Characterizing the multi-dimensional reaction dynamics of dihalomethanes using XUV-induced Coulomb explosion imaging

Site-selective probing of iodine 4d orbitals at 13.1 nm was used to characterize the photolysis of CH2I2 and CH2BrI initiated at 202.5 nm. Time-dependent fragment ion momenta were recorded using Coulomb explosion imaging mass spectrometry and used to determine the structural dynamics of the dissociating molecules. Correlations between these fragment momenta, as well as the onset times of electron transfer reactions between them, indicate that each molecule can undergo neutral three-body photolysis. For CH2I2, the structural evolution of the neutral molecule was simultaneously characterized along the C-I and I-C-I coordinates, demonstrating the sensitivity of these measurements to nuclear motion along multiple degrees of freedom.

Time-resolved relaxation and fragmentation of polycyclic aromatic hydrocarbons investigated in the ultrafast XUV-IR regime

Polycyclic aromatic hydrocarbons (PAHs) play an important role in interstellar chemistry and are subject to high energy photons that can induce excitation, ionization, and fragmentation. Previous studies have demonstrated electronic relaxation of parent PAH monocations over 10-100 femtoseconds as a result of beyond-Born-Oppenheimer coupling between the electronic and nuclear dynamics. Here, we investigate three PAH molecules: fluorene, phenanthrene, and pyrene, using ultrafast XUV and IR laser pulses. Simultaneous measurements of the ion yields, ion momenta, and electron momenta as a function of laser pulse delay allow a detailed insight into the various molecular processes. We report relaxation times for the electronically excited PAH^*, PAH^+* and PAH^2+* states, and show the time-dependent conversion between fragmentation pathways. Additionally, using recoil-frame covariance analysis between ion images, we demonstrate that the dissociation of the PAH²⁺ ions favors reaction pathways involving two-body breakup and/or loss of neutral fragments totaling an even number of carbon atoms.

High-pressure developments for resonant X-ray scattering experiments at I16

An experimental setup to perform high-pressure resonant X-ray scattering (RXS) experiments at low temperature on I16 at Diamond Light Source is presented. The setup consists of a membrane-driven diamond anvil cell, a panoramic dome and an optical system that allows pressure to be measured in situ using the ruby fluorescence method. The membrane cell, inspired by the Merrill-Bassett design, presents an asymmetric layout in order to operate in a back-scattering geometry, with a panoramic aperture of 100° in the top and a bottom half dedicated to the regulation and measurement of pressure. It is specially designed to be mounted on the cold finger of a 4 K closed-cycle cryostat and actuated at low-temperature by pumping helium into the gas membrane. The main parts of the body are machined from a CuBe alloy (BERYLCO 25) and, when assembled, it presents an approximate height of 20-21 mm and fits into a 57 mm diameter. This system allows different materials to be probed using RXS in a range of temperatures between 30 and 300 K and has been tested up to 20 GPa using anvils with a culet diameter of 500 µm under quasi-cryogenic conditions. Detailed descriptions of different parts of the setup, operation and the developed methodology are provided here, along with some preliminary experimental results.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Thermal contact conductance of demountable in vacuum copper-copper joint between 14 and 100 K

Thermal contact conductance (TCC) at material interfaces has a great impact upon the efficiency of cooling in cryogenic instruments, and is thus a crucial design parameter. Lack of reliable numerical data for demountable in vacuum bare (uncoated, dry, and without interposers) copper-copper joints prompted us to carry out systematic studies of TCC over the temperature range 14-100 K. We measured TCC as function of applied force for the contacts with surface roughness R(a) = 0.2, 1.6, and 3.2 μm. It is seen that with increasing temperature, the TCC of bare Cu-Cu contact initially rises following a generic power law dependency T(γ) with γ = 1.25 ± 0.02, reaching a maximum value at 40-50 K. TCC then decreases as temperature continues to rise towards 100 K. We show results that match those in the literature from low (4-20 K) and high (100-300 K) temperature domains, resulting in a unified smooth curve of temperature dependency of TCC for bare Cu-Cu joints. Temperature dependence is then described in a phenomenological model, accounting for the effects of changes in bulk conductivity and surface hardness with temperature. This model consistently explains the observed power law dependence of TCC as function of applied force and changes caused by roughness of contact surfaces.

Difficulty in brainstem death testing in the presence of high spinal cord injury

In the UK, when the standard brain death criteria are met, further investigations are not necessary. Confirmatory tests can be useful, however, when it is not possible to carry out all of the brainstem tests. We report the case of a patient with multiple trauma and a high spinal cord injury who was apnoeic. Confirmatory tests (EEG, brainstem, auditory evoked potential) were essential in supporting the diagnosis of brainstem death to allow withdrawal of artificial ventilation, as organ donation was being considered.

Specific organ gene transfer in vivo by regional organ perfusion with herpes viral amplicon vectors: implications for local gene therapy

BACKGROUND

Many gene therapy strategies would benefit from efficient, regional organ delivery of therapeutic genes.

METHODS

Regional perfusions of lung, liver, or bladder were performed to determine if rapid and efficient gene transfer can be accomplished in vivo, and to determine if in vivo gene transfer can be limited to the organ of interest. In addition, herpes simplex virus tumor necrosis factor (HSVtnf), carrying the human tumor necrosis factoralpha gene was used as a treatment for methylcholanthrene sarcoma in a syngeneic lung metastases model in Fisher rats.

RESULTS

A 20-minute perfusion using HSV carrying beta-galactosidase (HSVlac) produced significant expression of this marker gene isolated to the target organs, without organ-specific tissue injury or inflammation. Regional perfusion of organs with HSV carrying the cytokine gene tumor necrosis factor alpha also resulted in high-level local organ production of this cytokine (2851 +/- 53 pg/g tissue in perfused lung versus 0 for the contralateral lung). For the current vector construct, expression of the gene of interest peaked between 2 and 4 days and was undetectable by 2 weeks after perfusion. In animals undergoing perfusion as treatment for pulmonary sarcoma, there was no difference between tumor counts in lungs perfused with HSVlac (17 +/- 6) or HSVtnf (22 +/- 8), but either treatment resulted in lower tumor counts than controls (111 +/- 24 nodules per lung, P <.02).

CONCLUSIONS

Regional organ perfusion using herpes viral vectors is an effective and well-tolerated in vivo method of transiently delivering potentially toxic gene products to target organs in directing gene therapy. Regional lung perfusion with HSV amplicons reduces tumor burden in a rat model of pulmonary metastases, though HSVtnf cannot be demonstrated to augment the cytopathic effect of the HSV amplicon alone in the current model.

Evidence-based implementation of free phenytoin therapeutic drug monitoring

BACKGROUND

The majority of laboratories measure total phenytoin concentration for therapeutic drug monitoring. However, there are substantial interindividual variations in free phenytoin concentrations, the pharmacologically active component.

METHODS

We describe the process and data used to implement monitoring of free phenytoin only in an urban medical center. Over a 6-week period, total and free phenytoin concentrations were measured, clinical charts reviewed, and indications for alterations in the percentage of free phenytoin fraction were determined.

