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Regression of gastric malt-lymphoma after eradication of Helicobacter pylori. A three years follow-up report
A574 AGA ABSTRACTS
• G2347 ESTROGENS MODULATE GASTRODUODENAL HYPERPLASIA AND DYSPLASIA INDUCED BY N-METHYL-N'-NITRO-N-NITROSOGUANIDINE IN RATS. Martha Campbell-Thompson, K.K. Reyher, G.Y. Lauwers, K.T. Shiverick. College of Medicine, University of Florida, Gainesville, FL. Introduction. Gastric cancers are a significant cause of cancer-related deaths worldwide. Diet has been the most studied risk factor for gastric cancer with particular interest in N-nitroso compounds from broiled or smoked foods. Epidemiological studies and experimental animal models show that males have at least a two-fold higher incidence of gastric cancer. This study investigated the modifying effects of 1713-estradiol in rats during the initiation phase of gastroduodenal carcinogenesis induced by N-methyl-N'-nitro-Nnitrosoguanidine (MNNG). Methods. Male SD rats (N=33) were fed a soy protein free diet and implanted subcutaneously with Silastic tubes containing either 17~-estradiol or oil vehicle. One week later, rats were divided into groups treated with or without MNNG in the drinking water for 4 weeks. Histopathological features, cell kinetics (bromodeoxyuridine incorporation), and neuroendocrine hormone production of the gastroduodenal mucosa were determined. Results. Hyperplasia and dysplasia were observed in the antrum and duodenum in rats treated with MNNG. 1713-estradiol reduced foveolar hyperplasia and dysplasia of the antral glandular mucosa and blunting of duodenal villi. 17B-estradiol decreased the numbers of cells in S phase of the cell cycle and increased expression of mucin and gastrin. Serum testosterone levels and testicular weights (expressed as % body weight) were not significantly lowered by the estradiol implants in MNNG treated males. MNNG decreased body weight gain without altering food intake except in estradiol-treated animals which had both decreased weight gain and food consumption. Conclusions. These studies show that short-term continuous exposure to MNNG results in significant alterations in gastroduodenal cell proliferation and terminal differentiation. These cellular alterations include mucous and neuroendocrine cells which have critical roles in production of the mucosal barrier and in regulating mucosal growth and function. The present results indicate that 1713-estradiol exerts protective effects by influencing mucosal cell proliferation and differentiation when given during the initiation phase of gastroduodenal carcinogenesis in rats. Therefore, estrogens may decrease the susceptibility of gastrointestinal cells to ingested carcinogens by enhancing mucosal protection. • G2348 TARGETED RADIOPEPTIDE THERAPY: HIGH DOSE INDIUM-Ill OCTREOTIDE FOR NEUROENDOCRINE TUMOURS. M.E. Caplin, A.K. Burroughs, W. Miolcarek, A.J.W. Hilson, A.L. Jones, E.J. Wood and J.R. Buscombe. Neuroendocrine Tumour Clinic, Royal Free Hospital, London NW3, UK. Background: Indium-111 (In-111) labeled octreotide scintigraphy is now a well established highly sensitive and specific tool in diagnosing neuroendocrine tumours. Taking advantage of the avid binding of neuroendocrine tumours for octreotide (a synthetic analogue of somatostatin) a therapeutic role has been suggested for high does In-111 octreotide. Aim: The aim of this study was to determine the toxicity of high dose In-I 11 octreotide therapy. Methods: A prospective study was performed on 7 patients with advanced metastatic neuroendocrine tumours including 5 carcinoid tumours, 1 medullary carcinoma of thyroid and 1 gastrinoma. All these patients had been unresponsive to other therapeutic modalities. A total of nineteen therapies with high does I n - I l l octreotide were administered to these patients. All patients had a full medical examination prior to therapy and measurement of vital signs during therapy, Haematological and biochemical profiles were performed pre-treatment and post-treatment and subsequently one monthly post-treatment. Results: All patients tolerated the treatment well during the 30-60 minute infusion of In-111 octreotide. There was no evidence for early or late hepatic, endocrine or renal toxicity. In one patient there was a partially recoverable reduction in platelets after each treatment; another patient had a persistently low lymphocyte count. One patient died of unrelated causes after the first treatment, the remainder continue to receive regular therapy. Conclusion: There is no serious toxicity associated with high dose I n - I l l octreotide therapy even after repeated administrations. The therapeutic effect of this therapy is now being formally assessed. • G2349 LACK OF MUTATIONS OF THE PTEN TUMOR SUPPRESSOR GENRE IN THREE BANNAYAN-RILEY-RUVALCABA SYNDROME PATIENTS. JM Carethers, FB Funari, AF Zigman, JE Lavine, MC Jones, GE Graham, AS Teebi, H-J S Huang, DP Chauhan, CL Chang, WK Cavenee, and CR Boland. University of California, VAMC, Children's Hospital, and Ludwig Institute, San Diego, CA; McGill University and Children's Hospital, Montreal, Quebec, Canada. Bannayan-Riley-Ruvalcaba (BRR) syndrome is a congenital syndrome with features of macrocephaly, developmental delay, subcutaneous and visceral lipomas and hemangiomas, and intestinal juvenile polyposis. Recently,
