Systemic neutrophil-to-lymphocyte ratio in colorectal cancer: the relationship to patient survival, tumour biology and local lymphocytic response to tumour

Background:

Colorectal cancer (CRC) is a major cause of mortality and morbidity. The impact of inflammatory biomarkers (C-reactive protein etc.) on CRC is increasingly studied including systemic neutrophil-to-lymphocyte ratio (NLR) as they seem to predict outcome.

Methods:

All patients who underwent curative resection for CRC from 2000 to 2004 at Leeds Teaching Hospitals NHS Trust had pre-operative NLR calculated. Demographic, histopathological and survival data were collected. Tissue microarrays were created and stained to determine the mismatch repair (MMR) protein status of each tumour. Local lymphocytic response to the tumour was assessed and graded.

Results:

About 358 patients were eligible. Of these 88 had an NLR ⩾5, which predicted lower overall survival and greater disease recurrence. A high NLR is associated with higher pT- and pN-stage and a greater incidence of extramural venous invasion. MMR protein status was not associated with NLR. A pronounced lymphocytic reaction at the invasive margin (IM) indicated a better prognosis and was associated with a lower NLR.

Conclusion:

Neutrophil-to-lymphocyte ratio predicts disease-free and overall survival and is associated with a more aggressive tumour phenotype. The lymphocytic response to tumour at the IM is associated with NLR however dMMR is not. Neutrophil-to-lymphocyte ratio is a cheap, easy-to-access test that predicts outcome in CRC.

Developing core patient-reported outcomes in maternity: PRO-Maternity

Women-centred maternity PRO measures can generate outcome measures that will allow benchmarking of service delivery using meaningful outcomes that will drive service improvement to ensure commitment to a culture of openness, patient satisfaction, patient safety and the delivery of clinically effective care. Moreover, they can generate new insights into women’s perspectives of healthcare delivery, allowing changes in attitude, practice and organisational services. Once developed, the adoption of PRO measures within units is likely to come at additional cost. However, the expected benefits in improved woman and family satisfaction, reduced legal claims and the presence of an early indicator of compromised quality of care will have the potential to save a significant amount of money for individual units and the wider health economy.

The influence of geographical access to health care and material deprivation on colorectal cancer survival: evidence from France and England

This article investigates the influence of distance to health care and material deprivation on cancer survival for patients diagnosed with a colorectal cancer between 1997 and 2004 in France and England. This population-based study included all cases of colorectal cancer diagnosed between 1997 and 2004 in 3 cancer registries in France and 1 cancer registry in England (N=40,613). After adjustment for material deprivation, travel times in England were no longer significantly associated with survival. In France patients living between 20 and 90min from the nearest cancer unit tended to have a poorer survival, although this was not statistically significant. In England, the better prognosis observed for remote patients can be explained by associations with material deprivation; distance to health services alone did not affect survival whilst material deprivation level had a major influence, with lower survival for patients living in deprived areas. Increases in travel times to health services in France were associated with poorer survival rates. The pattern of this influence seems to follow an inverse U distribution, i.e. maximal for average travel times.

Screen-detected colorectal cancers are associated with an improved outcome compared with stage-matched interval cancers

Background:

Colorectal cancers (CRCs) detected through the NHS Bowel Cancer Screening Programme (BCSP) have been shown to have a more favourable outcome compared to non-screen-detected cancers. The aim was to identify whether this was solely due to the earlier stage shift of these cancers, or whether other factors were involved.

Methods:

A combination of a regional CRC registry (Northern Colorectal Cancer Audit Group) and the BCSP database were used to identify screen-detected and interval cancers (diagnosed after a negative faecal occult blood test, before the next screening round), diagnosed between April 2007 and March 2010, within the North East of England. For each Dukes' stage, patient demographics, tumour characteristics, and survival rates were compared between these two groups.

Results:

Overall, 322 screen-detected cancers were compared against 192 interval cancers. Screen-detected Dukes' C and D CRCs had a superior survival rate compared with interval cancers (P=0.014 and P=0.04, respectively). Cox proportional hazards regression showed that Dukes' stage, tumour location, and diagnostic group (HR 0.45, 95% CI 0.29–0.69, P<0.001 for screen-detected CRCs) were all found to have a significant impact on the survival of patients.

Conclusions:

The improved survival of screen-detected over interval cancers for stages C and D suggest that there may be a biological difference in the cancers in each group. Although lead-time bias may have a role, this may be related to a tumour's propensity to bleed and therefore may reflect detection through current screening tests.

