Résection rectale pour cancer par laparoscopie avec exérèse totale du mésorectum (ETM). Résultats à long terme d'une série de 179 patients

BACKGROUND

The purpose of this study was to evaluate the outcomes and the five-year survival of 179 consecutive patients with rectal carcinoma operated with a laparoscopic procedure between April 1992 and April 2003.

METHODS

Patients with obstructing, bulky cancers were excluded from this study. Tumor stage was defined according to the TNM classification. Preoperative radiation therapy was offered to T(3) N(0) or N(+) patients (45 Gy). The laparoscopic-assisted technique included total mesorectal excision (TME), primary high vascular ligation, centrifugal dissection of the mesentery, and "no touch" technique. All the N+ patients received adjuvant chemotherapy. The outcomes were defined as five-years recurrence (local recurrence and distant metastasis) and the diseases-free survival. The survival rates were calculated with the Kaplan-Meier test.

RESULTS

There were 108 males and 71 females, median age was 67 (range 39-88). There were 61 upper rectum localizations (34%), 68 middle rectum (38%) and 50 low rectum (28%). Twenty-nine patients required open conversion (16%). Surgical operative morbidity was 24% and medical morbidity was 4%. There were 60 stage I (40%), 25 stage II (16%), 49 stage III (32%), and 16 stage IV (10%). Ninety patients (71%) are alive and disease free, ten (5%) are alive with disease recurrence, and 37 patients (20%) are deceased. Only one case of trocar site implantation occurred after curative resection during an average follow up of 76 months. Five-year observed survival rate were 85% for stage I, 70% for stage II, and 63% for stage III.

CONCLUSION

In our experience laparoscopic rectal resection could be done safely. The oncologic outcome was similar to that of open surgery. Further randomized trials will be necessary to confirm the value of this technique.

Laparoscopic rectopexy for full-thickness rectal prolapse: a single-institution retrospective study evaluating surgical outcome

BACKGROUND

The laparoscopic approach promises to become the gold standard for the transabdominal management of full-thickness rectal prolapse. The aim of this study was to review our experience and to highlight the functional results achieved with this new technique.

METHODS

Forty-eight patients with full-thickness external prolapse underwent laparoscopic repair between February 1997 and February 2003. All patients underwent preoperative evaluation of their rectal function. Patients with isolated rectal ulcer without prolapse or with internal prolapse and patients deemed by the anesthesiologist to be unfit for general anesthesia were excluded from the study. The laparoscopic technique was either a mesh rectopexy without resection (n = 35) or a suture rectopexy with sigmoid resection (n = 13). Patients with intractable constipation preceding the development of the rectal prolapse were advised to have a resection-rectopexy. In the postoperative follow-up, attention was paid to mortality, morbidity, recurrent prolapse, incontinence, and constipation. Follow-up was done by clinical review and postal questionnaire.

RESULTS

There were no deaths and no septic or anastomotic complications. The postoperative morbidity rate was 5%. Oral intake was started on postoperative day 1. Discharge from the hospital was on postoperative day 4 in patients without sigmoid resection and on postoperative day 7 in patients with sigmoid resection. Two patients (4%) developed recurrent total prolapse during a median follow-up period of 36 +/- 15 months (range, 7-77). The functional results were good or excellent in 72% of the cases, without digitations or dyschesia. Continence was improved in 31% of the patients and remains unchanged in 64% of them. In 11 patients (23%), constipation was worsened by the procedure.

CONCLUSION

Laparoscopic rectopexy with or without resection is both safe and effective. Advantages include low-morbidity, improved cosmesis, the rapid return of intestinal function, early discharge from hospital, and a low recurrence rate. The fecal continence score is improved; however, constipation is frequently worsened.

Effects of hypothermic machine perfusion on rat liver function depending on the route of perfusion

BACKGROUND AND METHODS

The aim of this study was to evaluate the efficacy of hypothermic machine perfusion (HMP) to preserve rat livers according to the route of perfusion, i.e., via portal vein, hepatic veins (retrograde), or hepatic artery. Livers were preserved for 24 or 48 hr by simple cold storage (SCS) or by HMP. Preservation solution was supplemented with (HMP) or without (SCS) hydroxyethyl starch. After preservation, grafts were reperfused for 2 hr with an oxygenated Krebs-Henseleit bicarbonate buffer.

RESULTS

After 24 hr of preservation, total glutathione concentrations in HMP livers were similar (1287+/-37, 1418+/-118, and 1471+/-62 nmol/g in hepatic artery, portal vein, and hepatic vein HMP livers, respectively) and higher than in the SCS (833+/-118 nmol/g, P<0.05) group. These higher total glutathione values were due to higher reduced glutathione concentrations. ATP concentrations in the liver tissue were similar in HMP groups (0.75+/-0.4, 0.64+/-0.1, and 0.77+/-0.1 micromol/g in hepatic artery, portal vein, and hepatic vein HMP livers, respectively) and higher than in SCS (0.32+/-0.06 micromol/g, P<0.05). After 2 hr of normothermic reperfusion, bile production in the HMP portal and HMP retrograde groups were similar (391+/-29 ml and 372+/-25 ml) and higher than in the HMP artery or SCS groups (275+/-25 ml and 277+/-32 ml, respectively; P<0.05). Aspartate transaminase, alanine transaminase, lactate dehydrogenase, and purine nucleoside phosphorylase release into the perfusate of HMP portal and HMP retrograde perfused livers was similar and significantly lower compared to the HMP artery and SCS groups. At the end of reperfusion, no statistical differences were found for glutathione concentration and energetic reserves in the livers of each group. After 48 hr of preservation, livers from the HMP portal and HMP retrograde groups did significantly better than livers from the HMP artery or SCS groups.

CONCLUSIONS

This study confirms the superiority of HMP over SCS to preserve the liver graft. It shows that retrograde perfusion is similar to PV perfusion and that perfusion by HA is less beneficial.

Increased extracellular matrix remodeling is associated with tumor progression in human hepatocellular carcinomas

Matrix metalloproteinase-2 (MMP2) is a key enzyme in the process of extracellular matrix remodeling involved in tumor invasion and metastasis. The activation of MMP2 involves interplay with the membrane type-matrix metalloproteinase-1 (MT1-MMP) and the tissue inhibitor of metalloproteinase-2 (TIMP2). In vitro, activated hepatic stellate cells are a main source of MMP2 and collagen I induces MMP2 activation. The steady-state mRNA levels of MMP2, MT1-MMP, TIMP2, collagen I, collagen IV, and laminin gamma1 were compared with MMP2 activity in 55 hepatocellular carcinomas, 47 matching nontumor biopsies and 19 histologically normal livers. In hepatocellular carcinomas, increased collagen I mRNA levels were strongly associated with those of MMP2 (Spearman R =.74, P <.001), MT1-MMP (R =.65, P <.001) and TIMP2 (R = 0.61, P <.001). MMP2 activity was correlated with the mRNA expression of collagen I (R =.45 P <.01), collagen IV (R =.40, P <.01) and laminin gamma1 (R =.33, P <.05). Unlike collagen IV and laminin gamma1 mRNAs, MMP2, MT1-MMP, TIMP2, collagen I mRNA levels were increased in nonencapsulated compared with encapsulated tumors (P <.05). In addition, MMP2 activity was fourfold higher (P <.01) in tumors arising in cirrhotic livers than in those arising in noncirrhotic livers. Moreover, tumor recurrence was associated with 4.6- and 2.8-fold (P <.05) higher collagen I and MMP2 mRNA levels, respectively, in hepatocellular carcinomas arising in cirrhotic livers. Thus, a high extracellular matrix remodeling favors tumor progression in hepatocellular carcinomas.

