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Introduction Folate-mediated one-carbon metabolism (FOCM) is a key pathway necessary for nucleotide synthesis, DNA methylation, replication and repair. Genetic variants in FOCM genes, especially the MTHFR-C677T polymorphism, have been associated with colorectal neoplasia. Moreover, FOCM is an important target for chemotherapeutic drugs for the treatment of colorectal cancer (CRC), such as 5-fluorouracil (5-FU). We performed a comprehensive assessment of FOCM-related genetic variation in relation to CRC risk and survival in an unfortified population. Methods Associations of 457 tagging and candidate SNPs in 47 FOCM-related genes with CRC risk and survival were investigated within a German population-based case-control study (the DACHS- study). Using multivariate adjusted logistic (n = 1754 incident cases and 1781 matched controls) and Cox regression (5 years follow-up of CRC cases only; 585 deceased), we evaluated co-dominant, dominant, and log-additive modes of inheritance. SNPs were genotyped using the Illumina GoldenGate Assay. Correction for multiple testing was performed using false discovery rates (FDR). Results Individuals having both variant alleles of a candidate SNP in the ADH1C gene (rs1693482) had a significantly decreased risk of developing CRC (ORhet = 0.94 [95% CI = 0.81-1.10]; ORhzv = 0.74 [95% CI = 0.59-0.92]; p-trend = 0.013). Before correction for multiple testing, 19 nominally significant genetic main effects on CRC risk were observed. None of the studied tagging SNPs was significantly associated with risk after multiple test correction. One polymorphism in the PON1 gene (rs3917538) was significantly associated with overall survival (HRhet = 1.22 [95% CI = 1.03-1.45]; HRhzv = 2.00 [95% CI = 1.48-2.71]; p-trend = 0.01), after correction for multiple testing. Effect modification by 5-FU chemotherapy was observed between two polymorphisms (MTHFR-rs4846047 [Int-pFDR = 0.02] and TK1-rs1811086 [Int-pFDR = 0.02]) for the endpoint overall survival. Cases with variant alleles of these SNPs had a reduced effect of 5-FU on overall survival. Conclusion Genetic variation in FOCM appears to be associated with CRC risk and survival. Furthermore, 5-FU might interact with FOCM polymorphisms. Further large investigations are required to replicate our findings. Citation Format: Akke Botma, Katharina Buck, Yesilda Balavarca, Dominique Scherer, Nina Habermann, Reka Toth, Lina Jansen, Michael Hoffmeister, Hermann Brenner, Elisabeth J. Kap, Petra Seibold, Axel Benner, Alexis Ulrich, Barbara Burwinkel, Jenny Chang-Claude, Cornelia M. Ulrich. Folate-mediated one-carbon metabolism polymorphisms associated with risk and survival of colorectal cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4585. doi:10.1158/1538-7445.AM2015-4585

Introduction: Abdominal surgery for tumor removal is essential in the treatment of colorectal cancer (CRC). Incisional hernias (IH) are a common long-term complication after abdominal surgery with an incidence of 9-20%. Several risk factors for developing IH have been identified, including a higher body mass index (BMI). However, it is unknown whether specific abdominal fat compartments, such as subcutaneous or visceral fat, are associated with IH occurrence. Thus, the aim of this study was to explore whether subcutaneous or visceral fat compartments might be predictors of IH occurrence in CRC patients after oncologic surgery. Methods: This study was conducted on 139 newly-diagnosed colorectal cancer patients of the prospective cohort study ColoCare (NCT, Heidelberg, Germany) who underwent oncologic surgery at the surgical clinics of the University Hospital Heidelberg. Self-administered questionnaires were used to assess hernia occurrence at 3, 6, 12 and 24 months post-surgery. BMI was calculated (kg/m^2) and abdominal fat compartments were assessed by routine computed tomography (CT) scans. The total (TFA), subcutaneous (SFA) and visceral fat area (VFA) was quantified as area (cm^2) on level L3/L4 and L4/L5. Before analyses, fat data were grouped into two categories (high vs. low) by the median. Logistic regression was used to measure the association between BMI, TFA, SFA or VFA and IH occurrence. Results: Patients were on average 61.3 (±12.5) years old with 37% being female and 63% being male. Patients were diagnosed with either colon/rectosigmoid (53%) or rectal (47%) primary cancer. CT data on abdominal fat compartments were available for 56% (n = 80) of patients as CT scans were not performed on every subject during clinical routine. BMI was a statistically significant predictor of IH occurrence after adjusting for gender and age (Wald p-value Conclusion: Our findings underline BMI as a known predictive risk factor for IH. In addition, our study newly identified visceral, but not total or subcutaneous fat, as risk factors for IH. Further studies with an increased sample size are needed to test these associations in subgroups of patients, e.g. by gender or surgical procedures. In the future, these findings may help to preoperatively decide on prophylactic interventions, such as intraoperative mesh implantations, to reduce hernia occurrence. Citation Format: Jürgen Böhm, Johanna Nattenmüller, Frank Pianka, Biljana Gigic, Yesilda Balavarca, Nina Stüttgen, Petra Schrotz-King, Dominique Scherer, Alexis Ulrich, Markus K. Diener, Hans-Ulrich Kauczor, Cornelia M. Ulrich. Visceral abdominal fat is associated with incisional hernia occurrence after colorectal cancer surgery - the ColoCare Study. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3437. doi:10.1158/1538-7445.AM2015-3437