GASTROENTEROLOGY Vol. 114, No. 4 germline mutations in the PTEN gene on chromosome 10q23 were found in two out of three families with BRR syndrome. Germline mutations in PTEN have also been identified in Cowden disease, suggesting that BRR syndrome is allelic with Cowden disease. However, juvenile polyposis coli (JPC), a hamartomatous polyposis syndrome of which BRR may be a variant, has only wild-type PTEN. We sought to identify PTEN mutations in three patients diagnosed with BRR by a pediatric geneticist. Methods: Genomic DNA was extracted from peripheral blood leukocytes and amplified using primers specific for the genomic PTEN sequence. PCR products were subjected to DNA sequencing. In addition, RNA was obtained from immortalized lymphocytes, reversed transcribed into eDNA using primers specific for the PTEN sequence, and subjected to an in vitro transcription/translation (IV'IT) assay. The PTEN cDNAs were also sequenced for the presence or absence of mutations. Results: IV'IT revealed no truncation of PTEN protein in all three BRR patients. Sequencing of each eDNA showed no mutations, including missense mutations that might have been missed on IVTT analysis. Sequencing of genomic DNA revealed only the wild-type sequence in all three BRR patients. Conclusions: BRR is not always associated with germline mutations in the PTEN tumor suppressor gene. We speculate that BRR may have a heteregenous allelic etiology, one of which may be shared with JPC because both BRR and JPC share the phenotypic feature of intestinal juvenile polyposis. G2350 PRESENCE OF MICROSATELLITE INSTABILITY (MIN) IN THE NORMAL-APPEARING EPITHELIUM OF FAMILIAL JUVENILE POLYPS. JM Carethers, BM Lopez, AF Zigman, W-S Jo, JE Lavine, MC Jones, DP Chanhan, CL Chang, HD Appleman, and CR Boland. University of California, VAMC, and Children's Hospital, San Diego, CA and University of Michigan, Ann Arbor, Michigan. Juvenile polyposis coli (JPC) is an autosomal dominant familial disorder characterized by multiple juvenile polyps throughout the colon. Patients with JPC have a two to fourfold risk for adenocareinoma of the colon compared to the general population. A lamina propria cell with chromosome 10q23 deletions has been suggested as the neoplastic progenitor within juvenile polyps. Prior reports of familial juvenile polyps suggest that the polyp progresses through an adenomatous intermediate prior to development of carcinoma, which indicates that the final pathway to cancer in juvenile polyps must take place at the epithelial level. The mechanism for the evolution of neoplastic epithelium within the juvenile polyp, and increased risk for malignancy in JPC, is unknown. Methods: Sixty paraffin-embedded, formalin fixed juvenile polyps from seven patients with familial juvenile polyposis were microdissected into 131 domains that included surface epithelium, cyst epithelium, and lamina propria. Isolated DNA was amplified by PCR using radiolabeled primers specific for six dinucleotide microsatellite loci, electrophoresed on a polyacrylamide gel, and exposed to x-ray film. Results: Microsatellite instability, as defined by an insertion or deletion mutation in >40 % of the microsatellite markers, was present in 8 domains from five juvenile polyposis patients. Seven of the eight domains that demonstrated MIN were from cystic or surface epithelium, whereas one domain showed MIN within the lamina propria. Conclusions: Inactivation of DNA mismatch repair (MMR), as determined by the presence of MIN, appears to be a potential mechanism for neoplastic change within the normal-appearing epithelium of a familial juvenile polyp, Our results also suggest that some histologically "normal" epithelium of familial juvenile polyps may harbor genetic alterations at other DNA sequences sensitive to defective DNA MMR. G2351 REGRESSION OF GASTRIC MALT-LYMPHOMA A~'q'ER ERADICATION OF HELICOBACTER PYLORI. A THREE YEARS FOLLOWUP REPORT. A. Caroli, R. Follador, F. Nicoli, G. Vicario, A. Borsato, R. D'Este, A. Caminiti, P. Manante, A. Puglisi. Dpts of Gastroenterology, Surgery, Oncology and Pathology, Montebelluna Hospital, Italy. Various studies have suggested that eradication of Helicobacter pylori (H.p.) from patients with gastric low-grade-MALT-Lymphoma has resulted in tumor regression in the majority of the cases, but adequate follow-up is needed to show whether the remission is long lasting and that the patients can be considered cured. The aim of this report was to describe the outcome of a long-term follow-up after a successful H.p. eradication in patients with MALT-lymphoma. Patients and methods Fourteen consecutive patients (8 males and 6 females; mean age 60.2 years, range 46-80) affected by H.p. positive low-grade MALT-lymphoma of the stomach (diagnosis based on grade 5 of the histological scoring proposed by Wotherspoon), in clinical stage IE, that underwent successful H.p. eradication, were prospectively followed. Endoscopies with multiple gastric biopsy were repeated every three months until gastric lymphoma regression, and then every six months. Patients who did not respond after H.p, eradication and two consecutive positive endoscopies, were treated by surgery or chemotherapy. Results After H.p. eradication a complete regression of the lymphoma was obtained in 11/14 patients (78.5%). Of the three non responding patients, two underwent sugicai treatment and one was found to have a high-grade
