Case Report: Chemoimmunotherapy in microsatellite-instability-high advanced goblet cell carcinoma of the colon

Background

Mismatch repair (MMR) deficiency is a fundamental factor affecting the management treatment outcomes of colorectal cancer (CRC). MMR status can be diagnosed by both immunohistochemistry (IHC) polymerase chain reaction (PCR). Since tumors with MMR deficiency are prone to respond to immunotherapy immune checkpoint inhibitors are used to treat such tumors.

Case presentation

A 69-year-old male patient presented to an outside clinic with weight loss and abdominal pain. Radiological investigations detected a mesenteric mass of 10 cm, peritoneal implants, and mediastinal lymphadenopathy. The eventual biopsy result from the mesenteric mass was mucinous adenocarcinoma with a goblet cell pattern. Since the IHC result was unclear for deficiency in mismatch repair (dMMR) metastatic CRC (mCRC), the diagnosis was confirmed with PCR. The patient received 8 cycles of FOLFIRINOX + bevacizumab followed by FOLFOX combined with pembrolizumab. No adverse effect was reported related to immunotherapy which resulted in radiologic and metabolic regression. The patient underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). The final pathology results revealed a pathological complete response and R0 resection. In the 6th month follow-up, no recurrence or metastasis was reported.

Conclusion

Chemotherapy and immunotherapy combination is a promising treatment modality which can also be used for mCRC. This is the index case who received chemotherapy in combination with immunotherapy for mucinous adenocarcinoma of the colon with a goblet cell pattern and had pCR.

Discrepancy among microsatellite instability detection methodologies in non-colorectal cancer: Report of 3 cases

BACKGROUND

Microsatellite instability (MSI) is a predictive biomarker for cancer immunotherapy. The tumor-agnostic nature of MSI makes it a denominator for immunotherapy in several solid tumors. It can be assessed using next-generation sequencing (NGS), fluorescent multiplex PCR, and immunohistochemistry (IHC).

CASE SUMMARY

Here, we report 3 cases with discordant MSI results detected using different methods. A cholangiocellular carcinoma case revealed proficient mismatch repair (MMR) by IHC but high MSI (MSI-H) by liquid NGS. A cervical cancer case revealed deficient MMR by IHC, microsatellite stable by PCR, and MSI-H by NGS. Lastly, an endometrial cancer case revealed proficient MMR by IHC but MSI-H by NGS.

CONCLUSION

IHC for MMR status is the first choice due to several advantages. However, in cases of indeterminate IHC results, molecular testing by MSI-PCR is preferred. Recently, NGS-based MSI assays are being widely used to detect MSI-H tumors. All three methods have high accuracy; however, the inconsistencies between them may lead to misdiagnosis.

Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acıbadem Mehmet Ali Aydınlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

Sunitinib induced colitis manifesting as invasive diarrhea in a patient with renal cell carcinoma

INTRODUCTION

Sunitinib is a tyrosine kinase inhibitor that binds to vascular endothelial factor receptor currently used for the treatment of renal cell carcinoma, as well as for several other conditions such as gastrointestinal stromal tumors and pancreatic neuroendocrine tumors. We present a patient with invasive diarrhea who was treated with sunitinib for metastatic renal cell carcinoma.

CASE REPORT

Drug induced colitis was confirmed with colonoscopy from histopathological specimens. Clinical recovery of diarrhea was achieved with oral budesonide. Remarkably, the pathologic findings were observed in both the macroscopically normal mucosa and the mucosa with aphthous ulcers in the colon.

MANAGEMENT & OUTCOME

The patient was treated for sunitinib associated diarrhea, after exclusion of the other reasons. Metronidazole and piperacillin/tazobactam treatment were prescribed.

DISCUSSION

Diarrhea is a frequent symptom in patients treated with tyrosine kinase inhibitors, however the described pathologic findings have rarely been reported. Our aim is to emphasize the importance of close follow-up in patients treated with tyrosine kinase inhibitors, and to raise awareness on the management of sunitinib induced colitis.

Impact of Prolonged Neoadjuvant Treatment-surgery Interval on Histopathologic and Operative Outcomes in Patients Undergoing Total Mesorectal Excision for Locally Advanced Rectal Cancer

BACKGROUND

This study primarily aimed to assess the impact of prolonged neoadjuvant treatment-surgery interval (PNSI) on histopathologic and postoperative outcomes. Impacts of the mode of neoadjuvant treatment (NT) and surgery on the outcomes were also evaluated in the same patient population.

PATIENTS AND METHODS

Between February 2011 and December 2017, patients who underwent NT and total mesorectal excision for locally advanced rectal cancer were included. PNSI was defined as >4 and >8 weeks after short-course and long-course NT modalities, respectively.

RESULTS

A total of 44 (27%) patients received short-course NT (standard interval: n=28; PNSI: n=16) and 122 (73%) patients received long-course NT (standard interval: n=39; PNSI: n=83). Postoperative morbidity was similar between the standard interval and PNSI in patients undergoing short-course [n=3 (11%) vs. n=3 (19%), P=0.455] and long-course [n=6 (15%) vs. n=16 (19%), P=0.602] NT. PNSI was associated with increased complete pathologic response in patients receiving short-course NT [0 vs. n=5 (31%), P=0.002]. Compared with short-course NT, long-course NT was superior in terms of tumor response based on the Mandard [Mandard 1 to 2: n=6 (21%) vs. 6 (38%), P=0.012] and the College of American Pathologists (CAP) [CAP 0 to 1: n=13 (46%) vs. n=8 (50%), P=0.009] scores. Postoperative morbidity was similar after open, laparoscopic, and robotic total mesorectal excision [n=1 (14.2%) vs. n=21 (21%) vs. n=6 (12.5%), P=0.455] irrespective of the interval time to surgery and the type of NT.

CONCLUSIONS

PNSI can be considered in patients undergoing short-course NT due to its potential oncological benefits. The mode of surgery performed at tertiary centers has no impact on postoperative morbidity after both NT modalities.

Dealing with the gray zones in the management of gastric cancer: The consensus statement of the İstanbul Group

The geographical location and differences in tumor biology significantly change the management of gastric cancer. The prevalence of gastric cancer ranks fifth and sixth among men and women, respectively, in Turkey. The international guidelines from the Eastern and Western countries fail to manage a considerable amount of inconclusive issues in the management of gastric cancer. The uncertainties lead to significant heterogeneities in clinical practice, lack of homogeneous data collection, and subsequently, diverse outcomes. The physicians who are professionally involved in the management of gastric cancer at two institutions in Istanbul, Turkey, organized a consensus meeting to address current problems and plan feasible, logical, measurable, and collective solutions in their clinical practice for this challenging disease. The evidence-based data and current guidelines were reviewed. The gray zones in the management of gastric cancer were determined in the first session of this consensus meeting. The second session was constructed to discuss, vote, and ratify the ultimate decisions. The identification of the T stage, the esophagogastric area, imaging algorithm for proper staging and follow-up, timing and patient selection for neoadjuvant treatment, and management of advanced and metastatic disease have been accepted as the major issues in the management of gastric cancer. The recommendations are presented with the percentage of supporting votes in the results section with related data.

