Internal radiation therapy for patients with primary or metastatic hepatic cancer: a review

BACKGROUND

The limited efficacy of current approaches to the treatment of patients with hepatic cancer, including external beam radiation therapy and cytotoxic chemotherapy, has reawakened interest in the use of internal radiation therapy.

METHODS

The authors reviewed series of patients with liver metastases or hepatocellular carcinoma (HCC) treated with 1) interstitial irradiation and direct intratumoral injection of 90Y microspheres, 2) intraarterial infusion of (131)I-Lipiodol, 3) intraarterial infusion of 90Y microspheres, or 4) parenteral administration of radiolabeled monoclonal antibodies.

RESULTS

High dose rate interstitial irradiation with afterloading of (192)Ir resulted in local control of hepatic metastases for a median of 8 months and complete tumor eradication in 2 patients. Direct intratumoral injection of 90Y microspheres reduced the size of 90.6% of tumors and completely destroyed them in 8 patients. Treatment with arterial (131)I-Lipiodol resulted in a 17-92% response rate as well as a case of complete remission of unresectable HCC. It was found to be most effective against small tumors. No response was observed with liver metastases from colorectal carcinoma. Partial response was commonly achieved when patients with unresectable liver metastases or HCC were treated with intraarterial 9OY microspheres. Among four patients whose HCC became resectable following treatment with 90Y microspheres, two cases of complete remission were documented. In a prospective randomized trial, (131)I-antiferritin combined with chemotherapy was no more effective than chemotherapy alone.

CONCLUSIONS

The different approaches to internal radiation therapy that are reviewed in this article represent several ways in which radiation can be selectively targeted to hepatic tumors without undue radiation to the nontumorous liver. However, the efficacy of each of these therapies still needs to be evaluated in randomized controlled trials.

Should doctors practise resuscitation skills on newly deceased patients? A survey of public opinion

Trainee doctors must acquire skills in resuscitation, but opportunities for learning on real patients are limited. One option is to practise these skills in newly deceased patients. We sought opinions from 400 multiethnic guests at an open-access dinner dance for members of a local community. The questionnaire could elicit the responses strongly agree, agree, unsure, disagree or strongly disagree. 332 (83%) guests responded. For non-invasive techniques, 32% of responders supported practice without consent, 74% with consent. Support diminished with increasing invasiveness of procedure. 91% of the sample were uncomfortable about the procedures, the commonest reason being 'respect for the body' (264/302). 86% of responders felt that practice should last for no more than 5 minutes. The most popular solutions were for people to carry a personal card giving consent (89%) and establishment of a central register of individuals consenting to be practised upon after death (79%).

Staging and IgA VCA titre in patients with nasopharyngeal carcinoma: changes over a 12-year period

The distributions of 2093 patients with nasopharyngeal carcinoma (NPC), by stage, over a 12-year-period did not show any evidence of a shift towards early stages despite growing awareness of this prevalent malignancy. The IgA VCA titre was determined for 1880 of these patients. The median titre increased from 40 in stage I to 80 in stages II, III, and IV, before rising to 160 in stage V. The percentage of patients with a titre > or = 320 increased steadily with advancing stages. Within the same disease stage, the percentage of patients having a particular titre value and the median titre varied considerably from year to year. Better education of the general population and a better serological marker for screening are needed for the early detection of NPC.

Apoptosis of JHMV-specific CTL in the CNS in the absence of CD4+ T cells

The role of CD4+ T cells in altering the activity of cytotoxic T lymphocytes (CTL) during infection of the central nervous system (CNS) by the neuroptropic JHMV strain of mouse hepatitis virus was examined. Adoptive transfer of in vitro activated CTL into CD4-depleted and control recipients showed that CTL were not effective in reducing JHMV replication within the CNS. The distribution of CD4+ and CD8+ T cells within the CNS during JHMV infection showed that the CD4+ T cells remained in perivascular and subarachnoid spaces and few entered the parenchyma. By contrast approximately half of the CD8+ T cells entered the parenchyma. In CD4-depleted mice the trafficking of CD8+ T cells was not inhibited; however, the majority of the cells were found to be apoptotic. These data suggested that CD4+ T cells were not required for CTL induction but were required for the maintenance of CTL viability. The limited role of CD4+ T cells in CTL induction was confirmed by comparison of CTL activity from CD4-depleted and control mice.

New development of laparoscopic ultrasound and laparoscopic pelvic lymphadenectomy in the management of patients with cervical carcinoma

OBJECTIVES

The objectives of this study were to evaluate the use of laparoscopic ultrasonography (USG) in combination with laparoscopic pelvic lymphadenectomy in the management of patients with cervical carcinoma.

METHODS

A technique for detecting pelvic and para-aortic lymph node metastases through laparoscopic USG was developed. Laparoscopic USG was done prior to pelvic lymphadenectomy performed either laparoscopically or by laparotomy. Laparoscopic USG findings were compared with pathologic findings.

RESULTS

The sensitivity and specificity of laparoscopic USG in detecting pelvic lymph node metastases were 91 and 100%, respectively. Metastatic pelvic lymph nodes could be completely removed through laparoscopes in 7 of 11 patients, with no complications.

CONCLUSION

Laparoscopic USG is highly sensitive in detecting metastatic pelvic lymph nodes. Detection and removal of metastatic pelvic lymph nodes laparoscopically allow quick recovery from the operation and early commencement of radiotherapy.

Human alpha1,3/4-fucosyltransferases. I. Identification of amino acids involved in acceptor substrate binding by site-directed mutagenesis

In a previous study (Xu, Z., Vo, L., and Macher, B. A. (1996) J. Biol. Chem. 271, 8818-8823), a domain swapping approach demonstrated that a region of amino acids found in human alpha1, 3/4-fucosyltransferase III (FucT III) conferred a significant increase in alpha1,4-FucT acceptor substrate specificity into alpha1, 3-fucosyltransferase V (FucT V), which, under the same assay conditions, has extremely low alpha1,4-FucT acceptor substrate specificity. In the current study, site-directed mutagenesis was utilized to identify which of the eight amino acids, associated with alpha1,4-FucT acceptor substrate specificity, is/are responsible for conferring this new property. The results demonstrate that increased alpha1,4-FucT activity with both disaccharide and glycolipid acceptors can be conferred on FucT V by modifying as few as two (Asn86 to His and Thr87 to Ile) of the eight amino acids originally swapped from FucT III into the FucT V sequence. Neither single amino acid mutant had increased alpha1,4-FucT activity relative to that of FucT V. Kinetic analyses of FucT V mutants demonstrated a reduced Km for Galbeta1,3GlcNAc (type 1) acceptor substrates compared with native FucT V. However, this was about 20-fold higher than that found for native FucT III, suggesting that other amino acids in FucT III must contribute to its overall binding site for type 1 substrates. These results demonstrate that amino acid residues near the amino terminus of the catalytic domain of FucT III contribute to its acceptor substrate specificity.