Gastrointestinal Oricolog~j A575
April 1998 lymphoma; the last patient, with endoscopic picture of "gastritis", refused any treatment and did not show any changes of the endoscopic and histologic finding 26 months after diagnosis. Among the eleven patients with complete regression of the lymphoma, during a median follow-up period of 36 months, ten (91%) maintained remission of the desease. One patient relapsed with H.p. reinfection twelve months after the first successful treatment, and was reeradicated with further regression of the tumor. Conclusions Our data confirm previous reports suggesting that H.p. eradication can produce histological regression of low-grade MALTlymphoma of the stomach in a high percentage of cases. Furthermore, regression appear stable in most patients for at least 3 years. H.p. reinfection can produce relapse of the lymphoma, further enphasizing the need for complete eradication of the microrganism and prompt retreatment in case of reinfection. • G2352 PHARMACOLOGICAL MODULATION OF THE INFLAMMATORY RESPONSE INDUCED BY ABDOMINAL IRRADIATON. M CasadevaU, J Pan6s, A Salas, M Mollh, JL Osotio, C Conill, DN Granger,JM. Piqu6. Departments of Gastroenterology and Radiation Oncology, Hospital Clfnic, University of Barcelona, Spain; and Dept of Physiology, LSUMC, Shreveport,LA. In a previous study we showed that abdominal irradiation induced upregulation of endothelial ICAM-1 expression, which was followed in time by an increase in leukocyte recruitment and in microvascular permeability. Radiation-induced generation of oxygen free radicals by activated leukocytes in the mesentery was also observed. The aim of the present study was to assess the effect of two drugs, N-aeetylcysteine (NAC), a free radical scavenger, and tepoxalin (TEP), a dual cyclooxygenase/lipoxygenase inhibitor, on the inflammatory response and endothelial ICAM-1 expression induced by abdominal irradiation. Methods: 10 Gy abdominal irradiation were given to 3 groups of rats (n=5) pretreated with either vehicle (RAD), NAC (2g/kg, ip) or TEP (400mg/kg, po); a control group(n=6) sham irradiated was studied. Six hours after irradiation, leukocyte adhesion (cells/100~m) and emigration (cells/field), as well as vascular permeability (FITC-albumin leakage), were measured by intravital microscopy. Endothelial expresion of ICAM-1 was quantified in vivo by means of the double radiolabeled antibody technique. Results: Group
I
Adhesion Emigration, Vascular ICAM-1 ICAM-1 I permeability mesentery Small intest Cntrl 4 + 0.7 2 ± 0.8 0.1 ± 0.03 0.09 ± 0.05 0.08 ± 0.07 RAD 19±3" 6±0.9* 0.9±0.04* 0.14 ± 0.09:~ 0.13 ± 0.05:~ NAC 13±3" 3±1.3 0,4±0.05*# 0.14± 0.09:~ 0.17± 0.16~:# TEP 5 ± 0.7 1 ± 0. l 0.2 ± 0.07 0.12 ± 0.09:~ O.16 ± 0.06:~# (*) p < 0.05 vs control and TEP, (#) p < 0.05 vs RAD, :~p < 0.05 vs control. i
Conclusions: The inhibitor of leukotriene synthesis tepoxalin is effective in blunting the inflammatory response and microvascular dysfunction resulting from abdominal irradiation, whereas NAC has only a weak effect in preserving vascular barrier function. These effects do not result from inhibition of ICAM-1 upregulation.
• G2353 MULTIMODAL THERAPEUTIC APPROACH FOR RECURRENT COLORECTAL CANCER: ANALYSIS OF SURVIVAL. A. Cassano, C. Pozzo, D.C. Corsi, M. Mancini, P. Tarantini, C. Signorelli, C. Barone. Istituto di Medicina Intema e Geriatria, Universit~Cattolica del Sacra Cuore, Roma, Italy. Resection of colorectal metastases represents an actual treatment option which can improve survival in about 25% patients (pts) at 5 years. Few data are available about the results of curative resection in pts whose metastases are downstaged by chemotherapy and then submitted to adjuvant chemotherapy. In order to evaluate the role of this multimodal approach we reported the results of our study conducted on pts who developed recurrence following surgery for colorectal cancer. Of 534 pts treated for colorectal cancer in our department during the years 1985-1997, 54 had an operable recurrence, 35 as liver metastases, 15 lung and 4 pelvic. All pts were submitted to three cycles of chemotherapy with 5-fluorouracil and folinic acid; they were operated on and retreated with chemotherapy for six cures. Thirty eight patients had follow-up >12, 28 pts > 24months, 14 pts > 36 months, 10 pts > 48 months and 6 pts > 60 months. Overall DFS was 19 months (range 2-132+). Mean DFS of pts who had further recurrence was 15.3 months. DFS after hepatic resection is 19 months whereas after lung resection is 23.6 months. Nine pts died of recurrence, with a mean DFS of 12.1 months (range 4-19) and mean total survival of 44.7 months (range 13-144). Average survival time from the resection of recurrence was 32.1. Average follow-up of surviving pts was 29 months (range 4+-132+). Twenty-six pts are alive with no evidence of disease: 16 pts at 12 months, 13 at 24 months, 8 at 36 months, 5 at 48 months, 6 at 60 months or longer. These findings indicate that a multimodality treatment can result in a better outcome for colorectal cancer pts who develop resectable distant metastases. Although with the small number of lung recurrences, resection of pulmonary lesion resulted in a good outcome.