RESULTS

Of the 189 phenytoin requests from 139 patients, 136 data points were analyzed. Free phenytoin concentrations were 6.8-35.3%, with 50% outside the expected range of 8-12%. Clinical indications likely responsible for variations were hypoalbuminemia, drug interactions, uremia, pregnancy, and age. Overall, 30% of patients demonstrated a discrepancy between therapeutic, subtherapeutic, or supratherapeutic concentrations between free and total phenytoin concentrations. The largest discordance (53%) occurred in the patient group with free phenytoin <8% or >12%.

CONCLUSIONS

This study supports previous clinical findings that monitoring total phenytoin is not as reliable as free phenytoin as a clinical indicator for therapeutic and nontherapeutic concentrations. Thus, we recommend that therapeutic monitoring should use free phenytoin concentrations only.

Rapid activation of MDR1 gene expression in human metastatic sarcoma after in vivo exposure to doxorubicin

Overexpression of P-glycoprotein (Pgp), a multidrug transporter encoded by the MDR1 gene, is associated with chemoresistance in some human solid tumor malignancies. To date, analyses of MDR1 levels in solid tumors have examined constitutive increases in expression at relapse. In the present study, we have evaluated the acute induction of MDR1 gene expression in a solid human tumor as a function of time in response to in vivo exposure to chemotherapy. Five patients with unresectable sarcoma pulmonary metastases underwent isolated single lung perfusion with doxorubicin. Relative MDR1 gene expression was measured in metastatic tumor nodules and normal lung specimens after initiation of chemoperfusion. In four of five patients, a 3-15-fold (median, 6.8) increase in MDR1 RNA levels was detected in tumors at 50 min after administration of doxorubicin. In contrast, normal lung samples had very low levels of MDR1 RNA prior to perfusion, and no acute increases were observed after therapy. These findings demonstrate, for the first time, that MDR1 gene expression can be rapidly activated in human tumors after transient in vivo exposure to cytotoxic chemotherapy.

Pain at the end of the stem after revision total knee arthroplasty

A consecutive series of patients undergoing revision total knee arthroplasty was studied prospectively. Clinical and radiographic assessment was performed preoperatively, 6 and 12 months postoperatively, and annually thereafter. Evaluation consisted of a Knee Society clinical score and assessment of patient satisfaction. In addition, patients completed drawings of their lower extremity regarding the location and severity of the pain they experienced preoperatively and at minimum 2-year followup (mean, 36 months; range, 24-48 months). Pain that was localized to the diaphyseal region of the femur or tibia on the drawing was defined as pain at the end of the stem. Clinical, radiographic, and pain drawing data were completed for patients who had 66 of 78 revision total knee arthroplasties performed during the time of the study (85%). All procedures were performed with the same implant system and instrumentation and included fluted cobalt-chrome stems for all patients in whom the stem was implanted without cement and slightly underreamed (press fit). All femoral components had the surface cemented with the stems press fit. Sixteen of the tibial stems were cemented fully, whereas the remaining 50 tibial components were cemented on the surface only with the stems press fit. Localized pain at the end of the stem was present on the femoral side in seven of 66 patients (11%) and in seven of 50 patients with press fit tibial stems (14%). Patients with pain at the end of the stem at 2 to 4 years postoperatively had significantly lower preoperative function scores and overall Knee Society clinical score. Postoperatively, patients with pain at the end of the stem had a significantly lower clinical score; however the postoperative function score and Knee Society clinical score were not significantly different than scores of patients who did not have pain at the end of the stem. There was no correlation between the stem diameter and the occurrence of pain; however, there was a trend for percent canal fill to be higher on the tibial side in patients with pain (71% versus 63%), but this was not statistically significant. Three of the 16 patients with cemented tibial stems (19%) experienced pain at the end of the stem. Patients with press fit stems who had pain at the end of the stem were more likely to express dissatisfaction with the surgical procedure than patients without pain at the end of the stem.

Pulmonary metastasectomy for head and neck cancers

BACKGROUND

Distant metastases from carcinomas that arise from the head and neck region are infrequent. The most common site is the lung. To evaluate the results of resection of pulmonary metastases for head and neck cancers, we reviewed our own cases of these metastases.

METHODS

Between November 1966 and March 1995, 83 patients with pulmonary metastases from head and neck cancers underwent 94 thoracic operations. All patients had obtained or had obtainable locoregional control of their primary head and neck cancers. Kaplan-Meier and Cox regression models were used to analyze the prognostic factors for survival after metastasectomy.

RESULTS

Median age was 53 years (range, 17-77). Fifty-nine were male and 24 were female. Forty-one patients had squamous cell cancers, and 36 had glandular tumors that consisted mostly of thyroid and adenoid cystic carcinomas. The median disease-free interval from the time of treatment of the head and neck primary cancers to the development of pulmonary metastases was 27 months. Sixty-eight (82%) patients had complete resection. Overall operative mortality rate was 2%. Overall actuarial survival rate after metastasectomy was 50% at 5 years. Patients with glandular tumors had a 5-year survival rate of 64% compared with 34% for patients with squamous cell cancers. When the patients with glandular tumors were analyzed according to their histology, patients with adenoid cystic carcinomas had an 84% 5-year survival, but none remained disease-free. Patients with thyroid cancers fared similarly whether they were treated medically or surgically. On multivariate analysis, the adverse prognostic factors for patients with squamous cell cancers were incomplete resection, age greater than 50 years, and disease-free interval less than or equal to 2 years.

CONCLUSIONS

Approximately 30% of patients with pulmonary metastases from squamous cell cancers of the head and neck who underwent complete resection of all their metastases can expect to achieve long-term survival. The role of pulmonary resection for patients with glandular tumors is unclear.

Intestinal permeability after early postoperative enteral nutrition in patients with upper gastrointestinal malignancy

BACKGROUND

Increased intestinal permeability may lead to sepsis in resected upper gastrointestinal (GI) cancer patients. This study sought to determine whether these patients demonstrated increased intestinal permeability and if early postoperative enteral nutrition would alter this result.

METHODS

Nineteen patients undergoing complete resection of upper GI malignancy were randomized into two groups: the nonfed group received IV crystalloid, and the fed group started enteral nutrition by jejunostomy on postoperative day (POD) 1. Six nonoperative volunteers were controls. The lactulose/mannitol test was performed on PODs 1 and 5. Ten grams of lactulose and 5 g of mannitol were given, and urine was collected for 6 hours.

RESULTS

All patients (nonfed, 1.895+/-0.34; fed, 0.893+/-0.24) had elevated lactulose/mannitol ratios on POD 1 vs controls (0.262+/-0.1; p < .008 and p = .05). These elevated levels returned toward control levels in both groups by day 5 (nonfed, 0.533+/-0.1, p = .06; fed, 0.606+/-0.12, p = .08).

CONCLUSIONS

Major upper GI surgery for malignancy resulted in a significant increase in intestinal permeability on POD 1. With or without enteral nutrition, this measure of intestinal permeability returned to normal on POD 5 in well-nourished patients.

Growth hormone, alone and in combination with insulin, increases whole body and skeletal muscle protein kinetics in cancer patients after surgery

OBJECTIVE

To investigate the impact of growth hormone, alone and in combination with insulin, on the protein kinetics of patients with upper gastrointestinal (GI) tract cancer who have undergone surgery and are receiving total parenteral nutrition (TPN).

