[Management under anesthesia of a patient with renal cell carcinoma extending into the retrohepatic inferior vena cava with the aid of partial cardiopulmonary bypass]

A 70-year-old male with renal cell carcinoma extending into the retrohepatic inferior vena cava was scheduled for radical nephrectomy with vena caval resection under general anesthesia. He had received partial gastrectomy for gastric cancer twelve years before. Computed tomography and inferior vena cavography confirmed that the vena cava was almost completely occluded and that a collateral venous network was well established. It was considered that the surgical approach to the retrohepatic cavals area was technically very difficult, and that there was a high possibility of a pulmonary embolus during the surgical manipulation. To prevent a pulmonary embolus and get good control of the vena cava above the tumor and below the hepatic vein, we decided to use a partial cardiopulmonary bypass (CPB) until the vena cava was clamping above the tumor. Anesthesia was induced with propofol and fentanyl, and maintained with fentanyl and isoflurane-N2O-O2. In the partial CPB blood from the hepatic vein was drained from the inferior vena cava cannula through right atrium, oxygenated by microporus membrane oxygenator, and returned to the left femoral artery. Cannulation to drain the venous circulation entering the vena cava below the tumor was abandoned because the extensive collateral venous network ultimately drains into the superior vena cava. The partial CPB time was 90 min, and the bladder temperature during the CPB was 35-36 degrees C. During the 7.3 hr procedure, the pulmonary embolus did not occur and the total blood loss was 5515 ml. The patient made an uncomplicated recovery and was discharged 30 days after the operation. This newly reported partial-CPB method may be safe and effective for the management under anesthesia of other patients.

The role of the detection of hematogenous micrometastasis in prostate adenocarcinoma and malignant melanoma by RT-PCR

Recent studies reported the possibility of detecting prostate adenocarcinoma and malignant melanoma cells in peripheral blood using RT-PCR of prostatic specific antigen (PSA), prostatic specific membrane antigen (PSMA) and Tyrosinase mRNAs. The PCR results showed high variability, ranging between 0% and 100% of positivity in patients with advanced disease. Our purpose was to evaluate the presence of tumor marker mRNAs in peripheral blood of prostate cancer and melanoma patients by means of RT-nested-PCR. We tested 70 and 36 peripheral blood samples from prostate carcinoma and malignant melanoma patients, respectively. The RT-PCR analysis showed the presence of PSA cDNA in 9 out of 70 (12.9%); PSMA cDNA in 14 out of 70 (20%); and Tyrosinase cDNA in 2 out of 36 (5.5%) peripheral blood samples from melanoma patients. Our study confirms the applicability of this sensitive method to monitor disease status. Although, the RT-nested-PCR of Tyrosinase is able to detect neoplastic cells in peripheral blood specimens, we suggest the necessity of a great caution in interpreting PCR results when the nested method has been used.

Does long-term culture favor normal clonogenic cells from interferon-treated patients with chronic myelogenous leukemia?

We have tested whether peripheral blood mononuclear cells (PBMNCs) from interferon (IFN)-treated patients may lose residual BCR-ABL sequence-positive progenitor cells when long-term cultured for 35 days on allogeneic stromal cells. IFN-treated patients have low white blood cell counts and a fair number of BCR-ABL-negative colony-forming cells in the peripheral blood. Particularly, IFN responders show increased numbers of normal hematopoietic cells. We have quantitatively analyzed progenitor cells in PBMNCs of IFN-treated patients by combining the clonogenic assay in semisolid medium with interphase fluorescent in situ hybridization (FISH). Thus, the identification is possible of the BCR-ABL status of colony-forming progenitor cells. In IFN-treated patients, the number of BCR-ABL-positive CFCs is considerably decreased and BCR-ABL-negative CFCs appear in the peripheral blood. We could show that after LTC for 35 days of the same PBMNCs on irradiated allogeneic normal stromal cells residual BCR-ABL sequence-positive CFCs were still present. In some cases the relative number of BCR-ABL sequence-positive CFCs was found to be increased after LTC. A minor proportion of blood samples from IFN-treated patients did not give rise to CFCs after LTC on allogeneic stromal cells (three of 10 patients). Inter- and intraindividual variations can be found with regard to loss or gain of BCR-ABL sequence-positive colonies after LTC. We conclude that early CML progenitor cells persist in the peripheral blood of IFN-treated patients and that a certain proportion may survive long-term culture.