Developing Objective Metrics for Unit Staffing (DOMUS) study

OBJECTIVE

Safe midwifery staffing levels on delivery suites is a priority area for any maternity service. Escalation policies are tools that provide an operational response to emergency pressures. The aim of this study was to assess the feasibility of using a scoring system to contemporaneously assess the required staffing level based on demand and use this to determine delivery suite escalation level and utilise the information generated regarding clinical activity (Demand) and staffing levels (Capacity) to generate unit-specific calculation for the actual number of midwifery staff required.

SETTING

A maternity unit of a university-affiliated tertiary referral hospital.

DESIGN

Over a 12-month period, specifically designed scoring sheets were completed by delivery suite shift co-ordinators four times a day (04:00, 10:00, 16:00 and 22:00). Based on the dependency score (Demand) and the number of midwifery staff available (Capacity), an escalation level was determined for each shift. The 80th centile of the demand was used to determine optimal capacity.

RESULTS

A total of 1160 scoring sheets were completed. Average staff number throughout the year on any shift was 7 (range 3-11). Average dependency score was 7 (range 1-14). The 80th centile for demand was calculated to be 11.

CONCLUSIONS

This study stresses the importance and usefulness of a simple tool that can be used to determine the level of escalation on delivery suite based on an objective scoring system and can also be used to determine the appropriate staffing on delivery suite.

Sex-specific behavioral traits in the Brd2 mouse model of juvenile myoclonic epilepsy

Idiopathic generalized epilepsy represents about 30-35% of all epilepsies in humans. The bromodomain BRD2 gene has been repeatedly associated with the subsyndrome of juvenile myoclonic epilepsy (JME). Our previous work determined that mice haploinsufficient in Brd2 (Brd2+/-) have increased susceptibility to provoked seizures, develop spontaneous seizures and have significantly decreased gamma-aminobutyric acid (GABA) markers in the direct basal ganglia pathway as well as in the neocortex and superior colliculus. Here, we tested male and female Brd2+/- and wild-type littermate mice in a battery of behavioral tests (open field, tube dominance test, elevated plus maze, Morris water maze and Barnes maze) to identify whether Brd2 haploinsufficiency is associated with the human behavioral patterns, the so-called JME personality. Brd2+/- females but not males consistently displayed decreased anxiety. Furthermore, we found a highly significant dominance trait (aggression) in the Brd2+/- mice compared with the wild type, more pronounced in females. Brd2+/- mice of either sex did not differ from wild-type mice in spatial learning and memory tests. Compared with wild-type littermates, we found decreased numbers of GABA neurons in the basolateral amygdala, which is consistent with the increase in aggressive behavior. Our results indicate that Brd2+/- haploinsufficient mice show no cognitive impairment but have behavioral traits similar to those found in patients with JME (recklessness, aggression). This suggests that either the BRD2 gene is directly responsible for influencing many traits of JME or it controls upstream regulators of individual phenotypes.

New frontiers in pediatric Allo-SCT

The inaugural meeting of 'New Frontiers in Pediatric Allogeneic Stem Cell Transplantation' organized by the Pediatric Blood and Transplant Consortium (PBMTC) was held at the American Society of Pediatric Hematology and Oncology Annual Meeting. This meeting provided an international platform for physicians and investigators active in the research and utilization of pediatric Allo-SCT in children and adolescents with malignant and non-malignant disease (NMD), to share information and develop future collaborative strategies. The primary objectives of the conference included: (1) to present advances in Allo-SCT in pediatric ALL and novel pre and post-transplant immunotherapy; (2) to highlight new strategies in alternative allogeneic stem cell donor sources for children and adolescents with non-malignant hematological disorders; (3) to discuss timing of immune reconstitution after Allo-SCT and methods of facilitating more rapid recovery of immunity; (4) to identify strategies of utilizing Allo-SCT in pediatric myeloproliferative disorders; (5) to develop diagnostic and therapeutic approaches to hematological complications post pediatric Allo-SCT; (6) to enhance the understanding of new novel cellular therapeutic approaches to pediatric malignant and non-malignant hematological disorders; and (7) to discuss optimizing drug therapy in pediatric recipients of Allo-SCT. This paper will provide a brief overview of the conference.

