Cryotherapy of metastatic carcinoid tumors

BACKGROUND

To describe the use of hepatic cryotherapy to treat patients with symptomatic carcinoid metastates.

METHODS

Hepatic cryotherapy was performed on five patients with carcinoid syndrome resulting from metastatic carcinoid tumors. Intraoperative ultrasound was used to guide the cryotherapy and to assess the adequacy of freezing.

RESULTS

All five patients had relief of the carcinoid syndrome after treatment. In four of the five patients, the relief was prolonged (>3 months); in one patient, the relief of symptoms was transient (2 months). Four of five patients had a transient reduction in hormonal tumor markers (the fifth patient did not have hormonal-level follow-up). During a follow-up period of 2.5 years, four of the five patients died. The 6-month survival rate was 80%, the 1-year survival rate was 60%, the 2-year survival rate was 40%, and the 2.5-year survival was 20%. One patient is alive 30 months after treatment.

CONCLUSION

Hepatic cryotherapy can provide symptomatic relief for patients with hepatic metastates producing the carcinoid syndrome.

Cryoablation of unresectable malignant liver tumors

BACKGROUND

Unresectable malignant liver tumors, particularly metastases of gastrointestinal origin, are rapidly lethal in a vast majority of patients, regardless of treatment.

PATIENTS AND METHODS

We evaluated 58 patients by laparoscopy and/or laparotomy. Thirty-nine were treated with cryoablation of liver tumors using a liquid-nitrogen cryoprobe delivering a tumoricidal temperature of -196 degrees C with intraoperative ultrasound monitoring. Histologic evaluation showed that 25 patients had colorectal metastases, 3 had gastric tumors, 4 hepatocellular carcinomas, 6 carcinoids, and 1 gastrinoma.

RESULTS

All patients who received complete cryoablation are alive with a mean follow-up of 14 months. Five whose treatment could not be completed died between 3 and 9 months postoperatively. Thirteen patients (28%) have recurrent disease and 20 (51%) have no evidence of disease. There were no operative mortalities. Postoperative transient elevation of liver function tests and thrombocytopenia were noted. All patients received postoperative chemotherapy.

CONCLUSION

Cryoablation is an active and safe treatment for advanced liver malignancies.

Case report: MRI of extrapancreatic gastrinoma

Islet cell tumors are a relatively rare group of neuroendocrine tumors that are often difficult to image preoperatively. We present the magnetic resonance imaging characteristics of an uncommon and unusually large extrapancreatic gastrinoma.

Malignant melanoma in inflammatory bowel disease

Malignant melanoma occurred in 11 patients with inflammatory bowel disease (IBD). Six cases occurred in patients with ileocolitis, two in regional enteritis, one in granulomatous colitis, and two in patients with ulcerative colitis. The mean age at development of IBD was 24 yr, and at development of melanoma was 40 yr: the mean duration from onset of IBD to development of melanoma was thus 16 yr. All patients for whom complete information was available, except two, had received steroids and azulfidine for approximately a decade, as well as blood transfusions, usually multiple, and on repeated occasions. Six of the 11 patients had undergone one to seven prior operations (mean 3.5). All patients had wide radical excision of the melanoma, with or without concomitant or subsequent nodal dissection. Two patients (ages 25 and 36 yr) died rapidly from widely disseminated malignant melanoma. These cases may be coincidental, or else there may be an association between IBD and melanoma, related to immunosuppression either from the disease itself, from the medical and surgical therapy, and/or from x-ray exposure.

Circulating immune complexes in cancer patients

Circulating Immune Complexes (CIC) have been described in malignant diseases. To elucidate their potential clinical significance, CIC of seventy-eight patients with cancer and of seventy-one normal individuals were studied. Total protein and immunoglobulin composition of CIC were quantitatively measured. Patients sera had consistently higher titers of CIC than normal individuals. Sodium Dodecyl Sulfate/Polyacrylamide Gel Electrophoresis (SDS/PAGE) showed subtle differences in the CIC protein composition between patients and normal individuals.

Exclusion of small bowel from pelvis for postoperative radiotherapy for rectal cancer

The pelvis is the preferential site of disease when recurrence occurs after curative resection of rectal cancer. Postoperative adjuvant radiotherapy decreases local recurrence rates for Dukes stages B and C; however, after abdominoperineal or anterior resections, the small bowel descends into the lower pelvis, and, due to its low tolerance to radiation, optimal doses cannot be safely delivered unless the small bowel can be excluded from the pelvis. This can be achieved by cystopexy and/or by creating a pelvic sling with a knitted polypropylene mesh. Three cases are presented in which radiotherapy was satisfactorily delivered with these techniques.

Immunoglobulins (Ig) in circulating immune complexes (CIC) in cancer and inflammatory bowel disease (IBD)

Chronically inflamed tissues and most malignancies have antigenic properties. Patients with long-standing inflammatory bowel disease (IBD) are prone to development of colorectal cancer, which is known to shed antigens in the bloodstream. In an effort to study immunological aspects of these diseases, sera from patients with IBD and colorectal cancer were evaluated for presence of circulating antigen-antibody immune complexes (CIC), and compared to normal controls. CIC were precipitated by polyethylene glycol (PEG) and found to be elevated in all diseased groups. Dissociation of CIC and quantification of their antibody component revealed significant elevation of each immunoglobulin in IBD and in patients with colorectal cancer versus control: IgG = 1.776 +/- 1.573 vs 0.734 +/- 0.618 (P less than 0.001); IgA = 0.368 +/- 0.452 vs 0.090 +/- 0.198 (P less than 0.001); IgM = 0.434 +/- 0.235 vs 0.080 +/- 0.285 (P less than 0.001) serum total Ig levels were consistently much higher than CIC Ig. No correlation was found between the individual serum Ig components and the precipitable complexes-bound Ig, suggesting a selective recognition of antigenic components in the CIC, rather than non-specific association and subsequent precipitation of serum Ig. CIC may represent an easily accessible source of immunological determinants for the study of malignant and chronic inflammatory diseases.

