Suzana Angélica Silva Lustosa

Impact of extended lymphadenectomy on morbidity, mortality, recurrence and 5-year survival after gastrectomy for cancer: meta-analysis of randomized clinical trials

PURPOSE To compare morbidity, mortality, recurrence and 5-year survival between D1 and D2 or D3 for treatment of gastric cancer. METHODS Systematic review and meta-analysis of RCTs. Metaview in RevMan 4.2.8 for analysis; statistical heterogeneity by Cochrans Q test (P<0.1) and I(2) test (P>50%). Estimates of effect were calculated using random effects model. RESULTS D2 or D3 was associated with higher in-hospital mortality, with RR = 2.13, p=0.0004, 95% CI, 1.40 to 3.25, I(2)=0%, P=0.63; overall morbidity showed higher incidence in D2 or D3, RR = 1.98, p<0.00001, 95% CI, 1.64 to 2.38, I(2) = 33.9%, P=0.20; operating time showed longer duration in D2 or D3, weighted mean difference of 1.05, p<0.00001, 95% CI, 0.71 to 1.38, I(2) = 78.7%, P=0.03, with significant statistical heterogeneity; reoperation showed higher rate in D2 or D3, with RR = 2.33, p<0.0001, 95% CI, 1.58 to 3.44, I(2) = 0%, P=0.99; hospital stay showed longer duration in the D2 or D3, with weighted mean difference of 4.72, p<0.00001, 95% CI, 3.80 to 5.65, I(2) = 89.9%, P<0.00001; recurrence was analyzed showed lower rate in D2 or D3, with RR = 0.89, p=0.02, 95% CI, 0.80 to 0.98, I(2) = 71.0%, P = 0.03, with significant statistical heterogeneity; mortality with recurrent disease showed higher incidence in D1, with RR = 0.88, p=0.04, 95% CI, 0.78 to 0.99, I(2) =51.8%, P=0.10; 5-year survival showed no significant difference, with RR = 1.05, p=0.40, 95% CI, 0.93 to 1.19, I(2) = 49.1% and P=0.12. CONCLUSIONS D2 or D3 lymphadenectomy procedure is followed by higher overall morbidity and higher in-hospital mortality; D2 or D3 lymphadenectomy shows lower incidence of recurrence and lower mortality with recurrent disease, when analysed altogether with statistical heterogeneity; D2 or D3 lymphadenectomy has no significant impact on 5-year survival.

Ileostomy or colostomy for temporary decompression of colorectal anastomosis: systematic review and meta-analysis

PURPOSE The controversy regarding whether loop ileostomy or loop transverse colostomy is a better method for temporary decompression of colorectal anastomosis motivated this review. METHODS Five randomized trials were included, with 334 patients: 168 in the loop ileostomy group and 166 in the loop transverse colostomy group. The outcomes analyzed were: 1. Mortality; 2. Wound infection; 3. Time of stoma formation; 4. Time of stoma closure; 5. Time interval between stoma formation and closure; 6. Stoma prolapse; 7. Stoma retraction; 8. Parastomal hernia; 9. Parastomal fistula; 10. Stenosis; 11. Necrosis; 12. Skin irritation; 13. Ileus; 14. Bowel leakage; 15. Reoperation; 16. Patient adaptation; 17. Length of hospital stay; 18. Colorectal anastomotic dehiscence; 19. Incisional hernia; 20. Postoperative bowel obstruction. RESULTS Stoma prolapse was statistically significant (p = 0.00001), but with statistical heterogeneity; the sensitive analysis was applied, excluding the trials that included emergency surgery, and this showed: p = 0.02, with I2 = 0% for the heterogeneity test. CONCLUSIONS The outcomes reported were not statistically or clinically significant except for stoma prolapse. Better evidence for making the choice between loop ileostomy or loop colostomy requires large-scale randomized controlled trials.

