A Phase III Study of Pafolacianine Injection (OTL38) for Intraoperative Imaging of Folate Receptor-Positive Ovarian Cancer (Study 006)

PURPOSE

The adjunctive use of intraoperative molecular imaging (IMI) is gaining acceptance as a potential means to improve outcomes for surgical resection of targetable tumors. This confirmatory study examined the use of pafolacianine for real-time detection of folate receptor-positive ovarian cancer.

METHODS

This phase III, open-label, 11-center study included subjects with known or suspected ovarian cancer, scheduled to undergo cytoreductive surgery. The objectives were to confirm safety and efficacy of pafolacianine (0.025 mg/kg IV), given ≥ 1 hour before intraoperative near-infrared imaging to detect macroscopic lesions not detected by palpation and normal white light.

RESULTS

From March 2018 through April 2020, 150 patients received a single infusion of pafolacianine (safety analysis set); 109 patients with folate receptor-positive ovarian cancer comprised the full analysis set for efficacy. In 33.0% of patients (95% CI, 24.3 to 42.7; P < .001), pafolacianine with near-infrared imaging identified additional cancer on tissue not planned for resection and not detected by white light assessment and palpation, exceeding the prespecified threshold of 10%. Among patients who underwent interval debulking surgery, the rate was 39.7% (95% CI, 27.0 to 53.4; P < .001). The sensitivity to detect ovarian cancer was 83%, and the patient false-positive rate was 24.8%. Investigators reported achieving complete R0 resection in 62.4% (68 of 109) of patients. Drug-related adverse events were reported by 30% of patients (45 of 150) and most commonly included nausea, vomiting, and abdominal pain. No drug-related serious adverse events or deaths were reported.

CONCLUSION

This phase III study of pafolacianine met its primary efficacy end point, identifying additional cancers not otherwise identified or planned for resection. Pafolacianine may offer an important real-time adjunct to current surgical approaches for ovarian cancer.

Synthetic amyloid beta does not induce a robust transcriptional response in innate immune cell culture systems

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease that impacts nearly 400 million people worldwide. The accumulation of amyloid beta (Aβ) in the brain has historically been associated with AD, and recent evidence suggests that neuroinflammation plays a central role in its origin and progression. These observations have given rise to the theory that Aβ is the primary trigger of AD, and induces proinflammatory activation of immune brain cells (i.e., microglia), which culminates in neuronal damage and cognitive decline. To test this hypothesis, many in vitro systems have been established to study Aβ-mediated activation of innate immune cells. Nevertheless, the transcriptional resemblance of these models to the microglia in the AD brain has never been comprehensively studied on a genome-wide scale.

METHODS

We used bulk RNA-seq to assess the transcriptional differences between in vitro cell types used to model neuroinflammation in AD, including several established, primary and iPSC-derived immune cell lines (macrophages, microglia and astrocytes) and their similarities to primary cells in the AD brain. We then analyzed the transcriptional response of these innate immune cells to synthetic Aβ or LPS and INFγ.

RESULTS

We found that human induced pluripotent stem cell (hIPSC)-derived microglia (IMGL) are the in vitro cell model that best resembles primary microglia. Surprisingly, synthetic Aβ does not trigger a robust transcriptional response in any of the cellular models analyzed, despite testing a wide variety of Aβ formulations, concentrations, and treatment conditions. Finally, we found that bacterial LPS and INFγ activate microglia and induce transcriptional changes that resemble many, but not all, aspects of the transcriptomic profiles of disease associated microglia (DAM) present in the AD brain.

CONCLUSIONS

These results suggest that synthetic Aβ treatment of innate immune cell cultures does not recapitulate transcriptional profiles observed in microglia from AD brains. In contrast, treating IMGL with LPS and INFγ induces transcriptional changes similar to those observed in microglia detected in AD brains.

