Randomized clinical trial on the combination of preoperative irradiation and surgery in the treatment of adenocarcinoma of gastric cardia (AGC)--report on 370 patients

PURPOSE

An attempt was made to define the role of radiotherapy before operation for AGC.

METHODS AND MATERIALS

From January 1978 to May 1989, a prospective randomized trial on preoperative radiotherapy (R+S) vs. surgery alone (S) for AGC was carried out in 370 patients. Patients were randomized into a combined group (R+S, 171 patients) or a surgery alone group (S, 199 patients) by the envelope method. 8-MV photon or telecobalt was used for the preoperative radiation therapy, using anterior-posterior opposing parallel fields to deliver 40 Gy to the cardia, lower segment of the esophagus, fundus, lesser curvature, and hepatogastric ligament. Surgery was performed after 2 to 4 weeks rest.

RESULTS

The 5- and 10-year survival rates of the R+S Group and the S Alone Group were 30.10% and 19.75%, 20.26% and 13.30%, respectively. The survival curves of these two groups diverged right from the beginning after the operation over the ninth year. Statistics by Kaplan-Meier log rank test proves that the difference is significant (chi2 = 6.74, p = 0.0094). The immediate results were: resection rate 89.5% and 79.4% (p < 0.01); pathologic stage after resection T2 12.9% and 4.5% (p < 0.01), T4 40.3% and 51.3% (p < 0.05), lymph node metastasis rates 64.3% and 84.9% (p < 0.001); operative mortality rates 0.6% and 2.5%; intrathoracic leak rates 1.8% and 4.0%, respectively. The causes of failure were: local uncontrol and recurrence 38.6% vs. 51.7% (p < 0.025), regional lymph node metastasis 38.6% vs. 54.6% (p < 0.005), distant metastasis 24.3% vs. 24.7%.

CONCLUSION

Preoperative radiation therapy is able to improve the results of surgery for adenocarcinoma of the gastric cardia.

Versatile Synthesis of Dihydroquinolines and Quinoline Quinones Using Cyclobutenediones. Construction of the Pyridoacridine Ring System

1-BOC-2-lithio-1,4-dihydropyridines were condensed with 3,4-disubstituted cyclobutenediones to produce 1,2-adducts. Neat thermolysis under oxygen-free conditions produced substituted 1,4-dihydroquinoline hydroquinones in which the tert-butoxy residue of the BOC group was displaced by a phenolic residue, generating an oxazolone ring that functioned to protect both rings of the dihydroquinoline hydroquinone from untimely oxidation. Oxidative aromatization with concomitant loss of the oxazolone ring was achieved using 2 equiv of o-chloranil in acetic acid and provided substituted quinoline quinones in good yields. By use of this strategy, a concise synthesis of the pyridoacridine ring system was achieved.

Prospective multimodality treatment of SCLC--experience during the past 18 years

Lung cancer has been one of the leading malignancies in China. Since 1989 it has ranked first among common malignancies in the male population, and second in females. In 1975, a multimodality treatment study group for lung cancer was organized in our institute. The group has since expanded to 15 institutions in the Beijing and Tianjin area during the past four years. The present communication is based on our experiences and data, and tries to explain the treatment strategy of our study group.

Alternative splicing of ED-A and ED-B sequences of fibronectin pre-mRNA differs in chondrocytes from different cartilaginous tissues and can be modulated by biological factors

