P. Dutkowski

Basaloid squamous cell carcinoma of the esophagus

Basaloid squamous cell carcinoma (BSCC) is a recently recognized, poorly differentiated variant of squamous cell carcinoma (SCC), which is located predominantly in the upper aerodigestive tract.

Prognostic significance of cyclin D1 in esophageal squamous cell carcinoma patients treated with surgery alone or combined therapy modalities.

In the present study, the expression of cyclin D1, as detected by immunohistochemistry, was compared with other prognostic variables and its prognostic impact was evaluated in a group of 172 patients with squamous cell carcinoma (SCC) of the esophagus who underwent potentially curative resection therapy and in a second group of 38 patients with SCC of the esophagus who were treated by combined modality therapy (radiochemotherapy ± surgery). Expression of cyclin D1 in surgically treated carcinomas correlated negatively with tumor differentiation (p = 0.026) but positively with mitotic activity (p = 0.0199) and nodal status (p = 0.040). There were no significant correlations with pT category. Patients with cyclin D1‐positive carcinomas showed significantly worse overall survival than patients with cyclin D1‐negative carcinomas, both in univariate (p = 0.0016) and in multivariate survival analyses (p = 0.0038). Expression of cyclin D1 in carcinomas with multimodal treatment was correlated with poor response to chemotherapy (p = 0.026) but not with overall survival. We thus consider expression of cyclin D1 to be an important parameter, predicting an unfavorable overall survival of surgically treated esophageal cancer patients. Int. J. Cancer (Pred. Oncol.) 84:86–91, 1999.

bcl-2 expression and prognosis in squamous-cell carcinomas of the esophagus

The bcl‐2 proto‐oncogene is a known inhibitor of apoptosis and may be an important regulator of tumor growth. In the present study, bcl‐2‐protein expression was investigated by immunohistochemistry and correlated with prognosis in a series of 150 potentially curatively resected squamous‐cell carcinomas of the esophagus. For comparison bcl‐2‐protein expression was analyzed in normal esophageal mucosa, severe squamous dysplasias and carcinomas in situ. bcl‐2 immunoreactivity was found in 48 out of 150 invasive squamous‐cell carcinomas; the remaining carcinomas were completely negative. bcl‐2‐protein expression was found more frequently among poorly differentiated than among well‐differentiated tumors (p < 0.0001). No correlation was found between bcl‐2‐protein expression and the parameters tumor size, depth of invasion and nodal status. Moreover bcl‐2‐protein expression had no significant influence on overall survival. Whereas in normal mucosa bcl‐2 immunoreactivity was restricted to the basal‐cell layer, in 9 out of 15 severe squamous dysplasias and in 7 out of 14 carcinomas in situ bcl‐2 staining was detected in all epithelial layers. Thus bcl‐2‐protein is frequently expressed in invasive squamous‐cell carcinomas of the esophagus and in precursor lesions of esophageal cancer but has no significant impact on the outcome of esophageal cancer.

Carcinoma of the hypopharynx and the cervical oesophagus: a surgical challenge.

OBJECTIVE To report our results after reconstruction of the upper digestive tract for locally advanced carcinoma of the hypopharynx and cervical oesophagus. DESIGN Open study. SETTING Teaching University hospital, Germany. SUBJECTS Of the 517 patients who presented with carcinoma of the oesophagus between September 1985 and March 1997, 16 had a locally advanced tumour of the hypopharynx and 25 of the cervical oesophagus. INTERVENTIONS Free jejunal grafts were used after circular resection in all patients with carcinoma of the hypopharynx, and for the 3 with oesophageal carcinoma in whom we obtained adequate resection margins. In the remainder stomach was used in 21 and colon in 1. MAIN OUTCOME MEASURES Morbidity and mortality. RESULTS After jejunal grafting 1 patient died within 30 days and 2 died in hospital. After gastric or colonic reconstruction 2 patients died within 30 days and 4 in hospital. There was 1 anastomotic leak, 1 transplant became necrotic and had to be replaced, in 2 patients the recurrent nerve was damaged, 1 patient developed a wound infection and 1 a cardiac infarction. After gastric or colonic replacement 7 patients had paralysed recurrent laryngeal nerves, there was 6 anastomotic leaks, 1 chylous leak, 1 haemorrhage, and in 1 the transplant necrosed. CONCLUSION Despite the fact that we compared tumours in different sites, these results suggest that the jejunal graft is safer for upper oesophageal and hypopharyngeal reconstruction.

