Automated protamine dose assay in heparin reversal management after cardiopulmonary by pass

BACKGROUND

To evaluate the impact of automated Protamine Dose Assay (PDA) performed with Hemochron 8000 (International Technodyne Company, Edison, NJ) on the management of heparin reversal after cardiopulmonary bypass (CPB). PDA was compared with empirical protamine to heparin ratio with regard to calculation of the protamine dose, and the sensitivity of PDA and ACT to residual circulating heparin after protamine administration was investigated too.

METHODS

DESIGN

prospective and randomized study.

SETTING

cardiac surgical center of a General Hospital.

PARTICIPANTS

50 patients undergoing elective cardiac surgery with CPB.

INTERVENTIONS

after CPB patients randomly received protamine according to our standard empirical ratio of 1 mg. protamine/100 U. heparin (group S, 24 patients), or to PDA result (group T, 26 patients) based on protamine titration method of determining circulating heparin. After protamine administration ACT and PDA were performed to assess heparin reversal and detect residual circulating heparin. Based on the PDA result, additional protamine was administered in both groups when required.

MEASUREMENTS

in both groups basal and post-heparin ACT values, protamine doses, ACT and PDA after protamine administration were measured.

RESULTS

The protamine dose was significantly lower (30%) in patients treated according to PDA. In 20% of patients showing normal ACT PDA revealed still circulating heparin, and additional protamine was required. In all other cases ACT and PDA both confirmed heparin reversal.

CONCLUSIONS

PDA allowed us to administer a significantly lower amount of protamine. This can reduce incidence of adverse effects of over- and under-infusion of protamine. PDA also proved to be more sensitive than ACT in detecting residual circulating heparin after protamine administration.

Comparative analysis of CA 242 and CA 19-9 serum tumor markers in colorectal cancer patients. A longitudinal evaluation

OBJECTIVE

Following the encouraging results obtained on CA 242 as an adjunctive marker for colorectal cancer this study was designed to compare the clinical behavior of CA 242 to that of its related marker CA 19-9.

PATIENTS AND METHODS

Sera from 630 patients with benign (n = 201) or malignant (n = 429) colorectal diseases were evaluated. Moreover, 50 patients with colorectal cancer were longitudinally monitored during. post-surgical follow-up for either a minimum of 5 years or until time of recurrence. Serum CEA, CA 19-9 and CA 242 levels were determined before treatment and at each scheduled follow-up.

RESULTS

The distribution of CA 242 levels in colorectal cancer patients demonstrated a similar positivity rate (32.9%) compared to that of CA 19-9 (29.8%), although both sensitivities were lower than that of CEA (43.8%). Moreover, elevated CA 242 serum levels were found in metastatic disease (58.2%). A longitudinal evaluation demonstrated that serum CEA, CA 19-9 and CA 242 levels were elevated in 63.9%, 63.9% and 66.7% of recurrences. Combined evaluation of CEA, CA 19-9 and CA 242 serum levels in the overall population demonstrated a complementarity of CEA with the latter two markers. Conversely, a highly significant correlation was observed, suggesting that the two assays might recognize the same macromolecular complex.

CONCLUSION

CA 242 determination does not seem to offer a particular advantage over CA 19-9, while CEA remains the marker of choice in monitoring colorectal cancer patients.

