SUSCEPTIBILITY OF INJURED TISSUES TO HEMATOGENOUS METASTASES: AN EXPERIMENTAL STUDY

Oral Squamous Cell Carcinoma Metastasis to Anterolateral Thigh Flap Donor Site: A Case Report

In the realm of oncologic reconstructive surgery, local or distant autologous tissue is frequently used to improve function and appearance. Due to advances in microsurgery and intensive care, reconstructive free flap surgery has become the standard treatment for head and neck cancer. However, the complexity of interdisciplinary intervention and prolonged surgical time inevitably increase the risk of cross-contamination, potentially leading to donor site metastasis. According to the literature, tumor transmission to the donor site of free flaps is extremely rare. We present the case of a 54-year-old man with left tongue squamous cell carcinoma. Three months after tumor ablation and reconstruction with a free anterolateral thigh flap, the patient presented with a mass on the donor site of the left thigh, which was proven to be a metastasis. A systemic workup revealed multiple metastases. Six months after reconstruction, the patient died of COVID-19 pneumonia. The incidence and risk factors of donor site metastasis are not well known. The primary causes are direct implantation or hematogenous spread. Cross-contamination is primarily prevented by the surgeon's awareness and avoidance. The development of new-onset lesions at the donor site warrants additional testing to detect systemic disease progression during follow-up.

Iatrogenic giant cell tumor at bone graft harvesting site

30 year old female patient with giant cell tumor of the distal tibia initially treated at a peripheral nononcological center by curettage and autologous bone grafting from the ipsilateral iliac crest reported to us with local recurrence and an implantation giant cell tumor at the graft harvesting site which required extensive surgeries at both sites. The risk of iatrogenic direct implantation of tumor, often attributable to inadequate surgical planning or poor surgical techniques, and the steps to prevent such complication is reported here.

Tumour transfer to bone graft donor site: a case report and review of the literature of the mechanism of seeding

Purpose. Transmission of malignant tumour cells to a bone graft donor site is a rare complication of bone grafting.We report a case of seeding of malignant fibrous histiocytoma from the femur to a pelvic bone graft donor site.

Discussion. We review the literature, discuss the possible mechanism of tumour transfer and offer advice aimed at avoiding this complication.

Wound healing after trauma may predispose to lung cancer metastasis: review of potential mechanisms

Inflammatory oncotaxis, the phenomenon in which mechanically injured tissues are predisposed to cancer metastases, has been reported for a number of tumor types, but not previously for histologically proven lung cancer. We review clinical and experimental evidence and mechanisms that may underlie inflammatory oncotaxis, and provide illustrative examples of two patients with squamous cell carcinoma of the lung who developed distant, localized metastatic disease at sites of recent physical trauma. Trauma may predispose to metastasis through two distinct, but not mutually exclusive, mechanisms: (1) physical trauma induces tissue damage and local inflammation, creating a favorable environment that is permissive for seeding of metastatic cells from distant sites; and/or (2) micrometastatic foci are already present at the time of physical injury, and trauma initiates changes in the microenvironment that stimulate the proliferation of the metastatic cells. Further exploration of post-traumatic inflammatory oncotaxis may elucidate fundamental mechanisms of metastasis and could provide novel strategies to prevent cancer metastasis.

Surgery triggers outgrowth of latent distant disease in breast cancer: an inconvenient truth?

We review our work over the past 14 years that began when we were first confronted with bimodal relapse patterns in two breast cancer databases from different countries. These data were unexplainable with the accepted continuous tumor growth paradigm. To explain these data, we proposed that metastatic breast cancer growth commonly includes periods of temporary dormancy at both the single cell phase and the avascular micrometastasis phase. We also suggested that surgery to remove the primary tumor often terminates dormancy resulting in accelerated relapses. These iatrogenic events are apparently very common in that over half of all metastatic relapses progress in that manner. Assuming this is true, there should be ample and clear evidence in clinical data. We review here the breast cancer paradigm from a variety of historical, clinical, and scientific perspectives and consider how dormancy and surgery-driven escape from dormancy would be observed and what this would mean. Dormancy can be identified in these diverse data but most conspicuous is the sudden synchronized escape from dormancy following primary surgery. On the basis of our findings, we suggest a new paradigm for early stage breast cancer. We also suggest a new treatment that is meant to stabilize and preserve dormancy rather than attempt to kill all cancer cells as is the present strategy.

Expression of metalloproteases and their inhibitors in primary tumors and in local recurrences after mastectomy for breast cancer

AIMS

To investigate the expression of matrix metalloproteases (MMPs) and their inhibitors (TIMPs) in patients who develop local recurrence (LR) after mastectomy.

METHODS

We analyzed the expressions of MMP-1, -2, -7, -9, -11, -13, -14, TIMP-1, -2, and -3, using immunohistochemical techniques, in primary tumors from patients without tumoral recurrence (n = 50), patients who developed distant metastasis (n = 50), and from patients who develop LRs (n = 25). LRs of the latter group were also analyzed for MMPs expression. All the patients underwent mastectomy.

RESULTS

Score values for all MMPs and TIMPs were significantly higher in primary tumors of patients with distant metastasis. Primary tumors from patients with LR have lower expressions of MMPs and TIMPs compared with those from patients who developed distant metastasis, and with patients without recurrence for some MMPs. Remarkably, however, primary tumors from patients with LR showed significantly higher percentage of TIMP-1 and 2 expression in stromal cells compared to primary tumors from patients with distant metastasis or primary tumors from patients without tumoral progression. Furthermore, LRs had significantly higher MMP-9 expression than their corresponding primary tumors.

