Genomic evolution in Barrett's adenocarcinoma cells: critical roles of elevated hsRAD51, homologous recombination and Alu sequences in the genome

A prominent feature of most cancers including Barrett's adenocarcinoma (BAC) is genetic instability, which is associated with development and progression of disease. In this study, we investigated the role of recombinase (hsRAD51), a key component of homologous recombination (HR)/repair, in evolving genomic changes and growth of BAC cells. We show that the expression of RAD51 is elevated in BAC cell lines and tissue specimens, relative to normal cells. HR activity is also elevated and significantly correlates with RAD51 expression in BAC cells. The suppression of RAD51 expression, by short hairpin RNA (shRNA) specifically targeting this gene, significantly prevented BAC cells from acquiring genomic changes to either copy number or heterozygosity (P<0.02) in several independent experiments employing single-nucleotide polymorphism arrays. The reduction in copy-number changes, following shRNA treatment, was confirmed by Comparative Genome Hybridization analyses of the same DNA samples. Moreover, the chromosomal distributions of mutations correlated strongly with frequencies and locations of Alu interspersed repetitive elements on individual chromosomes. We conclude that the hsRAD51 protein level is systematically elevated in BAC, contributes significantly to genomic evolution during serial propagation of these cells and correlates with disease progression. Alu sequences may serve as substrates for elevated HR during cell proliferation in vitro, as they have been reported to do during the evolution of species, and thus may provide additional targets for prevention or treatment of this disease.

High linear energy transfer (LET) radiation therapy in recurrent, metastatic, or unresectable rectal adenocarcinoma

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Background: The purpose of this study was to retrospectively analyze the outcomes of patients with recurrent, metastatic, or unresectable rectal adenocarcinoma treated with mixed beam photon and high LET radiotherapy.

Methods: Between 1995 and 2005, the high LET database was queried to identify patients with rectal adenocarcinoma. Local control and overall survival (OS) were calculated using the Kaplan-Meier method. Acute and chronic toxicities were graded using the common terminology criteria for adverse events (CTCAE) v4.0 grading system. Biological equivalent dose (BED) was calculated for tumor and normal tissue of both the photon dose and neutron dose for 10 patients.

Results: 11 patients with recurrent, metastatic, or unresectable rectal adenocarcinoma were identified as being treated with mixed photon-neutron radiation. The median age of patients in the study was 58 (range: 38-79). There were 8 male patients and 3 female patients. Median follow-up was 6 months (range: 4-76 months). Patients received a median photon dose of 40Gy (range: 26-50.4Gy) and a median neutron dose of 8nGy (range: 6-10nGy). Seven patients received radiation given concurrently with 5-FU. The median OS was 16 months (range: 4-76 months), with 1 and 2-year OS of 56% and 22%, respectively. Local control was achieved in 9 of 11 (82%) patients. Local progression occurring in two patients occurred at 5 months after completion of RT. The median tumor BED in patients achieving local control was 72.5 Gy (range: 57.1-83.5 Gy). There was a nonsignificant difference in median normal tissue BED of patients with grade 3-4 late toxicity of 104.8 Gy (range: 81.1-115.1 Gy), compared with 95.3Gy (range: 89.0-104.6 Gy) for those patients with grade 1-2 late toxicity.

Conclusions: Our experience demonstrates that treatment of unresectable rectal tumors with mixed photon-neutron achieved excellent local control. With the added capabilities of intensity modulated neutron radiation therapy (IMNRT), the incidence of treatment-related morbidity may be improved while taking advantage of the superior tumor control that high-LET radiation can impart.

No significant financial relationships to disclose.

Mixed photon and neutron radiotherapy given concurrently with chemotherapy in unresectable pancreatic cancer

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Background: Unresectable tumors of the pancreas remain difficult to treat despite the advent of targeted radiotherapy and modern chemotherapy. Randomized trials exploring the efficacy of chemotherapy and radiation have demonstrated median survival of 9 to 11 months. These survival times have not improved appreciably in the modern era. The purpose of this study was to retrospectively review our institutional experience with unresectable pancreatic cancer treated with mixed photon-neutron radiotherapy given concurrently with chemotherapy.

Methods: Thirteen patients with unresectable tumors of the pancreas were treated between 1993 and 2001. All patients were treated with mixed photon-neutron radiotherapy given concurrently with chemotherapy. Median photon dose was 39.6 Gy (30.6-45Gy) and median neutron dose was 8 nGy (7-9 nGy). 12 of 13 patients were treated with neoadjuvant chemotherapy, followed by 5-FU given concurrently with radiotherapy. Median survival, overall survival, and local control were calculated for all patients.