Anthropometric and nutritional assessment in Italian elderly subjects

The aims of this anthropometric study on 486 non-institutionalized subjects aged 60 and over were to assess the body mass index (BMI), to evaluate possible sex and age-linked differences of BMI and to find whether there were any correlations with systolic and diastolic blood pressure. To this end, the subjects were divided into three age groups: A: 60-69 years, B: 70-79 years and C: > or =80 years old. The results showed a high prevalence (74%) of overweight or clearly obese subjects (BMI >25.1 for men and BMI > 23.9 for women) (70% male and 77% female). Both the BMI and diastolic blood pressure showed a decreasing trend in the three age groups and were significantly correlated in the total population (p < 0.001). A dietary investigation using a 24-hour recall method, repeated on three separate days, was carried out on a subsample of 90 subjects, selected at random from the total population. They underwent in-depth anthropometric assessment (BMI, four skinfolds, mid-arm, waist and hip circumferences, midarm muscle and fat areas, body fat percent). The trend of the anthropometric assessment reflected that of the total population. Total energy intake in both sexes did not significantly differ from the Italian RDA (Recommended Dietary Allowance). As regards the three macronutrients, no significant differences in protein and carbohydrate intakes were found between the sexes. However, in the females, fat intake was over the Italian DRA (30%) and below it in the males. Calcium intake was lower than the Italian RDA (1,000 mg/day) in most males (77%) and females (89%). However, iron and vitamin intakes were adequate in most subjects. As regards age-linked differences, there were non significant changes in the percentage of energy intake from proteins of the males whereas this decreased with age and was significantly different (p < 0.05) in the females. No significant differences were found in the percentage of energy intake from carbohydrates and fats.

Peritonectomy and hyperthermic antiblastic perfusion in the treatment of peritoneal carcinomatosis

AIMS

Some low-grade malignant tumours arising in the abdomen tend to remain loco-regionally confined to peritoneal surfaces, without systemic dissemination. In these cases complete surgical tumour cytoreduction followed by intra- or post-operative regional chemotherapy has curative potential. The aim of this study was to evaluate the outcome for patients treated in this way.

METHODS

Peritonectomy was performed, involving the complete removal of all the visceral and parietal peritoneum involved by disease. After peritonectomy, hyperthermic antiblastic perfusion was carried out throughout the abdominopelvic cavity for 90 min, at a temperature of 41.5-42.5 degrees C, with mitomycin C (3.3 mg/m2/l) and cisplatin (25 mg/m2/l) (for appendicular or colorectal primaries), or cisplatin alone (for ovarian primaries). Alternatively, the immediate post-operative regional chemotherapy was performed with 5-fluorouracil (13.5 mg/kg) and Lederfolin (125 mg/m2) (for colonic or appendicular tumours) or cisplatin (25 mg/m2) (for ovarian tumours), each day for 5 days.

RESULTS

Thirty-five patients affected by extensive peritoneal carcinomatosis were submitted to peritonectomy, with no residual macroscopic disease in all cases except three. Twenty-six patients were able to undergo the combined treatment involving loco-regional chemotherapy. Complications were observed in 54% of the patients and led to death in four of them. At a mean follow-up of 17 months overall 2-year survival was 55.2%, with a median survival of 26 months.

CONCLUSIONS

After a learning curve of 18 months the feasibility of the integrated treatment increased to more than 90%, while mortality decreased dramatically. The curative potential of the combined therapeutic approach seems high in selected patients with peritoneal carcinomatosis not responding to systemic chemotherapy. Careful selection of patients can minimize the surgical risk, but the treatment should currently be reserved for clinical trials.

Treatment of peritoneal carcinomatosis with intent to cure

BACKGROUND AND OBJECTIVES

Low-grade malignant tumors arise in the abdomen, do not infiltrate, and "redistribute" on the peritoneum with no extraregional spreading. In these cases, aggressive surgery combined with localized chemotherapy may provide cure.

METHODS

After removing the tumor with the regional peritoneum en bloc, intraabdominal hyperthermic chemoperfusion was performed throughout the abdominopelvic cavity. Alternatively, early intraabdominal chemotherapy, starting on the first postoperative day, was administered for 5 days.

RESULTS

Forty patients affected with extensive peritoneal carcinomatosis underwent peritonectomy, with no residual macroscopic disease except in four cases. Seventy-five percent of the patients underwent locoregional chemotherapy. Major complications were observed in 40% of the patients and led to death in five; there was a direct correlation to the duration of surgery (P = 0.03). At a mean follow-up of 20 months, the overall 2-year survival was 61.4%, with a median survival of 30 months.

CONCLUSIONS

After a learning curve of 18 months, the feasibility of the integrated treatment increased to greater than 90%, and mortality dramatically decreased. The combined treatment resulted in a high survival rate in patients with extensive carcinomatosis who were no longer responsive to traditional therapies.