Sarcocystis neurona schizonts-associated encephalitis, chorioretinitis, and myositis in a two-month-old dog simulating toxoplasmosis, and presence of mature sarcocysts in muscles

Sarcocystis neurona is an unusual species of the genus Sarcocystis. Opossums (Didelphis virginianus, D. albiventris) are the definitive hosts and several other species, including dogs, cats, marine mammals, and horses are intermediate or aberrant hosts. Sarcocysts are not known to form in aberrant hosts. Sarcocystis neurona causes fatal disease in horses (Equine Protozoal Myeloencephalitis, EPM). There are numerous reports of fatal EPM-like infections in other species, usually with central nervous system signs and associated with the schizont stage of S. neurona. Here, we report fatal disseminated S. neurona infection in a nine-week-old golden retriever dog from Mississippi, USA. Protozoal merozoites were identified in smears of the cerebrospinal fluid. Microscopically, lesions and protozoa were identified in eyes, tongue, heart, liver, intestines, nasal turbinates, skeletal muscle and brain, which reacted intensely with S. neurona polyclonal antibodies. Mature sarcocysts were seen in sections of muscles. These sarcocysts were ultrastructurally similar to those of S. neurona from experimentally infected animals. These data suggest that the dog is another intermediate host for S. neurona. Data suggest that the dog was transplacentally infected.

Abstract P2-02-06: Breast cancer in the elderly: Is MRI helpful?

Background: Guidelines support screening MRI in select high-risk groups; however, MRI is frequently obtained perioperatively and for breast cancer (BC) follow-up. Appropriate use of MRI in elderly patients remains unclear; we sought to identify the indications and implications of MRI use in our elderly BC population.

Methods: Women 70 years of age or older at first BC diagnosis with an MRI performed at our institution either perioperatively or in follow-up were included from a prospectively maintained database from 2000-2010. Univariate logistic regression was used to test associations with upgrade (additional ipsilateral, contralateral, new cancer, or recurrence) following perioperative MRI. Kaplan-Meier and competing risks methods were used to estimate survival and cumulative incidence.

Results: 305 breast cancers were identified in 286 patients. 133 patients were imaged with an MRI in the perioperative setting alone, 88 had only follow-up MRIs after BC treatment, and 65 had both. Patient, tumor, and treatment data are summarized in Table 1.

TableFactorN = 305Age, yearsMedian: 73 (range, 70-90)Means of Diagnosis Imaging189 (62%)Physical abnormality109 (36%)Other/incidental7 (2%)Mammographic density* Fatty21 (7%)Mild96 (32%)Moderate166 (55%)Extreme18 (6%)Tumor size*Median: 1.2cm (range 0.1-7.0)Histology DCIS +/- microinvasion44 (14%)Invasive ductal181 (59%)Invasive lobular68 (22%)Other12 (4%)ER positive*225 (86%)PR positive*159 (61%)HER2/neu positive*17 (7%)Final surgery* Lumpectomy217 (71%)Mastectomy87 (29%)Radiation following lumpectomy*169 (80%)Adjuvant chemotherapy*81 (27%)Adjuvant endocrine therapy*200 (69%)*for patients with information available 

Indications for perioperative MRI include: extent of disease evaluation for known cancer (155;78%); abnormal imaging (13;7%); protocol (13;7%); occult primary (10;5%); high-risk screening (5;3%); and abnormal physical exam (2;1%). MRI upgrade for occult primary cases was 4/10 (40%; 95% confidence interval (CI), 12.2-73.8%) and 21/188 (11.2%; 95% CI, 7.1-16.6%) for the remainder of perioperative cases; comprised of 9 contralateral and 5 additional ipsilateral cancers in women undergoing MRI for extent of disease evaluation, and 7 new cancers identified on MRIs for high-risk screening or abnormal imaging/physical exam. These lesions consisted of 10 DCIS and 11 node-negative invasive cancers (median size, 7mm; range, &lt;1-18mm). Analysis of imaging and tumor characteristics failed to find significant predictors of upgrade. 369 postoperative follow-up MRIs were performed in 153 patients with a median of 2 MRIs per patient (range, 1-8), and identified 7 upgrades (1.9%; 95% CI, 0.8-3.9%), for an overall patient upgrade rate of 4.6% (7/153). Median follow-up was 5.3 years. Five-year incidence of local, regional, and distant recurrence, and contralateral BC was 3.3%, 1.3%, 4%, and 3.7%, respectively. Five-year overall and recurrence-free survival (RFS) was 92% and 85.7%, respectively.