Pulmonary tumor embolism presenting as infarcts on computed tomography

Pulmonary tumor embolism is a rare cause of respiratory failure in patients with cancer and is only infrequently diagnosed during life. Chest radiographs are usually normal. Dilated and beaded peripheral pulmonary arteries may be present on computed tomography scans. The authors describe an unusual case of pulmonary tumor embolism presenting on computed tomography scans as bilateral, peripheral, wedge-shaped opacities. On autopsy, these opacities corresponded to areas of pulmonary infarction.

No-touch isolation technique reduces intraoperative shedding of tumor cells into the portal vein during resection of colorectal cancer

BACKGROUND

The mutant-allele-specific amplification (MASA) method is capable of detecting 1 genetically altered tumor cell among thousands of normal cells. The MASA enabled us to detect occult tumor cells undetectable by histopathologic examination of lymph nodes and blood samples.

METHODS

To investigate whether tumor manipulation during operation enhances cancer cell dissemination into the portal vein with use of MASA and to assess the effect of the no-touch isolation technique in the treatment of colorectal cancers, 27 colorectal cancers (17 were operated on conventionally and 10 were operated on according to the no-touch isolation technique) were screened for mutations in K-ras or p53. We next examined blood samples of the portal vein collected before, during, and after manipulation of tumors, using MASA to look for the specific mutation found in the primary tumors.

RESULTS

Somatic mutations were identified in 18 of these primary tumors (11 were in the conventional resection technique group and 7 were in the no-touch isolation technique group). In 8 of 11 (73%) conventional resection technique cases, we identified the same genetic alteration of the primary tumor in the portal blood during operation, whereas only 1 patient (14%) in the no-touch isolation technique group had a positive result.

CONCLUSIONS

The no-touch isolation technique may be useful to prevent cancer cells from being shed into the portal vein during surgical manipulation.

[Differential atypical ductal hyperplasia/DCIS/invasive carcinoma diagnosis and significance of micrometastases]

During the last years the increasing knowledge of preliminary stages of breast cancer has substantially contributed to the understanding and therapy of this disease. The definition and classification are shortly discussed.

[Histopathologic and biological prognostic factors of clinical stage I non-seminomatous germ cell tumors. Implications for risk-adjusted therapy]

Purpose of our study was to develop a reliable model to define clinical stage I nonseminomatous germ cell tumors (NSGCT) being at low risk and at high risk for occult retroperitoneal metastases based on pathohistological and immunohistochemical parameters in order to stratify the therapeutic approach. 3-5 paraffin-embedded formalin fixed tissue blocks of 149 clinical stage I NSGCT were available from all patients and were analyzed for histopathological features associated with pathological stage: presence/absence of vascular invasion, presence/absence of tunical invasion, percentage of each histological cell type present in the primary tumor. Immunohistochemical expression of MIB-1, p53, bcl-2, cathepsin D and e-cadherin was evaluated using a semiquantitative scoring ystem. Statistical analysis was performed by univariate and multivariate logistic regression models. Percentage of embryonal carcinoma [%EC (p < 0.001)] and presence of vascular invasion [VI (p < 0.0001)] were the most significant independent risk factors associated with pathological stage II disease. Combination of %EC and VI allowed correct prediction of final pathological stage in 88% of patients. Cut-off values including both variables identified correct pathological stage in 131/149 patients (88%). Less than 45% EC and absence of VI correctly identified pathological stage I disease in 91.5%; more than 80% EC and presence of VI correctly predicted pathological stage II in 88% of the patients. %EC and presence/absence of VI appear to be reliable prognosticators to identify both patients at high risk and at low risk for occult retroperitoneal disease. P53, bcl-2, MIB-1, cathepsin D and e-cadherin did not appear to be of prognostic value in clinical stage I NSGCT.

