Paolo Magistrelli

Gastrointestinal Sutureless Anastomosis Using Fibrin Glue: Reinforcement of the Sliding Absorbable Intraluminal Nontoxic Stent and Development of a Stent Placement Device

Sutureless anastomosis of the gastrointestinal tract using fibrin glue and sliding absorbable intraluminal nontoxic stents (SAINTs) has two shortcomings, stent shaft breakage and the lack of a transanal insertion device (TID) for low anterior resection. Reinforcement of the sucrose base SAINT (R-SAINT) is described. Sutureless anastomosis is attempted using a stapleless mechanical stapler (SS) and used as preprototype to screen histologically and mechanically for TID anastomoses in the small intestine. Finally, a prototype absorbable head SAINT placement device (SAINT-PD) intended for TID, similar to the SS, is utilized on the small intestine. Fifty-seven Landrace pigs weighing 25-35 kg were used to perform 58 anastomoses, including the small intestine (15 manual, 19 SAINT, 11 SS, 5 R-SAINT, 6 SAINT-PD) and large intestine (2 R-SAINT). All anastomoses performed with the R-SAINT succeeded on the first attempt even if the shaft cracked. The SS technique proved impractical, but the histological screen results from 7 to 60 days did approximate those of corresponding SAINT anastomoses. The SAINT-PD demonstrated operational improvement over the SS, but the histological results were similar to both the SS and SAINT. The advantages of the R-SAINT and SAINT-PD are that they leave no foreign bodies or pressure clamping devices at the anastomostic site. Larger studies may show the R-SAINT and the SAINT-PD to be practical, new surgical tools in sutureless fibrin glue anastomosis.

A case–control study on the effect of p53 and p73 gene polymorphisms on gastric cancer risk and progression

The p53 protein and its functional homologue p73 share several functions in modulating cell-cycle control and apoptosis. Based on the functional interaction between p53 and p73 in carcinogenesis, we investigated the combined effect of p73 G4C14-to-A4T14 and p53 gene polymorphisms and their interaction with selected environmental factors, on the risk for gastric cancer in a hospital-based case-control study conducted in Italy. The effect of these polymorphisms on cancer progression was also investigated. One hundred and fifteen gastric cancer cases and 295 hospital controls were genotyped for p73 G4C14-to-A4T14, and p53 exon 4 (Arg72Pro), intron 3 and intron 6 polymorphisms. An increased risk for gastric cancer was found to be associated with the inheritance of the p73 homozygous variant genotype among the gastric cancer intestinal histotype (odds ratio (OR)=6.75; 95% confidence interval (95% CI)=1.88-24.24). An effect modification of the p73 variant allele by gender was observed [(OR=2.82; 95%CI=1.24-6.40) among females, versus an OR of 0.70 (95%CI=0.32-1.54) among males; p-value for homogeneity among strata estimates =0.03]. Gene-gene interaction analyses demonstrated that individuals with combined p53 exon 4 and intron 6 variant alleles are borderline significantly protected from gastric cancer (OR=0.52; 95% CI=0.26-1.07; p-value for interaction =0.005), which was confirmed by the haplotype analysis. Finally, a poorer survival was observed among carriers of the variant allele of p53 intron 6 if compared with those carrying both wild-type alleles (p-value for log-rank test =0.02). This study shows that the p73 G4C14-to-A4T14 polymorphism may be a risk factor for gastric cancer, as reported from other studies in different tumour sites among Caucasians. Along with the protective effect of p53 exon 4-intron 6 allelic variants, already noted for breast and lung cancer, our results require confirmation from larger studies.