Treatment of peritoneal carcinomatosis with intent to cure

BACKGROUND AND OBJECTIVES

Low-grade malignant tumors arise in the abdomen, do not infiltrate, and "redistribute" on the peritoneum with no extraregional spreading. In these cases, aggressive surgery combined with localized chemotherapy may provide cure.

METHODS

After removing the tumor with the regional peritoneum en bloc, intraabdominal hyperthermic chemoperfusion was performed throughout the abdominopelvic cavity. Alternatively, early intraabdominal chemotherapy, starting on the first postoperative day, was administered for 5 days.

RESULTS

Forty patients affected with extensive peritoneal carcinomatosis underwent peritonectomy, with no residual macroscopic disease except in four cases. Seventy-five percent of the patients underwent locoregional chemotherapy. Major complications were observed in 40% of the patients and led to death in five; there was a direct correlation to the duration of surgery (P = 0.03). At a mean follow-up of 20 months, the overall 2-year survival was 61.4%, with a median survival of 30 months.

CONCLUSIONS

After a learning curve of 18 months, the feasibility of the integrated treatment increased to greater than 90%, and mortality dramatically decreased. The combined treatment resulted in a high survival rate in patients with extensive carcinomatosis who were no longer responsive to traditional therapies.

Nerve-sparing surgery in rectal cancer: feasibility and functional results

Traditional rectal cancer surgery has been burdened with a high rate of sexual and urinary dysfunctions due to intraoperative injury or the cutting of the sympathetic and/or parasympathetic nerves. The experience acquired in the last ten years with total mesorectal excisions has permitted the use of the "nerve-sparing" technique. The present study regards 239 patients from two surgical centres, most of whom underwent sphincter-saving radical surgery between 1994 and 1998 with the above mentioned technique for resectable colon cancer. Details regarding the technique were recorded in the last 58 patients, in order to examine the severity of the surgical damage. The subgroup with the longest follow-up, which included 36 patients, was diagnostically evaluated by a surgeon, psychologist, urologist and neurologist to analyze the risk of sexual and urinary dysfunctions. A complete nerve-sparing was performed in 86.3% of the cases. The parasympathetic nerve trunks were those most often damaged because of perineural tumor spreading. Partial to complete sexual impotence was observed in 44% of the patients and surprisingly, preoperative dysfunctions were detected by means of the multidisciplinary approach in one third of these patients. Therefore, only 30.5% of the patients presented with strictly postoperative sexual impotency, above all, those who had undergone high-dose preoperative chemoradiation for T3 or T4 middle to low rectal cancer. A prospective study was initiated to evaluate the genitourinary dysfunctions after rectal cancer surgery in all of the clinical phases by means of a multidisciplinary approach aimed at functional recovery and improved quality of life.

Evaluation of multiple bio-pathological factors in colorectal adenocarcinomas: independent prognostic role of p53 and bcl-2

About 40% of patients with colorectal carcinoma will develop local or distant tumour recurrences. Integrated analyses of bio-pathological markers, predictive of tumour aggressiveness, may offer a more rational approach to planning adjuvant therapy. To this end, we analysed the correlation between p53 accumulation, Bcl-2 expression, DNA ploidy, cell proliferation and conventional clinico-pathological parameters by testing the prognostic significance of these variables in a series of 171 colorectal carcinoma patients with long-term follow-up. The relationships among the various bio-pathological parameters, analysed by multiple correspondence analysis, showed 2 different clinico-biological profiles. The first, characterised by p53 negativity, Bcl-2 positivity, diploidy, low percentage of cells in S-phase (%S-phase), a low Ki-67 score, is associated with Dukes' A-B stage, well differentiated tumours and lack of relapse. The second, defined by p53 positivity, Bcl-2 negativity, aneuploidy, high %S-phase and elevated Ki-67 score, correlates with Dukes' C-D stage, poorly differentiated tumours and presence of relapse. When these parameters were examined according to Kaplan-Meier's method, significantly shorter disease-free (DFS) and overall survival (OS) were also observed in patients bearing p53 positive and Bcl-2 negative tumours, in Dukes' B stage. In multivariate analysis, p53 accumulation and Bcl-2 expression emerged as independent predictors of a worse and better clinical outcome, respectively. Our results indicate that, in colorectal adenocarcinomas, a biological profile, based on the combined evaluation of p53 and Bcl-2, may be useful for identifying high risk patients to be enrolled in an adjuvant setting, mainly in an early stage of the disease. Int. J. Cancer (Pred. Oncol.) 84:545-552, 1999.

