Outcome of surgery for chronic pancreatitis

BACKGROUND

In patients with chronic pancreatitis, surgery is indicated for the management of intractable pain or for the treatment of complications.

METHODS

Sixty-three consecutive patients (49 men and 14 women of median age 40 (range 20-72) years) who had undergone surgery over an 8-year interval for chronic pancreatitis were studied. The mortality and morbidity rates associated with surgery were assessed and quality of life was reviewed based on relief of symptoms, analgesic use, employment and long-term sequelae.

RESULTS

Forty-four patients (70 per cent) had alcoholic chronic pancreatitis. In 60 patients the principal indication for surgery was intractable pain. Eighteen patients had a duodenum-preserving resection of the pancreatic head (Beger operation); the other surgical procedures were Whipple resection (15), left-sided resection (13), total pancreatectomy (seven), pseudocystjejunostomy (five), pancreaticojejunostomy (one) and bypass procedures (four). The median inpatient stay was 12 days; 23 patients had postoperative complications including one death (2 per cent). There was improved pain control (P < 0.001), a reduction in opiate analgesia use, increase in percentage weight gain (P < 0.01 at 2 years) and return to employment following surgery. Although there was an increase in diabetes mellitus and need for enzyme supplementation these were easily controlled.

CONCLUSION

Surgery is an effective treatment in carefully selected patients with chronic pancreatitis but must be tailored to the pattern of disease in each individual.

Progress report. A randomized multicenter European study comparing adjuvant radiotherapy, 6-mo chemotherapy, and combination therapy vs no-adjuvant treatment in resectable pancreatic cancer (ESPAC-1)

CONCLUSION

The ESPAC-1 trial is the largest study of its kind in pancreatic cancer and should definitively address the question of the role of conventional methods of adjuvant treatment in pancreatic cancer.

BACKGROUND

At the joint International Association of Pancreatology and the European Pancreatic Club meeting in Mannheim, Germany (June 12-15, 1996) a satellite meeting of the European Study Group for Pancreatic Cancer (ESPAC) met to discuss the progress of the ESPAC-1 trial.

METHODS

A randomized multicenter study to address which, if any, of the following adjuvant treatments are of benefit in patients with resectable pancreatic cancer: radiotherapy (40 Gy with 5-FU as a sensitizing agent), 6 mo of chemotherapy (5-FU and folinic acid), or a combination of these treatments.

RESULTS

From February 1994 to June 1996 (the time of the Mannheim meeting) 221 patients so far have been recruited into the three treatment arms and one control arm.

Adjuvant chemotherapy in pancreatic cancer

There is increasing interest in the use of adjuvant treatment for pancreatic cancer since although postoperative mortality is much improved, median long-term survival is only on the order of 11-15 mo. Despite a proliferation of studies in advanced pancreatic cancer indicating a benefit for chemotherapy, there has only been one small randomized adjuvant trial. A combination of 5-fluorouracil, doxorubicin, and mitomycin-C demonstrated a significantly improved median survival (23 vs 11 mo in controls) but no significant improvement in 5-yr survival (4 vs 8%, respectively). At present there is insufficient evidence to support the routine use of adjuvant chemotherapy (even with radiotherapy) outside of controlled trials. What is required is large randomized trials of adjuvant chemotherapy. A further important question that needs addressing is the role of adjuvant radiotherapy (with concomitant chemotherapy) with or without sequential chemotherapy.