Methylenetetrahydrofolate reductase C677T and A1298C polymorphisms and susceptibility to gastric adenocarcinoma in an Italian population

Abstract Methylenetetrahydrofolate reductase (MTHFR) plays a central role in the metabolism of folate, which provides a methyl donor for DNA methylation and deoxynucleoside synthesis. We performed a case–control study to explore the relationship between two common MTHFR polymorphisms (C677T and A1298C), their combination and interaction with environmental exposures, on gastric adenocarcinoma susceptibility and progression in an Italian population. One hundred and two cases and 254 hospital controls, matched by age and gender, were enrolled. Individuals carrying the MTHFR 677T allele showed an increased risk of gastric cancer (odds ratio (OR) 1.62, 95% confidence interval (CI) 0.98–2.67), particularly among ever smokers (OR 2.10, 95% CI 1.07–5.33) and, among 677 TT individuals, those with a low intake of fruit and vegetables (OR 2.18, 95% CI 1.05–4.54). The strongest effect, however, was noted for the MTHFR 677 TT genotype among the diffuse gastric cancer histotype (OR 2.92, 95% CI 1.12–7.60). No association was detected for the effect of MTHFR A1298C polymorphism. Survival analysis did not show any association between each polymorphism on the overall survival, although when the analysis was restricted to the first year of follow-up after the surgical intervention an improved survival was noted among MTHFR 677 CC subjects compared with the T allele carriers (p value for log-rank test 0.02). In conclusion, MTHFR 677 (any T genotype) appears to modulate an individuals susceptibility to gastric cancer, particularly when combined with cigarette smoking and among those with a low intake of fruit and vegetables. Our results also suggest that an aberrant DNA methylation pattern, through impaired folate metabolism, might play a key role in gastric carcinogenesis. A possible survival effect of the MTHFR C677T genotype in gastric cancer patients deserves further investigations with larger sample sizes.

Human equilibrative nucleoside transporter 1 (hENT1) protein is associated with short survival in resected ampullary cancer

BACKGROUND Gemcitabine is an acceptable alternative to best supportive care in the treatment of advanced biliary tract cancers. The human equilibrative nucleoside transporter 1 (hENT1) is a ubiquitous protein and is the major means by which gemcitabine enters human cells. Moreover, recent reports indicate a significant correlation between immunohistochemical variations of hENT1 in tumor samples and survival after gemcitabine therapy in patients with solid tumors. MATERIALS AND METHODS We used immunohistochemistry to assess the abundance and distribution of hENT1 in tumor samples from radically resected cancer of the ampulla, and sought correlations between immunohistochemical results and clinical parameters including disease outcomes. RESULTS In the 41 individual tumors studied, 12 (29.3%) had uniformly high hENT1 immunostaining. Statistical analysis showed a significant correlation between hENT1 and Ki-67 (P = 0.04). No statistical significant differences were found between immunohistochemical findings and patient characteristics (sex, age, and tumor-node-metastasis). On univariate analysis, hENT1 and Ki-67 expression were associated with overall survival (OS). Specifically, those patients with overexpression of hENT1 showed a shorter OS (P = 0.022) and those with high Ki-67 staining showed a shorter survival (P = 0.05). CONCLUSIONS hENT1 expression is a molecular prognostic marker for patients with resected ampullary cancer and holds promise as a predictive factor to assist in chemotherapy decisions.

Concomitant preoperative radiochemotherapy in operable locally advanced rectal cancer

PURPOSE: The aim of this study was to examine the effectiveness of a combination of preoperative radiotherapy and chemotherapy for operable locally advanced rectal cancer (Stages II and III). METHODS: Chemotherapy and radiotherapy are started jointly on day one of the therapy. 5-Fluorouracil is given in a dosage of 1000 mg/ m2/day as a continuous 24-hour infusion for 4 days. Mitomycin C is given as a bolus intravenous at a dosage of 10 mg/m2 the first day. The radiation therapy is given to a total dosage of 37.8 Gy. Surgery is generally performed four to five weeks following completion of the radiation therapy. From March 1990 to April 1993, 34 patients with histologically documented adenocarcinoma of the rectum have been treated. Twenty-one lesions were located in the lower third of the rectum. Twenty-nine neoplasms were judged by initial clinical staging as Stage III. RESULTS: Patients compliance to the treatment have been 97 percent. Toxicity of treatment has been low (15 percent). Tumor sizes decreased 50 percent or more in about 80 percent of patients. Distance of the tumor from the anal canal increased in all but seven cases. Twenty-two anterior resections have been performed. The morbidity rate has been 24 percent. No postoperative mortality has been reported. Histologic examination of surgical specimens after integrated treatment showed in 10 cases a tumor confined to the rectal wall (T2), in 3 patients only a residual tumor limited to submucosa (T1), and in 5 (15 percent) patients no evidence of neoplastic cells (T0). CONCLUSIONS: We conclude that preoperative radiochemotherapy was generally well tolerated; in all cases we had a reduction of tumor sizes, surgery presented no technical difficulties, and there was the effect of stage reduction.

