Assessment of vascular invasion in gastric cancer: A comparative study

AIM: To evaluate and compare detection of lymphatic and blood vessel invasion (LVI and BVI) by hematox-ylin-eosin (HE) and immunohistochemistry (IHC) in gastric cancer specimens, and to correlate with lymph node status. METHODS: IHC using D2-40 (a lymphatic endothelial marker) and CD34 (a pan-endothelial marker) was performed to study LVI and BVI in surgical specimens froma consecutive series of 95 primary gastric cancer cases. The results of the IHC study were compared with the detection by HE using McNemar test and kappa index. The morphologic features of the tumors and the presence of LVI and BVI were related to the presence of lymph node metastasis. A χ2 test was performed to obtain associations between LVI and BVI and other prognostic factors for gastric cancer. RESULTS: The detection rate of LVI was considerably higher than that of BVI. The IHC study identified eight false-positive cases and 13 false-negative cases for LVI, and 24 false-positive cases and 10 false-negative cases for BVI. The average Kappa value determined was moderate for LVI (k=0.50) and low for BVI (k=0.20). Both LVI and BVI were statistically associated with the presence of lymph node metastasis (HE: P=0.001, P=0.013, and IHC: P=0.001, P=0.019). The mor-phologic features associated with LVI were location of the tumor in the distal third of the stomach (P=0.039), Borrmann’s macroscopic type (P=0.001), organ inva-sion (P=0.03) and the depth of tumor invasion (P=0.001). The presence of BVI was related only to the depth of tumor invasion (P=0.003). CONCLUSION: The immunohistochemical identification of lymphatic and blood vessels is useful for increasing the accuracy of the diagnosis of vessel invasion and for predicting lymph node metastasis.     

The role of lymphatic and blood vessel invasion in predicting survival and methods of detection in patients with primary operable breast cancer

Lymphovascular invasion (LBVI) has long been recognized as an essential step of metastases in patients with cancer. However, the process of invasion into lymphatic and blood vessels is still not well defined in breast cancer. To examine the evidence for LBVI, lymphatic vessel invasion (LVI) and blood vessel invasion (BVI) in predicting survival in patients with primary operable breast cancer, and to evaluate the detection methods of vessel invasion. A systematic review of data published from 1964 to 2012 was undertaken according to a pre-defined protocol. There is robust evidence that general LBVI and LVI are independent prognostic factors of poorer survival. The prognostic role of BVI remains unclear. Most studies detected LBVI using H&E stained sections. The overall weighted average of the LBVI rate using immunostaining was higher (35%) than H&E (24%). The LBVI rate using H&E was variable (9–50%) and less variable using immunostaining (32–41%). The overall weighted average of the LVI rate was similar using H&E and immunostaining (33% vs. 25%). The LVI rate using H&E was variable (10–49%) and less variable using immunostaining (21–42%). The overall weighted average of the BVI rate was similar using H&E and/or classical staining and immunostaining (16% vs. 10%). The BVI rates using H&E and/or classical staining approach (4–46%) and immunostaining (1–29%) were both variable. The LBVI and LVI are powerful prognostic factors in primary operable breast cancer. However, BVI was rarely specifically examined and its role in predicting survival is not clear. Further work is required using reliable specific staining to establish the routine use of LVI and BVI in the prediction of outcome in patients with primary operable breast cancer.     

Lymphatic vessel invasion detected by monoclonal antibody D2-40 as a predictor of lymph node metastasis in T1 colorectal cancer

Objective  When selecting patients who are at high risk for lymph node metastasis, the detection of lymphatic vessel invasion (LVI) is important. We investigated LVI detected by D2-40 staining as a predictor of lymph node metastasis in T1 colorectal cancer. Materials and methods  Clinicopathological factors including LVI were investigated in 136 patients who underwent colectomy with lymph node dissection for T1 colorectal cancer. We used immunostaining with monoclonal antibody D2-40 to detect LVI. Results  Lymph node metastases were found in 18 patients (13.2%), and LVI were detected in 45 (33%); lymph node metastasis was more frequently observed in LVI-positive groups (13/45 vs 5/91, p < 0.001). Both univariate and multivariate analyses revealed that LVI detected by D2-40 and a poorly differentiated histology at the invasion front were independent risk factors of lymph node metastasis. Conclusion  LVI detected by D2-40 is important for the prediction of lymph node metastasis.     

