Resection of colorectal liver metastases

From 1960 to 1992 a total of 1718 patients with liver metastases from colorectal carcinoma were recorded. Of these patients, 469 (27.3%) underwent hepatic resection, which was performed with curative intent in 434 patients (25.3%). Operative mortality in this group was 4.4%, being 1.8% (2 of 114) during the last 3 years. Significant morbidity was observed in 16% of patients with a decrease to 5% (6 of 112) for the last 3 years. A 99.8% follow-up until November 1, 1993 was achieved. Excluding operative mortality, there are 350 patients with "potentially curative" resection and 65 corresponding patients with minimal macroscopic (n = 19) or microscopic (n = 46) residual disease. The latter group demonstrated a poor prognosis, with median and maximum survival times of 14.4 and 56.0 months, respectively. Among the 350 patients having potentially curative resection, the actuarial 5-, 10-, and 20-year survivals were 39.3%, 23.6%, and 17.7%, respectively. Tumor-free survival was 33.6% at 5 years. In the univariate analysis, the following factors were associated with decreased crude survival: presence and extent of mesenteric lymph node involvement (p = 0.0001); grade III/IV primary tumor (p = 0.013); synchronous diagnosis of metastases (p = 0.014); satellite metastases (p = 0.00001); metastasis diameter of > 5 cm (p = 0.003); preoperative carcinoembryonic antigen (CEA) elevation (p = 0.03); limited resection margins (p = 0.009); extrahepatic disease (p = 0.009); and nonanatomic procedures (p = 0.008). With respect to disease-free survival, extrahepatic disease (p = 0.09) failed to achieve statistical significance, whereas patients with primary tumors in the colon did significantly better than those with rectal cancer (p = 0.04). The presence of five or more independent metastases adversely affected resectability (p < 0.05). However, once a radical excision of all detectable disease was achieved, no significant predictive value of an increasing number of metastases (1-3 versus > or = 4) on either overall (p = 0.40) or disease-free (p = 0.64) survival was found. Using Cox's multivariate regression analysis, the presence of satellite metastases, primary tumor grade, the time of metastasis diagnosis, diameter of the largest metastasis, anatomic versus nonanatomic approach, year of resection, and mesenteric lymph node involvement each independently affected both crude and tumor-free survival.

Hepatic metastases from colorectal carcinoma: impact of surgical resection on the natural history

From 1960 to 1987, 1209 patients with colorectal liver metastases were recorded, and followed until 1 January 1990. In 242 cases the diagnosis was based on external imaging, whereas 967 patients had operative confirmation and staging of their liver disease. Three groups of patients were analysed: group 1 involved 921 cases, of whom 902 were deemed non-resectable whereas 19 could not be unequivocally classified. Only 21 patients lived for longer than 3 years, seven survived for 4 years, but there were no 5-year survivors. Group 2 comprised 62 highly selected patients who at laparotomy demonstrated resectable metastatic spread confined to the liver, but this was not treated mainly because of a formerly different therapeutic approach. These patients had a significantly longer median survival time (14.2 versus 6.9 months), but also failed to achieve 5-year survival. The 226 patients forming group 3 underwent hepatic resection with intent to cure. Nine of them had minimal macroscopic disease left, and 34 with all gross tumour removed had positive margins. Survival of patients with these 43 eventually non-radical resections followed an identical course as in group 2 (median survival 13.3 months, maximum 42 months). Of the 183 patients with potentially curative resection ten died after surgery (5.5 per cent). Actuarial 5 and 10-year survival rates in the remaining 173 patients were 40 and 27 per cent with 25 and seven patients alive at respective periods of time. Until 1 January 1990, 64 patients remained free from recurrent disease for up to 24 years. In three patients the tumour status at death was unclear. The other 106 patients developed definite cancer relapse. Nevertheless they demonstrated a prolongation of survival time by a median of 1 year when compared with the 43 non-radically resected patients or the 62 untreated patients with resectable liver-only metastases, and accomplished a maximum survival time of 8 years. Radical excision of colorectal secondaries to the liver therefore offers effective palliation, and in a small number the chance of a cure.

