[Combination therapy with low dose adriamycin for advanced or recurrent breast cancer. Hokkaido Breast Cancer Treatment Study Group]

Comparative clinical trials among 3 regimens for patients with advanced or recurrent breast cancer were performed as a multi-institutional joint study. Arm-I of 3 regimens consisted of a 3-day consecutive administration of adriamycin (ADM) at 10 mg/body every 4 weeks, a daily oral administration of cyclophosphamide (CPA), 5-FU and tamoxifen (TAM) at 100 mg, 200 mg, and 20 mg, respectively, and a once-a-week intramuscular or subcutaneous injection of OK-432 (OK) gradually increased from the initial dose of 1 KE to the maintenance dose of 5 KE. Arm-II contained methotrexate (MTX) at 10 mg/body for 3 consecutive days every 4 weeks in place of ADM in Arm-I. Arm-III contained neither ADM nor MTX. Of 69 cases registered, 52 were eligible, leaving 6 non-eligible and 11 incomplete cases. The results of the overall evaluation of 48 complete cases other than 4, in which the tumor was not exactly measured, were as follows. Arm-I resulted in 2 CR and 3 PR out of 19 cases, the response rate being 23.6% (5/19). Arm-II resulted in 1 CR out of 15, the response rate being 6.7% (1/15). In Arm-III, no response cases were found. No significant difference was observed among three treatment groups (p = 0.055), but in Arm-I, the response rate was higher than in the other treatment groups, suggesting that there is a probability of useful combined use of ADM.

Role of surgical treatment for recurrent hepatocellular carcinoma after hepatic resection

From 1978 to 1989, 164 patients underwent hepatic resection for hepatocellular carcinoma at our institution. The carcinoma was resected completely in 149 patients. Sixteen patients were excluded from this study because it was not known whether they were recurrent or disease free, or because death occurred as a result of surgical complications. Recurrent disease occurred in 48.1% of the remaining 133 patients. Fifty-seven patients had recurrent tumor only in the residual liver. A second hepatic resection was performed in 14 cases, 22 received intraarterial chemotherapy and/or arterial embolization without resection,a nd the remaining 21 received no anticancer therapy. The 5-year survival rate of patients who had a second resection was 92.0%. Recurrences in distant organs occurred in 14 patients, and the recurrent carcinoma was resected in five cases. Four of these 5 patients survived more than 3 years after the second surgery. Aggressive surgical resection of recurrent HCC, even for distant metastasis, is a viable approach, and may produce long-term survivors.

[Adjuvant hepatic arterial chemotherapy on hepatocellular carcinoma with THP-adriamycin and carboplatin]

We studied the effect of adjuvant hepatic arterial chemotherapy with THP-adriamycin (THP) and carboplatin (CBDCA) in patients with hepatocellular carcinoma (HCC). Fifteen patients were treated by intraarterial infusion of THP 30 mg on the second and third week after hepatectomy. CBDCA 450 mg was further injected on the fourth week (group A). Intrahepatic arterial administration of the drug was carried out through the subcutaneously implanted reservoir; one to five courses of the protocol were performed (average 2 times). Transient leukocytopenia occurred in six cases, liver dysfunction in one case, duodenal ulcer in one case and occlusion of the catheter connected reservoir in three cases. Forty-two patients not treated with this protocol postoperatively were employed as historical control (group B). There were no significant differences between group A and B in operative procedures, tumor stage, clinical stage, tumor size and other histopathological findings including nuclear DNA ploidy pattern. The two-year cumulative disease-free survival rate was 78% in group A, which was significantly better than the 55% of group B (p < 0.05). It may be concluded that intrahepatic arterial chemotherapy using THP and CBDCA plays an important role to prevent recurrences of the tumor after hepatectomy in patients with HCC.

