Direct gene transfer for the understanding and treatment of human disease

Direct gene transfer has been used to develop molecular genetic interventions for acquired diseases in several animal models. Through the use of intravascular catheters or anatomically localized injection of DNA liposome complexes, specific tissues can be transduced with recombinant genes. Several promising applications of this method for the study of vascular biology have been demonstrated by direct gene transfer into arteries in vivo. Delivery, via catheter, of genes that modulate the thrombogenic or proliferative properties of vascular cells may someday provide therapy for stenotic lesions of atherosclerosis or following angioplasty. Cancer is another acquired disorder in which direct gene transfer may improve the efficacy of treatment. Introduction of class I MHC or cytokine genes with antitumor or immunostimulatory effects have demonstrated promise in animal models. Direct transfer of an allogeneic class I MHC gene into tumors in vivo induces a CD8+ CTL response against weak antigens on poorly immunogenic tumors. The efficacy of this antitumor response can be augmented to induce regression of actively growing established tumors. Additional strategies, such as intratumoral delivery of combinations of multiple cytokine and MHC genes, may serve to improve the antitumor response. A clinical gene therapy protocol is underway to analyze the safety and efficacy of DNA liposome-mediated gene transfer in humans. Development of improved gene delivery systems and introduction of recombinant genes into visceral tumors by intravascular catheter will extend the application of direct gene transfer to immunotherapy of malignancies. These clinical trials of direct gene transfer will help to develop new treatment strategies for human diseases.

[15-Methyl-PGF2 alpha vaginal suppository for induction of term labor]

The results of intravaginal 15-methyl PGF2 alpha (PG05) were compared with gemeprost (ONO-802, PGE1 analogue) pessary and oxytocin intravenous infusion for induction of labor at term. A total of 99 primipara with singleton pregnancy and cephalic presentation, accepted for induction, was randomly allocated into 3 groups: group 1, PG05 0.25 mg (n = 33), group 2, ONO-802 0.125 mg (n = 33), and group 3, oxytocin i.v. (n = 33). Among these, 30 cases had plasma PGs (PGE2 and PGF2 alpha) concentration determined before and after induction. Successful treatment was defined as active labor starting within 24 hours following induction or an increase of cervical Bishop score > 3. The success rates were not significantly different among the 3 groups (PG05 88%, ONO-802 100%, and oxytocin 79%), (P > 0.05). No significant difference existed in the plasma prostaglandin concentrations as well. It is suggested that PG05 may be used for induction of labor at term.

Regulated expression of a dominant negative form of Rev improves resistance to HIV replication in T cells

Infection by the human immunodeficiency virus (HIV) has remained refractory to treatment, and molecular genetic interventions have been developed for the treatment of the acquired immunodeficiency syndrome (AIDS). Previous studies have focused on the development of gene products which inhibit productive HIV replication, including transdominant proteins, RNA decoys and ribozymes. In this report, we show that appropriate expression vectors which optimize production and regulated synthesis of a transdominant mutant form of Rev improve its antiviral effect. The combination of a strong constitutive enhancer, a Tat activation response (TAR) regulatory element and transdominant Rev take advantage of three aspects of early viral gene expression to confer increased resistance to HIV replication. This vector may be useful, alone or in combination with other antiviral genes, to provide gene therapy for AIDS.

Direct gene transfer with DNA-liposome complexes in melanoma: expression, biologic activity, and lack of toxicity in humans

Direct gene transfer offers the potential to introduce DNA encoding therapeutic proteins to treat human disease. Previously, gene transfer in humans has been achieved by a cell-mediated ex vivo approach in which cells from the blood or tissue of patients are genetically modified in the laboratory and subsequently returned to the patient. To determine the feasibility and safety of directly transferring genes into humans, a clinical study was performed. The gene encoding a foreign major histocompatibility complex protein, HLA-B7, was introduced into HLA-B7-negative patients with advanced melanoma by injection of DNA-liposome complexes in an effort to demonstrate gene transfer, document recombinant gene expression, and determine the safety and potential toxicity of this therapy. Six courses of treatment were completed without complications in five HLA-B7-negative patients with stage IV melanoma. Plasmid DNA was detected within biopsies of treated tumor nodules 3-7 days after injection but was not found in the serum at any time by using the polymerase chain reaction. Recombinant HLA-B7 protein was demonstrated in tumor biopsy tissue in all five patients by immunochemistry, and immune responses to HLA-B7 and autologous tumors could be detected. No antibodies to DNA were detected in any patient. One patient demonstrated regression of injected nodules on two independent treatments, which was accompanied by regression at distant sites. These studies demonstrate the feasibility, safety, and therapeutic potential of direct gene transfer in humans.

