Recent developments in the diagnosis and therapy of well-differentiated neuroendocrine tumours

Well-differentiated neuroendocrine tumours (NETs) of the digestive tract are being increasingly detected, which is partly explained by the increased use of endoscopic and cross-sectional imaging as well as improved recognition at histopathological evaluation. After the discovery of this relatively indolent type of epithelial malignancy over 100 years ago, their sporadic occurrence and divergent biological behaviour at multiple primary sites have hampered dedicated studies into NET pathogenesis and testing of drug efficacy in well-designed clinical trials. The last decade, however, has seen significant improvements in the NET field regarding our understanding of their pathophysiology. This has been substantiated by novel and exciting diagnostic and therapeutic options, including superior positron emission tomography imaging, treatment with unlabelled and radiolabelled somatostatin analogues and inhibitors of the mammalian target of rapamycin and vascular endothelial growth factor pathways. This review summarises contemporary studies within NET patients, which have enriched our clinical repertoire for this disease and have been instrumental in securing a remarkable improvement of overall survival within recent years.

Bile acid-microbiota crosstalk in gastrointestinal inflammation and carcinogenesis

Emerging evidence points to a strong association between the gut microbiota and the risk, development and progression of gastrointestinal cancers such as colorectal cancer (CRC) and hepatocellular carcinoma (HCC). Bile acids, produced in the liver, are metabolized by enzymes derived from intestinal bacteria and are critically important for maintaining a healthy gut microbiota, balanced lipid and carbohydrate metabolism, insulin sensitivity and innate immunity. Given the complexity of bile acid signalling and the direct biochemical interactions between the gut microbiota and the host, a systems biology perspective is required to understand the liver-bile acid-microbiota axis and its role in gastrointestinal carcinogenesis to reverse the microbiota-mediated alterations in bile acid metabolism that occur in disease states. An examination of recent research progress in this area is urgently needed. In this Review, we discuss the mechanistic links between bile acids and gastrointestinal carcinogenesis in CRC and HCC, which involve two major bile acid-sensing receptors, farnesoid X receptor (FXR) and G protein-coupled bile acid receptor 1 (TGR5). We also highlight the strategies and cutting-edge technologies to target gut-microbiota-dependent alterations in bile acid metabolism in the context of cancer therapy.

The association between biliary tract inflammation and risk of digestive system cancers: A population-based cohort study

The relationship between biliary tract inflammation (BTI) and digestive system cancers is unclear. This study aimed to evaluate the association between BTI and the risks of digestive system cancers.Using the Taiwan National Health Insurance claims data, information on a cohort of patients diagnosed with BTI (n = 4398) between 2000 and 2009 was collected. A comparison cohort of sex-, age-, and index year-matched persons without BTI (n = 17,592) was selected from the same database. The disease was defined by the ICD-9-CM. Both cohorts were followed until the end of 2010 and incidences of digestive system cancers were calculated.The results revealed an increase in adjusted hazard ratio (aHR) of biliary tract cancer (24.45; 95% confidence interval [CI]: 9.20-65.02), primary liver cancer (1.53; 95% CI: 1.07-2.18), and pancreatic cancer (3.10; 95% CI: 1.20-8.03) in patients with both gallbladder and BTI. The aHR of stomach cancer was also found to be increased (2.73; 95% CI: 1.28-5.81) in patients with gallbladder inflammation only. There were no differences in esophageal cancer (aHR: 0.82; 95% CI: 0.23-2.87) and colorectal cancer (aHR: 0.92; 95% CI: 0.59-1.45). The aHR for digestive system cancers increased by 3.66 times (95% CI: 2.50-5.35) and 12.20 times (95% CI: 8.66-17.17) in BTI visits frequency averaged 2 to 4 visits per year and frequency averaged ≥5 visits per year, respectively.Patients with BTI have significantly higher risk of digestive system cancers, particularly biliary tract, pancreatic, and primary liver cancers, compared with those who are without it.

