Nomogram-Based Prognostic Evaluation of Gastric Cancer Patients with Low Counts of Examined Lymph Nodes Outperforms the Predictive Ability of the 7th and 8th Editions of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) staging system has limited accuracy in predicting survival of gastric cancer patients with inadequate counts of evaluated lymph nodes (LNs). We therefore aimed to develop a prognostic nomogram suitable for clinical applications in such cases.

METHODS

A total of 1511 noncardia gastric cancer patients treated between 1990 and 2010 in the academic surgical center were reviewed to compare the 7^th and 8^th editions of the AJCC staging system. A nomogram was developed for the prediction of 5-year survival in patients with less than 16 LNs evaluated (n = 546). External validation was performed using datasets derived from the Polish Gastric Cancer Study Group (n = 668) and the SEER database (n = 11,225).

RESULTS

The 8th edition of AJCC staging showed better overall discriminatory power compared to the previous version, but no improvement was found for patients with < 16 evaluated LNs. The developed nomogram had better concordance index (0.695) than the former (0.682) or latest (0.680) staging editions, including patients subject to neoadjuvant treatment, and calibration curves showed excellent agreement between the nomogram-predicted and actual survival. High discriminatory power was also demonstrated for both validation cohorts. Subsequently, the nomogram showed the best accuracy for the prediction of 5-year survival through the time-dependent ROC curve analysis in the training and validation cohorts.

CONCLUSIONS

A clinically relevant nomogram was built for the prediction of 5-year survival in patients with inadequate numbers of LNs evaluated in surgical specimens. The predictive accuracy of the nomogram was validated in two Western populations.

Varicocelectomy improves sperm parameters, sperm DNA integrity as well as the other critical semen features

Varicocele is a major entity defined within male infertility. In this report we have studied the influence of laparoscopic varicocelectomy on semen quality, biochemical parameters of seminal plasma and sperm DNA fragmentation. In this study, the semen samples from patients with left-side varicocele of grade II-III before and after laparoscopic varicocelectomy were compared to healthy individuals and separated into three groups. The volume of semen, sperm concentration (106/ml), motility (%), viability (%) and normal morphology (%) were assessed. Total antioxidant capacity (TAC), catalase (CAT), superoxide dismutase (SOD) and malondialdehyde (MDA) together with other biochemical substances in seminal plasma as alpha-glucosidase (α-Glu), fructose (Fr) and citric acid (CA) were determined by ELISA method. The spermatozoa activity including ion-transports through sodium, potassium ATPase (Na⁺, K⁺-ATPase) and calcium, magnesium ATPase (Ca²⁺, Mg²⁺-ATPase) were determined by using spectrophotometry. In addition, flow cytometry method for detection of sperm DNA fragmentation was used. The results showed, that three months after varicocelectomy such intervention led to significant postoperative improvement in volume of semen (p<0.001), total sperm count (p<0.001), sperm motility (p<0.001) and spermatozoa with normal morphology (p<0.001). We found decreased α-Glu levels due to varicocelectomy (p<0.05). There has been shown a high positive correlation between Na⁺, K⁺-ATPase and Ca²⁺, Mg²⁺-ATPase activity with total number of spermatozoa (p<0.05). The TAC levels and DNA fragmentation values after varicocelectomy can be considered as significant indicators of good prognosis after surgical intervention. It has to be emphasized that α-Glu levels and total sperm count expressed statistically significant both positive and negative predictive values for semen assessment. Varicocelectomy may lead to significant improvement of semen quality although the observations must be correlated with clinical pregnancies observed thereafter.

Sperm mitochondrial dysfunction and oxidative stress as possible reasons for isolated asthenozoospermia

Reduced sperm motility, defined as asthenozoospermia, is a frequent cause of male infertility, and is mainly connected with the dysfunction of sperm mitochondria. The aim of this study was to identify the proteins, and thereby the metabolic pathways, responsible for asthenozoospermia, using 2-DE and MALDI-TOF MS, and correlate the results obtained with those of two mitochondrial tests: JC-1 and MitoSox Red. The JC-1 test was performed to test sperm mitochondrial activity, and the MitoSox Red test was performed to check whether the observed sperm poor motility is associated with mitochondrial reactive oxygen species (ROS) production. To identify proteins strictly connected with reduced sperm motility, men with isolated asthenozoospermia (n = 4 versus 10 normozoospermic controls) alone were included in the study. The proteomic analyses resulted in the identification of 25 sperm proteins that are differentially expressed in asthenozoospermic individuals. Most of the identified proteins were downregulated and were involved in energy production; however, we have also identified structural sperm proteins and proteins secreted by the epididymis. The latter, together with the results from MitoSox Red assay, may provide insights into the pathophysiological basis of asthenozoospermia.