Proteinase inhibitors reduce basement membrane degradation by human breast cancer cell lines

The relative importance of different proteinases, and their inhibition, in the breakdown of human endothelial basement membrane (BM) by MDA-MB-231 and MCF7ADR human breast cancer cell lines has been studied using 35S-labelled BM-coated 96-well culture plates. Basement membrane degradation (BMD) was independent of cell proliferation above the seeding density. Inhibitors of aspartic (pepstatin and PD 134678-0073) and cysteine proteinases (E64) had little effect on BMD under normal culture conditions, suggesting that cathepsins D, B and L have only a minor role. In contrast, inhibitors of urokinase-type plasminogen activator (uPA) and/or plasminogen activation to plasmin (aprotinin, amiloride, EACA, tranexamic acid, anti-uPA antibody) all reduced BMD by MDA-MB-231 cells by approximately 30-40%, but only in the presence of serum or plasminogen. BB94, an inhibitor of matrix metalloproteinases (MMPs), also reduced BMD by about 30% under these conditions but was similarly effective in serum-free medium. Combinations of BB94 with any of the uPA/plasminogen activation inhibitors in serum-containing medium had additive effects, while BB94 with pepstatin and E64 under serum-free conditions reduced BMD to 16% of control. Serum-containing conditioned medium exhibited appreciable BMD, largely due to aprotinin-inhibitable activity. Although small reductions in cell proliferation were seen with some inhibitors, the combination of BB94 with E64 or E64d reduced the cell population by about 60% under serum-containing conditions. These in vitro observations suggest that combinations of proteinase inhibitors, particularly of uPA/plasminogen activation and MMPs, may merit clinical evaluation as potential antimetastatic therapy for breast cancer.

Prolonged intraperitoneal infusion of 5-fluorouracil using a novel carrier solution

A novel peritoneal carrier solution, Icodextrin 20 (7.5%), has allowed exploration of prolonged, intraperitoneal (i.p.) infusion of the cytotoxic drug 5-fluorouracil (5-FU). A phase I and pharmacokinetic study was performed to determine the toxicities and maximum tolerated dose of prolonged and continuous intraperitoneal 5-FU in patients with peritoneal carcinomatosis. Seventeen patients were entered into this study. Each patient had a Tenckhoff catheter placed into the peritoneal cavity under general anaesthetic. After initial flushing and gradual increase in exchange volumes with Icodextrin 20, 5-FU was administered daily from Monday to Friday, 50% as a bolus in the exchange bag and 50% in an elastomeric infusor device delivering continuous 5-FU to the peritoneal cavity at 2 ml h-1. Treatment was continued for 12 weeks or until intolerable toxicity developed. Abdominal pain and infective peritonitis proved to be the main dose-limiting toxicities. Initial problems with infective peritonitis were overcome by redesign of the delivery system, and it proved possible to deliver 300 mg m-2 5-FU daily (5 days per week) for 12 weeks. Pharmacokinetic studies showed i.p. steady-state 5-FU concentrations (mean 47 500 ng ml-1) that were > 1000-fold higher than systemic venous levels (mean 30 ng ml-1).

Duodenal gangliocytic paraganglioma presenting as an ampullary tumor

CONCLUSION

We report a case of a duodenal gangliocytic paraganglioma that had an unusual clinical presentation and atypical immunohistochemical features.

BACKGROUND

Duodenal gangliocytic paragangliomas are rare tumors of the gastrointestinal tract with approx 70 cases reported in the literature. The most common presentation is with gastrointestinal bleeding, whereas obstructive jaundice is very uncommon. Immunohistochemistry typically shows positive epithelial cell staining for somatostatin, pancreatic polypeptide, and other neuroendocrine markers.

METHODS

A 56-yr-old man presented with intermittent episodes of epigastric pain, vomiting, and obstructive jaundice. Upper gastrointestinal endoscopy revealed a pedunculated ampullary tumor that was subsequently confirmed by computed tomography. At operation, there was marked secondary obstructive chronic pancreatitis in the remaining pancreas necessitating a pylorus-preserving total pancreatectomy.

RESULTS

Histology confirmed typical features of a duodenal gangliocytic paraganglioma, but immunohistochemistry demonstrated negative staining for somatostatin and other polypeptides, which is in contrast to most other reported cases. Two years after surgery, the patient remains alive and well on medical treatment with no evidence of recurrent tumor.