Important roles of P2Y receptors in the inflammation and cancer of digestive system

Purinergic signaling is important for many biological processes in humans. Purinoceptors P2Y are widely distributed in human digestive system and different subtypes of P2Y receptors mediate different physiological functions from metabolism, proliferation, differentiation to apoptosis etc. The P2Y receptors are essential in many gastrointestinal functions and also involve in the occurrence of some digestive diseases. Since different subtypes of P2Y receptors are present on the same cell of digestive organs, varying subtypes of P2Y receptors may have opposite or synergetic functions on the same cell. Recently, growing lines of evidence strongly suggest the involvement of P2Y receptors in the pathogenesis of several digestive diseases. In this review, we will focus on their important roles in the development of digestive inflammation and cancer. We anticipate that as the special subtypes of P2Y receptors are studied in depth, specific modulators for them will have good potentials to become promising new drugs to treat human digestive diseases in the near future.

Halofuginone for fibrosis, regeneration and cancer in the gastrointestinal tract

Organ fibrosis and architectural remodeling can severely disrupt tissue function, often with fatal consequences. Fibrosis is the end result of chronic inflammatory reactions induced by a variety of stimuli, and the key cellular mediator of fibrosis comprises the myofibroblasts which, when activated, serve as the primary collagen-producing cells. Complex links exist between fibrosis, regeneration and carcinogenesis, and the concept that all organs contain common tissue fibrosis pathways that could be potential therapeutic targets is an attractive one. Because of the major impact of fibrosis on human health there is an unmet need for safe and effective therapies that directly target fibrosis. Halofuginone inhibits tissue fibrosis and regeneration, and thereby affects the development of tumors in various tissues along the gastrointestinal tract. The high efficacy of halofuginone in reducing the fibrosis that affects tumor growth and tissue regeneration is probably due to its dual role in inhibiting the signaling pathway of transforming growth factor β, on the one hand, and inhibiting the development of Th17 cells, on the other hand. At present halofuginone is being evaluated in a clinical trial for other fibrotic indication, and any clinical success in that trial would allow the use of halofuginone, also for all other fibrotic indications, including those of the gastrointestinal tract.

Raising public awareness

Upper gastrointestinal (GI) cancer nurse specialist Claire Sedgwick from Newcastle upon Tyne Hospitals NHS Foundation Trust was concerned to find poor awareness of the symptoms of upper gastrointestinal and oesophageal cancers.

New insights into the role of chronic inflammation and cytokines in the etiopathogenesis of gastroenteropancreatic neuroendocrine tumors

Although previously considered rare, recent epidemiological studies have revealed that the incidence (3.6/100,000) and prevalence (35/100,000) of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) has increased over the past few decades. Despite the progress in the understanding of GEP-NET molecular biology, there is still little advance in the early diagnosis due to lack of specific tumor markers. As the tumors are mostly detected in their late stage, they are not well controlled by either biotherapy or conventional chemotherapy, and thus represent a significant clinical issue. Chronic inflammation has been implicated in the development of GEP-NETs. This review presents recent findings that link pro-inflammatory cytokines to the molecular basis of GEP-NET tumorigenesis, leading to a more personalized approach to disease management and therapy.

[Gastropancreatoduodenal resection for malignant tumors, complicated with obstructive jaundice]

The experience of 329 gastropancreatoduodenal resections for malignant tumors of the periampullary zone has been reviewed. The obstructive jaundice complicated the disease in 237 (70%) patients. The fact required various modalities of the preoperative artificial bile drainage. To evaluate the jaundice influence on the perioperative period, patients were divided in 4 groups, considering the bile drainage modality and bilirubin blood levels. The early postoperative period was respectively analyzed, which led to the conclusion that bilirubin blood level has no influence on either intraoperative characteristics or postoperative morbidity and mortality. For the reason of that, radical treatment of the periampullary cancer, complicated by the obstructive jaundice, does not require preoperative bile drainage.

Risk of gastrointestinal malignancies and mechanisms of cancer development with obesity and its treatment

Gastrointestinal malignancies may be associated with obesity, defined specifically by increased body-mass index, and based largely on environmental factors rather than genetics. In particular, there seems to be a definite increase in the incidence of both oesophageal and colorectal cancer. Mechanisms associated with obesity include a particular metabolic state characterized by hyperinsulinemia, or insulin resistance, along with elevated serum leptin. Leptin is derived from adipocytes and appears to play a role in the regulation of ghrelin, a peptide derived from the stomach and small intestine that stimulates appetite and weight gain. In addition to these metabolic changes, there are other anatomical alterations that may indirectly predispose to cancer, including the predisposition of obesity to gastroesophageal reflux and, possibly, oesophageal cancer. Other mechanisms may involve adipocyte-derived cytokines, or adipokines, that may serve as signalling devices in the pathogenesis of cancer. Finally, pharmacologic and surgical avenues available for treatment of obesity, including lipase inhibitors and gastric or jejuno-ileal bypass procedures may set the stage for subsequent gastric or intestinal tract cancer.