Lymphatic Microvessel Density is an Independent Prognostic Factor in Colorectal Cancer

Purpose Although lymph node metastasis via lymphatic vessels often is related with an adverse outcome, it is not well known whether lymphatic spread to lymph node needs the development of the new lymphatic formation. In addition, the correlation between lymphangiogenesis and prognosis has not been well documented. This study was designed to assess the prognostic value of lymphangiogenesis and lymphatic vessel invasion in colorectal cancer. Methods We examined 106 colorectal cancer specimens by immunostaining for podoplanin, lymphatic endothelial specific marker. We evaluated lymphangiogenesis, as measured by lymphatic microvessel density, and lymphatic vessel invasion. We next investigated the association of these two parameters with the clinicopathologic findings and prognosis. Results A significant correlation was observed between high lymphatic microvessel density and positive lymphatic vessel invasion (P = 0.0003). Positive lymphatic vessel invasion was significantly associated with the presence of lymph node metastasis (P = 0.0071). The survival curves demonstrated that both high lymphatic microvessel density and positive lymphatic vessel invasion were correlated with an adverse outcome (P = 0.0004 and P = 0.009, respectively). In a univariate analysis, high lymphatic microvessel density and positive lymphatic vessel invasion were negatively associated with the overall survival (P = 0.0011 and P = 0.0118, respectively). Furthermore, high lymphatic microvessel density, but not lymphatic vessel invasion, correlated with a poor outcome in a multivariate analysis (P = 0.0114). Conclusions Our data suggested that lymphatic vessel invasion was related with lymph node metastasis and that both lymphatic microvessel density and lymphatic vessel invasion were related with an adverse outcome in colorectal cancer. Furthermore, lymphatic microvessel density may be a useful prognostic factor in colorectal cancer. *Deceased. The Poster presentation at the meeting of the Japanese Society of Gastroenterology, Sapporo, Japan, October 11 to 14, 2006. Reprints are not available.     

Clinical utility of grading criteria for submucosal invasion in the prognosis of T1 colorectal carcinomas

Background: The clinical utility of relative and absolute grading criteria for submucosal invasion in T1 colorectal carcinomas has been controversial. Methods: In 51 T1 colorectal carcinomas, depth of submucosal invasion was graded either according to a modified Haggitt's classification (a relative criterion) or by direct measurement using a micrometer (an absolute criterion), and immunostaining for E-cadherin, α-catenin, β-catenin, matrilysin, and CD44 variant 6 was performed on formalin-fixed, paraffin-embedded sections. The associations between lymph node metastasis or local recurrence (locoregional failure) and tumor budding, and clinicopathologic parameters and immunoreactivity were examined statistically. Results: By univariate analysis, tumor budding, histology, and the co-expression pattern of nuclear β-catenin and CD44 variant 6 were significantly associated with locoregional failure. The relative and absolute grading of submucosal invasion were not significantly associated with locoregional failure. Multivariate analysis showed that tumor budding alone was significantly associated with locoregional failure, and the association between the co-expression pattern of nuclear β-catenin and CD44 variant 6, and locoregional failure was marginally significant (P = 0.0502). Lymphatic invasion and absolute grading of depth and width of submucosal invasion were significantly associated with tumor budding, and the associations between tumor budding, and histologic differentiation and membranous α-catenin expression were marginally significant (P = 0.06; P = 0.08), whereas, a relative grading of submucosal invasion was not significant (P = 0.58). Analysis of variance showed that histologic differentiation and lymphatic invasion were independently and significantly associated with tumor budding (P = 0.005; P < 0.001). Conclusions: These results suggest that the grading of submucosal invasion, either relative or absolute, may not be a useful risk factor for lymph node metastasis or local recurrence in T1 colorectal carcinomas. Received: January 16, 2002 / Accepted: May 17, 2002 Acknowledgements. We thank Drs. Y. Shimada, K. Nunomura, and S. Uchiyama for providing tissue blocks. For expert technical assistance we thank Ms. N. Shiota and Ms. K. Ooshima. Reprint requests to: T. Masaki     

Lymphatic and/or blood vessel invasion in gastric cancer: relationship with clinicopathological parameters,biological factors and prognostic significance

