Increasing Incidence of Left-Sided Colorectal Cancer in the Young: Age Is Not the Only Factor.

BACKGROUND: Recent single-institution studies have shown that colorectal cancer (CRC) in patients < 50 is predominantly left-sided. The aims of this study were to 1 compare the incidence of left-sided CRC in patients under and over 50, 2 investigate this trend over time, and 3 examine whether racial differences exist in the anatomical distribution of CRC. METHODS: We used the Nationwide Inpatient Sample to identify all patients with colon or rectal cancer who underwent a resection from 2000 to 2014. Logistic regression models were used to determine the odds of a patient having a left-sided CRC based on age and race. RESULTS: A total of 1,547,589 patients underwent resection, with a mean age of 68.6. Overall, 65.1% of patients < 50 had a left-sided CRC compared with 47.2% of patients ≥ 50 (OR = 2.1; 95% CI 2.0, 2.1). The difference was greater as patients became older with 39.9% of patients > 70 having a left-sided CRC (< 50 vs ≥ 70; OR = 2.8; 95% CI 2.7, 2.9). The incidence of CRC in those under 50 increased over the study period due to an increase in left-sided tumors. The distribution of CRC varied with race, with African-Americans having a lower odds for left-sided CRC (OR = 0.89; 95% CI 0.87, 0.91) and Asians/Pacific Islanders having a higher odds (OR = 1.8; 95% CI 1.7, 1.9). CONCLUSION: In the < 50 age group, the incidence of CRC is increasing, with majority of these tumors left-sided. Tumor location varies with both age and race.

Assessing the impact of neoadjuvant chemotherapy on the management of the breast and axilla in breast cancer.

BACKGROUND: Nodal status is a sensitive prognostic indicator in breast cancer. Axillary metastases may be an indication for neoadjuvant systemic therapy. The aims of this study were to compare pathologic response rates to neoadjuvant chemotherapy (NAC) in the breast and axilla across different molecular subtypes of breast cancer and to compare the predictive value of axillary assessment before and after chemotherapy in determining final nodal status in this cohort of patients. PATIENTS AND METHODS: The cohort comprised patients undergoing NAC from 2003 to November 2012. Data regarding patient and tumor characteristics, management, and outcomes were obtained from a prospectively maintained database and analyzed using PASW Statistics, version 18 (SPSS Inc, Chicago, IL). RESULTS: Two hundred two cancers were identified in 196 patients. One hundred thirty-one (65%) diagnostic axillary procedures were performed, 105 (80%) before NAC, of which 93 (89%) were positive. In 28 (30%), downstaging was noted before NAC. Human epidermal growth factor receptor 2 (HER2) subtypes had the highest rate of complete pathologic response (n = 11 [61%]) and negative axillary clearance (AXCn) (n = 11 [69%]). Of 177 AXCns, 68 (38%) were negative before NAC. CONCLUSION: AXCn in patients undergoing NAC remains controversial. HER2 subtypes are less likely to have axillary involvement after NAC and may demand different management.

Successful laparoscopic management of an incarcerated obturator hernia.

Obturator hernia is a rare pelvic hernia that occurs primarily in multiparous, elderly (>70 years of age), thin females. This case highlights the successful laparoscopic mesh repair of an incarcerated obturator hernia in an octogenarian. The authors report a case of an incarcerated obturator hernia in an elderly female with subsequent high-grade small bowel and its successful laparoscopic operative management. A review of the relevant literature was also performed following a search on the online literature databases such as PUBMED and EMBASE. Laparoscopic mesh repair of the incarcerated obturator hernia and an ipsilateral femoral hernia found incidentally was successfully performed. A review of the literature showed a significant burden of morbidity and mortality associated with obturator hernias. Laparoscopic mesh repair has been previously shown to be a safe therapeutic modality. Small bowel obstruction and leg pain in a thin elderly lady should arouse suspicion for an incarcerated obturator hernia. Laparoscopic management of an incarcerated obturator hernia is a feasible and safe therapeutic option.

Temporal artery biopsy is not required in all cases of suspected giant cell arteritis.

BACKGROUND: Temporal artery biopsy (TAB) is performed during the diagnostic workup for giant cell arteritis (GCA), a vasculitis with the potential to cause irreversible blindness or stroke. However, treatment is often started on clinical grounds, and TAB result frequently does not influence patient management. The aim of this study was to assess the need for TAB in cases of suspected GCA. METHODS: We performed a retrospective review of 185 TABs performed in our institution from 1990 to 2010. Patients were identified through the Hospital In-Patient Enquiry database and theater records. Clinical findings, erythrocyte sedimentation rate, steroid treatment preoperatively, American College of Rheumatology (ACR) criteria for GCA score, biopsy result, and follow-up were recorded. RESULTS: Fifty-eight (31.4%) biopsies were positive for GCA. Presence of jaw claudication (P = 0.001), abnormal fundoscopy (P = 0.001), and raised erythrocyte sedimentation rate (P = 0.001) were significantly associated with GCA. The strongest association with positive biopsy was seen with the prebiopsy ACR score (P < 0.001). Twenty-four (13.7%) patients had undergone biopsy, despite no potential for meeting ACR criteria preoperatively. None of these were positive. Overall, 29 (16.4%) patients had management altered by TAB result. CONCLUSIONS: Our results confirm that TAB does not affect management in the majority of patients with suspected GCA. We conclude that TAB has benefit only for patients who score 2 or 3 on the ACR criteria for GCA without biopsy.

Bacterial superantigens enhance the in vitro proinflammatory response and in vivo lethality of the TLR2 agonist bacterial lipoprotein.

Bacterial superantigens are Gram-positive exotoxins that induce proinflammatory cytokine release in vitro, cause lethal shock in vivo, and can be detected in the bloodstream of critically ill patients. They also have a powerful priming effect on the TLR4 agonist LPS. The aim of this study was to investigate the relationship between superantigens and the TLR2 agonist bacterial lipoprotein (BLP). Priming of human monocytes or PBMCs with superantigens significantly enhanced proinflammatory cytokine TNF-α and IL-6 release in response to BLP stimulation. The priming effect of superantigens could be blocked by inhibiting p38 MAPK during the priming phase as opposed to NF-κB or ERK inhibition. This was consistent with higher expression of the phosphorylated p38 after superantigen priming and BLP or LPS stimulation. C57BL/6 mice with superantigen priming (10 µg/mouse) when challenged with BLP (600 µg/mouse) exhibited substantially higher mortality (100%) compared with mice without superantigen priming (zero). Mice given superantigen alone did not demonstrate any signs of illness. Mice challenged with both superantigen and BLP had significantly higher levels of serum TNF-α and IL-6 compared with those of mice challenged with either agent alone. Depletion of the monocyte/macrophage subpopulation significantly reduced the mortality rate from 100 to 20% in superantigen-primed, BLP-challenged C57BL/6 mice, with a 5- to 10-fold decrease in serum TNF-α and IL-6. Our results demonstrate that bacterial superantigens enhance the in vitro proinflammatory cytokine release and in vivo lethality of BLP. This novel finding may help to explain the massive proinflammatory cytokine release seen in superantigen-mediated septic shock.