Riad Haddad

Microsatellite Instability as a Prognostic Factor in Resected Colorectal Cancer Liver Metastases

Background: Two distinct genetic mutational pathways characterized by either chromosomal instability or high-frequency microsatellite instability (MSI-H) are currently recognized in the pathogenesis of colorectal cancer (CRC). Recently, it has been shown that patients with primary CRC that displays MSI-H have a significant, stage-independent, multivariate survival advantage. Untreated CRC hepatic metastases are incurable and are associated with a median survival of 4 to 12 months. Conversely, surgical resection in selected patients results in a 20% to 50% cure rate. The aim of this study was to investigate the prognostic importance of MSI-H in patients undergoing resection of hepatic CRC metastases.Methods: DNA was extracted from paraffin-embedded, resected metastatic CRC liver lesions and corresponding normal liver parenchyma from 190 patients. MSI-H status was determined by polymerase chain reaction–based evaluation of the noncoding mononucleotide repeats BAT-25 and BAT-26.Results: MSI was detected in tumors from 5 (2.7%) of the 190 CRC patients. All MSI-H tumors were in patients with node-positive CRC primary tumors. The median survival after hepatic resection of MSI-H and non–MSI-H tumors was 67 and 61 months, respectively (P = .9).Conclusions: These data suggest that MSI-H is not a common feature in resected CRC liver metastases and do not suggest a role for MSI in stratifying good versus poor prognosis in these patients.

Photodynamic therapy of colorectal cancer using a new light source : From in vitro studies to a patient treatment

PURPOSE: Photodynamic therapy (PDT) is a relatively new alternative modality for palliation of rectal cancer. Current source of light for PDT are laser systems that are expensive and not necessarily needed for PDT. We evaluated a new nonlaser light source for PDT, Versa-Light®.METHODS AND RESULTS:In vitroPDT—CT26 murine colon carcinoma cells were incubated with aluminum phthalocyanine (AlPcS4) for 48 hours and subjected to photoradiation using Versa-Light®,and viability was assessed. There was a significant decrease in viability of treated cells compared with controls.In vivoPDT—BALB/c mice were injected either subcutaneously or intrarectally with CT26 cancer cells. IP AlPcS4(2.5 mg/kg) was injected when tumors were visible. After 24 hours, mice were subjected to photoradiation. Massive tumor necrosis in response to PDT was observed. PDT also prolonged survival of treated mice. Patient treatment—A 70-year-old woman with recurrent local rectal carcinoma received intravenous Photofrin II®(2 mg/kg). After 48 and 96 hours, she was subjected to direct photoradiation. After the first light session, there was complete macroscopic disappearance of the tumor. Biopsies up to 10 weeks after the treatment showed no cancer cells in the treated area. Sixteen weeks later, a randomized biopsy from previous tumor site showed carcinoma cells. CONCLUSIONS: We believe that Versa-Light®,is a good light source for PDT. It was effective in bothin vitroand animal studies. It can also be safely used for clinical PDT.

In vitro and in vivo effects of photodynamic therapy on murine malignant melanoma