Expression of Bax, a pro‐apoptotic member of the Bcl‐2 family, in esophageal squamous cell carcinoma

Samples of normal esophageal squamous epithelium (n = 10), severe squamous cell dyplasia (n = 22), carcinoma in situ (n = 15), invasive squamous cell carcinoma (n = 172), lymph‐node metastasis (n = 21) and 2 permanent esophageal squamous cell carcinoma cell lines were analyzed immunohistochemically for Bax expression using a polyclonal anti‐Bax antibody. Immunostaining was evaluated according to a score system (0–8 points) based on the percentage of positive tumor cells and the relative immunostaining intensity. Cytoplasmatic staining for Bax protein was found uniformly in all cell layers of the normal esophageal squamous epithelium. In contrast, a gradual loss of immunoreactivity for Bax was found in a fraction of pre‐neoplastic and neoplastic lesions. Upon comparison of the amount of Bax expression between the different types of lesion, however, no significant differences were found between severe squamous cell dysplasias, carcinomas in situ, invasive carcinomas and lymph‐node metastases. In both esophageal carcinoma cell lines, immunoreactivity for Bax was found and confirmed by means of Northern blot analysis. In invasive carcinomas, Bax immunoreactivity was inversely correlated with Bcl‐2 expression (p = 0.0243) and decreased continuously with decreasing tumor differentiation (p = 0.0011). No correlation was found between Bax expression and the following parameters: depth of invasion, nodal status and tumor size. Bax expression had no influence on the post‐operative survival of esophageal cancer patients. Int. J. Cancer 73:508–513, 1997.

Bcl-2 upregulation after 3-nitropropionic acid preconditioning in warm rat liver ischemia.

We aimed to determine whether 3-nitropropionic acid (3-NPA) preconditioning protects rat livers against warm ischemia/reperfusion injury. We hypothesized that 3-NPA mediates its protective effects by Bcl-2 upregulation. Brown-Norway rats (200 g) were injected with 3-NPA (10 mg/kg intraperitoneally) 24 h before 90 min of selective warm in situ ischemia. In additional experiments, 30-day survival was studied after 90 min of warm liver ischemia and resection of nonischemic liver tissue. We demonstrate increased mRNA and protein levels of Bcl-2 by real-time polymerase chain reaction, immunohistochemistry, and Western blot analysis in 3-NPA-pretreated rats. All treated animals survived, whereas all untreated rats died within 3 days after selective ischemia and resection of the nonischemic tissue. This corresponded well with a significant decrease of caspases 3 and 9 activity at 1 h of reperfusion after preconditioning with 3-NPA as compared with untreated rats. The histological sections showed protection of liver tissue after 3-NPA by reduction of apoptotic and oncotic tissue damage. Lipid peroxidation in liver tissue was reduced after 3-NPA preconditioning. We show that subtoxic doses of the mitochondrial toxin 3-NPA induces tolerance to warm liver ischemia in rats associated by synthesis of Bcl-2. Bcl-2 upregulation might protect against the postischemic burst of reactive oxygen species and therefore reduces apoptotic- and oncotic-related cell death.

Leitlinien zur Therapie des Oesophaguskarzinoms

Fur die Wahl des operativen Vorgehens beim Oesophaguskarzinom ist die Lokalisation (supra-, infra-, bifurkal) sowie das Tumorstadium entscheidend. Voraussetzung fur ein Vorgehen mit kurativem Ziel ist die vollstandige Tumorentfernung (R0-Resektion). Thorakale Plattenepithelkarzinome werden adaquat in der Regel durch eine abdomino-thorakale Resektion mit abdomineller und mediastinaler Lymphknotendissektion behandelt. Die transmediastinale Dissektion erfullt nicht die Anspruche eines radikalchirurgischen Eingriffs und ist nur unter besonderen Bedingungen indiziert. Distale Adenokarzinome (Barrett-Karzinom) konnen sowohl transthorakal wie transhiatal radikal behandelt werden. Adjuvante Methoden nach RO-Resektion bei Oesophaguskarzinom sind derzeit auserhalb von Studien nicht indiziert. Neoadjuvante Masnahmen bei lokal fortgeschrittenen Tumoren befinden sich in der Erprobung.

