Patterns of failure after surgical cure of large liver tumors. A change in the proximate cause of death and a need for effective systemic adjuvant therapy

During a period of 7 years, we have aggressively treated liver tumors whether primary or metastatic. Our experience after 43 curative major liver resections has shown an excellent overall survival: 34 of 43 patients still alive a median of 12 months after liver resection (patient ages ranged from 21 to 85 years, median 57 years). Nineteen patients underwent right hepatic lobectomy, 9 trisegmentectomy, 5 left hepatic lobectomy, 5 extended left hepatic lobectomy, 4 right lobectomy plus left lobe wedge resection, and 1 patient underwent a major hilar wedge resection. Two patients died from sepsis and hepatic failure on or before the 60th postoperative day. One patient with no evidence of recurrent colorectal cancer was lost to follow-up after 2.5 years. One patient died without cancer 12 months after left hepatic lobectomy for colon cancer metastases. Cumulative survival for the entire series and for patients after resection of colorectal cancer metastases was the same: 1 year survival 90 percent; 2 year survival 75 percent, and 3 year survival 65 percent. Seventeen of 30 patients remain disease-free after resection of liver metastases. Of the 13 who had recurrence, 8 are still alive. Ten recurrences were outside of the residual liver (predominantly multiple pulmonary metastases). One recurrence was in the right hemidiaphragm, and only three were in the residual or regenerated liver. Serial carcinoembryonic antigen analysis was the best indicator of recurrence in these 13 patients, 12 of whom were asymptomatic. These data confirm that major liver resection can be performed with minimum postoperative mortality (4.7 percent in this series). More importantly, the majority of patients were cured of their liver metastases. The next goal should be the initiation of adjuvant systemic therapy trials after liver resection in such patients.

A proposed classification system for liver metastasis from colorectal carcinoma

A proposed classification system for liver metastasis from colorectal carcinoma is presented. This proposed system utilizes the prognostic factors of the extent of hepatic involvement by metastasis at the time of laparotomy, performance status, preoperative serum alkaline phosphatase level, and the presence or absence of extrahepatic intraabdominal disease at the time of laparotomy. Because of the several different modes of treatment for liver metastasis from colorectal carcinoma, it is necessary that a liver classification system be adopted so that different treatment groups will be comparable. The proposed system utilizes the extent of hepatic involvement by metastasis at laparotomy with a division into three subsets of patients described by a Roman numeral. Roman numeral I represents less than or equal to 25 per cent involvement of the liver by metastasis; Roman numeral II represents greater than 25 per cent but less than or equal to 50 per cent involvement by liver metastasis, and Roman numeral III represents greater than 50 per cent involvement by liver metastasis. An Arabic subscript number is used to describe the patients' performance status. Alkaline phosphatase levels are described by a subscript letter with a representing less than two times normal alkaline phosphatase, b representing greater than two times, but less than four times normal levels, and c representing greater than four times normal levels. At the time of laparotomy extrahepatic intra-abdominal disease is represented by the superscript letter E.

Sheathed catheter system for fluoroscopically guided retrograde catheterization, and brush and forceps biopsy of the upper urinary tract

A sheathed (coaxial) ureteral catheter has been designed for use in fluoroscopically guided retrograde procedures. Once the catheter has been inserted into the ureter the inner section is removed, leaving a semiflexible sheath as a conduit for biopsy forceps, curved catheters and other instruments. The sheath facilitates ureteral stenting, forceps biopsy of the renal pelvis and brush biopsy of all calices. The sheath also helps in percutaneous stone extraction by allowing retrograde passage and removal of balloon catheters with the patient in the prone position. Cystoscopy is needed initially to insert the catheter but not to pass instruments through the sheath. Thus, procedures can be completed in a standard fluoroscopy room.

Resection of the liver for metastatic cancer

In a 16 month period, 20 resections of the liver were performed by this author at a community hospital, ten of which were for metastatic cancer. At the end of two years, nine of the ten patients in whom the metastatic liver disease was resected were alive. The longest survival time presently is 43 months following resection of the liver, and this patient is clinically free of disease. Extensive resections of the liver for metastatic carcinoma of the liver have previously been done primarily at major cancer centers. Recent improvement in technology and support services available at community cancer centers is rapidly making such resections a safe and preferred method of managing isolated metastases to the liver.

