Induction of the expression of differentiation-related antigens on human colon carcinoma cells by stimulating protein kinase C

This study was undertaken to determine whether the phorbol diester, phorbol 12-myristate 13-acetate (PMA), causes differentiation of the human colon carcinoma cell line, SW 48. Under routine growth conditions, the cells are round, have a high nuclear-to-cytoplasmic ratio, and lack cytoplasmic vacuoles. After treatment for 1 hour with 100 nmol/L of PMA at 37 degrees C, the cells assumed a spread-out, flasklike shape, displayed a low nuclear-to-cytoplasmic ratio, and exhibited cytoplasmic vacuoles. An inert but lipophilic phorbol diester, 4 phorbol 12,13-didecanoate, failed to induce these morphological changes. Cell kinetic studies showed that whereas SW 48 cells have a doubling time of 35 hours, those incubated with 100 nmol/L of PMA have a doubling time of 90 hours. Although the flow cytometry histograms were similar until 8 hours into the cell cycle, the PMA-treated cells ultimately spent proportionately less time in S and more in G2/M. Finally, under routine growth conditions, SW 48 cells express neither carcinoembryonic antigen nor G7 antigen. These antigens, which are present on the surface of well-differentiated cells, were expressed after treatment of SW 48 with PMA. The data suggest that PMA causes profound changes in structure, cell growth kinetics, and antigen expression, consistent with induction of differentiation of the cell line SW 48.

Naloxone in septic shock

Treatment of septic shock is a persistent dilemma. The clinical use of agents such as naloxone has resulted in variable success. Because the dosage and timing of these agents are considered critical factors in their efficacy, we investigated both dosage and timing of naloxone. Thirteen consecutive patients with documented septic shock and resistance to a one-liter fluid challenge underwent invasive hemodynamic monitoring and the administration of naloxone by initial bolus of 0.03 mg/kg followed by infusion at a rate of 0.2 mg/kg.h over one hour. During the one-hour observation period, iv fluid administration, concomitant pressor agents, and respirator values were constant. After infusion, adjustments in fluid administration, respirator status, and pressor agents were made as required by the clinical situation. A significant increase in mean arterial pressure (MAP) over baseline (60 +/- 3 mm Hg) was noted at 5 min (77 +/- 6 mm Hg, p less than .005) and at 30 min (73 +/- 6 mm Hg, p less than .025). Similarly, a significant increase in systolic arterial pressure was noted over prenaloxone levels (89 +/- 3 mm Hg) at 5 min (114 +/- 6 mm Hg, p less than .001), 30 min (107 +/- 8 mm Hg, p less than .05), and at one hour (106 +/- 8 mm Hg, p less than .05). There was a moderate nonsignificant increase in cardiac index, pulmonary capillary wedge pressure, and systemic vascular resistance. No side-effects to naloxone were noted in our group. No effect on survival could be demonstrated. We found no overall effect on mortality. However, by its increase of MAP, naloxone may serve as a temporizing agent during the treatment of critically ill patients with septic shock.

Local management of pancreatic carcinoma: iodine-125 implantation

A retrospective review of patients with pancreatic carcinoma treated from 1983 to 1986 was performed. Group 1 comprise 11 patients judged surgically unresectable who were implanted with iodine-125 followed by external beam therapy post-operatively (Implant + XRT). Eight patients received external beam therapy alone (XRT) Group 2, and 23 patients underwent radical surgical resection (group 3). Median survival was 8 months in the implant + XRT group; 5 months in the XRT alone group and 7.5 months in the surgical group. Locoregional control was achieved in 8/11 (73%), 2/8 (25%), and 11/23 (48%) of these groups respectively. Pain was the most common presenting symptom, 38/42 (90%). Complete, lasting palliation was achieved in 8/10 (80%) of group one, 2/8 (25%) of group two, and 13/20 (65%) of group three patients. Despite surgical unresectability implant + XRT appears to offer similar results to radical surgery. The data are presented with respect to the implant technique, disappearance of the tumour on CT scan and patterns of failure.

