Ethiodized oil emulsion enhanced computerized tomography in the preoperative assessment of metastases to the liver from the colon and rectum

Selective reticuloendothelial (RE) cell uptake of ethiodized oil emulsion 13 (EOE-13), an emulsion of Ethiodol (ethiodized oil) roentgenographic contrast material in a phosphate buffer, permits detection of small metastatic lesions of the liver and spleen through enhancement of roentgenographic density differences on computerized tomography (CT) between tissues containing and not containing RE cells. To determine the efficacy of this contrast material in the assessment of patients with metastatic disease of the liver, routine CT and emulsion enhanced tomography (EOE) were performed in a series of 15 patients prior to surgical exploration for treatment of carcinoma of the colon and rectum. All patients were suspected of harboring hepatic metastasis on the basis of clinical examination, liver function tests or radionuclide scans. EOE consistently demonstrated the nature and location of hepatic defects. Surgical exploration failed to locate one metastasis that was judged to be real because of progressive enlargement on EOE and CT over a period of two years. CT scans detected metastases in three patients subsequently shown to have normal livers and failed to detect disease in one patient subsequently shown to have metastases. EOE contrast material provides a more sensitive and accurate picture of metastatic liver involvement from carcinoma of the colon and rectum than is available on routine CT. The information provided by the results of this test can be useful in preoperative planning when treatment of disease of the liver is considerable feasible.

Hepatic resection for metastases of the colon and rectum

Hepatic resection is the treatment of choice for a solitary metastatic deposit from a primary carcinoma of the large intestine in the absence of extrahepatic disease. This study was done to evaluate hepatic resection in the treatment of multiple hepatic metastases from carcinoma of the colon and rectum. Sixty-two patients underwent hepatic resection with an over-all operative mortality of 10 per cent, but a recent (1968-1981) mortality of 2 per cent. Three, five and ten year survival rates were 50, 34 and 21 per cent, respectively. No significant differences in survival patterns were noted comparing site (colon versus rectum), time interval from diagnosis of the primary to diagnosis of metastases (synchronous versus metachronous), sex (male versus female), size of the metastatic lesion (less than 5 centimeters versus greater than or equal to 5 centimeters) or number of metastatic lesions (single versus multiple). The pathologic stage of the primary carcinoma of the large intestine significantly (p less than 0.05) influenced survival patterns after hepatic resection with Dukes' B primary tumor having a median survival time of 123 months versus 27 months for patients with Dukes' C primary tumor. Sixty-seven per cent of those with a recurrence did so within the liver. Adjuvant chemotherapy had no demonstrable effect on survival patterns. Further improvement in survival statistics will require more sensitive staging procedures and effective adjuvant therapy, particularly for patients with Dukes' C primary carcinoma of the large intestine.

The implantable "Infusaid" infusion pump. The Sydney experience using 5-fluorouracil

The experience is reported of the use of the totally implantable "Infusaid" infusion pump in the treatment of 14 patients in our combined clinics for metastatic carcinoma in the liver by means of the antimetabolite 5-FU. At the time of this study the more active antimetabolite 5-FUDR was not available. A comparison is made of overseas reports of the use of 5-FUDR in the Infusaid infusion pump with the experience, in our clinic, of the use of 5-FU.

[The usefulness of CT in the preoperative diagnosis of metastatic lung nodules--a study with resected cases]

The reliability of the preoperative CT diagnosis was studied in patients with pulmonary metastases from osteosarcoma and colorectal cancer as compared with surgical and pathological findings. Seventy-six lesions among 111 surgically proven metastatic nodules were detected preoperatively by CT. But the predictive rate varied greatly depending upon the site and size of the lesions. CT is not so useful in subpleural and apical sites or with nodules of less than 0.2 cm in diameter.

