The Role of Minimally Invasive Surgery in the Treatment of Lung Metastases.

INTRODUCTION: The ideal surgical approach for pulmonary metastasectomy remains controversial. Thoracoscopic surgery may offer advantages in quality of life outcomes, with equivalent oncologic long-term results. This study aimed to demonstrate the validity of video-assisted thoracoscopic surgery (VATS) in the treatment of lung metastases. METHODS: In all 224 patients who underwent 300 VATS metastasectomies from January 2000 to December 2013 were retrospectively reviewed. Sixty-nine patients underwent major resection (68 thoracoscopic lobectomies and one pneumonectomy) and 155 patients underwent a wedge resection/segmentectomy. Complete curative pulmonary resections were performed in 219 (97%) cases. The Kaplan-Meier method was used to estimate survival curves. Univariate and subsequent multivariate Cox model regression were performed to identify independent factors of overall survival. RESULTS: One hundred eighty-six patients developed lung metastases from epithelial tumors, 28 from sarcomas, seven from melanomas, and three from germ cell tumors. The final pathological examination revealed no cases of R1 disease. After a mean follow-up of 40 months, 118 patients (53%) had died. According to a multivariate analysis, a better prognosis was not observed for patients with a particular histological type; in addition, disease-free interval time, age, number of metastases, and type of surgery did not have any statistical influence on long-term survival. CONCLUSIONS: Thoracoscopic surgery is a safe and efficacious procedure, with a five-year overall survival that is equivalent to open surgery.

Pancreaticojejunostomy Versus Pancreaticogastrostomy After Pancreaticoduodenectomy: An Up-to-date Meta-Analysis.

BACKGROUND: The reconstruction of the pancreas after pancreaticoduodenectomy (PD) is a crucial factor in preventing postoperative complications as pancreatic anastomosis failure is associated with a high morbidity rate and contributes to prolonged hospitalization and mortality. Several techniques have been described for the reconstruction of pancreatic digestive continuity in the attempt to minimize the risk of a pancreatic fistula. The aim of this study was to compare the results of pancreaticogastrostomy and pancreaticojejunostomy after PD. METHODS: A systematic review and meta-analysis were conducted of randomized controlled trials (RCTs) published up to January 2015 comparing patients with pancreaticogastrostomy (PG group) versus pancreaticojejunostomy (PJ group). Two reviewers independently assessed the eligibility and quality of the studies. The meta-analysis was conducted using either the fixed-effect or the random-effect model. RESULTS: Eight RCTs describing 1,211 patients were identified for inclusion in the study. The meta-analysis shows that the PG group had a significantly lower incidence rate of postoperative pancreatic fistulas [OR 0.64 (95% confidence interval 0.46-0.86), p = .003], intra-abdominal abscesses [OR 0.53 (95% CI, 0.33-0.85), p = .009] and length of hospital stay [MD -1.62; (95% CI 2.63-0.61), p = .002] than the PJ group, while biliary fistula, mortality, morbidity, rate of delayed gastric emptying, reoperation, and bleeding did not differ between the two groups. CONCLUSION: This meta-analysis suggests that the most effective treatment for reconstruction of pancreatic continuity after pancreatoduodenectomy is pancreaticogastrostomy. However, the advantage of the latter could potentially be demonstrated through further RCTs, including only patients at high risk of developing pancreatic fistulas.

Abdominal wall desmoid tumors: A proposal for US-guided resection.

BACKGROUND: Desmoid tumors (DTs) is a benign tumor with high tendency to infiltrative evolution and recurrence. Nowadays, in abdominal localization, the standard approach is surgery with R0 condition. The need to repair post-surgical wide wall defect requires conservative technique to decrease the incidence of incisional hernia and to obtain better quality of life (QoL). METHODS: We perform an abdominal wall desmoid resection using ultrasound guide. This technique ensures to spare a wide wall area and to obtain a multilayer reconstruction minimizing postoperative risk. This approach allows good oncological results and better managing abdominal wall post-resection defect. RESULTS: We use US guided surgery to get radical approach and wall tissue spare that allows us a multilayer reconstruction minimizing post-operative complications. No recurrences were observed in one year follow up period. CONCLUSION: Our experience represents first step to consider ultrasound mediated technique usefull to optimize wall resection surgery and to minimize following complications.

Ruptured aneurysm of replaced left hepatic artery.

