Abstract Introduction Mixed adenoneuroendocrine carcinoma (MANEC) is a rare neoplasm with dual adenocarcinomatous and neuroendocrine differentiation. Subgroup analysis demonstrates an increased frequency of both adenocarcinomas and neuroendocrine tumours in patients with Crohn’s disease (CD), though the incidence of MANEC is unknown. Method A 58-year-old male with a 31-year history of CD presented with small bowel obstruction. After failed conservative management, the patient underwent right hemicolectomy, with subsequent histology demonstrating MANEC. A literature search was performed to identify further cases of patients with concomitant MANEC and CD. Results 11 cases were identified. The mean duration of CD before presentation was 19.5 years, and 58% of cases involved the terminal ileum. 60% of cases demonstrated nodal spread and metastatic disease was evident in 25%. 42% of patients with MANEC were initially treated for an exacerbation of CD. Conclusions MANEC is a rare tumour of uncertain aetiology. The terminal ileum is commonly affected, with most cases exhibiting a longstanding CD history. Diagnosis is challenging, with symptoms of MANEC mirroring exacerbations of CD. Future research should strive to identify imaging modalities or biochemical markers which aid in distinguishing the two pathologies, preventing futile medical management of MANEC, and reducing the risk of metastatic spread due to delayed diagnosis.

Abstract Background Histone-deacetylase (HDAC) enzymes are a broad class of ubiquitously expressed enzymes that modulate histone acetylation, chromatin accessibility and gene expression. In models of Inflammatory bowel disease (IBD), HDAC inhibitors, such as Valproic acid (VPA) are proven anti-inflammatory agents and evidence suggests that they also inhibit fibrosis in non-intestinal organs. However, the role of HDAC enzymes in stricturing Crohn’s disease (CD) has not been characterised; this is key to understanding the molecular mechanism and developing novel therapies. Methods To evaluate HDAC expression in the intestine of SCD patients, we performed unbiased single-cell RNA sequencing (sc-RNA-seq) of over 10,000 cells isolated from full-thickness surgical resection specimens of non-SCD (NSCD; n=2) and SCD intestine (n=3). Approximately, 1000 fibroblasts were identified for further analysis, including a distinct cluster of myofibroblasts. Changes in gene expression were compared between myofibroblasts and other resident intestinal fibroblasts using the sc-RNA-seq analysis pipeline in Partek. Changes in HDAC expression and markers of HDAC activity (H3K27ac) were confirmed by immunohistochemistry in FFPE tissue from patient matched NSCD and SCD intestine (n=14 pairs). The function of HDACs in intestinal fibroblasts in the CCD-18co cell line and primary CD myofibroblast cultures (n=16 cultures) was assessed using VPA, a class I HDAC inhibitor. Cells were analysed using a variety of molecular techniques including ATAC-seq, gene expression arrays, qPCR, western blot and immunofluorescent protein analysis. Results Class I HDAC (HDAC1, p= 2.11E-11; HDAC2, p= 4.28E-11; HDAC3, p= 1.60E-07; and HDAC8, p= 2.67E-03) expression was increased in myofibroblasts compared to other intestinal fibroblasts subtypes. IHC also showed an increase in the percentage of stromal HDAC2 positive cells, coupled with a decrease in the percentage of H3K27ac positive cells, in the mucosa overlying SCD intestine relative to matched NSCD areas. In the CCD-18co cell line and primary myofibroblast cultures, VPA reduced chromatin accessibility at Collagen-I gene promoters and suppressed their transcription. VPA also inhibited TGFB-induced up-regulation of Collagen-I, in part by inhibiting TGFB1|1/SMAD4 signalling. TGFB1|1 was identified as a mesenchymal specific target of VPA and siRNA knockdown of TGFB1|1 was sufficient suppress TGFB-induced up-regulation of Collagen-I. Conclusion In SCD patients, class I HDAC expression is increased in myofibroblasts. Class I HDACs inhibitors impair TGFB-signalling and inhibit Collagen-I expression. Selective targeting of TGFB1|1 offers the opportunity to increase treatment specificity by selectively targeting meschenymal cells.

