Adenocarcinomas of the jejunum and ileum: a 25-year experience

Adenocarcinomas of the jejunum and ileum are rare gastrointestinal malignancies. Because few large published experiences exist, we reviewed patients with jejunal and ileal adenocarcinoma treated at our institution over the last 25 years. Between January 1976 and December 2001, 77 patients had an operation for a jejunal or ileal adenocarcinoma. Records were retrospectively reviewed for patient, tumor, and treatment variables. Factors affecting disease recurrence and patient survival were investigated. Fifty-two of the adenocarcinomas (67%) occurred in the jejunum and 25 occurred in the ileum (33%). Mean patient age was 63 +/- 14 years. Segmental bowel resection was performed in 50 patients (65%) with curative intent. Palliative operative procedures including resection or bypass were performed in 27 patients (35%). One (1%) patient had stage I, 18 (23%) stage II, 19 (25%) stage III, and 39 (51%) stage IV adenocarcinoma at diagnosis. Postoperatively, 12 patients had palliative and 18 adjuvant chemotherapy (n = 30), radiation therapy (n = 1), or combination treatment (n = 7). Median patient survival was 19 months. Sixty-six percent of patients who had a curative operation had a tumor relapse. Tumor stage had a highly significant effect (P < 0.0001) on median survival (72 months for stage I and II, 30 months for stage III, and 9 months for stage IV disease). In multivariate analysis of patients having curative treatment, tumor recurrence (P < 0.0001), stage (P < 0.0002), and weight loss (P < 0.001) were significant negative prognostic indicators. Most patients with adenocarcinoma of the jejunum or ileum present with advanced disease. Tumor stage, disease recurrence, and weight loss predicted patient outcome following a curative operation. Early recognition of these tumors requires a high index of suspicion.

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis from small bowel adenocarcinoma

INTRODUCTION

Peritoneal carcinomatosis (PC) is associated with a dismal prognosis. Small bowel adenocarcinoma is a rare etiology for PC. Due to the rarity, poor prognosis, and lack of standard treatment, we chose to review our experience with this disease process treated with cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC).

METHODS

From a prospective database of IPHC patients, six patients diagnosed with PC from adenocarcinoma of the small bowel were identified. Between 1995 and 2004 these patients underwent CS and IPHC with Mitomycin C. A retrospective review was performed on these patients with mortality as the primary outcome measure.

RESULTS

Three of the six patients in this series are still alive, with a mean follow-up of 19.7 months after treatment with CS and IPHC. Three patients died of disease progression 29, 30, and 45 months after IPHC. Median survival after diagnosis of small bowel adenocarcinoma was 54 months, while median survival after CS and IPHC for PC was 30.1 months.

CONCLUSIONS

Small bowel adenocarcinoma with PC remains an unusual therapeutic challenge. Treatment with CS and IPHC is an attractive option for patients in this setting.

Is imatinib justified as an adjuvant chemotherapy for patients with recurrent gastrointestinal stromal tumors

Imatinib, an inhibitor of the tyrosine kinase activity of c-kit, was used as an adjuvant chemotherapy in two patients who underwent curative surgery for recurrent gastrointestinal stromal tumors. One patient has maintained tumor-free survival for 12 months, while the other had rapid recurrence and metastasis of tumors 3 months after he discontinued the drug. The indication and effects of imatinib for prevention of recurrence of GIST after ablative surgery were discussed.

131I-meta-iodobenzylguanidine in the management of metastatic midgut carcinoid tumors

The management of metastatic neuroendocrine tumors incorporates multimodal therapy with surgery, biotherapy, and chemotherapy. Tumor-targeted therapies using radiolabeled octreotide and metaiodobenzylguanidine (mIBG) represent a novel treatment approach. The aim of this study was to evaluate the effectiveness of 131I-mIBG in the treatment of metastatic midgut carcinoid tumors. survival outcomes were assessed for patients treated at two regional cancer centers and then compared. One center used 131I-mIBG routinely in the management of metastatic carcinoid tumors (center A), and the other did not use this modality (center B). Only patients with histologically proven metastatic carcinoid tumor shown, or thought most likely, to be of midgut origin were included in the study. During the period 1980 to 2002, a series of 58 patients from center A with metastatic carcinoid tumor arising from the midgut underwent multimodality therapy with the addition of 131I-mIBG. Their median age was 64 years. The median dose of 131I-mIBG administered was 6751 MBq, and there was an average of 2.8 treatments per patient. During the same period, 58 patients with metastatic carcinoid were treated at center B with similar multimodality therapy without the use of 131I-mIBG therapy. Their median age was 65 years. Survivals at 3 and 5 years were 77% and 63%, respectively (95% CI 47-75), for group A. The 3- and 5-year survivals for group B were 56% and 47% (95% CI 34-59), respectively. The mean follow-up was 6.6 years for group A and 5.0 years for group B. Although retrospective in nature, this study suggests that the addition of 131I-mIBG therapy to the treatment protocol of patients with metastatic midgut carcinoid tumors prolongs survival.