A new technique for hepatic infusional chemotherapy

Constant-infusion intra-arterial chemotherapy is associated with a significantly greater tumor response rate and perhaps an improved survival rate. Many intra-arterial drug delivery systems have been described, the most popular of which is the implanted Infusaid pump. Unfortunately, this is an expensive device that requires considerable experience in its implantation and maintenance. This paper describes a simplified, inexpensive technique, which can comfortably and reliably provide intra-arterial hepatic chemotherapy to patients treated in most moderate-size community hospitals. Implantation requires angiography and a minor surgical procedure. Maintenance of the system is easy and inexpensive. While use of the Infusaid pump is preferable, this technique is a reasonable alternative for the following: 1) patients with very poor hepatic function, 2) patients who cannot afford the implanted pump, 3) patients who have concomitant extrahepatic tumor, 4) patients with noncolorectal metastasis to the liver, and 5) patients treated at hospitals that do not have implanted pump capabilities.

Modification of HT 29 cell response to the vasoactive intestinal peptide (VIP) by membrane fluidization

We used liposomes made with phospholipids of fatty acid chain length ranging from C12:0 to C16:0 to modify the cAMP dependent protein kinase (PK) activity of HT 29 cells induced by VIP or forskolin. Both VIP and forskolin effects were inhibited in dilauroylphosphatidylcholine (DLPC) treated cells. PK activity was slightly lowered when cells were treated by dimyristoylphosphatidylcholine (DMPC) liposomes. However neither VIP nor forskolin-induced PK activities were affected with dipalmitoylphosphatidylcholine (DPPC) liposomes. Furthermore, the binding of [125I]VIP to DLPC treated cells was drastically lowered whereas no change was observed when cells were incubated with DMPC or DPPC liposomes. On the other hand, the interaction of HT 29 cells with DLPC vesicles provoked a decrease in membrane cholesterol content with subsequent increase in membrane fluidity. These findings provide evidence that, in HT 29 cells, the mechanisms of VIP-receptor interaction and of adenylate cyclase activation is lipid dependent and is regulated by membrane fluidity.

[The CT scan coupled to the injection of lipiodol into the hepatic artery. Preliminary trial]

A preliminary study of CT findings for 13 malignant liver tumors evaluated after intra-arterial hepatic lipiodol injection is presented. Comparison with ultrasound, conventional CT before and after contrast material injection, and arteriography revealed the superiority of intra-arterial lipiodol injection coupled with CT examination for both the detection of hepatomas and disease extension workups, thanks to the detection of small multifocal lesions. There is no lipiodol uptake by the tumor in cases of metastases or cholangiocarcinoma. The same technique can be applied to non-surgery patients for therapeutic hepatic artery injections of an extemporaneous lipiodol emulsion, hydrosoluble contrast materials and oncostatic drugs. A review of over 100 cases in the Japanese literature emphasizes the efficacy of this therapeutic approach.

Regional intra-arterial chemotherapy of metastatic liver cancer

The rationale of regional intra-arterial chemotherapy of metastatic liver cancer is based on the possibility of providing higher levels and longer exposure time of the tumor to drugs. The recent availability of a totally implantable portable pump (Infusaid) had greatly reduced the catheter-related complications with very good patient compliance. An extensive review of the published results in colorectal carcinoma does not allow us to reach any firm conclusion on the validity of regional treatment: many authors report high response rates and satisfactory long term control of liver disease, but impact on survival is questionable because of extrahepatic tumor progression. Prospective randomized trials comparing systemic versus regional plus systemic chemotherapy are needed. Finally, our personal experience in colorectal and breast cancer is presented.

A microtitre cytotoxicity assay useful for the discovery of fermentation-derived antitumor agents

A microtiter cytoxicity assay using mammalian cell lines was developed to detect fermentation-derived antitumor agents. Two murine (AKR, B16) and four human (HTB-31, KB, MOSER, RCA) cell lines were used to evaluate 2000 fermentation broth supernatants. The mammalian cell lines tested showed different spectra for fermentation broth activity, as predicted by responses to known antitumor agents. Data were compared with standard antimicrobial assays historically used to screen for antitumor activity for this set of 2000 broths. There was an overlap of approximately 30% of broths identified as containing in vitro bioactivity by the two assay systems. Sixty-three antimicrobially active broths were tested for activity in P388 in vivo; the cytotoxicity assay predictive rate (40%) was twice that of the antimicrobial assays.