Conclusion: Our elderly patients had an excellent overall and RFS. MRI had the greatest benefit in women presenting with an occult primary. 11% of perioperative MRIs identified additional or new disease, while only 2% of follow-up MRIs resulted in an upgrade, calling into question the benefit of follow-up MRI imaging in elderly BC patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-02-06.

Integrating cancer survivors' experiences into UK cancer registries: design and development of the ePOCS system (electronic Patient-reported Outcomes from Cancer Survivors)

Background:

Understanding the psychosocial challenges of cancer survivorship, and identifying which patients experience ongoing difficulties, is a key priority. The ePOCS (electronic patient-reported outcomes from cancer survivors) project aims to develop and evaluate a cost-efficient, UK-scalable electronic system for collecting patient-reported outcome measures (PROMs), at regular post-diagnostic timepoints, and linking these with clinical data in cancer registries.

Methods:

A multidisciplinary team developed the system using agile methods. Design entailed process mapping the system's constituent parts, data flows and involved human activities, and undertaking usability testing. Informatics specialists built new technical components, including a web-based questionnaire tool and tracking database, and established component-connecting data flows. Development challenges were overcome, including patient usability and data linkage and security.

Results:

We have developed a system in which PROMs are completed online, using a secure questionnaire administration tool, accessed via a public-facing website, and the responses are linked and stored with clinical registry data. Patient monitoring and communications are semiautomated via a tracker database, and patient correspondence is primarily Email-based. The system is currently honed for clinician-led hospital-based patient recruitment.

Conclusions:

A feasibility test study is underway. Although there are possible challenges to sustaining and scaling up ePOCS, the system has potential to support UK epidemiological PROMs collection and clinical data linkage.

P2-08-01: Impact of Aromatase Inhibitors on Background Parenchymal Enhancement and Amount of Fibroglandular Tissue on Breast MRI

Background: On breast MRI, background parenchymal enhancement (BPE) and volume of fibroglandular tissue (FGT) have been shown to reflect a patient's hormonal status. Tamoxifen has been shown to reduce mammographic breast density and may serve as an early predictor of response in the prevention setting (Cuzick, JNCI 2011). We have shown that adjuvant tamoxifen can reduce BPE in the unaffected breast in women with breast cancer. We hypothesize that aromatase inhibitor (AI) induced endocrine changes in breast tissue should also be evident and therefore we performed a study to evaluate whether adjuvant AI therapy influences BPE or amount of FGT in the contralateral breast.

Methods: An electronic medical record review identified 856 postmenopausal women with stage I-III breast cancer who had at least two breast MRIs and took adjuvant AI treatment. A retrospective chart review was conducted to select those patients without a history of prior tamoxifen or raloxifene treatment who had a MRI of the contralateral breast both before and during 6 to 12 months of AI treatment. After exclusion of all irradiated breasts, 168 women were eligible. MRIs were performed between August 1999 and June 2010. Two radiologists who were blind to AI treatment status, independently rated level of BPE and amount of FGT using categorical scales: BPE — Minimal, Mild, Moderate, Marked; FGT — Fatty, Scattered, Heterogeneously Dense, Dense (based on proposed BIRADS criteria for BPE and on ACR criteria for FGT). Blinded side-by-side direct comparison evaluated whether there was a category change between the two MRIs. A consensus was reached in cases of disagreement. The Wilcoxon signed-rank test was used to assess changes in rating categories for BPE and FGT between before and during AI breast MRIs. A waiver of authorization was granted by the institutional review board for this study.

Results: In this study 127/168 (76%) women were treated with anastrozole, 33/168 (20%) with letrozole and 8/168 (5%) with exemestane. Based on the blinded side-by-side comparison, a category (or more) decrease in BPE occurred during treatment with AIs (p&lt;0.0001). There was an overall shift from higher to lower degree of BPE in 35% (45/127) of the women taking anastrozole while a category increase occurred in only one woman (1%; p &lt;0.0001). A similar result was seen in the women taking letrozole [45% (15/33) had a decrease versus 3% (1/33) an increase; p=0.0003] and exemestane [25% (2/8) had a decrease versus 12.5% (1/8) an increase; p=0.50]. For FGT a category decrease occurred in 5% (6/127) of anastrozole users while no increase occurred [0% (0/127), p=0.016]. The respective numbers for letrozole were 3% (1/33) and 0% (0/33), and nobody on exemestane had a change in FGT.