Allelic loss on chromosomes 8p, 22q and 18q (DCC) in human prostate cancer

Previous studies have suggested the involvement of tumour-suppressor genes on chromosomes 8p, 22q and 18q (DCC) in prostate cancer. The aim of this study was to further characterize these regions. We investigated 20 polymorphic regions on the 3 chromosome arms in 43 cancers and 10 cases of benign prostatic hyperplasia (BPH). Allelic loss was observed in 72% of cancers on 8p, 16% on 22q and 24% at DCC. For BPH, loss was observed in 20% on 8p and in 12% at DCC. The low incidence of LOH on 22q implies that this locus has no significant role in prostate carcinogenesis. At DCC, although the overall incidence was low, tumours with LOH were mostly of high grade or had metastases, suggesting a role for this gene in prostate cancer progression. On chromosome 8p, 29% of cancers had deletions at the LPL locus on 8p22 and 60% had deletions within a region flanked by the markers D8S339 and ANKI on 8p 11.1-p21.1. Within this region, 2 distinct areas of allelic loss were observed, at one or both ANKI and D8S255, and in the region defined by the markers D8S259-D8S505. For the regions 8p22 and ANKI-D8S255, tumours with metastases had a greater frequency of LOH compared to non-metastasizing tumours, suggesting the presence of putative metastasis-suppressor genes in these regions.

Randomized trial assessing the addition of interferon alpha-2a to fluorouracil and leucovorin in advanced colorectal cancer. Colorectal Cancer Working Party of the United Kingdom Medical Research Council

PURPOSE

To determine the effects of interferon alpha-2a (IFN alpha) on the efficacy and toxicity of fluorouracil (FUra) and leucovorin (LV) in patients with advanced colorectal cancer.

PATIENTS AND METHODS

Two hundred sixty chemotherapy-naive patients were randomized to FUra/LV alone or FUra/LV plus IFN alpha. All patients received: LV 200 mg/m2 intravenous (IV) infusion over 2 hours, then FUra 400 mg/m2 i.v. bolus plus 400 mg/m2 i.v. infusion over 22 hours, all repeated on day 2. Treatment was every 2 weeks for up to 12 cycles. Patients randomized to IFN alpha received 6 x 10(6) IU subcutaneously every 48 hours throughout. Objective response (OR) and toxicity were assessed conventionally; in addition, palliative benefit and adverse effects were assessed using quality-of-life (QoL) questionnaires.

RESULTS

There were no differences in OR rate, progression-free survival, or overall survival. OR rates in assessable patients were as follows: FUra/LV alone (n = 104), complete or partial response (OR) = 27%, no change (NC) = 34%; FUra/LV/IFN alpha (n = 101), OR = 28%, NC = 30%. Median survival was 10 months in both arms. Dose-limiting FUra toxicities were not significantly increased by co-administration of IFN alpha, and the delivered FUra dose-intensity was not significantly reduced. However, QoL was adversely affected: patients on IFN alpha were less likely to report improvement in pretreatment physical and psychologic symptoms, and more likely to report new or worsening symptoms.

CONCLUSION

IFN alpha, at a dose that impaired QoL, did not improve the efficacy of FUra/LV. The power of this trial is sufficient to exclude with 95% confidence a benefit of 15% in OR or 10 weeks in median survival. Accordingly, we cannot recommend the use of IFN alpha as a clinical modulator of FUra/LV in the treatment of advanced colorectal cancer.

Expression of collagenase (MMP2), stromelysin (MMP3) and tissue inhibitor of the metalloproteinases (TIMP1) in pancreatic and ampullary disease

