Hepatic resection for colorectal liver metastases

The lack of other effective treatment for colorectal liver metastases makes hepatic resection a primary treatment consideration. Between January 1980 and December 1990, 26 selected patients with liver colorectal metastases who underwent hepatic resection were reviewed. The age, sex, site of primary lesion, histological grade, lymph node involvement, location, size, and number of hepatic metastases, type of hepatic resection, and preoperative CEA blood levels were documented. Complete removal with histologically negative resection margins were accomplished in 24 patients. The extent of resection performed was hepatic lobectomy in 12 patients. Segmentectomy in eight patients, and wedge resection in four patients. The 5-year survival rate was 30.5 per cent. Patients with metachronous metastases showed a better survival rate than those with synchronous lesions--46.6% versus 13.6% respectively (P = 0.08). None of the other factors studied showed a significant effect on survival. All patients were followed from the time of hepatic resection to the time of this study or death. During a median follow-up of 30.9 months, 20 patients developed recurrence of their disease (60 per cent in the liver). There was no perioperative mortality. Morbidity arose in 66.6 per cent of patients, with a majority of the complications being minor. We conclude that hepatic resection can be performed safely enough to be recommended in selected patients.     

A case of surgical resection for metachronous multiple liver metastases of chromophobe cell renal carcinoma

A 64-year-old female was hospitalized because of multiple liver metastasis, during the postoperative observation of chromophobe cell renal carcinoma. Injection of Epirubicin/Lipodol into the right hepatic artery followed by transcatheter arterial embolization was performed two times, and the metastatic foci responded favorably to this therapy. Since no new metastatic tumors were observed in the liver nor any other organs, a partial hepatectomy was thus performed. The liver tumor was pathologically diagnosed to be metastasis of the chromophobe cell renal carcinoma. The postoperative course has been uneventful and at present, 6 months after the operation, no further tumors have been observed.     

Results of resection of gastric cancer with distant metastases

BACKGROUND/AIMS: The present study was carried out in order to examine the outcome of resection in cases of gastric cancer with distant metastases. METHODOLOGY: The survival rates of two hundred and eighty-one patients who had undergone resection for primary carcinomas of the stomach, and who had distant metastases according to the TNM classification, were studied. RESULTS: The 5-year survival rates for patients with metastasis to the peritoneum or group 3 nodes were 8.9% and 15.3% respectively and were significantly higher than the survival rates for patients with metastasis to the liver (0%), to group 4 nodes (2.2%) or to more than one site among the liver, lymph nodes and peritoneum (3.5%). Moreover, the 5-year survival rates for patients with metastasis to the peritoneum and N3 nodes increased significantly to 29.4% and 24.2%, respectively, when curative surgery was performed. CONCLUSIONS: The findings of the present study suggests that metastases to the adjacent peritoneum or group 3 nodes have a greater chance of being cured using radical surgery, and that gastrectomy with extended lymphadenectomy (D2-D3) may be used for advanced gastric cancer if there is no gross evidence of metastasis to the distant peritoneum, liver or group 4 nodes.     

Cryotherapy of the resection edge after liver resection for colorectal cancer metastases

A 35-year-old female was referred to our clinic with a complaint of left flank pain in 1993. Drip infusion pyelography showed a filling defect of 25 x 24 mm in size in the left ureteropelvic junction. Computed tomography and ultrasonography revealed it as the renal stone. Percutaneous nephroureterolithotomy and extracorporeal shock-were lithotomy were performed. The stone was composed of 2,8-dihydroxyadenine (DHA). The patient was diagnosed as having a partial deficiency of adenine phosphoribosyltransferase (APRT) from the low APRT activity and a genotype of a compound heterozygote APRT*J/APRT*Q0 by T-cell analysis. The urinary excretion of 2,8-DHA crystals disappeared by the postoperative treatment with allopurinol. Cases of 2,8-DHA urolithiasis reported in the Japanese literature are discussed.     

Indication of prophylactic hepatic arterial-infusion chemotherapy after hepatic resection for liver metastases from colorectal cancer

The purpose of this study was to clarify the indication of prophylactic hepatic arterial-infusion chemotherapy (PHAIC) after hepatic resection for liver metastases from colorectal cancer. Sixty-one patients underwent curative hepatectomy, and 27 of them were treated with PHAIC using implantable port. According to clinicopathological factors of primary colorectal cancer and liver metastases, the prognoses were analyzed. In conclusion, PHAIC was not useful for patients who had distant lymph node metastases (paraaortic lymph node) from primary cancer.     