Management of desmoid tumors

Desmoid tumors are rare, being less than 0.03 per cent of all neoplasms. Because of scarcity of data and relatively small numbers of patients, optimal treatment remains controversial. In this report, our experience with 36 patients evaluated and treated from 1960 to 1987 is analyzed. The most common primary site was the wall of the chest (ten); eight tumors originated in the abdominal wall. Nine patients had a history of previous trauma, and eight of these were women. Thirty-two patients had wide local excision and two had amputations. Clear margins were obtained in only 22 patients despite an attempt at wide resection in all instances. With a mean follow-up period of 41 months and a median of 24 months, only one of 22 patients with negative histologic margins had recurrence of tumor. Among the 11 patients with positive margins, four received postoperative radiation therapy and two remain disease-free; of the seven remaining patients with positive margins, three had recurrences. One patient with unresectable disease was treated with tamoxifen with regression of tumor and remains alive 15 months later. These data suggest that the best treatment of desmoid tumors remains resection with a clear margin of normal tissue surrounding the tumor. Adjuvant radiotherapy did not appear to decrease the rate of local recurrence.

Use of intraoperative ultrasound during hepatic resection in pediatric patients

Five pediatric patients with primary liver tumors were evaluated preoperatively with ultrasound (US), computerized tomography (CT), and angiography, and tentative operative plans were formulated. Intraoperative US was subsequently used to examine these children, resulting in changes in operative strategy of all five patients despite their extensive preoperative evaluations. Intraoperative ultrasound appears to provide the most accurate assessment of both the extent of tumor and its vascular relationships. Thus, operative strategies may be precisely tailored on the basis of such information, allowing rational resection where appropriate, while futile attempts at removal of inoperable lesions may be averted.

Intraoperative ultrasound of the liver affects operative decision making

The surgeon operating upon patients with primary or metastatic hepatic cancers must determine if resection is feasible and, if it is, the magnitude of required resection. In an attempt to determine which tests best aid the surgeon in these determinations, the authors prospectively compared preoperative computed tomography (CT) of the liver and intraoperative ultrasound (IOU) in 42 patients with liver tumors who underwent 45 exploratory operations. The primary diseases included colorectal cancer metastases in 27 patients, hepatoma in 11 patients, and metastatic cancers of other origins in 4 patients. In the 42 patients there were 89 identified hepatic lesions that were confirmed to be malignant by resection, biopsy, or continued growth on follow-up CT. The sensitivity of either test for detecting these lesions was 69/89 (77%) for CT and 87/89 (98%) for IOU. Resection was not feasible in 13 patients. Five had extrahepatic disease, 4 had more nodules discovered by IOU, 3 were found by IOU to have involvement of all three hepatic veins by tumor and 1 patient had portal-vein invasion. Alternatively, in four patients tumors thought to involve all three hepatic veins by CT were shown to be free of at least one hepatic vein, thereby permitting resection. In one patient who had been previously operated upon, a tumor thought to involve the remaining right hepatic vein was seen to be free of the vein, also permitting resection. Regarding the extent of resection, IOU was also helpful. Lesser procedures than anticipated were proved possible by IOU in seven patients. A more extensive resection was shown to be necessary by IOU in two patients. Thus, IOU affected the operative management in 22 of 45 operative episodes (49%). It was conclude that IOU is superior to both preoperative CT and surgical exploration in assessing both the feasibility and the extent of resection required for primary and secondary hepatic cancers. In the authors' experience, IOU is the most sensitive indicator of number of lesions present in the liver. In addition, the ability of IOU to determine hepatic venous anatomy is a helpful adjunct in determining resectability of liver tumors.

