Cancer-induced immunosuppression: implications for therapy?

Palliative Gastrectomy Improves the Survival of Patients with Metastatic Early-Onset Gastric Cancer: A Retrospective Cohort Study

Background: Recent studies have found that patients with incurable gastric cancer might benefit from palliative gastrectomy, but the impact of palliative gastrectomy on metastatic early-onset gastric cancer (mEOGC) patients remains unclear. Methods: We analyzed mEOGC patients enrolled in the Surveillance, Epidemiology, and End Results registry from January 2004 to December 2018. Propensity score matching (PSM) analysis with 1:1 matching and the nearest-neighbor matching method were used to ensure well-balanced characteristics between the groups of patients with palliative gastrectomy and those without surgery. Kaplan-Meier survival analysis and Cox proportional hazards regression models were used to evaluate the overall survival (OS) and cause-specific survival (CSS) risk with corresponding 95% confidence intervals (CIs). Results: Of 3641 mEOGC patients, 442 (12.1%) received palliative gastrectomy. After PSM, 596 patients were included in the analysis, with 298 in each group. For the matched cohort, the median survival was 8 months, and the 5-year survival was 4.0%. The median OS of mEOGC patients undergoing palliative gastrectomy was significantly longer than that of patients without surgery (13 months vs. 6 months, p < 0.001), and palliative gastrectomy remained an independent protective factor after adjusting for confounders (HR 0.459, 95% CI 0.382-0.552, p < 0.001), and the protective effect was robust in the subgroup analysis. Similar results were indicated in CSS. Stratified analyses by treatment modality also warranted the superiority of palliative-gastrectomy-based treatment in improving OS and CSS. Conclusions: mEOGC patients with palliative gastrectomy had a significantly longer survival time than patients without surgery. Exploratory analysis confirmed that surgery-based therapy modality was superior in improving survival time.

Nobel Prize for immune checkpoint inhibitors, understanding the immunological switching between immunosuppression and autoimmunity

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are a revolutionary form of immunotherapy in cancer. However, the percentage of patients responding to therapy is relatively low, while adverse effects occur in a large number of patients. In addition, the therapeutic mechanisms of ICIs are not yet completely described.

AREAS COVERED

The initial view (articles published in PubMed, Scopus, Web of Science, etc.) was that ICIs increase tumor-specific immunity. Recent data (collected from the same databases) suggest that the ICIs pharmacotherapy actually extends beyond the topic of immune reactivity, including additional immune pathways, such as disrupting immunosuppression and increasing tumor-specific autoimmunity. Unfortunately, there is no clear delimitation between these specific autoimmune reactions that are therapeutically beneficial, and nonspecific autoimmune reactions/toxicity that can be extremely severe side effects.

EXPERT OPINION

Immune checkpoint mechanisms perform a non-selective immune regulation, maintaining a dynamic balance between immunosuppression and autoimmunity. By blocking these mechanisms, ICIs actually perform an immunological reset, decreasing immunosuppression and increasing tumor-specific immunity and predisposition to autoimmunity. The predisposition to autoimmunity induces both side effects and beneficial autoimmunity. Consequently, further studies are necessary to maximize the beneficial tumor-specific autoimmunity, while reducing the counterproductive effect of associated autoimmune toxicity.

On the need for integrating cancer into the One Health perspective

Recent pandemics have highlighted the urgency to connect disciplines studying animal, human, and environment health, that is, the "One Health" concept. The One Health approach takes a holistic view of health, but it has largely focused on zoonotic diseases while not addressing oncogenic processes. We argue that cancers should be an additional key focus in the One Health approach based on three factors that add to the well-documented impact of humans on the natural environment and its implications on cancer emergence. First, human activities are oncogenic to other animals, exacerbating the dynamics of oncogenesis, causing immunosuppressive disorders in wildlife with effects on host-pathogen interactions, and eventually facilitating pathogen spillovers. Second, the emergence of transmissible cancers in animal species (including humans) has the potential to accelerate biodiversity loss across ecosystems and to become pandemic. It is crucial to understand why, how, and when transmissible cancers emerge and spread. Third, translating knowledge of tumor suppressor mechanisms found across the Animal Kingdom to human health offers novel insights into cancer prevention and treatment strategies.

Molecular Mechanisms and Targeted Therapies Including Immunotherapy for Non-Small Cell Lung Cancer

Lung cancer is the leading cause of cancer death worldwide. Molecular targeted therapy has greatly advanced the field of treatment for non-small cell lung cancer (NSCLC), which accounts for the majority of lung cancers. Indeed, gefitinib, which was the first molecular targeted therapeutic agent, has actually doubled the survival time of NSCLC patients. Vigorous efforts of clinicians and researchers have revealed that lung cancer develops through the activating mutations of many driver genes including the epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), c-ros oncogene 1 (ROS1), v-Raf murine sarcoma viral oncogene homolog B (BRAF), and rearranged during transfection (RET) genes. Although ALK, ROS1, and RET are rare genetic abnormalities, corresponding tyrosine kinase inhibitors (TKIs) can exert dramatic therapeutic effects. In addition to anticancer drugs targeting driver genes, bevacizumab specifically binds to human vascular endothelial growth factor (VEGF) and blocks the VEGF signaling pathway. The VEGF signal blockade suppresses angiogenesis in tumor tissues and inhibits tumor growth. In this review, we also explore immunotherapy, which is a promising new NSCLC treatment approach. In general, antitumor immune responses are suppressed in cancer patients, and cancer cells escape from the immune surveillance mechanism. Immune checkpoint inhibitors (ICIs) are antibodies that target the primary escape mechanisms, immune checkpoints. Patients who respond to ICIs are reported to experience longlasting therapeutic effects. A wide range of clinical approaches, including combination therapy involving chemotherapy or radiation plus adjuvant therapy, are being developed.

Who Will Benefit from Noncurative Resection in Patients with Gastric Cancer with Single Peritoneal Metastasis?

The value of noncurative resection for patients with gastric cancer with single peritoneal metastasis is still debatable. This study was undertaken to evaluate the survival benefit of resection in those patients. From 2006 to 2009, 119 patients with gastric cancer with single peritoneal metastasis were identified during surgery. Sixty-three of them had noncurative resection; the remainder had nonresection. Clinicopathological variables and survival were analyzed. Overall survival of patients in the noncurative resection group was longer than that in the nonresection group (14.869 vs 7.780 months). This survival advantage was still significantly better in the P1/P2 patients who underwent noncurative resection (mean survival time 21.164 vs 7.636 months, P = 0.001), but not in the P3 group ( P = 0.489). Multivariate analysis indicated that only noncurative resection retained a significant association with better prognosis in P1/P2 patients. The perioperative mortality rate in the resection group was not significantly higher than that of the noncurative group ( P = 0.747). Noncurative resection can prolong the survival of patients with gastric cancer with single P1/P2 peritoneal metastasis. This surgical approach should not be taken into account for those patients with P3 gastric cancer.

