Objective review of mediastinal lymph node examination in a lung cancer resection cohort.

BACKGROUND: Accurate staging of resected lung cancer requires mediastinal lymph node (MLN) examination. MLN dissection (MLND) and systematic sampling (SS) are acceptable procedures; random sampling (RS) and no sampling (NS) are not. Forty percent of US lung cancer resections have NS. We closely examined the pattern of MLN examination in a lung resection cohort. METHODS: This is a retrospective review of all lung cancer resections in Memphis, TN, from 2004 to 2007. We compared operating surgeons' claims to the pathology report and an audit of the operation narrative by an independent surgeon. RESULTS: Forty-five percent of resections were reported by surgeons as MLND, 8% RS, and 48% NS. None met pathology criteria for MLND, 9% were SS, 50% were RS, and 42% were NS. The concordance rate between the operating surgeon and pathology report was 39%. The surgeon audit suggested 29% of resections had MLND, 26% RS, and 45% NS. Concordance between operating and auditing surgeons was 71%. Sublobar resection, T1 stage, and age were associated with NS. CONCLUSIONS: Most resections had suboptimal MLN examination. Concordance was poor between surgeon claims, objective review of pathology reports, and an independent surgeon audit. The higher concordance between operating and auditing surgeons may suggest incomplete pathology examination of MLN material. The terms used by operating surgeons to describe MLN retrieval were often inaccurate.

A novel surgical approach to cardiac autotransplantation in complex cardiac sarcoma resection.

A 28-year-old woman was admitted to our institution, reporting progressive dyspnea, cough, and weight loss of 14 kg. Two-dimensional echocardiography revealed a left atrial mass, and cardiac magnetic resonance imaging showed localized involvement of the mass with adjacent structures. These clinical signs and radiographic images were highly suggestive of cardiac sarcoma. The patient underwent emergent mediastinal exploration, and an incisional biopsy of the mass showed high-grade sarcoma. Removing the tumor required radical en bloc resection of the left atrium, including the mitral valve, the left pulmonary vein, and the left lower lobe of the lung. Autotransplantation was necessary for the resection and reconstruction. We report a unique method of handling the right atrium to avoid the potential complications associated with bicaval anastomoses after autotransplantation.

Development of multiple complications in type 2 diabetes is associated with the increase of multiple markers of chronic inflammation.

Patients with type 2 diabetes (T2DM) are known at risk for developing cardiovascular disease (CVD), nephropathy, and cancer. We were interested to find out whether multiple markers associated with chronic inflammation are detectable in patients with T2DM and are increased in patients with T2DM who developed additional clinical complications. A sequence of multiple risk markers for atherogenesis, associated with chronic inflammation, was measured in patients with T2DM before and after the development of clinical complications. We found that multiple clinical complications frequently developed simultaneously in patients with T2DM. At the early stage of T2DM, only low levels and low percent elevations of multiple risk markers were detected. However, both the level and the percent elevation of these markers were found to increase with disease progression and the development of clinical complications. We believe that chronic inflammation not only contributes to the pathogenesis of T2DM but also continues to increase in T2DM patients who are developing additional clinical complications. It appears that these multiple markers are potentially useful not only for monitoring the progression of T2DM but also predicting the risk of developing macro- and microvascular disease, nephropathy, and cancer.

Esophageal perforations: new perspectives and treatment paradigms.

Despite significant advances in modern surgery and intensive care medicine, esophageal perforation continues to present a diagnostic and therapeutic challenge. Controversies over the diagnosis and management of esophageal perforation remain, and debate still exists over the optimal therapeutic approach. Surgical therapy has been the traditional and preferred treatment; however, less invasive approaches to esophageal perforation continue to evolve. As the incidence of esophageal perforation increases with the advancement of invasive endoscopic procedures, early recognition of clinical features and implementation of effective treatment are essential for a favorable clinical outcome with minimal morbidity and mortality. This review will attempt to summarize the pathogenesis and diagnostic evaluation of esophageal injuries, and highlight the evolving therapeutic options for the management of esophageal perforation.