Background Lymphatic and/or blood vessel tumoral invasion (LBVI) is a common histopathologic finding of gastric carcinomas, which could make it an additional cost efficient marker and help in the detection of patients at risk for recurrence. Materials and methods The subjects of this study were 144 patients with primary gastric adenocarcinoma, who consecutively underwent surgery. LBVI was evaluated by H&E staining and complementary with immunohistochemical staining with anti-CD34. Intratumoral levels of EGFR were analyzed with a radioligand technique, whereas c-erbB-2 and tPA were determined by ELISA methods; pS2, cathepsin D and hyaluronic acid by immunoradiometric assays; and VEGFR-1 and −2 by immunohistochemical assays. The mean follow-up period for these patients was 33.1 months. Results LBVI was present in 46 patients (31.9%). The presence of LBVI correlated significantly with tumor stage, lymph node involvement, surgical resectability, histological type and histological grade, being present in a higher percentage among II–IV tumor stage (P = 0.0001), poorly differentiated (P = 0.01), diffuse type (P = 0.009), R1–R2 (P = 0.002) and lymph node-positive (P = 0.005) tumors. In addition, statistical analysis demonstrated that LBVI was significantly associated with a poorer overall patients’ survival in the univariate analysis (P = 0.0001) as well as in the multivariate analysis (P = 0.009). However, our results failed to show any significant relationship between LBVI and any of the intratumoral biological parameters studied. Conclusion LBVI provides additional useful information that could be applied to identify gastric cancer patients at risk for recurrence, who might be candidates for further adjuvant therapies.     

Significance of immunohistochemical over-expression of CD44v6 as an indicator of malignant potential in esophageal squamous cell carcinoma

Purpose The aim of the current study was to find out a clinicopathologic significance of CD44v6 over-expression in esophageal squamous cell carcinoma (ESCC), which has not been elucidated fully.Methods Immunohistochemical expression of CD44v6 was examined for 81 ESCCs. Correlation of CD44 over-expression with the clinicopathologic features were investigated.Results Thirty-eight ESCCs (46.9%) had over-expression of CD44v6. The proportions of the incidence of lymph node metastasis (P=0.039), lymphatic permeation (P=0.003), and blood vessel invasion (P=0.037) in ESCCs with over-expression of CD44v6 were significantly higher than those in ESCCs without over-expression of CD44v6. The stage of the tumor in ESCCs with over-expression of CD44v6 was significantly more advanced (P=0.045). Survival rates of patients with ESCC with over-expression of CD44v6 were significantly worse (P=0.0005). Moreover, CD44v6 over-expression (P=0.048) as well as blood vessel invasion (P=0.014) and stage of the tumor (P=0.010) were factors independently associated with the unfavorable prognosis of the patients with ESCC.Conclusions Over-expression of CD44v6 can be an indicator of the malignant potential of ESCC.     

All patients with small intramural rectal cancers are at risk for lymph node metastasis

PURPOSE: Although local excision can be curative in patients with early-stage rectal cancer, approximately 20 percent of patients will develop local recurrence, many as a result of unrecognized and unresected regional lymph node metastases. Our objective was to determine if standard pathologic factors can predict lymph node metastases in small intramural rectal cancers and provide a basis for patient selection for nonradical surgery. METHODS: Between June 1986 and September 1996, 318 patients with T1 or T2 rectal cancers underwent radical resection at our institution. Of these, 159 patients (48 T1 and 111 T2) were potentially eligible for curative local excision (4 cm in size, 10 cm from the anal verge, no synchronous metastases), and the prevalence of lymph node metastases based on T stage and other pathologic factors was analyzed in this group. RESULTS: The overall frequency of lymph node metastasis was 15 percent (24/159 patients). T stage (T1, 10 percent; T2, 17 percent), differentiation (well-differentiated or moderately differentiated, 14 percent and poorly differentiated, 30 percent), and lymphatic vessel invasion (lymphatic vessel invasion-negative, 14 percent and lymphatic vessel invasion-positive, 33 percent) influenced the risk of lymph node metastasis. However, only blood vessel invasion (blood vessel invasion-negative, 13 percent and blood vessel invasion-positive, 33 percent) reached statistical significance as a single predictive factor (P=0.04). Tumors with no adverse pathologic features (low-risk group) had a lower overall frequency of lymph node metastasis (11 percent) compared with the remaining tumors (high-risk group, 31 percent;P=0.008). However, even in the most favorable group (T1 cancers with no adverse pathologic features) lymph node metastases were present in 7 percent of patients. CONCLUSION: In rectal cancer patients potentially eligible for local excision, the overall risk of undetected and untreated lymph node metastases is considerable (15 percent). The use of pathologic factors alone after local excision does not reliably assure the absence of lymph node metastases.Presented at the 51st Annual Cancer Symposium of the Society of Surgical Oncology, San Diego, California, March 26 to 29, 1998.     