Long-term survival with stable disease after multidisciplinary treatment for synchronous liver metastases from gastric cancer: A case report

INTRODUCTION

The liver is one of the most common sites of hematogenous metastases of gastric cancer. The 5-year overall survival rate of synchronous liver metastases from gastric cancer was less than 27%. We report a rare case of patient with synchronous liver metastases from gastric cancer who experienced stable disease for 7 years and 3 months following multidisciplinary modalities.

THE PRESENTATION OF A CASE

A 33-year-old woman was admitted to our institute because of abdominal pain lasting for a day. Haemoglobin level was 68 g/L. Computed tomography (CT) scan revealed hemoperitoneum, multiple round lesions within liver parenchyma. The pathological diagnosis was gastric cancer with liver metastases. Following multidisciplinary treatment, she experienced stable disease for7 years and 3 months. Currently, the patient remains alive with no recurrence.

CONCLUSION

We report a rare case of patient with synchronous liver metastases from gastric cancer who experienced stable disease for 7 years and 3 months following multidisciplinary modalities. Future trials are required to prospectively investigate the established regimen of multidisciplinary treatment.

Palliative gastrectomy plus chemotherapy versus chemotherapy alone for incurable advanced gastric cancer: a meta-analysis

BACKGROUND

Whether palliative gastrectomy combined with chemotherapy can improve the survival of patients with advanced gastric cancer remains controversial. We performed a meta-analysis to clarify whether palliative gastrectomy plus chemotherapy can benefit patients with incurable advanced gastric cancer and to explore the best candidates in this patient population.

METHODS

We searched the literature systematically using electronic databases including PubMed, EMBASE, and the Cochrane Library. And HRs and their 95% CIs were used to express the results for overall survival (OS) and progression-free survival (PFS).

RESULTS

One randomized controlled trial with 175 patients and 12 cohort studies with 2,193 patients were analyzed. The pooled HR for OS (HR=0.43, 95% CI=0.29-0.65, P<0.001), subgroup analysis of stage M1 (HR=0.53, 95% CI=0.40-0.72, P<0.001), peritoneal dissemination (HR=0.46, 95% CI=0.28-0.73, P=0.001), and liver metastasis (HR=0.46, 95% CI=0.33-0.65, P<0.001) all indicated the superiority of palliative gastrectomy plus chemotherapy. However, the pooled HR for PFS (HR=0.61, 95% CI=0.33-1.13, P=0.110) got separate outcome.

CONCLUSION

The results of this meta-analysis indicated that palliative gastrectomy plus chemotherapy can improve OS for incurable advanced gastric cancer. In addition, analyses based on liver metastasis and peritoneal dissemination demonstrated the advantages of palliative gastrectomy plus chemotherapy. However, the PFS of incurable advanced gastric cancer with palliative gastrectomy plus chemotherapy was no better than that under chemotherapy alone.

Palliative gastrectomy is beneficial in selected cases of metastatic gastric cancer

Background

Salvage chemotherapy is the mainstay of treatment for metastatic gastric cancer (mGC). This study aimed to clarify the effects of palliative gastrectomy (PG) and identify prognostic factors in mGC patients undergoing PG.

Methods

This was a retrospective review of 333 mGC patients receiving PG or a non-resection procedure (NR) between 2000 and 2010. Clinicopathological factors affecting the prognosis of these patients were collected prospectively and analyzed.

Results

One hundred and ninety-three patients underwent PG and 140 NR. The clinicopathological characteristics were comparable between the two groups except for metastatic pattern. There were no significant differences in postoperative morbidity and mortality between the two groups. The PG group had a significantly longer median overall survival compared with the NR group (7.7 months vs. 4.9 months). In the PG group, age ≤58 years, preoperative albumin level >3 g/dL, ratio of metastatic to examined lymph nodes ≤0.58, and administration of chemotherapy were independent prognostic factors in multivariate analysis.

Conclusions

Patients undergoing PG had better outcomes than those undergoing NR. Among the patients undergoing resection, age ≤58 years, a better preoperative nutritional status, less nodal involvement and postoperative chemotherapy independently affected patient survival.

A Prognostic Model in Metastatic or Recurrent Gastric Cancer Patients with Good Performance Status Who Received First-Line Chemotherapy

PURPOSE: Good performance status is widely known as a superior prognostic predictor. However, some patients have large survival differences despite having good performance status that are influenced by certain prognostic factors. The purpose of this study was to explore baseline host- or tumor-related factors and to establish a prognostic model for metastatic or recurrent gastric cancer patients with good performance status who received first-line chemotherapy. METHODS: A total of 310 metastatic or recurrent gastric cancer patients with good performance status who received first-line chemotherapy were enrolled. Prognostic significance was determined using multivariate Cox regression analysis. Incorporating all pretreatment indicators, a prognostic model was established. Overall survival outcomes were compared with different risk groups using the Kaplan-Meier method and log-rank test. RESULTS: In multivariate analysis, no previous gastrectomy [hazard ratio (HR) = 1.42; 95% confidence interval (CI) = 1.08-1.85], number of distant metastatic sites (HR = 1.47; 95% CI = 1.11-1.96), bone metastasis (HR = 2.20; 95% CI = 1.16–4.18), liver metastasis (HR = 1.77; 95% CI = 1.31-2.39), and an elevated neutrophil lymphocyte ratio (HR = 1.37; 95% CI = 1.04-1.79) were independent prognostic factors of overall survival. Patients were categorized into three risk groups according to their risk scores. Median survival times for the low-risk (0 point), intermediate-risk (1-3 points), and high-risk (≥ 4 points) groups were 19.7, 10.7 and 5.1 months, respectively (P < .001). CONCLUSIONS: A prognostic model was developed that could facilitate risk stratification for metastatic or recurrent gastric cancer patients with good performance status who received first-line chemotherapy to help clinicians choose an applicable treatment based on the estimated prognosis.

Comparison of Therapeutic Efficacy between Gastrectomy with Transarterial Chemoembolization Plus Systemic Chemotherapy and Systemic Chemotherapy Alone in Gastric Cancer with Synchronous Liver Metastasis

BACKGROUND

Systemic chemotherapy (SC) is the recommended treatment for gastric cancer with liver metastasis. However, the improvement in survival has been disappointing. The aim of this study was to compare the therapeutic efficacy of gastrectomy with transarterial chemoembolization plus SC (GTC) and SC alone for gastric cancer with synchronous liver metastasis.

METHODS

From January 2008 to December 2013, 107 gastric cancer patients with synchronous liver metastasis attending the four participating centers were enrolled in this multicenter, ambispective, controlled cohort study. Patients who underwent GTC (n = 32) were compared with controls who were received SC alone (n = 75). The primary endpoints of the study were overall survival (OS) and progression-free survival (PFS). The secondary endpoints were response rate to treatment and treatment-related adverse effects.

