Low PD-L1 expression in immune cells predicts the presence of nodal metastasis in early invasive (pT1) colorectal cancer: a novel tool to tailor surgical treatment

AIMS

The current criteria for surgical treatment after endoscopic resection of a pT1 colorectal carcinoma (CRC) are unsatisfactory because nodal involvement is rarely present. This study investigates the correlation between PD-L1 expression and nodal metastasis in pT1 CRCs to enable its use for tailoring surgical treatment after endoscopic removal.

METHODS AND RESULTS

Histopathological features of 81 surgically resected pT1 CRC, 19 metastatic and 62 non-metastatic cases were assessed. PD-L1 expression was evaluated by immunohistochemistry (clone 22C3) and independently assessed by two pathologists using tumour proportion score (TPS), combined positive score (CPS) and immune cell score (ICS). The correlation between PD-L1 expression and nodal metastasis, the optimal cut-off values, interobserver agreement and impact upon patients' surgical management were determined. PD-L1 expression in terms of CPS and ICS independently correlated with lymph node metastasis (PD-L1_CPS : OR = -2.5, 95% CI = -4.11 to -0.97, P = 0.008 and PD-L1_ICS : OR = -1.85, 95% CI = -2.90 to -0.79, P = 0.004) and < 1.2 CPS and <1.3% ICS were identified as the optimal cut-off values to discriminate between metastatic and non-metastatic patients. In our cohort, the implementation of these cut-off values would have avoided a significant rate of unnecessary surgeries in pN0 patients (PD-L1_CPS  = 43.2; PD-L1_ICS  = 51.9%). Ultimately, PD-L1 evaluation showed good interpathologist concordance in absolute terms [PD-L1_CPS interclass correlation coefficient (ICC) = 0.91; PD-L1_ICS ICC = 0.793] and using the identified cut-off values (PD-L1_CPS ICC = 0.848; PD-L1_ICS ICC = 0.756).

CONCLUSIONS

Our study shows that PD-L1 expression is an effective predictor of nodal status and could improve patient selection for surgery after endoscopic removal of pT1 CRCs.

Efficacy and safety of tenofovir, entecavir, and telbivudine for chronic hepatitis B in heart transplant recipients

BACKGROUND

Treatment of chronic hepatitis B (CHB) with polymerase inhibitors is key to prevent disease flares and progression toward advanced liver disease. Efficacy and tolerability of newer agents has been reported anecdotally in transplant recipients.

METHODS

In this prospective, observational study, we assessed outcomes of therapy with tenofovir (TDF), entecavir (ETV), and telbivudine (LdT) in 13 heart transplant recipients (HTR) with CHB.

RESULTS

Most patients were hepatitis B e antigen negative, had low baseline hepatitis B virus (HBV) DNA, and normal aminotransferases. Liver biopsy showed a median fibrosis score of 1.5 (range 0-4). Glomerular filtration rate (GFR) was <50 mL/min in 7 patients (54%). Two patients were started on de novo ETV before transplant. Eleven previously treated patients were switched to TDF (n = 9) or LdT (n = 2). Median treatment duration was 33 months (range 1-71). HBV DNA remained suppressed in 6 patients and became undetectable in 5. Aminotransferases went down to the normal range in all patients, with a single flare in 1 patient. One patient lost hepatitis B surface antigen. No cases occurred of hepatic decompensation, hepatocellular carcinoma, or liver-related death. The GFR remained largely stable, and no cases of TDF-related hyper-phosphaturia were observed.

CONCLUSIONS

This study indicates that newer antivirals are effective and safe in HTR with CHB.

