Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

AIM: To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) score to predict that outcome.

METHODS: We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint.

RESULTS: Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD (12.8 ± 3.9 vs 12.6 ± 4.7, P = 0.9) or in the mean CTP (7.6 ± 1.2 vs 7.7 ± 1.7, P = 0.8) between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures (MELD: 22.4 ± 8.7 vs 15.2 ± 6.4, P = 0.0007; CTP: 9.9 ± 1.8 vs 8.5 ± 1.8, P = 0.008). The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them (AUC = 0.755 ± 0.066 for MELD vs AUC = 0.696 ± 0.070 for CTP, P = 0.3).

CONCLUSION: The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.

Impact of obesity on the surgical outcome following repeat hepatic resection in Japanese patients with recurrent hepatocellular carcinoma

AIM: To evaluate the impact of obesity on the posto-perative outcome after hepatic resection in patients with hepatocellular carcinoma (HCC).

METHODS: Data from 328 consecutive patients with primary HCC and 60 patients with recurrent HCC were studied. We compared the surgical outcomes between the non-obese group (body mass index: BMI < 25 kg/m²) and the obese group (BMI ≥ 25 kg/m²).

RESULTS: Following curative hepatectomy in patients with primary HCC, the incidence of postoperative complications and the long-term prognosis in the non-obese group (n = 240) were comparable to those in the obese group (n = 88). Among patients with recurrent HCC, the incidence of postoperative complications after repeat hepatectomy was not significantly different between the non-obese group (n = 44) and the obese group (n = 16). However, patients in the obese group showed a significantly poorer long-term prognosis than those in the non-obese group (P < 0.05, five-year survival rate; 51.9% and 92.0%, respectively).

CONCLUSION: Obesity alone may not have an adverse effect on the surgical outcomes of patients with primary HCC. However, greater caution seems to be required when planning a repeat hepatectomy for obese patients with recurrent HCC.

Value of APACHEⅡ scoring system in predicting the prognosis of severe acute pancreatitis

AIM: To evaluate the value of APACHEⅡ scoring system in predicting the prognosis of severe acute pancreatitis (SAP).

METHODS: Three hundred consecutive SAP patients, admitted into West China Hospital of Sichuan University from 2004 to 2007, were studied retrospectively. Data associated to APACHEⅡscoring system were recorded. We analyzed the APACHEⅡscore of the patients with various outcomes and the relationship between the mortality and APACHEⅡscore on the 1^th, 3^th and 7^th day. The prediction results of dead and survived patients using 8, 9, 10, and 11 scores as the cut off points were also analyzed.

RESULTS: The APACHEⅡscore between the dead patients or patients with local complications and recovered patients showed significant differences (P = 0 and 0.001 < 0.01). The mortality rate increased with the growing APACHEⅡscore. The APACHEⅡscore on the 1^th, 3^th and 7^th day was positively correlated with mortality rates. And the correlation on the 3^rd day was the strongest. The APACHEⅡscore within 24 h no less than 10 score was the best cut off point to predict the prognosis of SAP.

CONCLUSION: APACHEⅡscoring system can dynamically predict the changes of SAP and play a very important role in assessing prognosis and guiding therapy.

Elevated serum endostatin levels is associated with favorable outcome in acute myeloid leukemia

INTRODUCTION

Endostatin is the C-terminal antiangiogenic fragment of the extracellular matrix protein collagen XVIII, and is generated by tumor-derived proteases. The levels and the prognostic relevance of serum endostatin in AML patient is not fully clear.

AIM

To evaluate serum levels of endostatin in acute myeloid leukemia patients before chemotherapy and after achieving complete remission and to correlate endostatin levels with patients outcome.

MATERIALS AND METHODS

Serum samples from 30 adult patients (22 males and 8 females, median age 37, range 19-66 years) with AML had been taken before chemotherapy was administered. In addition 20 out of 30 patients were reinvestigated again at complete remission (CR). Ten samples from healthy normal persons of matched age and sex were evaluated as a reference control group. Serum endostatin levels were determined using enzyme linked immune sorbent assay (ELISA).

RESULTS

Endostatin serum levels were not significantly different in the pretreatment AML patients as compared to that in normal controls (P>0.05). In AML patients the baseline endostatin levels were significantly lower than at CR (P=0.001). No significant correlation were detected between pretreatment serum endostatin levels and age, peripheral blood white cell counts, platelet counts, bone marrow blast cell counts, blast cell distribution ratio. The prognostic value of sE was also evaluated by dividing AML patients into high and low sE groups using the 75 percentile sE levels of the patients group as cutoff. The authors found that patients group in the high sE group survived for significantly longer time than those patients in the low sE group.

CONCLUSIONS

Elevated endostatin levels at AML diagnosis is a good prognostic marker for patients' outcome. Wide scale study is recommended in order to establish the clinical value of this study.

Twin pregnancy complicated with acute fatty liver

Twin pregnancy complicated with acute fatty liver was found in a woman of thirty-one years old, and skin itching, digestive symptoms and jaundice were main manifestations. Acute fatty liver of pregnancy (AFLP) is usually severe and termination of pregnancy plays a key role in the treatment of AFLP. Early diagnosis and suitable treating method may result in a favorable prognosis.

Graft-verse-host disease after liver transplantation: A report of two cases and review of literature

Graft-verse-host disease (GVHD) is an uncommon fatal complication following liver transplantation (LTx). In mainland China, only six cases have been reported with a morbidity rate up to 1%-2%. Definitive diagnosis was achieved by molecular techniques (HLA typing or PCR-STR) in only two cases and the remaining cases were diagnosed based on typical clinical features with exclusion of other possible causes. All patients died of septic shock or multiple organ failure even after administration of increased corticosteroids and supportive therapy, and reduced immunosuppressive agents. In our center, two cases of GVHD were found among 128 (1.56%) patients. One case was diagnosed by detecting lymphocyte macrochimerism through DNA-STR. Both of them died even after aggressive treatment. In China, the incidence of GVHD is similar to that reported by foreign centers except for an extremely bad prognosis. Rapid diagnosis is crucial for a better prognosis. In China, only 37.5% of cases are diagnosed by molecular methods. We recommend detecting lymphocyte macrochimerism through DNA-STR to get a rapid diagnosis, and interleukin 2-receptor antibody (basiliximab or daclizumab) therapy seems to be a good choice for the disease.

Correlation of integrin β3 mRNA and vascular endothelial growth factor protein expression profiles with the clinicopathological features and prognosis of gastric carcinoma

AIM: To investigate integrin β3 mRNA and vascular endothelial growth factor (VEGF) protein expression in gastric carcinoma, and its correlation with microvascular density, growth-pattern, invasion, metastasis and prognosis.

METHODS: In situ hybridization (ISH) of integrin β3 mRNA and immunohistochemistry of VEGF and CD34 protein were performed on samples from 118 patients with gastric cancer.

RESULTS: The positive rate of integrin β3 mRNA in non-tumor gastric mucosa (20%) was significantly lower than that of the gastric cancer tissue (52.5%, χ² = 10.20, P < 0.01). In patients of infiltrating type, stage T₃-T₄, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the positive expression rates of integrin β3 mRNA were significantly higher than those in patients of expanding type (P < 0.01), stage T₁-T₂ (P < 0.01), non-vessel invasion (P < 0.01), without lymphatic metastasis (P < 0.01), without hepatic and peritoneal metastasis (P < 0.01), respectively. In patients of infiltrating type, stage T₃-T₄, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the positive expression rates of VEGF protein were significantly higher than those in patients of expanding type (P < 0.01), stage T₁-T₂ (P < 0.01), non-vessel invasion (P < 0.01), without lymphatic metastasis (P < 0.01), without hepatic and peritoneal metastasis (P < 0.01), respectively. In patients of infiltrating type, stage T₃-T₄, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the mean MVD were significantly higher than those in patients of expanding type (P < 0.01), stage T₁-T₂ (P < 0.01), non-vessel invasion (P < 0.01), without lymphatic metastasis (P < 0.01), without hepatic and peritoneal metastasis (P < 0.01), respectively. It was found that the positive expression rate of integrin β3 mRNA was positively related to that of VEGF protein (P < 0.01) and MVD (P < 0.05), meanwhile the positive expression rate of VEGF protein was positively related to MVD (P < 0.05). The mean survival period in patients with positive expression of integrin β3 mRNA and VEGF, and MVD ≥ 54.9/mm² was significantly shorter than that in patients with negative expression of integrin β3 mRNA (P < 0.05) and VEGF (P < 0.01), and MVD < 54.9/mm² (P < 0.01). Five-year survival rate in patients with positive expression of integrin β3 mRNA and VEGF, and MVD ≥ 54.9/mm² was significantly lower than those with negative expression of integrin β3 mRNA (P < 0.05), VEGF (P < 0.05), and MVD < 54.9/mm² (P < 0.01).

CONCLUSION: Integrin β3 and VEGF expression can synergistically enhance tumor angiogenesis, and may play a crucial role in invasion and metastasis of gastric carcinoma. Therefore, they may be prognostic biomarkers and novel molecular therapeutic targets.

C-reactive protein levels during a relapse of Crohn’s disease are associated with the clinical course of the disease

AIM: To explore if C-reactive protein (CRP) levels might serve as a prognostic factor with respect to the clinical course of Crohn’s disease and might be useful for classification.

