Abstract Background: The purpose of this study was to evaluate bioelectrical impedance spectroscopy’s (BIS) ability to detect and monitor extracellular fluid accumulation of the upper limb as it relates to the extent of loco-regional therapy. Methods: A total of 125 patients with breast cancer from 4 clinical practices were evaluated with BIS at baseline and following loco-regional procedures. In order to assess the ability of BIS to detect subclinical changes by treatment modality, the change in L-Dex score from baseline to measurements taken within 180 days following surgery were calculated. Results: Mean age was 55 years with 68 patients (54.4%) undergoing sentinel lymph node (SLN) sampling while 57 (45.6%) underwent an axillary dissection (ALND). Sixty-five patients (52%) underwent radiation therapy (RT). Patients receiving RT had a significantly increased change in L-Dex score (0.8 v.-2.5, p=0.03) compared with those patients not receiving RT. For all patients, ALND was associated with a significantly increased change in L-Dex score (5.0 v. 0.3, p=0.003) compared with SLN. When stratifying by the number of nodes removed, a statistically significant increase in the change in L-Dex score was noted (0.4 v. 0.4 v. 4.3 v. 6.4, p=0.04) for 0-3, 4-6, 7-10 and greater than 10 lymph nodes removed. Conclusions: In this limited analysis, L-Dex scores paralleled the extent of axillary sampling and the addition of radiation therapy; these results demonstrate that BIS can be used to monitor patients for the early onset of edema as differences emerged within 180 days of surgery.
Keywords: bioimpedance; breast cancer; lymphedema; early detection; subclinical assessment

Abstract Aim: There exists a variation in practice in the management of tumours around the splenic flexure. We aim to determine the current opinion regarding the management of these tumours. Methods: An anonymised 10-part online questionnaire was sent to all members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI). Results: The response rate was 24% (111/464) with approximately half of respondents performing laparoscopic surgery. Electively, an extended right hemicolectomy is the preferred option by 63% of respondents followed by left hemicolectomy (23%) and segmental resection (14%). The upper sigmoid and rectosigmoid is the preferred site of anastomosis by 90% and 10% of respondents respectively. There were no significant differences in the type of operations performed by surgeons who practice laparoscopic or open surgery (p=0.10). A hand-sewn end-to-end anastomosis is most commonly performed (51%) followed by a stapled side-to-side (36%) and a stapled end-to-end (13%) technique. Extended right hemicolectomy is also the preferred option in obstructing tumours. Of surgeons who perform segmental resections, 27% perform an on-table lavage and 9% perform a defunctioning stoma. Internal herniation following laparoscopic resection was only reported by a handful of surgeons. Conclusion: Opinion and practice in the management of patients with tumours around the splenic flexure are divided. Further trials are indicated to determine the best practice.
Keywords: left hemicolectomy; splenic flexure tumours; extended right hemicolectomy

Abstract Medulloblastoma is one of the most frequent and aggressive tumors of childhood. The Sonic hedgehog (Shh) pathway, related to human development, is altered in most medulloblastomas: genes like Ptch, Smo, or Sufu suffer mutations in 15% to 25% of these tumors. We tested Shh inhibition in the Daoy medulloblastoma cell line by two methods: a molecular one, direct Gli1 siRNA inhibition; and a pharmacological inhibition of Smo, upstream of Gli1, by cyclopamine. Afterwards, a comparison of cellular and molecular responses was done. In general, we proved that cell viability, cell migration and cell colony formation decreased after Shh inhibition, which might confer a less tumorigenic status to Daoy cells. Moreover, we assessed the expression of different Gli1 target genes and other genes and found that Shh shows a crosstalk with oncogenes and tumor suppressor genes that have been described in numerous tumors. All these experiments give an overview of the Shh pathway in medulloblastoma, together with the demonstration of the efficacy of cyclopamine and Gli1 siRNA Shh inhibition in vitro.
Keywords: sonic hedgehog; cyclopamine; siRNA; Gli1, Ptch; Smo; in vitro tumorigenesis; medulloblastoma; Dao