SUMMARY BACKGROUND DATA

Patients with malignancies of the upper GI tract are at increased risk for malnutrition and perioperative death and complications. Standard nutritional support has not significantly altered outcome. Growth hormone (GH) and insulin have been shown to have some benefit in patients with cancer; however, their action in patients undergoing resection has not previously been studied.

METHODS

Thirty patients undergoing surgery for upper GI tract malignancies were prospectively randomized into one of three nutritional support groups after surgery: 10 patients received standard TPN, 10 received TPN plus daily injections of GH, and 10 received daily GH, systemic insulin, and TPN. The patients underwent a protein kinetic radiotracer study on the fifth day after surgery to determine whole body and skeletal muscle protein kinetics.

RESULTS

Patients who received standard TPN only were in a state of negative skeletal muscle protein net balance. Those who received GH and insulin had improved skeletal muscle protein net balance compared with the TPN only group. Whole body protein net balance was improved in the GH and the GH and insulin groups compared with the TPN only group. GH and insulin combined did not improve whole body net balance more than GH alone. GH administration significantly increased serum IGF-1 and GH levels. Insulin infusion significantly increased serum insulin levels and the insulin/glucagon ratio.

CONCLUSION

Growth hormone and GH plus insulin regimens improve protein kinetic parameters in patients with upper GI tract cancer who are receiving TPN after undergoing surgery.

Prolonged air leak following radical upper lobectomy: an analysis of incidence and possible risk factors

STUDY OBJECTIVES

To examine the incidence and clinical significance of prolonged air leak (PAL) in patients undergoing radical upper lobectomy and to determine potential risk factors for PAL in this group of patients.

DESIGN

Retrospective review of a prospective database.

SETTING

Experience of one thoracic surgeon at a tertiary care cancer center.

PATIENTS

One hundred consecutive patients undergoing right upper lobectomy and mediastinal lymph node dissection for non-small cell lung cancer over an 11-year period.

MEASUREMENTS

PAL was defined as an air leak lasting >7 days. Preoperative, intraoperative, and postoperative clinical data were collected and analyzed to determine the factors associated with PAL.

RESULTS

PAL was the most prevalent postoperative complication, comprising 25.5% of all complications seen, and lasting an average of 12.1+/-5.3 days. In 21 of the 26 patients with PAL, this complication was the only morbidity identified. There was no statistically significant difference in patient age, gender, preoperative FEV1 and diffusion of carbon monoxide, exposure to neoadjuvant chemotherapy, status of pulmonary fissures, or pathologic stage between the PAL group vs the remaining 74 patients without this complication. A significantly greater proportion of patients with PAL had FEV1/FVC ratio < or =50% (6/26 vs 5/74; p=0.02). Patients with PAL had significantly longer median length of hospital stay (11 vs 7 days; p=0.0001). Moreover, PAL was the single most common reason for an extended length of hospitalization (21/58, 36% of all causes).

CONCLUSION

PAL is an alarmingly common postoperative complication and is the most frequent cause of an extended length of hospital stay in patients undergoing radical upper lobectomy. Severe obstructive pulmonary disease predisposes patients to the development of this complication.

The total volar forearm musculocutaneous free flap for reconstruction of extended forequarter amputations

Forequarter amputation is performed for resection of large, invasive tumors of the shoulder girdle region. A substantial defect can usually be closed with local or regional flaps; however, a subset of the forequarter amputation group has emerged at this institution with more complex issues. These patients have extensively more invasive posterior tumors, some with chest wall/rib invasion. Local/regional flaps in these situations are inadequate, and free tissue transfer is the only viable option. The forequarter specimen can sometimes be used as a donor site, thereby eliminating the usual donor site morbidity. Variations of the total forearm free flap have been sparsely described in the literature--the majority being case reports of either pure fasciocutaneous or "filet of forearm" flaps. We report a series of 4 patients treated over a 5 year period at this institution using the previously undescribed total volar forearm musculocutaneous free flap based on the brachial artery and its venae comitantes. This flap includes the entire musculature of the volar forearm with fasciocutaneous extensions on either side of the musculocutaneous unit. All potentially ischemic dorsal musculature is discarded, leaving a flap that has central bulk and a relatively large dimension. The entire flap remains extremely well vascularized, and a substantial surface area of as much as 45 x 25 cm can be attained. A pedicle as long as 20 cm can be dissected as far proximally in the arm as is oncologically safe. A single artery and vein are anastomosed to either the intrathoracic or neck vessels. All four flaps survived completely with uncomplicated wound healing. The total volar forearm musculocutaneous flap is extremely well vascularized and highly reliable. The flap as described provides the ideal combination of large surface area, muscle bulk, and long vascular pedicle. It can be dissected rapidly to minimize ischemic time and could therefore be applicable to traumatic forequarter amputations. It has become the flap of choice for reconstruction of extended oncological forequarter amputation defects.

Primary sarcomas of the mediastinum: results of therapy

Primary sarcomas of the mediastinum are rare, and data concerning treatment and results of therapy are sparse.

OBJECTIVE

To assess presentation, management, prognostic factors, and survival in mediastinal sarcomas.

METHODS

We reviewed our experience with 47 patients with the diagnosis of primary sarcoma of the mediastinum. Data were collected from a computerized institutional database and medical records. Survival was analyzed by Kaplan-Meier method and comparisons of survival by log rank test.

RESULTS

The median age of 47 patients with mediastinal sarcoma was 39 years (range 2.5 to 69 years), with a male/female ratio of 1.6. The most common complaints were chest/shoulder pain (38%) and dyspnea (23%). The most common tumor types were malignant peripheral nerve tumor (26%), spindle cell sarcoma (15%), leiomyosarcoma (9%), and liposarcoma (9%). Operation was the primary treatment modality in 72% of cases (n = 34); 22 sarcomas (47%) were completely resected. The overall 5-year survival was 32%. High-grade lesions had a significantly decreased survival (5-year survival = 27%) compared with low-grade tumors (5-year survival = 66%) (p = 0.05). The overwhelming factor determining survival was the ability to completely resect the tumors (5-year survival 49% for complete resection; 3-year survival 18% for incomplete or no resection) (p = 0.0016). Despite complete resection, local recurrence occurred in 64% of cases.

CONCLUSION

Because the overall survival for patients with mediastinal sarcomas is 32% and the local recurrence is 64% for tumors completely resected, aggressive adjuvant therapy should continue to be systematically explored.

Isolated lung perfusion with antineoplastic agents for pulmonary metastases

Lung metastases is a major cause of death in cancer patients. A technique of isolated lung perfusion that uses infusions of high doses of local chemotherapy was developed in an attempt to control local disease. This technique prevents systemic side effects. Animal experiments have been encouraging and human trials are pending.

Medical and surgical management of pulmonary metastases from germ cell tumors

GCT is considered a curable tumor with a greater than 90% overall long-term survival. Pulmonary metastasis is common in patients with disseminated disease. First-line therapy in the management of patients with pulmonary metastases from germ cell tumors is cisplatin-based chemotherapy. Pulmonary metastasectomy has an important adjuvant role in a subset of patients who have residual radiographic abnormalities or progression of disease despite optimal chemotherapy. Surgical resection of residual pulmonary and mediastinal disease provides an accurate response assessment and consolidates the chemotherapy by removal of any viable GCT. Therefore, surgical resection of all residual masses is indicated in patients with NSGCT and normalized serum value of tumor markers after definitive systemic chemotherapy. Surgical resection or biopsy is a reasonable alternative in residual seminoma > or = 3 cm in diameter.