31Phosphorus magnetic resonance spectroscopy to evaluate medical therapy efficacy in peripheral arterial disease. A pilot study

BACKGROUND

Human and animal studies have shown that propionyl-L-carnitine, increasing carnitine content, improves the energy metabolism of ischemic skeletal muscle. The aim of the study was to evaluate the accuracy of Doppler continuous wave, Treadmill test and 31Phosphorus magnetic resonance spectroscopy in determining the efficacy of propionyl-L-carnitine in patients with peripheral arterial disease.

METHODS

EXPERIMENTAL DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Eighteen male patients with peripheral arterial disease (category 3) and 8 healthy volunteers form the basis of the study. Patients quit smoking, start physical training (2-3 Km walk per day) and were assigned to medical therapy consisting of propionyl-L-carnitine (8 patients) or placebo (10 patients). Patients were studied with Doppler continuous wave, Treadmill test and 31Phosphorus magnetic resonance spectroscopy at day 0 and at day 90. The following parameters were assessed by the principal component analysis: clinical (absolute claudication, ankle brachial index at rest and at 2, 5 and 10 minutes after completing Treadmill exercises) and biochemical (inorganic phosphorus/phosphocreatine ratio and pH profiles at 20% and 50% of the maximum load, the recovery half time of phosphocreatine, number of exercise steps and slope of linear relationship between muscle power and inorganic phosphorus/phosphocreatine ratio).

RESULTS

Final evaluation showed a significant improvement of clinical and biochemical variables (p < 0.05 and p < 0.02 respectively). Breaking down the results on the basis of the two study arms, 31Phosphorus magnetic resonance spectroscopy showed a significant improvement of biochemical variables in the group of patients treated with propionyl-L-carnitine (p < 0.05) and was more sensitive in the evaluation of changes induced by 90-day treatment as compared with the other noninvasive examinations.

CONCLUSIONS

31P-MRS permits the evaluation of muscle metabolic effect induced by PLC after a 90-day-period in patients affected by category 3 of peripheral arterial disease and it is a more sensitive tool in the evaluation of the pharmacological effects of medical therapy.

Preoperative chemoradiation with cisplatin and 5-fluorouracil for extraperitoneal T3 rectal cancer: acute toxicity, tumor response, sphincter preservation

PURPOSE

To evaluate the impact of preoperative external radiation therapy intensified by systemic chemotherapy including bolus cisplatin (c-DDP) and 4-day infusional 5-fluorouracil (PLAFUR-4) on tumor response and sphincter preservation in patients with extraperitoneal T3 rectal cancer with acceptable toxicity, and to compare the results to our previous experience with bolus mitomycin c (MMC) and 4-day infusion 5-FU (FUMIR).

METHODS AND MATERIALS

Between October 1995 and March 1998, 40 consecutive patients with resectable extraperitoneal adenocarcinoma of the rectum were treated with preoperative chemoradiation: slow infusion i.v. c-DDP, 60 mg/m2, day 1 and 29 plus 24-h continuous infusion i.v. 5-fluorouracil (5-FU) 1000 mg/m2, days 1-4 and 29-32, and concurrent external beam radiotherapy (45 Gy whole pelvis followed by 5.4 Gy boost). All but 3 patients had T3 disease. Surgery was performed 6-8 weeks after the end of chemoradiation.

