Reproductive health and endocrine disruption in women with breast cancer: a pilot study

PURPOSE

The purpose of this study was to assess whether incorporation of an original reproductive health assessment and algorithm into breast cancer care helps providers appropriately manage patient reproductive health goals and to follow laboratory markers for fertility and correlate these with menstruation.

METHODS

This prospective observational pilot study was set in an urban, public hospital. Newly diagnosed premenopausal breast cancer patients between 18 and 49 years old were recruited for this study prior to chemotherapy initiation. As the intervention, these patients received a reproductive health assessment and care per the study algorithm at 3-month intervals for 24 months. Blood samples were also collected at the same time intervals. The main outcome measures were to assess if the reproductive health management was consistent with patient goals and to track any follicle-stimulating hormone (FSH) and thyroid-stimulating hormone (TSH) level changes throughout treatment and post-treatment period.

RESULTS

Two patients were pregnant at study initiation. They received obstetric consultations, opted to continue pregnancies, and postpone treatment; both delivered at term without complications. One woman desired future childbearing and received fertility preservation counseling. All women received family planning consultations and received/continued effective contraceptive methods. Seventy-three percent used long-term contraception, 18 % remained abstinent, and 9 % used condoms. During chemotherapy, FSH rose to menopausal levels in 82 % of patients and TSH rose significantly in 9 %. While 82 % of women experienced amenorrhea, 44 % of these women resumed menstruation after chemotherapy.

CONCLUSIONS

The assessment and algorithm were useful in managing patients' reproductive health needs. Chemotherapy-induced endocrine disruption impacted reproductive health.

Reproductive health algorithm

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Background: About 692,000 women are newly diagnosed with various cancers yearly in the US, with breast being the most common, and 10% within reproductive age group. When concerned about survival, reproductive health is overlooked. The objective of this study was to incorporate a reproductive health algorithm into oncologic care of reproductive aged women.

Methods: This prospective observational study was conducted at John H. Stroger, Jr. Hospital of Cook County. Eleven newly diagnosed patients were recruited. The algorithm was implemented for each participant and they were surveyed quarterly for 2 years.

Results: The mean age of participants was 39 and mean living children was 1.9. Of the 11 women, two (18%) were pregnant at the time of recruitment and nine were not. Both pregnant subjects had an obstetric consultation and chose to continue the pregnancies. They delivered without complications. One began chemotherapy in the second trimester, the other began postpartum. After completion of the pregnancies, these women went into the “not pregnant” cohort. Of the now 11 women in the “not pregnant” cohort, one (9%) had not completed childbearing and 10 (91%) had. The one woman interested in childbearing underwent REI consultation and fertility preservation counseling. Of the women who had completed childbearing, 70% had adopted a long term contraceptive method, 10% a short term method and 20% were abstinent. All 11 women had a family planning consultation. Eighteen percent had already undergone permanent sterilization and 27% had an IUD in place at the time of diagnosis. An additional 27% selected an IUD. Seventy-two percent continued or began long term contraception. Eighteen percent remained abstinent throughout study period.

Conclusions: Conclusions from this study demonstrate that with the intervention of the algorithm and referral system, 100% of patients had a basic management plan consistent with reproductive health goals. Most selected a form of long term contraception prior to or on study. All sexually active women had a contraceptive plan in place post diagnosis and during treatment of cancer consistent with long term reproductive health goals. A cluster-design, multicenter, randomized controlled trial has been developed to further investigate and validate our findings.

Reproductive health importance in oncology care

e20744

Background: Based on a case series of patients, we recognized a disparity between patients’ reproductive health goals and conveyed health information by providers on reproductive health issues. The objective of this study was to assess the reproductive health interest amongst cancer care providers. Methods: This observational study was performed using a 13 item questionnaire that was administered to 15 healthcare professionals in oncology and allied health fields. The items in the questionnaire related to information regarding the importance of cancer care, sexuality, fertility preservation and contraception. Results: Of the providers surveyed, 11 were medical doctors, 3 were nurses, and 1 was indicated as other. On a scale of 0 to 10, 86.6% (n=13) rated cancer care as extremely important (10), 33% (n=5) felt the same for fertility preservation, and 46.6% (n=7) for sexuality. In a rank of importance, cancer care was first, followed by sexuality, fertility, and contraception. Only 33% (n=5) of providers always asked patients about interest in fertility preservation and with regards to contraception, only 33% (n=5) offer contraception to reproductive age patients. Conclusions: Although most providers felt that sexuality and fertility are important to women diagnosed with cancer, their practice and information provision does not reflect these findings. This highlights the significance of bringing closer together the goals of the health care providers with their actual practice to improve patient care.

No significant financial relationships to disclose.

Reproductive health assessment in women with cancer: A pilot study

19660

Background: Many women in the reproductive age group are diagnosed with cancer. Reproductive health issues remain an important concern in caring for these women. Based on a case series in our institution and a review of the literature, we found a paucity of literature and clinical acumen regarding reproductive health issues. The purpose of this study was to pilot a survey instrument to develop descriptive data on the reproductive goals of reproductive aged women (15–44yrs) presenting with cancer. Methods: A cross- sectional pilot survey study of 20 selected women diagnosed with various types of cancers presenting to Hematology-Oncology clinic of John.H.Stroger Jr. Hospital of Cook County, Chicago, from January through July 2006. A survey instrument was developed and performed a reproductive health assessment. Patients were interviewed about their obstetric/menstrual history, contraceptive motivations and choices as well as future child bearing options. Results: Of the 20 patients with mean age of 36.6 years who were surveyed, 90 % had breast cancer. Child bearing was completed by 50%, 45% desired future childbearing, 5% were unsure. Contraception was used by 55 %( n=11) of patients out of which 55 %(n=6) were using abstinence, 45% denied the use of any contraception. Amongst the patients who received chemotherapy with radiation and chemotherapy without radiation, 75% and 72.7% respectively continued to menstruate. Ten percent would continue pregnancy, if they become pregnant while on treatment. Conclusions: The result of this pilot study demonstrates some insight into the reproductive health needs and concerns of women diagnosed with cancer. A reproductive health assessment should be performed on all cancer patients who are in the reproductive age group. We plan a large prospective study providing a larger database that may aid in developing treatment plan.

No significant financial relationships to disclose.