Results: The median age of all patients was 65 years (46-75 years). Twelve patients had histologic diagnosis of adenocarcinoma, with the other having an islet cell carcinoma. All patients are now deceased. Median survival for all patients was 11.5 months (3.0-25.6 months). The 1 and 2- year overall survival was 46.2% and 7.7%, respectively. Local control of the primary tumor was excellent at 92.3%. The rate of distant metastasis was 76.9%. One patient experienced decline without documented recurrence. No grade ≥3 acute toxicities were reported. However, there were 2 grade 5 late toxicities, both caused by gastrointestinal bleeding.

Conclusions: Our experience demonstrates that treatment of unresectable pancreatic tumors with mixed photon-neutron radiotherapy given concurrently with chemotherapy results in excellent local control, with survival time equivalent to or exceeding that demonstrated in previous series. With the added capability of intensity modulated neutron radiation therapy (IMNRT), the incidence of treatment-related morbidity may be improved while taking advantage of the superior tumor control that high-LET radiation may impart.

No significant financial relationships to disclose.

Affinity purification of DNA and RNA from environmental samples with peptide nucleic acid clamps

Bispeptide nucleic acids (bis-PNAs; PNA clamps), PNA oligomers, and DNA oligonucleotides were evaluated as affinity purification reagents for subfemtomolar 16S ribosomal DNA (rDNA) and rRNA targets in soil, sediment, and industrial air filter nucleic acid extracts. Under low-salt hybridization conditions (10 mM NaPO(4), 5 mM disodium EDTA, and 0.025% sodium dodecyl sulfate [SDS]) a PNA clamp recovered significantly more target DNA than either PNA or DNA oligomers. The efficacy of PNA clamps and oligomers was generally enhanced in the presence of excess nontarget DNA and in a low-salt extraction-hybridization buffer. Under high-salt conditions (200 mM NaPO(4), 100 mM disodium EDTA, and 0.5% SDS), however, capture efficiencies with the DNA oligomer were significantly greater than with the PNA clamp and PNA oligomer. Recovery and detection efficiencies for target DNA concentrations of > or =100 pg were generally >20% but depended upon the specific probe, solution background, and salt condition. The DNA probe had a lower absolute detection limit of 100 fg of target (830 zM [1 zM = 10(-21) M]) in high-salt buffer. In the absence of exogenous DNA (e.g., soil background), neither the bis-PNA nor the PNA oligomer achieved the same absolute detection limit even under a more favorable low-salt hybridization condition. In the presence of a soil background, however, both PNA probes provided more sensitive absolute purification and detection (830 zM) than the DNA oligomer. In varied environmental samples, the rank order for capture probe performance in high-salt buffer was DNA > PNA > clamp. Recovery of 16S rRNA from environmental samples mirrored quantitative results for DNA target recovery, with the DNA oligomer generating more positive results than either the bis-PNA or PNA oligomer, but PNA probes provided a greater incidence of detection from environmental samples that also contained a higher concentration of nontarget DNA and RNA. Significant interactions between probe type and environmental sample indicate that the most efficacious capture system depends upon the particular sample type (and background nucleic acid concentration), target (DNA or RNA), and detection objective.

Laparoscopically assisted transsacral resection of rectal cancer with primary anastomosis. A preliminary review

BACKGROUND

The management of rectal cancer has been changing to include more sphincter-sparing procedures. We report our initial experience with a new technique incorporating laparoscopy and a transsacral approach for low or midlevel rectal cancer. Here, we tried to determine whether this sphincter-sparing method could produce acceptable morbidity and recurrence rates.

METHODS

Patients with rectal cancer 4 to 8 cm from the dentate line underwent laparoscopically-assisted transsacral resection (LTR) with primary anastomosis. With this technique, the rectosigmoid is mobilized via laparoscopy while the patient is in the supine position. Next, the patient is placed in the prone jackknife position, and a segment of rectum is resected by a transsacral approach. Age, estimated blood loss, length of time in the operating room, length of stay, and postoperative complications were noted. Aspects of the tumor pathology regarding stage, lymph nodes, tumor size, and presence of tumor at resection margins also were recorded.

RESULTS

A total of 13 patients, ages 26 to 70 years (mean, 52.5 years), underwent the procedure. No perioperative deaths occurred. The mean hospital stay was 9.6 days. The average size of the rectal lesion was 4.3 cm in the largest dimension. The average specimen contained 11.5 total, and 2.0 metastatic lymph nodes. Postoperative complications included two anastomotic breakdowns and two other wound complications. Late follow-up evaluation ranged from 10 to 30 months, with 11 of 13 patients alive (85% survival). Two local recurrences and three distant recurrences were noted at long-term follow-up assessment.

CONCLUSIONS

In selected patients with low or midlevel rectal cancer, LTR may be a viable option. Further experience is necessary to define its oncologic efficacy and whether routine temporary diverting colostomy is indicated.