RESULTS

No patient had Grade 4 acute toxicity. Grade 3 hematological toxicity was observed only in 2 (5%) patients. No patient had major gastrointestinal, skin, or urological acute toxicity. All patients had radical surgery. There was no perioperative mortality; perioperative morbidity rate was 12%. Overall, 23% (9 of 40) of patients had a complete pathological response and 10% (4 of 40) of patients had rare isolated residual cancer cells (Tmic). Comparing the stage at the diagnostic workup with the pathological stage, tumor downstaging was observed in 27 (68%) patients; nodal status downstaging was detected in 24 (60%) patients. Thirty-four (85%) patients had a sphincter-saving surgical procedure. In 4 of 10 (40%) patients who were definitive candidates for an abdominoperineal resection (APR), the sphincter was preserved, as it was in 13 of 13 (100%) probable candidates. Lengthening of the distance between the anorectal ring and the lower pole of the tumor > or =20 mm was observed in 9 (23%) patients. None of the patients had soilage after the sphincter-saving procedure. In our previous experience with FUMIR the complete pathological response was 9%, the sphincter-saving surgical procedure was performed in 66% cases, and the Grade 3+ toxicity was observed in 13% of patients.

CONCLUSIONS

The addition of c-DDP to 5-FU (PLAFUR-4) in a neoadjuvant radiochemotherapy schedule improved the pathological response rate in comparison with our previous experience. Toxicity was low indeed, thus we commenced another study adding one more day of 5-FU infusion (PLAFUR-5) to further improve our results.

A new surgical technique for the correction of the inverted nipple

Many techniques have been proposed over the years to correct the inverted nipple, a condition which causes both aesthetic and functional problems. In more severe cases, other than causing infections and inflammations, breastfeeding is impossible because of the lack of nipple erection. Reconstructive surgical techniques today are oriented toward methods that allow adequate filling to maintain the nipple permanently everted. In the technique we propose, the nipple is pulled out and extruded by way of a periareolar incision after sectioning the galactophorous ducts and fibrous tissue. To guarantee a permanent eversion, a single trilobed dermoglandular flap is created, overturned, and fixed to fill the "dead space" below the nipple after the lobes have been sutured together. Finally, two transfixed U-shaped sutures are employed to keep the flap in place. From an analysis of the various techniques and results obtained, this method appears to be effective above all in resolving the aesthetic problem in a stable manner and is simpler than the techniques that employ multiple flaps.

Colorectal Kaposi's sarcoma in an HIV-negative male in association with ulcerative rectocolitis: a case report

A rare case and the first reported in Italy of a classic form of colorectal Kaposi's sarcoma, associated with ulcerative rectocolitis, is presented. Following a total proctocolectomy, the patient was disease-free at four years. Some epidemiological risk factors such as sex, age, place of birth and both advanced malaria and immunodepressive therapies have also been evaluated. Thus far, only five similar cases have been reported in the literature. However, the epidemiological, clinical and prognostic features of this form of Kaposi's sarcoma must still be investigated.

Age as a risk factor in cervicofacial reconstruction

The Authors report their experience from January 1980 to January 1998 with 392 reconstructive flaps for the oncological reconstruction of the cervicofacial district. One hundred and forty-two were conventional flaps, 187 were myocutaneous or pedicled muscular ones and 63 were microvascular. Ninety percent of the patients had Stage IV disease, 80% were tumors involving the oral cavity structures, 40% of the patients had received preoperative radiotherapy; 35% of the cases were recurrences. The complications related to the surgery were evaluated for each type of flap, comparing them to the same flaps employed in patients > 70. Complications were divided into major and minor that were observed at an overall rate of 22%. With the use of conventional flaps, there was an 11.3% rate of minor complications and a 5.6% rate of major ones. Examining the 187 myocutaneous or pedicled muscular flaps, 21% of the overall 27% were minor and 6% were major complications. Of the remaining 63 free flaps, minor complications were observed in 4.7% and major complications in 14.2% of cases. Thirty-four of the 392 flaps, 24 of which were myocutaneous or pedicled muscular and 10 free flaps, were utilized in elderly patients and compared with the 216 of the same type, in patients < 70. A comparative analysis shows that there was a major complication rate of 11.7% in the flaps employed on the elderly patients as opposed to 7.9% for those employed in the younger patients. In terms of minor complications, a 20.5% complication rate was observed for those > 70 as opposed to 16.7% for patients < 70. A more detailed analysis of these data, enabled to postulate that the smaller group of flaps used in elderly patients is statistically influenced by the "dilution" of the complication rate in favour of the larger group of younger patients. Furthermore, by appropriately correcting the risk factors due to concomitant diseases that were not related to surgery in the older patients, a realignment of the results may be seen. Therefore, a careful preoperative study must be carried out in the elderly patients with cervicofacial tumors who are eligible for surgery to establish and possibly treat the concomitant disease responsible for the increased peri- and postoperative morbidity. In conclusion, complications in elderly patients are correlated to the state of co-morbidity and neither to age nor to the duration of the operation. Responsiveness may therefore be obtained also in elderly patients employing sophisticated techniques such as microvascular flaps.

