A local imbalance between MMP and TIMP may have an implication on the severity and course of appendicitis

Appendicitis while on alectinib for non-small cell lung cancer: a tale of two case reports

Introduction

Aberrant expression of anaplastic lymphoma kinase (ALK) is found in 3%-7% of patients with non-small cell lung cancer (NSCLC). Alectinib is a tyrosine kinase inhibitor used as first-line treatment targeting ALK-positive tumors. We herein report two cases of appendicitis highlighting it as a rare, possible adverse event of treatment with alectinib.

Case presentation

The first case is a 60-year-old woman with a previous history of stage 1 lobular breast cancer and early-stage lung cancer treated with segmentectomy, subsequently presenting with ALK-positive advanced NSCLC. Treatment with alectinib resulted in partial response, but she developed gastrointestinal symptoms that were assessed with computed tomography (CT) of the abdomen revealing right lower quadrant stranding without appendiceal visualization. Her symptoms continued despite an antibiotic course with re-imaging concerning for acute appendicitis, which was successfully treated with appendectomy and amoxicillin-clavulanic acid. The second case is a previously healthy 58-year-old man with advanced ALK-positive NSCLC who was started on first-line treatment with alectinib and subsequently diagnosed with asymptomatic acute appendicitis on re-staging CT abdomen. Signs on CT resolved with amoxicillin-clavulanic acid. Definitive treatment was conducted with a delayed elective appendectomy. Both patients remained on alectinib over the courses of appendicitis without interruption.

Conclusion

While appendicitis has not been previously described as an adverse effect of alectinib, its incidence in two patients at our center within several months following the administration of alectinib raises its suspicion as a possible adverse effect.

MESNA (2-Mercaptoethanesulfonate) Attenuates Brain, Heart, and Lung Injury Induced by Carotid Ischemia-Reperfusion in Rats

Background

Ischemia-reperfusion (I/R) causes organ dysfunction as a result of the increased formation of various reactive oxygen metabolites, infiltration of inflammatory cells, interstitial edema, cellular dysfunction, and tissue death.

Aim

The study aimed to investigate the cytoprotective effect of 2-mercaptoethanesulfonate (MESNA) against tissue damage in rats exposed to carotid ischemia-reperfusion.

Materials and Methods

Twenty-four male Wistar albino rats were divided into four groups (n = 6): sham, carotid I/R, I/R + MESNA (75 mg/kg), and I/R + MESNA (150 mg/kg) groups. To induce ischemia in rats, the carotid arteries were ligated with silk sutures for 10 min; the silk suture was then opened, and 1 h reperfusion was done. MESNA (75 and 150 mg/kg) was administered intraperitoneally 30 min before ischemia-reperfusion. Tissue samples from the animals were taken for histological examination, while the serum levels of some biochemical parameters were utilized to evaluate the systemic alterations. ANOVA and Tukey's post hoc tests were applied with a significance level of 5%.

Results

The ischemia-reperfusion-induced tissue damage as evidenced by increase in serum levels of alanine transaminase, aspartate aminotransferase, alkaline phosphatase, malondialdehyde, lactate dehydrogenase, and matrix metalloproteinases (MMP-1, -2, -8) was significantly (P < 0.05-0.0001) reversed after treatment with MESNA in a dose-dependent manner. Treatment with MESNA (75 and 150 mg/kg), significantly (P < 0.05-0.0001) decreased the I/R-induced increase in serum tumor necrosis factor-alpha (TNF-α) and Interleukin-1-beta (IL-1 β).

Conclusion

The results of this study suggest that MESNA has a protective effect on tissues by suppressing cellular responses to oxidants and inflammatory mediators associated with carotid ischemia-reperfusion.

Individual biomarkers in the blood are not yet applicable in diagnosing complicated appendicitis: A scoping review

BACKGROUND

Appendicitis is one of the most common surgical emergencies globally and it can both be difficult to diagnose but also to differentiate complicated from uncomplicated appendicitis preoperatively. The objective of this scoping review was to develop an overview of biomarkers in blood discriminating complicated from uncomplicated appendicitis and characterize their applicability in an acute setting including time, cost, and analysis technique required as well as their individual precision.