Helicobacter pylori-miRNA interaction in gastric cancer tissues: First prospective study from Turkey

Helicobacter pylori (H. pylori) is involved in the etiology of gastric cancer (GC). miRNAs are short RNAs that regulate gene expression by marking mRNAs for degradation. miRNAs are involved in tumorigenesis, metastasis, and cell proliferation. We aimed to investigate the miRNA expression profiles of tissues from H. pylori (+) and (-) GC patients. Forty GC patients, 20 H. pylori (+) and 20 H. pylori (-), and a healthy control group were included. The miRNA expression levels were investigated by microarrays and quantitative RT-PCR. We detected 9 upregulated and 4 downregulated miRNAs by microarray. We selected 5 upregulated and 5 downregulated miRNAs for the quantitative RT-PCR assay. The relative fold changes of miRNAs in the cancerous tissue and non-tumor mucosa specimens of H. pylori (+) GC patients for hsa-miR-194 were 4.24- and 3.83-fold higher, respectively, whereas the hsa-miR-145 expression levels were downregulated 0.33-fold and 0.43-fold, respectively, in the same group. The presence of H. pylori significantly upregulated hsa-miR-194 and downregulated hsa-miR-145 expression levels in H. pylori (+) GC cases, compared to H. pylori (-) GC cases. Regional differences in the virulence of H. pylori strains may also be involved in the up- or downregulation of miRNA expression levels.

Clinicopathological and prognostic significance of microsatellit instability (MSI) status and PDl-1 expression in Turkish patients with gastric cancer

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Background: The aim of this study was to evaluate the prognostic role of microsatellite instability (MSI) status and PD-L1 expression in surgically resected gastric cancer and the relationship of these parameters with clinicopathological features. Methods: Eighty six gastric cancer patients which had curative surgical resection at Acibadem Atakent and Maslak Hospitals between 2010 and 2017 were analysed. Tumor samples were evaluated with MSI and PD-L1 antibodies by immunohistochemical (IHC) methods. PD-L1 IHC scoring was performed using the combined positive score (CPS). Survival analysis was accomplished using the Kaplan-Meier method. Cox proportional hazard regression model was used to identify independent risk factors that affect patients' overall survival. Results: The rate of PD-L1 expression in tumor cells was 34.9% (n = 30) and the frequency of PD-L1 expression in immune cells with CPS (≥1%) was 57% (n = 49). MSI-H was detected in 11.6%(n = 10), and more observed in PD-L1 positive cases (p = 0.021). MSI-H status was significantly correlated with older age, increased tumor size, presence of PD-L1 expression, and adenocarcinoma subtype. PD-L1 expression was associated with lymph node metastasis, adenocarcinoma subtype, microsatellite instability, presence of preoperative treatment and improved response to preoperative chemotherapy. In our study, the impact of MSI status on survival was not demonstrated, but PD-L1 expression positivity(≥1%) in both tumor cells (15.7 vs 53.4 months, p = 0.008)and in immune cells (20.4 vs NR; p = 0.027) was associated with short overall survival. PD -L1 expression in tumor cells was an independent prognostic factor for overall survival in multivariate analysis (HR: 2.28, p = 0.047). Conclusions: PD-L1 expression was related to a poor prognosis in patients with gastric cancer and can represent a rational approach for PD-1/PD-L pathway-targeted immunotherapy.

Association of clinicopathological features with E-cadherin (CDH1) gene-160 C>A promoter polymorphism in Turkish colorectal cancer patients

Background and Aim of Study

The role of E-cadherin (CDH1) gene-160 C>A (rs16260) promoter polymorphism in colorectal cancer (CRC) still remains inconclusive. The aim of this study is to investigate the associations between the CDH1-160 C>A polymorphism with the susceptibility and clinicopathological development of CRC in the Turkish patients. To our knowledge, this is the first report examining the role of CDH1 polymorphism in Turkish CRC patients.

Materials and Methods

A total of 92 colorectal carcinoma cases (including 62 colon and 30 rectal cancer patients) and the corresponding adjacent normal tissues as controls were studied. The polymorphism was genotyped using polymerase chain reaction-restriction fragment length polymorphism analysis. Clinicopathological features including patient's age, gender, tumor stage, and tumor location (colon/rectum) were compared statistically with the polymorphism status.

Results

There was no significant difference in both genotype and allele frequencies of the CDH1 polymorphism between colorectal tumor cases and normal samples (P = 0.472 and 0.508, respectively). Furthermore, no significant associations were observed between the CDH1 polymorphism status and age, gender, tumor stage, and tumor location of the colorectal tumor cases (all P > 0.05).

Conclusions

These results indicate that CDH1-160 C>A polymorphism does not contribute to the genetic susceptibility of CRC and the polymorphism may not be a direct effect on the progression of the disease in Turkish CRC patients.

Gastroenteropancreatic neuroendocrine tumors: recommendations of Turkish multidisciplinary neuroendocrine tumor study group on diagnosis, treatment and follow-up

Gastroenteropancreatic neuroendocrine tumors (GEPNETs) are a relatively rare, heterogeneous group of diseases in which important advances have been observed in the diagnosis and treatment as well as in our understanding of the biology and genetics of the disease in recent years. Given the insufficient scientific data available on evidence-based management of GEPNETs and the differences in circumstances in individual countries, a multidisciplinary study group was established to provide guidelines for the management of GEPNETS. This study group consisted of a medical oncologist, endocrinologist, surgeon, pathologist, gastroenterologist, and a nuclear medicine specialist, who aimed to prepare a practical guide in the light of existing scientific data and international guidelines, to be used in common clinical practice.

Microsatellite instability and B-type Raf proto-oncogene mutation in colorectal cancer: Clinicopathological characteristics and effects on survival

Prognostic significance of microsatellite instability (MSI) status and B-type Raf proto-oncogene (BRAF) mutation in colorectal cancer is controversial. The aim of this study was to examine the clinical and pathological characteristics associated with microsatellite stability and the effect of MSI and BRAF mutation on the survival of patients with colorectal cancer. The study included 145 colorectal cancer cases. All the patients were examined for DNA mismatch repair (MMR) proteins with an immunohistochemical method. Molecular assessment of MSI was available in a subset of 41 patients. In addition, BRAF mutation analysis was performed in 30 cases. Immunohistochemically, MMR deficiency was present in 28 (19.3%) patients. Female gender (p = 0.001), lesion size ≥5 cm (p = 0.013), Crohn-like response (p = 0.035), and right-sided localization (p < 0.001) were significantly more frequent among MMR-deficient patients. The overall survival was 44.1 ± 5.1 months (95% confidence interval [CI], 33.7-54.4). Multivariate analyses identified only high tumor grade as an independent predictor of poor overall survival: odd ratio, 6.7 (95% CI 2.1-21.7), p = 0.002. In the subset of patients with available BRAF assessment (n = 30), a negative BRAF status was associated with better survival when compared to a positive BRAF status (36.7 ± 2.1 vs. 34.1 ± 7.2 months, p = 0.048). The sensitivity and specificity of the immunohistochemical method in predicting positive MSI status, with the molecular method as a reference, were 85.7% (95% CI: 56.2%-97.5%) and 88.9% (95% CI: 69.7%-97.1%), respectively. BRAF appears to be a significant predictor of a worse outcome in patients with colorectal cancer. Further studies with a large spectrum of clinical and biological variables are warranted.