Hepatic artery aneurysm is an uncommon and potentially fatal form of vascular disease. We report the case of a 53-year-old man with an isolated, nontraumatic rupture of an aneurysm of a replaced left hepatic artery originating from the left gastric artery. This case is unusual because the ruptured aneurysm involved an hepatic artery with a rare vascular pattern.

Repeated hepatic resection combined with inferior vena cava replacement: Case report and review of literature.

INTRODUCTION: Advanced tumors of the liver involving the inferior vena cava (IVC) have always been considered a contraindication to surgery. PRESENTATION OF CASE: We report a case of a patient, who previously underwent right hepatectomy, with recurrence of colorectal liver metastasis invading the IVC. The patient had a liver resection together with replacement of the vena cava using a ringed polytetrafluoroethylene (PTFE) graft tube. The operation was carried out in hepatic vascular exclusion (HVE) without the use of veno-venous bypass. The patient was healthy and tumor-free at 6 months post-surgery. DISCUSSION: In patients with hepatic malignancy involving the IVC, extended hepatic resection and reconstruction of the IVC is often the prerequisite to obtaining a resection margin. CONCLUSION: Extended hepatic resection with IVC reconstruction for hepatic malignancy may offer a chance of cure to selected patients who otherwise have poor survival rates.

Thoracoscopic lung metastasectomies: a 10-year, single-center experience.

INTRODUCTION: The ideal surgical treatment for pulmonary metastasectomy remains controversial. Minimally invasive surgery may offer advantages for quality of life outcomes, with equivalent oncologic long-term results. The purpose of our study was to confirm the validity of the thoracoscopic approach for pulmonary metastasectomy. METHODS: We retrospectively reviewed 164 patients who underwent 212 lung metastasectomies from January 2000 to December 2010. Complete curative pulmonary resections were performed in 159 (96.95 %) cases; 126 patients developed lung metastases from epithelial tumors: 28 from sarcoma, 7 from melanoma, and 3 from germ cell tumors. The mean disease-free interval (DFI) was 38.75 months. Fifty-four patients underwent a major VATS resection (53 thoracoscopic lobectomies and 1 pneumonectomy), and 110 patients underwent a wedge resection/segmentectomy. Lymph node sampling was performed in 117 cases. RESULTS: After a mean follow-up of 38 months, 87 patients (53 %) had died. All resection margins were tumor-free at final pathological examination. Multivariate analysis not confirmed in our series a better prognosis for patients with a particular histologic type and also DFI, age, number of metastases, and type of surgery did not statistically influence long-term survival. CONCLUSIONS: Thoracoscopic surgery is an acceptable procedure, safe and efficacious, with a 5-year overall survival that is equivalent to open surgery.

Immunological and molecular correlates of disease recurrence after liver resection for hepatocellular carcinoma.

The definition of the risk of hepatocellular carcinoma (HCC) recurrence after resection represents a central issue to improve the clinical management of patients. In this study we examined the prognostic relevance of infiltrating immune cell subsets in the tumor (TIL) and in nontumorous (NT) liver (LIL), and the expression of immune-related and lineage-specific mRNAs in HCC and NT liver derived from 42 patients. The phenotype of infiltrating cells was analyzed by flow cytometry, and mRNA expression in liver tissue was examined by real-time reverse transcription (RT)-PCR. The tumor immune microenvironment was enriched in inhibitory and dysfunctional cell subsets. Enrichment in CD4+ T-cells and in particular CD4 and CD8+ memory subsets within TIL was predictive of better overall survival (OS) and time to recurrence (TTR). Increased programmed death ligand 1 (PDL1) mRNA content and higher prevalence of invariant NKT (iNKT) cells were associated with shorter OS and TTR, respectively. By combined evaluation of infiltrating cell subsets along with mRNA profiling of immune and tumor related genes, we identified the intratumoral frequency of memory T-cells and iNKT-cells as well as PDL1 expression as the best predictors of clinical outcome. HCC infiltrate is characterized by the expression of molecules with negative regulatory function that may favor tumor recurrence and poor survival.

Late recurrence of a seminoma of the testis with a poorly differentiated neuroendocrine carcinoma component.

The frequency and clinical relevance of late recurrences of testicular germ cells tumors (GCTs) has increased in the past few decades because of the improved survival of patients following the introduction, in the late 1970s, of cisplatin-based chemotherapy. The late recurrences of GCT may take extremely variable features and occur several years after the primary tumor, making the diagnosis a challenge for both clinicians and pathologists. This study reports a case of a testicular seminoma that relapsed 28 years after surgery as an undifferentiated GCT with a heterologous component of neuroendocrine carcinoma that was initially misdiagnosed as a metastasis of primary intestinal tumor.