The syndromes of Sotos and Weaver: reports and review

The syndromes of Sotos and Weaver are paradigmatic of the daily nosologic difficulties faced by clinical geneticists attempting to diagnose and counsel, and to give accurate prognoses in cases of extensive phenotypic overlap between molecularly undefined entities. Vertebrate development is constrained into only very few final or common developmental paths; therefore, no developmental anomaly seen in humans is unique to ("pathognomonic" of) one syndrome. Thus, it is not surprising that prenatal overgrowth occurs in several syndromes, including the Sotos and Weaver syndromes. Are they sufficiently different in other respects to allow the postulation of locus (rather than allele) heterogeneity? Phenotypic data in both conditions are biased because of ascertainment of propositi, and the apparent differences between them may be entirely artificial as they were between the G and BBB syndromes. On the other hand, the Sotos syndrome may be a cancer syndrome, the Weaver syndrome not (though a neuroblastoma was reported in the latter); in the former there is also remarkably advanced dental maturation rarely commented on in the latter. In Weaver syndrome there are more conspicuous contractures and a facial appearance that experts find convincingly different from that of Sotos individuals. Nevertheless, the hypothesis of locus heterogeneity is testable; at the moment we are inclined to favor the hypothesis of allele heterogeneity. An international effort is required to map, isolate, and sequence the causal gene or genes.

Pseudocysts and pseudoaneurysms: surgical strategy

Eight patients over an 8-year period required operation for spontaneous hemorrhage as a complication of a pancreatic pseudocyst. Three patients presented with abdominal pain or jaundice and bled in hospital while undergoing work-up. Four patients were admitted with upper gastrointestinal bleeding and one with intraperitoneal bleeding. Five patients were managed by pancreatic resection (two of the head and three of the tail) and three were managed by arterial ligation and internal drainage. There was one death (mortality rate, 12.5%). The first four patients in the series had their operations delayed secondary to a perceived need for further work-up or an inability to make an exact diagnosis of the bleeding site. All rebled, necessitating an emergency operation. The last four patients underwent an expedited workup and operation. Successful treatment of bleeding pancreatic pseudocysts requires good surgical judgment, especially when nonoperative methods fail or aren't applicable. The risk of recurrent hemorrhage is high, suggesting the need for immediate intervention once the diagnosis is made. Resection provides definitive control, although selected patients with easily accessible vessels may be managed more conservatively with ligation and drainage.

Bleeding gastroduodenal ulcers: improved outcome from a unified surgical approach

We have adopted a uniform, aggressive approach to the management of upper gastrointestinal hemorrhage. Our protocol consists of admission to a surgical service, endoscopy within 24 hours, and liberal use of intensive care monitoring. Urgent or emergency surgery is recommended for the following criteria: 1) presence of shock upon admission; 2) resuscitation requirements of greater than 4 units of blood; 3) age 65 years or older; 4) ulcer size greater than 2 cm or with stigmata of recent hemorrhage; or 5) history of a previous admission for an ulcer complication. During the period 1986-1990, 66 patients met the criteria for operation. There were 45 males and 21 females with an average age of 53.5 years (range, 29-84). Thirty-seven bled from a gastric ulcer and 29 from a duodenal ulcer. They were transfused an average of 5.0 units of blood (range, 0-13). There were no hospital deaths, but 11 patients (16.7%) had 12 postoperative complications. We conclude that a unified, single team approach to gastroduodenal hemorrhage with expedited work-up and early operation prevents death from this treatable condition.

Differential diagnosis and management of unexplained bleeding

A brief overview of normal hemostasis is reviewed. Congenital and acquired causes of bleeding are discussed. Methods for evaluation of the coagulation system of the patient prior to an operative procedure are outlined. A strategy for characterizing intraoperative bleeding disorders and appropriate interventions are discussed.

Alternatives in the surgical management of in situ breast cancer. A meta-analysis of outcome

The surgical management of lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS) remains controversial. For in situ breast cancer local excision (LE), local excision and radiation therapy (LERT) and mastectomy (MAST) have all been advocated. A search of the English literature found 13 reports concerning the surgical management of LCIS and 12 reports concerning the management of DCIS. The data were combined in a meta-analysis of outcome. As expected, recurrence rates following LE with both LCIS 8.4%) and DCIS (17%) are high. However,the overall mortality following mastectomy for recurrence, LCIS (2.8%) and DCIS (2.3%) does not differ statistically from those treated initially with mastectomy for LCIS (0.9%) and DCIS (1.7%). We conclude from these data that local recurrence after breast conserving procedures for in situ breast cancer does not carry an ominous prognosis. This knowledge should aid in planning individual therapy.