Patients with rectal cancer are treated in multimodal concepts on the basis of their tumor stage. In the context of local excision, it is of major importance to assess the risk of lymph node metastases in patients with T1 or T2 tumors. To identify patients with an increased risk of lymph node metastases, the influence of the location of the tumor within the rectum (anterior, posterior, lateral) and of other variables on lymph node status was investigated.All consecutive patients undergoing low anterior resection or abdominoperineal resection for primary rectal cancer between October 2001 and September 2003 were included. A multivariate analysis was performed focussing on tumor location and other variables as potential predictive factors for lymph node metastases.Of 148 included patients, 135 (91%) had an anterior and 13 (9%) an abdominoperineal resection. All patients routinely underwent total mesorectal excision. A statistically significant correlation with positive lymph node status was found for patients with lymphatic invasion (P.0001), higher T stage (P.0001), presence of distant metastases (M1) (P = .0003), and circular growth of the tumor (P = .003), but not for tumor location. Multivariate analysis confirmed that patients without lymphatic invasion (odds ratio, .1; 95% confidence interval, .02-.48; P = .006) and with a low T stage (odds ratio, .07; 95% confidence interval, .002-.9; P = .004) have a significantly lower risk for positive lymph nodes.Location of rectal cancer (anterior, posterior, lateral) is not a good predictor for lymph node metastases.

Fast-track surgery is an interdisciplinary multimodal concept of minimally invasive surgery or new incision lines and “cutting old plaits” (e.g., the use of drains or tubes). It uses modern intraoperative anesthesia (e.g., fluid restriction) and analgesia, including new drugs and novel ways of administration (e.g., thoracic epidural analgesia) for postoperative pain relief, in combination with the immediate mobilization of the patient and early oral nutrition after the operation. This approach requires a cooperating team of motivated nurses, physiotherapists, anesthesiologists, and surgeons, in addition to continuous improvement of the processes involved. Moreover, extended patient education and information about the procedures and the expected time course are of the highest importance, as the active role of the patient is to be emphasized. This chapter describes the development and implementation of fast-track surgery in colorectal diseases at the Department of Surgery of the University Hospital of Heidelberg, Germany. Preliminary results of fast-track surgery suggest a significant and clear overall benefit for the patient. A shorter hospital stay and reduced systemic morbidity in addition to no increase in postoperative complications on an out-patient basis were found. However, to exclude a “bloody discharge” of the patients, thorough follow-up and quality control are mandatory. Although in the initial phase increased personnel care is necessary, in the new German reimbursement system with G-DRGs (German diagnosis-related groups) fast-track surgery seems to save resources in the long term.

The introduction of the total mesorectal excision (TME) has changed the treatment of rectal cancer dramatically by reducing the local recurrence rate. We report the results of 208 patients undergoing a low anterior resection (LAR, n=180) or abdominoperineal resection (APR, n=28) with TME between 1 October 2001 and 30 September 2003. No adjuvant therapy was administered to any patient; however, 108 patients received neoadjuvant radiotherapy or radiochemotherapy. Since February 2002, 51 patients underwent a short-course radiotherapy with 5×5 Gy prior to surgery in cases of a T3 tumor or positive lymph node in the preoperative CT-scan or endoanal ultrasound. Patients with a T4 tumor or T3 tumor close to the sphincter received radiochemotherapy. We discuss the results for mortality, morbidity, functional outcome, and overall survival between the LAR and APR groups. The mortality rate was 3% in the LAR and 0% in the APR group, whereas the morbidity was higher in the APR group. Anastomotic leakages occurred in eight patients (7%), and reoperations had to be performed in 14 LAR and four APR patients. After a median follow-up of 11 months, the overall survival was 93% for LAR and 89% for APR. To assess the functional outcome after TME, questionnaires were sent to all patients undergoing LAR and APR. In conclusion, the TME has become the gold standard for rectal cancer surgery. Neoadjuvant treatment modalities such as preoperative short term radiotherapy (5×5 Gy) or combined radiochemotherapy will most likely replace the adjuvant combined radiochemotherapy.