Machine learning aided diagnosis of hepatic malignancies through in vivo dielectric measurements with microwaves

In the past decade, extensive research on dielectric properties of biological tissues led to characterization of dielectric property discrepancy between the malignant and healthy tissues. Such discrepancy enabled the development of microwave therapeutic and diagnostic technologies. Traditionally, dielectric property measurements of biological tissues is performed with the well-known contact probe (open-ended coaxial probe) technique. However, the technique suffers from limited accuracy and low loss resolution for permittivity and conductivity measurements, respectively. Therefore, despite the inherent dielectric property discrepancy, a rigorous measurement routine with open-ended coaxial probes is required for accurate differentiation of malignant and healthy tissues. In this paper, we propose to eliminate the need for multiple measurements with open-ended coaxial probe for malignant and healthy tissue differentiation by applying support vector machine (SVM) classification algorithm to the dielectric measurement data. To do so, first, in vivo malignant and healthy rat liver tissue dielectric property measurements are collected with open-ended coaxial probe technique between 500 MHz to 6 GHz. Cole-Cole functions are fitted to the measured dielectric properties and measurement data is verified with the literature. Malign tissue classification is realized by applying SVM to the open-ended coaxial probe measurements where as high as 99.2% accuracy (F1 Score) is obtained.

Clinical and pathological characteristics and their effect on survival in elderly patients with gastrointestinal stromal tumors

PURPOSE

Gastrointestinal stromal tumors (GISTs) are common tumors of the gastrointestinal tract. Their most frequent location is the stomach. Although the clinical and pathological characteristics of the disease are well-known, the clinical and pathological characteristics and the response to treatment are not clear in elderly patients. The purpose of this study was to evaluate the characteristics of GISTs in elderly patients with an aim at improving the therapeutic methodology and survival.

METHODS

In this study, clinicopathological characteristics, evaluation of treatments administered and survival analyses were performed in patients aged 65 years or above, whose data were registered via a web-based patient records system following admission to three centers.

RESULTS

A total of 85 patients aged 65 years or above were included in the study. According to the risk classification, 24 (28.2%) were in the low risk group, 20 (23.5%) in the moderate risk group, and 41 (48.3%) in high risk group, while no patient was in the very low risk group. At baseline, 70% of the patients had localized disease and 30% metastatic disease. The tumor was located in the stomach in the majority of the patients (45.6%). The tumor size most commonly seen was 5-10 cm (N=31; 36.4%). Of the 85 patients 23 (27%) were treated with imatinib 400 mg/d. Eight patients (9.4%) with metastatic disease switched from imatinib to sunitinib. At a median follow-up of 76 months (range 1-323), median overall survival (OS) was 72 months, without significant difference between elderly and younger patients.

CONCLUSION

Clinicopathological characteristics and their prognostic impact on the disease course of elderly GIST patients should be elucidated in depth. Since age didn't show prognostic importance, other parameters should be used as prognostic/predictive factors in the tyrosine kinase inhibitors era in order to obtain improved therapeutic results.

Epidermal growth factor receptor in CRC patients in the era of the RAS

The aim of this study was to investigate EGFR expression patterns and the effect of EGFR expression on stage, prognosis and response to conventional chemotherapy agents other than monoclonal antibodies in CRC patients. This study included 59 metastatic CRC patients. The expression of EGFR was quantified by immunochemistry in biopsy specimens that were obtained before treatment was initiated. The cases were considered to be positive for EGFR if >1% of the tumor cells had complete circumferential membranous staining. The median age of the patients was 54.6 years, and 59% of the patients were male. Twenty-six patients presented with stage IV disease, and the remaining patients developed distant metastasis during follow-up. Fifty-one patients were treated with regimens containing irinotecan. The numbers of patients with EGFR expression in the primary tumors, the metastatic lymph nodes and the normal colonic tissue were 34 (65.4%), 10 (76.9%) and 34 (65.4%) respectively. The initial disease stage and lymph node stage were correlated with EGFR expression (p<0.05). Additionally, EGFR positivity was correlated with a statistically significant reduction in the response rate to chemotherapy, the overall survival (21 vs. 28 months) and the progression-free survival (15 vs. 22 months) in metastatic patiens treated with chemotherapy other than targeted therapies. In conclusion, EGFR expression in correlated with stage in all CRC patients and response to chemotherapy and survival in metastatic CRC patients.

Is perineural invasion (PN) a determinant of disease free survival in early stage colorectal cancer?

BACKGROUND/AIMS

The prognostic importance of perineural invasion (PN) in colorectal cancer (CRC) is unclear. The aim of this study to find out whether the PN was an independent stratification factor of postoperative relapse in curatively resected high-risk stage II & III CRC patients who were treated with adjuvant therapy.

METHODOLOGY

Data of patients with high risk stage II & all stage III CRCs treated with adjuvant chemotherapy were retrospectively analyzed. Pathological features of final surgical specimen were noted. Disease-free survival was determined by Kaplan-Meier estimator, with differences determined by multivariate analysis using the Cox multiple hazards model. Results were compared using the log-rank test.

RESULTS

PN was found to be positive in 26% in the files of 593 eligible patients. In 21% of the reports PN status was not reported. Presence of PN in the resected primary tumors did not have independent effect on DFS. Further analyses for importance of PN on DFS of colon or rectal cancers did not show any effect.

CONCLUSIONS

This study had failed to demonstrate any prognostic effect of PN for DFS in surgically resected stage II and III CRC patients who received adjuvant treatments.

Association KRAS G13D tumor mutated outcome in patients with chemotherapy refractory metastatic colorectal cancer treated with cetuximab

BACKGROUND/AIMS

Cetuximab is currently approved for the treatment of metastatic colorectal cancer (mCR) with KRAS wild-type. Prior few studies demonstrated that G13D mutated tumors could benefit from cetuximab. This study aims to investigate whether KRAS G13D mutated tumors benefit from cetuximab in the chemotherapy refractory patients.

