Prognostic significance of cyclooxygenase-2 and associated molecules in gastric cancer

Background and aims: Low stage and curative surgery are established factors for improved survival in gastric cancer. However, not all low-stage patients have a good prognosis. Cyclooxygenase-2 (COX-2) is known to associate with reduced survival in several cancers, and has been shown to play an important role in gastric carcinogenesis. Since new and better prognostic markers are needed for gastric cancer, we studied the prognostic significance of COX-2 and of markers that associate with COX-2 expression. We also studied markers reflecting proliferation and apoptosis, and evaluated their association with COX-2. Our purpose was to construct an accurate prognostic model by combining tissue markers and clinicopathogical factors. Materials and methods: Of 342 consecutive patients who underwent surgery for gastric cancer at Meilahti Hospital, Helsinki University Central Hospital, 337 were included in this study. Low stages I to II were represented by 141 (42%) patients, and high stages III to IV by 196 (58%). Curative surgery was performed on 176 (52%) patients. Survival data were obtained from the national registers. Slides from archive tissue blocks were prepared for immunohistochemistry by use of COX-2, human antigen R (HuR), cyclin A, matrix metalloproteinases 2 and 9 (MMP-2, MMP-9), and Ki-67 antibodies. Immunostainings were scored by microscopy, and scores were entered into a database. Associations of tumor markers with clinicopathological factors were calculated, as well as associations with p53, p21, and results of flow cytometry from earlier studies. Survival analysis was performed by the Kaplan-Meier method, and Cox multivariate models were reconstructed. Cell culture experiments were performed to explore the effect of small interfering (si)RNA of HuR on COX-2 expression in a TMK-1 gastric cancer cell line. Results: Overall 5-year survival was 35.1%. Study I showed that COX-2 was an independent prognostic factor, and that the prognostic impact of COX-2 was more pronounced in low-stage patients. Cytoplasmic HuR expression also associated with reduced survival in gastric cancer patients in a non-independent manner. Cell culture experiments showed that HuR can regulate COX-2 expression in TMK-1 cells in vitro, with an association also between COX-2 and HuR tissue expression in a clinical material. In Study II, cyclin A was an independent prognostic factor and was associated with HuR expression in the gastric cancer material. The results of Study III showed that epithelial MMP-2 associated with survival in univariate, but not in multivariate analysis. However, MMP-9 showed no prognostic value. MMP-2 expression was associated with COX-2 expression. In Study IV, the prognostic power of COX-2 was compared with that of all tested markers associated with survival in Studies I to III, as well as with p21, p53, and flow cytometry results. COX-2 and p53 were independent prognostic factors, and COX-2 expression was associated with that of p53 and Ki-67 and also with aneuploidy. Conclusions: COX-2 is an independent prognostic factor in gastric cancer, and its prognostic power emerges especially in low stage cancer. COX-2 is regulated by HuR, and is associated with factors reflecting invasion, proliferation, and apoptosis. In an extended multivariate model, COX-2 retained its position as an independent prognosticator. COX-2 can be considered a promising new prognostic marker in gastric cancer.Mahasyövän esiintyvyys ja sen aiheuttamat syöpäkuolemat ovat vähentyneet maailmanlaajuisesti viimeisten vuosikymmenten aikana. Suomessa diagnosoidaan alle 700 uutta mahasyöpää vuosittain, sairastuneista miesten osuus on kaksinkertainen naisiin verrattuna. Sosioekonomisten olojen parantumisen on ajateltu laskevan mahasyövän esiintyvyyttä, mutta tärkeimmäksi tekijäksi on kuitenkin katsottava Helicobacter pylorin löytyminen, sen merkityksen ymmärtäminen tämän syövän synnyssä, ja ennen kaikkea, sen häätö yhdistelmälääkehoidolla. Pääasialliset hyvän ennusteen tekijät ovat matala levinneisyysaste ja radikaali kirurginen hoito. Diagnostiikassa oleellisinta on sen varhaisuus. Mahalaukun tähystys koepaloineen, sekä tietokonetomografiatutkimus levinneisyyden selvittelyssä ovat oleellisimmat diagnostiset toimenpiteet. Kirurginen hoito sisältää mahalaukun poiston joko osittain tai kokonaan, sekä ympäröivien imusolmukkeiden poiston. Sytostaatti- eli syöpälääkehoitoa annetaan vain osalle potilaista toteutettuna joko sekä