Tiziana Balbi

Eicosapentaenoic acid free fatty acid prevents and suppresses colonic neoplasia in colitis-associated colorectal cancer acting on Notch signaling and gut microbiota

Inflammatory bowel diseases are associated with increased risk of developing colitis‐associated colorectal cancer (CAC). Epidemiological data show that the consumption of ω‐3 polyunsaturated fatty acids (ω‐3 PUFAs) decreases the risk of sporadic colorectal cancer (CRC). Importantly, recent data have shown that eicosapentaenoic acid‐free fatty acid (EPA‐FFA) reduces polyp formation and growth in models of familial adenomatous polyposis. However, the effects of dietary EPA‐FFA are unknown in CAC. We tested the effectiveness of substituting EPA‐FFA, for other dietary fats, in preventing inflammation and cancer in the AOM‐DSS model of CAC. The AOM‐DSS protocols were designed to evaluate the effect of EPA‐FFA on both initiation and promotion of carcinogenesis. We found that EPA‐FFA diet strongly decreased tumor multiplicity, incidence and maximum tumor size in the promotion and initiation arms. Moreover EPA–FFA, in particular in the initiation arm, led to reduced cell proliferation and nuclear β‐catenin expression, whilst it increased apoptosis. In both arms, EPA‐FFA treatment led to increased membrane switch from ω‐6 to ω‐3 PUFAs and a concomitant reduction in PGE2 production. We observed no significant changes in intestinal inflammation between EPA‐FFA treated arms and AOM‐DSS controls. Importantly, we found that EPA‐FFA treatment restored the loss of Notch signaling found in the AOM‐DSS control and resulted in the enrichment of Lactobacillus species in the gut microbiota. Taken together, our data suggest that EPA‐FFA is an excellent candidate for CRC chemoprevention in CAC.

Clonality analysis in primary oral squamous cell carcinoma and related lymph-node metastasis revealed by TP53 and mitochondrial DNA next generation sequencing analysis.

The chance of developing a neck nodal metastasis after initial treatment of oral squamous cell carcinoma varies from 12.4% to 62%. Despite being the main reason for cancer-related mortality, nodal metastases are still rarely subjected to molecular analyses, and our knowledge of the clonal heterogeneity of multiple lesions within the same patient is limited. The aim of the present study was to evaluate the relationship between primary oral cancer and lymph node metastasis in a series of patients with synchronous and metachronous metastases by 2 clonality tests: mt-DNA and TP53 sequence analysis. The study population consisted of 10 consecutive patients. Data identified in this study demonstrate that our assay based on next-generation analysis of TP53 and mt-DNA is simple, is reliable, allows high throughput, and may be applied to retrospective cases. The combination of mt-DNA and TP53 data analysis helped us to evaluate more precisely and consistently the genetic relationship among different tumor clones.

Genetic relationship between multiple squamous cell carcinomas arising in the oral cavity.

Histological and clinical criteria are generally used to differentiate second primary tumors (SPTs) from local recurrences. The purpose of the present study was to apply mitochondrial DNA (mtDNA) D‐loop analysis to differentiate SPTs from local recurrences and to validate the clinical classification.

Short-term treatment with eicosapentaenoic acid improves inflammation and affects colonic differentiation markers and microbiota in patients with ulcerative colitis

Patients with long-standing ulcerative colitis (UC) have an increased colorectal cancer (CRC) risk. In this pilot study we evaluated the effect of Eicosapentaenoic acid as free fatty acid (EPA-FFA) supplementation on mucosal disease activity, colonic differentiation markers and microbiota composition in UC patients. Twenty long-standing UC patients in stable clinical remission and with fecal calprotectin (FC) > 150 µg/g were enrolled (T0) and supplemented with EPA-FFA 2 g/daily for 90 days (T3). Endoscopic and histologic disease activities were measured by Mayo and Geboes scores, respectively. HES1, KLF4, STAT3, IL-10 and SOCS3 levels were determined using western blotting and qRT-PCR, while phospho-STAT3 levels were assessed by western blotting. Goblet cells were stained by Alcian blue. Microbiota analyses were performed on both fecal and colonic samples. Nineteen patients completed the study; seventeen (89.5%) were compliant. EPA-FFA treatment reduced FC levels at T3. Patients with FC > 150 µg/g at T3 (n = 2) were assumed as non-responders. EPA-FFA improved endoscopic and histological inflammation and induced IL-10, SOCS3, HES1 and KLF4 in compliant and responder patients. Importantly, long-term UC-driven microbiota composition was partially redressed by EPA-FFA. In conclusion, EPA-FFA supplementation reduced mucosal inflammation, promoted goblet cells differentiation and modulated intestinal microbiota composition in long-standing UC patients.