METHODS: In this retrospective cohort study we enrolled 94 patients from the inflammatory bowel disease (IBD) database of the University Medical Centre Utrecht. CRP levels during relapse were correlated with the number of relapses per year. Severity of relapses was based on endoscopic reports and prednisone use. Furthermore, patients were categorized in a low or high CRP group based on their CRP response during relapse and demographic and clinical features were compared.

RESULTS: Overall, a positive correlation between CRP levels, number of relapses, and severity of relapse was found (respectively r_s = 0.31, P < 0.01 and r_s = 0.50, P < 0.001). Employing a cut-off level of 15 mg/L, the index CRP level was found to discriminate patients with respect to the number of relapses per year, as well as for severity of relapses (respectively 0.25 ± 0.16 vs 0.36 ± 0.24, P < 0.05 and 4.4 ± 1.2 vs 3.2 ± 1.1 on a 10-point visual analogue scale, P < 0.001 for the high CRP and low CRP groups respectively). In addition, the high CRP group showed more cumulative days of prednisone use per year (107 ± 95 vs 58 ± 48, P < 0.05), as well as a better response to infliximab (93 % vs 33 %, P = 0.06).

CONCLUSION: A higher CRP level during relapse seems to be associated with a more severe clinical course of disease.

The prognostic value of atrial and brain natriuretic peptides, troponin I and C-reactive protein in patients with sepsis

AIM

To investigate the plasma levels of atrial and brain natriuretic peptides (ANP and BNP), cardiac troponin I (cTnI) and C-reactive protein (CRP) as prognostic factors for survival in patients with sepsis.

METHOD

Evaluation of serum levels of ANP, BNP, cTnI and CRP of patients on admission to an intensive care unit, two days later, and on the day of discharge from the intensive care unit or on the day of death.

RESULTS

ANP levels were significantly higher in the nonsurviving patients (day 1: 70.00+/-49.54 pg/mL; day 2: 138.85+/-143.15 pg/mL; and died/discharged day: 375.70+/-262.66 pg/mL) than surviving patients (day 1: 23.96+/-29.93 pg/mL; day 2: 10.06+/-6.03 pg/mL; died/discharged day: 6.68+/-100.98 pg/mL, P<0.001). The BNP levels were significantly higher in the nonsurvivors (day 1: 254.78+/-308.62 pg/mL; day 2: 383.22+/-307.19 pg/mL; and died/discharged day: 696.47+/-340.33 pg/mL), than survivors (day 1: 13.72+/-12.95 pg/mL; day 2: 7.20+/-5.85 pg/mL; died/discharged day: 4.51+/-4.64 pg/mL, P<0.001). The cTnI levels were significantly higher in the nonsurviving patients (day 2: 0.16+/-0.38 mug/L; died/discharged day: 0.78+/-2.48 mug/L) than surviving patients (day 2: 0.04+/-0.07 mug/L; died/discharged day: 0.02+/-0.01 mug/L, P<0.05). The CRP levels were significantly higher in the nonsurvivors (day 2: 119.3+/-71.5 mg/L; and died/discharged day: 145.7+/-74.7 mg/L) than survivors (day 2: 57.0+/-29.7 mg/L; died/discharged day: 26.8+/-24.0 mg/L, P<0.05). There were no significant differences between nonsurvivors and survivors for cTnI and CRP on day 1.

CONCLUSION

With the exception of cTnI and CRP on day 1, all of the parameters were significantly powerful to determine nonsurvivors on all days. Among these variables, BNP was the most powerful diagnostic parameter for the prediction of nonsurvivors on all days.

The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians?

A large number of prognostic factors have been associated with recovery from an episode of back pain, and much emphasis has been placed on psychosocial prognostic factors. The large number of prognostic factors and the lack of comparative analysis of different factors make use of these difficult in clinical practice. The aim of this study was to evaluate the comparative usefulness of a range of factors to predict outcome using data from a randomized controlled trial (RCT) in which 312 patients with sub-acute to chronic back pain received a mechanical evaluation and were sub-grouped based on the presence or absence of directional preference (DP). Patients were then randomized to treatment that was matched or unmatched to that DP. Patients with a minimal reduction of 30% in Roland-Morris Disability Questionnaire (RMDQ) score were defined as the good outcome group. Seventeen baseline variables were entered into a step-wise logistic regression analysis for the ability to predict a good outcome. Of the patients, 84 met the good outcome criteria and had a mean RMDQ decrease of 58.2% (9.8 points) in 4 visits. Leg pain, work status, depression, pain location, chronicity, and treatment assignment were significant predictors of outcome in univariate analysis. Only leg bothersomeness rating and treatment assignment survived multivariate analysis. Subjects with DP/centralization who received matched treatment had a 7.8 times greater likelihood of a good outcome. Matching patients to their DP is a stronger predictor of outcome than a range of other biopsychosocial factors.

The survival of osteosarcoma patients 10 years old or younger is not worse than the survival of older patients: a retrospective analysis

PURPOSE

This study aimed to assess whether a young age at the time of diagnosis with osteosarcoma has value to predict the prognosis.

MATERIALS AND METHODS

Sixty-seven children with stage II osteosarcoma were stratified according to the age of 10. There were 32 preadolescents (<or=10 years) and 35 adolescents (10<age<or=15 years). The patients were analyzed for their clinical characteristics, the histologic response to preoperative chemotherapy, event-free survival (EFS) and the patterns of relapse.

RESULTS

After a median follow-up of 54 months (range: 6 approximately 153 months), the 5-year EFS of the preadolescent and adolescent groups was 64.5+/-9.3% and 58.2+/-9.1%, respectively, and age did not have any statistical significance for survival (p=0.55). Cox regression analysis revealed that both the serum level of alkaline phosphatase and the histologic response to preoperative chemotherapy were significantly related to survival of the 67 patients. Those patients aged less than 7 years responded poorly to preoperative chemotherapy and their rate of amputation was 43%. However, their 5-year EFS was not statistically different from the older patients (57.1+/-18.7 vs 67.7+/-6.3%, respectively, p=0.58).

CONCLUSIONS

We could not find any statistical difference in the clinical characteristics and survival from osteosarcoma for the preadolescents and adolescents, so the current approach of having the same protocol for both groups of patients seems to be reasonable.

Large-artery stenosis predicts subsequent vascular events in patients with transient ischemic attack

Background and purpose

We investigated subsequent vascular events in patients with transient ischemic attack (TIA) and determined the predictors of such events among vascular risk factors including large-artery disease, TIA-symptom duration, and acute ischemic lesions on diffusion-weighted imaging (DWI).

Methods

We identified 98 consecutive patients with TIA who visited a tertiary university hospital and underwent DWI and brain magnetic resonance angiography within 48 hours of symptom onset. We reviewed the medical records to assess the clinical characteristics of TIA, demographics, and the subsequent vascular events including acute ischemic stroke, TIA, and myocardial infarction.

Results

Large-artery disease was detected in 55 patients (56%). Ten patients (10%) experienced TIA symptoms for longer than 1 hour, and acute infarctions on DWI were identified in 30 patients (31%). During the mean follow-up period of 19 months, seven patients (7%) had an acute ischemic stroke and 20 patients (20%) had TIA. Retinal artery occlusion in two patients, spinal cord infarction in one patient, and peripheral vascular claudication in one patient were also recorded. Cox proportional-hazards multivariate analysis revealed that large-artery disease was an independent predictor of subsequent cerebral ischemia (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.1-7.1; p=0.02) and subsequent vascular events (HR, 2.9; 95% CI, 1.2-6.7; p=0.01).

Conclusions

In patients with TIA, large-artery disease is an independent predictor of subsequent vascular events. Acute infarction on DWI and a symptom duration of more than 1 hour are not significantly correlated with a higher risk of subsequent vascular events. These findings suggest that the underlying vascular status is more important than symptom duration or acute ischemic lesion on DWI.

Relationship between survivin expression and recurrence, and prognosis in hepatocellular carcinoma

AIM: To study the expression of the inhibitor of apoptosis protein survivin in hepatocellular carcinoma (HCC), and its correlation with clinicopathological factors, cell proliferation, recurrence and prognosis after hepatectomy.

METHODS: Immunohistochemical staining of survivin and Ki-67 was performed by the standard streptavidin-peroxidase technique on paraffin sections of 55 cases of HCC.

RESULTS: The positive rate of survivin in HCC was 52.7% (29/55). Significant correlation was found between survivin expression with portal vein thrombi and intrahepatic matastasistic nodes (P < 0.05). The recurrent rate in survivin-positive HCC was significantly higher than that in survivin-negative HCC after hepatectomy, the 1- and 3-year survival rate in patients with survivin-positive tumors was significantly lower than that in patients with survivin-negative tumors (58.62 and 10.34% vs 76.92 and 30.77%, P < 0.05, log-rank test). The proliferation index (Ki-67) in survivin-positive HCC (33.83% ± 18.90%) was significantly higher than that in survivin-negative HCC (19.60% ± 19.35%) (P < 0.05).

CONCLUSION: Survivin may play an important role in progression of HCC by promoting cell proliferation, and may be positively correlated with high risk of disease recurrence and poor prognosis in HCC. Its expression may serve as a prognostic factor for patients with HCC after hepatectomy.