The impact of technology on the management of pancreatic pseudocyst. Fifth annual Samuel Jason Mixter Lecture

The records of 299 patients with 357 admissions for pancreatic pseudocysts seen between 1960 and 1989 were studied; 233 patients underwent operation. The natural history of pancreatic pseudocysts has been clarified by newer technology, such as ultrasonography, computer tomography, amylase isoenzyme measurements, and endoscopic retrograde cholangiopancreatography. All have influenced diagnosis, nonoperative management, and surgical operation. Differences between pancreatic pseudocysts associated with acute pancreatitis in contrast with chronic pancreatitis, and the complications of obstruction, hemorrhage, rupture, pancreatic ascites, infection, and jaundice can now be more rationally treated. Pancreatic pseudocysts and pancreatic ductal changes are now revealed earlier, especially by endoscopic retrograde cholangiopancreatography. Paradoxically, this information has encouraged nonoperative conservative therapy and also larger operations, eg, resection and adjunctive pancreaticojejunostomy. Partial resection of the pancreas together with the pancreatic pseudocysts was performed in 58 (25%) of the 233 patients. Recent technology permits cautious exploration of selective pancreatic pseudocyst drainage percutaneously or transgastroduodenally avoiding laparotomy.

Percutaneous Denver peritoneovenous shunt insertion

A simplified technique for insertion of a peritoneovenous shunt is described. By using a "peel-away" sheath at both ends of the shunt, the insertion is much quicker and less traumatic to the patient.

A community survey of the potential use of thrombolytic agents for acute myocardial infarction

We surveyed all patients admitted to nine community hospital coronary care units to determine what proportion could be candidates for thrombolytic therapy. During the 12-month study period, there were 4,115 admissions for possible acute myocardial infarction, and 1,076 (26%) had a discharge diagnosis of myocardial infarction. Patients with myocardial infarction had the following characteristics: 60% had ST elevation seen on the first ECG, 17% had ST depression without ST elevation, 75% were less than 75 years old, 75% had no contraindications to thrombolytic therapy, 78% arrived at hospital within six hours of onset of symptoms, and 94% arrived within 24 hours of symptoms. Criteria for administration of thrombolytic therapy can be grouped as restrictive (arrival within six hours of symptoms and ST elevation) or liberal (arrival within 24 hours of symptoms and ST elevation or ST depression). Applying these characteristics, 26% met restrictive criteria for treatment with thrombolytic therapy, and 36% met liberal criteria. Until liberal criteria (therapy up to 24 hours and ST depression) are convincingly shown to be of benefit, we believe clinicians should apply restrictive criteria to potential candidates for thrombolytic therapy.

Peritoneovenous shunt (PVS) for malignant ascites. An analysis of outcome

Fifty cases of malignant ascites were studied to determine what factors influenced outcome after peritoneovenous shunt. There were 36 women and 14 men. The five most common tumor types were colon, breast, gastric, pancreatic, and unspecified adenocarcinoma. Multivariate analysis between those patients surviving longer than 7 weeks (n = 20) and those who died in less than 7 weeks (n = 30) showed that women did uniformly better than men, even excluding the "female malignancies" (P less than 0.01). An elevated white blood cell count (WBC) and low platelets also were strong predictors of poor outcome (P less than 0.5 for difference in means between the two groups). Patients with pancreatic cancer and ascites fared poorly (80% mortality by 7 weeks) as did those with colon cancer (73% mortality by 7 weeks). By contrast, 50 per cent of the patients with breast and gastric cancer lived more than 7 weeks. Twelve patients had a LaVeen shunt placed, compared with 38 who had a Denver shunt. Fifty per cent of the La Veen shunts failed, with a mean time to failure of 69 days (P less than 0.01). Shunt failure, however, had no influence on overall survival.

Percutaneous endoscopic gastrostomy. New technique--old complications

Early reports support the percutaneous endoscopic gastrostomy (PEG) as an alternative to traditional gastrostomy with lower cost, greater ease of placement, and low morbidity and mortality. The authors' bias has been to attempt PEG on nearly all patients referred to gastrostomy tube prior to performing open gastrostomy. In this light, we reviewed our 32 month experience of 115 PEG placements in 112 adult patients, with a mean follow-up of 59.4 days. Placement was unsuccessful in ten per cent of patients and difficult in another six per cent. Minor postoperative complications not requiring intervention occurred in 9.5 per cent of patients, and major complications in 20 per cent. Infection was the most common postoperative problem. Thirty day mortality was 24 per cent. No patient died as a direct result of the procedure. The ten per cent failure rate is a consequence of attempting PEG as the initial procedure in greater than 90 per cent of patients. PEG can be employed as an initial procedure in even the sickest of patients with a high rate of success, and morbidity comparable to open gastrostomy. This knowledge allows early PEG placement in all types of patients, thereby facilitating their transfer to a non-acute care environment.