METHOD

This scoping review was reported in accordance with PRISMA-ScR. The included studies had to report on biomarkers measured in the blood for at least ten patients with suspected appendicitis. A systematic literature search was conducted on August 28, 2022, in PubMed and Embase but restricted to articles published in January 2000 and onwards. A protocol was uploaded to Open Science Framework prior to data extraction.

RESULTS

A total of 65 biomarkers were included from 52 studies, covering 14,312 patients. There was 60% routine- and 40% novel biomarkers based on the reported analysis technique. The most frequently investigated biomarkers within each group were white blood cell count and procalcitonin. The routine biomarkers were of low financial cost but poor diagnostic accuracy with sensitivity ranging between 15 and 100% and specificity between 27 and 100%. Novel markers were costly ranging from 275 to 800$, and their diagnostic accuracy was based on limited population sizes (median 34 patients) and reported for only 5% of the novel markers.

CONCLUSION

Routine biomarkers were applicable in an acute setting but had poor diagnostic accuracy. Novel biomarkers are being investigated for potential, but the concept is still premature due to lack of diagnostic accuracy studies reporting cost-benefit for individual markers and whether they can be applied in an acute setting.

Full-thickness skin grafts to reinforce the abdominal wall: a cross-sectional histological study comparing intra- and extraperitoneal onlay positions in mice

INTRODUCTION

In the repair of complex abdominal wall hernia, there can be a strong preference to avoid synthetic or biological implants as reinforcement material. Autologous full-thickness skin grafts (FTSG) have shown promising results. However, there are few clinical data on the use of FTSG in an intraperitoneal position and rudimentary knowledge about postoperative histological appearance of tissue remodelling and repair.

OBJECTIVE

To investigate the histological appearance of FTSG in the intraperitoneal onlay mesh (IPOM) position.

METHODS

Isogeneic FTSG was positioned in the IPOM (10 mice) and the onlay position (10 mice). After eight weeks, tissues were harvested for histological analysis. Tissue structure, inflammation and cell survival were investigated with histological and immunohistochemical staining.

RESULTS

Morphology was similar in both positions. Luciferase staining indicated both onlay and IPOM graft cell survival, with microvascular networks present. In both positions, FTSG showed ongoing tissue remodelling processes and cystic formations containing hair and epidermis. Low-grade acute phase and chronic inflammation were present. Integration was observed in 50% of the mice with similar appearances in IPOM and onlay grafts.

CONCLUSION

FTSG is tolerated, with comparable results either inside or outside the abdominal cavity, and in line with historic histological evaluations. The results suggest further research on FTSG as a potential future reinforcement material in selected cases of complex abdominal wall hernia repair.

Role of matrix metalloproteinases in tumour invasion: immunohistochemistry of peritoneum from peritoneal carcinomatosis

Colorectal cancer is one of the most common forms of cancer. Spread of tumour to the peritoneal cavity may lead to seeding of cancer cells that adhere to and invade the peritoneal membrane causing peritoneal carcinomatosis. Matrix metalloproteinases (MMPs) play an essential role in cancer cell invasion and dissemination. The aim of this study was to evaluate the morphology and presence of matrix metalloproteinases in peritoneal carcinomatosis. Biopsy samples of the parietal peritoneum were taken from patients undergoing cytoreductive surgery for peritoneal carcinomatosis. The samples were fixed in formalin, dehydrated and embedded in paraffin prior to cutting into 4-µm slices. Staining with haematoxylin/eosin was used for morphology studies, and MMP-1, MMP-2 and TIMP-1 levels were evaluated using immunohistochemistry and light microscopy. The microscopically tumour-free areas of the peritoneal membrane were thin compared to the peripheral invasion zone and the areas invaded by tumour. Peritoneum invaded by tumour was richly vascularised and contained inflammatory cells. MMP-1 was expressed in tumour-free peritoneum and in the invasion zone between tumour and peritoneal tissue, but not in tumour-invaded areas. MMP-2 and TIMP-1 were mostly expressed in the proximity of blood vessels and inflammatory cells in tumour-invaded areas, but was not seen in tumour-free areas. MMPs play an important role in the process of cancer cell invasion of the peritoneum in peritoneal carcinomatosis. The peripheral zone of the tumour appears to be of importance for tumour invasion.

