Pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions: differentiation using MRI

AIMS

To determine the differential magnetic resonance imaging (MRI) features of pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions.

MATERIALS AND METHODS

The MRI images of 64 patients with pituitary adenoma (n=38), craniopharyngioma (n=13), or Rathke cleft cyst (n=13) were retrospectively reviewed by three neuroradiologists. The following characteristics were evaluated: shape, volume, extent, component characteristics, signal intensities of solid portions on T2-weighted images, signal intensities of cystic portions on T1-weighted images, and enhancement patterns of solid portions and cyst walls of tumours. Fisher's exact test applied with Bonferroni correction was used for multiple comparison. A flowchart for differential diagnosis was constructed based on statistical analysis of the results.

RESULTS

A snowman shape, solid characteristics, and homogeneous enhancement of the solid portion were more common in pituitary adenomas (p<0.017). A superiorly lobulated shape, third ventricle compression by superior tumour extension, mixed solid and cystic characteristics, and reticular enhancement of the solid portion were more common in craniopharyngiomas (p<0.017). Finally, an ovoid shape, a small tumour volume, cystic characteristics, and no or thin cyst wall enhancement were more common in Rathke cleft cysts (p<0.017). The flowchart yielded diagnostic accuracies as follows: 92.1% in pituitary adenoma; 92.3% in craniopharyngioma; 92.3% in Rathke cleft cyst; and 92.2% overall.

CONCLUSION

A combination of MRI findings is helpful in the differential diagnosis of the three tumours involving both intrasellar and suprasellar regions.

Efficacy of moxibustion after rolling correction in dairy cows with abomasal displacement

This study was performed to assess the efficacy of moxibustion after rolling correction in dairy cows with abomasal displacement (AD). The experimental group comprised 86 Holstein cows with left displacement of the abomasum (LDA) and right displacement of the abomasum (RDA), with a mean age of 3.8 with AD during a 2-year period. The cows were rolled for correction of AD. After the rolling procedure, moxibustion was conducted on six acupoints once a day during the course of treatment. After repositioning the abomasums, the bilateral points of BL-20, BL-21 and BL-26 were then stimulated. During the follow-up of 1 week, 67 (93.1%) of 72 LDA and 12 (85.7%) of 14 RDA cows were released as cured after moxibustion. In conclusion, moxibustion effectively treats AD following rolling correction in dairy cows.

Liver transplantation for hepatocellular carcinoma with bile duct thrombi

In a few cases of hepatocellular carcinoma (HCC), jaundice results from obstructive causes, including tumor invasion or thrombi in the bile duct. We have reported herein our experience with liver transplantation (OLT) for HCC cares showing bile duct thrombi (BDT). From September 1996 to August 2004, 140 adult patients underwent OLT for HCC at our center. Four patients (2.9%) who had OLT performed for HCC had BDT and were included in this study. The patients were all men of mean age 57.0 years. The initial total bilirubin levels were in the range of 2.0 to 30.5 mg/dL. The sizes of the tumors ranged from 2.0 cm to 3.0 cm in diameter, all were single lesions. The median follow-up period was 20.6 months (range: 17.6 to 28.1 months). The only case in which the BDT was identified intraoperatively died 20 months after OLT due to multiple intrahepatic recurrences. The other three patients were alive, showing no evidence of recurrence at the end of follow-up. Although a series of four is too small to reach any conclusion, we suggest that OLT may be a treatment option for HCC with BDT in selected cases.

Intraductal papillary mucinous tumour of the pancreas: differentiation of malignancy and benignancy by CT

AIM

To retrospectively identify signs predictive of malignant intraductal papillary mucinous tumour (IPMT) of the pancreas on computed tomography (CT) images.

MATERIALS AND METHODS

Thirty-four benign and 21 malignant pancreatic IPMTs were evaluated. Preoperative helical CT images in these 55 cases of pathologically proven pancreatic IPMT were reviewed by two radiologists unaware of the histological grading. Tumour morphological types, locations, numbers and sizes of cystic lesions, maximum main pancreatic duct diameters, the presence of septa, mural nodule, wall thickening, and calcification in cysts, communication with the main pancreatic duct, peripancreatic haziness, protrusion of duodenal papilla, pancreatic atrophy, lymphadenopathy and distant metastasis were analysed using univariate and multivariate analysis.