Evaluation of hepatic resection and hepatic arterial infusion chemotherapy for multiple liver metastases from colon cancer

We examined the significance of hepatic resection and hepatic infusion chemotherapy for multiple liver metastases from colon cancer. Twelve patients underwent curative hepatic resection for multiple liver metastases (more than five), and 10 of them received arterial infusion chemotherapy. The number of metastases ranged 5 to 30 (mean 9.4). Recurrence rates in the remnant liver were 50%, and five-year survival rates were 31%.     

The impact of patient's age on surgical therapy of colorectal liver metastases

In a consecutive series of 90 hepatic resections for colorectal liver metastases which were performed during a 10-year period at one institution, the influence of patient's age on surgical strategies and postoperative results was investigated. The mean age of all patients was 61 +/- 11 years with a range from 27-78 years; 19 patients (21%) were younger than 50 years and 18 patients (20%) were older than 70 years. Thirty-six (40%) major and 54 (60%) minor hepatic resections were performed. The postoperative complication rate was 26% and resection mortality 3%. Estimated overall median survival time was 27 months, operative mortality included. 1-, 3-, and 5-year survival rates were 78%, 45%, and 32%, respectively. Although there is some suggestion that selection criteria are more aggressive in younger patients, neither surgical procedures nor postoperative results were found to be determined by the numeric age of the patient in a significant way.     

Medical and surgical management of pulmonary metastases from germ cell tumors

Campylobacter jejuni strains are able to produce at least two different cytotoxins called "cytolethal distending toxin" (CLDT) and "cytolethal rounding toxin" (CLRT). In this study, we investigated the corresponding changes in CHO-K1 cells using the cell counter and analyzer system CASY 1. Determination of the cell volume after toxin treatment of the cells is a useful criterion for differentiation between the cytotoxic activities produced by Campylobacter strains. Incubation of the cells with crude CLDT resulted in a decrease in the cell count combined with a dramatic increase of the mean cell volume in comparison to the control culture. A decrease in the cell count was also seen as a response to CLRT preparations, while this toxin had no effect on the mean cell volume determined. It was shown that only CLDT caused histone-associated DNA fragments in the cytoplasm of CHO-K1 cells indicating an apoptotic pathway of cell death. In addition, the polymerase chain reaction (PCR) was employed to screen Campylobacter strains for the presence of the cdtB gene sequence, which was detectable in all strains investigated.     

The surgical treatment of thoracolumbar metastases

Intrathecal implants of adrenal chromaffin cells are known to release analgesic substances such as catecholamines and opioid peptides. In the present study, bovine chromaffin cells were encapsulated in a permselective polymer membrane which protects the cells from the host immune system and allows grafting of xenogeneic cells without immunosuppression. The effects of such implants were evaluated on the pain behavior resulting from a chronic constrictive injury (CCI) of the rat sciatic nerve. Sprague-Dawley rats with a unilateral lesion were implanted in the lumbar subarachnoid space and tested for mechanical/thermal allodynia and hyperalgesia. A significant reduction in pain was observed after mechanical non-nociceptive stimulation in animals implanted with chromaffin cells. Furthermore, these animals showed decreased signs of spontaneous pain. However, response to thermal non-noxious stimuli or to painful mechanical stimuli was not significantly decreased. Abundant clusters of viable chromaffin cells intensely labeled with the anti-tyrosine hydroxylase antibodies were observed in the retrieved implants. These results establish the analgesic efficacy of intrathecal encapsulated chromaffin cells in a chronic pain model of nerve injury. Immunoprotected allo- or xenogeneic chromaffin cells acting as 'mini pumps' continuously delivering neuroactive substances could be a useful therapy for patients suffering from neuropathic pain.     