Background: MANEC is a rare entity and evidence on its prognosis and management is limited. Methods: Demographic/clinicopathological/survival data of consecutive patients (pts) with a diagnosis of MANEC (2010 WHO criteria) from 4 European centres were retrospectively reviewed. Results: Fifty-three pts were identified (01/06-03/17); median (med) age: 62 yrs (range 34-89), male: 70%, ECOG PS 0-1: 60%, with primary tumours from small/large bowel in 34 (64%), oesophagus/stomach: 13 (24.5%), pancreas/biliary tract: 5 (9.5%), unknown (UNK): 1 (2%). Forty percent had an adult comorbidity evaluation (ACE)-27 score of 0. The neuroendocrine (NE) component (predominant histology in 40%) was poorly-differentiated (PD) in 45 (85%) [Ki-67≥55%: 58%]. Most frequently-expressed immunohistochemical (IHC) markers were synaptophysin (100%), chromogranin A (CgA) (58.5%) and CDX2 (51%). Histology was PD NE in 64% from recurrent/metastatic sites (n = 14 pts). Of 28 (53%) pts with localised disease (LA), 26 (93%) had curative surgery (7 had neoadjuvant chemo-radiotherapy (CT-RT), 6 adjuvant CT, 1 peri-operative CT), 1 (3.5%) had definitive CT-RT and 1 (3.5%) had UNK management; 16 (57%) recurred. Forty-one pts (77%) were treated for advanced (adv) disease: 20 (49%) platinum-based CT, 3 (7%) irinotecan-based CT, 1 (2.4%) gemcitabine, 3 (7%) UNK CT regimen, 1 (2.4%) RT, 1 (2.4%) CT-RT, 11 (27%) best supportive care (BSC), and 1 (2.4%) UNK management. Med follow-up time was 10.4 months (mo) (95% Confidence Interval (CI) 5.15-13.09). Med overall survival (OS) for all pts was 18.6 mo (95% CI 11.4-40). Med recurrence-free survival and OS in pts with LA was 19.4 mo (95%CI 5.8-30.9) and 21 mo (95%CI 12.1-40). Med progression free survival (PFS) and OS in pts with adv disease was 4.6 mo (95%CI 3.3-6.7) and 13.6 mo (95%CI 8.8-33.1). On univariable analysis, ACE-27 score (0 vs ≥ 1) was prognostic for better PFS and OS (both p < 0.05); IHC negativity for CgA and active treatment (vs BSC) were prognostic for better PFS (both p < 0.05). Conclusions: PD NE histology in MANECs was predominant in both diagnostic and recurrent/metastatic tumour samples. Active treatments were offered to most pts but more effective therapy is clearly needed. Legal entity responsible for the study: The Christie NHS Foundation Trust Funding: The Christie Disclosure: All authors have declared no conflicts of interest.

Introduction The PlasmaJet system is a unique novel technology that utilises argon gas that is electrically excited into a plasma state. This argon plasma energy is highly focused in a beam that disperses rapidly with distance therefore causing minimal deep thermal tissue injury, unlike all other electrical devices such as diathermy, argon plasma coagulator or harmonic scalpel. Method The plasma stream that leaves the tip of the device releases kinetic, light and thermal energy that changes with distance and angulation to the tissue. These last two variables influence the dissection properties of the PlasmaJet. The closer the tip of device is to the tissue and the more acute the angulation, the greater is the kinetic and thermal energy stream, which produces to greater tissue separation and dissection. Results Plasmajet subjectively allows for easier and more efficient division of routine but also fibrotic “hostile” adhesions which would otherwise have been extremely difficult even with scalpel dissection. PlasmaJet appears to cause less bleeding compared to conventional dissection techniques, but needs formal evaluation. Plasmajet can be used across the spectrum of coloproctology (see Table 1). Inadvertent tissue injury can occur, and was noted in 1/97 major complex colorectal procedures. The complication was an enterotomy identified intra-operatively and repaired with no post-operative sequelae. No post-operative mortality was seen. A small number of collections (≥3 cm fluid diameter) were noted but were not significantly higher than unit data. Conclusion PlasmaJet represents a new surgical modality for efficient precise tissue dissection. It should be considered for any re-operative abdominal case where dense adhesions maybe encountered. It has minimal thermal penetration and is therefore very safe. It provides the surgeon with another valuable tool to aid difficult dissection of tenacious adhesions under very challenging conditions thereby improving patient outcomes. Disclosure of interest None Declared.