[Successful treatment with etoposide by oral administration for recurrence of gastric diffuse large B-cell lymphoma after surgical resection--a case report]

A 64-year-old woman, who had been treated for gastric diffuse large B-cell lymphoma (DLBCL) by total gastrectomy and received 3 courses of CHOP therapy at 61 years of age, was diagnosed with recurrence of DLBCL in the small intestine. After the small intestinal tumor was resected, multiple metastases were found in the liver. Because intensive chemotherapy was difficult for her poor performance status, 50 mg of etoposide daily by oral was administered for 21 consecutive days. After one course of chemotherapy, liver metastases and lymph node swelling almost disappeared without severe adverse effects, and after five courses she achieved complete remission. Though DLBCL invaded the central nervous system, the abdominal regions had been free from recurrence for 12 months. This case report suggests that oral etoposide therapy is useful for gastrointestinal DLBCL which has metastasized to the liver.

Chromogranin A as a determinant of midgut carcinoid tumour volume

Neuroendocrine (NE) tumours are characterized by their capacity to synthesize, store and release hormonal products. These substances are stored in neurosecretory vesicles together with chromogranin A (CgA). The concentration of plasma CgA in patients with NE tumours is thought to reflect the degree of NE differentiation, total tumour burden and effect of medical treatment. The aim of this study was to analyse the correlation between tumour weight and plasma CgA levels as well as the influence of treatment with a long-acting somatostatin analogue (octreotide) using nude mice with xenografted human ileal carcinoid tumours. There was a correlation between tumour weight and plasma CgA levels in all animals (p < 0.00001). In octreotide-treated mice, plasma CgA levels were significantly reduced versus untreated animals (p = 0.037). In conclusion, this study demonstrates that plasma CgA levels are closely correlated to tumour burden, and that plasma CgA is well suited for monitoring the clinical course and outcome of treatment in patients with NE tumours.

Hemophagocytic syndrome in ileum-origin B-cell lymphoma

A 56 year-old-man was admitted due to upper abdominal tumor and was diagnosed as having stage IVb diffuse B-cell malignant lymphoma that originally developed in the terminal ileum. The first and the second administrations of CHOP (cyclophosphamide, 750 mg/m(2); adriamycin, 50 mg/m(2); vincristine, 1.4 mg/m(2); and prednisolone, 100 mg/day) therapy were effective; however, the third course of therapy was postponed because of an episode of massive hematochezia. After this episode, lymph nodes began to enlarge and progressive pancytopenia occurred. Bone marrow smear showed the proliferation of reactive histiocytic cells which phagocytized red blood cells, white blood cells, and platelets. B-cell lymphoma-associated hemophagocytic syndrome (B-LAHS) was diagnosed. This case is extremely rare because: (1) LAHS occurred in an ileum-origin B-cell lymphoma, and (2) LAHS developed during an interval after chemotherapy.

Extrapulmonary small cell carcinoma following augmentation enterocystoplasty

Tumours developing after urinary tract or bladder reconstruction with intestinal tissue have well been described. Adenocarcinomas and transitional cell carcinomas are the most frequent histological features. We report here a case of small cell carcinoma developing after augmentation enterocystoplasty. This rare observation is an opportunity to review the literature about extrapulmonary small cell carcinoma and tumours developing after uro-intestinal reconstruction surgery.

[Clinical course of an ileal carcinoid with mesenteric metastasis]

This paper aim is to present the case of a male patient, age 63 admitted in hospital for non-specific gastroenterologic symptoms easily attributed to colecyst calculosis; the anamnesis and careful clinical examination have avoided a useless cholecystectomy and permitted to establish indication for laparotomy; during that was found an ileal tumor with massive metastasis in the base of mesentery. The surgical attitude was dictated by histological diagnostic difficulties (prostate adenocarcinoma metastasis), so it has given up the idea of tumor excision (unjustified intraoperative risk for a metastasis), performing a bypass of the ileal tumor by an enteroenterostomy, then the patient was sent to the Oncological Department. Postoperative evaluation of the patient finally permitted to establish the neuroendocrine origin of the tumor; after oncological treatment (chemotherapy), about 10 months after operation the patient didn't present any sign of tumor (tumor markers and CT scan within normal). The paper emphasizes the problem of practicing an aggressive surgical treatment for carcinoid intestinal tumors with mesenteric metastasis but also brings attention to nonsymptomatic forms of cholecyst calculosis that may hide associated malignant tumors undetected by laparoscopic cholecystectomy.

Intestinal and extra-intestinal cancer in Crohn's disease: follow-up of a population-based cohort in Copenhagen County, Denmark

AIM

To determine the long-term risk of intestinal and extra-intestinal malignancies in Crohn's disease patients in Copenhagen County, Denmark.

METHODS

In Copenhagen County, a strictly population-based cohort of 374 patients with Crohn's disease diagnosed between 1962 and 1987 was followed until 1997 in order to determine the long-term risk of intestinal and extra-intestinal malignancies. Information on cancer occurrence was provided by the Danish National Cancer Registry and confirmed by the examination of hospital files. The observed number of cases was compared with the expected number, calculated from individually computed person-years at risk and 1995 cancer incidence rates for the background population.