RESULTS

Main duct IPMTs were more likely to be malignant (71%) than branch duct (23%) or combined type IPMTs (28%; p=0.002). Among the branch duct type and combined types, large cystic lesion (p=0.018), the presence of a mural nodule (p=0.018), a thickened wall (p=0.009), and peripancreatic haziness (p=0.039) were found to predict malignancy.

CONCLUSION

CT is helpful in the preoperative differentiation of malignant and benign pancreatic IPMT. The presence of a dilated main pancreatic duct, mural nodules, thickened wall and peripancreatic haziness may be used as independent predictive signs of malignancy.

Grand Canonical Monte Carlo Simulation Study on the Catenation Effect on Hydrogen Adsorption onto the Interpenetrating Metal−Organic Frameworks

Among recently synthesized isoreticular metal-organic frameworks (IRMOFs), interpenetrating IRMOFs show high hydrogen adsorption capacities at low temperature and under ambient pressure. However, little is known about the molecular basis of their hydrogen binding properties. In this work, we performed grand canonical Monte Carlo (GCMC) simulations to investigate the effect of catenation on the interactions between hydrogen molecules and IRMOFs. We identified the adsorption sites and analyzed the adsorption energy distributions. The simulation results show that the small pores generated by catenation can play a role to confine the hydrogen molecules more densely, so that the capacity of the interpenetrating IRMOFs could be higher than that of the non-interpenetrating IRMOFs.

EGF-independent activation of cell-surface EGF receptors harboring mutations found in gefitinib-sensitive lung cancer

Several somatic mutations within the tyrosine kinase domain of epidermal growth factor receptor (EGFR) have been identified that predict clinical response of non-small-cell lung carcinoma (NSCLC) patients to gefitinib. To test the hypothesis that these mutations cause constitutive EGF receptor signaling, and to investigate its mechanistic basis, we expressed representative examples in a null background and analysed their biochemical properties. Each mutation caused significant EGF-independent tyrosine phosphorylation of EGFR, and allowed the receptor to promote Ba/F3 cell mitogenesis in the absence of EGF, arguing that these are oncogenic mutations. Active mutated receptors are present at the cell surface and are fully competent to bind EGF. Recent structural studies show that the inactive EGFR tyrosine kinase domain is autoinhibited by intramolecular interactions between its activation loop and alphaC helix. We find that mutations predicted to disrupt this autoinhibitory interaction (including several that have not been described in NSCLC) elevate EGF-independent tyrosine kinase activity, thus providing new insight into how somatic mutations activate EGFR and other ErbB family members.

Outcome of Patients With Recurrent Hepatocellular Carcinoma in Liver Transplantation

Liver transplantation (OLT) is the treatment of choice for patients with hepatic cirrhosis related hepatocellular carcinoma (HCC). Among 156 liver transplant patients for HCC from June 1996 to February 2005, 23 had recurrent HCC. To evaluate risk factors that affect early recurrence of HCC after OLT, we divided the 23 patients into two groups: early (< or =12 months) and late (>12 months) recurrences. Among them, 15 patients were dead and eight alive patients had been followed to 31 July 2005. The most common recurrence site was the grafted liver (n = 15), next was bone (n = 11), lung (n = 8), lymph node (n = 6), brain (n = 4), skin (n = 2), adrenal gland (n = 1). There were no significant differences between the two groups in age or tumor size, number of tumors, cell differentiation, alpha-feto protein levels, tumor staging, number of patients within Milan criteria, steroid pulse therapy, infectious diseases, and immunostaining of tumor. In our study, there were no risk factors that predict early tumor recurrence. We noticed that more patients in the early recurrence group were excluded by Milan criteria due to a more progressed tumor staging with higher mean levels of serum alpha-feto protein.

Diagnostic radiopacity and hepatotoxicity following chloroform ingestion: a case report

BACKGROUND

Diagnostic imaging can help in the management of toxicologic emergencies. The authors report on a patient who presented to the emergency department with coma and suppressed respirations after ingestion of an unknown substance.