Factors influencing the natural history of colorectal liver metastases

Palliative treatment of unresectable colorectal liver metastases is common and often justified with reference to historical data on the natural history of the disease. However, in view of the improved diagnostic accuracy of modern imaging techniques, these previously published series do not provide sufficient guidance to judge the prognostic efficacy of palliative treatment. In the late 1970s we started prospectively to collect data on consecutive patients with colorectal liver metastases according to a standard protocol. We now present data derived from this series on factors that may affect outcome in untreated patients. Between January, 1980, and December, 1990, 1099 consecutive patients were recorded, of whom 566 (51.5%) received no treatment for their hepatic tumour. Excluding 34 early deaths and 48 patients with a second malignant tumour, 484 patients provided the basis for analysis. All patients were followed up to July 1, 1993, or death. At the closing date of the study only 1 untreated patient was still alive. The impact of various factors on survival was analysed by univariate and multivariate analyses. Six independent determinants of survival were identified in the following order: percentage liver volume replaced by tumour (LVRT), grade of malignancy of the primary tumour, presence of extrahepatic disease, mesenteric lymph-node involvement, serum carcino-embryonic antigen, and age. The subsequent combination of the independently significant factors, separately for patients with up to or more than 25% LVRT, yielded a prognostic tree that displayed median survival times of various subgroups of 3.8 to 21.3 months. These findings provide a framework to estimate the survival expectancy of untreated patients, thereby allowing improved assessment of the prognostic significance of palliative therapeutic approaches.

Surgery for colorectal cancer metastatic to the liver. Optimizing the results of treatment

Overall, hepatic resection appears to be an important means of curing patients with metastatic colorectal cancer isolated to the liver. The only absolute contraindication to surgery was the impossibility of a radical removal of tumor: if residual disease will remain after the hepatic resection, this operation is not indicated. A possible second contraindication to surgery is the presence of tumor in the hepatic or celiac lymph nodes. Such metastases from liver metastases signal a biologic grade of tumor that is almost sure to spread to other sites. However, one patient of the 25 in this group did survive long term when positive lymph node groups were dissected. Further clinical experience with this form of the disease along with trials of regional adjuvant therapies such as intraperitoneal chemotherapy may be needed. The presence of extrahepatic metastases at the time of liver resection should be considered a relative contraindication to this surgery, but if the patient can be made clinically disease free, long-term disease-free survival may result. It seems imperative that all patients with hepatic metastases be evaluated by an experienced hepatic surgeon for a curative resection. If the patient has between one and four metastases, a 25 per cent long-term disease-free survival rate can be expected. Patients who have a radical resection of more than four metastases should be considered to be in an experimental group in whom more data are needed. In our current state of knowledge, making such patients clinically disease free is their only chance for long-term survival. Other factors besides the number of metastases that will affect the prognosis of the patient include the disease-free interval between colorectal resection and liver resection, the pathologic margin of resection on the liver specimen, and the presence or absence of mesenteric lymph node metastases from the primary cancer. These factors should be considered when determining the prognosis in a given patient and should be used as stratification variables in prospective trials. However, from our analysis of available data, these factors should not be considered contraindications to hepatic resection.

Treatment of colorectal liver metastases

BACKGROUND

Surgical resection is the only potentially curative treatment for colorectal liver metastases, with 5-year survival rates approaching 40 per cent. However, at present only 20-25 per cent of such lesions are deemed resectable. This review examines developments in neoadjuvant and adjuvant treatments of colorectal liver metastases that aim to improve the results of surgical management of this disease.

METHODS

A literature review was undertaken based on a Medline search from 1970 to May 1998.

RESULTS

Further evolution in surgical technique is unlikely to lead to a dramatic increase in the resectability rate of colorectal liver metastases. Recent developments in neoadjuvant and adjuvant chemotherapy schedules, together with a range of interventional radiological procedures and interstitial lytic techniques, show promise in terms of extending the limits of resectability and decreasing recurrence rates associated with these lesions. Using multimodality regimens 5-year survival rates of 40 per cent are now being reported for lesions that were initially considered irresectable.

CONCLUSION

Patients with colorectal liver metastases should be assessed in units that can offer all the specialist techniques necessary to deliver optimum care. Incorporation of newer neoadjuvant and adjuvant treatments into management strategies should occur in the setting of randomized trials.