RESULTS

The risk of small bowel adenocarcinoma was significantly increased, independent of age and gender (standardized morbidity ratio, 66.7; 95% confidence interval, 18.1-170.7). The risk of colorectal cancer was not increased, either in the total group of patients or in patients with colonic Crohn's disease exclusively (standardized morbidity ratio, 1.64; 95% confidence interval, 0.20-5.92). Extra-intestinal cancer did not occur more frequently than expected.

CONCLUSIONS

This population-based study of patients with Crohn's disease revealed no increase in colorectal cancer risk, possibly due to maintenance treatment with 5-aminosalicylic acid preparations and surgery in treatment failure. In contrast, the risk of small bowel cancer was increased more than 60-fold, but the numbers were small. The risk of extra-intestinal cancer was not increased and no lymphomas were observed.

[A 63-old patient with right-sided hypogastric pain at 6 months after appendectomy]

Anhand einer Fallbeschreibung werden die Differentialdiagnosen bei rechtsseitigem Unterbauchschmerz mit den entsprechenden weiterführenden Abklärungen besprochen. Schwerpunktmässig wird im Kommentar anhand des beschriebenen Falles auf die Bildgebung von Dünndarmprozessen und im speziellen auf das diffuse, grosszellige B-Zell-Lymphom (Schwerpunkt Therapie, Prognose) eingegangen.

Thymidine and hypoxanthine protection patterns of the folic acid-enhanced synergies for combinations of trimetrexate plus a polyglutamylatable inhibitor of purine or thymidylate synthesis against human ileocecal HCT-8 cells

In order to examine the intracellular locus of the folic acid (PteGlu)-enhanced synergies of trimetrexate (TMQ) plus the thymidylate synthase (TS) inhibitor, raltitrexed (RTX), and TMQ plus the glycinamide ribonucleotide formyltransferase (GARFT) inhibitor, AG2034, comprehensive protection studies with thymidine (dThd) and hypoxanthine (HX) were conducted in a 96-well plate cell growth inhibition (sulforhodamine B) assay. Current modeling techniques were extended to characterize these protection patterns involving multiple-agent interaction. Wild-type human ileocecal HCT-8 cells and DW2, a subline deficient in folylpoly-gamma-glutamate synthetase (FPGS) were individually treated for 96 h with TMQ, AG2034 and a 1:1 mixture of TMQ:AG2034 or with TMQ, RTX, and a 1:1 mixture of TMQ:RTX in the presence of PteGlu (2.3 or 40 micro M) and the protection agents (10 micro M dThd and/or 100 micro M HX). Drug treatments were randomly assigned to wells. Both isobols and 3-dimensional concentration-effect surfaces were used to assess the nature and the intensity of drug interactions. The structural Hill model was fitted to data with weighted non-linear regression for most cases. A so-called 'double Hill' model was sometimes more appropriate when a plateau in the middle of the concentration-effect curve was found. In HCT-8 and DW2 cells at 2.3 and 40 micro M PteGlu, inhibition of DHFR by TMQ induced antithymidylate and antipurine effects; AG2034 and RTX selectively inhibited de novo purine or thymidine synthesis, respectively. dThd protection increased the PteGlu-enhancement of the TMQ + AG2034 synergy, whereas HX protection increased the PteGlu-enhancement of the TMQ + RTX synergy. The PteGlu-enhanced synergies of TMQ + AG2034 and TMQ + RTX occur primarily through inhibition of purine synthesis and inhibition of thymidylate synthesis, respectively. These results further substantiate the hypothesis that the nonpolyglutamylatable DHFR inhibitor, TMQ, acts as a modulator by decreasing the protection by PteGlu of cells against the polyglutamylatable AG2034 and RTX.

Partial intestinal obstruction due to childhood refractory hon-Hodgkin's lymphoma, successfully treated with taxol

In this report, we present a six-year-old male patient with partial intestinal obstruction due to refractory Non-Hodgkin's lymphoma (NHL) whose partial obstruction was successfully treated with Taxol(R) without any surgical intervention. Following an unsuccessful treatment attempt to treat his high-grade (stage 3) B-cell lymphoma with standard and second-line chemotherapy regimens he was started on radiotherapy and third line chemotherapy during which he was admitted with partial obstructive ileus as a result of tumor progression. Treatment was continued with Taxol(R) and resulted in total cure of the ileus with reduction of palpable tumor mass over 24 h without necessitating any surgery. Taxol(R) (200 mg/m (2)/week) was administered without any major side effects/toxicities for six courses. A control CT of the abdomen revealed a significant reduction in tumor size. After the next course, the patient developed severe thrombocytopenia that unfortunately did not resolve before the patient died as a result of further tumor growth and dissemination. Although there are studies that report response to Taxol(R) treatment in adult patients with refractory NHL, our review of the literature failed to demonstrate any report about the effectiveness of Taxol(R) in childhood NHL. In conclusion, our case may indicate that Taxol(R) can be effective and be administered safely in an outpatient setting in children with refractory NHL with the aim of prolonging the survival without sacrificing good quality of life. Studies on larger number of patients are needed to make a definitive conclusion about the value of Taxol(R) in refractory childhood NHL.