Prognostic value of lateral lymph node metastasis for advanced low rectal cancer

AIM: To evaluate the risk factors for lateral lymph node metastasis in patients with advanced low rectal cancer, in order to make the effective selection of patients who could benefit from lateral lymph node dissection, as well as the relationship of lateral lymph node metastasis with local recurrence and survival of patients with advanced low rectal cancer.

METHODS: A total of 96 consecutive patients who underwent curative surgery with lateral pelvic lymphadenectomy for advanced lower rectal cancer were retrospectively analyzed. The relation of lateral lymph node metastasis with clinicopathologic characteristics, local recurrence and survival of patients was identified.

RESULTS: Lateral lymph node metastasis was observed in 14.6% (14/96) of patients with advanced low rectal cancer. Lateral lymph node metastasis was detected in 10 (25.0%) of 40 patients with tumor diameter ≥ 5 cm and in 4 (7.1%) of 56 patients with tumor diameter < 5 cm. The difference between the two groups was statistically significant (χ² = 5.973, P = 0.015). Lateral lymph node metastasis was more frequent in patients with 4/4 diameter of tumor infiltration (7 of 10 cases, 70.0%), compared with patients with 3/4, 2/4 and 1/4 diameter of tumor infiltration (3 of 25 cases, 12.0%; 3 of 45 cases, 6.7%; 1 of 16 cases, 6.3%) (χ² = 27.944, P = 0.0001). The lateral lymph node metastasis rate was 30.0% (9 of 30 cases), 9.1% (4 of 44 cases) and 4.5% (1 of 22 cases) for poorly, moderately and well-differentiated carcinoma, respectively. The difference between the three groups was statistically significant (χ² = 8.569, P = 0.014). Local recurrence was 18.8% (18 of 96 cases), 64.3% (9 of 14 cases), and 11.0% (9 of 82 cases) in patients with advanced low rectal cancer, in those with and without lateral lymph node metastasis, respectively. The difference between the two groups was statistically significant (χ² = 22.308, P = 0.0001). Kaplan-Meier survival analysis showed significant improvements in median survival (80.9 ± 2.1 m, 95% CI: 76.7-85.1 m vs 38 ± 6.7 m, 95% CI: 24.8-51.2 m) of patients without lateral lymph node metastasis compared with those with lateral lymph node metastasis (log-rank, P = 0.0001).

CONCLUSION: Tumor diameter, infiltration and differentiation are significant risk factors for lateral lymph node metastasis. Lateral pelvic lymphadenectomy should be performed following surgery for patients with tumor diameter ≥ 5 cm. Lateral lymph node metastasis is an important predictor for local recurrence and survival in patients with advanced low rectal cancer.

Early prediction of major depression in chronic hepatitis C patients during peg-interferon α-2b treatment by assessment of vegetative-depressive symptoms after four weeks

AIM: To study the predictive value of the vegetative-depressive symptoms of the Zung Depression Rating Scale for the occurrence of depression during treatment with peg-interferon α-2b of chronic hepatitis C (CHC) patients.

METHODS: The predictive value of vegetative-depressive symptoms at 4 wk of treatment for the occurrence of a subsequent diagnosis of major depressive disorder (MDD) was studied in CHC patients infected after substance use in a prospective, multi-center treatment trial in Belgium. The presence of vegetative-depressive symptoms was assessed using the Zung Scale before and 4 wk after the start of antiviral treatment.

RESULTS: Out of 49 eligible patients, 19 (39%) developed MDD. The area under the ROC curve of the vegetative Zung subscale was 0.73, P = 0.004. The sensitivity at a cut-point of > 15/35 was 95% (95% CI: 74-100). The positive predictive value equalled 44% (95% CI: 29-60).

CONCLUSION: In this group of Belgian CHC patients infected after substance use, antiviral treatment caused a considerable risk of depression. Seven vegetative-depressive symptoms of the Zung scale at wk 4 of treatment predicted 95% of all emerging depressions, at a price of 56% false positive test results.

Prognostic Significance of in situ Phenotypic Marker Expression in Diffuse Large B-cell Lymphomas

Diffuse large B-cell lymphomas (DLBCL) are the most common lymphoid malignancies, and encompass all malignant lymphomas characterized by large neoplastic cells and B-cell derivation. In the last decade, DLBCL has been subjected to intense clinical, phenotypic and molecular studies, and were found to represent a heterogeneous group of tumors. These studies suggested new disease subtypes and variants with distinct clinical characteristics, morphologies, immunophenotypes, genotypes or gene expression profiles, associated with distinct prognoses or unique sensitivities to particular therapy regimens. Unfortunately, the reliability and reproducibility of the molecular results remains unclear due to contradictory reports in the literature resulting from small sample sizes, referral and selection biases, and variable methodologies and cut-off levels used to determine positivity. Here, we review phenotypic studies on the prognostic significance of protein expression profiles in DLBCL and reconsider our own retrospective data on 301 primary DLBCL cases obtained on a previously validated tissue microarray in light of powerful statistical methods of determining optimal cut-off values of phenotypic factors for prediction of outcome.

Prognostic factors analysis of 118 elderly postoperative patients with gastric cancer

AIM: To study the relationship between clinical characteristics, postoperative chemotherapy and prognosis in elderly patients with gastric cancer.

METHODS: One hundred and eighteen elderly postoperative patients with gastric cancer were retrospectively analyzed from January 1997 to January 2006 in our hospitals, using Kaplan-Meier and Cox regression analysis to evaluate candidate prognosis factors, such as gender, clinical stage, differentiation, invasion depth, lymph node metastasis, distant metastasis, lymph-vascular space invasion, number of surgical resection lymph nodes, tumor residual and postoperative chemotherapy.

RESULTS: In univariate survival analysis, clinical stage, invasion depth, lymph node metastasis, distant metastasis, postoperative chemotherapy and tumor residual were obviously correlated with the prognosis (P < 0.05). In multivariable analysis, postoperative chemotherapy, tumor residual and clinical stage were confirmed to be independent factors (P = 0.000, P = 0.000 and P = 0.002).

CONCLUSION: Postoperative chemotherapy, tumor residual and clinical stage are independent prognostic factors in elderly postoperative gastric cancer patients, with stage Ⅲ and Ⅳ elderly patients that accept postoperative chemotherapy having an obvious survival advantage. However, postoperative chemotherapy does not improve survival in stage Ⅰ and Ⅱ elderly patients.

Neural cell adhesion molecule-180 expression as a prognostic criterion in colorectal carcinoma: Feasible or not?

AIM: To evaluate the frequency of neural cell adhesion molecule (NCAM)-180 expression in fresh tumor tissue samples and to discuss the prognostic value of NCAM-180 in routine clinical practice.

METHODS: Twenty-six patients (16 men, 10 women) with colorectal cancer were included in the study. Fresh tumor tissue samples and macroscopically healthy proximal margins of each specimen were subjected to flow-cytometric analysis for NCAM-180 expression.

RESULTS: Flow-cytometric analysis determined NCAM-180 expression in whole tissue samples of macroscopically healthy colorectal tissues. However, NCAM-180 expression was positive in only one case (3.84%) with well-differentiated Stage II disease who experienced no active disease at 30 mon follow-up.

CONCLUSION: As a consequence of the limited number of cases in our series, it might not be possible to make a generalisation, nevertheless the routine use of NCAM-180 expression as a prognostic marker for colorectal carcinoma seems to be unfeasible and not cost-effective in clinical practice due to its very low incidence.

Serum transforming growth factor-β1 level reflects disease status in patients with esophageal carcinoma after radiotherapy

AIM: To evaluate the relationship between changes in serum transforming growth factor β1 (TGFβ1) level and curative effect of radiotherapy (RT) in patients with esophageal carcinoma.

METHODS: Ninety patients with histologically confirmed esophageal carcinoma were enrolled. Serum samples for TGFβ1 analysis were obtained before and at the end of RT. An enzyme-linked immunosorbent assay was used to measure serum TGFβ1 level. Multivariate analysis was performed to investigate the relationship between disease status and changes in serum TGFβ1 level.

RESULTS: Serum TGFβ1 level in patients with esophageal carcinoma before RT was significantly higher than that in healthy controls (P < 0.001). At the end of RT, serum TGFβ1 level was decreased in 67.82% (59/87) of the patients. The overall survival rate at 1, 3 and 5 years was 48.28% (42/87), 19.54% (17/87) and 12.64% (11/87), respectively. Main causes of death were local failure and regional lymph node metastasis. In patients whose serum TGFβ1 level decreased after RT, the survival rate at 1, 3 and 5 years was 61.02% (36/59), 28.81% (17/59) and 18.64% (11/59), respectively. The survival rate at 1 year was 17.86% (5/28) in patients whose serum TGFβ1 level increased after RT, and all died within 18 mo (P < 0.01).

CONCLUSION: Serum TGFβ1 level may be a useful marker for monitoring disease status after RT in patients with esophageal carcinoma.

Value of ΔMELD in evaluating the prognosis of patients with decompensated cirrhosis

AIM: To assess the prognostic significance of ΔMELD (longitudinal modifications of the model for end-stage liver disease over time) in patients with decompensated liver cirrhosis.