METHODOLOGY

We retrospectively compared progression-free survival (PFS), overall survival (OS) and response rate (RR) according to KRAS mutation status in 105 patients with mRC treated at the Cerrahpasa Medical School Hospital, between October 2008 and October 2011, with cetuximab alone or in combination with chemotherapy.

RESULTS

PFS was significantly longer in patients G13D mutated tumors (6.81 months) than in patients with other KRAS mutated tumors (5 months) (p=0.027). No significant difference in PFS between patients G13D mutated and KRAS wild-type tumors was detected. No significant difference in OS was detected in patients between G13D mutated tumors and other KRAS mutated tumors. However, patients with KRAS wild-type tumors had significantly longer OS (16.1 months) than patients with mutated tumors (8.9 months) (p=0.025). RR in patients with other KRAS mutated tumors, was significantly worse than those with G13D mutated tumors (p=0.002).

CONCLUSION

Our study demonstrated an association between the presence KRAS G13D mutanted and survival chemotherapy in refractory metastatic colorectal cancer treated with cetuximab.

What is the optimal treatment in clinical stage T3N0M0 rectal cancer?

PURPOSE

Some previous studies suggested that certain rectal cancer patients with stage T3N0 and favorable features may be adequately treated with surgery and adjuvant chemotherapy. However, the optimal management of clinical (c) T3N0 rectal adenocarcinoma based on preoperative imaging is unclear. In this study, we aimed to determine the frequency of lymph node metastases in patients clinically staged as T3N0 rectal adenocarcinoma following preoperative chemoradiotherapy (CTR).

METHODS

The medical records of 105 patients with clinico- imaging stage T3N0M0 rectal cancer who received preoperative CRT between 2004-2011 were retrospectively analyzed. Chemotherapy used concurrently with preoperative radiotherapy (RT) was protracted 5-fluorouracil (5FU) infusion.

RESULTS

Twenty-seven percent of the patients clinically staged as T3N0 before preoperative CRT had pathological (p) lymph node involvement on surgical material. The rate of pathological lymph node involvement was 0% in pT1, 20% in pT2 , 35% in pT3 and 34% in pT4 patients. A significant association was demonstrated between pT stages and pN status (p=0.03).

CONCLUSION

Our study demonstrated that the accuracy of preoperative imaging for staging rectal cancer is limited because at least 27% of the patients may have undetected lymph node involvement after preoperative CRT in surgical material.

Preoperative versus postoperative chemoradiotherapy in stage T3, N0 rectal cancer

BACKGROUND

The study populations of previous preoperative chemoradiotherapy (pre-CRT) studies have consisted of mixed clinical stages, such as cT3-cT4 and/or cN positive. For this reason, it has not been possible to demonstrate whether pre-CRT is of benefit for individual subgroups.

METHODS

The medical records of 137 rectal cancer patients with clinical stage T3, N0 disease who received either pre-CRT or postoperative chemoradiotherapy (post-CRT) between 2002 and 2011 were retrospectively analyzed. The regimen of pre-CRT consisted of slow fluorouracil (5FU) infusion and that of post-CRT consisted of bolus 5FU and leucovorin concurrent with radiation.

RESULTS

Following pre-CRT, significant downstaging was achieved. However, administration of pre-CRT did not influence the type of surgical resection in tumours ≤5 cm distant from the anal verge (p = 0.14). Pathological complete response was achieved in 16 % of the patients in the pre-CRT group. The local recurrence rate (LRR) at 5 years was 5.7 % in the pre-CRT and 11.1 % in the post-CRT groups (p = 0.04). The distant recurrence rate (DRR) at 5 years was 76 % and 77 % in the pre-CRT and post-CRT groups, respectively (p = 0.1). Overall survival was similar in two groups (74.8 % vs. 75.3 %, p = 0.3).

CONCLUSIONS

The treatment of stage T3, N0 rectal cancer patients with pre-CRT followed by surgery decreased LRR, but did not improve DRR or OS as compared with surgery followed by post-CRT in our patient cohort.

Analysis of PTEN, BRAF and PI3K status for determination of benefit from cetuximab therapy in metastatic colorectal cancer patients refractory to chemotherapy with wild-type KRAS

We investigated predictive values of BRAF, PI3K and PTEN in cetuximab responses in KRAS wild-type (+) chemotherapy refractory, metastatic colorectal cancer (CRC) patients. Primary tumour tissues of 41 KRAS wild-type mCRC patients receiving cetuximab-based chemotherapy were investigated for PI3K, PTEN, KRAS and BRAF mutations. Progression-free survival (PFS) and overall survival (OS) periods were calculated with Kaplan-Meier method and the Cox proportional hazards model was used. PTEN and PI3K expressions were 63 and 42 %, respectively. BRAF mutation was observed as 9.8 % among patients. Tumours with BRAF mutation had statistically lower response rates (RR) for cetuximab-based treatment than tumours with BRAF wild type (0 vs. 58 %, p = 0.02). PTEN expressing tumours had statistically higher RR for cetuximab-based treatment than tumours with PTEN loss (42 vs. 12 %, p = 0.04). PI3K expression had worse significant effect on cetuximab RR than PI3K non-expressed tumours (15 vs. 44 %, p = 0.023). Median PFS was significantly longer in patients with PTEN expression (14 months) than in patients with PTEN loss (5 months) (HR, 0.4; p = 0.028). Median PFS was significantly longer in patients with PI3K non-expression (15.2 months) than in patients with PI3K expression (4.1 months) (HR, 0.31; p = 0.001). Significant difference in PFS and OS between patients with BRAF mutated and BRAF wild-type tumours was not detected. However, patients with PTEN expression had significantly longer OS (15.1 months) than patients with PTEN loss tumour (9.9 months) (HR, 0.34; p = 0.008). Patients without PI3K expression had significantly longer OS (18.2 months) than patients with PI3K expression (10.1 months) (HR, 0.27; p = 0.001). Multivariate analyses revealed that PTEN expression (HR, 0.48; p = 0.02) and absence of PI3K expression (HR, 0.2; p = 0.001) were independent prognostic factors for increased PFS. Similarly, PTEN overexpression (HR, 0.62; p = 0.03) and absence of PI3K expression (HR, 0.27; p = 0.005) were independent prognostic factors for increased OS. In PTEN loss, PI3K expression may be used as biomarkers to further select KRAS wild-type patients undergoing anti-epidermal growth factor receptor treatment.

The relation between pathological complete response and clinical outcome in patients with rectal cancer

BACKGROUND/AIMS

Preoperative chemoradiotherapy (CRT) is the standard treatment modality in locally advanced rectal cancer. The primary aim was to correlate pathological complete response (pCR) with patient outcome, and the secondary objective was to identify predictive factors of pCR.

METHODOLOGY

Patients with clinical stage II/III rectal cancer who received preoperative CRT between 2002 and 2010 were retrospectively studied.The median radiotherapy dose was 54 Gy (range, 45 to 64 Gy), and all patients received concurrent infusional 5-fluorouracil-based chemotherapy.