Treatment of biliary obstruction caused by metastatic cancer

Over an 8-year period, among 41 patients with obstructive jaundice caused by metastases to the liver or lymph nodes adjacent to the porta hepatis, palliative biliary decompression was established surgically in 11, by percutaneous transhepatic biliary drainage (PTBD) in 25, and by both methods in 2. Three patients had no drainage procedure performed. Early mortality after drainage occurred in 6 of 38 patients, and the median survivals (actuarial) for the remaining 32 patients were 4.5 months for the surgical group (range 2 to 21 months) and 4 months for the PTBD group (range 2 to 14 months). Although there were trends toward more frequent hospital readmissions and episodes of cholangitis in the PTBD group, the only statistically significant difference was in the number of catheter manipulations required. We concluded that when patients develop obstructive jaundice as a manifestation of metastatic cancer, useful palliation can be achieved by either surgical or percutaneous decompression.

Management of biliary obstruction in patients with unresectable carcinoma of the pancreas

Clinical and pathologic data from 73 patients with unresectable carcinoma of the pancreas treated from 1980 to 1987 were reviewed to evaluate the efficacy of biliary enteric bypass and percutaneous transhepatic biliary drainage (PTBD) in the treatment of malignant biliary obstruction. Fifty-two patients underwent biliary enteric bypass with no operative deaths and with a 15% operative morbidity. These patients had a median postoperative hospitalization of 12 days. Four patients (8%) eventually developed recurrent jaundice, and three of these were successfully treated with PTBD. The median survival for these 52 patients was 7 months. Twenty-one patients underwent PTBD with an 81% technical-success rate. These patients had a 33% early complication rate and a 33% in-hospital mortality. The median hospitalization was 13 days postdrainage. Of the 14 patients surviving the initial hospitalization, 86% developed late complications requiring 16 hospital admissions and ten emergency room visits for a total of 155 days of hospitalization. The median survival for those patients undergoing PTBD was 4 months from the time of diagnosis and 2 months from the time of catheter drainage. Surgical bypass offers excellent palliation for malignant biliary obstruction with extremely low morbidity and mortality in properly selected patients; PTBD is useful in the treatment of those patients with extensive disease, who are poor surgical candidates, or who have failed previous surgical drainage. There is a role for both of these palliative procedures in the management of patients with biliary obstruction from pancreatic cancer.

Immunohistology of the benign lymphoepithelial lesion in AIDS-related lymphadenopathy: a case report

We report a case of a benign lymphoepithelial lesion of the parotid gland in a patient with progressive generalized lymphadenopathy (PGL) related to human immunodeficiency virus. Serologic studies and immunoperoxidase studies for lymphocyte subsets, which have not previously been reported in this lesion, suggest involvement of an intraparotid lymph node by PGL rather than Sjogren's syndrome.

Postoperative radiation as adjuvant treatment for carcinoma of the oral cavity, larynx, and pharynx: preliminary report of a prospective randomized trial

A prospective randomized trial was performed in patients with advanced squamous cell carcinomas (SCC) of the oral cavity, larynx, and pharynx to examine the effect of adjuvant postoperative radiation therapy on locoregional recurrence and survival following "curative" resection. Fifty-one patients with stage III or IV SCC treated from 1981 through 1984 were randomized to receive either surgery alone (n = 27) or surgery with postoperative radiation (n = 24). Five patients were excluded from the study after randomization because of ineligibility or protocol violations. Overall recurrence rates of 55.6% and 36.8% were noted in the surgery and surgery with adjuvant radiotherapy arms, respectively (p = NS). This trend towards a higher recurrence rate in the surgery only arm was in part due to the development of lymph node metastases in the contralateral, nonoperated neck. Thus far, no significant differences in either locoregional or overall survival have been noted between the two treatment arms. In this preliminary analysis, adjuvant postoperative radiotherapy does not appear to improve disease-free or overall survival.

Megacolon with myenteric hypoganglionosis in a foal

A 6-month-old Clydesdale filly had chronic abdominal distention and intermittent febrile episodes. Abdominal surgery revealed impaction of the right dorsal colon, which was relieved by evacuation of contents through an enterotomy. Four days after surgery, abdominal distention recurred and progressed. The filly was euthanatized. Necropsy revealed the right dorsal colon to be markedly distended with digesta. Microscopically, there was a marked reduction in myenteric ganglion cells in the right dorsal colon and cecum and mild to moderate reduction of myenteric ganglion cells in the left ventral and transverse colon.