Conclusions: After 6 to 12 months of treatment with adjuvant AIs, there was a statistically significant category (or more) decrease in BPE. BPE is more sensitive than FGT to changes in normal breast stroma that occur during adjuvant treatment with AIs and BPE may be a marker of anti-hormonal activity in the breasts.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-01.

Chronic non-communicable disease risk factor survey 2010 among University of the West Indies staff at Cave Hill, Barbados

OBJECTIVE

To determine the prevalence of risk factors for chronic non-communicable diseases (CNCDs) among staff of The University of the West Indies (UWI), Cave Hill campus, in Barbados.

METHODS

A self-administered questionnaire comprising validated questions from the WHO STEPS NCD Risk Factor Survey, the Jamaica Healthy Lifestyle (JHL) Survey and the Behaviour Risk Factor (BRF) Survey, was conducted during the Staff Health Day in May 2010, and at four locations on campus during July 2010. Standardized measurements of weight, height and blood pressure were taken. Data were analysed using EXCEL and STATA and results were compared to the Barbados 2007 STEPS NCD survey.

RESULTS

The target population was all staff at the Cave Hill campus of UWI. The coverage rate was 25.2% (269/1068); 63.8% of males and 75% of females were either overweight or obese. Ninety-seven per cent ate less than the recommended 5 fruits and vegetables per day. Low levels of physical activity were reported in 51.9% of males and 62.2% of females. Thirty-two per cent of males and 13% of females were binge drinkers. All participants had at least one of the risk factors (current daily smoker < 5 fruits and vegetables/day, physical inactivity, overweight/obese and raised blood pressure) whilst 48% of males and 57.2% of females demonstrated three or more risk factors. These results are similar to those found in the Barbados STEPS NCD risk factor survey of 2007.

CONCLUSION

The results confirm a similar high prevalence of NCD risk factors among Cave Hill UWI staff as among the Barbadian population. The study reveals opportunities to inform policy on strategies to positively impact the risk factors.

Breast MRI Screening of Women with a Prior High-Risk Lesion: Preliminary Results

Purpose: To determine the frequency of breast cancer detection in women at increased risk due to a prior high-risk lesion.Materials and methods: An IRB approved retrospective review was performed of the records of 2184 breast MRIs starting from 1999, to identify patients who commenced screening breast MRI who had a history of a prior high risk lesion. Eighty-three women were identified who had a prior biopsy demonstrating a high-risk lesion such as atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS). History, imaging, and pathologic findings were reviewed.Results: Histologies of prior high-risk lesions in these 83 women were ADH in 24, LCIS in 54 and ALH in 5. The median length of MRI follow-up was four (range, 1-9) years. Biopsies were recommended based on MRI findings in 39 (47%) of 83 women, yielding cancer in seven (8%) women (four of whom also had benign biopsies), and benign findings only in 32 (39%) women. Six of the seven women who developed a breast cancer also had a family history of breast cancer. Histologic findings in these seven cancers were ductal carcinoma in situ (DCIS) in 4 (57%) and invasive cancer in three (43%). Invasive cancer histologies (n=3) were ductal in one and lobular in two; maximal histologic size was 2.0 cm. This large invasive cancer had a mammographic, sonographic, and palpable correlate, and was node-positive; the other cancers were identified by MRI only. Among these seven cancers, two (29%) were detected in screening year 1, two (29%) in screening year 2, two (29%) in screening year 3 and one in screening year 4 (14%). Three (43%) of the seven cancers were in the contralateral breast. In these 83 women, the likelihood of detecting cancer by MRI was higher in those with, rather than without, a family history of breast cancer (6/54=11% vs. 1/29=3%) and in women with prior LCIS rather than prior ADH (6/54=11% vs. 1/24=4%).Conclusion: Breast MRI detected cancer in 7 (8%) of 83 women with a prior high-risk lesion, six (86%) of whom also had a family history of breast cancer. Among these cancers, all were detected during the first four years of screening and less than half were invasive (43%). Further work with more patients is needed to determine the utility of breast MRI screening in women with specific prior high-risk lesions, with and without additional risk factors.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4002.