It is now recognised that epithelial-stromal interactions are important in a wide range of disease processes including neoplasia and inflammation. Metalloproteinases are central to matrix degradation and remodelling, which are key events in tumour invasion and metastasis and may also be involved in tissue changes occurring in chronic inflammation. Immunohistochemistry was performed on sections from 50 patients with pancreatic cancer (n = 27), ampullary cancer (n = 12), low bile duct cancer (n = 3), neuroendocrine tumours (n = 3) and chronic pancreatitis (n = 5), using antibodies raised against collagenase (MMP2), stromelysin (MMP3) and tissue inhibitor of metalloproteinase (TIMP1) and developed using the avidin-biotin complex method. Abundance of MMP2, MMP3 and TIMP1 was greater in pancreatic and ampullary cancer than any other pathology and immunoreactivity in the malignant epithelial cells in pancreatic and ampullary cancer was greater than in the stromal tissues (in pancreatic cancer: MMP2 100% vs 37%, MMP3 93% vs 15%, TIMP1 93% vs 4%, P < 0.0001). There were strong correlations between the immunoreactivity of the two antibodies for MMP2 (P < 0.0001), between MMP2 and TIMP1 (P < 0.0001) and between MMP3 and TIMP1 (P < 0.0001). The immunoreactivity for TIMP1 in pancreatic and ampullary cancers with lymph node metastases was significantly less compared with those cases without lymph node metastases (P < 0.02) and there was an association between increased immunoreactivity for MMP2 and the degree of tumour differentiation (P < 0.01). The results implicate MMP2, MMP3 and TIMP1 in the invasive phenotype of pancreatic and ampullary cancer.

Advances in diagnosis and treatment of pancreatic cancer

This review focuses on key advances in diagnosis and treatment of pancreatic cancer, with a particular emphasis on the expanding potential application of molecular techniques and the great strides made in evolving safe pancreatic resection. The epidemiology of pancreatic cancer is reviewed, and recent advances for potential screening are reported. Improvements in operative morbidity and mortality following pancreatic resection have led to calls for more radical surgery, and the results of conventional and extended radical surgery are compared. Recently combined multimodality adjuvant therapy has been used following "curative resection" for pancreatic cancer, and the current status concerning use of this treatment is addressed. Although there is insufficient evidence to recommend routine use of adjuvant therapy, there are sufficient encouraging data to advocate entering patients in large, adjuvant therapy trials. In addition to safe resectional surgery, advances in novel molecular therapy mean that the outlook for patients with pancreatic cancer should no longer be considered hopeless.

Loss of the chromosomal region 10q23-25 in prostate cancer

Loss of the chromosomal region 10q23-25 is a frequent event in the progression of prostate adenocarcinoma. A candidate tumor suppressor gene from this region, Mxi1 at 10q25, has recently been shown to be mutated in a small number of prostate tumors. To more strictly define those regions of 10q loss that are likely to be involved in tumor advancement, we have constructed a detailed deletion map spanning 10q23-25 that incorporates Mxi1. Sixty-two % (23 of 37) of tumors analyzed exhibited some degree of 10q23-25 loss. Our data suggest the presence of a prostate tumor suppressor gene(s) near the 10q23-24 boundary, which was deleted in the overwhelming majority (22 of 23) of tumors showing loss. In contrast, specific loss of Mxi1, as opposed to loss of other 10q23-25 regions or of the entire region, was observed in only 1 of 23 tumors and was accompanied by loss of markers at the 10q23-24 boundary. Furthermore, we failed to detect any mutations in Mxi1 in those tumors showing Mxi1-associated marker loss by either single-strand conformation polymorphism analysis or direct DNA sequencing.

Dietary omega-3 fats reduce proliferation and tumor yields at colorectal anastomosis in rats

BACKGROUND & AIMS

Colorectal anastomoses show increased mucosal crypt cell proliferation rates (CCPRs) and often form the site for tumor recurrence after resection of colorectal cancer. The aim of this study was to assess the effects of a 20% omega-3 fat diet on CCPRs and anastomotic tumor formation compared with an isocaloric 20% saturated fat diet in experimental colorectal cancer.

METHODS

One hundred sixty male Wistar rats were administered azoxymethane or saline for 6 weeks, after which a colonic anastomosis or sham operation was performed. CCPR, mucosal fatty acids, and tumor yield were analyzed at the anastomosis and proximal and distal colon sites at 15 and 23 weeks.

