Meta-analysis of colorectal cancer follow-up after potentially curative resection

Background

After potentially curative resection of primary colorectal cancer, patients may be monitored by measurement of carcinoembryonic antigen and/or CT to detect asymptomatic metastatic disease earlier.

Methods

A systematic review and meta-analysis was conducted to find evidence for the clinical effectiveness of monitoring in advancing the diagnosis of recurrence and its effect on survival. MEDLINE (Ovid), Embase, the Cochrane Library, Web of Science and other databases were searched for randomized comparisons of increased intensity monitoring compared with a contemporary standard policy after resection of primary colorectal cancer.

Results

There were 16 randomized comparisons, 11 with published survival data. More intensive monitoring advanced the diagnosis of recurrence by a median of 10 (i.q.r. 5–24) months. In ten of 11 studies the authors reported no demonstrable difference in overall survival. Seven RCTs, published from 1995 to 2016, randomly assigned 3325 patients to a monitoring protocol made more intensive by introducing new methods or increasing the frequency of existing follow-up protocols versus less invasive monitoring. No detectable difference in overall survival was associated with more intensive monitoring protocols (hazard ratio 0·98, 95 per cent c.i. 0·87 to 1·11).

Conclusion

Based on pooled data from randomized trials published from 1995 to 2016, the anticipated survival benefit from surgical treatment resulting from earlier detection of metastases has not been achieved.

Role of adenosine deaminase and the influence of age on the diagnosis of pleural tuberculosis

OBJECTIVE

1) To determine factors affecting adenosine deaminase (ADA) levels in pleural fluid (PF), and 2) to establish the optimal ADA cut-off level for a Brazilian population.

DESIGN

ADA levels in PF of 309 patients were analysed to investigate pleural effusion. All patients were evaluated for age, sex and presence of tuberculosis (TB) based on a positive pleural biopsy. Differences in ADA levels between groups were analysed using Kruskal-Wallis one-way analysis of variance. Logistic regression analysis was also carried out to predict the occurrence of TB. ADA cut-off levels were selected using the receiver operating characteristic (ROC) curve.

RESULTS

The mean PF ADA level was significantly higher in the tuberculous pleural group than in non-tuberculous pleural patients (63.3 ± 29 IU/l vs. 19 ± 31 IU/l, P < 0.001). There was a significant correlation between PF ADA levels and age: for patients aged ⩾45 years, the ROC curve for ADA had an area under the curve of 0.91. An ADA level of 29 IU/l resulted in a sensitivity of 88.6% and specificity of 91.5%.

CONCLUSIONS

There is a significant negative correlation between PF ADA level and age. The use of a lower ADA cut-off reduces the number of false-negative results.

Pulmonary metastasectomy for colorectal cancer: long-term survival and prognostic factors

BACKGROUND

Despite the development of novel chemotherapy and biological agents, surgery is still an important option for patients with pulmonary metastases. Predictors of survival usually include disease-free interval, histology of the primary tumor, number of metastases and complete resection. The aim of this study was to report the outcomes of patients with pulmonary metastases from colorectal carcinoma submitted to surgical resection, and to identify prognostic factors that significantly affect overall survival.

METHODS

We retrospectively analyzed 120 patients with previously treated colorectal carcinoma that had developed pulmonary metastases, admitted between 1990 and 2006. Overall survival was estimated using Kaplan-Meier analysis. The log-rank and Breslow tests were used to compare survival differences for each variable. Multivariate analyses to determine the independent prognostic factors for overall survival were performed using the Cox proportional hazard model as identified by the univariate analyses.

RESULTS

The median follow-up was 20.3 months (range: 3.27-134.2 months). The patients included in this study underwent a total of 165 thoracotomies (mean of 1.37 thoracotomies/patient). The median overall survival for all patients was 34.73 months, with an estimated 5-year survival rate of 24.39%. Multivariate analyses identified unilateral lesions, neoadjuvant chemotherapy at lung resection and complete resection as independent prognostic factors for overall survival.

CONCLUSIONS

These results indicate that prognostic factors identified in studies on pulmonary metastasectomy for all primary tumors should be interpreted carefully for patients with possibility of pulmonary metastasectomy from colorectal carcinoma.

Pulmonary metastasectomy from head and neck tumors

AIM

Isolated pulmonary metastases from head and neck cancer occur in 20%-30% of patients affected by head and neck neoplasms. Surgical resection is well accepted as a standard approach to treat metastases from head and neck cancer isolated to the lungs. Many studies reported overall five-year survival ranging from 20% to 30%. The aim of this study is to determine demographics and clinical treatment-related variables associated with long-term (60-month) overall survival in patients with lung metastases undergoing pulmonary metastasectomy from head and neck tumors.

METHODS

A retrospective review was performed of patients who were admitted with lung metastases and underwent thoracotomy for resection after treatment of the primary tumor. Data were collected regarding primary tumor features, demographics, treatment, and outcome.

RESULTS

Median follow-up time of all patients was 36.4 months (range: 0-288 months). The postoperative complication rate was 14.4%, and the 30-day mortality rate was 0%. The 60-month overall survival rate for all patients was 35.5%. Multivariate analysis identified the number of nodules at CT scan, the disease-free interval, and histological type as independent prognostic factors for overall survival.

CONCLUSION

Lung metastasectomy is a safe and potentially curative procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after lung resection.

ErbB receptors and fatty acid synthase expression in aggressive head and neck squamous cell carcinomas

SUMMARY

Overexpression of ErbB receptors is frequent in head and neck squamous cell carcinomas (HNSCC) and seems to be correlated with tumor progression and metastasis. Fatty acid synthase (FASN), the key lipogenic enzyme responsible for the endogenous synthesis of fatty acids, is regulated by ErbB2 and overexpressed in several human malignancies.

METHODS

This study was performed to examine the immunohistochemical expression patterns of ErbB1, ErbB2, ErbB3, ErbB4, and FASN in a tissue microarray, containing 33 representative areas from aggressive primary HNSCC (whose patients had distant metastasis), and 21 matched lung metastasis.

RESULTS

Strong correlation among the expression of ErbB family receptors was found (ErbB1-ErbB2 P = 0.008, ErbB1-ErbB4 P = 0.018, EbB2-ErbB3 P = 0.001, ErbB2-ErbB4 P = 0.006, ErbB3-ErbB4 P=0.012) in the HNSCC. FASN expression was significantly associated with ErbB2 (P = 0.024). Lymphatic permeation was correlated with ErbB3 (P = 0.033) and histological grade with ErbB4 staining (P = 0.050). ErbB1 and ErbB2 were found mainly in patients with smoking habit (P = 0.011 and P = 0.027), and ErbB2 was associated with alcohol consumption and clinical stage (P = 0.014 and P = 0.031). Finally, FASN was overexpressed in lung metastasis, in comparison with matched HNSCC samples (P = 0.006).