Results of surgical treatment of cervical esophageal diverticula

On the basis of 20 years' experience, the authors present the immediate and long-term results of operative treatment of Zenker's diverticulum. Comparison of two methods of surgery - diverticulopexia (in 21 patients) and excision (in 16), both associated with upper esophageal sphincter myotomy - shows good immediate and longterm results (from 1 to 19 years), with disappearance of symptoms (dysphagia) in all patients. There was no perioperative mortality. Postoperative complications were most commonly of pulmonary origin and were observed in a third of patients in both groups. In two patients from the group treated with excision, a leak from the suture line occurred, which healed spontaneously. These two patients had transient dysphagia in the postoperative period. On the basis of this analysis, the authors conclude that diverticulopexia is a safer surgical procedure than excision, giving less complications and a very good long-term functional result.

Aspergillus fumigatus proteases, Asp f 5 and Asp f 13, are essential for airway inflammation and remodelling in a murine inhalation model

BACKGROUND

In susceptible individuals, exposure to Aspergillus fumigatus can lead to the development of atopic lung diseases such as allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS). Protease allergens including Asp f 5 and Asp f 13 from Aspergillus fumigatus are thought to be important for initiation and progression of allergic asthma.

OBJECTIVE

To assess the importance of secreted protease allergens Asp f 5 (matrix metalloprotease) and Asp f 13 (serine protease) in Aspergillus fumigatus-induced inflammation, airway hyperactivity, atopy and airway wall remodelling in a murine model following chronic exposure to secreted allergens.

METHODS

BALB/c mice were repeatedly intranasally dosed over the course of 5 weeks with culture filtrate from wild-type (WT), Asp f 5 null (∆5) or Asp f 13 null (∆13) strains of Aspergillus fumigatus. Airway hyper-reactivity was measured by non-invasive whole-body plethysmography, Th2 response and airway inflammation by ELISA and cell counts, whilst airway remodelling was assessed by histological analysis.

RESULTS

Parent WT and ∆5 culture filtrates showed high protease activity, whilst protease activity in ∆13 culture filtrate was low. Chronic intranasal exposure to the three different filtrates led to comparable airway hyper-reactivity and Th2 response. However, protease allergen deleted strains, in particular ∆13 culture filtrate, induced significantly less airway inflammation and remodelling compared to WT culture filtrate.

CONCLUSION

Aspergillus fumigatus-secreted allergen proteases, Asp f 5 and Asp f 13, are important for recruitment of inflammatory cells and remodelling of the airways in this murine model. However, deletion of a single allergen protease fails to alleviate airway hyper-reactivity and allergic immune response. Targeting protease activity of Aspergillus fumigatus in conditions such as SAFS or ABPA may have beneficial effects in preventing key aspects of airway pathology.

Biological properties of human skeletal myoblasts genetically modified to simultaneously overexpress the pro-angiogenic factors vascular endothelial growth factor-A and fibroblast growth factor-4

Myocardial infarction results in cardiomyocyte loss and may eventually lead to cardiac failure. Skeletal myoblast transplantation into the scar area may compensate for this observed cell loss by strengthening the weakened myocardium and inducing myogenesis. Moreover, skeletal myoblasts may serve as potential transgene carriers for the myocardium (i.e., delivering pro-angiogenic factors, which may potentially improve blood perfusion in infarcted heart). We examined the influence of the simultaneous overexpression of two potent pro-angiogenic factors, fibroblast growth factor-4 (FGF-4) and vascular endothelial growth factor (VEGF), on human primary myoblast proliferation, cell cycle, resistance to hypoxic stress conditions and myogenic gene expression, as well as the induction of pro-angiogenic activities. We used a bicistronic plasmid vector encoding two factors introduced via an efficient myoblast electroporation method. The levels of overexpressed proteins were assessed, and their functionality at capillary formation was evaluated. This combined approach led to a high level of non-viral transient overexpression of both pro-angiogenic proteins, which proved to be potent regulators of blood vessel development assayed in capillary formation tests. We demonstrated in in vitro conditions that the transfection of human skeletal myoblasts with both FGF-4 and VEGF did not affect their basic biological properties such as the cell cycle, proliferation or expression of myogenic lineage-specific genes, and the modified cells adapted to oxidative stress conditions. Overall, the results obtained suggest that the applied combined approach with the use of two pro-angiogenic genes overexpressed in skeletal muscle stem cells may be an interesting alternative for the effective therapy of myocardial infarction in animal models and/or prospective clinical trials.

