Radiological and endoscopic imaging methods in the management of cystic pancreatic neoplasms

The management of cystic pancreatic neoplasm (CPN) is a clinical dilemma because of its clinical presentations and malignant potential. Surgery is the best treatment choice ; however, pancreatic surgery still has high complication rates, even in experienced centers. Imaging methods have a definitive role in the management of CPN and computed tomography, magnetic resonance imaging, and endoscopic ultrasonography are the preferred methods since they can reveal the suspicious features for malignancy. Therefore, radiologists, gastroenterologists, endoscopists, and surgeons should be aware of the common features of CPN, its discrete presentations on imaging methods, and the limitations of these modalities in the management of the disease. This study aims to review the radiological and endoscopic imaging methods used for the management of CPN.

Rare cystic liver lesions: A diagnostic and managing challenge

Cystic formations within the liver are a frequent finding among populations. Besides the common cystic lesions, like simple liver cysts, rare cystic liver lesions like cystadenocarcinoma should also be considered in the differential diagnosis. Thorough knowledge of each entity’s nature and course are key elements to successful treatment. Detailed search in PubMed, Cochrane Database, and international published literature regarding rare cystic liver lesions was carried out. In our research are included not only primary rare lesions like cystadenoma, hydatid cyst, and polycystic liver disease, but also secondary ones like metastasis from gastrointestinal stromal tumors lesions. Up-to date knowledge regarding diagnosis and management of rare cystic liver lesions is provided. A diagnostic and therapeutic algorithm is also proposed. The need for a multidisciplinary approach by a team including radiologists and surgeons familiar with liver cystic entities, diagnostic tools, and treatment modalities is stressed. Patients with cystic liver lesions must be carefully evaluated by a multidisciplinary team, in order to receive the most appropriate treatment, since many cystic liver lesions have a malignant potential and evolution.

Evaluation of hepatic cystic lesions

Hepatic cysts are increasingly found as a mere coincidence on abdominal imaging techniques, such as ultrasonography (USG), computed tomography (CT) and magnetic resonance imaging (MRI). These cysts often present a diagnostic challenge. Therefore, we performed a review of the recent literature and developed an evidence-based diagnostic algorithm to guide clinicians in characterising these lesions. Simple cysts are the most common cystic liver disease, and diagnosis is based on typical USG characteristics. Serodiagnostic tests and microbubble contrast-enhanced ultrasound (CEUS) are invaluable in differentiating complicated cysts, echinococcosis and cystadenoma/cystadenocarcinoma when USG, CT and MRI show ambiguous findings. Therefore, serodiagnostic tests and CEUS reduce the need for invasive procedures. Polycystic liver disease (PLD) is arbitrarily defined as the presence of > 20 liver cysts and can present as two distinct genetic disorders: autosomal dominant polycystic kidney disease (ADPKD) and autosomal dominant polycystic liver disease (PCLD). Although genetic testing for ADPKD and PCLD is possible, it is rarely performed because it does not affect the therapeutic management of PLD. USG screening of the liver and both kidneys combined with extensive family history taking are the cornerstone of diagnostic decision making in PLD. In conclusion, an amalgamation of these recent advances results in a diagnostic algorithm that facilitates evidence-based clinical decision making.

Cystadenocarcinoma of the appendix: an incidental perioperatory finding in a patient with adenocarcinoma of the ascending and sigmoid colon: case report and review of literature

BACKGROUND

Primary adenocarcinomas of the appendix are uncommon, constituting 1% of all colorectal malignancies. Appendiceal malignancies often present atypically, thus creating diagnostic challenges. Although there are many pathology reports of primary cystadenocarcinoma of the appendix, only a limited number of cases have appeared in the radiological or surgical literature. We present a unique case of primary cystadenocarcinoma of the appendix occurring concurrently with adenocarcinoma of the colon, and overview the clinical and therapeutic difficulties posed by this rare entity.

CASE PRESENTATION

A mucocele of the appendix, due to mucinous cystadenocarcinoma, was documented as an incidental perioperatory finding in a 68-year-old female. The patient was admitted due to rectal haemorrhage and underwent colonoscopy with biopsy, X-ray, abdominal ultrasonography and CT scan. Degenerated adenomatous polyp of the ascending colon and mucinous adenocarcinoma of the sigmoid colon invading the parietal peritoneum of the uterine and vagina was diagnosed. At laparoscopy, a cystic appendiceal lesion was found, without perforation. The patient underwent right hemicolectomy, sigmoidectomy and hysterectomy associated with salpingo-oophrectomy.

CONCLUSIONS

Preoperative diagnosis of an underlying malignancy in a mucocele is important for patient management, but is difficult to reach by imaging studies alone. Synchronous colon cancer may occur in patients with appendiceal mucoceles. In such patients, the colon should be investigated. Surgery is the recommended method of treatment.

Cystic neoplasms of the exocrine pancreas

The increasing use of radiological imaging has led to greater detection of small and asymptomatic cystic lesions of the pancreas. Most are resectable, but not all are neoplastic. This review provides an update on the histopathology, immunohistochemistry, molecular biology, pathogenesis and management of cystic neoplasms of the exocrine pancreas. These include the serous, the mucinous cystic, the intraductal papillary mucinous and the solid pseudopapillary neoplasms. Recently reported variants are described and very rare cystic variants of other pancreatic epithelial and mesenchymal neoplasms are briefly mentioned.

Presentation and management of pancreatic cystic neoplasms

Pancreatic cystic neoplasms are less frequent than other pancreatic tumors, but because of the wide availability and improvement of modern imaging methods, these neoplasms are being recognized with increasing frequency and it is often possible to be differentiated preoperatively not only from other cystic pancreatic disorders but also from one another. Most patients have no symptoms while clinical signs are not really useful in the clinical work up, and when they are present, they never help us to identify the type of pathology. Treatment differs with the diagnosis. Serous cystic neoplasms are uniformly benign and usually do not mandate resection unless this lesion is symptomatic. In contrast, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have a premalignant or malignant tendency, and therefore should be managed aggressively by pancreatic resection; in the absence of invasive disease, prognosis is excellent after appropriate surgery, but the presence of invasive malignancy signifies a poor prognosis. Solid pseudopapillary neoplasms have nonaggressive behavior and their management is related to the extension of the disease. The purpose of this article is to review the types of pancreatic cystic neoplasms, their diagnosis, indications for surgical treatment, and outcome.