METHODS: A cohort of 181 patients with decompensated liver cirrhosis was studied. Initial MELD and Child-Pugh score and classification were calculated at entry. MELD score was obtained for each patient according to the modified formula by Kamath. After initial assessment, all the patients had a second evaluation that was performed in the follow-up period. ΔMELD was calculated as second MELD subracted initial MELD, and divided by the time interval (months). Kaplan-Meier survival analysis was used to compare the survival in sub-groups ranked by the initial MELD, ΔMELD and Child-Pugh classification. The area under the receiver operating characteristic (ROC) curve (AUC) was used to compare initial MELD, ΔMELD and Child-Pugh classification in predicting accuracy. The variables, including gender, age, etiology and ascites were entered into a Cox proportional hazard model in survival analysis to determine the risk ratio.

RESULTS: All subgroups ranked by initial MELD, ΔMELD and Child-Pugh classification were significantly different from each other in pairwise comparisons. The AUC values generated by the ROC curves for the ΔMELD, initial MELD and Child-Pugh classification were 0.865, 0.729 and 0.626, respectively, in predicting 6-month survival. The differences in AUCs between ΔMELD, initial MELD and Child-Pugh classification were significant in pairwise comparisons. On multivariate Cox regression, there were five variables including ascites, bilirubin, albumin, encephalopathy and international normalized ratio (INR) being the independent risk factors for increasing delta MELD.

CONCLUSION: ΔMELD is a useful prognostic indictor for decompensated liver cirrhosis. Prognosis using ΔMELD is superior to initial MELD and Child-Pugh score and classification.

Elucidation of the relationship of BNIP3 expression to gemcitabine chemosensitivity and prognosis

AIM: To evaluate the significance of BNIP3 in the pathogenesis of pancreatic cancer, we analyzed the relationship between the expression of BNIP3 and survival rate of the patients with pancreatic cancer, or chemosensitivities in pancreatic cancer cell lines, particularly for gemcitabine, the first-line anti-tumor drug for pancreatic cancer.

METHODS: To compare the expression level of BNIP3 with the resistance to gemcitabine, eight pancreatic cancer cell lines were subjected to gemcitabine treatment and the quantitative real-time RT-PCR method was used to evaluate BNIP3 expression. Immunohistochemical analysis was also performed using 22 pancreatic cancer specimens to study relationship between BNIP3 expression and survival rate.

RESULTS: Although no significantly positive association between BNIP3 mRNA level and gemcitabine chemosensitivity was observed, pancreatic cancer cell lines that were sensitive to gemcitabine treatment tended to show high levels of BNIP3 expression. The converse, an absence of BNIP3 expression, was not correlated with gemcitabine resistance. We further compared the BNIP3 expression profiles of resected primary pancreatic cancer specimens with the prognosis of the patients, and found a tendency of favorable prognosis and low BNIP3 expression.

CONCLUSION: High levels of BNIP3 expression cannot be used as one of the predicting factors for gemcitabine chemosensitivity, and some yet to be known factors will have to fill the gap for the accurate prediction of pancreatic cancer chemosensitivity to gemcitabine. However, BNIP3 expression may have an impact on prediction of prognosis of patients with pancreatic cancer.

Importance of MutL homologue MLH1 and MutS homologue MSH2 expression in Turkish patients with sporadic colorectal cancer

AIM: To assess the incidence of MLH1 (the human MutL homologue) and MSH2 (the human MutS homologue) protein expression in Turkish patients with sporadic colorectal cancers and to compare their survival and clinicopathological features.

METHODS: We validated the tissue microarray technology in 77 colorectal carcinomas by analyzing the immunohistochemical expression of proteins involved in two main pathways of colorectal carcinogenesis: p53 protein for loss of heterozygosity tumors; MLH1 and MSH2 proteins for microsatellite instability (MSI).

RESULTS: Our analysis showed that 29 (39.2%) had loss of MLH1 expression, 5 (6.8%) had loss of MSH2 expression and 2 cases had loss of expression of both proteins. We found that 60% of MSH2-negative tumors were located in the right side of the colon; all MSH2-negative cases were women. In addition, the loss of MSH2 expression was correlated with low p53 expression. Neither MLH1 nor MSH2 expressions were associated with prognosis, although there seemed a tendency of longer survival (71.7 ± 8.65 mo vs 47.08 ± 5.26 mo) for the patients with MLH1-negative versus MLH1-positive carcinomas. There were not significant differences in overall and recurrence-free survival among MLH1/MSH2-positive and -negative cases.

CONCLUSION: Our data supports that Turkish patients with MLH1- and MSH2-defective tumors have some distinct features from each other. Although prognostic importance remains controversial, immunohistochemical analysis of mismatch repair genes may be used as a routine histopathological examination of sporadic colorectal carcinomas.

Sinonasal tract angiosarcoma: a clinicopathologic and immunophenotypic study of 10 cases with a review of the literature

BACKGROUND

Primary sinonasal tract angiosarcoma are rare tumors that are frequently misclassified, resulting in inappropriate clinical management. There are only a few reported cases in the English literature.

MATERIALS AND METHODS

Ten patients with sinonasal tract angiosarcoma were retrospectively retrieved from the Otorhinolaryngic Registry of the Armed Forces Institute of Pathology.

RESULTS

Six males and four females, aged 13 to 81 years (mean, 46.7 years), presented with epistaxis and bloody discharge. Females were on average younger than their male counterparts (37.8 vs. 52.7 years, respectively). The tumors involved the nasal cavity alone (n = 8) or the maxillary sinus (n = 2), with a mean size of 4.3 cm; the average size was different between the genders: males: 2.8 cm; females: 6.4 cm. Histologically, all tumors had anastomosing vascular channels lined by remarkably atypical endothelial cells protruding into the lumen, neolumen formation, frequent atypical mitotic figures, necrosis, and hemorrhage. All cases tested (n = 6) demonstrated immunoreactivity with antibodies to Factor VIII-RA, CD34, CD31, and smooth muscle actin, while non-reactive with keratin and S-100 protein. The principle differential diagnosis includes granulation tissue, lobular capillary hemangioma (pyogenic granuloma), and Kaposi's sarcoma. All patients had surgery followed by post-operative radiation (n = 4 patients). Follow-up was available in all patients: Six patients died with disease (mean, 28.8 months); two patients had died without evidence of disease (mean, 267 months); and two are alive with no evidence of disease at last follow-up (mean, 254 months).

CONCLUSIONS

Sinonasal tract angiosarcoma is a rare tumor, frequently presenting in middle-aged patients as a large mass usually involving the nasal cavity with characteristic histomorphologic and immunophenotypic features. Sinonasal tract angiosarcoma will often have a poor prognosis making appropriate separation from other conditions important.

Squamous cell carcinoma of the descending colon: report of a case and literature review

It is very rare that squamous cell carcinoma (SCC) arises from colorectal epithelium. An 89-year-old man was treated in 2001 with chief complaints of anorexia, abdominal pain, and low grade fever. The histological diagnosis as SCC was determined by biopsy during a colonoscopy. We diagnosed primary SCC of the colon because except in the colon no malignant lesions were found by systemic CT. Surgical complete resection was performed. However, he died three months after surgical resection because of hepatic metastasis and cachexia. The prognosis of this disease seems to be worse than that of adenocarcinoma.

Role of serum interleukin-18 as a prognostic factor in patients with hepatocellular carcinoma

AIM: To determine whether serum interleukin-18 (IL-18) levels correlated with clinicopathologic features and prognosis in patients with hepatocellular carcinoma (HCC).

METHODS: Serum IL-18, IL-6 and IL-12 levels were measured by enzyme-linked immunosorbent assay (ELISA) from 70 patients with HCC and 10 healthy controls.

RESULTS: Serum IL-18, IL-6 and IL-12 levels of patients with HCC were significantly higher that those of the controls. The levels of IL-18 correlated significantly with the presence of venous invasion and advanced tumor stages classified by Okuda’s criteria. Patients with high serum IL-18 levels (≥ 10⁵ pg/mL) had a poorer survival than those with low serum IL-18 levels (< 10⁵ pg/mL) (4 and 11 mo, respectively, P = 0.015). Multivariate analyses showed that serum IL-18 level, but not IL-6 and IL-12 levels, was a significant and independent prognostic factor of survival.

CONCLUSION: These findings demonstrate that serum IL-8 may a useful biological marker of tumor invasiveness and an independent prognostic factor of survival for patients with HCC. Thus, the detailed mechanisms of IL-18 involving in tumor progression should be further investigated.

Expression of G3BP and RhoC in esophageal squamous carcinoma and their effect on prognosis

AIM: To investigate the expression and significance of G3BP and RhoC proteins in esophageal squamous carcinoma (ESC).

METHODS: The expression of G3BP and Rhoc proteins in 80 cases of ESC was detected by immunohistochemistry. The relationship was studied between the expression of the two proteins and tumor size, differentiation degree, TNM stage, lymph node metastasis and prognosis of ESC.