[Host immunological status modification by various chemotherapeutic drugs]

There are many unsolved problems about the effects on a host's cellular immunologic status by various chemotherapeutics used routinely. Thus, we performed an experimental study mainly on these effects using mouse effector cells. We administered the usual therapeutic dosage of various chemotherapeutic agents to 8-week female C57BL/6 mice, and 3 days after these administrations all mice were sacrificed and splenectomised. The number of splenocytes in whole spleen, LAK precursor cell activity, NK cell activity, and IL-2 productivity were determined, and these results were compared with those for normal mice. Although CY, 5-FU, MMC and LIB exhibited immunologic depressive effects, BLM and PEP showed augmentative effects, and ADR and CDDP no effects. It seemed important that the appropriate drug selection be made on the basis of the above data in order to be the best therapeutic regimen for the individual patient's malignancy.

[A simple method for estimation of liver volume using CT-scan after major hepatic resection]

We developed a new system to estimate liver volume using CT-scan images printed on the films. This device is composed of X-Plan360i (Ushikata Shokai, Tokyo) and personal computer. Thirty-five patients with hepatocellular carcinoma were estimated those liver volume before and 4 to 6 weeks after hepatic resection. The presumed liver volumes calculated preoperatively were significantly correlated with the weight of the resected specimen. The postoperative increasing rates of residual liver volume was regulated by resected liver volume ratio and severity of associated cirrhosis. Four cases which suffered from postoperative liver insufficiency showed the lower postoperative rates than the patients without liver insufficiency. Measurement of liver volume with this method is simple and promises to play an important role for evaluate hepatic reserve.

Postoperative chemoimmunotherapy for the treatment of liver cancer

A randomized study using spleen-derived lymphokine-activated killer (LAK) cells in hepatocellular carcinoma (HCC) is reported. We induced cytotoxic lymphocytes from resected spleen of HCC. The effect of recombinant interleukin-2 (rIL-2)-activated spleen cells for prevention of recurrence of HCC after hepatic resection was studied. Enough mononuclear cells could be harvested from the resected spleens. The induction of activated spleen cells was carried out by culture in fresh medium containing 1,500 JU/ml of IL-2. The cytotoxicity of the activated spleen cells maintained high levels during the culture period ranging from 3-30 days. These autologous activated spleen cells were administered to patients 2 days after the intra-arterial infusion of Adriamycin. A randomized study using these spleen LAK cells resulted in lower recurrence rates in the LAK IL-2-treated group. No severe side effects were observed. The lymphocytes derived from resected spleens were useful as the source of effector cells in clinical adoptive immunochemotherapy for HCC, because of their higher cytotoxicity and the simplicity of gaining a large amount of cells.

Isolation and culture of human hepatocytes from resected liver tissue as a bioreactor for a hybrid artificial liver

To use cultured human hepatocytes as a hybrid artificial liver, effective methods for isolating and culturing the hepatocytes from resected surgical specimens were investigated. Two different procedures for isolating hepatocytes, perfusion and agitation with a collagenase solution (Method 1) and perfusion with a mixed solution of collagenase and dispase (Method 2), were examined. The yield of isolated hepatocytes obtained by Method 2 (13.31 x 10(6) cells/g of liver) was significantly higher than that by Method 1 (0.94 x 10(6)). The warm ischemia time (0-90 min) of the liver fragments obtained did not disturb the viability and yield of the isolated hepatocytes. The gluconeogenesis and urea synthesis of the cultured human hepatocytes were well preserved for 10 days. These results show that for prolonged human hepatocyte culture (10 days), isolation from resected human liver tissues by a combination of the proteolytic enzymes collagenase and dispase was effective and warm ischemia was tolerated for up to 90 min, which indicates the possibility of using cultured human hepatocytes as a hybrid artificial liver.