A panel of multiple markers associated with chronic systemic inflammation and the risk of atherogenesis is detectable in asthma and chronic obstructive pulmonary disease.

Asthma and chronic obstructive pulmonary disease (COPD) are both lung diseases involving chronic inflammation of the airway. The injury is reversible in asthma whereas it is mostly irreversible in COPD. Both patients of asthma and COPD are known at risk for cardiovascular disease (CVD) and type 2 diabetes (T2DM), nephropathy, and cancer. We measured multiple risk markers for atherogenesis in 55 patients with asthma and 62 patients with COPD. We wanted to know whether risk markers for atherogenesis corresponding to sequence of events of chronic inflammation were also detectable in the airway inflammatory diseases. Elevation of almost all markers involving inflammation of the endothelial cells in the coronary artery were detectable in asthma and COPD involving the inflammation of the epithelial cell lining of the airway. Both the level and % elevation of all markers were found mostly higher in COPD, the more severe form of the lung disease. We believe that these markers are useful for predicting risk of developing clinical complications such as CVD.

Cosmetic liposuction causes only transient elevation of acute inflammatory response and does not advance to oxidative and nitrosative stress.

Cosmetic liposuction is a surgical procedure performed on normal nonobese subjects to remove unwanted fat. We are interested to know whether the impact of acute inflammatory response induced by liposuction differs from that of chronic inflammation and whether acute inflammatory response will also advance further and cause oxidative and nitrosative stress leading to various clinical complications. In our investigation we monitored 15 nonobese women prior to liposuction, and one day and one month after the surgery with multiple markers associated with chronic inflammation and oxidative stress. Our results indicate that liposuction causes only a transient elevation of acute inflammatory markers such as interleukin-6 (IL-6), high sensitive C-reactive protein (hCRP), and serum amyloid A (SAA), and a transient decrease of nitric oxide (NO). Apparently the impact of liposuction for normal subjects did not advance beyond acute inflammatory response; there was little change in the levels of markers corresponding to downstream events of chronic systemic inflammation such as adhesion molecules, urinary microalbumin (uMA), homocysteine (Hcy), uric acid (UA), and markers of oxidative stress, including urinary 8-hydroxydeoxyguanosine (8-OhdG) and 3-nitrotyrosine (3NT). It appears that the acute inflammatory response of cosmetic liposuction does not lead to impaired renal function and oxidative and nitrosative damage, which are frequently associated with chronic inflammation.

Multiple risk markers for atherogenesis associated with chronic inflammation are detectable in patients with renal stones.

Patients with renal stones are known to be at risk of clinical complications such as cardiovascular disease (CVD), nephropathy, and cancer. Recently, it has been realized that almost all risk markers for CVD, nephropathy, etc. are all markers associated with the sequence of reactions of chronic inflammation. It has been reported that chronic inflammation is involved not only in the pathogenesis of nephrolithiasis but also contributes to the development of clinical complications in this condition; therefore, we decided to find out whether these multiple markers are detectable in patients with renal stones so that they can be used to predict the risk of clinical complications in these patients. There were 33 patients with nephrolithiasis included in this study. We found that almost all major markers of chronic inflammation were elevated in patients with renal stones, including proinflammatory cytokine, acute inflammation markers, adhesion molecules, urinary microalbumin (uMA), myeloperoxidase (MPO), 8-hydroxydeoxyguanosine (8-OHdG), 3-nitrotyrosine (3NT), and monocyte chemoattractant protein. It appears that it is possible to assess the risk of clinical complications by monitoring these markers in patients with renal stones.

Elevation of CA 19-9 and chromogranin A, in addition to CA 125, are detectable in benign tumors in leiomyomas and endometriosis.