Safety and short-term toxicity of a novel cationic lipid formulation for human gene therapy

Among the potential nonviral vectors for human gene therapy are DNA-liposome complexes. In a recent clinical study, this delivery system has been utilized. In this report, a novel cationic lipid, dimyristyloxypropyl-3-dimethyl-hydroxyethyl ammonium (DMRIE), has been substituted into the DNA-liposome complex with dioleoyl phosphatidylethanolamine (DOPE), which both improves transfection efficiencies and allows increased doses of DNA to be delivered in vivo. The safety and toxicity of this DNA-liposome complex has been evaluated in two species, mice and pigs. The efficacy of DMRIE/DOPE in inducing an antitumor response in mice after transfer of a foreign MHC has been confirmed. No abnormalities were detected after administration of up to 1,000-fold higher concentrations of DNA and lipid than could be tolerated in vivo previously. Examination of serum biochemical enzymes, pathologic examination of tissue, and analysis of cardiac function in mice and pigs revealed no toxicities related to this treatment. This improved cationic lipid formulation is well-tolerated in vivo and could therefore allow higher dose administration and potentially greater efficiency of gene transfer for gene therapy.

Direct transfer of transforming growth factor beta 1 gene into arteries stimulates fibrocellular hyperplasia

The arterial wall responds to thrombosis or mechanical injury through the induction of specific gene products that increase cellular proliferation and connective tissue formation. These changes result in intimal hyperplasia that is observed in restenosis and the early phases of atherosclerosis. Transforming growth factor beta 1 (TGF-beta 1) is a secreted multi-functional protein that plays an important role in embryonal development and in repair following tissue injury. However, the function of TGF-beta 1 in vascular cell growth in vivo has not been defined. In this report, we have evaluated the role of TGF-beta 1 in the pathophysiology of intimal and medial hyperplasia by gene transfer of an expression plasmid encoding active TGF-beta 1 into porcine arteries. Expression of TGF-beta 1 in normal arteries resulted in substantial extracellular matrix production accompanied by intimal and medial hyperplasia. Increased procollagen, collagen, and proteoglycan synthesis in the neointima was demonstrated by immunohistochemistry relative to control transfected arteries. Expression of TGF-beta 1 induced a distinctly different program of gene expression and biologic response from the platelet-derived growth factor B (PDGF B) gene: procollagen synthesis induced by TGF-beta 1 was greater, and cellular proliferation was less prominent. These findings show that TGF-beta 1 differentially modulates extracellular matrix production and cellular proliferation in the arterial wall in vivo and could play a reparative role in the response to arterial injury.

Fluorine-18 labelled substituted benzazepines as potential radiotracers for imaging dopamine D1 receptors by positron emission tomography

High affinity and selective fluorinated derivatives of 7-chloro-8-hydroxy-3-methyl-1-(3'-aminophenyl)-2,3,4,5-tetrahydro-1H-3- benzazepine (SCH 38548) for dopamine D1 receptors have been prepared. The derivatives exhibit subnanomolar to nanomolar affinities for dopamine D1 receptors and micromolar to millimolar affinities for dopamine D2 and 5-HT2 receptors. Biodistribution of N-(3-[18F]fluoropropyl)SCH 38548 in rats showed specific uptake and retention (0.64% injected dose/g at 30 min) of the radiotracer in the striata with striata to cerebellum ratios reaching 12 at 2 h post-injection. Preliminary positron emission tomography scans in rhesus monkeys indicate selective uptake of the radiotracer in the striata.