G2354
ABSENCE OF MICROSATELLITE INSTABILITY AT TARGET SEQUENCES WITHIN THE TGFI3 TYPE H AND IGF II RECEPTOR GENE IN THYROID CARCINOMA ASSOCIATED WITH FAMILIAL ADENOMATOUS POLYPOSIS. Cetta F., Montalto G., Zuckermann M., *Toil P., *Lor~ F., °Cama A., °Battista P., °Mariani Costantini R. Institute of Surgical Clinics, *Pathology and **Endocrinology, University of Siena; °Department of Pathology, University of Chieti; Italy. Two FAP kindreds had 4 patients with thyroid carcinoma. Three patients (all females, aged 20, 22 and 36 respectively) belonged to the former, one patient (female, aged 20 years) to the latter. All tumors were papillary carcinomas. The aim of the present study has been to analyze microsatellite instability (MI) in this particular type of thyroid tumors and to compare observed findings with those obtained in 47 other thyroid tumors not belonging to FAP patients. All neoplasms were analyzed for instability at 10 dinucleotide microsatellite loci and at 2 mononucleotide repeats within the coding sequences of TGF[3 type II receptor (TI3R II) and IGF II receptor (IGF IIa) genes respectively. MI was detected in 11/52 cases (20.5%), 6 (11.7%) with MI at 1-2 loci and 5 (9.8%) with MI at 3 or more loci (RER+ phenotype). No mutations in the T[3R II and IGF IIR repeats were observed. MI was significantly more frequent in follicular adenomas and carcinomas than in papillary and Htirtle cell type tumors: 3/9 follicular histotype tumors (33.3%) resulted RER+, versus 1/30 papillary carcinomas (3.4%) (p< 0.01). In particular, all 4 patients with FAP associated thyroid tumors were RER-. On the contrary, 3 of these 4 patients had activation of the ret-PTC oncogene, a chimeric gene resulting from the fusion of the ret protoncogene with other genes (H4, RI a, subunit of cyclic AMP and ele), respectively. The specific isoform was ret-PTCp Conclusion: MI is frequently associated with the follicular histotype, whereas it is less frequent both in papillary carcinomas and in Hiirtle cell type tumors. In particular, MI was always absent in all 4 patients with FAP associated thyroid carcinoma, which are typically papillary and show a high rate of ret-PTC activation, a feature that is restricted to the papillary histotype. MI may contribute to tumor progression and clonal expansion of follicular thyroid tumors, but is likely less or not involved in the tumorigenesis of papillary carcinomas. G2355
HEPATOBLASTOMA AND THYROID CARCINOMA CO-SEGREGATE WITH CONGENITAL HYPERTROPHY OF THE RETINAL PIGMENT EPITHELIUM (CHRPE) IN PATIENTS WITH FAMILIAL ADENOMATOUS POLYPOSIS. Cetta F., *Morgese G., *Petracci M, °Olschwang S., **Battista P., *Acquaviva A., Zuckermann M., Baldi C., Cetta D., Montalto G. Institute of Surgical Clinics, *Pediatrics and **Ophthalmology, University of Siena, Italy; °Fondation J. Dausset, Paris; ***Department of Pathology, University of Chieti, Italy. Congenital hypertrophy of the retinal pigment epithelium (CHRPE) is a frequent finding in patients with familial adenomatous polyposis coli (FAP), occurring in 40-80% of cases. On the contrary, thyroid carcinoma (THYRC) and hepatoblastoma (HPBL), despite being established since long time as associated extracolonic manifestations, were rarely reported. There have been about 70 cases of THYRC and 33 patients with HPBL associated with FAP. The reported relative risk (RR) has been 160 for THYRC and 1000 for HPBL. The specifi c mutations of the APC gene in kindreds with FAP associated THYRC have been reported only recently. In particular, most case reports decribed a single THYRC per kindred. Only 4 couples of siblings with FAP associated THYRC have been reported up to now. We have recently observed a kindred with 3 siblings (out of 5 with colonic polyps) affected by FAP and THYRC and 1 sibling affected by HPBL. In particular, the latter was a 2-yearold girl, who underwent typical right lobectomy because of a liver mass (initial diameter 13 X 9,5 cm, final diameter 4,7 X 3 cm, three months after preliminary chemotherapy). Histologic examination showed a mixed type fetal HPBL. The patient is recurrence free 10 years after surgery. This family had an APC mutation at codon 1061. Reported APC mutations in other families with THYRC were at codon 1309 and 1209 (1). In addition, mutation at codon 848 were reported in 2 sisters from Japan, aged 15 and 12 years, respectively. Six additional patients from Pads had mutations at codon 599, 778, 1061, 993, 976 and 140, respectively. APC mutations in patients with HPBL detected up to now were at codon 1230 (2 patients), 1061 (in 3 patients), 1189, 554, 541 and 141,213, 215, 279, 302. In another patient with hepatocellular adenoma APC mutation was at codon 1451. Except this last mutation, that is in the genornic area which cosegregates with desmoids, most of these mutations were in exon 15, in the genomic area usually associated with CHRPE (2, 3). Typical CHRPE was actually found in most affected patients. In particular, in the kindred with APC mutation at codon 848, one patient also had desmoid tumours. A similar finding, i.e. desmoids and THYRC, sometimes also associated with CHRPE, has been described in other reports with unknown APC mutation. In conclusion, present data, even if preliminary, suggest that HPBL and in particular THYRC usually co-segregate with CHRPE, even if this association is stronger for THYRC and less constant for HPBL. The awareness that patients with HPBL and THYRC usually have APC mutations which cluster in a well defined genomic areas, could facilitate both earlier diagnosis and better treatment. In particular, intensive screening for HPBL before age 2 and for thyroid nodules after age 15, respectively, is recommended, when a single patient or an entire kindred have CHRPE and/or mutations in exon 15. [1] Cetta F. et al. Gastroenterology 1997, 112:A545; [2] Cetta F. et al. J. Clin. Endocrinol. Metab. 1997, 82:2015-2017; [3] Cetta F. et al. Histopathology 1997; 31:231-236.