Leberstoffwechsel während kalter ischämischer Inkubation in UW-Lösung am Rattenmodell

Simple cold storage of livers for transplantation activates glycolysis due to lack of oxygen. Energy derived from glycolysis may be critical for cell survival and liver cell death may occur once glycolysis is inhibited in the liver due to accumulation of end products or lack of substrates (glycogen). The relationship between cell death (lactate dehydrogenase, LDH release), anaerobic glycolysis (lactate production), and glycogen content of liver tissue was studied during cold incubation of liver slices in UW solution. Rat livers slices from male Sprague Dawley rats were incubated at 4°C in UW solution, with continuous gentle shaking, under conditions of chemical hypoxia (KCN, 5 mM). The rate of lactate production, LDH release, ATP and glycogen content were measured spectrophotometrically and by HPLC. Lactate increased nearly linearly for the first 48 h of incubation; total lactate which had accumulated after 48 h was 33.9±0.81 µmol/g and at 96 h nearly the same, 31.3±1.2 µmol/g. Glycolysis stopped, apparently, because of the depletion of liver slice glycogen which was initially 228.8±1.7 µmol/g wet wt. It decreased to 34.7±2.7 µmol/g at 48 h and to 18.7±1.1 µmol/g at 72 h and remained at this level for the next 24 h. An increased leakage of LDH occurred once glycogen metabolism (and accumulation) ceased. LDH release could be stimulated after only a few hours of cold incubation of liver tissue slices by adding glycolysis inhibitor (iodoacetic acid) to the medium. After 24 h, LDH release was 24.4±1.8% and increased to 52.8±5.2% (P<0.05, Studentst-test) with iodoacetic acid. Adding a glycolytic substrate (fructose, 10 mM) to the medium maintained lactate production for 96 h. The stimulation of glycolysis by fructose also reduced cell death: LDH release was significantly lower at 72- and 96-h incubation (P<0.001, two-way ANOVA). The ATP content was significantly higher with fructose (P<0.001). Adding glucose (20 mM) and fructose (10 mM) in combination resulted in prolonged cell survival, significantly delayed glycogen depletion and significantly higher ATP content at 48 and 72 h (two-way ANOVA). Livers from rats who had fasted for 24 h demonstrated the same LDH release at 48 h when incubated with glucose (20 mM) and fructose (10 mM). In conclusion, LDH leakage from hypoxic cold-stored liver slices is related to anaerobic glycolysis. Anaerobic glycolysis appears to continue slowly under hypothermia and provides sufficient energy for maintenance of cell viability. A stimulation of glycolysis in the cold is possible by fructose and results in prolonged cell survival under hypothermic conditions. Glycogen depletion can be slowed down by combining glucose and fructose.ZusammenfassungDie Lagerung von Transplantationslebern in kaltem Medium führt zur Aktivierung der Glykolyse aufgrund des Sauerstoffmangels. Die glykolytische Energie ist möglicherweise entscheidend für das Überleben der Zelle, und Leberzellen sterben möglicherweise ab, sobald die Glykolyse aufgrund der Anhäufung von Endprodukten oder Mangel an Substrat (Glykogen) inhibiert wird. Die Zusammenhänge zwischen Zelltod (LDH-Freisetzung), anaerober Glykolyse (Laktatproduktion) und dem Glykogengehalt von Lebergewebe wurden an Leber-Slices, die in kalter UW-Lösung inkubiert wurden, untersucht. Rattenleber-Slices von männlichen Sprague-Dawley-Ratten wurden bei 4°C inkubiert. Der Gesamtlaktatwert betrug nach 48 h 33,9±0,81 µmol/g und nach 96 h 31,3±1,2 µmol/g. Der ursprüngliche Glykogengehalt von 228,8±1,7 µmol/g Feuchtgewicht nahm auf 34,7±2,7 µmol/g nach 48 h und 18,7±1,1 µmol/g nach 72 h ab und blieb die nächsten 24 h bei diesem Wert. Eine zunehmende LDH-Freisetzung trat auf, sobald der Glykogenmetabolismus zum Erliegen kam. Die LDH-Freisetzung konnte nach wenigen Stunden Inkubation in kaltem Medium durch Zugabe von Glykolyseinhibitoren (Jodessigsäure) zum Medium stimuliert werden. Nach 24 h betrug die LDH-Freisetzung 24,4±1,8% und stieg auf 52,8±5,2% (p<0,05, Student-t-Test) nach Zugabe von Jodessigsäure. Nach Zugabe eines glykolytischen Substrats zum Medium (Fruktose 10 mM) wurde die Laktatproduktion für 96 h aufrechterhalten. Die Stimulation der Glykolyse durch Fruktose reduzierte auch die Rate an Zelltod: Die LDH-Freisetzung war nach 72 h und 96 h Inkubation signifikant geringer als bei Zellen, die ohne Fruktose inkubiert worden waren (p<0,001, Two-way-ANOVA). Der ATP-Gehalt lag in den Ansätzen mit Fruktosezugabe ebenfalls signifikant höher (p<0,001). Die Zugabe von Glukose (20 mM) und Fruktose (10 mM) gemeinsam resultierte in einer verlängerten Zellüberlebenszeit, signifikant erniedrigtem Glykogenverbrauch und signifikant höherem ATP-Gehalt nach 48 und 72 h (Two-way-ANOVA). Lebern von Ratten, die 24 h gehungert hatten, zeigten über 48 h dieselbe LDH-Freisetzung, wenn sie mit Glukose (20 mM) und Fruktose (10 mM) inkubiert wurden. Daraus läßt sich schließen, daß die LDH-Freisetzung aus hypoxischen Leber-Slices, die in kalter Lösung inkubiert wurden, mit der anaeroben Glykolyse zusammenhängt. Die anaerobe Glykolyse scheint auch während der Hypothermie, allerdings langsam, abzulaufen und genügend Energie für die Aufrechterhaltung der Lebensfähigkeit der Zellen bereitzustellen. Die Stimulation der Glykolyse bei gekühlten Zellen ist durch Fruktose möglich und resultiert in einer verlängerten Überlebenszeit der Zellen unter hypothermen Bedingungen. Die Glykogenentleerung kann durch die Kombination von Glukose-und Fruktosezugabe verlangsamt werden.

