Tumor recurrence and options for further treatment after resection of liver metastases in patients with colorectal cancer

The aim of this study was to evaluate the pattern of recurrence and its impact on therapy in patients undergoing liver resection for colorectal metastases. Within 7 years 105 patients were operated on; 75 patients were followed up for at least 2 years postoperatively with a median follow-up of 30 months (range 24-93 months). The median time interval when patients were free of tumor recurrence was only 9 months. The initial recurrence site was the liver in 47% and the other sites were extrahepatic in 39%. Seventy-one percent of the patients developed disseminated metastases as the disease progressed. The median survival time after diagnosis of tumor recurrence was 14 months and was significantly affected by the type of treatment used for the recurrence. Surgical resection was followed by a 23-month median survival, while systemic and intra-arterial chemotherapy led to a 14- and 15-month median survival time, respectively. Untreated patients had a median survival of only 4 months. It is concluded that liver resection for colorectal secondaries leads to a very limited number of disease-free survivors after 5 years. As a few patients may profit from a surgical treatment even in cases of recurrence, surgery should not be regarded as useless.

Hepatic arterial infusion (HAI) chemotherapy for liver metastases of colorectal cancer using 5-FU

Thirty-three patients with liver metastases of colorectal cancer were treated by intra-arterial 5-FU chemotherapy. The median survival time of all patients was 14 months. A partial remission could be observed in nine patients, and a further 15 patients had stable disease. Patients were treated on an outpatient basis and the toxicity of treatment was mild. We observed no case of sclerosing cholangitis or chemical hepatitis. Intra-arterial 5-FU chemotherapy provided treatment results similar to those reported for FUdR but with less hepatobiliary toxicity.

Setting up a decision support system with decision tables

The aim of our study was to develop a decision support system using a conventional method which can be used as a shell for different applications. So it was necessary to find a method which allows separation of decision principles and decision algorithms. In addition, documentation of the patient records should be simplified. This could be attained by using the decision table technique and the programming language MUMPS. The general system developed was applied to the therapy decision for patients with liver metastases. The application system was clinically evaluated in a randomized group of patients. In 84% of the study group the therapy proposal of the system concurred with the therapy actually applied. Representation of knowledge in the form of tables is easily understandable by physicians. Since decision tables can be seen as a medium of communication between physician and system manager, knowledge acquisition is simplified.

Assessment of serial carcinoembryonic antigen: determinations to monitor the therapeutic progress and prognosis of metastatic liver disease treated by regional chemotherapy

It is difficult, time-consuming, and expensive to evaluate the therapeutic efficacy of regional chemotherapy of metastatic liver disease by means of imaging procedures. Therefore it was the aim of this study to find out whether serial carcinoembryonic antigen (CEA) determinations yield reliable data on the therapeutic progress and the individual prognosis of these patients. Since there exists no generally accepted modality to assess CEA curves of patients receiving chemotherapy, we developed our own criterion and tested it in a group of 35 patients. For each patient an individual reference level (CEA-means) was fixed which was obtained as the arithmetical mean of serial CEA values taken during the first three courses of chemotherapy (reference time). On the basis of CEA-means the marker curves of the 35 patients could be divided into two groups. After the reference time the CEA values of group 1 (12 patients) never decreased below CEA-means. Survival of these patients was significantly (P = 0.00001) shorter than that of the 23 patients (group 2) who showed a decrease in their CEA curves below CEA-means after the reference time. Beyond this it could be observed that the improvement in survival was significantly greater in those patients who showed a CEA decrease below CEA-means for a prolonged period (3 months). This difference in prognosis is not an artefact due to different pretherapeutic conditions but is a sign of different responses to therapy. The decrease in CEA values below the individual reference level (CEA-means) is a certain sign of the efficacy of the chosen chemotherapy. A continuous rise of the CEA curve above CEA-means signifies an ineffective intrahepatic chemotherapy or extrahepatic tumor manifestation. In this case an intensive diagnostic workup of the patient and possibly a modification of the therapy are indicated.