RESULTS: The positive expression rate of G3BP in ESC was 71.25%; and the rate in the lymph node metastasis group was significantly higher than that in the non-lymph node metastasis group (Z = -2.283, P = 0.022), but no relations were found between G3BP expression and tumor size, differentiation degree and TNM stage (P > 0.05). The group with G3BP positive expression had shorter survival time than the group with G3BP negative expression (P = 0.000). The positive expression rate of RhoC in ESC was 66.25%; and the rate in the lymph node metastasis group was significantly higher than that in the non-lymph node metastasis group (Z = -2.115, P < 0.05), but no relations were found between RhoC expression and tumor size, differentiation degree and TNM stage (P > 0.05). The RhoC positive expression group had a shorter survival time than the RhoC negative expression group (P < 0.001. The expression of G3BP protein correlated positively with the expression of RhoC in ESC tissues (r_s = 0.656, P < 0.001).

CONCLUSION: The expression of G3BP and RhoC protein is closely related to the lymph node metastasis and survival in ESC patients. G3BP and RhoC proteins can be considered as predictors of prognosis in ESC patients.

Effect of lymph node micrometastases on prognosis of gastric carcinoma

AIM: To evaluate the relationship between lymph node micrometastases and prognosis of patients with gastric carcinoma and to evaluate the significance of the new assessment of nodal status in determining the pN categories in the 5th edition of the UICC TNM classification.

METHODS: A total of 850 lymph nodes from 30 patients with gastric carcinoma who underwent gastrectomy with lymphadenectomy were assessed by reverse transcription polymerase chain reaction assay in addition to histologic examination. Cytokeratin-20 gene marker was used in this assay.

RESULTS: Routine examination by HE staining confirmed metastasis in 233 lymph nodes from 20 patients. All these 233 lymph nodes were cytokeratin-20 positive. Moreover, lymph node micrometastases were detected in an additional 67 lymph nodes in 12 of these 20 patients. Lymph node micrometastases were also detected in 10 lymph nodes from 2 of 10 patients who had no obvious metastases identified by HE staining. Totally, lymph node micrometastases were identified by the reverse transcription polymerase chain reaction assay in 77 (12.5%) lymph nodes from 14 (46.7%) patients with gastric carcinoma. Of 27 patients who underwent curative resection, 7 (25.9%) were up-staged (fromIB stage to II stage in 1 patient, from IB stage to IIIA stage in 1 patient, from II stage to IIIA stage in 1 patient, from IIIA stage to IIIB stage in 1 patient, from IIIA stage to IV stage in 1 patient, from IIIB stage to IV stage in 2 patients). In a median follow-up of 32 (range 8-36) mo, Kaplan-Meier survival analysis showed significant improvements in median survival (22.86 ± 3.17 mo, 95% CI: 16.64-29.08 mo vs 18.00 ± 7.4 mo, 95% CI: 3.33-32.67 mo) of patients with negative lymph node micrometastases over patients with positive lymph node micrometastases (log-rank, P < 0.05).

CONCLUSION: Lymph node micrometastases have a significant impact on the current staging system of gastric carcinoma, and are significant risk factors for prognosis of patients with gastric carcinoma.

Effects of neoadjuvant radiochemotherapy on pathological stage and prognosis of middle and advanced esophageal carcinoma

AIM: To evaluate the effects of neoadjuvant radiochemotherapy on the pathological stage and prognosis of middle and advanced esophageal carcinoma.

METHODS: Between January 1991 and December 2000, 473 patients with middle and advanced esophageal carcinoma were randomly divided into four groups; neoadjuvant radiotherapy (n = 118), neoadjuvant chemotherapy (n = 119), neoadjuvant radiochemotherapy (n = 118) and control (surgery alone) (n = 118). The differences in resection rates, pathological stage, treatment-related complications and survival rates were statistically analyzed.

RESULTS: The data showed that the radical resection rate for patients in the radiotherapy, chemotherapy and radiochemotherapy groups was increased compared with that of the control group (97.5%, 86.6% and 98.3% vs 73.7%, all P < 0.01). The pathological stages of the radiotherapy and radiochemotherapy groups were more significantly regressed than that of the control group (P < 0.01). The chemotherapy group did not show the same effect. Treatment-related complications of the three neoadjuvant groups showed no significant difference from that of the control group (P > 0.05). The 3-year survival rates of the radiotherapy and radiochemotherapy groups were significantly higher than that of the control group (69.5% and 73.7% vs 53.4%, both P < 0.01). The 5-yr survival rate of the radiochemotherapy group was higher than that of the radiotherapy group, but did not demonstrate statistical significance (45.0% vs 40.7%, P > 0.05).

CONCLUSION: The rational application of neoadjuvant radiochemotherapy appears to provide a modest survival benefit and to improve the quality of life for patients with middle and advanced esophageal carcinomas.

E-cadherin and beta-catenin expression in Epstein-Barr virus-associated gastric carcinoma and their prognostic significance

AIM: To examine the role of E-cadherin and beta-catenin in carcinogenesis and to assess their prognostic implication in Epstein-Barr virus-associated gastric carcinomas (EBV-GCs).

METHODS: We compared the frequency of E-cadherin and beta-catenin expression in 59 EBV-GCs and 120 non-EBV-GCs, and examined the association between patients' prognosis and the expressions of these proteins.

RESULTS: Neither the cellular-membranous nor the cytoplasmic E-cadherin expression showed any difference between EBV-GCs and non-EBV-GCs. On the other hand, loss of membranous expression of beta-catenin occurred more frequently in non-EBV-GCs than EBV-GCs [odds ratio = 0.41; 95% confidence interval (CI), 0.19-0.90]. Furthermore, the nuclear and/or cytoplosmic expression of beta-catenin was seen more frequently in EBV-GCs than non-EBV-GCs (odds ratio = 2.23; 95% CI, 0.97-5.09), and was observed in a larger proportion of carcinoma cells of EBV-GCs than non-EBV-GCs (P = 0.024). Survival analysis for non-EBV-GC revealed that lymph node metastasis was significantly associated with poor prognosis (P < 0.001). Among EBV-GCs, the depth of invasion (P = 0.005), lymph node metastasis (P = 0.004) and an intestinal type by Lauren classification (hazard ratio = 9.47; 95% CI, 2.67-33.6) were significantly associated with poor prognosis. On the other hand, nuclear and/or cytoplasmic expression of beta-catenin was associated with a better prognosis in patients with EBV-GC (hazard ratio = 0.32; 95% CI, 0.11-0.93).

CONCLUSION: We observed more frequent preservation of beta-catenin in cell membrane and accumulation in nuclei and/or cytoplasm in EBV-GCs than in non-EBV-GCs. Factors involved in the prognosis of EBV-GCs and non-EBV-GCs are different in the two conditions.

Telomerase activity in colorectal cancer, prognostic factor and implications in the microsatellite instability pathway

AIM: To determine whether the telomerase activity is related to the Microsatellite instability (MSI) genetic pathway and whether it means a difference in the survival.

METHODS: The population consisted of 97 colorectal cancer patients. MSI determination was performed in accordance with the NCI criteria using PCR and Genescan. Telomerase activity was determined by the TRAP-assay, an ELISA procedure based on the amplification of telomeric repeat sequences.

RESULTS: 6.2% showed high MSI (MSI-H), 10.3% showed low MSI (MSI-L) and 83.5% did not show this alteration (MSS). Positive telomerase activity was detected in 92.8% of the patients. 83.3% of MSI-H tumors showed positive telomerase against 93.8% of MSS tumors. In the overall survival analysis the absence of telomerase activity conferred a better prognosis.

CONCLUSION: Previous works have shown that tumors which develop via the MSI pathway present a better prognosis. No link between telomerase activity and MSI status is observed, although sample sizes are small. Patients with telomerase negative tumors had better overall survival than patients with telomerase positive tumors.

Early bile duct cancer

Bile duct cancers are frequently diagnosed as advanced diseases. Over half of patients with advanced bile duct cancer present with unresectable malignancies and their prognosis has been very poor even after curative resections. Although there has been a need to diagnose bile duct cancer at its early stage, it has been a difficult goal to achieve due to our lack of knowledge regarding this disease entity. Early bile duct cancer may be defined as a carcinoma whose invasion is confined within the fibromuscular layer of the extrahepatic bile duct or intrahepatic large bile duct without distant metastasis irrespective of lymph node involvement. Approximately 3%-10% of resected bile duct cancers have been reported to be early cancers in the literature. The clinicopathological features of patients with early bile duct cancer differ from those of patients with advanced bile duct cancer, with more frequent asymptomatic presentation, characteristic histopathological findings, and excellent prognosis. This manuscript is organized to emphasize the need for convening an international consensus to develop the concept of early bile duct cancer.

Study of circumferential resection margin in patients with middle and lower rectal carcinoma

AIM: To clarify the relationship between circumferential resection margin status and local and distant recurrence as well as survival of patients with middle and lower rectal carcinoma. The relationship between circumferential resection margin status and clinicopathologic characteristics of middle and lower rectal carcinoma was also evaluated.

METHODS: Cancer specimens from 56 patients with middle and lower rectal carcinoma who received total mesorectal excision at the Department of General Surgery of Guangdong Provincial People’s Hospital were studied. A large slice technique was used to detect mesorectal metastasis and evaluate circumferential resection margin status.