Systematische klinikinterne Qualitätssicherung in der Chirurgie

Summary. Between April 1993 and December 1995 the perioperative courses of 3183 patients were recorded within the frame work of a quality assurance project at the Department of Surgery, University of Mainz. The age of the operated patients and the rate of morbidity increased significantly during the observation period. Morbidity and mortality were not correlated to increasing need for intensive care. Morbidity was dependent on the surgical approach and also on the surgeon. On the other hand, high numbers of operations did not necessarily correlate with low complications rates. The concept described makes it possible to compare quality assurance among different hospitals, helps surgeons to recognize and improve their weak points, and serves as an additional method for monitoring the quality of treatment in the clinic.Zusammenfassung. An der Klinik und Poliklinik für Allgemein- und Abdominalchirurgie der Johannes Gutenberg-Universität Mainz wurden im Rahmen eines Programms zur systematischen klinikinternen Qualitätssicherung zwischen dem 1. 4. 1993 und 31. 12. 1995 3183 Patienten und deren perioperativer Verlauf erfaßt. Es zeigte sich eine signifikante Zunahme des Alters und der Morbidität der operierten Patienten. Bei Zunahme der Notwendigkeit intensivmedizinischer Maßnahmen blieben Morbidität und Letalität gleich. Die postoperativen Komplikationsraten waren abhängig von der Art und der Dringlichkeit des Eingriffs und schwankten bei den einzelnen Operateuren. Hohe Operationszahlen bedeuteten nicht immer niedrige postoperative Komplikationsraten. Das Konzept erlaubt den Qualitätsvergleich mit anderen Institutionen, hilft dem einzelnen Operateur Schwachpunkte zu erkennen und zu beseitigen und ist als ergänzendes Instrument zur Qualitätskontrolle und Qualitätsverbesserung geeignet.

Beeinflussung des Leberzellmetabolismus, der Freisetzung von reaktiven Sauerstoffspezies sowie Apoptoseaktivierung durch hypotherme oxygenierte Leberperfusion

Two different methods of liver preservation were compared : simple cold storage (CS) and hypothermic oxygenated perfusion extracorporal (HOPE). After 10 h of preservation (4°C) with modified UW solution reperfusion was performed by isolated liver perfusion for 90 minutes. Reperfusion injury was estimated by release of cytosolic enzymes, formation of superoxide anions, determination of lipid peroxidation, glycolytic metabolites, bileflow and by PCR analysis. The results showed that after cold storage the formation of reactive oxygen species was significant higher as compared with perfused livers. Correspondingly expressions of mediators (TNFα, NF kappa B, MIP-2, SAPK) and apoptosis (Caspase 9, bax, bak) were detected after CS and were not detectable after HOPE. Additional experiments demonstrated that a short period of hypothermic oxygenation following cold storage (10hCS + 3hHOPE) also could prevent mediator and apoptosis activation. Thus preconditioning of cold injured livers by HOPE is suggested.