Multilocular cystadenoma and cystadenocarcinoma of the prostate

BACKGROUND

Multicystic prostatic tumors are rare, with only a few reported cases of prostatic cystadenoma and cystadenocarcinoma in the scientific literature.

METHODS

A retrospective review of our tumor registry over the last 25 years identified 2 rare cystic tumors of the prostate: 1 multilocular cystadenoma and 1 multilocular cystadenocarcinoma.

RESULTS

The first case illustrates the clinical and pathologic features of prostatic multilocular cystadenoma. A 42-year-old man presented with a 16-cm suprapubic mass causing displacement of adjacent visceral organs. Pathologic examination after prostatectomy confirmed it to be a multilocular cystadenoma of the prostate. The patient's postoperative course was uneventful, and his serum prostate-specific antigen level remained at < or =0.04 ng/ml throughout the course of his disease. In the second case, we present an 80-year-old male presenting with a 12-cm cystic mass of the prostate. His serum prostate-specific antigen level remained at > or =9.0 ng/ml throughout the course of his disease. The tumor had an aggressive local growth pattern, with invasion into perirectal adipose tissue. This patient underwent a pelvic exenteration, followed by adjuvant systemic chemotherapy and complete androgen blockade. Despite aggressive treatment, he had 3 recurrences over 4 months but remains alive with disease at 23-month follow-up.

CONCLUSIONS

Cystadenocarcinoma of the prostate is locally aggressive and should be included in the differential diagnosis of cystic lesions of the prostate.

[Two cases of primary peritoneal cystadenocarcinoma--diagnosis, treatment, and clinical feature]

Primary peritoneal adenocarcinoma is rare, originating in the paramesonephric duct (müllerian duct). We report two cases of primary peritoneal adenocarcinoma. Both patients received a surgical resection. The pathological diagnosis of the resected specimen was papillary adenocarcinoma with clear cell carcinoma. The response after the combination chemotherapy using CDDP and TS-1 was "PR", and these treatments were effective to improve the patients' quality of life in each case.

Improved survival with clinical guidelines? Evaluation of a quality register linked to clinical guidelines for ovarian cancer in the western health care region in Sweden between 1 September 1993 and 1 June 1998

BACKGROUND

New clinical guidelines (CGs) for ovarian cancer in the western health care region in Sweden were established, beginning in September 1993 and still in effect.

METHODS

A retrospective evaluation of 5 years of quality registration linked to CGs for ovarian cancer in this region was undertaken. The study material comprised 718 patients. Relative survival rates for the studied patients were compared with National Cancer Register data for the western health care region during the same period. The National Cancer Register data were also used to compare survival rate during the studied period and the preceding 5-year period.

RESULTS

Relative 5-year survival rate in our material was 46.1%. Relative survival in western Sweden during the studied period was found to be improved compared with that during the preceding period (P<0.02).

CONCLUSIONS

The CGs have led to an improved, tighter organization, with fewer clinicians in special 'tumor teams' performing more aggressive tumor reduction surgery. Chemotherapy prescription is centralized, while the actual administration is decentralized. This has probably been important for the good 5-year survival results.

Is there a role for chemoradiation in the management of cystadenocarcinoma of the pancreas?

Despite a paucity of data, cystadenocarcinoma of the pancreas has been considered to be resistant to chemoradiation, with a limited effect similar to that of the more common pancreatic adenocarcinoma. We describe a case of a partially excised cystadenocarcinoma with a positive surgical margin that was treated by neoadjuvant chemoradiation. No epithelial elements were found on histologic examination after reresection. Three previous cases of dramatic response of pancreatic cystadenocarcinoma to chemoradiation have been described in the literature. The current dogma alleging poor response of pancreatic cystadenocarcinoma to chemoradiation may be in error.

[Cerebellar metastasis from ovarian carcinoma. A case report]

This report presents an unusual case of 40-year-old woman with complete locoregional remission of ovarian carcinoma, presented with a single cerebellar metastasis. Surgical excision of the cerebellar lesion, followed by brain irradiation, resulted in complete resolution of her symptoms.

[Clinical presentation, differential diagnosis and treatment of lacrimal gland tumours]

PURPOSE

We describe the tumours occurring in the lacrimal gland fossa region, the important symptoms and the principles of the therapy.

METHODS

We surveyed the patients observed and operated at the National Institute of Neurosurgery, Budapest, Hungary.

RESULTS

Space-occupying lesions of lacrimal gland fossa are: 1. Epithelial lacrimal gland tumours, which may be benign or malignant (benign pleomorphic adenoma, malignant pleomorphic adenocarcinoma, adenoid cystic carcinoma, other carcinomas). 2. Lymphoproliferative tumours (lymphoma, leukaemia, Hodgkin's disease, lymphosarcoma, plasmocytoma). 3. Pseudotumours (chronic inflammation, granuloma, sarcoidosis, reactive lymphoid hyperplasia). 4. Other tumours (dermoid cyst, haemangioma, neurinoma, haemangiopericytoma, metastatic tumour). In our Institute, 42% of the tumours of the lacrimal fossa was epithelial, 50% was lymphoid or pseudotumour, and 8% other tumours. Of the 59 primary epithelial tumours 62.7% was benign and 37.3% was malignant. The differential diagnosis and management are based on the clinical presentations, imaging studies and histological examination.

CONCLUSIONS

Pleomorphic adenomas of the lacrimal gland should be diagnosed on radiological and clinical evidence, and biopsy avoided to prevent the recurrences and malignant transformation. The prognosis of pleomorphic adenomas depends on the early diagnosis and radical surgical excision of the lesion. In cases of suspected malignant epithelial tumours, lymphomas and pseudotumours, biopsy is indicated for the choice of appropriate treatment.