Background Enhancement Patterns on Screening Breast MRI – Impact on Biopsy Rate and Short Interval Follow Up

Introduction:Marked background enhancement is one of the perceived limiting factors on breast MRI possibly obscuring suspicious lesions and reducing both the sensitivity and specificity of detection of small cancers. Background enhancement on MRI refers to the normal physiological enhancement of the woman's fibroglandular tissue and varies with age, hormonal status, menstrual cycle and breast glandularity. Patterns of enhancement vary greatly and marked enhancement can occur even when the MRI is performed in week 2 of the menstrual cycle or in postmenopausal women.Aim:To determine what impact background enhancement has on biopsy rate and short interval follow up rate.Method:231 consecutive baseline screening MRIs, in women aged between 16 -79 (average age 48) performed between Jan 2003 and Oct 2004 were selected. Indications for screening included significant family history (46.3%), personal history of contralateral mastectomy (25.1%), personal history of atypia (19.5%), other (3.0%), personal history of mantle radiation (2.2%), personal history of breast cancer &gt; 5 years previously (2.2%), personal history of ovarian cancer (1.7%).The background enhancement in each case was described as minimal (&lt; 25% glandular tissue showing enhancement), mild (25-50% enhancement), moderate (50-75% enhancement) and marked (&gt; 75% enhancement).The BIRADS category, positive predictive value of biopsy and false positive rate was determined and compared for enhancement patterns.Results:Of 231 screening studies 26.6% demonstrated minimal enhancement, 32.8% mild enhancement, 22.7% moderate enhancement and 17.9% marked enhancement. Patients with minimal/mild enhancement had significantly higher rate of normal (BIRADS 1/2) examinations than those with moderate/marked enhancement (47.8% vs. 30.5%, p = 0.008). Patients with minimal/mild enhancement had significantly lower rate of six month followup (BIRADS 3) (38.97% vs. 53.68%, p = 0.02). No significant difference in biopsy rate was noted (11.7% minimal/mild enhancement vs. 14.7% moderate/marked enhancement, p = 0.5). No significant difference in positive predictive value of biopsy between the groups was noted (35.7% for moderate/marked enhancement vs. 25% for minimal/mild enhancement, p = 0.52).Conclusion:No significant association was found between background enhancement pattern and biopsy rate or false positive rate. However, patients with moderate/marked enhancement were significantly more likely to be given a category of BIRADS 3 and assigned to short interval follow up. The increased rate of BIRADS 3 in patients with moderate/marked background enhancement may be related to reduced reader confidence in these patients. Recognition of normal background enhancement patterns is important to limit the number of patients undergoing short interval followup.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4020.

Intra-vaginal hydrosonography and cervical length assessment in pregnant women before induction of labour: A modified technique

The objective of this study was to demonstrate a new simple technique in introducing saline into the vagina during trans-vaginal scan. This technique will help to identify the cervical length properly when it is difficult to delineate the cervix. This is a prospective study, which included 104 pregnant women who booked to have induction of labour at term over a period of 3 years. Women who were included in the study underwent a transvaginal scan to measure cervical length. Sterile saline was introduced into the vagina using either an ordinary syringe or an Endosampler and the cervical length re-measured. When the outer border of the cervix was not clearly visualised, there was a highly statistically significant difference (p < 0.001) between the medians of pre-and post-saline cervical length measurements. In contrast, no significant difference between the medians (p > 0.05) was detected when the outer border of the cervix was clearly delineated. In those women, who had previous surgery to the cervix, it was very difficult to identify the cervix at all without the saline injection during transvaginal scanning. We conclude that intra-vaginal saline can be used as a contrast medium to help delineate the cervix if it is difficult to identify during transvaginal scan. The Endosampler makes the introduction of the saline into the vagina easy, controlled and well tolerated.

Global analysis of nuclear receptor expression and dysregulation in human osteoarthritic articular cartilage: reduced LXR signaling contributes to catabolic metabolism typical of osteoarthritis

OBJECTIVE

Compare the expression and regulation of nuclear receptors (NRs) in osteoarthritic and normal human articular cartilage.

METHOD

The transcriptional levels of 48 NRs and additional related proteins were measured in mRNA from human articular cartilage from subjects with osteoarthritis (OA) and compared to samples from subjects without OA, using microarrays, individual quantitative reverse transcriptase polymerase chain reaction assays, and a custom human NR TaqMan Low Density Array (TLDA). The functional effect of liver X receptor (LXR) activity in cartilage was studied by measuring proteoglycan (PG) synthesis and degradation in articular cartilage explant cultures following treatment with the synthetic LXR agonist T0901317.