Owing to the complexity of distal rectal cancer its management requires a multidisciplinary approach. The diagnosis and the response after neoadjuvant chemoradiotherapy are not easy to assess and therefore the surgical approach is heterogeneous. The purpose of this survey is to evaluate the experiences of members of the Italian Society of Surgery in diagnosis and treatment strategies for rectal cancer and compare it with international practice. A questionnaire was devised comprising 18 questions with 11 sub-items making a total of 29 questions and submitted online to all the 2,500 members of the SIC starting from July 2010. The survey was completed in June 2011. The overall response rate was 17.8 % (444). The majority of the Italian surgeons’ responses were in line with the international consensus reflecting the complex management of distal rectal cancer. Other opinions, especially those on staging, diverge from the common view of MRI being the gold standard in the assessment of loco-regional diffusion of the disease and on the superiority of FDG PET-CT versus CT for systemic staging. The timing for the re-staging and for surgery following neoadjuvant chemoradiotherapy does not reflect the international opinion. Italian surgeons are also exposed to the common difficulties encountered internationally in the management of distal rectal cancer. Probably, the implementation of an Italian rectal cancer registry and of many national and international multicentre studies may improve the management of rectal cancer in Italy.

Background: The modifications of connective tissue surrounding metastatic lymph nodes in a murine model of rectal cancer are described.Methods: Athymic nude mice (n = 36) were inoculated with 10 x 10(5) ht-29 cancer cells into the submucosal layer of the rectum. Control mice (n = 5) were treated with a sterile buffer. Tumor and the involved lymph nodes were visualized in vivo by magnetic resonance imaging at 1 to 4 weeks after cell injection. After the sacrifice, the excised samples were processed for histology.Results: After one week from cell injection all treated animals developed rectal cancer. Since the first week, neoplastic cells were visible in the nodes. In the surrounding connective tissue, the diameter of the adipocytes was reduced and a mesenchymal-like pattern with stellate cells embedded in an oedematous environment was visible. Since the second week, in the perinodal connective an enlargement of the stroma was present. The tissue was organized in cords and areas with extracellular accumulation of lipids were found. At the fourth week, we observed an enlargement of multilocular areas and lobules of elongated elements almost devoid of lipid droplets. In control animals, in absence of neoplastic masses, pelvic nodes were surrounded by a typical connective tissue characterized by unilocular adipocytes with groups of multilocular adipocytes.Conclusions: We have developed a model of rectal cancer with nodal metastases. Using this model, the work demonstrates that around secondary lesions, the morphogenetic events follow a standard evolution characterized by an early phase with lipolysis and mesenchymalization and later phases with a brown-like phenotype acquisition. (C) 2012 Published by Elsevier Masson SAS.

The coexistence of colorectal cancer and abdominal aortic aneurysm has been observed with increasing frequency, raising several questions about therapeutic and surgical strategies for management of both diseases. This study has reviewed 440 cases (359 cases analyzed) of colorectal cancer associated with abdominal aortic aneurysm recovered in the literature from year 1987 to 2010. In 120 cases, patients were treated in one stage; in 239 cases, they were treated in two stages. The treatment in two stages was associated with a morbidity of 26.4%, with a mortality of 5% and prosthetic infection of 0.8%. The treatment in one stage had rates of complications and mortality of 13.3% and 4.2% respectively and no cases of prosthetic infection. Analysis of the literature shows that the treatment in two stages exposes patients to a higher risk of complications and prosthetic infection.