Transient and stable transfections of mouse myoblasts with genes coding for pro-angiogenic factors

Cardiomyocyte loss in the ischaemic heart can be the reason of many complications, eventually being even the cause of patient's death. Despite many promises, cell therapy with the use of skeletal muscle stem cells (SMSC) still remains to be modified and improved. Combined cell and gene therapy seems to be a promising strategy to heal damaged myocardium. In the present study we have investigated the influence of a simultaneous overexpression of two potent pro-angiogenic genes encoding the fibroblast growth factor-4 (FGF-4) and the vascular endothelial growth factor-A (VEGF-A) on a myogenic murine C2C12 cell line. We have demonstrated in in vitro conditions that myoblasts which overexpressed these factors exhibited significant changes in the cell cycle and pro-angiogenic potential with only slight differences in the expression of the myogenic genes. There was not observed the influence of transient or stable overexpression of FGF-4 and VEGF on cell apoptosis/necrosis in standard or oxidative stress conditions comparing to non transfected controls. Overall, our results suggest that the possible transplantation of myoblasts overexpressing pro-angiogenic factors may potentially improve the functionality of the injured myocardium although the definite proof must originate from in situ conducted pre-clinical studies.

Implications of overweight in gastric cancer: A multicenter study in a Western patient population

AIMS

The purpose of this study was to evaluate the effects of overweight on surgical and long-term outcomes in a Western population of patients with gastric cancer (GC).

METHODS

An electronic database of all patients with resectable GC treated between 1986 and 1998 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group was reviewed. Overweight was defined as a body mass index (BMI) of 25 kg/m(2) or higher.

RESULTS

Four hundred and ninety-two of 1992 (25%) patients were overweight. Postoperatively, higher BMI was associated with higher rates of cardiopulmonary complications (16% vs 12%, P = 0.001) and intra-abdominal abscess (6.9% vs 2.9%, P < 0.001). However, other complications and mortality rates were unaffected. The median disease-specific survival of overweight patients was significantly higher (36.7 months, 95% confidence interval (CI) 29.0-44.4) than those with BMI<25 kg/m(2) (25.7 months, 95%CI 23.2-28.1; P = 0.003). These differences were due to the lower frequencies of patients with T3 and T4 tumours, metastatic lymph nodes, distant metastases, and non-curative resections. A Cox proportional hazards model identified age, depth of infiltration, lymph node metastases, distant metastases, and residual tumour category as the independent prognostic factors.

CONCLUSIONS

Overweight is not the independent prognostic factor for long-term survival in a Western-type population of GC.

Bcl-Xl protein expression in laryngeal squamous cell carcinoma

The Bcl-2 family of proteins regulate one of the steps in an evolutionary conserved apoptotic pathway. The long splice variant of Bcl-X (Bcl-Xl) is a potent antagonist of apoptosis. The aim of the study was to evaluate the relation between the presence of immunohistochemically detectable Bcl-Xl protein in laryngeal squamous cell carcinomas (LSCCs) and clinicopathological data, as well as DNA ploidy status and proliferative activity. In 50 specimens of LSCC, Bcl-Xl protein expression was evaluated immunohistochemically. Proliferative activity (SG2M-phase index) and DNA ploidy were measured by flow cytometry. In our study, Bcl-Xl protein expression decreased with decreasing tumour differentiation (P = 0.04). The majority of patients with Bcl-Xl protein immunoreactivity had no metastatic lymph node involvement (P = 0.01). Other factors such as age, gender, primary tumour size (pT) and type of cancer (keratinizing/non-keratinizing) were not associated with Bcl-Xl protein level. There was no correlation between Bcl-Xl protein and SG2M-phase index or DNA ploidy status. Our findings show that expression of Bcl-Xl protein is increased in a great fraction of laryngeal cancers. Further studies, however, are needed to clarify association between Bcl-Xl protein expression and clinical course of patients.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

[Peroxidation components of sperm lipid membranes in male infertility]