Immunotherapy of malignancy by in vivo gene transfer into tumors

The immune system confers protection against a variety of pathogens and contributes to the surveillance and destruction of neoplastic cells. Several cell types participate in the recognition and lysis of tumors, and appropriate immune stimulation provides therapeutic effects in malignancy. Foreign major histocompatibility complex (MHC) proteins also serve as a potent stimulus to the immune system. In this report, a foreign MHC gene was introduced directly into malignant tumors in vivo in an effort to stimulate tumor rejection. In contrast to previous attempts to induce tumor immunity by cell-mediated gene transfer, the recombinant gene was introduced directly into tumors in vivo. Expression of the murine class I H-2Ks gene within the CT26 mouse colon adenocarcinoma (H-2Kd) or the MCA 106 fibrosarcoma (H-2Kb) induced a cytotoxic T-cell response to H-2Ks and, more importantly, to other antigens present on unmodified tumor cells. This immune response attenuated tumor growth and caused complete tumor regression in many cases. Direct gene transfer in vivo can therefore induce cell-mediated immunity against specific gene products, which provides an immunotherapeutic effect for malignancy, and potentially can be applied to the treatment of cancer and infectious diseases in man.

Recombinant fibroblast growth factor-1 promotes intimal hyperplasia and angiogenesis in arteries in vivo

The prototype members of the heparin-binding fibroblast growth factor (FGF) family, acidic FGF (FGF-1) and basic FGF (FGF-2), are among the growth factors that act directly on vascular cells to induce endothelial cell growth and angiogenesis. In vivo, the role of the FGF prototypes in vascular pathology has been difficult to determine. We report here the introduction, by direct gene transfer into porcine arteries, of a eukaryotic expression vector encoding a secreted form of FGF-1. This somatic transgenic model defines gene function in the arterial wall in vivo. FGF-1 expression induced intimal thickening in porcine arteries 21 days after gene transfer, in contrast to control arteries transduced with an Escherichia coli beta-galactosidase gene. Where there was substantial intimal hyperplasia, neocapillary formation was detected in the expanded intima. These findings suggest that FGF-1 induces intimal hyperplasia in the arterial wall in vivo and, through its ability to stimulate angiogenesis in the neointima, FGF-1 could stimulate neovascularization of atherosclerotic plaques. Potentially, gene transfer of FGF-1 could also be used as a genetic intervention to improve blood flow to ischaemic tissues in selected clinical settings.

Gene transfer in vivo with DNA-liposome complexes: lack of autoimmunity and gonadal localization

Direct gene transfer into localized arterial segments can be performed in vivo by transfection with DNA-liposome complexes. This technique holds promise for the treatment of human diseases, including malignancy and cardiovascular disorders. We have previously characterized the potential toxicity of this form of treatment in mice in vivo (Stewart et al., 1992). In this report, we examined two issues relevant to long-term expression of foreign recombinant genes: (i) the potential for autoimmune damage to major organs and (ii) DNA localization in gonadal tissue. Autoimmunity and toxicity of allogeneic major histocompatibility (MHC) gene transfer was assessed in mice after induction of an immune response to a recombinant murine class I MHC gene by direct gene transfer in vivo. Histological examination of brain, heart, lung, liver, kidney, spleen, and skeletal muscle revealed no clinically significant immunopathology or organ damage. The toxicity of gene delivery by DNA liposomes was also analyzed in pigs and rabbits in vivo. No histopathology was observed following the introduction of plasmids encoding several different gene products, and analysis of serum following DNA liposome delivery revealed no abnormalities of serum biochemical parameters. The potential for transfer of recombinant DNA into testes and ovary in animals was evaluated by the polymerase chain reaction. Although evidence of recombinant plasmid was consistently observed in transfected, but not untransfected, arterial sites and occasionally in lung, kidney, spleen, and liver, no plasmid DNA was detected in testes or ovary. These studies suggest that uptake of recombinant DNA following direct gene transfer by liposomal transfection in major organs is not associated with autoimmunity, toxicity, or gonadal localization.(ABSTRACT TRUNCATED AT 250 WORDS)

Gene transfer in vivo with DNA-liposome complexes: safety and acute toxicity in mice

DNA can be introduced into a variety of cell types after formation of liposomal complexes with cationic lipids. In this report, conditions have been established to optimize the production of DNA-liposome complexes that efficiently transfect cells. The safety and toxicity of this method of gene delivery have been assessed after in vivo administration, either by intravenous or direct intratumor injection. Nine to eleven days after intravenous injection, DNA was found primarily in heart and lung tissue by PCR analysis. No abnormalities were evident from histologic examination of tissue, examination of tissue-specific serum enzymes, routine biochemical parameters, or electrocardiographic monitoring. DNA-liposome complexes can therefore be used for the delivery of recombinant genes in vivo with minimal toxicity.