Race as a risk factor for developing osteonecrosis of the jaw after long term bisphosphonate therapy in patients with metastatic breast cancer

596

Background: Association between osteonecrosis of the jaw (ONJ) and bisphosphonate treatment has been increasingly reported in the literature. Methods: This is a retrospective review of a single institution’s experience with patients diagnosed with bone metastasis secondary to breast cancer, who developed ONJ while treated with bisphosphonates (Zoledronic acid - Zometa; Pamidronate - Aredia), between 1.1.2001 and 10.30.2005. Presentation, age, race, and outcome were reviewed. Logistic Regression was used to test for statistical significance. Results: 161 patients with bone metastasis secondary to breast cancer treated with bisphosphonates were reviewed (82 African American, 29 Caucasians, 26 Hispanic, 15 Asian and 9 others.). ONJ developed in 6 (3.7%) patients, 5 of which were Caucasians. Logistic regression adjusting for dose shows that the odds ratio for developing ONJ comparing Caucasians with non-Caucasians is 45.7 (p=0.016). Age did not impact occurrence of ONJ. All 6 patients developed ONJ after a minimum of 31 months of treatment. Two patients had a history of previous tooth extraction. In four other patients, ONJ appeared spontaneously. One patient, who presented with an abscess, developed sepsis which resulted in the patient’s death. Two patients were treated with debridement and antibiotics and their lesions healed. Three other patients ended up suffering from a chronically exposed bone. Conclusion: ONJ is a serious complication of bisphosphonate therapy and it affected a significant proportion of our patients. Our data suggests that Caucasians may be more susceptible. Since sample size is small, determining if race is a risk factor for the development of ONJ, while on bisphosphonate therapy, will require further investigation.

No significant financial relationships to disclose.

p53 expression in breast cancer is more likely to predict survival in African-American than Hispanic or white women

10001

Background: Abnormal nuclear accumulation of p53 protein may predict poorer survival & aggressive tumor biology in African-American (AA) women with breast cancer. We hypothesized that compared to Hispanics or whites, survival would be worse for AA women with p53 positive tumors. Methods: Tumors from 195 consecutive AA, 46 Hispanic & 52 white women were evaluated for p53 expression with IHC, using antibody Pab1801 on paraffin embedded tissue, at the SHCC MBCCOP, in Chicago. Staining was scored on the UK Receptor Group 0–8 system with score ≥2 read as positive. Survival was computed by the Kaplan-Meier method & correlated with p53 expression. Univariate analyses were done with two-sided log-rank test & multivariate analysis was done with Cox proportional-hazards model. Results: There were no significant differences between racial groups regarding tumor size, grade, node status, stage, estrogen receptor (ER) status, treatment & p53 expression. Hispanics were significantly younger (p=0.014). For AA, Hispanic & white women respectively, p53 expression was 29.2%, 34.8% & 18.8%. High grade (p=0.0001) & negative ER status (p=0.006) were significantly associated with p53 expression in AA women; similar results were seen in whites (p=0.014 & p=0.031 respectively), however although the trend for grade was similar, only negative ER status was significantly associated with p53 expression in Hispanics. AA women with p53 positive tumors had significantly worse survival compared to AA women with p53 negative tumors (Hazard Ratio=1.945; 95% CI=1.040–3.638; p=0.037). However, comparison of survival between races for women with p53 positive tumors (p=0.793) and also for women with p53 negative tumors (p=0.4027) was not different. Multivariate analysis demonstrated that there was no interaction (p=0.523) between p53 expression & stage as predictors of poor survival in AA women. Conclusions: Analyses between racial groups demonstrated that AA, Hispanic & white women with breast tumors with abnormal p53 expression had similar associations with high tumor grade, negative ER status and survival. However within racial groups, abnormal p53 expression was only able to predict significantly worse survival in AA women. This association appeared to be independent of stage.

[Table: see text]

Biochemical mechanism of cross-resistance to paclitaxel in a mitomycin c-resistant human bladder cancer cell line

9-fold more resistant to mitomycin C (MMC) than parental cells (J82/WT). The IC(50) values for paclitaxel in J82/WT and J82/MMC-2 cell lines were 0.7+/-0.03 and 2.8+/-0.7 microM, respectively (P<0. 05). Thus, the J82/MMC-2 cell line exhibited 4-fold cross-resistance to paclitaxel compared with J82/WT. Intracellular accumulation of [(3)H]paclitaxel was comparable in J82/WT and J82/MMC-2 cell lines. There were no qualitative or quantitative differences between the J82/WT and J82/MMC-2 cell lines in terms of their alpha-tubulin and beta-tubulin contents. Paclitaxel-induced apoptosis could not be detected in either cell line over a wide range of drug concentrations. These results indicate that cross-resistance to paclitaxel in the J82/MMC-2 cell line is not linked to reduced drug accumulation, increased drug efflux, alterations in tubulin content or reduced paclitaxel-induced apoptosis. Paclitaxel-induced DNA strand breakage, however, determined by alkaline elution, was markedly lower in the J82/MMC-2 cell line than in J82/WT. These results suggest that paclitaxel cross-resistance in J82/MMC-2 may be attributed to reduced paclitaxel-induced DNA strand breakage. The precise mechanism of reduced paclitaxel-induced DNA strand breakage in J82/MMC-2 cell line relative to J82/WT cells, however, remains to be elucidated.

Mechanism of inhibition of benzo[a]pyrene-induced forestomach cancer in mice by dietary curcumin

Curcumin (diferuloylmethane), the major yellow pigment in turmeric, has been shown to inhibit benzo[a]pyrene (BaP)-induced forestomach cancer in mice through mechanism(s) not fully understood. It is well known that while cytochrome P4501A1 (CYP1A1) and epoxide hydrolase (EH) are important in the conversion of BaP to its activated form, (+)-anti-7,8-dihydroxy-9,10-oxy-7,8,9,10-tetrahydrobenzo[a]pyrene [(+)-anti-BaPDE], the detoxification of (+)-anti-BaPDE is accomplished by glutathione (GSH) S-transferases (GST). Therefore, it seems reasonable to postulate that curcumin may exert anti-carcinogenic activity either by inhibiting activation of BaP or (and) by enhancing the detoxification of (+)-anti-BaPDE. Administration p.o. of 2% curcumin in the diet to female A/J mice for 14 days, which has been shown to cause a significant inhibition in BaP-induced forestomach tumorigenesis, resulted in a modest but statistically significant reduction in hepatic ethoxyresorufin O-deethylase (EROD) activity, a reaction preferentially catalyzed by CYP1A1. While EROD activity could not be detected in the forestomach of either control or treated mice, curcumin feeding caused a statistically significant increase (approximately 2.3-fold) in hepatic EH and GST activities. Hepatic and forestomach GSH levels, and forestomach EH and GST activities were not affected by curcumin treatment. Even though the levels of various hepatic GST isoenzymes were significantly increased upon curcumin feeding, maximum induction was noticed for the pi class isoenzyme (mGSTP1-1), which among murine hepatic GSTs is highly efficient in the detoxification of (+)-anti-BaPDE. In conclusion, the results of the present study suggest that curcumin may inhibit BaP-induced forestomach cancer in mice by affecting both activation as well as inactivation pathways of BaP metabolism in the liver.