RESULTS

Median follow-up time was 48.3 months (range, 24 to 96 months) and 51 months (range, 44 to 110 months) for no-pCR and pCR groups, respectively. Eighteen patients (18.6%) had pCR. The 5-year overall survival was 95% for patients with pCR and 74.8% in patients without pCR (p=0.009). The 5-year local relapse free survival was 87.5% and 95% for the no-pCR and pCR groups, respectively (p=0.09). The 5-year distant relapse free survival was 93% in pCR group and 79.8% in no-pCR group (p=0.02). The 5-year distant free survival was 94% and 66% in patients with and without pCR, respectively (p=0.017). The clinical T4 (p=0.043) and pretreatment carcinoembryonic antigen level (CEA) >5ng/mL (p=0.012) were significantly associated with a lower pCR rate. In the multivariate logistic regression analysis, pretreatment CEA level >5ng/mL (p=0.008) was the only independent factor associated with a lower pCR rate.

CONCLUSIONS

Patients with pCR after preoperative CRT had a significantly improved outcome. Furthermore, the pretreatment CEA level was independently associated with pCR.

Are high initial CEA and CA 19-9 levels associated with the presence of K-ras mutation in patients with metastatic colorectal cancer?

In certain cell culture studies, significant CEA expression was observed in K-ras mutant cells. However, the relationship between high CEA levels and K-ras status has not been sufficiently investigated. In the present study, we aimed to determine the prognostic role of initial CEA and CA 19-9 values in metastatic colorectal cancer patients according to the status of K-ras. Between 2000 and 2010, a total of 215 patients with metastatic colorectal cancer who were treated and followed up in our oncology center were analyzed. Smokers were excluded from the study. The clinicopathological findings and initial CEA and CA19-9 values were determined. K-ras mutation analysis was performed using quantitative PCR evaluation of the DNA from the tumor tissues. Eighty-two patients (38.1 %) were female and 133 (61.9 %) were male, with a median age of 59 years (range 27-83). Based on tumor localization, 127 patients (59 %) were classified as colon cancer patients and 88 patients (41 %) were classified as rectal cancer patients. The majority of patients (83.3 %) had pure adenocarcinoma histology, while 36 cases (16.7 %) had mucinous adenocarcinoma. The initial CEA levels were detected to be high (>5 ng/mL) in 108 of the patients (50.2 %), while high levels of initial CA 19-9 (>37 ng/mL) were found in 90 patients (41.8 %). K-ras mutations were detected in 99 of the patients (46 %). K-ras was found to be wild type in 116 patients (54 %). Significant differences were detected between the K-ras wild-type and mutant groups with respect to age and the initial serum CEA levels. Patients with K-ras mutations were younger (p = 0.04) and had higher initial CEA levels (p = 0.02) compared to patients with K-ras wild type. The median overall survival (OS) time and 3-year OS rate for patients with a high initial CEA level (>5 ng/mL) were significantly shorter than those of patients with a low initial CEA level (<5 ng/mL) (50.5 months and 61.8 % vs. 78.6 months and 79.1 %, p = 0.014). Furthermore, the patients with low initial CA 19-9 levels (<37 ng/mL) had a significant better median OS interval and 3-year OS rate (76.1 months and 80.1 %) compared to patients with high initial CA 19-9 levels (>37 ng/mL) (37.6 months and 55.7 %, p = 0.04). Multivariate analysis indicated that stage at the time of diagnosis (p < 0.001) and low initial serum CEA level (p = 0.037) were independent prognostic factors of OS. For K-ras mutant patients, the stage at diagnosis (p = 0.017), low initial serum CEA level (p = 0.001), and low initial serum CA 19-9 level were found to be independent prognostic indicators of OS. Our findings demonstrate for the first time that the presence of a K-ras mutation correlated with high initial CEA and CA 19-9 levels in patients with metastatic colorectal cancer. Patients with high initial CEA and CA 19-9 levels may potentially predict the presence of a K-ras mutation, and this prediction may guide targeted therapies in these patients.

Gastrointestinal stromal tumors in Turkey: experiences from 3 centers

BACKGROUND

Gastrointestinal stromal tumors (GIST) are rare tumors of the gastrointestinal system. The most common primary site of GIST is the stomach. The treatment is primarily surgery, and the standard medical therapy is imatinib. Long-term survival can be obtained with good follow-up and treatment.

MATERIALS AND METHODS

In this study, data entry was performed using a web-based patient registry system for patients who were referred to 3 centers and retrospectively were diagnosed with GIST.

RESULTS

The study cohort consisted of 249 patients, including 160 men (64.3%) and 89 women (35.7%). The mean age was 59 years (range 21-90 years). Initially, 69.9% of the patients had local disease, while 30.1% had metastatic disease. The tumor was located in the stomach in 45.6% of patients. According to the Fletcher risk classification, the very low risk group included 8 subjects (3.2%), the low risk group included 40 subjects (16.1%), the moderate risk group included 56 subjects (22.5%), and the high risk group included 117 subjects (47%); the unspecified group included 28 subjects (11.5%).

CONCLUSION

These data are important for revealing the clinicopathologic characteristics and survival data of patients with GIST, who are treated and followed up in Turkey.

The role of K-RAS and B-RAF mutations as biomarkers in metastatic colorectal cancer

PURPOSE

Unlike cetuximab, there is a paucity of biomarkers for bevacizumab as predictors of outcome in metastatic colorectal cancer (mCRC) patients. Obviously exploring the worth of some potential markers in this setting is warranted. The purpose of this study was to investigate the predictive value of the presence of K-RAS and B-RAF mutations on the outcome of patients with mCRC treated with FOLFIRI and bevacizumab combination therapy.

METHODS

A total of 172 patients with mCRC were evaluated. K-RAS and B-RAF mutations were analyzed by quantitative PCR. Median progression-free survival (PFS) and overall survival (OS) were compared utilizing chi-square and Mann-Whitney U tests, respectively.

RESULTS

Forty-four percent (N=77) of the patients were found to harbor K-RAS mutations and 6 (7.5%) were positive for B-RAF mutations. In baseline no difference in PFS and OS was observed between the groups with or without K-RAS mutation. No relationship was established between K-RAS and B-RAF mutation status and baseline CEA and CA19-9 tumor markers levels.

CONCLUSION

K-RAS and B-RAF mutations do not seem to be predictive of treatment outcome as potential biomarkers for bevacizumab therapy in mCRC. However, not only the presence of K-RAS and B-RAF mutations but also the different biological behavior of the various subtypes of mutations should be considered as potential determinants in the final outcome of this disease.

Extended pancreaticoduodenectomy for a huge cystic-cavernous lymphangioma: a case report

CONTEXT

Cystic-cavernous lymphangioma is a rare cystic tumor especially for adults and pancreas.