Quantitation of chemokines (MDC, TARC) expression in mucosa from Crohn's disease and ulcerative colitis

Chemokines and their receptors are involved in the migration of different mononuclear cells. Among them macrophages-derived chemokines (MDC) and thymus-and activation regulated chemokine (TARC) belong to a new cluster of genes involve in Th2 lymphocytes homing. Cytokines appear to play a significant role in pathogenesis of inflammatory bowel diseases with an excessive Th1 response in chronic lesions of Crohn's disease (CD) and a Th2 pattern in both earlier mucosal CD lesions and in mucosa of ulcerative colitis (UC). Here we demonstrate that RNAm coding for MDC and TARC are expressed in mucosa from CD and UC patients. Using real-time fluorescent RT-PCR, MDC and TARC mRNA were increased in CD inflamed mucosa. Moreover MDC and TARC transcripts were increased in inflamed CD specimen compared to non-involved CD mucosa. These differences both discriminate CD from UC patients. Additionally, MDC protein was produced in isolated mononuclear cells from peripheral blood (PBMC) or mucosa (LPMC) from UC and CD patients: spontaneously, MDC production from PBMC was increased in CD compared to UC patients. MDC production from CD PBMC was also higher than that found in healthy controls. Together, these data indicate that MDC should be involved in the lymphocytes homing in mucosa from CD patients.

A new mutation of E-cadherin gene in familial gastric linitis plastica cancer with extra-digestive dissemination

Over a 12-month period, we diagnosed poorly differentiated infiltrative independent-cell gastric adenocarcinoma in two brothers and one sister aged 41 to 47 years. Their father had died from antral cancer at the age of 34 years. These cancers had two characteristic clinical features: rapid course and distant malignant dissemination. In all three patients, polymerase chain reaction-sequencing of the E-cadherin (CDH1) gene of white blood cells identified a heterozygous nonsense mutation of exon 3, producing a stop codon at position 95 (Q95X), resulting in a truncated protein. The alteration of this protein, which plays a crucial role in epithelial cell adhesion, probably explains the clinical expression in this type of familial diffuse gastric cancer.

Tumor hepatocytes and basement membrane-Producing cells specifically express two different forms of the endostatin precursor, collagen XVIII, in human liver cancers

Endostatin is an endogenous inhibitor of angiogenesis and tumor growth in mice, which may be generated by proteolytic cleavage of collagen XVIII. In normal tissues, 2 variants of the endostatin precursor, namely the SHORT and LONG forms, regulate tissue specificity. We analyzed 53 human liver biopsies (18 hepatocellular carcinomas, 16 metastases of colorectal cancer, 3 cholangiocarcinomas, and 16 controls) by RNA dot blots, double-labeling immunohistochemistry, and in situ hybridization, using common and variant-specific probes. Tumor hepatocytes expressed the LONG form, whereas cholangiocarcinoma cells expressed the SHORT form, which was deposited in tumor basement membranes. Metastatic colorectal carcinoma cells did not express collagen XVIII. In the stromal compartment of primary and metastatic cancers, myofibroblasts and vascular endothelial cells expressed the SHORT form. Both basement membrane components, collagen IV and the SHORT collagen XVIII form, were codistributed and their mRNA levels strongly correlated (R =.75, P <.001). In addition, freshly isolated human hepatocytes expressed the LONG form and culture-activated stellate cells the SHORT form. Moreover, the full-length LONG form is a plasma protein. Thus, the LONG form is a hepatocyte-specific variant, and the SHORT form is a major component of the tumor extracellular matrix in primary and metastatic liver cancers. In the clinical context, the global expression of the endogenous endostatin precursor, collagen XVIII, in liver cancer results from the combined expression profiles of tumor cells, stromal cells, and nontumor hepatocytes at the advancing edge of the tumor, particular to each type of cancer.

Tumor progression is associated with a significant decrease in the expression of the endostatin precursor collagen XVIII in human hepatocellular carcinomas

Endostatin inhibits angiogenesis and tumor growth in mice. The role of its endogenous precursor collagen XVIII in human cancer is unknown. In normal tissues, two variants of collagen XVIII, namely, the short and long forms regulate tissue specificity, the long form being almost exclusively expressed by hepatocytes in the liver. We analyzed RNA arrays from 57 hepatocellular carcinomas (HCCs) with common and variant-specific probes and investigated the relationships between collagen XVIII expression and angiogenesis by measuring the CD34-positive microvessel density. Low collagen XVIII expression by tumor hepatocytes was associated with large tumor size (r, -0.63; P < 0.001) and replacement of trabeculae with pseudoglandular-solid architecture (chi2, 28; P < 0.001), which indicate tumor progression. Tumors expressing the highest collagen XVIII levels were smaller and had lower microvessel density (P = 0.01) than those expressing moderate levels; and HCCs with the lowest collagen XVIII levels approached a plateau of microvessel density, which indicated that a decrease in collagen XVIII expression is associated with angiogenesis in primary liver cancer. HCCs recurring within 2 years of resection showed 2.2-fold lower collagen XVIII mRNA than nonrecurring ones (P = 0.02). The findings relied on the hepatocyte-specific long form. Thus, the endogenous expression of the endostatin precursor decreases along with tumor progression in HCCs.

Characterization and inhibition by a wide range of xenobiotics of organic anion excretion by primary human hepatocytes

Organic anion secretion by human hepatocytes was characterized using primary liver parenchymal cell cultures and the anionic fluorescent dye carboxy-2',7'-dichlorofluorescein (CF). Probenecid, a well-known common blocker of the membrane transport process for anions, was shown to increase CF accumulation in primary human hepatocytes by inhibiting cellular CF efflux in a dose-dependent manner, thereby establishing the presence of an efflux system for organic anions in cultured hepatocytes. Outwardly directed transport of CF from hepatocytes was found to be temperature-dependent; it was not altered by changes in the ionic composition of the incubation medium used in efflux experiments. In addition to probenecid, various structurally and functionally unrelated xenobiotics such as glibenclamide, rifampicin, vinblastine, MK-571, indomethacin, and cyclosporin A were shown to inhibit secretion of CF by primary human hepatocytes, thus suggesting that organic anion excretion by human liver may be impaired by various drugs. Northern blot and Western blot analyses of the expression of multidrug resistance proteins (MRP), such as MRP1 and MRP2, which are known to mediate cellular outwardly directed transport of organic anions indicated that MRP2 was present at substantial levels in cultured human hepatocytes as well as in their in vivo counterparts, whereas MRP1 expression was only barely detectable. These results therefore suggest that MRP2, unlike MRP1, may contribute to the organic anion efflux system displayed by primary human hepatocytes and inhibited by a wide range of xenobiotics.

Detoxifying activity in pig livers and hepatocytes intended for xenotherapy

BACKGROUND

Both livers and hepatocytes from pigs have been proposed for the treatment of end-stage liver diseases, as an alternative to allogeneic liver transplants. However, little is known of the capability of porcine hepatocytes to fulfill the biotransformation pathways of toxic compounds, including those released from livers in acute failure. We have studied the activity and expression of detoxifying enzymes in porcine livers and in cultured hepatocytes and their induction by phenobarbital.

METHODS

Cytochromes P450 (CYP) 1A, 2B, and 3A and GST-like activities were tested with the following specific substrates: 7-ethoxyresorufin, 7-pentoxyresorufin, nifedipine, testosterone, 1-chloro-2,4-dinitrobenzene, 1,2-dichloro-4-nitrobenzene, and ethacrinic acid. CYP 1A1/2-, 2B1/2-, 2E1- and 3A4-related and GSTalpha proteins were analyzed by Western blotting and CYP 1A1/2, 2B1/2, 2C6, 2E1, and 3A4, aldehyde dehydrogenase, epoxide hydrolase, and GSTalpha-like RNA by Northern blotting.