Topiramate increases cerebral GABA in healthy humans

Topiramate (TOP) is a novel anticonvulsant drug with multiple mechanisms of action used in the treatment of epilepsy. Measurements of cerebral GABA were obtained in six controls using 1H MRS at baseline and at 3 and 6 hours following the administration of 3 mg/kg of TOP. Brain GABA concentrations rose by 72% at 3 hours and by 64% at 6 hours compared with baseline (p < 0.004). This study demonstrates that TOP significantly increases human cerebral GABA concentrations in healthy individuals.

Longitudinal analysis of multiple indicators of health decline among spousal caregivers

The hazards for experiencing major health events were studied longitudinally among 150 spousal caregivers of Alzheimer's disease (AD) patients and 46 married control participants. Based on longitudinal assessments from one to six years, the hazards of reaching any of three health events (extended physical illness or disability > 1 month, unhealthy medical rating from a nurse interview, or hospitalization) were not significantly different in a group comparison of caregivers to controls (Cox proportional hazards assumption, p > .05). However, there was a trend [X2(1, N = 107) = 3.13, p = .08] for caregivers to have a greater hazard for serious illness. Among caregivers only, a greater hazard for reaching at least one of these health events was associated with providing more activities of daily living (ADL) assistance [X2(1, N = 125) = 3.83, p = .05] but not with problem behaviors of the AD patient (p > .05). These results suggest that providing extensive ADL assistance may have health implications for spousal AD caregivers, while caregiving, per se, does not. Furthermore, these physical health impacts of caregiving may be best characterized using multidimensional assessments. Contrary to our guiding hypothesis, caregivers encountering more problem behaviors of their AD spouse were less likely to be hospitalized, X2(1, N = 145) = 5.88, p = .02. This finding may reflect a reluctance by caregivers to schedule necessary medical care when their spouses are most problematic, and this may have further long-term health implications for caregivers.

The angiographic diagnosis of colonic carcinoma

Carcinoma of the colon is a common cause of chronic iron deficiency anaemia in elderly patients and is conventionally diagnosed by either barium enema or colonoscopy. Occasionally these studies are inconclusive and individuals may proceed to further imaging, including angiography. Between December 1991 and October 1996, 337 patients were referred for visceral angiography to determine the cause of chronic gastrointestinal bleeding. In seven of these individuals (two males and five females with an age range of 65-74 years), all of whom had been investigated by barium enema and colonoscopy, both reported as showing no cause for bleeding, an arteriographic diagnosis of colonic carcinoma was made. Four of these demonstrated patchy areas of increased vascularity whilst three were predominantly hypovascular. Early venous drainage was seen in five. Marked irregularity and truncation of vasa rectae was present in six; more subtle irregularity was visible in one. The mural veins were irregular with or without truncation in five of the six patients in whom they were visualized. The marginal artery was angiographically involved in only two cases and in one of these the tumour was irresectable. It is important to recognize that a previous 'normal' colonoscopy and barium enema does not exclude a colonic neoplasm, even if advanced, and that this diagnosis may be made angiographically. Confusion with other pathologies, such as angiodysplasia, should be prevented by close scrutiny of vasa rectae at the site of arteriographic abnormality, which will usually demonstrate vascular irregularity and truncation highly suggestive of malignancy.

Selective internal radiation therapy for nonresectable hepatocellular carcinoma with intraarterial infusion of 90yttrium microspheres

PURPOSE

To evaluate the efficacy of intraarterial 90yttrium (90Y) microspheres in nonresectable hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

Patients with nonresectable HCC, but without extrahepatic disease, who also had lung shunting < 15% and tumor-to-normal ratio > or =2, as determined by simulation using (99m)technetium macroaggregated albumin, were entered into the study. The radiation dose delivered to the lungs, tumor, and normal liver was estimated by a partition model. 90Y microspheres were infused into the hepatic artery at the time of hepatic angiography or through an implanted arterial portacatheter under fluoroscopy. Repeated treatments were given for residual or recurrent tumor. Response to treatment was monitored by serum alpha-fetoprotein or ferritin levels, together with serial computed tomography.

RESULTS

Seventy-one patients, including 20 patients with postoperative recurrence, were initially treated with an activity of 0.8 to 5.0 Giga-Becquerel (GBq) (21.6-135.1 mCi) (median 3.0 GBq or 81.1 mCi) of 90Y microspheres. There was a 50% reduction in tumor volume in 19 (26.7%) patients after the first treatment. However, the overall objective response in terms of changes in alpha-fetoprotein levels was 89% [partial response (PR) 67%, complete response (CR) 22%] among the 46 patients with raised pretreatment levels. The serum ferritin level in the other 25 patients dropped by 34 to 99% after treatment. Treatment was repeated in 15 patients. The maximum number of treatments was 5 and the maximum total activity was 13.0 GBq (351.4 mCi), given in 3 treatments. The estimated radiation doses to the nontumorous liver ranged from 25 to 136 Gy (median 52 Gy) in the first treatment and the highest total radiation dose was estimated to be 324 Gy. For the tumors, the estimated radiation doses ranged from 83 to 748 Gy (median 225 Gy) in the initial treatment and the highest cumulative dose reached was 1580 Gy. The residual tumors were resected in 4 patients. Two of these had complete histological remission, but only occasional viable tumor cells were found in the necrotic centers of the tumors resected from the other 2 patients. The median survival of the 71 patients was 9.4 months (range 1.8 to 46.4 months). Treatment was well tolerated and there was no bone-marrow toxicity, or clinical evidence of radiation hepatitis or pneumonitis.

CONCLUSIONS

Selective internal radiation therapy using 90Y microspheres is effective for selected cases of nonresectable HCC and is well tolerated. The objective response rate in terms of drop in tumor marker levels is higher than that based on reduction in tumor volume shown by computed tomography. The nontumorous liver appears more tolerant to internal radiation than external beam radiation. Selective internal radiation treatment may convert nonresectable tumors to resectable ones.