Identifying patients with T3-T4 node-negative colon cancer at high risk of recurrence

PURPOSE: Adjuvant chemotherapy is effective for node-positive colon cancer patients. In node-negative patients, it could be justified in high-risk patients. The purpose of this study was to determine clinical and pathological findings associated with tumor recurrence in T3-T4 node-negative colon cancer patients. METHODS: From 1974 to 1993, 108 patients undergoing colectomy for T3-4N0M0 colon cancer, without adjuvant chemotherapy, followed until death or for a minimum of five years, were divided into two groups: patients without recurrence (n=74) and those dead from colon cancer or alive with recurrence (n=34). Thirty-three clinical and pathological findings were studied. RESULTS: In univariate analysis, the following were significantly associated with a high risk of tumor recurrence: male patients (P=0.006), bowel obstruction (P<0.001), weight loss >5 Kg (P=0.03), circumferential tumor (P=0.02), macroscopic or microscopic pericolic organ invasion (T4 stage;P<0.001), perineural invasion (P=0.02), vascular invasion (P=0.045), poor tumor differentiation (P=0.005), mesocolic invasion>1cm (P=0.009), less than 14 uninvolved nodes on the specimen (P=0.03), and visceral peritoneal invasion (T4;P<0.001). In multivariate analysis, the following were independent prognostic factors of recurrence: male patients (P=0.005), bowel obstruction (P=0.002), pericolic organ invasion (i.e., T4 tumor;P=0.02), and less than 14 uninvolved nodes on a specimen (P=0.01). On the other hand, preoperative carcinoembryonic antigen serum level, size and tumor location, blood transfusion, and mucin production were not associated with higher risk of tumor recurrence. CONCLUSION: Our study identifies a subgroup of patients with node-negative colon cancer at high risk of recurrence, who could be included in priority trials of adjuvant chemotherapy.Presented at the meeting of The American Society of Colon and Rectal Surgeons in Boston, Massachusetts, June 24 to 29, 2000.     

Predictive value of histology at the invasive margin in the prognosis of early invasive colorectal carcinoma

To accurately select patients with malignant colorectal polyps who are at high risk of adverse outcome, we examined the predictive value of clinicopathological factors, with special attention paid to the histology at the invasive margin. We examined 75 submucosal carcinomas from 75 patients, initially resected by polypectomy, including endoscopic, trans-anal, trans-sacral, and trans-sphincteric local excision. The associations between clinicopathological features such as sex and age; tumor size, location, shape, depth of submucosal invasion, vascular invasion, histology at the central part, and histology at the invasive margin; and the presence or absence of a residual adenomatous component and adverse outcome were examined by univariate and multivariate logistic regression analyses. Lymph node metastases were found in 2 patients, local recurrence in 4, and distant metastases in 2. Univariate logistic regression analysis showed that unfavorable histology at the invasive margin was significantly associated with lymph node metastasis or local recurrence (P = 0.0373), whereas the association of lymphatic invasion and vascular (lymphatic or venous) invasion with lymph node metastasis or local recurrence had marginal significance (P = 0.0785; P = 0.0990). Multivariate logistic regression analysis, with unfavorable histology at the invasive margin and lymphatic invasion as independent variables, showed that unfavorable histology alone had significance (P = 0.0373) in predicting adverse outcome. Widely accepted criteria such as massive submucosal invasion, positive vascular invasion, and poorly differentiated histology, were less useful in predicting adverse outcome. These results suggest that unfavorable histology at the invasive margin is a useful risk factor for predicting lymph node metastasis or local recurrence in patients with malignant colorectal polyps. Received: March 23, 1999 / Accepted: August 27, 1999     

Factors affecting tumor recurrence after curative surgery for NSCLC: impacts of lymphovascular invasion on early tumor recurrence

Background

Although surgery is potentially curative treatment for non-small cell lung cancer (NSCLC), the risk of postoperative disease recurrence is still high. This study was conducted to assess the factors associated with postoperative tumor recurrence in patients who underwent curative surgery for NSCLC.

Methods

One hundred seventy-one patients who underwent curative surgery for NSCLC were included in this study. Clinicopathological factors of histologic type, pathologic TNM stage, T stage, N stage, lymphovascular invasion (LVI), perineural invasion (PNI), surgical procedure, adjuvant chemotherapy and adjuvant radiotherapy were investigated. Gender, age, and clinicopathologic factors were included in univariate and multivariate analyses using the Kaplan-Meier method and Cox proportional hazards model, respectively. Mann-Whitney U and Kruskal-Wallis tests were used to investigate the significance of differences in recurrence-free interval (RFI) according to clinicopathological factors.