RESULTS

Enzymatic activities reflecting the expression of CYP 1A-, CYP 2B-, CYP 2E1-, and CYP 3A-like genes, that is, ethoxyresorufin-O-deethylase, pentoxyresorufin-O-deethylase, nifedipine oxidase and testosterone 6beta-hydroxylase, and chlorzoxazone 6-hydroxylase, were identified in pig livers. CYP 1A and CYP 2E1, GSTalpha-like proteins, CYP 1A, 2C, and 2E, epoxide hydrolase, aldehyde dehydrogenase, and GST like RNA were expressed in vivo and in vitro. CYP 2B and CYP 3A RNA and proteins, and their associated activities were induced by phenobarbital.

CONCLUSIONS

Porcine hepatocytes express the most important biotransformation enzymes and their corresponding activities and RNA. Thus, livers and hepatocytes from pigs can detoxify a large spectrum of exogenous and endogenous compounds, which makes them a convenient substitute for allogeneic transplants for patients with liver failure.

Who benefits from portal vein resection during pancreaticoduodenectomy for pancreatic cancer?

Portal vein resection during pancreaticoduodenectomy has recently experienced renewed interest. We describe our results with this procedure over a 20-year period. Among 88 consecutive pancreatectomies for cancer of head of the pancreas, 14 included en bloc removal of the portal vein. There was no hospital mortality. Only 21% were found to have histologically confirmed cancer invasion, and the remainder had inflammatory adherence. Two-year survival was 15% compared to 34% for patients who did not have portal vein resection. There were no 5-year survivors. We discuss our results in light of other recent reports.

Proximal bile duct cancer: high resectability rate and 5-year survival

OBJECTIVE

To review and update the authors' experience with resectional surgery for proximal bile duct carcinoma (Klatskin tumor) and assess the role of liver resection over the past 25 years.

BACKGROUND

Until recently, resection of proximal bile duct carcinoma was uncommon, with most patients undergoing palliative procedures. The authors adopted a radical surgical approach aimed at definitive cure in 1974. Recent reports suggest that resection improves outcome.

METHODS

The records of 40 of 94 patients (23 men, 17 women, age range 34-81 years) diagnosed with proximal bile duct carcinoma who underwent resection between 1968 and 1993 were reviewed. According to the Bismuth classification, there were five type I, four type II, 25 type III, and six type IV lesions; 11 patients underwent tumor resection alone, and 25 patients had combined tumor and liver resection (seven of these also underwent an associated regional vascular resection). In 3 patients, venous allografts were harvested from cadaveric donors and used to reconstruct the portal vein. Four patients underwent liver transplantation; in two, organ cluster-type resections including the liver with porta hepatitis and pancreas were performed.

RESULTS

The resectability rate in the more recent period of the study was 49.4%. Most type I, three (of four) type II, T in situ, T1a, T1b, and all stage 0 tumors were resected without hepatectomy. In the other subgroups of tumors, the main surgical procedure was hepatectomy. Thirty-day mortality was 12.5%. After tumor resection alone, survival at 1, 3, and 5 years was 81.8%, 45.5%, and 27.3%, respectively. After tumor resection and hepatectomy without vascular resection, 1-, 3-, and 5-year survival was 66.7%, 16.7%, and 6%, respectively. With vascular resection, survival rates were similar: 64%, 20%, and 4%, respectively.

CONCLUSION

The type of surgery required to achieve cure is closely related to tumor location, TNM classification, and staging. Increasing resectability through the use of hepatectomy improves survival and offers a chance of cure in patients with more advanced disease.

Analysis of Ki-67, p53 and Bcl-2 expression in the dysplasia-carcinoma sequence of Barrett's esophagus

The grading of dysplasia in Barrett's esophagus has prognostic importance, however observer variation limits the reliability of simple histological analysis alone. We investigated Ki-67, p53 and Bcl-2 expression in Barrett's esophagus, in the sequence from Barrett's low-grade dysplasia to high-grade dysplasia and infiltrating adenocarcinoma. Forty-four esophagectomy specimens were utilized: 39 specimens with esophageal dysplasia and adenocarcinoma and 5 specimens with esophageal dysplasia only. This gave 83 sections (2 sections for specimens with dyplasia and carcinoma) examined from 44 patients. The sections were examined for Ki-67, p53 and Bcl-2 reactivity by immunohistochemistry. Low-grade dysplasia was present in 14 sections, high-grade dysplasia in 30 sections and carcinoma in 39 sections. Ki-67 expression occurred in 2 out of 14 (14%) sections with low-grade dysplasia, in 22 out of 30 (73%) sections with high-grade dysplasia and in 34 out of 39 (87%) sections with carcinoma (p<0.001). p53 protein expression was found in 1 of 14 (7%) sections with low-grade dysplasia, in 18 of 30 (60%) sections with high-grade dysplasia and in 33 of 39 (85%) sections with carcinoma (p<0.001). Expression of Bcl-2 was found in 11 of 14 (84%) sections with low-grade dysplasia but immunoreactivity was not seen in any section with high-grade dysplasia or Barrett's carcinoma. Our results indicate that overexpression of Ki-67, Bcl-2 protein and p53 mutations can be identified as early events during neoplastic progression in Barrett's esophagus. These data support the hypothesis that, in the progression of Barrett's metaplasia to adenocarcinoma, the balance of proliferation/apoptosis plays an important role.

Primary liver hemangiopericytoma associated with hypoglycemia: report of a second case

Hemangiopericytoma is an uncommon vascular tumor which usually develops in soft tissues. It has been exceptionally described in the liver and only one case associated with hypoglycemia has been reported in this organ. A giant hemangiopericytoma which was revealed by life-threatening hypoglycemia is described. Imaging and pathological features are presented. The patient, a 73 year-old woman, was treated by hepatectomy. She is perfectly well after a 3-year follow-up, without any evidence of recurrence.

A refined approach to the repair of postcholecystectomy bile duct strictures

OBJECTIVE

To assess the results of a refined approach to repair of postcholecystectomy bile duct strictures.

DESIGN

An 11-year retrospective review of patients who had surgical repair of bile duct strictures developing late after cholecystectomy.

SETTING

A major university teaching hospital in France.

PATIENTS AND INTERVENTIONS

During an 11-year period from 1987 to 1997, 22 patients (mean [+/-SD] age, 55+/-15 years) were operated on for bile duct strictures after cholecystectomy (11 after laparoscopic surgery and 11 after open surgery). Thirteen (59%) of the 22 patients had previous repair. Most patients had episodic cholangitis (14 patients [64%]) and biochemical evidence of cholestasis (20 patients [91%]). There were 5 Bismuth type 1 strictures; 4, type 2; 7, type 3; 5, type 4; and 1, type 5. The average (+/-SD) time from initial surgery to repair was 6.3+/-9.6 years. Intraoperative cholangiography was used to plan the repair in 18 patients (82%). Fifteen patients (68%) were repaired with high Hepp-Couinaud hepaticojejunostomies. The last 4 patients had the hilum exteriorized by the posterior approach to improve access.

RESULTS

There was 1 intraoperative complication (bleeding) and 4 postoperative complications (biloma, fistula, and 2 cholangitis). There were no deaths; mean (+/-SD) length of stay was 12.8+/-5.8 days; and mean (+/-SD) follow-up was 4.8+/-3.3 years (range, 1-10.7 years). Three patients were reoperated on, 1 with an obstructed Roux-en-Y limb and the 2 others for incisional hernias. Eighteen patients remain well, 3 had sporadic recurrent cholangitis after surgery that resolved spontaneously, and 1 patient remains unwell requiring antibiotics to control cholangitis.

