Primary hepatocellular carcinoma with hepatitis B antigenemia: effects of chemotherapy

Eight patients with primary hepatocellular carcinoma (PHC) whose blood was positive for hepatitis B surface antigen (HBsAg) received treatment with cyclophosphamide, adriamycin, and 5-fluorouracil. In 4 cases, a rise in serum HBsAg titer occurred after chemotherapy. In 2 cases involving drug-related leukopenia, the rise in HBsAg titer was marked and associated with a sharp rise in the serum transaminase level (SGOT), up to 1700 in 1 case. Lower-dosage chemotherapy was safely resumed after SGOT had returned to pretreatment levels. No evidence of immunodeficiency after chemotherapy was revealed by in vitro testing of lymphocyte and granulocyte function, percentage of circulating T-cells, and immunoglobulin and complement levels. All 8 cases were negative for e antigen (eAg) and 4 were anti-positive. In 3 of 4 cases, anti-e became negative after chemotherapy, but all remained eAg negative. The negative eAg tests in these cases of PHC suggest they are not highly infectious, in spite of increased HBsAg titers in blood following chemotherapy.

Cytology of the liver, spleen and peritoneum obtained by sheathed brush during laparoscopy

A sheathed cytology brush, fashioned to be used during laparoscopy, is described for brushing the surface of the liver, spleen and peritoneum. The method has had no morbidity or complication in 100 consecutive patients. and has been highly successful in obtaining diagnostic cytological material from malignant neoplasms involving the liver (94%) and peritoneum (100%). In two cases, biopsies of tumor nodules were nondiagnostic, while brush cytology definitively documented malignancy. Because the brushing induces minimal trauma and is quick and simple to perform, it is suggested that brush cytology be considered a supplement to needle and forceps biopsies during laparoscopy. The stainless steel sheath on the brush eliminates concern over loss of cytologic material during brush withdrawal.

Laparoscopic diagnosis of suspected liver neoplasms. Value of prior liver scans

To study the efficacy of standard blood tests of liver function (LFTs) and technetium-99m liver scan followed by laparoscopy in the diagnosis of solid malignant tumors of the liver, 100 consecutive patients were evaluated who had these tests because of clinical suspicion of liver neoplasm. Malignant liver tumors were present in 65 of the 100 patients. Laparoscopy diagnosed 60 of the 65, and the neoplasms were documented pathologically by directed biopsy (92% sensitivity, 100% specificity). In 8 patients, hepatoma was diagnosed and staged for possible resection. A negative "blind" biopsy had been performed in 23 of the 60 patients with liver neoplasms diagnosed at laparoscopy. LFTs and liver scans together were good screening tests (95% sensitivity) but had low specificity (46%). Liver scans also provided information as to probable tumor location in the liver, guiding the insertion site for the laparoscope, and directing deep-needle biopsies if no surface lesions were seen.

Anticoagulation and high dose liver radiation: a preliminary report

Two groups of patients were observed for evidence of acute radiation hepatitis during "high dose" radiation to the liver. The first group of 18 patients with metastatic liver disease received an average of 4,050 rad to the whole liver. Half received anticoagulation with warfarin. One patient on anticoagulation developed evidence of acute radiation hepatitis while 2 patients did so without anticoagulation. Eleven patients with Hodgkin's disease received 4,000 rad to the left lobe of the liver during extended field radiation. Four of these 11 patients were anticoagulated to therapeutic range. Only one of the fully anticoagulated patients showed changes on liver scan consistent with radiation hepatitis whereas three did so without anticoagulation. No serious sequelae from anticoagulation occurred in either group. These preliminary data suggest that anticoagulation may be safely administered with high dose hepatic radiation and that further trials with anticoagulation are warranted.

Anticoagulation and high dose liver radiation: a preliminary report

Two groups of patients were observed for evidence of acute radiation hepatitis during "high dose" radiation to the liver. The first group of 18 patients with metastatic liver disease received an average of 4,050 rad to the whole liver. Half received anticoagulation with warfarin. One patient on anticoagulation developed evidence of acute radiation hepatitis while 2 patients did so without anticoagulation. Eleven patients with Hodgkin's disease received 4,000 rad to the left lobe of the liver during extended field radiation. Four of these 11 patients were anticoagulated to therapeutic range. Only one of the fully anticoagulated patients showed changes on liver scan consistent with radiation hepatitis whereas three did so without anticoagulation. No serious sequelae from anticoagulation occurred in either group. These preliminary data suggest that anticoagulation may be safely administered with high dose hepatic radiation and that further trials with anticoagulation are warranted.

Cutaneous manifestation of internal malignancies (I). Acanthosis nigricans

Skin changes may be the first clue to a neoplastic process at a stage when it still is treatable (Such as the development of Acanthosis Nigrican (AN) in an otherwise healthy adult). Ninety percent of the neoplasm responsible for the development of AN originate in the abdomen. The tumor, even in a subclinical state, seems to possess unidentified properties that activate the dermatosis.