Gender-related differences in susceptibility of A/J mouse to benzo[a]pyrene-induced pulmonary and forestomach tumorigenesis

Benzo[a]pyrene (BP) is a suspected human carcinogen and is known to produce tumors in the lung and forestomach of mice. Glutathione (GSH) S-transferases (GST) play a major role in the detoxification of the ultimate carcinogen of BP, (+)-anti-7,8-dihydroxy-9,10-oxy-7,8,9,10-tetrahydrobenzo[a]pyrene ((+)-anti-BPDE). Previous studies have shown gender-related differences in the expression of GST isoenzymes in mice. The present study was designed to test the hypothesis whether gender-related differences in the expression of GST isoenzymes can affect the susceptibility of mice to BP-induced lung and forestomach tumorigenesis. The expression of pi class isoenzyme mGSTP1-1, which is highly efficient in the detoxification of (+)-anti-BPDE, was approximately 3.0- and 1.5-fold higher in the liver and forestomach of male A/J mouse, respectively, as compared with the female. The levels of other major GST isoenzymes, mGSTA3-3 (alpha class), mGSTM1-1 (mu class) and mGSTA4-4 (alpha class), were also significantly higher in the liver of the male mouse as compared with the female. While pulmonary mGSTP1-1 expression did not differ significantly between male and female A/J mice, the expression of mGSTA3-3, mGSTM1-1 and mGSTA4-4 was significantly higher (1.4-4.0-fold) in the lung of the male A/J mouse as compared with the female. At lower concentrations of BP (0.5 mg BP/mouse), the tumor incidence/multiplicity was significantly higher in the lung as well as in the forestomach of female mice as compared with male mice. For example, while 30% of the female mice developed pulmonary tumors 26 weeks after the first 0.5 mg BP administration, none of the male mice had tumors in their lungs. At higher doses of BP (1.5 mg BP/mouse), however, this differential was either abolished or relatively less pronounced. Our results suggest that up to a certain threshold of BP exposure the levels of GST isoenzymes may be an important determinant of susceptibility to BP-induced tumorigenesis in mice.

ATP-dependent transport of glutathione conjugate of 7beta, 8alpha-dihydroxy-9alpha,10alpha-oxy-7,8,9,10-tetrahydrobenzo[a]pyrene in murine hepatic canalicular plasma membrane vesicles

Glutathione (GSH) S-transferases (GSTs) have an important role in the detoxification of (+)-anti-7,8-dihydroxy-9,10-oxy-7,8,9, 10-tetrahydrobenzo[a]pyrene [(+)-anti-BPDE], which is the ultimate carcinogen of benzo[a]pyrene. However, the fate and/or biological activity of the GSH conjugate of (+)-anti-BPDE [(-)-anti-BPD-SG] is not known. We now report that (-)-anti-BPD-SG is a competitive inhibitor (Ki 19 microM) of Pi-class isoenzyme mGSTP1-1, which among murine hepatic GSTs is most efficient in the GSH conjugation of (+)-anti-BPDE. Thus the inhibition of mGSTP1-1 activity by (-)-anti-BPD-SG might interfere with the GST-catalysed GSH conjugation of (+)-anti-BPDE unless one or more mechanisms exist for the removal of the conjugate. The results of the present study indicate that (-)-anti-BPD-SG is transported across canalicular liver plasma membrane (cLPM) in an ATP-dependent manner. The ATP-dependent transport of (-)-anti-[3H]BPD-SG followed Michaelis-Menten kinetics (Km 46 microM). The ATP dependence of the (-)-anti-BPD-SG transport was confirmed by measuring the stimulation of ATP hydrolysis (ATPase activity) by the conjugate in the presence of cLPM protein, which also followed Michaelis-Menten kinetics. In contrast, a kinetic analysis of ATP-dependent uptake of the model conjugate S-[3H](2,4-dinitrophenyl)-glutathione ([3H]DNP-SG) revealed the presence of a high-affinity and a low-affinity transport system in mouse cLPM, with apparent Km values of 18 and 500 microM respectively. The ATP-dependent transport of (-)-anti-BPD-SG was inhibited competitively by DNP-SG (Ki 1.65 microM). Likewise, (-)-anti-BPD-SG was found to be a potent competitive inhibitor of the high-affinity component of DNP-SG transport (Ki 6.3 microM). Our results suggest that GST-catalysed conjugation of (+)-anti-BPDE with GSH, coupled with ATP-dependent transport of the resultant conjugate across cLPM, might be the ultimate detoxification pathway for this carcinogen.

Differential induction of NAD(P)H:quinone oxidoreductase by anti-carcinogenic organosulfides from garlic

This study was undertaken to elucidate the mechanism of organ specificity and differential efficacy of garlic organosulfides (OSCs) [diallyl sulfide (DAS), diallyl disulfide (DADS), diallyl trisulfide (DATS), dipropyl sulfide (DPS) and dipropyl disulfide (DPDS)] in preventing benzo(a)pyrene (BP)-induced tumorigenesis in mice. The results of the present study reveal a good correlation between chemopreventive efficacies of garlic OSCs and their inductive effects on the expression of NAD(P)H:quinone oxidoreductase (NQO), an enzyme implicated in the detoxification of activated quinone metabolites of BP. Treatment of mice with DADS and DATS, which are potent inhibitors of BP-induced forestomach tumorigenesis, resulted in a statistically significant increase (2.4- and 1.5-fold, respectively) in forestomach NQO activity. In addition, DADS and DATS were much more potent inducers of forestomach NQO activity than DAS, which is a weak inhibitor of BP-induced forestomach tumorigenesis than the former compounds. Propyl-group containing OSCs (DPS and DPDS), which do not inhibit BP-induced tumorigenesis, did not affect forestomach NQO activity. Similar to forestomach, a good correlation was also observed between effects of these OSCs against BP-induced pulmonary tumorigenesis and their effects on NQO expression in the lung. For example, treatment of mice with DAS, which is a potent inhibitor of BP-induced pulmonary tumorigenesis, resulted in about 3.2-fold increase in pulmonary NQO activity. On the other hand, this activity was increased by about 1.5-fold upon DATS administration, which does not inhibit BP-induced cancer of the lung. In conclusion, our results suggest that induction of NQO may be important in anti-cancer effects of garlic OSCs.