Colon cancer: surgical therapy

Successful treatment of colon cancer is founded on surgical resection of the primary lesion and the regional lymph nodes. The significant number of patients so resected who experience no recurrence, even with positive lymph nodes, indicates that the disease still was confined regionally and that the therapy was effective. Cancer in about 50 per cent of patients does recur, however, and, outside of a small proportion who can be resected again, all patients with recurrence die. There is virtually no curative nonsurgical therapy for colorectal carcinoma.

Surgical management of pseudomembranous colitis

The authors recently studied two cases of pseudomembranous colitis (PMC) that required surgery and combined them with previously reported cases in the literature, which required surgery to propose guidelines for the surgical management of PMC. A total of 21 patients were studied. Indications for surgery included refractory disease in seven patients, toxic megacolon in 12 patients, and perforation in two patients. Operative management ranged from decompressive cecostomy to total proctocolectomy. The best results were obtained with subtotal colectomy and ileostomy. It is concluded that PMC should be managed surgically in a manner analogous to ulcerative colitis. If there is no improvement after 7 days of aggressive medical management, surgical intervention, ileostomy with subtotal colectomy is indicated to prevent complications. Complications of PMC, toxic megacolon and perforation, should also be managed with ileostomy and subtotal colectomy as simple decompression or segmental resection does nothing to alter the underlying disease process.

Gastrojejunostomy: is it helpful for patients with pancreatic cancer?

A retrospective review of palliative outcome of gastrojejunostomy in patients with pancreatic cancer was conducted. Eighty-one patients were analyzed in two groups depending on duodenal patency. Forty-five patients (group I) had no evidence of duodenal obstruction. Thirty-six patients (group II) had evidence of impingement on the duodenum by the pancreatic cancer. A third subset of patients was also studied for outcome. These 21 patients (five group I and 16 group II) had nausea and vomiting as major symptoms and were judged to have the most to gain from gastrojejunostomy. Patients were categorized by outcome. Poor outcome was defined as either death during the hospitalization for gastrojejunostomy or death within 30 days of operation even if the patient left the hospital. Risk for poor outcome depended on group. In group I, 18 of 45 patients (40%) had a poor outcome compared with 25 of 36 (70%) patients in group II (p less than 0.001). Nineteen of the 21 (90%) patients with nausea and vomiting had a poor outcome. It is an unfortunate paradox that the more patients need gastrojejunostomy for pancreatic cancer, the less likely they are to have a favorable outcome. Gastric outlet obstruction in pancreatic cancer appears to be a terminal event. A prospective study is needed to see if any true palliation of vomiting can be affected in these patients.

Analysis of hyperamylasemia in patients with severe head injury

To evaluate the influence of severe head injury (SHI) on amylase activity, we studied the amylase profile of 60 patients with SHIs and Glasgow Coma Scores less than 10. Fourteen additional multiple trauma patients without head injuries were studied as a control group. We excluded patients with pancreatic injury and abdominal trauma. Total serum amylase (TA), pancreatic isoamylase (PA), and nonpancreatic isoamylase (NPA) levels were measured on Days 0, 2, 4, 7, and 14 postinjury. Values greater than 2 SD above the normal mean were considered elevated. All SHI patients were comatose; 14 died. In the SHI group, TA increased in 23 patients, PA increased in 40, and NPA increased in 14. The source of hyperamylasemia was PA in 14, NPA in one, and mixed in 8 patients. While PA increases occurred throughout the study, NPA elevations occurred early. These increases did not correlate with shock (BP less than 80 mm Hg; 17 patients), facial trauma (24 patients), or associated injury (29 patients). On Day 7 postinjury, the mean TA (215 du%) and the mean PA (203.8 du%) were significantly elevated in the SHI patients compared to controls (122.1 du%, P less than 0.05, Wilcoxon's rank sum test). These data indicate that serum amylase is not a reliable index of pancreatic injury in patients with SHI. Severe head injury and multiple trauma activate pathways that increase amylase levels in the blood, suggesting a central nervous system regulation of serum amylase levels.