[Surgical treatment of gastrointestinal stromal tumors: personal cases]

Surgical management of gastrointestinal stromal tumors: our experience. Gastrointestinal stromal tumors (GIST) are rare neoplasm even if they are the most common mesenchimal malignancies of the gastrointestinal tract. GIST have long been a source of confusion and controversy, in particular to define their pathological classification, preoperative diagnosis, management strategies, and prognosis. A radical resection of the tumor is often possible and always recommended. Recent studies have identified its principal pathogenic defect. An effective adjuvant therapy treatment (STI571) have been found for advanced and metastatic GIST.

[Urogenital expression of a tumor of the terminal ileum]

Malignant tumors of the small bowel are usually associated with digestive and general symptoms. We report the case of a 26-year-old patient who presented with right lumbar pain and right testicular pain. Final diagnosis was lymphoma of the terminal ileum involving the right pelvic ureter and the right vas deferens. We discuss frequency and mechanisms of this very unusual extension of malignant small bowel tumors.

Successful treatment of gastrointestinal follicular lymphoma with rituxan and combination chemotherapy

The clinical course of follicular lymphoma (FL) is well known. Although it is a chemosensitive disease, thereby allowing substantial palliation, recurrence is the rule; only a small subset who presents with limited stage disease is cured. Multiple attempts have been made over the past two decades to improve the survival of patients with FL, and a large number of phase III trials have been reported. These have included a variety of different therapeutic interventions, such as combination chemotherapy, recombinant interferons, new cytotoxic drugs, and immunologic agents. Most studies have not demonstrated that the use of a particular therapy convincingly prolongs survival. Follicular lymphoma cells express CD20 and are associated in most cases with the t(14:18) chromosomal translocation. Rituximab is a chimeric monoclonal antibody directed against the B-cell CD20 antigen, which has been utilized for the therapy of B-cell non-Hodgkin's lymphoma. Rituximab was shown to be active in FL, and studies of its effectiveness in combination with cytotoxic chemotherapy to increase the response rate are forthcoming.

Isolated metastatic myocardial carcinoid tumor in a 48-year-old man

This brief report describes an asymptomatic patient with a myocardial mass. Two-dimensional echocardiography, technetium Tc 99m cardiac nuclear scan, and transesophageal echocardiography were performed to define the mass. The mass, which involved the subvalvar right ventricular free wall, was resected and determined to be a metastatic carcinoid tumor by histologic and immunohistochemical analysis. Further investigation revealed the presence of a midgut carcinoid tumor located within the terminal ileum, which was also resected surgically. The patient recovered well after surgery and adjunctive chemotherapy. To our knowledge, this is the first report of comprehensive nuclear and echocardiographic imaging, supplemented by surgical and pathologic findings, in an asymptomatic patient with isolated myocardial metastasis of an ileal carcinoid tumor.

Lymphoma in an ileostomy

Lymphoma developing in an ileostomy is an extremely rare complication. The presentation is similar to the commoner, yet still rare, adenocarcinoma but the staging and management of the condition differs.

[Mediterranean lymphoma mimicking Crohn's disease]

We report an uncommon localization of mediterranean lymphoma of the terminal ileum in a 28 year-old male patient. Ultrasound and Computed Tomography showed moderate regular and symmetrical intestinal wall thickening simulating Crohn's disease. We highlight the role of computed tomography in the diagnosis, staging and detection of complications.

Complete histological regression of metastatic carcinoid tumour after treatment with octreotide

A 69-year-old woman was admitted with facial flushing, weight loss and intermittent diarrhoea. Urinary 5-hydroxyindole-acetic acid (5-HIAA) level was elevated at 200 micromol/24 h (normal: < 50). Computerized tomography (CT) demonstrated multiple enhancing liver metastases with biopsy proven carcinoid metastases with no evidence of primary tumour at this stage. Octreotide was initiated, resulting in marked improvement in carcinoid symptoms. Nine years later, she presented with abdominal pain and slightly deranged liver function tests. Repeat colonoscopy at this stage, showed an ileal tumour causing impending obstruction, necessitating urgent right hemicolectomy. Histology demonstrated primary carcinoid tumour. She continued on octreotide. Three years later at the age of 81 years, she suffered a fatal haemorrhagic stroke. Autopsy revealed complete regression of hepatic carcinoid metastases.

Time-lapse video reveals immediate heterogeneity and heritable damage among human ileocecal carcinoma HCT-8 cells treated with raltitrexed (ZD1694)

BACKGROUND

Cellular heterogeneity in drug response has important clinical implications, and is believed to develop over many generations during clonal evolution in human tumors. The purpose of this study was to determine the level of heterogeneity exhibited by sister cells soon after their birth.

METHODS

Human ileocecal carcinoma cells (HCT-8) were followed up to 11 days in vitro after a 2-h exposure to 1 microM raltitrexed (IC(95)) in a time-lapse video system.

RESULTS

Over five experiments, 414 cells were followed after exposure to raltitrexed. Immediate sterility occurred in 74% of treated cells. Only 6% of cells could produce more than two generations of offspring, and heterogeneity in drug response was seen. Comparing sister cells < 24 h old, the more proliferative sibling produced up to 73 times more offspring, with a median ratio of 9.0 (control median = 1.19). Offspring of prolific drug-treated cells had a decreased probability of division (68% compared with 92%) and an increased average interdivision time (19.0 h compared with 15.1 h).

