Prognostic factors in metastatic gastric carcinoma

Although its incidence has declined over last half-century, gastric cancer remains the second most frequent cause of cancer death in the world. The ⅔ of the patients are metastatic at diagnosis. The current study aimed to identify some determinants of survival in patients with metastatic gastric carcinoma.

MATERIALS AND METHODS

It was a retrospective study that involved 49 patients treated with palliative chemotherapy between January 2000 and December 2010. Factors included: age, gender, performance status, metastatic diagnosis onset (at diagnosis or later); specific metastatic sites, number of metastatic localizations, response to chemotherapy, and hemoglobin rate.

RESULTS

In univariate analysis, factors associated to a better survival were: metastasis at diagnosis, good performance status, response to chemotherapy and single metastatic site. Independent factors in multivariate analysis were: metastasis at diagnosis and single metastatic site.

CONCLUSION

Our study confirmed many determinants on survival described in the literature.

Buschke - Lowenstein anal tumor: an ambiguous entity

The Buschke - Lowenstein tumor is a rare sexually transmitted disease. Its location at the anal margin is also very rare. The most incriminated risk factor is human papillomavirus infection. Its clinical form may be confusing with other tumor and infectious lesions. Histologically, it is characterized by a well-differentiated malpighian proliferation. It represents local aggressive behavior. The treatment of reference remains the surgery with healthy margins of excision. Other treatments have been tested, but their effectiveness remains uncertain. We report here a new case of anal margin Buschke - Lowenstein tumor with a review of the literature.

Iatrogenic colorectal Kaposi's sarcoma complicating a refractory ulcerative colitis in a human immunodeficiency negative-virus patient

Kaposi sarcoma is an unusual tumor associated to a human herpes virus-8 infection involving the skin or internal organs. Iatrogenic Kaposi's sarcoma often occurs in patients receiving immunosuppressive therapy. So far, a few Kaposi's sarcoma cases have been reported in the literature associated with inflammatory bowel diseases. We report a 53-year-old male diagnosed with a severe refractory ulcerative colitis who was treated with corticosteroids and azathioprine. The patient underwent a colectomy after the failure of medical treatment. Histological examination of the colon showed findings suggestive of Kaposi's sarcoma. Immunohistochemistry for human herpes virus-8 was positive in the colonic lesions. Correspondence.

An unusual case of gallbladder cancer

Pure squamous cell carcinoma (SCC) of gallbladder is a very rare tumour and is responsible for only 3% of the malignant neoplasm of this organ. We report a case of SCC of gallbladder in a 58-year-old woman. Through this new observation, we propose to study the clinicopathologic features, pathogeny and treatment of this rare entity.

Ileal pouch-anal anastomosis: Points of controversy

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most commonly used procedure for elective treatment of patients with ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in order to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. In this review of the literature of restorative proctocolectomy with ileal pouch-anal anastomosis, we discuss these technical modifications, limiting our discussion to the current points of controversy. The current "hot topics" for debate are: indications for ileal pouch-anal or ileo-rectal anastomosis, indications for pouch surgery in the elderly, indeterminate colitis and Crohn's disease, the place of the laparoscopic approach, transanal mucosectomy with hand-sewn anastomosis vs. the double-stapled technique, the use of diverting ileostomy and the issue of the best route for delivery of pregnant women. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with ongoing prospective evaluation of the procedure are required to settle these issues.