CONCLUSIONS

  The results showed that high FASN immunohistochemical expression is a feature of HNSCC lung metastasis, and ErbB1-ErbB2, ErbB1-ErbB4, ErbB2-ErbB3, ErbB2-ErbB4, and ErbB3-ErbB4 expression levels are correlated in the respective primary tumors, being ErbB2 the preferred coexpression partner of all the other ErbB receptors.

High frequency of immature dendritic cells and altered in situ production of interleukin-4 and tumor necrosis factor-alpha in lung cancer

INTRODUCTION

Antigen-presenting cells, like dendritic cells (DCs) and macrophages, play a significant role in the induction of an immune response and an imbalance in the proportion of macrophages, immature and mature DCs within the tumor could affect significantly the immune response to cancer. DCs and macrophages can differentiate from monocytes, depending on the milieu, where cytokines, like interleukin (IL)-4 and granulocyte-macrophage colony-stimulating factor (GM-CSF) induce DC differentiation and tumor necrosis factor (TNF)-alpha induce DC maturation. Thus, the aim of this work was to analyze by immunohistochemistry the presence of DCs (S100+ or CD1a+), macrophages (CD68+), IL-4 and TNF-alpha within the microenvironment of primary lung carcinomas.

RESULTS

Higher frequencies of both immature DCs and macrophages were detected in the tumor-affected lung, when compared to the non-affected lung. Also, TNF-alpha-positive cells were more frequent, while IL-4-positive cells were less frequent in neoplastic tissues. This decreased frequency of mature DCs within the tumor was further confirmed by the lower frequency of CD14-CD80+ cells in cell suspensions obtained from the same lung tissues analyzed by flow cytometry.

CONCLUSION

These data are discussed and interpreted as the result of an environment that does not oppose monocyte differentiation into DCs, but that could impair DC maturation, thus affecting the induction of effective immune responses against the tumor.

Expression of a dendritic cell maturation marker CD83 on tumor cells from lung cancer patients and several human tumor cell lines: is there a biological meaning behind it?

The present paper shows, for the first time, the membrane expression of the dendritic cell maturation marker CD83 on tumor cells from lung cancer patients. CD83 was also detected on freshly cultured fibroblast-like cells from these tissues and on several adherent human tumor cell lines (lung adenocarcinomas P9, A459 and A549, melanomas A375 and C81-61, breast adenocarcinomas SKBR-3 and MCF-7 and colon carcinoma AR42-J), but not in the non-adherent MOT leukemia cell line. CD83 may have immunosuppressive properties and its expression by cancer cells could have a role in facilitating tumor growth.

Management of neuroendocrine tumors: a meeting of experts from Latin America

A panel of experts from Latin America convened in Brazil, in May of 2007, for consensus recommendations regarding the management of neuroendocrine tumors (NETs) of the gastrointestinal tract and pancreas. The recently introduced World Health Organization classification of NETs represents a step forward, but the former classification of carcinoids into foregut, midgut and hindgut is still likely to be useful in the near future. Macroscopic description of the tumor should be followed by light microscopic examination and immunohistochemical staining, whereas other techniques might not be widely available in Latin America. Surgery remains the mainstay of treatment for patients with potentially curable tumors, and adequate selection is paramount in order to optimize treatment results. Regarding systemic therapy, patients with well-differentiated tumors or islet-cell carcinomas may be categorized as having indolent disease, while patients with poorly differentiated, anaplastic, and small-cell carcinomas, or with atypical carcinoids, may be approached initially as having aggressive disease. Somatostatin analogues play a cytostatic role in indolent tumors, and chemotherapy may play a role against other, more aggressive NETs. Obviously, there is an urgent need for novel therapies that are effective against NETs.

In vitro breast cancer cell lethality of Brazilian plant extracts

In this study we screened the cytotoxicity of 1220 plant extracts obtained from 351 plants belonging to 74 families occurring in the Amazon and Atlantic rain forests against MCF-7 human breast adenocarcinoma cell lines. All extracts were tested at a dose of 100 microg/mL. Only 11 aqueous or organic extracts belonging to the Annonaceae, Apocynaceae, Araceae, Clusiaceae, Flacourtiaceae, Leguminosae, Olacaceae and Violaceae showed marked lethal activity. Vismia guianensis and Annona hypoglauca extracts showed the greatest lethal activity.

Osteosarcoma pulmonary metastasis: Prognostic factors of 88 patients submitted to surgical resection

20502

Background: Pulmonary metastasis from Osteosarcoma occurs in 30% to 40% of cases. Chemotherapy and surgical resection are the current preferred options for these patients, although overall outcome remains poor, with few patients achieving long term overall survival. Prognostic factors for better selecting these patients are needed. Methods: We reviewed the survival and the prognostic factors from 88 consecutive patients with pulmonary metastasis from osteosarcoma, submitted to metastasectomy at a single institution. Clinical and demographic variables, related to the primary tumor as well as to the pulmonary metastases and treatment procedures were registered. Univariate ( Log-rank and Breslow tests) and multivariate analysis (Cox-regression) were performed to identify significant prognostic factors related to overall survival. Results: Median follow-up time was 34 months, and 12.5% were alive without disease, 14.8% were alive with disease, 58% were dead of disease, 1,1% were dead from other causes, and 14.8% were lost to follow-up. The overall 5- year survival was 19%. Disease free interval (DFI), number of thoracotomies and complete resection at last thoracotomy were significant prognostic factors at univariate analysis. Median survival from first thoracotomy for patients with DFI = 12 months was 24.6 months, compared to 9.6 months for DFI < 12 months (p= 0.0014). Complete resection at last thoracotomy significantly improved median overall survival (19.1 versus 9.6 months) (p=0.0117). Cox-regression analysis showed only disease free interval more than 12 months (p=0.014) and complete resection at last thoracotomy (p=0.003) to be independent significant prognostic factors. Sex, age, site and stage of primary tumor, number of lung nodules, bilateral nodules, and chemotherapy treatment for lung metastases did not significantly impact on survival. Conclusion: Disease free interval and complete resection at last thoracotomy are significant prognostic factors for patients with resected pulmonary metastasis from osteosarcoma.

No significant financial relationships to disclose.

In vitro prostate cancer cell growth inhibition by Brazilian plant extracts

In the present study, 1220 plant extracts obtained from 352 plants belonging to 73 families that grow in the Amazon and Atlantic rain forests were screened for cytotoxicity against PC-3 prostate cancer cell lines. Extracts were tested in the single dose of 100 microg/mL. Activity was observed in 17 aqueous or organic extracts belonging to Annonaceae, Apocynaceae, Araceae, Capparaceae, Commelinaceae, Flacourtiaceae, Lecythidaceae, Leguminosae, Passifloraceae, Rutaceae, and Violaceae.

Response to chemotherapy in patients with lung metastases: how many nodules should be measured?