Prepouch ileitis, myth or reality? The first case with acute abdomen

To the Editor: Restorative proctocolectomy with ileo pouch–anal anastomosis (IPAA) is a well-established procedure for ulcerative colitis (UC) in selected patients. Pouchitis is a common condition in many patients after restorative proctocolectomy. A similar condition, termed prepouch ileitis, characterized by inflammation proximal to the pouch, has also been recently described. This condition is poorly understood and generally considered of little clinical relevance. We describe the first case of a potential life-threatening complication from perforated ileitis of the new terminal ileum 2 years after restorative proctocolectomy for a nonresponder UC. In May 2004 a 62-year-old man with a history of UC nonresponding to medical treatment was referred for surgery. Restorative proctocolectomy (RPC) with IPAA and diverting loopileostomy was performed. The postoperative course was uneventful and 3 months later the patient underwent ileostomy closure with side-to-side mechanical anastomosis. In January 2006 the patient was diagnosed with rheumatic polymyalgia and uveitis and treated with immunosuppressants. In September 2006 he was admitted to the Emergency Department complaining of nausea, vomiting, fever, abdominal pain, and hematic diarrhea. Chest and abdominal x-rays were within normal limits. Pouchoscopy with biopsies was performed and he was treated for acute pouchitis with antibiotics and mesalazine with little improvement. Two weeks later he was transferred to our surgical unit with signs of peritonitis. The laboratory data were within normal limits. A double contrast computed tomography (CT) scan (intravenous and transanal) was performed: a copious amount of free abdominal air was detected and minimal leakage of the transanal contrast was found in the new terminal ileum (NTI); the pouch was regular (Fig. 1). A significant amount of purulententeric fluid was detected in the abdomen with clear signs of diffuse peritonitis (fluid culture was positive for E. coli and Enterococcus faecium). A double perforation was detected at the site of the side-to-side anastomosis (previously made for the ileostomy closure) located about 30 cm above the IPAA. Ileal resection, closure of the distal ileal stump, and end-ileostomy was performed. The postoperative period was complicated by prolonged septic status in the intensive care unit. Twenty-five days after surgery he was discharged in good condition. Two years later the patient is in good health. Laboratory analysis, pouchgram, pouchoscopy, and enteric magnetic resonance imaging (MRI) are all within normal limits. The macroscopic appearance of the specimen showed a severe ulcerating mucosa with 2 full-thickness discontinuities through the bowel (Fig. 2a). Villous atrophy alternated with pseudopolypoid lesions; mucosal chronic inflammatory cell infiltrate accompanied by neutrophils in the lamina propria were detected (Fig. 2b,c). Granuloma was not seen in any section. A second analysis of the previously resected colon and rectum excluded Crohn’s disease (CD) or indeterminate colitis (IC). A diagnosis of prepouch Ileitis (PI) was made according to the histopathological features reported by Bell et al. Pouchitis is a common condition after restorative proctocolectomy. Bell et al recently reported a series of 15 patients (2.6% of 571), with inflammation of the NTI after RPC with IPAA for pathologically confirmed UC. They describe this pathologic condition as a distinct disease called PI. Clinical and histochemical characteristics seem to overlap with pouchitis. PI seems to have a distinct etiopathogenesis and can occur independently of pouchitis, CD, or IC. Coexistent pouchitis was reported only in 7/15 patients (47%). Other authors have described this condition, which is often associated with chronic refractory pouchitis and mucosal changes that lessen in severity at the more proximal end. What we describe here is a case of acute abdomen following perforation of the NTI 2 years after RPC and IPAA. Terminal ileitis was not found to be associated with CD or IC. This is the first reported case of perforated PI. Endoscopic evaluation of the NTI should become mandatory for patients after proctocolectomy and IPAA who present with clinical symptoms of pouchitis, even in the absence of any direct evidence of pouch inflammation. Although nowadays no relation is identified with any risk factor, nevertheless a side-to-side ileostomy closure could be a circumstance predisposing for fecal stasis resulting in mucosal irritation and inflammation. This aspect should be considered in further analysis of the phenomenon. Despite the limited clinical magnitude, clinicians should be aware that perforation of the NTI can occur. This life-threatening complication should be included in the differential diagnosis of patients with abdominal pain after RPC.

p16 protein expression and correlation with clinical and pathological features in osteosarcoma of the jaws: Experience of 37 cases

In literature, no markers have been reported as predictive and prognostic factors in osteosarcoma of the jaw.