Within the last 20 years various achievements have been made in the treatment of rectal cancer, improving survival and quality of life of rectal cancer patients. Especially the introduction of the total mesorectal excision (TME) and the use of modern staplers, making anastomoses possible in the deep pelvis, have increased our ability to cure more and more low rectal cancers by sphincter-preserving low anterior resections. Consequently, the interest in functional results after rectal reservoir reconstruction has increased significantly. Various randomized controlled trials have shown that the colon J-pouch (CJP) as a rectal reservoir reconstruction leads to better early functional results compared to the straight coloanal anastomosis (CAA). However, 30% of the patients with CJP faced late evacuation problems, requiring the chronic use of enemas or laxatives. This rate could be decreased to 10% by shortening the limb of the CJP from 8-10 cm to 5-6 cm. The transverse coloplasty pouch (TCP) was developed to provide early functional results comparable to the CJP, while avoiding these late evacuation problems. We report the early postoperative and functional results of 106 patients undergoing low anterior resections with TCP due to rectal cancer between October 2001 and the end of September 2003. Furthermore, we report on a single-center randomized controlled trial to compare the new TCP technique with the gold standard technique of CJP, which we started in October 2002. The objectives were to compare the two pouch reconstruction techniques in terms of morbidity, mortality and functional results.

The introduction of the total mesorectal excision (TME) has changed the treatment of rectal cancer dramatically by reducing the local recurrence rate. We report the results of 208 patients undergoing a low anterior resection (LAR, n = 180) or abdominoperineal resection (APR, n = 28) with TME between 1 October 2001 and 30 September 2003. No adjuvant therapy was administered to any patient; however, 108 patients received neoadjuvant radiotherapy or radiochemotherapy. Since February 2002, 51 patients underwent a short-course radiotherapy with 5x5 Gy prior to surgery in cases of a T3 tumor or positive lymph node in the preoperative CT-scan or endoanal ultrasound. Patients with a T4 tumor or T3 tumor close to the sphincter received radiochemotherapy. We discuss the results for mortality, morbidity, functional outcome, and overall survival between the LAR and APR groups. The mortality rate was 3% in the LAR and 0% in the APR group, whereas the morbidity was higher in the APR group. Anastomotic leakages occurred in eight patients (7%), and reoperations had to be performed in 14 LAR and four APR patients. After a median follow-up of 11 months, the overall survival was 93% for LAR and 89% for APR. To assess the functional outcome after TME, questionnaires were sent to all patients undergoing LAR and APR. In conclusion, the TME has become the gold standard for rectal cancer surgery. Neoadjuvant treatment modalities such as preoperative short term radiotherapy (5x5 Gy) or combined radiochemotherapy will most likely replace the adjuvant combined radiochemotherapy.

Within the last 20 years various achievements have been made in the treatment of rectal cancer, improving survival and quality of life of rectal cancer patients. Especially the introduction of the total mesorectal excision (TME) and the use of modern staplers, making anastomoses possible in the deep pelvis, have increased our ability to cure more and more low rectal cancers by sphincter-preserving low anterior resections. Consequently, the interest in functional results after rectal reservoir reconstruction has increased significantly. Various randomized controlled trials have shown that the colon J-pouch (CJP) as a rectal reservoir reconstruction leads to better early functional results compared to the straight coloanal anastomosis (CAA). However, 30% of the patients with CJP faced late evacuation problems, requiring the chronic use of enemas or laxatives. This rate could be decreased to 10% by shortening the limb of the CJP from 8-10 cm to 5-6 cm. The transverse coloplasty pouch (TCP) was developed to provide early functional results comparable to the CJP, while avoiding these late evacuation problems. We report the early postoperative and functional results of 106 patients undergoing low anterior resections with TCP due to rectal cancer between October 2001 and the end of September 2003. Furthermore, we report on a single-center randomized controlled trial to compare the new TCP technique with the gold standard technique of CJP, which we started in October 2002. The objectives were to compare the two pouch reconstruction techniques in terms of morbidity, mortality and functional results.

To present a case of methicillin-resistant Staphylococcus aureus (MRSA) infection following bile duct stenting in a patient with malignant biliary obstruction.A 78-year-old male patient was admitted to a community hospital with progredient painless jaundice lasting over two weeks, weight loss and sweating at night. Whether a stent should be implanted pre-operatively in jaundiced patients or whether these patients should directly undergo surgical resection, was discussed.ERC and a biopsy from the papilla of Vater revealed an adenocarcinoma. In addition, a 7-Ch plastic stent was placed into the common bile duct. Persistent abdominal pain, increasing jaundice, weakness and indigestion led to the transfer of the patient to our hospital. A pylorus-preserving pancreatoduodenectomy was performed. Intraoperatively, bile leaked out of the transected choledochus and the stent was found to be dislocated in the duodenum. A smear of the bile revealed an infection with MRSA, leading to post-operative isolation of the patient.As biliary stents can cause severe infection of the bile, the need for pre-operative placement of biliary stents should be carefully evaluated in each individual case.