Detection of blood stage antigens of Plasmodium vivax by sandwich ELISA using pan-species monoclonal antibodies and polyclonal antibodies

This paper reports an improved PcAb-McAb-ELISA test to detect blood stage Plasmodium vivax antigen in which the plates were coated with rabbit anti-P. cynomolgi polyclonal antibody to capture the antigens in test samples and two monoclonal antibodies, M26-32 and 3F9, were added together to react with the captured antigens. The coincidence rate with this test was 93% with microscopically confirmed P. vivax cases, 97% with normal samples, 95% with microscopically negative fever cases from nonendemic areas and 86% from endemic areas, respectively. The sensitivity was greater than 1 parasite/10(5) RBC.

Evidence for atrial natriuretic peptide-(5-28) production by macrophages of the rat spleen: an immunochemical and nonradioactive in situ hybridization approach

Atrial natriuretic peptide (ANP), a 28-amino acid peptide, is produced and secreted by cardiac atriocytes to modulate cardiovascular functions. Recently, biologically active receptors for ANP have been demonstrated in the spleen; we report here the production of ANP-(5-28) and its 15-kDa (K) mol wt (Mr) presumptive precursors by macrophages of rat splenic tissues. Splenic, hypothalamic, and heart tissues were collected from adult male Sprague-Dawley rats and acid extracted for ANP assay. The splenic content of immunoreactive (ir) ANP (mean +/- SEM, 428 +/- 68 pg/tissue; n = 7) was approximately a fifth of that found in the hypothalamus and about 4 orders of magnitude lower than that in the heart of the same animals. The Sephadex G-50 column profile of splenic extracts revealed two immunoreactive peaks; the major peak eluted in positions consistent with 15K Mr, while a minor peak coeluted with synthetic rat ANP-(1-28) of 3K Mr. HPLC analysis of the 3K Mr species showed a single peak of immunoreactivity, which eluted with a retention time similar to that of ANP-(5-28). In rat splenic sections, immunoperoxidase localization of ir-ANP revealed positive cells sparsely distributed in marginal sinuses and the red pulp of the tissue; employing a double staining technique, S22, a surface marker for macrophages, was colocalized on the same splenocytes. Furthermore, colorimetric in situ hybridization with antisense oligonucleotide probes labeled with digoxigenin, identified specific signals for pro-ANP mRNA in splenocytes of tissue sections. In monolayer cultures of vehicle-treated splenocytes, approximately 87% of the adherent cells stained positive for S22; this marker was colocalized with ir-ANP in approximately 15% of the cells. Twenty-four-hour treatment with lipopolysaccharide (50 micrograms/ml), a bacterial endotoxin, tripled the proportion of adherent cells (32 +/- 4%; P less than 0.01) staining positive for ir-ANP over that in control cultures (mean +/- SEM, 11 +/- 3%; 10(4) cells/sample; n = 5). Furthermore, an equivalent dose of lipopolysaccharide, but not Concanavalin-A (50 micrograms/ml), quadrupled ir-ANP content compared to that in vehicle-treated cultures (less than 5 pg/well). Thus, our findings suggest that ANP-(5-28) is produced by a small population of splenic macrophages and raise the possibility that the peptide may play a signalling role at the tissue level.

Correlation between CT and DNA contents in peripheral lung cancers

The DNA contents of 30 lung cancers were correlated with preoperative chest CT findings. Tumors with diameters less than 4 cm had lower DNA contents than larger ones, and tumors with spiculated margins had lower DNA than those with lobulated or smooth margins. As DNA contents are correlated with prognosis, the border configuration of peripheral lung cancers may be enough to predict prognosis.

A preliminary study of radioimmunoimaging by 131I-COC183B2 monoclonal antibody in patients with epithelial ovarian cancer

Monoclonal antibody 131I-COC183B2, developed in our laboratory and proved to fit for human treatment was injected intraperitoneally or subcutaneously in 13 patients. In 8 cases with i.p. injection the disease corresponded with the image, i.e. 3 primary ovarian epithelial cancers showed positive images, 1 ovarian Krukenberg tumor was negative and the other 4 negative images included 1 uterine myoma and 3 ovarian teratomas. In the subcutaneous injection group, 4 cases had ovarian carcinoma, surgery and chemotherapy. Two negative images corresponded with the clinical status-in good health, another negative case had metastatic left supraclavicular lymph node due to ovarian mucinous adenocarcinoma. The last negative image in this group was a case of benign ovarian teratoma which was proved after surgery. The 1 positive case was waiting to be proved by a scheduled third operation. The computer scintigram calculation of T/NT was 5.35 to 13.7. The results suggest that this monoclonal antibody can be used for radioimmunoimaging for the localization of ovarian carcinoma, which is not only helpful for clinical staging and differential diagnosis but is also a good follow-up method.