Peritoneal tuberculosis

The peritoneum is one of the locations outside the most common pulmonary tuberculosis. Peritoneal tuberculosis poses a public health problem in endemic regions of the world. The phenomenon of migration, the increased use of immunosuppressive therapy and the epidemic of AIDS have contributed to a resurgence of this disease in regions where it was previously controlled. The aim of this review is to expose the clinical, biologic end radiologic futures of the peritoneal tuberculosis and to present the methods of diagnosis and treatment. The diagnosis of this disease is difficult and still remains a challenge because of its insidious nature, the variability of presentation and limitations of available diagnostic tests. The disease usually presents a picture of lymphocytic exudative ascites. There are many complementary tests with variable sensitivities and specificities to confirm the diagnosis of peritoneal tuberculosis. Isolation of mycobacteria by culture of ascitic fluid or histological examination of peritoneal biopsy ideally performed by laparoscopy remains the investigation of choice. The role of PCR, ascitic adenosine deaminase, interferon gamma and the radiometric BACTEC system can improve the diagnostic yield. An antituberculous treatment with group 1 of the WHO for 6 months is sufficient in most cases.

[Cystic lymphangioma of the pancreas: an exceptional location]

Cystic lymphangioma of the pancreas is a rare benign vascular tumor. Its histogenesis is still hypothetical and preoperative diagnosis is difficult. We report a new case in a 14-year-old girl hospitalized for pain in the epigastrium and vomiting. Radiologic findings concluded in a cystic tumor of the head of the pancreas. The mass was completely excised. The pathological examination of the surgical specimen revealed cystic formations whose wall consisted of a squamous endothelial epithelium on a fibrous tissue and a few scattered lymphoid clusters, arguing in favor of a cystic lymphangioma.

[Pancreatic hydatid cyst: an exceptional localization]

Pancreatic hydatid cysts are rare. They account for 1% of all hydatid cysts and are extremely rare in children. This may explain the problems diagnosing this condition. We report on a new case of pancreatic hydatic cyst in an 11-year-old girl who was admitted with a previous history of abdominal pain and jaundice. We discuss the diagnostic features of pancreatic hydatid cyst and therapeutic modalities.

[Intrauterine device and pelvic tumor: two case reports of pelvic actinomycosis with pseudotumor from tropical zones]

Pelvic actinomycosis is a rare chronic disease caused by actinomycete species. The pseudotumorous form is the most common and often leads to misdiagnosis. The purpose of this report is to describe two cases of pelvic actinomycosis involving women with a history of intrauterine contraceptive device (IUD) use. Diagnosis was based on pelvic mass and the findings of surgery undertaken for suspicion of an advanced ovarian tumor with hepatic metastasis in one case and for a tumor of the right ovary in the other case. Diagnosis was confirmed by histological examination of a biopsy specimen in the first case and of the surgical specimen (right ovariectomy) in the second case. Long-term antibiotic therapy was effective in both patients. Based on these two cases and review of the literature, discussion focuses on diagnostic pitfalls, natural course, and therapeutic options for this particular infection.

[Intestinal perforation in a Tunisian woman: peritonitis due to a fishbone]

Diagnosis of foreign body perforation of the gastrointestinal tract can be difficult. The purpose of this report is to describe a case of acute peritonitis after perforation of the ileum by a fish bone that was detected by computed tomography.

[Laparoscopic treatment of perforated duodenal ulcer: 84 cases in Tunisia]

INTRODUCTION

The purpose of this study was to evaluate the feasibility, efficacy and safety of the laporascopic treatment of perforated duodenal ulcer.

METHODS

This retrospective study included patients who underwent laparoscopic treatment of perforated duodenal ulcer during the seven-year period from 2001 to 2007. The procedure included direct suture of the perforated ulcer followed by peritoneal lavage. All patients received medical treatment including Helicobacter pylori eradication and proton pump inhibitor therapy.

RESULTS

A total of 84 patients underwent laparoscopic surgery for perforated duodenal ulcer during the study period. There were 81 men and 3 women with a mean age of 28 years. Laparoscopic examination confirmed diagnosis of perforated duodenal ulcer in all cases. Direct suture of the ulcer was successful in 72 cases. In the remaining 12 cases conversion to open surgery was necessary due to difficulty in achieving peritoneal lavage in 6 cases, ulcer size and edge friability in 5, and septic shock in one. The mean duration of the procedure was 95 minutes (range, 60 to 180 minutes). The mean postoperative complication rate was 15.4%. Complications included peritonintis in one case and digestive fistula in one. There were no postoperative deaths. All patients were re-examined after 25 months. Two patients presented recurrences after the laparoscopic treatment and required tri-therapy.