Objective: With the introduction of cross-sectional imaging methods the number of lesions per patient that can be evaluated is frequently large and most oncologists and study protocols use only one lesion or a few ‘representative’ lesions to evaluate chemotherapy response. Intra-patient response variability can therefore affect evaluation reproducibility. This study evaluates intra-individual variation in response to chemotherapy in patients with multiple lung metastases. Methods: We prospectively studied chest CT images of patients with solid tumors and pulmonary metastases under systemic chemotherapy being evaluated for tumor response. The response of 566 pulmonary nodules in 41 evaluations was determined by both WHO and RECIST criteria in order to determine intra-individual tumor response variation. Results: There was almost perfect agreement between the WHO and the RECIST criteria for the evaluation of tumor response. High intra-individual variability of tumor response was observed in a significant proportion of the evaluations. A new nodule was the main criterion for determination of disease progression. A mean of 35% of the total number of nodules of a patient have a response evaluation different from that calculated with all the nodules together. Conclusions: Intra-individual variation in tumor response of pulmonary metastases is elevated in some patients. Selecting any or some nodules for response evaluation could significantly influence therapeutic response perception.

Analysis of the toxic potential of Palicourea corymbifera (Müll. Arg.) Standl. in laboratory animals

Palicourea species may produce bovine toxicity. Palicourea corymbifera grows in terra firme forests within the Amazon rain forest and in Tropical America, particularly in spots that gave place to gazing areas. The lyophilized extract done with the aerial organs of P. corymbifera were analyzed in male and female mice. Results revealed a significant toxicity: LD50 was 1.10 (1.04-1.15)g/kg for male mice, and 1.05 (1.00-1.10)g/kg for female mice. Locomotion was affected as well as there were reflexes linked to environmental stimuli in addition to changes in posture. Progressive central nervous system stimulus signs such as trembling and convulsions were detected, the latter followed by the animal's death. Macroscopic histopathological exams performed on the liver, kidneys and lungs of mice submitted to necropsy did not indicate the existence of lesions. General activity of animals, measured in an open field, was reduced as a result of the administration of the extract. Duration of locomotion and rearing frequency were reduced, in opposition to an increase in the duration of immobility. Thin layer chromatography analysis showed that monofluoroacetic acid is present in the lyophilized extract, but other qualitative techniques as gas chromatography/mass spectrometry and 19F nuclear magnetic resonance showed that the MFAA was not present in the extract, and that the toxicity is related to other compound, although the toxic profile is very similar to that of MFAA. P. corymbifera was shown to be significantly toxic to laboratory animals and investigation of the possible toxic substance shall be done.

Screening of antibacterial extracts from plants native to the Brazilian Amazon Rain Forest and Atlantic Forest

More than 20% of the world's biodiversity is located in Brazilian forests and only a few plant extracts have been evaluated for potential antibacterial activity. In the present study, 705 organic and aqueous extracts of plants obtained from different Amazon Rain Forest and Atlantic Forest plants were screened for antibacterial activity at 100 microg/ml, using a microdilution broth assay against Staphylococcus aureus, Enterococcus faecalis, Pseudomonas aeruginosa and Escherichia coli. One extract, VO581, was active against S. aureus (minimum inhibitory concentration (MIC)=140 microg/ml and minimal bactericidal concentration (MBC)=160 microg/ml, organic extract obtained from stems) and two extracts were active against E. faecalis, SM053 (MIC=80 microg/ml and MBC=90 microg/ml, organic extract obtained from aerial parts), and MY841 (MIC=30 microg/ml and MBC=50 microg/ml, organic extract obtained from stems). The most active fractions are being fractionated to identify their active substances. Higher concentrations of other extracts are currently being evaluated against the same microorganisms.

Chemotherapy versus best supportive care in stage IV non-small cell lung cancer, non metastatic to the brain

Stage IV non-small cell lung cancer is a fatal disease, with a median survival of 14 months. Systemic chemotherapy is the most common approach. However the impact in overall survival and quality of life still a controversy.

OBJECTIVES

To determine differences in overall survival and quality of life among patients with stage IV non-small cell lung cancer non-metastatic to the brain treated with best supportive care versus systemic chemotherapy.

PATIENTS

From February 1990 through December 1995, 78 eligible patients were admitted with the diagnosis of stage IV non-small cell lung cancer. Patients were divided in 2 groups: Group A (n=31 - treated with best supportive care ), and Group B (n=47 - treated with systemic chemotherapy).

RESULTS

The median survival time was 23 weeks (range 5 - 153 weeks) in Group A and 55 weeks (range 7.4 - 213 weeks) in Group B (p=0.0018). In both groups, the incidence of admission for IV antibiotics and need of blood transfusions were similar. Patients receiving systemic chemotherapy were also stratified into those receiving mytomycin, vinblastin, and cisplatinum, n=25 and those receiving other combination regimens (platinum derivatives associated with other drugs, n=22). Patients receiving mytomycin, vinblastin, and cisplatinum, n=25 had a higher incidence of febrile neutropenia and had their cycles delayed for longer periods of time than the other group. These patients also had a shorter median survival time (51 versus 66 weeks, p=0.005).

CONCLUSION

In patients with stage IV non-small cell lung cancer, non-metastatic to the brain, chemotherapy significantly increases survival compared with best supportive care.

Pathophysiology of cancer cachexia

Cancer cachexia is a frequent complication observed in patients with malignant tumors. Although several decades have passed since the first focus on the metabolic dysfunction's associated with cancer, few effective therapeutic interventions have been successfully introduced into the medical armamentarium. The present study thoroughly reviews the basic pathophysiology of cancer cachexia and the treatment options already investigated in that field. Experimental and clinical studies were evaluated individually in order to clarify the intricate alterations observed in tumor-bearing patients. The difficulties in introducing sound and effective nutritional support or metabolic manipulation to reverse cancer cachexia are outlined in this review.

Stereological estimates of nuclear star volume and vessels as predictors of chemotherapy response in small cell carcinoma of the lung: a preliminary report

AIMS

This study was designed to evaluate the role of morphometric and clinical parameters in predicting chemotherapy responder patients with small cell carcinoma of the lung.

METHODS AND RESULTS

Morphometric studies were performed by means of point counting techniques. Forty-six patients were included in this study. Group 1 patients (n = 19) were those without response to chemotherapy; Group 2 (n = 27) was composed by patients with partial or complete response to chemotherapy. Logistic regression analysis was used to attain the best separation of non-responder from responder patients. Star volume of the nuclei and vessel were selected during the backward procedure as relevant variables to characterize the two groups of patients. The overall sensitivity of the model was 80.43%.

CONCLUSIONS

Our results indicate that histopathological data may help to predict the chemotherapy response in patients with small cell lung carcinoma, and encourage the use of morphometric procedures in histopathological analysis of this type of lung tumours.