The alternative splicing of the ED-A and ED-B segments of fibronectin pre-mRNA was examined in epiphyseal, costal, and meniscal cartilage from 3-week-old beagles and in nasal, tracheal, articular, and meniscal cartilage from 1- and 2-year-old Labrador retrievers. In contrast to the 100% expression of ED-B(+) mRNA that has been reported for embryonic chick cartilage (Bennett, V.D., Pallante, K.M., and Adams, S.K. (1991) J. Biol. Chem. 266, 5918-5924), all cartilages studied expressed both the ED-B(+) and ED-B(-) forms of fibronectin mRNA with the exception of the trachea, in which expression was 100% ED-B(-). Of all cartilages studied, only the meniscus had detectable levels of ED-A(+) mRNA. Placing articular cartilage chondrocytes in primary monolayer culture dramatically up-regulated the expression of ED-A(+) mRNA to 25% of the total, and this expression was further increased by the addition of transforming growth factor beta 1 or fucoidan to the culture medium. The expression of ED-B(+) mRNA remained at about 18% in the cultured chondrocytes and was not further affected by either transforming growth factor beta 1 or fucoidan. In contrast, dibutyryl cyclic adenosine monophosphate decreased the relative expression of both the ED-A(+) and ED-B(+) forms of fibronectin pre-mRNA. We concluded that the expression of ED-B(+) fibronectin remains relatively high in chondrocytes from cartilaginous canine tissues (15-35%) with the exception of the trachea, in contrast to the less than 10% expression of ED-B(+) fibronectin reported for other non-fetal tissues.

Accumulation of fibronectin in articular cartilage explants cultured with TGF beta 1 and fucoidan

Fibronectin is a glycoprotein involved in cell matrix interactions. In osteoarthritis, fibronectin levels in the lesion cartilage are elevated up to 20-fold above control levels. In these experiments, explants of disease-free cartilage cultured in the presence of a combination of TGF beta 1 and the sulfated fucopolysaccharide, fucoidan, accumulated fibronectin at levels comparable to those found in osteoarthritic lesions. TGF beta 1 increased fibronectin synthesis, most of which was released to the medium. The addition of fucoidan favored retention of the newly synthesized fibronectin within the matrix. The fibronectin which accumulated as a result of these treatments was similar to the fibronectin in normal and osteoarthritic cartilage with respect to the ED-B+ alternative splice form. No change in the proteoglycan content of the cartilage explants with elevated fibronectin levels was detected.

Inefficient processing of human protein C in the mouse mammary gland

Vitamin K-dependent plasma protein, human Protein C (HPC) has been expressed in transgenic mice, using a 4.2 kb mouse whey acidic protein (WAP) promoter, 9.0 kb HPC gene and 0.4 kb 3' flanking sequences. Expression was mammary gland-specific and the recombinant human Protein C (rHPC) was detected in milk at concentrations of 0.1 to 0.7 mg ml-1. SDS-PAGE revealed that the single, heavy and light chains of rHPC migrated with increased electrophoretic mobility, as compared to HPC. Enzymatic deglycosylation showed that these molecular weight disparities are in part due to differential glycosylation. The substantial increase observed in the amount of single chain protein, as well as the presence of the propeptide attached to 20-30% of rHPC, suggest that mouse mammary epithelial cells are not capable of efficient proteolytic processing of rHPC. The Km of purified rHPC for the S-2366 synthetic substrate was similar to that of plasma-derived HPC, while the specific activity was about 42-77%. Amino acid sequence analyses and low anticoagulant activity of purified rHPC suggest that gamma-carboxylation of rHPC is insufficient. These results show that proteolytic processing and gamma-carboxylation can be limiting events in the overexpression of fully biologically active rHPC in the mouse mammary gland.

Regulation of human protein C gene expression by the mouse WAP promoter

A 4.1 kb mouse whey acidic protein (mWAP) promoter was cloned from a C57BL/6 cosmid library. The tissue-specific and developmental pattern of expression of a hybrid gene comprised of the mWAP promoter fragment and the human protein C (HPC) gene was analysed in transgenic mice. The corresponding RNA was detected mainly in the mammary gland, with 'leakage' of expression in the salivary gland and kidney. The developmental pattern of transgene expression differed from that of the endogenous WAP gene. In particular, recombinant HPC (rHPC) transcripts were detected earlier in pregnancy than WAP RNA, with no significant increase during lactation. This indicates that regulatory elements responsible for developmental regulation are located outside the 4.1 kb mWAP gene promoter fragment, or if present, may be subject to position effects. Precocious expression of the transgene did not compromise the health or nursing abilities of transgenic females. Expression of rHPC affected the appearance of the mammary alveoli and alveolar epithelial cells in lactating transgenic mice. The alveoli were less distended and alveolar epithelial cells appeared cuboidal with centrally positioned nuclei. We suggest that the inefficient intracellular processing of rHPC can alter the histological appearance of alveolar epithelial cells in the transgenic mammary gland.