Results

Median RFI was 20 months. Univariate and multivariate analyses for overall recurrence identified T stage, N stage, and LVI as significant factors (P=0.045, 0.044, and <0.001, respectively). Pathologic stage (P=0.005) was the only factor that was significantly associated with locoregional recurrence. T stage (P=0.040) and LVI (P<0.001) were significantly associated with distant recurrence. The difference in 2-year freedom from recurrence between LVI positive and negative groups was significant (14.9% vs. 44.6%, P<0.001). LVI was the only factor that was significantly associated with a shortened mean RFI (P<0.001).

Conclusions

LVI had a significant effect on both overall and distant recurrence rates as well as on early tumor recurrence after curative surgery for NSCLC.     

Does immunohistochemical staining have a clinical impact in early gastric cancer conducted endoscopic submucosal dissection?

AIM: To evaluate clinicopathologic parameters and the clinical significance related lymphovascular invasion (LVI) by immunohistochemical staining (IHCS) in endoscopic submucosal dissection (ESD).METHODS: Between May 2005 and May 2010, a total of 348 lesions from 321 patients (mean age 63 ± 10 years, men 74.6%) with early gastric cancer (EGC) who met indication criteria after ESD were analyzed retrospectively. The 348 lesions were divided into the absolute (n = 100, differentiated mucosal cancer without ulcer ≤ 20 mm) and expanded (n = 248) indication groups after ESD. The 248 lesions were divided into four subgroups according to the expanded ESD indication. The presence of LVI was determined by factor VIII-related antigen and D2-40 assessment. We compared LVI IHCS-negative group with LVI IHCS-positive in each group.RESULTS: LVI by hematoxylin-eosin staining (HES) and IHCS were all negative in the absolute group, while was observed in only the expanded groups. The positive rate of LVI by IHCS was higher than that of LVI by HES (n = 1, 0.4% vs n = 11, 4.4%, P = 0.044). LVI IHCS-positivity was observed when the cancer invaded to the mucosa 3 (M3) or submucosa 1 (SM1) levels, with a predominance of 63.6% in the subgroup that included only SM1 cancer (P < 0.01). In a univariate analysis, M3 or SM1 invasion by the tumor was significantly associated with a higher rate of LVI by IHCS, but no factor was significant in a multivariate analysis. There were no cases of tumor recurrence or metastasis during the median 26 mo follow-up.CONCLUSION: EGCs of the absolute group are immunohistochemically stable. The presence of LVI may be carefully examined by IHCS in an ESD expanded indication group with an invasion depth of M3 or greater.     

Correlation of integrin β3 mRNA and vascular endothelial growth factor protein expression profiles with the clinicopathological features and prognosis of gastric carcinoma

AIM： To investigate integrin β3 mRNA and vascular endothelial growth factor （VEGF） protein expression in gastric carcinoma, and its correlation with microvascular density, growth-pattern, invasion, metastasis and prognosis. METHODS： In situ hybridization（ISH） of integrin β3 mRNA and immunohistochemistry of VEGF and CD34 protein were performed on samples from 118 patients with gastric cancer. RESULTS： The positive rate of integrin β3 mRNA in non-tumor gastric mucosa （20%） was significantly lower than that of the gastric cancer tissue （52.5%, X^2 = 10.20, P 〈 0.01）. In patients of infiltrating type, stage T3-T4, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the positive expression rates of integrin β3 mRNA were significantly higher than those in patients of expanding type （P 〈 0.01）, stage T1-T2 （P 〈 0.01）, non-vessel invasion （P 〈 0.01）, without lymphatic metastasis （P 〈 0.01）, without hepatic and peritoneal metastasis （P 〈 0.01）, respectively. In patients of infiltrating type, stage T3-T4, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the positive expression rates of VEGF protein were significantly higher than those in patients of expanding type （P 〈 0.01）, stage T1-T2 （P 〈 0.01）, non-vessel invasion （P 〈 0.01）, without lymphatic metastasis （P 〈 0.01）, without hepatic and peritoneal metastasis （P 〈 0.01）, respectively. In patients of infiltrating type, stage T3-T4, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the mean MVD were significantly higher than those in patients of expanding type （P 〈 0.01）, stage T1-T2 （P 〈 0.01）, non-vessel invasion （P 〈 0.01）, without lymphatic metastasis （P 〈 0.01）, without hepatic and peritoneal metastasis （P 〈 0.01）, respectively. It was found that the positive expression rate of integrin β3 mRNA was positively related to that of VEGF protein （P 〈 0.01） and MVD （P 〈 0.05）,     

MUC6 down-regulation correlates with gastric carcinoma progression and a poor prognosis: an immunohistochemical study with tissue microarrays