Reserpine-induced alterations in mucus production and calmodulin-binding proteins in a human epithelial cell line

The characterization of a mucus-producing human cell line (HC-84) derived from a colon carcinoma and its response to in vitro reserpine treatment is reported. Mucous granules were demonstrated within these cells on the basis of electron microscopic examination and incorporation of [3H]glucosamine with subsequent autoradiographic analysis. Fluorographic analysis of total HC-84 cell protein after incubation with [3H]glucosamine indicated that the majority of tritium was incorporated into two proteins with molecular weights of 115 and 120 kD. When total HC-84 protein was subjected to immuno-blot analysis utilizing rabbit antibody against human intestinal mucus, only these two proteins (115K and 120K) reacted positively, indicating a direct correlation between [3H]glucosamine incorporation and mucus production. Immunofluorescence localization of mucus within HC-84 cells utilizing this same antibody resulted in a punctate pattern of fluorescence within the cytoplasm. Treatment of HC-84 cells with 30 microM reserpine for 7 days resulted in a three-fold increase in mucus production compared with controls. There was also a concomitant loss of a 30K calmodulin-binding protein in cells treated with reserpine. These cells represent a useful system for studying the effect of reserpine on the processes of mucus synthesis and secretion.

Targeting of liposomes: monoclonal antibodies coupled to phospholipid vesicles provide selective transfer of trapped reagents into cultured cells

Monoclonal antibodies were incorporated in small unilamellar vesicles by means of ultrasonic irradiation. In order to increase the incorporation efficiency, the immunoglobulins were previously treated at low pH (pH 2), following recent suggestions on the existence of a lipid soluble conformational isomer for serum IgG. The lipid to protein ratios obtained were comparable to the values obtained by other authors using covalent coupling of the antibody to the lipid matrix. Liposome-incorporated monoclonal antibodies directed towards carcinoembryonic antigen (CEA) provided increased transfer of the fluorescent dye carboxyfluorescein from liposomes into cultured human colon carcinoma cells. Another independent experiment was performed on the drug-resistant CHO cell line B30, using a monoclonal antibody to a cell surface marker of drug resistance. Selective liposome mediate drug killing was observed following incubation of the cells with liposomes containing the antitumor agent drug, daunorubicin.

In vitro drug sensitivity of tumor cells is correlated with drug-induced inhibition of DNA synthesis

The objective of this study was to develop a rapid in vitro method for predicting the response of human tumors to anticancer drugs. In this study an attempt was made to correlate the drug effects on the relative incorporation of (3H) thymidine (ThdR) into DNA with the sensitivity of tumor cells to that drug. The results of the study indicate that following treatment of the cells with adriamycin (ADR) or 1-(2-chloroethyl)-3-(4-methyl cyclohexyl)-1 nitrosourea (MeCCNU), there was a significant inhibition of DNA synthesis in the drug-sensitive cells. However, the inhibition was relatively small in the drug-resistant cells. Following cytosine arabinoside (Ara-C) treatment, a dramatic recovery in the rate of DNA synthesis was seen in Ara-C-resistant cells but not in cells sensitive to Ara-C. Thus, the method described in this study appears to be capable of distinguishing whether a tumor cell line is sensitive or resistant to a given drug.

Computed tomography for metastatic lesions of the osseous pelvis

Significant metastatic lesions of the osseous pelvis can be easily missed by conventional x-ray studies. Although the radionuclide bone scan is the method of choice for detection of metastatic lesions of the osseous pelvis, computed tomography should be used as a complementary study in certain patients.

In vitro translational activity of messenger RNA following treatment of human colon carcinoma cells with sangivamycin

Total mRNA from human colon carcinoma cell line HT-29 treated with the pyrrolopyrimidine antibiotic, sangivamycin(7-deaza-7-carboxamidoadenosine), was assessed in vitro using a reticulocyte lysate translation system. Under conditions of known drug-induced cell lethality, sangivamycin-modified mRNA showed a diminished translational capacity. The decreased activity of drug-modified mRNA increased in proportion to the time-dependent cytocidal effects of sangivamycin in this cell line. These data suggest that the lethal effects of this drug may be associated, in part, with a reduced ability of drug-modified mRNA to sustain translation in situ.

Portal scanning for liver metastases in colorectal carcinoma

In a prospective study over 2 years, 14 patients suffering from colorectal cancer had radionuclide liver scans performed via the portal route. Technetium-99m-labelled macro-aggregates of human serum albumen were injected via the cannulated umbilical vein, distributed through the portal system of the liver and their presence recorded by a gamma camera. Of 11 patients with clinically normal livers and no metastases found at laparotomy, five had abnormal portal scans, two of these dying from multiple liver metastases during follow-up. None of the patients with normal portal scans died with liver metastases within the 2-year study period.