RESULTS

The median OS was 14.0 months (95% confidence interval [CI ]: 13.1-14.9 months) in the GTC treatment group and 8.0 months (95% CI : 6.6-9.4 months) in SC group, this difference being statistically significant (P < 0.001). The median PFS was significantly longer in the GTC than in the SC group (5 months, 95% CI : 2.2-7.8 months vs. 3 months, 95% CI : 2.3-3.4 months, respectively) (P < 0.001). The rate of response to treatment was significantly better in the GTC than the SC group (59.4% vs. 37.4%, respectively) (P = 0.035). According to multivariate analysis, OS in patients receiving combination treatment was significantly correlated with the size (P = 0.037) and extent of liver metastases (P < 0.001). PFS was also correlated with the extent of liver metastases (P = 0.003).

CONCLUSIONS

GTC is more effective than SC alone in patients with gastric cancer with synchronous liver metastasis. GTC therapy prolongs the survival of selected gastric cancer patients with synchronous liver metastasis.

Chemoresponse after non-curative gastrectomy for M1 gastric cancer

Background

M1 gastric cancer has a poor oncologic outcome with a median survival of less than 1 year despite aggressive chemotherapy. Recent trials include chemotherapy combined non-curative gastrectomy. This study evaluated the chemoresponse after non-curative gastrectomy in M1 gastric cancer and the survival benefit.

Methods

Between January 2000 and December 2010, 660 patients received chemotherapy for gastric cancer at the Department of Hemato-Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea. Data was collected retrospectively from the medical records. Patients who received preoperative or adjuvant chemotherapy, who underwent other surgeries like gastrojejunal bypass or exploratory laparotomy, who died within 3 months due to seriously advanced gastric cancer, who were lost to follow-up, or whose medical records were unsuitable for data collection were excluded. The remaining 101 patients had received chemotherapy only (CTx group, n = 76) or chemotherapy after non-curative gastrectomy (NCG + CTx group, n = 25). Clinicopathologic characteristics, chemoresponse, and overall survival were compared between the two groups.

Results

There were no significant differences between the two groups in clinicopathologic characteristics including age, sex, body mass index (BMI), comorbidity, histologic differentiation, tumor location, clinical T stage, and initial site of distant metastasis. Chemoresponse was checked on two separate occasions from the initiation of chemotherapy: first chemotherapy regimen and until the third regimen change. The NCG + CTx group showed more favorable chemoresponse than the CTx group in both checks (60% and 72% vs. 18.4% and 23.7%). The NCG + CTx group showed longer overall survival than the CTx group (26 vs. 11 months).

Conclusions

Non-curative gastrectomy in M1 gastric cancer could improve chemoresponse and extend overall survival.

The result of conversion surgery in gastric cancer patients with peritoneal seeding

Purpose

Palliative gastrectomy and chemotherapy are important options for peritoneal seeding of gastric cancer. The treatment stage IV gastric cancer patient who respond to induction chemotherapy, is converted to gastrectomy (conversion therapy or conversion surgery). This study explored the clinical outcomes of gastric cancer patients with peritoneal seeding who had undergone conversion therapy.

Materials and Methods

Between 2003 and 2012, gastric cancer patients with peritoneal seeding, as determined by preoperative or intraoperative diagnosis were reviewed retrospectively. Clinicopathologic characteristics and clinical outcomes of patients with peritoneal seeding were analyzed.

Results

Forty-three patients were enrolled. Eighteen patients had undergone conversion surgery and 25 patients continued conventional chemotherapy. Among the 18 conversion patients, 10 received clinically curative resection. The median follow-up period was 28.5 months (range 8 to 60 months) and the total 3-year survival rate was 16.3%. The median survival time of the patients who received clinically curative conversion therapy was 37 months, and the 3-year survival rate was 50%. The median follow-up for non-curative gastrectomy patients was 18 months. No patient treated using chemotherapy survived to 3 years; the median survival time was 8 months. The differences in survival time between the groups was statistically significant (P<0.001).

Conclusions

In terms of survival benefits for gastric cancer patients with peritoneal seeding, clinically curative conversion therapy resulted in better clinical outcomes.

Identification of prognostic factors and surgical indications for metastatic gastric cancer

BACKGROUND

The treatment of metastatic gastric cancer is not uniform, and the prognostic factors and indications for surgery are currently unclear. This retrospective study aimed to identify the prognostic factors and clinical indications for surgery in patients with metastatic gastric cancer.

METHODS

A total of 123 consecutive patients with gastric cancer and synchronous distant metastasis treated between January 1999 and December 2011 were reviewed. Patient, tumor, laboratory, surgical, and chemotherapy factors were analyzed, with overall survival as the endpoint. Univariate analyses were performed using the log-rank test, multivariate analyses were performed using the Cox proportional hazards model, and Kaplan-Meier curves were used to estimate survival. Significance was set at p<0.05.

RESULTS

The median overall survival time was 13.1 months. Ninety-eight patients received chemotherapy. Twenty-eight patients underwent gastrectomy with metastasectomy and 55 underwent gastrectomy without metastasectomy. The median overall survival time for patients who underwent gastrectomy with metastasectomy, gastrectomy without metastasectomy, and no surgical intervention was 21.9 months, 12.5 months, and 7.2 months, respectively (p<0.001). Multivariate analysis identified gastrectomy with or without metastasectomy, performance status (PS) ≥ 3, neutrophil-to-lymphocyte ratio (NLR) >3.1, and carbohydrate antigen 19-9 (CA19-9) level >37 U/mL as predictors of poor survival. NLR and CA19-9 level were also independent prognostic factors in the group of patients who underwent surgery.

CONCLUSIONS

High pretreatment NLR, CA19-9 level, and PS are predictors of poor prognosis in patients with metastatic gastric cancer. In selected patients, gastrectomy can be performed safely, and may be associated with longer survival.

Role of metastasectomy on overall survival of patients with metastatic gastric cancer

PURPOSE

The role of metastasectomy has been debatable and unclear in the treatment for patients with metastatic gastric cancer. Therefore, this study was designed to evaluate the role of metastasectomy on the overall survival of these patients.

MATERIALS AND METHODS

In 2,406 patients who underwent gastrectomy for gastric cancer between 1998 and 2010, 188 (7.8%) patients had their first surgery for metastatic gastric cancer. To minimize the bias of systemic chemotherapy, 99 patients who received postoperative chemotherapy (fewer than 2 cycles) were excluded. The primary gastrectomy or metastasectomy had not been enforced in the following cases. Patients with far advanced peritoneal dissemination, multiple liver and lung metastasis (more than 2), and a poor general condition (Eastern Cooperative Oncology Group>2) were excluded. Based on the metastasectomy, the patients were classified into two groups, gastrectomy with metastasectomy and gastrectomy only group.