Purpose MUC6 was first discovered by screening a gastric mucosa cDNA library and is expressed in the mucous cells of the neck zone and antral glands of the stomach. The aim of the present study was to clarify whether down-regulation has any clinicopathological or prognostic significance in gastric neoplasia.Methods Expression of MUC6, MUC5AC and MUC2 was examined using tissue microarrays for immunohistochemistry in gastric carcinomas (n = 225), adenomas (n = 40), and normal mucosa (n = 89) and compared with clinicopathological parameters and survival data.Results MUC6 expression was lower in gastric carcinomas than in adenomas or normal mucosa (P < 0.05) and inversely correlated with tumor size, depth of invasion, lymphatic and venous invasion, lymph node metastasis and UICC staging (P < 0.05). Positive links with expression of MUC2 and MUC5AC were noted (P < 0.05). MUC6 expression was lower in diffuse-type than intestinal-type lesions (P < 0.05). Kaplan–Meier analysis indicated that cumulative survival of patients with no MUC6 expression was significantly lower than with weak, moderate or strong expression in all and even advanced gastric carcinoma (P < 0.05). Multivariate analysis showed three independent prognostic factors, depth of invasion, lymphatic and venous invasion, to concordantly affect the relationship between MUC6 expression and prognosis.Conclusions Down-regulation of MUC6 may contribute to malignant transformation of gastric epithelial cells and underlie the molecular bases of growth, invasion, metastasis and differentiation of gastric carcinoma. Altered expression might therefore be employed as an indicator of pathobiological behaviors and prognosis of gastric carcinoma.     

Correlation of integrin β3 mRNA and vascular endothelial growth factor protein expression profiles with the clinicopathological features and prognosis of gastric carcinoma

AIM: To investigate integrin 133 mRNA and vascular endothelial growth factor (VEGF) protein expression in gastric carcinoma, and its correlation with microvascular density, growth-pattern, invasion, metastasis and prognosis. METHODS: In situ hybridization(ISH) of integrin β3 mRNA and immunohistochemistry of VEGF and CD34 protein were performed on samples from 118 patients with gastric cancer. RESULTS: The positive rate of integrin 133 mRNA in non- tumor gastric mucosa (20%) was significantly lower than that of the gastric cancer tissue (52.5%, x2 = 10.20, P ＜ 0.01). In patients of infiltrating type, stage T3-T4, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the positive expression rates of integrin β3 mRNA were significantly higher than those in patients of expanding type (P ＜ 0.01), stage T1-T2 (P ＜ 0.01), non-vessel invasion (P ＜ 0.01), without lymphatic metastasis (P ＜ 0.01), without hepatic and peritoneal metastasis (P ＜ 0.01), respectively. In patients of infiltrating type, stage T3-T4, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the positive expression rates of VEGF protein were significantly higher than those in patients of expanding type (P ＜ 0.01), stage T1-T2 (P ＜ 0.01), non-vessel invasion (P ＜ 0.01), without lymphatic metastasis (P ＜ 0.01), without hepatic and peritoneal metastasis (P ＜ 0.01), respectively. In patients of infiltrating type, stage T3-T4, vessel invasion, lymphatic metastasis, hepatic or peritoneal metastasis, the mean MVD were significantly higher than those in patients of expanding type (P ＜ 0.01), stage T1-T2 (P ＜ 0.01), non-vessel invasion (P ＜ 0.01), without lymphatic metastasis (P ＜ 0.01), without hepatic and peritoneal metastasis (P ＜ 0.01), respectively. It was found that the positive expression rate of integrin β3 mRNA was positively related to that of VEGF protein (P ＜ 0.01) and MVD (P ＜ 0.05), meanwhile the positive expression rate of VEGF protein was positively related to NVD (P ＜ 0.05). The mean survival period in patients with positive expression of integrin β3 mRNA and VEGF, and MVD ≥ 54.9/mm2 was significantly shorter than that in patients with negative expression of integrin β3 mRNA (P ＜ 0.05) and VEGF (P ＜ 0.01), and MVD ＜ 54.9/mm2 (P ＜ 0.01). Five-year survival rate in patients with positive expression of integrin β3 mRNA and VEGF, and MVD ≥ 54.9/mm2 was significantly lower than those with negative expression of integrin β3 mRNA (P ＜ 0.05), VEGF (P ＜ 0.05), and NVD ＜ 54.9/mm2 (P ＜ 0.01). CONCLUSION: Integrin β3 and VEGF expression can synergistically enhance tumor angiogenesis, and may play a crucial role in invasion and metastasis of gastric carcinoma. Therefore, they may be prognostic biomarkers and novel molecular therapeutic targets.     