Billings natural family planning in Shanghai, China

With cervical mucus, or Billings, method of family planning, a woman learns to recognize the characteristics of her cervical mucus that identify the fertile phase in her menstrual cycle. She and her partner abstain from sexual activity during a period from the first indication of mucus until four days after the mucus peak day, which includes ovulation. They also abstain during menses, because mucus can be confused with menstrual bleeding. This method of family planning is used widely, worldwide, by couples seeking a natural, reliable method of family planning. Between July 1988 and May 1990, 688 couples of child-bearing age, most of whom were parous, used the Billings method for contraception. Five hundred and fifty of these couples used the method for more than 12 months. Efficacy, continuation rates, and discontinuation rates were analyzed using life-table analysis for 10,175 woman-months of data collected. The net cumulative discontinuation rates per 100 women at 12 and 18 months were 19.85 and 34.58, respectively, resulting in continuation rates of 80.15 and 65.42. The discontinuation rates per 100 women for method-related reasons at 12 and 18 months were 1.61 and 2.84, respectively, while the discontinuation rates for unintended pregnancy were 1.02 and 1.18. During the study, 67 subjects volunteered to have vaginal smears taken from the upper part of the vaginal wall for cytologic examinations, and among them serum and urine LH levels were measured in 10 subjects and urinary estrogen and progesterone were assayed in 35 cases. These tests related other indications of the menstrual cycle to the ability of the women to judge ovulation by cervical mucus. Our research suggests that further investigation of the Billings method is warranted and that careful planning and organization are needed to disseminate the method more broadly.

Operable squamous esophageal cancer: current results from the East

From 1958 through 1992 a total of 3603 patients underwent surgery for esophageal squamous cell carcinoma in our department. Among these patients 3099 resections were performed, for an overall resectability of 86.0%. Of the resections, 2341 (75.5%) were classified as curative and 758 (24.5%) palliative. The overall morbidity and 30-day mortality rates were 23.4% and 3.8%, respectively. For resected cases the mortality was 4.0%. The more than 5-year follow-up rate of patients with resection was 97%. The actual 5-, 10-, and 15-year survival rates were 30.4%, 23.6%, and 17.9%, respectively. Recurrence or metastasis remained the cause of death in 60.9% and 25.5% of patients who lived longer than 5 years and 15 years, respectively, after operation. The TNM staging, lymph node metastasis, extra-esophageal invasion, tumor differentiation, tumor length, and category of operation were major determinants influencing long-term prognosis. The left thoracotomy approach was used exclusively in 2613 cases (84.3% of all resected cases) in which intrathoracic resections and anastomoses were performed. The stomach was used as a substitute for the esophagus in 98.8% of the resected cases compared with 1.2% colon transplants. The former procedure was far safer than the latter. Above-average results presented in this paper support the surgical policy we have pursued thus far: to resect the primary tumor by partial or subtotal esophagectomy and to remove all lymph nodes wherever they were found in all patients with disease earlier than stage III. Early detection and early treatment no doubt are the only ways to materially improve the long-term surgical results.

[Surgical results of neck reconstruction in esophageal cancer located at and above the high mid-thoracic segment--a report of 414 cases]

From July 1960 through 1990, a total of 414 patients with esophageal carcinoma, including cervical 29 cases, upper thoracic 239 cases and high mid-thoracic 146 cases, were operated on with reconstruction in neck. The overall resectability rate was 90.8%. The incidences of anastomotic leakage and recurrent laryngeal nerve injury were 20.5% and 12%, respectively. The resection mortality was 7.4% (within 30 days postoperatively). The 1-, 3-, 5-, 10- and 15-years survival rates were 72.3%, 39.5%, 33.1%, 26.6% and 20.5%, respectively. The authors consider that cervical esophagogastrostomy for reconstruction of esophagus after subtotal esophagectomy is an important method and a routine operative type for the surgical management of esophageal cancer at or above high mid-thoracic segment. The main factors influencing the postoperative long-term results were p-TNM stage, lymph node metastasis and the type of resection, either palliative or curative. The preoperative irradiation might remarkably increase resectability, but hardly improved long-term survival.