[Gap junctions and their role in physiology and pathology of the digestive tract]

Gap junctional intercellular communication (GJIC) is a mechanism of direct cell-to-cell signalling and is mediated by gap junctions (GJs), consisting of transmembrane proteins called connexins (Cxs). GJIC plays a critical role in tissue development and differentiation and is important in the maintenance of tissue homeostasis resulting from homeostasis through the exchange of ions, signalling molecules, nucleotides, and other small molecules (less than 1kDa) between adjacent cells. Because gap junctions are sites of the propagation or conduction of action potentials between adjacent cells, it is possible that they participate in the generation of rhythmic peristaltic movements by contributing to synchronous contraction in the muscle layer. Many physiological roles have been proposed for gap junctions, such as the maintenance of tissue homeostasis, regulation of tissue development, electrical and metabolic coupling, as well as the regulation of cellular growth, differentiation and apoptosis. Altered expressions of connexins have been observed in various pathological processes of the digestive tract, such as Hischsprung's disease, esophageal cancer, gastric cancer, and colorectal cancer. Using a variety of techniques such as transmission electron microscopy, Lucifer Yellow transfer and immunohistochemistry, gap junctions in the digestive tracts of mammalian species have been identified. This work is a review of recent studies on the role of GJIC in the physiology and pathology of the digestive tract.

[Clinical analysis of 55 ovarian metastatic tumors from digestive system]

BACKGROUND & OBJECTIVES

Ovarian metastasis of digestive system tumors is a special way of tumor metastasis, which the diagnosis and treatment are difficult. The objective of this paper is to seek the clinical characteristics of ovarian metastatic tumors from digestive system, to aid correct diagnosis and treatment, so that to improve their curative effect.

METHODS

The authors collected the information of 55 patients with ovarian metastatic tumors from digestive system, and analyzed 12 items of the patients including their age, menorrhea and child-bearing, details of original tumors and metastatic tumors, pathologic types, ascites, clinical symptoms, tumor markers, time of metastasis, diagnosis, treatment, curative effect, etc.

RESULTS

Misdiagnosis rate of the team was 30.9%. Survival rate of 1 year, 3 years, and 5 years were 22.4%, 4.1%, and 2.0% in 49 patients, followed up respectively.

CONCLUSION

Ovarian metastatic tumors from digestive system are easy to be misdiagnosed, and have poor prognosis. Careful long-term follow-up and active operation and chemotherapy may be effective to improve their curative effect.

Surgical and interventional palliative treatment of upper gastrointestinal malignancies

Malignancies of the upper gastrointestinal tract, including the oesophagus, stomach, liver, bile ducts and pancreas, are highly virulent diseases. While curative therapies relieve symptoms caused by these cancers, most of these treatments prove unsuccessful in the control of tumour due to occult residual disease. This review covers only planned palliative procedures for these conditions where patient factors (e.g. performance status or patient wishes) or tumour factors (e.g. locally advanced or known metastatic disease) prevent potentially curative intervention. For most patients, palliation of luminal obstruction, pain or other symptoms is the most worthwhile treatment that can be offered with present therapies.

Site-specific epithelial-mesenchymal interactions in digestive neuroendocrine tumors. An experimental in vivo and in vitro study

Little is known about the functional interactions between digestive neuroendocrine tumor cells and their stromal microenvironment. The focus of our study is whether mesenchymal cells modulate peptide expression, cell proliferation, and invasiveness in digestive neuroendocrine tumor cells. We designed an experimental in vivo and in vitro study using the mouse enteroendocrine cell line STC-1. In vivo, STC-1 cells were injected subcutaneously in 18 immunosuppressed newborn rats. At day 21, all animals presented poorly differentiated neuroendocrine tumors with lung metastases. Subcutaneous tumors were usually limited by a capsule containing basement membrane components and myofibroblasts that presented a low mitotic index. Lung tumors were devoid of capsule and poor in myofibroblasts, and their mitotic index was high. The profile of peptide expression in STC-1 tumors was different from that of cultured STC-1 cells. In vitro, STC-1 cells were cultured with fibroblasts of different origins, including dermis, lung, digestive tract, and liver. Based on their origin, myofibroblasts differentially modulated hormone synthesis, proliferation, spreading, and adhesion of STC-1 cells. In conclusion, our results show that site-specific functional interactions between mesenchymal and neuroendocrine cells may contribute to modulating the behavior of digestive neuroendocrine tumors, depending on their growth site.