Both Pbx1 and E2A-Pbx1 bind the DNA motif ATCAATCAA cooperatively with the products of multiple murine Hox genes, some of which are themselves oncogenes

E2A-PBX1 is the oncogene produced at the t(1;19) chromosomal breakpoint of pediatric pre-B-cell leukemia. Expression of E2A-Pbx1 induces fibroblast transformation and myeloid and T-cell leukemia in mice and arrests differentiation of granulocyte macrophage colony-stimulating factor-dependent myeloblasts in cultured marrow. Recently, the Drosophila melanogaster protein Exd, which is highly related to Pbx1, was shown to bind DNA cooperatively with the Drosophila homeodomain proteins Ubx and Abd-A. Here, we demonstrate that the normal Pbx1 homeodomain protein, as well as its oncogenic derivative, E2A-Pbx1, binds the DNA sequence ATCAATCAA cooperatively with the murine Hox-A5, Hox-B7, Hox-B8, and Hox-C8 homeodomain proteins, which are themselves known oncoproteins, as well as with the Hox-D4 homeodomain protein. Cooperative binding to ATCAATCAA required the homeodomain-dependent DNA-binding activities of both Pbx1 and the Hox partner. In cotransfection assays, Hox-B8 suppressed transactivation by E2A-Pbx1. These results suggest that (i) Pbx1 may participate in the normal regulation of Hox target gene transcription in vivo and therein contribute to aspects of anterior-posterior patterning and structural development in vertebrates, (ii) that E2A-Pbx1 could abrogate normal differentiation by altering the transcriptional regulation of Hox target genes in conjunction with Hox proteins, and (iii) that the oncogenic mechanism of certain Hox proteins may require their physical interaction with Pbx1 as a cooperating, DNA-binding partner.

Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intra-abdominal infections requiring surgery

To assess the significance of initial empiric parenteral antibiotic therapy in patients requiring surgery for community-acquired secondary peritonitis, 425 patients hospitalized between January 1999 and September 2001 in 20 clinics across Germany were followed for a total of 6,521 patient days. Perforated appendix (38%), colon (27%), or gastroduodenum (22%) were the most common sites of infection. Escherichia coli was the most common pathogen. A total of 54 (13%) patients received inappropriate initial parenteral therapy not covering all bacteria isolated, or not covering both aerobes and anaerobes in the absence of culture results. Clinical success, predefined as the infection resolving with initial or step-down therapy after primary surgery, was achieved in 322 patients (75.7%; 95% confidence interval (CI), 70.6-81.2). Patients were more likely to have clinical success if initial antibiotic therapy was appropriate (78.6%; 95% CI, 73.6-83.9) rather than inappropriate (53.4%; 95% CI, 41.1-69.3). Patients having clinical success were estimated to stay 13.9 days in hospital (95% CI, 13.1-14.7), while those who had clinical failure stayed 19.8 days (95% CI, 17.3-22.3). In conclusion, appropriateness of initial parenteral antibiotic therapy was a predictor of clinical success, which in turn was associated with length of stay.

Resection of colorectal liver metastases

INTRODUCTION

Surgical resection is presently the only approach that offers patients with liver metastases from colorectal carcinoma substantial chance of cure. This article summarizes the current literature as well as the author's personal experience.

BACKGROUND AND DISCUSSION

Since 1980, 5-year survival figures have ranged from 21% in collected series to 48% in single-institution series. The 30-day mortality of elective liver resection in non-cirrhotic patients ranges now between 0% and 5%. The overwhelming indicator of prognosis is the completeness of tumor removal according to the R-classification. The specific impact of all other factors should therefore be analyzed by excluding non-radical procedures and operative mortality. Among patient characteristics, age and gender do not significantly affect outcome, while the Karnofski stage is important. Regarding the primary tumor, the effect of staging and location is predominantly apparent in patients with synchronous metastases. Timing of metastasis detection is of some importance, as most authors found a slightly better outcome for metachronously detected metastases. With respect to the liver involvement, multiplicity of metastases and bilateral disease both seem to be of minor importance after R0-resection, while satellite lesions are significant in many series. The actual number of metastases is of minor effect, with a slight superiority in 5-year survival for patients with one to three nodules relative to patients with four nodules or more in most series, but identical results in the author's own experience. The maximum diameter as an indicator of tumor burden represents a significant prognosticator in half of the reports analyzed. Extrahepatic disease reduces 5-year survival, but direct tumor invasion to adjacent structures, local recurrent disease, or one or few pulmonary metastases are no contraindication to liver resection as long as a R0-situation can be achieved. In contrast, lymph-node metastases at the liver hilum predict a poor outcome. They are likely to prove as a clear contraindication. With respect to the operative approach, a clear margin of 1 cm or more should be aimed at but, if the size or location of metastases do not allow a 1-cm margin, resection should still be performed, making every surgical effort to ensure a complete rim of unaffected tissue. Anatomic resections reduce the incidence of non-radical procedures and may improve survival. Whether there is an independent effect of operative blood loss, need for blood transfusion, and intraoperative hypotension on prognosis is still unclear. Adjuvant chemotherapy or radiotherapy after R0-resection is unlikely to improve results. There are also no convincing data available demonstrating a prognostic benefit when a non-curative resection is supplemented by any medical treatment. In patients with recurrent disease, a re-resection is possible in roughly 20%. Survival from the time of re-intervention ranges from 21% to 57% after 5 years and, thus, justifies a close follow-up policy after R0-resection of the initial liver metastases.