ennen että jälkeen leikkauksen, pelkästään leikkauksen jälkeen, tai yhdistettynä sädehoitoon. Ei kuitenkaan tiedetä tarkasti, miksi potilailla, joilla on samassa vaiheessa todettu ja samalla tavalla hoidettu syöpä, on erilainen taudinkulku ja ennuste. Siksi onkin tärkeää löytää uusia mitattavia ennusteellisia tekijöitä, kasvainmerkkiaineita, jotta oikeat potilaat valikoituisivat näihin usein varsin raskaisiin hoitoihin. Syklo-oksigenaasi-2 (cyclooxygenase-2, COX-2) on avainentsyymi tulehdusreaktion synnyssä. Se muuntaa arakidonihaposta prostaglandiiineja, jotka aiheuttavat tulehdusreaktion elimistössä. Fysiologisten vaikutusten lisäksi COX-2:n on todettu aiheuttavan mahasuolikanavan kasvaimia koe-eläimissä. COX-2 estää ohjelmoitua solukuolemaa eli apoptoosia, stimuloi uudisverisuonten muodostumista ja lisää niiden entsyymien tuotantoa, jotka puolestaan lisäävät etäpesäkkeiden syntyä. Näin ollen COX-2 on tärkeä mahasyövän syntyyn vaikuttava tekijä. Ennusteellisena tekijänä sen on todettu toimivan useissa muissa syövissä, kuten rinta-, paksusuoli-, ruokatorvi- ja haimasyövässä. COX-2:a voidaan salvata aspirinilla ja muilla tulehduskipulääkkeillä. Viimeaikaiset, laajat epidemiologiset tutkimukset ovat paljastaneet, että yli 75 mg aspirinia vuorokaudessa käyttävillä potilailla on verrokkeja merkittävästi pienempi riski sairastua ja kuolla maha-suolikanavan syöpään. Tämän väitöstutkimuksen tarkoituksena oli selvittää COX-2:n ja siihen liittyvien molekyylien merkitys mahasyövän ennusteeseen, sekä muodostaa näistä tekijöistä laskennallinen, ennusteellinen malli. Meilahden sairaalassa vuosina 1983-1999 mahasyövän vuoksi leikatuista 342 potilaasta 337 otettiin mukaan tähän tutkimukseen. Potilaiden mediaani-ikä oli 66 vuotta, matalaa levinneisyyttä (stage I-II) edusti 141 (42%) potilasta ja korkeaa (stage III-IV) 196 (58%). Radikaali, parantava leikkaus päästiin tekemään 176:lle potilaalle (52%). Kuolleisuustiedot saatiin valtakunnallisista rekistereistä. Leikkauspreparaateista tehtyjä paraffiiniblokkeja käyttäen kunkin potilaan syöpäkudosta värjättiin immunohistokemiallisin menetelmin. Värjäykset suoritettiin vasta-aineilla, jotka ilmensivät kasvainmerkkiaineista COX-2, lähetti RNA:ta stabiloivaa proteiinia HuR, solunjakautumista säätelevää proteiinia cyclin A, solukalvoja pilkkovia gelatinaaseja MMP-2 ja MMP-9, sekä solujen jakautumisaktiivisuutta ilmentävää proteiinia Ki-67. Lisäksi hyödynnettiin aiemmin määritettyjä värjäyksiä p53- ja p21- proteiineista, jotka osaltaan säätelevät solunjakautumista, sekä virtaussytometrialla määritettyjä muuttujia kunkin kasvaimen kasvupotentiaalista (S-phase fraction ja DNA ploidy). HuR:n kautta tapahtuvaa COX-2:n säätelyä mahasyöpäsoluissa (TMK-1) tutkittiin soluviljelytöillä. Immunohostokemialliset värjäykset tutkittiin mikroskoopilla ja luokiteltiin erillisten periaatteiden mukaan. Saadut numeeriset arvot syötettiin tietokantaan ja laskettiin näiden värjäystulosten korrelaatio potilaskohtaisiin, kliinispatologisiin muuttujiin, kuten ikä, sukupuoli, taudin levinneisyys, histologinen tyypitys ja leikkaustyyppi. Lisäksi määritettiin kunkin kasvainmerkkiaineen esiintymisen korrelaatio potilaiden elossaololukuihin, ja verrattiin merkkiaineiden ennusteellista merkitystä toisiinsa sekä kliinispatologisiin muuttujiin. Viisivuotiselossaololuku koko aineistossa oli 35.1%. Mahasyövän huonoon ennusteeseen korreloivat korkea levinneisyysaste, ei-radikaali leikkaus, sekä COX-2, HuR, cyclin A ja MMP-2. Erillisissä osatöissä suoritetuissa monimuuttuja-analyyseissä itsenäisinä ennustetekijöinä toimivat COX-2 ja cyclin A, mutta kaikki tässä tutkimuksessa käytetyt muuttujat huomioivassa monimuuttujamallissa kasvainmerkkiaineista ainoastaan COX-2 ja p53 säilyivät itsenäisinä ennustetekijöinä. Lisäksi havaittiin, että COX-2:n ennusteellinen merkitys on suurempi varhaisvaiheen mahasyövissä, jotka yleensä ovat kirurgisesti hoidettavissa. Soluviljelytöissä kävi ilmi, että HuR säätelee COX-2:n tuotantoa solun sisällä. COX-2 on lupaava kasvainmerkkiaine mahasyövässä, ja sen ennusteellisen merkityksen painottuminen varhaisvaiheen syöpiin kertoo näiden kasvainten aggressiivisesta kasvutaipumuksesta. Ne varhaisvaiheen syöpää sairastava potilaat, joiden kasvaimista löytyy korkeat COX-2 -pitoisuudet, saattaisivat eniten hyötyä leikkaushoidon lisäksi annettavista syöpälääkehoidoista. Erityisen kiinnostavaa on mahdollisuus salvata COX-2:a aspiriinilla ja muilla tulehduskipulääkkeillä. Tulevaisuudessa onkin syytä tutkia laajemmin COX-2:n ja mahasyövän lääkehoitojen yhteyksiä