CASE REPORT

We reported a case of a 33-year-old woman who presented with a visible and palpable abdominal mass found to be a huge lymphangioma of the pancreas. An abdominal magnetic resonance imaging (MRI) showed a multiloculated, lobulated T1 hypo/hyper, T2 hyperintense cystic mass extending from right subhepatic space to the pelvis measuring 155x167x100 mm. A pancreaticoduodenectomy was performed encompassing the distal stomach and a segment of the transverse colon, because of their close, inseparable relationship to the mass. The cystic mass was histopathologically diagnosed as partly cavernous and partly cystic lymphangioma.

CONCLUSION

To our knowledge this is the first case of pancreatic lymphangioma requiring additional organ resection besides a standard pancreaticoduodenectomy. To reduce recurrences, we recommend a complete resection for this pathology, even though its benign nature.

An alternative sutureless repair technique with amelogenin for duodenal perforation

BACKGROUND

Among the various sutureless techniques, fibrin glue has proved to be effective in the treatment of peptic ulcer perforation as an alternative to classical suture repair. Albeit rare, a potential disadvantage of fibrin glue use is viral transmission or anaphylaxis. The aim of this study is to introduce a new technique for the closure of duodenal perforation using a novel recombinant enamel protein called amelogenin.

METHODS

In this case-control experimental study, 32 adult male Wistar Albino rats weighing 250-300 g were randomly divided into four groups, each containing 8 rats. Duodenal perforation of 0.2 cm were performed in the postpyloric region in all rats. Each group received primary repair, primary repair with omentoplasty, fibrin glue, and amelogenin, respectively. All animals were killed on the postoperative day five and the bursting pressure measurements, hydroxyproline levels and histopathologic values of the wound site were evaluated.

RESULTS

Bursting pressure levels of the fibrin glue and amelogenin groups were significantly lower than the primary repair and primary repair with omentoplasty groups (P < 0.05) However, no significant difference existed between the fibrin glue and amelogenin groups in this respect (P > 0.05). There was also no statistically significant difference among all groups regarding tissue hydroxyproline levels and histopathologic values (P > 0.05).

CONCLUSION

Application of amelogenin as an alternative sutureless repair technique did not improve wound healing in this animal model of duodenal perforation.

Evaluation of diverting ileostomy in laparoscopic low anterior resection for rectal cancer

BACKGROUND

Diverting ileostomy is believed to mitigate the effects of anastomotic complications in low anterior resections (LAR) for rectal cancer. However, there are no data about the effects of diverting ileostomy on the outcomes of laparoscopic LAR METHODS: We retrospectively reviewed the medical records of 77 consecutive rectal cancer patients who had undergone laparoscopic LAR with (n = 23) or without (n = 54) diverting ileostomy. The patients' data were recorded and supplemented on short-term follow-up visits and included standard demographics, operative procedure, location of the cancer, and final pathologic diagnosis. We noted length of hospitalisation, complications, and time interval from ileostomy creation to closure. Morbidity and mortality were also included.

RESULTS

Surgical intervention requiring anastomotic leakage occurred in three patients who underwent laparoscopic LAR without diverting ileostomy. The anastomosis level of patients who underwent laparoscopic LAR with diverting ileostomy was significantly lower than that of patients who underwent laparoscopic LAR without diverting ileostomy (p < 0.05).

CONCLUSION

Anastomosis level and total mesorectal excision are the main factors for creation of diverting ileostomy in laparoscopic LAR Laparoscopic LAR without diverting ileostomy could be selectively performed. Our study provides a basis for further prospective randomised studies on the role of diverting ileostomy in LAR.

Macroglossia and generalized edema not due to hypothyroidism

We present a 69-year-old male patient with the macroglossia, dysphagia and generalized edema. He was seen previously by other physicians and diagnosed as hypothyroidism. With thyroid stimulating hormone in normal range, tongue biopsy revealed primary systemic amyloidosis. Amyloidosis is the most common cause of macroglossia. Primary systemic amyloidosis should be suspected when laboratory does not support hypothyroidism especially if the enlarged tongue is firm and additional findings are present.

Effect of corticosteroid dose and duration of administration on colonic anastomosis

BACKGROUND

Surgical intervention under concomitant steroid therapy can be complicated by impaired anastomotic healing. The aim of this experimental study was to investigate the effects of a corticosteroid (methylprednisolone) on healing colonic anastomoses in relation to the dose and duration of administration.

METHODS

Fifty male Spraque-Dawley rats weighing 200-220 g were divided into five groups each containing 10 rats. No treatment was given in the control group. Group HDST: high-dose methylprednisolone (1 mg/kg/day, intramuscular) treatment for a short term of 2 days; group HDLT: high-dose methylprednisolone treatment for a long term of 60 days; group LDST: low-dose methylprednisolone (0.28 mg/kg/day) treatment for a short term of 2 days; and group LDLT: low-dose methylprednisolone treatment for a long term of 60 days. Standard left colonic anastomosis was performed in all rats. Anastomotic bursting pressure, hydroxyproline measurement, and histopathological data were evaluated in all groups on postoperative day 4.

RESULTS

The mean anastomotic bursting pressure value was significantly lower in the HDLT group (P < 0.05). The mean hydroxyproline levels were significantly lower in all groups (P < 0.05). Histopathological results demonstrated significant changes according to neutrophil infiltration, granulation tissue formation, presence of vascularization, and peritonitis in the HDLT, LDST, and LDLT groups (P < 0.05).

CONCLUSIONS

High and low doses of the corticosteroid produced adverse effects on the healing of colon anastomosis in rats regardless of whether it was administered over a long or short preoperative period. However, the most prominent negative effect was associated with high-dose, long-term corticosteroid administration.

Cytoplasmic accumulation of glycogen synthase kinase-3beta is associated with aggressive clinicopathological features in human prostate cancer

BACKGROUND

Activation of glycogen synthase kinase-3 (GSK-3) is involved in the regulation of cell growth, differentiation, mobility, proliferation and survival. However, its clinicopathologic significance remains unclear in prostate cancer (PCa).

MATERIALS AND METHODS

A tissue microarray was produced from 640 samples. Sections were immunostained with an antibody against the non-phosphorylated form of GSK-3(GSK-3beta) and were digitized. Spearman correlation test was processed for correlations between GSK-3beta and biological and clinicopathological variables. The prognostic value of GSK-3beta was analyzed by Cox Regression model.

RESULTS

Cytoplasmic GSK-3beta was higher in PCa than in normal prostate (mean expression index 4.55 vs. 3.50, p<0.0001). Conversely, nuclear expression was higher in normal prostate than that in PCa (3.38 vs. 2.04, p<0.0001). Cytoplasmic levels of GSK-3beta were correlated with clinical stage (rho=0.095, p=0.0337), lymph node metastasis (rho=0.116, p=0.0096), extracapsular extension (rho=0.092, p=0.0392), and Gleason score (rho=0.167, p=0.0002). Increased cytoplasmic GSK-3beta expression was correlated with high Ki-67 labeling index (rho=0.319, p<0.0001), low apoptotic index by TUNEL (rho=-0.118, p=0.0134), high levels of androgen receptor (rho=0.292, p<0.0001) and p-Akt (rho=0.396, p<0.0001). Patients with higher cytoplasmic levels of GSK-3beta had a two-fold risk of biochemical recurrence-free survival compared to those with lower levels of GSK-3beta [HR 1.934 (1.020-3.667), p=0.043].