RESULTS: Local recurrence occurred in 12.5% (7 of 56 cases) of patients with middle and lower rectal carcinoma. Distant recurrence occurred in 25% (14 of 56 cases) of patients with middle and lower rectal carcinoma. Twelve patients (21.4%) had positive circumferential resection margin. Local recurrence rate of patients with positive circumferential resection margin was 33.3% (4/12), whereas it was 6.8% (3/44) in those with negative circumferential resection margin (P = 0.014). Distant recurrence was observed in 50% (6/12) of patients with positive circumferential resection margin; conversely, it was 18.2% (8/44) in those with negative circumferential resection margin (P = 0.024). Kaplan-Meier survival analysis showed significant improvements in median survival (32.2 ± 4.1 mo, 95% CI: 24.1-40.4 mo vs 23.0 ± 3.5 mo, 95% CI: 16.2-29.8 mo) for circumferential resection margin-negative patients over circumferential resection margin-positive patients (log-rank, P < 0.05). 37% T₃ tumors examined were positive for circumferential resection margin, while only 0% T₁ tumors and 8.7% T₂ tumors were examined as circumferential resection margin. The difference between these three groups was statistically significant (P = 0.021). In 18 cancer specimens with tumor diameter ≥ 5 cm 7 (38.9%) were detected as positive circumferential resection margin, while in 38 cancer specimens with a tumor diameter of < 5 cm only 5 (13.2%) were positive for circumferential resection margin (P = 0.028).

CONCLUSION: Our findings indicate that circumferential resection margin involvement is significantly associated with depth of tumor invasion and tumor diameter. The circumferential resection margin status is an important predictor of local and distant recurrence as well as survival of patients with middle and lower rectal carcinoma.

Prognostic significance of HIF-2α/EPAS1 expression in hepatocellular carcinoma

AIM: To evaluate the prognostic significance of HIF-2α/EPAS1 expression in hepatocellular carcinoma (HCC).

METHODS: Surgical specimens from 315 patients with HCC as well as 196 adjacent noncancerous lesions and 22 cases of normal liver tissue were investigated by immunohistochemistry (IHC) for HIF-2α/EPAS1 using a standard detection system. Correlations with clinicopathological factors, VEGF, microvessel density (MVD), and prognosis were analyzed.

RESULTS: Immunoreactivity of HIF-2α/EPAS1 was positive in 69.5% of HCC, 55.6% of adjacent noncancerous tissue, and 0% of normal liver tissue. And it was significantly correlated with tumor grade, venous invasion, intrahepatic metastasis, necrosis, and capsule infiltration. Correlation analysis of HIF-2α/EPAS1 with angiogenic factor VEGF (P < 0.001), and MVD (P = 0.016) was also noted. HIF-2α/EPAS1 protein was less frequently expressed in low MVD cases, whereas a high rate of expression was noted in cases with both medium and high MVD (P = 0.042). By Kaplan-Meier analysis, strong HIF-2α/EPAS1 staining (> 50% of tumor cells) in HCC correlated with a shortened survival in patients (Cox's regression, P < 0.001, r = 3.699).

CONCLUSION: We conclude that HIF-2α/EPAS1 expression may play an important role in tumor progression and prognosis of HCC. Assessment of HIF-2α/EPAS1 expression in HCC may be used as a diagnostic tool and possibly a target in the treatment of HCC.

Anemia and heart failure: a cause of progression or only a consequence?

Anemia is one of the most frequent co-morbidities in the patients with heart failure. Its prevalence increases from 4-7% in the subjects with asymptomatic left ventricular dysfunction to >30% in the patients with severe heart failure. Renal insufficiency, activation of inflammatory mediators, and treatment with renin-angiotensin antagonists seem to be its main determinants. The results of many studies agree in showing that anemia is a powerful independent determinant of survival in patients with heart failure. However, the mechanisms of this relation are still incompletely understood. Moreover a favourable effect on prognosis of the correction of anemia has not been shown, yet, and also controlled studies assessing its effects on exercise tolerance have yielded controversial results.

Predicting prognosis of rectal cancer patients with total mesorectal excision using molecular markers

AIM: To explore the prognostic variables in rectal cancer patients undergoing curative total mesorectal excision and the effect of postoperative chemotherapy in advanced rectal cancer.

METHODS: A total of 259 consecutive rectal cancer patients treated with curative total mesorectal excision between 1999 and 2004 were collected. p53, p21, PCNA, and CD44v6 were examined using immunohistochemistry (IHC). The correlation between clinicopathological or molecular variables and clinical outcomes, including local recurrence, metastasis, disease-free survival and overall survival, was analyzed.

RESULTS: The median follow-up was 44 mo. Five-year survival rates and 5-year disease free survival rates were 75.43% and 70.32%, respectively. Multi-analysis revealed TNM staging, preoperative CEA, and CD44v6 level were independent risk factors predicting overall survival or disease free survival. The hazard ratio of peroperative CEA was 2.65 (95% CI 1.4-5) and 3.10 (95% CI 1.37-6.54) for disease free survival and overall survival, respectively. The hazard ratio of CD44v6 was 1.93 (95% CI 1.04-3.61) and 2.21 (95% CI 1.01-4.88) for disease free survival and overall survival, respectively. TNM staging was the only risk factor predicting local recurrence. Postoperative chemotherapy without radiotherapy did not improve patients’ outcome.

CONCLUSION: TNM staging, preoperative CEA and CD44v6 were independent prognostic factors for rectal cancer patients with total mesorectal excision. Postoperative chemotherapy may be only used together with radiotherapy for rectal cancer patients.

Prognostic value of DNA alterations on chromosome 17p13.2 for intrahepatic cholangiocarcinoma

AIM: To characterize and evaluate DNA alterations among intrahepatic cholangiocarcinoma (ICC) patients.

METHODS: DNA from tumor and corresponding normal tissues of 52 patients was amplified with 33 arbitrary primers. The DNA fragment that alters most frequently in ICC was cloned, sequenced, and identified by comparison with known nucleotide sequences in the genome database (www.ncbi.nlm.nih.gov). The DNA copy numbers of the allelic alterations in cholangiocarcinoma were determined by quantitative real-time PCR and interpreted as allelic loss or DNA amplification by comparison with the reference gene. Associations between allelic imbalance and clinicopathological parameters of ICC patients were evaluated by χ²-test. The Kaplan-Meier method was used to analyze survival rates.

RESULTS: From 33 primers, an altered DNA fragment (518 bp) amplified from BC17 random primer was found frequently in the tumors analyzed and mapped to chromosome 17p13.2. Sixteen of 52 (31%) cases showed DNA amplification, while 7 (13%) showed allelic loss. Interestingly, DNA amplification on chromosome 17p13.2 was associated with a good prognosis, median survival time (wk) of amp vs no amp was 44.14 vs 24.14, P = 0.002; whereas allelic loss of this DNA sequence corresponded with a poor prognosis, median survival time (wk) of loss vs no loss was 18.00 vs 28.71, P = 0.019). Moreover, Kaplan-Meier curves comparing the DNA alterations with survival depicted highly significant separation that the median survival time equal to DNA amplification, allelic loss, and normal was 44.14 wk, 18.00 wk, and 24.29 wk, respectively (P = 0.005).

CONCLUSION: Alterations in the DNA sequence on chromosome 17p13.2 may be involved in cholangio-carcinogenesis, and could be used as a prognostic marker in the treatment of ICC patients.

Survivin: Potential role in diagnosis, prognosis and targeted therapy of gastric cancer

Survivin is a protein that is highly expressed in a vast number of malignancies, but is minimally expressed in normal tissues. It plays a role as an inhibitor of cell death in cancer cells, thus facilitating the growth of these cells. In the case of gastric cancer, survivin is over-expressed in tumor cells and plays a role in the carcinogenesis process. Several studies on gastric cancer have indicated that there is a relationship between survivin expression and the ultimate behavior of the carcinoma. Since the expression pattern of survivin is selective to cancer cells, it has been described as an “ideal target” for cancer therapy. Currently, several pre-clinical and clinical trials are on-going to investigate the effects of interfering with survivin function in cancer cells as a biologic therapy. Survivin is a potentially significant protein in the diagnosis, prognosis and treatment of gastric tumors.

Expression level of beta-catenin is associated with prognosis of esophageal carcinoma

AIM: To examine the association of beta-catenin with the clinicopathologic features and prognosis of esophageal squamous cell carcinoma (ESCC).

METHODS: Beta-catenin mRNA expression level in 40 ESCC patients (28 males and 12 females, age range 38-82 years, median 60 years) was analyzed by real-time PCR. Beta-catenin mRNA expression levels in tumor cells were categorized as weaker (level 1) or equal to or stronger (level 2) than those in endothelial cells. We examined the correlation between the beta-catenin expression and the clinicopathological factors and prognosis of ESCC patients.

RESULTS: Level 2 beta-catenin expression was found in 29 patients. ESCC with level 2 expression had a higher rate of lymphnode metastasis (0.0776 ± 0.0369 vs 0.3413 ± 0.1803, P < 0.001) and deeper tumor invasion (0.0751 ± 0.0356 vs 0.3667 ± 0.1928, P < 0.001), and a poorer survival rate (P = 0.0024) than ESCC with level 1 expression.

CONCLUSION: Beta-catenin expression in ESCC is of great importance.

Hospital mortality prediction of four severity scoring models on hepatitis B and acute-on-chronic liver failure: an analysis of 76 cases

AIM: To compare the applicability between liver failure special severity scoring systems and intensive care unit (ICU) general severity scoring systems on predicting the hospital mortality of critical hepatitis B and acute-on-chronic liver failure patients.