Induction of glutathione S-transferase pi as a bioassay for the evaluation of potency of inhibitors of benzo(a)pyrene-induced cancer in a murine model

There is a growing need for short-term and cost-effective bioassay to assess the efficacy of potential chemo-preventive agents. We report that the induction of glutathione (GSH) S-transferase pi (mGSTP1-1) by a chemo-preventive agent can be used as a reliable marker to assess its efficacy in retarding chemical carcinogenesis induced by benzo(a)pyrene (BP), which is a widespread environmental pollutant and believed to be a risk factor in human chemical carcinogenesis. This conclusion is based on 1) the relative contribution of mGSTP1-1 of the liver and forestomach of female A/J mice in the detoxification of the ultimate carcinogenic metabolite of BP, (+)-anti-7,8-dihydroxy-9, 10-oxy-7,8,9, 10-tetrahydrobenzo(a)pyrene [(+)-anti-BPDE]; and 2) a positive correlation between the induction of hepatic and forestomach mGSTP1-1 by 5 naturally occurring organosulfides (OSCs) from garlic (diallyl sulfide, diallyl disulfide, diallyl trisulfide, dipropyl sulfide and dipropyl disulfide) and their effectiveness in preventing BP-induced forestomach neoplasia in mice. In the liver, the combined contribution of other GSTs in the detoxification of (+)-anti-BPDE was far less than the contribution of mGSTP1-1 alone. Likewise, in the forestomach, the contribution of mGSTP1-1 far exceeded the combined contribution of other GSTs. Studies on the effects of OSCs against BP-induced forestomach neoplasia revealed a good correlation between their chemo-preventive efficacy and their ability to induce mGSTP1-1 expression in the liver (r = -0.89; p < 0.05) as well as in the forestomach (r = -0.97; p < 0.05). Our results suggest that the induction of mGSTP1-1 may be a reliable marker for evaluating the efficacy of potential inhibitors of BP-induced cancer in a murine model.

Mechanism of differential efficacy of garlic organosulfides in preventing benzo(a)pyrene-induced cancer in mice

The mechanism of differential efficacies of diallyl sulfide (DAS), diallyl disulfide (DADS), diallyl trisulfide (DATS), dipropyl sulfide (DPS) and dipropyl disulfide (DPDS) in preventing benzo(a)pyrene (BP)-induced cancer in mice has been investigated by determining their effects on the enzymes of BP activation/inactivation pathways. With the exception of DATS, treatment of mice with other organosulfides (OSCs) caused a small but significant increase (37-44%) in hepatic ethoxyresorufin O-deethylase (EROD) activity. However, the forestomach EROD activity did not differ significantly between control and treated groups. Only DAS treatment caused a modest but statistically significant reduction (about 25%) in pulmonary EROD activity. These results suggest that while reduction of EROD activity may, at least in part, contribute to the DAS-mediated inhibition of BP-induced lung cancer, anticarcinogenic effects of OSCs against BP-induced forestomach carcinogenesis seems to be independent of this mechanism. Treatment of mice with DAS, DADS and DATS resulted in a significant increase, as compared with control, in both hepatic (3.0-, 3.2- and 4.4-fold, respectively) and forestomach (1.5-, 2.7- and 2.7-fold, respectively) glutathione transferase (GST) activity toward anti-7beta,8alpha-dihydroxy-9alpha,10alpha-oxy-7,8,9,10-tetrahydrobenzo(a)pyrene (anti-BPDE), which is the ultimate carcinogen of BP. The pulmonary GST activity was not increased by any of the OSCs. Even though epoxide hydrolase (EH) activity was differentially altered by these OSCs, a correlation between chemopreventive efficacy of OSCs and their effects on EH activity was not apparent. The results of the present study suggest that differences in the ability of OSCs to modulate GST activity toward anti-BPDE may, at least in part, account for their differential chemopreventive efficacy against BP-induced cancer in mice.

Mechanism of increased sensitivity to etoposide in a mitomycin C-resistant human bladder cancer cell line

The mechanism of increased sensitivity to etoposide (VP-16) in a human bladder cancer cell line (J82/MMC-2), which is >9-fold more resistant to mitomycin C (MMC) compared with parental cells (J82/WT), was investigated. Colony formation assays, following 1 hr drug exposure, revealed that about a 2.2-fold higher concentration of VP-16 was required to kill 50% of the J82/WT cell line compared with J82/MMC-2. The MTT assays, following continuous drug exposure, also showed that the J82/MMC-2 cell line was significantly more sensitive to VP-16 compared with J82/WT. Accumulation of VP-16 was significantly higher in the J82/MMC-2 cell line compared with J82/WT at every drug concentration tested. Likewise, intracellular VP-16 retention was significantly higher in the J82/MMC-2 cell line compared with J82/WT when drug uptake was measured as a function of varying incubation time and at a fixed VP-16 concentration. The efflux of VP-16 from the J82/MMC-2 cell line was equivalent to that from J82/WT. In agreement with the results of drug uptake studies, the levels of VP-16-induced protein-DNA complexes were markedly higher in the J82/MMC-2 cell line compared with J82/WT. The catalytic activity of topoisomerase II (topo II) in 0.35 M NaCl nuclear extract of J82/WT cells was equivalent to that of J82/MMC-2. The levels of topo II mRNA were also comparable in these cells. Our results suggest that the mechanism responsible for the collateral sensitivity of the J82/MMC-2 cell line to VP-16 may be attributable to a relatively higher drug accumulation in this cell line compared with parental cells.