RESULTS

Diet, carcinogen treatment, and surgery all had significant effects on CCPR with omega-3 fats producing the lowest CCPR at all sites. There were fewer tumors (P < 0.02), including a marked reduction of anastomotic tumors in omega-3 fat-fed animals that was associated with a significant reduction of arachidonic acid in mucosal and tumor lipids.

CONCLUSIONS

Dietary omega-3 fat significantly reduced colonic CCPR and tumor yield, including at the site of anastomosis. Dietary omega-3 fats may be of value to patients after colorectal resection and anastomosis for cancer and warrant further testing.

Bile acid absorption from ileoanal pouches using enema scintigraphy

It is unclear whether bile acid absorption is affected by ileoanal pouch construction. Bile acid absorption was measured in the abdomen of 16 patients with pouches (nine with good and seven with poor pouch function based on a clinical score) and in six patients with an end ileostomy using a radiolabelled synthetic bile acid (75SeHCAT) enema and dynamic scintigraphy. The median (interquartile range) 75SeHCAT absorption was 81 (79-87) per cent in patients with ileostomy, 46 (43-53) per cent in patients having well functioning pouches, and 24 (18-38) per cent in the group with poor pouch function (P < 0.01). Log transformation of the absorption curves revealed a two-component uptake (fast component t1/2 = 1.4-7.2 min; slow component t1/2 = 16-144 min) in all patients with ileostomy, in eight of nine patients with pouches with good function, and in one of seven patients with a poorly functioning pouch (P < 0.05); in the other six patients with poorly functioning pouches, only the slow component of absorption was present. This test showed significantly reduced bile acid absorption in patients with an ileoanal pouch and gave an objective discrimination between well and poorly functioning pouches.

Activities of phospholipase A2 and diacylglycerol lipase are increased in human colorectal cancer

Experimental, clinical and epidemiological studies have implicated arachidonic acid and its metabolites as important mediators in colorectal carcinogenesis. Although arachidonic acid levels are increased in tumour membrane lipids, its availability for metabolic processes is not known. The activities of phospholipase A2 (PLA2) and diacylglycerol lipase therefore were assessed in tumour and normal mucosal specimens from 20 patients with colorectal cancer using 14C-radiolabelled substrates. The median (interquartile range) PLA2 activity was increased in tumour tissue (10.5 (6.0, 18.5) pmol arachidonic acid mg-1 h-1) compared with that in normal mucosa (5.6 (2.5, 8.5) pmol arachidonic acid mg-1 h-1) (P < 0.001, Wilcoxon signed rank test). Activity of diacylglycerol lipase was also greater in tumoral tissue (47.4 (21.6, 82.1) pmol arachidonic acid mg-1 h-1) than in mucosa (19.1 (9.4, 42.9) pmol arachidonic acid mg-1 h-1) (P < 0.005). There was no correlation between either PLA2 or diacylglycerol lipase activity and myeloperoxidase activity, suggesting that these increases were not directly attributable to tumour inflammatory cell infiltrate. Augmentation of arachidonic acid release in colorectal tumours may have implications for therapy.

Expression of protein kinase C isoenzymes in colorectal cancer tissue and their differential activation by different bile acids

Expression of protein kinase C (PKC) isoenzymes was determined in paired samples of normal mucosa and colorectal cancer tissue from 13 patients. Total PKC activity in cancer tissue was significantly decreased compared to that in normal mucosa. Western blotting, using PKC isoenzyme-specific antibodies, showed that two PKC isoenzymes, PKC beta and PKC epsilon, were significantly decreased in cancer tissue. The level of PKC delta was increased in cancer tissue and the expression of PKC alpha and zeta was not altered significantly. Primary bile acids--cholic acid (CA) and chenodeoxycholic acid (CDCA)--and the principal secondary bile acids--deoxycholic acid (DCA), lithocholic acid (LCA) and ursodeoxycholic acid (UDCA)--were found to be potent and selective activators of partially purified PKC isoenzymes. PKC beta 1 was the isoenzyme most effectively activated by secondary bile acids. Our data provide a model for the involvement of secondary bile acids in colorectal carcinogenesis through specific PKC isoenzyme modulation in colorectal mucosa.