Effects of a urinary trypsin inhibitor on acute circulatory insufficiency after surgical operation

OBJECTIVE

To assess the effectiveness of an urinary trypsin inhibitor (UTI) on a surgical stress, particularly the influences on cytokines and diuretic hormones.

SUBJECTS AND METHODS

Sixteen patients with carcinoma of the digestive system and predicted to suffer from circulatory insufficiency were enrolled. Selection of group was divided alternatively. UTI was administered for 5 consecutive days, at a dose of 300,000 units per day. Urine and blood specimens were collected before, immediately after, and 1, 3, and 5 days after surgery. Interleukin 8 (IL-8), polymorphonuclear leukocyte elastase (PMNE), vasopressin (ADH), atrial natriuretic peptide (ANP), angiotensin II (AT-II), and endothelin 1 (ET-1) in the blood, and N-acetyl-D-glucosaminidase (NAG) in the urine, were determined.

RESULTS

A UTI group was 9 patients, and a control group was 7 patients. The operation time was significantly longer in the UTI group than in the control group. In the UTI group, the elevation of IL-8, PMNE/WBC, ADH, urinary NAG, and BUN were significantly inhibited. AT-II and ET-1, in the UTI group, tended to be suppressed, and ANP showed the similar changes in the two groups.

CONCLUSION

UTI is considered effective in the prevention of excessive reaction against major surgery.

Endocrine diffuse system. Histological and functional aspects interrelated with tumoral pathology

It was first believed that all these endocrine cells are deriving from the neural crests; in time were discovered more than 40 different types of such cells with different origins and only 6 or 7 are deriving from the neural crests. Serotonin-secreting cells show yellow fluorescence, while those secreting cathecolamines show a green fluorescence, with formaldehyde. The most usual method for the stain of the cells of the endocrine diffuse system is the silver salts impregnation. In the electron microscopy the cells show dense granules, which are modified in appearance in the malignancies developed from such cells. Most of the hormones secreted in the intestine were found also to be hormones secreted in the central nervous system. The border between benign proliferation and malignant tumors arising from these endocrine cells is not well defined. DNES--diffuse neuroendocrine system.

Effects of medroxyprogesterone acetate on appetite, weight, and quality of life in advanced-stage non-hormone-sensitive cancer: a placebo-controlled multicenter study

PURPOSE

To investigate the effects of medroxyprogesterone acetate (MPA) on appetite, weight, and quality of life (QL) in patients with advanced-stage, incurable, non-hormone-sensitive cancer.

PATIENTS AND METHODS

Two hundred six eligible patients were randomized between double-blind MPA 500 mg twice daily or placebo. Appetite (0 to 10 numerical rating scale), weight, and QL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC-QLQ-C30]) were assessed before the start of treatment (t = 0), and 6 weeks (t = 6) and 12 weeks (t = 12) thereafter.

RESULTS

One hundred thirty-four patients (68 MPA and 66 placebo) were assessable at t = 6 and 99 patients (53 MPA and 46 placebo) at t = 12. A beneficial effect of MPA on appetite was observed after both 6 weeks (P = .008) and 12 weeks (P = .01) of treatment. After 12 weeks, a mean weight gain of 0.6 +/- 4.4 kg was seen in the MPA, versus an ongoing mean weight loss of 1.4 +/- 4.6 kg in the placebo group. This difference of 2.0 kg was statistically significant (P = .04). During the study, several areas of QL deteriorated in the total group of patients. With the exception of an improvement in appetite and possible also a reduction in nausea and vomiting, no measurable beneficial effects of MPA on QL could be demonstrated. The side effects profile of MPA was favorable: only a trend toward an increase in (usually mild) peripheral edema was observed.

CONCLUSION

In weight-losing, advanced-stage non-hormone-sensitive cancer patients, MPA exhibits a mild side effects profile, has a beneficial effect on appetite, and may prevent further weight loss. However, general QL in the present study was not measurably influenced by MPA treatment.