Usefulness of selective preoperative chest x-ray films. A prospective study

Preoperative screening chest x-ray studies continue to be used widely despite the high cost and reported low-yield. Most physicians now use "clinical judgment" to mitigate the frequency of chest x-ray. To determine the usefulness of "selective" preoperative chest x-ray studies, 403 consecutive patients undergoing operation were prospectively studied. Chest x-ray films were analyzed both for abnormality and the frequency with which the changes seen on x-ray films led to cancellation of surgery or resulted in a further evaluation of the pathology discovered. There were 228 male and 175 female patients, (average age: 54 years). A total of 166 (41%) patients had operations performed without a preoperative chest x-ray study. The x-ray studies on 136 of the 237 patients who had preoperative chest x-ray were considered normal. A variety of abnormalities such as effusion, cardiomegaly, atelectasis, or granuloma were found in the remaining 101 patients. Sixty-four of these patients were known from previous studies to have the abnormality that was recorded. Eight of 37 (21%), who had surgery as scheduled, subsequently underwent evaluation for the new pulmonary problem detected on x-ray films. Only two operations were cancelled as a result of the screening x-ray. The majority of abnormalities detected were already known or were considered insufficient for further evaluation. In a metropolitan area of Michigan the cost for a chest x-ray is $70. Projected nationwide, more than $1 billion could be saved on needless "selective" preoperative chest x-ray studies each year. These data suggest that preoperative chest x-ray is still widely overused.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal obstruction in cancer patients. An assessment of risk factors and outcome

Eighty-four patients with a total of 104 admissions for intestinal obstruction who each also had a history of cancer had their records reviewed to determine what variables, if any, would help predict outcome. Multivariate discriminate analysis was used to assign the patient into one of three outcome possibilities: 1) alive and well, 2) alive with intestinal obstruction, and 3) dead. The computer accurately assigned outcome 71 per cent of the time. Twenty-four per cent of the patients had no cancer found at laparotomy, and had good results. Patients with carcinomatosis did poorly. Females fared much better than males. The natural history of patients with intestinal obstruction and cancer is that about 35 per cent leave the hospital eating normally, 20 per cent are alive but unable to eat, and 45 per cent die on the same hospital admission or shortly thereafter.

Upper gastrointestinal endoscopy for diagnosis of complications of regional hepatic chemotherapy

Seven of 26 patients undergoing insertion of "Infusaid" perfusion pumps with hepatic artery catheters for regional hepatic perfusion with 5 fluorodeoxyuridine were diagnosed to have gastritis (n = 5) or penetrating duodenal ulcers with catheter exposure (n = 2). Diagnosis is best achieved by esophagogastroduodenoscopy. The ulcers required removal of the pumps and gastric resections. The gastritis responded only to cessation of drug infusion. These complications represent a significant risk to regional hepatic chemotherapy. Physicians caring for this group of patients will be unable to predict which individuals will suffer these complications when using preoperative or postoperative parameters such as age, sex, tumor type, arterial anatomy or flow patterns on nuclear isotope scanning. A high index of suspicion must be maintained during the critical third and fourth cycles of chemotherapy in all patients undergoing regional hepatic chemotherapy.

The poor man's isoamylase analysis (wheat inhibitor). Does it work?

The value of a wheat inhibitor assay to measure the pancreatic isoamylase fraction in the serum was evaluated in a clinical trial. Fifty-four patients with a variety of disorders and wide range in serum amylase levels were studied comparing pancreatic isoamylase levels measured by both cellulose acetate membrane electrophoresis and wheat inhibitor assay. The overall correlation was excellent (r = 0.96), and was best when the total serum amylase was high. The predominate serum isoamylase was correctly predicted in 45 of 54 (83%) patients, with an overall specificity of 73 per cent and sensitivity of 96 per cent. Because it is easy to perform, the test is recommended for clinical use by those without access to more sophisticated forms of isoamylase analysis.

Serum amylase and its isoenzymes: a clarification of their implications in trauma

Previous reports on the use of the serum amylase level to assess pancreatic injury in patients with blunt abdominal trauma have been disappointing. The availability of methods to measure the serum isoamylases (P & NP) might be expected to improve the accuracy with which the serum amylase level is used. Sixty-one patients treated for a variety of blunt trauma injuries were studied. All categories of injury were included. Isoamylase levels were determined from admission sera and were compared to injuries found at laparotomy. Three patients had major pancreatic injury but only two of these patients showed a rise in the pancreatic isoamylase. Sixteen additional patients had a rise in the pancreatic isoamylase without evidence of pancreatic injury. Eight of these patients had no component of abdominal injury whatsoever. Two patients with isolated head injury had substantial elevations of pancreatic isoamylase. The regulation of serum amylase is multifactorial and variable. The measurement of serum isoamylase levels does not offer great improvement over the serum amylase in evaluating patients with blunt abdominal trauma.

Outcome after peritoneo-jugular shunting of pancreatic ascites

Three patients with pancreatic ascites documented by ascitic fluid protein greater than 2.5 g/dl and elevated amylase in their peritoneal fluid were treated by peritoneo-jugular shunting (PJS). Patient 1 was so treated inadvertently; Patient 2 had resolving amylase levels but increasing amounts of ascites; Patient 3 had clear, active pancreatic ascites. None incurred untoward effects from this procedure. Ventilatory compromise from reduced diaphragmatic excursion was ameliorated in all patients. Two patients required no further therapy. The third patient was greatly improved in preparation for definitive surgical therapy for a leaking pancreatic pseudocyst. The infusion of enzyme-rich fluids into the circulation may be responsible for certain systemic effects of pancreatitis. Coagulation defects are a known complication of PJS for the ascites of Laennec's cirrhosis. There was no evidence of histamine-mediated cardiovascular collapse, exacerbation of respiratory failure, or coagulation defects in these patients. We conclude that these complications are not the inevitable results of PJS of pancreatic ascites.