This short review aims at summarizing the available data pertaining to the usefulness of F-18 FDG PET/CT in rectal cancer. It is specifically focused on the emerging role of F-18 FDG PET/CT in assessing the response to neoadjuvant combined radiochemotherapy in locally advanced rectal cancer. It also probes the possibility of finding standardized PET/CT parameters that are capable of differentiating responders from nonresponders in whom therapeutic approach could be modified.

Background: The prognostic value of T subclassification in patients with gastric carcinoma has been just implemented in the new MCC TNM staging system, which has reclassified T2a and T2b into T2 and T3 tumors, respectively. The aim of the present study was to validate the prognostic significance of the new T categorization within the frame of the latest TNM staging system.Methods: We retrospectively reviewed the records of 686 T2/T3 patients among 2155 subjects who underwent radical resection for gastric carcinoma at six Italian centers from 1988 through 2006.Results: Upon multivariate analysis, the new T categories, extent of lymph node dissection (D) and patient's age were retained by the survival model as independent prognostic factors. In particular, the death risk for patients with T3 tumors was higher than that of patients with T2 tumors (HR: 1.42, P = 0.005).Among the 686 patients previously classified as having T2 tumors, patients with T2 and T3 disease were 270 (39.4%) and 416(60.6%), respectively. After a median follow-up of 55 months, the 5-year overall survival rates were 67.3% and 52.3% for patients with T2 and T3 tumors, respectively (P < 0.001). The survival advantage for the T2 as compared to T3 category was maintained even when NO and N+ patients were separately considered (P = 0.0154 and P < 0.001, respectively).Conclusions: Our data confirm the prognostic difference between the newly proposed T2 and T3 categories, which should be implemented in the routine clinical practice to improve risk stratification of patients with gastric cancer. (C) 2011 Elsevier Ltd. All rights reserved.

Purpose: The aim of this work is to characterize the shape and the volume of the internal anal sphincter (IAS) in normal subjects by three-dimensional anorectal ultrasonography. Methods: Thirty-nine normal volunteer males (mean age 58.5 +/- 18.7) and 25 females (mean age 59.4 +/- 14.1) were submitted to anorectal ultrasonography.The tissue is defined by a semiautomatic procedure. Measurements of thickness, length and volume were assessed automatically.The software provides an average number of 57,600 thickness measurements, 360 length measurements for each zone (90 for each quadrant) and seven volume measurements (one for each anatomical area). The mean values of magnitudes were calculated for the entire volume in each quadrant and zone. Age and gender-related variations were analyzed.Results: In assessments of the whole tissue, only thickness was gender-related, with greater thickness for females (male thickness: 1.81 +/- 0.47 mm, female thickness 2.16 +/- 0.57 mm, P-value < 0.01). In the distal zone: thickness, length and volume were all larger in females (for male and female respectively: 1.83 +/- 0.49 mm vs 2.34 +/- 0.58 mm, P-value < 0.01, for the thickness; 10.87 +/- 2.10 mm vs 12.18 +/- 2.21 mm, P-value < 0.02 for the length and 1501 +/- 605 mm(3) vs 2169 +/- 871 mm3, P-value < 0.01 for the volume). In the medial zone, only thickness was gender-related, with greater thickness in females (male thickness: 2.04 +/- 0.60 mm, female thickness: 2.44 +/- 0.74 mm, P-value < 0.02). The only variation observed in the proximal zone concerned length, larger in males (respectively: 11.27 +/- 2.84 mm vs 9.55 +/- 2.43 mm, P-value < 0.02).The male population was significantly positively correlated with ageing for volume in the whole tissue (rho = 0.32, P-value < 0.05), and for both thickness and volume in the medial zone (rho = 0.33, P-value < 0.05 for thickness; rho = 0.39, P-value < 0.02 for the volume). Conclusion: This new method is useful to understand both functional anal disorders and local damage which may affect only part of the muscle tissue. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