CONCLUSION

The previous "clear" contraindications to liver resection have become less important. Future efforts may be directed to more accurate patient selection and new approaches of neoadjuvant and adjuvant therapeutic strategies.

[Resection of colorectal liver metastases. What prognostic factors determine patient selection?]

AIM OF THE STUDY

Based on a consecutive series of patients undergoing liver resection for colorectal metastases, indicators of prognosis and selection criteria were evaluated.

PATIENTS AND METHODS

From 1960 to 1998, a total of 654 patients underwent resection of colorectal liver metastases. In 516 patients (78.9%) this was an R0 resection for initial metastatic disease. These patients form the basis for the investigation.

RESULTS

30-day mortality in this group was 5.8%, while the total procedure-related mortality was 8.3%. Significant morbidity was observed in 16% of patients. Follow-up information until 1 January, 2000 was achieved in 99.5% of patients. Including operative mortality, the actuarial 5-, 10-, and 20-year survival is 38 +/- 5%, 27 +/- 6% und 24 +/- 24%, rising to 41 +/- 5%, 29 +/- 6% and 26 +/- 26% after excluding operative deaths. Tumor-free survival is 35 +/- 5% at 5 years. In the multivariate analysis the following factors are associated with decreased crude survival: extrahepatic tumor (P < 0.0001), intraoperative hypotension (P = 0.0001), non-anatomical procedures (P = 0.0002), a metastasis diameter > or = 5 cm (P = 0.0002), unfavourable grading of the primary tumor (P = 0.0003), satellite metastases (P = 0.0069), mesenteric lymph node involvement (P = 0.0260), use of FFP (P = 0.0307) and synchronous diagnosis of metastases (P = 0.1240). With respect to disease-free survival metastasis diameter is first, followed by extrahepatic disease (P < 0.0001 each). Satellite metastases are removed, while the primary tumor site becomes important with inferior results for rectal cancer (P = 0.0188). The other factors remain stable and in the same order. The number of independent tumor nodules as well as the width of resection margin fail to be significant in both univariate and multivariate analysis.

CONCLUSION

These results underline the paramount importance of an R0 resection, but diminish the relevance of most commonly used "contraindications". For the actual decision on liver resection, beside the possibility of achieving an R0 situation, safety aspects regarding comorbidity and acceptable extent of parenchyma loss represent the prime limitation.

Radical operations for carcinoma of the gallbladder: present status in Germany

Despite the overall poor prognosis of gallbladder carcinoma, it appears that, in resectable lesions, an aggressive surgical approach promises improvement in survival rates. Radical treatment of gallbladder carcinoma is based on a detailed knowledge of the lymphatic, venous, direct, and intraductal modes of spread of gallbladder carcinoma. Customized therapy of gallbladder carcinoma takes staging into consideration: if one is dealing with gallbladder carcinoma with macroscopic liver infiltration (T3 or T4), or with a pre- or intraoperatively diagnosed gallbladder carcinoma with an unknown depth of infiltration, an en bloc resection of the gallbladder with adjacent liver segments IVb and V, perhaps including IV, as well as a dissection of the hepatoduodenal ligament should be performed. If the carcinoma is missed intraoperatively at the time of cholecystectomy for other indications, in the presence of a T2 gallbladder carcinoma in proximity to the liver bed, reoperation with dissection of the hepatoduodenal ligament and resection of liver segments IVb and V should be performed. In the presence of T1 gallbladder carcinoma, simple cholecystectomy is adequate. This concept is based on our experience with 113 patients with gallbladder carcinoma who underwent treatment in our department from January, 1970 to June, 1989. Sixty-seven percent of the gallbladder carcinomas were resected, 30% for cure and 37% palliatively. In 33%, the operation was limited to an exploratory laparotomy or a palliative operation, or no operation was performed. Of the curatively resected carcinomas (n = 34), 7 were Stage I, 7 Stage II, 9 Stage III, and 11 Stage IV.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of positron emission tomography on strategy in liver resection for primary and secondary liver tumors

PURPOSE

Outcome of patients with metastatic disease mainly depends on accurate preoperative tumor staging. 18[F]fluorodeoxyglucose positron emission tomography (18F-PET) has been proven to be a valuable diagnostic tool in a number of different tumors but its direct influence on liver surgery has not been thoroughly investigated.