Analysis of the correlation between p53 and bcl-2 expression with staging and prognosis of the colorectal adenocarcinoma

PURPOSE To analyze the correlation between p53 and bcl-2 expression and colorectal adenocarcinoma staging and prognosis. METHODS This was a retrospective series of 125 colorectal adenocarcinoma patients (67 women and 58 men; ages 30-87 years) who underwent surgery with curative intent. The mean follow-up was 28.5 months (range: 2-96 months). TNM staging, tumor recurrence, survival and cancer-related mortality were analyzed. Immunoreactivity was evaluated using DO7 (Dako) for p53 and K492 (Dako) for bcl-2. Tumors with accumulation of staining for cytoplasmic bcl-2 or nuclear p53 in more than 10% of cells were considered positive. Statistical analysis utilized Pearson chi-squared, log-rank and Wilcoxon tests, and Kaplan-Meier survival estimation (significance level: p<0.05). RESULTS p53+ was found in 11.8% (14/118), bcl-2+ in 50% (58/116) and associated p53+/bcl-2+ in 6.4% (7/109) of the tumors. There was no significant correlation between expression of these biomarkers and TNM I, II, III and IV staging (p=0.385 for p53; p=0.461 for bcl-2). For tumor recurrence, p53+ was found in 9.5% (2/21), bcl-2+ in 50% (11/22), and associated p53+/bcl-2+ in 5.2% (1/19) of the tumors (p=0.714, p=1.000 and p=0.960, respectively). For survival analysis, p53+: 57 months (45.0-68.0), bcl-2+: 78 (37.0-89.0), and p53+/bcl-2+: 62 (56.0-68.0) (p=0.319). For cancer-related mortality, p53+: 8.3% (3/36), bcl-2+: 47.2% (17/36), and p53+/bcl-2+: 5.9% (2/36) of the patients (p=0.432, p=0.688 and p=0.907, respectively). CONCLUSION No correlation was found between tumor expression of p53 and bcl-2 and the TNM staging, recurrence, survival and cancer-related mortality in colorectal adenocarcinoma.

Surgical treatment of gastroesophageal reflux disease: total or partial fundoplication? Systematic review and meta-analysis

CONTEXT Although the high incidence of gastroesophageal reflux disease (GERD) in the population, there is much controversy in this topic, especially in the surgical treatment. The decision to use of a total or partial fundoplication in the treatment of GERD is still a challenge to many surgeons because the few evidence found in the literature. OBJECTIVE To bring more clear evidence in the comparison between total and partial fundoplication. DATA SOURCES A systematic review of the literature and metaanalysis with randomized controlled trials accessed from MEDLINE, LILACS, Cochrane Controlled Trials Database was done. The outcomes remarked were: dysphagia, inability to belch, bloating, recurrence of acid reflux, heartburn and esophagitis. For data analysis the odds ratio was used with corresponding 95% confidence interval. Statistical heterogeneity in the results of the metaanalysis was assessed by calculating a test of heterogeneity. The software Review Manager 5 (Cochrane Collaboration) was utilized for the data gathered and the statistical analysis. Sensitive analysis was applied using only trials that included follow-up over 2 years. RESULTS Ten trials were included with 1003 patients: 502 to total fundoplication group and 501 to partial fundoplication group. The outcomes dysphagia and inability to belch had statistical significant difference (P = 0.00001) in favor of partial fundoplication. There was not statistical difference in outcomes related with treatment failure. There were no heterogeneity in the outcomes dysphagia and recurrence of the acid reflux. CONCLUSION The partial fundoplication has lower incidence of obstructive side effects.

Expression profiling using a cDNA array and immunohistochemistry for the extracellular matrix genes FN-1, ITGA-3, ITGB-5, MMP-2, and MMP-9 in colorectal carcinoma progression and dissemination.