METHODS: The data of 76 patients with hepatitis B and acute-on-chronic liver failure were retrospectively analyzed. The patients were divided into dead group (n = 34) and survival group (n = 42). Two liver failure special severity scoring models, MELD and SMSVH, and ICU general severity scoring models, acute physiology and chronic health evaluationⅡ (APACHEⅡ) and APACHEⅢ, were used in the analysis. The receiver operating characteristic (ROC) curves were drawn up to assess the ability of these models in hospital mortality discrimination.

RESULTS: The scores in death group were significantly higher than those in survival group (MELD: 38.19 ± 8.09 vs 24.12 ± 7.16; SMSVH: 5.29 ± 1.36 vs 4.19 ± 1.09; APACHEⅡ: 15.47 ± 4.06 vs 10.79 ± 2.56; APACHEⅢ: 73.50 ± 17.79 vs 60.02 ± 10.06; all P < 0.01). The areas under ROC curves for these 4 models were 0.906 (MELD), 0.848 (APACHEⅡ), 0.770 (APACHEⅢ) and 0.749 (SMSVH).

CONCLUSION: MELD exhibits the best ability to predict hospital mortality.

Analysis on clinicopathological characteristics and prognosis of 576 patients with primary colorectal cancer

AIM: To analyze the clinicopathological characteristics of primary colorectal cancer and explore the influencing factors on the prognosis of patients.

METHODS: The clinical data of 576 patients with colorectal cancer diagnosed by colonoscopy during the past five years in the second affiliated hospital of Sun Yat-Sen University were analyzed retrospectively.

RESULTS: The occurrence rate of colorectal cancer was not significantly different between patients of different ages. The frequency of abdominal pain (χ² = 7.20, P < 0.05), the proportion of mucinous adenocarcinoma (χ² = 43.71, P < 0.05) and the rate of lymph node metastasis (χ² = 4.47, P < 0.05) in adolescent group were significantly higher than those in the mid-aged and aged one. The number of thin individuals was markedly higher in the aged group than that in the adolescent and mid-aged group (χ² = 9.64, P < 0.05). High differentiation was also observed in the aged patients (χ² = 8.06, P < 0.05). The overall 5-year survival rate was 61.79% (43.64%, 87.16% and 53.79% in the adolescent, mid-aged, and aged patients, respectively). The prognosis of colorectal cancer was associated with the age, tumor cell differentiation, lymph node metastasis, Dukes stages and the radical operation.

CONCLUSION: The frequency of abdominal pain, the malignant degree and the proportion of lymph node metastasis are the highest in the young patients. Age and Dukes staging are the independent factors correlated with the prognosis.

Prognosis analysis of patients with decompensated liver cirrhosis using the model of end-stage liver disease

AIM: To compare the capability of the model for end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) in predicting the prognosis of patients with decompensated liver cirrhosis (DLC) using receiver operating characteristic (ROC) curve.

METHODS: The data of 171 DLC patients were analyzed with a cohort method. The patients were graded with MELD formula into 4 (MELD ≤ 9, 10 ≤ MELD ≤ 19, 20 ≤ MELD ≤ 29, MELD ≥ 30) and 3 (A, B and C) groups, respectively. The death rate was observed within 1 mo and 3 mo in different groups. The predictive accuracy of the two systems was evaluated by ROC curve.

RESULTS: The mortality rates of patients with MELD ≤ 9, 10 ≤ MELD ≤ 19, 20 ≤ MELD ≤ 29 and MELD ≥ 30 were 10.6%, 23.9%, 68.0% and 75.0% within 1 mo respectively, and 10.6%, 28.4%, 80.0% and 84.4% within 3 mo respectively. While the mortality rates of patients with Child-Pugh A, B and C were 9.7%, 21.1% and 44.9% within 1 mo respectively, and 9.7%, 23.9% and 52.2% within 3 mo respectively. When MELD was used to predict the mortality within 1 and 3 mo, the values of area under the curve (AUC) were 0.832 and 0.844, respectively, higher than those as CTP was used (0.768 and 0.772).

CONCLUSION: Both MELD and Child-Pugh scores can predict the short-term prognosis of DLC patients, but the predictive capability of MELD system is better than that of CTP systems.

Biomarkers in bladder cancer: present status and perspectives

Bladder cancers are a mixture of heterogeneous cell populations, and numerous factors are likely to be involved in dictating their recurrence, progression and the patient's survival. For any candidate prognostic marker to have considerable clinical relevance, it must add some predictive capacity beyond that offered by conventional clinical and pathologic parameters. Here, the current situation in bladder cancer research with respect to identification of suitable prognostic markers is reviewed. A number of individual molecular markers that might predict bladder cancer recurrence and progression have been identified but many are not sufficiently sensitive or specific for the whole spectrum of bladder cancer diseases seen in routine clinical practice. These limitations have led to interest in other molecular parameters that could enable more accurate prognosis for bladder cancer patients. Of particular interest is the epigenetic silencing of tumor suppressor genes. Since the methylation of these genes can correlate with a poor prognosis, the methylation profile may represent a new bio-marker that indicates the risk of transitional cell carcinoma development. In addition, bladder cancer research is likely to be revolutionized by high-throughput molecular technologies, which allow rapid and global gene expression analysis of thousands of tumor samples. Initial studies employing these technologies have considerably expanded our ability to classify bladder cancers with respect to their survivability. Future microarray analyses are likely to reveal particular gene expression signatures that predict the likelihood of bladder cancer progression and recurrence, as well as patient's survival and responsiveness to different anti-cancer therapies, with great specificity and sensitivity.

Upregulation of hypoxia inducible factor 1α mRNA is associated with elevated vascular endothelial growth factor expression and excessive angiogenesis and predicts a poor prognosis in gastric carcinoma

AIM: To investigate the implication of the hypoxia inducible factor HIF-1α mRNA in gastric carcinoma and its relation to the expression of vascular endothelial growth factor (VEGF) protein, tumor angiogenesis invasion/metastasis and the patient's survival.

METHODS: In situ hybridization was used to examine expression of HIF-1α mRNA, and immunohistochemical staining was used to examine expression of VEGF protein and CD34 in 118 specimens from patients with gastric carcinoma.

RESULTS: The positive rates of HIF-1α mRNA and VEGF protein were 49.15% and 55.92%, respectively. Positive expressions of HIF-1α and VEGF in stage T₃-T₄ tumors and those with vessel invasion, lymph node metastasis and distant metastasis were dramatically stronger than stage T₁-T₂ cases and those without vessel invasion, lymph node metastasis and distant metastasis. The mean microvascular density (MVD) in stage T₃-T₄ tumors and those with vessel invasion, lymph node metastasis and distant metastasis was significantly higher than stage T₁-T₂ tumors and those without vessel invasion, lymph node metastasis and distant metastasis. The mean MVD in tumors with positive HIF-1α and VEGF expression was significantly higher than that in tumors with negative HIF-1α and VEGF expression. The expression of HIF-1α was positively correlated with VEGF protein. There were positive correlations between MVD and expression of HIF-1α and VEGF. The mean survival time and the 5-year survival rate in cases with positive expression HIF-1α and VEGF and MVD value ≥ 41.5/0.72 mm² were significantly lower than those with negative expression of HIF-1α and VEGF and MVD value < 41.5/0.72 mm².

CONCLUSION: Overexpression of HIF-1α is found in gastric carcinoma. HIF-1α may induce the angiogenesis in gastric carcinoma by upregulating the transcription of VEGF gene, and take part in tumor invasion and metastasis. They can be used as prognostic markers of gastric cancer in clinical practice.

Expression and significance of intratumoral interleukin-12 and interleukin-18 in human gastric carcinoma

AIM: To explore the effect of intratumoral expressions of interleukin-12 (IL-12) and interleukin-18 (IL-18) on clinical features, angiogenesis and prognosis of gastric carcinoma.

METHODS: The expressions of IL-12 and IL-18 from 50 samples of gastric cancer tissue were analyzed by immunohistochemistry, and microvessel density (MVD) was determined with microscopic imaging analysis system.

RESULTS: The positive expression rates of IL-12 and IL-18 were 44% (22/50) and 26% (13/50), respectively. IL-12 was significantly associated with pathologic differentiation, depth of invasion, lymph node metastasis, distant metastasis, and TNM stage, and IL-18 was closely related to distant metastasis. Intratumoral IL-12 and IL-18 expressions were not statistically related to MVD scoring. IL-12-positive patients survived significantly longer than those with IL-12-negative tumors, but there was no significant difference between IL-18-positive patients and IL-18-negative ones. The multivariate analysis with Cox proportional hazard model revealed IL-12, MVD and T stage were independent prognostic factors.

CONCLUSION: The positive expressions of IL-12 and IL-18 can play an important role in progression and metastasis of gastric cancer, and IL-12 might be an independent factor of poor prognosis in gastric carcinoma.

Expression of CXC chemokine receptor CXCR4 in colorectal carcinoma and its correlation with prognosis Meng-Xian Zhang, Iqbal Kashif, Shi-Ying Yu

AIM: To investigate the expression of chemokine receptor CXCR4 in colorectal carcinoma and its correlation with the clinicopathologic characteristics and prognosis.