Histological differentiation between chronic pancreatitis and pancreatic cancer, especially in biopsy material, remains challenging and the frequent association of 'secondary' chronic pancreatitis (due to ductal obstruction) with pancreatic cancer causes additional diagnostic problems. Our study, using anti-ErbB2 antibodies from Santa Cruz and Dako in tissues from the normal pancreas, chronic pancreatitis and pancreatic cancer showed that these antibodies discriminate between primary chronic pancreatitis and 'secondary' chronic pancreatitis due to pancreatic cancer. Tissues from 28 pancreatic cancer patients, 15 chronic pancreatitis patients and 12 organ donors or early autopsy cases were subjected to immunohistochemical studies using polyclonal ErbB2 antibodies from Santa Cruz and Dako. The Santa Cruz antibody immunoreacted with islet cells in all tissues from the normal pancreas and pancreatic cancer but not in any chronic pancreatitis specimen. The Dako antibody showed a membrane staining of ductal and ductular cells only in chronic pancreatitis cases but in none of the normal or cancer specimens. Moreover, in chronic pancreatitis cases, ductular cells were stained with the Santa Cruz antibody only in the severe form, but not in the mild or moderate form of the disease. The utilized ErbB2 antibodies discriminate between the normal pancreas, chronic pancreatitis and pancreatic cancer. Hence, these antibodies seem to present an additional useful aid in the surgical pathology of pancreatic diseases.

The introduction of the total mesorectal excision (TME) and the use of modern staplers have improved outcome and increased the rate of sphincter-preserving low anterior resections in rectal cancer. Consequently, the interest in functional results after rectal reservoir reconstruction increased significantly.A review of the current literature was conducted on the development of colon pouch procedures with a particular focus on the transverse coloplasty pouch compared with the colon J-pouch and other current techniques of reconstruction after TME such as the side-to-end anastomosis.The colon J-pouch (CJP) became the "gold standard" for rectal reservoir reconstruction owing to better early functional results compared with the straight coloanal anastomosis (CAA). However, 30% of the patients with CJP faced late evacuation problems requiring the chronic use of enemas or laxatives. This rate could be decreased by shortening the limb of the CJP from 8-10 to 5-6 cm, but the late evacuation problems remained in approximately 10% of the patients. An overview of the current knowledge on technical and functional aspects as well as indications and results of the transverse coloplasty pouch (TCP) is presented.The TCP was developed to provide early functional results comparable to the CJP while avoiding the late evacuation problems. Functional results after TCP, small colon J-pouch and side-to-end anastomosis are similar. Evacuation problems after TCP have not been reported.

Histological differentiation between chronic pancreatitis and pancreatic cancer, especially in biopsy material, remains challenging and the frequent association of 'secondary' chronic pancreatitis (due to ductal obstruction) with pancreatic cancer causes additional diagnostic problems. Our study, using anti-ErbB2 antibodies from Santa Cruz and Dako in tissues from the normal pancreas, chronic pancreatitis and pancreatic cancer showed that these antibodies discriminate between primary chronic pancreatitis and 'secondary' chronic pancreatitis due to pancreatic cancer. Tissues from 28 pancreatic cancer patients, 15 chronic pancreatitis patients and 12 organ donors or early autopsy cases were subjected to immunohistochemical studies using polyclonal ErbB2 antibodies from Santa Cruz and Dako. The Santa Cruz antibody immunoreacted with islet cells in all tissues from the normal pancreas and pancreatic cancer but not in any chronic pancreatitis specimen. The Dako antibody showed a membrane staining of ductal and ductular cells only in chronic pancreatitis cases but in none of the normal or cancer specimens. Moreover, in chronic pancreatitis cases, ductular cells were stained with the Santa Cruz antibody only in the severe form, but not in the mild or moderate form of the disease. The utilized ErbB2 antibodies discriminate between the normal pancreas, chronic pancreatitis and pancreatic cancer. Hence, these antibodies seem to present an additional useful aid in the surgical pathology of pancreatic diseases.

Recent surgical concepts for primary rectal cancer include the combination of surgery and short-term neoadjuvant radiotherapy (STNR). This is usually given in a dose of 25 Gy over five days in order to reduce local recurrence rates. Clinical studies have shown that local recurrence is found in some patients despite STNR. We identified molecular patterns of the Wnt- and apoptosis pathways as well as expression of junction-associated molecules in rectal cancer specimens of patients who received STNR and in those who did not. Expression patterns were examined by immunohistochemistry and molecular techniques such as LightCycler RT-PCR and Western blot analysis in 25 sporadic rectal adenocarcinoma specimens derived from STNR-patients or non-pretreated donors, respectively. The molecular pattern in response to STNR was heterogeneous and was reflected by responders who show activation of apoptosis and cellular remodeling, whereas the group of non-responders from STNR did not show such reaction and was very similar to untreated controls. Enhanced expression of beta-catenin was generally mediated by STNR, but exclusively in the responder group impaired expression of c-Myc and junction-associated molecules as well as cleavage of poly-ADP-ribose polymerase and of the caspase substrate cytokeratin 19 were found. The molecular profile suggests that STNR interferes with Wnt-signaling and c-Myc expression. STNR in its present form is not suitable to fully complete the sequence of apoptosis in all rectal adenocarcinomas.