Cholecystectomy in cardiothoracic organ transplant recipients

OBJECTIVES

To assess the risks associated with cholelithiasis and cholecystectomy in cardiothoracic organ transplant recipients at this hospital and to identify any differences with potential causal significance between the group with known gallstones and the transplant recipient group as a whole.

DESIGN

Medical records survey.

SETTING

Tertiary care university hospital.

PATIENTS

Six hundred forty-five patients had cardiothoracic organ transplantation at this hospital between February 1, 1984, and May 31, 1996. Gallstones were detected in 37 (5.7%) of these patients and 32 patients underwent cholecystectomy, of which 29 operations were performed primarily for symptomatic gallstone disease. All cholecystectomies were performed after transplantation.

MAIN OUTCOME MEASURES

Mortality, morbidity, postoperative biliary disease.

RESULTS

Patients with gallstones were significantly older than the transplant patient group as a whole (Student t test, P=.001); they were more likely to be female (chi2 test, P=.05); and they had a higher body mass index (t test, P=.001). There were no significant differences in the maximum serum bilirubin level during the transplantation admission, incidence of diabetes mellitus, cholestyramine use, or cyclosporine dosage during the first 12 months after transplantation. Cholecystectomy was performed after a median 5-month symptomatic period, mostly by the minilaparotomy method. Forty-five percent of cholecystectomies were urgent or semi-urgent. One patient died of lung infection on the second postoperative day. The median postoperative stay was 3 days. At a median 33 months' follow-up, 4 patients have had further biliary problems (2 patients with common bile duct stones, 1 patient with intrahepatic stones, and 1 patient with biliary dyskinesia). Four other patients with asymptomatic gallstones who did not receive cholecystectomy have remained asymptomatic for between 15 and 67 months.

CONCLUSIONS

Cholecystectomy by the minilaparotomy or laparoscopic methods, with routine operative cholangiography, is the preferred treatment for symptomatic gallstones in cardiothoracic organ transplant recipients. Although the optimum management of asymptomatic gallstones in these patients remains unclear, our favorable experience with a policy of reserving cholecystectomy for symptomatic cases seems noteworthy.

Role for IL-15/IL-15 receptor beta-chain in natural killer 1.1+ T cell receptor-alpha beta+ cell development

Mouse TCR alphabeta+ cells expressing NKR-P1 (NK1+ T cells in the C57BL/6 strain) are classified as a unique subset that require beta2m-associated, MHC class I-like molecules for development and preferentially express particular V beta and V alphaJ domains of the TCR. We show here that NK1+ T cells express the IL-2R beta/IL-15R beta that is normally present on conventional NK cells, but not T cells. In mice lacking IL-2R beta/IL-15R beta chain, the number of NK1+ T cells is dramatically reduced. However, in IL-2-deficient mice, NK1+ T cells develop normally. Moreover, NK1+ T cells proliferate upon stimulation by IL-15, and the proliferation is blocked by the addition of anti-IL-2R beta/IL-15R beta Abs. Collectively, our data indicate that NK1+ T cells require IL-2R beta/IL-15R beta chain in an IL-2-independent manner and demonstrate that IL-15 plays a crucial role during development.

Role for IL-15/IL-15 receptor beta-chain in natural killer 1.1+ T cell receptor-alpha beta+ cell development

Mouse TCR alphabeta+ cells expressing NKR-P1 (NK1+ T cells in the C57BL/6 strain) are classified as a unique subset that require beta2m-associated, MHC class I-like molecules for development and preferentially express particular V beta and V alphaJ domains of the TCR. We show here that NK1+ T cells express the IL-2R beta/IL-15R beta that is normally present on conventional NK cells, but not T cells. In mice lacking IL-2R beta/IL-15R beta chain, the number of NK1+ T cells is dramatically reduced. However, in IL-2-deficient mice, NK1+ T cells develop normally. Moreover, NK1+ T cells proliferate upon stimulation by IL-15, and the proliferation is blocked by the addition of anti-IL-2R beta/IL-15R beta Abs. Collectively, our data indicate that NK1+ T cells require IL-2R beta/IL-15R beta chain in an IL-2-independent manner and demonstrate that IL-15 plays a crucial role during development.

Polymerase chain reaction-based identification of a novel serpin from human dendritic cells

A subtraction library of CD40-stimulated human tonsil dendritic cells has been constructed using a polymerase chain reaction approach adapted for low numbers of cells. From this library we identified a cDNA for a serine protease inhibitor, a serpin, which is absent from monocytes, B cells and T cells but expressed in CD40-activated monocyte- and progenitor cell-generated dendritic cells. In addition, the serpin is expressed in a lung fibroblast cell line and keratinocytes. Its mRNA is detected only in tonsil and thymus. The serpin described here reportedly functions as a megakaryocyte maturation factor in the presence of interleukin (IL)-3 and IL-11. This suggests that dendritic cells may promote the immune response by protecting IL-3 and IL-11 or other essential proteins from degradation.

Identification and analysis of a novel member of the ubiquitin family expressed in dendritic cells and mature B cells

Using a cDNA subtraction technique, a novel member of the ubiquitin family was isolated from human dendritic cells. This gene encodes a diubiquitin protein containing tandem head to tail ubiquitin-like domains, with the conservation of key functional residues. Expression of this 777-bp mRNA was restricted to dendritic cells and B cells, with strong expression in mature B cells. Southern blot analysis indicated that a single copy of this gene is present. In situ hybridization on tonsillar tissue showed expression in epithelial cells and isolated cells within the germinal center. With respect to an expressed-sequence tag (EST) this cDNA could be localized to the major histocompatibility complex class I region of chromosome 6. Comparative analysis and the expression pattern of this gene suggests a function in antigen processing and presentation.

Arteriovenous shunts in patients with hepatic tumors

The study aimed to investigate the influence of tumor type, tumor size, tumor vascularity and treatment on arteriovenous shunts between the liver and lungs in patients with hepatic cancer.

METHODS

Our previous assessment of the degrees of lung shunting using intra-arterial 99mTc-macroaggregated albumin in 125 patients with hepatocellular carcinoma (HCC) was extended to include 377 patients with HCC and 25 patients with colorectal liver metastases. Patients were given 111 MBq (3 mCi) of 99mTc-macroaggregated albumin during hepatic angiography. The lungs and the liver were localized as regions of interest on the digitized gamma scintigraphic image. The total counts taken over the lungs divided by the total counts taken over both the lungs and the liver gave the percentage of lung shunting. Tumor size was measured by computerized tomography or ultrasound scan. Tumor vascularity was assessed based on the degree of neovascularization. Linear regression and Wilcoxon rank test were used for statistical analysis.