We have studied the lipid peroxidation product (malondiadehyde-MDA) levels after thiobarbituric acid reaction, spectrophotometrically and by a high-performance liquid chromatography (HPLC) with UV detection in seminal plasma as well as in the cell fraction. Semen samples were obtained from healthy volunteers and infertile males. Ejaculates were previously classified into studied subgroups according to standard andrological criteria (sperm number, motility, morphology) and defined as: normozoospermia (K), azoospermia (Az), teratozoospermia (T), asthenoteratozoospermia (AT), oligoasthenoteratozoospermia (OAT) and idiopathic infertility (NIF). MDA is a good marker for lipid peroxidation. There were found elevated MDA concentrations (determined by HPLC) in seminal plasma of the all analysed pathological semen samples, especially in patients with OAT. The more pronounced differences between healthy controls and NIF patients were observed in intracellular compartment. The lipid peroxidation of rich in unsaturated fatty acids sperm membranes is considered to be one of the most important effects from ROS-induced cell damage what may lead to persistent infertility.

Liver transplantation in the experience of the centre commencing the program

From 1989 to 1999, 43 orthotopic liver transplantations (OLT) in 40 patients (3 retransplantations) were performed in our Department. The most common indications for OLT were noninflammatory, primary cholestatic liver diseases and postinflammatory liver cirrhosis. Fourty OLT's were done for elective indications, three--on emergency basis, because of fulminant liver failure. The majority of transplantations was performed with classical technique with the excision of retrohepatic vena cava and routine use of the extracorporeal veno-venous bypass. Only in 4 patients the piggyback technique was used and performed without temporary portocaval anastomosis. All 3 patients transplanted for fulminant liver failure died in the perioperative period. Twenty four patients are still alive and well, the longest period of observation exceeding 5 years.

[Results of treatment for angiosarcoma in children hospitalized in Department of Pediatric Hematology and Oncology (Wroclaw University School of Medicine) in 1989-1998]

Angiosarcoma is a neoplasm included to sarcoma of soft tissue. In the period 1989-1998 9 children with angiosarcoma were treated in Department of Paediatric Hematology and Oncology.

Effects of prenatal gamma-irradiation on postnatal astrogliogenesis in the hippocampal formation of rat

Female Wistar rats were exposed to a single 1.0 Gy dose of gamma radiation on gestational days 13, 15, 17 or 19 (E13, E15, E17 and E19, respectively). Their 8- and 16-day old male offsprings were injected with 3H-thymidine and sacrificed 4 h after the injection. Brain sections were immunostained for S100beta protein and subjected to autoradiography. Thereafter, the dorsal part of the hippocampal formation was examined microscopically and numbers and locations of proliferating astrocytes were recorded. Following prenatal irradiation, the intensity of astrocyte proliferation was considerably reduced, especially in the region of dentate gyrus. The reduction showed regular trend of changes being much stronger in brains irradiated on E19 than in those irradiated on E13. The changes, therefore, were related to the stage of brain development at which the irradiation was performed. A possible role of neuronal regulatory influence on the postnatal development of glial cells was discussed.

Inhibition of reinforcing effects of morphine and naloxone-precipitated opioid withdrawal by novel glycine site and uncompetitive NMDA receptor antagonists

The glycine site (MRZ 2/570 and L-701,324), and uncompetitive (MRZ 2/579) NMDA receptor antagonists inhibited morphine-produced behaviors related to drug-abuse. The expression of morphine dependence was blocked by pretreatment with all three compounds (3-7.5 mg/kg); the effects of glycine/NMDA antagonists were not dose-dependent. Mice which were morphine-free for 3 days still displayed a significant severity of the withdrawal syndrome when challenged again with naloxone. This extinction of a residual morphine dependence was markedly diminished by treatment with similar doses of NMDA receptor antagonists at the test following the wash-out period. The rewarding impact of morphine was investigated in rats using the place preference (CPP) paradigm. All NMDA receptor antagonists (2.5-10 mg/kg) inhibited both the acquisition and expression of morphine-induced CPP. Once established, morphine-induced CPP was observed until 2 weeks after conditioning. NMDA receptor antagonists given for 3 days after the end of conditioning did not influence the extinction of morphine-induced CPP. Microdialysis studies revealed that the behaviorally effective doses of MRZ 2/579 resulted in a brain concentration close to its in vitro potency as an NMDA receptor antagonist. These data suggest that novel glycine site and uncompetitive NMDA receptor antagonists may have therapeutic potential in the treatment of opioid abuse.