As the best-known tumor marker for ovarian carcinoma, CA 125 has also been commonly used to monitor patients with common benign gynecologic diseases such as endometriosis and leiomyoma. Both of these benign tumors are known to be at risk of developing into cancer. During the screening of an asymptomatic population with multiple tumor markers, including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), prostate-specific antigen (PSA), CA 125, CA 19-9, CA 15-3, chromogranin A (CgA), and squamous cell carcinoma antigen (SCC), we have detected elevated tumor markers in 142 individuals; 19 of them were diagnosed with endometriosis or leiomyoma or both. In addition to the detection of elevation of CA 125 in these benign tumors, elevated CA 19-9 or CgA was also found in these patients with endometriosis or leiomyoma. Many patients only had elevated CA 19-9 or CgA; the elevation of CA 125 was not detected. It appears that instead of monitoring only CA 125, as is traditionally done, multiple tumor markers, including CA 19-9, CgA, and CA 125, should be measured simultaneously in women with clinical disorders associated with the ovary or uterus in order to detect gynecologic benign tumors and in order to prevent further development of cancer.

Establishment of an in-house ELISA and the reference range for serum amyloid A (SAA): complementarity between SAA and C-reactive protein as markers of inflammation.

INTRODUCTION: Serum amyloid A (SAA) and C-reactive protein (CRP) are both acute-phase reactants synthesized by the liver upon stimulation by proinflammatory cytokines reflecting both the acute and chronic inflammatory states. METHODS: We have established a one-step, sandwich ELISA on microplate for SAA using commercial antibodies for coating and detection. RESULTS: This in-house ELISA has a sensitivity of 0.12 mg/l. Both within-day and between-day CVs were <10%. The in-house assay correlated well with the commercial ELISA kit from Anogen (r=0.95). We also established the reference range for apparently healthy Chinese. Statistically higher SAA values were found in those >50 years old. No difference was found between genders. We found only slightly increased levels of SAA in early stage of type 2 diabetics, but highly increased levels of SAA were detected in patients with acute myocardial infarction, generally associated with intense inflammation. At the early stage of type 2 diabetes associated with low inflammation, SAA was found to be complementary to CRP in test sensitivity. CONCLUSIONS: Based on our data and reports from the literature we believe that SAA responds differently than CRP in inflammatory diseases such as in type 2 diabetes and acute myocardial infarction, and is complementary to CRP in test sensitivity.

Establishment of a sandwich ELISA using commercial antibody for plasma or serum 3-nitrotyrosine (3NT). Elevation in inflammatory diseases and complementary between 3NT and myeloperoxidase.

BACKGROUND: Amino acid tyrosine residue of a protein can be nitrated to form 3-nitrotyrosine (3NT), which is now being considered as a marker of inflammation, oxidative and nitrosative stress. METHOD: An in-house ELISA has been established using the same commercial antibody for both binding and detection of 3NT containing proteins. RESULTS: The sensitivity of the in-house ELISA was 1.8 nmol/l. The imprecision was <10% at all concentrations. The in-house assay correlates well with a commercial kit (r=0.89). In addition to EDTA plasma, we found that both heparinized plasma and serum can also be used to quantify 3NT concentration. Using the in-house ELISA we have detected increased concentrations of 3NT in diseases known to be associated with inflammation and also in subjects with polyps. As marker of oxidative stress and inflammation, both 3NT and myeloperoxidase are complementary to each other in test sensitivity. CONCLUSION: This ELISA can be used in the clinical laboratories to monitor the inflammatory disease activity and assess early risks that are associated with inflammation, oxidative and nitrosative stress.

Development of an ELISA for myeloperoxidase on microplate: normal reference values and effect of temperature on specimen preparation.

BACKGROUND: Myeloperoxidase (MPO), a leukocyte enzyme, is implicated in both the pathogenesis and the progression of atherosclerosis. METHODS: We developed a sandwich ELISA on microplate using commercial antibodies for the measurement of plasma MPO. RESULTS: The in-house ELISA has a sensitivity of 15 ng/ml. Both within-day and between-day imprecision were <10%. The in-house assay was well correlated with the commercial kit from Oxis (gamma=0.96). We have established normal reference range for MPO for apparently healthy Chinese. No statistical difference was found between males and females and the various age groups. Because the coating antibodies used by two different kits are different in their affinities for MPO, the analysis by the in-house ELISA that was approximately three times that of the Oxis kit when testing the same specimens. We found that it is necessary to keep the heparinized whole blood on ice before centrifugation in order to prevent further release of MPO from the leukocytes at room temperature. For the same reason, serum is not recommended for MPO measurement. We also found that either pooled human plasma or serum containing MPO can be used as calibrators. CONCLUSIONS: We believe that this ELISA for MPO is useful to assess risk for inflammation, oxidative stress, nitrosative stress, and for predicting cardiac events.