Abstract This study evaluated the impact of social support programs on improving cancer related disability, neuro-cognitive dysfunction and enhancing participation (quality of life (QoL), social reintegration) in brain tumour (BT) survivors. Participants (n=43) were recruited prospectively following definitive treatment in the community. Each BT survivor received an individualised social support program which comprised: face-to-face interview for education/counselling plus peer support program or community education/counselling sessions. The assessments were at baseline (T1), 6-week (T2) and 6-month (T3) post-intervention using validated questionnaires: depression anxiety stress scale (DASS), functional independence measure (FIM), perceived impact problem profile (PIPP), cancer rehabilitation evaluation system–short form (CARES-SF), a cancer survivor unmet needs measure (CaSUN), McGill quality of life questionnaire (MQOL) and Brief COPE. Participants’ mean age was 53 years (range 31–72 years), the majority were female (72%); median time since BT diagnosis was 2.3 years and almost half (47%) had high grade tumours. At T2, participants reported higher emotional well-being (DASS ‘anxiety’ and ‘stress’ subscales, p<0.05; FIM ‘cognition’ subscale, p<0.01), improved function (FIM ‘motor’ subscale, p<0.01) and higher QoL (CARES-SF ‘global’ score, p<0.05; MQOL ‘physical symptom’ subscale, p<0.05). At the T3 follow-up, most of these effects were maintained. The intervention effect for BT specific coping strategies emerged for the Brief COPE ‘self-distraction’ and ‘behavioural disengagement’ domains, (p<0.05 for both). There were no adverse effects reported. A post-treatment social support program can improve physical and cognitive function and enhancing overall QoL of BT survivors. Social support programs need further evaluation and should be encouraged by clinicians within cancer rehabilitative services.
Keywords: brain neoplasm; social support program; function; cognition; quality of life

Abstract Objective: This study aims to determine the cost of colorectal cancer (CRC) management and compare the cost effectiveness of cetuximab and bevacizumab in the management of CRC. Method: This economic evaluation study from a societal perspective involves collecting resource utilization data based on the clinical pathway of colorectal cancer management. The cost calculated includes drugs, human resources, administrative, investigations as well as capital cost. Patient’s cost was also calculated based on an interview with colorectal cancer patients. Effectiveness estimates for monoclonal antibody (cetuximab and bevacizumab) treatment were modeled from study respondents based on references from other studies. Results: Cost of treating a case of colorectal cancer in stage I is RM13,623 (RM12,467-RM14,777), stage II RM19,753 (RM16,734-RM23,520), stage III RM24,972 (RM20,291-RM29,654) and stage IV RM27, 163 (RM23, 192-RM31,133). Cost of CRC management increase with the increasing stage of the disease (Kruskal Wallis, X²=106, p<0.001). Based on estimates of 2671 new cases of CRC, the incremental cost of cetuximab is RM20, 556 480 and bevacizumab is RM7,557,953 at 50% stage III and IV as compared to the conventional chemotherapy. The incremental cost per quality adjusted life years gained for cetuximab is RM38,869 and RM14,290 for bevacizumab. Although both types of monoclonal antibody are considered cost effective (based on WHO guidelines of less than three times of GDP), bevacizumab is considered more cost effective than cetuximab. Cost effectiveness was sensitive to the percentage of late stages of CRC. Conclusions: Cost of treating late stage of CRC is high and bevacizumab are more cost effective compared to cetuximab in the management of the late stage of CRC.
Keywords: economic evaluation; cost effectiveness, colorectal cancer, monoclonal antibody

Abstract Objective: The purpose of this study was to assess survival and recurrence site and rate in patients with histological high grade endometrial cancer (grade 3 endometrioid and non endometrioid carcinoma) treated with staging surgery, which included pelvic lymphadenectomy without para aortic lymph node dissection. We have also looked at other histological factors within this group in relationship to survival. Methods: A total of 120 patients diagnosed with high grade endometrial cancer between August 2002 and December 2008 were included in the study. All of them underwent total abdominal (TAH) or laparoscopic assisted vaginal hysterectomy (LAVH) with bilateral salpingo oophorectomy (BSO), with pelvic lymphadenectomy, with or without omentectomy. Results: Pelvic lymph node positivity was noted in 37 patients (31%). The mean follow up was 47 months. Forty-four patients (37%) developed recurrence with a mean time to relapse of 20 months. The majority of the recurrences (77%) occurred in both the para aortic area and at distant sites. Among 44 patients with recurrence, 37 (84%) were lymphovascular invasion (LVSI) positive at primary histology as compared to 41 (54%) patients without recurrence with LVSI (p<0.05); The proportion of patients with more than 50% myometrial invasion was much higher among the group with recurrence (34 (77%)) in comparison with those who did not show recurrence (40 (53%))(p<0.05). Kaplan-Meier overall survival rate for patients with FIGO stage I was 84%, stage II 70%, stage III 29% and stage IV 20%. Patients with positive pelvic lymph nodes had a 23% survival in contrast to 78% survival without lymph nodal disease (p<0.001). Conclusions: High grade histological subtype of endometrial cancer is a significant risk factor for para aortic lymph nodal involvement and distant relapse. The majority of recurrences of high grade endometrial tumours were distant, which suggests that other additional treatment modalities should be considered in this high risk group.
Keywords: endometrial cancer; lymphadenectomy; lymphovascular space invasion; myometrial invasion; recurrence