Acute biliary pancreatitis

The development of acute pancreatitis occurs in 4-8% of patients with symptomatic gallstones. Individuals predisposed to acute pancreatitis tend to have small gallstones (with or without larger gallstones), a wide cystic duct and a common channel between the biliary and pancreatic ducts. The importance of this relationship is demonstrated by the ability of urgent endoscopic sphincterotomy (ES) to improve the outcome of a predicted severe attack and to virtually abolish recurrent attacks in patients who are unable to undergo cholecystectomy. Cholesterolosis is an established cause of acute pancreatitis, occurring in up to 29% of cases with cholesterolosis. Biliary crystals are an important marker of microlithiasis or a propensity to form further gallstones following their passage into the duodenum following an attack. A combination of ultrasonography and a serum liver transaminase of > 60 IU/I (< 48 hr o an attack) are necessary to provide optimum sensitivity and specificity for gallstones as a prompt for the use of ERCP and ES in severe cases. Biliary sludge as a cause of acute pancreatitis is not proven. 25-30% of patients will develop complications with a mortality of around 8%. Urgent diagnosis of gallstones and treatment by ES can result in substantial improvement in outcome.

Cyclin/proliferation cell nuclear antigen immunohistochemistry does not improve the prognostic power of Dukes' or Jass' classifications for colorectal cancer

Immunohistochemistry of cyclin/proliferation cell nuclear antigen (PCNA) is an attractive alternative to tumour cell proliferation activity determined by flow cytometry which has been shown to be independently predictive of survival in patients with colorectal carcinoma and to enhance Dukes' classification. Dukes' and Jass' histopathological classifications were determined in 91 patients who had undergone curative resection for cancer of the colon (n = 51) or rectum (n = 40) and followed up for a minimum of 10 years. PCNA immunohistochemistry was possible in 79 tumours. Univariate analysis revealed that Jass' (P < 0.0001) and Dukes' classifications (P < 0.0002) were powerful predictors of survival but that the PCNA index had little prognostic power (P = 0.4). Multivariate analysis of both classifications showed similar predictive power and the PCNA index improved the prediction of survival when used with either classification for patients with colon cancer (chi 2 = 5.3, 1 d.f., P = 0.02 for each combination). The PCNA index, however, was not predictive for rectal cancer. Patients with the lowest PCNA index had the worst prognosis.

Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study

The trends in treatment and outcome of 13,560 patients with pancreatic cancer, and in incidence of the disease, in the West Midlands health region were determined between 1957 and 1986 using data from the West Midlands Region Cancer Registry. Patients were divided into those diagnosed in the first 20 years (1957-1976, n = 7888) and the most recent 10 years (1977-1986, n = 5672). The disease was more common in men and the incidence increased up to 1970 after which it levelled off. In the 1977-1986 period a lower proportion of patients had laparotomy alone (825 (14.5 per cent) versus 1552 (19.7 per cent)), a similar proportion had bypass surgery (2010 (35.4 per cent) versus 2760 (35.0 per cent)), while a greater proportion had supportive care (2710 (47.8 per cent) versus 3368 (42.7 per cent)) but the resection rates were the same (145 (2.6 per cent) versus 208 (2.6 per cent)). The 30-day mortality rates between the two periods improved for resection (40 (27.6 per cent) versus 94 (45.2 per cent)), bypass surgery (436 (21.7 percent) versus 691 (25.0 per cent)) and laparotomy (372 (45.1 per cent) versus 873 (56.3 per cent)). The 12-month survival rate for bypass did not significantly differ during the study (14.9 per cent versus 12.4 per cent) but there was a significant improvement in the 5-year survival for resection (9.7 per cent versus 2.6 per cent, P < 0.015). The resection rates were low and 30-day mortality rates for surgery were high compared with those of other published series.