RESULTS

There was no significant difference between both groups in clinicopathological characteristics except for the mean age (P=0.047). The univariate analysis for overall survival show statistical significances in metastasectomy (P=0.026), distal gastrectomy (P=0.047), and combined resection of another organ (P=0.047) group. With a multivariate analysis, metastasectomy was a significant factor in patient survival after surgery (odds ratio 1.679; P=0.034).

CONCLUSIONS

Based on our results, we assume that a detailed strategy for surgery is needed to improve the overall survival of patients with metastatic gastric cancer. Therefore, we suggest that a metastasectomy can help prolong overall survival in some patients with metastatic gastric cancer.

Cancer: a missing link in ecosystem functioning?

Cancer is a disease that affects the majority of metazoan species and, before directly causing host death, is likely to influence the competitive abilities of individuals, their susceptibility to pathogens, their vulnerability to predators, and their ability to disperse. Despite the potential importance of these ecological impacts, cancer is rarely incorporated into model ecosystems. We describe here the diversity of ways in which oncogenic phenomena, from precancerous lesions to generalized metastatic cancers, may affect ecological processes that govern biotic interactions. We argue that oncogenic phenomena, despite their complexity, can have significant and sometimes predictable ecological consequences. Our aim is to provide a new perspective on the ecological and evolutionary significance of cancer in wildlife, and to stimulate research on this topic.

The clinical value of non-curative resection followed by chemotherapy for incurable gastric cancer

BACKGROUND

The clinical value of a non-curative resection for gastric cancer is still controversial. We analyzed the clinical outcomes of patients who underwent non-curative gastric resection.

METHODS

Data from a total of 178 patients who underwent non-curative resection for advanced gastric cancer at Seoul St. Mary's hospital were reviewed. Factors related to the incurability were classified as peritoneal metastasis (P), liver metastasis (H), extra-abdominal metastasis (X), direct adjacent organ invasion that was unresectable (T). The clinicopathologic data, survival, and quality of life of patients were evaluated.

RESULTS

The overall median survival time was 12.1 months, and that for the patients with gastrectomy with chemotherapy was 14.3 months. Operation-related complications occurred in 20 patients (11.2 %). Five patients (2.8 %) died of postoperative complications within 30 days, and 43 patients (24.2 %) had symptoms and signs of gastric outlet obstruction or uncontrolled bleeding. The mean duration of postoperative hospital stay was 15.9 days for those symptomatic patients, and the symptom-relieved period was 8.6 months.

CONCLUSIONS

There might be a role for non-curative resection followed by chemotherapy for incurable gastric cancer, in terms of survival, and this treatment approach should be carefully considered because of the high mortality rate associated with the disease. A large, randomized, prospective study is warranted to prove the benefit of non-curative resection in patients with incurable gastric cancer.

Clinical outcomes according to primary treatment in gastric cancer patients with peritoneal seeding

Purpose

Peritoneal seeding of gastric cancer is known to have a poor prognosis. With the diagnosis of peritoneal seeding, there is no effective treatment modality. Gastrectomy with chemotherapy or primary chemotherapy is basically one of major options for this condition. This study was conducted to compare the clinical outcomes of these treatments and to identify the better way to improve the prognosis of patients with peritoneal seeding.

Materials and Methods

Between 2001 and 2007, gastric cancer patients with peritoneal seeding by preoperative or intraoperative diagnosis were reviewed retrospectively. The enrolled patients were divided as primary gastrectomy and primary chemotherapy group. Clinicopathologic characteristics and clinical outcomes of groups were analyzed and compared.

Results

Fifty-four patients were enrolled. 21 patients belonged to the group of primary gastrectomy and 33 patients were to the primary chemotherapy group. Among 33 patients of the primary chemotherapy group, 17 patients were received only chemotherapy and 16 patients were received gastrectomy due to the good responses of primary chemotherapy. The 3 years survival rates were 14% in primary gastrectomy group, 55% in patients who received gastrectomy after primary chemotherapy, and 0% in patients with primary chemotherapy only.

Conclusions

Although this study had many limitations, some valuable information was produced. In terms of survival benefits for the gastric cancer patients with peritoneal seeding, primary gastrectomy and additional gastrectomy after primary chemotherapy revealed the better clinical outcomes. But, prospective randomized clinical study and multi-center study are should be performed to decide proper treatment for gastric cancer patients with peritoneal seeding.

Palliative gastrectomy and other factors affecting overall survival in stage IV gastric adenocarcinoma patients receiving chemotherapy: a retrospective analysis

OBJECTIVE

Most patients with gastric cancer present with locally advanced or metastatic disease and usually receive palliative therapy. We sought to identify factors influencing overall survival in patients with stage IV gastric cancer receiving palliative chemotherapy.

PATIENTS AND METHODS

The records of 311 patients with histological diagnosis of gastric adenocarcinoma were retrospectively reviewed and 17 clinicopathological and therapeutic parameters were evaluated for their influence on overall survival.

RESULTS

In multivariate analysis nine factors were found to independently influence survival: no previous palliative gastrectomy [Hazard ratio (HR, 12; CI 7.969-18.099)], single agent chemotherapy instead of combination chemotherapy (HR, 1.35; CI 1.068-1.721), histological grade III (HR, 1.39; 95% CI 1.098-1.782), the presence of hepatic (HR, 1.6; 95% CI 1.246-2.073) and abdominal metastasis (HR, 1.33; 95% CI 1.039-1.715), CA 72-4 > 7 U/L (HR, 1.39; 95% CI 1.026-1.887), LDH > 225 U/L (HR, 1.72; 95% CI 1.336-2.236], need for blood transfusions (HR, 1.58; 95% CI 1.213-2.082), and weight loss > 5% (HR, 1.96; 95% CI 1.352-2.853) at the time of initial diagnosis. Patients were stratified as low (0-2 factors), intermediate (3-6 factors) and high (7-9 factors) risk and the median survival was 76, 40 and 11 weeks, respectively.

CONCLUSION

Nine clinical and laboratory factors that adversely affect survival in patients with stage IV gastric cancer who receive chemotherapy were identified. Their concurrent presence seems to have an additive effect as patients with seven to nine factors have the worse prognosis. Palliative gastrectomy and combination chemotherapy appear to be associated with improved survival.

The value of resection of primary tumor in gastric cancer patients with liver metastasis

PURPOSE

Surgery for gastric cancer with synchronous liver metastasis is applied for palliation. The aim was to determine whether surgical removal of the primary tumor provides a better survival and disease progression

METHODS

Sixty-two patients are classified according to the primary tumor were removed or not. Patients and tumor characteristics, removal of the primary tumor are examined as the factors that were affecting overall survival and metastatic progression-free survival.

