 1 ) analog, for protecting the gastroduodenal mucosa (GDM) from the effects of diclofenac sodium (DS). Fifty mongrel dogs were randomly allocated to five groups. HSV alone was performed in group I dogs (controls) to standardize the operation. DS was given intramuscularly for 12 consecutive days to the group II dogs, whereas in the group III dogs HSV was performed, followed a month later by DS administration, as in group II. DS was given in combination with misoprostol for 12 days to the group IV dogs. HSV was performed on the group V dogs, and a month later DS and misoprostol were given, as in group IV. After sacrificing the animals the GDM was examined for macroscopic and histologic lesions. Statistical analysis was made by Fisher’s exact test. HSV alone did not protect the gastric or duodenal mucosa from the effects of DS (p = 0.474 andp = 0.62, respectively). Misoprostol alone also did not offer significant protection to the gastric or the duodenal mucosa (p = 0.08 andp = 0.65, respectively). The combination of HSV plus misoprostol protected the gastric mucosa (group V,p = 0.007) but not the duodenal mucosa (group V,p = 0.08). Hence HSV or misoprostol alone offers no protection to the GDM from the effects of DS. The combination of HSV and misoprostol offers significant protection only to gastric mucosa. Enhancement of the mucosal defense mechanisms combined with strong reduction of gastric acidity may offer adequate protection to gastric mucosa from the effects of nonsteroidal antiinflammatory drugs.

Spontaneous biloma due to an intrahepatic cholangiocarcinoma: An extremely rare case report with long term survival and literature review

Cholangiocarcinomas are tumors that arise from the ductal epithelium of the intrahepatic or extra-hepatic bile ducts. Patients are usually asymptomatic or may present with weight loss, fatigue, loss of appetite and abdominal pain (intrahepatic cholangiocarcinomas) or jaundice (extra-hepatic cholangiocarcinomas). Subcapsular bile vessel rupture, due to intrahepatic cholangiocarcinoma, is an extremely rare clinical presentation, which is an emergent and potentially life-threatening complication. We report the case of a 79-year-old female patient suffering from an intrahepatic cholangiocarcinoma that completely obliterated the left main hepatic duct. This obstruction in intrahepatic bile flow had resulted in intraperitoneal rupture of subcapsular bile vessels (not infiltrated by the tumor) of the left liver lobe and formation of spontaneous biloma. The patient was admitted for acute abdominal pain. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) revealed the tumor and an upper abdominal fluid collection. Since the patient was hemodynamically stable and afebrile, a CT-guided percutaneous aspiration of the collection was undertaken, showing a biloma. A left hepatectomy was performed two weeks later and today, sixty months since the incident, the patient enjoys good health, with no signs of local recurrence or distant metastases. Intraperitoneal rupture of bile ducts and subsequent spontaneous biloma formation, due to an intrahepatic cholangiocarcinoma which completely obstructed the left main hepatic duct, is a unique situation and this is the first time to be reported. Prompt surgical management can lead to successful treatment of this rare and difficult entity.

Surgical site infections in general surgery operations in North West Greece: A prospective pilot study

Aim-BackgroundSurgical site infections (SSIs) are an important cause of morbidity and mortality that add to the cost of hospitalization. The aim of the present pilot study is to assess the incidence rate of SSIs and associated risk factors in the Department of Surgery at the University Hospital of Ioannina.MethodsA prospective active surveillance study was performed for patients undergoing general surgery from December 2010 to May 2011. Patients were inspected daily for the development of SSIs for a period of 30 days in accordance with the standard definitions for SSIs and protocols as outlined by the National Nosocomial Infections Surveillance (NNIS) system. Univariate analysis was applied to evaluate the association between potential risk factors and SSIs.ResultsSixteen of the 207 patients developed SSIs (rate 7.7%). The majority were women (81.2%). The most common microorganisms were gram negative (61.5%). Univariate analysis showed that females, an ASA score >2, increased duration (>24 hrs) of chemoprophylaxis, and an NNIS score >1 were associated with an increased risk for SSIs.ConclusionThis pilot study identified factors associated with increased SSI rates. The continuation of the study is expected to provide helpful information toward ways of preventing and reducing SSIs.

Subtotal gastrectomy for diffused hemorrhagic gastritis induced by radiation, following liver resection for hilar cholangiocarcinoma. A case report

INTRODUCTION A rare case of hemorrhagic gastritis induced by radiation is presented, which was resistant to conservative treatment and required subtotal gastrectomy. PRESENTATION OF CASE A 56-year-old male was initially undergone right hepatectomy, resection of the extrahepatic biliary tree, hilar lymph node dissection and hepatico-jejunostomy due to advanced hilar cholangiocarcinoma. Because of the extent of the disease, chemo-radiotherapy was administered. The patient received a total radiotherapy dose of 57.6Gy in 32 sessions. Unfortunately, diffused hemorrhagic gastritis induced by radiation was developed, which was resistant to conservative treatment (endoscopic hemostasis, transfusion). A subtotal gastrectomy was performed. The patient is in good condition 45 months after the liver resection, but with local recurrence. CONCLUSION In resistant situations to conservative treatment and recurred bleeding of diffused hemorrhagic gastritis induced by radiation, surgical management may have a role.Highlights • Diffused, hemorrhagic, radiation induced gastritis is a rare condition within Emami’s recommended TD5/5 and in low fraction of radiation.• When it occurs, it can be managed conservatively in the majority of cases.• Surgical management may have a role in the management of cases which are refractory to conservative management (three case reports worldwide).

Undifferentiated carcinoma of the head of pancreas with osteoclast-like giant cells presenting as a symptomatic cystic mass, following acute pancreatitis: Case report and review of the literature.

Highlights • Pancreatic undifferentiated carcinomas with OGCs are very rare neoplasms that may have an atypical clinical presentation.• Less than a hundred cases have been described until today.• Early diagnosis and aggressive surgical treatment is the only way to prolong survival.

A case of encapsulating peritoneal sclerosis presented shortly after renal transplantation

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD), characterized by extensive intraperitoneal fibrosis and encasement of bowel loops. It typically associates with long-term PD and progressive loss of ultrafiltration. The management of EPS has evolved substantially from the original report of this entity and now includes immunosuppressive agents, antifibrotic agents, nutritional support, and surgical intervention. Although the exact cause of this condition remains obscure and despite the possible positive effect of immunosuppression on EPS, it has been described in the post-transplant setting upon the discontinuation of PD. We report such a case of a former PD patient who presented with EPS a month after renal transplantation. This article will highlight the current views regarding the management of post-transplant EPS and introduce the problem of long-term PD patients on the deceased-donor transplant waiting list.