Chemohormonal therapy of unresectable hepatocellular carcinoma

This article reports a prospective randomized controlled study to investigate the effect of sex hormone therapy combined with intra-arterial chemotherapy for hepatocellular carcinoma (HCC). Thirty patients with unresectable HCC were randomly divided into two groups. A catheter was inserted into the hepatic artery of all patients. The first group (group A) was administered 60 mg/m2 of cisplatin (CDDP) on day 15 and 13 mg/m2 of Adriamycin (ADM) on day 1 and 8 postoperatively via the hepatic artery cannula; in addition, a daily dose of 150 mg 5-fluorouracil (5-FU) was administered orally. Tamoxifen (TAM) 25 mg/m2 daily and medroxyprogesterone acetate (MPA) 400 mg/m2 daily were also administered orally. TAM and MPA administration were alternated every 4 weeks. For the second group (group B) the same protocol of anticancer drugs administration, without the hormonal agents, was given. At least three courses of the treatments were carried out. Twelve patients in group A and 14 in group B were evaluated. Partial response of the hepatic tumor to the treatments was observed in 33.3% of group A patients and 21.4% of group B patients, a difference that was not statistically significant. The 1-year survival rate was 44.5% in group A and 33.0% in group B. The performance status of 25% of the patients in group A was significantly improved compared with 14.3% in group B (p < 0.05). TAM- and MPA-combined chemotherapy may not prolong the survival of patients with HCC, although it improves their quality of life.

Surgical treatment of congenital biliary dilatation associated with pancreaticobiliary maljunction

The excisional surgical treatment of 50 patients with congenital biliary dilatation (CBD) associated with pancreaticobiliary maljunction (PBMJ) was analyzed. There were two patients who had early complications of lesser bile juice leakage with a maximum duration of 21 days, but no pancreatic juice leakage was noticed. As a late complication, two strictures at the anastomotic portion of the hepaticojejunostomy and one intrahepatic gallstone formation were encountered, but no malignant lesion was evident. Both patients with strictures could be predicted using postoperative cholangiography performed two weeks postoperatively and underwent hepaticojejunostomy. Intrahepatic gallstones were treated with lateral segmentectomy of the liver and electrohydraulic lithotripsy through percutaneous transhepatic cholangioscopy. Accordingly, these results suggest that excisional surgical treatment is the most appropriate method for CBD with PBMJ; however, special care must be taken, such as creating a sufficiently wide anastomotic stoma to enable free drainage of bile into the intestine; also, there should be precautions against ischemia at the anastomotic portion. The importance of the postoperative cholangiography to predict the postoperative outcome should be emphasized. Furthermore, causes of intrahepatic gallstone formation should be studied in such instances.

[A case of spontaneous biloma accompanied with incarcerated choledocholithiasis]

A 55-year-old man was admitted with abdominal pain and nausea. CT-scan and US showed no abnormal findings. On the 5th hospital day, a large mass was palpable on the upper abdomen, and CT-scan (7th hospital day) demonstrated a large, cystic mass below the left lobe. A thoracentesis under ultrasound guidance obtained bile-stained fluid. PTCD revealed choledocholithiasis and severe dilatation of the common bile duct and the left branch. After conservative treatment, cholecystectomy and choledocholithotomy were performed. Biloma occurred mainly traumatically or iatrogenically. This case had a spontaneous biloma, and only 11 cases have been previously reported as spontaneous biloma in Japan.

Intra-arterial infusion chemotherapy on unresectable hepatocellular carcinoma under occlusion of hepatic arterial flow

Intra-arterial infusion chemotherapy (IAIC) by occluding hepatic arterial flow augments intrahepatic drug concentrations, resulting in response rates higher than those with conventional infusion methods. We recently developed an intra-hepatic artery catheter and device attached with an implantable double-lumen reservoir that can be used for repeated IAIC in outpatient clinics. Eight patients with unresectable hepatocellular carcinoma were treated by infusion of anticancer drugs using this method. The catheter was inserted into the hepatic artery under laparotomy. The occlusion balloon was attached to the common hepatic artery, and catheters were connected to the subcutaneous double-lumen reservoir. Approximately 0.5 ml of distilled water was injected through the one port of the double-lumen reservoir to inflate the balloon, which compressed the artery within the cylinder-like occluder. 4'-O-tetrahydropyranyladriamycin (THP-ADM) was used as the anticancer agent, and two patients received combined administration with carboplatin. Three to seven repeated infusions were possible without any severe side effects. This treatment was also easy to perform in the outpatient clinic. Six of the eight patients survived for more than 2 years, an improvement over the survival rates obtained in a previous conventional IAIC group. We conclude that IAIC with THP-ADM for unresectable hepatocellular carcinoma under occluding blood flow using our device is more convenient and more effective than other available methods.