The BH3-mimetic ABT-737 targets the apoptotic machinery in cholangiocarcinoma cell lines resulting in synergistic interactions with zoledronic acid.

PURPOSE: In TFK-1 and EGI-1 cholangiocarcinoma cell lines, zoledronic acid (ZOL) determines an S-phase block without apoptosis. Here, we investigated the occurrence of apoptosis stigmata when ZOL is associated to the BH3-mimetic ABT-737. METHODS: In EGI-1 and TFK-1 cholangiocarcinoma cell lines untreated or treated with ABT-737 alone or in combination with ZOL, the pro-survival protein's pattern (BCL-2, BCL-XL, MCL-1, HSP72, HSP27) was investigated by biochemical criteria along with the occurrence of mitochondrial damage evaluated by cytofluorimetric analysis using a cationic dye. RESULTS: ABT-737 induced growth inhibition and significantly affected the colony-forming ability of both EGI-1 and TFK-1 cells. However, activated PARP-1 or/and caspase-3 cleavage (apoptosis markers) were detected only at the highest ABT-737 concentrations used. Combined treatment showed synergistic effect by converting the predominant cytostatic effect of ZOL into a cytotoxic one as shown by striking increment of mitochondrial harmed cells along with PARP-1 activation and caspase-3 cleavage. CONCLUSION: The lack of apoptosis following ZOL treatment in these cholangiocarcinoma cell lines appears to be multifactorial and could be ascribed to the large constitutive expression of pro-survival proteins. The efficacy of ZOL treatment requires a concomitant unleashing of apoptosis using a selective BH3-mimetic as ABT-737. The rational targeting of specific components of the apoptotic pathway may appear a useful approach to improve the treatment of refractory or relapsed cholangiocarcinoma. Combined treatment could be further explored in in vivo tumor model of cholangiocarcinoma.

The node ratio as prognostic factor after curative resection for gastric cancer.

INTRODUCTION: The depth of the tumor invasion and nodal involvement are the two main prognostic factors in gastric cancer. Staging systems differ among countries and new tools are needed to interpret and compare results and to reduce stage migration. The node ratio (NR) has been proposed as a new prognostic factor. MATERIALS AND METHODS: We retrospectively reviewed 282 patients who underwent curative resection for gastric cancer at Parma University Hospital between 2000 and 2007. TNM stage, NR, overall survival, survival according to nodal status, and survival according to the total number of nodes retrieved were calculated. RESULTS: At univariate analysis, the TNM stage, number of metastatic nodes, NR, and depth of tumor invasion, but not the number of nodes retrieved, were significant prognosis factors. Patients with more than 15 nodes retrieved in the specimen survived significantly longer (p < 0.04). This was confirmed for all N or NR classes within N groups. There was a correlation between the number of nodes retrieved and N but not with the NR category. NR was an independent prognostic factor at Cox regression. CONCLUSION: NR is a reliable and sensitive tool to differentiate patients with similar characteristics, probably more so than the TNM system. NR is not strictly related to the number of nodes retrieved and this may potentially decrease the stage migration phenomenon. More trials are needed to validate this factor.

Radiofrequency thermal ablation for hepatocellular carcinoma stimulates autologous NK-cell response.

BACKGROUND & AIMS: Radiofrequency thermal ablation (RFA) is a minimally invasive technique used as standard local therapy of hepatocellular carcinoma and second-line treatment for metastatic liver tumors. Studies in preclinical models and in patients have shown that thermal destruction of tumor tissue can enhance anti-tumor cellular responses, but our knowledge of its impact on natural killer (NK) cells is still very limited. METHODS: Thirty-seven patients undergoing RFA for hepatocellular carcinoma were studied for peripheral blood lymphocytes counts followed by phenotypic and functional characterization of NK-cell population. RESULTS: Peripheral blood lymphocytes kinetics revealed an increased frequency and absolute number of NK cells expressing higher levels of activatory along with reduced levels of inhibitory NK receptors, and increased functional NK-cell activity. A prevalent expansion of the CD3(-)CD56(dim) NK subset was observed compared to the CD3(-)CD56(bright) counterpart. Interferon-gamma production, anti-K562 cell cytotoxicity, and antibody-dependent cell cytotoxicity, appeared consistently increased in terms of both absolute activity and killing efficiency at 4 weeks after RFA, as compared to baseline. Interestingly, when recurrence-free survival was assessed in 2 groups of patients separated according to higher vs lower enhancement of cytotoxicity and/or interferon-gamma production, a significant difference was observed, thus suggesting a potential predictive role of NK functional assays on efficacy of RFA. CONCLUSIONS: RFA can lead to stimulation of NK cells with a more differentiated and proactivatory phenotypic profile with general increase of functional activities. This observation may be relevant for development of adjuvant immunotherapeutic strategies aimed at enhancing NK-cell responses against primary and metastatic liver tumors.