Bilateral metastatic breast cancer as the first manifestation of ovarian cancer: case report

BACKGROUND

Breast metastasis from primary ovarian cancer is extremely rare. The rarity of this finding may be the reason for its common misinterpretation as primary breast carcinoma.

DESIGN

Case report.

SETTING

A university hospital.

RESULTS

A case of a patient with primary ovarian papillary serous cystadenocarcinoma who initially presented with a solitary bilateral breast mass and abdominal distention is reported.

CONCLUSIONS

Blood-borne metastasis from the ovary to the breast can show a varied clinical picture that should be differentiated from that of primary breast carcinoma.

Advanced ovarian carcinoma as a chronic disease: a case report and review

Epithelial ovarian cancer is the fifth most common visceral malignancy in U.S. women, with the highest incidence in the sixth decade. There are often no early manifestations. Approximately 70% of patients present with advanced disease. Transvaginal ultrasonography is the single most useful test in the evaluation of a suspected pelvic mass. Treatment is based on the stage of the disease at presentation. Surgery is the mainstay of treatment. Chemotherapy is important in controlling residual disease following cytoreductive surgery and as neoadjuvant therapy in patients with advanced disease. The standard chemotherapy for advanced ovarian cancer is currently paclitaxel-carboplatin or paclitaxel-cisplatin. We present a patient who had an unusually prolonged survival after receiving ifosfamide-based combination chemotherapy. The data from the Sioux Valley Hospital USD Medical Center Cancer Registry also suggests that ifosfamide-based combination chemotherapy prolongs survival in patients with advanced ovarian cancer.

[Ovarian epithelial carcinoma--a malignant disease sparing no age group]

INTRODUCTION

Ovarian epithelial carcinoma is one of the most common gynecologic malignancies and the fifth most frequent cause of cancer death in women. Ovarian cancer affects women 65 years of age and older more frequently than younger women.

MATERIAL AND METHODS

Four young patients with ovarian epithelial carcinoma were treated at the Institute of Oncology in Sremska Kamenica, Serbia and Montenegro, in the period 1981-2000. The median age at diagnosis was 17.3 years. Final histopathological findings revealed cystadenocarcinoma, either mucinous or serous. The stage of the disease was established using International Federation of Gynecology-Obstetrics (FIGO) Calssification. Spread of the disease dictated the extent of operation and post-operative chemotherapy. Patients were strictly followed-up at the Institute.

RESULTS

The first two patients underwent unilateral adnexectomy as initial treatment. Final histopathological examination revealed an epithelial ovarian carcinoma, stage IIIa and IIb. Total hysterectomy with unilateral adnexectomy and total omentectomy were performed in both patients as second treatment with chemotherapy, according to the Cisplatin/Carboplatin and Cyclophos-phamide (CP) protocol following surgery. Another two patients underwent total hysterectomy with bilateral adnexectomy and total omentectomy as initial treatment with chemotherapy, CP protocol, following surgery. Both patients had stage IIc. Despite treatment, in two patients with stage IIIa and IIc, metastases were diagnosed. In 2 patients survival was over five years. One patient lived less than 3 years, and one less than 4 years.

DISCUSSION

Ovarian carcinomas are difficult to diagnose at early stage. Histologic confirmation of the diagnosis, surgical staging, and aggressive surgical debulking, when possible, are all part of the initial evaluation and treatment. In most cases, surgery is followed by chemotherapy. The risk increases from 15.7 to 54 per 100,000 in the age group 40-79 years. Our study included 4 patients, medium age 17.3, with epithelial ovarian carcinoma which warns us to think twice when we get an adolescent patient with an adnexal mass.

CONCLUSION

Advancing age, the major risk factor for development of ovarian carcinoma is, of course, unalterable. We investigated 4 patients medium age 17.3 years, with epithelial ovarian carcinoma. Pelvic masses found in women of reproductive age, must also be evaluated preoperatively to determine the probability of malignancy.

Intraoperative placement of a self-retaining Foley catheter for continuous drainage of malignant ascites

Malignant ascites in advanced cancer is usually treated by repeated paracentesis, causing both discomfort and inconvenience to patients in the terminal stages of disease. We present a case of advanced ovarian carcinoma in which intraoperative placement of a Foley's self-retaining catheter into the peritoneal cavity was used to facilitate long-term continuous drainage of malignant ascites. This is a simple, convenient and cost-effective method which decreases the need for repeated hospital admissions. The aim complication might be peritonitis, but with proper care of the device and the use of antibiotics, this was not seen in our patient.

Lung cancer in pregnancy: case reports and review of the literature

Lung cancer diagnosed in pregnancy is rare. The number of reported cases has been escalating in recent years, probably reflecting the increasing number of women of reproductive age who smoke. This review presents three cases of lung cancer in pregnancy with different manifestations and outcomes, with a review of the literature. Physicians should have a low threshold using different diagnostic tools for investigating unusual symptoms during pregnancy without fear for fetal safety. Once diagnosed, lung cancer represents a major ethical and medical dilemma. The optimal management of lung cancer in pregnancy is not known, because of the rarity of the cases reported during pregnancy and insufficient follow-up data.