MATERIALS AND METHODS

Between July 1999 and March 2000, 50 consecutive patients with 174 suspected liver lesions were admitted to the University Hospital Jena. All 50 patients underwent abdominal ultrasound, CT-scan, and 18-FDG positron emission tomography scanning. In 23 patients the diagnostic work-up was completed by MRI scan.

RESULTS

Altogether there were a total of 174 histologically proven intrahepatic lesions, nine of which were benign. The sensitivity, specificity, and positive predictive value of PET for all hepatic lesions was 82%, 25%, and 96% compared with 63%, 50%, and 96% for abdominal ultrasound, 71%, 50%, and 97% for CT-scan, and 83%, 57%, and 97% for MRI-scan. In 23 of 50 patients 24 extrahepatic lesions were identified. In these patients the sensitivity and specificity of PET-compared to abdominal ultrasound, CT-scan, and MRI-scan for all extrahepatic lesions-was 63% and 60%, 29% and 25%, 47% and 50% and 40% and 50%, respectively. The findings on PET scan had a direct impact on operative management in nine patients (18%).

CONCLUSIONS

Our series demonstrates good sensitivity and specificity for the detection of primary and secondary liver lesions which is superior to ultrasound and CT scan but not to MRI scan. The main value of PET scan consists in the detection of extrahepatic tumor (64%). Due to better detection of extrahepatic tumor, FDG-PET is a very useful addition to the currently used anatomically-based images in all cases of advanced tumor spread with high risk of extrahepatic tumor.

Prospective randomised trial on adjuvant hepatic-artery infusion chemotherapy after R0 resection of colorectal liver metastases

BACKGROUND AND AIMS

The liver represents the predominant site of cancer relapse after curative resection of hepatic metastases from colorectal carcinoma. Adjuvant intra-arterial chemotherapy was therefore considered a promising therapeutic approach in high-risk patients.

PATIENTS/METHODS

From July 1984 to December 1985, a total of 42 consecutive patients underwent R0 resection of colorectal liver metastases. Thirty patients with mesenteric lymph-node metastases (Dukes C) were randomised into two groups. In 14 group-A patients, a hepatic artery port catheter was placed during liver resection. Four courses of adjuvant chemotherapy were administered at 4-week intervals, consisting of mitomycin C (8 mg/m2, day 1) and 5-fluorouracil (800 mg/m2, days 1-5). Sixteen group-B patients served as controls. The 12 patients with no mesenteric lymph-node metastases (Dukes A/B) were included in the follow-up program.

RESULTS

After 5 years, 64% of Dukes A/B patients and 29% of Dukes C patients were alive (P<0.01). The probability of remaining free of recurrent disease after 5 years and 10 years was 55% and 18%, respectively (P<0.01). No significant difference in either 5-year survival (25% vs 31%) or long-term disease-free status (15% vs 23%) was detected between groups A and B. The initial tumour relapse was shifted towards extrahepatic sites in group-A patients, but no difference was obtained regarding the definite distribution of recurrent disease.

CONCLUSION

Routine application of adjuvant regional chemotherapy after R0 liver resection is not warranted.

Preconditioning of donor livers with prostaglandin I2 before retrieval decreases hepatocellular ischemia-reperfusion injury

BACKGROUND

Prostaglandins have been shown to protect against a variety of liver insults, including ischemia-reperfusion injury. Decreased graft injury and improved survival have been demonstrated in animal studies of liver transplantation after donor pretreatment with prostaglandin before organ retrieval. This potential clinical application has not been examined in human subjects.

PATIENTS AND METHODS

One hundred and six liver donors were randomly assigned to receive either prostaglandin I2 (epoprostenol, 500 microg intravenous bolus) immediately before cold perfusion or no drug as control. Donor and recipient characteristics were recorded, and liver function tests were monitored after transplant to assess the effect of epoprostenol on graft injury.

RESULTS

Donor pretreatment with epoprostenol significantly improved the rapidity and homogeneity of graft reperfusion. Epoprostenol pretreatment also significantly reduced peak values of transaminases after transplantation: serum glutamic-pyruvic transaminase, control (851+/-121 international units [IU]/L) and epoprostenol (463+/-78 IU/L); serum glutamic-oxalaacetic transaminase, control (870+/-127 IU/L) and epoprostenol (463+/-78 IU/L); serum glutamate dehydrogenase, control (458+/-95 IU/L) and epoprostenol (170+/-30 IU/L); P<0.01 for all, by t test. Serum levels of bilirubin and alkaline phospatase were not significantly altered by donor pretreatment with epoprostenol.