Characterization of a BMS-181174-resistant human bladder cancer cell line

This study was undertaken to elucidate the mechanism of cellular resistance to BMS-181174, a novel analogue of mitomycin C (MMC), in a human bladder cancer cell line. The BMS-181174-resistant variant (J82/BMS) was established by repeated continuous exposures of parental cells (J82) to increasing concentrations of BMS-181174 (9-40 nM) over a period of about 17 months. A 2.6-fold higher concentration of BMS-181174 was required to kill 50% of J82/BMS cell line compared with J82. The J82/BMS cell line exhibited collateral sensitivity to 5-fluorouracil (5-FU), but was significantly more cross-resistant to MMC, melphalan, taxol, doxorubicin and VP-16. NADPH cytochrome P450 reductase and DT-diaphorase activities, which have been implicated in bioreductive activation of MMC, were significantly lower in the J82/BMS cell line than in J82. The cytotoxicity of BMS-181174, however, was not affected in either cell line by pretreatment with dicoumarol, which is an inhibitor of DT-diaphorase activity. These results argue against a role of DT-diaphorase in cellular bioactivation of BMS-181174, a conclusion consistent with that of Rockwell et al (Biochem Pharmacol, 50: 1239-1243, 1995). BMS-181174-induced DNA interstrand cross-link (DNA-ISC) frequency was markedly lower in J82/BMS cell line than in J82 at every drug concentration tested. The results of the present study suggest that cellular resistance to BMS-181174 in J82/BMS cell line may be due to reduced DNA-ISC formation. However, the mechanism of relatively lower BMS-181174 induced DNA-ISC formation in J82/BMS cell line than in parental cells remains to be clarified.

Glutathione S-transferases of female A/J mouse liver and forestomach and their differential induction by anti-carcinogenic organosulfides from garlic

This study characterizes glutathione (GSH) S-transferase (GST) isoenzymes of the liver and forestomach of the female A/J mouse and compares their specificities in catalyzing the conjugation of GSH with 7beta,8alpha-dihydroxy-9alpha,10alpha-oxy-7,8,9, 10-tetrahydrobenzo[a] pyrene (anti-BPDE), the ultimate carcinogenic metabolite of benzo[a]pyrene (BP). The GST activity in female A/J mouse liver was expressed by a minimum of seven isoenzymes which arose from different homo- or heterodimeric combinations of at least two alpha class (designated as alpha1 and alpha4), four micro class (micro1 to micro4), and one pi class GST subunit. The GST isoenzyme composition of A/J mouse forestomach appeared to be different from that of the liver. For example, while GST isoenzymes containing micro3 and micro4 type subunits were selectively expressed in the liver, an alpha class heterodimeric GST isoenzyme (containing alpha2 and alpha3 subunits) was expressed in the forestomach but could not be detected in the liver. The (+)-anti-BPDE appeared to be a better substrate than the (-)-enantiomer for all GSTs, except for isoenzymes containing the alpha4 type GST subunit. The murine pi class GST isoenzyme displayed relativey higher specific activity toward (+)-anti-BPDE compared to other GSTs. The specific activities of mouse GSTs toward (+)-anti-BPDE were in the order of pi > micro > alpha. These results suggest that the pi class GST isoenzyme may play an important role in providing protection against BP-induced cancer. Therefore, it seems logical to postulate that the ability of a chemoprotector to increase the expression of GST pi may be an important determinant of its effectiveness against BP-induced cancer. To test the validity of this contention, we have determined the effects on hepatic and forestomach GST isoenzyme/subunit expression of three naturally occurring organosulfides (OSCs) from garlic, which significantly differ in their effectiveness against BP-induced forestomach cancer. Treatment of mice with diallyl sulfide (DAS) and diallyl trisulfide (DATS), which are potent inhibitors of BP-induced fore- stomach cancer in mice, resulted in a significant increase in hepatic and forestomach GST activity toward anti-BPDE. On the contrary, this activity was not increased in either organ by dipropyl sulfide (DPS), which is ineffective against BP-induced forestomach cancer. The chemopreventive efficacy of these OSCs correlated with their ability to increase the expression of GST pi. For example, DAS treatment resulted in approximate increases of 1.7- and 2.2-fold in hepatic and forestomach GST pi expression, respectively, over the control. Treatment of mice with DATS, which is a relatively more potent inhibitor of BP-induced forestomach cancer than DAS, resulted in about 3.8- and 3.2-fold increases, respectively, in hepatic and forestomach GST pi expression over the control. On the contrary, the expression of hepatic and forestomach GST pi was increased only marginally (10-20%) upon DPS administration. In conclusion, the results of the present study suggest that induction of GST pi can be used as a bioassay for screening potential inhibitors of BP-induced cancer.

Novel anti-carcinogenic activity of an organosulfide from garlic: inhibition of H-RAS oncogene transformed tumor growth in vivo by diallyl disulfide is associated with inhibition of p21H-ras processing

In this study, we report a novel anticarcinogenic activity of an organosulfur compound from garlic, diallyl disulfide (DADS). DADS treatment significantly inhibited the growth of H-ras oncogene transformed tumors in nude mice. As compared to controls, the appearance of tumors was also delayed markedly by oral administration of DADS. The inhibition of tumor growth by DADS treatment correlated with the inhibition of p21H-ras membrane association in the tumor tissue. The levels of membrane associated p21H-ras were markedly lower in the tumor tissues of DADS treated mice as compared to controls. An opposite trend, however, was evident for cytosolic p21H-ras. Furthermore, DADS treatment resulted in a significant inhibition of hepatic as well as tumoral 3-hydroxy-3-methylglutaryl coenzyme A reductase activity. These results indicate that DADS suppresses the growth of H-ras oncogene transformed tumors in nude mice by inhibiting the membrane association of tumoral p21H-ras.

Lack of a role of glutathione in cellular nonenzymatic activation of BMS-181174, a novel analogue of mitomycin C

Recent studies, using a cell-free system, have suggested that thiol-dependent nonenzymatic bioactivation may be responsible for the superior antitumor activity of the mitomycin C analogue BMS-181174 [N-7-[2-(4-nitrophenyldithio)ethyl]mitomycin C] when compared to the parent compound. If operational in tumor cells, this pathway could have enormous clinical implications since tumor cell resistance to a variety of anticancer agents is often associated with increased glutathione (GSH) levels and BMS-181174 may be used to reverse this mechanism of resistance. The present study was undertaken to determine the role of GSH in cellular activation of BMS-181174 using a pair of well-characterized human bladder cancer cells (J82 and SCaBER) as a model. A 20-h pretreatment of J82 and SCaBER cells with a nontoxic concentration of D,L-buthionine-S,R-sulfoximine (BSO) caused about 80-88% reduction in cellular GSH levels. Surprisingly, the sensitivity of both cells to BMS-181174 was increased, not reduced, by BSO-induced GSH depletion. On the other hand, the cytotoxicity of BMS-181174 was significantly reduced in both cells by a 4-h pretreatment with 1 mM GSH. Like BSO, a 4-h pretreatment with another thiol compound (cysteine) resulted in a statistically significant sensitization of both cells to BMS-181174. Cellular GSH levels were not affected in either of the cell lines by pretreatment with GSH or cysteine. In conclusion, the results or the present study argue against a role of GSH in cellular nonenzymatic activation of BMS-181174 in J82 and SCaBER cells.