The biological relevance of HPLC-purified vasoactive intestinal polypeptide monoiodinated at tyrosine 10 or tyrosine 22

Three major forms of monoiodinated VIP (M125I-VIP) were isolated after chloramine-T iodination and HPLC purification. The iodinated tyrosine residue was located in each form of M125I-VIP using arginase C and trypsin digestion for obtaining defined fragments containing only one tyrosine residue. The HPLC isolated iodinated fragments thus obtained were used for HPLC comigration studies with iodinated synthetic C and N terminal VIP fragments and for amino acid analysis. The first two eluting peaks 1 and 2 are (M125I-Tyr10-VIP); peak 1 has an oxidized methionine; peak 3 is a (M125I-Tyr22-VIP) which also has an oxidized methionine. A reduced counterpart of peak 3 named peak 4 was isolated by further HPLC analysis. The ability of the different species of M125I-VIP to stimulate adenosine cyclic 3',5'-phosphate (cAMP) production in transformed colonic cells in culture (HT-29) was compared to that of native VIP. The mean potencies of the M125I-VIP species expressed as a percentage relative to the potency of native VIP were, peak (1): 0.98; (2): 0.84; (3): 1.38; (4): 1.48, in the range of concentrations tested (2-60 pM). The M125I-Tyr22-VIP are significantly more active than native VIP (P less than 0.01). Oxidation of methionine or iodination of tyrosine 10 does not significantly modify the biological activity of VIP. We conclude that iodination of Tyr-22 located in the apolar helical COOH-terminal of VIP increases the effectiveness of VIP interaction with its receptors. Thus the tyrosyl residue and the localized hydrophobic features of VIP are critically involved in the function of this neurotransmitter.

Avoidance of gastroduodenal toxicity in patients receiving hepatic arterial 5-fluoro-2'-deoxyuridine

Gastroduodenal inflammation and ulceration have been frequently observed in patients receiving continuous hepatic arterial infusions of 5-fluoro-2'-deoxyuridine (FUDR) for liver malignancy. Thirty-five patients with metastatic colon cancer received hepatic arterial FUDR administered with implanted infusion pumps. At surgery, particular care was taken to identify and divide those vessels arising from the hepatic arteries distal to the point of cannulation that supplied the superior border of the distal stomach and proximal duodenum. None of the patients developed signs or symptoms of gastritis or ulcer attributable to chemotherapy. We contend that gastritis and ulcer in patients receiving hepatic arterial FUDR are due to misperfusion of drug into the upper gastrointestinal tract and that these complications can be largely avoided by use of appropriate surgical techniques.

Hepatic resection for metastatic colon and rectal cancer. An evaluation of preoperative and postoperative factors

Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate.

Sclerosing cholangitis after continuous hepatic artery infusion of FUDR

Eight of 46 (17.4%) patients treated in our trial of continuous hepatic artery infusion (CHAI) of fluorodeoxyuridine (FUDR) by Infusaid pump developed biliary strictures. The lesions were clinically, radiographically, and pathologically identical to the idiopathic sclerosing cholangitis frequently seen in association with inflammatory bowel disease. Treatment included immediate cessation of intraarterial FUDR, and surgical or percutaneous drainage of the biliary tree if it was dilated. Two of the eight patients died of the complication. Three patients stabilized after biliary system drainage, and two patients improved on observation only. The pathogenesis of this complication is not understood. This report details the clinical and pathological features of this entity.

Clinical trial of adjuvant chemotherapy after surgical resection of colorectal cancer metastatic to the liver

Adjuvant chemotherapy consisting of 5-fluorouracil and semustine was given to 26 patients who had undergone resection (with curative intent) of hepatic metastatic lesions from a primary colorectal carcinoma. Our objective was to obtain preliminary observations regarding the effectiveness of this regimen for improving the long-term survival associated with hepatic resection alone in these patients (the overall 5-year survival after hepatic resection is 25% at our institution). At the time of analysis, the malignant disease had progressed in 19 of our patients, and 17 patients had died. For all patients who receive adjuvant chemotherapy, the median duration of survival is 34 months, and the estimated 5-year survival is 15%. Statistical analysis indicated no significant advantage in survival for the study patients in comparison with 26 control patients who were treated with hepatic resection only and were closely matched for prognostic factors. Because 5-fluorouracil plus semustine conferred no apparent beneficial effects as an adjuvant treatment in this exploratory study, we do not recommend a definitive randomized trial of this regimen.

