Medial thigh myocutaneous flap for covering extended hemipelvectomy

When a large tumour involves the buttock and anterolateral upper thigh, modifications to the classical hemipelvectomy may be required for its removal. Herein, we report the use of a medial myocutaneous flap for coverage of soft tissue defects produced by such procedures.

Sphincter-saving surgery with and without pre-operative radiation therapy as treatment for adenocarcinoma of the mid-rectum

AIMS

To determine if pre-operative radiation therapy induces a local response in patients with complete tumour penetration into the rectal wall and allows for anal sphincter preservation, we compared the results from pathological specimens and local recurrences as measurable end-points in patients treated with pre-operative radiation therapy plus low anterior resection vs. those only treated with low anterior resection.

METHODS

From January 1986 to December 1992, we treated 62 patients with mid-rectal adenocarcinoma (5-10 cm from the anal verge as determined by rigid proctosigmoidoscopy with the patient in the jackknife position). Pre-operative evaluation included: complete blood cell count, chemistry profile and the determination of carcinoembryonic antigen, chest X-ray, barium enema or colonoscopy and CT scan of the abdomen and pelvis. Only tumours potentially curative by resection in patients with performance status 0-2 (ECOG) were included. Twenty-one patients received pre-operative radiation therapy at a dose of 45 Gy delivered to the pelvis; 4-8 weeks later a low anterior resection was performed. Forty-one patients were treated with low anterior resection alone. Surgical specimens were classified according to the Astler-Coller modification of Dukes' classification.

RESULTS

There were 36 males and 26 females, with a mean age of 56 years. The surgical specimens of those treated only with surgery were classified as: A, 5; B1, 4; B2, 15; C1, 2; and C2, 15. Postirradiated specimens: no residual tumour, 3; A, 4; B1, 4; B2, 7; C2, 3. One surgical death occurred in the group who underwent surgery alone. The median follow-up was 50 months in patients treated with surgery alone vs. 62 months in the combined approach group. Local recurrences occurred in 15/40 patients treated with surgery alone and in 2/21 of those treated with the combined approach (P = 0.043). Anal sphincter continence was classified as excellent by 24/40 patients treated with surgery only and by 18/21 patients treated with the combined approach. The 5-year survival period was 58% in the surgery only group and 82% in the group with combined treatment (P = 0.08).

CONCLUSIONS

The use of pre-operative radiation therapy plus low anterior resection was associated with a lower rate of local recurrence and with a higher number of surgical specimens with no lymph node metastases. Thus, this combined treatment modality should be further evaluated as a possible treatment of mid-rectal cancers in good surgical candidates selected for sphincter-saving procedures.

Nicotine gum, 2 and 4 mg, for nicotine dependence. A double-blind placebo-controlled trial within a behavior modification support program

The effectiveness of nicotine gum in combination with a behavior modification program was studied. The nicotine dependence of participating smokers (N = 322) was assessed. One hundred sixty-eight smokers were labeled as high nicotine dependent and 154 as moderate to low dependent. In a randomized double-blind procedure, the high-dependent smokers were given gum containing 4 mg of nicotine (87) or 2 mg of nicotine (81) and the smokers with medium or low dependence were given gum containing 2 mg (76) or a placebo gum (78). The smokers were also randomized to familiarizing themselves with the medication a week before quit day (112) or to regular use, that is starting gum use on the quit day (122). In the high-dependent group, sustained and chemically verified nonsmoking rates at 6 weeks, 1 year, and 2 years were, respectively, 60%, 39%, and 34% in the subjects given the 4-mg dose compared with 41%, 16%, and 16% for those using the 2-mg dose. In the group with medium or low dependence, the success rates at the same time periods were 70%, 49%, and 39% for the subjects given the 2-mg dose and 38%, 22%, and 17% for those given placebo gum. The differences in success rates were significant at least at the p < 0.02% level for all comparisons. Familiarizing with the gum as compared with regular use gave fewer reports of side effects, 15% vs 34%, p < 0.001. A trend toward better success rates at 6 weeks, although not statistically significant, was observed for the familiarization group, 61% vs 52%. The study shows that high nicotine-dependent smokers need higher doses of nicotine replacement, in this case the 4-mg dose rather than the 2-mg dose, whereas 2 mg is superior to placebo among less dependent smokers. These results compare favorably with those reported from the more recent nicotine patch therapy.