MIXED INTESTINAL‐ AND DIFFUSE‐TYPE HISTOLOGY IS A RISK FACTOR FOR LYMPH NODE METASTASIS OF SUBMUCOSAL INVASIVE GASTRIC CANCER

Background: Endoscopic submucosal dissection is expected to increase the number of node‐negative submucosal invasive gastric cancers, particularly differentiated‐type adenocarcinomas that can be treated conservatively. Methods: Two hundred and seven consecutive surgically treated cases of differentiated‐type early gastric cancer with submucosal invasion were analyzed clinicopathologically. Comparison was made between patients with node‐positive (n = 33) and node‐negative cancer (n = 174). Whole sections of surgical specimens were reviewed and reclassified as pure intestinal type or mixed type. The intramucosal and submucosal components were also described histologically, and the depth of invasion from the muscularis mucosae as well as the width of submucosal invasion was measured. Results: Twenty‐four of 33 (73%) node‐positive cases were of the mixed type, whereas 71 of 174 (41%) node‐negative cases were of the mixed type (P < 0.01). As for the intramucosal histology, the ratio of mixed‐type was also higher in the node‐positive group (58% vs 34%; P < 0.05). Other factors associated with lymph node metastasis were larger tumor size (P = 0.003), deeper submucosal invasion (P < 0.001) and wider submucosal extension (P = 0.004), and lymphatic permeation (P < 0.001). Multivariate analysis demonstrated that lymphatic permeation (P = 0.001, OR 4.76), and mixed‐type histology (OR 2.56) were independent risk factors. Conclusions: Histological heterogeneity is a risk factor for metastasis of submucosal invasive gastric cancer to lymph nodes. Heterogeneity of mucosal components is also a significant risk factor and thus a good predictor of lymph node metastasis, potentially useful in distinguishing patients ineligible for conservative therapy.     

Curative Resection of T1 Colorectal Carcinoma: Risk of Lymph Node Metastasis and Long-Term Prognosis

PURPOSE The features of T1 colorectal adenocarcinoma and the risk determination of lymph node metastasis were reviewed. Prognostic factors were assessed to verify whether the risk of lymph node metastasis would influence the long-term prognosis.METHODS Patients undergoing curative resection of T1 colorectal adenocarcinoma at the Taipei Veterans General Hospital from December 1969 to August 2002 were retrospectively studied. Patients with synchronous colorectal cancer, distant metastasis, familiar adenomatous polyposis, or inflammatory bowel disease were excluded. The associations between lymph node metastasis and clinicopathologic variables were evaluated univariately using chi-squared test, Fisher’s exact test, or Student’s t -test, and multivariately using logistic regression. Univariate analysis by the log-rank test and multivariate analysis by Cox regression hazards model determined the factors influencing the overall survival.RESULTS A total of 159 patients were included. Sixteen patients (10.1 percent) had lymph node metastasis. The risk of lymph node metastasis included histologic grade (P = 0.005), lymphatic vessel invasion (P = 0.023), inflammation around cancer (P = 0.049), and budding at the invasive front of tumor (P = 0.022). Age (P = 0.001) and number of total sampling lymph nodes (P < 0.0001) were found to be the factors influencing the overall survival.CONCLUSIONS Variables that predict lymph node metastasis in surgically resected T1 colorectal carcinoma may not impact the long-term prognosis.Supported by a grant from the Research Foundation of Taipei Veterans General Hospital.     

A pilot randomized trial comparing CD34‐selected versus unmanipulated hemopoietic stem cell transplantation for severe,refractory rheumatoid arthritis

Objective

Evidence from animal studies, case reports, and phase I studies suggests that hemopoietic stem cell transplantation (HSCT) can be effective in the treatment of rheumatoid arthritis (RA). It is unclear, however, if depletion of T cells in the stem cell product infused after high‐dose chemotherapy is beneficial in prolonging responses by reducing the number of infused autoreactive T cells. This pilot multicenter, randomized trial was undertaken to obtain feasibility data on whether CD34 selection (as a form of T cell depletion) of an autologous stem cell graft is of benefit in the HSCT procedure in patients with severe, refractory RA.

Methods

Thirty‐three patients with severe RA who had been treated unsuccessfully with methotrexate and at least 1 other disease‐modifying agent were enrolled in the trial. The patients received high‐dose immunosuppressive treatment with 200 mg/kg cyclophosphamide followed by an infusion of autologous stem cells that were CD34 selected or unmanipulated. Safety, efficacy (based on American College of Rheumatology [ACR] response criteria), and time to recurrence of disease were assessed on a monthly basis for up to 12 months.