Prevention of neoplastic port site implants in laparoscopy: an experimental study

Enthusiasm about the application of videolaparoscopy to oncologic diseases has been limited by the growing number of port site implants. Adult Wistar rats were submitted to 6-7 mm Hg carbonic gas pneumoperitoneum. Rats were randomly divided into two groups: group I rats with tumor (200,000 viable cells of Walker tumor) and group 11 rats with no tumor. The pneumoperitoneum was deflated after 30 min. Group I was further randomized into five groups: no treatment; or abdominal irrigation with saline, heparin, chemotherapy (doxorubicin), or chemotherapy associated with heparin. After a period lasting no more than 18 days, the abdominal wall and intraperitoneal organs macroscopically affected were studied histologically. Chemotherapy groups had no port site implants and were significantly different (p < 0.05) than the no treatment, saline, and heparin solution groups, which had incisional implants at frequencies of 100%, 85.7%, and 82.5%, respectively. Intraperitoneal irrigation with chemotherapy solution was effective in preventing incisional implants in this animal model.

Follow-up in lung cancer: how often and for what purpose?

OBJECTIVES

The present study evaluates the cost-effectiveness of two follow-up routines: a strict follow-up with frequent visits, imaging, and laboratory examinations was compared to a follow-up with infrequent visits that were scheduled mainly on the basis of the patient's symptoms.

METHODS

A retrospective evaluation was undertaken of 130 patients who underwent a complete resection of non-small cell lung cancer (NSCLC). All patients had complete follow-up for at least 2 years after their operation. The patients were separated into two groups: strict (n = 67), with a routine follow-up policy; and symptom (n = 63), seen on a symptom-oriented basis. The costs of the follow-up routines and the yield of each schedule were compared between the two groups.

RESULTS

There were no significant differences in the disease-free interval until the first detection of recurrence. In most patients, metastatic diseases were diagnosed on the basis of symptoms, rather than by routine tests. The patients who had recurrent cancer diagnosed after surgery had a dismal survival rate irrespective of the follow-up schedule. The majority of patients with recurrence died of malignancy within a 2-year period. The costs of strict vs symptom follow-up were significantly different, because of the greater number of routine imaging procedures performed in patients having strict follow-up. On the other hand, when we analyzed only the frequency of hospitalization and the cost per day of hospital treatment for medical problems other than cancer recurrence, the patients in the strict group had a less expensive follow-up than the patients in the symptom group.

CONCLUSIONS

The present study showed that a more cost-effective routine follow-up scheme should be advised for patients with completely resected NSCLC, without affecting overall outcome. Routine imaging follow-up is of questionable value, and it may be indicated only in academic settings.

[Surgical removal of pulmonary metastasis: prospective study in 182 patients]

PURPOSE

The present study evaluates the results of surgical treatment of lung metastases, as well as attempts to identify subgroups of patients who would benefit the most from the operation.

CASE AND METHODS

This is a prospective analysis of patients with history of neoplasia, submitted to resection of pulmonary nodules, with the diagnosis or suspicion of metastases. The 182 patients were operated upon through a lateral thoracotomy.

RESULTS

The patients submitted to pulmonary resection for suspected metastases showed no malignant tissue in 34 patients (18.6%), and in six patients (3.2%) were diagnosed a second lung primary tumor. Overall survival of the patients was 28% at 56 months, and disease-free survival was 9%. Multivariate analysis showed that disease free interval (p = 0.002), complete resection (p = 0.039), and number of malignant nodules resected (p = 0.016) significantly affected overall survival. Disease-free survival was affected only by complete resection (p = 0.0001) and number of malignant nodules resected (p = 0.004).

CONCLUSION

Resection of pulmonary metastasis improve survival in a selected group of patients. More studies are necessary to define the value of other therapies in the results of survival in resected pulmonary metastasis.

Use of pentastarch solution in the treatment of patients with hemorrhagic hypovolemia: randomized phase II study in the emergency room

This study evaluates the hemodynamic effects of the administration of 10% pentastarch solution (PS) during the initial treatment of hypovolemia in trauma patients. This prospective randomized phase II study included trauma patients admitted to the emergency room with hemorrhagic hypovolemia: systolic blood pressure (SBP) < 90 mmHg. Upon admission, the patients were randomized to receive 10% PS (n = 12) or isotonic 0.9% NaCl solution (IS) (n = 11), infused intravenously in 250-ml boluses, repeated until SBP > 100 mmHg. Blood pressure, infused volumes necessary to maintain SBP, and overall survival rates were determined and compared between groups. SBP increased significantly following either IS (from 64.4 +/- 9.2 mmHg to 111.1 +/- 6.3 mmHg), or PS (from 63.7 +/- 10.6 mmHg to 108.1 +/- 9.8 mmHg) when compared to admission values (p < 0.05). Endovenous volumes infused were greater (p = 0.001) in IS patients (1420 +/- 298 ml) than in PS patients (356 +/- 64 ml). No blood was transfused into PS patients, compared to 370 +/- 140 ml of red blood cells transfused into IS patients (p = 0.015). Mortality rates were similar in the two groups (p = 0.725). We concluded that PS is a safe, efficient method for inducing hemodynamic recovery of hypovolemic trauma patients, with a clear reduction in the intravenous volumes required for acute resuscitation.

Surgical treatment of lung metastases of head and neck tumors

BACKGROUND

Head and neck tumors often spread to the lungs, with a variety of presentations. The ideal treatment for those patients is still controversial. Resection of lung metastases was shown to significantly influence overall survival of patients.

OBJECTIVE

To evaluate results of surgical resection of lung nodules in patients with head and neck primary tumors.

METHODS

A retrospective analysis was made of 53 patients with head and neck tumors and lung nodules (no other metastases detected in other organs) admitted to our department. They were separated into two groups: OPER (thoracotomy, n = 26), and NOTOPER (no thoracotomies, n = 27). Overall survival was compared (Kaplan-Meier, log-rank) between groups.

RESULTS

Overall median survival of all patients was 10 months, of OPER 20 months, and of NOTOPER 6 months (P <0.0001). Complete resection (n = 19) of lung metastases was associated with the greatest survival rate (median 23 months). Patients submitted to incomplete resection (n = 7) had a median survival of 16 months, compared with 7 months for patients who received only chemotherapy (n = 7) and 4 months for patients (n = 20) with no treatment (P <0.0001).

CONCLUSION

Resection of lung metastases offers a significant survival benefit for patients with head and neck primary tumors, when compared with the current chemotherapeutic regimens. It should be considered for all patients clinically fit and who present with no extrapulmonary disease.

Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies

BACKGROUND

Individual trials of small-volume resuscitation of 7.5% NaCl (HS) with and without 6% dextran 70 (HSD) for the treatment of trauma have failed to provide convincing evidence of efficacy. We performed a meta-analysis to evaluate the effects of HS and HSD on survival until discharge or for 30 days. We identified eight double-blinded, randomized controlled trials of HSD and six trials of HS. In all cases, administration of 250 ml of HSD or HS was compared with a control group administration of 250 ml of isotonic crystalloid for the treatment of hypotension either in the field or at admission to the emergency department.

METHODS

A fixed-effects meta-analysis was performed with the Mantel-Haenszel method of combining results from multiple studies.