RESULTS

Patients with HCC had a higher median (7.6%) and a wider range (< 1-75.4%) of percentages of lung shunting when compared with those with colorectal liver metastases (median, 4.7%; range, < 1-23.9%). The lung shunting correlated with the tumor size in the 377 patients with HCC (r = 0.359; p < 0.0001). Excluding one outlier, we found a similar correlation in 24 patients with colorectal metastases (r = 0.686; p < 0.0001). In HCC, the mean lung shunting increased with increasing tumor size, up to 15 cm, and then remained almost unchanged, up to a size of > 20 cm. The mean lung shunting also increased with increasing vascularity grades, as assessed by hepatic angiography. The difference between any two vascularity grades was statistically significant (p = 0.0001-0.0148). Similar analysis by subgroups in colorectal liver metastases was impossible because of the small number of patients. Lung shunting decreased in HCC patients after the tumors were treated, but it might increase or decrease when the disease recurs.

CONCLUSION

The lung shunting was influenced by the type, size and vascularity of the hepatic tumor. The change in lung shunting with the status of the tumor after treatment further suggests a neoplastic nature of the blood vessels involved in the arteriovenous shunt.

Tumour-to-normal uptake ratio of 90Y microspheres in hepatic cancer assessed with 99Tcm macroaggregated albumin

The selective delivery of a high dose of radiation to malignant hepatic tumours by infusion of non-biodegradable yttrium-90 (90Y) microspheres via the hepatic artery while sparing the non-tumorous liver parenchyma depends on the tumour-to-normal uptake ratio (T/N) of the therapeutic radiopharmaceutical. Using intrahepatic arterial technetium-99m macroaggregated albumin (99Tcm-MAA), the effect of tumour type, tumour vascularity assessed by hepatic angiography (HAG), tumour size and the degree of extrahepatic shunting on the T/N was investigated in 377 patients with hepatocellular carcinoma (HCC) and 25 patients with colorectal liver metastases. HCC was shown to have a wider range of T/N (0.2-26.5) compared with liver metastases (2.3-7.2). HCC with vascularity grade 1 on HAG had significantly lower T/N but there was no significant difference in HCC with higher vascularity grades. This confirmed that vascularity on HAG does not predict T/N. Overall there was no correlation between T/N and tumour size. Large tumours (> 20 cm) had a significantly lower T/N, probably due to necrosis in the tumour centres. A decrease in mean T/N with increasing percentages of lung shunting was observed in HCC. Determination of T/N by simulation with 99Tcm-MAA is recommended before internal radiation therapy with 90Y microspheres.

The integrated patient information system

The complexity and potential impact of today's health care crisis requires a comprehensive approach to problem analysis and innovative thinking in developing solution strategies. Patient care, by its information-intensive nature, involves extensive information processing for decision-making, and requires the support of an effective and efficient information system. Therefore, information Technology must play a critical part in developing any solution strategy. Blue Chip, as an industry leader in leveraging information Technology to create innovative business processes, took the challenge and found a solution to the problem of comprehensive patient information processing. Through the generous support of the Agency for Health Care Policy and Research, a branch of the US Public Health Service, the company completed research and development under two Small Business Innovative Research grants. After 3 years of intensive study, design, and development, Blue Chip created an integrated Patient information System called Care-Centric.

Cytokine gene expression profile of circulating CD4+ T cells in active pulmonary tuberculosis

T lymphocytes, particularly CD4+ cells, are thought to play an important role in the immune defense against Mycobacterium tuberculosis through the release of their wide array of cytokines. In vitro studies suggest that Mycobacterium-specific T-cell clones are of the TH1 subtype. Using the technique of reverse transcription-polymerase chain reaction, we have investigated the capacity for cytokine gene expression profile in ex vivo circulating CD4+ T cells from 20 patients with active pulmonary tuberculosis compared with that of 30 normal healthy tuberculin-positive volunteers. Venous blood samples were collected from the former prior to the initiation of chemotherapy. A significant increase in interleukin (IL-2) expression (p < 0.001) and a significant decrease in IL-5 expression (p < 0.0001) were observed in patients with tuberculosis but no differences were seen in the expression of IL-4 and interferon gamma between the two study groups. Our data support a TH1-like immune response in active tuberculosis.

Clinical evaluation of the partition model for estimating radiation doses from yttrium-90 microspheres in the treatment of hepatic cancer

Radiation doses to the tumour and non-tumorous liver compartments from yttrium-90 microspheres in the treatment of hepatic cancer, as estimated by a partition model, have been verified by correlation with the actual doses measured with a beta probe at open surgery. The validity of the doses to the lungs, the tumour and non-tumorous liver compartment as estimated by the partition model was further evaluated in clinical settings. On the basis of the observation that one of three patients who received more than 30 Gy from a single treatment and one of two patients who received more than 50 Gy from multiple treatments developed radiation pneumonitis, it was deduced that an estimated lung dose < 30 Gy from a single treatment and a cumulative lung dose < 50 Gy from multiple treatments were probably the tolerance limits of the lungs. Three of five patients who received lung doses > 30 Gy as estimated by the partition model and were predicted to develop radiation pneumonitis, did so despite the use of partial hepatic embolization to reduce the degree of lung shunting. Furthermore, a higher radiological response rate and prolonged survival were found in the group of patients who received higher tumour doses, as estimated by the partition model, than in the group with lower estimated tumour doses. Thus the radiation doses estimated by the partition model can be used to predict (a) complication rate, (b) response rate and (c) duration of survival in the same manner as the actual radiation doses measured with a beta probe at open surgery. The partition model has made selective internal radiation therapy using 90Y microspheres safe and repeatable without laparotomy.

