Validation of the new AJCC TNM staging system for gastric cancer in a large cohort of patients (n = 2,155): focus on the T category

BACKGROUND

The prognostic value of T subclassification in patients with gastric carcinoma has been just implemented in the new AJCC TNM staging system, which has reclassified T2a and T2b into T2 and T3 tumors, respectively. The aim of the present study was to validate the prognostic significance of the new T categorization within the frame of the latest TNM staging system.

METHODS

We retrospectively reviewed the records of 686 T2/T3 patients among 2155 subjects who underwent radical resection for gastric carcinoma at six Italian centers from 1988 through 2006.

RESULTS

Upon multivariate analysis, the new T categories, extent of lymph node dissection (D) and patient's age were retained by the survival model as independent prognostic factors. In particular, the death risk for patients with T3 tumors was higher than that of patients with T2 tumors (HR: 1.42, P = 0.005). Among the 686 patients previously classified as having T2 tumors, patients with T2 and T3 disease were 270 (39.4%) and 416 (60.6%), respectively. After a median follow-up of 55 months, the 5-year overall survival rates were 67.3% and 52.3% for patients with T2 and T3 tumors, respectively (P < 0.001). The survival advantage for the T2 as compared to T3 category was maintained even when N0 and N+ patients were separately considered (P = 0.0154 and P < 0.001, respectively).

CONCLUSIONS

Our data confirm the prognostic difference between the newly proposed T2 and T3 categories, which should be implemented in the routine clinical practice to improve risk stratification of patients with gastric cancer.

Changing clinical and pathological features of gastric cancer over time

BACKGROUND

The aim of the present multicentre observational study was to evaluate potential changes in clinical and pathological features of patients with gastric cancer (GC) treated in a 15-year interval.

METHODS

A centralized prospective database including clinical, surgical, pathological and follow-up data from 2822 patients who had resection of a primary GC was analysed. The analysis focused on three periods: 1991-1995 (period 1), 1996-2000 (period 2) and 2001-2005 (period 3). Surgical procedure, pathological classification and follow-up were standardized among centres.

RESULTS

The number of resections decreased from 1024 in period 1 to 955 and 843 in periods 2 and 3 respectively. More advanced stages and a smaller number of intestinal-type tumours of the distal third were observed over time. Five-year survival rates after R0 resection (2320 patients) did not change over time (overall: 56·6 and 51·2 per cent in periods 1 and 3; disease-free: 66·8 and 61·1 per cent respectively). Decreases in survival in more recent years were related particularly to more advanced stage, distal tumours and tumours in women. Multivariable analysis showed a lower probability of overall and disease-free survival in the most recent interval: hazard ratio 1·22 (95 per cent confidence interval 1·06 to 1·40) and 1·29 (1·06 to 1·58) respectively compared with period 1. Recurrent tumours were more frequently peritoneal rather than locoregional.

CONCLUSION

Overall and disease-free survival rates after R0 resection of GC were unchanged over time.

Dynamical heterogeneities in irreversible gels: analogy with spin glasses

We describe the sol-gel transition by introducing an order parameter, defined as the average of local variables, and its fluctuations. It can be shown that these quantities are related to percolation quantities, but in principle they can be measured without resorting to connectivity properties. In this framework it appears that the dynamical transition associated with gelation is a real thermodynamic transition, as happens in spin glasses. The strong analogies between the sol-gel transition and the spin glass transition are also discussed.

Self-tuning phase separation in a model with competing interactions inspired by biological cell polarization

We present a theoretical study of a system with competing short-range ferromagnetic attraction and a long-range antiferromagnetic repulsion, in the presence of a uniform external magnetic field. The interplay between these interactions, at sufficiently low temperature, leads to the self-tuning of the magnetization to a value which triggers phase coexistence, even in the presence of the external field. The investigation of this phenomenon is performed using a Ginzburg-Landau functional in the limit of an infinite number of order parameter components (large N model). The scalar version of the model is expected to describe the phase separation taking place on a cell surface when this is immersed in a uniform concentration of chemical stimulant. A phase diagram is obtained as a function of the external field and the intensity of the long-range repulsion. The time evolution of the order parameter and of the structure factor in a relaxation process is studied in different regions of the phase diagram.