Disagreement between hospital medical records and a structured patient interview on the type and date of the first symptom in cancers of the digestive tract

Medical records have often been found to be less reliable than interviews to patients when data on the initial signs and symptoms of cancer, and the out-of-hospital diagnostic process are sought; in spite of this, a large body of research on "diagnostic delay" in cancer is based on clinical records. As part of a study on delay in neoplasms of the digestive tract we analyzed the agreement on the type and date of the initial symptom between hospital records and a structured personal interview. Records were abstracted for a random sample (N = 60) of 183 patients interviewed. Concordance on the date of the first symptom was deemed to exist if the difference was +/- 30 days. The Kappa index (kappa) and the overall proportion of agreement (with its corresponding 95% confidence interval) were used. Medical records and structured personal interviews were concordant on the type of the first neoplastic symptom in only 61% of cases (kappa = 0.50): 67% in esophagus cancer (kappa = 0.49), 60% in stomach cancer (kappa = 0.52), and 61% in colorectal cancer (kappa = 0.50). Records underestimated the occurrence of anorexia as first symptom and overestimated weight loss and dysphagia. Only 56% of cases were date-concordant, the agreement being lower in colorectal cancer (46%) than in esophageal (67%) and stomach cancer (75%). Records indicated the first symptom to have occurred at a later date than interviews in 33% of cases; overall, a study based on hospital records would have underestimated the symptom to diagnosis interval by 2.2 months per patient. Only 40% of cases were totally (symptom and date) concordant. Marked discrepancies may exist between the information contained in medical records and what patients report during a structured interview. The quality of medical records data on the duration and nature of cancer symptoms should be assessed before its use in etiologic and evaluative research.

Age-related neoplasia in a lifetime study of ad libitum-fed and food-restricted B6C3F1 mice

Longevity, body weight, and age-specific neoplasia were determined in 1,064 B6C3F1 mice as part of a coordinated study of food restriction (FR). Restricted animals were offered 60% of the diet consumed by the ad libitum (AL) group. Longevity data were derived from a set of 56 animals of each sex from each diet group, which were examined whenever dead or moribund. For cross-sectional data, a parallel set of 210 animals were sacrificed in groups of 12-15 at 6-mo intervals. Lifetime body weight was reduced in the FR mice approximately proportional to restriction (i.e., 40%). Food restriction increased the age at 50% survival (median) by 36% in both sexes and increased the maximal lifespan (mean age of oldest 10%) by 21.5% in males and by 32.5% in females. In 56 males of the longevity groups, there were 89 neoplasms in the AL subgroup versus 53 in FR; 56 AL females had 100, versus 58 in 55 FR females. Increase in lifespan of the restricted animals was achieved primarily by decrease in incidence and delay of onset of fatal tumors, of which lymphoma was the most prominent. This report catalogs all of the neoplasms (1,103) observed in longevity and cross-sectional groups, by diet, sex, and age. These data add to the existing knowledge base needed for future studies of dietary restriction and aging as well to evaluate nutrition of animals used in bioassays.

Fibrinolytic activity of ascites caused by alcoholic cirrhosis and peritoneal malignancy

Coagulopathy is a well recognised complication of peritoneovenous shunting for ascites. The relative contributions of primary fibrinolysis and disseminated intravascular coagulation remain controversial. Plasminogen activating activity was significantly lower in malignant ascites (n = 10, median < 0.02 (range < 0.02-1.26) IU/ml) than in alcoholic ascites (n = 10, 1.07 (0.30-1.49) IU/ml) (p < 0.05). Fibrinolytic activity was determined by a balance between tissue plasminogen activator and plasminogen activator inhibitor-1. There was no significant difference between the two groups in the concentration of tissue plasminogen activator (34 (12-64) ng/ml in malignant ascites v 29 (12-43) ng/ml in alcoholic ascites), but the concentration of plasminogen activator inhibitor-1 was significantly higher in malignant ascites (736 (213-1651) ng/ml) than in alcohol ascites (29 (12-43) ng/ml) (p < 0.05). Malignant ascites contained significantly higher concentrations of urokinase (0.7 (< 0.1-1.3) ng/ml v 0.2 (< 0.1-0.6) ng/ml in alcoholic ascites) and plasminogen activator inhibitor-2 (33 (< 6-140) ng/ml v 9 (< 6-28) ng/ml alcoholic ascites). The plasminogen activating activity of alcohol ascites may lead to primary fibrinolysis after peritoneovenous shunting. The considerably lower activity found in malignant ascites may explain why coagulopathy after shunting is less pronounced in this group of patients.