RESULTS

The mean follow-up time was 243±23 days. The mean survival of the resection and nonresection groups were 422±50 and 170±16 days (p = 0.0001), respectively. After adjustment for other covariates, resection was associated with a trend toward improvement in overall survival (p = 0.003; relative risk RR: 0.34; 95% confidence interval (CI): 0.17-0.66) and improvement in metastatic progression-free survival (p = 0.07, RR = 0.51; 95% CI: 0.25-1.07).

CONCLUSIONS

Excision of the primary tumor has an effect on metastatic progression-free survival and overall survival.

Survival benefit of non-curative gastrectomy for gastric cancer patients with synchronous distant metastasis

BACKGROUND

The prognosis for gastric cancer patients with distant metastasis is very poor. The purpose of this study was to evaluate the survival benefit of non-curative gastrectomy for gastric cancer patients with synchronous distant metastasis.

METHODS

From 1992 to 2002, 253 gastric cancer patients with synchronous distant metastasis underwent surgery at the Department of Surgery, Ruijin Hospital, China. The clinicopathological characteristics and survival were compared between resection and non-resection groups.

RESULTS

The 5-year survival rate was 6.5% for patients in resection group and 0% for patients in non-resection group (P < 0.001). Multivariate analysis showed that liver metastasis, peritoneal dissemination, and non-resection were significantly associated with poor prognosis in gastric cancer patients with distant metastasis. The survival difference between resection and non-resection groups was only observed in patients with single peritoneal dissemination (P < 0.001), but were not in patients with single liver metastasis (P = 0.428), distant nodes involvement (P = 0.490) and multiple metastatic sites (P = 0.192), respectively.

CONCLUSIONS

Our results suggests that there were no survival benefit from non-curative gastrectomy for patients with single liver, distant nodes, or multiple sites metastasis. However, only patients with single peritoneal dissemination had survival benefit from non-curative resection. The value of non-curative resection should be evaluated by well-designed clinical trials.

Hepatic ablation for neuroendocrine tumor metastases

The indolent nature of neuroendocrine tumors and their proclivity to be hormonally active warrant aggressive treatment for advanced stage disease with hepatic metastases. Cytoreduction has been associated with improved symptom control as well as prolonged survival compared with those treated with medical therapy. The primary modalities of cytoreduction employed are resection, ablation, and embolization. In particular, radiofrequency ablation has been utilized with good results and minimal morbidity for treating patients with advanced neuroendocrine disease.

The surgeon's role in immunotherapy

Immunotherapy in the multidisciplinary care of the cancer patient will play an increasingly important role in cancer therapy for solid tumors. Strategies to optimize surgical management for an effective immune response against tumors should be acknowledged and promoted by the surgical community. Immunotherapy can serve as a beneficial adjunct to surgical excision for high-risk and recurrent tumors, with the attraction of decreased toxicity and disability over current adjuvant treatment methods. It is important that surgeons recognize immunotherapy's potential and play an active role in developing immunotherapy treatment regimens, for without surgical involvement many of these therapies may never come to fruition. This article reviews the key roles that surgeons play in immunotherapy treatment and research.

Surgical resection of colorectal liver metastases in patients with expanded indications: a single-center experience with 501 patients

PURPOSE

This study was designed to investigate survival after curative resection of colorectal liver metastases in patients with expanded indications.

METHODS

A total of 501 patients had 545 liver resections for metastatic colorectal cancer. There were no predefined criteria for resectability with regard to the number or size of the tumors, locoregional invasion, or extrahepatic disease, except that resection had potential to be complete and macroscopically curative. All patients who had curative hepatic resection were advised to start postoperative adjuvant chemotherapy.

RESULTS

A total of 259 patients had expanded indications (52 percent), including 14 with liver metastases >10 cm, 194 with bilateral deposits, 140 with four or more liver metastases, and 73 with extrahepatic disease. The overall actuarial survival rates at one, three, five, and ten years were 88, 67, 45, and 36 percent, respectively, for patients with classic indications and 84, 53, 34, and 24 percent, respectively, for patients with expanded indications (P = 0.0009). In the group of expanded indications, there were more patients who received preoperative than postoperative chemotherapy: 72 (28 percent) vs. 18 (7 percent; P < 0.0001), and 148 (70 percent) vs. 131 (61 percent; P = 0.0466). In a multivariate analysis, four or more liver metastases and extrahepatic disease were independent predictors of poor outcome. Adjuvant chemotherapy significantly improved survival (P = 0.0002).

CONCLUSIONS

This study suggested that liver resection should be indicated in patients with expanded indications. The extent of the benefits of preoperative and postoperative chemotherapy needs to be quantitated.

Can surgery for cancer accelerate the progression of secondary tumors within residual minimal disease at both local and systemic levels?

BACKGROUND

Surgical removal remains the principal treatment modality in the management of lung cancer. Our aim is to characterize the effects of tumor removal on subsequent tumor recurrence at both local and systemic levels.

METHODS

C57/BL6 mice [10/group] underwent a mammary fat pad inoculation of 3LL cells [5 x 10(5)/animal] and were divided into two groups. Group 1 served as control while mice in group 2 were further subdivided into groups 2A and 2B. After 2 weeks, all mice in 2A were killed, and primary tumors and lungs were excised. At 2 weeks, primary tumors were excised completely for all mice in group 2B. These mice were then recovered and recurrent tumor growth evaluated for a further 2 weeks. Four weeks from the onset of the study, all remaining primary tumors and lungs were excised from groups 1 and 2.

RESULTS

After 4 weeks undisturbed growth, primary tumors in group 1 reached a mean size of 2.85 +/- 0.33 cm. After 2 weeks growth, primary tumors in groups 2A and 2B were comparable at 1.36 +/- 0.44 m and 1.53 +/- 0.29 cm, respectively. Two weeks after primary tumor excision, recurrent tumors in group 2B had reached a mean size of 2.65 +/- 0.74 cm. Moreover, for several animals, recurrent tumors rapidly reached similar volumes to that of primary tumors in group 1. Primary tumors were typically encapsulated and nonadherent. In contrast, recurrent tumors were locally invasive and adherent to chest wall and wound. Interestingly, pulmonary metastatic burden was increased in group 2B relative to group 1. Histologic examination revealed increased mitosis in recurrent tumors when compared with primary tumors.

CONCLUSIONS

Tumor removal is followed by accelerated growth of locally recurrent tumors and metastases. Moreover, recurrent tumors are more locally invasive than primary tumors. These findings strongly indicate that resection may be followed by tumor progression in residual disease.

Treatment of synchronous peritoneal carcinomatosis and liver metastases from colorectal cancer

AIM

To report our experience of peritoneal carcinomatosis (PC) discovered during abdominal exploration in patients with liver metastases (LM).