MUC4 is highly expressed in human pancreatic tumours and pancreatic tumour cell lines, but is minimally or not expressed in normal pancreas or chronic pancreatitis. Here, we investigated the aberrant regulation of MUC4 expression in vivo using clonal human pancreatic tumour cells (CD18/HPAF) grown either orthotopically in the pancreas (OT) or ectopically in subcutaneous tissue (SC) in the nude mice. Histological examination of the OT and SC tumours showed moderately differentiated and anaplastic morphology, respectively. The OT tumour cells showed metastases to distant lymph nodes and faster tumour growth (P

Metabolic activation of many toxins, carcinogens, drugs, and anti-cancer agents is governed by the cytochrome P450 (CYP) drug-metabolizing enzyme system. To help elucidate the role of this enzyme system in the pathogenesis of chronic inflammatory and malignant pancreatic diseases, we compared the immunohistochemical expression pattern of 8 CYP-enzymes in 24 normal, 20 chronic pancreatitis, and 21 pancreatic cancer specimens using antibodies to CYP 1A1, 1A2, 2B6, 2C8/9/19, 2D6, 2E1, and 3A4, and the NADPH cytochrome P450 oxido-reductase (NA-OR). Compared to the normal pancreas, a higher frequency of immunopositivity for CYP 1A2, 2B6, 2C8/9/19, 2D6, and NA-OR was found in chronic pancreatitis, and of all CYPs but 1A2 in pancreatic cancer. On the other hand, CYP 1A1 and 2E1 antibody staining was less frequently observed in chronic pancreatitis. In all specimens with pancreatic polypeptide (PP)-rich regions (pancreas head), more islet cells than ductal and acinar cells were immunopositive. Moreover, the immunoreactivity of islet cells from PP-rich specimens with anti-CYP antibodies was consistently more frequent and intense than in islet cells from PP-poor areas (body and tail). Immunoreactivity for xenobiotic-metabolizing enzymes was frequently observed in the normal pancreas, chronic pancreatitis, and pancreatic cancer, and displayed differences of its frequency and intensity between the 3 groups. Considering immunohistochemical evidence of enzyme expression and pancreatic blood supply together, islet cells appear to be an important and possible early site of CYP-enzyme induction in pancreatic diseases.

N-nitroso-bis(2-oxopropyl)amine (BOP) induces pancreatic ductal adenocarcinoma in Syrian golden hamsters, but not in rats or mice. To examine whether this difference is due to the diversity in the presence and distribution of enzymes involved in the metabolism of BOP, the cellular expression of nine cytochrome P-450 isozymes (CYP1A1, CYP1A2, CYP2B6, CYP2C8,9,19, CYP2D1, CYP2E1, CYP3A1, CYP3A2, and CYP3A4) and of three glutathione S-transferase isozymes (GST-pi, GST-alpha, and GST-mu) was investigated in the pancreas of hamsters, rats, and mice by immunohistochemistry.We found a wide species variation in the presence and cellular localization of the enzymes and a lack of several enzymes, including GST-alpha in islets, CYP2B6, CYP2C8,9,19, CYP3A1 in acinar cells, and CYP3A4 in ductal cells, in the rat as compared with hamster and mouse.Although the results could not clarify the reasons for the species differences in the pancreatic carcinogenicity of BOP, the presence of most of the cytochrome P-450 isozymes in pancreatic islets of all three species highlights the important role of the islets in drug metabolism.

We investigated the cellular expression of 9 cytochrome P450-isozymes (CYP1A1, CYP1A2, CYP2B6, CYP2C8,9,19, CYP2D1, CYP2E1, CYP3A1, CYP3A2, CYP3A4) and 3 glutathione S-transferase-isozymes (GST- π , GST- α, GST- μ ) in the pancreas of hamsters, mice, rats, rabbits, pigs, dogs and monkeys, and in comparison with the human pancreas. A wide variation was found in the cellular localization of these enzymes between the 8 species. Most enzymes were expressed in the pancreas of the hamster, mouse, monkey and human, whereas rats, pigs, rabbits and dogs were lacking several isozymes. However, in all of the species the islet cells expressed more enzymes than ductal and acinar cells. An exclusive expression of enzymes in the islet cells was found in the hamster (CYP2E1), mouse (CYP1A1, CYP1A2, GST- α, GST- μ ), rat (CYP2C8,9,19), rabbit (CYP1A2, CYP2B6, GST- π), and pig (CYP1A1). Although no polymorphism was found in the pancreas of animals, in human tissue four enzymes were missing in about 50% of the cases. The results imply a greater importance of the islet cells in the metabolism of xenobiotics within the pancreas. The differences in the distribution of these drug-metabolizing enzymes in the pancreas between the species call for caution when extrapolating experimental results to humans.