Zoledronic acid determines S-phase arrest but fails to induce apoptosis in cholangiocarcinoma cells.

Cholangiocarcinoma is the second most common primary hepatic neoplasia and the only curative therapy is surgical resection or liver transplantation. Biphosphonates (BPs) are an emerging class of drugs widely used to treat bone diseases and also appear to possess direct antitumor activity. In two human cholangiocarcinoma cell lines (TFK-1 and EGI-1) we investigated, for the first time, the activity of zoledronic acid by determining proliferation, cell cycle analysis and apoptosis. The results obtained indicate that zoledronic acid induces cell-narrowing and growth inhibition, both reversed by 25 microM GGOH, and significantly affects the colony-forming ability of these cells. The inhibition by zoledronic acid of Rap1A prenylation was reversed in cell co-treated with GGOH. At 10-50 microM zoledronic acid exerted an S-phase cell cycle arrest which was confirmed by changes in the level of cyclins and of regulators p27(KIP1) and pRb. Interestingly, the expression level of cyclin A (putative S-phase marker) shows a dose-dependent increment in contrast to the decrement of cyclin D1 (putative G1 phase marker). However, neither hypodiploid cells nor cleaved PARP or caspase-3 was detected. The lack of TP53 or loss of its function, the large constitutive expressions of anti-apoptotic proteins Bcl-xL and HSP27 together with the low level of the pro-apoptotic Bax are the likely factors which protect cells from apoptosis. In conclusion, our study indicates that zoledronic acid induces S-phase arrest and cell-narrowing, both reversed by GGOH and, by changing the delicate balance between pro- and anti-apoptotic proteins, allows survival of cholangiocarcinoma cells.

Response to cytosolic nickel of Slow Vacuolar channels in the hyperaccumulator plant Alyssum bertolonii.

We applied the patch-clamp technique to investigate the transport properties of the Slow Vacuolar (SV) channel identified in leaf vacuoles of Alyssum bertolonii Desv., a nickel hyperaccumulator plant growing in serpentine soil of the northern Apennines (Italy). SV currents recorded in vacuoles from adult plants collected in their natural habitat showed high sensitivity towards cytosolic nickel. Dose-response analyses indicated half-maximal current inhibition at submicromolar concentrations, i.e. up to three orders of magnitude lower than previously reported values from other plant species. The voltage-dependent increase of residual currents at saturating nickel concentrations could be interpreted as relief of channel block by nickel permeation at high positive membrane potentials. Including young plants of A. bertolonii into the study, we found that SV channels from these plants did not display elevated nickel sensitivity. This difference may be related to age-dependent changes in nickel hyperaccumulation of A. bertolonii leaf cells.

Defunctioning stoma in high-risk rectal anastomosis.

BACKGROUND: Ileostomy in rectal surgery is not always indicated for protecting the anastomosis. METHODS: We examined patients who underwent low rectal resection surgery for carcinoma between June 2005 and December 2007. We categorized the patient's characteristics according to the American Society of Anesthesiologists (ASA). We estimated hospital stay, and postoperative Dukes stage. RESULTS: 68 patients, 47 males and 21 females (mean age 67.8 years, range 40-85 years) treated with low rectal resection for carcinoma. An ileostomy was performed in 29 out of 68 patients (42.6%). Six postoperative ileostomy cases led to the appearance of peritonitis from anastomotic fistula. Among the patients with ileostomy 19 pts. (65.5%) belonged to ASA II and 10 pts.(34.5%) to ASA III; among those patients without ileostomy, 32 (82.05%) ASA II and 7 (17.95%) ASA III (p = n.s.). Of patients who underwent the first protective surgical procedure, 4 belonged to ASA II (66.6%) and 2 to ASA III (33.3%). The mean hospital stay for the non ileostomy group was 7.64 +/- 0.7 days, while it was 7.36 +/- 0.49 (p = n.s.) for the ileostomy group. The mean stay of postoperative ileostomy for leakage was 10.83 +/- 1.16 days. CONCLUSIONS: Ileostomy cannot completely prevent the onset of leakage, but may reduce overall hospitalization time.