Radical retroperitoneal tumor surgery with resection of the psoas major muscle

Three patients with extensive retroperitoneal cancer are presented, in whom the psoas muscle was resected as part of a radical tumor excision. The resection of the psoas muscle, including the femoral nerve, which travels in its substance, and the genitofemoral and ilioinguinal nerves, caused little morbidity (denervation weakness of the quadriceps and anterior high numbness) and improved the quality of the excision. Ablation of the psoas muscle is technically possible; it may improve the patient's outlook both for palliation and for curative intent.

Pharmacology and toxicology of a seven-day infusion of 1-beta-D-arabinofuranosylcytosine plus uridine in dogs

In vitro studies of certain lymphoid tumor cells show potentiation of 1-beta-D-arabinofuranosylcytosine (ara-C) effects by uridine because it elevates intracellular uridine triphosphate, resulting in increased ara-C triphosphate levels. Seven-day continuous i.v. infusions of uridine at 123 mg/kg/h (2.5 g/sq m/h) were studied in 5 male beagles. Steady state levels of uridine were reached within 4 to 6 h and ranged from 2 to 5 X 10(-4) M over the course of the infusion. Steady state uracil levels ranged from 4 to 10 X 10(-4) M. After the end of infusion, uridine and uracil levels fell with a half-life of approximately 15 and 18 min, respectively. Toxicity in 2 dogs treated at this dose was limited to minimal diarrhea and a transient rise of alkaline phosphatase to 2 to 3 times normal. No drug toxicity was evident at sacrifice on Days 7 or 72. Three dogs received a 7-day infusion of ara-C plus uridine followed approximately 4 weeks later by an infusion of ara-C alone (or the same drugs in the reverse sequence). Coinfusion of 2.5 or 5.0 mg/kg/day (50 or 100 mg/sq m/day) of ara-C had no significant effects on uridine plasma levels or postinfusion half-lives. Similarly, no consistent effect was seen of uridine on ara-C plasma levels. Uridine coinfusion with ara-C resulted in a definite potentiation of myelosuppression; at 5.0 mg/kg/day X 7 of ara-C white blood cell and platelet nadirs (X 10(3)/microliters) were 0.8 and 15 as compared to 3.6 and 66, respectively, with ara-C alone. One-third of the dogs developed reversibly elevated transaminases with the combination treatment. The results show that a minimally toxic dose of uridine enhances bone marrow and probably hepatic toxicity of coadministered ara-C.

A unique surgical approach for massive retroperitoneal tumors

A unique approach to retroperitoneal tumors is described, utilizing an inverted U-shaped incision that allows exposure of the retroperitoneum, great vessels, and intraperitoneal organs.

Hemicorporectomy--perioperative management: a case presentation and review of literature

Hemicorporectomy , or translumbar amputation, is a dramatically drastic surgical salvage procedure for patients with uncontrolled locally extensive pelvic-perineal malignancies. Several successful cases have been reported in the world literature [3-6] and careful perioperative management has been crucial. The case presented is that of a massive recurrent chondrosarcoma of the pelvis with special emphasis on close monitoring and finely tuned supportive care; unusual manifestations of neuroleptic malignant syndrome and of narcotic withdrawal are discussed.

Mallory-Weiss syndrome secondary to cis-platinum chemotherapy: an unusual complication

The Mallory-Weiss syndrome is a relatively infrequent cause of digestive tract bleeding and most cases have been described in alcoholics. Nonoperative management is frequently successful. We present here a case of sudden onset of wretching and vomiting after IV infusion of cis-platinum for recurrent carcinoma of the uterine cervix in which the patient had profuse hematemesis secondary to three posterior gastroesophageal tears requiring operative intervention after failure of nonsurgical management. This is an unusual complication of antineoplastic chemotherapy and its prevention is emphasize in this paper.

Preoperative and postoperative immunological evaluation of patients with colorectal cancer

Twenty-two patients with cancer of the colon and rectum were studied: preoperative and postoperative cell-mediated and humoral immune factors were assessed, and local concentration of immunoglobulins in tumor tissue and in normal mucosa were measured. Lymphocyte function was found to be reduced in 50% of stage A and B and 66% of stage D patients. On the other hand, when the lymphoblastogenesis was performed in the presence of normal AB plasma, a partial restoration of lymphocyte function was noted, indicating the presence of a serum blocking factor in the blood of these patients. While there was no apparent decrease of B cell subpopulation, 57% of the tested patients showed significant reduction of T lymphocytes. Marked reduction of serum immunoglobulin levels, specifically IgG and IgM, was observed preoperatively followed by a gradual return toward normal values after surgical resection of neoplastic growth. It is noteworthy that tumor tissue contained more IgG and IgA than normal mucosa. However, IgM was below detection level both in normal and tumor tissues.

Serum immunoglobulins in colorectal cancer

Preoperative serum immunoglobulins were measured in 102 patients with colorectal carcinoma. There were no differences in the mean values of IgA, IgM or IgG between stages. There was an association, however, between advanced stage of disease and a combination of low levels of IgA (less than or equal to 200 mg/dl) or high levels of IgM (greater than or equal to 125 mg/dl). The ratio of IgA/IgM was also found to be lower in advanced disease. It was felt that low levels of IgA and high IgM may represent an altered immune response and thus be a prognostic indicator.