Splenic granulomas in a patient with severe Crohn's disease associated with multiple extraintestinal manifestations.

The patient is a 41-year-old man who came to our attention in October 2009, presenting a long history of ileocolic steroid-dependent CD, starting with fever, perianal fistulization, and rectal bleeding 20 years before (1989). We present a summary of his clinical history. Since 1993 the patient experienced episodes of severe exacerbations accompanied by extraintestinal relapsing manifestations: one-sided asymmetrical seronegative arthritis, pyoderma gangrenosum, and erythema nodosum. He was first treated with sulfasalazine (SASP), local and systemic steroids, then with methotrexate, 6mercaptopurine, without achieving full remission. More than once surgical curettage of perianal disease and local infusion of infliximab were needed. In 1998 he underwent ileocecal resection for an obstructive complication and concomitant abdominal abscess with fistulization. A month later a severe aphthous stomatitis with cervical lymph nodes inflammation and fever occurred: bacterial culture on various specimens (blood, excretion, swab) and serological tests (for cytomegalovirus [CMV], human immunodeficiency virus [HIV], Epstein–Barr virus [EBV], toxoplasma, Echo-Cox virus) excluded the most probable infective etiologies; this appearance was first considered an extraintestinal localization of CD—it responded to high doses of steroids, but relapsed at steroid tapering, becoming a chronic lymphadenitis, with a minimal effective dose of methylprednisolone 16 mg. The analysis of lymphocyte subpopulations did not demonstrate any abnormality. Chest xray, abdominal ultrasound, echocardiography, skin test for anergy, and ACE were normal. Finally, alcohol-acid-resistant bacilli were found in the expectorated analysis and the histological lymph node examination revealed the presence of a chronic granulomatous necrotizing suppurative lymphadenitis probably due to an atypical mycobacteriosis, which seemed to respond to a 4-fold antimycobacterial therapy for addiction to a tapering course of steroids. However, the same appearance, including an intermitting fever, relapsed 3 months later (1999); at this time the research for BK or atypical mycobacteria on biopsies was negative and transesophageal echocardiography, bone marrow biopsy, and bronchoscopy did not suggest anything significant. The treatment with 6-mercaptopurine failed due to intolerance, while cyclosporine was ineffective; on the contrary, the patient experienced two episodes of seizures and a left frontorolandic intracerebral deep lesion was diagnosed, requiring a neurosurgical intervention. In 2003 he had a relapse of lymphadenitis with evidence of splenomegaly associated with platelets depletion; the analysis of osteomedullary biopsy showed no abnormality. From 2006 to 2009 the progressive increase of the spleen size, monitored through ultrasound every 6 years, led both the hematologists and the gastroenterologists to consider a hypothesis of splenectomy. When he came to our attention (October 2009) he reported a good well-being when taking a daily dose of 5 mg beclometasone, which controlled the fever. He did not present any sign of lymphadenitis. He described an increase of temperature following every attempt to discontinue steroids. After performing the necessary screening tests, we decided to introduce a biologic therapy with adalimumab following the classic administration schedule, thus managing to reduce the beclometasone dosage (5 mg every 3 days) within 2 months. Inflammatory markers remained elevated. Then the tomographic evidence of marked splenomegaly (bipolar diameter of about 20 cm) with splenic vessels ectasia, left kidney compression and dislocation, and multiple enlarged abdominal lymph nodes caused us to consider a new surgical and hematological consultation, which led to the resolution of splenectomy in January 2010 (surgical specimen size: 19 18 12 cm). The histological examination revealed a congestive microgranulomatous splenomegaly etiologically attributable to CD. The granulomas, localized in some follicles within the white pulp and also in splenic perihilar lymph nodes, were noncaseating, epithelioid granulomas without necrosis, containing neutrophil infiltration rarely showing aseptic microabscesses (Fig. 1). During the following months the patient condition improved, although he was not steroid-free yet. Unfortunately, a few months later (July) an acute myeloproliferative syndrome occurred (cytotype FAB M1) which needed a polychemotherapy treatment. Our patient quickly gained remission after the induction cycle, but the leukemia phenotype requires bone marrow transplantation, for which the patient is still waiting for a donor. Concerning the fever and the inflammatory disease, he gained a complete remission after chemotherapy treatment. Copyright VC 2011 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.21665 Published online 11 February 2011 inWiley Online Library (wileyonlinelibrary.com).