The value of diagnostic aids in detecting pancreas cancer

By contract with the National Cancer Institute, the accuracy of diagnostic techniques was assessed in 184 patients suspected of having pancreas cancer. Of 138 patients who were operated upon, 89 were found to have pancreas duct cancer, 30 had cancer of a different site of origin in the head of the pancreas region and in 19 there was no evidence of cancer at operation. All of the 46 patients who were not operated upon, 13 proven to have cancer and 33 patients discharged as free of cancer, were followed in our clinic. The majority of our patients presented with signs and symptoms of biliary obstruction. Computerized transaxial tomography (CTT) gave a "correct" diagnosis in 31 of 33 patients (94%) with proven cancer, there were 2 patients with a false negative report and a false positive diagnosis occurred in 8 of 20 patients (40%) without cancer. Celiac angiography (CA) gave a correct diagnosis in 78 of 94 patients (83%) with cancer, a false negative in 17%, and a false positive in 32%. 76Selenomethionine pancreas scan correctly diagnosed 27 of 36 patients (75%) with cancer, gave a false negative in 25% and a false positive in 31%. Ultrasonography gave a correct diagnosis in 18 of 27 patients with cancer (67%), a false negative in 33% and a false positive in 28%. Endoscopic retrograde cholangiopancreatography diagnosed correctly 8 of 11 cases (73%) of cancer, there were false negative diagnoses in 3 cases (27%) and false positives in 3 of 14 patients (21%). Duodenal aspiration techniques gave a very low percentage of correct diagnoses. Chronic pancreatitis most commonly gave rise to a false positive diagnosis. Serum alkaline phosphatase was elevated in 82% of patients, gave 18% false negatives and 33% false positives. Carcinoembryonic antigen (CEA) was elevated (greater than 2.5 ng/ml) in most of the pancreas cancer patients but also in patients with other cancers and with non-cancerous diseases. In our hands, CTT, CA, alkaline phosphatase, 75Se-methionine and ultrasonography, in descending order, have given the highest percentage of correct diagnoses but false positive and false negative diagnoses prevented any single test from being conclusive.

Herpetic esophagitis in patients with cancer: ante mortem diagnosis by brush cytology

Ante mortem diagnosis of herpetic esophagitis has been made in four immunosuppressed patients with cancer. The diagnosis was made by brush cytology at the time of esophagoscopy. All four patients had severe dysphagia unresponsive to nystatin therapy and the diagnosis of herpes infection excluded the use of Amphotericin B for resistant moniliasis. The diagnosis of herpes virus infection of the esophagus has been previously made almost exclusively at post mortem examination. Herpetic esophagitis is shown to be not necessarily a preterminal complication in cancer patients. In three of the four patients the esophagitis resolved as the patients responded to anti-tumor therapy.

Peritoneoscopy in Hodgkin disease. Confirmation of results by laparotomy

Peritoneoscopy was used to evaluate the liver in 35 previously untreated patients with Hodgkin disease. Four were found to have hepatic involvement. Of the 31 patients with normal peritoneoscopies, only one had liver disease demonstrated subsequently at confirmatory exploratory laparotomy. The diagnostic accuracy of peritoneoscopy was 93% for patients at high risk for hepatic disease and 97% for all patients studied. Morbidity from the procedure was minimal. There was no mortality. Peritoneoscopy is a highly accurate staging procedure that should be considered as an antecedent or as an alternative to laparotomy in patients with Hodgkin disease. Its accuracy and minimal morbidity should be considered in the critical selection process of determining which individuals should undergo laparotomy.

Identical twins discordant for ulcerative colitis with colon cancer

A 22-year-old patient with a 16-year history of ulcerative colitis who developed multifocal anaplastic colon cancer is presented. His identical twin, proven by blood type, HL-A, and fingerprint analyses, has been completely asymptomatic. This report suggests that ulcerative colitis results from a polygenic predisposition without full penetrance. Subsequent development of colon cancer seems more likely related to the inflammatory disease that an independent genetic determinant.

Endoscopic diagnosis of advanced gastric cancer. Factors influencing yield

Factors influencing diagnostic yield by directed endoscopic biopsy and cytology were studied in 50 patients with advanced gastric cancer using a forward-viewing panendoscope. The diagnostic yield was higher for exophytic lesions than for infiltrative tumor, and directed brush cytology alone was more productive than directed biopsy alone. The lesions that provided non-diagnostic tissue were mostly recurrent or infiltrative cancers, and were most often in the cardia, antrum, or were of the linitis plastica type. The combination of infiltrative character and location in antrum or cardia, especially if recurrent, often resulted in non-diagnostic biopsy and cytology specimens.

Menetrier's disease and adenocarcinoma of the pancreas

A 74-year old woman with abdominal pain and edema was diagnosed to have Menetrier's disease on surgical full thickness gastric wall biopsy. Two months later, she complained of increasing severe abdominal pain radiating to the back, unusual in Menetrier's. Work-up showed classic Menetrier's disease with large gastric folds, achlorhydria, gastrointestinal protein loss and hypoalbuminemia. A celiac arteriogram, however, suggested a pancreatic neoplasm and adenocarcinoma of the body of the pancreas was confirmed at laparotomy. This is the first report of the concurrence of these two diseases. The difficulty of differentiating Menetrier's from occult gastrointestinal cancer is discussed.

Carcinoma complicating Crohn's disease. Report of seven cases and review of the literature

Seven cases of adenocarcinoma complicating Crohn's disease are reviewed. In three of the patients, small bowel cancers developed in association with reginal enteritis. In four patients, carcinoma of the colon was superimposed on Crohn's colitis. In two of these, the adenocarcinoma infiltrated chronic colocutaneous fistulas. Review of the literature shows an increasing number of reports of carcinoma complicating Crohn's disease, with a total of 36 cases of small bowel cancer and 30 cases of colon cancer previously reported. The significane of these and our own cases is discussed. The possibility of carcinoma must be kept in mind by clinicians following patients with Crohn's disease. Adenocarcinoma complicating Crohn's disease occurs at a younger age, on the average, and in areas similar to the distribution of Crohn's disease rather than the usual distribution of the cancer. Preoperative diagnosis is difficult, but changes in the nature of chronic fistulas should be investigated.