CONCLUSION

Cytoplasmic accumulation of GSK-3beta is potentially associated with a pro-survival mechanism that promotes PCa development and progression.

Role of host interleukin 1beta gene (IL-1B) and interleukin 1 receptor antagonist gene (IL-1RN) polymorphisms in clinical outcomes in Helicobacter pylori-positive Turkish patients with dyspepsia

BACKGROUND

Helicobacter pylori infection leads to different clinical outcomes depending on both host and bacterial factors. In a recent study, we identified H. pylori cagE and babA2 genotypes as independent predictors of duodenal ulcer (DU) and gastric cancer (GC) in dyspepsia patients, but no previous studies have examined the role of host-related genetic factors in Turkey. This time our aim was to evaluate whether polymorphisms of the interleukin 1B (IL-1B) and the interleukin 1 receptor antagonist (IL-1RN) genes are important factors in the differential expression of gastroduodenal diseases in H. pylori-positive dyspepsia patients.

METHODS

Ninety-three H. pylori-positive patients, 30 with nonulcer dyspepsia (NUD), 30 with DU, and 33 with GC, were investigated. The IL-1B-511 and IL-1B-31 biallelic polymorphisms, and the IL-1RN intron 2 variable number tandem repeat were genotyped by polymerase chain reaction and single-strand confirmation polymorphism analysis.

RESULTS

The IL-1RN-1/1 genotype was significantly more prevalent among patients with NUD than among those with GC (chi(2) = 9.270; P = 0.002), and the IL-1RN-1/2 genotype was significantly more common in patients with GC (chi(2) = 6.01; P = 0.014). Multivariate regression analysis showed that cagE, babA2, and IL-1RN-1/2 genotypes were independent predictors of GC, but when patients with benign disorders were grouped together (NUD + DU) and compared with patients with GC, regression analysis disclosed that babA2 (P = 0.000) and IL-1B-31 gene polymorphisms (CC or CT) (P = 0.01) were the only independent markers of GC.

CONCLUSIONS

When analyzed together with host genetic factors, the well established bacterial risk factor babA2 seems to be the most important predictor of malignant disorders, and the presence of the IL-1B-31TT genotype emerges as a protective factor against them.

Mechanical bowel preparation with different solutions in rats with selective left colonic ischemia and reperfusion injury

BACKGROUND

The aim of this study was to evaluate the effects of preoperative mechanical bowel preparation (MBP) on colonic ischemia/reperfusion (I/R) injury.

METHODS

Seventy adult male Sprague-Dawley rats were divided randomly into 7 equal groups of 10 rats each. Groups were assigned as follows: group I = sham surgery; group II = I/R of left colon (control group); group III = intravenous heparin and metronidazole followed by I/R of the left colon; groups IV through VII = before I/R of the left colon, heparin and metronidazole and MBP were performed with sodium chloride (NaCl), Na phosphate, polyethylene glycol, and mannitol, respectively. Histopathologic and biochemical parameters were evaluated.

RESULTS

According to the histopathologic changes, the groups least affected by I/R injury were groups V and VII. Catalase activity was significantly higher in groups V and VII, and copper-zinc superoxide dismutase activity was significantly higher in group VII compared with the control group (P <.002).

CONCLUSIONS

MBP with sodium phosphate and mannitol appears to be more protective against I/R injury.

The contributions of virtual colonoscopy to laparoscopic colorectal surgery

BACKGROUND/AIMS

Operative tumor or polypectomy site localization and synchronous colonic lesions are challenging problems especially in laparoscopic surgery. We designed this prospective study to determine the contributions of virtual colonoscopy to laparoscopic colorectal surgery.

METHODOLOGY

Virtual colonoscopy was performed in 40 consecutive patients who had undergone laparoscopic resection for colorectal neoplasm. Preoperative findings of optical colonoscopy and virtual colonoscopy, operative data, tumor localizations and histopathologic findings were assessed.

RESULTS

Accuracy rates for virtual colonoscopy and optical colonoscopy were 97.5% and 55%, respectively (P<0.05). Polypectomy site was localized with virtual colonoscopy in five patients. There were nine partially obstructing tumors that did not allow optical endoscope passage. Four of six synchronous tumors (one tumor and three polyps) couldn't be shown with optical colonoscopy because of distal obstructing tumor. Histopathologic investigations revealed adenocarcinoma (n=34), adenoma demonstrating low-grade dysplasia (n=3) and high-grade dysplasia (n=2) and neuroendocrine carcinoma (n=1). Mean tumor size was 4 (1.5-10) cm. Mean proximal and distal surgical margins were 15 (5-36) cm and 7.3 (0.8-27) cm, respectively. Overall patient preference was 87.5% for virtual colonoscopy.

CONCLUSIONS

Correct localization of colorectal neoplasm or polypectomy site is mandatory before laparoscopic colorectal surgery. Virtual colonoscopy is a safe, minimally invasive three-dimensional imaging method and may be an alternative localization technique.

A child with primary Sjögren syndrome and a review of the literature

Primary Sjögren syndrome (pSS) is an uncommon disease in childhood. Childhood pSS might have different clinical manifestations than adult pSS. We describe a 13-year-old girl with multiple episodes of bilateral parotid swelling lasting 2 years. Her history included severe arthralgia, local edema, and purpura episodes since 9 years of age. During her 3-week hospitalization, 2 episodes of parotid swelling occurred, which both resolved in 48 hours. Ultrasonography and magnetic resonance images of parotid glands showed parenchymal inhomogeneity related to adipose degeneration and nodular pattern. Investigations showed elevated erythrocyte sedimentation rate, the presence of hypergammaglobulinemia, positive antinuclear antibody, and elevated rheumatoid factor, anti-Sjögren syndrome antigen A, and anti-Sjögren syndrome antigen B. Histopathologic examination of labial minor salivary glands revealed focal periductal lymphocytic infiltrate and sialoduct ectasia. She was diagnosed as having pSS. Recurrent parotid swelling is a more characteristic feature of disease in children, and this finding should alert the clinician to the possible diagnosis of pSS.

