High-energy underwater shock wave treatment for internal iliac muscle metastasis of prostatic cancer: a first clinical trial

[Muscular metastasis]

INTRODUCTION

Neoplasia is quite rare in myology. For unknown reasons, muscular metastasis are rarely described in cancer.

METHOD

Our work was a retrospective study with analysis of the medical literature and the presentation of one case of muscular metastasis revealed by a limitation of mouth opening in a 58-year-old Caucasian man (metastatic infiltration of the right pterygoid muscle secondary to a poorly differentiated adenocarcinoma of the lower third of the esophagus).

RESULTS

In addition to our case, we found 174 cases of cancer with muscular metastasis. Most of cases were observed in males (male/female ratio=2/1). The mean age at onset was 58.5 years (range: 13-89 years). The muscular metastasis were rarely found before the diagnosis of cancer (only in 37%), and usually appeared during disease progression, with other (extramuscular) metastases in 60% of cases. Prognosis was poor with less than 2.5% survival beyond 72 months. In most cases, muscular metastasis presented as a unique (78%), painful (61%) and palpable (63%) muscular mass, even if other asymptomatic muscular metastasis could be present. The mean localization of muscular metastasis was the lower limbs (46%), particularly in the proximal part (38% of all the muscular metastasis). The most frequent cancers were localized in lung, urinary tract, digestive tract and genital tract. When the muscular biopsy showed an "adenocarcinoma", in men the primitive cancers were localized in the digestive tract (35%), kidney (20%), and lung (18%) and in women, the genital tract and breast (23.5%). When the muscular biopsy showed a "squamous-cell carcinoma", in men the primitive cancers were localized in the lung (81%) and in women the cervix (64%).

CONCLUSION

These results highlight the importance of searching for muscular metastasis in patients with a focal, painful and palpable muscular mass. The muscular biopsy and immunohistochemical data can be helpful in identifying the primary cancer.

The potential for enhancement of mouse melanoma metastasis by diagnostic and high-amplitude ultrasound

The potential for enhancement of the metastatic spread of cells from mouse melanoma tumors was examined for exposure to diagnostic ultrasound (DUS) and high-amplitude ultrasound (HAUS) without and with ultrasound (US) contrast agent. The melanoma cell line B16-D5, which is metastatic specifically to lung, was cultured and implanted on a hind leg of female C57/bl6 mice. For DUS, tumors were scanned using 1.5-MHz harmonic B-mode imaging with 1-Hz intermittent frame triggering at 2.1 MPa (equivalent MI = 1.7) in a 37 degrees C water bath. For HAUS, a 1.35-MHz focused transducer directed 1-ms bursts at 5 MPa to the tumor at a 1-Hz rate. A total dose of 1 mL/kg Optison was injected during exposures. Exposure without contrast agent received the same exposure followed by the contrast agent with the US off. The primary tumor was removed surgically one day after US. Lungs were removed after four weeks for evaluation of metastases. Experiments involved exposure without and with contrast agent in groups of 20 mice. For DUS, mean counts of 0.8 +/- 0.3 (standard error) and 1.3 +/- 0.9 (P = 0.62) metastases were found for groups exposed without and with contrast, respectively. For HAUS, mean counts of 3.4 +/- 1.2 and 5.9 +/- 1.7 (P = 0.35) metastases were found for groups exposed without and with contrast, respectively. The lack of effect of DUS exposure with contrast confirms a previous finding. However, the HAUS counts and incidence were significantly larger than the DUS results (P < 0.05) in a two-way analysis of variance. This indicates a potential for HAUS to enhance metastasis.

Contrast-aided diagnostic ultrasound does not enhance lung metastasis in a mouse melanoma tumor model

OBJECTIVE

The purpose of this research was to test the hypothesis that contrast-aided diagnostic ultrasound (CADUS) could exacerbate the metastatic spread of mouse melanoma tumor cells to the lungs.