CONCLUSIONS

Our data indicate differences in MMPs/TIMPs expression between primary tumors of patients with LRs and of those with distant metastasis, both after mastectomy for breast cancer.

The effects of surgery on tumor growth: a century of investigations

A few clinical investigations suggest that while primary breast cancer surgical removal favorably modifies the natural history for some patients, it may also hasten the metastatic development for others. The concepts underlying this disease paradigm, i.e. tumor homeostasis, tumor dormancy and surgery-driven enhancement of metastasis development, have a long history that is reviewed. The review reveals the context in which these concepts were conceived and structured to explain experimental data and shows that they are not so new and far fetched. The idea that surgical cancer resection has both beneficial and adverse effects upon cancer spread and growth that result from the modulation of tumor dormancy by the resection should be considered a potentially fruitful working hypothesis.

Benefits of povidone-iodine solution in colorectal operations: science or legend

Povidone-iodine solution (Betadine) has long been accepted as an effective topical broad spectrum antiseptic, disinfectant, and tumoricidal agent. In colorectal operations, this solution generally has been used for the purpose of minimizing postoperative septic complications and reducing cancer recurrence, although the optimal application, advantages, and undesirable side effects have been debated. With limited prospective, randomized, controlled trials and insufficient data available, this article examines the safe and effective clinical applications of this solution for colorectal operations.

Local recurrence after mastectomy for breast cancer: analysis of clinicopathological, biological and prognostic characteristics

BACKGROUND

Despite the increasing use of breast-conserving therapy, modified radical mastectomy retains an important role in primary as well as in salvage treatment of breast cancer. Nevertheless, a significant number of patients will eventually develop a local recurrence (LR).

AIMS

To identify the potential prognostic factors at the time of the first isolated LR, and to compare the expression of several parameters of the molecular biology of breast carcinomas by primary tumors and paired isolated LRs.

METHODS

We analyzed the medical records from 1,087 women who underwent mastectomy for breast cancer, out of which 98 developed LRs as the first manifestation of tumor progression. We investigated the prognostic value of various classical prognostic factors, at the time of mastectomy as well as when the diagnosis of LR was made. In addition, by using tissue microarrays and immunohistochemical techniques, we analyzed the expression of estrogen (ER), progesterone (PR) and androgen receptors (AR), ki67, p53, c-erbB-2 and apolipoprotein D in primary tumors and paired isolated LRs from a subset of patients (n = 25).

RESULTS

Patients who developed distant metastases as well as patients with local recurrent disease showed a significantly higher percentage of larger tumors, node-positive status and higher tumoral grade than patients without evidence of tumoral recurrence. Furthermore, patients with LR had a better outcome compared with those with distant metastases, although the former received less frequently adjuvant systemic therapy and/or radiotherapy. Tumor size, histological grade, ER and PR status, and a shorter disease-free interval (<12 months) were significantly associated with overall survival amongst mastectomized patients that developed isolated LR. There was a significant concordance between primary tumors and LRs regarding the expression of the following factors: ER, PR and p53. However, we were not able to demonstrate similar findings for AR, c-erbB-2 and ki67. In addition, ER, PR and p53 status in the LRs were significantly associated with a poorer overall survival.

CONCLUSIONS

Based on classical clinicopathological factors as well as on some new biological parameters we have been able to identify subgroups of mastectomized patients with LR differing in their prognosis. Thus, at the present time it would be possible to select group of patients candidates for further and individualized therapeutic strategies.

Metastasis of head and neck carcinoma to the site of percutaneous endoscopic gastrostomy: case report and literature review

BACKGROUND

Patients with head and neck cancer often need a percutaneous endoscopic gastrostomy to provide adequate nutrition because of inability to swallow after tumor radiation therapy. However, metastasis of the original tumor to the gastrostomy exit site may occur.

METHODS

We describe the case of a 61-year-old man with stage III (T2 N1) squamous cell carcinoma of the tongue in whom a PEG tube was placed to circumvent anticipated difficulties in swallowing after radiation therapy. We also compare this case with similar cases in the literature.

RESULTS

Soreness and erythema near the gastrostomy site reported by the patient were diagnosed as cellulitis, and two courses of antibiotic treatment were prescribed. However, a biopsy showed that the original squamous cell carcinoma had metastasized to the gastrostomy exit site. The "pull" method of tube placement had been used in this patient and in all 19 cases of metastasis reported in the literature.

CONCLUSIONS

Metastatic cancer should be considered in patients with head and neck cancer who have unexplained skin changes at the gastrostomy site. Our experience with this case and review of the literature indicate that, in patients with head and neck cancer, "pull" procedures for placement of gastrostomy tubes may induce metastasis by direct implantation of tumor cells because of contact between the gastrostomy tube and tumor cells. Methods of tube insertion that avoid such contact are preferred.

Metastatic non-small cell lung carcinoma with involvement of extremity musculature: case report and review of the literature

Hematogenous dissemination of non-small cell lung carcinoma (NSCLC) metastatic to skeletal musculature in the absence of osseous involvement is an infrequent occurrence. We retrospectively reviewed our institution's indexed database for patients evaluated from 1975 through 1997 who were diagnosed as having skeletal musculature metastases from NSCLC. Eight men and 2 women were identified (age range, 51-80 years at time of metastases). Four primary adenocarcinomas, 4 primary lung squamous cell carcinomas (SCCs), and 2 poorly differentiated primary NSCLCs were identified. Approximate tumor sizes ranged from 10 cm3 to 288 cm3. External-beam radiation therapy was used in 7 of 10 cases; complete surgical excision was performed in 3 cases. Patients with known neoplasm who have extremity pain and negative findings on bone scan should be evaluated for soft tissue tumor involvement because such findings significantly affect clinical management. One case of lung SCC metastatic to the quadratus femoris muscle in a 63-year-old man is discussed in detail.