Colorectal cancer dissemination depends on extracellular matrix genes related to remodeling and degradation of the matrix structure. This investigation intended to evaluate the association between FN-1, ITGA-3, ITGB-5, MMP-2, and MMP-9 gene and protein expression levels in tumor tissue with clinical and histopathological neoplastic parameters of cancer dissemination. The expression associations between ECM molecules and selected epithelial markers EGFR, VEGF, Bcl2, P53, and KI-67 have also been examined in 114 patients with colorectal cancer who underwent primary tumor resection. Quantitative real-time PCR and immunohistochemistry tissue microarray methods were performed in samples from the primary tumors. The gene expression results showed that the ITGA-3 and ITGB-5 genes were overexpressed in tumors with lymph node and distant metastasis (III/IV-stage tumors compared with I/II tumors). The MMP-2 gene showed significant overexpression in mucinous type tumors, and MMP-9 was overexpressed in villous adenocarcinoma histologic type tumors. The ECM genes MMP9 and ITGA-3 have shown a significant expression correlation with EGFR epithelial marker. The overexpression of the matrix extracellular genes ITGA-3 and ITGB-5 is associated with advanced stage tumors, and the genes MMP-2 and MMP-9 are overexpressed in mucinous and villous adenocarcinoma type tumors, respectively. The epithelial marker EGFR overactivity has been shown to be associated with the ECM genes MMP-9 and ITGA-3 expression.

HNF4A expression as a potential diagnostic tool to discriminate primary gastric cancer from breast cancer metastasis in a Brazilian cohort

BackgroundAmong the many challenges in cancer diagnosis is the early distinction between metastatic cancer and a secondary tumor. This difficulty stems from the lack of markers that offer high sensitivity and specificity and can be easily applied in routine laboratory work. An example of this challenge is distinguishing gastric metastases originating from breast cancer from a gastric primary tumor. Hepatocyte nuclear factor 4 alpha (HNF4A) has been suggested as a potential marker in these cases.The aim of this study was to analyze the expression of HNF4A, estrogen receptor (ER), progesterone receptor (PR) and gross cystic disease fluid protein 15 (GCDFP-15) in a Brazilian cohort.MethodsWe performed immunohistochemistry analysis of HNF4A, ER, PR and GCDFP-15 in 126 patients divided into three cohorts: primary breast cancer, primary gastric cancer and both types of tumors.ResultsOur data confirmed the sensitivity and specificity of the HNF4A marker compared to other currently used clinical markers.ConclusionHNF4A alone could be a gold standard marker for distinguishing primary gastric cancer from breast metastasis, thus validating its potential clinical use, especially in populations with high genetic diversity.

Accuracy of preoperative biopsies compared with surgical specimens in the diagnosis of colorectal adenocarcinoma.

Objective Since the first data from a patient with colorectal adenocarcinoma are obtained by biopsy, this study evaluated the accuracy of diagnosis by biopsy as compared with the diagnostic potential of the surgical specimen, considering the histological type, grade of differentiation, and immunohistochemical expression of p53. Methods. The specimens were obtained from 80 patients assisted at Hospital São Paulo. The biopsy and surgical specimen sections were stained by hematoxylin–eosin and immunohistochemistry and compared by 3 pathologists blinded to the evaluations. Results. The accuracy for the histological types was 88%. The grade of differentiation presented an accuracy of 70% with Kappa = .48. The expression of protein p53 exhibited an accuracy of 68% with Kappa = .22. Conclusion. The preoperative biopsy of colorectal adenocarcinoma presented good accuracy compared with histopathological examination of the surgical specimen, but with weak to moderate effective degree of agreement between the results.

Handsewn or stapled colorectal anastomosis? Or how evidence based is surgical practice

Responding to increasing demands for costeffectiveness relation a recent randomized trial which compared the cost of stapled and handsutured anastomosis in the gastrointestinal tract, has concluded that stapled anastomosis are not efficcient and should be reserved for individual indications. 1 However, one can admit that in the general surgical practice, preference for stapler is so overwhelming that cost-effectiveness approach is being neglected since the first anastomotic machine has been fired. As a matter of fact most surgeons do not regard this as an issue of concern and as a result it has not been considered as a major study endpoint in the literature. 2