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

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

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

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

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

Forkhead protein FKHR and its phosphorylated form p-FKHR in human prostate cancer

In vitro studies suggest that the proapoptotic function of forkhead protein FKHR is probably inactivated by means of phosphorylation through the protein kinase B pathway. However, the clinical significance of FKHR in prostate cancer remains unclear. Six hundred forty radical prostatectomies were used for building tissue microarrays. Slides were stained with antibodies against FKHR and phosphorylated FKHR (p-FKHR). Correlations with clinicopathologic parameters were analyzed by Spearman rank test. Cox regression test and Kaplan-Meier test were used to determine the probability of disease recurrence, which is defined as a serum prostate-specific antigen (PSA) level greater than 0.4 ng/mL after radical prostatectomy. Nuclear FKHR level was higher in normal prostate than in benign prostatic hyperplasia and prostate cancer (P = .0000). Nuclear expression of FKHR was correlated with preoperative PSA level (rho = 0.108, P = .029), extracapsular extension (rho = 0.137, P = .005), and seminal vesicle invasion (rho = 0.101, P = .039). FKHR expression was not a significant indicator of biochemical failure by either univariate or multivariate analysis. Nuclear p-FKHR expression correlated with patients' age (rho = 0.179, P = .0003), Gleason score (rho = 0.130, P = .0083), extracapsular extension (rho = 0.227, P = .0000), clinical stage (Union Internationale Contre le Cancer system) (rho = 0.166, P = .0007), and lymph node status (rho = 0.101, P = .0401). Cytoplasmic p-FKHR correlated with patients' age (rho = 0.146, P = .0030) and clinical stage (rho = 0.117, P = .0180). Cytoplasmic p-FKHR was a significant indicator of biochemical recurrence (P = .0164; hazard ratio, 1.114-2.929). Nuclear p-FKHR strongly correlated with phosphorylated protein kinase B (rho = 0.368, P = .0000), androgen receptor (rho = 0.385, P = .0000), and Skp-2 (rho = 0.170, P = .0036). Our data suggest that the proapoptotic role of FKHR is probably regulated by several signaling pathways in prostate cancer.

Hemangiopericytoma of the parotid gland: a case report

Hemangiopericytomas are uncommon neoplasms of vascular origin that mostly arise from extremities, retroperitoneum, and pelvic fossa. They are rarely found in the parotid gland. A 35-year-old female patient presented with a swelling in the right preauricular region. Fine-needle aspiration biopsy performed twice yielded an extraordinary amount of blood. A cytological diagnosis could not be made. Computed tomography showed a homogenous, well-shaped mass in the parotid gland. Superficial parotidectomy was performed. Histopathological diagnosis was made as hemangiopericytoma. No evidence for local recurrence or distant metastasis was seen within a follow-up of 36 months.

Prevalence of Helicobacter pylori vacA, cagA, cagE, iceA, babA2 genotypes and correlation with clinical outcome in Turkish patients with dyspepsia

BACKGROUND

Distinct virulence factors of Helicobacter pylori have been associated with clinical outcome of the infection; however, considerable variations have been reported from different geographic regions and data on genotypes of Turkish H. pylori isolates are sparse.

AIM

To determine the prevalence of specific genotypes of H. pylori in Turkish patients with dyspepsia.

MATERIALS AND METHODS

Ninety-three H. pylori-positive patients [30 with non-ulcer dyspepsia (NUD), 30 with duodenal ulcer (DU), and 33 with gastric cancer (GC)] who were admitted to our endoscopy unit due to dyspepsia were enrolled in the study. H. pylori infection was confirmed in all patients by histology and rapid urease test (RUT). The presence of vacA alleles, cagA, cagE, iceA, and babA2 genotypes were determined by polymerase chain reaction (PCR). Chi-squared test and Fisher's exact test were used for statistical comparisons and multivariate regression analysis was performed to find out independent predictors of different clinical outcomes.

RESULTS

Turkish strains examined predominantly possessed the vacA s1,m2 (48.4%) and s1,m1 (40.7%) genotypes. The vacA s1a genotype was detected in 66.7, 96.4, and 87.9% of isolates from patients with NUD, DU, and GC, respectively, and its presence was significantly associated with that of DU (p = .004), GC (p = .043), and cagA gene (p = .021). None of the cases was found to harbor the s1c genotype. The frequencies of the cagA and cagE genes among studied isolates were 73.6 and 59.3%, respectively. The cagA gene was significantly associated with the presence of DU (p = .004) and GC (p = .003), and the cagE gene, too, was significantly associated with the presence of DU (p = .002) and GC (p = .000). All H. pylori isolates possessed the iceA gene. In all, 68 isolates (74.7%) were positive for iceA1 and 23 (25.3%) for iceA2. The frequency of icea1 gene was significantly higher in cases with GC (85%) than in cases with NUD (60%) (p = .026). The frequency of babA2 gene was 23.3, 46.4, and 87.9% in isolates of patients with NUD, DU, and GC, respectively. When compared to cases with NUD (p = .000) and DU (p = .000), the presence of babA2 gene was significantly higher in cases with GC. Multivariate regression analysis disclosed cagE (p = .006) and vacA s1a (p = .027) genotypes to be independent predictors of DU and babA2 (p = .000) and cagE (p = .013) genotypes to be independent predictors of GC.

CONCLUSIONS

H. pylori vacA s1a, cagA, cagE genotypes have significant relations with the presence of DU and GC, and iceA1, babA2 with GC in Turkish patients with dyspepsia, whereas cagE and vacA s1a genotypes are independent predictors of DU, and babA2 and cagE genotypes are independent predictors of GC.

Analysis of serum antibody profile against H pylori VacA and CagA antigens in Turkish patients with duodenal ulcer

AIM: To investigate the frequency of seropositivity against CagA, VacA proteins and to determine their independent effects on the development of duodenal ulcer (DU) in Turkish patients.

METHODS: The study was designed as a prospective one from a tertiary referral hospital. Dyspeptic patients who were referred to our endoscopy unit for upper gastrointestinal endoscopy between June 2003 and March 2004 and diagnosed to have DU or nonulcer dyspepsia (NUD) were included. Biopsies from the antrum and body of the stomach were taken in order to assess the current H pylori status by histology, rapid urease test and culture. Fasting sera were obtained from all patients and H pylori status of all sera was determined by IgG antibodies using an enzyme-linked immunosorbent assay (ELISA) kit. All seropositive patients were further analysed using Western blot assays detecting IgG antibodies against CagA and VacA proteins. The χ² test was used for statistical comparison of the values and age-sex adjusted multiple regression analysis was used to determine the independent effects of CagA and VacA seropositivities on the development of DU.

RESULTS: Sixty-three patients with DU and 62 patients with NUD were eligible for the final analysis. Seropositivity for anti-CagA was detected in 51 of 62 (82%), and in 55 of 63 (87%) patients with NUD and DU, respectively (P = no significance), and seropositivity for anti-VacA was found in 25 of 62 (40% ) and in 16 of 63 (25%) patients, with NUD and DU, respectively.

CONCLUSION: These findings suggest that none of these virulence factors is associated with the development of DU in the studied Turkish patients with dyspepsia.