METHODS

Ingestion of chloroform with radiopaque material in the bowel on abdominal radiograph was documented. The patient was treated with haemoperfusion, activated charcoal, and laxatives to decrease the toxicities.

RESULTS

Hepatotoxicity occurred on post-ingestion day 3 and elevation of liver enzymes reached peak levels on post-ingestion day 5. The patient received N-acetylsystein and supportive care during hospitalisation. The patient improved from hepatic dysfunction and was discharged without complication on post-ingestion day 11.

CONCLUSION

Radiographic studies in toxicology may confirm a diagnosis and assist in therapeutic intervention.

Methacholine and adenosine 5'-monophosphate challenges in children with post-infectious bronchiolitis obliterans

Airway hyperresponsiveness (AHR) is a characteristic feature of asthma, but is also frequently demonstrated by children and adults with chronic obstructive lung diseases. AHR is usually measured by bronchial challenges using direct or indirect stimuli. The aim of this study was to compare these two types of bronchial challenge in children with post-infectious bronchiolitis obliterans (BO). Methacholine and adenosine 5'-monophosphate (AMP) challenges were used as tools for the evaluation of AHR to direct and indirect stimuli, respectively, in children with post-infectious BO (n = 28). These results were compared with those of asthmatic (n = 30) and control children (n = 25). Altogether, twenty-two patients (78.6%) with post-infectious BO were hyperreactive to methacholine with a provocative concentration causing a 20% fall in forced expiratory volume in one second (PC20) of <16 mg x mL(-1), but only six (21.4%) were hyperreactive to AMP with a PC20 of <200 mg x mL(-1). All patients with asthma responded positively to methacholine, and most (28, 93.3%) also responded positively to AMP. The majority of controls were insensitive to both challenges. Airway hyperresponsiveness to methacholine is a frequent, but by no means universal, finding in children with post-infectious bronchiolitis obliterans, but is usually not accompanied by airway hyperresponsiveness to adenosine 5'-monophosphate. This finding suggests that airway hyperresponsiveness in patients with post-infectious bronchiolitis obliterans has characteristics that differ from those of asthmatic subjects.

Selective inhibition of polymorphonuclear neutrophils by resuscitative concentration of hypertonic saline

OBJECTIVES

This study investigated the effect of hypertonic saline on the role of polymorphonuclear neutrophils (PMNs) in the inflammatory response and the effect of hypertonic saline infused at different phases in relation to an inflammatory stimulus.

MATERIALS AND METHODS

PMNs were isolated from peripheral blood of healthy volunteers (Boyum's method) and cultured in three different media ([Na+] = 140 mmol/l, 180 mmol/l, and 200 mmol/l). PMNs were then stimulated with fMLP (N-formyl-methionyl-leucyl-phenylalanine) and H2O2 synthesis was quantified by flow cytometry at 5, 30, 60, 120, and 180 minutes. PMNs were treated with hypertonic saline before, simultaneously with, and after fMLP stimulation, and H2O2 synthesis quantified again.

RESULTS

H2O2 synthesis was two or three times higher in fMLP stimulated than in non-stimulated PMNs, and it reached maximum level at 120 minutes. In the absence of fMLP stimulation, there was no significant difference between control and hypertonic saline with regard to activity of H2O2 synthesis. In the presence of fMLP stimulation, H2O2 synthesis significantly decreased in PMNs treated with hypertonic saline. There was no significant difference between the two hypertonic saline solutions ([Na+] = 180 mmol/l and 200 mmol/l) with regard to H2O2 synthesis. However, H2O2 synthesis decreased in PMNs treated with hypertonic saline before and simultaneously with fMLP stimulation, but was not significantly decreased in the cells treated with hypertonic saline after fMLP stimulation.

CONCLUSIONS

Hypertonic saline appears to decrease H2O2 in stimulated neutrophils. This may be a further beneficial role of hypertonic saline when used clinically as an early resuscitation fluid.