[Induction of polyvalent immunity against Actinobacillus pleuropneumoniae in an experimental rat model]

Using an experimental model of passive immunity in the rat, the immunizing effect of live cells of Actinobacillus pleuropneumoniae serotypes 1, 3, 5, 7, 9 and 12 was tested against a challenge with serotype 1. It was observed that serotypes 5, 7 and 9 induced polyvalent immunity. Additionally, agglutinating antibodies to the homologous and heterologous serotype were titrated in the sera of immunized mothers; the results indicated that groups immunized with serotypes 5, 7 and 9 had higher titers against serotype 1.

Expression of interferons-alpha and -beta, tumor necrosis factor-alpha and transcription factors, IRF-1 and IRF-2, in leukocytes induced during interferon production

Analysis of gene expression in peripheral blood lymphocytes is of special interest because it could reflect physiological conditions. We have examined the expression and compared the relative amounts of specific mRNAs for interferons (IFN-alpha and IFN-beta), tumor necrosis factor-alpha (TNF-alpha) and interferon regulatory factors (IRF-1 and IRF-2) from interferon primed and Sendai virus induced peripheral blood leukocytes. Results obtained showed that IRF-1 was highly inducible by IFN treatment, IFN-alpha, TNF-alpha and IRF-2 were weakly induced by IFN treatment, and IFN-beta was not inducible by priming the cells with recombinant human IFN-alpha 2b. The IFN-alpha, IFN-beta, IRF-2 and TNF-alpha transcripts increased upon viral infection. The IRF-1 mRNA was rapidly induced by IFN treatment and decreased after Sendai virus infection. Our results show that, in peripheral blood lymphocytes, IFN-alpha and -beta genes have a different response to IFN induction, thus suggesting different regulatory mechanisms for IFN induction of type I IFN genes in peripheral blood lymphocytes.

Efficient expression and secretion of recombinant alpha amylase in Pichia pastoris using two different signal sequences

We have cloned and expressed a bacterial thermostable alpha amylase gene in Pichia pastoris using the methanol-controlled alcohol oxidase (AOX1) promoter. Two integrative vectors were constructed with two different secretion signal sequences in order to obtain efficient secretion of the protein. One vector contains the structural gene encoding the mature alpha amylase fused to the SUC2 gene signal sequence from Saccharomyces cerevisiae. In the other vector, the alpha amylase is expressed with its own signal sequence. In both cases, the alpha amylase were secreted into the culture medium with high efficiency, around 2.5 and 0.9 g/l respectively.

[The mechanisms of the dissemination and the treatment of ovarian metastases in colonic adenocarcinoma]

OBJECTIVE

The aims of this study are: 1) To known the frequency of ovarian metastasis, 2) to define the role of the surgical therapy and 3) to establish the mechanism of spread of colorectal cancer to the ovaries.

MATERIAL AND METHODS

Between 1989 and 1993 624 patients with colorectal adenocarcinoma; were treated, 19 (7.7%) had ovarian metastasis; they were divided in 2 groups according to the diagnostic time: A) synchronous; B) metachronous. In most patients a peritoneal lavage were performed; the primary tumor was resected.

RESULTS

The median age was 41.4 years. In group A: there were 9 patients; in 3 of them underwent elective surgery and in 6 an exploratory celiotomy due to colonic obstruction or perforation. The primary tumor was located in the sigmoid in 8 patients and in cecum in 1; the stage of the primary tumor was follows: B1, 2; B2, 3; C2, 4. The ovarian metastasis were located in the left ovary in 6; right, 2, and bilateral 1. The peritoneal lavage was positive in 6, and negative in 3. In group B: there were 10 patients; one underwent elective surgery and 9 exploratory celiotomy. The primary tumor was located in the sigmoid in 9, caecum in 1. The stage of the primary tumors were: B2, 4; C2 4; D, 2. The ovarian metastasis were located: left, 5; right, 1; bilateral, 4. The peritoneal lavage was positive in 6, negative in 2. The 5-year survival in group A was 16% in group B, 0%.

CONCLUSION

Ovarian metastasis were associated with advanced metastatic diseases. The treatment of synchronous ovarian metastasis is the resection of primary tumor plus bilateral oophorectomy, and in metachronous metastasis it is palliative. The mechanism of spread to the ovaries is by direct implantation and hematogenous.