METHODS

The melanoma cell lines B16 and B16-D5 (metastatic specifically to lung) were implanted on a hind leg of female C57/bl6 mice. Growing tumors were scanned by 1.5-MHz diagnostic ultrasound in a 37 degrees C water bath. Four hundred image frames were triggered at a 1-Hz rate with 4 retro-orbital injections of an ultrasonographic contrast agent at dosage of 10 microL/kg at 100-second intervals. Sham-treated mice received 400 frames of ultrasonography followed by the contrast agent with the ultrasound off. The primary tumor was surgically removed 1 day after ultrasound administration. Lungs were removed and evaluated blind after 2 weeks of bleaching in Fekete solution.

RESULTS

Three experiments were performed. The first experiment involved scanning sham and CADUS groups of 20 mice each with B16 tumors; B16 metastasis was not enhanced. The second experiment repeated this test with the D5 cell line; the metastasis enhancement was marginally significant for average number (0.3 and 3.2; P = .06) and incidence (3 and 9 of 19; P = .08) in mice without tumor recurrence. Finally, a third experiment was performed to clarify ambiguous results in the second experiment and consisted of 2 groups of 40 mice each. In this larger experiment, the results were essentially equal for the sham and CADUS groups.

CONCLUSIONS

Overall, the results do not support the hypothesis of CADUS-enhanced metastasis.

Lithotripter shockwave-induced enhancement of mouse melanoma lung metastasis: dependence on cavitation nucleation

PURPOSE

To confirm a previous report of metastasis enhancement by lithotripter shockwaves (LSW) and to test the hypothesis that this effect is attributable to cavitation.

MATERIALS AND METHODS

The metastatic B16-D5 melanoma cell line was implanted on the hind legs of female C57/b16 mice 12 days before tumor treatment. The tumors were treated with 500 LSW in a waterbath arrangement. The effect of augmented cavitation nucleation was tested by intratumor injection of air bubbles or ultrasound contrast agent gas bodies (UCAGB). The primary tumor was surgically removed on day 1 after treatment. The six groups of mice were sham, LSW, sham + air bubbles, LSW + air bubbles, sham + UCAGB, and LSW + UCAGB. Data were collected for the 113 mice that survived at least 25 days. Lung evaluations were performed blind after 2 weeks of bleaching in Fekete's solution.

RESULTS

The outcomes of the three sham groups were very similar and indicated that the simple injection of material into the tumor did not increase metastasis. In comparison with the pooled shams, both the LSW + air bubbles and LSW + UCAGB groups had statistically significant increases in metastasis counts. Only the LSW + UCAGB group had a significant increase in incidence of metastasis relative to the pooled shams. The LSW + UCAGB also had significantly reduced survival.

CONCLUSION

Shockwaves can enhance metastasis from tumors, and this effect is attributable to cavitation.

Management of metastatic disease to soft tissue

Metastases to soft tissue are rare clinical problems. Most metastases are caused by carcinomatous deposits in the skeletal muscle, with lung carcinoma being the most common primary cause. Pain is more commonly observed in association with metastatic soft tissue masses than for soft tissue sarcomas. Treatment should be individualized, but for most carcinomas, initial radiotherapy treatment is recommended. Prognosis varies with the underlying disease, but for the typical patient with a metastatic carcinoma, mean survival duration is approximately 6 months.

Distant soft tissue metastases: a series of 30 new patients and 91 cases from the literature

BACKGROUND

Thirty patients with soft-tissue metastases were reviewed retrospectively and compared with 91 cases previously reported. Soft tissue metastases were most commonly presented to the musculoskeletal oncologist as a painful mass in patients with no history of cancer. In this setting, lung carcinoma was the most frequent primary source. The purpose of this article is to report the largest single series of distant soft-tissue metastases and to compare the findings with those of the literature.

METHODS

Thirty consecutive patients were referred to musculoskeletal oncologists. Their cases were reviewed retrospectively for comparison with 91 cases from the clinical literature.

RESULTS

The most common clinical presentation of the soft-tissue mass was as the presenting symptom of previously undiagnosed cancer or concurrent with the primary source of cancer. A minority of cases were discovered in the setting of widespread metastases. Twenty-one new patients had carcinomas, 6 sarcomas, and 1 each multiple myeloma, lymphoma, and melanoma. Lung carcinoma was the most common primary source. The most common presenting symptom was that of a painful mass. Skeletal muscle of the thigh was the most common site. Radiological features were not specific. Soft tissue sarcoma was a common clinical misdiagnosis. Twenty-one new patients were dead of disease at a mean 5.4 months (range 1-19 months) after diagnosis of the metastasis: this percentage was similar to that reported in the literature.