AbstractBackground: The role of photodynamic therapy (PDT) in the treatment of malignant melanoma is not well defined, nor is it known whether the dark melanoma cells absorb the light used in PDT. Methods:In vitro studies: 2×105 B16 murine melanoma cells were incubated with aluminum phthalocyanine (AlpcS4, 2.5 mg/kg) and were then subjected to photoradiation (50, 100 or 200 J/cm2). Viability was then assessed.In vivo studies: Histology: C57/B1 mice received 2×105 B16 cells subcutaneously and were randomized into study (PDT) and three control groups. AlpcS4 2.5 mg/kg was injected intraperitoneally and the mice were exposed to light (100 J/cm2). After 24 hours they were sacrificed and underwent autopsies. Survival: 40 mice were randomized into PDT (40 J/cm2) and control groups and were monitored for 50 days. Tumor growth: 40 mice were randomized into one control and three treatment groups (PDT on day 3, 6, or 12 after injection with B16 cells), and were monitored for 50 days. Temperature: Tumor temperatures before and at the end of PDT were recorded. Results:In vitro studies: PDT caused a decrease in cell viability to 15.5±0.7%, 11.5±2.1%, and 1.5±0.7% (at 50, 100, and 200 J/cm2, respectively;P<.001). A significant reduction in thymidine incorporation was noted at all energy levels.In vivo studies: Histology: PDT caused massive tumor necrosis. Survival: PDT prolonged the survival of mice (41±13.4 days) compared to controls (15.8±3.8 days,P<.001). Tumor growth: 31 days after injection with B16 cells, the tumor size was 2.6±0.3 cm in the control group and 1.6±0.2, 0.9±0.3, and 1.0±0.4 cm in the PDT groups (days 3, 6 and 12, respectively;P<.01). Temperature: PDT increased skin temperature to 42.8°C±1.3°C, 45.3°C±3.5°C, and 51.7°C±2.7°C at 40, 60, and 100 J/cm2, respectively (P<.01). Conclusions: Photodynamic therapy was found to have significant effects in experimental melanoma in mice. The role of PDT in human melanoma remains to be studied.

Photodynamic therapy of cancer of the esophagus using systemic aminolevulinic acid and a non–laser light source: a phase I/II study

Abstract Background: Surgery is the mainstay for the treatment of carcinoma of the esophagus and is also considered to be effective for palliation of dysphagia. Patients who are unfit for surgery represent a difficult therapeutic problem. The goal of the present study was to evaluate the effects of photodynamic therapy by using systemic administration of 5-aminolevulinic acid and a non–laser light source on carcinoma of the esophagus. Methods: Patients were given 60 mg/kg 5-aminolevulinic acid orally. Twenty-four hours later gastroscopy was performed. After initial localization of the tumor with the use of white light, the light source was switched to the red light band at 100 J/cm 2 for 600 seconds. Gastroscopy was repeated at 48 hours and 7 days after the treatment. The degree of dysphagia was recorded before and 14 days after treatment. Results: Five patients with advanced nonresectable tumors or who were unfit for surgery were treated. Two patients had squamous cell carcinoma of the mid-esophagus and three had adenocarcinoma of the distal esophagus. Mild self-limiting photosensitivity was noted in all patients. Liver and renal function tests as well as hemoglobin level and white blood cell count were not affected by the treatment. Improvement of dysphagia was observed in four patients who had pretreatment dysphagia. The patient with the early stage of disease continued to eat a normal diet. Conclusions: Photodynamic therapy with systemic aminolevulinic acid as a photosensitizer and a non–laser light source is feasible and safe in advanced-stage esophageal cancer. It can be an effective modality for the relief of dysphagia in these patients.

Immunoguided Lymph Node Dissection in Colorectal Cancer: A New Challenge?

AbstractKnowledge of lymphatic involvement in patients with colorectal cancer is important in surgery and in the postoperative decision-making process. Fifty-eight patients with recurrent colorectal cancer underwent operation with the RIGS® (Radioimmunoguided Surgery) technology. Preoperatively, patients were injected with 1 mg monoclonal antibody (MoAb) CC49 (anti-TAG-72-tumor-associated glycoprotein) labeled with 2 mCi of iodine 125. Traditional surgical exploration was followed by survey with a gamma-detecting probe. Localization of MoAb on tumor was noted in 54/58 patients (93%). Traditional exploration identified 117 suspected tumor sites. With RIGS, 177 suspected tumor sites were detected. In 17 of the 58 patients (27.5%), at least one occult tumor site identified by RIGS was confirmed by pathology with hematoxylin & eosin (H & E) staining. This finding resulted in 16 major changes in surgical plan. RIGS performance varied between lymphatic and non-lymphatic tissue, with a positive predictive value (PPV) of 95.6% and negative predictive value (NPV) of 90% in non-lymphoid tissue compared to PPV of 40% and NPV of 100% in lymphoid tissue. In patients with tumors that localize, no RIGS activity in lymph nodes signifies no tumor, while decisions based on RIGS activity in lymph nodes requires H & E confirmation. Using this guideline, additional information acquired by RIGS can help the surgeon in making an informed decision during surgery and in planning postoperative therapy.