Laparoscopically assisted colon surgery

Laparoscopy has been used in surgical procedures more frequently in the past decade because it reduces postoperative pain, decreases the length of hospitalization, decreases the duration of disability, and provides a better cosmetic result. We retrospectively reviewed our experience with laparoscopic colon surgery at Baylor University Medical Center. Since 1995, we have done 17 procedures, including 10 colon resections and 7 colostomies. The results in these patients have been quite good: only 1 patient was converted to an open procedure, and the remaining 16 patients experienced no mortality, major morbidity, or wound infection.

Abdominal insufflation does not cause hematogenous spread of colon cancer

BACKGROUND AND PURPOSE

Previous investigators have suggested that port-site recurrences are possibly a result of abdominal insufflation, forcing viable cancer cells into the circulation to metastasize and thrive in areas of trauma. Using a syngeneic animal cancer model, we tested the hypothesis that pneumoperitoneum increases the incidence of wound metastasis by a blood-borne mechanism.

METHODS

Male BD IX rats (N = 150) were injected intraperitoneally with 2 x 10(5) viable syngeneic 1,2-dimethylhydralazine-induced colon cancer cells (DHD-K12). Animals were divided into three groups: A (abdominal insufflation with 3-cm incision on the back into muscle remote from the peritoneum); B (3-cm back incision alone); and C (control group with 3-cm midline abdominal incision). Three weeks after surgery, the animals were euthanized and autopsied.

RESULTS

In the two groups with back wounds, the incidence of cancer growth at the incision was zero, as demonstrated grossly and by histologic sample (A: 0/47, B: 0/43). In contrast, the autopsied control group had a 42% incidence of metastasis to the wound (25/59). There seemed to be no difference in the distribution of intra-abdominal disease between those rats that underwent insufflation and those that did not.

CONCLUSION

It is unlikely that pneumoperitoneum promotes hematogenous wound implantation of free intraperitoneal cancer cells.

Rectal washout eliminates exfoliated malignant cells

PURPOSE

Irrigation of the rectal stump before anastomosis after resection for carcinoma is accepted colorectal surgical practice. However, not all surgeons perform this routinely, and it has never been established conclusively that irrigation of the rectal stump eliminates exfoliated malignant cells or even reduces local recurrence. The patients of a surgeon whose standard surgical practice involved rectal irrigation were compared with those of a surgeon who does not routinely practice rectal irrigation.

METHOD

Ten patients were given rectal washout with 200 to 500 ml of normal saline introduced via a Foley catheter per rectum. Ten patients were not given rectal washout. In both groups the anastomosis was performed with a circular stapler, and the stapler and donuts were rinsed in 200 ml of normal saline. The saline was sent for cytologic examination and classified as malignant cells seen or no malignant cells seen. The cytopathologist was blinded to the washout status.

RESULTS

Of the ten patients who had rectal washout performed, none had malignant cells seen. Of the ten patients who did not have rectal washout performed, eight had malignant cells seen in the cytology (P = 0.007; two-tailed Fisher's exact probability test).

CONCLUSION

Rectal washout eliminates exfoliated malignant cells in the rectum in the vicinity of the anastomosis.

Laparoscopic staging of bladder tumor: concerns about port site metastases

Since the first laparoscopic pelvic lymph node dissection (LPLND) was performed for prostate cancer, only one case of port site metastasis has been reported, an incidence of 0.1%. On the other hand, three cases of port site metastasis have been reported after laparoscopic staging of transitional-cell carcinoma (TCC) of the bladder, a reported incidence of almost 4%. Herein, we review the circumstances of these three cases and address the potential risk factors and possible preventive measures regarding LPLND and port site metastasis in patients with TCC of the bladder.

The potential role of integrin receptor subunits in the formation of local recurrence and distant metastasis by mouse breast cancer cells

BACKGROUND

The mechanisms by which surgical injury fosters tumor growth are examined.

METHODS

TA3Ha mouse breast tumor line and its subline (TA3AD) differing in their metastatic abilities as tested by two models were used. In model a, TA3Ha/TA3AD tumors were grown in the mammary fat pads of mice and then surgically removed with a curative intent. In model b, TA3Ha/TA3AD cells were injected intravenously into mice subjected to liver or spleen wedge resection. Frequency of tumor formation at various sites was assessed. Expression of integrin, immunoglobulin, and proteoglycan cell adhesion receptors on TA3Ha and TA3AD cells was examined by flow cytometry. The roles of these receptors in metastasis were examined by blocking them by selected ligands and/or antibodies.

RESULTS

Frequencies of local recurrence and axillary metastasis after surgical resection, were 43% (32/74), and 37% (27/74) with TA3Ha tumors and 4% (1/29) at both sites with TA3AD tumors. Tumors at surgically injured spleen and the liver were seen in 75% (141/189) and 45% (107/240) of the mice with TA3Ha cells and in 8% (3/38) and 10% (4/42) of the mice with TA3AD cells. alpha 5 and CD44 receptors were expressed by TA3Ha cells but not by TA3AD cells. Other receptors examined were similarly expressed by both cell lines. Blocking of alpha 5 receptor by fibronectin reduced tumor implantation in a dose-dependent manner.

CONCLUSIONS

The data suggest a correlation among the ability to implant at surgically injured sites, to form local recurrence, and to express the fibronectin receptor subunit.