Vaginal metastasis of gestational trophoblastic neoplasia resulting in hemorrhage: A case report

Complete molar pregnancies complicate approximately 1 in 1500 pregnancies in the United States and result in gestational trophoblastic neoplasia in about 15-20% of these cases. Vaginal metastasis is the second most common site of metastasis and may present with vaginal bleeding and hemorrhage. This report describes a case of a 19-year-old Hispanic primigravida who presented with hemorrhage from an anterior vaginal wall metastasis two weeks after dilation and curettage for complete molar pregnancy. Hemorrhage resolved after extrusion of the lesion from the anterior vaginal wall. Pathology showed markedly atypical trophoblastic tissue from the lesion. Vaginal involvement of gestational trophoblastic neoplasia can present with life-threatening hemorrhage.

Is Robotic-Assisted Surgery Safe in the Elderly Population? An Analysis of Gynecologic Procedures in Patients ≥ 65 Years Old

BACKGROUND

The elderly population is expanding worldwide but is underrepresented in clinical trials. We sought to assess the safety of robotic gynecologic surgery in an elderly cohort and to identify factors associated with unfavorable outcomes.

METHODS

All patients ≥ 65 years who underwent a robotically assisted procedure at a single institution between May 2007 to December 2016 were divided into three age groups: 65-74 (Group 1); 75-84 (Group 2); ≥ 85 (Group 3). Perioperative outcomes were recorded in patients who did not require conversion to laparotomy. We compared clinical variables among groups and performed multivariate logistic regression to detect variables associated with major complications (≥ Grade 3) or 90-day mortality.

RESULTS

We retrospectively identified 982 cases: 685 in Group 1; 249 in Group 2; 48 in Group 3. Median age = 71 years. Median BMI = 28.9. Malignancy was documented in 72.8% of cases; the majority were endometrial cancer (61.8%). Thirty-four patients (3.5%) were readmitted within 30 days. Seventy-seven (7.8%) had a postoperative complication, and 23 (2.3%) had a major complication. Ninety-day mortality was 0.5%. There was significant difference between groups with respect to body mass index (P = 0.026), ECOG PS (P ≤ 0.001), > 5 comorbidities (P = 0.005), hospital stay (P < 0.001), major complications (P = 0.001), and 90-day mortality (P < 0.001). On multivariable logistic regression, age ≥ 85 years was associated with major complications. Body mass index, age ≥ 85 years, and major complications were significantly associated with 90-day mortality.

CONCLUSIONS

Robotic-assisted surgery appears to be safe in an elderly cohort. The incidence of overall and major complications is consistent with those reported in the literature. Patients ≥ 85 years old appear to be at higher risk of unfavorable outcomes.

Patterns of FIRST recurrence of stage IIIC1 endometrial cancer with no PARAAORTIC nodal assessment

OBJECTIVE

To assess the rates and distribution of first recurrence in patients with FIGO stage IIIC1 endometrial cancer (EC) who did not undergo paraaortic dissection at surgical staging.

METHODS

We retrospectively selected all (n = 207) stage IIIC1 patients treated at a single institution from 5/1993-1/2017. Sites of first recurrence were identified, disease-free (DFS) and overall survival (OS) calculated, multivariate logistic regression performed to identify factors associated with recurrence.

RESULTS

Three-year DFS and OS were 66.5% and 85.7%, respectively. The most common histology was endometroid (64.2%). Three-year DFS was 81% (SE±3.8%) endometrioid vs. 39.5% (SE±6.6%) non-endometrioid (P < 0.001). Three-year OS was 96.9% (SE±1.8%) endometrioid vs. 65.6% (SE±6.7%) non-endometrioid (P < 0.001). Sixty-two (30.1%) patients recurred. Patterns of recurrence were: 14 (8.3%) multiple sites, 17 (8.2%) abdominal, 14 (6.8%) extra-abdominal, 17 (8.3%) isolated nodal (8 of these (3.9%) paraaortic). Patients with isolated tumor cells (ITCs) in lymph nodes only had 12/71 (17%) recurrence rate vs. 50/135 (37%) for patients with micro-/macrometastasis. On univariate analysis, grade (HR 4.67 95%CI 1.5-14.5, P = 0.008), histology (HR 4.9 95%CI 2.6-9.3, P < 0.001), myometrial invasion (HR 1.9 95%CI 1.04-3.5, P = 0.04), pelvic washing (HR 2.2 95%CI 1.1-4.5, P = 0.03), tumor volume in pelvic LNs (ITC vs. micro-/macrometastasis; HR 0.3 95%CI 0.2-0.7, P = 0.003) were associated with recurrence. On multivariate analysis, only histology was associated with recurrence (HR 7.88 95%CI 3.43-18.13, P < 0.001).