Characterization of local inflammatory response in an isolated lung perfusion model

BACKGROUND

Current phase I trials of isolated lung perfusion for treatment of pulmonary metastases have an arbitrarily determined length of perfusion. Our objective was to examine the temporal course of the local and distant inflammatory response as a function of the length of perfusion (ischemia) and subsequent reperfusion in an equivalent animal model.

METHODS

Sixty male Fischer 344 rats were randomized into four groups (n = 15). Each group underwent left isolated lung perfusion with buffered Hespan for 10, 30, 60, or 90 minutes. Subsequently, two subgroups of five animals within each group were allowed to reperfuse for 1 or 3 hours, respectively. Non-perfused right lung was used as control. At each time point, lung specimens were assayed for TNF-alpha by ELISA and histologic sections were examined.

RESULTS

There was no significant difference between the left and right lung tissue levels of TNF-alpha at the termination of the ischemic period. However, on reperfusion, the left lung TNF-alpha levels increased significantly above the ischemia baseline in all groups, with a greater magnitude of rise in the groups with 60 and 90 minutes of preceding ischemia (12,757 +/- 1985 vs. 3524 +/- 494 pg/g, and 16,914 +/- 1657 vs. 6530 +/- 1104 pg/g, respectively; p < 0.05). There was no significant elevation in tissue levels of TNF-alpha in the right lung. Histologic changes consistent with early pulmonary edema were first detected at 12 hours following onset of reperfusion.

CONCLUSIONS

Reperfusion following prolonged pulmonary ischemia during isolated lung perfusion results in a significant elevation of local tissue levels of TNF-alpha and may render the perfused lung vulnerable to the adverse effects of the inflammatory cascade.

Metastatic adenocarcinoma involving a mesothelial/monocytic incidental cardiac excrescence (cardiac MICE)

Mesothelial/monocytic incidental cardiac excrescence (MICE) is a recently described, peculiar microscopic finding in the endocardium or pericardium. These lesions are characterized by a mixture of mesothelial cell clusters and histiocytes, aggregated by fibrin. They have been interpreted as reactive or even artifactual, and the importance of distinguishing these aggregations from metastatic carcinoma has been emphasized. We report a unique case of a MICE that was seeded by clusters of metastatic adenocarcinoma cells. The patient was a 38-year-old woman with no history of previous cardiac instrumentation who was found to have an adenocarcinoma of the right lung involving the hilus but apparently not invading the pericardium. At surgery, a small fragment of tissue was found floating in the pericardial cavity, and microscopic examination revealed a cluster of histiocytes, mesothelial cells and fibrin (components of usual, benign MICE) in which rare pleomorphic adenocarcinoma cells were scattered. Unlike the surrounding mesothelial cells and histiocytes, the pleomorphic cells stained for carcinoembryonic antigen, epithelial membrane antigen, and BerEP4 and focally produced intracellular mucin, confirming their malignant glandular nature. It is possible that the surrounding mesothelial cells, histiocytes, and fibrin were formed in response to invasion of the pericardial space by adenocarcinoma. This case indicates that not all lesions with the characteristic architecture of MICE can be dismissed as non-neoplastic without careful evaluation of both the cellular constituents and the clinical circumstances.

The effects of endobronchial cuff inflation on double-lumen endobronchial tube movement after lateral decubitus positioning

OBJECT

This study was designed to measure changes in tracheal and bronchial lumen distances from mainstem and secondary carina with lateral positioning, and to assess whether inflation of the endobronchial cuff before lateral positioning would further secure a double-lumen endobronchial tube (DLT) and reduce movement.

DESIGN

Prospective study.

SETTING

University-affiliated cancer center.

PARTICIPANTS

Fifty adult patients scheduled for elective thoracic surgical procedures requiring the placement of a left DLT.

INTERVENTIONS

Patients were sequentially assigned to either the endobronchial cuff-inflated group or the deflated group during lateral positioning. After induction of general anesthesia, a left polyvinylchloride (PVC) DLT was placed and the position confirmed. In the supine position, the distance from the tip of the tracheal lumen to main carina was measured using a fiberoptic bronchoscope (FOB) passed through the tracheal lumen, and the distance from the bronchial lumen to secondary carina was measured with the FOB passed through the bronchial lumen. The patients were then positioned laterally and a second set of measurements taken. Overall movement was determined by increases and decreases in tracheal and bronchial distances obtained by substracting supine values from lateral values.

MEASUREMENTS AND MAIN RESULTS

There was significant tracheal movement in 40 of 50 patients, with a mean of 0.92 +/- 1.0 cm. This was predominantly in the upward direction, as seen in 35 of 50 patients. There was significant bronchial movement in 37 of 50 patients, with a mean of 0.92 +/- 1.15 cm. Also, predominance in the upward direction was seen in 34 of 50 patients.

CONCLUSIONS

DLTs move with lateral positioning, regardless of endobronchial cuff inflation. The movement is predominantly in the upward direction. Therefore, fiberoptic visualization in the supine position should be used only to confirm that the endobronchial lumen is placed on the appropriate side and the cuff is at least 1 cm inside the left mainstem bronchus. Final positioning should always be verified in the lateral position.

Promising survival with three-dimensional conformal radiation therapy for non-small cell lung cancer

PURPOSE

Local failure is a major obstacle to the cure of locally advanced non small-cell lung cancer. Three-dimensional conformal radiation therapy (3-DCRT) selects optimal treatment parameters to increase dose to tumor and reduce normal tissue dose, potentially representing an enhancement of the therapeutic ratio of radiation therapy for lung cancer. We performed this analysis of 45 non-small cell lung cancer patients treated with 3-DCRT alone, to evaluate the ability of computer derived lung dose volume histograms to predict serious pulmonary toxicity, to assess the feasibility of this approach, and to examine the resulting survival.

METHODS

There were 28 males (62%) and 17 females (38%). The median age was 65 (range: 38-82). Tumor stage was Stage I/II in 13%, IIIa in 42%, and IIIb in 44%. The histology was squamous in 44%, adenocarcinoma in 36%, and other non-small cell histologies in the others. Only 47% of patients. had combined favorable prognostic factors (i.e. KPS < or = 80, and < or = 5% wt. loss). The median dose of radiation to gross disease was 70.2 Gy (range: 52.2-72 Gy) delivered in fractions of 1.8 Gy, 5 days per week.