CONCLUSION

Laparoscopic suture of perforated duodenal ulcer is safe and effective. It avoids the need for laparotomy that is associated with a risk for septic and parietal complications. Since medical treatment is effective for ulcerous disease, there are currently no indications for radical treatment.

[Pelvic pseudotumoral actinomycosis: two cases]

INTRODUCTION

Pelvic actinomycosis is a rare suppurative disease that should be included in the differential diagnosis of gynecological cancers.

CASE REPORTS

We report two women aged 40 and 41 years with pelvic tumor-like actinomycosis. Physical examination disclosed a pelvic mass in both cases. CT-scan showed annexial infiltrative tumor in both cases with liver metastasis and peritoneal carcinosis in one case each. Surgical procedure consisted in right annexectomy in one case and peritoneal biopsy in the other. Pathologic diagnosis was diagnostic of actinomycosis. Both patients were treated by penicillin G 20 million IU/day during two weeks and then by amoxicilline 3g/day per day during six months. Clinical outcome showed significant improvement in both cases with complete regression of hepatic and pelvic lesions on CT-scan in one case.

CONCLUSION

Pelvic actinomycosis is a rare suppurative disorder, commonly associated with a long term wearing of intra-uterine device. Diagnosis is difficult, often delayed and pelvic actinomycosis could mimic gynaecologic neoplasia.

[Two pelvic tumors which should not be operated, lymphoma of Burkitt and actinomycosis]

The treatment of the pelvic tumors depends of their histological nature. Some of them require only one medical treatment without recourse to surgery. We report two rare cases of pelvic tumors occurring in young adults. For the first case, actinomycosic nature was related to the histological study of the surgical biopsies. Concerning the second case, the lymphatic nature of a tumor of the low rectum was retained on the immunohistochimic study of the endoscopic biopsies. The evolution was uneventful in the two cases after a medical treatment containing penicillin G or a chemotherapy. We discuss at the time of these two observations the diagnostic difficulties and the therapeutic methods of these rare affections.

[Severe rectal bleeding in an Tunisian woman: colonic tuberculosis mimicking a tumor]

Since colonic tuberculosis is uncommon and its bifocal pseudo-tumor form is exceptional, differential diagnosis with the colonic cancer is exceedingly difficult. The purpose of this report is to describe a case of primary colonic tuberculosis in two separate locations discovered in a patient presenting with persistent massive hematochezia. A 69-year-old woman was examined for hematochezia, abdominal pain and recent weight loss. Colonoscopy revealed the presence of two ulcerated tumor-like lesions in right colon. One of these lesions caused significant stenosis. Histological examination of biopsy specimens was inconclusive. Colonic tumor with bleeding was considered as the most likely diagnosis. Surgical exploration demonstrated one tumor in the cecum and another in the ascending colon. Right hemicolectomy was performed. Histological examination of the surgical specimen demonstrated a granulomatous reaction pattern with caseous necrosis. Conventional antituberculosis treatment led to clinical improvement.

CUX1 and E2F1 regulate coordinated expression of the mitotic complex genes Ect2, MgcRacGAP, and MKLP1 in S phase