CONCLUSIONS

Hepp-Couinaud hepaticojejunostomy without stenting remains a reliable repair of postcholecystectomy strictures. Intraoperative cholangiography and exteriorizing the hilum by the posterior approach are useful adjuncts to this technique.

Differential expression and origin of membrane-type 1 and 2 matrix metalloproteinases (MT-MMPs) in association with MMP2 activation in injured human livers

Matrix metalloproteinase-2 (MMP2) activation is associated with basement membrane remodeling that occurs in injured tissues and during tumor invasion. The newly described membrane-type MMPs (MT-MMPs) form a family of potential MMP2 activators. We investigated the localization and steady-state levels of MT1-MMP and MT2-MMP mRNA, compared with those of MMP2 and tissue inhibitor of MMP-2 in 22 hepatocellular carcinomas, 12 liver metastases from colonic adenocarcinomas, 13 nontumoral samples from livers with metastases, 10 benign tumors, and 6 normal livers. MMP2 activation was analyzed by zymography in the same series. The expression of MT1-MMP mRNA and the activation of MMP-2 were increased in hepatocellular carcinomas, metastases, and cholestatic nontumoral samples. MT2-MMP mRNA was rather stable in the different groups. MT1-MMP mRNA levels, but not MT2-MMP mRNA, correlated with MMP-2 and tissue inhibitor of MMP-2 mRNA levels and with MMP2 activation. In situ hybridization showed that MT1-MMP mRNA was expressed in stromal cells, and MT2-MMP mRNA was principally located in both hepatocytes and biliary epithelial cells. Consistently, freshly isolated hepatocytes expressed only MT2-MMP mRNA, and culture-activated hepatic stellate cells showed high levels of MT1-MMP mRNA. These results indicate that in injured livers, MMP2 activation is related to a coordinated high expression of MMP2, tissue inhibitor of MMP-2, and MT1-MMP. Furthermore, the finding of a preferential expression of MT2-MMP in hepatocytes, together with our previous demonstration that the activation of stellate cell-derived MMP2 in co-culture requires interactions with hepatocytes (Am J Pathol 1997, 150:51-58), suggests that parenchymal cells might play a pivotal role in the MMP2 activation process.

Neoadjuvant chemotherapy and hyperfractionated radiotherapy with concurrent low-dose chemotherapy for squamous cell esophageal carcinoma

PURPOSE

We conducted a prospective study of neoadjuvant treatment for squamous cell carcinoma of the esophagus, modifying the chemotherapy protocol by adding l-folinic acid and giving bifractionated radiotherapy with a cis-diaminedichloroplatinum (CDDP) injection before each fraction.

METHODS AND MATERIALS

Thirty-two patients, 30 men, 2 women, mean age 56.2+/-8.9 years, with resectable squamous cell carcinoma of the esophagus (TNM stage I=4, IIA=4, IIB=13, III=11) were included. Chemotherapy, CDDP (80 mg/m2 D2), 5-fluorouracil (5-FU; 600 mg/m2, D1-4), and l-folinic acid (200 mg/m2, D1-4), was given in two sessions with a 3-week interval during which the patients received radiotherapy (45 Gy), two fractions per day (150 cGy/fraction). A 3-mg injection of CDDP was given prior to each fraction. Patients underwent surgery 4 to 7 weeks after neoadjuvant therapy.

RESULTS

No severe side effects were observed in 12 patients. Grade 3 effects (WBC, platelets, mucositis) occurred in 16 patients and grade 4 effects (platelets, mucositis) in four including 1 death due to septicemia with an infected catheter. Surgery was performed in 29 patients; 26 had resectable tumors (81%). Operative mortality was 10%. The 26 surgical specimens showed complete response (n=18), persistent microscopic residues (n=4), or not significant modification (n=4). Survival at 1, 2, and 3 years was 81, 61, and 51.6% and disease-free survival was 75, 59, and 54% respectively.

CONCLUSIONS

This new therapeutic combination is aggressive and associated with a high postoperative mortality but has a remarkable histological effect since complete response was achieved in 56% (95% CI: 39-73%) of the patients and 3-year survival reached 52%, a very high rate in our experience.

Collagen XVIII is localized in sinusoids and basement membrane zones and expressed by hepatocytes and activated stellate cells in fibrotic human liver

Type XVIII collagen is a recently discovered nonfibrillar collagen associated with basement membranes in mice and expressed at high levels in human liver. We studied the origin, distribution, and RNA levels of type XVIII collagen in normal and fibrotic human livers by in situ hybridization, immunohistochemistry, and Northern and dot blots and compared procollagen alpha1(XVIII) RNA levels with those of procollagen alpha1(IV) and laminin gamma1, the two major components of liver basement membranes. In normal liver, type XVIII collagen was heavily deposited in perisinusoidal spaces and basement membrane zones. The major source of type XVIII collagen was hepatocytes and, to a lesser extent, endothelial, biliary epithelial, and vascular smooth muscle cells and peripheral nerves. In cirrhosis, type XVIII collagen formed a thick deposit along capillarized sinusoids. Grain counts after in situ hybridization showed myofibroblasts to increase their expression 13-fold in active and twofold in quiescent fibrosis, whereas hepatocytes increased their expression only twofold in both active and quiescent fibrosis. Activated stellate cells in vitro expressed type XVIII collagen at high levels. These data indicate that type XVIII collagen is a component of the perisinusoidal space and is associated with basement membrane remodeling. Hepatocytes and activated stellate cells are important sources of type XVIII collagen in normal and fibrotic liver respectively, which suggests tissue-specific regulation of its expression.

[Polymorphism of the microsatellites and tumor necrosis factor genes in chronic inflammatory bowel diseases]

OBJECTIVES

Multiplex family studies have excluded chromosome 6 as a candidate gene of susceptibility to inflammatory bowel disease. However, one recent study suggested that a gene involved in the pathogenesis of Crohn's disease is located on chromosome 6 confering to a microsatellite allelic combination (a2, b1, c2, d4, e1) a strong genetic risk factor in Crohn's disease. The aim of our study was to determine simultaneously the polymorphisms of the TNF microsatellites and of the genes coding for TNF synthesis in patients with inflammatory bowel disease.

PATIENTS AND METHODS

Sixty patients with ulcerative colitis, 100 patients with Crohn's disease were compared to 64 healthy ethnically matched controls. Five TNF microsatellite loci (a, b, c, d, e) were typed using polymerase chain reaction PCR, and two dimorphisms of TNF alpha and TNF beta (intron 1) were studied by restriction fragment length polymorphism (RFLP).

RESULTS

Allelic frequencies of TNF microsatellites and of TNF alpha and beta genes were similar in Crohn's disease, ulcerative colitis and controls. Five loci microsatellite haplotypes, especially a2 b1 c2 d4 e1 allelic combination, were not more frequent in Crohn's disease (25%) compared to ulcerative colitis (27%) or controls (20%). Subgroups stratification according to clinical characteristics did not modify haplotype frequencies. Analysis of our data taking simultaneously into account the MHC alleles (DRB*01 or DRB1*04) did not modify our data; however, it suggested that extended haplotype on short arm of chromosome 6 differed between patients and controls. Linkage disequilibrium (delta = -360.10(-4); P < 0.01) between a2, b1, c2, d4, e1 allelic combination and DRB1*04 allele was observed only in Crohn's disease.