Non-cancerous ulcer in the esophagus after radiotherapy for esophageal carcinoma--a report of 27 patients

Twenty-seven patients with non-cancerous ulcers (NCU) (radiation ulcer) after radiotherapy for esophageal carcinoma are presented. Two-thirds of them had been misdiagnosed as uncontrolled or recurrent cancers, leading to improper management. Patients with NCU in the esophagus are characterized by having severe pain in the chest or back, especially on swallowing. On X-ray films, the lesions appear as superficial ulcerations with a line of demarcation above and below the ulcer margin. The wall opposite the ulcer is not usually involved and the ulcer infrequently invades the nearby organs. On conservative treatment, they usually heal and the symptoms are relieved. Seven out of 27 patients have survived from 20 months to 13 years without any evidence of disease.

The effects of actinidia sinensis planch (kiwi) drink supplementation on athletes training in hot environments

On the basis of studying the problems and experimental data of athletes training in hot environments, we designed an athletic drink choosing actinidia sinensis planch (ASP), also known as kiwi fruit, as the basic component, and assessed its effects in athletes both at site of training and in the laboratory. The main results were as follows: (1) In athletes riding on a Monark ergometer (maintaining HR at 150 beat/min), the work time to exhaustion was longer (149 +/- 3 min vs 120 +/- 1 min), and the work load was larger (947 +/- 36 KJ vs 833 +/- 28 KJ) when supplementing the ASP drik than when they drank the placebo, P less than 0.01) (2) Supplements with the ASP drink expanded the blood volume of athletes. Hematocrit increased significantly after exercise in athletes consuming placebo, but no significant changes were found in those consuming the ASP drink. (3) The ASP drink which contained 5% carbohydrate maintained the blood glucose concentration of athletes at a normal level even when training lasted more than 2.5 hours and without noticeable effect on plasma insulin levels. (4) Supplement of small amount of multi-minerals in the ASP drink helped to decrease the mineral level changes in serum and sweat after intensive training, but it did not cause kaliemia or affect urinary output. (5) Data on urinary vitamin C content indicated that the vitamin C status of athletes supplementing the ASP drink improved. The ASP drink is not only effective but also fragrant, tasty, refreshing and thirst quenching, and it appears to have no side effects.

The beta-globin stage selector element factor is erythroid-specific promoter/enhancer binding protein NF-E4

The analysis of transcriptional regulatory proteins is often hampered because such factors are present in cells in only sparing abundance. Although direct biochemical purification has been successfully applied to the analysis of many of these factors, such methods are labor intensive and expensive. We have developed an alternative strategy to identify and characterize such trans-acting factors and have used it to analyze the proteins that interact with the chicken adult beta-globin gene enhancer and promoter. The methodology involves (1) a sensitive 'reverse' radioimmunoassay used for the identification of antibodies to sequence-specific DNA-binding proteins, and (2) a monoclonal antibody-based DNase I footprint selection technique, which unambiguously identifies proteins responsible for particular footprints. Because this methodology relies on the isolation of antibodies to sequence-specific DNA-binding proteins, it should be of general utility in studying any trans-acting regulatory factor for which a specific DNA-binding sequence can be identified. In the present analysis, we report the identification of a 65-kD protein that is present only in mature definitive (adult) chicken erythroid cells. We show that this protein (termed NF-E4) binds to closely related sequences present in both the beta-globin promoter and enhancer. Biochemical analysis of extracts prepared from both nonerythroid and a variety of erythroid cell types suggests that NF-E4 is the trans-acting factor that confers definitive erythrocyte stage-specific transcriptional activation to the adult beta-globin gene.