CONCLUSIONS

Isolated paraaortic recurrence in stage IIIC1 EC is uncommon. Micro-/macrometastasis were associated with twice the recurrence rate compared to ITC. These data will help clinicians counsel patients with stage IIIC1 EC regarding paraaortic assessment.

Continuous improvement in primary Debulking surgery for advanced ovarian cancer: Do increased complete gross resection rates independently lead to increased progression-free and overall survival?

OBJECTIVES

To assess complete gross resection (CGR) rates and survival outcomes in patients with advanced ovarian cancer who underwent primary debulking surgery (PDS) during a 13-year period in which specific changes to surgical paradigm were implemented.

METHODS

We identified all patients with stage IIIB-IV high-grade ovarian carcinoma who underwent PDS at our institution, with the intent of maximal cytoreduction, from 1/2001-12/2013. Patients were categorized by year of PDS based on the implementation of surgical changes to our approach to ovarian cancer debulking (Group 1, 2001-2005; Group 2, 2006-2009; Group 3, 2010-2013).

RESULTS

Among 978 patients, 78% had stage IIIC disease and 89% had disease of serous histology. Carcinomatosis was found in 81%, and 60% had bulky upper abdominal disease (UAD). Compared to Group 1, those who underwent PDS during the latter 2 time periods had higher ASA scores (p < 0.001), higher-stage disease (p < 0.001), and more often had carcinomatosis (p = 0.015) and bulky UAD (p = 0.009). CGR rates for Groups 1-3 increased from 29% to 40% to 55%, respectively (p < 0.001). Five-year progression-free survival (PFS) rates increased over time (15%, 16%, and 20%, respectively; p = 0.199), as did 5-year overall survival (OS) rates (40%, 44%, and 56%, respectively; p < 0.001). On multivariable analysis, CGR was independently associated with PFS (p < 0.001) and OS (p < 0.001).

CONCLUSIONS

Despite higher-stage disease and greater tumor burden, CGR rates, PFS and OS for patients who underwent PDS increased over a 13-year period. Surgical paradigm shifts implemented specifically to achieve more complete surgical cytoreduction are likely the reason for these improvements.

Perioperative epidural use and survival outcomes in patients undergoing primary debulking surgery for advanced ovarian cancer

OBJECTIVE

Epidurals are associated with improved outcomes in some solid tumors, presumably due to their effect on surgical stress response. There are limited data on the prognostic significance of epidural anesthesia in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. We sought to assess the impact of epidural anesthesia on the survival outcomes of patients undergoing PDS for advanced ovarian cancer.

METHODS

In this retrospective study, consecutive patients with stage IIIB-IV epithelial ovarian, fallopian tube, or peritoneal carcinoma who underwent PDS at our institution from 01/2005-12/2013 were identified. Progression-free survival (PFS) and overall survival (OS) with regard to epidural use were analyzed.

RESULTS

Of 648 patients, 435 received an epidural and 213 did not. Patients in the former group were more likely to have higher stage disease (stage IV disease, 26% vs. 16%, respectively; P = .005), carcinomatosis (87% vs. 80%, respectively; P = .027), and bulky upper abdominal disease (66% vs. 58%, respectively; P = .046). Complete gross resection was achieved in 48% and 32%, respectively (P < .001). For the epidural vs. non-epidural groups, median PFS was 20.8 months and 13.9 months, respectively (P = .021); median OS was 62.4 months and 41.9 months, respectively (P < .001). After controlling for confounding factors, including residual disease, epidural use was independently associated with a decreased risk of progression (HR = 1.327; 95% CI, 1.066-1.653) and death (HR = 1.588; 95% CI, 1.224-2.06).