Laparoscopic appendectomy for complicated acute appendicitis

The role of laparoscopic appendectomy in complicated appendicitis is still not widely accepted. The authors report their retrospective study performed to evaluate the effectiveness of the laparoscopic approach in the management of complicated appendicitis. From January 2003 to October 2008, 552 patients underwent appendectomy in our surgical department. Among these, 358 were not complicated appendicitis while 194 were complicated. Of the 194 cases of complicated appendicitis, 121 patients underwent laparoscopic appendectomy while the remaining 73 cases were treated by conventional open surgery. The average length of hospital stay was 5.7 days, with a range from 4 to 13 days. Post-operative complications were observed in a total 11 patients (9.1%), including 3 cases of intra abdominal abscess (2.5%), 2 cases of umbilical wound infection (1.6%) and 6 cases of prolonged ileus (4.9%). Our experience suggests that the laparoscopic procedure is a valid, safe and feasible option to manage acute complicated appendicitis.

[Radiological study of anastomotic leakages following colorectal surgery]

The anastomotic leakage is one of the most serious complications following colorectal surgery. The incidence rate is between 3% and 21% considering the different experiences, pathology and surgical techniques. Our aim is to verify the role of radiological study in 45 patients with clinical and subclinical colorectal anastomotic leakage total anastomoses = 252). In 31 patients at risk, the operation was concluded with a loop ileostomy. The radiological study gastrografin enema was performed in all patients (26 symptomatic and 19 asymptomatic patients with loop ileostomy). The dehiscence incidence resulted 5.5%: 14 of 252 patients. In our experience the radiological study of selected colorectal anastomoses allowed to show the site and the flow of the leakage and to plan the proper management. In asymptomatic patients the study allowed to programme a specific follow up in patients with higher risk of postinflammatory stenosis or perhaps neoplastic relapse.

[Primary duodenal adenocarcinoma: report of three cases, prognostic factors and therapeutic approach]

Three cases of histologically proven primary non-ampullary adenocarcinoma of the duodenum, observed in our Department from 2001 to 2004, are described. The cases were treated by pancreaticoduodenectomy, duodenal resection and transduodenal excision, respectively. The rarity of this pathology is documented by few retrospective studies and justifies discussion about the main prognostic factors and the best therapeutic approach. We analyze diagnostic, therapeutic and prognostic factors after a revision of literature.

[Covered perforation of solitary cecal diverticulum: case report]

Acute right lower abdominal pain is often clinically difficult to diagnose. The diagnosis, especially in young patients, is frequently oriented to appendicular disease. Surgical exploration only confirms diagnosis or surprises the surgeon, revealing an unexpected right colon diverticulitis. This emergency condition challenges the surgeon with the dilemma about the best therapeutic choice: conservative or radical treatment? The elective localization of diverticulitis to the right colon is very rare (6.6-14%). The authors report a case of covered perforation of a solitary cecal diverticulum.

[Surgical timing in bleeding liver adenoma: case report]

The diagnosis of liver adenoma, which etiopathogenesis most often involves a prolonged assumption of estrogen (90% of adenomas occurs in women after more than 5 years of estrogen therapy), always imposes a surgical resection. The reason depend from neoplasia characteristics like the malignant evolution (4%) and the high risk of abdominal/intratumoral bleeding (30-50%), that increases during pregnancy and postpartum period. Regression of lesion after discontinuation of hormone therapy is rare and does not remove the degeneration and/or haemorrhagic risk. Liver resection should be performed with appropriate selective endovascular embolization, considering that an inept emergency surgery may impose a greater risk ot the liver, exposing the patient to major risk of morbidity and mortality. The correct timing from embolization to elective surgery is not yet standardized in the literature. The surgeon's personal experience and mainly a careful patient follow-up suggest the timing of surgery after embolization. The authors relate their own experience about the therapeutic strategy and surgical timing in a case of bleeding liver adenoma.