Curative radiotherapy of early operable non-small cell lung cancer

The results of 44 patients with early operable non-small cell lung cancer treated from January 1975 through 1981 are retrospectively analysed. All were proven by pathology and/or cytology and denied surgery in our joint Chest Clinic for various reasons. 55-70 Gy/6-7 weeks was delivered by conventional fractionation through A-P portals by telecobalt and/or 25-35 MeV high energy electron beam or 8 MV X-ray. 40 Gy/4 weeks was given prophylactically to the mediastinum. The 1-, 3-, and 5-year survival rates, 93, 55, and 32%, are superior to what is reported in the literature. In the present series, the favorable factors are: (1) patients without any intercurrent disease but refused operation; (2) T1 lesions; (3) complete regression of the lesion at the conclusion of radiotherapy; (4) doses ranging from 69 to 70 Gy. It is shown that early non-small cell lung cancer can be cured by radiotherapy alone giving survival rates comparable to surgery. Prospective randomized clinical trials are warranted.

Investigation on the enantiomeric impurity of epinephrine hydrochloride injections

Epinephrine enantiomers were derived into diastereoisomers with the chiral reagent 2,3,4,6-tetra-O-acetyl-beta-D-glucopyranosylisothiocyanate. The resolution was carried out on a C18 column. The Rs between (-)-R- and (+)-S-isomers was 2.3. The retention time could be changed by adding a proper amount of acetoinitrile into the mobile phase. The results showed that (+)-S-isomer in the epinephrine hydrochloride injections increased during the period of storage.

[Preliminary evaluation of the combination of Chinese herbal medicine (destagnation) and radiotherapy for esophageal cancer]

From May 1973 to March 1979, a prospective randomized clinical trial on 425 patients with esophageal cancer was conducted. 194 patients were allotted into the destagnation plus radiotherapy group, the other 231 into radiotherapy only group. The result shows that the combination of destagnation and radiotherapy does not give a result superior to radiotherapy alone. However, destagnation does not increase either hematogenous, lymphatic metastasis, perforation or hemorrhea of the esophageal cancer.

[Carcinoma of esophagus treated by 8MV X-ray and checked by simulator]

From January 1, 1978 to December 31, 1983, 570 patients with carcinoma of esophagus were treated by 8 MV X-ray and checked by the Philips simulator. In order to assess their value, a series of 3,798 patients reported previously was used for comparison. To further evaluate the effect of 8 MV X-ray and simulator separately, a series of 154 patients was treatment by non-8 MV X-ray during the same period. The results showed that the 1 and 3 year survival rates of 8 MV X-ray series were better than the 3,798 series (P less than 0.01). It means that after the use of simulator and 8 MV X-ray the survival rates were improved. As compared to the radiation other than 8 MV X-ray, there was no difference between 8 MV X-ray and non-8 MV X-ray series, which means that the improvement may have been due to the better localization by the simulator. Having more importance, no radiation myelitis was found after the use of simulator. The sex, age, length, location, X-ray type, NSD and causes of failure were compared in these groups.

[Superior sulcus cancer of the lung--report on 45 patients]

From 1960 to 1980, 45 patients with superior sulcus cancer of the lung were seen in our hospital. 39 were male and 6 were female. The youngest was 28 years old and the eldest was 75. The presenting symptoms and signs were back and shoulder pain in 32 patients, compression of the brachial plexus in 17, Horner's syndrome in 12, supraclavicular mass in 11, superior cava vena obstruction in 4, shadow in the apex in 45, destruction of the rib in 19 (10 in the second rib), destruction of the adjacent vertebra in 8 (5 in T3) and destruction of the clavicle in 1. In 18 patients proved by pathology and cytology, 8 were adenocarcinoma, 3 squamous cell carcinoma, 3 undifferentiated and 4 unclassified carcinoma. 27 patients were diagnosed by X-ray films. 40 patients were admitted for treatment. 3 recieved chemotherapy alone and all of them died in one year. Of the 6 treated by radiation plus chemotherapy, 3 survived for one year but all died in two years. 2 were treated by radiation plus operation and none survived for more than 3 years. 29 were treated by radiation only. The 1, 3 and 5 year survival rates were 51%, 13.7% and 6.9%. Destruction of the rib or the adjacent vertebral body was irrelative to the prognosis but the presence of supraclavicular mass reduced the survival rate. Cause of death was local recurrence in 48% (13/27) and distant metastasis in 48% (13/27). The authors suggest that radical en bloc resection together with radiation the worth further study.