A diffuse positivity (≥50%) of C4d in kidney graft peritubular capillaries (PTC) significantly correlates with the presence of acute or chronic antibody-mediated rejection. In contrast, significance of a “focal” deposit (10%–50%) is not yet completely defined. The purpose of this study was to assess the impact of focal positive C4d staining on graft survival. We retrospectively reviewed 63 renal biopsies in 54 kidney transplant recipients. They were performed between January 2005 and December 2008 because of graft impairement, namely, a significant increase in serum creatinine and/or urinary protein. C4d positivity was assessed by immunohistochemistry on paraffin-embedded sections, in combination with conventional histopathologic evaluation. Biopsies were classified as negative (<10%) versus with focal (10%–50%) or diffuse deposits (>50%). Cumulative survival was calculated by the Kaplan-Meier method, and Cox regression analysis was used for the multivariate analysis. Focal C4d staining in PTC significantly correlated with worse graft survival (P = .006), similarly to diffuse C4d staining. On multivariate analysis, focal C4d staining prognostically correlated with graft survival, but not recipient or donor age, prior transplantation, number of HLA mismatches or the presence of tubulitis in the sample. Focal C4d staining was associated with worse graft survival.

BACKGROUND:Tumour regression grade (TRG) is used to evaluate responses to induction therapy in cancer of the oesophagus or cardia. This study aimed to determine whether inclusion of node category could improve the prognostic accuracy provided by TRG, and explore the prognostic value of an alternative classification based on size of residual foci and node category.METHODS:Patients with oesophageal or cardia cancer treated with neoadjuvant chemoradiotherapy followed by resection were studied. Treatment-induced response at the primary site was evaluated by TRG and by a method whereby patients were classified as having no residual cancer, minimal residual disease (MRD) or as non-responders.RESULTS:Between 2000 and 2007, 108 patients underwent resection. Disease-related survival decreased with increasing TRG in node-negative (N0) patients (P < 0.001), whereas in node-positive (N+) patients it was poor irrespective of TRG (P = 0.241). For N0 disease, 3-year survival in patients with MRD (58 (95 per cent confidence interval 26 to 80) per cent) was intermediate between that in patients with no residual cancer (85 (70 to 93) per cent) and non-responders (28 (4 to 59) per cent). Worst prognosis was for N+ disease (21 (9 to 36) per cent).CONCLUSION:Node category should be considered when evaluating response to induction therapy in oesophageal or cardia cancer. A new classification based on size of residual foci and node category seems promising.

Der extramammäre Morbus Paget (EMPD) ist häufig mit Adnextumoren oder viszeralen synchronen oder metachronen malignen Tumoren assoziiert. Ziele dieser Arbeit waren die retrospektive Untersuchung der aus 6 EMPD-Fällen vorliegenden Ergebnisse sowie die Auswertung der Literatur.

PURPOSE:The detection and classification of hepatic vessels in diagnostic images are essential for hepatic pre-surgery planning. Our team has developed a tool for classification, analysis, and 3D reconstruction of the hepatic and portal systems.METHODS:Our software first extracts a graphic representation of a set of connected voxels, representing both systems. It then calculates two binary volumes representing the main part of the two venous systems. Finally, it combines these results to obtain the correct vessel classification.RESULTS:Segmentation steps are semi-automatic and require about 40 min to complete. Schematization and classification steps are automatic and require about 17 min for results.CONCLUSION:The software provides a correct and detailed reconstruction even where pathologies have caused morphological and geometrical variations in the vessels. The time required for the entire procedure is compatible with clinical requirements, providing an efficient tool for diagnosis and surgical planning.