INTRODUCTION In our previous study, glutathione S-transferase-pi (GST-pi), a phase II drug metabolizing enzyme, was found to be expressed in pancreatic ductal and ductular cells but not acinar cells of the normal pancreas, chronic pancreatitis, and secondary pancreatitis caused by pancreatic cancer. A greater percentage of the cells expressing GST-pi was shown in the islets of chronic pancreatitis specimens compared with the normal pancreas and secondary pancreatitis. AIMS AND METHODOLOGY To examine whether the increased number of islet cells expressing GST-pi and the absence in the acinar cells are compensated for by other GST isozymes, we investigated the expression of GST-alpha and GST-mu in the same specimens. RESULTS Unlike the distribution of GST-pi, the distribution of GST-alpha and GST-mu in islets did not show marked differences between the three groups. However, in four of 18 primary chronic pancreatitis specimens, more islet cells (approximately 25%) expressed GST-alpha than in the normal pancreas and secondary chronic pancreatitis (both approximately 10%). The reactivity of cancer cells to GST-alpha, GST-mu, and GST-pi was similar to the ductal cells in the normal pancreas, chronic pancreatitis, and secondary chronic pancreatitis. Contrary to the expression of GST-pi, no statistically significant differences were found in the distribution of GST-alpha and GST-mu in the normal pancreas, chronic pancreatitis, and secondary chronic pancreatitis. CONCLUSION The expression of the other GSTs does not compensate for the variation of expression of GST-pi. There was no specimen in each group that did not express at least one GST isozyme in islet, acinar, and ductal cells.

Umwelttoxine und -karzinogene spielen eine massgebliche Rolle in der Pathogenese des Pankreaskarzinoms. Die Aktivierung von endo- und exogenen (Pra-) Karzinogenen erfolgt in > 90% uber ein Cytochrom P450 (CYP) abhangiges Enzymsystem (Tabelle 1). Aktivierte Karzinogene werden von nachgeschalteten Glutathion S-Transferasen (GST) metabolisiert und deaktiviert. Die Verteilung und Aktivitat dieser Enzyme unterliegen einer grossen interindividuellen Variabilitat. Da 4/5 aller Pankreaskarzinome im Kopfbereich des Organs lokalisiert sind, war es Ziel dieser Studie Unterschiede in der Verteilung von Karzinogen-metabolisierenden Enzymen in der ventralen (Kopf) und dorsalen (Corpus-, Schwanzbereich) Pankreasanlage zu untersuchen.

One of the characteristics of pancreatic cancer is its tendency to invade neural tissue. We hypothesized that the affinity of cancer cells for nerve tissue is related to the presence of growth factors in neural tissue and their receptors in cancer cells. Sections of pancreatic cancer and normal pancreatic tissue were examined by immunohistochemistry for the expression of the neurotrophins NGF, BDNF, NT-3, NT-4, and their receptors TrkA, TrkB, and TrkC, as well as the low-affinity receptor, p75NTR. TrkA expression was found in duct, islet, and cancer cells; TrkB was found in the α-cells of the islet only. The anti-pan-Trk antibody (TrkB3), which is presumed to recognize all three receptors, immunoreacted with duct and acinar cells in normal tissue and with cancer cells. The staining with TrkC was similar to that of TrkA. The low-affinity receptor p75NTR was expressed in the neural tissue and in scattered duct cells of the normal tissue only. Duct and acinar cells, as well as neural tissue and cancer cells, showed weak to strong immunoreactivity with NGF. NT-3 expression was noted in capillary endothelia and erythrocytes. NT-4 showed specific staining for ductule cells. The expression and distribution of neurotrophins and their receptors suggest their role in the potential of pancreatic cancer cells for neural invasion.

The silent course of pancreatic cancer and its explosive fatal outcome have hindered studies of tumor histogenesis and the identification of early biochemical and genetic alterations that could help to diagnose the disease at a curable stage and develop therapeutic strategies. Experimental animal models provide important tools to assess risk factors, as well as preventive and therapeutic possibilities. Although several pancreatic cancer models presently exist, only models that closely resemble human tumors in morphological, clinical, and biological aspects present useful media for preclinical studies. Because an estimated 70% of human tumors are induced by carcinogens and because a significant association has been found between cigarette smoking and pancreatic cancer, chemically induced models are of particular value. Moreover, in such models the etiology, modifying factors, effects of diets, and naturally occurring products can be studied and early diagnostic, preventive, and therapeutic possibilities sought out. Many of the existing models are described in this review, and the advantages and shortcomings of each model and their clinical implications are discussed.

An abnormal glucose metabolism occurs in up to 80% of pancreatic cancer patients shortly or a few months before the first clinical admission. Reasons for this abnormality are obscure. We investigated immunohistochemically the pattern of islets in 14 pancreatic cancer specimens and used 14 chronic pancreatitis samples and 10 normal pancreata as controls. To study the topographical relationship of these islets to the cancer, islets in four different arbitrary zones within and around the cancer were evaluated. Ten out of 14 cancer specimens showed a significant loss of beta cells (p0.005) and eight of them also showed a significant increase of alpha cells (p0.005), all of them from hyperglycemic patients. Most affected islets were found within zone 1 (intratumoral) and zone 2 (peritumoral), to a lesser extent in zone 3 (acini close to tumor) and none in zone 4 (acini remote from tumor). No comparable changes were found in chronic pancreatitis patients. The incidence of 72% with alteration of islets in our material correlates with the frequency of abnormal glucose levels in human pancreatic cancer patients. Our findings support the notion that islet cell abnormalities is likely caused by substances released from cancer cells.