Can Intestinal Fatty Acid Binding Protein (I-FABP) Be A Marker in the Diagnosis of Abdominal Pathology?

OBJECTIVES

Biochemical markers play an important role in the early diagnosis of abdominal pain. This study aimed to investigate the diagnostic value of intestinal type fatty acid binding protein (I-FABP) in patients with abdominal pathology.

METHODS

This prospective and descriptive study was performed at the University Hospital Emergency Department. Serum I-FABP levels of patients presenting with acute abdominal pain were measured at time of admission and were compared with those of healthy individuals.

RESULTS

The mean I-FABP level of the 171 patients enrolled in this study was 170.1±543.4 pg/ml, while that of a healthy control group was 61.4±47.4 pg/ml. Although I-FABP levels were higher in the patient group, this difference was not statistically significant (p>0.05). However, I-FABP levels of patients with mesenteric ischemia and intra-abdominal mass were significantly higher than those of healthy individuals (p≤0.05).

CONCLUSIONS

I-FABP levels that are evaluated at time of admission in patients presenting with abdominal pain to the emergency department are significantly higher in patients with mesenteric ischemia and intra-abdominal mass than are those of healthy individuals.

Evaluation of effects on the peritoneum after intraperitoneal α-radioimmunotherapy with (211)At

The introduction of the short-lived α-emitter (211)At to intraperitoneal radioimmunotherapy has raised the issue of the tolerance dose of the peritoneum. The short range of the α-particles (70 μm) and the short half-life (7.21 h) of the nuclide yield a dose distribution in which the peritoneum is highly irradiated compared with other normal tissues. To address this issue, mice were injected with (211)At-trastuzumab to irradiate the peritoneum to absorbed doses ranging between 0 and 50 Gy and followed for up to 34 weeks. The peritoneum-to-plasma clearance of a small tracer, (51)Cr-ethylenediamine tetraacetic acid, was measured for evaluation of the small solute transport capacity of the peritoneal membrane. The macroscopic status of the peritoneum and the mesenteric windows was documented when the mice were sacrificed. Biopsies of the peritoneum were taken for morphology and immunohistochemical staining against plasminogen activator inhibitor-1 and calprotectin. Peritoneum-to-plasma clearance measurements indicated a dose-dependent decrease in peritoneal transport capacity in irradiated mice. However, macroscopic and microscopic evaluations of the peritoneal membrane showed no difference between irradiated mice versus controls. The results imply that the peritoneal membrane tolerates absorbed doses as high as 30-50 Gy from α-particle irradiation with limited response.

Local and systemic expressions of MMP-9, TIMP-1 and PAI-1 in patients undergoing surgery for clinically suspected appendicitis

BACKGROUND/AIMS

To examine, compare and correlate the expressions of matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinase 1 (TIMP-1) and plasminogen activator inhibitor type 1 (PAI-1) in appendiceal tissue and pre- and postoperative blood samples in patients undergoing surgery for clinically suspected appendicitis.

METHODS

Fifty-seven patients with complete tissue and blood samples were included and divided into groups of noninflamed appendix/lymphadenitis (n = 7), phlegmonous appendicitis (n = 30), gangrenous appendicitis (n = 11) and perforated appendicitis (n = 9). The protein expressions were assessed with ELISAs. The local expressions of MMP-9, TIMP-1 and PAI-1 were correlated with the systemic expressions at the time of surgery while the systemic individual differences between surgery and recovery were compared.