METHODS

Liver resection plus cytoreductive surgery were combined in 24 patients with LM and moderate PC from colorectal origin treated with a curative intent between January 1993 and November 2003.

RESULTS

The mean operative time was 357+/-112 min and median blood loss was 719 ml. One postoperative death occurred and postoperative morbidity was 58%. The mean hospital stay was 21.4+/-4.2 days. Three-year overall and disease-free survival rates were respectively 41.5% (confidence interval [CI]: 23-63) and 23.6% (CI: 11-45). Seven patients are disease-free with a mean follow-up of 27.8 months after their last surgery, 3 having a repeated hepatectomy. Three patients developed a peritoneal recurrence and 13 had recurrence in the liver. The only significant prognostic factor was a number of LMs of less than 3 (p < 0.01).

CONCLUSION

A combined treatment of LM plus PC is feasible and is beneficial in selected patients presenting three or fewer metastases.

Is there a role for palliative gastrectomy in patients with stage IV gastric cancer?

Patients with metastatic gastric cancer are currently not considered operative candidates and are most often offered systemic therapy. Palliative resection of the primary tumor has been considered irrelevant to the outcome and has been recommended only for palliation of symptoms. We have examined the role of palliative gastrectomy and its impact on survival in patients with stage IV gastric cancer at initial diagnosis between 1990 and 2000. A total of 105 patients with stage IV disease were identified during this period; 81 of them (77.1%) had no resection, and 24 (22.9%) underwent palliative gastric resection. Mean survival in those without resection who received chemotherapy (with or without radiation) treatment was 5.9 months (95% confidence interval 4.2-7.6). For those with resection and adjuvant therapy, mean survival time was 16.3 months (95% confidence interval 4.3-28.8 months). Kaplan-Meier survival analysis showed significantly better survival in those with resection and adjuvant therapy (log-rank test, P = 0.01). Mortality and morbidity rates associated with palliative resection were 8.7% and 33.3%, respectively, which did not differ statistically from the 3.7% and 25.3% in patients who underwent curative gastrectomy during same period of time. However, the length of hospitalization (22 versus 16 days) was significantly higher compared with those without stage IV disease. These data suggest that palliative resection combined with adjuvant therapy may improve survival in a selected group of patients with stage IV gastric cancer. Palliative gastrectomy plus systemic therapy should be compared with systemic therapy alone in a randomized trial.

Hat die palliative Resektion bei gastrointestinalen Tumoren noch einen Stellenwert?

Before any palliative tumor resection, the morbidity and mortality risks must be carefully weighed against the continued prognosis (including quick and lasting relief of discomfort from the tumor) and alternative strategies such as bypass, chemotherapy, and radiotherapy. Multimodal concepts have seen considerable progress in recent years, and endoscopic and interventional methods have expanded the instrumentarium for palliative tumor therapy. Thus the value of palliative resection must be reassessed. The most important criteria and study results are described here, as they have resulted in increased interest in palliative tumor resection within a multimodal treatment for most gastrointestinal tumors. More studies are needed to learn how much can realistically be expected of these new approaches.

Surgically induced accelerated local and distant tumor growth is significantly attenuated by selective COX-2 inhibition

BACKGROUND

Even after apparently curative resection, lung cancer recurrence continues to lead to high mortality levels. The aim of this study was to assess the effects of cyclooxygenase-2 (COX-2) inhibitor on local and systemic recurrent tumor growth.

METHODS

C57BL/6 mice underwent mammary fat pad inoculation with 3LL cells. After two weeks growth, flank tumors were resected completely and followed for recurrent tumor growth. Postresection mice were randomized to receive placebo alone (group 1) or the selective COX-2 inhibitor, rofecoxib (group 2), daily for two weeks by tube feeding. Recurrent tumor growth kinetics were compared for both groups. Two weeks following primary tumor excision animals were sacrificed, after which lungs were resected and pulmonary metastatic burden was assessed using the lung-body weight ratio. Apoptotic and mitotic indices were established for recurrent tumors and lungs, using hematoxylin and eosin histology.

RESULTS

Two weeks postexcision of the primary tumor, recurrent tumors in the placebo group were significantly greater than the treatment group (p = 0.002). While primary tumors were typically encapsulated and not adherent, recurrent tumors in the placebo group were invasive, adherent to the chest wall and the overlying wound. In contrast, recurrent tumors in the treatment group were nonadherent to the chest wall. Moreover, postoperative pulmonary metastatic burden was significantly reduced in treated animals. Histologic examination revealed increased apoptosis as well as an increase in the apoptosis-mitosis ratio in treated animals.

CONCLUSIONS

Primary tumor excision was associated with accelerated local and systemic tumor recurrence. However, these effects were significantly attenuated using selective COX-2 inhibition. The COX-2-inhibition was associated with increased levels of apoptosis. These findings endorse a role for COX-2 inhibition in the secondary prevention of lung cancer recurrence at both local and systemic levels.

Hepatic and extrahepatic colorectal metastases: when resectable, their localization does not matter, but their total number has a prognostic effect

BACKGROUND

The presence of extrahepatic disease (EHD) is considered a contraindication to hepatectomy in patients with colorectal liver metastases. After resection, the prognosis is based more on the total number of resected metastases (located inside and outside the liver) than on the site of these metastases (only inside the liver or not).

METHODS

A total of 308 patients with colorectal cancer underwent hepatectomy, and 84 (27%) also underwent resection of miscellaneous EHD. The study was a prospective data registration and retrospective analysis. When considering the total number of resected metastases, each liver metastasis and each EHD location was counted as one lesion. Univariate and multivariate analyses were performed.

RESULTS

The median follow-up was 99 months. The overall 5-year survival rate was 32%. In the multivariate analysis, the total number of metastases (inside or outside the liver) had a greater prognostic value than the criterion "presence or absence of EHD." Considering the total number of resected metastases (whatever their site), 5-year survival rates were 38% (SD: 4%) in the group with one to three metastases, 29% (SD: 5%) in patients with four to six metastases, and 18% (SD: 5%) in patients with more than six metastases (P = .002). A very simple prognostic score based on sex and the total number of metastases is proposed.

CONCLUSIONS

EHD, when resectable, is no longer a contraindication to hepatectomy. More importantly, the total number of the metastases, whatever their location, has a stronger prognostic effect than the site of these metastases.

Results of R0 resection for colorectal liver metastases associated with extrahepatic disease

BACKGROUND

Extrahepatic malignant disease has always been considered an absolute contraindication to hepatectomy for colorectal liver metastases. This study reports the long-term outcome and prognostic factors of patients undergoing extrahepatic disease resection simultaneously with hepatectomy for liver metastases.