CONCLUSIONS

Reduction of ischemia-reperfusion injury by administration of epoprostenol before graft retrieval may have important applications in liver transplantation. Further studies are required to establish the mechanism of this effect and to define its precise role in clinical practice.

[Anatomical and atypical liver resections]

Liver resection has evolved to an established treatment for various malignant primary and secondary hepatic tumours, some benign tumours, and other conditions. The anatomical approach, the preferred concept of the author, rests on knowledge of the intrahepatic segmentation according to the portal structure branching and the course of major hepatic veins. As most of the malignant tumours respect the corresponding intrahepatic boundaries this resectional approach offers superior tumour clearance and, probably, better long-term outcome. Besides the four standard resections along the main fissure and left intersectorial plane, respectively, there are less common sector-orientated procedures including central hepatectomies and operations along the right intersectorial plane. Segment-orientated resections are defined by additional use of the transverse boundary according to the cranially and caudally directed third-order ramification of the portal trunks. Despite the advantage of anatomical resections there are rational indications for non-anatomical procedures such as removal of small benign tumours, excision of HCC in liver cirrhosis, re-resection following major hepatectomies, an excision biopsy in a non-resectable situation, and liver trauma care. Irrespective of the resectional approach, routine use of intraoperative ultrasound, maintenance of a low central venous pressure during parenchyma transsection, intermittent hilar clamping, and ischemic preconditioning all contribute to a safe and oncologically effective operation. In the future, augmentation of the liver remnant by preoperative portal vein embolisation, and multicentre trials on multidisciplinary strategies, may help to enhance resectability and to improve both safety and long-term outcome.

Rectal prolapse: which surgical option is appropriate?

Numerous surgical procedures have been suggested to treat rectal prolapse. In elderly and high-risk patients, perineal approaches such as Delorme's procedure and perineal rectosigmoidectomy (Altemeier's procedure) have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Functional results of transabdominal procedures, including mesh or suture rectopexy and resection-rectopexy, are thought to be associated with low recurrence rates and improved continence. Transabdominal procedures, however, usually imply rectal mobilization and fixation, colonic resection, or both, and some concern is voiced that morbidity, in terms of infection or leakage, and mortality could be increased. If we focus on surgical outcome, our own experience of laparoscopic resection-rectopexy for rectal prolapse shows that the laparoscopic approach is safe and effective, and functional results with respect to recurrence are favorable. However, the controversy "which operation is appropriate?" cannot be answered definitely, as a clear definition of rectal prolapse, the extent of a standardized diagnostic assessment, and the type of surgical procedure have not been identified in published series. Randomized trials are needed to improve the evidence with which the optimal surgical treatment of rectal prolapse can be defined.

Pulmonary resection for metastatic colon and upper rectum cancer. Is it useful?

The predictive value of the route of venous drainage on prognosis was investigated in a consecutive series of 44 patients who underwent curative resection of pulmonary metastases from colorectal carcinoma. The primary tumor was located in the colon in 14 patients and in the upper third of the rectum in 11 patients, thus indicating blood drainage directed toward the portal vein (Group I). In 10 and 9 cases, respectively, the initial growth was in the middle and lower thirds of the rectum with the venous outflow at least partially directed into the vena cava (Group II). There was no obvious difference between the two groups regarding the initial site of cancer relapse. The liver was involved in 4 of 15 patients failing in Group I as opposed to 4 of 13 patients with hematogenous relapse in Group II. Median survival and tumor-free survival times were significantly longer in patients in Group I (58.4 and 50.2 months) than in patients in Group II (30.9 and 16.8 months), and, even more pronounced, in colon cancer patients (75.4 and 60.2 months) when compared with rectal cancer patients (31.0 and 17.9 months). In contrast, survival curves did not differ significantly if either the two groups with different routes of drainage (5-year survival 53 percent vs. 38 percent, 5-year tumor-free survival 43 percent vs. 37 percent), or tumors of the colon and rectum (5-year survival 67 percent vs. 38 percent, 5-year tumor-free survival 60 percent vs. 32 percent) were compared using the log-rank test. Similar trends were obtained for the subgroup of 34 patients without previous or simultaneous extrapulmonary recurrent disease at the time of lung resection. The primary tumor site does therefore not become a major criterion in selecting patients for surgical resection.