Hyperamylasemia after cardiopulmonary bypass

Postpump pancreatitis has been described to occur in patients undergoing cardiac surgery with cardiopulmonary bypass. Twenty patients were prospectively analyzed with sera drawn for total serum amylase, pancreatic isoamylase, and nonpancreatic isoamylase levels. Six of 19 patients were found to be hyperamylasemic postoperatively, the majority of which were not due to pancreatic isoamylasemia . No patient had clinical pancreatitis. These findings suggest that elevations of serum amylase is common after cardiopulmonary bypass and is not indicative of pancreatitis.

Alcohol-induced salivary hyperamylasemia

The effects of alcohol intoxication on serum amylase levels were tested in both normal subjects and chronic alcoholics. Paired samples of ethanol levels and isoamylase levels in the normal subjects (n = 11) showed a rise in both total serum amylase (P less than 0.01) and nonpancreatic isoamylase (P less than 0.05) after drinking. Unpaired cohort groups of sober chronic alcoholics at a rehabilitation facility (n = 46) and intoxicated chronic alcoholics in an emergency room (n = 58) were also compared. Average blood alcohol levels in the intoxicated controls were 93 mg% compared to a level of 301 mg% in the intoxicated chronic alcoholic. Intoxication superimposed on chronic alcoholism caused a moderate rise in the total serum amylase (NS) and a significant elevation of the nonpancreatic isoamylase (P less than 0.01). Sober chronic alcoholics had a significantly greater average total serum amylase (P less than 0.001) and nonpancreatic isoamylase (P less than 0.01) than the normal controls. No difference in the average pancreatic isoamylase levels was seen in any group. These data suggest a biphasic response to alcohol on the serum amylase level. Acute and chronic changes appear to operate independently. The cause for these effects is speculative. Isoamylase analysis is needed in the alcoholic population to sort out the meaning of hyperamylasemia.

Hyperamylasemia: a result of intracranial bleeding

The unexpected finding of hyperamylasemia in a patient with isolated head injury prompted a study of amylase levels in patients with various degrees of cranial trauma. None of seven patients with isolated maxillofacial trauma had hyperamylasemia. This group was studied to discount injury to salivary glands as a source of elevated amylase levels. Only one of ten patients with simple cranial injury without computerized tomographic (CT) scan evidence of intracranial bleeding had hyperamylasemia. Six of ten patients with CT scans positive for intracranial bleeding had hyperamylasemia. Isoamylase analysis showed that the source of the hyperamylasemia was varied. These results suggest a central neural control of serum amylase levels. The reliability of the serum amylase level as an indication of pancreatic trauma in a patient with concomitant head injury is questioned.

Foregut mucosal defects: an etiology of hyperamylasemia

To evaluate a preliminary correlation of hyperamylasemia to upper gastrointestinal bleeding, total serum amylase and serum isoamylase profiles were determined in 50 patients with upper gastrointestinal bleeding. Etiologies of the bleeding were determined in 46 patients including gastritis or duodenitis in 25, gastric ulcers in 12, duodenal ulcers in 3, Mallory-Weiss tears in 3, gastric carcinoma in 2, and esophageal varices in 1. Gastritis or duodenitis was seen incidentally in 14 more patients. Hyperamylasemia was seen in 38 patients, most commonly being due to a rise of both nonpancreatic and pancreatic isoamylases (18 patients). In 13 patients it was due to an elevation of nonpancreatic amylase alone, and in 7 patients secondary to elevated pancreatic isoamylase alone. Acute pancreatitis raises only the pancreatic component and cannot explain the hyperamylasemia in most of these patients. Hyperamylasemia did not correlate to etiology of the bleeding; gastritis or duodenitis present in the majority of these patients appears to be the unifying factor. Since both nonpancreatic and pancreatic amylases are present in the duodenum and the stomach with pyloric reflux, reabsorption of intraluminal amylase across damaged mucosa is postulated as a mechanism to explain the observed isoamylase patterns. The possibility of decreased amylase clearance as an explanation is unlikely. An alternative central nervous system mechanism might be invoked. It is concluded that hyperamylasemia is a complex event which the use of isoamylase analysis is beginning to elucidate. The hyperamylasemia seen commonly in patients presenting with upper gastrointestinal bleeding does not imply the presence of acute pancreatitis.