METHODS

From January 1987 to January 2001, 75 patients underwent a complete R0 resection of extrahepatic disease simultaneously with hepatectomy for colorectal liver metastases. They were inscribed in a registry and then prospectively followed up. They represented 25% of the 294 patients who underwent an R0 hepatectomy for colorectal liver metastases during the same period.

RESULTS

The mortality rate was 2.7%, and morbidity was 25%. After a median follow-up of 4.9 years (range, 1.7-13.4 years), the overall 3- and 5-year survival rates were 45% and 28%, respectively. By using a Cox model, there was a significant difference in survival between patients with single versus multiple sites of extrahepatic disease. Also, the presence of more than five liver metastases was a significant parameter.

CONCLUSIONS

Extrahepatic disease in colorectal cancer patients with liver metastases should no longer be considered as a contraindication to hepatectomy. However, this intended R0 resection cannot be performed in 50% of laparotomized patients, and negative prognostic factors for surgery include the presence of multiple extrahepatic disease sites or more than five liver metastases.

Excisional surgery for cancer cure: therapy at a cost

Excisional surgery is one of the primary treatment modalities for cancer. Minimal residual disease (MRD) is the occult neoplastic disease that remains in situ after curative surgery. There is increasing evidence that tumour removal alters the growth of MRD, leading to perioperative tumour growth. Because neoplasia is a systemic disease, this phenomenon may be relevant to all patients undergoing surgery for cancer. In this review we discuss the published work that addresses the effects of tumour removal on subsequent tumour growth and the mechanisms by which tumour excision may alter residual tumour growth. In addition, we describe therapeutic approaches that may protect patients against any oncologically adverse effects of tumour removal. On the basis of the evidence presented, we propose a novel therapeutic paradigm; that the postoperative period represents a window of opportunity during which the patient may be further protected against the oncological effects of tumour removal.

Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases

BACKGROUND

Extrahepatic disease has always been considered an absolute contraindication to hepatectomy for liver metastases. The present study reports the long-term outcome and prognostic factors of patients undergoing resection of extrahepatic disease simultaneously with hepatectomy for liver metastases.

METHODS

From January 1987 to January 2001, 111 (30 per cent) of 376 patients who had hepatectomy for colorectal liver metastases underwent simultaneous resection of extrahepatic disease with curative intent.

RESULTS

Surgery was considered R0 in 77 patients (69 per cent) and palliative (R1 or R2) in 34 patients (31 per cent). The mortality rate was 4 per cent and the morbidity rate 28 per cent. After a median follow-up of 4.9 years, the overall 3- and 5-year survival rates were 38 and 20 per cent respectively. The 5-year overall survival rate of patients with R0 resection only (n = 75) was 29 per cent. The difference in survival between patients with and without extrahepatic disease discovered incidentally at operation was significant, as was the number of liver metastases.

CONCLUSION

Extrahepatic disease in patients with colorectal cancer who also have liver metastases should no longer be considered an absolute contraindication to hepatectomy. However, the presence of more than five liver metastases and the incidental intraoperative discovery of extrahepatic disease remain contraindications to hepatic resection.

An attempt to clarify indications for hepatectomy for liver metastases from breast cancer

BACKGROUND

Liver metastases (LM) from breast cancer are generally considered as disseminated disease with a poor prognosis. However in selected patients hepatectomy may be an important adjunct to systemic treatment.

METHODS

Fifty-four breast cancer patients (mean age 49.2 +/- 5.2 years) with LM as the sole site of metastatic disease (except for bone metastases in 3 patients) underwent hepatectomy between 1986 and 2000. The mean number of LM was 4.0 +/- 8. All patients presented either a stable disease or an objective response to chemotherapy. The last 25 patients also underwent hepatic artery catheter installation in order to receive postoperative hepatic artery infusion chemotherapy (HAIC).

RESULTS

The postoperative morbidity was 12.9%. There was no postoperative mortality. R0 and R1-R2 resections were obtained in, respectively, 81.5% and 18.5% of patients. After a median follow-up of 32 months the median survival was 34 +/- 9 months, with 3- and 5-year overall survival rates of 50% and 34%, and 3- and 5-year disease-free survival rates of 42% and 22%, respectively. The number of LM, the presence of hilar lymph nodes (33%), and the completeness of resection had no significant prognostic impact. The only factor influencing survival in both the univariate and multivariate analysis was the hormone receptor status (P = 0.03): the relative risk of death was increased by 3.5-fold when negative. In the HAIC group, the liver recurrence rate decreased from 60.5% to 31.2% without any impact on global survival.

CONCLUSIONS

Hepatectomy is beneficial for selected patients with isolated LM. Indications should be based more on technical (low operative risk, probable R0 resection) than on oncologic criteria. The decision is simple for young patients but more difficult for older patients in whom a negative hormone receptor status appears to be a contraindication.

Premenopausal status accelerates relapse in node positive breast cancer: hypothesis links angiogenesis, screening controversy

Much attention has been given to determining the benefit of mammographic screening to reduce breast cancer mortality. Eight randomized clinical trials have been conducted in four countries: the US, Canada, Scotland and Sweden. Trials report an early and stable 30% reduction in breast cancer mortality for women aged 50-59. For women under 50, unexpectedly, the early years of screening produce a disadvantage to the screened population. Only in later years does an advantage appear. To help understand this, we studied relapse patterns using a breast cancer database of 1,173 pre- and postmenopausal, node negative and positive patients treated with surgery only and having 16-20 years of follow-up. This approach is relevant since at least five of the eight screening trials began before the widespread use of adjuvant chemotherapy in the 1980s. Surgical cure rates were independent of menopausal status. However, a major difference in early relapse rate was found. In premenopausal and node positive patients, 27% of all distant relapses occurred within the first 10 months following resection. This is twice the early relapse frequency of any other clinical group. Using computer simulation, we interpret that these early relapses probably result from a disadvantage induced at surgery. A disinhibition or surgery/wounding induced angiogenic surge might be responsible. Disinhibition is known to occur in animal models such as Lewis lung where lung metastases are avascular and dormant until the primary is removed. Sudden outgrowth of tumor after wounding has been observed for a century. According to the simulation, in breast cancer this induction apparently accelerates inevitable relapses by a median of two years. This is offset in later years with a balancing reduction in relapses. These data suggest that the angiogenic switch may be upregulated more frequently among premenopausal women, perhaps depending upon the sex hormones. The acceleration would cause 0.11 deaths per 1,000 screened aged 40-49 subjects in years 2-3, a value comparable to the early year excess mortality in trials of a significant 0.15 deaths per 1,000 subjects. Equal screening advantage is predicted for node negative (but not node positive) pre- and postmenopausal patients. The acceleration of relapse after surgery may explain the paradoxical effect of mammographic screening for women under 50.