Rho GTPases are critical for mitosis progression and completion of cytokinesis. During mitosis, the GDP/GTP cycle of Rho GTPases is regulated by the exchange factor Ect2 and the GTPase activating protein MgcRacGAP which associates with the kinesin MKLP1 in the centralspindlin complex. We report here that expression of Ect2, MgcRacGAP, and MKLP1 is tightly regulated during cell cycle progression. These three genes share similar cell cycle-related signatures within their promoter regions: (i) cell cycle gene homology region (CHR) sites located at -20 to +40 nucleotides of their transcription start sites that are required for repression in G(1), (ii) E2F binding elements, and (iii) tandem repeats of target sequences for the CUX1 transcription factor. CUX1 and E2F1 bind these three promoters upon S-phase entry, as demonstrated by chromatin immunoprecipitation, and regulate transcription of these genes, as established using promoter-luciferase reporter constructs and expression of activated or dominant negative transcription factors. Overexpression of either E2F1 or CUX1 increased the levels of the endogenous proteins whereas small interfering RNA knockdown of E2F1 or use of a dominant negative E2F1 reduced their expression levels. Thus, CUX1, E2F, and CHR elements provide the transcriptional controls that coordinate induction of Ect2, MgcRacGAP, and MKLP1 in S phase, leading to peak expression of these interacting proteins in G(2)/M, at the time they are required to regulate cytokinesis.

[Contribution of Western blotting to the diagnosis of hydatidosis]

The aim of this study is to evaluate the contribution of the immunoWesternblot for the diagnosis and the post surgical follow-up of the hydatidosis. 71 sera from patients with hydatidosis confirmed by surgery were studied. All had a negative hydatic serology by screening tests (enzyme-linked immunosorbent assay, hemagglutination, electrosyneresis). 12 patients with sera in pre and post operative were monitored for 2 years. The Echinococcus Western blot IgG permitted to rectify the diagnosis of hydatidosis in 67.6 %. The rate of positivity was 100 % for the multivesicular liver cysts, 60 % for the young cysts and 50 % for the calcified cysts. Western blot permitted to rectify the diagnosis of lung cysts in 62.5 % of cases and in 50 % of cranial-spinal localizations. Analysis of Western Blot evolution in the 12 patients followed in pre and post-surgical revealed the disappearance of the bands 16, 18 and 26-28kDa in 8 month in the 8 patients with complete exeresis. This study proved the value added of Western blot compared to the other traditional techniques for the immunodiagnostic and the post-surgical monitoring of hydatidosis.

Regulation of Rho signaling pathways in interleukin-2-stimulated human T-lymphocytes

Rho GTPases are key regulators of many cellular functions, including cytoskeleton organization which is important for cell morphology and mobility, gene expression, cell cycle progression, and cytokinesis. In addition, it has recently been recognized that Rho GTPase activity is required for development of the immune system, as well as for the specialized functions of the peripheral cells that act in the immune response such as antigen presenting cells and lymphocytes. Stimulation of T lymphocytes with interleukin-2 (IL-2) induces clonal expansion of antigen-specific populations and provides a model to study cell cycle entry and cell cycle progression. We have performed gene expression analysis in a model of human T lymphocytes, which proliferate in response to IL-2. In addition to changes in genes relevant to cell cycling and to the antiapoptotic effects of IL-2, we have analyzed expression and variations of more than 300 genes involved in Rho GTPase signaling pathways. We report here that IL-2 regulates the expression of a number of proteins, which participate in the Rho GTPase pathways, including some of the GTPases themselves, GDP/GTP exchange factors, GTPase activating proteins, as well as GDIs and effectors. Our results suggest that regulation of expression of components of the Rho GTPase pathways may be an important mechanism in assembling specific signal transduction cascades that need to be active at certain times during the cell cycle. Some of our findings may also be relevant to the roles of Rho GTPases in T lymphocyte functions and proliferation.