Fasting-induced increases of arcuate NPY mRNA and plasma corticosterone are blunted in the rat experienced neonatal maternal separation

This study was conducted to examine the effects of neonatal maternal separation on the hypothalamic expression of feeding peptides in later life. Pups in maternal separation (MS) groups were separated from their dam for 3 h daily from postnatal day (PND) 1-14, while pups in non-handled (NH) groups were left undisturbed. Rats were sacrificed on PND 60 to examine the gene expression of neuropeptide Y (NPY) and pro-opiomelanocortin (POMC) in the hypothalamic arcuate nucleus by mRNA in situ hybridization. Half of the rats from each group were food-deprived for 48 h before sacrifice. POMC mRNA expression increased in the free fed MS group compared with the free fed NH group. Food deprivation significantly decreased the arcuate POMC mRNA level in both groups. Body weight gain, basal levels of plasma corticosterone, leptin, and arcuate NPY mRNA were not modulated by experience of neonatal maternal separation. However, fasting-induced increases of plasma corticosterone and arcuate NPY expression were blunted in MS rats. These results suggest that neonatal maternal separation may increase the basal expression level of arcuate POMC mRNA, while inhibit the fasting-induced expression of arcuate NPY mRNA, later in life. Lastly, the altered expression of arcuate NPY mRNA, but not of arcuate POMC mRNA, appeared to be related with altered activity of the hypothalamic-pituitary-adrenal gland axis in offspring by neonatal maternal separation.

Induction of interleukin-8 production via nuclear factor-kappaB activation in human intestinal epithelial cells infected with Vibrio vulnificus

Vibrio vulnificus, a Gram-negative estuarine bacterium, is a causative agent of food-borne diseases, such as life-threatening septicaemia and wound infection disease. V. vulnificus penetrating into the epithelial barrier stimulates an inflammatory response in the adjacent mucosa. Therefore, interaction between V. vulnificus and epithelial cells is important for understanding of both the immunology of mucosal surfaces and V. vulnificus. In this study, we investigated the effect and action mechanism of V. vulnificus infection on production of interleukin (IL)-8, a proinflammatory cytokine, in human intestinal epithelial INT-407 cells. V. vulnificus infection significantly induced IL-8 production in a time- and multiplicity of infection (MOI)-dependent manner, as determined by human IL-8 enzyme-linked immunosorbent assay (ELISA). In addition, V. vulnificus infection significantly increased IL-8 mRNA levels in INT-407 cells, indicating that the increased IL-8 production by V. vulnificus occurred at the transcriptional level. V. vulnificus infection also enhanced IL-8 gene promoter activity in INT-407 cells transiently transfected with IL-8 promoter constructs, but this effect was impaired in INT-407 cells transfected with IL-8 promoter constructs deleted or mutated of a kappaB site. V. vulnificus infection increased the nuclear factor-kappaB (NF-kappaB) binding activity to a kappaB site and the degradation of IkappaB-alpha protein in a time- and a MOI-dependent manner. Furthermore, BAY11-7082, an inhibitor of NF-kappaB activation, significantly reduced the IL-8 production, NF-kappaB binding activity and IkappaB-alpha degradation induced by V. vulnificus infection. Taken together, these results indicate clearly that V. vulnificus infection significantly induces IL-8 production in human intestinal epithelial cells via NF-kappaB activation.

Solid-pseudopapillary tumours of the pancreas: 14 years experience

BACKGROUND

Solid-pseudopapillary tumour of the pancreas (SPTP) is a low-grade malignancy lesion that is distinct from other pancreatic tumours. Preoperative diagnosis is often inaccurate and treatment strategies remain controversial. The present study reviews the clinical features, diagnosis, treatment, and outcome of Asian patients with SPTP from a single institution.

METHODS

The medical records and images of patients who underwent surgery for SPTP between June 1990 and December 2003 were retrospectively reviewed. Study eligibility required that patients had undergone surgical resections and that the SPTP had been pathologically demonstrated.