The integrated treatment of peritoneal carcinomatosis. A preliminary experience

Some low-grade malignant tumors arising in the abdomen, lack of infiltrative attitude and "redistribute" on the peritoneum with no extraregional spreading. In this cases the complete tumor cytoreduction followed by intra- or postoperative regional chemotherapy has curative intent. Peritonectomy is the complete removal of all the parietal peritoneum and the visceral peritoneum involved by disease. After peritonectomy hyperthermic antiblastic perfusion is carried out throughout the abdomino-pelvic cavity for 60 minutes, at a temperature of 41.5 degrees C, with mitomycin C (3.3 mg/m2/Lt of perfusate) and cisplatin (25 mg/m2/Lt) (appendicular or colorectal primary), or cisplatin alone is (ovarian primary). Alternatively the immediate postoperative regional chemotherapy is performed with 5-fluorouracil (13.5 mg/Kg) and Lederfolin (125 mg/m2) (colic or appendicular tumor) or cisplatin (25 ng/m2) (ovarian tumor), each day for 5 days. Twenty patients affected by extensive peritoneal carcinomatosis (12 ovarian, 5 colonic, 1 appendicular, 1 mesothelial and 1 gastric primary) were submitted to peritonectomy with no residual macroscopic disease in all cases except three. Six patients were treated with intraoperative intra-abdominal hyperthermic antiblastic perfusion, while immediate postoperative intra-abdominal chemotherapy was given in 4 patients and systemic chemotherapy in other 5. Hospital mortality was 20%. At a mean follow-up of 11 months 14 patients are alive, 11 without disease and the median overall survival is 10.2 months. The curative potential of the combined therapeutic approach seems high in patients with peritoneal carcinomatosis from ovarian or colorectal primary not responding to systemic chemotherapy. Selection criteria of patients can strictly affect the surgical risk and the treatment has to be reserved for controlled clinical trials.

Inflammatory aneurysm of the abdominal aorta. A prospective clinical study

OBJECTIVE

This study was undertaken to investigate a consecutive series of abdominal aortic aneurysm studied with histology to highlight the etiology, the incidence, the value of preoperative studies and intraoperative findings.

EXPERIMENTAL DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Between 1992 and 1994, 102 patients underwent elective surgical repair of an abdominal aortic aneurysm. The patients were prospectively divided as having an inflammatory aneurysm (IA) or an atherosclerotic aneurysm (AA) on the basis of preoperative and intraoperative findings. Further histological evaluation assigned the patients to one of the two groups.

RESULTS

The incidence of IA was 15%. Overall, symptoms, CT scan studies, aneurysmal wall thickness, white glistening perianeurysmal fibrosis, bleeding from the aneurysmal wall and adhesion to the duodenum diagnosed 11 (73%) cases of IA. Histology showed that a granulomatous reaction against some components of the atherosclerotic plaques resulting in an auto-allergic response to this component could initiate the inflammatory process thus resulting in a progressive adventitial and peri-adventitial fibrosis with inflammation, lymphadenitis and lymphatic dilatation.

CONCLUSIONS

Preoperative and intraoperative findings underestimate the incidence of IA. Aortic resection can prevent the progression of the inflammatory process and the complications usually observed when the exposure to the allergen determines an involvement of the periaortic structures.

Evaluation of the CA 242 tumor antigen as a potential serum marker for colorectal cancer

OBJECTIVE

The present study was designed to define the performance of serum CA 242 as a marker in colorectal cancer patients.

PATIENTS AND METHODS

Serum samples from 1,013 subjects (440 healthy volunteers, 384 patients with primary or recurrent colorectal carcinoma and 189 with benign colorectal diseases) were evaluated.