Metachronous hepatic metastases from gastric carcinoma: a multicentric survey

BACKGROUND

The treatment of hepatic metastases from gastric cancer is controversial, due to biologic aggressiveness of the disease.

OBJECTIVE

To survey the clinical approach to the subset of patients presenting with metachronous hepatic metastases as sole site of recurrence after curative resection of gastric cancer, focusing on the results achieved by different therapies and to investigate the prognostic factors of major clinical relevance.

METHODS

Retrospective multi-center chart review evaluating 73 patients, previously submitted to D >or= 2 gastrectomy for gastric cancer, who developed exclusive hepatic recurrence. Prognostic factors related to the patient, to the gastric malignancy and its treatment, and to the metastatic disease and its therapy were evaluated.

RESULTS

Forty-five patients received supportive care, 17 were submitted to chemotherapy, and 11 to hepatic resection. Survival was independently influenced by the variables T (p=0.019), N (p=0.05) and G (p=0.018) of the gastric primary and by the therapeutic approach to the metastases (p<0.005). In particular, T4 gastric cancer, presence of lymph-node metastases and G3 tumor displayed a negative prognostic value. Therapeutic approach to the metastases was the principal prognostic variable: 1, 2, and 3 years survival rates were 22.2%, 4.4% and 2.2%, respectively, for patients without specific treatment; 44.9%, 12.8% and 6.4% after chemotherapy (p=0.08) and 80.8%, 30.3% and 20.2% after surgical resection (p<0.001).

CONCLUSIONS

Our data suggest some clinical criteria that may facilitate selection of therapy for patients with hepatic recurrence after primary gastric cancer resection. The best survival rates are associated with surgical treatment, which should be chosen whenever possible.

Dynamical heterogeneity in a model for permanent gels: different behavior of dynamical susceptibilities

We present a systematic study of dynamical heterogeneity in a model for permanent gels upon approaching the gelation threshold. We find that the fluctuations of the self-intermediate scattering function are increasing functions of time, reaching a plateau whose value, at large length scales, coincides with the mean cluster size and diverges at the percolation threshold. Another measure of dynamical heterogeneities-i.e., the fluctuations of the self-overlap-displays instead a peak and decays to zero at long times. The peak, however, also scales as the mean cluster size. Arguments are given for this difference in the long-time behavior. We also find that the non-Gaussian parameter reaches a plateau in the long-time limit. The value of the plateau of the non-Gaussian parameter, which is connected to the fluctuations of diffusivity of clusters, increases with the volume fraction and remains finite at the percolation threshold.

Shear- and vibration-induced order-disorder transitions in granular media

By molecular dynamics simulations we investigate the order-disorder transitions induced in granular media by an applied drive combining vibrations and shear. As the steady state is attained, the pack is found in disordered configurations for comparatively high intensities of the drive; conversely, ordering and packing fractions exceeding the random close packing are found when vibrations and shear are weak. As forcing amplitudes get smaller, we find diverging time scales in the dynamics, as the system enters a jamming region. Under this perspective, our picture supports the intuition that externally applied forcing has, in driven granular media, a role similar to temperature in thermal systems.

The prognostic value of N-ratio in patients with gastric cancer: validation in a large, multicenter series

AIMS

The proportion between metastatic and examined lymph nodes (N-ratio) has been proposed as an independent prognostic factor in patients with gastric cancer. In the present work we validated the reliability of N-ratio in a large, multicenter series.

PATIENTS AND METHODS

We retrospectively reviewed the data of 1853 patients who underwent radical resection for gastric carcinoma. Survival of patients with >15 (Group-1, n=1421) and those with < or =15 (Group-2, n=432) lymph nodes examined was separately analyzed in order to evaluate the influence of lymph node dissection on disease staging. N-ratio categories (N-ratio 0, 0%; N-ratio 1, 1-9%; N-ratio 2, 10-25%; N-ratio 3, >25%) were determined by the best cut-off approach.

RESULTS

At multivariate analysis, N-ratio (but not TNM N-category) was retained as an independent prognostic factor both in Group-1 and Group-2 (HR for N-ratio 1, N-ratio 2 and N-ratio 3=1.67, 2.96 and 6.59, and 1.56, 2.68 and 4.28, respectively). After a median follow-up of 45.5 months, the 5-year overall survival rates of TNM N0, N1 and N2 patients were significantly different in Group-1 vs Group-2. This was not the case when adopting the N-ratio classification, suggesting that a low number of excised lymph nodes can lead to patients being understaged using the N-category, but not N-ratio. Moreover, N-ratio identified subsets of patients with significantly different survival rates within TNM N1 and N2 categories in both groups.