Interaction of the tyrosine phosphatase SHP-2 with Gab2 regulates Rho-dependent activation of the c-fos serum response element by interleukin-2

Gab2 (Grb2-associated binder-2), a member of the IRS (insulin receptor substrate)/Gab family of adapter proteins, undergoes tyrosine phosphorylation in response to cytokine or growth factor stimulation and serves as a docking platform for many signal transduction effectors, including the tyrosine phosphatase SHP-2 [SH2 (Src homology 2)-domain-containing tyrosine phosphatase]. Here, we report that, following IL-2 (interleukin-2) stimulation of human T lymphocytes, SHP-2 binds tyrosine residues 614 and 643 of human Gab2 through its N- and C-terminal SH2 domains respectively. However, the sole mutation of Tyr-614 into phenylalanine is sufficient to prevent Gab2 from recruiting SHP-2. Expression of the Gab2 Tyr-614-->Phe (Y614F) mutant, defective in SHP-2 association, prevents ERK (extracellular-signal-regulated kinase) activation and expression of a luciferase reporter plasmid driven by the c-fos SRE (serum response element), indicating that interaction of SHP-2 with Gab2 is required for ERK activation in response to IL-2. Further investigation of IL-2-dependent induction of SRE showed that expression of a constitutively active mutant of the RhoA GTPase synergizes with IL-2 for SRE-driven transcription, whereas a dominant-negative mutant reduces the IL-2 response. Thus, in response to IL-2, full induction of the SRE requires ERK-dependent as well as Rho-dependent signals that target the Ets-box and the CArG-box respectively. We also report that the synergy between Gab2/SHP-2 and RhoA for IL-2-dependent CArG-box-driven transcription depends upon MEK (mitogen-activated protein kinase/ERK kinase) activation, and is likely to involve regulation of the serum response factor co-activator MAL. Our studies thus provide new insights into the role of Gab2 and SHP-2 in IL-2 signal transduction.

A defect in hematopoietic stem cell migration explains the nonrandom X-chromosome inactivation in carriers of Wiskott-Aldrich syndrome

A defect in cell trafficking and chemotaxis plays an important role in the immune deficiency observed in Wiskott-Aldrich syndrome (WAS). In this report, we show that marrow cells from WAS protein (WASP)-deficient mice also have a defect in chemotaxis. Serial transplantation and competitive reconstitution experiments demonstrated that marrow cells, including hematopoietic progenitors and stem cells (HSCs), have decreased homing capacities that were associated with a defect in adhesion to collagen. During development, HSCs migrate from the liver to the marrow and the spleen, prompting us to ask if a defect in HSC homing during development may explain the skewed X-chromosome inactivation in WAS carriers. Preliminary evidence has shown that, in contrast to marrow progenitor cells, fetal liver progenitor cells from heterozygous females had a random X-chromosome inactivation. When fetal liver cells from WASP-carrier females were injected into irradiated recipients, a nonrandom inactivation of the X-chromosome was found at the level of hematopoietic progenitors and HSCs responsible for the short- and long-term hematopoietic reconstitution. Therefore, the mechanism of the skewed X-chromosomal inactivation observed in WAS carriers may be related to a migration defect of WASP-deficient HSCs.

[Unusual locations of hydatid cysts]

The most common sites of hydatid disease (HD) are represented by the liver and the lungs. In 10% of cases, HD arises in unusual viscera: mainly spleen (0.9 to 8%) and also kidney, bones, heart, brain, peritoneum (0.5 to 5%). Other exceptional location was described in less than 1% of all cases of hydatid cysts. Ultrasonography and CTscan are highly suggestive of HD, while serologic tests are variable. The cysto-pericystectomy is the gold standard procedure but sometimes unsuitable for particular sites. In that cases a conservative approach (partial pericystectomy) is mandatory to preserve the organ function. The place of adjuvant medical treatment remains questionable.

[Hydatid cyst of the pancreas. Apropos of 7 cases]

The authors present a series of seven cases of hydatid cysts of the pancreas. This localization is rare since it accounts for less than 1% of the various sites of hydatid disease. The clinical signs are variable according to degree of bilio-pancreatic involvement. The preoperative diagnosis was established in three patients by ultrasonography, computed tomography and positive serology. Protruding dome was used in five patients. Distal pancreatectomy without splenectomy and Whipple resection were performed in other patients. There was no mortality and the postoperative morbidity was dominated by external biliary or pancreatic fistulae and local sepsis.