Day-care laparoscopic cholecystectomy with diathermy hook versus fundus-first ultrasonic dissection : a randomized study

To examine the impact of day-care laparoscopic cholecystectomy (LC) with ultrasonic scissors dissection versus diathermy hook dissection method in a randomized setting. From April 2012 to September 2014, a total of 169 elective day-care patients were randomized to undergo either laparoscopic cholecystectomy with ultrasonic scissors using fundus-first approach (n = 88) or diathermy hook dissection starting from the triangle of Calot (n = 79). Main measures of outcome were operative time, same-day discharge and intraoperative complications. Secondary outcome measures were postoperative pain (numeric rating scale), postoperative nausea and vomiting (PONV), readmissions and 30-day morbidity. Median operative time was similar in the ultrasonic dissection and diathermy hook dissection groups (45 vs 45 min, p = 0.95). Same-day discharge was possible in 77 patients (87 %) in the ultrasonic dissection group and in 69 patients (87 %) in the diathermy group, p = 0.98. Intraoperative gallbladder perforations, mean intraoperative bleeding, postoperative pain and PONV at 1, 2 and 4 h (p = 0.78) did not differ significantly between the study groups. Day-care LC using either diathermy hook or ultrasonic dissection resulted in excellent same-day discharge in both groups (87 %). LC with ultrasonic dissection does not offer any clinical advantages compared to diathermy dissection.Peer reviewe

Standard Lymphadenectomy for Esophageal and Lung Cancer : Variability in the Number of Examined Lymph Nodes Among Pathologists and Its Survival Implication

AIM: We compared variability in number of examined lymph nodes between pathologists and analyzed survival implications in lung and esophageal cancer after standardized lymphadenectomy. METHODS: Outcomes of 294 N2 dissected lung cancer patients and 132 2-field dissected esophageal cancer patients were retrospectively examined. The primary outcome was difference in reported lymph node count among pathologists. Secondary outcomes were overall and disease-specific survival related to this count and survival related to the 50% probability cut-off value of detecting metastasis based on the number of examined lymph nodes. RESULTS: The median number of examined lymph nodes in lung cancer was 13 (IQR 9-17) and in esophageal cancer it was 22 (18-29). The pathologist with the highest median number of examined nodes had > 50% higher lymph node yield compared with the pathologist with the lowest median number of nodes in lung (15 vs. 9.5, p = 0.003), and esophageal cancer (28 vs. 17, p = 0.003). Survival in patients stratified by median reported lymph node count in both lung (adjusted RMST ratio < 14 vs. ≥ 14 lymph nodes 0.99, 95% CI 0.88-1.10; p = 0.810) and esophageal cancer (adjusted RMST ratio < 25 vs. ≥ 25 lymph nodes 0.95, 95% CI 0.79-1.15, p = 0.612) was similar. The cut-off value for 50% probability of detecting metastasis by number of examined lymph nodes in lung cancer was 15.7 and in esophageal cancer 21.8. When stratified by this cut-off, no survival differences were seen. CONCLUSION: The quality of lymphadenectomy based on lymph node yield is susceptible to error due to detected variability between pathologists in the number of examined lymph nodes. This variability in yield did not have any survival effect after standardized lymphadenectomy.publishedVersionPeer reviewe