Semiquantification of circulating hepatocellular carcinoma cells by reverse transcriptase polymerase chain reaction

Hepatocellular carcinoma (HCC) is one of the most common and rapidly fatal malignancies worldwide. Treatment options are severely limited by the frequent presence of metastases. If hepatocyte-specific mRNAs are detected in the circulation, it is possible to infer the presence of circulating, presumably malignant, liver cells. If these can be quantified, it is possible to predict the likelihood of haematogenous metastasis. In this investigation, we have attempted to gain an index of the mass of circulating HCC cells (with reference to the number of hepatoblastoma cells) by measuring the amounts of PCR products for albumin (alb) mRNA and alpha-fetoprotein (afp) mRNA by reverse transcriptase polymerase chain reaction (RT-PCR) and Southern blot analysis. For calibration, total RNA from 1-10(6) HepG2 cells was mixed with total RNA from 10(6) normal peripheral mononuclear cells. A linear relationship was demonstrated between the amount of alb- or afp PCR product and the level of HepG2 total RNA spiked. The assay is sensitive down to a detection level of one HepG2 cell. Alb mRNA was detected in 50% of 18 normal subjects and afp mRNA in only two normal subjects. The alb mRNA cut-off level for the normal was exceeded by seven normal subjects and 34 out of 64 HCC patients, and that for afp mRNA was exceeded by six HCC patients but none of the normal subjects. The level of alb mRNA detected was not linearly proportional to the amount of afp mRNA detected in peripheral blood of the same patients, suggesting heterogeneous expression of alb and afp genes in different circulating tumour cells. In addition, no significant linear association between the levels of afp mRNA and serum AFP was observed. Semiquantification of both mRNA markers for HCC cell detection may prove useful in prediction of metastases.

Preliminary longitudinal assessment of quality of life in patients with major depression

This study examines the longitudinal relationships between a health-related quality of life measure and depressive symptoms in patients with major depression. One hundred eighteen patients with primary major depression and 81 controls were evaluated. The patients were divided into three groups based on Diagnostic Interview Schedule criteria for a major depressive episode at baseline (T1) and 6 months later (T2). Results indicate that the Quality of Well-Being (QWB) measure is sensitive to different levels of depressive symptoms over a 6-month period. The QWB is a health-related quality of life and cost/utility measure that may be useful for pharmacoeconomic analysis. The reduction in quality of life associated with symptoms of depression is comparable to that observed with chronically physically ill patients. As a generic symptom/function measure, the QWB may be very useful in evaluating public health policy.

Assessment of proliferating cell nuclear antigen in nasopharyngeal carcinoma tissue and its relation to clinical findings

47 newly diagnosed patients with nasopharyngeal carcinoma (NPC) were studied using the proliferating cell nuclear antigen (PCNA) immunostaining technique. The results were reproducible as shown by assessment of three separate sections performed for each patient. No statistical correlation was found between PCNA labelling index (LI) and Ho's clinical staging or time required to achieve complete remission of the local disease. A higher PCNA LI was associated with a poorer disease-free survival. The literature on the use of PCNA in human tumours is reviewed.

'Hepatoma-specific' alphafetoprotein may permit preclinical diagnosis of malignant change in patients with chronic liver disease

The only hope for effective treatment of hepatocellular carcinoma (HCC or 'hepatoma') lies in early diagnosis. Measurement of the serum alphafetoprotein (AFP) level is potentially a useful screening test. When grossly raised, it is almost diagnostic of HCC. However, modestly elevated levels may also arise in patients with benign chronic liver disease, and this markedly decreases the test's specificity and hence its clinical value. In 582 consecutive attendees at an outpatient clinic for people with chronic liver disease, a single blood sample was taken for analysis of 'total' AFP and the 'hepatoma-specific' AFP isoform. Using ultrasonography as the primary screening method, patients with AFP levels > or = 50 ng ml-1 were followed up throughout the study or until HCC was diagnosed on the basis of conventionally defined criteria. On entry into the study, 53 patients had an AFP concentration > = or 50 ng ml-1 and the 'hepatoma-specific' AFP isoform was detected in 26 of these. During an 18-month follow-up period, a diagnosis of HCC was established by conventional methods in 19 (17 'definite' and two 'probable') of these 26 patients. In only two cases was there ultrasound evidence of tumour development at the time AFP was first found to be elevated; in the remainder a diagnosis of HCC, based on ultrasound screening, was established at a median time of 3.6 months (range 1-18 months) after entry into the study. Among those 27 without the 'hepatoma-specific' isoform, one developed a 'definite' HCC and two developed 'probable' tumours. With the application of 'hepatoma-specific' AFP, the positive predictive value of the test was 73.1%, compared with only 41.5% using the conventional 'total' AFP test. Application of this test for the 'hepatoma-specific' AFP markedly increases the positive predictive value of AFP and, in some cases, permits the presence of tumour to be inferred before it could be detected by routine ultrasound examination.

Serum levels of CYFRA 21-1 in nasopharyngeal carcinoma and its possible role in monitoring of therapy

CYFRA 21-1 is a fragment of cytokeratin expressed by simple epithelia and their malignant counter-parts. Serum CYFRA 21-1 levels were studied in 240 new cases of nasopharyngeal carcinoma and 19 patients who developed distant metastases. A reference range of < 2 U/ml for our local Chinese population was established in 55 sex- and age-matched healthy volunteers. The nasopharyngeal carcinoma patients had significantly higher marker levels than the healthy controls and the mean level increased with advancing stage. However, the low percentage of elevation in early stages means that the marker is not useful for screening. The overall percentage (52.5) of elevation in 240 newly diagnosed squamous cell carcinoma of the nasopharynx is comparable to that of squamous cell carcinoma of the lungs, suggesting that the expression of CYFRA 21-1 is related to the cell type rather than the tissue type of the carcinoma, 46 (95.8%) of 48 patients with metastatic nasopharyngeal carcinoma showed an elevated value of CYFRA 21-1. This extremely high percentage implies that it is very unlikely for a patient with a normal value to have distant metastasis. This may permit major economies in radiological screening for distant metastasis. Preliminary results from serial measurement of the marker indicated its potential for monitoring response to treatment and for early detection of distant metastasis.

The mechanism of action of cyclosporin A and FK506

The immunosuppressants cyclosporin A (CsA), FK506, and rapamycin suppress the immune response by inhibiting evolutionary conserved signal transduction pathways. CsA, FK506, and rapamycin bind to their intracellular receptors, immunophilins, creating composite surfaces that block the activity of specific targets. For CsA/cyclophilin and FK506/FKBP the target is calcineurin. Because of the large surface area of interaction of the drug-immunophilin complex with calcineurin, FK506 and CsA have a specificity for their biologic targets that is equivalent to growth factor-receptor interactions. To date, all the therapeutic as well as toxic effects of these drugs have been shown to be due to inhibition of calcineurin. Inhibition of the action of calcineurin results in a complete block in the translocation of the cytosolic component of the nuclear factor of activated T cells (NF-AT), resulting in a failure to activate the genes regulated by the NF-AT transcription factor. These genes include those required for B-cell help such as interleukin (IL-4) and CD40 ligand as well as those necessary for T-cell proliferation such as IL-2. The purpose of this article is to illustrate the means by which these drugs produce immunosuppression.