RESULTS

Twenty-eight patients with SPTP were identified. Eighteen patients (64.3%) reported the predominant symptom of 'vague abdominal pain', five patients (17.8%) had an apparent 'abdominal mass', and five patients (17.8%) without overt symptoms had masses that were discovered incidentally during screening. All patients underwent magnetic resonance (MR) imaging (n = 22) and/or computed tomography (n = 17), with a specificity of 90.9% and 76.4%, respectively. All masses were well-circumscribed, except for a tumour in one patient (3.6%), which adhered to the stomach wall and metastasized to the liver. Two patients (7.1%) underwent enucleation, while 25 patients (89.3%) received curative resection. The patient with the liver metastases underwent distal pancreatectomy and splenectomy with partial hepatectomy. The mean follow up was 66.9 months. No mortality occurred during follow up but the patient with the liver metastasis had progressive deterioration.

CONCLUSION

Symptoms of SPTP are indistinct and preoperative diagnosis is often inaccurate. Magnetic resonance imaging improves SPTP diagnosis. In general, the prognosis of well-circumscribed SPTP is favourable after curative resection.

Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic-assisted gastrectomy

BACKGROUND

During laparoscopic-assisted gastrectomy, it is impossible to identify early gastric cancer (EGC) lesions; therefore, a precise localization technique is needed. In this study, we used laparoscopic ultrasonography (LUS) after endoscopic clipping as a method of localizing EGC and evaluated the effectiveness of this method.

METHODS

A prospective study of 17 patients who had undergone laparoscopic-assisted gastrectomy was performed. Three endoscopic clips were applied just proximal to the tumor during the preoperative endoscopy. The applied clips were detected from the serosal side of the stomach using LUS. The serosal surface of the lesion was marked with dye.

RESULTS

In all patients, endoscopic clips were applied proximal to the lesion without complications, and the applied clips were confirmed by plain abdominal radiography. The clips were successfully detected by LUS in all patients. In the resected specimen, the serosal surface, marked with dye, was always just above the clips in the anterior wall or on the anterior wall opposite the clips applied in the posterior wall. The mean detection time was 4.7 min (range, 2-8). With this procedure, two patients underwent total gastrectomy and 15 patients underwent distal subtotal gastrectomy with gastroduodenostomy or gastrojejunostomy. Histological examination confirmed that the resection margins were tumor free in all patients. There was no operative morbidity related to the LUS procedure.

CONCLUSIONS

Using LUS to detect endoscopic clips is an easy, safe, and accurate method to localize EGC lesions in laparoscopic-assisted gastrectomy.

Can we expand the Milan criteria for hepatocellular carcinoma in living donor liver transplantation?

INTRODUCTION

The Milan criteria, namely, tumors 5 cm or less in diameter in patients with single hepatocellular carcinoma (HCC), no more than 3 tumor nodules, and each 3 cm or less in diameter in patients with multiple tumors, are accepted for cadaveric liver allocation. However, in living donor liver transplantation (LDLT), graft donation may only depend on the donor's intention. The aim of this study was to elucidate the feasibility of Milan criteria in LDLT.

MATERIALS AND METHODS

From January 2001 to December 2002, 46 cases of liver transplantation (LT) for HCC included 5 hospital mortalities and 3 cadaveric transplantations, all of which were excluded. We classified the patients into Group I cases that met the Milan criteria and Group II cases that did not meet the Milan criteria. The analyses examined tumor-related risk factors affecting recurrence and survival, such as tumor size, number of tumor nodules, and presence of microvascular and macrovascular invasion.

RESULTS

Twenty-one cases belonged to Group I and 17 to Group II. There was no significant difference in the recurrence or survival rates between Groups I and II. The risk factors affecting recurrence were macrovascular invasion and tumor size (5 cm). The number of tumor nodules and microvascular invasion did not appear to affect recurrence. The risk factor affecting survival was macrovascular invasion.

CONCLUSION

We suggest that in selected cases the Milan criteria could be extended to increase the number of tumor nodules as long as the HCC were small and did not macrovascular invasion.