Acute alcohol intoxication: significance of the amylase level

To evaluate the effects of acute alcohol intoxication on serum amylase and isoamylase levels, 58 clinically intoxicated patients with blood alcohol levels greater than 100 mg/dL were studied. Comparisons were made to normal control and a sober chronic alcoholic group. Admitting serum isoamylase levels were determined by cellulose acetate membrane electrophoresis and serum amylase levels measured by the Amylochrome technique. The average blood alcohol level in the intoxicated group was 301 +/- 99 mg/dL. Thirty of the 58 patients had hyperamylasemia (greater than 207 IU). Twenty-five of these 30 patients had hyperamylasemia from nonpancreatic sources (increased salivary isoamylase). Two of the 30 patients had pancreatic hyperamylasemia and three patients had elevated levels of both isoamylases. Neither of the patients with pancreatic hyperamylasemia had clinical evidence of acute pancreatitis. Although nine of the 58 patients had abdominal pain and clinical symptoms suggestive of acute pancreatitis, none of these patients had elevated pancreatic isoamylase. The finding of hyperamylasemia in acutely intoxicated patients is common. This is most frequently due to a rise in the salivary (nonpancreatic) isoamylase. The reliability of the total serum amylase as an indication of pancreatic disease in the intoxicated patient is questioned.

A correlation between clinical pancreatitis and isoenzyme patterns of amylase

Fifty-seven patients admitted with the clinical diagnosis of acute pancreatitis had isoamylase analysis on their sera to determine the source of their hyperamylasemia. Our objective was to correlate the isoamylase pattern with our clinical observations. Thirty-nine of 57 patients (68%) had pancreatic hyperamylasemia as expected, but 18 of 57 patients (32%) had normal levels of pancreatic amylase. The hyperamylasemia in the latter group was due either to nonpancreatic hyperamylasemia (16 of 57) of macroamylasemia (2 of 57). Consequently, hyperamylasemia associated with abdominal pain, nausea, and vomiting led to the incorrect diagnosis of acute pancreatitis in 32% of the patients. The measurement of isoamylase profiles can be done rapidly and inexpensively. Knowledge that hyperamylasemia is nonpancreatic in origin may have an important influence on treatment, hospitalization, and the extent of laboratory and radiologic investigation.

A continuing appraisal of pancreatic ascites

Pancreatic ascites is a distinct clinical entity characterized by elevated amylase and protein levels in the ascitic fluid. This should be distinguished from the ascites of cirrhosis, tuberculosis or metastatic carcinoma. Precise delineation of the ductal anatomy by endoscopic retrograde pancreatography preoperatively will enhance the ability of the surgeon to plan a rational operation and will, thereby, provide the best results. Medical treatment may obviate surgical intervention in a small number of instances but contains intrinsic hazards and should not be prolonged beyond three weeks. In carefully selected patients, limited pancreatic resection, encompassing the site of leakage, produces excellent results.

Aged amylase: a valuable test for detecting and tracking pancreatic pseudocysts

Amylase-rich fluid that incubates ("ages") within a pancreatic pseudocyst undergoes a change that can be detected by isoenzyme analysis of amylase from the serum. This aging is a result of deamination of the asparagine and glutamine residues on the amylase molecule. Eighteen of 20 patients with surgically proved pseudocysts had greater than 15% aged (deaminated) amylase in their serum. Levels of aged amylase returned to normal following treatment of their pseudocysts. Twenty of 23 patients with acute pancreatitis had levels of aged amylase below 15% (P less than .05). A criterion of 15% aged amylase resulted in 87% specificity, and 91% sensitivity for the diagnosis of pseudocysts. Because this test is noninvasive and easy to perform, it should become the ideal screen for patients at risk of development of pseudocysts, Endoscopic retrograde pancreatography, ultrasonography, and abdominal computed tomographic scanning should be reserved for confirmation of the diagnosis when the result of isoenzyme analysis is positive.

Pulmonary effects of albumin resuscitation for severe hypovolemic shock

The effect of albumin when added to the resuscitation regimen of patients in hypovolemic shock was studied in a randomized prospective manner in 52 injured patients who received an average of 15.3 transfusions, 9.6 liters of balanced electrolyte solution, and 980 ml of fresh frozen plasma. Before and during operation, 27 patients received an average of 25 gm of albumin and 150 gm/day for three to five days. Patients who received albumin had greater dependence on respiratory support, averaging eight days while receiving ventilatory support with volume ventilator compared with three days in patients not receiving albumin. Furthermore, patients receiving albumin had forced inspiratory oxygen/Pao2 ratios that were statistically and significantly higher than those of patients not receiving albumin during all phases of their hospital course. These effects were associated with increased plasma volumes caused by the oncotic effects of albumin and by its interference with saline diuresis. On the basis of this preliminary report, albumin seems to have a detrimental effect on respiratory function.