Somatic mutations in human Ig variable genes correlate with a partially functional CD40-ligand in the X-linked hyper-IgM syndrome

X-linked hyper-IgM (HIGM-1) syndrome is a rare disorder resulting from mutations in the CD40-ligand (CD40L) gene. This defect is associated with normal or elevated serum levels of IgM, and with low to undetectable levels of serum IgG, IgA, and IgE. We analyzed the somatic mutation status in Ig V genes from three unrelated HIGM-1 patients by reverse-transcription PCR and sequence analysis. Two patients (B.S. and P.S.) expressed unmutated VH6 genes. In contrast, one patient (A.T.) was found to express mutated VH6 genes. Whether the presence of somatic mutations in this patient was related to a functional CD40L was assessed by deriving T cell clones from his peripheral blood cells. Upon activation, these T cell clones expressed weakly and transiently surface CD40L, and were able to induce limited isotype switch of normal native B cells, indicating residual CD40L function. Altogether, our results 1) confirm the central role played by CD40L in the generation of somatic mutation (patients B.S. and P.S.), 2) provide an unusual illustration of the relative dissociation between somatic mutation and isotype switching (patient A.T.), and 3) demonstrate a further complexity of the X-linked HIGM syndrome that may occur despite a partially functional CD40L.

Somatic mutations in human Ig variable genes correlate with a partially functional CD40-ligand in the X-linked hyper-IgM syndrome

X-linked hyper-IgM (HIGM-1) syndrome is a rare disorder resulting from mutations in the CD40-ligand (CD40L) gene. This defect is associated with normal or elevated serum levels of IgM, and with low to undetectable levels of serum IgG, IgA, and IgE. We analyzed the somatic mutation status in Ig V genes from three unrelated HIGM-1 patients by reverse-transcription PCR and sequence analysis. Two patients (B.S. and P.S.) expressed unmutated VH6 genes. In contrast, one patient (A.T.) was found to express mutated VH6 genes. Whether the presence of somatic mutations in this patient was related to a functional CD40L was assessed by deriving T cell clones from his peripheral blood cells. Upon activation, these T cell clones expressed weakly and transiently surface CD40L, and were able to induce limited isotype switch of normal native B cells, indicating residual CD40L function. Altogether, our results 1) confirm the central role played by CD40L in the generation of somatic mutation (patients B.S. and P.S.), 2) provide an unusual illustration of the relative dissociation between somatic mutation and isotype switching (patient A.T.), and 3) demonstrate a further complexity of the X-linked HIGM syndrome that may occur despite a partially functional CD40L.

Partition model for estimating radiation doses from yttrium-90 microspheres in treating hepatic tumours

A uniform distribution of yttrium-90 (90Y) microspheres throughout the entire liver has always been assumed for dose calculation in treating hepatic tumours. A simple mathematical model was formulated which allows estimation of the activities of a therapeutic dose of 90Y microspheres partitioned between the lungs, the tumour and the normal liver, and hence the radiation doses to them. The doses to the tumour and normal liver were verified by intra-operative direct beta-probing. The percentage of activity shunted to the lung and the tumour-to-normal tissue ratio (T/N) were obtained from gamma scintigraphy using technetium-99m-labelled macroaggregated albumin (MAA) which simulates the 90Y microspheres used in subsequent treatment. The intrahepatic activity was partitioned between the tumour and the normal liver based on the T/N and their masses determined from computerized tomography slices. The corresponding radiation doses were computed using the MIRD formula. The estimated radiation doses were correlated with the doses directly measured using a calibrated beta-probe at laparotomy by linear regression. The radiation doses to the tumour and the normal liver, estimated using the partition model, were close to that measured directly with coefficients of correlation for linear regression: 0.862 for the tumours and 0.804 for the normal liver compartment (P<0.001). The partition model permits a distinction between the radiation doses received by the tumour and the normal liver to be made and the doses thus estimated are close to the actual doses received. The optimal doses to the tumour and normal liver and hence the required quantity of 90Y microspheres to be administered can be easily predetermined.

Transrectal ultrasound in the evaluation of cervical carcinoma and comparison with spiral computed tomography and magnetic resonance imaging

38 women with biopsy proven untreated cervical carcinoma were prospectively studied with transrectal ultrasound (TRUS), spiral computed tomography (SCT) and magnetic resonance imaging (MRI). 20 women had radical hysterectomy and pelvic lymphadenectomy with detailed histological evaluation of the parametra. The echographic features of cervical carcinoma on TRUS are a hypoechoic (60%) or isoechoic (40%) (relative to normal uterine muscle/cervical stroma), poorly defined mass lesion with indistinct margins in an enlarged cervix. This relatively high percentage of isoechoic tumours and relative lack of contrast resolution may pose a problem in the identification of some tumours, and to our knowledge has not been previously reported. Further limitations of TRUS are in the evaluation of advanced cervical cancer, due to bulky tumours rendering poor access to the parametrium and pelvic sidewall. The overall accuracy in staging of early cervical cancer (less than stage 2b) was 85% for examination under anaesthesia (EUA), 75% for TRUS, 65% for MRI and 50% for SCT. The positive predictive value in evaluating the parametra in this group of patients was also lower for SCT (14%) and MRI (33%) compared with TRUS (100%). In the evaluation of advanced cervical cancer (stage 2b or higher), there was poor correlation between TRUS and EUA, with MRI showing the best correlation with EUA. We conclude that SCT is inferior to both TRUS and MRI in the staging of early stage cervical cancer.

Strong association between hyperferritinaemia and metastatic disease in nasopharyngeal carcinoma

We have investigated the role of serum ferritin, in relation to disease stages, in patients with nasopharyngeal carcinoma. Patients with localised disease (Ho's stage I-IV) had levels which were not significantly different from age, sex matched normal subjects and there was no relationship between mean serum ferritin levels and stage. However, in patients with metastatic disease levels were grossly elevated with mean levels increased more than 6-fold compared to normal subjects and patients with localised disease. Furthermore, among the small group of patients with localised disease but hyperferritinaemia, the subsequent development of metastatic disease within 1 year was significantly much higher (32.4%) than in those with levels falling within the reference range (10.3%). Hyperferritinaemia is strongly associated with, and may predict, metastatic disease in patients with nasopharyngeal carcinoma.