Cloning of a Xenopus laevis muscarinic receptor encoded by an intronless gene

The Xenopus laevis oocyte has endogenous sites that bind muscarinic agonists, which have been pharmacologically characterized as M3 and/or M1 receptor subtypes. In order to define the molecular identify of the receptor protein we have analyzed a Xenopus oocyte cDNA library and cloned a 2.9 kb cDNA fragment encoding a muscarinic receptor (xMR). The deduced amino acid sequence reveals a protein of 484 residues with an apparent molecular weight of 54,188 Da. Amino acid comparison with previously cloned mammalian muscarinic receptors showed a 78% identity with the human m4 subtype, presenting at the same time clustered differences within the amino-terminal region and third intracellular loop Genomic Southern analysis displayed the presence of one main gene belonging to this subtype, and the PCR analysis revealed an intronless gene.

Could the piggyback operation in liver transplantation be routinely used?

OBJECTIVE

To determine if orthotopic liver transplantation with inferior vena cava preservation, performed without using caval cross clamping or venovenous bypass, can minimize hemodynamic instability and low renal perfusion pressure.

DESIGN

A prospective case series of 44 consecutive adult orthotopic liver transplantations, with a maximum follow-up of 30 months.

SETTING

An institutional university referral center.

PATIENTS

Between November 1990 and May 1993, 39 consecutive adult liver transplant recipients underwent transplantation with the following primary diagnoses: alcoholic cirrhosis (n = 23), viral cirrhosis (n = 9), primary biliary cirrhosis (n = 2), Wilson's disease (n = 2), primary sclerosing cholangitis (n = 1), fulminant hepatic failure (n = 1), and secondary hepatic malignant neoplasm (n = 1); five had repeated orthotopic liver transplantation.

INTERVENTION

Orthotopic liver transplantations were performed using the piggyback technique, but with placement of the vascular clamp on the inferior vena cava laterally instead of across it so that it remained patent throughout the anhepatic stage. Favorable anatomic conditions in the recipients were not considered; venovenous bypass was not used.

MAIN OUTCOME MEASURES

Intraoperative hemodynamic profile, blood loss and replacement, surgical time and complications, and patient survival.

RESULTS

No significant hemodynamic changes with lateral clamping and no increases in surgical complications, rate of retransplantation, blood product requirements, or survival rate compared with the standard procedure.

CONCLUSION

The piggyback operation could be routinely used in orthotopic liver transplantation.

Resonance energy transfer determination of the distance between the four cysteine-364 residues in Saccharomyces cerevisiae phosphoenolpyruvate carboxykinase

Each of the four subunits of the Saccharomyces cerevisiae phosphoenolpyruvate carboxykinase has one cysteine residue (Cys-364) that is protected against alkylation by MnATP and that is thought to be located at (or close to) the active site (M. Alvear, M. V. Encinas, S. Latshaw, R. G. Kemp, and E. Cardemil, 1992, Biochim. Biophys. Acta 1119, 35-38). To determine the distance relationships between these residues within this tetrameric enzyme, we have derivatized one of these reactive thiols with N-acetyl-N'-(5-sulfo-1-naphthyl) ethylenediamine (AEDANS) and the others progressively with 4-[N-[(acetoxy)ethyl]-N-methylamino]-7-nitrobenz-2-oxa-1,3-diazole (ANBD). In the doubly labeled protein nonradiative singlet-singlet energy transfer between AEDANS (donor) and ANBD (acceptor) was observed. The efficiency of the energy transfer is proportional to the number of occupied acceptor sites. From these data it has been determined that one of the acceptor sites is 33 A from the donor, and the remaining two sites are 44-46 A from the donor. Cross-linking experiments revealed that mainly cross-linked dimers were produced upon reaction of the enzyme with o-phthalaldehyde and dithiobissuccinimidylpropionate. We interpret these results as an indication that this tetrameric enzyme is most likely composed of an association of two dimers.

Prognostic profile in rectal cancer

PURPOSE

The purpose of this article was to review the prognostic factors of significance in rectal cancer.

METHODS

This is a retrospective review of various reports and an examination of our data.

RESULTS

Current imaging techniques with endorectal ultrasound, magnetic resonance imaging with a rectal probe, and possibly tagged monoclonal antibodies allow for presurgical assessment of the invasion of the rectal wall and detection of lymph node involvement.