Imaging for oncologic staging and follow-up: review of current methods and novel approaches.

PURPOSE: To review the current radiological methodologies and guidelines for staging and followup in oncology, and to give a perspective based on the available new technologies in oncologic radiology. MATERIALS AND METHODS: The literature on cancer radiologic quantification in diagnostic phase and follow-up has been reviewed. The main concepts and guidelines (official and non-official) have been extracted taking into account the period of publication and the available technology. The current World Health Organization (WHO) and Response Evaluation Criteria In Solid Tumors (RECIST) guidelines have been critically evaluated on the basis of technical literature on quantitative radiology applied to oncology. Pitfalls of previous and current guidelines have been exploited on the basis of currently available techniques for quantification. RESULTS: Errors due to operator, scanner, software, and measurement technique inconsistency are all together far more relevant than the recognized thresholds applied for detecting therapeutic response. For this reason the volumetric assessment of cancer disease should be introduced. CONCLUSION: Even though the technical constraints are still prominent in the clinical practice, the design of clinical trials should be planned taking into account these new volumetric quantitative techniques.

Intracellular proton regulation of ClC-0.

Some CLC proteins function as passive Cl(-) ion channels whereas others are secondary active chloride/proton antiporters. Voltage-dependent gating of the model Torpedo channel ClC-0 is modulated by intracellular and extracellular pH, possibly reflecting a mechanistic relationship with the chloride/proton coupling of CLC antiporters. We used inside-out patch clamp measurements and mutagenesis to explore the dependence of the fast gating mechanism of ClC-0 on intracellular pH and to identify the putative intracellular proton acceptor(s). Among the tested residues (S123, K129, R133, K149, E166, F214L, S224, E226, V227, C229, R305, R312, C415, H472, F418, V419, P420, and Y512) only mutants of E166, F214, and F418 qualitatively changed the pH(int) dependence. No tested amino acid emerged as a valid candidate for being a pH sensor. A detailed kinetic analysis of the dependence of fast gate relaxations on pH(int) and [Cl(-)](int) provided quantitative constraints on possible mechanistic models of gating. In one particular model, a proton is generated by the dissociation of a water molecule in an intrapore chloride ion binding site. The proton is delivered to the side chain of E166 leading to the opening of the channel, while the hydroxyl ion is stabilized in the internal/central anion binding site. Deuterium isotope effects confirm that proton transfer is rate limiting for fast gate opening and that channel closure depends mostly on the concentration of OH(-) ions. The gating model is in natural agreement with the finding that only the closing rate constant, but not the opening rate constant, depends on pH(int) and [Cl(-)](int).

Determinants of anion-proton coupling in mammalian endosomal CLC proteins.

Many proteins of the CLC gene family are Cl(-) channels, whereas others, like the bacterial ecClC-1 or mammalian ClC-4 and -5, mediate Cl(-)/H(+) exchange. Mutating a "gating glutamate" (Glu-224 in ClC-4 and Glu-211 in ClC-5) converted these exchangers into anion conductances, as did the neutralization of another, intracellular "proton glutamate" in ecClC-1. We show here that neutralizing the proton glutamate of ClC-4 (Glu-281) and ClC-5 (Glu-268), but not replacing it with aspartate, histidine, or tyrosine, rather abolished Cl(-) and H(+) transport. Surface expression was unchanged by these mutations. Uncoupled Cl(-) transport could be restored in the ClC-4(E281A) and ClC-5(E268A) proton glutamate mutations by additionally neutralizing the gating glutamates, suggesting that wild type proteins transport anions only when protons are supplied through a cytoplasmic H(+) donor. Each monomeric unit of the dimeric protein was found to be able to carry out Cl(-)/H(+) exchange independently from the transport activity of the neighboring subunit. NO(3)(-) or SCN(-) transport was partially uncoupled from H(+) countertransport but still depended on the proton glutamate. Inserting proton glutamates into CLC channels altered their gating but failed to convert them into Cl(-)/H(+) exchangers. Noise analysis indicated that ClC-5 switches between silent and transporting states with an apparent unitary conductance of 0.5 picosiemens. Our results are consistent with the idea that Cl(-)/H(+) exchange of the endosomal ClC-4 and -5 proteins relies on proton delivery from an intracellular titratable residue at position 268 (numbering of ClC-5) and that the strong rectification of currents arises from the voltage-dependent proton transfer from Glu-268 to Glu-211.