RESULTS

The measurement of serum CA 242 levels in the population of healthy subjects demonstrated the presence of positive levels in approximately 5% of the cases. Interestingly, similar results (5.8%) were obtained in patients with benign colorectal disease, demonstrating the high specificity of CA 242. When serum samples from colorectal cancer patients were analyzed, a sensitivity of 34.9% was observed. Moreover, 18.6% Stage A and B patients had positive CA 242 levels, compared to 33.3% and 58.8% of Stage C and D patients, respectively, indicating a correlation with the stage of disease. A comparison between preoperative and immediate postoperative CA 242 levels showed a consistent relationship between the efficacy of surgery and the reduction in serum CA 242 levels; further, elevated CA 242 levels were present in the immediate postsurgical follow-up of patients undergoing palliative surgery. A longitudinal evaluation of serum CA 242 levels demonstrated that this marker was indicative of the status of disease.

CONCLUSIONS

The results obtained suggest the possible utility of CA 242 in monitoring the disease status, providing a rationale for future studies focusing on the longitudinal monitoring of colorectal cancer patients.

A simple microfluidic system for patterning populations of neurons on silicon micromachined substrates

The purpose of this paper is to describe a low-cost simple technique based on the hydraulically driven deposition of adhesion molecules for patterning populations of neurons on silicon micromachined substrates. First, the design and fabrication process of the silicon micromachined substrates and the design of a flow-through chamber for the localised deposition of adhesive proteins are described. The experimental protocol for the deposition of the adhesive proteins is then presented. Finally, the results of experiments of 'entrapment' of chick embryo spinal cord neurons in microstructures of the silicon substrates and of formation of patterned biological neural networks are shown.

Diagnostic and prognostic value of peritoneal immunocytology in gastric cancer

PURPOSE

Among the clinical factors with a pivotal role in the prediction of outcome for patients with gastric cancer, intraperitoneal (i.p.) microscopic dissemination may represent an important cause of recurrences, even in the early stages of the disease. In this context, the cytologic examination of intraoperative peritoneal washings may be essential to identify metastatic free cells, although a number of false-negative cases may be encountered.

PATIENTS AND METHODS

To determine whether immunocytochemical (ICC) methods that used a panel of three monoclonal antibodies (MoAbs), B72.3, AR3, and BD5, directed to gastric cancer-associated antigens can improve peritoneal cytology by providing more accurate prognostic indications, we immunocytochemically and morphologically evaluated 144 peritoneal washings sampled from patients surgically treated for gastric cancer.

RESULTS

The ICC analysis allowed the identification of metastatic free peritoneal cells in 35% of the patients, with a 14% improvement over routine cytopathology (P < .0001). Furthermore, a 54-month survival analysis by Kaplan-Meier curves showed a statistically significant decrease in overall survival (OS) in patients with stages I through III disease with peritoneal microscopic disease detected morphologically and/or by ICC at the time of the primary surgery.

CONCLUSION

Our data indicate that the use of a combination of selected MoAbs may allow the identification of cytologically false-negative cases that provide valuable prognostic information. This may be useful to stratify patients on more adequate therapeutic trials.

The role of multiploidy as unfavorable prognostic variable in colorectal cancer

OBJECTIVE

To analyze the prognostic value of DNA multiploidy in a prospective study on frozen surgical tissue samples from primary colorectal cancer.

SUMMARY BACKGROUND DATA

Survival data from eleven prospective studies collectively comprising about thirteen hundred patients showed that aneuploidy correlated with a 5-year disease-free survival (DFS) significantly poorer than diploidy, and showed the limited prognostic value of results from retrospective studies employing paraffin-embedded material.

METHODS

Multiple tumor samples of fresh/frozen surgical tissues from 120 colorectal cancer patients who had undergone radical surgery were taken for flow cytometric analysis of DNA content, and proliferative activity, shown as percentage of cells in S-phase (%S). The minimum follow-up of this series was 30 months. Univariate and multivariate analyses determined the independent significance of both clinical and biological variable on DFS.