• G2347 ESTROGENS MODULATE GASTRODUODENAL HYPERPLASIA AND DYSPLASIA INDUCED BY N-METHYL-N'-NITRO-N-NITROSOGUANIDINE IN RATS. Martha Campbell-Thompson, K.K. Reyher, G.Y. Lauwers, K.T. Shiverick. College of Medicine, University of Florida, Gainesville, FL. Introduction. Gastric cancers are a significant cause of cancer-related deaths worldwide. Diet has been the most studied risk factor for gastric cancer with particular interest in N-nitroso compounds from broiled or smoked foods. Epidemiological studies and experimental animal models show that males have at least a two-fold higher incidence of gastric cancer. This study investigated the modifying effects of 1713-estradiol in rats during the initiation phase of gastroduodenal carcinogenesis induced by N-methyl-N'-nitro-Nnitrosoguanidine (MNNG). Methods. Male SD rats (N=33) were fed a soy protein free diet and implanted subcutaneously with Silastic tubes containing either 17~-estradiol or oil vehicle. One week later, rats were divided into groups treated with or without MNNG in the drinking water for 4 weeks. Histopathological features, cell kinetics (bromodeoxyuridine incorporation), and neuroendocrine hormone production of the gastroduodenal mucosa were determined. Results. Hyperplasia and dysplasia were observed in the antrum and duodenum in rats treated with MNNG. 1713-estradiol reduced foveolar hyperplasia and dysplasia of the antral glandular mucosa and blunting of duodenal villi. 17B-estradiol decreased the numbers of cells in S phase of the cell cycle and increased expression of mucin and gastrin. Serum testosterone levels and testicular weights (expressed as % body weight) were not significantly lowered by the estradiol implants in MNNG treated males. MNNG decreased body weight gain without altering food intake except in estradiol-treated animals which had both decreased weight gain and food consumption. Conclusions. These studies show that short-term continuous exposure to MNNG results in significant alterations in gastroduodenal cell proliferation and terminal differentiation. These cellular alterations include mucous and neuroendocrine cells which have critical roles in production of the mucosal barrier and in regulating mucosal growth and function. The present results indicate that 1713-estradiol exerts protective effects by influencing mucosal cell proliferation and differentiation when given during the initiation phase of gastroduodenal carcinogenesis in rats. Therefore, estrogens may decrease the susceptibility of gastrointestinal cells to ingested carcinogens by enhancing mucosal protection. • G2348 TARGETED RADIOPEPTIDE THERAPY: HIGH DOSE INDIUM-Ill OCTREOTIDE FOR NEUROENDOCRINE TUMOURS. M.E. Caplin, A.K. Burroughs, W. Miolcarek, A.J.W. Hilson, A.L. Jones, E.J. Wood and J.R. Buscombe. Neuroendocrine Tumour Clinic, Royal Free Hospital, London NW3, UK. Background: Indium-111 (In-111) labeled octreotide scintigraphy is now a well established highly sensitive and specific tool in diagnosing neuroendocrine tumours. Taking advantage of the avid binding of neuroendocrine tumours for octreotide (a synthetic analogue of somatostatin) a therapeutic role has been suggested for high does In-111 octreotide. Aim: The aim of this study was to determine the toxicity of high dose In-I 11 octreotide therapy. Methods: A prospective study was performed on 7 patients with advanced metastatic neuroendocrine tumours including 5 carcinoid tumours, 1 medullary carcinoma of thyroid and 1 gastrinoma. All these patients had been unresponsive to other therapeutic modalities. A total of nineteen therapies with high does I n - I l l octreotide were administered to these patients. All patients had a full medical examination prior to therapy and measurement of vital signs during therapy, Haematological and biochemical profiles were performed pre-treatment and post-treatment and subsequently one monthly post-treatment. Results: All patients tolerated the treatment well during the 30-60 minute infusion of In-111 octreotide. There was no evidence for early or late hepatic, endocrine or renal toxicity. In one patient there was a partially recoverable reduction in platelets after each treatment; another patient had a persistently low lymphocyte count. One patient died of unrelated causes after the first treatment, the remainder continue to receive regular therapy. Conclusion: There is no serious toxicity associated with high dose I n - I l l octreotide therapy even after repeated administrations. The therapeutic effect of this therapy is now being formally assessed. • G2349 LACK OF MUTATIONS OF THE PTEN TUMOR SUPPRESSOR GENRE IN THREE BANNAYAN-RILEY-RUVALCABA SYNDROME PATIENTS. JM Carethers, FB Funari, AF Zigman, JE Lavine, MC Jones, GE Graham, AS Teebi, H-J S Huang, DP Chauhan, CL Chang, WK Cavenee, and CR Boland. University of California, VAMC, Children's Hospital, and Ludwig Institute, San Diego, CA; McGill University and Children's Hospital, Montreal, Quebec, Canada. Bannayan-Riley-Ruvalcaba (BRR) syndrome is a congenital syndrome with features of macrocephaly, developmental delay, subcutaneous and visceral lipomas and hemangiomas, and intestinal juvenile polyposis. Recently,