CONCLUSIONS

In this musculoskeletal oncology referral-based clinical series, soft tissue metastases most commonly occur in patients with a painful soft tissue mass and no history of cancer. Lung is the most frequent primary source. Treatment should be individualized according to the underlying disease and its prognosis.

Ultrasonic enhancement of gene transfection in murine melanoma tumors

The enhancement of gene transfection by ultrasound (US) was evaluated in vitro and in vivo using the B16 mouse melanoma model. Cultured cells were either exposed in suspensions in vitro or implanted subcutaneously in female C57BL/6 mice for 10-14 days and, subsequently exposed, in vivo. For comparison to results with a luciferase plasmid, a reporter plasmid for green fluorescent protein (GFP) was used to evaluate transfection efficiency. US was supplied by a system, similar to a Dornier HM-3 lithotripter, that produced shock waves (SW) of 24.4 MPa peak positive and 5.2 MPa peak negative pressure amplitudes at the focus. The plasmids were mixed with the suspensions to achieve 20 ,microL mL(-1), or were injected intratumorally to provide 0.2 mg DNA per mL of tumor. Acoustic cavitation was promoted by retaining 0.2 mL of air in the 1.2-mL exposure chambers in vitro and by injecting air at 10% of tumor volume in vivo. In vitro, cell counts declined to 5.3% of shams after 800 SW exposure, with 1.4% of the cells expressing GFP after 2 days of culture. In vivo, 2 days after 400 SW exposure, viable-cell recovery from excised tumors was reduced to 4.2% of shams and cell transfection was enhanced by a factor of about 8, reaching 2.5% of cell counts (p < 0.005 in t-test). These results show that strong tumor ablation induced by US shock wave treatment can be coupled with simultaneous enhancement of gene transfection.

Metastatic carcinoma to skeletal muscle. A report of 15 patients

The records of 15 patients with metastatic carcinoma to skeletal muscle treated between 1979 and the present were reviewed. Fourteen patients were referred with a diagnosis of soft tissue sarcoma and one with suspected infection. There was a previous diagnosis of carcinoma in eight patients but seven patients had no prior diagnosis of a known malignancy. Primary tumors were lung (eight), melanoma (two), gastrointestinal (one), kidney (one), and bladder (one). No primary tumor could be identified in two patients. Local control of metastatic lesions was achieved by radiotherapy in 11 patients as an initial measure. Two patients underwent wide excision and one declined treatment for local tumor control. Eight patients died within 12 months of presentation and survival analysis indicated a 25% overall survival at 60 months. Two patients remained free of disease at 132 months and 72 months. From this study and a review of 52 cases reported in the literature, the authors are unable to find any clinical or radiographic characteristics that distinguish metastatic carcinoma to muscle from soft tissue sarcomas. Surgical resection can be reserved for cases in which radiation does not provide local control.

Ultrasound-induced tissue ablation: studies on isolated, perfused porcine liver

Minimally invasive methods for the treatment of cancers, such as high-intensity focused ultrasound (HIFU) and high-energy shock waves (SW), have been proposed recently. Their feasibility for treatment of human cancer needs to be confirmed. A simplified model of isolated perfused pig liver that is close to the human liver in vivo has been proposed. The objective was to study the feasibility of deep focused tissue ablation with HIFU and SW in large organs approaching the size of the human liver. The model was demonstrated to be physiologically valid during the first 2 h of anoxic perfusion with a composite saline solution; arterial and portal pressure, enzymes, urea levels and bile secretion remained stable. It can simulate the major effects of perfusion and physical phenomena that occur in vivo during treatment. Histological analysis revealed no major changes. Previous results obtained in vivo in animal models at a depth of 2-3 cm were successfully reproduced and deeper lesion arrays at 4, 6, 8 and 9 cm from the surface were produced using the same principles. The depth of 9 cm from the liver surface is consistent with an extracorporeal treatment of most of the liver segments in man. Other applications of the model are proposed, particularly for the study of the role of interferences such as ribs and intestinal gas, blood perfusion and respiratory movements.