Exfoliated malignant cells in glove and instrument washings following head and neck surgery

Loco-regional recurrence following resection of squamous cell carcinoma of the upper aero-digestive tract is a major problem. Cells exfoliated from malignant tumours have been considered capable of implanting and giving rise to local recurrence or metastatic deposits. A prospective study was performed examining washings from the gloves and instruments used in major head and neck operations to determine if exfoliated cells were indeed present. Following removal of the main tumour specimen all surgeons washed their hands in a solution containing a cell fixative and all instruments were soaked in the solution. Samples were then centrifuged and stained using a modified PAP technique. On occasions nuclear fragments consistent with squamous cell carcinoma were present in both glove and instrument washings. We recommend that all surgeons change gloves and instruments following removal of the main tumour specimen and prior to irrigation of the operative field with a tumoricidal agent.

The exfoliation of free malignant cells in the peritoneal cavity during resection of colorectal cancer

The presence of free malignant cells in the peritoneal cavity following potentially curative resection of colorectal cancer may be responsible for some cases of local recurrence. Twenty-six patients (age 58-88 years, male:female 12:14) undergoing colorectal cancer surgery were studied to determine frequency of occurrence of tumour cells in the peritoneal cavity using an immuno-magnetic cell separation technique. Peritoneal washings were collected after opening the peritoneal cavity and also prior to closure. A murine monoclonal antibody specific for epithelial cells was added to the peritoneal washings followed by magnetic labelled goat-antimouse antibody. The labelled tumour cells were retrieved by passing through the magnetic activated cell sorter (MACS). Tumour cells were detected in peritoneal washings from 11 patients (preresection only n = 0, post-resection only n = 6, and both n = 5). Five of these 11 patients had potentially curative surgery. This study supports the use of MACS in detecting free malignant cells in the peritoneal cavity.

Does transurethral resection of a clinically benign prostate gland increase the risk of developing clinical prostate cancer? A 10-year follow-up study

BACKGROUND

Theoretical considerations have raised the suspicion that transurethral resection of the prostate (TURP) may increase the risk of developing prostate cancer in clinically benign prostate glands. Previous studies have not shown an increased risk among men who had undergone TURP for benign prostatic hyperplasia compared with the risk in age-matched control subjects. However, in all of these studies, all men with stage T1 prostate cancer in the TURP-group were excluded, possibly creating a bias, because no similar exclusion could be made for the controls.

METHODS

The incidence and mortality of clinical prostate cancer were studied in 198 patients who had TURP and in 203 age-matched male control subjects. In both groups, all patients with known prostate cancer and patients with suspected cancer by digital rectal examination were excluded from the study. However, patients with stage T1 cancer found by the TURP were included in the comparison between the groups.

RESULTS

The mean age in the two groups was 67 +/- 6 years. The patients were followed for an average of 10.2 +/- 1.2 years and 10.4 +/- 1.8 years in the TURP group and the control group, respectively. Clinical prostate cancer developed in six patients who had TURP and subsequently in five control (odds ratio, 0.8 [0.2-3.1]; P < 0.97). Before follow-up, three men in each group died because of prostate cancer (odds ratio, 1.3 (0.24-7.45); P < 0.97).

CONCLUSIONS

The results of this study suggest that neither benign prostatic hyperplasia nor TURP increased the risk of developing clinical prostate cancer over the next 10 years in patients with a benign prostate gland determined by rectal examination before TURP.

Abdominal wall metastases following laparoscopy

Only 18 cases of recurrence at the sites of cannula insertion after laparoscopy have been reported in the literature, ten of them in the past year. The period between laparoscopic surgery and presentation of wound metastasis varies widely, from 7 days to 10 months; the lesions are typically hard, craggy and painful. The most likely mechanism is direct implantation of viable exfoliated tumour cells but three aspects specific to laparoscopy may also be important. First, there may be increased exfoliation of tumour cells following manipulation by laparoscopic instruments of an unsuspected malignancy. Second, there may be repeated close contact between tumour-laden instruments and the port. Third, the passage of resected tissue through a small incision may coat the wound with potentially malignant cells.

Effect of fibrin sealant on perianastomotic tumor growth in an experimental model of colorectal cancer surgery

Viable intraluminal tumor cells can penetrate a clinically intact rodent colonic anastomosis and give rise to perianastomotic tumor growth. The aim of this study was to determine whether transanastomotic cell migration can be prevented by fibrin-based tissue sealant. Following distal colonic transection and reanastomosis with 5/0 silk sutures, Fischer F344 rats were randomly allocated to three experimental groups. In Group A, a circumferential ring of tissue sealant was placed around the serosal surface of the anastomosis; in Group B, sealant was limited to 50 percent of the anastomotic circumference; and, in Group C, no sealant was applied. All rats then had 10(5) Mtln3 carcinoma cells injected into the proximal colonic lumen via a rectal catheter. The incidence of perianastomotic tumor at 21 days was significantly lower in Group A (3 of 14 animals) than in Group B (11 of 16 rats) (P = 0.012; Fisher's exact test) or Group C (10 of 14 rats; P = 0.011). A further experiment demonstrated that sealant did not protect the anastomosis when tumor cells were instilled directly into the peritoneal cavity. A topical carcinocidal action therefore appears unlikely, but our results suggest that a circumferential anastomotic ring of fibrin sealant forms an effective mechanical barrier preventing intraluminal tumor cells from reaching the peritoneal cavity.