CONCLUSION

Percentages of patients with Crohn's disease or ulcerative colitis carrying TNF microsatellite or TNF alpha and beta gene haplotypes were similar to those of healthy controls. These data argue against involvement of the TNF locus without exclusion of short arm of chromosome 6 implication in Crohn's disease pathogenesis.

Laminin isoforms in non-tumoral and tumoral human livers. Expression of alpha1, alpha2, beta1, beta2 and gamma1 chain mRNA and an alpha chain homologous to the alpha2 chain

BACKGROUND/AIMS

Laminins, the major non-collagenous basement membrane components, are involved in various biological processes. Laminin isoforms have never been characterized in human livers. The expression of five laminin mRNA was investigated in livers with or without cancer and in hepatoma cells and, by comparison, in both rat hepatoma and hepatic stellate cells.

METHODS

Laminin alpha1, alpha2, beta1, beta2 and gamma1 mRNA was detected by northern blot and/or RT-PCR in livers without chronic disease (n=5), in both tumoral and non-tumoral areas of livers with hepatocellular carcinomas (n=13) or metastases (n=18), in human HBGC2 and rat Faza-567 hepatoma cell lines, and in 6-day-old rat hepatic stellate cell cultures.

RESULTS

Laminin alpha1, alpha2 and beta1 mRNA were found in 25-33% and gamma1 mRNA in 58% of the livers, the signal for laminin beta2 mRNA being faint in all the samples. Laminin alpha2, beta1, beta2 and gamma1 mRNA were expressed in hepatoma and stellate cells. The laminin alpha2 cDNA probe recognized a 3.5 kb mRNA different from the expected 9 kb mRNA. Using degenerated oligonucleotides, RT-PCR products from both rat hepatoma and stellate cells revealed 90% identity with the alpha2 chain sequence. Antibodies against peptide deduced from the conserved C-terminal domain of both alpha1 and alpha2 chains recognized polypeptides corresponding to the degradation products of alpha2 chain in liver extracts and both media and cell layers from hepatoma and stellate cells. In addition, a Mr=130000 polypeptide was revealed by these antibodies in liver extracts and cell layers, which was consistent with the expected size deduced from the 3.5 kb mRNA.

CONCLUSIONS

This first report on laminin isoforms in human livers indicates that laminin 1 (alpha1-beta1-gamma1), 2 (alpha2-beta1-gamma1), 3 (alpha1-beta2-gamma1) and 4 (alpha2-beta2-gamma1) mRNA and a polypeptide homologous to the alpha2 isoform, which could correspond to a truncated form of this chain, are usually expressed in non-tumoral and/or tumoral livers.

[Hepatocytes in cell therapy]

Cell-based therapy could represent an alternative treatment to orthotopic liver transplantation in acute liver failures and for the correction of genetic defects of various enzymatic functions. Several recent studies indicate that hepatocytes injected either in the spleen or in portal vein can restore liver-specific function(s) in animal model systems. Alternatively, an extracorporal hybrid bioartificial liver might provide liver-specific functions, maintain the patient alive and allow spontaneous recovery of the patient's own liver, or act as a bridge toward liver transplantation in acute liver failures. Various drawbacks of devices such as flat culture substrates, hollow-fiber bioreactors or microcarriers led us to develop a reliable extracorporeal bioartificial liver based on alginate-entrapped hepatocytes. This system was used successfully for the correction of the Gunn rat genetic defect which results in the lack of bilirubin conjugation. The development of this system for clinical purposes requires large yields of functional hepatocytes. We isolated porcine hepatocytes by collagenase perfusion of the liver and cells were immobilized within alginate beads which were subsequently inoculated in a bioreactor. Porcine hepatocytes expressed liver-functions at high levels, particularly those involved in detoxification and biotransformation processes; they were immunoisolated from immunoglobins and could be cryopreserved. This system represents a promising tool for the design of an extracorporeal bioartificial liver in human beings.

Gastric bypass for malignant esophagotracheal fistula: a series of 21 cases

OBJECTIVE

Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula.

METHODS

Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n = 19) or ligature (n = 2).

RESULTS

Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1-30) and 17 days (3-57), respectively. Among the 13 survivors, pulmonary infections (n = 2) and cervical fistulae (n = 5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them.

CONCLUSION

The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.

Sp1-mediated transactivation of LamC1 promoter and coordinated expression of laminin-gamma1 and Sp1 in human hepatocellular carcinomas

The laminin-gamma1 chain is present in most basement membranes and is involved in various physiological and pathological processes, including carcinogenesis in the liver. We have investigated the role of the transcription factor Sp1 in the activation of the LamC1 gene, which encodes laminin-gamma1, both in hepatocytes and in human hepatocellular carcinomas. DNAse I hypersensitive sites were mapped in the murine LamC1 promoter using early hepatocyte primary cultures in which LamC1 becomes activated. Three hypersensitive sites were found in enhancer-like elements that contain GC-rich regions. Gel-shift analyses showed that specific complexes were resolved using GC-containing oligonucleotides and Faza 567 hepatoma cells, which constitutively express laminin-gamma1 at a high level. Increased GC-binding activity was observed using nuclear extracts from early hepatocyte cultures versus normal liver. Sp1 overexpression in normal hepatocytes transfected with an Sp1 expression vector induced a marked increased of laminin-gamma1 mRNA content and co-transfection of promoter fragments in Drosophila melanogaster SL2 cells demonstrated that Sp1 transactivates LamC1. In human hepatocellular carcinomas, Sp1 and laminin-gamma1 mRNA were simultaneously expressed at high levels, and gel-shift experiments demonstrated a higher GC-binding activity to Sp1 compared with control livers. In situ hybridization indicated that cells exhibiting a high content of laminin-gamma1 mRNA were also strongly positive for Sp1 mRNA, including both cancer cells at the invasion front and stromal cells. These results show that Sp1 is involved in the activation of LamC1 that occurs in human hepatocellular carcinomas.

Overexpression of matrix metalloproteinase-2 and tissue inhibitor of matrix metalloproteinase-2 in liver from patients with gastrointestinal adenocarcinoma and no detectable metastasis

Degradation of basement membranes is a key step in tumoral invasion, mainly mediated by matrix metalloproteinases (MMPs) and their inhibitors (TIMPs). Since the liver is a main target for metastases from gastrointestinal adenocarcinoma, we have investigated MMP2 and TIMP2 expression by RT-PCR, in situ hybridization and zymography in the liver of patients with gastrointestinal adenocarcinomas and no detectable hepatic metastasis (n = 12), in tumoral and nontumoral liver from patients with hepatic metastasis (n = 9) and in control liver (n = 4). MMP2 and TIMP2 mRNA levels were increased in liver from patients with gastrointestinal adenocarcinomas and no detectable metastasis, compared with those of either control liver (5-fold and 3.2-fold, respectively) or nontumoral areas of liver from patients with metastasis (7.8-fold and 3-fold, respectively). MMP2 and TIMP2 transcripts were located in mesenchymal cells of portal tracts and sinusoids. MMP2 was mainly in its latent form. In liver from patients with hepatic metastasis, the tumoral/nontumoral ratios for MMP2 and TIMP2 mRNA were 6.2 +/- 4 and 1.5 +/- 0.4, respectively. Both transcripts were localized in the stromal cells of liver metastases, and the active form of MMP2 was found only in the tumoral areas. In the matching nontumoral areas the signals for MMP2 and TIMP2 mRNA were restricted to mesenchymal cells in portal tracts and sinusoidal cells. Our data show that liver stromal cells express high levels of MMP2 and TIMP2 in patients with colonic carcinoma without liver metastasis, suggesting the distant induction of these transcripts by the primary tumor.