Detection of carcinomas in an asymptomatic Chinese population: advantage of screening with multiple tumor markers.

A total of 73,443 asymptomatic individuals were screened on a voluntary basis for cancer at Chang Gung Memorial Hospital in Taiwan using a panel of tumor markers, including alpha fetoprotein (AFP), CA 125, CA 15-3, CA 19-9, carcinoembryonic antigen (CEA), prostate specific antigen (PSA), chromogranin A (CgA), and squamous cell specific antigen (SCC). The results are derived from data collected from January 1998 to October 2003. A total of 210 cancers (approximately 0.3%) were detected, including cancers of the liver, lung, colon, prostate, stomach, pancreas, breast, cervix, ovary, and bladder. Of the tumor markers monitored, elevated CA 19-9, CEA, and CA 125 were the most frequently detected in a variety of cancers. It was surprising to find that many cancers were not detected by their dominant markers but by the elevation of tumor markers not recommended for monitoring their tumor activity. Screening with multiple circulating tumor markers provides improved sensitivity for cancer detection in asymptomatic individuals before they reach the fatal advanced stage. Screening with multiple tumor markers also allows cancers to be detected in the absence of their dominant markers. If we had not measured the multiple tumor markers, these cancers would have gone undetected.

Linking inflammation and atherogenesis: Soluble markers identified for the detection of risk factors and for early risk assessment.

Increasing evidence has shown that atherogenesis is not only caused by hypercholesterolemia. Several risk factors including abdominal obesity, dyslipidemia, hyperglycemia, bacterial and viral infection, hyperhomocysteinemia have been identified recently, all mediated through inflammation, which can lead to atherosclerosis. Several events have also been identified to be involved in the overall inflammation reaction in the blood vessel which include endothelium dysfunction, expression of adhesion molecules, recruitment of leukocytes to the injured endothelium, migration of monocytes to the arterial intima, and transformation of monocytes to macrophages. In order to facilitate the assessment of early risk for atherogenesis we have made an effort in this review to identify soluble markers that will allow the detection of these risk factors and the identification of associated inflammation events. Since early risks for atherogenesis are largely preventable with dietary modification and lifestyle changes, capable of detecting early risks by monitoring soluble risk markers is conceivably important for asymptomatic individuals to avoid serious or fatal consequences of atherosclerosis. These soluble markers should also be useful for monitoring the effectiveness of intervention and for the identification of therapeutic targets.

Association of soluble markers with various stages and major events of atherosclerosis.

The purpose of this review is to identify soluble markers from the recent literature that facilitate the early prevention and early detection of atherosclerosis, and that may serve as therapeutic targets. Soluble markers associated with various stages and major events of atherosclerosis were identified. We divided the process of atherosclerosis into several stages, including stages for the early risk, plaque expansion, and stable and unstable angina-though excluding the end stage of myocardial infarction. For major events taking place prior to and during the progression of atherosclerosis we included events such as endothelial dysfunction in the artery, expression of adhesion molecules at the injured endothelium, continued inflammatory responses, oxidative stress, and ischemia. We found that reactions such as cell injury, adhesion, inflammation, and oxidative stress occur not only at the early stage of risk but persist throughout the process of atherosclerosis. Most markers associated with these major events are clustered together at any time of the disease. Few markers are characteristic of individual stages. We noted that reactions such as inflammation are continuously intensified with the progression of the disease. Finally, we underscore the importance of measuring a panel consisting of minimal numbers of multiple markers with the maximal sensitivity for early risk assessment, diagnosis, and prognosis. We envision that patterns characteristic of various stages of atherosclerosis may be identifiable with the use of the multiple markers described in this review.