[Cooperative Study of Surgical Adjuvant Chemotherapy for Colorectal Cancer (fourth report): five-year results after surgery]

In collaboration with 428 institutions nation-wide, comparative studies on the optimal daily dosage of UFT were carried out for non-curative resection cases of colorectal cancer for two years from January 1984 to December 1985. The administration method employed was as follows. Group C received 12 mg/m2 of MMC on the day of operation, followed by 6 mg/m2 every 2 months 6 times, and from the 2nd week after the operation 600 mg/body of UFT was continuously administered every day for 1 year. Group D received 400 mg/body of UFT every day and the same amount of MMC as Group C. Analysis was made of 556 evaluable cases. There was no difference in the survival rate between the two groups. With respect to the dosage per body weight (kg), 8-12 mg/kg of UFT produced good prognoses and less side effects than the group which received more than 12 mg/kg. It seems necessary to administer UFT at its optimal dosage for colorectal cancers.

[Cooperative Study of Surgical Adjuvant Chemotherapy for Colorectal Cancer (third report): five-year results after surgery]

Beginning in January 1984, in collaboration with 357 institutions nationwide, comparative studies on curative resection cases of colorectal cancer and a control group were conducted for 2 years. The following method of administration was employed; Group A received 12 mg/m2 of MMC on the day of operation, followed by 6 mg/m2 every 2 months 6 times. From the 2nd week after the operation, 800 mg/body/day of Futraful was administered for one year. Group B received no treatment. Altogether 2786 cases were collected and, excluding ineligible cases, 2477 evaluable cases were analyzed. There was no difference in either survival rate or disease free rate, but after the bias of background factors was corrected by the hazard model, the disease free rate was better with Group A, and there was a significant difference with the rectum. According to the Dukes classification, in the Dukes C cases with the rectum Group A had higher rate of survival, disease free rate and lower rate of metastasis to the liver and local recurrence of cancer.

The effect of tube feeding on postprandial gastroesophageal reflux

Distal esophageal pH in supine position was monitored for 6 hours in 13 asymptomatic infants. During this period the patients received 15 to 20 mL/kg of 5% glucose solution twice every 3 hours. Each meal was fed orally or through a pH sensor tube. When the patient was fed through a tube, the meal was introduced into the stomach or into the distal esophagus. The extent of reflux during 2 hours after feeding was compared between oral and tube feeding. Comparing oral and intragastric tube feeding, intragastric tube feeding showed significantly fewer reflux events, a smaller percentage of time in the esophageal pH below 4, and a shorter duration of the longest single reflux event. Comparing oral and intraesophageal tube feeding, intraesophageal tube feeding showed the same pattern. The data indicated that tube feeding significantly diminishes the postprandial reflux.

Inflammatory pseudotumor of the liver in children: report of cases and review of the literature

Two pediatric cases of inflammatory pseudotumor of liver were reported and compared with seven previously reported cases. Clinical presentation was variable but often consisted of fever and vague abdominal symptoms. These two cases were considered to be clinically malignant because angiographically one showed hypervascularity and the other showed the portal vein draining into the lesion to be occluded. There are four previous reports of similar cases complicated with occlusive phlebitis within and around the lesion. All but two of the reported cases underwent major hepatectomy or liver transplantation. However, because of the benign nature of the lesion, the treatment might be more conservative after adequate diagnostic procedures, including needle biopsy, are applied.

Liver regeneration following portacaval shunt in rats: 3',5'-cyclic AMP changes in plasma and liver tissue

Hepatic regeneration following portacaval shunt was evaluated in the light of the changes of 3',5'-cyclic AMP (cAMP) levels in plasma and liver tissue, and also plasma cAMP levels after glucagon administration, using a 70% hepatectomy and portacaval shunt model in rats. Ratios of liver to body weight recovered to 60% of pre-operative ratios 2 weeks after the operation. Plasma cAMP level decreased slightly, but insignificantly, 1 day and 3 days after the operation, then recovered to the pre-operative level. Hepatic cAMP concentration increased for 2 weeks after the operation. Plasma cAMP levels induced after glucagon administration did not increase until 3 days after the operation and were only 50% of pre-operative levels 4 weeks after the operation. From these results, liver regeneration following the portacaval shunt was remarkably delayed, but continued until at least 2 weeks after the operation.