New approach to surgical management of early esophageal thoracic perforation: primary suture repair reinforced with absorbable mesh and fibrin glue

Esophageal perforation is a life-threatening situation and represents a major therapeutic challenge. Results have improved in recent years particularly as a result of progress in antibiotic therapy and the use of total parenteral nutrition. Surgical management retains a predominant role, involving early primary closure and thoracic drainage. We have made an addition to the surgical management by applying an absorbable mesh and fibrin glue to the repaired site. Seven patients (ages 38-79 years) were treated as described. The mean interval from leak to surgery was 28 hours. Six patients had an uneventful postoperative course with a mean hospital stay of 34 days (range 26-45 days). In one case the technique failed and the patient required an exclusion-diversion procedure. All 7 patients recovered without mortality. We believe that this technique provides a real improvement for this precarious esophageal repair.

Patterns of intermediate filaments, VLA integrins and HLA antigens in a new human biliary epithelial cell line sensitive to interferon-gamma

BACKGROUND/AIMS

Intra-hepatic bile ducts are the primary site of damage in several immunologically mediated liver diseases. However, immunological processes underlying biliary epithelial cell recognition by T lymphocytes are poorly understood. Therefore, a convenient in vitro model that could mimic these immunologic disorders would be of great interest.

METHODS

A human cell line (HuGB) was established from a metastasis of gallbladder adenocarcinoma in the liver. Intermediate filament expression was analysed by immunostaining, and gamma-glutamyl transpeptidase and albumin secretion were measured. VLA integrin expression pattern, expression of HLA class I and II antigens and ICAM-1 protein were analysed by flow cytometry and their modulation by interferon-gamma was quantitated using a QIFIKIT commercial kit.

RESULTS

Histological analysis showed high similarity between the initial gallbladder adenocarcinoma and the established cell line. Cytokeratins 8 and 19 and vimentin showed strong positive staining in the established cell line. Gamma-glutamyl transpeptidase was secreted by these cells while albumin expression was negative. HuGB cells also expressed VLA-alpha2, VLA-alpha3, VLA-alpha6, VLA-beta1, but not VLA-alpha1, VLA-alpha4 and NCAM, a pattern of adhesion molecule expression compatible with the biliary epithelium. Also, similar to the biliary epithelium found in normal liver, HuGB cells expressed abundant HLA class I but few HLA class II antigens. We found that the expression of HLA antigens and ICAM-1 protein were increased during interferon-gamma treatment of HuGB cell line.

CONCLUSIONS

Both phenotypic and morphological characteristics of HuGB cells suggested their biliary origin. Sensitivity of HuGB cells to interferon-gamma suggests that this new cell line could represent a suitable model to investigate the up-regulation of membrane antigens occurring in immune diseases involving biliary epithelial cells.

Survival, proliferation, and functions of porcine hepatocytes encapsulated in coated alginate beads: a step toward a reliable bioartificial liver

Orthotopic liver transplantation is the most effective treatment for fulminant hepatic failure. As an alternative treatment, an efficient extracorporeal bioartificial liver should contain a large yield of functional hepatocytes with an immunoprotective barrier, for providing temporary adequate metabolic support to allow spontaneous liver regeneration or for acting as a bridge toward transplantation. Survival, proliferation, and functions of porcine hepatocytes were evaluated in primary cultures and after embedding in alginate beads, which were subsequently coated with a membrane made by a transacylation reaction between propylene glycol alginate and human serum albumin. Disruption of total pig livers by collagenase perfusion/recirculation allowed the obtention of up to 10(11) hepatocytes with a viability greater than 95%. Hepatocytes in conventional cultures or embedded in coated alginate beads survived for about 10 days, secreted proteins, particularly albumin, and maintained several phase I and II enzymatic activities, namely ethoxyresorufin-O-deethylase, oxidation of nifedipine to pyridine, phenacetin deethylation to paracetamol, glucuroconjugation of paracetamol, and N-acetylation of procainamide. Typical features of mitosis and [3H]thymidine incorporation indicated that porcine hepatocytes proliferated in both conventional cultures and alginate beads. The efficacy of the membrane surrounding alginate beads for protecting cells from immunoglobulins was tested by embedding HLA-typed human lymphocytes, which were subsequently incubated with specific anti-HLA immunoglobulin G and complement. These data show that large yields of porcine hepatocytes that are embedded in coated alginate beads remain functional and are isolated from large molecular weight molecules, such as immunoglobulins. This system represents a promising tool for the design of an extracorporeal bioartificial liver, containing xenogeneic hepatocytes, to treat acute liver disease in humans.

In situ detection of matrix metalloproteinase-2 (MMP2) and the metalloproteinase inhibitor TIMP2 transcripts in human primary hepatocellular carcinoma and in liver metastasis

BACKGROUND/AIMS

Metalloproteinase (MMP)-2 and the metalloproteinase inhibitor TIMP2, play a critical role in tumor invasion. We have investigated the cellular sources of MMP2 and TIMP2 in primary and secondary human liver cancers.

METHODS

Using in situ hybridization and zymography, we analyzed surgical biopsies from matching pairs of tumoral and non-tumoral liver from six hepatocellular carcinomas and seven liver metastases and from four liver donors. The cellular sources of MMP2 and TIMP2 were further characterized using an anti-alpha-smooth muscle actin antibody on contiguous sections.

RESULTS

In hepatocellular carcinoma and liver metastases, in situ hybridization showed that MMP2 and TIMP2 mRNA were expressed by anti-alpha-smooth muscle actin-positive cells at the invasive front. Slender fibroblasts embedded in a denser matrix were MMP2(+)/TIMP2(+)/anti-alpha-smooth muscle actin(+). Intratumor microvessels showed a strong labeling for MMP2 but weak for TIMP2 mRNA. In contrast, the endothelial lining of the central veins was MMP2(+)/TIMP2(+) in non-tumoral areas with signs of blood-flow obstruction. In control livers, MMP2 and TIMP2 mRNA distribution was restricted to fibroblasts and endothelial cells within portal tracts and scattered sinusoidal cells. Direct zymography of samples comprising the invasive front revealed variable amounts of both proMMP2 and its active form in hepatocellular carcinoma, whereas strong bands corresponding to both active and latent forms of MMP2 were detected in liver metastases.

CONCLUSIONS

The striking density of MMP2(+)/TIMP2(+)/anti-alphaSM(+) stellate-shaped cells in the perisinusoidal space adjacent to liver tumors suggests that hepatic stellate cells, upon differentiation to myofibroblasts, may contribute to the dissemination of liver metastases through the sinusoidal network.

Cell-based therapy of acute liver failure: the extracorporeal bioartificial liver

The need for an alternative treatment to orthotopic liver transplantation for acute liver failure is a major issue, and systems capable of temporarily providing liver functions are being actively tested. Liver assist devices based on detoxication by dialysis or hemoperfusion through various membranes or cartridges proved to be inefficient because of their lack of metabolic function. An extracorporeal hybrid bioartificial liver might be an appropriate treatment, since it can provide liver-specific functions, maintain the patient alive, and allow spontaneous recovery of the patient's own liver or act as a bridge toward liver transplantation. Many devices have been proposed, including flat culture substrates, hollow-fiber bioreactors, or microcarriers, using xenogenic hepatocytes or hepatoma cell lines. Various drawbacks of these devices led us to attempt to develop a reliable extracorporeal bioartificial liver based on alginate bead-entrapped hepatocytes. This system was used successfully for the correction of the Gunn rat genetic defect, which results in lack of bilirubin conjugation. The development of this system for clinical purposes requires large yields of functional hepatocytes. We have isolated normal porcine hepatocytes by collagenase perfusion of the liver. Cells were immobilized in membrane-coated alginate gel beads, which were subsequently inoculated into a bioreactor. Porcine hepatocytes expressed liver-specific functions at high levels, particularly protein neosynthesis and enzymatic activities involved in detoxication and biotransformation processes. In addition, hepatocytes entrapped in coated alginate beads were isolated from immunoglobulins. This system represents a promising tool for the design of an extracorporeal bioartificial liver in human beings.