Human mammaglobin mRNA is a reliable molecular marker for detecting occult breast cancer cells in peripheral blood

Occult carcinoma cells in peripheral blood of breast cancer (BC) patients is generally associated with poor disease prognosis. Reverse transcriptase-polymerase chain reaction (RT-PCR) is a sensitive method for revealing rare circulating cancer cells. The target mRNA must be carefully chosen, as it must be expressed only by malignant cells. In this study, we developed a nested RT-PCR assay for mammaglobin (hMAM) and assessed both its specificity and its sensitivity in the detection of cancer cells in peripheral blood of BC patients. hMAM mRNA was detected by RT-PCR in 156/165 (95%) of fresh BC tissues analyzed. All samples from 66 healthy blood donors and 151 patients with benign breast disease were hMAM negative as assessed by nested RT-PCR. In contrast, hMAM was detected in 16/137 (12%) of peripheral blood samples deriving from BC patients: 0/9 in stage 0, 1/50 (2%) in stage I, 3/33 (9%) in stage II, 1/18 (5%) in stage III and 11/27 (41%) in stage IV. Using nested RT-PCR, we were able to amplify hMAM transcript of one tumour cell/10(6) normal cells. Our data demonstrate that hMAM mRNA detection by RT-PCR is a specific assay potentially suitable for identification of occult cancer cells in peripheral blood of BC patients.

[A case of intestinal obstruction after migration of esophageal endoprosthesis]

Endoscopic dilatation and stenting are the procedures of choice in the treatment of oesophago-gastric anastomotic stricture following oesophagectomy, leading to immediate relief of dysphagia with a low procedure-related risk. Prosthesis displacement is a described late complication, easy detected and sorted out whenever possible with endoscopic retrieval. A case in which stent migration ended at the terminal part of the small intestine, presenting with the clinical features of mechanical ileum, is described.

[Kimura disease]

Kimura's disease is a chronic inflammatory pathology belonging to the angio-lymphatic proliferative disorders. The clinical features are a tumour-like swelling usually in the head and neck, with or without lymphadenopathy, often accompanied by eosinophilia and elevated serum IgE. It could be confused with angiolymphoid hyperplasia with eosinophilia. Other clinical differential diagnosis to Kimura's disease are reactive lymphadenopathy, lymphoma, parotid tumor with nodal metastasis and Mikulicz disease. The diagnosis is achieved by excisional biopsy which is also the therapy of choice. The prognosis is excellent. A case of Kimura's disease in an Italian female is presented together with a review of the literature.

[Frey's syndrome: physiopathology and medical therapy]

Frey syndrome (gustatory sweating, auricolotemporal syndrome) is a complication of parotidectomy, probably caused by misdirection of regenerating fibers in the auricolotemporal nerve. The authors review the pathophysiology and describe the treatment used in this entity.

[Femoro-popliteal bypass with reversed saphenous vein. Experience in a General Surgery Department]

Femoro popliteal bypass with reversed saphenous vein are "the gold standard" for revascularization of lower extremities with femoro popliteal occlusion. This form of therapy is usually performed in a Vascular Surgery Department. We report the experience of a General Surgery Department, with patency of 90% at two years.

[The conservative treatment of infected vascular prostheses in surgery to revascularize the lower limbs]

Infected vascular grafts are associated with very high rates of limb loss and mortality. "Classic" treatment has invariably included graft excision. Recent reports have suggested that a more conservative approach may be indicated in selected cases, leaving the graft in place and using an aggressive local treatment associated with appropriate intravenous antibiotics. The authors report their experience with two patients with infected prosthetic vascular grafts in the groin. They both had purulent drainage from the groin wound, with the graft exposed close to the femoral anastomosis. They were both treated successfully without graft removal, and both graft maintained patency, with a follow-up of 22 and 19 months.

[Intraportal air secondary to gastric dilatation. A clinical case]

The authors report a case of hepatic portal venous gas (HPVG) secondary to massive gastric dilatation in a diabetic patient following blunt trauma. Both flat plate of the abdomen and ultrasound of the liver were necessary to reach the correct diagnosis. They review the pertinent literature and stress the importance of an accurate nosologic assessment of this uncommon entity in order to avoid undue mishaps.

[Crural hernia after inguinal hernia repair. A technical note]

A case of femoral hernia following repair of an inguinal hernia with the Shouldice method is presented. The authors discuss the pathogenesis, suggest the use of ultrasound for a precise preoperative diagnosis, and propose the "plug" technique of Lichtenstein as the method of choice for the repair. This method offers a minimally invasive approach, without disturbing the previous inguinal repair and it is very simple to perform.