CONCLUSIONS

Short-term exposure to raltitrexed resulted in increased interdivision times and production of sterile offspring extending seven generations. Cellular heterogeneity (difference in proliferation potential comparing drug-treated sister cells) was evident without a period of clonal evolution.

[Primary ileocecal lymphoma: report of 30 cases]

OBJECTIVE

To investigate the best therapeutic method for primary ileocecal non-Hodgkin's lymphoma.

METHOD

Clinicopathologic features of 30 patients who had been treated from June 1964 to September 1993 were analyzed retrospectively.

RESULT

Twenty-eight patients (93%) underwent resection of their disease. Eleven patients had the resection followed by chemotherapy. Eleven patients had the resection followed by chemotherapy and radiotherapy. All had pathologic evidence. Twenty-nine patients were categorized as B-cell type NHL. One had T-cell lesion. Eleven patients had stage I disease, 11 stage II, 4 stage III, and 4 stage IV. The 5-year survival rate was 36.67%.

CONCLUSION

The prognostic factors are stage of the disease and treatment modality. Adequate initial surgery combined with radiotherapy and chemotherapy may provide optimum therapy for patients with primary ileocecal lymphoma.

Carcinoid tumor regression with high-dose octreotide acetate: a patient report

A patient who had carcinoid tumor of the ileum and liver and intraabdominal lymph-node metastases sustained a substantial (more than 50%) reduction of metastatic tumor burden when treated with accelerated-dosage octreotide.

Comparative studies on the expression of somatostatin receptor subtypes, outcome of octreotide scintigraphy and response to octreotide treatment in patients with carcinoid tumours

We have compared the expression of somatostatin receptor (sstr) subtypes with the outcome of somatostatin receptor scintigraphy and the effect of somatostatin receptor activation in patients with disseminated carcinoid tumours. Tumour tissues from nine patients with midgut carcinoids (ileal) and three patients with foregut carcinoids (gastric, thymic) were analysed using Northern blotting. Expression of somatostatin receptors was demonstrated in all tumours (12 out of 12), with all five receptor subtypes present in 9 out of 12 tumours. Somatostatin receptor scintigraphy using [111In]DTPA-D-Phe1-octreotide visualized tumours in all patients (12 out of 12). The 111In activity concentrations in tumour tissue (T) and blood (B) were determined in three tumours 1-7 days after injection of the radionuclide. The T/B 111In activity concentration ratios ranged between 32 and 651. Clinically, treatment with the long-acting somatostatin analogue octreotide resulted in marked symptom relief accompanied by a significant reduction in tumour markers, for example urinary-5-HIAA levels (28-71% reduction). Incubation of midgut carcinoid tumours in primary culture with octreotide (10 microM) resulted in a reduction in spontaneously secreted serotonin (45-71% reduction) and 5-HIAA (41-94% reduction). The results demonstrate that carcinoid tumours possess multiple somatostatin receptor subtypes and that somatostatin analogues such as octreotide, which preferentially bind to somatostatin receptor subtype 2 and 5, can be used in the diagnosis and medical treatment of these tumours. In the future, novel somatostatin analogues with subtype specific receptor profiles may prove to be of value for individualizing the treatment of disseminated carcinoid tumour disease.

Clinical evaluation of in-feed zinc bacitracin for the control of porcine intestinal adenomatosis in growing/fattening pigs

This field trial was designed to investigate whether the incorporation of zinc bacitracin into pig feed would prevent porcine intestinal adenomatosis. Two hundred-and-eighty-eight weaned pigs on a farm with a previous history of the disease were divided into 16 pens of 18 pigs. Two dietary regimens of zinc bacitracin were tested: from weaning up to 100 days of age, either 300 or 200 ppm zinc bacitracin were incorporated; from 100 to 125 days of age, either 200 or 100 ppm zinc bacitracin were added; and from 125 to 156 days of age (slaughter), either 100 or 50 ppm zinc bacitracin were added. The results were compared with a positive control group which received 60, 60 and 30 ppm salinomycin during the same periods, and with a negative control group which received no antibacterial and/or performance enhancer. The mortality, diarrhoea scores, average daily weight gains, average daily feed intakes and feed conversion ratios of the pigs were assessed. At slaughter, samples of ileum were taken from eight randomly selected pigs per group for bacteriological and histopathological examinations. The three treated groups all performed better than the control group, and the group receiving the high dose regimen of zinc bacitracin performed significantly better than the groups receiving the low dose of zinc bacitracin or salinomycin.

Efficient symptomatic control of carcinoid tumors with somatostatin in patients with disease progression under alpha-interferon therapy

BACKGROUND/AIMS

We report--as a retrospective observation--on eight patients with malignant carcinoid tumors.

MATERIALS AND METHODS

All patients were initially treated with alpha-interferon and received the longacting somatostatin analogue octreotide (SMS 201-995) after disease progression. Tumor growth was monitored by CT-scan or ultrasound. In addition, serum CgA and urinary 5-HIAA values were determined.