Liver resection and needle liver biopsy cause hematogenous dissemination of liver cells

We have investigated whether liver resection and needle liver biopsy cause dissemination of liver cells into peripheral blood circulation, using a reverse-transcription polymerase chain reaction (RT-PCR)-based assay targeted against alpha-fetoprotein (AFP) mRNA. Twelve patients with and 16 without primary liver cancer (PLC) undergoing liver resection were tested before skin incision, after liver mobilization, after hepatic parenchyma transection, after abdominal wall suture, and 4 days after surgery. Two patients with and 20 without PLC were tested before, 20 minutes after, and 24 hours after needle liver biopsy. Six of 14 patients with and 0 of 36 patients without PLC scored positive before intervention (P <.001). Liver cell spreading was induced at different times after surgery and liver biopsy in 14 of 14 patients with but also 23 of 36 without PLC (P <.05). We conclude that liver resection and needle liver biopsy induce release of cells from the liver, which are not necessarily liver tumor cells, into the peripheral blood circulation. This may be, however, an important mechanism of liver cancer cell dissemination deserving further investigations.

Extended hepatectomy with ePTFE graft vena caval replacement and hepatic vein reconstruction: a case report

A 69 year-old man with a history of thoracoplastic surgery for pulmonary tuberculosis, who required a blood transfusion and subsequently tested positive for hepatitis C virus, developed a right hypochondrial mass, swelling of the lower extremities and malaise. A huge hepatocellular carcinoma invading the suprahepatic vena cava with tumor thrombi was diagnosed radiographically. An extended right hepatectomy with supra- to retrohepatic IVC resection was performed in an en bloc fashion using a centrifugal pump for hepatic vascular exclusion (HVE). The supra- to retrohepatic IVC was replaced with an expanded polytetrafluoroethylene (ePTFE) graft, 20 mm x 10 cm in size, and the left hepatic venous confluence was reconstructed. Twenty-one months after surgery, the patient is in good condition without recurrence of tumor.

Autologous peripheral blood stem cell transplantation for lung cancer

Lung carcinoma, the most frequent cause of cancer-related death in both men and women, remains a difficult therapeutic problem. Small-cell lung carcinoma, despite its high response rate to chemotherapy, is associated with a rapid recurrence and ultimately limited overall survival. In attempts to exploit tumour chemosensitivity, high-dose chemotherapy (HDC) combining several active drugs has been studied to improve outcome. In addition, haematopoietic stem cell support has been used to allow dose escalation without major myelosuppression. In contrast to small-cell carcinoma, non-small-cell carcinoma of the lung is generally not very responsive to chemotherapy, and results with dose intensity in unresectable tumour have so far been very disappointing. We review the results of HDC in terms of response and survival, and discuss potential strategies to improve the effectiveness of dose intensity.

Surgical management for adrenal gland metastasis of hepatocellular carcinoma

BACKGROUND/AIMS

Although the adrenal gland is one of the common sites for metastasis from hepatocellular carcinoma, the significance of adrenalectomy for treatment of metastatic hepatocellular carcinoma still remains unclear.

METHODOLOGY

Analysis of 4 patients with adrenal metastasis from among 390 patients with hepatocellular carcinoma admitted to our department between October 1994 and December 1997, and a review of 79 cases reported between 1984 and 1997, were performed.

RESULTS

Four patients with adrenal metastasis, right in 2 and left in 2, underwent surgical treatment. Three of the patients developed tumor thrombi in the renal vein or inferior vena cava. Diagnosis of adrenal metastasis was made by ultrasonography or computed tomography scan, following an increase in serum tumor markers. Adrenalectomy with removal of the venous tumor thrombi was performed successfully. Three patients died of recurrence within 1 year, and one patient died due to other causes showing no recurrence at autopsy. The literature review revealed the left-sided metastases were significantly larger than the right-sided ones (p < 0.01). There was no significant difference in the survival periods between left and right metastasis, or between patients who underwent adrenalectomy and those treated by other means (p > 0.05).