[A step towards a bioartificial liver: temporary extracorporeal replacement using isolated hepatocytes]

The mortality rate of fulminant hepatic failure is about 80%. Besides orthotopic liver transplantation, specific therapies are not currently available. Indeed, not only removal of toxins is required, by means of dialysis or hemoperfusion, but specific hepatic functions must be provided to allow spontaneous liver regeneration or as a bridge before liver transplantation. Treatment with an extracorporeal bioartificial liver is an attractive approach. This system was successfully used for the correction of the Gunn rat genetic defect which results in the lack of bilirubin conjugation. The development of this system for clinical purpose requires both a large yield of functional hepatocytes and their immunoprotection in an appropriate device. We have isolated normal porcine hepatocytes by collagenase perfusion of the liver; cells are subsequently entrapped within membrane-coated alginate beads which are inoculated in a bioreactor. Plasma from an animal undergoing fulminant hepatic failure by end-to-site portocaval shunt and whole porta hepatic tightening circulates within the bioreactor. Porcine hepatocytes express liver-specific functions at high levels, particularly secretion of plasma proteins and several enzyme activities involved in the detoxication and biotransformation of xenobiotics. In addition, hepatocytes are immunoseparated from circulating immunoglobulins. Ethical concerns are discussed in the field of physiopathology, immunopathology and public health, as a prerequisite to create departments of Cell Therapy, in the near future.

Diagnosis and therapy for ampullary tumors: 63 cases

From 1970 to 1992 a total of 63 patients underwent operation for ampullary tumor: 40 pancreatoduodenectomies (PDs), 3 total PDs, 8 ampullectomies, and 12 bypass or exploratory laparotomies. The resectability rate was 68%. There were 9 benign tumors, 1 anaplastic tumor, and 53 adenocarcinomas. According to Martin's classification, there were 7 stage I, 11 stage II, 14 stage III, and 21 stage IV tumors. All patients with stage I, II, and III tumors underwent resection. Patients with stage IV tumors had either resection (n = 11) or bypass (n = 10). The mean duration of hospital stay was 20.6 days. Operative mortality was 12.7% for the whole series and 7.5% after PD (2.5% for the last 10 years). Overall survival was 40% at 5 years (85% for stage I, 65% for stage II, 44% for stage III, and 8% for stage IV). Survival was better for stages I, II, and III after PD than after ampullectomy. For stage IV patients survival was 70% after PD versus 20% after bypass at 1 year and 25% versus 0% after 2 years. In our opinion, PD should be proposed even for benign lesions because two of our patients had to undergo repeat operation (PD) 4 and 22 years later, respectively, for stage IV disease. PD is our choice for all tumors of the ampulla.

Experimental colonic carcinogenesis: a new animal model

The aim of this work was to develop an animal model of accessible colonic tumours simulating human carcinogenesis. A segment of the colon was exteriorized to the skin in 60 rats and swabbed with N-methyl-N-nitrosourea. All the animals developed tumoral abnormalities or frank dysplasic tissue 7 months after the beginning of the experiment. This animal model which closely mimics human colonic carcinogenesis is particularly interesting because tumour development can be monitored in live animals without interrupting normal intestinal functions.

[Surgical treatment of hepatocarcinoma in cirrhosis]

In 1986, our institution published the first results of surgical résection of hepatocarcinoma in cirrhotic patients. The aim of this paper is to present long term results of this surgical management. From April 1978 to February 1992, 74 patients were operated on at the surgical clinic of University Medical Center of Rennes (35000) France. There were 60 hepatectomies and 14 transplantations. The mean age was 60.2 years-9 years and the sex ratio: 70 males and 4 females. The etiology was alcoholic in 43 patients (58%), post hepatitis (B and C) in 22 patients (30%) and due to hemochromatosis in 9 patients (12%). According to the Child Pugh classification, 48 patients were Child A, 11 Child B and one Child C in the hepatectomy group and 9 patients Child A and 5 Child B in transplantation group. The operative mortality was 10% in hepatectomy group and 35.7% in liver transplantation group. Overall survival was 61.8% at 1 year, 47.1% at 2 years, 38.2% at 3 years and 20% at 5 years. 5 year survival is 21.4% after transplantation and 18.5% after resection. This difference is not significant. In conclusion, according to 5 years survival and to operative mortality the treatment of choice is hepatectomy in HCC in cirrhotic patients. However the best treatment is the prevention of cirrhosis.

Venous allografts: a useful alternative to venous autografts in digestive surgery

Over a 16 month period seven patients underwent surgery using venous allografts either to reconstruct the portal vein, or to construct a mesocaval 'H' graft or a shunt between the coronary vein and the subhepatic inferior vena cava. The allografts were harvested during multiorgan procurement from the bifurcation of the inferior vena cava, the common iliac vein and the external iliac vein and kept in a preservation solution at 4 degrees C for a mean time of 6 days (range 1-29) before use. Subsequent thrombosis was clinically evident in only two patients. The use of venous allografts appears to be a useful alternative to other venous replacements.

Increased liver iron stores in patients with hepatocellular carcinoma developed on a noncirrhotic liver

Iron was systematically studied in the nontumorous liver of 24 patients with hepatocellular carcinoma (HCC) developed on a noncirrhotic liver compared with 4 control groups (cirrhosis with and without HCC, liver metastasis, and normal liver) matched according to age, sex, and presence of chronic alcoholism. Assessment of liver iron was made by (1) histology according to iron distribution and quantification (total iron score: 0 to 60), and (2) biochemistry (liver iron concentration-N < 36 mumol/g) with calculation of the hepatic iron index (liver iron concentration/age). Patients with hepatocellular carcinoma developed on a noncirrhotic liver presented with (1) histological iron in 83%; (2) parenchymal iron excess significantly more frequent (90%) than in controls; (3) total iron score (15 +/- 12) and liver iron concentration (81 +/- 96) significantly greater than in controls; and (4) hepatic iron index significantly increased (1.4 +/- 1.5) when compared with control groups, except for the hepatocellular carcinoma complicating cirrhosis group (0.9 +/- 1.1). This study (1) shows a mild but unquestionable parenchymal iron excess in the nontumorous liver of most patients presenting with hepatocellular carcinoma developed on a noncirrhotic liver and, at a lesser extent, on cirrhosis, (2) should incite others to study the putative role of iron in the development of liver cancer both in patients with cirrhosis and those without it, whatever the cause of the underlying liver disease, and (3) add argument to take into account and to treat any liver iron excess, even when mild.