Effect of photodynamic therapy on normal fibroblasts and colon anastomotic healing in mice.

Photodynamic therapy as an adjuvant modality to surgical resection of colon cancer is feasible provided that it does not affect healing of the anastomosis. The aim of this study was to evaluate the effects of photodynamic therapy on the viability of normal fibroblasts and on the healing process of colonic anastomosis in mice. Both in vitro and in vivo methods were employed. For in vitro study, 2 x 105 human fibroblasts were incubated in triplicate with 5-aminolevulinic acid (2.5 μ g/well) for 48 hours. Cells then underwent photoradiation at light doses of 50,100, and 200 joules/cm2 using a nonlaser light source. Viability was assessed by methylene blue dye exclusion. For in vivo studies, 60 mice were randomized into study and control groups and underwent laparotomy involving colonic anastomosis. The anastomosis underwent photodynamic therapy using 5-aminolevulinic acid (60 mg/kg) as a photosensitizer and a nonlaser light (40 joules/cm2). On postoperative days 1, 4, 7, 14, and 21, six mice were killed and subjected to bursting pressure and histologie examinations. Results of in vitro study showed pretreatment cell viability to be 96% to 99% in both groups. Photodynamic therapy caused no significant change in fibroblast viability at all light doses. Results of in vivo studies showed that the mean bursting pressure of both groups dropped to a low peak on day 4. Subsequently there was a gradual increase in bursting pressure along the examined time points (P <0.001). There was no difference in bursting pressure between the two groups for all time points examined. It was concluded that photodynamic therapy has no effect on viability of normal human fibroblasts and no adverse effects on healing of colonic anastomosis.

Photodynamic therapy for Bowen's disease and squamous cell carcinoma of the skin

BACKGROUND Photodynamic therapy involves the activation by visible light of a previously administered photosensitizing agent in order to cause tumor necrosis. Skin tumors can be treated with topical photosensitizers and thus avoiding systemic side effects. In this study we evaluate the immediate and long-term effects of photodynamic therapy (PDT), using aminolevulinic acid (ALA) as a photosensitizer and a non-laser light source, on Bowens disease (intra-epithelial squamous cell carcinoma) and on frank squamous cell carcinoma (SCC) of the skin. METHODS ALA in cream form (20%) was topically applied on biopsy-proven Bowens disease or SCC of the skin. The lesions were covered with occlusive and light-shielding dressing. Sixteen hours later, they were submitted to a 10-min light session using Versa-Light™, a non-laser light source (spectral output of 580-720nm and 1250-1600nm, 100J/cm(2)). The initial evaluation was done 21 days post-treatment and every 3m thereafter. Patients that did not respond to treatment after two to three sessions were referred to surgery. RESULTS Forty Bowens disease lesions (24 patients) and 43 SCC lesions (18 patients) underwent treatment. Median follow-up was 21±8m. No patient had any remarkable side effects. Thirty-four Bowens disease (85%) lesions completely responded as did 32 SCC lesions (74%). CONCLUSIONS Our findings showed that PDT is highly effective in treating Bowens disease and SCC lesions and can be used as a first treatment modality in so far as its use does not preclude the subsequent surgery recommended for the small percentage of failures.

Octreotide ameliorates glucose intolerance following acute experimental pancreatitis.