CONCLUSIONS

The rationality of surgical treatment for adrenal metastasis from hepatocellular carcinoma still remains controversial. However, we believe that adrenalectomy would be a safe procedure and increases the chance of survival for patients.

[Retroperitoneal sarcomas: 1. Natural history and preoperative evaluation]

The disease is usually disseminated via the blood stream. These large tumors displace adjacent organs and are usually close to vital structures. High rate of local or peritoneal recurrence may be explained by resection problems. Local recurrence is the most frequent cause of patient death. No adjuvant treatment has proved to be beneficial on survival. Diffusion of the disease is usually hematogenous. Hepatic and pulmonary metastases are the most common, while lymph node invasion is very rare. This account for no systematic lymph node dissection in these tumors. Preoperative biopsy through a retroperitoneal route under CT scan vision is advised, before operation. NMR and CT scan are the best tools to assess extension of tumor through anatomical structures. Quality of surgical resection is the main factor which determine prognosis in term of local or peritoneal recurrence risk. This risk is best evaluated by pathological examination which must determine whether the specimen is or not complete.

Experimental study of the effect of intraperitoneal heparin on tumour implantation following laparoscopy

BACKGROUND

Conclusions drawn from clinical reports of port site metastases following laparoscopic resection of intra-abdominal malignancy are now supported by a burgeoning experimental literature which suggests that laparoscopy promotes tumour metastasis to wounds. This study investigated the effect of intraperitoneal blood and heparin on the incidence of tumour cell implantation and port site metastasis.

METHODS

Twenty-four Dark Agouti rats underwent laparoscopy with carbon dioxide insufflation and the instillation of a tumour cell suspension and/or blood into the peritoneal cavity. Rats were allocated randomly to one of the following study groups (six rats per group): (1) controls; (2) intraperitoneal blood (2 ml blood introduced from a syngeneic donor rat); (3) intraperitoneal heparin; (4) intraperitoneal blood and heparin. Rats were killed 7 days after the procedure, and the peritoneal cavity and port sites were examined for the presence of tumour.

RESULTS

Tumour implantation and port site metastases were reduced by the intraperitoneal administration of heparin, but increased by the presence of intraperitoneal blood.

CONCLUSION

The results of this study suggest that tumour implantation following laparoscopy is promoted by the presence of intraperitoneal blood and that this effect may be reduced by the use of intraperitoneal heparin.

Sialyl Lewis X expression in vascular permeating lesions as a factor for predicting colorectal cancer metastasis

BACKGROUND/AIMS

To evaluate the potential of sialyl Lewis X (SLX) expression for predicting residual liver recurrence, we examined the vascular permeating lesions surrounding the metastatic liver tumors for SLX as a marker of residual liver recurrence.

METHODOLOGY

Twenty-eight cases of metastatic liver tumors of colorectal cancers were examined using SLX monoclonal antibody for SLX expression in surrounding vascular permeating lesions.

RESULTS

The cumulative residual liver recurrence rate in cases positive for SLX (SLX(+)) expression in the vascular permeating lesions surrounding the metastatic liver tumor was significantly higher than in the negative cases (p < 0.05). Furthermore, logistic regression analysis revealed that SLX positivity in the lesions surrounding the metastatic liver tumor was an important discriminant for residual liver recurrence (p = 0.0197).

CONCLUSIONS

These results indicated that SLX expression in vascular permeating lesions surrounding the metastatic liver tumor is a predictive factor for residual liver recurrence.