CONCLUSIONS

N-ratio is a simple and reproducible prognostic tool that can stratify patients with gastric cancer, including those cases with limited lymph node dissection. These data support the rationale to propose the implementation of N-ratio into the current TNM staging system.

Phenomenology and theory of horizontally oscillated granular mixtures

We overview the physics of a granular mixture subject to horizontal oscillations, recently investigated via experiments and molecular dynamics simulations. First we discuss the rich phenomenology exhibited by this system, which encompasses both segregation and dynamical instabilities. Then we show that the phenomenology can be explained via an effective interaction approach, by which the driven, non-thermal, granular mixture in mapped into a monodispersed thermal system of particles interacting via an effective potential. After determining the effective interaction we discuss its microscopic origin and investigate how it induces the observed phenomenology. Finally, as much as in thermal fluids, from the effective interaction we derive a Cahn-Hilliard dynamics equation, which appears to capture the essential characteristics of the dynamics of the granular mixture.

Static and dynamic heterogeneities in a model for irreversible gelation

We study the structure and the dynamics in the formation of irreversible gels by means of molecular dynamics simulation of a model system where the gelation transition is due to the random percolation of permanent bonds between neighboring particles. We analyze the heterogeneities of the dynamics in terms of the fluctuations of the self-intermediate scattering functions: in the sol phase close to the percolation threshold, we find that this dynamic susceptibility increases with the time until it reaches a plateau. At the gelation threshold this plateau scales as a function of the wave vector k as k(eta-2), with eta being related to the decay of the percolation pair connectedness function. At the lowest wave vector, approaching the gelation threshold it diverges with the same exponent gamma as the mean cluster size. These findings suggest an alternative way of measuring critical exponents in a system undergoing chemical gelation.

Kinetics of bond formation in cross-linked gelatin gels

In chemical cross-linking of gelatin solutions, two different time scales affect the kinetics of the gel formation in the experiments. We complement the experimental study with Monte Carlo numerical simulations of a lattice model. This approach shows that the two characteristic time scales are related to the formation of single bond cross-linker-chain and of bridges between chains. In particular, their ratio turns out to control the kinetics of the gel formation. We discuss the effect of the concentration of chains. Finally our results suggest that by varying the probability of forming bridges as an independent parameter, one can finely tune the kinetics of the gelation via the ratio of the two characteristic times.

Columnar and lamellar phases in attractive colloidal systems

In colloidal suspensions, at low volume fraction and temperature, dynamical arrest occurs via the growth of elongated structures that aggregate to form a connected network at gelation. Here we show that, in the region of parameter space where gelation occurs, the stable thermodynamical phase is a crystalline columnar one. Near and above the gelation threshold, the disordered spanning network slowly evolves and finally orders to form the crystalline structure. At higher volume fractions the stable phase is a lamellar one, which seems to have a still longer ordering time.

Complex viscosity behavior and cluster formation in attractive colloidal systems

The increase in viscosity that is observed in attractive colloidal systems by varying the temperature or the volume fraction can be related to the formation of structures due to particle aggregation. In particular we have studied the nontrivial dependence of the viscosity from the temperature and the volume fraction in the copolymer-micellar system L64. The comparison of the experimental data with the results of numerical simulations in a simple model for gelation phenomena suggests that this intriguing behavior can be explained in terms of cluster formation and that this picture can be quite generally extended to other attractive colloidal systems.

Size segregation in granular media induced by phase transition

In order to study analytically the nature of the size segregation in granular mixtures, we introduce a mean field theory in the framework of a statistical mechanics approach, based on Edwards' original ideas. For simplicity we apply the theory to a lattice model for a hard sphere binary mixture under gravity, and we find a new purely thermodynamic mechanism that gives rise to the size segregation phenomenon. By varying the number of small grains and the mass ratio, we find a crossover from the Brazil nut to the reverse Brazil nut effect, which becomes a true phase transition when the number of small grains is larger then a critical value. We suggest that this transition is induced by the effective attraction between large grains due to the presence of small ones (depletion force). Finally the theoretical results are confirmed by numerical simulations of the 3d system under taps.