[Intra-arterial infusion chemotherapy for metastatic hepatic tumor of colo-rectal cancer]

Effect of intraarterial infusion chemotherapy on metastatic liver tumor (28 cases) of colo-rectal cancer was compared with that of oral or intravenous chemotherapy (8 cases). The efficacy of the selective intraarterial chemotherapy was 40%, non-selective intraarterial chemotherapy, 11.1% and oral or intravenous chemotherapy 0%, respectively. Mean survival time of the intraarterial chemotherapy was 11.1 months, and that of oral or intravenous chemotherapy was 6.0 months, suggesting greater efficacy of the intraarterial infusion chemotherapy. Especially, the selective intraarterial infusion chemotherapy will be an effective therapy for inoperable metastatic liver tumor.

Hepatic trisegmentectomy for metastatic colorectal cancer

Radical hepatic resections for metastatic liver disease have been infrequently done and widely criticized. Seven patients are evaluated who had trisegmentectomies performed for extensive liver metastases from colorectal primaries. There was 1 postoperative death. Of the 6 evaluable patients. 4 (66%) were alive at 12 months. Mean survival currently exceeds 20 months with the longest survivor alive at 41 months. Radical hepatic resections may offer this group of "hopeless' patients many months of productive life.

Peculiar ultrastructural features in the cytoplasm of cells from human effusions associated with malignant disease

A peculiar structure revealed by the electron microscope in a few cells from two human pleural fluids, showing the morphologic features of metastasizing cancer cells in effusions, is described. It has the appearance of a rod-shaped pentalaminary structure approximately 25-35 nm thick formed by an outer double membrane, surrounding a central, more dense axis showing transverse striations at about 10-nm intervals. The double membrane often exhibits a terminal expansion connected with the endoplasmic reticulum and it is sometimes associated with microfilaments. These structures could be a variant of or represent a step in the formation of confronting cisternae, but the periodic striations they show in the more dense lamella give them some resemblance to a Langerhan's cell granule. To date, such striations have not been seen in confronting cisternae.

[Significance of major hepatectomy for metastatic liver malignancy]

Major hepatectomies for 24 metastatic liver tumors including 13 of colo-rectum origin were performed. The cumulative survival rate in 23 cases excluding one case of operative death is 67.4%, 44.3% and 29.1% for 1, 3 and 5 year, respectively. The significant difference was observed in survival rate between H1(n = 16) and H2 - 3 (n = 7). In colo-rectum origin group the survival rate of solitary H1 was better than that of multiple H1 significantly. The Japanese Colon Cancer Research Meeting reported the relative survival rate of 33 cases of H1 colo-rectum origin including 2 of hepatectomized cases. The survival rate of the present 11 hepatectomized cases in the same category is significantly better than that in the report of Colon Cancer Research Meeting, which shows utility of hepatectomy for H1 metastatic tumor. Although in H2 - 3 group 5 of 7 cases died within one year after hepatectomy, 2 particular cases survived 22 months and 57 months. The primary lesions of these two were leiomyosarcoma of the jejunum and carcinoid tumor of the lung. The indication for major hepatectomy for metastatic liver malignancy is the tumor of H1, especially solitary and the slow growing or some kind of functioning tumor.

Cordycepin analog of (A2'p)2A: evidence that it functions as a prodrug of cordycepin

The effect of the cordycepin trimer analog of (A2'p)2A on cell growth, cell viability and nucleic acid synthesis was assessed in human colon carcinoma cell line HT-29 in vitro. The cordycepin analog, (3'dA2'p)2(3)'dA reduced 24 hr cell growth by 50% at 10(-4)M and decreased cell viability by 98% under these conditions. The cytotoxicity and inhibitory effects of (3'dA2'p)2(3)'dA on DNA and RNA synthesis were potentiated 5-10-fold by the presence of the adenosine deaminase inhibitor, 2'-deoxycoformycin, and closely resembled those of the parent drug, cordycepin. Chromatographic analyses of the stability of (3'dA2'p)2(3)'dA in the tissue culture medium indicated that it was hydrolyzed to the dimer and monomer forms with a half life of approximately 2 hr. No intact (3'dA2'p)2(3)'dA was detectable intracellularly, but large concentrations of cordycepin nucleotide metabolites were formed, particularly in the presence of 2'-deoxycoformycin.