RESULTS

Overall, HS was not effective in improving survival with a weighted mean difference in survival of the HS group versus the isotonic control group equal to 0.6%. The results with HSD were more positive, with an increase in survival in seven of eight trials. The mean difference in survival rates favoring HSD (n = 615) over controls (n = 618) was 3.5% (p = 0.14, two-tailed; p = 0.07, one-tailed). The odds ratio was estimated to be 1.20 in favor of HSD with a 95% confidence interval of 0.94 to 1.57.

CONCLUSIONS

The meta-analysis of the available data shows that HS is not different from the standard of care and that HSD may be superior.

Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and hypotension

BACKGROUND

Resuscitation with hypertonic saline/dextran (HSD) has been suggested to be efficacious in patients who have traumatic brain injury and are hypotensive. We undertook a cohort analysis of individual patient data from previous prospective randomized double-blinded trials to evaluate improvements in survival at 24 hours and discharge after initial treatment with HSD in patients who had traumatic brain injury (head region Abbreviated Injury Score > or = 4) and hypotension (systolic blood pressure < or = 90 mm Hg).

METHODS

All variables and end points were defined before initiation of data handling. Investigators were blind as to the treatment. Case report forms were received from six studies. Of these, 223 patients met the inclusion for traumatic brain injury. Comparisons between HSD and standard of care were made using stratified analysis and logistic regression to assess efficacy, confounding, and interaction. Potential confounding variables of pre-fluid treatment, Glasgow Coma Scale score (3-8 vs. 9-15), injury type, and systolic blood pressure can be considered a priori factors that were known before randomization. Effects of the various trials was also considered.

RESULTS

Treatment with HSD resulted in a survival until discharge of 37.9% (39 of 103) compared with 26.9% (32 of 119) with standard of care (p = 0.080). Using logistic regression, adjusting for trial and potential confounding variables, the treatment effect can be summarized by the odds ratio of 2.12 (p = 0.048) for survival until discharge.

CONCLUSIONS

Patients who have traumatic brain injuries in the presence of hypotension and receive HSD are about twice as likely to survive as those who receive standard of care.

Prognostic factors to predict outcome following the administration of hypertonic/hyperoncotic solution in hypovolemic patients

Hypertonic solutions effectively improve hemodynamic parameters in patients admitted to the emergency room. However, no significant differences in outcome were observed compared with standard isotonic treatment in most previously published studies. This study evaluates pretreatment prognostic factors that predict a beneficial effect of hypertonic solution in patients admitted to the emergency room with hemorrhagic hypovolemia in a prospective double-blind fashion. The patients (n = 212) were randomized upon admission to receive 250 mL intravenous (i.v.) bolus of hypertonic 7.5% NaCl + 6% dextran (HSD, n = 101), or isotonic 0.9% NaCl solutions (IS, n = 111) as the first treatment, followed by standard resuscitation. Pretreatment factors assessed were sex, age, cause of hypovolemia, revised trauma score (RTS), Glasgow index, and mean arterial pressure (MAP) on admission. Both groups were compared for survival at 24 h and 30 days postadmission. Infused volumes were registered. HSD administration significantly increased MAP and reduced i.v. crystalloid infusions to maintain hemodynamic parameters, compared with IS. There was no difference between groups in the number of blood transfusions administered. Overall complication rates in both groups were similar (24%). There was a significant difference (p < .03) in overall (30 days) survival rate between HSD (73%) and IS (64%) groups. The 24 h survival rate was significantly lower in IS (72%) compared with HSD (87%); p < .01. Multivariate analyses showed that RTS and MAP were identified as independent predictors for 24 h survival in the group that received HSD. When evaluated for overall survival rate, hypertonic infusion benefited significantly only patients with MAP < 70 mmHg (p < .01).

Morphometric evaluation of argyrophilic nucleolar organizer region is useful in predicting long-term survival in squamous cell carcinoma of the lung

Nucleolar organizer regions identified by means of an argyrophilic technique (AgNOR) were quantified by digital image analysis in 81 patients with squamous cell carcinoma of the lung. Survival rate was modeled as function of AgNOR expression by Cox regression models controlled for staging, histologic grade, age, and sex. Our results indicate that AgNOR expression has a significant prognostic role. Tumors at lower stages have a lower expression of AgNOR than those with more advanced disease. Tumors with high histopathologic grade have a higher expression of AgNOR. Patients with low AgNOR expression presented a higher survival rate than those with higher amounts of AgNOR. The foregoing results strongly encourage the development of prospective trials to assess the real role of AgNOR in determining prognosis in squamous cell carcinoma of the lung.

Usefulness of morphometric evaluation of histopathologic slides in predicting long-term outcome of patients with squamous cell carcinoma of the lung. A preliminary report

The present work was designed to evaluate the role of morphometric parameters in contributing to establish prognosis in 35 patients who underwent surgical resection of squamous cell carcinoma (SCC) of the lung. Morphometric studies were performed by means of point counting techniques. Patients considered as disease-free survivors, ie, those without tumor recurrence for more than 60 months (n = 6), were designated as DOWELL, whereas the remaining 29 patients comprised the DOBAD group. In order to characterize DOWELL patients, multivariate models combining numeric and categoric variables were constructed considering numeric variables (age and morphometric parameters) or indexes for categoric data such as stage, and presence of residual tumor. Staging, incomplete tumor resection, and nucleus-cytoplasm ratio were selected by the model as significantly associated with survival. In addition, nuclear volume contributed (although nonsignificantly per se) to further refine the model by increasing its r value. Our results indicate that histopathologic data, when evaluated quantitatively, could predict prognosis in patients with SCC, together with staging and clinical data and encourage the use of morphometric procedures in the histopathologic analysis of SCC.

The effect of prolonged hyperglycemia on metabolic alterations in the subtotally pancreatectomized rat

A delayed onset of diabetes is characteristic of subtotally pancreatectomized patients in whom persistent hyperglycemia per se is documented to lead to the development of insulin resistance. This study was conducted to elucidate the metabolic alterations seen during transition of the acute to chronic phase after subtotal pancreatectomy (SP). Eight male Sprague-Dawley rats were studied 2 weeks after surgery in the acute phase, and the other eight at 4 weeks in the chronic phase. Phosphoenolpyruvate carboxykinase (PEPck) for gluconeogenesis and the malic enzyme for de novo fatty acid synthesis in the liver showed a reciprocal change, the former activity being increased, while the latter was suppressed. Both alterations were more pronounced in the chronic phase. In the acute phase, lipoprotein lipase (LPL) for triglyceride clearance decreased in the adipose tissue, while that in the cardiac and skeletal muscle became significantly elevated. The latter elevations were decreased in the chronic phase. Sustained hyperglycemia in the SP rats not only increased the changes in PEPck and malic enzyme activities but reversed the tissue-specific muscle LPL elevations. These changes might help to explain the wasting condition seen in surgically induced diabetic patients.