GASTROENTEROLOGY Vol. 114, No. 4 germline mutations in the PTEN gene on chromosome 10q23 were found in two out of three families with BRR syndrome. Germline mutations in PTEN have also been identified in Cowden disease, suggesting that BRR syndrome is allelic with Cowden disease. However, juvenile polyposis coli (JPC), a hamartomatous polyposis syndrome of which BRR may be a variant, has only wild-type PTEN. We sought to identify PTEN mutations in three patients diagnosed with BRR by a pediatric geneticist. Methods: Genomic DNA was extracted from peripheral blood leukocytes and amplified using primers specific for the genomic PTEN sequence. PCR products were subjected to DNA sequencing. In addition, RNA was obtained from immortalized lymphocytes, reversed transcribed into eDNA using primers specific for the PTEN sequence, and subjected to an in vitro transcription/translation (IV'IT) assay. The PTEN cDNAs were also sequenced for the presence or absence of mutations. Results: IV'IT revealed no truncation of PTEN protein in all three BRR patients. Sequencing of each eDNA showed no mutations, including missense mutations that might have been missed on IVTT analysis. Sequencing of genomic DNA revealed only the wild-type sequence in all three BRR patients. Conclusions: BRR is not always associated with germline mutations in the PTEN tumor suppressor gene. We speculate that BRR may have a heteregenous allelic etiology, one of which may be shared with JPC because both BRR and JPC share the phenotypic feature of intestinal juvenile polyposis. G2350 PRESENCE OF MICROSATELLITE INSTABILITY (MIN) IN THE NORMAL-APPEARING EPITHELIUM OF FAMILIAL JUVENILE POLYPS. JM Carethers, BM Lopez, AF Zigman, W-S Jo, JE Lavine, MC Jones, DP Chanhan, CL Chang, HD Appleman, and CR Boland. University of California, VAMC, and Children's Hospital, San Diego, CA and University of Michigan, Ann Arbor, Michigan. Juvenile polyposis coli (JPC) is an autosomal dominant familial disorder characterized by multiple juvenile polyps throughout the colon. Patients with JPC have a two to fourfold risk for adenocareinoma of the colon compared to the general population. A lamina propria cell with chromosome 10q23 deletions has been suggested as the neoplastic progenitor within juvenile polyps. Prior reports of familial juvenile polyps suggest that the polyp progresses through an adenomatous intermediate prior to development of carcinoma, which indicates that the final pathway to cancer in juvenile polyps must take place at the epithelial level. The mechanism for the evolution of neoplastic epithelium within the juvenile polyp, and increased risk for malignancy in JPC, is unknown. Methods: Sixty paraffin-embedded, formalin fixed juvenile polyps from seven patients with familial juvenile polyposis were microdissected into 131 domains that included surface epithelium, cyst epithelium, and lamina propria. Isolated DNA was amplified by PCR using radiolabeled primers specific for six dinucleotide microsatellite loci, electrophoresed on a polyacrylamide gel, and exposed to x-ray film. Results: Microsatellite instability, as defined by an insertion or deletion mutation in >40 % of the microsatellite markers, was present in 8 domains from five juvenile polyposis patients. Seven of the eight domains that demonstrated MIN were from cystic or surface epithelium, whereas one domain showed MIN within the lamina propria. Conclusions: Inactivation of DNA mismatch repair (MMR), as determined by the presence of MIN, appears to be a potential mechanism for neoplastic change within the normal-appearing epithelium of a familial juvenile polyp, Our results also suggest that some histologically "normal" epithelium of familial juvenile polyps may harbor genetic alterations at other DNA sequences sensitive to defective DNA MMR. G2351 REGRESSION OF GASTRIC MALT-LYMPHOMA A~'q'ER ERADICATION OF HELICOBACTER PYLORI. A THREE YEARS FOLLOWUP REPORT. A. Caroli, R. Follador, F. Nicoli, G. Vicario, A. Borsato, R. D'Este, A. Caminiti, P. Manante, A. Puglisi. Dpts of Gastroenterology, Surgery, Oncology and Pathology, Montebelluna Hospital, Italy. Various studies have suggested that eradication of Helicobacter pylori (H.p.) from patients with gastric low-grade-MALT-Lymphoma has resulted in tumor regression in the majority of the cases, but adequate follow-up is needed to show whether the remission is long lasting and that the patients can be considered cured. The aim of this report was to describe the outcome of a long-term follow-up after a successful H.p. eradication in patients with MALT-lymphoma. Patients and methods Fourteen consecutive patients (8 males and 6 females; mean age 60.2 years, range 46-80) affected by H.p. positive low-grade MALT-lymphoma of the stomach (diagnosis based on grade 5 of the histological scoring proposed by Wotherspoon), in clinical stage IE, that underwent successful H.p. eradication, were prospectively followed. Endoscopies with multiple gastric biopsy were repeated every three months until gastric lymphoma regression, and then every six months. Patients who did not respond after H.p, eradication and two consecutive positive endoscopies, were treated by surgery or chemotherapy. Results After H.p. eradication a complete regression of the lymphoma was obtained in 11/14 patients (78.5%). Of the three non responding patients, two underwent sugicai treatment and one was found to have a high-grade