Abstract Purpose: to evaluate the diagnostic accuracy of (18) F-FDG positron emission tomography/ computerized tomography (PET/CT) for the detection of peritoneal carcinomatosis (PC) of colorectal cancer (CRC). Methods: one hundred and forty six eligible patients referred for a PET/CT to evaluate CRC at a single institution were included consecutively and retrospectively. After joint training on 20 similar patient files, two nuclear physicians reviewed the PET/CT scans blindly and independently using a method specifically designed for PC detection. The gold standard was either histological results from surgical exploration for resected patients (n=65) or clinical follow up defined as the 3-month CT follow up supplemented by one year of clinical information and CT monitoring for non-resected patients (n=81). As secondary objectives we evaluated the interobserver reliability between the two PET/CT readings and the diagnostic accuracy of a contemporary ceCT (n=69) or CT component of the PET/CT (n=77) reviewed by an independent radiologist . The extent of PC according to a simplified Sugarbaker index (PCI) was examined for the operated subgroup, when PCI was available from the surgeon and PET/CT (n=12). Results: according to the gold standard, 35/146 patients had PC (including 19 of 65 patients with histological gold standard and 16 of 81 patients with clinical follow up gold standard). Sensitivity and specificity of PET/CT were 88% and 96% respectively and positive and negative predictive values and accuracy, 88%, 96% and 94% respectively. For CT alone, the corresponding values were: 68%, 92%, 72%, 90% and 86%. The interobserver agreement for the detection of peritoneal carcinomatosis in PET/CT showed high agreement at 0.91 (Kappa). Median PCI was 3 [range: 1–13] when assessed by surgeons and 4 [range: 1–10] on PET/CT. Focal uptake was the most frequently observed sign on PET. Conclusions: PET/CT appears to be an accurate and reproducible test for PC diagnosis in colorectal cancer using an interpretation method specifically designed for PC detection. To confirm these results and to evaluate peritoneal carcinomatosis extension accurately, a prospective observational study using iodine contrast-enhanced PET/CT as a first imaging technique for pre-operative staging and potentially involving further independent reviewers remains to be undertaken.
Keywords: PET/CT; peritoneal carcinomatosis; colorectal cancer; diagnostic accuracy

Abstract Gastric cancer is the fourth most common cancer and the second leading cause of cancer death in the world. Penetration of the gastric serosa and lymphatic spread are the two most important factors affecting prognosis in gastric cancer. Patients with peritoneal carcinomatosis from gastric cancer show a particularly poor prognosis. A few treatment strategies have been tested and proposed to increase survival rates. The cornerstone of treatment remains complete cytoreductive surgery associated with a different combination of chemotherapy regimen. It has been demonstrated as systemic adjuvant, systemic neoadjuvant and above all hyperthermic intraperitoneal chemotherapy improve the survival, when used in the prevention and treatment of peritoneal carcinomatosis from gastric cancer. Few new molecules have been introduced enhancing the effect of chemotherapy by biologically targeting its objective. However further studies are needed.
Keywords: gastric cancer; peritoneal metastasis; carcinomatosis; HIPEC; chemotherapy; neoadjuvant; adjuvant; treatment; prevention

Abstract Ovarian cancer (OC) is one of the most frequent mortality causes among female neoplasms. A lot of data is available on the efficiency and the relative safety of the different treatments. In the last twenty years the overall survival (OS) and the disease free survival (DFS) have enormously incremented thanks to the combined chemotherapy regimens and the incredible progresses of surgery. These progresses are also related to the increased ability in managing patients more and more compromised, i.e. older and weaker. In addition to that, more than twenty years ago, Sugarbaker et al. started to treat the peritoneal cancer diffusion as a loco-regional disease. This change of practice has been demonstrated to be a real revolution by following studies.
Keywords: randomized trial; HIPEC, ovarian cancer; carcinosis; quality of life