Characteristics of older patients with back pain in general practice: BACE cohort study

BACKGROUND

Although back pain is common among older people, limited information is available about the characteristics of these patients in primary care. Earlier research suggests that the severity of back symptoms increases with older age.

METHODS

Patients aged >55 years visiting a general practitioner with a new episode of back pain were included in the BACE study. Information on patients' characteristics, characteristics of the complaint and physical examination were derived from the baseline measurement. Cross-sectional differences between patients aged >55-74 and ≥75 years were analysed using an unpaired t-test, Mann-Whitney U-test or a chi-square test.

RESULTS

A total of 675 back pain patients were included in the BACE study, with a median age of 65 (interquartile range 60-71) years. Patients aged >55-74 years had a mean disability score (measured with the Roland Disability Questionnaire) of 9.4 [standard deviation (SD) 5.8] compared with 12.1 (SD 5.5) in patients aged ≥75 years (p ≤ 0.01). The older group reported more additional musculoskeletal disorders and more often had low bone quality (based on ultrasound measurement of the heel) than patients aged >55-74 years. Average back pain severity over the previous week showed no difference (p = 0.11) between the age groups, but severity of back pain at the moment of filling in the questionnaire was higher (p = 0.03) in the older age group.

CONCLUSIONS

In this study, older back pain patients reported more disabilities and co-morbidity. However, the clinical relevance of these differences for the course of the back pain episode in older patients remains a subject for further research.

Bile-independent absorption of cyclosporine from a microemulsion formulation in liver transplant patients

A microemulsion formulation of CsA, which was anticipated to be independent of bile for oral absorption, was compared with the currently marketed formulation in liver transplant patients with external biliary drainage. Eleven patients aged 47.6 +/- 13.1 years and weighing 75.8 +/- 5.7 kg received single 400-mg oral doses of each formulation in a randomized, crossover protocol on days 4 and 6 after transplant. Serial venous blood samples were collected over a 12-hr period after each administration and whole blood CsA concentrations were determined by a validated RIA specific for the parent compound. Systemic exposure to CsA was consistently higher from the microemulsion formulation in all patients, as judged by the peak concentration and the area under the curve. Specifically, the area under the concentration-time curve was 943 +/- 400 vs. 2378 +/- 911 ng.hr/ml, indicating an average 156% higher bioavailability from the microemulsion compared with the currently marketed formulation in liver transplant patients in the absence of bile.

Impact of mycophenolate mofetil versus azathioprine on early recurrence of hepatitis C after liver transplantation

The aim of this study was to evaluate the impact of mycophenolate mofetil (MMF) on incidence, delay, severity and clinical course of early recurrent hepatitis C after liver transplantation (LT). A total of 21 hepatitis C virus (HCV)-positive patients after LT were prospectively enrolled in this study. All of them received a quadruple induction cyclosporine A (CsA)-based immunosuppression, augmented by MMF (n=12) or by azathioprine (n=9, AZA). MMF tended to delay recurrent disease (50+/-35 versus 35+/-35 weeks, P=0.5) with significantly lower levels of aminotransferases (P<0.05). Furthermore, patients under MMF revealed less severe allograft fibrosis at disease recurrence (stage of fibrosis: 1.5+/-0.5 versus 2.2+/-1.2; P=0.07). But stage of fibrosis significantly increased in the MMF-group (P<0.05) during 6 months of antiviral treatment. Three patients in the MMF-group and none of the controls suffered from severe fibrosing cholestatic recurrent hepatitis C. Initial post-LT administration of MMF tended to delay recurrent hepatitis C and to limit initial HCV-related biochemical and morphological graft dysfunction. But during clinical follow-up, its immunosuppressive capabilities exceeded possible antiviral properties, finally leading to significant progression of graft fibrosis. Thus, concomitant dose reduction of other basic immunosuppressants might be useful in this clinical setting.

Characterization of functional thrombin receptors in human pancreatic tumor cells (MIA PACA-2)

In this article, the "tethered ligand" thrombin receptor was identified on human pancreatic tumor cells, MIA PaCa-2, using immunofluorescence studies with a monoclonal anti-thrombin receptor antibody. Pharmacological characterization, using 3H-labeled thrombin receptor activating peptide-6 (TRAP-6) as radioligand, demonstrated a single class of high-affinity binding sites (KD = 9.1+/-1.8 x 10(-7) M) and a binding capacity of 13.9+/-0.7 fmol/mg protein. These binding sites represent functional thrombin receptors, as shown by alpha-thrombin- and TRAP-6-induced mobilization of free intracellular calcium, protein kinase C translocation from cytosol to the cell membrane, and stimulation of DNA synthesis in MIA PaCa-2 cells. These results provide the first identification of tethered ligand thrombin receptor in human pancreatic cancer cells and suggest thrombin receptor involvement in mechanisms of human pancreatic tumor progression.