Buffered diffusion around a spherical proton pumping cell: a theoretical analysis.

H(+) ions are a substrate of many active and passive membrane transporters in all cells. Absolute proton fluxes are often quantified using intracellular pH sensitive microelectrodes or pH sensitive dyes. These measurements, however, rely on a priori estimates of the intracellular buffer capacity and on the assumption of diffusive equilibrium inside the cell. Here, assuming local equilibrium of protons with a single mobile buffer, we model the diffusion of H(+) in the extracellular medium around an H(+) pumping cell to estimate the expected pH changes as a function of time, distance from the cell, extracellular buffer capacity, and the absolute proton flux across the membrane. In particular, using accurate numerical simulation, we gauge the range of validity of an explicit, analytical solution of the linearized, nonstationary diffusion equation. Our results provide a framework to quantify the absolute membrane proton flux, if spatiotemporal information about the extracellular pH change is available, e.g., using imaging of pH dependent fluorescent dyes.

The zinc binding site of the Shaker channel KDC1 from Daucus carota.

KDC1 is a voltage-dependent Shaker-like potassium channel subunit cloned from Daucus carota which produces conductive channels in Xenopus oocytes only when coexpressed with other plant Shaker potassium subunits, such as KAT1 from Arabidopsis thaliana. External Zn(2+) determines a potentiation of the current mediated by the dimeric construct KDC1-KAT1, which has been ascribed to zinc binding at a site comprising three histidines located at the S3-S4 (H161, H162) and S5-S6 (H224) linkers of KDC1. Here we demonstrate that also glutamate 164, located in close proximity of the KDC1 S4 segment, is an essential component of the zinc-binding site. On the contrary, glutamate 159, located in symmetrical position with respect to E164 in the sequence E(159)XHHXE(164) but more distant from the voltage sensor, does not play any role in zinc binding. The effects of Zn(2+) can be expressed as a "shift" of the gating parameters along the voltage axis. Kinetic modeling shows that Zn(2+) slows the closing kinetics of KDC1-KAT1 without affecting the opening kinetics. Possibly, zinc affects the movement of the voltage sensor in and out of the membrane phase through electrostatic modification of a site close to the voltage sensor.

The expression of HSP27 is associated with poor clinical outcome in intrahepatic cholangiocarcinoma.

BACKGROUND: The heat shock proteins (HSPs) 27-kDa (HSP27) and 72-kDa (HSP72), are ubiquitous chaperone molecules inducible in cells exposed to different stress conditions. Increased level of HSPs are reported in several human cancers, and found to be associated with the resistance to some anticancer treatments and poor prognosis. However, there is no study of the relationship between HSPs expression and patient's prognosis in intrahepatic cholangiocarcinoma (IHCCA). In this exploratory retrospective study, we investigated the expressions of HSP27 and HSP72 as potential prognostic factors in IHCCA. METHODS: Thirty-one paraffin-embedded samples were analyzed by immunohistochemical methods using HSP27 and HSP72 monoclonal antibodies. Proliferation rate was assessed in the same specimens by using monoclonal antibody against phosphorylated histone H3 (pHH3). Fisher's exact test was used to assess the hypothesis of independence between categorical variables in 2 x 2 tables. The ANOVA procedure was used to evaluate the association between ordinal and categorical variables. Estimates of the survival probability were calculated using the Kaplan-Meier method, and the log rank test was employed to test the null hypothesis of equality in overall survival among groups. The hazard ratio associated with HSP27 and HSP72 expression was estimated by Cox hazard-proportional regression. RESULTS: The expression of HSP27 was related to mitotic index, tumor greatest dimension, capsular and vascular invasion while the expression of HSP72 was only related to the presence of necrosis and the lymphoid infiltration. Kaplan-Maier analysis suggested that the expression of HSP27 significantly worsened the patients' median overall survival (11 +/- 3.18 vs 55 +/- 4.1 months, P-value = 0.0003). Moreover HSP27-positive patients exhibited the worst mean survival (7.0 +/- 3.2 months) in the absence of concomitant HSP72 expression. CONCLUSION: The expression of HSP27, likely increasing cell proliferation, tumor mass, vascular and capsular invasion, might promote aggressive tumor behaviour in IHCCA and decrease patients' survival. Immunohistochemical detection of HSP27 on routine sections may provide a reliable prognostic marker for IHCCA able to influence the therapeutic strategies for this cancer.