Implementation of Multimodality Therapy and Minimally Invasive Surgery: Short- and Long-term Outcomes of Gastric Cancer Surgery in Medium-Volume Center

Background Multimodal treatment of gastric cancer includes careful preoperative staging, perioperative oncological treatment, and selective minimally invasive approach. The aim was to evaluate whether this approach improves short- and long-term outcomes in operable gastric cancer. Methods This study included 181 gastric cancer patients who underwent curative intent surgery in Central Finland Central Hospital between years 2005 and 2021 for gastric or esophagogastric junction adenocarcinoma. Those 65 patients in group 1 operated between years 2005-2010 had open surgery with possible adjuvant therapy. During the second period including 58 patients (2011-2015), perioperative chemotherapy and minimally invasive surgery were implemented. The period, when these treatments were standard practise, was years 2016-2021 including 58 patients (group 3). Outcomes were lymph node yield, major complications and 1- and 3-year survival rates. Results Median lymph node yield increased from 17 in group 1 and 20 in group 2 to 23 in group 3 (p p = 0.007; group 2 vs. group 3, p = 0.018), respectively. Overall 1-year survival rates between study groups 1-3 were 78.5% vs. 69.0% vs. 90.2% (p = 0.018) and 3-year rates 44.6% vs. 44.8% vs. 68.1% (p = 0.016), respectively. For overall 3-year mortality, adjusted hazard ratio (HR) was 1.02 (95%CI 0.63-1.66) in group 2 and HR 0.37 (95%CI 0.20-0.68) in group 3 compared to group 1. Conclusions In medium-volume center, modern multimodal therapy in operable gastric cancer combined with minimally invasive surgery increased lymph node yield and improved long-term survival without increasing postoperative morbidity.</p

Immunophenotype based on inflammatory cells, PD-1/PD-L1 signalling pathway and M2 macrophages predicts survival in gastric cancer

BackgroundImmune response against cancer has prognostic impact but its role in gastric cancer is poorly known. The aim of the study was to assess the prognostic significance of immune cell score (CD3+, CD8+), tumour immune escape (PD-L1, PD-1) and immune tolerance (Clever-1). MethodsAfter exclusion of Epstein-Barr virus positive (n = 4) and microsatellite instable (n = 6) tumours, the study included 122 patients with GC undergoing D2 gastrectomy. CD3+ and CD8+ based ICS, PD-L1, PD-1 and Clever-1 expressions were evaluated. Differences in survival were examined using Cox regression adjusted for confounders. The primary outcome was 5-year survival. Results The 5-year overall survival rate was 43.4%. High ICS was associated with improved overall survival (adjusted HR 0.48 (95% CI 0.26-0.87)) compared to low ICS. In the high ICS group, patients with PD-L1 expression (5-year survival 69.2 vs. 53.1%, p = 0.317), high PD-1 (5-year survival 70.6 vs. 55.3% p = 0.312) and high Clever-1 (5-year survival 72.0% vs. 45.5% (p = 0.070) had poor prognosis. Conclusions High ICS was associated with improved survival. In the high ICS group, patients with high PD-L1, PD-1 and Clever-1 had poor prognosis highlighting the importance of immune escape and immune tolerance in GC.</p

Metabolic Regulation in Progression to Autoimmune Diabetes

Recent evidence from serum metabolomics indicates that specific metabolic disturbances precede β-cell autoimmunity in humans and can be used to identify those children who subsequently progress to type 1 diabetes. The mechanisms behind these disturbances are unknown. Here we show the specificity of the pre-autoimmune metabolic changes, as indicated by their conservation in a murine model of type 1 diabetes. We performed a study in non-obese prediabetic (NOD) mice which recapitulated the design of the human study and derived the metabolic states from longitudinal lipidomics data. We show that female NOD mice who later progress to autoimmune diabetes exhibit the same lipidomic pattern as prediabetic children. These metabolic changes are accompanied by enhanced glucose-stimulated insulin secretion, normoglycemia, upregulation of insulinotropic amino acids in islets, elevated plasma leptin and adiponectin, and diminished gut microbial diversity of the Clostridium leptum group. Together, the findings indicate that autoimmune diabetes is preceded by a state of increased metabolic demands on the islets resulting in elevated insulin secretion and suggest alternative metabolic related pathways as therapeutic targets to prevent diabetes