RESULTS

There was a positive correlation between tissue and plasma PAI-1 (p < 0.05). The individual differences for plasma MMP-9 and PAI-1 were statistically nonsignificant, while they were higher for TIMP-1 in patients with perforated appendicitis compared with phlegmonous (p < 0.0001) and gangrenous appendicitis (p < 0.01).

CONCLUSIONS

Plasma PAI-1 reflected the levels in appendiceal tissue at the time of surgery. Systemic TIMP-1 could have the potential of distinguishing perforated from nonperforated appendicitis.

Matrix metalloproteinases are possible mediators for the development of alimentary tract mucositis in the dark agouti rat

Alimentary tract (AT) mucositis is a serious and debilitating side-effect of cancer therapy primarily characterized by damage of the mucous membranes throughout the AT. It is well established that this damage is a result of up-regulation of stress response genes and pro-inflammatory cytokines. Matrix metalloproteinases (MMPs) have been shown to function in several of the pathways known to be up-regulated in mucositis and play a key role in tissue injury and inflammation in many gastrointestinal disorders. This study aims to characterize the expression of multiple MMPs including MMP-1, -2, -3, -9 and -12 and their inhibitors, tissue inhibitor of metalloproteinase (TIMP)-1 and -2, in a rat model of irinotecan-induced mucositis. Dark agouti rats were administered a single 200 mg/kg intraperitoneal dose of irinotecan and killed at 1, 6, 24, 48, 72, 96 and 144 h following treatment. Hematoxylin and eosin staining, immunohistochemistry and realtime polymerase chain reaction were used to assess histopathological damage and MMP expression in the jejunum and colon. Marked histopathological evidence of mucositis was observed in the jejunum and colon as early as six hours following irinotecan treatment. A significant alteration in both gene expression and tissue levels of MMPs and TIMPs was noted following irinotecan. The increase in MMP-2, -3, -9 and -12 levels was associated with inflammatory infiltrate and maximum tissue damage. In contrast, MMP-1 expression correlated with tissue restitution. TIMP-1 and -2 levels were significantly altered in the jejunum following irinotecan. The augmentation in the expression profiles of MMPs and their inhibitors correlated with histopathological alterations observed in the tissue following irinotecan. This prompts the consideration of MMPs as possible mediators of chemotherapy-induced mucositis.

MMP-9/TIMP-1 imbalance induced in human dendritic cells by Porphyromonas gingivalis

Matrix metalloproteinase-9 (MMP-9) cleaves collagen, allowing leukocytes to traffic toward the vasculature and the lymphatics. When MMP-9 is unregulated by tissue inhibitor of metalloproteinase-1 (TIMP-1), this can lead to tissue destruction. Dendritic cells (DCs) infiltrate the oral mucosa increasingly in chronic periodontitis, characterized by infection with several pathogens including Porphyromonas gingivalis. In this study, human monocyte-derived DCs were pulsed with different doses of lipopolysaccharide of P. gingivalis 381 and of Escherichia coli type strain 25922, as well as whole live isogenic fimbriae-deficient mutant strains of P. gingivalis 381. Levels of induction of MMP-9 and TIMP-1, as well as interleukin-10 (IL-10), which reportedly inhibits MMP-9 induction, were measured by several approaches. Our results reveal that lipopolysaccharide of P. gingivalis, compared with lipopolysaccharide from E. coli type strain 25922, is a relatively potent inducer of MMP-9, but a weak inducer of TIMP-1, contributing to a high MMP-9/TIMP-1 ratio.Whole live P. gingivalis strain 381, major fimbriae mutant DPG-3 and double mutant MFB were potent inducers of MMP-9, but minor fimbriae mutant MFI was not. MMP-9 induction was inversely proportional to IL-10 induction. These results suggest that lipopolysaccharide and the minor and the major fimbriae of P. gingivalis may play distinct roles in induction by DCs of MMP-9, a potent mediator of local tissue destruction and leukocyte trafficking.