Serous tumors involving extra-abdominal/extra-pelvic sites after the diagnosis of an ovarian serous neoplasm of low malignant potential

The involvement of extra-abdominal/extra-pelvic sites by serous tumors after the diagnosis of an ovarian serous neoplasm of low malignant potential is extremely rare. In this study we present the clinicopathologic features of 12 such cases seen at our institution during a period of 19 years (1980-1999). The patients' age ranged from 19 to 50 years (mean 33 years). By FIGO staging the original ovarian tumors were distributed as follows: stage I, 4; stage II, 2; stage III, 5; unknown stage, 1. All patients were treated surgically. Ten patients also received adjuvant therapy (radiotherapy, 2; chemotherapy and radiotherapy, 4; chemotherapy, 3; intraperitoneal 32P, 1). The interval between the diagnosis of the ovarian neoplasm and the subsequent tumor involving an extra-abdominal/extra-pelvic site ranged from 4 to 240 months (mean 124 months). Sites of extra-abdominal/extra-pelvic involvement and the number of cases were as follows: left neck lymph nodes (LNs), 4; left and right neck LNs, 1; pleura, 2; lung, 1; mediastinum, 1; chest wall, 1; axillary and chest LNs, 1; and vertebral body, 1. Eight patients were treated with chemotherapy, 1 with radiotherapy, 2 with chemotherapy and radiotherapy, and 1 with surgery alone. Follow-up ranging from 5 months to 18 years was available in 11 patients. Six patients died of disease and 5 patients were alive with no evidence of disease. In this small series of cases, no definitive clinical or pathologic feature related to the occurrence of extra-abdominal/extra-pelvic serous tumors was found. Based on the LN involvement and the endosalpingiosis seen in some cases, these tumors might develop from circulating neoplastic serous cells or from areas of endosalpingiosis involving extra-abdominal/extra-pelvic sites.

Treatment options for other hepatic malignancies

1. Resection rates for cholangiocarcinoma (unrelated to primary sclerosing cholangitis) have increased to 54% to 79%, and the subsequent 5-year survival rates are 24% to 31%. 2. Multimodality approaches involving various combinations of chemotherapy, irradiation, and surgery increasingly are being used to treat cholangiocarcinoma. 3. The role of liver transplantation in the management of cholangiocarcinoma is limited by the perception that it is inappropriate to use scarce organs when 5-year survival rates are 25%. 4. Liver transplantation is an important intervention in patients with tumors that remain unresectable after chemotherapy. The role of liver transplantation in patients with extrahepatic disease that responds to chemotherapy is controversial. Careful timing of surgery is required to avoid secondary drug resistance. 5. Liver transplantation has been successfully applied to a range of rare hepatic malignancies, but small numbers preclude strong recommendations on the appropriateness of this practice.

High-dose melphalan-based chemotherapy and autologous stem cell transplantation after second look laparotomy in patients with chemosensitive advanced ovarian carcinoma: long-term results

The importance of dose intensity has been suggested in ovarian carcinoma. We retrospectively evaluated the long-term results of melphalan-based high-dose chemotherapy (HDC) with hematopoietic rescue in a unicentric series of 33 patients with advanced ovarian cancer sensitive to first-line chemotherapy. Before HDC, treatment with debulking surgery and platinum-based chemotherapy was followed by second-look operation (SLO). HDC consisted of melphalan (n = 8), melphalan and cyclophosphamide (n = 9), or melphalan, etoposide and carboplatinum (n = 16). Toxicity was mainly hematological. One death occurred from infection during aplasia. With a median follow-up of 60 months after intensification, the 5-year progression-free survival (PFS) rate was 29% and the 5-year overall survival (OS) rate was 45%. Survival differed significantly according to tumor status at SLO. Women with microscopic or macroscopic disease at SLO, ie with a pathological partial response to first-line therapy (PPR), had survivals of 7% at 5 years, similar to other salvage therapies. Better results were obtained in the 20 women with a complete pathological response (PCR) at SLO with 43% 5-year PFS (median, 51 months) and 75% 5-year OS (median not reached). In conclusion, melphalan-based HDC with hematopoietic rescue had an acceptable toxicity in patients with chemosensitive advanced ovarian cancer. In situations of salvage therapy for patients in PPR, this treatment was not effective in long-term analysis. On the contrary, long-term results were favorable in patients with PCR, suggesting further prospective randomized studies comparing HDC and other consolidation treatments should be undertaken in this particular situation.

Combined hepatocellular and cystadenocarcinoma presenting as a giant cyst of the liver--a case report

Primary cystic lesions of the liver are very rare. Most of the solid tumours are hepatocellular carcinomas (HCC) with a smaller number being cholangiocarcinomas. The association of HCC with other primary liver malignancies is also extremely rare. This case report is about a 27 year old male patient who presented with a giant cystic lesion of the left liver. A CT scan showed a cystic lesion with internal septations and a thrombus in the main portal vein. The patient underwent an extended left hepatectomy and a portal venotomy with removal of the thrombus. Coexistent hepatocellular and cystadenocarcinoma were reported on histopathological examination. The patient was put on 5-FU postoperatively. He is doing well 11 months after surgery.

Role of vascular endothelial growth factor in ovarian cancer: inhibition of ascites formation by immunoneutralization

Ovarian cancer is characterized by the rapid growth of solid intraperitoneal tumors and large volumes of ascitic fluid. Vascular endothelial growth factor (VEGF) augments tumor growth by inducing neovascularization and may stimulate ascites formation by increasing vascular permeability. We examined the role of VEGF in ovarian carcinoma using in vivo models in which intraperitoneal or subcutaneous tumors were induced in immunodeficient mice using the human ovarian carcinoma cell line SKOV-3. After tumor engraftment (7 to 10 days), some mice were treated with a function-blocking VEGF antibody (A4.6.1) specific for human VEGF. A4.6.1 significantly (P < 0.05) inhibited subcutaneous SKOV-3 tumor growth compared with controls. However, tumor growth resumed when A4.6.1 treatment was discontinued. In mice bearing intraperitoneal tumors (IP mice), ascites production and intraperitoneal carcinomatosis were detected 3 to 7 weeks after SKOV-3 inoculation. Importantly, A4.6.1 completely inhibited ascites production in IP mice, although it only partially inhibited intraperitoneal tumor growth. Tumor burden was variable in A4.6.1-treated IP mice; some had minimal tumor, whereas in others tumor burden was similar to that of controls. When A4.6.1 treatment was stopped, IP mice rapidly (within 2 weeks) developed ascites and became cachectic. These data suggest that in ovarian cancer, tumor-derived VEGF is obligatory for ascites formation but not for intraperitoneal tumor growth. Neutralization of VEGF activity may have clinical application in inhibiting malignant ascites formation in ovarian cancer.