[Surgical treatment of hepatocarcinoma in cirrhosis]

In 1986, our institution published the first results of surgical resection of hepatocarcinoma in cirrhotic patients. The aim of this paper is to present long term results of this surgical management. From April 1978 to February 1992, 74 patients were operated on at the surgical clinic of University Medical Center of Rennes (35000) France. There were 60 hepatectomies and 14 transplantations. The mean age was 60.2 years +/- 9 years and the sex ratio: 70 males and 4 females. The etiology was alcoholic in 43 patients (58%), post hepatitis (B and C) in 22 patients (30%) and due to hemochromatosis in 9 patients (12%). According to the Child Pugh classification, 48 patients were Child A, 11 Child B and one Child C in the hepatectomy group and 9 patients Child A and 5 Child B in transplantation group. The operative mortality was 10% in hepatectomy group and 35.7% in liver transplantation group. Overall survival was 61.8% at 1 year, 47.1% at 2 years, 38.2% at 3 years and 20% at 5 years. 5 year survival is 21.4% after transplantation and 18.5% after resection. This difference is not significant. In conclusion, according to 5 years survival and to operative mortality the treatment of choice is hepatectomy in HCC in cirrhotic patients. However the best treatment is the prevention of cirrhosis.

Sequential chemotherapy and radiotherapy for patients with squamous cell carcinoma of the esophagus

BACKGROUND

Despite surgical improvements the prognosis of patients with squamous cell carcinoma (SCC) of the esophagus remains poor, with a 5-year survival rate of less than 20%. Most patients do not undergo surgery with curative intent. The aim of this study was to assess the toxicity and efficacy of sequential chemoradiotherapy.

METHODS

Between May 1986 and June 1991, 50 patients with nonmetastatic SCC of the esophagus were included in this study. Three patients had recurrence after surgery, 8 patients were classified Stage I disease, 24 Stage II, 5 Stage III, and 10 Stage VI. Treatment consisted of cisplatin (100 mg/m2 on Days 1 and 29), 5-fluorouracil (5-FU) (600 mg/m2 on Days 2-9 and Days 30-33) and 30 Gy of radiotherapy (2 Gy x 15 on Days 8-26 and 30 Gy on Days 36-54).

RESULTS

Thirty-seven patients (74%) received the whole treatment course; treatment was modified for 8 patients because of Grades III and IV hematologic, digestive, or renal toxicity. Five patients did not complete treatment because of disease progression or death. Median survival was 13 months; 1- and 2- year survival rates were 63% (49-75) and 36% (25-50), respectively. No late treatment complications were observed (in the 11 survivors after 2 years.

CONCLUSIONS

Sequential chemoradiotherapy of SCC of the esophagus was well tolerated with acceptable acute morbidity and resulted in local control and survival results at least equivalent to those in trials of neoadjuvant chemoradiotherapy plus surgery.

UW-preservation of cultured human gallbladder epithelial cells: phenotypic alterations and differential mucin gene expression in the presence of bile

In orthotopic liver transplantation, extended cold ischemia of the graft may induce cell damage, particularly in biliary epithelium. We have investigated the effects of a cold University of Wisconsin (UW) solution on cultured human gallbladder biliary epithelial cells (GBEC) exposed or not exposed to stagnant bile. In UW solution, morphological alterations of cultured GBEC were not prominent under light microscopy after 16 hours at 4 degrees C, being more striking after 24 to 48 hours. Ultrastructural examination of GBEC showed a condensation of chromatin at the periphery of the nuclei after 16 hours in cold UW solution. Both protein and DNA syntheses were strikingly reduced in these cells. After rewarming in standard Williams' medium at 37 degrees C for 24 hours, cultured GBEC exhibited both normal morphology and function. As in both freshly isolated and routinely cultured GBEC, rewarmed cells expressed various mucin genes, namely MUC1, MUC3, MUC4, MUC5AC, and MUC5B genes, whereas MUC2 mRNAs were barely detectable. A dramatic decline in the steady-state mRNA levels of both MUC3 and MUC5B was found in cultured GBEC versus freshly isolated cells. Addition of bile into UW solution at 4 degrees C had no significant effect on GBEC morphology and DNA and protein syntheses. When bile was added during the rewarming period, both protein and DNA syntheses were strongly reduced. Addition of bile during either storage in UW solution or rewarming period induced increased steady-state MUC2, MUC3 and MUC5AC mRNA levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Transforming growth factor-beta 1 down-regulates basal and polycyclic aromatic hydrocarbon-induced cytochromes P-450 1A1 and 1A2 in adult human hepatocytes in primary culture

The effects of interleukin (IL)-1 beta, IL-4, IL-6, tumor necrosis factor (TNF)-alpha, interferon (IFN)-alpha, IFN-gamma, and transforming growth factor (TGF)-beta 1 on cytochrome P-450 (CYP) 1A expression and polycyclic aromatic hydrocarbon (PAH)-mediated induction in primary human hepatocyte cultures were determined. Most cytokines that were previously found to decrease basal CYP expression could counteract PAH induction of CYP1A mRNA and its associated ethoxyresorufin-O-deethylation (EROD) activity. IL-1 beta and TNF-alpha blocked 3-methylcholanthrene (3-MC)-induced EROD activity by up to 25 and 44%, respectively. IFN-alpha and IFN-gamma antagonized EROD induction by up to 61 and 70%, respectively. TGF-beta 1 proved to be the most effective cytokine, because 72 hr of treatment with 2 ng/ml TGF-beta 1 produced nearly 100% inhibition of 3-MC- and benzo(a)pyrene-induced CYP1A1 and CYP1A2 mRNAs and EROD activity. Treatment with cycloheximide in combination with 3-MC led to superinduction of CYP1A mRNA, under which conditions TGF-beta 1 did not block induction, suggesting the requirement for protein synthesis for the suppressive effect of the cytokine. In addition, TGF-beta 1 augmented AP-1-binding activity, suggesting that fos and/or jun protooncogene products could be implicated in the response. Our results demonstrate that IL-1 beta, TNF-alpha, and IFNs antagonized PAH-mediated induction of CYP1A gene expression in human hepatocytes. In addition, we report the finding of a novel effect of TGF-beta 1, which was able to prevent CYP1A1 and -1A2 induction by two different PAHs.

Surgical management of hepatocellular carcinoma in genetic haemochromatosis

From 1975 to 1989, 51 patients presenting with hepatocellular carcinoma complicating genetic haemochromatosis were managed in our institution. Twenty-one patients underwent a laparotomy. Laparotomy was limited to surgical exploration or palliation in 8 patients in whom the tumour was deemed unresectable. Thirteen patients underwent either a partial hepatectomy (11 patients) or a total hepatectomy and liver transplantation (2 patients). Actuarial survival at 1 and 3 years following partial hepatectomy was 56% and 40% respectively. There was one hospital death in the resection group and in the transplant group. Only 3 patients have remained free of tumour recurrence after a mean follow-up of 18 months. Common clinical and histological features for patients with this condition included masculine gender, age 50 years or above, 10 or more years of history of diagnosed genetic haemochromatosis, high alcohol intake, and grade III or IV hepatic fibrosis.

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus

BACKGROUND

Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin.

METHODS

Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection.

RESULTS

Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year.

CONCLUSIONS

The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus

BACKGROUND

Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin.

METHODS

Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection.

RESULTS

Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year.

CONCLUSIONS

The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus

BACKGROUND

Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin.

METHODS

Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection.

RESULTS

Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year.

CONCLUSIONS

The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus

BACKGROUND

Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin.

METHODS

Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection.

RESULTS

Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year.

CONCLUSIONS

The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus

BACKGROUND

Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin.

METHODS

Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection.

RESULTS

Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year.

CONCLUSIONS

The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

Oesophageal perforation: primary suture repair reinforced with absorbable mesh and fibrin glue

Despite major advances in the management of intrathoracic oesophageal perforation, morbidity and mortality rates remain high1,2. Currently accepted management3 includes early thoracotomy, cleansing of the mediastinum, oesophageal suture and pleural space drainage. Even when performed at an early stage, primary oesophageal suture repair remains precarious, however. Experience of oesophageal primary suture reinforced with absorbable mesh and fibrin glue is reported.