Giant cell carcinoma of the pancreas is a rare tumor. Its histogenesis is still controversial. In a Syrian hamster pancreatic cancer model, tumors similar to human giant cell carcinomas have been induced at an extremely low rate of incidence and after the use of high doses of pancreatic carcinogens. Thus far no tumors of giant cell type have been induced by the in vitro treatment of hamster pancreatic ductal cells with the potent pancreatic carcinogen N-nitrosobis(2-oxopropyl)amine (BOP). In the present study we report the induction of giant cell carcinoma from hamster islets treated with BOP in vitro. The results suggest that in hamsters some component of islet cells, probably stem cells, are the origin of giant cell carcinoma.

3090 Background: VXM01 is an orally available, bacterially transmitted DNA vaccine targeting VEGFR-2. Pre-clinically, VXM01 showed anti-tumor activity in multiple tumor types. This first-in-human study was designed to evaluate the safety and tolerability of VXM01. Secondary endpoints included VEGFR-2 specific T-cell responses, tumor perfusion changes, and related biomarkers. Methods: A randomized, double-blinded, placebo-controlled, dose-escalation study was conducted in 45 patients with advanced pancreatic cancer. VXM01 or placebo was given on days 1, 3, 5, and 7. Doses were escalated from 10(6) CFU to 10(10) CFU over 5 dose groups, each including 6 VXM01 and 3 placebo patients. VEGFR-2 specific T-cell activity was monitored by ELISpot and T(reg) specificity assays before, during and after the vaccination course. Tumor perfusion was assessed by DCE-MRI on days 0 and 38. Biomarkers included CA19-9, VEGF-A and collagen IV. Results: Patients were enrolled from 12/2011 to 10/2012. Most commonly observed AEs were leukopenia, abdominal pain, and diarrhea, which were all equally distributed between treatment and placebo group. While a mild elevation in average blood pressure was observed in the VXM01 group over the placebo group, the hypertension adverse event rate did not differ between both groups. No DLTs were observed. VEGFR-2 specific effector T-cell response was increased in 57% of evaluable VXM01 treated patients, during and after the vaccination course. In 25% of the VXM01 group, the T-cell response score post-vaccination was higher than maximum placebo levels. In contrast, VEGFR-2 specific T(reg) responses were overall reduced in vaccinated patients. DCE-MRI data indicated a >33% drop in K(trans)/tumor perfusion in 35% of evaluable VXM01 treated patients vs. 10% in the placebo group. Mean changes were -4% (VXM01) and +15% (placebo). Reduced tumor perfusion correlated with VEGFR-2 specific T-cell responses and biomarker responses. Conclusions: VXM01 appeared safe and was well tolerated without DLTs across 5 tested dose levels. The data suggest further that VXM01 induces and enhances a VEGFR-2 specific T-cell response and impacts tumor perfusion. Clinical trial information: ISRCTN68809279.

To report an unplanned interim analysis of a prospective, one-armed, single center phase I/II trial (NCT01566123). Between 2007 and 2013, 27 patients (pts) with primary/recurrent retroperitoneal sarcomas (size > 5 cm, M0, at least marginally resectable) were enrolled. The protocol attempted neoadjuvant IMRT using an integrated boost with doses of 45–50 Gy to PTV and 50–56 Gy to GTV in 25 fractions, followed by surgery and IOERT (10–12 Gy). Primary endpoint was 5-year-LC, secondary endpoints included PFS, OS, resectability, and acute/late toxicity. The majority of patients showed high grade lesions (FNCLCC G1:18%, G2:52%, G3:30%), predominantly liposarcomas (70%). Median tumor size was 15 cm (6–31). Median follow-up was 33 months (5–75). Neoadjuvant IMRT was performed as planned (median dose 50 Gy, 26–55) in all except 2 pts (93%). Gross total resection was feasible in all except one patient. Final margin status was R0 in 6 (22%) and R1 in 20 pts (74%). Contiguous-organ resection was needed in all grossly resected patients. IOERT was performed in 23 pts (85%) with a median dose of 12 Gy (10–20 Gy). We observed 7 local recurrences, transferring into estimated 3- and 5-year-LC rates of 72%. Two were located outside the EBRT area and two were observed after more than 5 years. Locally recurrent situation had a significantly negative impact on local control. Distant failure was found in 8 pts, resulting in 3- and 5-year-DC rates of 63%. Patients with leiomyosarcoma had a significantly increased risk of distant failure. Estimated 3- and 5-year-rates were 40% for PFS and 74% for OS. Severe acute toxicity (grade 3) was present in 4 pts (15%). Severe postoperative complications were found in 9 pts (33%), of whom 2 finally died after multiple re-interventions. Severe late toxicity (grade 3) was scored in 6% of surviving patients after 1 year and none after 2 years. Combination of neoadjuvant IMRT, surgery and IOERT is feasible with acceptable toxicity and yields good results in terms of LC and OS in patients with high-risk retroperitoneal sarcomas. Long term follow-up seems mandatory given the observation of late recurrences. Accrual of patients will be continued with extended follow-up. NCT01566123 .