Paracrine growth regulation of human colon carcinoma organ-specific metastasis

The process of cancer metastasis consists of a series of steps resulting in the spread of malignant cells beyond the site of origin and formation of metastases in distant organs. The outcome of this nonrandom process depends, in part, on the interaction of unique tumor cells with a compatible organ microenvironment. The molecular basis of the intrinsic capacity of distinct malignant cells to colonize specific organs and the degree to which host factors influence this process is under intense investigation. Biological analyses of human colon carcinoma tumors obtained from surgical specimens and implanted orthotopically into athymic nude mice revealed that these tumors are heterogeneous for metastatic properties. Moreover, recent evidence using this model suggest that whereas nonmetastatic and highly metastatic cells can grow at local sites, growth in the secondary liver-specific site was associated only with highly metastatic HCC cells. These cells also respond to mitogenic signals produced by damaged normal tissues, suggesting that physiological signals can be utilized by neoplastic cells. Molecular characterization of highly metastatic HCC cells selected in the nude mouse model as well as in situ mRNA hybridization of archival HCC surgical specimens for specific growth factor receptors correlated with the malignant cell's ability to respond to organ-specific growth factors. This article will focus on biological and molecular evidence supporting the hypothesis that organ-derived, paracrine growth factors regulate the site-specific growth of receptive malignant cells that possess the appropriate receptors.

Effect of suture material on tumour cell adherence at sites of colonic injury

In an experimental animal model, radiolabelled viable intraperitoneal adenocarcinoma cells adhered in similar numbers to normal rat colon and that injured by a 1-cm colotomy, with median cell counts of 7002 and 8602 respectively (P not significant). Repair of the colotomy with interrupted silk resulted in a significant increase in the median number of cells adhering to the injury site (21,888; P = 0.0001 versus normal colon). Repair with Prolene had no effect on tumour cell adherence (a median of 7449 cells adhered; P not significant versus normal colon). Tumour cell adherence at sites of colonic injury is dependent on the suture material used and not on the injury itself in this model. This may be important when choosing suture type for anastomosis in patients undergoing surgery for colorectal cancer.

The role of fibronectin in tumor implantation at surgical sites

Fibronectins are a family of glycoproteins with modular functional domains. They mediate cell-cell and cell-matrix interactions which are important in embryogenesis, wound healing, metastasis and other processes. We present data on the influence of fibronectin on wound implantation of a murine mammary carcinoma line, TA3Ha. Fibronectin used in these studies was derived from bovine plasma, human serum, human foreskin fibroblasts, and mouse embryo cultures. TA3Ha cells rarely form tumors in the liver of syngeneic mice when injected intravenously but after hepatic wedge resection, 45% (107/240) of the mice develop tumors in the hepatic wound. Wound implantation is markedly reduced when the cells are pre-exposed to 200 micrograms/ml bovine plasma fibronectin (13%, P = 0.007), human serum fibronectin (0%, P = 0.02), human cellular fibronectin (0%, P = 0.02), or mouse cellular fibronectin (0%, P = 0.04). Lung colonization is also reduced by these fibronectins. These effects are not due to a cytotoxic action of fibronectin, since intraperitoneally injected fibronectin-treated cells form ascites tumor as effectively as do control untreated cells. Local application of a solution containing 0.25 mg/ml mouse cellular fibronectin to the hepatic wound reduces the frequency of tumor implantation from 45% to 5% (1/21, P = 0.001). No tumor implantation inhibition is seen when only suspending medium or albumin in suspending medium is used. The mechanism by which topical application of fibronectin reduces hepatic wound implantation of tumor cells is unclear, but this finding raises an exciting possibility of preventing local recurrence of cancer.

Significance of local recurrence after mastectomy for breast cancer

In a retrospective study 678 patients who underwent (modified) radical mastectomy between 1970 and 1986 were analysed. By comparing the groups of patients who experienced local recurrence, regional recurrence or distant metastasis during follow-up with patients who remained free of disease, we have tried to gain some insight into the significance of local recurrence. By looking at the prognostic factors and the disease-free period there is hardly any difference between the patients with either a local, regional or distant recurrence. Actuarial survival of patients with local recurrence is slightly better than the survival of patients with distant metastasis (P = 0.009). From our results and from the literature we conclude that an isolated local recurrence after mastectomy for breast cancer is, in most cases, a first manifestation of metastatic disease. Probably only a minority of the local recurrences is caused by tumour cells left behind in the operation field.

Inhibition of tumor implantation at sites of trauma by Arg-Gly-Asp containing proteins and peptides

We report on the inhibition of wound implantation by TA3Ha mammary carcinoma cells by Arg-Gly-Asp containing proteins and peptides using a hepatic wedge resection model. Intravenously injected TA3Ha cells rarely form tumor in the liver of syngeneic mice, but after hepatic wedge resection, 45% (107/240) of the mice develop tumors in the hepatic wound. Hepatic wound implantation is significantly (P = 0.01) inhibited by pretreating the cells with whole mouse plasma, but not with fibrinogen-depleted plasma or serum. Tumor inhibition is also achieved by pretreatment of cells with fibrinogen (P = 0.05-0.0004), fibronectin (P = 0.007) and laminin, but not by albumin. The active domain appears to be the RGDS sequence since the deca- and tetrapeptides containing RGDS inhibit wound implantation (P less than 0.05). However, the tetrapeptide Arg-Gly-Glu-Ser has no such activity. None of these agents affects ascites tumor formation by the intraperitoneally injected cells, suggesting that anchorage independent growth of cells is not affected. We propose that proteins and peptides containing RGD occupy the binding sites and prevent the cells from interacting with cell adhesion proteins in healing wounds. Proteins and/or peptides containing RGD may be useful for preventing local recurrence in postsurgical cancer patients.