A seminested RT-PCR assay for HER2/neu: initial validation of a new method for the detection of disseminated breast cancer cells

BACKGROUND

Initial validation of a seminested reverse transcription-polymerase chain reaction (RT-PCR) assay for HER2/neu for use in detecting circulating tumor cells in the peripheral blood or bone marrow of breast cancer patients is described. RT-PCR assays for other epithelial markers, including the cytokeratins and carcinoembryonic antigen frequently lack specificity, sensitivity, or both. Thus, there is a need for an assay that is both sensitive and specific to be used to monitor breast cancer patients for micrometastatic or minimal residual disease.

METHOD AND RESULTS

Assay conditions were optimized using the MCF7 breast cancer cell line and the Raji B-cell lymphoma cell line. The assay can detect as little as 3 mg of MCF7 RNA within a background of 3 mg of Raji RNA. The assay was positive in 12 of 12 breast tumors. None of the 33 peripheral blood or stem cell samples form patients without evidence of breast cancer were positive. Peripheral blood from 17 breast cancer patients was collected immediately before surgery and evaluated. The assay was positive in five of six patients with Stage II, four of eight patients with Stage I and one of three patients with Stage 0 disease.

CONCLUSIONS

The seminested HER2/neu RT-PCR assay compares favorably with RT-PCR assays for other epithelial cell markers in terms of both sensitivity and specificity as a method to detect disseminated breast cancer cells. In breast cancer patients, the higher the disease stage, the more frequently was the assay positive.

[Vena cava invasion in kidney carcinoma--a typical example of multidisciplinary surgery]

Between 1987 and 1998, a total of 79 patients with renal cell carcinoma and venal caval thrombus underwent radical nephrectomy with removal of the tumor thrombus. Of these patients, nine had atrial thrombus extension. Actuarial 5 year survival for patients without metastasis was 39%. For patients with tumor thrombi not invading the right atrium (state I-III) the 5 year survival rate was up to 50% and was not related to the cranial extent of the tumor thrombus. We conclude that an aggressive multispeciality surgical approach is justified as it provides prolonged survival even in patients with large vena caval thrombi.

[Surgical therapy of tumor embolism of the vena cava in renal cell carcinoma]

Radical nephrectomy (Nx) with vena caval thrombectomy represents the only realistic chance of cure for patients with renal cell carcinoma with extension into the vena cava inferior (VCI). For stage III, with tumor extension in the retrohepatic VCI up to the diaphragm, a venous bypass technique is described. From July, 1996 through April, 1998, Nx combined with thrombectomy of the VCI was performed by isolation of the VCI, temporary occlusion of the hepatoduodenal ligament, and temporary extracorporal femoral-axillary veno-venous bypass with the Biomedicus pump. Radical resection of tumor thrombus from the VCI was accomplished under direct vision with minimal blood loss and without cardiopulmonary complications. With a follow-up of 21, 16, 9, 2, and 1 months, respectively, all patients are so far free of complications and without recurrent or metastatic disease.

Percutaneous transheptic cholangioscopic ethanol injection for intrabiliary tumor thrombi due to hepatocellular carcinoma

Interventional treatments such as transcatheter arterial embolization and placement of a biliary endoprosthesis have been carried out in cases of inoperable hepatobiliary malignancy. We report here a case of recurrent intrabiliary tumor thrombi due to hepatocellular carcinoma, successfully treated by cholangioscopic ethanol injection in which the intrabiliary tumor thrombi were completely eliminated.

[Treatment strategy for and clinical results in patients with recurrent esophageal cancer]

In the current study, we evaluate the frequency and pattern of recurrence in patients with esophageal cancer. Among 116 patients who had undergone curative resection for esophageal cancer, recurrence was found in 33 (28.4%). The most frequent pattern of recurrence was lymphatic (54.5%), followed by the mixed type (18.2%), hematogenic (12.1%), locoregional (12.1%), and anastomotic (3.0%) patterns. Recurrence was found within 1 year after surgery in 18 (54.5%), within 2 years in 12 (36.4%), and within 3 years in 3 (9.1%). In patients with recurrence, lymph node metastasis and advanced stage were seen more frequently than in those without recurrence. The prognosis for patients with recurrent disease is poor. However, in some cases surgical resection, systemic chemotherapy, hepatic arterial infusion chemotherapy, and local radiation therapy have proven to be effective. The most appropriate therapy should be selected based on the region of extension and patient performance status to provide optimum treatment of recurrent disease.