Background Industry sponsorship has been identified as a factor correlating with positive research findings in several fields of medical science. To date, the influence of industry sponsorship in general and abdominal surgery has not been fully studied. This protocol describes the rationale and planned conduct of a systematic review to determine the association between industry sponsorship and positive outcome in randomised controlled trials in general and abdominal surgery. Methods/design A literature search in the Cochrane Library, MEDLINE and EMBASE and additional hand searches in relevant citations will be conducted. In order to cover all relevant areas of general and abdominal surgery, a new literature search strategy called multi-PICO search strategy (MPSS) has been developed. No language restriction will be applied. The search will be limited to publications between January 1985 and July 2014. Information on funding source, outcome, study characteristics and methodological quality will be extracted. The association between industry sponsorship and positive outcome will be tested by a chi-squared test. A multivariate logistic regression analysis will be performed to control for possible confounders, such as number of study centres, multinational trials, methodological quality, journal impact factor and sample size. Discussion This study was designed to clarify whether industry-sponsored trials report more positive outcomes than non-industry trials. It will be the first study to evaluate this topic in general and abdominal surgery. The findings of this study will enable surgical societies, in particular, to give advice about cooperation with the industry and disclosure of funding source based on empirical evidence. Systematic review registration PROSPERO CRD42014010802 Electronic supplementary material The online version of this article (doi:10.1186/2046-4053-3-138) contains supplementary material, which is available to authorized users.

Background Blinding is a measure in randomized controlled trials (RCT) to reduce detection and performance bias. There is evidence that lack of blinding leads to overestimated treatment effects. Because of the physical component of interventions, blinding is not easily applicable in surgical trials. This is a protocol for a systematic review and empirical study about actual impact on outcomes and future potential of blinding in general and abdominal surgery RCT. Methods/design A systematic literature search in CENTRAL, MEDLINE and Web of Science will be conducted to locate RCT between 1996 and 2015 with a surgical intervention. General study characteristics and information on blinding methods will be extracted. The risk of performance and detection bias will be rated as low, unclear or high according to the Cochrane Collaboration’s tool for assessing risk of bias. The main outcome of interest will be the association of a high risk of performance or detection bias with significant trial results and will be tested at a level of significance of 5 %. Further, trials will be meta-analysed in a Mantel-Haenszel model comparing trials with high risk of bias to other trials at a level of significance of 5 %. Discussion Detection and performance bias distort treatment effects. The degree of such bias in general and abdominal surgery is unknown. Evidence on influence of missing blinding would improve critical appraisal and conduct of general and abdominal surgery RCT. Systematic review registration PROSPERO 2015:CRD42015026837. Electronic supplementary material The online version of this article (doi:10.1186/s13643-016-0226-4) contains supplementary material, which is available to authorized users.

Background High-grade soft tissue sarcomas are a heterogeneous, complex group of aggressive malignant tumors showing mesenchymal differentiation. Recently, soft tissue sarcomas have increasingly been classified on the basis of underlying genetic alterations; however, the role of aberrant DNA methylation in these tumors is not well understood and, consequently, the usefulness of methylation-based classification is unclear. Results We used the Infinium HumanMethylation27 platform to profile DNA methylation in 80 primary, untreated high-grade soft tissue sarcomas, representing eight relevant subtypes, two non-neoplastic fat samples and 14 representative sarcoma cell lines. The primary samples were partitioned into seven stable clusters. A classification algorithm identified 216 CpG sites, mapping to 246 genes, showing different degrees of DNA methylation between these seven groups. The differences between the clusters were best represented by a set of eight CpG sites located in the genes SPEG, NNAT, FBLN2, PYROXD2, ZNF217, COL14A1, DMRT2 and CDKN2A. By integrating DNA methylation and mRNA expression data, we identified 27 genes showing negative and three genes showing positive correlation. Compared with non-neoplastic fat, NNAT showed DNA hypomethylation and inverse gene expression in myxoid liposarcomas, and DNA hypermethylation and inverse gene expression in dedifferentiated and pleomorphic liposarcomas. Recovery of NNAT in a hypermethylated myxoid liposarcoma cell line decreased cell migration and viability. Conclusions Our analysis represents the first comprehensive integration of DNA methylation and transcriptional data in primary high-grade soft tissue sarcomas. We propose novel biomarkers and genes relevant for pathogenesis, including NNAT as a potential tumor suppressor in myxoid liposarcomas.