Normal human IgD+IgM- germinal center B cells can express up to 80 mutations in the variable region of their IgD transcripts

Somatic hypermutation in immunoglobulin variable region genes occurs within germinal centers. Here, we describe a subset of germinal center dark zone centroblasts that express only sIgD and have accumulated up to 80 mutations per heavy chain variable region (IgVH delta gene). Over half of the hypermutated IgVH delta sequences were found to be clonally related. This level of mutation is not observed in either IgVH gamma transcripts from the same sample or IgVH delta transcripts from peripheral blood, suggesting that these cells neither undergo isotype switch nor mature into circulating memory B cells. Optimal growth of these cells in vitro depends on CD40 ligand, T cell cytokines, and a fibroblast stroma, a combination possibly mimicking the dark zone microenvironment. Our hypothesis is that these cells may be sequestered within germinal centers, where their somatic mutation machinery is triggered. The isolation of these hypermutated B cells may represent a critical step for studying both the biology and biochemistry of somatic hypermutation.

Four IgG anti-islet human monoclonal antibodies isolated from a type 1 diabetes patient recognize distinct epitopes of glutamic acid decarboxylase 65 and are somatically mutated

The selective destruction by an autoimmune process of the beta cells in the pancreas is the hallmark of the type 1 insulin-dependent diabetes mellitus. What triggers islet cell-specific autoreactive T and B cells, however, remains unclear. Identification of the targets of the anti-islet cell autoantibodies frequently found in insulin-dependent diabetes mellitus patients and analysis of their sequences should provide some insights into the nature of this disease. We have combined EBV transformation with CD40 activation of peripheral B cells from one patient with insulin-dependent diabetes mellitus to isolate four B cell clones that secrete islet cell-specific autoantibodies, These four human monoclonal autoantibodies are of the IgG1 isotype, and they each recognize a different epitope of the glutamic acid decarboxylase enzyme. Analysis of their variable gene sequences shows that, while clonally unrelated, three of the four human monoclonal autoantibodies use a member of the VH4 family, and two have rearranged the same delta light chain variable gene. The IgG1 isotype of the four autoantibodies as well as the presence of somatic mutations in both heavy and light chain genes provide concrete evidence for their derivation by a T cell-dependent immune response.

Four IgG anti-islet human monoclonal antibodies isolated from a type 1 diabetes patient recognize distinct epitopes of glutamic acid decarboxylase 65 and are somatically mutated

The selective destruction by an autoimmune process of the beta cells in the pancreas is the hallmark of the type 1 insulin-dependent diabetes mellitus. What triggers islet cell-specific autoreactive T and B cells, however, remains unclear. Identification of the targets of the anti-islet cell autoantibodies frequently found in insulin-dependent diabetes mellitus patients and analysis of their sequences should provide some insights into the nature of this disease. We have combined EBV transformation with CD40 activation of peripheral B cells from one patient with insulin-dependent diabetes mellitus to isolate four B cell clones that secrete islet cell-specific autoantibodies, These four human monoclonal autoantibodies are of the IgG1 isotype, and they each recognize a different epitope of the glutamic acid decarboxylase enzyme. Analysis of their variable gene sequences shows that, while clonally unrelated, three of the four human monoclonal autoantibodies use a member of the VH4 family, and two have rearranged the same delta light chain variable gene. The IgG1 isotype of the four autoantibodies as well as the presence of somatic mutations in both heavy and light chain genes provide concrete evidence for their derivation by a T cell-dependent immune response.

Generation and characterization of a human monoclonal autoantibody that acts as a high affinity interleukin-1 alpha specific inhibitor

Interleukin-1 (IL-1) defines two polypeptides, IL-1 alpha and IL-1 beta, that possess a wide spectrum of biological effects. Two natural antagonists of IL-1 action have been characterized: the IL-1 receptor antagonist (IL-1Ra) and a soluble form of the type II IL-1 receptor. Neutralizing autoantibodies to IL-1 alpha have also been detected in sera of healthy individuals and patients with autoimmune or inflammatory diseases. To characterize such antibodies molecularly, we attempted to generate B cell clones producing anti-IL-1 alpha human monoclonal antibody (HuMAb) by combining Epstein-Barr virus-immortalization and CD40-activation of B lymphocytes from individuals with circulating anti-IL-1 alpha. We describe herein the generation and properties of a natural IgG4/kappa anti-IL-1 alpha monoclonal autoantibody, HuMAb X3, that bound specifically to human IL-1 alpha, but not to IL-1 beta and IL-1Ra, with a high affinity (Kd = 1.2 x 10(-10)M). HuMAb X3 inhibited IL-1 alpha binding to IL-1 receptors and neutralized biological activities of both recombinant and natural forms of IL-1 alpha. A recombinant form of HuMAb X3 was found to display identical specific IL-1 alpha antagonism. The presence of somatic mutations within X3 variable regions suggests an antigen-driven affinity maturation. This study extends the demonstration of the presence of high affinity neutralizing anti-IL-1 alpha autoantibodies that can function as a third type of IL-1 antagonist.

Isoelectric focusing of alphafetoprotein in patients with hepatocellular carcinoma--frequency of specific banding patterns at non-diagnostic serum levels

Serum levels of alphafetoprotein are raised in 60-80% of patients with hepatocellular carcinoma. Although widely used as a serum marker, frequent false-positive results in patients with benign liver disease, result in poor specificity. This occurs particularly when levels of alphafetoprotein fall between 50-500 ng ml-1, the so-called 'grey area'. Recent reports suggest that isoelectric focusing of alphafetoprotein demonstrates certain bands that are more specific for hepatocellular carcinoma. Our aim was to determine whether the apparent specificity of this new approach is gained at the expense of decreased sensitivity. Sera from 110 patients with a 'non-diagnostic' serum alphafetoprotein level (50-500 ng ml-1) were examined by isoelectric focusing and quantified by densitometric scanning. Ten patients with chronic liver disease and a raised serum alphafetoprotein level (50-500 ng ml-1), but with no evidence of hepatocellular carcinoma, were also studied. Isoelectric focusing revealed characteristic hepatocellular carcinoma bands (bands +II and +III) in 96% patients overall, and 100% of those with levels of total alphafetoprotein greater than 100 ng ml-1. No such bands were seen among ten subjects with cirrhosis but without hepatocellular carcinoma. Bands that are characteristic of hepatocellular carcinoma (bands +II or +III) are seen in the great majority of hepatocellular carcinoma patients; their absence makes a diagnosis of hepatocellular carcinoma extremely unlikely.