Megaesophagus and aspiration pneumonia secondary to gastric ulceration in a foal

A 3-month-old foal with a history of persistent fever and leukocytosis was found to have pneumonia, ulceration of the squamous portion of the stomach, and dilatation of the distal portion of the esophagus. The foal was euthanatized and necropsied. The distal portion of the esophagus was severely dilated, and there was severe ulceration and mural thickening of the stomach at the cardia. Because of the severe gastric ulceration and mural thickening, the gastroesophageal junction was fixed in an open position, permitting gastroesophageal reflux. The megaesophagus and pneumonia were considered to have resulted from chronic gastroesophageal reflux.

Gastrointestinal sarcomas. Analysis of prognostic factors

Clinical and pathologic data from 51 patients with primary sarcomas of the gastrointestinal tract treated from 1951 through 1984 were reviewed to determine clinical presentation, histologic features, treatment, and prognostic factors. The most common signs and symptoms were abdominal pain (62%), gastrointestinal bleeding (40%), and/or abdominal mass (38%). The primary site was stomach in 50%, small bowel in 30%, colorectum in 15%, and esophagus in 5%. Virtually all the sarcomas were leiomyosarcomas. Distribution was uniform among the three histologic grades; although 88% of Grade 1 tumors could be completely excised, only 35% of Grade 3 tumors could be completely resected. The 5-year survival rate was 75% for Grade 1 tumors, 16% for Grade 2 tumors, and 28% for Grade 3 tumors (p = 0.0013, Grade 1 vs. 2 and 3). Thirty of the 51 patients (59%) had curative resection with an operative morbidity rate of 24% and an operative mortality rate of 12%; at 5 years the disease-free survival rate was 58% and the overall survival rate was 63% (48% at 10 years). Eleven patients (42%) had recurrent disease develop at a median interval of 2 years after complete tumor excision. Twenty-one patients (41%) had partial excision or biopsy only of their tumors with an operative morbidity rate of 28%, operative mortality rate of 8%, and median survival of only 9 months. Overall, patients whose tumors were confined to the site of origin had a 58% 5-year survival rate compared with 20% for those whose tumors had invaded adjacent organs (p less than 0.05). If the tumor was less than 10 cm in size, the 5-year survival rate was 78%, significantly better than the 38% for tumors greater than 10 cm (p = 0.03). These data suggest that histologic grade, local invasiveness, size, and extent of resection are the most important prognostic factors for patients with primary gastrointestinal sarcomas. Patients who have resection of all gross tumor, especially if it is well differentiated and localized, have a good prognosis.

Acute toxicity of petroleum- and shale-derived distillate fuel, marine: light microscopic, hematologic, and serum chemistry studies

Rats were gavaged with 60, 48, 38, 30, or 24 ml/kg of either petroleum (P) or shale (S)-derived distillate fuel, marine (DFM). Surviving rats were killed 14 days after dosing. There was a slight difference in toxicity of the two fuels but neither fuel was very toxic. The LD50/14 was 43 ml/kg for P-DFM and 50 ml/kg for S-DFM. Lesions in rats that died indicated hepatic and renal toxicity. In another study, rats were gavaged with 24 ml/kg of either P- or S-DFM and killed at 1, 2, or 3 days after dosing. Prominent clinicopathologic findings included loss of body weight, hematologic evidence of dehydration, transient leukopenia, and serum chemistry and histopathologic alterations indicative of mild hepatic and renal toxicity.