CONCLUSIONS

Tumor penetration of the rectal wall and lymph node metastases are the most important prognostic indicators in rectal cancer and predict local and distant recurrences. When lymph node metastases occur, they are more common in small lymph nodes (< 5 mm). Patients with lymph node metastases always need to be considered for multimodality therapy. Tumors larger than or equal to T3 or with associated lymph node metastases should not be treated with sphincter-saving surgical procedures alone.

Rochalimaea henselae infection in acquired immunodeficiency syndrome causing inflammatory disease without angiomatosis or peliosis. Demonstration by immunocytochemistry and corroboration by DNA amplification

Rochalimaea henselae causes bacillary angiomatosis, bacillary peliosis, and persistent bacteremia. Difficult to cultivate, it is detectable in infected tissues by immunocytochemistry. This technique demonstrated R henselae in autopsy specimens obtained from three deceased patients who had acquired immunodeficiency syndrome, with pathologic tissue changes lacking neoangiogenic features. From the first patient, the cause of nodular collections of lymphocytes and nonepithelioid histiocytes in the liver, spleen, lymph nodes, bone marrow, and heart eluded detection until immunocytochemical identification of R henselae. In the second case, unexpected gross and microscopic necroinflammatory nodules in the liver and spleen contained Warthin-Starry-staining bacilli identified as R henselae immunocytochemically. The third patient was found to have pathologic changes in his liver and spleen comparable with those of the second case, as well as several other disseminated infections. In two cases, identification of R henselae was corroborated through sequencing polymerase chain reaction-amplified bacterial DNA recovered from tissue; in one case, DNA could not be amplified, possibly because of postmortem degradation. Application of the immunocytochemical technique thus has expanded the recognized spectrum of histopathologic findings associated with R henselae infection in acquired immunodeficiency syndrome, as well as proving to be potentially more sensitive than DNA amplification for this purpose when applied to autopsy tissues.

Bowel rest, intravenous hydration, and continuous high-dose infusion of octreotide acetate for the treatment of chemotherapy-induced diarrhea in patients with colorectal carcinoma

BACKGROUND

A prospective trial was conducted involving 16 patients with colorectal adenocarcinoma using a regimen of continuous-infusion octreotide acetate (Sandostatin [octreotide acetate], Sandoz, East Hanover, NJ for the treatment of severe diarrhea induced by the weekly schedule of 5-fluorouracil (5-FU) in combination with leucovorin who were refractory to opiate therapy.

METHODS

Fifteen patients had tissue-documented metastatic colorectal adenocarcinoma. An additional patient was treated adjuvantly. Fifteen patients were treated with chemotherapy consisting of 5-FU and high-dose leucovorin. The octreotide acetate regimen used was a continuous infusion of 50 micrograms/h for 12 hours followed by 100 micrograms/h for 12 hours and subsequently 150 micrograms/h for 72 hours. All patients were previous failures of diphenoxylate atropine (Lomotil diphenoxalate], Searle, Chicago, IL) given 2.5 mg orally after each loose bowel movement, but no more than 20 mg in a 24-hour period. Opiate therapy was not continued beyond 48 hours. All patients also were treated with bowel rest (nothing by mouth) and intravenous fluid hydration as well as octreotide acetate.

RESULTS

Complete resolution of diarrhea was seen in 15 of 16 patients (94%). In 4 patients this was accomplished during the 100 micrograms/h infusion, and in 11 patients during the 150 micrograms/h infusion. Recurrence of diarrhea was seen in two patients after a complete cycle of octreotide acetate. Both patients were restarted at 150 micrograms/h for 72 hours of octreotide acetate with resolution of the diarrhea within 36 hours of the infusion. No toxicity related to octreotide acetate was seen in this trial.

CONCLUSION

The continuous-infusion regimen of octreotide acetate 150 micrograms/h is an effective and safe schedule for the treatment of chemotherapy-induced diarrhea together with bowel rest and intravenous fluid hydration in a group of patients in whom the majority were treated with the weekly schedule of 5-FU and high-dose leucovorin.

Limited proteolysis of Saccharomyces cerevisiae phosphoenolpyruvate carboxykinase

Incubation of Saccharomyces cerevisiae phosphoenolpyruvate carboxykinase with trypsin under native conditions cases a time-dependent loss of activity and the production of protein fragments. Cleavage sites determined by sodium dodecyl sulfate polyacrylamide gel electrophoresis and sequence analyses identified protease-sensitive peptide bonds between amino acid residues at positions 9-10 and 76-77. Additional fragmentation sites were also detected in a region approximately 70-80 amino acids before the carboxyl end of the protein. These results suggest that the enzyme is formed by a central compact domain comprising more than two thirds of the whole protein structure. From proteolysis experiments carried out in the presence of substrates, it could be inferred that CO2 binding specifically protects position 76-77 from trypsin action. Intrinsic fluorescence measurements demonstrated that CO2 binding induces a protein conformational change, and a dissociation constant for the enzyme CO2 complex of 8.2 +/- 0.6 mM was determined.