CONCLUSIONS

Perioperative epidural use was independently associated with improved PFS and OS in these patients. Epidural anesthesia at the time of PDS may be warranted in this setting.

Less versus more radical surgery in stage IB1 cervical cancer: A population-based study of long-term survival

BACKGROUND

Standard surgical treatment for women with stage IB1 cervical cancer consists of radical hysterectomy. This study assesses survival outcomes of those treated with less radical surgery (LRS; conization, trachelectomy, simple hysterectomy) compared to more radical surgery (MRS; modified radical, radical hysterectomy).

METHODS

Using the Surveillance, Epidemiology and End Results database, we identified women <45 years with FIGO stage IB1 cervical cancer diagnosed from 1/1998 to 12/2012. Only those who underwent lymph node (LN) assessment were analyzed. Disease-specific survivals (DSSs) of LRS were compared with those of MRS.

RESULTS

Of 2571 patients, 807 underwent LRS and 1764 underwent MRS, all with LN assessment. For LRS vs. MRS, 28% vs. 23% were diagnosed with adenocarcinoma (p = 0.024), 31% vs. 39% had G3 disease (p < 0.001), 40% vs. 45% had tumor size >2 cm (p < 0.001), and 27% vs. 29% received adjuvant radiation therapy (p = 0.005). Median follow-up was 79 months (range, 0-179). Ten-year DSS for LRS vs. MRS was 93.5% vs. 92.3% (p = 0.511). There was no difference in 10-year DSS when stratified by tumor size ≤2 cm (LRS 95.1% vs. MRS 95.6%, p = 0.80) or > 2 cm (LRS 90.1% vs. MRS 88.2%, p = 0.48). Factors independently associated with increased risk of death included adenosquamous histology (HR 2.37), G3 disease (HR 2.86), tumors >2 cm (HR 1.82), and LN positivity (HR 2.42). Compared to MRS, LRS was not associated with a higher risk of death.

CONCLUSIONS

In a select group of young women with stage IB1 cervical cancer, LRS compared to MRS does not appear to compromise DSS.

Abstract 3422: miR-200c-driven mesenchymal-to-epithelial transition as a therapeutic target in uterine carcinosarcomas

Introduction and purpose of study: Uterine carcinosarcoma (UCS) is an aggressive and rare malignancy with poor prognosis and limited treatment options. These biphasic tumors, consisting of epithelial and mesenchymal components, are hypothesized to evolve from less aggressive endometrial adenocarcinomas (EACs) through epithelial-mesenchymal transition (EMT). EMT is a reversible process, and mesenchymal-epithelial transition (MET) has been shown to decrease tumor aggressiveness. Inducing MET has been suggested for treatment of cancers with a mesenchymal phenotype. In our studies, we investigated the importance of EMT in the evolution of UCS by depleting miR-200, a family of microRNAs critical for EMT, in EAC cell lines. We also explored the role of miR-200 overexpression as a driving force for MET in UCS with a focus on finding novel therapeutic approaches to the treatment of this aggressive disease.

Experimental procedures: To test whether UCSs evolve from EACs, we depleted miR-200b/c in EAC cell lines, Ishikawa and MFE-280. For the MET studies, we stably overexpressed miR-200c in UCS cell lines, SNU685 and JHUCS1. Gene expression was measured using TaqMan and whole transcriptome sequencing (RNA-seq) assays. Immunoblotting was performed on the EMT-relevant proteins. Cell adhesion and in vitro cell proliferation were measured using commercially available assays. In vivo tumor growth of JHUCS1 miR-200c-overexpressed cells was measured in xenografted mice.