Inhibition of tumor implantation at sites of trauma by plasminogen activators

The authors report on the influence of plasminogen activators (PA) on implantation of TA3Ha mammary tumor cells in the healing hepatic wounds of syngeneic strain A mice. Intravenously injected TA3Ha cells, although they rarely metastasize to the liver, formed tumors in the hepatic wounds of a significant percent (42%, P less than 0.0001) of mice. The frequency of tumor formation declined as the interval between surgery and tumor cell inoculation was increased. Furthermore, preexposure of cells to fibrinogen, fibronectin, laminin, or peptides containing the arginine-glycine-aspartic acid-serine residues dramatically reduced the frequency of tumor formation in the hepatic wounds. These results indicate that TA3Ha cells interact with fibrinogen-related proteins in the wound to aid their attachment and growth. Because these proteins are susceptible to digestion by plasmin, PA were used in this study to examine whether administration of these drugs to the mice would modulate tumor formation in the liver wounds. Among the PA tested, human plasmin B-chain-streptokinase complex (B-SK) and recombinant tissue plasminogen activator (t-PA) inhibited tumor implantation in a dose-related manner. Administration of 900 units (U) of B-SK or 3300 U of t-PA per mouse reduced the frequency of tumor formation from 42% to 0% (P = 0.02) and 11% (P = 0.02), respectively. The B-SK was complexed with p-nitrophenyl-p-guanidinobenzoate; it did not activate the plasminogen or inhibit tumor formation in the hepatic wounds. Although urokinase activated the plasminogen, it did not inhibit tumor implantation in the hepatic wound. Heparin, an anticoagulant that prevents conversion of fibrinogen to fibrin without being fibrinolytic, had no influence on tumor formation in the hepatic wounds. The PA can generate plasmin that digests the cell attachment proteins in wounds and consequently inhibits tumor cell attachment.

Cervical adenocarcinoma metastasizing to the skin incision: a case report

In a patient previously operated upon for cervical adenocarcinoma, an abdominal wall swelling of identical histology developed in the surgical incision line. The skin involved was the site of external irradiation. The case is discussed and the literature reviewed.

Facilitation by partial hepatectomy of tumor growth within the rat liver following intraportal injection of syngeneic tumor cells

The effects of both mechanical trauma and regeneration on the growth of intraportally injected tumor in the rat liver were investigated using two-thirds partial hepatectomy (PH). Tumor grew at the excision scar when PH was performed less than 2 days before tumor injection (34/34 animals). However, when the PH was performed 4-7 days before injection, tumor developed within the regenerating lobe, but not at the scar (50/51). Injecting the same cell dose into rats with intact livers caused few tumors to develop in 12/30 animals. Intraportally injected 51Cr-labelled tumor cells distributed uniformly in the liver irrespective of the time after PH. Patterns of tumor take seen at different times after PH were not due to selective trapping of the injected cells. Liver extracts showed that epidermal growth factor-like activity was unaltered by PH, while heparin-binding growth factor activity peaked at 2 days post-PH, before the incidence of tumor growth in the parenchyma increased. We observed two peaks of DNA synthesis at days 1 and 4 post-PH by pulse labeling with [125I]deoxyuridine and bromodeoxyuridine. Bromodeoxyuridine immunohistochemistry showed the first peak to be confined to hepatocytes. The second peak involved non-hepatocytes and coincided with the beginning of enhanced tumor take in the regenerating lobe.

The influence of surgical trauma on experimental metastasis

Influence of surgical trauma on experimental metastasis in healing wounds is investigated using a transplantable murine mammary carcinoma cell line, TA3Ha. Intravenous injection of 10(5), 10(6), and 2 x 10(6) TA3Ha cells into syngeneic Strain A mice led to liver or kidney tumor development in none of the 96, ten, and ten mice tested, respectively. In contrast, injection of 10(5) cells into mice immediately after hepatic wedge resection performed using milliwatt carbon dioxide laser and electrocautery resulted in tumor formation at the site of trauma in 21/37 (57%) and 25/52 (48%) mice, (P less than 0.001) respectively. Similar results were obtained in mice subjected to partial nephrectomy using the laser (nine of 18) and electrocautery (eight of 13). These results clearly demonstrate that surgical trauma renders a nonprivileged organ susceptible to experimental metastasis formation, and that at least in this model both laser and electrocautery have similar effects. Tumor cell injection 1, 7, and 10 days posthepatic surgery resulted in 36%, 20%, and 0% tumor formation, respectively, indicating that the earlier events in wound healing support tumor implantation and/or growth better than those later on. Frequency of tumor formation at sites of trauma in the peritoneum induced by scalpel blade, laser, and electrocautery were 28%, 50% and 82%, respectively. Peritoneal tumors were seen in 33% of the nonsurgical mice. Skin incisions induced with the three above probes had little influence on experimental metastasis formation. Thus the influence of trauma on tumor formation is not uniform in every organ.

Enhanced growth of tumour cells in healing colonic anastomoses and laparotomy wounds

In the past, it has been noted that experimental tumour cells inoculated into the peritoneal cavity or into the lumen of the bowel will grow at a recently formed colonic anastomosis. However, it has previously been unclear whether the healing process enhances tumour growth or whether the presence of a suture line merely allows the tumour cells to gain access to the tissues. In the present study, using the hooded Lister rat, we have confirmed these findings by showing that growth of the syngeneic MC28 sarcoma and OES5 breast carcinoma occurs preferentially at colonic anastomoses and laparotomy wounds after intraperitoneal injection, and at colonic anastomoses after intraluminal injection. In previous studies using the MC28 sarcoma and the OES5 breast carcinoma injected by the intracardiac route (so that tumour cells reach normal and healing tissues in approximately equal numbers) we have shown that tumour growth is enhanced in healing wounds but not in the surrounding normal tissues when cells reach a healing colonic anastomosis or laparotomy wound within 2 h of its formation. Furthermore, by studying the distribution of radiolabelled tumour cells after intracardiac injection, we have calculated that the probability of a tumour cell leading to a deposit in a healing anastomosis or laparotomy wound is increased 1,000 fold compared to normal tissue. No previous studies have combined the data for intracardiac, intraluminal and intraperitoneal injection of tumour cells using the same animal model. We conclude that the same phenomenon of tumour growth enhancement in colonic anastomoses and laparotomy wounds reported after intracardiac injection of tumour cells may well be enhancing tumour growth after intraperitoneal and intraluminal injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Preferential growth of bloodborne cancer cells in colonic anastomoses