Microplate ELISAs for soluble VCAM-1 and ICAM-1.

Soluble vascular cell adhesion molecule (sVCAM-1) and soluble intercellular adhesion molecule (sICAM-1) are adhesion molecules that are detectable in the serum of patients with cancer, cardiovascular diseases (CVD), and type 2 diabetes. This report describes enzyme-linked immunosorbent assays (ELISAs) on microplates for sVCAM-1 and sICAM-1. The ELISAs have the sandwich test format; polyclonal antibodies are coated on microwells and a one-step procedure is used in which the serum specimen and detecting antibody are added simultaneously to an antibody-coated well. These assays both use HRP-conjugated sheep anti-mouse-IgG to generate the color for quantification. Sensitivities for detecting sVCAM-1 and sICAM-1 are 49 and 40 ng/ml, respectively. Coefficients of variation for within-day and day-to-day replicate analyses are <10%. Results by these in-house ELISAs for serum sVCAM-1 and sICAM-1 compared well with those obtained with commercial kits from R&D Systems, Inc. (correlation coefficients = 0.98 and 0.99 for sVCAM-1 and sICAM-1, respectively). Reference values for serum sVCAM-1 and sICAM-1 levels were measured in 369 apparently healthy Chinese adults, age 30 to 79 yr. There was no significant effect of gender on the reference values for sVCAM-1 or sICAM-1. Serum sVCAM-1 levels (mean +/- SD) were higher in subjects 60 yr old (625 +/- 126 ng/ml), compared to those <60 yr old (525 +/- 110 ng/ml) (p <0.001). Age did not significantly affect the reference values for serum sICAM-1 levels (mean +/- SD, 249 +/- 86 ng/ml). The authors believe that these simple, inexpensive ELISAs will be useful for assessing the risks for development of cancer, CVD, and type 2 diabetes.

Microplate ELISA for urine microalbumin: reference values and results in patients with type 2 diabetes and cardiovascular disease.

An ELISA for urine microalbumin using microtiter plates has been developed. The assay uses polyclonal anti-human albumin antibody for coating the microtiter plates and the same antibody conjugated with horseradish peroxidase for detection. The assay sensitivity is 1.6 microg/ml. Results by this in-house ELISA show good correlation (r = 0.99) with those obtained by a commercial assay using the Behring BNII autoanalyzer. Within-day and between-day CVs are 10%. Reference values for microalbumin in 769 urine specimens from healthy Chinese subjects were higher in women than men and higher in subjects 50 yr than in those <50 yr of age. Elevated mean concentrations of urine microalbumin were observed in patients with type 2 diabetes and CVD. This in-house ELISA is simple, sensitive, precise, and especially suited for laboratories without expensive autoanalyzers.

Enzymatic assay of homocysteine on microtiter plates or a TECAN analyzer using crude lysate containing recombinant methionine gamma-lyase.

An enzymatic assay for plasma homocysteine was developed that uses a crude lysate of E. coli containing the recombinant enzyme, methionine gamma-lyase. The assay uses a commercially available fluorophore and 96-well microtiter plates; it can be performed manually or with the TECAN automated analyzer. The CVs for within-run and between-run precision are < 10%. Close correlation (r > 0.9) was obtained between results by this enzymatic method vs a reference HPLC procedure. In a Chinese population, the concentration of plasma total homocysteine was found to be gender- and age-dependent. Mean concentrations of plasma total homocysteine increased with age and were higher in men than women. Serum homocysteine concentrations did not differ significantly from those in plasma, provided the whole blood specimens were kept at 4 degrees C for 2 hr, or at room temperature for < 45 min, between venepuncture and centrifugation.

Prognostic significance of DCC and p27Kip1 in colorectal cancer.