In vivo induction of neoplastic growth in nude mouse connective tissue adjacent to xenografted human tumors

Induction of neoplastic growth of murine stroma cells within the human tumor xenograft was observed after serial passage of CEA and beta 2-microglobulin producing human colonic SLu tumor xenografts in nu/nu BALB/c mice. Mouse tumors within the human tumor xenografts were identified using specific immunohistologic staining techniques for mouse histocompatibility marker or human CEA. These mixed tumors could be distinguished from normal human tumor xenografts by a different relationship between development of the tumor marker in the serum and tumor size. We were able to establish transformed murine cells from human xenografts, either induced by SC injection of 1 X 10(6) tumor cells of the SLu cell line or by human SLu or mammary carcinoma tissue serially passaged in athymic animals. The established human and murine cell lines were characterized by cytogenetic methods. Transformed murine cells were then continuously passaged in tissue culture. The transformed mouse fibroblasts proved to possess tumorigenicity in nude mice. In the case of SLu-derived mouse tumor cells, tumors also developed in the immunocompetent BALB/c mice using 1 X 10(6) to 5 X 10(6) tumor cells for SC transplantation.

Role of resection in the management of metastases to the liver

The results of 22 hepatic resections for metastatic disease are reviewed. There were no operative deaths and survival was encouraging. Life-table analysis of all 22 patients predicted a 5-year survival of 56.4%, and if 16 patients who had primary colorectal tumours are considered separately, the expected 42-month survival was 42.2%. Patients with a single metastasis generally lived longer, and there was no difference in survival between hepatic metastases resected synchronously or metachronously. The authors recommend an aggressive approach to the treatment of hepatic metastases.

[Surgical treatment of pulmonary metastasis]

We carried out a study on the surgical treatment and indications, and organ specificities of metastatic pulmonary cancer treated in this hospital until 1981. As for the indications for surgical treatment, the conditions that the primary lesion should be controlled, and that there are no metastases to parts other than the lungs are the same as before. However, in the case of the uterus and colon, it is considered that the indications may be further extended to include bilateral resection should there be only 1-2 lesions on both side. Recently, we carried bilateral resection on several cases, and managed to obtain satisfactory results.

Effect of micronutrients, antioxidants and related compounds on the mutagenicity of 3,2'-dimethyl-4-aminobiphenyl, a colon and breast carcinogen

The possible antimutagenic effects of butylated hydroxytoluene (BHT), ethoxyquin, disulfiram, indole-3-carbinol, indole-3-acetonitrile, sodium selenite and alpha-tocopherol on 3,2'-dimethyl-4-aminobiphenyl-induced mutagenicity were studied using the Ames Salmonella/mammalian microsome assay system with strains TA98 and TA100. All seven compounds were nonmutagenic in both bacterial tester strains. The addition of or 50-250 micrograms of sodium selenite, 5-50 mg of alpha-tocopherol or 50-250 microgram of BHT per plate inhibited DMAB-induced mutagenicity in TA98 and/or TA100. Ethoxyquin, disulfiram and indole-3-carbinol increased DMAB-induced mutagenicity in TA100, whereas these compounds had little or no effect in TA98-3-acetonitrile had very little effect in either strain.

[Surgical resection of hepatic metastases of cancers of the colon and rectum]

Surgical resection of metastatic colorectal carcinoma remains controversial. Few patients are eligible for resection since out of 2,725 patients operated upon for colonic or rectal adenocarcinomas in 11 years, 14 p. 100 had liver metastases and only 0.9 p. 100 could be resected. Twenty-nine patients who have undergone partial liver resections for metastatic colorectal carcinomas are reported. The primary neoplasms were Duke's class B(8), Dukes' C (12) or extended to another organ (5). Local extension was unknown in 4 cases. Eight metastases were unique and measured less than 5 cm; seven, although unique, measured more than 5 cm. Fourteen patients had multiple but unilateral hepatic deposits. Twenty major resections and 9 wedge liver resections were performed. One patient died (3.4 p. 100). Average hospital stay was 19 days. Pain was relieved by surgery in 10/11 patients. In 19 patients follow-up exceeds one year: six underwent the resection of a unique and small liver metastasis: one died after 3 and a half years and two are doing well 4 and 10 years after surgery. Thirteen patients underwent major liver resections for large or multiple liver deposits: 9 lived less than one year and 4 are alive after 16, 19, 26 and 60 months respectively. All patients with a follow-up of less than one year are alive. The low operative mortality, the efficacy in relieving pain, and the prolonged survival which can be obtained in some cases justify an aggressive surgical approach to colorectal liver metastases.