Nuclear/cytoplasmic ratio correlates strongly with survival in non-disseminated neuroendocrine carcinoma of the lung

In order to verify whether quantitative morphological indices of neuroendocrine carcinoma of the lung may help to predict survival, 47 biopsies (from 37 males and 10 females; 16-82 years of age) were studied by light microscopy. Areal fractions of nuclei, cytoplasm, stroma, and blood vessels were determined using a standard point counting method. The counts were made in six non-coincident microscopic fields in each case, and the areal fractions of nuclei, of the entire tumour cell, stroma, blood vessels and the nuclear/cytoplasmic ratio were computed. In a multivariate linear regression analysis, survival in months after biopsy was considered the dependent variable of age and of all morphometric parameters listed above. The significance level was set at 5%. For all patients (disregarding staging) survival was negatively correlated (P < 0.001, multiple r = 0.5435) with age and nuclear/cytoplasmic ratio. When only patients with disease confined to the thorax (stages I, II and III) were taken into account, the accuracy of the function predicting survival increased considerably (P = 0.004, multiple r = 0.7957). The use of simple stereological methods, therefore, proved to be of value in predicting survival in patients with neuroendocrine carcinomas of the lung.

Hypertonic solutions in the treatment of hypovolemic shock: a prospective, randomized study in patients admitted to the emergency room

BACKGROUND

The infusion of small volumes of hypertonic saline solution or hypertonic saline plus dextran 70 is remarkably effective in restoring adequate hemodynamic conditions after hypovolemic shock. This prospective double-blind study compares the immediate hemodynamic effects of a bolus infusion of 7.5% NaCl or 7.5% NaCl plus 6% dextran 70 (both 2400 mOsm/L) in severe hypovolemia.

METHODS

One hundred five adult patients admitted in hypovolemic shock (systolic blood pressure less than 80 mm Hg) were revived on arrival to the emergency room and administration of a 250 ml intravenous bolus of hypertonic saline solution (n = 35), hypertonic saline plus dextran (n = 35), or isotonic saline solution (n = 35). This infusion was immediately followed by standard crystalloid and blood replacement until systolic pressure reached 100 mm Hg. Mean arterial pressure (MAP) was measured every 5 minutes, and all intravenous infusions were registered. Plasma volume expansion was calculated from plasma protein concentration measurements. Patients were followed up throughout their hospital course, and results of treatment were recorded.

RESULTS

At the end of the infusion period, and 5 and 10 minutes after infusion, MAP was significantly higher in patients receiving either hypertonic solution, compared with the group receiving isotonic solution. All groups showed similar trends toward restoration of hemodynamic parameters thereafter. The calculated plasma volume expansion, immediately after the bolus infusion, was significantly higher (24.1% +/- 1.8% and 24.9% +/- 1.1%) in the hypertonic groups, compared with isotonic groups (7.9% +/- 1.3%). Significantly greater volumes of fluids were required to restore systolic pressure in the patients receiving isotonic saline solution than in the groups receiving hypertonic solution. There were no significant differences between the groups receiving hypertonic solutions. The incidence of complications was low, and the mortality rate was similar in all groups.

CONCLUSIONS

Infusion of 250 ml hypertonic saline solution in patients with severe hypovolemia was not related to any complications, nor did it affect mortality rates; it improved MAP significantly, acutely expanded plasma volume by 24%, and reduced significantly the volumes of crystalloids and blood required in their resuscitation.

Respiratory system mechanics in patients treated with isotonic or hypertonic NaCl solutions

Twenty-one patients who underwent elective surgery for coronary artery bypass were studied right after chest wall closure. They were anesthetized, paralyzed, and artificially ventilated with a constant-flow ventilator. Airflow, changes in lung volume, and tracheal pressure were measured. Respiratory system resistance (Rrs,max) was partitioned into its homogeneous (Rrs,min) and uneven (Rrs,u) components. Respiratory system elastance (Ers) was also measured. The subjects were randomly divided into two groups injected with test solutions just after chest wall closure: eleven patients received isotonic saline (0.9% NaCl solution), whereas the remaining ten were injected with hypertonic saline (7.5% NaCl solution). In all patients, mechanical parameters were measured at six different times: just before infusion, at 5 and 10 min (end of infusion); and at 15, 20, and 25 min after beginning of injection. No statistically significant differences were observed in respiratory system mechanical parameters between groups or between different times within each group. Our data suggest that hypertonic saline infusion does not result in significant changes in respiratory system mechanics in patients submitted to coronary artery bypass.

Organ blood flow in Fischer-344 rats bearing MCA-induced sarcoma

Although blood flow is central to systemic metabolism, little is known about the effect of tumor on the perfusion of host tissues. This study evaluated the effects of a methylcholanthrene-induced sarcoma on blood flow to intra-abdominal organs and skeletal muscle of Fischer-344 rats anesthetized with pentobarbital sodium. Animals were studied by aortic injection of radiolabeled microspheres when the tumors reached 20% of body weight. Total-organ arterial flows in spleen, liver, small intestine, and pancreas were each increased to 50-150% in tumor bearers relative to controls (P less than 0.05). Portal venous flow and flow per gram to hindlimb muscle were 60 +/- 20 and 300 +/- 100% greater, respectively, in tumor-bearing animals (P less than 0.005). This study shows that tumor growth can be associated with large changes in organ flow and distribution of cardiac output. The increase in skeletal muscle flow in the tumor bearers, which lost normal tissue weight relative to pair-fed controls (P less than 0.05), is in marked contrast to decreased muscle flow previously observed in simple starvation.

The hemodynamic response to hemorrhage in tumor-bearing animals

Tumor-bearing rats submitted to hypovolemia have higher mortality rates than have non-tumor-bearing control rats. To determine the mechanisms underlying this sensitivity to hemorrhage, we studied Fischer-344 rats with subcutaneous methylcholanthrene-induced sarcoma (tumor burden, 10% body weight) to determine hematologic and blood volume alterations. Subsequently we used the same animal model in an unanesthetized condition to determine the sensitivity to hemorrhage and resuscitation, as well as vascular responsiveness to vasoactive agents. The rats were separated into two groups: control and tumor-bearing rats (TBR). Sensitivity to hemorrhage and resuscitation was determined by bleeding the conscious rats (15 ml/kg) and resuscitating them with 0.9% NaCl (45 ml/kg). Vascular responsiveness was determined after injection of varying doses of phenylephrine and nitroglycerin, with continuous measurement of mean arterial pressure (MAP). Rate of increase of MAP, maximum MAP, relative increase in MAP (maximum minus baseline), rate of recovery toward baseline MAP, and duration of the response were determined. There was a significant anemia in TBR, but blood volume was similar in both groups. Baseline MAP was significantly higher in control rats (125.3 +/- 8.1 mm Hg) compared with TBR (107.5 +/- 6.0 mm Hg). After hemorrhage, MAP in TBR reached significantly lower levels than in control rats. In addition, after saline resuscitation, MAP in TBR did not return to baseline levels, whereas MAP in control rats returned to prehemorrhage MAP. With nitroglycerin, MAP decreased to lower levels in TBR than in control rats. With phenylephrine, the maximum MAP reached was significantly higher, and the response to phenylephrine was maintained for a significantly longer period in control rats compared with TBR. We conclude that TBR are more sensitive to hypovolemic events in association with decreased oxygen-carrying capacity, profound hypotension, and altered overall vascular responsiveness to sympathetic stimuli.