The progression of colorectal cancer is a multistage process associated with specific molecular alterations. The stepwise accumulation of these multiple genetic mutations progressively results in the acquisition of neoplastic cell behavior. The genetic abnormalities associated with the expression of metastatic phenotype, therefore, may be of prognostic significance in the clinical treatment of colorectal cancer patients. In this study, the immunohistochemical expression of the deleted in colorectal cancer gene (DCC) and p27Kip1 was assessed in 168 paraffin-embedded, formalin-fixed tumors of patients with stage II and III colorectal cancer. Kaplan-Meier survival curves and log-rank statistics were used to analyze survival times after curative primary tumor resection, and Cox proportional hazards models were used to adjust the assessment of demographic and clinical covariates. Loss of DCC or p27Kip1 expression had no influence on survival in patients with stage II or III colorectal cancer. The 5-year survival rates of DCC-positive and DCC-negative tumors were 51.8% and 35.7% (P=0.40), respectively. The 5-year survival rate of patients with p27Kip1-positive tumors was 47.9%, whereas the rate for patients with p27Kip1-negative tumors was 38.8% (P=0.68). After adjustment for all evaluated variables, neither DCC or p27Kip1 was found to be a predictor of survival (risk ratio for DCC, 0.98; 95% confidence interval, 0.66-1.56; P=0.92; risk ratio for p27Kip1, 0.87; 95% confidence interval, 0.58-1.29; P=0.49). The present study demonstrated that the expression of neither DCC nor p27Kip1 was predictive in poor survival outcome in patients with stage II or III colorectal cancer.

The NF-kappaB/IkappaB signaling system: a molecular target in breast cancer therapy.

The nuclear factor kappaB (NFkappaB) superfamily of eukaryotic transcription factors plays an important role in carcinogenesis. NF-kappaB and its regulators are linked to various signal transduction pathways as well as transcriptional activation events that mediate critical stages of cell proliferation. These intracellular signaling processes are thought to regulate chromatin structure to accommodate transcription, apoptosis, cell-cycle control, and cell transformation. In this capacity, uncontrolled or aberrant NF-kappaB activity may, in part, be responsible for breast cancer progression. Constitutive NF-kappaB expression may predict the metastatic potential of breast tumors, indicating early use of adjuvant therapy and suggesting NF-kappaB inhibition as a novel treatment. In this review, we discuss the regulatory mechanisms and physiological significance of NF-kappaB activation, and highlight recent advances in the development of NF-kappaB as an integral mediator of mammary carcinogenesis.

Ghrelin: integrative neuroendocrine peptide in health and disease.

OBJECTIVE: Ghrelin is a novel gastric hormone recognized in 1999 as a mediator of growth hormone release. Since growth hormone is anabolic, an important function of ghrelin may be to coordinate energy needs with the growth process. Newly discovered biologic roles of ghrelin imply that it may have other important physiological functions as well. This is a review of recent clinically relevant, yet less well-known, physiologic actions of ghrelin. SUMMARY BACKGROUND DATA: Ghrelin has profound orexigenic, adipogenic, and somatotrophic properties, increasing food intake and body weight. Secreted predominantly from the stomach, ghrelin is the natural ligand for the growth hormone secretagogue receptor in the pituitary gland, thus fulfilling criteria of a brain-gut peptide. The brain-gut axis is the effector of anabolism by regulating growth, feeding, and metabolism via vagal afferents mediating ghrelin signaling. However, the wide tissue distribution of ghrelin suggests that it may have other functions as well. METHODS: Systematic literature review of all PubMed citations between 1999 and August 2003 focusing on clinically relevant biochemical and physiological characteristics of ghrelin. RESULTS: Ghrelin is an important component of an integrated regulatory system of growth and metabolism acting via the vagus nerve, and is implicated in a variety of altered energy states such as obesity, eating disorders, neoplasia, and cachexia. It also enhances immune responses and potentially down-regulates anti-inflammatory molecules. Ghrelin's role as a brain-gut peptide emphasizes the significance of afferent vagal fibers as a major pathway to the brain, serving the purpose of maintaining physiologic homeostasis. CONCLUSIONS: The discovery of ghrelin has increased our understanding of feeding regulation, nutritional homeostasis, and metabolic processes. Further characterization of ghrelin's functions will likely generate new pharmacological approaches to diagnose and treat different disease entities including those related to the over-nutrition of obesity and the catabolic response to surgical trauma.