Evaluation of lymphocytic responses after treatment with Bacillus Calmette-Guerin and interferon-alpha 2b for superficial bladder cancer

Bladder wash-derived lymphocytes from superficial bladder cancer patients involved in high dose BCG, low dose BCG, and low dose BCG with IFN-alpha treatments were examined. We found an increasing trend in the percentage of CD3 T cells with each weekly intravesical instillation and the proportion of CD3 T cells expressing the gammadelta T cell receptor was significantly higher in patients receiving standard dose BCG than those receiving low dose BCG or low dose BCG plus IFN-alpha. Most patients had a predominance of CD4 T cells, while some had more CD8 T cells. The CD4/CD8 ratio did not vary much during the instillations. Surprisingly, both patients and normal control individuals had high percentages of CD69- and CD45RO-positive lymphocytes in the bladder wash and this was not reflected in lymphocytes from peripheral blood collected in parallel. We found no differences in lymphocyte phenotypes, cytokine production, and clinical outcome in the patients from three arms. This may reflect that the qualitative and quantitative immune responses elicited from the three treatments are similar. However, the lymphokine-activated killing ability of peripheral blood lymphocytes against allogeneic cell-lines from the cancer patients was depressed compared to normal individuals and the cytotoxicity appeared to be enhanced after intravesical treatment.

Human papillomavirus infection and esophageal cancer: a nationwide seroepidemiologic case-control study in Sweden

BACKGROUND

Infection with human papillomavirus (HPV) type 16 has been implicated as a risk factor for esophageal squamous cell carcinoma in three seroepidemiologic studies. We conducted a larger, population-based study to verify this association and to investigate possible confounding factors.

METHODS

We performed a nationwide case-control study in Sweden of HPV16 or HPV18 infection and risk of esophageal squamous cell carcinoma or esophageal/gastroesophageal adenocarcinoma. Tumors were strictly classified by their location and histologic type. Case subjects with incident cancers and population-based control subjects donated blood samples and were interviewed in person about potential confounding factors. An enzyme-linked immunosorbent assay was used to detect HPV seropositivity. Multivariate analyses were conducted to study relationships between HPV seropositivity, level of education, smoking (all tobacco) status, alcohol consumption, and cancer risk.

RESULTS

We compared 121 case subjects with esophageal squamous cell carcinoma and 173 case subjects with adenocarcinoma of the esophagus or gastroesophageal junction with 302 population-based control subjects. The age- and sex-adjusted odds ratios (ORs) for squamous cell carcinoma were 1.0 (95% confidence interval [CI] = 0.5-2.0) for persons seropositive for HPV16 and 0.5 (95% CI = 0.2-1.1) for persons seropositive for HPV18 in comparison with seronegative individuals. The corresponding ORs for adenocarcinoma were 1.2 (95% CI = 0.7-2.2) and 0.2 (95% CI = 0.1-0.7), respectively. Adjustments for smoking status, alcohol consumption, and level of education did not alter the results.

CONCLUSIONS

We found no evidence of a positive association between HPV16 or HPV18 infection and either form of esophageal cancer. Our results do not support conclusions from previous studies.

Preoperative oral supplement with immunonutrients in cancer patients

BACKGROUND

Early postoperative enteral nutrition with immune-enhancing supplements has helped to restore immune function and reduce infectious complications in patients with cancer undergoing major gastrointestinal operations. The aim of this study was to evaluate the effectiveness of similar supplements (containing arginine and arginine plus omega-3 fatty acids) given preoperatively for 1 week before cancer surgery.

METHODS

In this randomized, double-blinded study, patients scheduled to undergo elective resection of upper gastrointestinal tumors were given one of three different oral liquid supplemental diets (control, arginine, arginine plus omega-3 fatty acids) to be taken each day for 7 days before surgery. Blood samples were obtained upon enrollment, on the morning of surgery, and on postoperative day 1 for analysis of immunologic function.

RESULTS

Mean serum ornithine (a metabolite of arginine) levels were significantly higher compared with controls, but no significant increase in mean serum arginine levels was noted on the morning of surgery for those patients who received arginine as part of the supplement. In conjunction with these findings, there were no differences among groups in mean lymphocyte mitogenesis, mean peripheral blood mononuclear cell production of cytokines, or clinical outcomes.

CONCLUSIONS

Use of oral liquid supplements in this fashion did not improve lymphocyte proliferation or monocyte functions in patients with cancer undergoing major surgery.

Tissue prostaglandin levels in familial adenomatous polyposis patients treated with sulindac

BACKGROUND

Recent work has demonstrated a correlation between frequency of aspirin ingestion and colorectal cancer prevention. Sulindac, another nonsteroidal anti-inflammatory drug (NSAID), has been shown to cause polyp regression and a fall in cell proliferation in patients with familial adenomatous polyposis, who are destined to develop colorectal cancer unless the colon is removed. However, the mode of action of NSAIDs in colorectal carcinogenesis prevention remains to be determined, although a prostaglandin-mediated mechanism seems likely.

METHODS

Rectal or duodenal biopsies from 20 patients with familial adenomatous polyposis, who had been randomized to sulindac or placebo, were analyzed for prostaglandin (PG) E2 and F2 alpha levels before and after treatment.

RESULTS

A significant fall in prostaglandin E2 and F2 alpha levels was seen in patients who were on sulindac; this correlated with a visual improvement in number and size of polyps in the same patients (P = 0.0096; PGE2, P = 0.036; PGF2 alpha, Spearman's rank correlation).

CONCLUSIONS

Nonsteroidal anti-inflammatory drugs may prevent colorectal cancer by their inhibition of prostaglandin synthesis. Prostaglandins may be implicated in carcinogenesis through an increase in cell proliferation, through immunosuppression, by increasing neovascularization, or via a mutagenic effect.

Effect of perioperative chemoimmunotherapy with cyclophosphamide and autologous tumor vaccine in murine MBT-2 bladder cancer

The in vitro cytotoxic activity of splenocytes from C3H/He mice implanted subcutaneously with 10(6) syngeneic MBT-2 tumor cells on day 0 was significantly enhanced after cyclophosphamide (100 mg./kg., intraperitoneally) given 2 days before tumor resection on day 17, with or without active specific immunization with BCG plus autologous irradiated tumor cells (vaccine) 1 week after tumor resection. Furthermore, a significantly lower tumor incidence was seen in mice challenged with 10(5), but not 10(6), tumor cells per mouse 24 hours after tumor resection on day 17 and treated with cyclophosphamide on day 15 and postoperatively with vaccine than was found in nontreated tumor resected mice. Phenotypic analysis of cells from spleen showed that cyclophosphamide pretreatment and postoperative vaccine, either singly or in combination, induced a significant increase of both CD44+ memory T cells and CD11b+ myeloid/macrophage cells. Thus, in addition to a specific antitumor immune response, a nonspecific cytolytic mechanism may also play a role in the observed antitumor effect.