COX-2 expression of ampullary carcinoma : correlation with different histotypes and clinicopathological parameters

Epidemiological studies suggest that regular intake of nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with reduced incidence of gastrointestinal cancer. Several lines of evidence indicate that the antineoplastic effect of NSAIDs is attributable to COX-2 inhibition. The aim of our study was to assess COX-2 expression in a series of primary untreated ampullary carcinomas and its possible correlation with clinicopathological parameters. In the present study, 45 surgical specimens of invasive ampullary carcinomas were histologically classified into pancreaticobiliary, intestinal, and unusual types. COX-2 expression by immunohistochemical method was analyzed. High COX-2 expression was detected in 35 (77.8%) ampullary carcinomas. Among these, 20/21 (95.2%) were classified as intestinal, 9/18 (50%) pancreaticobiliary, and 6/6 (100%) unusual type. A significant statistical difference in terms of COX-2 expression was found between pancreaticobiliary vs intestinal type (P=0.002). Furthermore, a negative significant statistical correlation was found between T factor and COX-2 expression (P=0.047). The different COX-2 expression among histopathological types supports the concept of histogenetical difference of ampullary carcinomas. Furthermore, the high rate of COX-2 expression in the intestinal subtype of ampullary carcinoma may represent the rational for a histotype-tailored therapy targeting COX-2.

K-ras mutations in circulating DNA from pancreatic and lung cancers: bridging methodology for a common validation of the molecular diagnosis value.

To the Editor: In their article, BLow Correspondence Between K-ras Mutations in Pancreatic Cancer Tissue and Detection of K-ras Mutations in Circulating DNA,[ Marchese et al reported that there was no change in the early diagnosis, by serological markers, of pancreatic cancer. Furthermore, they suggested that K-ras mutation in serum is an unsatisfactory method. In particular, they did not observe matching between K-ras mutations in neoplastic tissue samples and in circulating DNA samples (70%). The same authors reported previously the same statement in a letter in reply to Maire et al. Maire et al stated that the sensitivity, specificity, and positive and negative predictive values of serum KRAS2 mutations for the diagnosis of pancreatic cancer were 47%, 87%, and 85% and 52%, respectively. However, Dabritz et al in a review published in recent times, by analyzing different studies from 9 different laboratories, concluded that the detection of mutated KRAS2 in patients with colorectal and pancreatic cancer was potentially promising, and the possible usefulness of KRAS2 as a clinically important tumor marker should encourage future research. In a newest but preliminary work, Dabritz et al by means of peptide nucleic acidYmediated polymerase chain reaction (PCR; using wild-type peptide nucleic acid with realtime PCR using specific hybroprobes) detected K-ras mutations in tissue and plasma samples of patients with pancreatic cancer with a very high sensitivity. In our experience on nonYsmall cell lung cancer (NSCLC), K-ras status in circulating DNA appears not to be univocally correlated with DNA from tumor tissue; thus, discordant results were obtained in 22 lung cancer patients after extraction of DNA from both plasma and tissue. These results are in agreement with those reported by Marchese et al in pancreas cancer patients. Both two experiences suggested that the detection of K-ras mutations in plasma DNA in its present form is not appropriate to confirm or screen for pancreatic and/or NSCLC. More sensitive and/or quantitative PCR test, such as the one used by Dabritz et al, may improve the molecular diagnosis, at least for pancreas and lung cancer. Similar conclusions were also reported by Trumper et al who tested K-ras for diagnosing pancreatic cancer from pancreatic juice and bile. Moreover, we observed that serum K-ras was mutated also in as much as 30.0% of 40 noncancer hospital controls, while it was wild-type in 100% of 10 young healthy volunteers (Table 1). Similar findings are reported in the literature, and many reasons may be hypothesized. Looking carefully at the Table 8 reported in the review of Sorenson, it appears that the number of plasma from normal individuals is very few (57 subjects in 9 different laboratories), and only 1 study analyzed 28 subjects; this suggests that the falsepositive rate of ~2.5% estimated by Sorenson might be not correct. Our suggestion is that molecular markers need rigorous testing before being introduced into the common clinical practice, and the choice of control group in such test series is an extremely delicate procedure, and more robust experiments have to be designed. Furthermore, methodological harmonization in different types of cancer could translate knowledge and experience for the sake of economy, efficiency, and translational power.