RESULTS

All patients responded with relief of symptoms within a few days after the start of octreotide therapy. A regression of the tumor size did not occur, however four patients showed no significant progress over a period of nine to more than eighteen months. The endocrine parameter chromogranin A--determined by immunoluminometric assay (ILMA)--was elevated in all eight patients regardless of symptoms and showed a close correlation with the course of disease. The urinary 5-HIAA values were only elevated in seven patients. In addition, 123I-SMS 204-090 scintigraphy could be performed in six patients. Using this method most of the primary tumors and metastases could be detected.

CONCLUSIONS

Only octreotide therapy showed a sufficient symptomatic control and has to be considered as progress in drug therapy for patients with malignant carcinoid tumors. In addition, chromogranin A is an interesting endocrine parameter for the follow-up of the secretory activity.

[Multiple carcinoid tumors of the small intestine]

Multiple carcinoid tumours of the small bowel with more than 3 lesions are very unusual. We report a case of a 44-year-old man who presented with more than 40 carcinoid tumours localized in the ileum, associated with hepatic metastases and carcinoid tricuspid valve involvement. The site of the primary tumour was not determined by usual imaging techniques. The patient underwent laparotomy in order to resect liver metastases. The diagnosis of multiple carcinoid tumours of the small bowel was made during the abdominal exploration. There was no intraepithelial endocrine cell hyperplasia in the mucosa adjacent to the small bowel tumours. After a 6-month follow-up, the carcinoid syndrome had completely disappeared.

Inhibition of P-glycoprotein-mediated vinblastine transport across HCT-8 intestinal carcinoma monolayers by verapamil, cyclosporine A and SDZ PSC 833 in dependence on extracellular pH

The ability of the multidrug resistance modifiers R- and R,S-verapamil (VPL), cyclosporine A (CsA) and its non-immunosuppressive derivative SDZ PSC 833 (PSC 833) to inhibit P-glycoprotein (P-gp)-mediated transepithelial flux of tritiated vinblastine was investigated using tight and highly resistant (R > 1,400 omega cm2) monolayer cultures of intestinal adenocarcinoma-derived HCT-8 cells grown on permeable tissue-culture inserts. Apical addition of these chemosensitizers inhibited drug flux (137 pmol h-1 cm-2; range, 133-142 pmol h-1 cm-2) in the basal to apical secretory direction at clinically relevant concentrations, with PSC 833 showing the highest activity, exhibiting inhibition at concentrations as low as 10 ng/ml (9 nM). Acidification of the modulator-containing apical compartment to an extracellular pH (pHo) of 6.8 had no influence on MDR reversal by CsA at 1 microgram/ml (0.9 microM; flux inhibition, 52%) or by PSC 833 at 100 ng/ml (0.09 microM; flux inhibition, 60%), in contrast to R,S- and R-VPL, which showed decreased inhibition and caused less accumulation of vinblastine in HCT-8 cells under this condition (flux inhibition of 35% and 23%, respectively, at pHo 6.8 vs 50% and 43%, respectively, at pHo 7.5). P-gp-mediated rhodamine 123 efflux from dye-loaded single-cell suspensions of HCT-8 cells as measured by flow cytometry was not impeded at pHo 6.8 in comparison with pHo 7.5 in standard medium, but at low pHo the inhibitory activity of R-VPL (29% vs 60% rhodamine 123 efflux inhibition) was diminished significantly, again without a reduction in the effect of PSC 833 (rhodamine 123 flux inhibition, 75%). In conclusion, drug extrusion across polarised monolayers, which offer a relevant model for normal epithelia and tumour border areas, is inhibited by the apical presence of R,S- and R-VPL, CsA and PSC 833 at similar concentrations described for single-cell suspensions, resulting in increased (2.2- to 3.7-fold) intracellular drug accumulation. Functional apical P-gp expression, the absence of paracellular leakage and modulator-sensitive rhodamine 123 efflux in single HCT-8 cells indicate a P-gp-mediated transcellular efflux in HCT-8 monolayers. In addition to its high MDR-reversing capacity, the inhibitory activity of PSC 833 is not affected by acidic extracellular conditions, which reduce the VPL-induced drug retention significantly. As far as MDR contributes to the overall cellular drug resistance of solid tumours with hypoxic and acidic microenvironments, PSC 833 holds the greatest promise for clinical reversal of unresponsiveness to the respective group of chemotherapeutics.