RESULTS

Seven patients did not complete 3-DCRT due to disease progression outside the port. Follow-up data are mature: the median follow up of the 6 survivors is 43.5 months (35-59). Thoracic progression occurred in 46%. Median survival (all 45 patients.) is 15.7 months and survival is 32% at 2 years and 12% at 59 months. Pulmonary toxicity > or = grade 3 occurred in 9% of patients. Dose volume histograms were available in 31 patients and showed a correlation between risk of pulmonary toxicity and indices of dose to lung parenchyma. Grade 3 or higher pulmonary toxicity occurred in 38% (3/8) of patients with > 30% of lung volume receiving > or = 25 Gy, versus 4% (1/23) of patients with < or = 30% lung receiving > or = 25 Gy (P = 0.04). Grade 3 or higher pulmonary toxicity occurred in 29% (4/14) of patients with a predicted pulmonary normal tissue complication probability of 12% or higher versus 0% (0/17) in patients with a predicted probability of less than 12% (P = 0.03).

CONCLUSIONS

Despite adverse prognostic criteria median survival is encouraging and may be higher than some combined modality approaches. Dose volume histogram parameters may be useful to determine the maximum dose for individual patients and thereby permit avoidance of toxicity.

Early postoperative enteral nutrition improves peripheral protein kinetics in upper gastrointestinal cancer patients undergoing complete resection: a randomized trial

BACKGROUND

Patients with upper gastrointestinal (GI) tract malignancies are at risk for malnutrition and postoperative morbidity and mortality. We examined the protein kinetic effects of early enteral feeding in this population and compared it with results in patients receiving IV fluid.

METHODS

Twenty-nine patients undergoing resection of an upper GI tract malignancy were prospectively randomized to either enteral feeding starting on postoperative day (POD) 1 via a jejunostomy tube (FEED, n = 12) or IV fluid (IVF, n = 17). On POD5, all patients underwent a protein metabolic study using [3H]phenylalanine to determine forearm skeletal muscle (nmol phenylalanine/100 g/min) protein net balance. Free fatty acids (FFA, mEq/dL) and insulin levels (mU/mL) were measured.

RESULTS

Protein net balance was significantly less negative in the FEED group compared with the IVF group (-1.4 +/- 0.8 vs -5.0 +/- 1.4, p < .05). Respiratory quotient was significantly increased in patients receiving enteral feeding (0.85 +/- 0.02 vs 0.78 +/- 0.02 FEED vs IVF, p < .05). FFA levels were significantly decreased in the FEED group (0.36 +/- 0.04 vs 0.85 +/- 0.07, p < .05). Insulin levels were significantly elevated in the FEED group (19.8 +/- 4.5 vs 9.3 +/- 0.8, p < .05). Insulin levels correlated with amino acid fluxes.

CONCLUSIONS

Postoperative enteral nutrition in upper GI cancer patients results in an improvement in protein kinetic net balance and amino acid flux across peripheral tissue. In addition, insulin levels are elevated, and this elevation correlates with amino fluxes across the forearm. By improving peripheral protein kinetics, early postoperative enteral nutrition may potentially contribute to a decrease in postoperative morbidity and mortality in upper gastrointestinal cancer patients.

Comparison of two algorithms and their associated charges when evaluating adrenal masses in patients with malignancies

OBJECTIVE

This study was performed to compare two proposed algorithms used when evaluating an adrenal mass discovered during staging evaluation of a patient with a known malignancy. Such evaluation was meant to lead to determination of the relative charges associated with each algorithm.

SUBJECTS AND METHODS

Fifty-four patients with known malignancies who required evaluation of an adrenal mass underwent both chemical shift imaging (CSI) and CT-guided for CSI. The hospital charges incurred for each procedure and any associated complications were normalized using national relative-value scale charges and conversion factors. A decision analysis was performed to compare the relative charges that would have been incurred if adrenal MR imaging had been performed in all patients, followed by CT-guided biopsy only in those patients with MR findings not diagnostic of adrenocortical adenoma, and the relative charges incurred if only CT-guided adrenal biopsy had been performed in every patient.

RESULTS

Twenty-three (43%) of 54 adrenal masses were shown to be metastases by CT-guided biopsy. The sensitivity and specificity of CSI for the diagnosis of adrenocortical adenoma were 94% and 100%, respectively. The charges incurred by performing MR imaging as the initial examination with subsequent CT-guided biopsy only in those patients with CSI findings not diagnostic of adenoma would have been similar to those incurred by first performing CT-guided adrenal biopsy in every patient.

CONCLUSION

CSI is an accurate, noninvasive technique for evaluating adrenal masses in patients with cancer. If CT-guided biopsy is used only when CSI is not diagnostic of adrenocortical adenoma, the associated charges would be virtually the same as when CT-guided biopsy is performed as the first test in every patient. Moreover, biopsies could have been avoided in 54% of these patients.

Regression of uterine low-grade smooth-muscle tumors metastatic to the lung after oophorectomy

BACKGROUND

Metastatic uterine low-grade smooth-muscle tumors may present with pulmonary symptoms and radiographic lung abnormalities consistent with metastatic neoplasms. Ovarian hormone stimulation of these smooth-muscle tumors has been suggested, but the role of surgical or medical oophorectomy has not been established in patients with metastatic disease.

CASES

Two women with histologically confirmed uterine low-grade smooth-muscle tumors metastatic to the lung had progressive and complete tumor regression after oophorectomy and no further therapy.

CONCLUSION

Some uterine low-grade smooth-muscle tumors metastatic to the lung regress after oophorectomy. Removing ovarian hormone stimulation may result in complete tumor regression without the need for further therapy.

Glutathione metabolism in patients with non-small cell lung cancers

Non-small cell lung cancer (NSCLC) is the leading cause of cancer death in the United States. Because NSCLC is highly chemoresistant, it is, usually not treatable. Altered glutathione (GSH) metabolism is thought to be one major mechanism of chemoresistance, and GSH levels are reported to be elevated in NSCLC. The main objective of this study is to delineate the potential mechanisms involved in elevation of tissue GSH, including extraction from the circulation by NSCLC. Twenty consecutive patients with NSCLC were enrolled. At the time of lobectomy, pulmonary artery and vein were identified, and blood flow was measured by an electromagnetic probe. Subsequently, blood samples were drawn from pulmonary artery, the vein draining the tumor-bearing lobe, and a normal lobe. Immediately after lobectomy, tumor and lung specimens were snap frozen. NSCLC tumor specimens had higher levels of GSH compared with lung tissue (20.8 +/- 9.4 versus 11.6 +/- 3.0 nmol/mg protein, respectively; P < 0.05). The tumor demonstrated higher activity of the enzyme gamma-glutamyl transpeptidase, a membrane-bound enzyme involved in transmembrane uptake of GSH, than lung tissue (41.9 +/- 26.4 versus 22.4 +/- 12.3 units/mg protein, respectively; P < 0.05). Also, the tumor-bearing lobe showed elevated extraction of GSH and two of its component amino acids compared with lung tissue (GSH uptake: 0.60 +/- 0.67 versus 0.20 +/- 0.40 microM/min, respectively; P < 0.05). NSCLC tumors are able to extract circulating GSH and its constituent amino acids to synthesize intracellular GSH. Increased activity of gamma-glutamyl transpeptidase may be one mechanism underlying increased GSH uptake by NSCLC.