Complete cDNA sequence of a cytochrome P-450 inducible by glucocorticoids in human liver

HLp is a human liver cytochrome P-450 that is immunochemically related to the glucocorticoid-inducible liver cytochrome P-450p in the rat and its homologue in the rabbit, P-450 LM3c. To investigate the structure and regulation of HLp, we used a monoclonal antibody that recognizes purified HLp to screen a human liver cDNA library in lambda gt11. We isolated and sequenced two overlapping cDNA clones that span the entire 2011 bases of an mRNA that codes for a protein of 504 amino acids. The predicted amino-terminal amino acid sequence of this protein is identical to the first 20 residues determined from purified HLp. HLp mRNA shares more than 70% sequence homology with related proteins from the rat and rabbit but less than 40% homology with other published cytochrome P-450 genes. Moreover, Southern blot analysis of human and rat genomic DNA revealed 50 and 60 kilobases of DNA, respectively, hybridizable to the HLp cDNAs. Blot analysis of human liver RNA from five patients revealed major (2.2 kilobase) and minor (3.0 kilobase) bands that hybridized to HLp cDNAs. The apparent concentration of these hybridizable mRNAs as well as the amounts of immunoreactive HLp protein in microsomes from the same liver were increased in a dose-dependent relationship in three patients who received dexamethasone, a potent glucocorticoid. Furthermore, in samples of RNA and of microsomes isolated from cultures of a human hepatoma cell line (Hep G2) incubated for 120 hr in medium containing dexamethasone, there was a 6-fold induction of the two mRNA species hybridizable to HLp cDNAs and a 3-fold induction of immunoreactive HLp protein as compared to the values for cultures incubated in steroid-free medium. We conclude that HLp is a human representative of a conserved glucocorticoid-inducible cytochrome P-450 gene family whose mechanism of induction involves accumulation of HLp mRNA.

Reconstruction of the bile duct with transanastomotic U tubes

Thirty-one adult patients have undergone reconstruction of the bile duct using a transanastomotic U tube to stent biliary-enteric anastomoses. The U tube is brought through the substance of the liver into the proximal part of the bile duct, threaded through the anastomosis, usually to a Roux-en-Y limb of jejunum and then withdrawn from the jejunum through a separate enterotomy. Both ends of the Silastic (silicone rubber) catheter are then brought out the abdominal wall through separate stab incisions and secured to the abdominal wall. In 21 patients, the procedure was performed for benign disease. There were no operative deaths. Recurrent strictures developed in two patients (9.5 per cent). There were seven infectious complications, none of which were life-threatening. Preoperative bilirubin levels averaged 9.5 milligrams per cent; postoperative bilirubin levels averaged 2.6 milligrams per cent. Recurrent stricture developed in two patients at 20 and 19 months after removal of the U tubes. In ten patients, the obstruction of the biliary tract was secondary to malignant disease--seven primary tumors of the biliary tract and three metastatic tumors. Operative mortality was 20 per cent. Among the patients who survived the operation, the average bilirubin level was 6.6 milligrams per cent as compared with the average preoperative level of 14.4 milligrams per cent.

Identification of an inducible form of cytochrome P-450 in human liver

It has not yet been determined whether human liver contains inducible cytochromes P-450 similar to those that catalyze the oxidative metabolism of foreign substances in animals. We carried out immunoblot analyses of liver microsomes isolated from eight patients and found that each contained a cytochrome P-450, termed HLp, that reacted with antibodies directed against P-450p, a rat liver cytochrome that is inducible by the anti-glucocorticoid pregnenolone-16 alpha-carbonitrile, by glucocorticoids, by anti-seizure drugs, and by such macrolide antibiotics as triacetyloleandomycin. In the two patients who received dexamethasone and anti-seizure medications and in the one patient who was given triacetyloleandomycin, the concentrations of immunoreactive HLp and the ability to demethylate erythromycin and/or to convert triacetyloleandomycin to a metabolite that forms a spectral complex with cytochrome P-450 heme (catalytic properties unique to P-450p in rat liver) were significantly higher as compared to the values for patients who received no inducing drugs. We purified HLp to homogeneity and found that it was immunochemically related to P-450p and to its homologue in the rabbit (LM3c), actively demethylated erythromycin in a reconstituted system, exhibited electrophoretic mobility identical to that of P-450p, and shared 57% homology in its NH2-terminal amino acid sequence with that of a pregnenolone-16 alpha-carbonitrile-inducible rat cytochrome P-450. We conclude that HLp is a human representative of the multigene family of the glucocorticoid-inducible cytochromes P-450.