Technique of laparoscopic ultrasound examination of the liver and pancreas

Since the introduction of a recent laparoscopic ultrasound (LU), the value of this modality in examining the liver and pancreas has been reported. However, a precise scanning technique of LU has not previously been described. Based on our experience with intraoperative ultrasound during laparotomy, we have developed a technique for complete examination of the entire organs using a rigid LU probe. A 7.5-MHz rigid probe, 10 mm in diameter, was employed. The scanning was performed through three trocar ports: right subcostal, subxiphoid, and umbilical. For the liver, the subcostal scanning provided fundamental transverse views. The subxiphoid and umbilical scanning delineated the areas unable to be imaged by the subcostal scanning. For the pancreas, the subcostal and umbilical scanning demonstrated longitudinal and transverse views, respectively. The subxiphoid scanning enhanced examination of the pancreatic head. Three basic probe maneuvers (advancement-withdrawal, lateral movement, and rotation) and various scanning techniques (contact, probe-standoff, and compression scanning) should be utilized appropriately. With a rigid probe, complete LU examination of the liver and pancreas is possible using these techniques. We believe the present scanning method will help more surgeons learn LU.

Biochemical characterization of a mitomycin C-resistant human bladder cancer cell line

This study describes characteristics of a mitomycin C (MMC)-resistant human bladder cancer cell line, J82/MMC-2, which was established by repeated in vitro exposures of a 6-fold MMC-resistant variant (J82/MMC) to 18 nM MMC. A 9.6-fold higher concentration of MMC was required to kill 50% of the J82/MMC-2 sub-line compared with parental cells (J82/WT). NADPH cytochrome P450 reductase and DT-diaphorase activities were significantly lower in J82/MMC-2 cells compared with J82/WT, suggesting that reduced sensitivity of J82/MMC-2 cells to MMC resulted from impaired drug activation. Consistent with this hypothesis, the formation of MMC-alkylating metabolites was significantly lower in J82/MMC-2 cells compared with J82/WT. Furthermore, DT-diaphorase activity in J82/MMC-2 cells was significantly lower compared with the 6-fold MMC-resistant variant. Glutathione (GSH) levels were comparable in all 3 cell lines. Although GSH transferase (GST) activity was significantly higher in the J82/MMC-2 cells compared with J82/WT, this enzyme activity did not differ between 6- and 9.6-fold MMC-resistant variants. Whereas DNA polymerase alpha mRNA expression was comparable in these cell lines, levels of DNA ligase I mRNA were slightly lower in both MMC-resistant variants relative to J82/WT. However, the DNA polymerase beta mRNA level was markedly higher in the J82/MMC-2 cell line compared with either J82/WT or J82/MMC. Thus, emergence of a higher level of resistance to MMC in J82/MMC-2 cells compared with J82/MMC may be attributed to (i) impaired drug activation through further reduction in DT-diaphorase activity and (ii) enhanced DNA repair through over-expression of DNA polymerase beta.

Modulation of cisplatin sensitivity and accumulation by interferon alpha-2A in human squamous carcinoma cell lines

This study was undertaken to elucidate the mechanism(s) of potentiation of cisplatin (CDDP) cytotoxicity by interferon alpha-2a (IFN alpha-2a) in human squamous carcinoma cell lines SCC-25 and SCC-4. IFN alpha-2a treatment significantly increased the cytotoxicity of CDDP in both cell lines in a dose-dependent manner. In SCC-25 cells, the cytotoxicity of CDDP was increased by about 2- and 4-fold, respectively, by treating the cells with 400 and 800 IU/ml IFN alpha-2a. Sensitivity of SCC-4 cells to CDDP was increased by about 3- and 7-fold, respectively, by 400 and 800 IU/ml IFN alpha-2a treatment. Drug uptake experiments revealed approximately 1.4- to 5-fold higher platinum accumulation in IFN alpha-2a-treated cells as compared to respective controls. Cellular levels of glutathione (GSH) and GSH transferase, which have been suggested to be important determinants of tumor cell sensitivity to CDDP, were not altered by IFN alpha-2a treatment in either of the cell lines. Northern blot analysis showed a moderate increase (about 30-40%) in the level of MT-IIA mRNA by IFN alpha-2a treatment in these cells. Our results suggest that IFN alpha-2a-mediated sensitization of SCC-25 and SCC-4 cell lines to CDDP in vitro may be due to an increase in intracellular platinum accumulation.

Characterization of a human bladder cancer cell line selected for resistance to BMY 25067, a novel analogue of mitomycin C

This study describes characteristics of a human bladder cancer cell line, SCaBER/R, selected for resistance to a mitomycin C (MMC) analogue BMY 25067. The SCaBER/R cell line was isolated by repeated 24 h exposures of the parental cells to 0.09 microM BMY 25067 (IC90, 24 h drug exposure) over a period of about 180 days. Approximately 2.2-fold higher concentration of BMY 25067 was required to kill 50% of the SCaBER/R cell line compared with parental cells (p < 0.001). The IC20 and IC90 values for BMY 25067 were also significantly higher in the SCaBER/R cell line than in SCaBER. Unlike most MMC resistant cell lines, the SCaBER/R cell line displayed a marked cross-resistance to 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and lacked cross-resistance to cisplatin, doxorubicin or VP-16. The SCaBER/R cell line also displayed a marked cross-resistance to the parent drug (MMC) and BMY 25282, another analogue of MMC. NADPH cytochrome P450 reductase activity, an enzyme implicated in bio-reductive activation of MMC, did not differ significantly in these cells. DT-diaphorase activity, another MMC activation enzyme, was significantly lower in the SCaBER/R cell line when compared to the SCaBER cells. These results suggest that relatively lower sensitivity of SCaBER/R cell line to MMC and BMY 25067 may result from impaired drug activation. Cellular levels of glutathione (GSH) and GSH-transferase (GST), which have been suggested to affect the cytotoxicity of MMC, were comparable in SCaBER and SCaBER/R cell lines. BMY 25067 induced DNA interstrand cross-links (DNA-ISC) could not be detected in either of the cell lines even at drug concentrations which produced a significant cell kill. These findings suggest that (a) cellular resistance to BMY 25067 in the SCaBER/R cell line may be due to impaired drug activation, and (b) the nature of the cytotoxic produced by BMY 25067 may be different from that of MMC.