[Infected pseudoaneurysms of the upper limb. A case re-evaluation]

The authors report a case of infected pseudoaneurysm of the brachial artery in a drug addict, treated with aneurysm excision and brachio-brachial bypass with inverted saphenous vein. They review the literature on the subject and management options.

[The Knight-Griffen technique in colorectal surgery]

The use of stapling devices has changed the practice of colorectal surgery. The authors report their experience with the "double stapling" technique introduced by Knight and Griffen in 1980 for the performance of low colorectal anastomosis. They treated 42 patients, with a mean age of 63.2 years. In 34 surgery was performed for rectal adenocarcinoma, while 8 patients were being reoperated on for closure of a colostomy after Hartmann's operation. In one patient a diverting colostomy was fashioned because of poor bowel cleansing, secondary to a stenosing rectal carcinoma. Mortality was nil. There were no clinical anastomotic leaks. There were 2 cases of late postoperative anastomotic stenosis that responded to endoscopic pneumatic dilatation.

[Rectal foreign bodies. Principles of therapy]

The authors report their experience with the treatment of endorectal foreign bodies (EFB). They review the literature on the subject and examine the various therapeutic options. Considering the possible complications of leaving an EFG in place for prolonged period of times in the hope of spontaneous delivery, they suggest that immediate removal is always indicated. They describe various technical modalities for endoscopic removal, that can avoid laparotomy in the majority of cases.

[Local anesthesia in anal surgery. Technical note and immediate results]

The authors report their experience with the use of local anesthesia in anal surgery (hemorrhoids, anal fissures and fistulas). They describe their technique in detail, stressing the importance of thorough knowledge of the neuroanatomy of the anal canal and of a stepwise blockage of all sensory and motor fibers to the area. They report their results on 300 anal procedures performed under local anesthesia, with good patient acceptance.

[Subacute Budd-Chiari syndrome treated with rTPA. Considerations on a case]

The authors report on a case of hepatic vein thrombosis or Budd-Chiari syndrome (BCS) successfully treated with recombinant Tissue Plasminogen Activator (rTPA). They briefly outline the etiology and symptomatology of this disease as well as the various surgical procedures used for treatment. Medical therapy has been so far poorly effective in treatment BCS, but recently various reports seem to indicate that rTPA may have a role. The authors suggest that rTPA may be used as the only therapy in selected cases, or in treating patients that are not candidates for surgical intervention, or as a temporizing measure to improve symptoms in patients awaiting surgery.

[Calculosis of the cystic duct]

The authors report on three cases of cystic duct syndrome, a fairly uncommon complication of cholelithiasis, consisting in migration of a large gallstone from the gallbladder to the common bile duct, resulting in the formation of a common cavity between cystic, hepatic and common bile ducts. They review the pathogenesis of this entity, as well as the diagnostic modalities best suited to a precise diagnosis. They stress that surgical therapy must be chosen on a case by case basis, trying to restore a functional extrahepatic biliary tree.

[Caroli's disease associated with cholangiocarcinoma. A case of our own observation]

The authors report a case of Caroli's disease associated with cholangiocarcinoma. The patient presented with pain and jaundice and ultrasonography disclosed multiple common bile duct stones, cystic dilatation of the extrahepatic biliary tree and a mass in the right lobe of the liver. At operation, after a frozen section demonstrated cholangiocarcinoma, a common bile duct exploration, right hepatic lobectomy and hepato-jejunostomy were performed. They review the literature on the subject and stress the fact that hepatic tumors are associated with Caroli's disease in 7% of cases. Therefore, in these patients, when a stenosis of the biliary tree is found, multiple diagnostic manoeuvres are indicated in order to exclude the presence of malignancy.

Spontaneous rupture of the liver

A case of spontaneous hepatic rupture associated with bacterial cholangiohepatitis, an entity not previously described as an etiologic factor, is reported and the literature reviewed. Awareness of the pathophysiology of this process and avoidance of certain procedures are important parts of the surgical armamentarium.