Lesser sac endoscopy and laparoscopy in pancreatic carcinoma definitive diagnosis, staging and palliation

Laparoscopy with lesser sac endoscopy (LSE) were used in combination from 1987 to 1992 in 103 patients for differentiation between pancreatic carcinoma and other peripancreatic pathology, staging, and palliation. LSE identified pancreatic carcinoma in 38 patients; pancreatic cystadenocarcinoma in 2 patients; pancreatic cystadenoma in 3 patients; pancreatic adenoma in 1 patient; pancreatic metastases from liver in 2 patients; and pancreatic cysts in 5 patients. False negative diagnosis of pancreatic carcinoma occurred in two cases. Nontumor pancreatic pathology was revealed in 10 patients. Specifically, acute pancreatitis was found in four patients, and chronic pancreatitis was found in six patients. Extrapancreatic cancers were identified in 15 patients: retroperitoneal extraorgan tumors were found in 2 patients; extrahepatic biliary tract cancer in 6 patients; gallbladder cancer in 1 patient; liver cancer in 3 patients; and stomach cancer in 1 patient. In five cases no pathology was found. Overall correct definitive diagnosis was established in 101 patients. Sensitivity of laparoscopy with LSE for pancreatic carcinoma diagnosis proved to be 95 per cent (38 of 40 patients), for pancreatic tumors diagnosis 96.22 per cent (51 of 53 patients); specificity of the method 100 per cent; and accuracy of diagnosis 98 per cent (101 of 103 patients). Thus, the accuracy of the method was as high as the accuracy of combination of all known modalities. Criteria of unresectability were revealed with the combination of LSE and laparoscopy in 75 per cent (30 of 40 cases) of pancreatic carcinoma. Moreover, laparoscopy allowed palliation of pancreatic carcinoma. Laparoscopic cholecystostomy was performed in 10 patients, and laparoscopic cholecystojejunostomy with enteroenterostomy was performed in 6 patients.

Orthotopic xenografts of human melanoma and colonic and ovarian carcinoma in sheep to evaluate radioimmunotherapy

Extrapolation to humans from experimental radioimmunotherapy in nude mouse xenograft models is confounded by large relative tumour size and small volume of distribution in mice allowing tumour uptake of radiolabelled antibodies unattainable in patients. Our large animal model of human tumours in cyclosporin-immunosuppressed sheep demonstrated tumour uptake of targeted radiolabelled monoclonal antibodies comparable with uptakes reported in clinical trials. Sheep immunosuppression with daily intravenous cyclosporin augmented by oral ketoconazole maintained trough blood levels of cyclosporin within the range 1000-1500 ng ml(-1). Human tumour cells were transplanted orthotopically by inoculation of 10(7) cells: SKMEL melanoma subcutaneously; LS174T and HT29 colon carcinoma into bowel, peritoneum and liver; and JAM ovarian carcinoma into ovary and peritoneum. Tumour xenografts grew at all sites within 3 weeks of inoculation, preserving characteristic morphology without evidence of necrosis or host rejection. Lymphatic metastasis was demonstrated in regional nodes draining xenografts of melanoma and ovarian carcinoma. Colonic LS1 74T xenografts produced mucin and carcinoembryonic antigen (CEA). The anti-CEA IgG1 monoclonal antibody A5B7 was radiolabelled with iodine-131 and administered intravenously to sheep. Peak uptake at 5 days in orthotopic human tumour transplants in gut was 0.027% DI g(-1) (percentage of injected dose per gram) and 0.034% DI g(-1) in hepatic metastases with tumour to blood ratios of 2-2.5. Non-specific tumour uptake in melanoma was 0.003% DI g(-1). Uptake of radiolabelled monoclonal antibody in human tumours in our large animal model is comparable with that observed in patients and may be more realistic than nude mice xenografts for prediction of clinical efficacy of radioimmunotherapy.

Regional chemotherapy with hemofiltration: a rationale for a different treatment approach to advanced pancreatic cancer

BACKGROUND/AIMS

Since 1989, thirty-two patients with advanced, intra-abdominal pancreatic cancer were treated with regional chemotherapy in combination with extracorporeal hemofiltration.

PATIENTS AND METHODS

Eleven patients had locally advanced, unresectable cancer, and ten had advanced disease with liver metastases. Three patients had developed liver metastases following a radical resection. One patient had an incomplete resection with local residual disease, and a second had developed a local recurrence after a radical resection. One patient had an unresectable cystadenocarcinoma. Five patients had failed prior systemic therapies for unresectable pancreatic cancer. The patients underwent 85 treatments with regional chemotherapy plus hemofiltration, an average of 2.7 treatments per patient.

RESULTS

Of 21 patients treated primarily with regional chemotherapy plus hemofiltration, there were two complete responses (9%) and eight partial responses (38%), an overall total response rate of 47%. The average survival for patients with Stage II/III localized, unresectable disease is 13 months and that for Stage IV unresectable disease with liver metastases is 9 months.

CONCLUSIONS

Patients with recurrent disease following a radical resection or having failed prior systemic therapies generally had no benefit from regional chemotherapy plus hemofiltration.

[Percutaneous drainage of refractory necrotizing tumors: experience in 9 patients]

PURPOSE

The ranking of percutaneous drainage treatment in necrolytic advanced tumours was assessed.

METHOD

9 patients with refractory symptomatic necrolytic tumours were treated for alleviation by percutaneous drainage. Additionally, an attempt to sclerose the necrotic cavity was performed in 6 patients (6 x mitoxantrone 30 mg/24 hrs, of which 1 x additionally 98% alcohol).

RESULTS

In 5 of the 9 patients symptomatic relief was obtained, but complete sclerosing of the necrotic cavity succeeded in only two patients. In two patients with necrotic tumours of the pelvis there was a bacterial superinfection of the tumour necrosis.

CONCLUSION

Percutaneous alleviation is only occasionally successful in patients with necrolytic tumours. Therapy becomes effective probably only in case of successful sclerosing of the tumorous cavity.