Promyelocytic leukemia (PML) gene expression is a prognostic factor in ampullary cancer patients

BACKGROUND Promyelocytic leukemia (PML) tumor suppressor gene plays a key role in acute PML pathogenesis but its involvement in pathogenesis and prognosis of solid cancers has not been defined yet. PATIENTS AND METHODS In all, 62 ampullary adenocarcinoma patients who underwent curative surgery between 1996 and 2005 were included. Expression analysis of PML was carried out by immunohistochemical staining and correlated with disease-free survival (DFS) and overall survival (OS). RESULTS In 24 tumor specimens (38.7%), PML was classified as absent, in 16 (25.8%) as focally expressed and in 22 (35.5%) as diffusely expressed. By univariate analysis, DFS was significantly influenced by pathological T stage (P=0.03), lymph nodal involvement (P=0.002), and PML expression (P=0.001). DFS in patients without PML expression was 28.0 months versus 45.1 and 75.5 for patients with focal and diffuse expression, respectively. OS in the group of patients without PML expression, with focal expression, and with diffuse expression was 40, 48, and 77 months, respectively (P=0.002). By a multivariate analysis, PML expression was the strongest prognostic factor for DFS (P=0.003) and the only statically significant prognostic factor for OS (P=0.009). CONCLUSIONS Our preliminary data suggest PML as a novel prognostic tool for ampullary cancer patients.

Cavernous hemangioma of the gallbladder. Case report and review of the literature.

Hemangiomas are common benign tumors; they frequently occur in the liver but very rarely in the gallbladder, with only seven cases reported in the scientific literature to date. We here report an additional patient, a 49-year-old white woman presenting with an echogenic lesion of the gallbladder that was incidentally discovered. Cholecystectomy was performed after computed tomography had revealed a gallbladder neoplasm; pathological examination showed the mass to be a cavernous hemangioma. No postoperative complications occurred and the patient is alive and free of recurrence five years after the operation. We present a review of the literature on this topic with special emphasis on the diagnostic and therapeutic challenges these lesions may entail. Hemangiomas of the gallbladder may have extremely variable presentations (from non-specific abdominal pain to acute syndromes resembling cholangitis or choledocholithiasis) and can mimic different lesions (liver tumors, sarcoma). Only surgical exploration can provide a correct diagnosis. Excision is indicated as these lesions may grow to huge sizes, compress adjacent structures or bleed. Conclusions Gallbladder hemangiomas are uncommon benign tumors. A preoperative diagnosis is difficult to make. Surgical excision is mandatory both in reaching a final diagnosis and in preventing bleeding or compression of vital structures.

Radiofrequency Thermal Ablation (RFA) of Liver Tumors: Open Surgical or Percutaneous Approach?

Summary RFA was used to ablate 81 liver lesions: 61 liver metastases and 20 hepatomas. An open surgical approach was adopted in 19 instances (27.5%), 12 of which were simultaneously treated for associated diseases, and percutaneous treatment was adopted in 50 instances (72.5%). The CT liver control at 6 months showed a complete necrosis in 50 lesions (66.3%). The advantages of the percutaneous approach include less invasiveness, reduced postoperative pain, shorter hospitalization, reduced costs and less discomfort in repeating the procedure. In conclusion, radiofrequency liver nodule ablation could be considered, today, as one of the promising and versatile techniques for loco-regional liver cancer control.