Gastrointestinal Oricolog~j A575
April 1998 lymphoma; the last patient, with endoscopic picture of "gastritis", refused any treatment and did not show any changes of the endoscopic and histologic finding 26 months after diagnosis. Among the eleven patients with complete regression of the lymphoma, during a median follow-up period of 36 months, ten (91%) maintained remission of the desease. One patient relapsed with H.p. reinfection twelve months after the first successful treatment, and was reeradicated with further regression of the tumor. Conclusions Our data confirm previous reports suggesting that H.p. eradication can produce histological regression of low-grade MALTlymphoma of the stomach in a high percentage of cases. Furthermore, regression appear stable in most patients for at least 3 years. H.p. reinfection can produce relapse of the lymphoma, further enphasizing the need for complete eradication of the microrganism and prompt retreatment in case of reinfection. • G2352 PHARMACOLOGICAL MODULATION OF THE INFLAMMATORY RESPONSE INDUCED BY ABDOMINAL IRRADIATON. M CasadevaU, J Pan6s, A Salas, M Mollh, JL Osotio, C Conill, DN Granger,JM. Piqu6. Departments of Gastroenterology and Radiation Oncology, Hospital Clfnic, University of Barcelona, Spain; and Dept of Physiology, LSUMC, Shreveport,LA. In a previous study we showed that abdominal irradiation induced upregulation of endothelial ICAM-1 expression, which was followed in time by an increase in leukocyte recruitment and in microvascular permeability. Radiation-induced generation of oxygen free radicals by activated leukocytes in the mesentery was also observed. The aim of the present study was to assess the effect of two drugs, N-aeetylcysteine (NAC), a free radical scavenger, and tepoxalin (TEP), a dual cyclooxygenase/lipoxygenase inhibitor, on the inflammatory response and endothelial ICAM-1 expression induced by abdominal irradiation. Methods: 10 Gy abdominal irradiation were given to 3 groups of rats (n=5) pretreated with either vehicle (RAD), NAC (2g/kg, ip) or TEP (400mg/kg, po); a control group(n=6) sham irradiated was studied. Six hours after irradiation, leukocyte adhesion (cells/100~m) and emigration (cells/field), as well as vascular permeability (FITC-albumin leakage), were measured by intravital microscopy. Endothelial expresion of ICAM-1 was quantified in vivo by means of the double radiolabeled antibody technique. Results: Group
I
Adhesion Emigration, Vascular ICAM-1 ICAM-1 I permeability mesentery Small intest Cntrl 4 + 0.7 2 ± 0.8 0.1 ± 0.03 0.09 ± 0.05 0.08 ± 0.07 RAD 19±3" 6±0.9* 0.9±0.04* 0.14 ± 0.09:~ 0.13 ± 0.05:~ NAC 13±3" 3±1.3 0,4±0.05*# 0.14± 0.09:~ 0.17± 0.16~:# TEP 5 ± 0.7 1 ± 0. l 0.2 ± 0.07 0.12 ± 0.09:~ O.16 ± 0.06:~# (*) p < 0.05 vs control and TEP, (#) p < 0.05 vs RAD, :~p < 0.05 vs control. i
Conclusions: The inhibitor of leukotriene synthesis tepoxalin is effective in blunting the inflammatory response and microvascular dysfunction resulting from abdominal irradiation, whereas NAC has only a weak effect in preserving vascular barrier function. These effects do not result from inhibition of ICAM-1 upregulation.
• G2353 MULTIMODAL THERAPEUTIC APPROACH FOR RECURRENT COLORECTAL CANCER: ANALYSIS OF SURVIVAL. A. Cassano, C. Pozzo, D.C. Corsi, M. Mancini, P. Tarantini, C. Signorelli, C. Barone. Istituto di Medicina Intema e Geriatria, Universit~Cattolica del Sacra Cuore, Roma, Italy. Resection of colorectal metastases represents an actual treatment option which can improve survival in about 25% patients (pts) at 5 years. Few data are available about the results of curative resection in pts whose metastases are downstaged by chemotherapy and then submitted to adjuvant chemotherapy. In order to evaluate the role of this multimodal approach we reported the results of our study conducted on pts who developed recurrence following surgery for colorectal cancer. Of 534 pts treated for colorectal cancer in our department during the years 1985-1997, 54 had an operable recurrence, 35 as liver metastases, 15 lung and 4 pelvic. All pts were submitted to three cycles of chemotherapy with 5-fluorouracil and folinic acid; they were operated on and retreated with chemotherapy for six cures. Thirty eight patients had follow-up >12, 28 pts > 24months, 14 pts > 36 months, 10 pts > 48 months and 6 pts > 60 months. Overall DFS was 19 months (range 2-132+). Mean DFS of pts who had further recurrence was 15.3 months. DFS after hepatic resection is 19 months whereas after lung resection is 23.6 months. Nine pts died of recurrence, with a mean DFS of 12.1 months (range 4-19) and mean total survival of 44.7 months (range 13-144). Average survival time from the resection of recurrence was 32.1. Average follow-up of surviving pts was 29 months (range 4+-132+). Twenty-six pts are alive with no evidence of disease: 16 pts at 12 months, 13 at 24 months, 8 at 36 months, 5 at 48 months, 6 at 60 months or longer. These findings indicate that a multimodality treatment can result in a better outcome for colorectal cancer pts who develop resectable distant metastases. Although with the small number of lung recurrences, resection of pulmonary lesion resulted in a good outcome.