B-chronic lymphocytic leukemias can undergo isotype switching in vivo and can be induced to differentiate and switch in vitro

B-chronic lymphocytic leukemias (B-CLL) represent expanded clones of resting B lymphocytes that mostly express surface IgM (sIgM). The present study shows that B-CLL cells, freshly isolated from two patients, were sIgM+, sIgG-, and sIgA- but expressed IgG and IgA transcripts. cDNA cloning and sequencing showed that the VDJ segments associated to gamma and alpha heavy chain transcripts are identical to those from mu transcripts, thus showing that B lymphocytes giving rise to CLL cells have undergone isotype switching in vivo. Stimulation of these B-CLL cells through surface CD40 in the presence of interleukin-10 induced them to secrete IgG and IgA, proving that they can also differentiate into Ig-secreting cells. Finally, CD40-stimulated B-CLL cells were induced to switch towards IgE in response to interleukin-4, as shown by the presence of specific VDJ-C epsilon transcripts and the secretion of IgE. Therefore, B-CLL cells tested herein can undergo isotype switching in vivo and can be induced to undergo further isotype switching and differentiation in vitro.

Plasticity of the T cell receptor repertoire in TCR beta-chain transgenic mice

The potential alpha beta T cell receptor (TCR) repertoire in normal mice is extremely large and estimated by M. M. Davis and P. J. Bjorkman (Nature 334, 395, 1988) to include 5.2 x 10(18) different receptor molecules. This tremendous diversity provides the basis for T cell recognition of the universe of antigens including bacterial, viral, and allogeneic epitopes. Expression of a single TCR beta-chain transgene should alter the repertoire by limiting the available diversity, therefore, creating holes in the repertoire or producing TCR with decreased affinity. To determine the effect of drastically decreasing the size of the repertoire, we investigated T cell responses in TCR beta-chain transgenic mice expressing the V beta 8.2 transgene. Previous results showed that > 98% of T cells in these mice express the transgene; thus, the TCR repertoire is reduced by orders of magnitude. We tested the T cell responses of the transgenic mice and nontransgenic littermates to nine different MHC haplotypes in mixed lymphocyte reactions, five protein antigens, and eight immunogenic peptides. Surprisingly, the transgenic mice responded to all antigenic stimuli tested indicating the lack of a hole in the TCR repertoire. Interestingly, however, the response in every case was quantitatively lower than the response by the nontransgenic littermates. In contrast, transgenic and nontransgenic T cells responded equivalently to stimulation with mitogens or to stimulation with immobilized alpha-TCR mAb indicating that the transgenic T cells had a normal capacity to respond. To differentiate between decreased TCR affinity and decreased precursor frequency, we performed a limiting dilution analysis to the peptide antigens CI:NP and OVA324-339. The results showed approximately a three-to eight-fold decrease in the frequency of transgenic T cells responding to the peptide compared to nontransgenic littermates. We previously showed that the response to cI84-98 and PLP could be blocked with anti-V beta 8 mAb indicating that V beta 8.2-bearing T cells are capable of responding to peptide antigen. Analysis of TCR V alpha chain expression by PCR and flow cytometry showed similar V alpha expression in both the transgenic and the nontransgenic mice. These results demonstrate tremendous plasticity in the TCR repertoire permitting T cell responses by the transgenic mice to all antigens tested. However, the decreased magnitude of the responses may impair the capacity to defend against natural pathogens. Therefore, although the large TCR repertoire of normal mice may not be necessary to produce in vitro responses to many experimental antigens, it may confer survival benefits in natural environments.

In vitro uptake of bromodeoxyuridine by human nasopharyngeal carcinoma (NPC) and its relation to clinical findings

A cell kinetic study of 27 newly diagnosed patients with nasopharyngeal carcinoma (NPC) using the in vitro bromodeoxyuridine (BrdU) technique was performed. The results were reproducible as demonstrated by three independent sections performed on each patient. No correlation between BrdU labelling index (LI) and Ho's clinical staging was found. A higher LI was associated with the development of distant metastases (P = 0.057). Statistically significant correlation was found between low LI and longer duration required to achieve complete remission in the primary site of disease (P = 0.026). This study suggests a potential role for in vitro BrdU labelling index as a prognosticator for NPC prior to treatment.

Primary mediastinal malignant germ cell tumour. Single institution experience in Chinese patients and correlation with specific alpha-fetoprotein bends

Ten Chinese patients were reviewed, all with mediastinal germ cell tumours and treated in our centre during the past 8 years. Three patients with pure seminomas were given chemotherapy with or without radiotherapy. AB achieved complete remission with no relapse. Seven patients with non-seminomatous germ cell tumours (NSGCT) were given chemotherapy, with or without surgery. Two patients with rapid decay of alpha-fetoprotein (AFP) levels (half-life less than or equal to 7.2 days) during chemotherapy achieved complete remission with no relapse. Five patients with prolonged decay of AFP levels (half-life > 7.2 days) failed to achieve complete remission with initial chemotherapy and all but one patient died between 5 and 9 months later. One patient developed acute megakaryocytic leukaemia. Using isoelectric focusing, AFP bands specific to NSGCT were quantified, and comparison was made with the total AFP in five cases. In each case the change in NSGCT-specific AFP concentration in response to therapy closely paralleled that of total AFP. Estimation of NSGCT-specific AFP offers no apparent advantage in monitoring disease response or progression.

Obstructive jaundice secondary to hepatocellular carcinoma

This prospective study aimed to identify different groups of patients with the rare pathology of biliary obstruction caused by hepatocellular carcinoma (HCC). Patients were evaluated with blood tests, chest radiography, ultrasound of the liver and endoscopic retrograde cholangiopancreatography/percutaneous transhepatic cholangiography. Patients who were potentially operable were further assessed with selective hepatic angiography and computed tomography (CT). Of the 38 patients with obstructive jaundice secondary to HCC, the levels of obstruction were extrahepatic in 19 patients and intrahepatic in 19 patients. The clinical presentations and blood biochemistry were similar in these two groups of patients. "Curative' resection was significantly more common in extrahepatic obstruction (8/19) than in intrahepatic obstruction (0/19) (chi 2 with Yates correction P = 0.001). All non-resectable tumours, except in four patients with terminally ill disease, were palliated with stents. Survival in patients who had "curative' liver resection was significantly better than in those who had no resection (median survival 25.3 vs. 2.1 months, log-rank test P = 0.004). Patients with extrahepatic biliary obstruction secondary to HCC had a better chance of being treated by liver resection, which resulted in a significantly improved survival rate compared to patients with intrahepatic obstruction.