Nursing diagnoses and functional health patterns in patients receiving external radiation therapy: cancer of the digestive organs

A descriptive study using clinical methodology was conducted to identify and describe core and site-specific symptoms reported by 15 patients with cancer of the digestive organs who received external radiation therapy. A 47-item Radiation Symptom Scale was designed by the investigators for this study. Symptoms identified by patients with a mean occurrence of at least "sometimes" were considered potential defining characteristics and were submitted to a panel of experts for identification of nursing diagnoses. Seventeen nursing diagnoses, with their associated defining characteristics, were identified and classified within eight Functional Health Patterns (FHP). Half of the nursing diagnoses were formulated within the Nutritional-Metabolic and Elimination patterns. Four of the FHPs were related to primarily functional patterns; four were primarily psychological-behavioral. Results of the study describe the nursing needs of patients who receive radiotherapy to the digestive organs.

[Comparative study of 24-hour continuous gastric pH-measurements in healthy people and in patients with pancreatic neoplasms treated with duodeno-pancreatic head resection]

The Authors compare pH measurements taken over a 24-h period to monitor, using an original method, a sample group of 11 healthy subject and a series of patients suffering from gastroenteropancreatic diseases. The data obtained confirm the utility of the functional study of gastrointestinal secretion.

[Expression of cytokeratins during embryogenesis and in pathologic epithelia]

Epithelial cell intermediate filaments, or cytokeratins, are excellent markers for cell differentiation. During embryogenesis, cytokeratins specific of a stage of differentiation step always become detectable before corresponding morphologic changes: for instance, cytokeratins 5 and 14 are found around the eight week, shortly before stratification of the epithelium occurs, and cytokeratins 1 and 10 are produced before morphologic evidence of keratinization becomes detectable. Among potential diagnostic applications, analysis of cytokeratin patterns of epidermal cells desquamated in the amniotic fluid may provide earlier and less invasive diagnosis than fetoscopic biopsies. Similarly, a review of cytokeratins expressed in a variety of epithelial diseases (involving the epidermis, digestive tract, respiratory tract, urogenital tract, or breast) demonstrated persistence of the original tissue pattern in some instances (this was the case for the majority of simple epithelia) but not in others (complex epithelia). This suggests that cytokeratins may prove valuable as markers for specific tumor stages or types and may provide earlier information than morphologic studies.

Adaptive mutagenesis--cause of alimentary cancer?

The tissues of the alimentary tract react to abnormal functional demands or to injury from environmental chemicals by reactions which involve change in morphology, functional characteristics and cellular proliferation. The work hyperplasia, wound repair or response to xenobiotics may become distorted by inherent, or induced, genomic abnormalities of the affected cells. It seems that some of the reactions are 'programmed' or 'planned' and depend on predetermined changes in gene expression. Although the reactions permit survival in the face of environmental hazards, the necessary alterations in gene expression may predispose to malignant change in the affected cells.

[Dihydroetorphine hydrochloride for moderate and severe cancer pain]

One hundred and three patients with moderate and severe cancer pain were given a sublingual analgesic agent--dihydroetorphine hydrochloride (DHE). Relief of cancer pain was moderate or complete in 89.3% (92/103). The average relief time (ART) was 3.9 hours and the average time before effectiveness was 20 minutes. In patients with acute or chronic cancer pain, moderate and complete pain-relief rates were 91.3% and 82.2% (P = 0.237). Difference of ART between them was insignificant (P = 0.299). The main clinical side-effects were somnolence (60%), dizziness (72%), nausea (30%), vomiting (16.5%), constipation (5%) and shortness of breath (8%). In two of the patients, the administration of DHE had to be stopped due to its side-effects. Age, sex and site of cancer pain were not related to the analgesic effects of DHE, but the pain-relief in patients with bladder cancer was poor (P less than 0.001). Within certain range, increase in dose was able to enhance its analgesic effect (P less than 0.001) and reduce drug resistance (P less than 0.001).