Diffuse mesenteric amyloidosis: CT, sonographic, and pathologic findings

We report an unusual case of diffuse infiltration of the mesentery by amyloidosis. The CT, sonographic, and operative findings mimicked abdominal carcinomatosis.

The continuing problem of carcinoma of the pancreas

The courses of 208 patients with adenocarcinoma of the pancreas were reviewed. The lesion was located in the head of the pancreas in 142 patient, (68%) and of these, in 22 patients the diagnosis was confirmed histologically at postmortem examination; 21 patients underwent laparotomy and biopsy with a 33% operative mortality and a 3.4-month average survival; 89 patients underwent biliary and/or gastric bypass with a 24% mortality and 4.8-month average survival; 10 patients underwent pancreaticoduodenectomy with a 20% mortality and 14.6-month average survival. The lesion was located in the body or tail of the pancreas in 77 patients (32%); and, of these, 15 patients had histologic confirmation of clinical diagnoses at postmortem examination; 19 patients underwent biopsy of extra-abdominal metastases and survived an average of 1.4 months; 27 patients underwent laparotomy and biopsy with a 26% operative mortality and 3.5-month average survival; 4 patients underwent gastric and/or biliary bypass with a 50% mortality and 4.5-month average survival; one patient underwent noncurative distal pancreatectomy and survived 1 month postoperatively. No patient was cured of his disease. Of the 55 operative survivors of biliary bypass alone for carcinoma of the head of the pancreas, 5 (9%) required subsequent gastroenterostomy for duodenal obstruction.

Improved survival following complete excision of retroperitoneal sarcomas

Charts and slides of 47 patients with primary retroperitoneal sarcomas (excluding pediatric rhabdomyosarcoma) were reviewed to determine clinical presentation, histologic features, extent of surgical resection, operative morbidity and mortality, use of radiation and/or chemotherapy, and survival data. Most patients presented with pain and a palpable mass. Leiomyosarcomas and liposarcomas were the most common tumors. Eighteen of the 47 patients (38%) had complete tumor excision; 68% required resection of adjacent organs. Operative morbidity was 33% with no mortality. After complete resection, the disease-free 5-year survival was 50% and the overall survival was 70% at 5 years; 10-year disease-free survival was 25% with an overall 58% survival at 10 years. Eleven patients (61%) developed recurrent disease with a median interval of 5 years following complete excision. Six patients received adjuvant radiation and/or chemotherapy with four remaining disease-free from 46 to 61 months. Eighteen patients underwent partial excision of tumor and 11 patients underwent biopsy only; these groups had similar survival curves with only 4% alive at 5 years. Their operative morbidity was 18% and mortality was 7%; median time to clinical evidence of tumor progression was 12 months. Sixty per cent of these patients received therapeutic radiation and/or chemotherapy, but their survival was the same as those undergoing surgery alone. These data emphasize the importance of an aggressive surgical approach in the treatment of retroperitoneal sarcomas. Complete tumor resection and total excision of recurrences will allow many patients long-term survival.

Tubed pectoralis major musculocutaneous flaps for cervical esophageal replacement

Five patients undergoing laryngopharyngectomy and cervical esophagectomy for cancer were reconstructed using a tubed pectoralis major musculocutaneous flap for esophageal replacement. One patient had no complications, 2 had pinpoint fistulas with rapid healing, a fourth died of a myocardial infarction, and the fifth had a partial breakdown requiring secondary flap closure. This flap is safe, reliable, and easy to rotate and tube on itself; use of the tubed pectoralis major musculocutaneous flap obviates the necessity for laparotomy for colon interposition, gastric pull-through, or jejunal free grafts. In addition, microvascular anastomoses are not required. Therefore, it is recommended as an excellent means of replacing the cervical esophagus and should be considered a method of choice in debilitated patients.