G2354
ABSENCE OF MICROSATELLITE INSTABILITY AT TARGET SEQUENCES WITHIN THE TGFI3 TYPE H AND IGF II RECEPTOR GENE IN THYROID CARCINOMA ASSOCIATED WITH FAMILIAL ADENOMATOUS POLYPOSIS. Cetta F., Montalto G., Zuckermann M., *Toil P., *Lor~ F., °Cama A., °Battista P., °Mariani Costantini R. Institute of Surgical Clinics, *Pathology and **Endocrinology, University of Siena; °Department of Pathology, University of Chieti; Italy. Two FAP kindreds had 4 patients with thyroid carcinoma. Three patients (all females, aged 20, 22 and 36 respectively) belonged to the former, one patient (female, aged 20 years) to the latter. All tumors were papillary carcinomas. The aim of the present study has been to analyze microsatellite instability (MI) in this particular type of thyroid tumors and to compare observed findings with those obtained in 47 other thyroid tumors not belonging to FAP patients. All neoplasms were analyzed for instability at 10 dinucleotide microsatellite loci and at 2 mononucleotide repeats within the coding sequences of TGF[3 type II receptor (TI3R II) and IGF II receptor (IGF IIa) genes respectively. MI was detected in 11/52 cases (20.5%), 6 (11.7%) with MI at 1-2 loci and 5 (9.8%) with MI at 3 or more loci (RER+ phenotype). No mutations in the T[3R II and IGF IIR repeats were observed. MI was significantly more frequent in follicular adenomas and carcinomas than in papillary and Htirtle cell type tumors: 3/9 follicular histotype tumors (33.3%) resulted RER+, versus 1/30 papillary carcinomas (3.4%) (p< 0.01). In particular, all 4 patients with FAP associated thyroid tumors were RER-. On the contrary, 3 of these 4 patients had activation of the ret-PTC oncogene, a chimeric gene resulting from the fusion of the ret protoncogene with other genes (H4, RI a, subunit of cyclic AMP and ele), respectively. The specific isoform was ret-PTCp Conclusion: MI is frequently associated with the follicular histotype, whereas it is less frequent both in papillary carcinomas and in Hiirtle cell type tumors. In particular, MI was always absent in all 4 patients with FAP associated thyroid carcinoma, which are typically papillary and show a high rate of ret-PTC activation, a feature that is restricted to the papillary histotype. MI may contribute to tumor progression and clonal expansion of follicular thyroid tumors, but is likely less or not involved in the tumorigenesis of papillary carcinomas. G2355
HEPATOBLASTOMA AND THYROID CARCINOMA CO-SEGREGATE WITH CONGENITAL HYPERTROPHY OF THE RETINAL PIGMENT EPITHELIUM (CHRPE) IN PATIENTS WITH FAMILIAL ADENOMATOUS POLYPOSIS. Cetta F., *Morgese G., *Petracci M, °Olschwang S., **Battista P., *Acquaviva A., Zuckermann M., Baldi C., Cetta D., Montalto G. Institute of Surgical Clinics, *Pediatrics and **Ophthalmology, University of Siena, Italy; °Fondation J. Dausset, Paris; ***Department of Pathology, University of Chieti, Italy. Congenital hypertrophy of the retinal pigment epithelium (CHRPE) is a frequent finding in patients with familial adenomatous polyposis coli (FAP), occurring in 40-80% of cases. On the contrary, thyroid carcinoma (THYRC) and hepatoblastoma (HPBL), despite being established since long time as associated extracolonic manifestations, were rarely reported. There have been about 70 cases of THYRC and 33 patients with HPBL associated with FAP. The reported relative risk (RR) has been 160 for THYRC and 1000 for HPBL. The specifi c mutations of the APC gene in kindreds with FAP associated THYRC have been reported only recently. In particular, most case reports decribed a single THYRC per kindred. Only 4 couples of siblings with FAP associated THYRC have been reported up to now. We have recently observed a kindred with 3 siblings (out of 5 with colonic polyps) affected by FAP and THYRC and 1 sibling affected by HPBL. In particular, the latter was a 2-yearold girl, who underwent typical right lobectomy because of a liver mass (initial diameter 13 X 9,5 cm, final diameter 4,7 X 3 cm, three months after preliminary chemotherapy). Histologic examination showed a mixed type fetal HPBL. The patient is recurrence free 10 years after surgery. This family had an APC mutation at codon 1061. Reported APC mutations in other families with THYRC were at codon 1309 and 1209 (1). In addition, mutation at codon 848 were reported in 2 sisters from Japan, aged 15 and 12 years, respectively. Six additional patients from Pads had mutations at codon 599, 778, 1061, 993, 976 and 140, respectively. APC mutations in patients with HPBL detected up to now were at codon 1230 (2 patients), 1061 (in 3 patients), 1189, 554, 541 and 141,213, 215, 279, 302. In another patient with hepatocellular adenoma APC mutation was at codon 1451. Except this last mutation, that is in the genornic area which cosegregates with desmoids, most of these mutations were in exon 15, in the genomic area usually associated with CHRPE (2, 3). Typical CHRPE was actually found in most affected patients. In particular, in the kindred with APC mutation at codon 848, one patient also had desmoid tumours. A similar finding, i.e. desmoids and THYRC, sometimes also associated with CHRPE, has been described in other reports with unknown APC mutation. In conclusion, present data, even if preliminary, suggest that HPBL and in particular THYRC usually co-segregate with CHRPE, even if this association is stronger for THYRC and less constant for HPBL. The awareness that patients with HPBL and THYRC usually have APC mutations which cluster in a well defined genomic areas, could facilitate both earlier diagnosis and better treatment. In particular, intensive screening for HPBL before age 2 and for thyroid nodules after age 15, respectively, is recommended, when a single patient or an entire kindred have CHRPE and/or mutations in exon 15. [1] Cetta F. et al. Gastroenterology 1997, 112:A545; [2] Cetta F. et al. J. Clin. Endocrinol. Metab. 1997, 82:2015-2017; [3] Cetta F. et al. Histopathology 1997; 31:231-236.