Summary of the data: Compared to EAC cells, UCS cells had undetectable miR-200c expression. Depletion of miR-200b/c in EAC cells resulted in expected increased ZEB1 and decreased E-cadherin expression. The lack of increased N-cadherin, vimentin and morphologic changes, even in the presence of exogenous TGF-β suggests partial EMT induction. Overexpression of miR-200c in UCS cells resulted in full MET, with a decrease in ZEB1, ZEB2, N-cadherin and vimentin and an increase in E-cadherin. Increased cellular adhesion was observed along with typical MET morphologic changes. miR-200c overexpression led to inhibited UCS cell proliferation and metabolic activity. Overexpression of miR-200c in vivo resulted in substantially smaller tumors compared to mice bearing control UCS cells.

Conclusions: Our data suggest that mechanisms additional to, or other than EMT, are necessary for the evolution of UCS from EAC. UCS cell lines, however, readily undergo robust MET in the setting of increased miR-200c expression rendering them less aggressive. These findings suggest that miR200 overexpression through advanced microRNA therapeutics may lead to new options for the treatment of uterine carcinosarcomas.

Citation Format: Jill H. Tseng, Maria Bisogna, Lien N. Hoang, Narciso Olvera, Douglas A. Levine, Petar Jelinic. miR-200c-driven mesenchymal-to-epithelial transition as a therapeutic target in uterine carcinosarcomas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3422. doi:10.1158/1538-7445.AM2017-3422

Diverting ileostomy during primary debulking surgery for ovarian cancer: Associated factors and postoperative outcomes

OBJECTIVE

To examine the use, as well as postoperative and long-term oncologic outcomes of diverting loop ileostomy (DI) during primary debulking surgery (PDS) for ovarian cancer.

METHODS

Patients with stage II-IV ovarian, fallopian tube, or primary peritoneal carcinoma who underwent colon resection during PDS from 1/2005-1/2014 were identified. Demographic and clinical data were analyzed.

RESULTS

Of 331 patients, 320 (97%) had stage III/IV disease and 278 (84%) had disease of high-grade serous histology. Forty-four (13%) underwent a DI. There were no significant differences in age, comorbidity index, smoking status, serum albumin, or attending surgeon between the DI and non-DI groups. Operative time (OR=1.21; 95% CI, 1.03-1.42; p=0.02) and length of rectosigmoid resection (OR=1.04; 95% CI, 1.01-1.08; p=0.02) were predictors of DI on multivariable analysis. The overall anastomotic leak rate was 6%. A comparison of groups (DI vs non-DI) showed no significant differences in major complications (30% vs 23%; p=0.41), anastomotic leak rate (5% vs 7%; p=0.60), hospital length of stay (10 vs 9days; p=0.25), readmission rate (23% vs 17%; p=0.33), or interval to postoperative chemotherapy (41 vs 40days; p=0.20), respectively. Ileostomy reversal was successful in 89% of patients. Median follow-up was 52.6months. There were no differences in median progression-free (17.9 vs 18.6months; p=0.88) and overall survival (48.7 vs 63.8months; p=0.25) between the groups.

CONCLUSIONS

In patients undergoing PDS, those with longer operative time and greater length of rectosigmoid resection more commonly underwent DI. DI does not appear to compromise postoperative outcomes or long-term survival.

Lifestyle and Weight Management Counseling in Uterine Cancer Survivors: A Study of the Uterine Cancer Action Network

OBJECTIVE

The purpose of this study was to examine the experiences, attitudes, and preferences of uterine cancer survivors with regard to weight and lifestyle counseling.

MATERIALS AND METHODS

Members of the US Uterine Cancer Action Network of the Foundation for Women's Cancer were invited to complete a 45-item, Web-based survey. Standard descriptive statistical methods and χ tests were used to analyze responses.

RESULTS

One hundred eighty (28.3%) uterine cancer survivors completed the survey. Median age was 58 years, 85% were white, and median survivorship period was 4.4 years. Most had stage I-II disease (69%) and were overweight or obese (65%). Eighty-nine percent of respondents received care by a gynecologic oncologist. Increased respondent body mass index was associated with decreased exercise frequency (P = 0.016). Only 50% of respondents underwent any weight/lifestyle counseling, with those living in the West and Southwest reporting the highest rates (70.8% and 69.2%, P = 0.011). Most who received counseling felt that discussions were motivating, performed in a sensitive manner, and did not undermine the patient-physician relationship. Specific recommendations were rarely offered; there were no reported referrals to weight loss programs or bariatric specialists, and few (6%) reported referrals to nutritionists. Respondents (85%) preferred their gynecologic oncologist address weight using direct, face-to-face counseling with specific recommendations regarding interventions and referral to specialists. Finally, self-reported overweight respondents experienced greater success with weight loss compared to those reporting obesity or morbid obesity (30.8% vs 15.8% vs 12.5%, P = 0.011).