[Intraarterial chemoembolization therapy for unresectable liver cancer using plachitin particles]

Plachitin formed of both poly-N-acetyl-D-glucosamine (chitin) and cis-diamminedichloroplatinum (CDDP), was used as an arterial chemoembolization therapy against unresectable liver cancer. One gram of Plachitin contained 300 mg of CDDP. The Plachitin particle was 50-100 microns in diameter. Plachitin particles (50-100 mg) were injected via hepatic artery once or twice every week, and the total amount of 300 mg was considered one course of this therapy. The size and number of tumors were measured by computer tomography (CT). Pharmacokinetics of this drug was also assessed by serum and urine platinum (Pt) concentration. Three patients underwent the chemoembolization therapy using plachitin particles. Case 1 had multiple hepatocellular carcinomas. The tumor regression rate was 39% after two courses of this therapy. Serum alpha-fetoprotein (AFP) level decreased from 1,182 ng/ml to 300 ng/ml. Case 2 suffered from bile duct cystadenocarcinoma. After three courses of the therapy, the tumor regression rate was 84.4%. Serum carbohydrate antigen 19-9 (CA19-9) decreased from 731 U/ml to 75 U/ml. Case 3 had synchronous multiple liver metastases from sigmoid colon cancer. The tumor regression rate was 77% after one course of the therapy. Carcinoembryonic antigen (CEA) and CA19-9 decreased from 406 ng/ml to 65 ng/ml and from 4,800 U/ml to 790 ng/ml, respectively. The response rate of the 3 cases was 66.7%. The peak levels of the serum Pt concentration of three patients were 0-0.4 microgram/g throughout the therapy, but peak urine Pt concentrations were observed during one course of the therapy of three patients ranging from 0.5 microgram/g to 3.2 micrograms/g, and decreased gradually for three weeks after the first course. Adverse effects of Plachitin particles for arterial chemoembolization were epigastralgia, nausea, fever, and elevation of serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. These adverse effects were observed in all patients, but were transient. Catheter obstruction occurred in one patient (case 2). Cholecystitis, pancreatic pseudocyst, and duodenal ulcer were noticed in case 3. No renal hypofunction was observed. Plachitin might be a useful agent for arterial chemoembolization therapy for primary and secondary liver cancer.

Immunomodulation in patients with epithelial ovarian cancer after adoptive transfer of tumor-infiltrating lymphocytes

The immunomodulation determined by natural killer cell activity, delayed-type hypersensitivity to purified protein derivative and phytohemagglutin, and phenotypic changes of peripheral blood lymphocytes was characterized in 12 patients with epithelial ovarian cancer who received adoptive transfer of tumor-infiltrating lymphocytes (TILs) after cisplatin-containing chemotherapy (TIL group). As a control, 10 patients with epithelial ovarian cancer who did not receive infusions of TIL were also examined in the same fashion. In the TIL group, peripheral blood lymphocytes showed increased percentages of cells bearing the CD8 antigen, in contrast to stable percentages of CD4 antigen-bearing cells, resulting in a decreased ratio of CD4+ to CD8+ cells. The percentages of CD16 and CD56 antigen-bearing cells also increased in proportion to augmentation of natural killer cell activity against K562 cells. Additionally, with regard to cell-mediated immunity determined by delayed-type hypersensitivity to phytohemagglutin and purified protein derivative, significantly and slightly enlarged erythema was observed 2 and 8 weeks, respectively, after the injection of TILs (phytohemagglutin, P < 0.05; purified protein derivative, not statistically significant). The control group showed no major changes in any of the immunological markers. These results suggest the possibility that the adoptive transfer of TILs induces immunoactivation of cellular immunity and enhances natural killer activity in patients with epithelial ovarian cancer.

Tumor DNA ploidy and prognosis of patients with serous cystadenocarcinoma of the ovary

BACKGROUND

Although it is important to determine any relationship between tumor DNA ploidy and its biologic behavior, the correlation between DNA ploidy and the prognosis of patients with ovarian cancer is not conclusive. Accordingly, the authors evaluated the clinical application of DNA ploidy in ovarian cancer.

METHODS

Flow cytometric measurements were performed in 45 selected patients with well-differentiated serous cystadenocarcinoma of the ovary, Stages Ic-IV. All of them had the same surgical procedure, with retroperitoneal lymphadenectomy including paraaortic nodes, followed by the same postoperative chemotherapeutic regimen.

RESULTS

Of the 45 ovarian cancers, 28 were diploid and 17 were aneuploid. The 2-year survival rate and the estimated 5-year survival rate for patients with diploid tumors were significantly greater than those for patients with aneuploid tumors (73.2% versus 46.7% and 29.1% versus 22.4%, respectively). The 2-year survival rate in patients with advanced disease (Stage III or IV) was also significantly higher for those with diploid tumors (53.3% versus 37.4%, respectively), but the estimated 5-year survival rate was similar in both groups (8.9% versus 9.1%, respectively). Patients with advanced disease had aneuploid tumors more frequently than those with early-stage disease. A significantly higher incidence of retroperitoneal lymph node metastasis was observed in aneuploid tumors than in diploid tumors (43.8% in diploid tumors versus 86.7% in aneuploid tumors). The authors found no difference in the response to chemotherapy between diploid and aneuploid tumors.

CONCLUSIONS

Although tumor DNA ploidy was not as reliable as conventional parameters such as surgical stage in establishing prognosis, it may provide an indicator of lymph node involvement.

Target therapy of ovarian carcinoma by monoclonal antibodies bearing chemical drugs entrapped in liposomes

Monoclonal antibody COC166-9 against ovarian carcinoma was conjugated with adriamycin or cisplatinum entraped in liposomes as immunochemical liposomes MLA and MLP respectively. MLA was shown to have the highest effect than adriamycin or other groups on SKOV3 (ovarian cancer cell line) growth inhibition. MLA was also used in target therapy on nude mice bearing human ovarian carcinoma by xenograft of SKOV3 cells. The observations of tumor volumes revealed that this target therapy other than the controls presents a significantly better result which gives a hopeful clue to ovarian carcinoma treatment.