The long-term effects of octreotide, thesynthetic analog of the hormone somatostatin, on acuteexperimental pancreatitis were studied. Acutepancreatitis was induced in rats by intraparenchymalinjections of 0.5 ml 5% or 10% sodium taurocholate.Octreotide (10 mg/kg/day, subcutaneously), or salineinjections as controls, were started four hours later,and their effects were assessed 30, 60, and 90 daysafter the induction of pancreatitis. Neitherintrapancreatic saline injections nor octreotideadministration without the induction of pancreatitiscaused any biochemical or histological abnormalities.Taurocholate-induced pancreatitis was followed by remarkablehyperglycemia, which was ameliorated by octreotide.Thirty days after induction of pancreatitis, glucoselevels were 269 ± 21 mg/100 ml and 153 ±17 mg/100 ml in the control and octreotide treated animals,respectively (P < 0.02). Octreotide administrationwas associated with increased pH values after 60 and 90days (P < 0.05 for the 90 days group). The levels ofhematocrit, calcium, and amylase were already within thenormal ranges after 30 days and were unaffected byoctreotide. There were no signs of chronic exocrineinsufficiency and all the surviving rats gained weight during the follow-up. However, the relativeweights of the pancreases of the octreotide-treatedanimals were higher than those of the controls 30 daysafter IOP. Histopathological evaluation demonstrated regeneration of the pancreatic tissue, andincreased number and hypertrophy of the islets ofLangherhans. There were no significant differenceswhether the octreotide treatment was given for only 48or 96 hr. Survival was significantly improved byoctreotide; only one octreotide-treated rat (2.5%) with10% taurocholate-induced pancreatitis died, while six(15%) of the control animals succumbed (P < 0.05). These studies provided data on the sequelae ofacute pancreatitis and showed that octreotide may havelong-term beneficial effects in this disease.

Anchoring the diaphragm after blunt trauma

A 36 year old man sustained a blunt chest injury after his motorcycle crashed onto a pillar. At the scene, the patient was disturbed, agitated and confused. His initial pulse was 140 beats per minute, and therefore he was intubated. Because the sound of breathing over his left chest was decreased, a needle decompression was performed and the patient was transferred to this trauma centre. On physical examination reduced breath sounds over the left chest and a distended abdomen were found. The blood pressure was 110/70 mmHg, and the heart rate 130 beats per minute. Chest x-ray revealed a left haemothorax (Fig. 1A), and a chest tube was inserted which yielded 500 ml of blood. Diagnostic peritoneal lavage (DPL) was grossly negative, but after a litre of warm saline had been introduced to the abdominal cavity the chest tube output increased instantly. The patient was transferred to the operating theatre. At operation, a splenectomy was performed for grade IV splenic laceration. The left hemi diaphragm was found to be completely avulsed from the thoracic cage (Fig. 2). A band of Gore-tex, (Gore-tex soft tissue patch, W.L. Gore & Associates, Germany) was used to reinforce the diaphragmatic rent. Ethilon No. 0 Sutures (Eticon, UK) were used to join the edges of the diaphragm to the Gore-tex. They were passed behind and in front of the rib several times to clasp an adequate part of the edges of the diaphragm and the Gore-tex patch. This type of suture was repeated until the diaphragm was approximated to the wall of the chest (Figs. 3, 1B). The recovery and follow-up were unremarkable.

Localization of monoclonal antibody CC49 in colonic metastasis from renal cell carcinoma

We report a rare case of solitary metastasis from renal cell carcinoma which manifested as a primary colonic tumour 5 years after nephrectomy. A monoclonal antibody CC49 (anti-TAG-72 antibody), used in Radioimmunoguided Surgery, was found to localize in the tumour. Pathological examination revealed metastasis of renal cell carcinoma in the colon. Immunohistochemistry with CC49 showed moderate staining of the colonic mucosa around the metastasis with no reaction in the tumour itself. Based on this case and other published studies, we conclude that TAG-72, the antigen manifested in many adenocarcinomas, can be up-regulated and expressed in normal colonic mucosa adjacent to another tumour as a result of stimulations, such as cytokine release, in response to this tumour.