Results of surgical treatment of T3 lung carcinoma according to the combined resection of involved organs

A new TNM staging system was decided last year by UICC, consequently T3N0M0 was transferred from stage IIIA to stage IIB. Although T3 is defined to include tumors with direct invasion to adjacent organs. Those are chest wall, parietal pleura, diaphragma and pericardium, however results of surgical treatment according to the combined resection of involved organs described above have not been investigated yet enough. Eighty-nine cases with T3 from 1996 were divided into two groups, patients from 1986 to 1990 and from 1994 to 1998. In the former phase 46 cases were resected and its 5-year survival rate was 15.6%. Better prognosis with significant difference was shown in patients between N0 (5-year survival: 25.1%) and N1 + N2 (5-year survival: 4.0%). In the latter phase 43 cases underwent surgery and its 3-year survival was 24.0%. In the prognoses according to the involved adjacent organs, patients with combined resection of parietal pleura showed the best survival in comparison with patients of chest wall resection and pericardial resection, but there was no significant difference in these 3 groups. Two patients with combined resection of diaphragma are well alive.     

Results of surgical resection in patients over the age of 70 years with non small-cell lung cancer

Calcium release from the sarcoplasmic reticulum (SR) depending on depolarization of the transverse tubular membrane (TTM) caused by rapid ionic replacement was measured in skeletal muscle triadic vesicles using a stopped-flow apparatus and Fura-2, a membrane-impermeable Ca2+ indicator. Calcium release was triggered by an increase in the magnitude of depolarization. This Ca2+ release was inhibited by ruthenium red, digoxin and dantrolene, and enhanced by caffeine. Thus, Ca2+ release was found to occur through the SR Ca2+ release channel via TTM depolarization and to be able to cause skeletal muscle contraction. Calcium release curves could be divided into two phases. In contrast to other previous studies, in the fast phase the amount of released Ca2+ increased with an increase in the magnitude of depolarization but the Ca2+ release rate did not; on the other hand, in the slow phase the Ca2+ release rate increased but the amount of Ca2+ did not. Furthermore, the Ca2+ release rate was controlled by the luminal Ca2+ concentration of the SR only in the fast phase. These independent dual kinetics of Ca2+ release were explained by the calsequestrin regulation model.     

The surgical management of multiple lung metastases

From 1970 to June, 1976, 56 patients who had multiple metastatic tumors of the lung were treated by lung resection. Most of the bilateral lung lesions were removed through a median sternotomy so as to avoid staged bilateral thoracotomy. The surgical mortality was 1.8%. A total of 26 patients are alive at 7 to 69 months (estimated median survival, 20.7 months). Patients with tumor doubling time of less than 40 days had lower survival results (median, 9.5 months), compared to patients with tumor doubling time of more than 40 days (median not yet reached). The type of primary tumor, tumor-free interval, number of lesions removed, and presence of unilateral as opposed to bilateral lung metastases did not seem to affect the therapeutic results.     

Vascular resection during surgical resection for advanced gallbladder carcinoma

We evaluated the results of vascular resection during surgical resection for advanced gallbladder carcinoma. Twelve patients underwent vascular resection (portal vein in 11, hepatic artery in 2, inferior vena cava in 2) in 58 resected patients with advanced gallbladder carcinoma (stage III and IV). The surgical rate was higher in the nonvascular resection group (61%) than in the vascular resection group (25%) (p < 0.05). Surgical morbidity and mortality rates were not significantly different between the two groups. The survival rate was remarkably higher in the curative resection group (n = 29) (55.6% at 1 year, 30.3% at 3 years, 20.8% at 5 years) than in the noncurative resection group (n = 29) (26.3% at 1 year, 0% at 2 years) (p < 0.05). Survival rates of the nonvascular resection group (n = 46) were 45.3% at 1 year, 23.4% at 3 years, and 16.1% at 5 years. However, no patient in the vascular resection group (n = 12) survived longer than 2 years. In conclusion, vascular resection during surgical resection for advanced gallbladder carcinoma does not result in a more favorable prognosis, despite similar surgical risk as in nonvascular resection procedures.     

The approach to the patient with single and multiple liver metastases, pulmonary metastases, and intra-abdominal metastases from colorectal carcinoma

Recurrent colorectal carcinoma constitutes a major health care problem, with 90,000 patients diagnosed annually with metastatic disease. Recent advances have offered treatment to selected patients with liver, lung, and intra-abdominal metastases. Resection of liver secondary tumors improves 5-year survival from 0% to approximately 30% and offers the only possibility for cure. As experience mounts, hepatic surgery can be performed with quite acceptable morbidity and mortality. Adjuvant therapies are being developed that may improve results with surgery alone. Cryoablation is a new technique that appears to effectively eradicate liver tumors, but its role remains to be defined. In patients with unresectable disease, the benefit of hepatic artery infusion of chemotherapy is unproven. Resection of pulmonary metastases significantly improves survival in patients with solitary nodules. Consistent data regarding the benefit of pulmonary metastatectomy in patients with multiple nodules are not available. Combined cytoreductive surgery and intraperitoneal hyperthermic chemotherapy is being investigated as a treatment for peritoneal carcinomatosis from colorectal cancer. Although selected patients may benefit, this combined treatment modality appears to be less effective in patients with colorectal cancer than with other types of cancer.     