Surgical considerations for patients with Wilms' tumor

Despite the advances in multimodal treatment of Wilms' tumor, surgical staging and tumor resection remain a central component of therapy. Although standard approaches are available through multicenter studies, such as the NWTS and SIOP, controversy exists regarding several aspects of surgical management. Recent data call into question the need for contralateral exploration in the era of modern imaging. Various methods are available for managing caval tumor thrombus. Bilateral Wilms' tumor requires a special surgical strategy. The surgeon plays a key role in determining whether preoperative chemotherapy should be used to facilitate surgical resection. The role of partial nephrectomy is still being defined. And finally, surgery plays an important role in the management of tumor recurrence. Surgeons must be fully aware of the data and philosophical issues that pertain to these areas if they are to fulfill their role in the multidisciplinary team caring for children with Wilms' tumor.

Use of reverse-transcriptase polymerase chain reaction (RT-PCR) for carcinoembryonic antigen, cytokeratin 19, and maspin in the detection of tumor cells in leukapheresis products from patients with breast cancer: comparison with immunocytochemistry

This study evaluates the role of reverse-transcriptase polymerase chain reaction (RT-PCR) assay for carcinoembryonic antigen (CEA), cytokeratin 19 (CK19), and maspin transcripts to identify breast cancer cells (BCC) in leukapheresis products (LP) collected from breast cancer (BC) patients and compares these results with those obtained using immunocytochemistry (IC). Eighty-four LP obtained from 33 patients with stage II-III BC and control subjects without BC were screened for the presence of BCC by IC and CK19, CEA, and maspin expression using RT-PCR. CEA RT-PCR and IC were the only specific markers, as no false positives were detected in any patients without BC. CK19 RT-PCR gave 11% false positives, whereas maspin RT-PCR with 25% was the most unspecific marker. In LP from BC patients, positive results were observed in 70% and 63% for CK19 and CEA RT-PCR, respectively. For maspin RT-PCR, this percentage was 22%, and for IC it was 17%. There was a good correlation between the CEA and CK19 RT-PCR (p = 0.018). No correlation between CEA and CK19 RT-PCR and IC was found, and although 5 of the 6 IC+ samples were CEA+/CK19+, great discrepancies in the group of IC- samples were observed. Our data suggest that RT-PCR assays for CEA and, to a lesser extent, for CK19 have more sensitivity and specificity than IC to detect BCC in LP.

[A case of hepatocellular carcinoma with tumor thrombus in the right atrium successfully treated by arterial administration of lipiodol-SMANCS]

In February, 1996, a 73-year-old male with liver dysfunction was admitted to our hospital for further examination and treatment of liver tumor. The liver tumor was revealed by imaging examination, which was mainly in the S4-S8 of liver with a thrombus growing from the right anterior branch to the right branch of the portal vein, and from the right hepatic vein to the inferior vena cava and right atrium. The serum AFP and PIVKA-II levels were elevated to 3.610 ng/ml and 54 AU/ml, respectively. The patient was diagnosed as having hepatocellular carcinoma, and was treated by arterial administration of anticancer drugs (epirubicin hydrochloride, mitomycin C and carboplatin) and TAE. Though the main tumor (S4-S8 of liver) was reduced by TAE, the portal and atrial tumor thrombus did not respond. One month after TAE (20 May, 1996), the first arterial administration of Lipiodol-SMANCS was given, followed by 4 successive procedures with an interval of about 1.5 months (total dose 15 mg), resulting in remarkable tumor thrombus shrinkage and reduction of AFP levels to 80 ng/ml. This case shows that arterial administration of SMANCS may be one of the effective treatments for hepatocellular carcinoma, even with tumor thrombus of hepatic vein, IVC and right atrium.