Regional chemotherapy via pulmonary artery with blood flow occlusion in a solitary tumor nodule model

This study is to evaluate low dose doxorubicin pulmonary artery perfusion with blood flow occlusion compared to systemic administration in a model of solitary intrapulmonary sarcoma nodule in the rat. Tumor nodule was developed via injection of methylcholanthrene-induced sarcoma into the left lung. Doxorubicin was perfused into the left pulmonary artery at a rate of 50 microliters/min for 2 min with 20 min blood flow blockage in all experiments. Pharmacokinetics, toxicity, treatment efficacy were compared between lung perfusion groups and intravenous groups. Doxorubicin levels in tumor, left lung, right lung, heart and serum were measured. Animal daily weights were recorded and a right pneumonectomy was performed following treatment to assess toxicity and tolerated perfusion dose. Tumors were weighed following treatment to evaluate treatment efficacy. Doxorubicin delivered via pulmonary artery caused a significant higher drug level in tumor tissue and perfused lung with a low drug level in heart, right lung and serum as compared to intravenous administration. Animals in perfusion groups had normal growth pattern and survived after pneumonectomy when a dose of 0.5 mg/kg doxorubicin was perfused. Tumor weight was significantly decreased after treated with 0.5 mg/kg of doxorubicin lung perfusion as compared to same dose of doxorubicin intravenous treatment. Pulmonary artery perfusion with blood flow occlusion may offer an effective lung chemotherapeutic model. 0.5 mg/kg doxorubicin for lung perfusion has acceptable local lung toxicity and no significant systemic toxicity and is pharmacokinetically and therapeutically superior to systemic administration in this solitary intrapulmonary tumor nodule model in the rat.

Management of malignant esophagorespiratory fistula

For patients with malignant esophagorespiratory fistula, four important points need to be stressed: (1) once the diagnosis is made, treatment should be instituted immediately; (2) all treatment is palliative and directed at stopping soilage of the respiratory tract; (3) the type of therapy is dictated by the performance status of the patient at presentation; and (4) esophageal bypass offers the best palliation for those able to tolerate the procedure.

Depletion of high energy phosphate compouds in the tumor-bearing state and reversal after tumor resection

BACKGROUND

Cancer cachexia is a syndrome manifested by a variety of metabolic abnormalities that include depletion of host energy stores. We studied liver and skeletal muscle high energy phosphate compounds, inorganic phosphorus (Pi), and the energy charge in tumor-bearing (TB), pair fed non-tumor-bearing (NTB), and tumor-bearing resected (RES) rats.

METHODS

F344 rats were randomized into TB (n = 13), NTB (n = 13), and RES (n = 5) groups. On day 0, the flanks of the TB and RES animals were injected with 1 x 10(7)n methylcholanthrene (MCA)-induced sarcoma cells. On day 19, TB and NTB rat liver and skeletal muscle were analyzed for adenine nucleotides, phosphocreatine, and Pi, and RES animals underwent tumor resection followed by tissue analysis 10 days later.

RESULTS

Although the liver adenylate energy charge was maintained, the level of liver adenosine monophosphate was significantly increased and the liver adenosine diphosphate level was decreased in the TB animals (3.55 +/- 0.6, 3.70 +/- 0.3 mumoles/gm dry weight, p < 0.05, p = 0.05, respectively) when compared with the NTB animals (3.06 +/- 0.4, 4.00 +/- 0.5 mumoles/gm dry weight, respectively). Muscle adenosine diphosphate levels were significantly decreased in the TB animals (1.57 +/- 0.7 mumoles/gm dry weight) as compared with NTB animals (2.23 +/- 0.7 mumoles/gm dry weight, p < 0.05). In addition, muscle adenosine triphosphate, phosphocreatine, and phosphocreatine/adenosine triphosphate ratios were significantly decreased in TB animals (19.94 +/- 4.5, 81.51 +/- 12.8, and 4.20 +/- 0.8 mumoles/gm dry weight, respectively) as compared with NTB animals (24.44 +/- 1.9, 116.72 +/- 7.5, and 4.81 +/- 0.4 mumoles/gm dry weight, respectively, p < 0.05) and RES animals (24.08 +/- 3.3, 124.10 +/- 12.2, and 5.19 +/- 0.5 mumoles/gm dry weight, respectively, p < 0.05).

CONCLUSIONS

These alterations in high energy phosphate compounds in liver and skeletal muscle indicate that although the energy charge is maintained, energy depletion occurs early in the tumor-bearing state. These changes are tumor specific, not related to anorexia, and revert to non-tumor-bearing levels after tumor resection.

Detection of circulating donor deoxyribonucleic acid by microsatellite analysis in a liver transplant recipient

The diagnosis of graft-versus-host disease following liver transplantation may be delayed because the clinical and pathological features are nonspecific. We report the use of microsatellites to support a diagnosis of GVHD in a patient who developed fever and a skin rash 28 days after liver transplantation. The pattern of microsatellite alleles amplified from the peripheral blood on day 51 posttransplant indicated that recipient and donor DNA were present in approximately equal proportions. Microsatellite typing is a simple and rapid method to identify high levels of circulating donor DNA to support a diagnosis of GVHD following liver transplantation.

Relationship of early postoperative dysrhythmias and long-term outcome after resection of non-small cell lung cancer

STUDY OBJECTIVES

To determine whether supraventricular tachydysrhythmias (SVTs) occurring early after thoracic surgery for non-small cell lung cancer (NSCLC) are associated with poor long-term survival.

DESIGN

Prospective, cohort.

SETTING

Referral cancer center.

PATIENTS

Seventy-eight patients undergoing resection of NSCLC.

INTERVENTIONS

Examination of univariate and multivariate effects of factors that might influence long-term survival: advanced age, sex, perioperative chemotherapy, extent of pulmonary resection, tumor stage, and SVT occurrence.

RESULTS

In this group of patients, 10 of 78 (13%) developed early postoperative SVT. Log-rank analysis showed SVT occurrence (p = 0.01), age of 70 years or older (p = 0.04), and perioperative chemotherapy (p = 0.005) to predict poor long-term survival. Multivariate Cox regression analysis identified SVT occurrence (p = 0.007; relative risk [RR], 2.8; 95% confidence interval [CI], 1.3 to 6.1) and perioperative chemotherapy (p = 0.004; RR, 2.6; 95% CI, 1.4 to 5.1) to be independently associated with decreased survival. No other clinical or laboratory characteristic tested differentiated those patients who did or did not develop postoperative SVT.

CONCLUSIONS

Early SVT occurrence after resection of NSCLC is associated with poor long-term survival. Although the etiology for this is unclear, this intriguing observation, not previously reported (to our knowledge), may be used in larger trials examining the effects of these and other factors on survival from lung cancer surgery.

Radiation-associated malignant tumors of the chest wall

BACKGROUND

Malignant postirradiation cancers of the chest wall are uncommon, and data concerning results of treatment are sparse. We assessed patient characteristics as well as prognostic factors of these tumors compared with those arising de novo and analyzed treatment results of both groups.

METHODS

Records of 361 patients with primary malignant tumors of the chest wall admitted to our institution between 1949 and 1989 were reviewed retrospectively. Previous radiotherapy to the site of the tumor was noted with latency period and dose. Survival was calculated via the Kaplan-Meier method, and comparisons of survival were made by log-rank analysis.