Serous carcinoma of the peritoneum after oophorectomy

BACKGROUND

Prophylactic oophorectomy in premenopausal women has been recommended to prevent ovarian cancer. However, serous carcinoma of the peritoneum, which is indistinguishable from ovarian carcinoma, can occur after oophorectomy.

CASES

Two cases are reported of serous carcinoma of the peritoneum after oophorectomy. Presentation, management, and outcome are similar to those for ovarian carcinoma.

CONCLUSION

More data are needed to quantify the risk of carcinoma after oophorectomy. Such knowledge may change the risk-benefit calculations of recommending prophylactic oophorectomy to premenopausal women at a certain age, and must be discussed with the patient who is considering prophylactic oophorectomy with or without other planned surgery.

Papillary serous adenocarcinoma of the endometrium: a clinicopathologic study of 19 cases

Survival in 19 patients with papillary serous adenocarcinoma of the endometrium treated at the University of Vermont during the period 1960-1987 was significantly worse than that for 360 patients with other types of endometrial cancer. Deaths were associated with extrauterine spread and deep myometrial invasion detected at the time of surgery. Two patients without myometrial invasion and with extrauterine spread who also died may have developed synchronous peritoneal serous carcinoma.

Mucinous cystadenocarcinoma of the appendix with pseudomyxoma peritonei presenting as total uterine prolapse. A case report

Mucinous cystadenocarcinoma of the appendix occurred with symptoms limited only to a total uterovaginal prolapse. Preoperative intravenous pyelogram and pelvic ultrasonography demonstrated the presence of a large pelvic mass. Exploratory laparotomy revealed the mass to be appendiceal adenocarcinoma, which was treated with extirpation of all the visible tumor and repair of the anatomic defect.

[Maintenance of the activation of peritoneal macrophage in patients with ovarian cancer by the repeated administration of sizofiran and interferon gamma]

Four patients with ovarian cancer were treated with a 20mg injection of sizofiran, a MW 450,000 beta-1,3-glucan, intramuscularly one day before and 4,7,11,14,18 and 21 days after second look laparotomy and with the administration of 2 million units of interferon gamma intraperitoneally at 0,4,7,11,14,18 and 21 days after second look laparotomy. Peritoneal macrophages were obtained from the patients by peritoneal washing with saline through an indwelled tube. The number of macrophages was increased to about 30 times after the treatment. The concentrations of interleukin 1, interferon gamma, tumor necrosis factor and prostaglandin E2 in the media of 24-hour cultured macrophage with 10 micrograms/ml of LPS were also increased throughout the treatment. These data suggest that the every 3 to 4 day treatment with sizofiran and interferon gamma maintained the activation of peritoneal macrophages which might lead to retention of the antitumor activity in patients with ovarian cancer.

Stage I ovarian epithelial carcinoma: survival analysis following definitive treatment

Between 1977 and 1986, 55 patients with surgical stage I ovarian epithelial carcinoma were managed in a definitive fashion, which included surgical staging and adjuvant therapy in 51 of 55 patients (93%) and second-look laparotomy. The mean follow-up time from the data of reassessment surgery was 94 months, allowing sufficient time to facilitate the identification of one or more subgroups of patients at risk of having persistent disease or developing a recurrence. Treatment failures were detected at second-look laparotomy in 6 patients (11%), and an additional 5 patients (9%) subsequently had recurrences after being declared free of disease at second-look reassessment. Analysis of pathologic variables identified grade and substage as important prognostic factors, with 8 of the 9 deaths (89%) being associated with Broders grade 3 or 4 and/or stage IC. Within the bivariate model consisting of patients harboring poorly differentiated (grade 3 or 4) stage IC lesions, 6 of 14 patients (43%) are dead from disease, yielding a long-term survival rate that at best approximates the survival rate associated with optimally reduced (microscopic residual) stage III patients subjected to contemporary adjuvant therapy and reassessment surgery. These data suggest that intensive therapy as utilized in advanced disease, including platinum-based chemotherapy, second-look laparotomy, and innovative salvage or investigational consolidation therapy, is equally applicable to this "high-risk" stage I group.

Preoperative diagnostic imaging of normal-sized ovary carcinoma syndrome

We treated a patient with a massive amount of ascites, the cytology of which contained adenocarcinoma (class V). The left ovary was slightly enlarged and the preoperative diagnostic imaging (PDI) suggested the presence of a malignancy. The right ovary was of normal size and the PDI presented no evidence of malignancy. the intra- and postoperative histological diagnosis was serous cystadenocarcinoma of the right ovary and fibroma of the left ovary. Therefore, this case can be classified as one of a normal-sized ovary carcinoma syndrome. Difficulties involved in the preoperative diagnosis of this syndrome and drawbacks of PDI are discussed.

[The prognosis of ovarian cancer depends on the CA125 value at the end of induction therapy]

The prognosis of ovarian cancer depends on the CA125 value at the end of induction therapy. The relationship between the prognosis and the CA125 value at the end of induction therapy was analysed in 16 ovarian cancers. In the group with a CA125 value less than 35 units/ml after the induction therapy (initial surgery + 3 courses of chemotherapy) all patients have survived for 18-45 months since the initial treatment to the present, whereas in the group with a CA125 value above 35 units/ml all patients died within 16 months after the initial treatment. Comparison of the survival rates in these two groups showed a significant difference. These results suggest that the most important factor that affects prognosis in patients with ovarian cancer is the normalization of the CA125 value after the induction therapy.

A technique for managing terminally ill ovarian carcinoma patients

A patient with terminal ovarian carcinoma was admitted with malnutrition, abdominopelvic pain, and an inoperable complete small bowel obstruction after failing standard therapy and several experimental regimens for her disease. Despite this serious situation, she had an overall high performance status. Instead of administering intravenous narcotics, providing nasogastric suction, and giving other supportive care to make her apparently imminent death as comfortable as possible, her malnutrition was treated with total parenteral nutrition administered through an indwelling central venous catheter during the night hours only. The pain was successfully treated with an indwelling epidural catheter with the continuous infusion of morphine through a portable pump carried by a shoulder strap. The intestinal obstruction was relieved by a percutaneous endogastric tube which drained spontaneously into a leg bag. This regimen allowed the patient complete daytime mobility. She remained active, largely at home, with slowly progressing tumor until her death 9 months after the institution of this supportive care.