Cost-analysis and effectiveness of one-stage laparoscopic versus two-stage endolaparoscopic management of cholecystocholedocholithiasis: a retrospective cohort study

Abstract Background One–stage laparoscopic common bile duct (CBD) stone clearance and laparoscopic cholecystectomy (LCBDE+LC) for cholecystocholedocholithiasis ( CCL) can be performed with similar short and long-term outcomes than two-stage endoscopic retrograde cholangiography followed by subsequent LC (ERCP+LC). This study examined retrospectively the outcome and hospital costs of one-stage versus two-stage treatment of CBD stones. Methods From January 1999 and December 2014, 217 consecutive, elective patients underwent one-stage (LCBDE + LC ) or two-stage (ERCP + subsequent LC ) treatment for CBD stones. The data from the one-stage management was collected prospectively, and from the two-stage management retrospectively. The main measure of outcome was hospital costs, with the success of one-stage versus two-stage management, postoperative morbidity and postoperative stay as secondary outcome measures. Results One-stage laparoscopic transcystic management was the least costly option compared to laparoscopic one-stage transductal approach (TC 5455€ versus TD 9364, p < 0.001) or two-stage management (6913 €, p = 0.02). Overall success rate of primary intervention (including conversions to open surgery) for CBD stone clearance was 96.9%, 97.0% and 98.3% after transcystic one-stage, transductal one-stage and two-stage approach, p = 0.79. Postoperative morbidity was 15.5% versus 7.5%, p = 0.64, and postoperative hospital stay median 2 days (IQR 2–5) versus 4.5 days ( IQR 3–7), p < 0.001 in the one-stage and two-stage management groups. Conclusions Our study shows that laparoscopic one-stage transcystic management of CCL results in high rate of CBD clearance, fewer procedures per patient, shorter hospital and lower costs than the two-stage management. Therefore the one-stage transcystic management seems to be an attractive strategy for the treatment of CCL depending on local resources and surgical expertise

Can We Increase the Resection Rate by Minimally Invasive Approach? Experience from 100 Minimally Invasive Esophagectomies

Background. Whether we can increase the resection rate of esophageal cancer by minimally invasive esophagectomy (MIE) is unknown. The aim was to report the number and results of MIE in high-risk patients considered unsuitable for open surgery and compare these results to other operated patients and to high-risk patients not undergoing surgery. Methods. At Central Finland Central Hospital, between September 2012 and July 2018, the number of operated MIEs was 100. Of these, 10 patients were prospectively considered unfit for open approach. Nineteen additional high-risk patients with operable disease were ruled out of surgery. The short- and long-term outcomes of these 3 groups were compared. Results. In patients eligible for any approach (n=90), MIE only (n=10), and no surgery (n=19), WHO performance status Grade 0 was observed in 66.7%, 20.0%, and 5.3%, respectively; stair climbing with ≥4 stairs was successfully completed in 77.8%, 50%, and 36.8%, respectively. Between any approach and MIE only groups, rate of major complications (Clavien-Dindo ≥3a) was 6.7% vs. 50.0% (p<0.001) without a difference in median hospital stay (9 vs. 10 days, p=0.542). Readmission rates were 4.4% vs. 30.0% (p=0.003). Survival rates were 100% vs. 80% (p<0.001) at 90-days, 91.5% vs. 66.7% (p=0.005) at 1-year, and 68.9% vs. 53.3% (p=0.024) at 3-years, respectively. In comparison between MIE only and no surgery groups, these survival rates from day of diagnosis were 80% vs. 100%, 68.6% vs. 67.1%, and 45.7% vs. 32.0% (p=0.290), respectively. Conclusions. By operating patients unsuitable for open approach with MIE, the resection rate increased 11.1%. These high-risk patients had, however, higher early morbidity and reduced long-term survival compared to other operated patients. Though there seems to be long-term benefit of surgery compared to nonsurgical patients, we have to be cautious when offering surgery to those considered unfit for open surgery