Long-term combination of interferon alfa-2b and ribavirin for hepatitis C recurrence in liver transplant patients

The purpose of this study was to evaluate the feasibility, tolerability and efficacy of long-term combination therapy with interferon-alfa 2b (IFNalpha-2b) and ribavirin (Rb) for recurrent hepatitis C after liver transplantation. Fifteen patients with histologically confirmed hepatitis C after liver transplantation were treated. After a basic course of 12 months (IFNalpha-2b 3 MU/3 times a week; Rb 3 x 200 mg/day), patients achieving clearance of viremia underwent maintenance therapy with ribavirin (3 x 200 mg/day). Patients without virological response continuously received combination therapy. Levels of HCV RNA, aminotransferases and bilirubin were followed. Therapy led to a significant decline of transaminases and bilirubin in all patients (p < 0.05). Sixty-four per cent of patients had clearance of viremia after 12 months. Sustained virolo gical response was 88%. In patients without virological response, continuation of combination therapy prevented another biochemical relapse of hepatitis. Treatment was accompanied by severe hematological side-effects, requiring medical support in a majority of patients. In two patients (13.5%), therapy finally had to be withdrawn because of major hematological disorders. These results indicate that long-term combination therapy with IFNalpha-2b and Rb is effective in the treatment of recurrent hepatitis C and in preventing further relapse of disease after liver transplantation, but side-effects may require cessation of therapy.

Putative colon cancer risk factors damage global DNA and TP53 in primary human colon cells isolated from surgical samples

This study describes a novel in vitro method in genetic toxicology that is based on detection of chemical-induced DNA damage connected with altered migration of TP53 in primary human colonocytes. Techniques were developed to isolate high numbers of human epithelial colon cells from surgical tissues. High quantities of viable cells were obtained per donor. The primary cells were treated with the endogenous risk factors trans-2-hexenal, and hydrogen peroxide. Global DNA damage and repair were measured by single-cell gel electrophoresis (Comet assay). We compared responses of primary colon cells to HT29clone19A, a differentiated human colon tumour cell line, for which the karyotype was analysed with 24-colour FISH. Both compounds were genotoxic in both cell types and most of the induced DNA damage was repaired after 30 min. Specific migration of TP53 was determined by fluorescence in situ hybridization (Comet FISH). Using primary colon cells, we quantified the migration of TP53 signals into the comet tails. In these cells TP53 was more sensitive than global DNA for genotoxicity induced by trans-2-hexenal and H(2)O(2). HT29clone19A cells cannot be used for Comet FISH because of their aberrant karyotype. The approach described allows us to obtain more knowledge of putative risk factors in colon carcinogenesis.

Thrombin enhances adhesion in pancreatic cancer in vitro through the activation of the thrombin receptor PAR 1

BACKGROUND

Thrombin, the central enzyme of the coagulation cascade, induces proliferation in different solid tumours. The effect is mainly mediated through the functional thrombin receptor PAR 1, a member of the G-protein coupled receptor family. The aim of this study was to assess the role of thrombin on adhesion of pancreatic cancer to extracellular matrix proteins and endothelial cells in vitro.

MATERIALS AND METHODS

The human pancreatic adenocarcinoma cell line MIA PaCa-2 was treated with thrombin and the thrombin-receptor-activating peptide (TRAP), respectively. As a control the cells were pre-incubated with the thrombin-receptor-inhibiting peptide (T1). The cells were incubated on microtiter plates, which were pre-coated with extracellular matrix proteins (fibronectin, laminin, collagen IV) or human umbilical vein endothelial cells (HUVECs), for 30 and 60 min, respectively. The number of adherent cells were measured using the MTT method. ANOVA was used for statistical analysis.

RESULTS

Thrombin enhanced the adhesion of MIA PaCa-2 cells to extra-cellular matrix proteins and endothelial cells significantly (P< or =0.001). The effects of thrombin could be mimicked by TRAP. Pre-incubation with T1 inhibited the effect.

CONCLUSION

Thrombin enhances adhesion of pancreatic adenocarcinoma to extracellular matrix proteins and endothelial cells in vitro. The effect is mediated through the thrombin receptor PAR 1. The results emphasize the role of thrombin and PAR 1 in pancreatic tumour biology.