RESULTS

In 351 patients with primary malignant tumors of the chest wall, 21 lesions (6%) arose in an irradiated field. Eighty-eight patients had chondrosarcoma (age range 5-86 years, median 49; male:female [M:F] ratio 1.3:1), two cases of which arose in an irradiated field; 38 patients had osteosarcoma (age range 11-78 years, median 42; M:F ratio 1.5:1), 11 cases (29%) of which arose in an irradiated field; 149 patients had soft-tissue sarcoma (age range 1-86 years, median 38; M:F ratio 2:1) seven cases (5%) of which arose in an irradiated field; 52 patients had Ewing's sarcoma (age range 2-39 years, median 16; M:F ratio 1.6:1) no cases of which arose in an irradiated field; and 24 patients had a solitary plasmacytoma (age range 37-75 years, median 59; M:F ratio 2.4:1) one case (5%) of which arose in an irradiated field. Prior radiotherapy had been performed for Hodgkin's disease (n = 8), breast cancer (n = 5), and various other indications (n = 8). The maximum radiation dose administered ranged from 1,250 to 9,500 cGy (median 4,140). The latency period from previous irradiation to diagnosis ranged from 2 to 19 years (median 7). The primary therapy of all radiation-associated tumors was resection, except for three patients. There was no significant difference in survival between those malignant chest wall tumors arising in an irradiated field compared with those arising de novo.

CONCLUSIONS

Twenty-nine percent of patients with primary osteosarcoma and 2-5% of patients with primary chondrosarcoma, soft-tissue sarcoma, or plasmacytoma of the chest was seen at this institution have a tumor arising in the field of prior irradiation. Because the outcome after operative therapy appears to be similar, these patients should be offered identical treatment to those whose tumors arise de novo.

Simultaneous retroperitoneal, thoracic, and cervical resection of postchemotherapy residual masses in patients with metastatic nonseminomatous germ cell tumors of the testis

PURPOSE

We report our experience with simultaneous resection of residual masses above and below the diaphragm in patients with metastatic nomseminomatous germ cell tumor (NSGCT) of the testis.

MATERIALS AND METHODS

Twenty-four patients underwent simultaneous resection of residual postchemotherapy masses in the retroperitoneum and chest, including three who also had radical neck dissection. All had been heavily pretreated with chemotherapy and five had undergone previous retroperitoneal lymph node dissections (RPLNDs).

RESULTS

The combined procedure was performed with no mortality and low morbidity. The median length of the procedure was 5 hours 45 minutes, median blood loss 500 mL, and median length of hospital stay 9 days. Complications included one patient with chylous ascites and one with a prolonged air leak, both of which resolved with conservative management. Eighteen patients had similar pathologic findings in all sites: 13 with necrosis only and five with teratoma only. Six patients had discordant pathology in the abdomen and chest, including one with viable tumor in the chest only and two with viable tumor in the abdomen only. The overall actuarial 5-year survival rate for all patients was 79%.

CONCLUSION

Simultaneous resection of neck, chest, and abdominal residual masses after chemotherapy for germ cell tumors is both a feasible and safe alternative to staged excision in selected patients who require surgical intervention at multiple sites and fulfills the objective of rendering patients disease-free in a single operative procedure.

Selective glutathione repletion with oral oxothiazolidine carboxylate (OTZ) in the radiated tumor-bearing rat

Oxothiazolidine carboxylate (OTZ) is a cysteine prodrug which augments intracellular glutathione (GSH) levels. We examined the effects of oral OTZ on tumor and host tissue reduced GSH levels in fasting and radiated models of GSH depletion. In addition, we studied the tumor's ability to utilize OTZ via the enzyme, oxoprolinase. Fischer 344 rats (n = 40) were implanted with MCA sarcoma and studied at 10% tumor burden. Treatment consisted of 10 mmol/kg OTZ or buffer orally. After a 24-hr fast, 16 animals were treated and tumor, kidney, jejunal, and colonic mucosa were collected after 4 hr. Significant increases in GSH with OTZ (n = 8) vs buffer (n = 8) were seen in kidney (5.6 +/- 0.4 vs 4.3 +/- 0.9; P < 0.01), jejunum (13.8 +/- 1.3 vs 12.1 +/- 1.1; P < 0.05), and colon (6.7 +/- 1.2 vs 5.3 +/- 0.6; P < 0.05), but not tumor (8.9 +/- 2.4 vs 10.6 +/- 1.4; P = 0.12). Sixteen animals were treated 4 hr before and 18 hr following 1100 cGy of abdominal radiation and at 4 days, tumor, jejunal, and colonic mucosa were collected. Significant increases in GSH with OTZ (n = 8) vs buffer (n = 8) were noted in jejunum (9.3 +/- 1.1 vs 7.5 +/- 1.8; P < 0.05) and colon (5.6 +/- 1.1 vs 4.3 +/- 0.9; P < 0.05) but not tumor (8.4 +/- 1.6 vs 7.6 +/- 1.4; P = 0.34). To determine tissue oxoprolinase activity, tumor, kidney, liver, jejunal, and colonic mucosa were collected from 8 animals. Oxoprolinase activity was highest in the kidney (814 +/- 145) with no difference noted between liver and tumor (280 +/- 117 and 324 +/- 137, respectively). Oral OTZ selectively increases reduced GSH levels in normal tissues compared to tumor following fasting and whole abdominal radiation. This increase does not appear to be due to a differential activity of oxoprolinase. OTZ may have a role in protection against toxicity associated with oxidative injury by selective repletion of normal host tissue GSH levels.

Erythromycin stimulates gastric emptying after esophagectomy with gastric replacement: a randomized clinical trial

Delayed gastric emptying after esophagogastrectomy can pose a significant early postoperative problem. Because erythromycin, which stimulates the gastric antral and duodenal motilin receptor, has been shown to significantly increase gastric emptying in patients with diabetic gastroparesis, we decided to evaluate its effect on gastric emptying after esophagogastrectomy.

METHODS

Twenty-four patients (18 men and six women, age range 41 to 79 years, median 66 years) were randomized to receive either erythromycin lactobionate (200 mg in 50 ml normal saline solution intravenously) (n = 13) or placebo (50 ml normal saline solution intravenously (n = 11) 11 days after esophagogastrectomy (with pyloric drainage procedure). After erythromycin or placebo had been infused over a 15-minute period, patients ingested a solid meal (scrambled egg with bread) labeled with technetium 99m sulfur colloid (500 microCi) over approximately 15 minutes. Dynamic images of the stomach were then acquired over 90 minutes in the supine position by gamma imaging. Results were expressed as percentage of counts retained in the stomach (percent gastric retention) over time.

RESULTS

There were no side effects of erythromycin. In the placebo group, the mean percent of radiolabeled meal retained in the stomach after 90 minutes was 88%, which was significantly greater than in the erythromycin group, 37% (p < 0.001). In addition, analysis of covariance demonstrated that the rate of gastric emptying (slope of the line) was significantly greater in the erythromycin-treated group than in the placebo group (p < 0.0001).

CONCLUSION

Early satiety after esophagogastrectomy may be due to delayed gastric emptying and not due to a decrease in the gastric reservoir. Intravenous erythromycin significantly improves gastric emptying in patients after esophagogastrectomy by stimulating gastric motility.