METHODS: Immunohistochemistry was used to detect the expression of CXCR4 and tumor microvessel density (MVD) in 67 tissue specimens of colorectal carcinoma, and the correlation between the CXCR4 expression and clinicopathologic factors was evaluated.

RESULTS: The positive rate of CXCR4 expression was 56.7% in colorectal carcinoma, which was correlated with lymph node metastasis, clinical staging and MVD as well as the survival of patients, but not with the sex and age of patients, tumor location, T staging, and pathological types. The expression of CXCR4 was 40.6%, 68.2% and 76.9% in cases of N0, N1 and N2 stage, 39.4% and 73.5% in cases of Ⅰ+Ⅱ and Ⅲ stage, respectively. The positive rate of CXCR4 expression was significantly lower in the case with low MVD than that with high MVD (36.4% vs 74.3%, P < 0.01), and the CXCR4-positive case had a higher recurrent or metastatic rate (47.4% vs 24.1%, P < 0.05) and a lower 3-year survival rate (32.6% vs 71.3%, P < 0.05) than the CXCR4-negative one.

CONCLUSION: Positive CXCR4 expression and high tumor MVD are associated with the poor prognosis of patients, and they can be used as potential predictive factors for the recurrence or metastasis of colorectal cancer.

Correlations of serum nitric oxide, interleukin-6, interleukin-10 and tumor necrosis factor levels with the prognosis of patients with liver cirrhosis

AIM: To study the roles of serum nitric oxide (NO), interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor (TNF) in the prognosis of patients with liver cirrhosis.

METHODS: Nitrate reductase assay and double-antibody sandwich enzyme-linked immunosorbent assay were used to examine the serum levels of NO, IL-6, IL-10 and TNF in 56 patients with liver cirrhosis before and after treatment, and 30 healthy individuals served as controls.

RESULTS: High levels of NO, IL-6, and TNF and low level of IL-10 were observed in patients with cirrhosis. After treatment, the serum levels of NO (129.21 ± 27.32 mmol/L vs 92.18 ± 25.68 mmol/L, P < 0.05), IL-6 (198.5 ± 23.2 mg/L vs 147.0 ± 19.1 mg/L, P < 0.05), and TNF (179.2 ± 23.5 pg/dL vs 121.4 ± 17.5 pg/dL, P < 0.05) were significantly elevated while the level of IL-10 (33.4 ± 7.2 mg/L vs 51.6 ± 18.5 mg/L, P < 0.05) was markedly decreased in patients with aggravated hepatic function as compared with those before therapy. However, the levels of NO (58.63 ± 12.25 mmol/L vs 94.36 ± 23.45 mmol/L, P < 0.05), IL-6 (90.3 ± 12.7 mg/L vs 148.5 ± 15.8 mg/L, P < 0.05) and TNF (78.2 ± 14.3 pg/dL vs 124.9 ± 20.1 pg/dL, P < 0.05) were decreased while the level of IL-10 (89.3 ± 18.9 mg/L vs 48.8 ± 9.5 mg/L, P < 0.05) was elevated in patients with improved hepatic function after treatment in comparison with those before treatment.

CONCLUSION: The serum levels of NO, IL-6, IL-10 and TNF are correlated with the prognosis of patients with liver cirrhosis.

Evaluation of prognostic markers in severe drug-induced liver disease

AIM: To analyze the outcome of patients with severe drug-induced liver disease (DILD) associated with jaundice classified as hepatocellular, cholestatic or mixed liver injury and to evaluate the validity of Hy’s rule and the most important predictors for outcome.

METHODS: The Adverse Drug Reaction Advisory Committee was set up in 1997 in our hospital to identify all suspicions of DILD following a structured prospective report form. Liver damage was divided into hepatocellular, cholestatic, and mixed types according to laboratory and histologic criteria when available. Further evaluation of causality assessment was performed.

RESULTS: From January 1997 to December 2004, 265 patients were diagnosed with DILD，and 140 (52.8%) of them were female. hepatocellular damage was the most common (72.1%), the incidence of death was 9.9% in patients with hepatocellular damage and 9.5% in patients with cholestatic/mixed damage (P < 0.05). There was no difference in age of dead and recovered patients. The proportion of females and males was similar in recovered and dead patients, no difference was observed in duration of treatment between the two groups. The serum total bilirubin (P < 0.001), direct bilirubin (P < 0.001) and aspartate transaminase (AST) (P = 0.013) values were higher in dead patients than in recovered patients. Chinese herbal medicine was the most frequently prescribed, accounting for 24.2% of the whole series. However, antitubercular drugs (3.4%) were found to be the primary etiological factor for fetal DILD. Factors associated with the development of fulminant hepatic failure were hepatic encephalopathy (OR = 43.66, 95% CI = 8.47-224.95, P < 0.0001), ascite (OR = 28.48, 95% CI = 9.26-87.58, P < 0.0001), jaundice (OR = 11.43, 95% CI = 1.52-85.96, P = 0.003), alcohol abuse (OR = 3.83, 95% CI = 1.26-11.67, P = 0.035) and direct bilirubin (OR = 1.93, 95% CI = 1.25-2.58, P = 0.012).

CONCLUSION: Death occurs in 9.8% of patients with DILD. Chinese herbal medicine stands out as the most common drug for DILD. While antitubercular drugs are found to be the primary etiological factor for fetal DILD, hepatic encephalopathy, ascites, jaundice, alcohol abuse and direct bilirubin levels are associated with the death of DILD patients.

Significance of Survivin expression and its correlation with Bcl-2 protein expression in colorectal carcinoma

AIM: To study the expression of Survivin and its correlation with expression of Bcl-2 protein in colorectal carcinoma.

METHODS: The expression of Survivin and Bcl-2 protein was evaluated by immunnohistochemistry in 52 case of colorectal carcinoma. The relationship between Survivin expression and clinical indexes as well as Bcl-2 expression was analyzed.

RESULTS: Survivin was expressed in 27 of 52 (51.9%) colorectal carcinoma cases. The expression of Survivin showed no correlation with the age, sex, tumor location, size, differentiation degree, pathologic types and lymph node metastasis (P > 0.05). The 5-year survival rate was lower in patients with high Survivin expression than that in those with low Survivin expression (52.94% vs 83.33%, P = 0.0304). There was no significant relationship between Survivin and Bcl-2 expression (P > 0.05).

CONCLUSION: Survivin expression may play a strong inhibitory role in the apoptosis of colorectal cancer cells, and the patients with high Survivin expression have an unfavorable prognosis. No correlation is found between Survivin and Bcl-2 expression.

Clinical features and prognosis of patients with extrahepatic metastases from hepatocellular carcinoma

AIM: To assess the clinical features and prognosis of 151 patients with extrahepatic metastases from primary hepatocellular carcinoma (HCC), and describe the treatment strategy for such patients.

METHODS: After the diagnosis of HCC, all 995 consecutive HCC patients were followed up at regular intervals and 151 (15.2%) patients were found to have extrahepatic metastases at the initial diagnosis of primary HCC or developed such tumors during the follow-up period. We assessed their clinical features, prognosis, and treatment strategies.

RESULTS: The most frequent site of extrahepatic metastases was the lungs (47%), followed by lymph nodes (45%), bones (37%), and adrenal glands (12%). The cumulative survival rates after the initial diagnosis of extrahepatic metastases at 6, 12, 24, and 36 mo were 44.1%, 21.7%, 14.2%, 7.1%, respectively. The median survival time was 4.9 mo (range, 0-37 mo). Fourteen patients (11%) died of extrahepatic HCC, others died of primary HCC or liver failure.

CONCLUSION: The prognosis of HCC patients with extrahepatic metastases is poor. With regard to the cause of death, many patients would die of intrahepatic HCC and few of extrahepatic metastases. Although most of HCC patients with extrahepatic metastases should undergo treatment for the primary HCC mainly, treatment of extrahepatic metastases in selected HCC patients who have good hepatic reserve, intrahepatic tumor stage (T0-T2), and are free of portal venous invasion may improve survival.

Value of platelet count in the prognosis of patients with pyogenic liver abscess

AIM: To study the relationship between platelet count and the prognosis of patients with pyogenic liver abscess.

METHODS: A total of patients with pyogenic liver abscess were diagnosed by computed tomography (CT), magnetic resonance imaging (MRI) and liver punctures, and the average focus size was 6.54 cm in diameter. Blood routine examination was performed everyday, combined with B-ultrasonography every three days. The relationship between the dynamic changes of platelet count and the prognosis of pyogenic liver abscess patients was analyzed.

RESULTS: Within one week, 43 (38.39%) patients were found with maximal platelet count more than or equal to 400 × 10⁹/L, and 22 patients (19.64%) with platelet count less than 400 × 10⁹/L. More than one week, 29 patients (25.89%) were with maximal platelet count more than or equal to 400 × 10⁹/L, 18 patients (16.07%) with platelet count less than 400 × 10⁹/L. Thrombocytosis occurred quickly in the patients in hospital less than one week, whose maximal platelet count was more than or equal to 400 × 10⁹/L, and their clinical symptoms were improved remarkably as compared with those of patients in hospital more than one week, with maximal platelet count less than 400 × 10⁹/L (P < 0.05).

CONCLUSION: Pyogenic liver abscess patients, in whom thrombocytosis occurs in short time, have a favorable prognosis. Blood count is an important indicator for the prognosis of Pyogenic liver abscess.