Accuracy of viscera slide detection of abdominal wall adhesions by ultrasound

Viscera slide is the normal, longitudinal movement of the intraabdominal viscera caused by respiratory excursions of the diaphragm. By detecting areas of restricted viscera slide, ultrasonic imaging was used to identify anterior abdominal wall adhesions prior to laparotomy or laparoscopy. Transcutaneous ultrasound examination was performed on 110 patients. A prediction of adhesions was made for each patient and then compared to the findings during subsequent laparotomy or laparoscopy. Only patients with previous abdominal surgery or history of peritonitis demonstrated adhesions. Sensitivity and specificity of viscera slide ultrasound in predicting adhesions were 90% and 92%. Nine out of 10 false results involved misinterpretation of ultrasound images of the lower one-third of the abdomen. Ultrasonic imaging of viscera slide is highly accurate in detecting abdominal wall adhesions. This technique is most useful in guiding the insertion of trocar in laparoscopic surgery, and as a noninvasive method in studying the formation of adhesions.

Technique of ultrasound examination during laparoscopic cholecystectomy

Intracorporeal ultrasonography was used as a new method to examine the bile ducts during laparoscopic cholecystectomy. A prototype rigid 7.5-MHz ultrasound probe, 10 mm in diameter and 50 cm in length, was introduced during 25 laparoscopic cholecystectomies. A dual scanning technique was developed for complete examination of the bile duct. This entailed transverse scanning via the subxyphoid trocar and longitudinal scanning via the umbilical trocar. The intrahepatic ducts were also visualized by placing the probe on the liver surface. Color Doppler imaging was useful to quickly distinguish the duct from vascular structures. Laparoscopic ultrasonography clearly delineated the bile ducts in all operations except one. The time required for imaging was significantly shorter for ultrasonography than for cholangiography. Our preliminary experience demonstrates that a complete examination of the bile ducts can be performed with intracorporeal ultrasonography in a relatively short period of time.

Differentiation of breast tumors by ultrasonic tissue characterization

The ability of ultrasonic tissue characterization to differentiate and classify benign and malignant breast tissues in vivo in patients with palpable breast masses and in vitro in excised breast tissue was evaluated. One-hundred and twenty-four in vivo and 89 in vitro studies were performed using a technique of UTC based on parameters from the power spectrum of backscattered echoes. Sensitivities and specificities for diagnosing carcinoma were 86 and 84% for in vivo studies and 94 and 92% for in vitro studies. These UTC parameters provided threshold values for color-coding breast lesion images. The results of this preliminary investigation suggest that UTC provides a basis for assessing more accurately lesions suspected of being malignant prior to biopsy and possibly for evaluating breast lesions noninvasively.

Operative ultrasonography during hepatobiliary and pancreatic surgery

On the basis of our experience with operative ultrasonography during hepatobiliary and pancreatic surgery, its indications, benefits, and disadvantages are summarized. High-resolution operative ultrasound scanning of the liver, biliary tract, and pancreas was performed during 357, 735, and 242 operations, respectively. The benefits of operative ultrasonography were categorized as acquisition of diagnostic information otherwise not available, replacement for or complement to operative radiography, and guidance of surgical procedures. Operative ultrasonography provided beneficial information during 73 of 82 hepatic operations (89.0%), 57 of 69 noncalculous biliary operations (82.6%), and 177 of 242 pancreatic operations (73.1%). Operative ultrasonography was significantly superior (sensitivity 93.3%) to other screening tests for diagnosing liver metastasis from colorectal carcinoma evaluated in 189 patients, and it detected previously unrecognized metastatic tumors in 18 patients (9.5%). For screening common bile duct calculi during 666 operations, operative ultrasonography and operative cholangiography were comparable in all indices of accuracy except for a higher predictability of a positive test of operative ultrasonography (94.8% versus 71.7%). For diagnosing portal vein invasion of pancreatic carcinoma, operative ultrasonography provided better overall accuracy than preoperative studies (89.7% versus 64.1%). On the basis of operative ultrasound findings, previously planned surgical procedures were altered in 32 of 82 hepatic operations (39.0%) and 24 of 145 pancreatic operations for chronic pancreatitis (16.6%). Operative ultrasound guidance of various surgical procedures was performed during 88 hepatic and 84 pancreatic operations, including 40 ultrasound-guided hepatectomies and 42 pancreatotomies. Operative ultrasonography has a number of advantages, such as safety and speed in performance, wide application, high diagnostic accuracy, and ability of guiding procedures. Its disadvantages are the limitation of the fields of view in certain applications, the need for special equipment, and a slow learning curve.

Operative color Doppler imaging for general surgery

Operative CDI was performed during 125 general surgical operations (53 hepatic, 25 biliary, 24 pancreatic, 7 esophagogastric, 10 pulmonary, 3 kidney transplant, and 3 soft tissue operations). Operative CDI provided beneficial information in 108 of 125 operations (86.4%). On the basis of operative CDI findings, surgical management was altered in 34 of 125 operations (27.2%), most frequently hepatic and pancreatic operations. Operative CDI demonstrated advantages over B-mode imaging in (1) detection and localization of small blood vessels that are impossible or difficult to identify by B-mode imaging, (2) rapid and definitive distinction of blood vessels from other hypoechoic areas, such as tissue spaces and ducts, (3) determination of the relation of tumors to vascular structures such as vascular invasion of carcinoma, (4) confirmation of blood flow to organs after surgical procedures, and (5) clearer needle localization for guidance of needle placement by color motion marking.

Technique of ultrasonic detection and mapping of abdominal wall adhesions

A technique for noninvasive ultrasound examination to detect and map abdominal wall adhesions is described. The examination is based on the demonstration of movement of abdominal viscera during real-time imaging. This movement is called viscera slide and either occurs spontaneously as a result of respiratory movement or may be induced by manual compression. Abdominal wall adhesions produce a restriction of viscera slide. Ultrasonic demonstration of restricted viscera slide has been used for the precise localization and mapping of abdominal wall adhesions prior to abdominal surgery. The technique may be particularly useful in providing safe initial access in patients undergoing laparoscopy who are at increased risk for trocar injury of viscera due to abdominal wall adhesions resulting from previous surgery or peritonitis.