[The effect of age-related changes on the hypophyseo-adrenal and sympathetico-adrenal systems in patients with cancer of the digestive tract and lungs]

An analysis of the activity of pituitary-adrenal and sympathetic-adrenal systems in patients with cancer of the digestive canal and lungs with consideration of age, sex and stage of the disease indicates that not age but the development of the tumour process is the leading factor in disorders of the neuroendocrine homeostasis. Therapeutic measures are discussed.

Reticulo-endothelial function in obstructive jaundice

A study of reticulo-endothelial function was performed in 30 patients with obstructive jaundice. Reticulo-endothelial phagocytic function, measured by the clearance of intravenous human micro-aggregated albumin, was significantly depressed in jaundiced patients compared with non-jaundiced controls (P less than 0.001). There was a significant correlation (P less than 0.001) between phagocytic function and plasma bilirubin level but not with transaminase or bile salt level. Phagocytic function was not related to the presence of malignancy, but was markedly reduced in patients with cholangitis. There was no reduction in hepatic sinusoidal blood flow, opsonin levels (fibronectin, IgG, complement) or serum opsonic activity to account for the reticulo-endothelial dysfunction.

[Nutritional status of patients with digestive system cancer: preoperative prognostic significance]

We have attempted to establish a prognostic nutritional index prospectively in 633 patients with digestive carcinoma making it possible to predict tumor resectability and occurrence of postoperative complications. The following factors were studied prior to surgery: age, sex, weight loss index, triceps skinfold thickness, midarm circumference, lymphocyte count, plasma albumin, transferrin and prealbumin levels, delayed hypersensitivity as investigated by 8 skin tests. The prognostic nutritional index was calculated using Mullen's formula. Unidimensional and multidimensional studies (linear discriminant and logistic discriminant analyses with partial correlations) were used for the statistical analysis. Mortality was 6,7 p. 100 while 16,2 p. 100 of patients presented a postoperative complication. The following variables showed a significant correlation with the resectability of the tumour: weight loss (p less than 0.0001), triceps skinfold thickness (p less than 0.01), midarm circumference (p less than 0.01), total lymphocyte count (p less than 0.01), plasma transferrin (p less than 0.01), delayed hypersensitivity (p less than 0.05). In the occurrence of postoperative complications there was a statistically significant value only to weight loss (p less than 0.001) and delayed hypersensitivity (p less than 0.05). Logistic discriminant analysis gave a linear model predicting tumor resectability in 78 p. 100 of patients and postoperative complications in 86 p. 100 of patients in which weight loss and delayed hypersensitivity were statistically significant. No prognostic value of Mullen's index was found. This study shows that assessment of the preoperative nutritional status of patients with gastrointestinal cancer makes it possible to predict tumor resectability and postoperative complications.

[Adrenal-posterior pituitary imbalance in digestive cancer patients]

In a group of 10 patients with a cancer of the digestive tract, some investigations, performed before the surgical intervention, showed the evidence of an adrenal-postpituitary imbalance in favour of the second term. During a water loading, the plasmatic cortisol rates stayed more higher by cancerous subjects than by controls (but not the plasmatic aldosterone rates); nevertheless, the vasopressin secretion rates could be considered as more higher yet in cancerous subjects because the free water clearances were significantly lowered by these patients. Such results have to be put in relation with the opposite effects of vasopressin and corticoids on the cell mitosis, as well as with some therapeutical attempts that end to check this type of endocrine imbalance.

[Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients]

Based on assessment of 200 malnourished cancer patients of digestive organs, a multiparameter index of nutritional status was defined to relating the risk of postoperative complications to base line nutritional status. The linear predictive model relating the risk of operative complication, mortality or both to nutritional status is given by the relation: prognostic nutritional index (PNI) = 10 Alb. + 0.005 Lymph. C., where Alb. is serum albumin level (g/100 ml) and Lymph. C. is total lymphocytes count/mm3 peripheral blood. When applied prospectively to 189 gastrointestinal surgical patients those who were malnourished and treated by TPN preoperatively, this index provided an accurate, quantitative estimate of operative risk. In general, resection and anastomosis of gastrointestinal tract can be safely practiced when the index is over 45. The same procedure may be dangerous between 45 and 40. In below 40, this kind of operation may be contraindicated. The prognostic nutritional index is useful also to know the prognosis of patients with terminal cancer. Despite practicing TPN to cancer patients with near terminal stages, if the PNI remains below 40 and total lymphocytes count remains below 1,000/mm3, the patients has high possibility to die within the next two months.