Echolaparoscopic-guided alcohol injection of liver metastases

At Nuremberg Southern Hospital we have been using endovascular therapy for aortic aneurysms for the past 3 years. Between August 1994 and August 1997, 193 patients with infrarenal aortic aneurysms were treated with endovascular stent grafts. Besides using commercially available modular systems of the Stentor type (MinTec/Vanguard*, Boston Scientific) we also participated in a multicenter study implanting EGS devices (EVT in 65 patients). Follow-up examinations must strive to detect thrombotic complications as well as endoleaks with high sensitivity and specificity. To avoid aneurysm rupture significant increase in aneurysm diameter must be detected in a timely fashion to select patients for additional corrective endovascular procedures or conversion to open surgical therapy. A close follow-up regimen therefore is absolutely mandatory for all patients undergoing endovascular aortic grafting, particularly when new prosthetic devices are being introduced. Prosthetic devices that have been adequately tested using controlled study designs and are commercially available may be followed-up using a standardized follow up scheme as delineated. Particularly during the first postoperative year color duplex with use of an intravenous ultrasound enhancing agent has been used successfully to detect even minor endoleaks originating from retrograde perfusion via aortic side branches (lumbar or inferior mesenteric artery). Only patients with documented endoleaks or suspected outflow obstruction requiring further intervention need to undergo diagnostic arteriography. After conventional aneurysm repair yearly duplex scans are usually sufficient to follow the normal patient. Patients who have undergone endovascular therapy, however need to be followed much closer using duplex as well as abdominal CT scans. This will logically result in significantly higher follow up costs. Periinterventional costs of endovascular aortic reconstruction currently exceed those of conventional aortic repair by approximately 50%. Given the current health care finance situation it is questionable whether endovascular therapy of abdominal aneurysm will become standard practice in Germany.     

Lipiodol avidity of neuroendocrine liver metastases

AIMS: Lipiodol has been shown to concentrate in most hepatocellular carcinomas as well as in some liver metastases, including those of neuroendocrine origin. Our aim was to determine the proportion of neuroendocrine liver metastases that take up lipiodol and to identify tumour characteristics that predict avidity. METHODS: Avidity was assessed in 12 patients with neuroendocrine liver metastases by performing an abdominal CT scan immediately after selective hepatic arterial injection of 5 ml of unlabelled lipiodol and this was correlated with number and size of lesions as well as angiographic and plain CT scan features. RESULTS: In seven patients the tumours displayed lipiodol avidity (four solitary, three multiple); five patients had non-avid lesions (all multiple). A large dominant liver tumour was the only predictor of avidity (mean diameter of largest lesion 9 cm vs. 3 cm for patients with non-avid tumours: P=0.01). Avidity was not related to vascularity or CT density of lesions. CONCLUSIONS: Although this is a small study, it would appear that approximately 50% of neuroendocrine liver metastases selectively concentrate lipiodol, which could have implications for targeted cancer therapy.     

Induced hypertensive chemotherapy with angiotensin-II for liver metastases from gastric cancer

The theoretical purpose of induced hypertensive chemotherapy used together with injection of Angiotensin-II is to increase the delivery of anticancer drug to the target tumor tissue by increasing blood flow in the tumor. Angiotensin-II (0.1 mg) was dissolved in 50 ml of normal saline, and given through a peripheral vein by a microinfusion pump. When systolic pressure rose to about 140 to 150 mmHg, Mitomycin C (10 to 20 mg/body) was given for 10 minutes via implanted port, whose tip was located in hepatic artery, followed by continuous infusion of 5-FU at 250 mg/day for 5 days. Response could be measured in 4 of all cases (66.7%). CR was found in 2 and PR in 2. Bone metastases or systemic lymph node metastases occurred after a few months in one CR case and one NC case. We concluded that this mode of chemotherapy was a useful measure for the treatment of liver metastases from gastric cancer.