Evaluation of therapeutic response using iodine-131-B72.3 monoclonal antibody in patients with ovarian carcinoma

We used radiolabelled monoclonal antibodies (MoAbs) to prove disease persistence after treatment for ovarian carcinoma. Twelve patients with histologically confirmed ovarian carcinoma were studied. They received 5 mCi (1 mg) of iodine-131-B72.3 by intravenous injection before and after a complete course of chemotherapy. Images were obtained with a LFOV gamma camera 2 h after MoAb administration and daily up to 6 days. Before treatment 8 patients had a true positive scan. Questionable antibody uptake was observed in 2 patients while 1 had a true negative scan and 1 a false-negative examination. After treatment the therapeutic response was evaluated. Five patients had partial remission and antibody scan showed persistence of disease in all patients except 1. Four patients showed progression of the disease and 1 no change. The antibody scan was positive in 4 and questionable in 1. Two patients had complete remission and negative antibody scans. Computed tomography (CT) could not always discriminate postoperative fibrosis from tumour lesions, especially when the peritoneum was involved in the disease. High serum levels of tumour markers were constantly associated with the presence of tumour lesions, but normal values did not guarantee absence of disease. We conclude than the antibody scan is complementary to CT and serum tumor markers in the definition of therapeutic response.

Primary peritoneal papillary serous adenocarcinoma: clinical and management aspects

From January 1, 1984 to April 30, 1990, 38 patients were surgically found to have an intraabdominal disease resembling epithelial ovarian cancer. This diagnosis was confirmed in 31 patients; the remaining 7 met the criteria of primary peritoneal papillary serous carcinoma. Five of these were diagnosed retrospectively and two during surgery. The mean age at diagnosis was 61.2 years. Tumor histology revealed papillary serous carcinoma in six and mixed (papillary serous and papillary clear cell carcinoma) in one patient. Optimal debulking was achieved in three of seven cases (42.8%). Cisplatin-based combination chemotherapy was administered to all in the study group. Complete response was obtained in four patients, with one surviving for 76 months. The median survival in these patients was 34.5 months (range 6-76 months). Currently, three patients with complete response are alive with clinically undetectable disease. CA-125 assays were available in three cases and blood levels corroborated the clinically determined status of the disease. Tumor steroid hormone receptor status was determined in one case and revealed low levels of estrogen and progesterone receptors. To the best of our knowledge, the usefulness of CA-125 in the diagnosis, management, follow-up, and determination of tumor steroid hormone receptor status, mixed papillary serous and clear cell subtype histological patterns for primary peritoneal papillary serous carcinoma are first described in this report. It seems that this neoplasm may be treated and followed up as in epithelial ovarian cancer, obtaining long-term survival; however, the biologic behavior and management problems of this relatively new entity deserve further clinical experience.

Osseous metaplasia in ovarian papillary serous cystadenocarcinoma

The finding of osseous metaplasia within an ovarian papillary serous cystadenocarcinoma is very rare. A review of the medical literature reveals only two previously published cases where mature bone was found in an ovarian serous cystadenocarcinoma. This report presents an additional case of this unusual phenomenon whose clinical significance remains uncertain.

[Superficial lymph node metastasis from ovarian cancer--an analysis of 31 cases]

From March 1958 to June 1988, 53 cases of ovarian cancer with superficial lymph node metastasis (SLM) were treated in our hospital comprising 5.6% of patients with malignant ovarian tumors in the same period. Of 53 cases, 31 were proven by histopathology, and 27 had serous adenocarcinoma. Of these 31 cases, 15 with Stage IV lesion had SLM at time when first seen in the clinic and the others developed SLM during treatment or afterwards. The median survival was 34.7, 11.8 and 12.9 months in Grades I, II and III, respectively. Prognosis is related to pathological grade. The median survival was 36.5 months in 10/31 patients treated with surgery combined with chemotherapy and radiotherapy, 9.1 months in 6/31 treated with surgery plus chemotherapy, 22.4 months in 3/31 treated with radiotherapy only and 8.5 months in 6/31 treated with chemotherapy only. It is suggested that aggressive treatment can improve survival.

[Therapy of ascites with tumor necrosis factor in ovarian cancer]

The biotechnological production of human recombinant tumour necrosis factor (rHuTNF) makes this drug available for clinical application. This endogenous compound exhibits tumouricidal activity and regulatory functions within the immune system. 20 out of 23 (87%) patients with refractory recurrent malignant ascites from ovarian cancer were successfully treated in a phase-I and II-study. The production of ascites was either completely suppressed or reduced to a minimum for at least 4 weeks after maximally three intraperitoneal (i.p.) applications. Two of the three non-responders were mucinous carcinomas. In the phase-I study the evaluation of a maximal tolerable dose was not possible due to the rapid therapeutic success at low doses of TNF. The effective dosage was 0.08-0.14 mg TNF/m2 given i.p. Side effects which occurred 2 to 24 hours after the application of TNF were flue-like symptoms combined with general malaise. The side effects were not dose related. All concomitant signs and symptoms could be minimized by prophylactic or therapeutic application of indometacine, paracetamol or pethidine. This applied especially for the typical early phase cytokine side effects e.g. chills and febrile temperatures. The side effects were not dose related. The i.p. treatment with rHuTNF appears to be a novel practicable and effective method for palliation in patients with recurrent ascites even in multiple pretreated patients.

Brain metastases in epithelial ovarian carcinoma; two case reports

The cases of two patients with epithelial ovarian carcinoma who had been treated with surgery and cisplatin-containing combination chemotherapy and had developed brain metastases are described. Modern protocols for management of advanced-stage epithelial ovarian carcinoma have resulted in prolonging the lives of the patients sufficiently for central nervous system metastases to become apparent and possible resistence of the 'blood brain' barrier to the currently used chemotherapeutic agents may have left the CNS 'unprotected' from metastases.