[Liver resection in patients with metastases of colorectal cancers. Results and prognostic factors]

From October 1981 until July 1987 82 patients underwent hepatic resection for liver metastases of colorectal primary tumors. Operative mortality was 4.8%. This included, the median survival time was 25 months in a group of patients followed-up for at least one year postoperatively. Factors showing statistically significant influence on survival are: node-negative primary tumor, less than four metastases resected, only one liver lobe involved and decrease of CEA below 5 micrograms/ml if preoperatively elevated. Factors showing only a tendency to result in improved survival rates are the grading of the primary tumor and the percentage of liver involvement by tumor. The survival time after liver resection is similar in patients with synchronous and metachronous metastases. Thus, the time interval between the removal of the primary tumor and the detection of liver metastases seems to be gained lifetime.

Reduction or loss of HLA-A,B,C antigens in colorectal carcinoma appears not to influence survival

Primary colorectal carcinomas of an unselected group of 159 patients 126 of whom could be curatively resected were examined for the expression of MHC class I antigens with monoclonal antibody W6/32 directed against a non-polymorphic determinant of HLA-A,B,C heavy chain. One hundred and nine (68.6%) were found to express HLA-A,B,C antigens in normal quantities, 33 (20.8%) showed a substantial reduction in expression, while 17 (10%) lacked these antigens either completely or incompletely. The loss of HLA-A,B,C was inversely correlated with the degree of differentiation. The tendency of mucinous carcinomas to lack class I antigens was statistically not significant. Tumours with distant metastatic spread at the time of operation tended to be normal with respect to HLA-A,B,C expression. Within the curatively resected group, poor differentiation and mucus production were risk factors for survival as could be shown by life table analysis after a maximum follow-up of 39 months. In contrast, the mode of HLA-A,B,C expression of the primary tumour did not influence survival within this time of observation. We conclude that in spite of increasing experimental data suggesting the contrary, the presence or absence of MHC class I antigens does not seem to profoundly modify tumour biology, at least in human colorectal carcinoma.

Preoperative chemotherapy in esophageal cancer. A phase II study

Forty-two patients with localized squamous cell carcinoma of the esophagus were treated according to a phase II study with cisplatin, vindesine and bleomycin (modified Kelsen schedule) prior to surgery. In 17 of these patients partial remission was achieved and in two cases complete remission. Of the 40 patients who were candidates for surgery, 4 were inoperable. In 22 cases the tumor was removed in a potentially curative manner and in 14 patients a palliative resection was performed. There were 4 post-operative deaths among 36 resected patients. Anastomic leakage occurred in 5 and severe cardiopulmonary complications in 4 patients. The side effects of the preoperative treatment were acceptable. A high resectability rate and a comparatively high survival rate in patients who responded to chemotherapy suggest that the preoperative treatment employed might be of value.

[Preoperative chemotherapy in esophageal cancer: an advantage or danger for surgical intervention?]

42 patients with localized squamous cell carcinoma of the esophagus were treated according to a phase II study with cisplatin, vindesine and bleomycin (Kelsen-Schema) prior to surgery. In 18 of these patients partial remission was achieved and in two cases complete remission. Of the 40 patients which were presented to surgical treatment, 4 were inoperable, in 22 cases the tumor was removed in a potentially curative manner and in 14 patients a palliative resection was performed. The postoperative mortality was 4 of 36 resected patients. Anastomotic leakage was found in 5 patients and severe cardiopulmonary complications in 4 patients. The side effects of the preoperative treatment were acceptable and seem justified by the high resectability rate and the significant improvement in survival of patients who responded to chemotherapy.

Carcinoembryonic antigen, CA 19-9, and CA 125 in normal and carcinomatous human colorectal tissue