Intracardiac injection, in hooded Lister rats, of syngeneic MC28 sarcoma cells never induced tumour growth in normal bowel. Tumour growth occurred at the site of a colonic anastomosis if surgery preceded tumour injection but not if it followed tumour injection, even by as little as 1 h. Maximum enhancement of tumour growth occurred when the healing process had progressed between 2 and 8 days, with a peak at 5 to 7 days. The enhancing effect was largely over by the time the healing had progressed 14 days. The syngeneic OES5 breast carcinoma also grew at colonic anastomoses when surgery preceded tumour injection by 5 days, but not in normal colon. The MC28 sarcoma also grew at ileal anastomoses but not in the normal ileum after intracardiac injection. By injecting radiolabelled sarcoma cells, an estimate of the probability of a single bloodborne tumour cell lodging at a colonic anastomosis and leading to a tumour deposit was calculated to be of the order of 1:43 whereas the probability of the cell lodging in normal colon and causing a deposit is less than 1:4 x 10(4).

Mechanisms of organ selective tumour growth by bloodborne cancer cells

The sites of tumour development for 6 rat tumours injected into syngeneic rats via different vascular routes was determined. Xenografts of human tumours were also injected intra-arterially (i.a.) into immunosuppressed rats. Following intravenous (i.v.) and intraportal (i.ptl.) injection of cells tumour colonies localized in lung and liver respectively due to tumour cell arrest. Arterially injected radiolabelled cells disseminated and arrested in a similar distribution to cardiac output and did not 'home' to any organs. Following arterial injection of unlabelled tumour cells colonies grew in many organs. While the pattern of growth for a particular tumour varied with the cell dose, the 'arterial patterns' for all of the tumours studied followed a similar pattern. Some organs (eg adrenals, ovaries and periodontal ligament) were consistently preferred, others (eg skin and skeletal muscle) only supported tumour growth following the delivery of large numbers of cells, while in some tissues (eg spleen and intestines) tumour never grew. Viable tumour cells could be demonstrated by bioassay in many organs for up to 24h after i.a. injection. However tumour growth only occurred in certain organs and the pattern of this growth was not related to the number of tumour cells arrested or their rate of autolysis. This site preference could be expressed quantitatively as the probability of an arrested cell developing into a tumour and was considered a 'soil effect'. Site preference was not directly related to organ vascularity. Organ colonisation was promoted by steroid treatment but the mechanism was unclear and was not secondary to T-cell immunosuppression or prostaglandin synthesis suppression. The adrenal glands were preferred sites of tumour growth but pharmacological manipulation of adrenal function did not alter tumour growth to this organ. Sites of injury and healing were preferred sites of tumour colonisation and this could not be accounted for by increased delivery of tumour cells to these regions. The possibility that the macrophage component of the inflammatory response promoted tumour growth was suggested from studies in which the interval between trauma and inoculation of tumour cells was varied as well as by promotion of intraperitoneal (i.p.) tumour growth by a macrophage infiltrate.

Exfoliated cells and in vitro growth in colorectal cancer

Cells exfoliated from colorectal cancers may only be implicated in local recurrence if they are proven to be viable and capable of growth. Thirty patients with primary colorectal cancer were studied. Cells were obtained from primary tumour, uninvolved mucosa, mesorectum, lumen of the bowel, luminal mucus, serosal surface of the bowel and from washings of the tumour bed after dissection. Colonies grew in vitro in monolayer culture from 21/30 primary tumours; 11/41 mesorectum specimens; 11/27 luminal washings; 14/29 luminal mucus specimens; 1/27 serosal surface washings and 3/13 post-dissection washes. Colonies stained positively for the epithelial markers cytokeratin and desmosomes and also for carcinoembryonic antigen. Cells capable of in vitro growth are present in these various sites and, if spilled at operation, may well be implicated as one of the factors leading to local recurrence.

Skeletal muscle metastases from lung cancer

Hematogenous metastases to the limb skeletal muscles are extremely rare. Better understanding of the mechanisms resulting in the relative resistance of skeletal muscle to metastases could have bearing on therapeutic interventions for prevention of metastases. Three patients with non-small cell lung cancer and metastases in the proximal limb muscles are presented. Skeletal muscle metastases may present as painful masses in the proximal skeletal muscles. Subcutaneous and osseous metastases which are more frequent must be excluded by careful physical examination, bone scan and x-rays. Computed tomography (CT) can confirm the location of the tumor within the fascial planes of skeletal muscles and may help in the accurate delineation of the radiation portal. The tumor can be diagnosed and more common causes, such as hematoma or abscess, can be excluded by thin needle aspiration with cytologic examination. Clinical recognition of metastases in this unusual site is important based on our report that total tumor dose of 3600 to 4200 cGy of radiation in fractions of 300 cGy, 5 days a week, is effective in palliation of swelling and pain.

Occult adenocarcinoma metastatic to a skin graft donor site

Internal malignancies present with metastases to the skin 0.4% of the time. Cutaneous metastases not uncommonly develop in areas of damaged skin such as radiodermatitis and surgical scars. This report involves a 78-year-old male with metastatic adenocarcinoma from an unknown primary site that presented in a split-thickness skin graft donor site. This appears to be the first reported case of internal malignancy metastatic to skin altered by grafting.