Factors affecting graft survival after living donor liver transplantation

Living donor liver transplantation (LDLT) has been considered as an alternative option to resolve the shortage of cadaveric donor organs, despite the ethical aspects of the donor procedure. The objective of this study was to analyze the risk factors affecting graft survival in LDLT. From June 1996 to December 2002, 141 patients who underwent LDLT were retrospectively analyzed. Graft survival rates were 82.5%, 80%, 77.3%, and 77.3% at 6 months, 1 year, 3 years, and 5 years, respectively. The factors influencing graft survival in univariate analysis were graft-to-recipient body weight ratio (GRWR) less than 0.8% (P = .0009), intraoperative transfusion of more than six packed RBC units in addition to the use of cell saver amounts (P = .0001), left lobe grafts in adults causing small-for-size situations (P = .0135), and donor age (P = .0472). The multivariate analysis demonstrated that GRWR less than 0.8% (P = .002) and intraoperative transfusion of more than six packed RBC units (P = .014) were independent factors that decreased graft survival rates. The graft selection of greater than 0.8% of GRWR and reduction of intraoperative RBC transfusion improve graft survival.

Posttransplantation lymphoproliferative disorder in pediatric liver transplantation

INTRODUCTION

The aim of this study was to evaluate the clinical features of risk factors for posttransplantation lymphoproliferative disorder (PTLD) in pediatric liver transplantation.

MATERIALS AND METHODS

Between June 1996 and June 2002, among 41 pediatric patients who underwent liver transplantation, 7 died in the postoperative period. Thirty-five patients, including 1 patient who died of PTLD, were reviewed. Based on the serology results, patients were divided into a high-risk group (EBV-naive recipients of EBV-positive grafts) and a low-risk group (patients other than those in the high-risk group).

RESULTS

Five of 41 patients (12.2%) developed PTLD. All of them belonged to the high-risk group. The incidence of PTLD in the high-risk group was 31.3% (5 of 16). The mean duration between operation and diagnosis for PTLD was 9.8 months. Primary EBV infection developed at a median of 6 months after transplantation. Three of 5 patients developed rejection before the diagnosis of PTLD. One patient was diagnosed with laryngeal and gastrointestinal PTLD, whereas the other 4 had gastrointestinal PTLD. They experienced the following symptoms and signs: anemia (100%), hypoalbuminemia (100%), fever (80%), diarrhea (80%), gastrointestinal bleeding (80%), and anorexia (60%).

CONCLUSION

The common features of PTLD development were as follows: (1) EBV-positive donors placed into EBV-naive recipients, (2) primary EBV infection approximately 6 months after transplantation, (3) young age, 1 year old at operation, and (4) requirement for intensive posttransplantation immunosuppression.

Small-for-size graft in adult living-donor liver transplantation

In the era of living donor liver transplantation (LDLT), graft size is related to recipient prognosis. This study was performed to compare the clinical outcomes according to the graft-to-recipient weight ratio (GRWR) in adult LDLT. Seventy-nine adult patients who had undergone LDLT between June 1997 and June 2002 were retrospectively analyzed. The patients were divided into two groups according to the GRWR (group I, GRWR < 0.8%, n = 11; group II, GRWR > or = 0.8%, n = 68). The mean follow-up period was 19.4 (range 1 to 48) months. The recipients were 62 men (78.5%) and 17 women (21.5%) of mean age 45.2 (range 18 to 63) years. The overall patient survival rates were 74.7% at 1 year and 70.7% at 2 years. The patient survival rate in group I was 54.6% at 1 year and 40.9% at 2 years, whereas that in group II was 77.9% at 1 year and 75.3% at 2 years, showing a significant difference (P = .03). There were no significant differences in postoperative total bilirubin, transaminase enzyme level, prothrombin time (INR), portal vein flow on Doppler sonography, amount of ascites through the drain, complications, or acute rejection rates between the two groups. In conclusion, the minimum acceptable graft size in an adult-to-adult LDLT is GRWR of 0.8%. This study suggests that careful postoperative management and/or technical modifications during surgery are necessary, because small-for-size grafts (GRWR < 0.8%) result in lower patient survival rates.