The influence of intraoperative hypotension and perioperative blood transfusion on disease-free survival in patients with complete resection of colorectal liver metastases

An increased interest in surgical treatment of liver metastases from colorectal origin has evolved recently. However not all patients benefit from this approach, with early recurrence and death still being encountered. To evaluate clinical as well as perioperative factors that might significantly affect the outcome of patients with completely resected colorectal liver metastases, we examined 116 patients who underwent resection between September 1987 and August 1989. Median follow-up time was 13.2 months (0.6 to 31.4 months). The overall survival rate was 91% at 1 year and 75% at 2 years. Median survival was not reached. Median disease-free survival time was 11.5 months, with 49.4% and 21.2% of the patients being free of disease at 1 and 2 years, respectively. By univariate analysis, site of primary colorectal cancer, preoperative carcinoembryonic antigen (CEA) level, size of metastases, number of metastases, length of operation time, percentage mean arterial pressure, number of hypotensive episodes, duration of hypotensive episodes, and whole blood transfusion significantly affected recurrence rate following resection. However only site of primary tumor, CEA, number of metastases, and number of hypotensive episodes remained significant in the multivariate analysis. The most significant single factor that affected recurrence rate was the number of hypotensive episodes during the operative procedure. It is concluded that hypotensive episodes, even when well controlled, should be avoided during operation to maximize the chances of cure and prolong disease-free survival of patients with colorectal liver metastases.

Effects of hypovolemia and transfusion on tumor growth in MCA-tumor-bearing rats

Pretransplant blood transfusion has been shown to significantly affect the outcome of renal transplantation. Evidence regarding the association of blood transfusions with growth or recurrence of solid tumors is still conflicting both in clinical and in experimental studies, although diminished survival has been suggested in several studies. To determine the influence of blood transfusions and hypovolemia, as separate or combined factors, on tumor growth, we evaluated the weight of a subcutaneously implanted sarcoma (methylcholanthrene-induced) in 35 rats. After reaching 1% tumor burden (day 0), the animals were separated into two groups: hypovolemia (shed volume, 15 ml/kg) or normovolemia. These groups were further divided according to resuscitation: OO (no resuscitation), BL (receiving syngeneic blood stored in citrate phosphate dextrose for 4 days, 15 ml/kg), SL (receiving 0.9% sodium chloride, 45 ml/kg). Tumor dimensions were determined daily by external measurement, and tumor weight was calculated. Hypovolemia exerted a significant influence on tumor growth, independent of the resuscitation modality. The rats that received blood transfusions showed an increased rate of tumor growth, compared to the animals that received saline solution or no treatment. No interaction was noted between the effects produced by hypovolemia and blood transfusion. We conclude that the hypovolemic event enhanced tumor growth independently of the resuscitation, and transfusion of citrate phosphate dextrose-blood stored for 4 days did influence tumor growth in this model. We suggest that the effect of blood transfusion in patients with cancer has to be redefined to account for the influence of possible hypovolemic events.

Tumor-induced alterations in tissue lipoprotein lipase activity and mRNA levels

To elucidate the mechanisms of hypertriglyceridemia observed in the tumor-bearing rat, tissue lipoprotein lipase (LPL) activity and LPL mRNA levels were examined in the fed and fasted states at different degrees of tumor burden and after tumor removal. LPL activity in the epididymal fat pad and cardiac muscle in the 24-h-fasted rats was significantly decreased with increasing tumor burden (r = -0.53, P less than 0.05 and r = -0.72, P less than 0.01, respectively). Tumor removal completely reversed these changes. In contrast, no change in LPL activity was detected in the fed state since food intake stimulated LPL activity to the same extent in both tumor-bearing (TBR) and control rats. LPL activity in the diaphragm and skeletal muscle was only marginally altered in TBR, as compared to controls. LPL mRNA from the epididymal fat pad and cardiac muscle migrated to the same site on agarose gel and hybridized to a LPL-specific complementary DNA probe. The decline in LPL activity in epididymal fat pad observed in TBR was associated with a decrease in LPL mRNA levels. In contrast, there was no significant difference in LPL mRNA levels in cardiac muscle between the two groups despite significantly suppressed enzyme activity in tumor bearers. This study provides evidence that hypertriglyceridemia in TBR is due in part to tumor-dependent suppression of adipose and cardiac LPL activity in the fasted state, which is stimulated by the presence of tumor. Unlike cardiac LPL, the tumor-induced changes in adipose LPL activity are regulated at the mRNA level in this tumor model.

Metabolic alterations in obstructive jaundice: effect of duration of jaundice and bile-duct decompression

We examined the effect of prolonged bile duct obstruction, and subsequent biliary decompression, on biochemical and metabolic parameters, using a reversible jaundice model in male Fischer 344 rats. The animals were studied after biliary obstruction for varying periods (4 days, one week, and two weeks) and following decompression. They were sacrificed one or two weeks following decompression. All the rats were compared to sham operated, pair-fed, controls. Obstructive jaundice rapidly increased bilirubin, liver enzymes, serum free fatty acid, and triglyceride levels. Glucose levels were significantly decreased in the jaundice rats compared to their pair-fed controls. Only after two weeks of jaundice was significant hypoalbuminemia observed. Following decompression, all biochemical and metabolic values gradually returned to normal levels, except for albumin. Hypoalbuminemia was not reversed within the two-week post-decompression period. The rats jaundiced for two weeks had significantly higher mortality, compared to the other groups. We conclude that prolonged jaundice adversely affects the metabolic capacity of the rats, with albumin concentration being markedly decreased, and that biliary decompression could not reverse completely all the alterations seen with cholestasis, especially following two weeks of bile duct obstruction.

Axillary dissection in melanoma. Prognostic variables in node-positive patients

We evaluated the importance of 14 clinical and pathologic variables as determinants of prognosis in patients with malignant melanoma and positive regional lymph nodes at axillary dissection. The records of 197 patients operated on between 1974 and 1984 were reviewed. Univariate analysis indicated as prognostically significant the number (p less than 0.001) and percentage (p less than 0.001) of positive nodes, highest nodal status (p less than 0.001), macroscopic or microscopic nodal metastases (p = 0.002), presence or absence of extranodal disease (p = 0.003), clinical stage (III versus less than III, p = 0.015), and site (considered as trunk versus other locations, p = 0.02). However, by multivariate analysis, only three variables were shown to be independent determinants of survival: percentage of positive nodes (p = 0.004), presence or absence of extranodal disease (p = 0.012), and site (trunk versus other locations, p = 0.019). Combining these three variables, subsets of patients with markedly different prognoses could be generated. It is possible to predict a favorable outcome for patients with less than 10% positive nodes, no extranodal disease, and a primary lesion at a site other than the trunk. It is also possible to recognize that the prognosis is very poor for patients with extranodal disease and truncal primary lesions, regardless of the percentage of positive lymph nodes. Finally it was verified that the prognosis is always unfavorable when the percentage of positive lymph nodes is very high.