[Sleeve (bronchoplastic) lobectomy for the treatment of carcinoma of the lung: report of 135 cases]

135 cases of lung cancer were treated by sleeve (bronchoplastic) lobectomy within 24 years. 90 (66.7%) of them were of squamous cell carcinoma. Postoperative TNM classification showed 81 cases (60.0%) of stage I disease, 33 (24.4%) of stage II, 20 (14.8%) of stage III and 1 (0.7%) of stage IV. Upper lobe sleeve resection was used in 77.7% of the cases (right upper 57, left upper 48). Left upper sleeve lobectomy in 5 cases was accompanied by sleeve resection and reanastomosis of the left main pulmonary artery. One patient (0.7%) died of pulmonary thrombosis. The morbidity rate was 6.6%. Late complications included scar stricture of the anastomosis in 16 cases and recurrence at the site of anastomosis in 5. The 5- and 10-year survival rate was 56.2% and 42.9% respectively. For squamous cell carcinoma in particular, the 5-year survival was 60%. The indications and techniques of this operation are discussed in detail. Sleeve lobectomy had the advantages of preserving as much normal lung tissue as possible while keeping the principle of radical resection uncompromised. The low operative mortality and good long-term survival warrant its popularization.

[Transabdominal termino-esophago-proximal gastrectomy for portal hypertension. An analysis of 61 cases]

The results of transabdominal termino-esophago-proximal gastrectomy in 61 patients with portal hypertension were presented. The patients were followed up for 2 to 7.5 years. Two patients died from the surgery. There was no esophageal varix rebleeding during the follow-up period. We conclude that it is a good method for controlling bleeding varices.

Group IIIA-metal hydroxides indirectly neutralize the voltage sensor of the voltage-dependent mitochondrial channel, VDAC, by interacting with a dynamic binding site

The voltage-dependent, anion-selective mitochondrial channel, VDAC, undergoes two different conformational changes from the open to a closed state under positive and negative applied electric fields. Micromolar quantities of aluminum hydroxide and other metal trihydroxides have recently been shown to be able to inhibit this voltage-dependent closure (Dill et al. (1987) J. Membr. Biol. 99, 187-196; Zhang and Colombini (1989) Biochim. Biophys. Acta 991, 68-78). It was suggested that the inhibition results from the neutralization of the positively charged voltage sensors by the metal species. In the present study, the dynamics of the metal-binding site accompanying channel closure was investigated by adding In(OH)3 to only one side of the membrane and examining its effect on the channel's gating processes. Indium added to open channels inhibited channel closure only when the metal-containing side was on the lower potential side of the applied field. If indium was added only to the higher-potential side, the channels closed and tended to remain closed after the field was abolished. The addition of metal hydroxide after closing the channels with a negative potential on the metal side did not result in channel re-opening as would be expected for sensor neutralization. Inhibition occurred immediately, however, if the channels were first allowed to open briefly. The closed-state selectivity seemed to be very similar in the absence or presence of the metal, indicating that the metal-binding sites are not located within the pore of the channel in the closed conformation. The results are consistent with a voltage-dependent translocation across the membrane of each of two metal-binding sites on VDAC. This translocation is tightly coupled with channel opening and closing.

Inhibition by aluminum hydroxide of the voltage-dependent closure of the mitochondrial channel, VDAC

Micromolar quantities of aluminum have been found (Dill et al. (1987) J. Membrane Biol. 99, 187-196) to reduce the voltage dependence of the mitochondrial outer membrane channel, VDAC, from Neurospora crassa. In the present study, various metallic and organic ions were tested for possible aluminum-like effect, and only the trivalent metals exhibited a similar ability to reduce the channels voltage dependence. However, trivalency alone was not sufficient because lanthanum (III) had no effect. Quantitative analyses with three group IIIA metals (A1, Ga, and In) showed that, of the structural characteristics examined, the ability to form sufficient M(OH)3 at experimental pH was the primary property shared by all the effective metals. While providing new insight into the nature of VDAC's sensor, these results also indicate that aluminum-cell interaction may result from the presence of AI(OH)3 in solution in addition to the widely accepted AI3+-mediated interactions. While the [AI3+] is vanishingly low at neutral pH, the trihydroxide is the major form and should be considered as an important candidate for aluminum-induced cellular effects.