In 115 primary colorectal carcinomas and 64 normal colorectal mucosa specimens the concentrations of carcinoembryonic antigen (CEA), CA 19-9, and CA 125 were measured. The determinations were performed in cytosols by use of radioimmunometric and enzymeimmunometric assays and related to the wet tissue weight. In the cancer tissue the CEA levels ranged from 5.5 to 1990 micrograms/g tissue and were significantly higher (P less than 0.0001) than those found in the normal mucosa (1.2-58.6 micrograms/g). The CA 19-9 content in carcinoma specimens (120-72660 U/g) was also significantly higher (P = 0.011) than in the normal mucosa (37-5800 U/g). In contrast, no significant difference of the CA 125 concentrations between the normal and the cancer tissue was found. The relative operating characteristic (ROC) curves for the three markers corroborate CEA as the marker superior to CA 19-9. On the other hand is shown that CA 125 is completely unable to discriminate between normal and cancer tissues. A decreasing CEA tissue concentration and an increasing dedifferentiation of colorectal cancers were significantly (P = 0.018) related with each other. Higher tumor stages implied significantly higher tissue marker values of CA 19-9 (P = 0.027) and CA 125 (P = 0.0008). The findings correspond quite well with serum examinations of the three markers which have been reported earlier.

Drug level monitoring: chromatography of some minor groups of drugs

Some important facts about the chromatographic separation of a number of selected categories of drugs are summarized. The data refer to the chromatographic method of choice, stationary phase, mobile phase (carrier gas), detection procedure and (where available) method sensitivity. Also, fundamental instrumental parameters, namely injector, column and detector temperature, carrier gas and mobile phase flow-rate and gradient set-up are reported here. In all cases also the source material used for analysis is specified. The data are presented in table form, each table dealing with a particular category of drugs. The following categories of drugs are being dealt with: anthelmintics, antiarteriosclerotics, antibacterials, anticholinergics and cholinergics, anticoagulants, antidiabetics, antiemetics, antimycotics, antihistamines, antimalarials, antiparasitics, antiparkinsonics, antitussives, antiulcer drugs, antiviral compounds, appetite depressants and immunosuppressives.

The human eccrine sweat gland adenylate cyclase system: response to agonists

Cyclic AMP accumulation has been measured in whole human sweat glands. The mean rate in glands from 19 subjects was 0.519 +/- 0.316 pmol of cyclic AMP formed 5 min-1 micrograms-1 of DNA, which is comparable with that reported for other tissues. Cyclic AMP accumulation in the sweat gland is stimulated fourfold by prostaglandin (PG) E1 and fivefold by PGE2 (0.1 mmol/l), in accord with stimulation in renal tubules and medullary membranes. Bradykinin (10 micrograms/ml) increases the rate threefold and this is substantially prevented by indomethacin (1.5 X 10(-5) mol/l), as also is a fivefold stimulation by cyclic GMP (10(-5) mol/l). Mecholyl (10(-2) mol/l) and isoprenaline (6 X 10(-6) mol/l) increase the rate five- and four-fold respectively, and these agonist effects are largely abolished by atropine and propranolol. The stimulation and inhibition pattern suggests a direct action of PGE, enhancement of prostaglandin synthetase by cyclic GMP and stimulation of guanylate cyclase by mecholyl and bradykinin. Isoprenaline presumably stimulates adenylate cyclase directly. This complex chain of events, from cholinergic stimulation to an enhancement of adenylate cyclase, demonstrated in vitro, constitutes a potential for flexible and fine control of sweat gland function.

Limitations of diagnostic value of the sweat test

The sweat test, even if carried out by an experienced technician, sometimes lacks reproducibility owing presumably to physiological variations (patient's diet, temperature, and other factors at present unrecognized). Some patients are particularly prone to exhibit this variability and in them a single sweat test is almost valueless. The aldosterone status is believed to be responsible for a reciprocal relationship between sweat sodium and potassium concentrations: tests done on 8 patients show that a high sweat potassium is associated with a correspondingly lower sodium--a circumstance which must be borne in mind when interpreting a patient's sweat sodium. Of 30 patients presenting with a variety of symptoms compatible with a diagnosis of cystic fibrosis and with sweat sodium ranging from 50 to 75 mEq/1 (50-75 mmol/1), only 4 have proved to have cystic fibrosis after several years of observations; 13 have later been diagnosed as having asthma. The problem of the 'grey area' of uncertainty is aggravated by the heterozygous state which is also associated with a sweat sodium in this range. Repeated sweat tests are indicated if the sweat sodium lies within the 'grey area', and the diagnostic importance accorded the test should diminish as the sodium value approaches this area. The diagnosis of cystic fibrosis must remain in doubt unless there is strong supportive clinical evidence.