Clinicopathological features of incidental hepatocellular carcinoma in liver transplantation

The incidence of detecting hepatocellular carcinoma (HCC) in a removed recipient liver after a liver transplant is not rare. The clinical features are expected to be different from the preoperatively diagnosed HCC. The aim of this study was to evaluate the clinicopathological features of incidental HCC. This study retrospectively analyzed five cases of incidental HCC among 51 liver transplant cases of HCC operated from September 1996 to February 2002. The proportion of an incidental HCC was 9.8%. The mean age was 46.2 years with a higher prevalence in may (80%, four cases). The alpha-fetoprotein level was normal or mildly elevated. HBsAg was positive in all cases. Imaging studies revealed regenerative or dysplastic nodules, or no specific lesion. The pathological findings demonstrated a mean size of 1.16 cm, multiplicity in three cases (60%), no microvascular invasion, and Edmonson grade I (60%) and II (40%). There was no recurrence of the HCC. However, two patients died due to an intracranial hemorrhage and a graft failure, respectively. In conclusion, incidentally found HCC showed less invasive pathological features and a better prognosis.

A phase II trial of capecitabine in previously untreated patients with advanced and/or metastatic gastric cancer

BACKGROUND

Capecitabine (Xeloda) is a novel, oral, selectively tumor-activated fluoropyrimidine with proven activity in the treatment of advanced colorectal cancer. This trial was conducted to evaluate the efficacy, safety and feasibility of capecitabine in previously untreated patients with advanced and/or metastatic gastric cancer, with a view to replacing 5-fluorouracil (5-FU) in such patients.

PATIENTS AND METHODS

Forty-four patients received capecitabine 1250 mg/m2 twice daily (2500 mg/m2/day) for 14 days followed by 7 days of rest, for up to six cycles.

RESULTS

Capecitabine produced an objective response rate of 34% (all partial responses) and stable disease in 14 patients (30%). The median time to disease progression (TTP) was 3.2 months [95% confidence interval (CI) 2.7-6.4 months] and median overall survival was 9.5 months (95% CI 6.9-13.2 months). Hand-foot syndrome (HFS), nausea, anorexia, diarrhea and vomiting were the most common adverse events. While HFS was the most frequent grade 3/4 toxicity (National Cancer Institute Common Toxicity Criteria), only 9% of patients experienced grade 3 HFS. Severe myelosuppression was not reported during the study.

CONCLUSIONS

Capecitabine monotherapy is active and well tolerated as first-line therapy in patients with advanced/metastatic gastric cancer. Larger comparative trials investigating capecitabine-based combination regimens in patients with advanced gastric cancer are warranted.

Microvascular Tumor Embolism: Independent Prognostic Factor After Liver Transplantation in Hepatocellular Carcinoma

Microscopic tumor cell dissemination may be a more important factor in the recurrence of hepatocellular carcinoma (HCC) after liver transplantation, probably because of posttransplant immunosuppression. The presence of microvascular tumor embolism was undetermined as a factor for HCC recurrence after orthotopic liver transplantation (OLT). This study evaluated whether microvascular tumor embolism affects recurrence-free survival and correlates with other clinicopathologic factors after OLT among patients with HCC. From September 1996 to June 2003, 72 OLTs for HCC were enrolled in this study. Median follow-up was 22.8 months. Among 41 patients without microvascular tumor embolism, 1-year, 2-year, and 5-year recurrence-free survival rates were all 97.6%, while these rates were 77.3%, 68.2%, and 59.7%, respectively, for 31 patients (43.1%) with microvascular tumor embolism (P = .0006). The 5-year recurrence-free survival rate showed significant differences for a pT2 tumor (P = .0073), for maximal tumor size <3 cm (P = .0328), for > or =5 cm solitary tumor (P = .0095), and for the presence of a tumor capsule (P = .0012), within the Milan criteria (P = .0376). At multivariate analysis, significant independent predictors for HCC recurrence were microvascular tumor embolism and histopathologic grade. In conclusion, microvascular tumor embolism is an independent predictor of HCC recurrence after liver transplantation. Although OLT is a safe and effective treatment for HCC within the Milan criteria, the presence of microvascular tumor embolism at pathologic examination can predict its recurrence. In these cases, the feasibility of immunosuppressive therapy or adjuvant chemotherapy must be considered to prevent tumor recurrence.