Morbidity and mortality following abdominoperineal resection for rectal adenocarcinoma

From 1979 through 1986, 56 patients, 38 males (68%) and 18 females (32%), underwent an abdominoperineal resection with a wide perineal dissection for primary adenocarcinoma of the rectum. The open perineal wounds required a mean time of 6 months to completely heal. Estimated blood loss by the surgeon ranged from 200 ml to 4200 ml with a mean of 1112 ml and a median of 1000 ml. Twenty-six patients (46%) developed postoperative or intraoperative complications. Nineteen patients (34%) underwent incidental surgery with no associated morbidity. The most commonly occurring complication was impotence in 69% of male patients. The next most common complication was bladder dysfunction with urinary retention in 14 patients (25%) and urinary incontinence in five patients (9%). There were two postoperative deaths (4%). Although the morbidity was significant, greater than 90% of the complications were treatable and resolved without major sequellae.

In-111 CYT-103 monoclonal antibody imaging in patients with suspected recurrent colorectal cancer

Recurrent colorectal cancer is seen in as many as 40% of patients after curative resection. In view of the limitations of endoscopic and cross-sectional imaging, external immunoscintigraphy has been added to the follow-up regimen of patients at high-risk of recurrent disease. The authors investigated the utility of immunoscintigraphy with Indium-111 (In-111) CYT-103 (site specifically labeled conjugate of monoclonal antibody B72.3) in 19 patients with suspected recurrences after previous curative resection of colorectal carcinoma. Local or regional recurrences (4 patients) and liver metastasis (6 patients) were indicated by physical examination and computed tomography (CT), whereas nine patients had occult disease with increasing serum carcinoembryonic antigen (CEA) levels and negative conventional workups. Serum CEA levels were elevated (mean, 22 ng/ml) in all patients. Approximately 4.3 mCi In-111 labeled to 1.0 mg CYT-103 was administered intravenously to each patient. Planar and single photon emission computed tomography (SPECT) imaging were performed 2-5 days after infusion. The final diagnosis of recurrence or metastasis was established in 18 patients by second-look surgery or biopsy. One patient died before exploration. Tumor was identified at the following locations: pelvis (12 patients), abdominal wall (2 patients), retroperitoneum (1 patient), liver (5 patients), and omentum (2 patients). Superiority of monoclonal antibody (MoAb) scan is noted in the detection of pelvic and intraabdominal recurrences (100%) versus CT scan (43%). Liver metastases were identified with equal facility by both modalities. In-111 CYT-103 scan findings influenced the management of 10 (55%) of 18 patients. Surgery was avoided in one patient with disseminated metastases detected by the scan. Correct identification of occult local recurrences was made in six patients. An isolated liver metastasis was confirmed in one patient with equivocal CT scan. Finally, additional intraabdominal lesions were detected in two patients. These results suggest an important and beneficial role for In-111 CYT-103 MoAb imaging in patients with suspected recurrent colorectal carcinomas, particularly in patients in whom cross-sectional imaging is negative; such imaging may prevent patients from undergoing unnecessary surgical exploration.

Nd:YAG laser as a therapeutic option in the management of gastrointestinal cancer

We report the use of ELT utilizing an Nd:YAG laser in a group of patients with cancer who represented a significant surgical risk. Effective palliation was achieved, with minimal morbidity, and the quality of life of most of our patients was preserved or enhanced, at a minimal physiologic cost. In carefully selected patients, ELT has proved to be a safe and highly effective procedure for the management of gastrointestinal cancers. It should be considered a valuable addition to the treatment armamentarium of the practicing clinician dealing with patients with advanced cancers or patients with significant medical conditions precluding surgical resection.

Complete disappearance of a leiomyosarcoma of the lower extremity following preoperative hyperthermia and intra-arterial doxorubicin

Leiomyosarcoma of the extremities is an unusual tumor. Herein we report a unique and what we believe is the first case of a patient in whom there was complete disappearance of such a tumor following regional hyperthermia and chemotherapy.