RESULTS

Thirty-one of 48 NRs analyzed by TLDA were found to be measurably expressed in human articular cartilage; 23 of these 31 NRs showed significantly altered expression in OA vs unaffected cartilage. Among these, LXRalpha and LXRbeta, and their heterodimeric partners retinoid X receptor (RXR)alpha and RXRbeta were all expressed at significantly lower levels in OA cartilage, as were LXR target genes ABCG1 and apolipoproteins D and E. Addition of LXR agonist to human OA articular chondrocytes and to cartilage explant cultures resulted in activation of LXR-mediated transcription and significant reduction of both basal and interleukin (IL)-1-mediated PG degradation.

CONCLUSIONS

Articular cartilage expresses a substantial number of NRs, and a large proportion of the expressed NRs are dysregulated in OA. In particular, LXR signaling in OA articular cartilage is impaired, and stimulation of LXR transcriptional activity can counteract the catabolic effects of IL-1. We conclude that LXR agonism may be a possible therapeutic option for OA.

The need for a revised staging system of metastatic (M) colorectal cancer (CRC): Evidence from a national perspective on survival following surgically treated (HPX) liver metastases

4099

Background: AJCC V.6 (2002) places all patients with MCRC beyond the lymph node basin of the primary tumor in a homogenous Stage 4. Patients with inoperable hepatic MCRC can be made operable with curative intent with chemotherapy yet remaining in Stage 4. Via the linkage of routine health datasets across England this population-based study sought to determine the impact of HPX for MCRC on stage-matched survival at initial presentation. Methods: All patients between 1998–2001 undergoing surgery for CRC in England were identified via the national-linked cancer registry HES dataset. All care episodes in the 3 years following initial colorectal surgery were examined to determine the frequency of subsequent HPX. Kaplan-Meier curves and log- rank tests were used to examine 5-year survival following HPX for MCRC compared to all Stage 3 and Stage 4 at presentation. Survival was calculated from the date of resection of each patient's primary colorectal tumor. Results: 68,307 individuals were identified as undergoing surgery for primary CRC over the study period. 20,298 were Stage 3 at presentation. 1,483 (2.2%) subsequently underwent HPX <3 years of their colorectal operation. 55 patients died within 30 days of HPX (mortality rate: 3.7%). Crude 5-year survival of patients who underwent HPX was 41.6% (95%CI 39.0–44.1%) from time of initial colectomy. This survival rate was significantly better than that for both Stage 3 (38.6% (95%CI 37.9%-39.2%, P<0.01) and 4 (6.1% 95%CI 5.3–6.9%, P<0.01) overall. Conclusions: 5-year survival following HPX for MCRC is better than that seen overall for all Stage 3 patients (with MCRC confined to the regional draining lymph node basin) following initial colectomy. Our data support the hypothesis that all MCRC that is potentially resectable with curative intent should be stratified within Stage 3, and Stage 4 should only contain those MCRC patients for whom surgery is not an option. If further evidence emerges to support this theory then a revision of the current staging system will be required.

[Table: see text]

Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene?

OBJECTIVE

To determine the variation in the rates of use of abdominoperineal excision (APE) by cancer network, hospital trust and surgeon across England between 1998 and 2004 and determine if any variation could be explained by differences in patient characteristics such as stage of disease, age, gender or socioeconomic deprivation.

DESIGN

Retrospective study of a population-based dataset comprised of cancer registry and hospital episode statistics data.

SETTING

All NHS providers of rectal cancer surgery within England.

PATIENTS

31,223 patients diagnosed with rectal cancer and receiving a major abdominal procedure within the NHS in England between 1998 and 2004.

MAIN OUTCOME MEASURE

Rates and odds of use of APE were determined in relation to patient case-mix and each patient's managing surgeon, trust and cancer network.

RESULTS

The rate of use of APE decreased from 30.5% in 1998 to 23.0% in 2004. Males, the economically deprived and those managed by surgeons operating on fewer than seven rectal cancer cases per year were all significantly more likely to receive an APE. There were also significant variations in the odds of receiving an APE over time and between individual surgeons and hospital trusts independently of patient case-mix.

CONCLUSIONS

Over the study period the use of APE decreased but statistically significant variation was observed in its application independently of case mix. Reducing this variation will remove inequalities, reduce colostomy rates, and improve outcomes in rectal cancer. Rates of APE use could be a national performance measure.