Detection of preoperatively unrecognized multiple pancreatic pseudocysts by intraoperative ultrasonography. Report of two cases

During two pancreatic operations, intraoperative ultrasonography detected multiple pancreatic pseudocysts that were unrecognized preoperatively. In each operation, a single pseudocyst was detected by preoperative ultrasonography, computed tomography, and intraoperative surgical exploration. In addition, high-resolution ultrasonography used during the operations also identified and precisely localized additional smaller pseudocysts. Also, the use of color Doppler imaging during the operations enabled the delineation of small blood vessels around the pseudocysts. The accurate diagnosis of multiple pseudocysts and the precise anatomic information provided by intraoperative ultrasonography permitted appropriate surgical treatment of the pancreatic pseudocysts which, in turn, might help prevent recurrence of the disease.

Accuracy of intraoperative ultrasonography in diagnosing liver metastasis from colorectal cancer: evaluation with postoperative follow-up results

The accuracy of intraoperative ultrasonography in diagnosing liver metastasis was evaluated at the time of surgery and at follow-up in 189 patients with colorectal cancers. Evaluation at the time of operation revealed that the sensitivity of intraoperative ultrasonography (93.3%) was significantly (p less than 0.0001) higher than that of preoperative ultrasonography (41.3%), conventional computed tomography (47.1%), and surgical exploration (66.3%). Twenty-two of 104 metastatic liver tumors were detected solely by intraoperative ultrasonography in 18 patients (9.5% of total patients). These 22 tumors were small in size (4 x 4 mm to 15 x 18 mm) and nonpalpable during operation. During the postoperative follow-up period of 18 months or more (mean 35.6 months, median 37.1 months) after colorectal surgery, liver metastases that were unrecognized during surgery appeared in 13 (6.9%) patients. Re-evaluation based on these follow-up results indicated that the sensitivity of intraoperative ultrasonography decreased to 82.3%, which was still significantly (p less than 0.0005) better than that of other methods. Intraoperative ultrasonography was capable of identifying 18 of 31 (58.1%) patients in whom liver metastases were otherwise unrecognized at the time of operation. Intraoperative ultrasonography is more accurate in diagnosing liver metastasis than traditional screening methods, and may have a beneficial impact on the management of colorectal cancer.

Surgical treatment of peptic ulcer disease

Elective surgery for peptic ulcer disease has diminished significantly over the past 15 years. However, emergency surgery has not shown a decline. Some series have even reported an increase in hospitalizations and operations for hemorrhage. The appropriate surgical procedure for peptic ulcer disease must be tailored to the specific needs of the individual patient. During emergency operations for hemorrhage from duodenal ulcer, we recommend suture ligature of the bleeding vessel and vagotomy-pyloroplasty for high-risk patients, or vagotomy-antrectomy for the lower-risk patient. Bleeding gastric ulcers should be resected, if possible. For massive hemorrhage from stress ulceration requiring surgery, near-total or total gastrectomy should be performed. Perforated duodenal ulcers are best managed by closure and a definitive ulcer operation, such as vagotomy-pyloroplasty. Perforated gastric ulcers are best excised but may be simply closed if conditions do not favor resection. In these situations, biopsy should be performed. We recommend truncal vagotomy-antrectomy for patients presenting with obstruction. Vagotomy (truncal or proximal gastric) with drainage is an acceptable alternative in this situation. For patients with intractable ulcer disease or for those who are noncompliant, proximal gastric vagotomy is the preferred operation. However, other operations may need to be considered, depending on the specific situation. Recurrent ulceration needs appropriate work-up to determine the possible cause. Although patients with ulcer recurrence initially may be placed on medical treatment, about 50% will require reoperation. The most effective procedure for peptic ulcer disease is truncal vagotomy-antrectomy, which has a recurrence rate of less than 1%. The procedure with the least morbidity and the fewest undesirable side effects is proximal gastric vagotomy. Ulcer recurrence after proximal gastric vagotomy or truncal vagotomy-pyloroplasty is in the range of 10% to 15%.

Carcinoma of the anal gland: case report and review of the literature

Anal gland cancer is often insidious in its presentation with no evidence of an intraluminal mass. It is frequently slow-growing and often thought to be a perirectal or ischiorectal abscess. Repeated incision and drainage is performed until a biopsy reveals the diagnosis. A very wide resection is then necessary to totally remove the tumor.

Treatment of laryngeal carcinoma with conservative surgery and postoperative radiation therapy

Thirteen patients with carcinoma of the supragiottic larynx (N = 10), vocal cord (N = 2), and pyriform sinus (N = 1) were treated with conservative surgery followed by radiation therapy. This plan was chosen because clinically or histologically proven lymph node metastases were present and because the primary cancer had one or more of the following factors that were adverse to patient survival: (1) the tumor extended beyond the limits of safe, conservative laryngeal surgery; (2) it infiltrated surrounding soft tissues, ie, preepiglottic space; (3) it was close to the resected margin; and (4) perineural invasion was present. Laryngeal function has been adequate in all but two patients: one has persistent aspiration one year after treatment, and one has a narrow airway after an extended supraglottic laryngectomy that included the anterior third of both cords and a portion of the subglottis at the anterior commissure with adjacent thyroid cartilage. One patient died in the immediate postoperative period, and this case cannot be evaluted. Twelve patients who completed treatment have been followed up for a median of 30 months (1 1/2 through 3 1/2 years), and all have remained free of recurrent disease.

Inguinal node metastases

Twenty-two hundred and thirty-two patients with inguinal node metastases were reviewed. The primary site of malignancy was determined in 2210 (99%) of these patients and was, in order of frequency, skin of the lower extremities, cervix, vulva, skin of the trunk, rectum and anus, ovary and penis. The determinant three-year survival rate for the remaining 22 patients with metastatic disease from an unknown primary site was 50%. The source of the primary (stomach) was discovered in only one of the 22 patients; however, the treatment of choice was superficial groin dissection, and if surgical excision was adequate, radiation therapy did not appear to be necessary to obtain local control.

Malignant fibrous histiocytoma: report of five cases and a review of the literature

Five cases of malignant fibrous histiocytoma are presented and the relevant literature is reviewed. All the patients had locally extensive tumor or eventual recurrent or metastatic disease. Determining malignancy by histologic criteria is difficult. Therefore, histologic, gross, and clinical behavior of the tumor is important. Though the role of radiation therapy and chemotherapy is not yet established, it appears that at least wide "cancer resection," if possible, is the treatment of choice. The unusually high incidence of nonresectable, recurrent, or metastatic disease in retroperitoneal histiocytomas raises the question as to whether all three modalities of therapy should be used in the treatment of tumors at this particular site.