Respiratory system mechanics in guinea pigs after acute hemorrhage: role of adrenergic stimulation

We evaluated the effects of acute blood loss on the respiratory mechanics of guinea pigs. We measured respiratory system elastance (Ers) and resistance (Rrsmax) using the end-inflation occlusion method. Rrsmax was partitioned into its homogeneous component (Rrsmin) and that due to the unevenness within the respiratory system (Rrsu). Respiratory mechanics were studied both before and immediately after bleeding in eight animals. Another eight guinea pigs had received propranolol previously and were also submitted to hemorrhage. Propranolol-treated animals showed higher control values of Rrsmax (p less than .02) and Rrsmin (p less than .0001). Animals not treated with propranolol exhibited a decrease (p less than 0.001) in Rrsmax after hemorrhagic hypovolemia (from 0.375 +/- 0.051 to 0.323 +/- 0.042 cm H2O/ml.sec), due to a decrease (p less than 0.005) in Rrsmin (from 0.140 +/- 0.031 to 0.094 +/- 0.032 cm H2O/ml.sec), whereas Ers and Rrsu did not change. Propranolol-treated animals showed an increase (p less than .001) in Rrsmax (from 0.512 +/- 0.133 to 0.664 +/- 0.144 cm H2O/ml.sec), Rrsu (p less than 0.01) from 0.252 +/- 0.09 to 0.345 +/- 0.139 cm H2O/ml.sec, and Ers (p less than 0.001) (from 4.565 +/- 0.933 to 5.402 +/- 1.24 cm H2O/ml) after bleeding. The results indicate that the immediate effects of acute bleeding on respiratory mechanics are significantly influenced by catecholamines.

Lipid kinetic alterations in tumor-bearing rats: reversal by tumor excision

Cancer cachexia is frequently accompanied by hyperlipidemia. To identify the mechanisms underlying this alteration in lipid metabolism, free fatty acid (FFA) and very low density lipoprotein-associated triacylglycerol (VLDL-TG) kinetics were determined in tumor-bearing (subcutaneously implanted methylcholanthrene-induced sarcoma) Fischer 344 rats. The animals were studied after chronic vascular catheterization, in an unanesthetized, undisturbed state, after 24 hr of fasting. They were separated into three groups: control (n = 5), tumor-bearing (n = 5, tumor burden = 10% body weight), and 7 days after tumor excision (n = 5). VLDL-TG and FFA kinetics were assessed by a constant infusion of [3H]palmitate-labeled VLDL-TG and [14C]palmitate bound to albumin, respectively. FFA rate of appearance (FFA-Ra) and clearance (FFA-Cl) and VLDL-TG rate of appearance (VLDL-TG-Ra) and clearance (VLDL-TG-Cl) were determined at steady state. We observed that the tumor-bearing rats had significantly increased FFA-Ra and VLDL-TG-Ra, decreased VLDL-CL, and maintained FFA-Cl, when compared to control. These alterations returned to normal levels after tumor excision. The results suggest that the hyperlipidemia observed in tumor-bearing rats is due to elevated lipolysis rate, maintained rate of plasma FFA clearance, increased triacylglycerol production and VLDL secretion by the liver, and decreased VLDL-TG clearance from plasma. These alterations were reversed 7 days following tumor excision.

Hypovolemic shock resuscitation with hyperosmotic 7.5% NaCl: effects on respiratory system mechanics

The infusion of the hypertonic 7.5% NaCl solution stimulates the afferent vagal innervation of the lungs. In order to verify if this reflex elicits any respiratory mechanical alterations, normovolemic (n = 18) and hypovolemic (n = 18) (20 ml of shed blood/kg) guinea pigs were studied. The animals were assigned to groups of nine receiving either isotonic 0.9% NaCl or hypertonic 7.5% NaCl solutions (4 ml/kg body weight). Passive respiratory system elastance (Ers) and the maximal value of the resistance (Rrsmax) were measured. The latter was further partitioned into its minimal value (Rrsu) using the constant flow inflation method. Ers, Rrsmax, Rrsmin, and Rrsu were measured before and at 0, 2, 5, 10, and 15 minutes following the infusion. The results showed that both isotonic and hypertonic solutions, at the given volume rate, caused no significant alterations of respiratory mechanics in normovolemic and hypovolemic animals.

The role of lung innervation in the hemodynamic response to hypertonic sodium chloride solutions in hemorrhagic shock

The role of pulmonary innervation in the genesis of hemodynamic responses to hypertonic salt solutions was assessed in an animal model of total lung denervation by total division of the pulmonary hilum followed by reimplantation of the organ. This was performed in 10 mongrel dogs (weighing 12 to 20 kg) randomly assigned to two groups: group I (five dogs) was comprised of animals with catheters placed in the pulmonary artery of the denervated lung; group II (five dogs) was comprised of animals with catheters placed in the pulmonary artery of the intact lung; a control group (group III) (five dogs) was submitted to a sham thoracotomy with catheters inserted in either pulmonary artery. On the seventh postoperative day the mean arterial pressure (MAP) was monitored and severe hemorrhagic shock (MAP = 40 mm Hg) was produced in all animals. After 30 minutes of shock the shed blood was discarded and 5% of the shed volume (+/- 2 ml/kg) was infused through the pulmonary catheter in the form of a hypertonic NaCl solution (2400 mosm/L). MAP continued to be measured for the 30 minutes following the infusion period. A significant rise of MAP was uniformly observed in animals of groups II and III. In group I low elevations of MAP were observed during the infusion period, followed by a return to shock levels on discontinuation of the infusion. The results suggest that selective lung denervation abolished the beneficial cardiovascular effects of hypertonic NaCl infusion during resuscitation from severe hemorrhagic shock without affecting the plasma osmolality pattern.

The effect of major trauma on the pathways of thyroid hormone metabolism

In order to evaluate the effects of severe trauma on the levels of thyroxine (T4), 3,3',5-triiodothyronine (T3), and 3,3',5'-triiodothyronine (reverse-T3, r-T3), blood samples were collected from traumatized patients on the first post-trauma day. The plasma concentrations of T3 were significantly decreased (mean, 47.4 ng/dl); T4 levels were in the normal range (mean, 6.6 mcg/dl) and r-T3 levels were significantly elevated (mean, 80.8 ng/dl). The oxygen extraction by the muscular tissue was also determined in these patients and found to be elevated; however, no correlation could be established between the extraction ratios and the thyroid hormone levels. This deviation in the peripheral conversion of T4 into r-T3 with a decreased production of T3 also accompanies severe systemic illnesses and probably represents a form of T4 inactivation conditioned by the metabolic demands of the body. This alternate pathway of thyroid hormone metabolism is enhanced by elevated blood levels of catecholamines, glucose, or glucocorticoids as well as by decreased insulin plasma concentrations, all known to follow major trauma and other catabolic conditions.