[Results of surgical treatment for Zenker's diverticula]

From 1976 to 1996, thirty nine patients were surgically treated for pharyngoesophageal diverticulum. The present study aimed to compare two methods of operative treatment of Zenker's diverticulum: excision (group I) and pexy, both of which were associated with upper esophageal sphincter myotomy. The main indication for surgery was dysphagia. The diagnosis of Zenker's diverticulum was based on clinical symptoms and the result of upper GI tract barium examination. In 75% of patients the diameter of diverticulum exceeded 2 cm. No patient died in the perioperative period. The main complications observed in the postoperative period were of pulmonary origin. In group I (excision) a leakage from the suture line occurred in 2 patients (12.5%). Time of follow-up ranged from 1 to 20 years (mean: 7 years). The comparison of both methods of treatment employed is in favour of diverticulopexy, being a safer and less complications-bearing method, although both of them give similar functional results.

[Esophageal resection for cancer--analysis of postoperative complications from personal materials]

The aim of the present study was to analyse the rate of postoperative complications in patients after esophageal resection for cancer, as well as the dependence of its frequency from surgical tactics employed during the operation. Postoperative complications occurring in 38 patients who underwent esophagectomy and intrathoracic esophagogastric anastomosis (treated from 1978 to 1987) were compared with the same data of 74 patients (1988-1996) in whom the operation consisted of the total intrathoracic esophagectomy, cardia, lesser curvature of the stomach and large regional lymph nodes dissection. In these latter cases the esophagogastric anastomosis was performed in the neck. The most frequent postoperative complications in both groups were of cardiopulmonary origin. The anastomotic leak occurred less frequently in patients with cervical esophagogastric anastomosis. However, when occurred, healing was more likely by local drainage and conservative treatment. Anastomotic leaks after intrathoracic esophagogatric anastomoses were usually fatal. In these cases the only chance of patient's survival was an aggressive surgical treatment consisting of disconnection of alimentary tract: esophageal fistula in the neck and feeding jejunostomy.

[Complications of laparoscopic cholecystectomy]

Complications of laparoscopic cholecystectomy were evaluated in the group of 1.284 patients operated on from June 1991 to December 1996. Serious complications were observed in 38 (2.9%) patients. Conversion to open cholecystectomy was required in 50 patients, including 4 patients with common bile duct injury, 3 patients with bleeding from the gall bladder bed, 2 with cholecysto-duodenal fistula and 6 with intraperitoneal adhesions. In 35 patients the conversion was performed due to inflammatory changes in the Calot triangle. The authors did not observe any serious vascular injury as well as lethal complications. They conclude, that the correct indications to surgery and adequate surgical technique are the most important factors preventing the complications.

[Analysis of morbidity risk in patients after liver resection]

The authors present the retrospective analysis of the morbidity risk in patients undergoing hepatic resection for various indications. The most important complications, according to the literature, were: postoperative liver failure, massive pleural effusion, ascites resistant to pharmacological treatment, intraperitoneal hemorrhage or septic complications requiring relaparotomy. There was the correlation between the increased morbidity and preoperative risk factors like: diabetes mellitus, liver insufficiency with coagulopathy, and intraoperative blood loss, requiring massive transfusions.

Results of surgical treatment of cervical esophageal diverticula

On the basis of 20 years' experience, the authors present the immediate and long-term results of operative treatment of Zenker's diverticulum. Comparison of two methods of surgery--diverticulopexia (in 21 patients) and excision (in 16), both associated with upper esophageal sphincter myotomy--shows good immediate and long-term results (from 1 to 19 years), with disappearance of symptoms (dysphagia) in all patients. There was no perioperative mortality. Postoperative complications were most commonly of pulmonary origin and were observed in a third of patients in both groups. In two patients from the group treated with excision, a leak from the suture line occurred, which healed spontaneously. These two patients had transient dysphagia in the postoperative period. On the basis of this analysis, the authors conclude that diverticulopexia is a safer surgical procedure than excision, giving less complications and a very good long-term functional result.

Recurrences after surgical treatment of patients with post-thrombotic syndrome of the lower extremities

A Linton flap operation was performed in 148 patients with post-thrombotic syndrome of the lower extremities. One-hundred and five patients were followed up from 6 months to 10 years and 14.5% of cases had recurrent ulcers. The most common causes of recurrence was further deep venous thrombosis or remaining incompetent perforating veins. All patients with a recurrence of their ulcer had a further operation and incompetent perforating veins were ligated and divided with good clinical results.