Pharmacologic rationale for fluoropyrimidine-leucovorin combination: biochemical mechanisms

Fluoropyrimidines, 5-fluorouracil (5-FU), and 5-fluorodeoxyuridine (FdUrd) are effective inhibitors of DNA synthesis. Inhibitory action is potentiated both in vitro and in vivo by the addition of leucovorin (LV; either the natural [6S] isomer or the mixture of the unnatural and natural [6R,S] isomers). The inhibition of DNA is subsequent to thymidylate synthase inhibition mediated by the formation of a covalently bound ternary complex consisting of 5-fluorodeoxyuridine monophosphate, 5,10-methylenetetrahydrofolate, and thymidylate synthase. In vitro exposure of cells to varying concentrations of [6R,S]LV or [6S]LV increases intracellular pools of the reduced folate cofactor. The effect of [6S]LV is both dose and time dependent. The in vitro effective concentration of [6S]LV is approximately 1 to 10 mumol/L, depending on cell type. While HCT-8 cells demonstrated optimal modulation of 5-FU and FdUrd cytotoxicity with 1 mumol/L of [6S]LV for 5 hours, the SE cells required higher doses of LV and longer exposure time. Thus, dependent on the cell type, higher concentration (10 mumol/L) and duration of exposure (greater than 5 hours) may be essential for an effective modulation of fluoropyrimidine action. Clinically, to achieve the concentration and conditions found optimal in an in vitro system, a dose of 500 mg/m2 by 5-hour infusion appears to be the present optimal dose and schedule of [6R,S]LV administration in combination with 5-FU.

Treatment of malignant midgut carcinoid tumours with a long-acting somatostatin analogue octreotide

Treatment with the somatostatin analogue octreotide, SMS 201-995 (Sandostatin), has been carried out in a series of 23 patients with malignant midgut carcinoid tumours. The patients received initially 50 micrograms twice a day for six months, thereafter a median of 100 micrograms twice daily. Six of 22 evaluable patients (28%) showed objective tumour response lasting for 6 to 30 months. Stable disease was observed in 8 of the 22 patients (36%) and progressive disease in a further 8 patients (36%). A subjective response with decrease of diarrhoea or flushing was noted in 11 out of 22 patients (50%). Two out of 6 patients with objective response demonstrated a significant decrease of tumour size lasting for 6 and 30 months respectively. In order to maintain the clinical response, the dose had to be increased in all 6 responders. The adverse effects included development of diabetic blood glucose levels in 8 out of 22 patients (36%). Albumin-modified serum calcium levels were significantly reduced after treatment with octreotide 50 micrograms twice a day. One patient developed symptoms of hypocalcemia which was reversed by supplementation with calcium and D-vitamins. The somatostatin analogue SMS 201-995 has a beneficial effect in the treatment of patients with the carcinoid syndrome. However, the precise role of the drug in the long-term management of these patients has to be further investigated.

Surgical implications of primary gastrointestinal lymphoma of childhood

Our purpose was to summarize information from a large single institution's experience regarding the role of surgical resection in the management of non-Hodgkin's lymphoma in children and adolescents. Fifty-eight children were treated for primary gastrointestinal non-Hodgkin's lymphoma. The tumors usually presented in the ileocolic region (n = 54). Twenty-one children presented with intussusception. Complete surgical resection of tumor was accomplished in 32 patients, partial resection in 20, and biopsy only in 6. All patients were given lymphoma protocols employing chemotherapy and irradiation. Forty-four (76%) of 58 patients are surviving from 1 year to greater than 20 years from diagnosis. Thirty-one of 32 patients who underwent complete resection followed by protocol management are surviving, compared with 13 of 26 children with residual gross disease. The results indicate that children with primary gastrointestinal non-Hodgkin's lymphoma benefit from complete surgical resection when feasible.

[Invagination as a complication of malignant lymphoma]

Benign or malignant neoplasms are usually the underlying pathological factor initiating intussusception in the older child. Two cases of non-Hodgkin lymphoma are reported. The surgical procedure and chemotherapy are discussed.

Effects of sandostatin on plasma chromogranin-A levels in neuroendocrine tumors

We have determined the effects of Sandostatin (SMS 201-995, Sandoz) on chromogranin-A (CgA) in the blood of 14 patients with neuroendocrine tumors of the gastroenteropancreatic axis, 7 with carcinoid tumors, 5 with gastrinomas, and 1 each with a glucagonoma and tumor-secreting vasoactive intestinal peptide. Two thirds of the patients had elevated plasma CgA. Sandostatin administration suppressed CgA in 12 of the 14 patients. In 8 of 10, the clinical response to Sandostatin paralleled the reduction in CgA levels. There was a strong correlation between the change in CgA levels and the respective blood concentration of the hormone produced by the tumor. Serial measurement of CgA may provide an additional means of monitoring these tumors and their secretory activity where other measures are not available.

Involvement of the ileocaecal region by non-Hodgkin's lymphoma in adults: clinical features and results of treatment

Between January 1977 and January 1988, 19 patients with non-Hodgkin's lymphoma (NHL) involving the ileocaecal region were cared for by the CRC Wessex Medical Oncology Unit. Fifteen of these patients had primary ileocaecal NHL (stages IE or IIE) and four had secondary involvement of this region (stage IV). The commonest clinical presentation was with abdominal pain and a palpable mass in the right iliac fossa. Bulky (greater than 10 cm) disease was a particularly common feature, and complete surgical removal was possible in only seven patients. All patients had intermediate (18) or high grade (one) NHL using the Working Formulation. The commonest histological subtype was diffuse large cell. Seventeen patients received postoperative therapy, comprising local radiotherapy in one and combination chemotherapy in the remaining 16. Eleven of the 19 patients remain disease-free 6-60 months from diagnosis. Because of the high incidence of bulky disease at this site, postoperative therapy may be indicated, even for patients with apparently completely excised stage I disease.