Skin metastases within the previous radiation field after prophylactic postoperative radiotherapy for breast cancer

A case of breast cancer is described in which recurrent growth of tumor appeared to occur selectively in areas previously treated by prophylactic irradiation. This metastasis was the only lesion found 6 months after treatment. The possible mechanisms underlying this phenomenon are discussed.

Hypothesis: increasingly intensive locoregional treatment of breast cancer may promote recurrence

Evidence is presented compatible with the hypothesis that the inevitable tissue injury to the breast engendered by mastectomy or primary radiotherapy may in itself be a factor facilitating recurrence through a variety of local, regional, and systemic tumor-promoting mechanisms. The potential for tumor enhancement appears to be commensurate with the extent of injury and concerns both local and systemic recurrence. The hypothesis lends itself well to experimental testing. If confirmed, it will point to the importance of minimizing any form of tissue injury in the process of treating primary breast cancer, be it by operation or irradiation and curtailing the extent or intensity of both.

Temperature elevation during brachytherapy for carcinoma of the uterine cervix: adverse effect on survival and enhancement of distant metastasis

Possible effects of fever during intracavitary radiation therapy on patient survival, local-regional control or metastatic spread of disease were analyzed in a group of 398 patients with previously untreated, invasive carcinoma of the uterine cervix, managed with a combination of external beam irradiation and intracavitary radium (ICR) applications at Yale-New Haven Medical Center and affiliated hospitals from January 1953 through December 1977. Cox step-wise proportional hazard models were used to test for the influence of elevated temperatures during ICR placements, controlling for the influence of other pretreatment patient parameters, including FIGO stage, age, blood count, prior supracervical hysterectomy and number of prior pregnancies. Increasing maximum temperatures noted during ICR placements were associated with: decreased patient survival (p = 0.014) and increased frequency with time of distant metastasis as the initial sites of treatment failure (p = 0.038). When patients were dichotomized on the basis of maximum temperature during ICR, distant metastasis as the initial site(s) of treatment failure was noted twice as frequently in patients with maximum temperatures greater than or equal to 101.0 degrees F (12.5%; 10/80 patients) than in those with maximum temperatures less than 101.0 degrees F during ICR placement (6.3%; 20/318 patients). No statistically significant differences were noted between the two groups in their distributions by stage, age, histology, year of diagnosis, or pretreatment hemoglobin, and the sites of distant metastasis and time course for clinical detection were similar in both groups. These results are in agreement with prior clinical studies in cancer of the uterine cervix which noted a poor prognosis in patients with cancer of cervix who developed fever during treatment. In addition, the finding of an association between an increased frequency of distant metastasis and temperature elevation during the ICR provides, for the first time, clinical data supporting the reports of an alteration or enhancement of distant metastasis following the application of whole body hyperthermia in murine, rabbit and canine tumors.

Brain metastasis localized to an area of infarction

A patient with adenosquamous carcinoma of the cervix developed brain metastases limited to an area of evolving infarction. This preferential localization of tumor in an area of previous tissue injury with neovascularization provides support, in the human, for the importance of local vascular factors in the development of brain metastases.

Divergency between incidence of microscopic and macroscopic metastases

In a rat fibrosarcoma model (D-12), the incidence of macroscopic metastases was generally low but critically dependent on the site of the primary tumor implant; surgical removal of the primary tumor either induced or markedly enhanced the outgrowth of macroscopic metastases (Keller 1981). The present histological and biological findings indicate that dissemination of neoplastic cells and colonization of draining lymph nodes is a spontaneous, early occurring and continuing process. The incidence of micrometastases within lymph nodes by far exceeded the incidence of macroscopically evident metastases. Other evidence suggests that the growth characteristics of D-12 tumor cells derived from metastases are not measurably different from D-12 cells inducing primary tumor growth.

Inflammatory oncotaxis after testing the skin of the cancer patient

A case is presented in which a patient with Dukes C adenocarcinoma of the sigmoid colon subsequently developed a soft tissue metastasis at the site of a marked delayed type hypersensitivity response to the commonly used skin test antigen Dinitrochlorobenzene (DNCB). A possible cause and the implications of this rare occurrence are discussed. It is concluded that the inflammatory response to DNCB and the subsequent metastasis in this patient were causally related. Physicians who utilize skin testing in cancer patients should be aware of the possibility of "inflammatory oncotaxis" with the development of metastatic lesions in unusual places.

Digestion of the fifth component of complement by leukocyte enzymes. Sequential generation of chemotactic activities for leukocytes and for tumor cells

Leukocytes contain within their lysosomal granules enzymatic activity that will generate from C5 chemotactic activity for leukocytes (neutrophils) and tumor (Walker carcinosarcoma) cells. Similar activity has been found in phagocytic supernatant fluids from neutrophils and in purified preparations of the leukocyte neutral proteases elastase and cathepsin G. White leukotactic activities can be generated from either the third (C3) or the fifth (C5) components of complement, only C5 serves as a source for generation of the chemotactic activity for tumor cells. As has been previously shown with trypsin, the C5-related chemotactic activities generated by leukocyte proteases are time-dependent: leukotactic activity appears early, then disappears, and is replaced by chemotactic activity for tumor cells. The generation of these chemotactic activities from C5 is blocked by prior treatment of leukocyte preparations with the neutral protease inhibitor Trasylol. The demonstration that enzyme activities from leukocytes have the ability to generate tumor cell chemotactic factors from C5 suggests a possible mechanism by which the development of metastatic lesions may be promoted at sites of tissue injury or inflammation.