RESULTS

Values of %S equal to or higher than 17.3 correlated with a 5-year DFS poorer than values lower than 17.3 (44.5% vs 85.2% respectively; p = .03), even if only in patients younger than 64. The subgroup with multiploid tumors showed a significantly poorer 5-year DFS (44.5% vs. 62.6% in the non multiploid patients; p = .02). Subgrouping the Dukes'B stage alone by multiploidy, the difference in DFS was much more evident (31.2% vs. 68% respectively; p = .0004) and multivariate analysis showed multiploidy as the only significant variable. Above all, adjuvant therapy did not absolutely modify the unfavorable outcome of the multiploid Dukes'B patients.

CONCLUSIONS

The prospective evaluation of ploidy allowed us to identify a very high-risk subgroup of patients with multiploid tumors. This biological characterization was easy to demonstrate and, above all in node-negative patients, reliable and very effective in terms of prognosis. The presence of multiploidy should result in a more aggressive therapeutic approach in the adjuvant setting.

Preoperative chemoradiation for extraperitoneal T3 rectal cancer: acute toxicity, tumor response, and sphincter preservation

PURPOSE

To evaluate whether or not an intermediate dose of preoperative external radiation therapy intensified by systemic chemotherapy could improve the tumor response, sphincter preservation, and tumor control.

METHODS AND MATERIALS

Between March 1990 and December 1995, 83 consecutive patients with resectable extraperitoneal adenocarcinoma of the rectum were treated with preoperative chemoradiation: bolus i.v. mitomycin C (MMC), 10 mg/m2, Day 1 plus 24-h continuous infusion i.v. 5-fluorouracil (5FU) 1000 mg/m2, Days 1-4, and concurrent external beam radiotherapy (37.8 Gy). All but 2 patients had T3 disease. Surgery was performed 4-6 weeks after the end of chemoradiation.

RESULTS

Total Grade 3-4 acute toxicity during chemoradiation was observed in 11 (13%) patients: hematological Grade 3 toxicity was recorded in 8 (10%) patients, and Grade 4 toxicity was recorded in 2 (2%) patients. Grade 3 diarrhea was seen in 2 (2%) patients. No patient had major skin or urological acute toxicity. Two patients had no surgery: 1 died before surgery from septic complications after Grade 4 hematological toxicity; 1 refused surgery and is still alive after 6 years. There was no postoperative mortality and the overall perioperative morbidity rate was 25%. The analysis of tumor response involved 81 patients. Overall, 9% (7) of 81 patients had a complete pathologic response. Comparing the stage at the diagnostic workup with the pathologic stage, tumor downstaging was observed in 46 (57%) patients. We had 7 (9%) pT0, 5 (6%) pT1, 33 (41%) pT2, and 36 (44%) pT3. Nodal status downstaging was detected in 46 patients (57%). No evidence of nodal involvement was observed in 59 patients (73%). The incidence of tumor response was affected significantly by the number of quarters of rectal circumference involved (p = 0.03) and, marginally, by the length of the tumor (p = 0.09). The distance between the lower pole of the tumor and the anorectal ring had no influence. Of the patients, 63 (78%) had a sphincter-saving surgical procedure. In 12 (44%) of 27 patients candidate for an APR, the sphincter was preserved, as it was in 19 (95%) of 20 probable candidates. Lengthening of the distance between the anorectal ring and the lower pole of the tumor > 20 mm was observed in 21 patients (26%). Of 63 patients, 4 (6%) had moderate soilage after the sphincter-saving procedure.

CONCLUSION

Preoperative combined modality therapy seems to afford some potential advantages in nonrandomized trials: patients are able to tolerate higher chemotherapy doses and they experience a lower acute toxicity. Tumor downstaging and resectability rates are high; sphincter preservation is feasible. Larger T3 tumors remained less influenced by this treatment; thus, taking into account the low toxicity rate recorded, a more aggressive schedule should be applied in these resectable tumors.

[A case of retroperitoneal fibrosis with spontaneous regression]

Retroperitoneal fibrosis has an unknown pathogenesis. Medical treatment should be preferred to surgery. However, surgical treatment is required when an ureteral involvement is present. A case of retroperitoneal fibrosis with spontaneous regression is reported. Current knowledge on pathogenesis, diagnosis and preferred treatment is outlined.