[Is immunosuppressor treatment effective in lymphocytic gastritis? Apropos of a case associated with an intestinal lymphoma]

We report the case of a patient with "lymphocytic gastritis" surprisingly associated with an intestinal lymphoma which was treated after intestinal resection by corticosteroids and a combination of antimitotic agents. Comparing gastric mucosa before and 3 months after therapy, we observed a striking reduction of inflammation. Such a case suggests the possibility of a beneficial effect of immunosuppressive therapy on "lymphocytic gastritis" and favors the hypothesis of an immunological disorder.

Tumor regression of an ileal carcinoid under the treatment with the somatostatin analogue SMS 201-995

A 53-year-old man with metastatic ileal carcinoid ultimately failed to respond to conventional measures of surgery and was finally treated with a new long acting somatostatin analogue, SMS 201-995 for 7 months. SMS 201-995 not only gave symptomatic relief but also induced a reduction in metastatic tumor mass.

DTIC therapy in patients with malignant intra-abdominal neuroendocrine tumors

Malignant intra-abdominal neuroendocrine tumors are rare; consequently, a standard chemotherapeutic protocol for patients with unresectable disease has not been established. This prompted a review of our experience with dimethyltriazeno imidazole carboxamide (dacarbazine) (DTIC) treatment for these tumors. From 1976 to 1986, 14 patients were treated with DTIC for metastatic neuroendocrine tumors. There were seven men and seven women whose ages ranged from 19 to 76 years. Diagnoses included eight nonfunctioning islet-cell carcinomas, three retroperitoneal neuroendocrine tumors, two glucagonomas, and one ileal carcinoid. Before DTIC chemotherapy, four patients were treated with streptozotocin and 5-FU, and one was treated with cytoxan and methotrexate without response. Two patients who were initially treated with DTIC with no response were subsequently treated with streptozotocin and 5-FU without benefit. Standard treatment with DTIC consisted of monthly cycles of 250 mg/m2/day administered intravenously for 5 days. Seven patients had an objective response to DTIC with both improvement in quality of life and a decrease of more than 50% in tumor size on computerized tomography (CT) or liver scanning. Response duration ranged from 1 to 10 years. One patient with a glucagonoma was treated for two years and had no evidence of disease at laparotomy 7 years later. Four patients with nonfunctioning islet cell carcinoma had a positive response to DTIC, but three of these patients had tumor recurrence 3 to 6 years after treatment. Two patients with retroperitoneal neuroendocrine tumors had a positive response to DTIC treatment. One patient with a glucagonoma and one with a nonfunctioning islet-cell tumor had equivocal responses with transient clinical improvement but no objective changes in tumor size. Five patients did not respond; two were given DTIC therapy as a last resort and died 1 and 12 days later. Of the other three patients, two died 6 months and one 2 years after treatment. DTIC chemotherapy was effective in 50% of patients with intra-abdominal neuroendocrine tumors. Although DTIC therapy was associated with nausea, no major gastrointestinal, hematologic, or renal complications were noted. This favorable experience with DTIC chemotherapy for nonresectable intra-abdominal neuroendocrine tumors indicates that further clinical evaluation and use are warranted.

The use of a long-acting somatostatin analogue in the treatment of advanced endocrine malignancies with gastrointestinal symptoms

Four patients with advanced endocrine malignancies were treated with a somatostatin analogue (SMS 201-995) for palliation of hormone-induced symptoms during 3-6 months. Two had the carcinoid syndrome (one midgut and one foregut), one had medullary thyroid carcinoma and an ectopic ACTH syndrome, and one patient had a metastatic gastrinoma. The carcinoid patients had excellent symptomatic relief with a low dose of the drug, 50 micrograms subcutaneously twice daily, in one case despite progression of tumour disease and biochemical tumour markers. These findings indicate an action of the drug not only on hormonal release but also at peripheral sites. The patient with medullary thyroid carcinoma had relief of gastrointestinal symptoms when the drug dose was increased (100 micrograms twice daily). The levels of ACTH in peripheral blood were reduced, but not the calcitonin levels. The gastrinoma patient had undergone a major pancreatic resection (Whipple procedure) and was treated with omeprazole. SMS 201-995 reduced the peripheral gastrin levels acutely, but during the treatment fasting gastrin values increased, and the tumour growth progressed. Treatment was stopped owing to elevated fasting glucose level, increased steatorrhoea, and clinical attacks of cholangitis. Special attention is advocated for patients with major pancreatic resection and biliary reconstruction, who may be susceptible to physiological effects of somatostatin (or its analogues)--that is, impaired insulin release and decreased motility.

Therapy of malignant APUD cell tumors. Effectiveness of DTIC

Eleven patients with malignant APUD tumors, five islet cell carcinomas, five carcinoid tumors and one medullary carcinoma of the thyroid were treated with DTIC. Nine of 11 patients benefitted from treatment. A literature review revealed that other APUD tumors responded when treated with DTIC. DTIC is a useful agent for treatment of malignant APUDomas, and may be the drug of choice for islet cell carcinoma of the pancreas.