[Modified radical mastectomy in local anesthesia]

The authors report their experience on the use of local anesthesia for modified radical mastectomy. They have used this modality in five patients who could not undergo general anesthesia because of underlying severe medical illness and in a sixth one who adamantly refused general anesthesia. They describe in detail the technique used, stressing the importance of a thorough knowledge of regional neuroanatomy. There were no complications in their small series. The authors conclude by stating that the use of local anesthesia may expand the indications for "toilet mastectomy" to include patients in poor medical condition, unsuitable for general anesthesia.

[Surgical treatment of toxic megacolon]

After an introduction on the various aetiological factors involved in toxic megacolon, its onset, medical treatment and indications to surgery, the paper describes personal experience with seven cases. The report highlights the importance of medical treatment which is recommended as the appropriate initial therapeutic approach. Then after a review of evolving surgical techniques, it is suggested , again on the basis of personal experience, that the surgical approach should be neither excessively aggressive (total proctocolectomy with permanent ileostomy) nor excessively conservative (multistoma decompression). According to this report, the operation of choice is currently subtotal colectomy plus ileostomy and sigmoidostomy which combine modest morbidity and mortality with the possibility of future reconstruction.

[Acute intestinal infarction. Diagnostic and therapeutic problems]

The authors report their experience in thirteen cases of mesenteric infarction. They emphasize the difficulty in diagnosing and treating this entity, considering also the impossibility in most centers of performing emergency selective angiography of the superior mesenteric artery (SMA) When feasible, mesenteric rivascularization should always be attempted, followed 24 hours later by a "second look" procedure.

[Inguinal hernia surgery under local anesthesia. Technical note and immediate results]

The authors report their experience on local anesthesia for inguinal hernia repair in 164 patients. They describe the neuroanatomy of the inguinal region as well as the technique of loco-regional anesthesia. The Shouldice repair was most frequently employed, followed by the Bassini repair. Local anesthesia was very well tolerated by the patients, sometimes with the addition of mild sedation. The postoperative course was definitely shortened by the use of local anesthesia, and all patients were able to take a regular diet and to walk few hours after surgery.

[Biliary surgery and cholescintigraphy with iminodiacetic acid (IDA) analogs. An evaluation of the results and the complications]

Hepatobiliary scintigraphy with analogs of iminodiacetic acid (IDA) has become one of the primary tools in the diagnosis of biliary tract diseases, especially in the evaluation of surgical results and detection of complications that may arise from biliary operative procedures. We have performed cholescintigraphy in 19 patients. Of them, 9 underwent choledochojejunostomy with Roux-en-Y reconstruction for recurrent choledocholithiasis, 1 underwent right hepatic resection for metastasis extirpation, 8 were post cholecystectomy patients effected with upper abdominal pain located either in the epigastric region or right upper quadrant referable to post cholecystectomy syndrome and the last exhibited chronic pancreatitis ans suspicious sphincter of Oddi stenosis. The scintigraphy data were compared with the information yielded by sonography, intravenous cholangiogram (IVC) and, when possible, by endoscopic retrograde cholangiopancreatography (ERCP). Scans were considered pathologic when one or more of the following criteria were present: a) delayed biliary to bowel transit (greater than 1 hr), b) abnormal time-activity dynamic, c) no intestinal activity (obstruction), d) apparent ductal dilatation. In the group of biliary-enteric anastomosed patients, cholescintigraphic findings have shown 3 normal cases, 3 cases of biliary-intestinal obstruction confirmed by surgery, and 3 with abnormal activity retention in the jejunum loop due, in 2 patients, to hypokinesia since the quick emptying following the administration of 10 mg i.v. of metoclopramide, while in the other one, the surgery reexploration exhibited the presence of adhesions producing intestinal stricture. in the last patient of this group, the cholescintigraphy was performed to detect possible biliary leaks. In the post cholecystectomy patients, the cholescintigraphy exhibited in 3 cases dilated common duct with functional patency since the normal biliary-bowel transit time (less than 1 hr); this was confirmed by sonogram and IVC.(ABSTRACT TRUNCATED AT 250 WORDS)