Jamming transition in granular media: a mean-field approximation and numerical simulations

In order to study analytically the nature of the jamming transition in granular material, we have considered a cavity method mean-field theory, in the framework of a statistical mechanics approach, based on Edwards' original idea. For simplicity, we have applied the theory to a lattice model, and a transition with exactly the same nature of the glass transition in mean-field models for usual glass formers is found. The model is also simulated in three dimensions under tap dynamics, and a jamming transition with glassy features is observed. In particular, two-step decays appear in the relaxation functions and dynamic heterogeneities resembling ones usually observed in glassy systems. These results confirm early speculations about the connection between the jamming transition in granular media and the glass transition in usual glass formers, giving moreover a precise interpretation of its nature.

Traumatic lesions of the diaphragm. Our experience in 33 cases and review of the literature

We reviewed 33 consecutive patients with diaphragmatic injuries. Twenty-nine were admitted in emergency conditions after blunt (22 patients) or penetrating injury, presenting shock, dyspnoea, coma or acute abdomen in 21 cases; major associated lesions were found in 23 patients. Four patients presented acute complications of visceral herniation 2, 4, 84 and 216 months after the trauma. The diagnosis was preoperative in 23 cases, intraoperative in 9; in one case it was missed at laparotomy, becoming evident the day after. The sensibility of preoperative chest x-ray and CT was 86% and 100% in presence of visceral herniation, 14% and 0% in absence of visceral hernia. The diaphragmatic repair was always obtained by direct suture, following 20 haemostatic procedures (liver, spleen, mesenterium) and two bowel resections. The mortality rate was 24.4%; the morbidity rate was 48%. Traumatic lesions of the diaphragm are generally expression of particularly severe trauma whose outcome is mainly influenced by the associated lesions. They are also correlated to specific morbidity and mortality, so the surgical exploration is mandatory whenever this injury is suspected, considering that the preoperative diagnosis relies on visceral dislocation. Associated lesions influence the surgical strategy but a direct suture is usually effective in preventing specific complications.

Percolation model for enzyme gel degradation

We study a model for the gel degradation by an enzyme, where the gel is schematized as a cubic lattice, and the enzyme as a random walker, that cuts the bonds over which it passes. The model undergoes a (reverse) percolation transition, which for low density of enzymes falls in a universality class different from random percolation. In particular, we have measured a gel fraction critical exponent beta=1.0+/-0.1, in excellent agreement with experiments made on the real system.

Percolation and Burgers' dynamics in a model of capillary formation

Capillary networks are essential in vertebrates to supply tissues with nutrients. Experiments of in vitro capillary formation show that cells randomly spread on a gel matrix autonomously organize to form vascular networks. Cells form disconnected networks at low densities and connected ones above a critical density. Above the critical density the network is characterized by a typical mesh size approximately 200 microm, which is approximately constant on a wide range of density values. In this paper we present a full characterization of a recently proposed model which reproduces the main features of the biological system, focusing on its dynamical properties, on the fractal properties of patterns, and on the percolative phase transition. We discuss the relevance of the model in relation with some experiments in living beings and proposed diagnostic methods based on the measurement of the fractal dimension of vascular networks.

[Results of elective open surgery for juxtarenal aortic aneurysms]

Review of the most significant surveys (data base: Pub Med on September 2003) of elective open surgery for Juxtarenal aneurysms and personal results of 106 cases (9.3% of AAA consecutively operated in the last 11 yrs.) are reported. Mortality and morbidity are discussed related to: technique of aortic cross-clamping; protective measures on splanchnic and renal perfusion; risks from previous CAD and chronic renal failure. Over all, the main predictive factor is the accuracy of the selected technique, without any difference among different approaches, and the same results of infrarenal aneurysms can be obtained.

Monodisperse model suitable to study the glass transition

We study the properties of a monodisperse lattice glass model with a simple geometrical interpretation, which reproduces many features of glass forming liquids, such as the cage effect, vanishing diffusivity, and the presence of two time scales in relaxation functions. The model has a crystalline ground state at high density, but has no tendency to crystallize when quenched, even at extremely low cooling rates, which makes it suitable for the study of the glass transition. We study the model in mean field on random regular graphs, finding a scenario analogous to p-spin models.