Accelerated rejection of allografted rat liver perfused with anti-ICAM-1 monoclonal antibody

Infusion of mouse anti-rat ICAM-1 into the portal vein of ACI rat liver graft before transplantation resulted in accelerated rejection by LEW recipients (2.9 +/- 2.5 days), when compared to the ACI liver grafts perfused with either Lactate-Ringer's solution (9.8 +/- 1.3) or anti-human ICAM-1 mAb (9.8 +/- 3.1). Histologic features of anti-rat ICAM-1 perfused grafts were spotty ischemic necrosis, whereas those of control grafts were marked cellular infiltration. These combined survival and histologic data suggest that the accelerated rejection may be mediated by vascular deterioration.

[Malignancy of hepatocellular carcinoma evaluated with nuclear DNA ploidy pattern]

Nucleus DNA ploidy analysis was performed by flow cytometry on 81 patients with hepatocellular carcinoma. DNA ploidy patterns were divided into two groups; diploid pattern and aneuploid pattern, which were estimated by the rate of the first peak channel on histograms. DNA aneuploidy significantly correlated with serum AFP level (p < 0.01), TNM stage (p < 0.01), and pathological findings: vp (p < 0.5), im (p < 0.01). The aneuploid cases showed better prognosis than the diploid cases (Generalized-Wilcoxon test, p < 0.01). In the diploid cases, recurrent tumors manifested almost solitary isolated. The disease free period after hepatectomy was longer in diploid cases (mean 24.2 months) than in aneuploid cases (mean 14.4 months). There was a higher frequency of aneuploid cases of recurrence within 2 years compared to diploid cases. Two and half year survival rates after recurrence of diploid cases (69.6%) was significantly better than those of aneuploid cases (38.2%) (p < 0.05). The DNA ploidy pattern of hepatocellular carcinoma plays an important role in predicting the malignant potentials of the disease.

[A clinical study of liver resections in patients with small hepatocellular carcinoma less than three centimeter in diameter]

Liver resections for 52 cases with small hepatocellular carcinoma (HCC) less than 3cm in diameter were clinically studied. The 5-year-survival rate was 57.1%, which was better than that of percutaneous ethanol injection (PEI) therapy. Histological study revealed infiltration to the capsule in 48.1%, of which 20% had extra-capsular invasion. This finding seemed to be an important problem in PEI therapy. The group in which resected area was much larger than the extent of tumors had a tendency having good cumulative survival and non-recurrence rates. It is thought that the curative resection should be intended for small HCC if the patient has enough hepatic reserve to undertake a curative operation.

[Augmentation of LAK cell-accumulation in tumor tissue and its therapeutic effect after chemotherapy]

We investigated the therapeutic effects of a combination of chemotherapy with adoptive immunotherapy on BMT-11 fibrosarcoma in C57BL/6 mice. Although no significant therapeutic effects were brought about by CY alone or LAK.rIL-2 alone, CY plus LAK/rIL-2 brought about significant therapeutic effects such as a reduced proportion of dead mice (63%) and prolongation of the mean survival times of dead mice (64.4 days). We transferred radioactive 111In-labeled effector cells into untreated and CY-treated tumor bearing mice. LAK cell-accumulation (% dose/g) at the tumor site was only 2.7% in untreated mice and 19.7 in CY-treated mice. On the other hand, CTL.rIL-2 therapy exhibited significant therapeutic effects by itself. The accumulation of CTL was 9.1% in untreated tumors and only slightly enhanced by CY-chemotherapy. These results suggest that the therapeutic effects of adoptive immunotherapy depend on the accumulation of transferred effector cells at the tumor site and are augmented by the enhanced accumulation of effector cells after chemotherapy.