In vitro chemosensitivity tests on human tumor xenografts by clonogenic assay: the combined use of mitomycin C with alpha-interferon or gamma-interferon

Using the human tumor clonogenic assay technique, the effects of Mitomycin C plus either alpha-interferon or gamma-interferon were studied against five human tumor xenografts serially transplanted into nude mice (three gastric and two colon cancers). When the survival fraction found with the drug combination was smaller than the multiplication of survival fractions with either drug alone, the combined effect was defined as synergism. Similarly, antagonistic effect was defined when the survival fraction of drug combination was larger than the larger one observed in either interferon or Mitomycin C alone. Four out of five human tumor xenografts (three gastric and one colon cancers) showed synergistic effects in combination of alpha-interferon with Mitomycin C. Though two gastric cancer xenografts exhibited synergistic effects in combination of gamma-interferon with Mitomycin C, antagonistic effects, which was not found in combination of alpha-interferon with Mitomycin C, were observed in one gastric cancer and one colon cancer xenografts.

Treatment of colorectal cancer hepatic metastases by hepatic artery chemotherapy

Our clinical experience with 69 patients with metastatic colorectal cancer to the liver treated with hepatic artery chemotherapy is reviewed. All patients have had a minimum of six months follow-up. The Infusaid implantable drug delivery system was used by direct laparotomy in one third, and via the transaxillary approach in the remaining two thirds. Two thirds of the patients had at least 25 percent of the liver replaced with tumor. Chemotherapeutic agents included FUdR, mitomycin C, and BCNU. The overall response rate was 51 percent and 69 percent for the three-drug combination. Efficacy was not different in patients who had received prior systemic fluorouracil. Median survival from start of hepatic artery chemotherapy was one year.

[Surgical treatment of hepatic metastases]

355 patients with hepatic metastases were followed between 1970 and 1984 at the Hôpital Paul Brousse. 132 cases were of colonic origin: 32 were treated by means of hepatic resection (including 5 metastasectomies), 7 by intra-hepatic anastomosis and 5 by devascularisation. The other 88 patients did not receive any surgical treatment. In 148 of the other 233 patients, the metastases were of non colonic gastro-intestinal or rectal origin and in the remaining 75 cases the metastases were derived from another site. 12 patients were treated by hepatic resection, 6 by devascularisation, 2 by intra-hepatic anastomosis and 2 by intubation of the bile ducts. One patient (0.5 per cent) died during the post-operative period following these operations. The long term survival was 73 per cent at 1 year and 29 per cent at 3 years. In conclusion, some patients are definitely cured by hepatic resection, although these patients cannot be predicted. For this reason, the surgeon's role consists of trying to decrease as much as possible the operative risk and to propose this type of treatment to all patients in which it may be beneficial.

The implanted pump in metastatic colorectal cancer of the liver. Risk versus benefit

Forty patients with colorectal cancer metastatic to the liver were treated with an implanted pump for hepatic artery perfusion. Regional chemotherapy utilized floxuridine with half of patients also receiving monthly cisplatin. Follow-up was 13 to 29 months. Responses to treatment occurred in 19 patients (47 percent) and correlated with survival of more than 1 year. Several factors produced significant reductions in survival: presence of extrahepatic disease, large tumor volume, jaundice, ascites, or both, and elevated liver chemistry values. These prognostic factors should govern patient selection. Toxicity included gastritis, peptic ulcer, disruption of arterial integrity, and severe chemical effects on the hepatic cells, the bile ducts, and the gallbladder. Over half of the patients had serious toxicity. Two died from biliary strictures without autopsy evidence of tumor. Steps to avoid life-threatening toxicity include ligation of all hepatic artery branches to the stomach, prophylactic cholecystectomy, and reduction of chemotherapy at the first sign of toxicity.