Results

All patients were living at the end of the study, with no major unexpected toxicities. Overall, on an intent‐to‐treat basis, ACR 20% response (ACR20) was achieved in 70% of the patients. An ACR70 response was attained in 27.7% of the 18 patients who had received CD34‐selected cells and 53.3% of the 15 who had received unmanipulated cells (P = 0.20). The median time to disease recurrence was 147 days in the CD34‐selected cell group and 201 days in the unmanipulated cell group (P = 0.28). There was no relationship between CD4 lymphopenia and response, but 72% of rheumatoid factor (RF)–positive patients had an increase in RF titer prior to recurrence of disease.

Conclusion

HSCT can be performed safely in patients with RA, and initial results indicate significant responses in patients with severe, treatment‐resistant disease. Similar outcomes were observed in patients undergoing HSCT with unmanipulated cells and those receiving CD34‐selected cells. Larger studies are needed to confirm these findings.

     

Vascular Invasion is Underrecognized in Colorectal Cancer Using Conventional Hematoxylin and Eosin Staining

Purpose This study was designed to test the hypothesis that highlighting vascular spaces with histochemical or immunohistochemical stains facilitates the identification of extramural and intramural vascular invasion in resected colorectal cancer specimens compared with routine hematoxylin and eosin staining. Methods Archival tumor sections from 50 resected colorectal cancers, in which extramural vascular invasion was not seen within the original tissue sections, were stained with hematoxylin and eosin, elastic van gieson histochemistry, and immunohistochemistry for CD31 and CD34. Two observers assessed the stained sections and the agreed incidence of vascular invasion using the four staining methods was compared. Results Vascular invasion was more commonly identified in Dukes C (pTanyN1/2) (vascular invasion seen in 24 of 25 cases by at least 1 method) than Dukes B tumors (pT3/4N0) (vascular invasion seen in 14 of 25 cases by at least 1 method). Vascular invasion was identified in significantly more cases using elastic van gieson (24 cases; P = 0.0001), CD31 (18 cases; P = 0.0064), and CD34 (21 cases; P < 0.0001) than with hematoxylin and eosin alone (5 cases). Conclusions This study was novel in that it compared both histochemical and immunohistochemical methods for identifying vascular invasion in cases of colorectal cancer in which vascular invasion had not been identified during initial reporting. Highlighting of endothelium significantly increases the observed incidence of vascular invasion in colorectal cancer compared with hematoxylin and eosin alone. Elastic van gieson seemed sensitive for the presence of vascular invasion but with uncertain specificity. The possibility that these immunohistochemical methods may identify a subset of patients with colorectal cancer who may benefit from chemotherapy warrants further study. Supported by The Institute of Biomedical Sciences, United Kingdom.     

Salvage surgery after definitive chemoradiotherapy for esophageal cancer

Background Definitive chemoradiotherapy has been performed as a first-line treatment for esophageal cancer, whereas salvage surgery might be the only reliable treatment for patients with recurrence after definitive chemoradiotherapy.Methods We reviewed 38 patients with squamous cell carcinoma who underwent esophagectomy and 6 patients who underwent lymphadenectomy after definitive chemoradiotherapy (≥50 Gy).Results The median survival time and 5-year survival rate after salvage esophagectomy were 16 months and 27%, respectively. Three of the 7 patients who had cervical esophageal cancer underwent cervical esophagectomy with laryngeal preservation. Two patients (5.2%) who underwent salvage esophagectomy with three-field lymphadenectomy before 1997 died of postoperative complications, but no patient died of complications thereafter. Although the overall survival after salvage esophagectomy was correlated with residual tumor (R) (P = 0.0097), the median survival time of 7 patients with residual tumors (R₂) was 7 months. Overall postoperative survival was closely correlated with the response to chemoradiotherapy (P < 0.0001) but was not associated with histologic effects on resected specimens. Survival was significantly correlated with the depth of viable tumor invasion (pT) (P = 0.0013) and with lymph node metastasis (pN) (P < 0.0001). Long-term survival was achieved in 5 of the 6 patients who underwent salvage lymphadenectomy.Conclusions Salvage surgery should be considered for patients with recurrence after definitive chemoradiotherapy. Salvage lymphadenectomy may be useful for recurrence confined to the lymph nodes whereas postoperative complications of salvage esophagectomy should be warranted.