Randomized clinical trial on the combination of preoperative irradiation and surgery in the treatment of esophageal carcinoma: report on 206 patients

From June 1977 to May 1985, a prospective randomized clinical trial on pre-operative radiation for esophageal carcinoma was carried out in 206 patients. Lesions under 8 cm in length and patients younger than 65 years, at least on semi-liquid diet and not contra-indicated for surgery were randomized into a combined group (104 patients) or a surgery alone group (102 patients). Eight MV X ray units were used for the pre-operative radiation using A-P portals to deliver 4,000 cGy to the whole mediastinum and the left gastroepiploic lymphatic chain. Surgery was carried out after 2 to 4 week's rest. The immediate results of the combined group and the surgery alone group were: resection rate 93% and 85%, operative mortality 5% and 6%, intra-thoracic anastomotic leak 0% and 1%, positive pathology at the esophageal stump 0% and 2%, and lymph nodes metastasis 27% and 35% respectively. The 5-year survival rates of the combined group and the surgery alone group were 35% and 30%. We have noticed that those patients with lesions showing radiation reaction of grade III gave a 5-year survival of 50% (12/24). Because intra- and extra-thoracic lymphnode metastasis caused failures (41% and 34% of these two groups), increasing the preoperative tumor dose to 60 Gy or designing post-operative irradiation to cover the bilateral supraclavicular areas was necessary. The whole mediastinum and the left gastroepiploic lymphatics could further improve the results of surgery. Further studies are needed.

[Surgical management of adenocarcinoma of the gastric cardia--experience in 937 patients]

A total of 937 patients with adenocarcinoma of the gastric cardia were operated on within a period of 27 years. The overall resectability rate was 74.5%, the operative mobility was 16.0% and the resection mortality was 1.7% (within 30 days postoperatively). The incidences of anastomotic leakage and pulmonary complications were 3.7% and 3.2%, respectively. These two major complications carried mortality rates of 19.2% and 4.8% and accounted for 50% of the post-operative death. The 1-, 3-, 5-, and 10- year survival rates were 66.9%, 30.0%, 19.5% and 10.3%, respectively. The authors advise regular subtotal proximal gastrectomy when the cancer is confined to the stomach only or extends distally within one third of the lesser curvature. The main factors influencing the long-term results are lymph node metastasis, carcinomatous invasion to gastric serosa and the type of resection, either palliative or curative.

[Experience in the surgical treatment of 748 patients with lung cancer]

A series of 748 patients with lung cancer as treated by surgery from 1961 to 1984 is reported. Regular lobectomy was done in 445 (74%) patients, bronchoplastic lobectomy in 67 (11.2%), segmental or wedge excision in 15 (2.5%) and pneumonectomy in 74 (12.3%) in which the ratio of left to right pneumonectomy was 2.9:1. Overall resection rate was 80.4% (601/748) and resection mortality was 1.2% (7/601) (death within 30 days of operation). Overall 5 year survival rate was 42% (169/402). The 5 year survival rate was 35.3% for pneumonectomy, 54.1% for bronchoplastic lobectomy, 42.3% for regular lobectomy and 16.7% for segmental or wedge excision. In this analysis, emphasis is laid to the therapeutic validity of the different modes of surgery. Statistical data show that only when the indication of different surgical interventions are strictly adhered to and the reasonable procedures are carried out, could better results be obtained. In surgical treatment of lung cancer, it is an important principle to eradicate the tumor and its metastatic foci as thorough as possible and to conserve the respiratory function as much as possible. Regular lobectomy has now become the "standard" and first choice operation. Pneumonectomy should be reserved for the patients with absolute necessity due to the extent of the lesion, adequate cardiopulmonary function and possibility of a permanent cure. Pneumonectomy is substituted by bronchoplastic lobectomy to a certain degree, preserving more of the lung function and improving the living quality after operation and long term results. Extensive practice of this surgical modality is advised.