[Impact of imaging tests on the negative appendectomy rate]

INTRODUCTION

Negative appendectomies and perforated appendectomies have traditionally been quality indicators in surgery. The aim of this study is to analyze the emergency appendectomies in our hospital regarding the use of imaging tests and a review of the literature to analyze the quality of diagnosis in acute appendicitis.

MATERIAL AND METHODS

Retrospective study including all patients operated on for suspected acute appendicitis at a single institution for one year (2007). Data gathered from histology and imaging tests reports. Analysis of the histology results, imaging test used and its diagnostic accuracy. Comparison with quality levels published in the international literature.

RESULTS

A total of 394 patients were included in the study, the overall rate of negative appendectomy was 9.6%. Abdominal ultrasound (AU) was performed on 54.6% of patients and abdominal CT-scan on 10.2% of them, and 4.2% of the patients had both tests. AU positive predictive value was 82%. CT-scan positive predictive value was 97%.

CONCLUSION

The negative appendectomy rate (9.6%) in our centre shows values lower than the published ones in historical series but superior to the one published recently in the USA. The use of imaging tests in our hospital is lower than the one published in the USA, although similar to data reported in other European countries.

Progress of tissue injury in appendicitis involves the serine proteases uPA and PAI-1

OBJECTIVE

Serine proteases and the matrix metalloproteinases (MMPs) are key factors in the proteolytic cascade and participate in extracellular matrix (ECM) degradation. Fibrinolytic activators and inhibitors may have an effect on inflammatory cells, thereby modulating the inflammatory response. It is reasonable to assume that they may be implicated in the tissue injury in acute appendicitis that subsequently leads to appendix perforation. The purpose of this study was to investigate the expression and distribution of urokinase-type plasminogen activator (uPA) and plasminogen-activator inhibitor type 1 (PAI-1) in appendicitis.

MATERIAL AND METHODS

Expression of uPA and expression of PAI-1 were measured in tissue specimens from patients with appendicitis (n=30) and in control specimens (n=9), using the quantitative ELISA technique. Distribution of enzymes was studied with immunohistochemistry. The uPA and PAI-1 levels in the subgroups of appendicitis and controls were compared.

RESULTS

The overall expressions of uPA and PAI-1 were greater in appendicitis than in control specimens (p <0.001 and p<0.0001, respectively). Expressions of uPA and PAI-1 in phlegmonous (n=15), gangrenous (n=6) and perforated appendicitis (n=9) were all higher than those in controls (n=9), (p<0.01). Moreover, the PAI-1 level was elevated in perforated appendicitis compared with phlegmonous appendicitis (p<0.01). uPA staining was observed in connection with vascular endothelial cells and the serosa stained intensely in specimens from perforated appendicitis.

CONCLUSIONS

The expression of uPA and especially the over-expression of PAI-1 seem to correlate to the progression of local inflammatory response in acute appendicitis.

Matrix metalloproteinases: key regulators in the pathogenesis of chemotherapy-induced mucositis?

Chemotherapy is an effective anticancer treatment; however, it induces mucositis in a wide range of patients. Mucositis is the term used to describe the damage caused by radiation and chemotherapy to mucous membranes of the alimentary tract. This damage causes pain and ulceration, vomiting, bloating and diarrhoea, depending on the area of the alimentary tract affected. Although treatment is available for a small subset of patients suffering from mucositis, the majority rely on pain relief as their only treatment option. Much progress has been made in recent years into understanding the pathobiology underlying the development of mucositis. It is well established that chemotherapy causes prominent small intestinal and colonic damage as a result of up-regulation of stress response genes and pro-inflammatory cytokines. However, better understanding of the mediators of this damage is still required in order to target appropriate treatment strategies. Possible mediators of mucositis which have not been well researched are the matrix metalloproteinases (MMPs). MMPs have been shown to function in several of the pathways which are known to be up-regulated in mucositis and contribute to tissue injury and inflammation in many pathological conditions. This prompts the consideration of MMPs as possibly being key mediators in mucositis development.