Effect of human growth hormone on human pancreatic carcinoma growth, protein, and cell cycle kinetics

The role of human growth hormone (hGH) as a nutritional adjunct for cancer patients is controversial because of its potential mitogenic effects on tumor growth. No studies to date have examined the effect of hGH on human tumor response in vivo. In Vitro: Athymic mice were injected (s.c.) daily with hGH (GH, n=14) or saline (CTL, n=14). On Day 10, serum was collected and added to human pancreatic carcinoma cells in culture. In Vivo: Athymic mice were inoculated (s.c.) with human pancreatic carcinoma cells. On Day 14, mice were randomized to receive daily either hGH (GH, n=14) or saline (CTL, n=12). On Day 29, animals received [3H]phenylalanine for tissue protein fractional synthetic rate (FSR) measurement. Tumors were excised and cell cycle kinetics analyzed. Data are expressed as mean +/- SEM. Statistical analysis was performed by unpaired t test and/or ANOVA where appropriate. In Vitro: Serum from GH-treated animals had elevated IGF-1 levels (287 +/- 34 ng/ml vs 157 +/- 53 ng/ml, P<0.001) and significantly stimulated cell growth (No. cells x 10(3)/well) compared with CTL serum (925 +/- 31 vs 747 +/- 38, P<0.001). In Vivo: Serum for GH-treated animals had elevated IGF-1 levels (287 +/- 34 ng/ml vs 157 +/- 53 ng/ml, P<0.001) and significantly stimulated cell growth (No. cells x 10(3)/well) compared with CTL serum (925 +/- 31 vs 747 +/- 38, P<0.001). In Vivo: Growth hormone had no significant effect on tumor growth rate (mm3/day) (1.45 +/- 0.47 CTL vs 1.57 +/- 0.66 GH), final tumor weight (mg) (0.19 +/- 0.15 CTL vs 0.17+/- 0.06 GH), DNA Index (1.5 +/- 0.1 CTL vs 1.5 +/- 0.1 GH), percent S phase (20.3 +/- 3.3 CTL vs 22.1 +/- 3.0 GH), or tumor FSR (%/day) (51.1 +/- 17.8 CTL vs 70.2 +/- 61.1 GH). Growth hormone significantly elevated serum IGF-1 levels (ng/ml) (176 +/- 48 CTL vs 222 +/- 53 GH, P<0.005) and liver FSR (%/day) (62.8 +/- 17.8 CTL vs 79.7 +/- 12.7 GH, P<0.005). Serum of GH-treated mice increased human pancreatic cell growth in vitro. In vivo, GH administration raised serum IGF-1 levels and increased liver protein FSR, without tumor growth, cell cycle kinetics, or protein FSR.

Inferior vena cava filters in cancer patients: indications and outcome

PURPOSE

Our experience with inferior vena cava (IVC) filter placement to prevent pulmonary emboli (PE) in cancer patients with deep vein thromboses (DVT) was reviewed to identify indications, patient characteristics, complications, and long-term outcome.

METHODS

Charts of 182 patients with cancer were retrospectively analyzed. All patients had received an IVC filter in our institution between January 1980 and April 1992.

RESULTS

Of 182 patients, 103 were men and 79 were women. Median age was 59 years (range, 15 to 88). Eight patients (4%) had stage I disease, 22 patients (12%) stage II, 37 patients (20%) stage III, and 115 patients (63%) stage IV. A DVT was diagnosed in 97 patients (53%), a PE in 46 patients (25%), and a combination in 39 patients (21%). Indications for IVC filter placement were DVT or PE in the presence of contraindications to anticoagulation therapy (perioperative, n = 58; CNS metastases, n = 20; thrombocytopenia, n = 7; bleeding, n = 61; others, n = 24; total, N = 170) or anticoagulation failure (recurrent PE, n = 6; recurrent DVT; n = 6; total N = 12). Filter placement complications (n = 6, 3%) included malposition (n = 3), migration (n = 1), arrhythmia (n = 1), and wound infection (n = 1), but no deaths. After filter placement, four patients developed a recurrent PE, and 11 patients developed a recurrent DVT. No significant postthrombotic complications were observed.

CONCLUSION

IVC filter placement patients with advanced cancer and thrombotic complications is safe, well tolerated, and can offer effective therapy/prophylaxis with a low incidence of treatment failure.

Adrenal masses in patients with malignancy: prospective comparison of echo-planar, fast spin-echo, and chemical shift MR imaging

PURPOSE

To assess echo-planar, fast spin-echo (SE), and chemical shift magnetic resonance (MR) imaging in differentiation of adrenal adenomas from malignant adrenal masses in patients with known malignancy.

MATERIALS AND METHODS

Sixty-eight adrenal masses (23 malignant, 45 benign) in 68 patients with known malignancy were examined with echo-planar, fast SE with and without fat suppression, and chemical shift pulse sequences.

RESULTS

With a cutoff T2 value of 75 msec, the sensitivity of echo-planar imaging for benign lesions was 82%, and specificity was 96%. With a cutoff adrenal mass-to-spleen signal intensity ratio of 0.80, the sensitivity of fast SE imaging for benign lesions was 53%, and specificity was 96%. With a cutoff adrenal mass-to-spleen ratio of 0.55, the sensitivity of chemical shift imaging for benign lesions was 80], and specificity was 100%.

CONCLUSION

Chemical shift imaging and calculated T2 values from echo-planar imaging are promising techniques for differentiation of adrenal adenomas from malignant adrenal masses and can obviate biopsy.

Energy depletion in the liver and in isolated hepatocytes of tumor-bearing animals

Cancer cachexia has a great impact on morbidity and mortality in patients undergoing surgery. Failure to maintain lean tissue against tumor-induced hypermetabolism results in cumulative weight loss and ultimate failure of the host. Cellular free energy is among the factors that regulates metabolic pathways and may be altered in the tumor-bearing state. We studied in-vivo and in-vitro ATP levels and metabolic parameters in Fischer rats bearing a methylcholanthrene-induced sarcoma to elucidate the energy state. Tissue ATP was measured in freeze-clamped liver and muscle in 15 tumor-bearing rats (TBR) at different tumor burdens and their pair-fed controls (CTR) by bioluminescence assay. Plasma metabolites, hormones, and enzymes were determined in the same animals. Liver ATP level was lower in TBR with a 5% tumor burden: 3.07 +/- 0.56 (SE) nmole/mg tissue vs CTR: 5.33 +/- 0.60 (P < 0.05), 10% TBR: 2.48 +/- 0.54 vs CTR: 4.05 +/- 0.63 (n.s.), and 20% TBR: 1.91 +/- 0.21 vs CTR: 3.86 +/- 0.40 (P < 0.01). Muscle ATP was not different between TBR and CTR. This progressive loss of liver ATP was associated with decreased plasma insulin level (P < 0.001) and with increased alkaline phosphatase level (P < 0.01) by multiple regression. In vitro, hepatocytes were isolated from 8 TBR and 8 CTR by in-situ liver perfusion with collagenase and the cellular ATP was measured before and after 60 min incubation with glucogenic substrates. Hepatocytes from TBR decreased ATP by 42% (P < 0.05) in 10 mM lactate with higher gluconeogenesis, while control hepatocytes maintained the ATP.(ABSTRACT TRUNCATED AT 250 WORDS)