Local excision for rectal carcinoma.

Local excision is an alternative approach to radical proctectomy for rectal cancer, but from an oncologic standpoint, it is a compromise, and its role remains controversial. Careful patient selection is essential because local excision is generally considered only for early rectal cancer with no evidence of nodal metastasis, parameters that can be predicted by clinical examination, and various radiologic modalities with variable accuracy. In this review, we present the literature evaluating the oncologic adequacy of local excision, including transanal endoscopic microsurgery and the results of salvage surgery after local excision. An overview of local excision in the context of perioperative adjuvant therapies is included. Finally, we suggest a treatment algorithm for local excision in rectal cancer.

Surgery for inflammatory bowel disease.

Despite the new and ever expanding array of medications for the treatment of inflammatory bowel disease (IBD), there are still clear indications for operative management of IBD and its complications. We present an overview of indications, procedures, considerations, and controversies in the surgical therapy of IBD.

Modulating leukocyte recruitment in inflammation.

Much information has been obtained regarding how white cells are recruited in the microcirculation to sites of inflammation. In this review we summarize the leukocyte recruitment cascade, highlighting the molecular mechanisms that underlie each of the major steps. Major emphasis is placed on the selectins and integrins and their role in rolling and adhesion. Intraluminal crawling and emigration are also briefly discussed. In addition, we summarize some of the data that implicate these molecules in eosinophil recruitment in animal models of asthma and in lymphocyte recruitment in skin contact sensitivity. There is a growing body of evidence to suggest that leukocyte recruitment could be used as an effective means for future therapeutics, and some of these issues are also raised.

A down-regulatable E-selectin ligand is functionally important for PSGL-1-independent leukocyte-endothelial cell interactions.

P-selectin glycoprotein-1 (PSGL-1) supports P-selectin-dependent rolling in vivo and in vitro. However, controversy exists regarding the importance of PSGL-1-dependent and -independent E-selectin rolling. Using antibodies against PSGL-1 and PSGL-1(-/-) mice, we demonstrated abolition of P-selectin-dependent rolling but only partial inhibition of E-selectin-mediated rolling in the cremaster microcirculation following local administration of tumor necrosis factor alpha (TNF-alpha). In vitro studies demonstrated that binding of recombinant mouse E-selectin chimera to PSGL-1(-/-) neutrophils was dramatically decreased in mice treated systemically but not locally with TNF-alpha. Further, PSGL-1 blockade abolished E-selectin-dependent rolling in wild-type mice following systemic TNF-alpha administration but not local TNF-alpha administration. Together, these data support an E-selectin ligand present on PSGL-1(-/-) neutrophils that is down-regulatable upon systemic but not local activation. To determine whether the PSGL-1-independent E-selectin ligand was physiologically important, we used a P- and E-selectin-dependent cutaneous contact hypersensitivity model. Binding studies showed no E-selectin ligand down-regulation in this model. The few cells that rolled on E-selectin ligand following PSGL-1 antibody administration or in PSGL-1 deficiency were sufficient to induce profound contact hypersensitivity. In conclusion, E-selectin mediates PSGL-1-dependent and independent rolling and the latter can be down-regulated by systemic activation and can replace PSGL-1 to support the development of inflammation.

A critical temporal window for selectin-dependent CD4+ lymphocyte homing and initiation of late-phase inflammation in contact sensitivity.

Contact sensitivity (CS) is an inflammatory disorder characterized by early and late phases of leukocyte recruitment. We used a noninvasive intravital microscopy technique allowing for the direct visualization of leukocyte rolling and adhesion on blood vessel endothelium. By blocking specific adhesion molecules, we elucidated the molecular mechanisms mediating early leukocyte recruitment to be E- and P-selectin and demonstrated that leukocyte recruitment in the late phase had a different adhesive profile (mainly alpha(4)-integrin). Complete blockade of E- and P-selectin within the first 2 h of leukocyte-endothelial cell interactions (but not later) eliminated selectin-independent leukocyte recruitment at 24 h. Despite the predominance of neutrophils in the early phase, specific elimination of CD4(+) lymphocytes in the early phase eliminated the late response. CD4(+) lymphocytes homed to skin via E- and P-selectin within the early phase and induced the late phase response. Addition of these same CD4(+) lymphocytes 2 h after antigen challenge was too late for these cells to home to the skin and induce late phase responses. Our data clearly demonstrate that the antigen-challenged microenvironment is only accessible to CD4(+) lymphocytes for the first 2 h, and that this process is essential for the subsequent recruitment of other leukocyte populations in late phase responses.