PURPOSE:The aim of this paper is to provide a method for measuring the internal anal sphincter on the basis of the quantitative analysis of three-dimensional endosonographic images. A software calculates a large set of measurements which are able to describe the three-dimensional shape of the muscle.METHODS:A software provides four types of measurements: thickness, length, area and volume. The different magnitudes are estimated using the same reference system. The measurements obtained are modeled by functions that describe their spatial trend. The precision and reproducibility of the method was tested on a phantom before a study was performed on fifteen healthy patients. The measurements were carried out by two different operators. The inter-observer variability were assessed.RESULTS:In the phantom measurements the mean errors and the standard deviation were: 0.05 +/- 0.1 mm for the thickness, 0.02 +/- 0.12 mm for the length, -4.43 +/- 2.4 mm(2) for the area, -20.69 +/- 20.83 mm(3) for the volume. The maximum absolute differences between the measurements carried out by the two operators was: 0.18 mm for the thickness (in the 95% of the case), 1.69 mm(2) for the area (in the 95% of the case), and 0.25 mm for the length, and 29.46 mm(3) for the volume. The human IAS assessments were evaluated on each segment. The mean of the all tissue measurements carried out were (mean +/- SD): 1.71 +/- 0.34 mm for the thickness, 33.24 +/- 6.10 mm for the length, 111.28 +/- 29.08 mm(2) for the area. The mean of the volume measurements of the entire tissue was: 4124 +/- 1160 mm(3). Inter-observer variability was observed only in the anterior proximal segment for the thickness measurements by Wilcoxon's signed rank test (P value = 0.048) and for the volume assessments by the limits of agreement method (-118 to 78 mm(3)). The mean percentage errors and the limit of agreement for the measurements of the entire tissue were: 0.27 and (-0.11 to 0.12 mm) for the thickness, -2.32 and (-3.88 to 2.33 mm) for the length, -0.05 and (-9.71 to 9.83 mm(2)) for the area, -1.89 and (-366 to 240 mm(3)) for the volume.CONCLUSION:The assessments of accuracy and precision of the method result satisfactory for all four type of measurements. The reproducibility analysis confirms very good inter-observer agreement for the phantom measurements and for the most part of the IAS segments evaluations. Inter-observer variability was seen only for the thickness and volume measurements of the anterior-proximal segment. Our method provides a high number of measurements with good accuracy enabling a very detailed study of IAS morphology.

AIM:Extramammary Paget's disease is a rare neoplastic condition, often associated with a synchronous or metachronous underlying skin or visceral malignancies. The aim of this study was to evaluate retrospectively the results we got in 5 cases of perianal Paget's disease and to revise what literature have reported about this issue.PATIENTS AND METHODS:Five patients with perianal EMPD were consecutively treated in our Division between March 1996 and December 2006. In 3 cases the disease was limited to the epidermidis, in one case with multiple recurrences there was dermal infiltration, and one patient had a low rectal adenocarcinoma with pagetoid phenomenon. The surgical treatment we performed in all patients was a wide perianal excision, followed by reconstruction with cutaneous grafts; the resection of rectal adenocarcinoma was carried out using the transanal approach. In two cases we performed a temporary stoma with the sigmoid colon to help the wound healing.RESULTS:We didn't record any complication neither postoperative nor at long time. Two patients developed a local recurrence, but none of our patients showed distant metastases. Four patients are alive and free from disease and one, who developed a multiple local recurrences, died for heart failure.DISCUSSION:The studies available in literature clearly distinguish between a primary EMPD (intraepidermal/intradermal) and secondary disease which is associated with anorectal adenocarcinomas and is thought to be a pagetoid phenomenon, while few informations can derive from those cases in which the disease is associated with an underlying cutaneous adnexal carcinoma. Disease tend to relapse even after a radical surgery and can have metastatic spread, also in intraepidermal form.CONCLUSIONS:Perianal EMPD is a complex disease, difficult to recognize and the association with synchronous or metachronous malignancies imposes long term clinical and instrumental follow up.