CONCLUSIONS

Uterine cancer survivors reported high obesity, low activity rates, and a desire for substantive weight loss counseling from their gynecologic oncologists. Respondents suggested that current counseling practices are inadequate and incongruent with their needs. Further research to define optimal timing, interventional strategies, and specific recommendations for successful lifestyle changes in this population is warranted.

Thoracoscopic sympathectomy for palmar hyperhidrosis: effects on pulmonary function

Palmar hyperhidrosis, probably caused by an over-reactivity of sympathetic nerves passing through the second and the third thoracic sympathetic ganglia (T2 & T3 ganglia), can only be cured by sympathectomy. Such sympathetic denervation may also alter pulmonary function. Previous studies have shown that open sympathectomy can cause significant deterioration in pulmonary function, however, the surgical procedure itself may contribute to the change. Recently thoracoscopic sympathectomy has been developed as a minimally invasive but effective treatment for palmar hyperhidrosis. In order to investigate the effect of sympathectomy, pulmonary function was compared before and four weeks after operation in 20 patients. Forced vital capacity (FVC) (-2.3%), forced expiratory volume in one second (FEV1) (-6.1%), and FEV1/FVC (-4.6%) were all slightly but significantly decreased four weeks after thoracoscopic sympathectomy. Also the instantaneous forced expiratory flow at 75%, 50% and 25% of the FVC (Vmax25, Vmax50, Vmax75) in flow-volume curves were decreased (-1.6%, -8.4%, and -20% respectively). Therefore, thoracoscopic sympathectomy minimises pulmonary restrictive effects but allows subclinical small airway obstructive effects to become more evident.

Endoscopic extraperitoneal lumbar sympathectomy for plantar hyperhidrosis: case report

A right sided endoscopic retroperitoneal lumbar sympathectomy was performed on a 23 year old female who had plantar hyperhidrosis. After the operation, the right foot temperature increased and the plantar hyperhidrosis was relieved. During the follow up period, both feet were warm and dry, although only the right side lumbar sympathectomy had been performed. The outcome appeared to be compatible with that of an open procedure but with minimal invasiveness.

Peripheral cholangiocarcinoma with thoracic spine metastasis: a successful surgically treated case

In this study we present a rare case of cholangiocarcinoma with metastasis to the thoracic spine. A 63-year-old female with peripheral cholangiocarcinoma associated with hepatolithiasis presented low back pain as a result of a thoracic spine (T12) compression fracture. Spine surgery and pathological examination revealed a metastatic mucinous adenocarcinoma of unknown origin. Two weeks after the spine surgery, a nontender palpable abdominal mass was found at the epigastric area. Abdominal sonography (US), abdominal computed tomography (CT), and magnetic resonance cholangiopancreaticogram (MRCP) revealed a hepatic tumor, hepatolithiasis, and gallbladder empyema. The patient underwent hepatic resection, cholecystectomy, and choledocholithotomy with T-tube stent. Pathological examination with immunohistochemical stain revealed hepatolithiasis concurrent with mucinous cholangiocarcinoma. Postoperative course was uneventful and no recurrence was noted during a 1-year follow-up period.

Icteric-type hepatoma: magnetic resonance imaging and magnetic resonance cholangiographic features

BACKGROUND

We evaluated the imaging features of magnetic resonance imaging (MRI) and magnetic resonance cholangiography (MRC) of icteric-type hepatoma and correlated these with the findings of endoscopic retrograde cholangiography (ERC), percutaneous cholangiography, and surgery.

METHODS

Thirteen patients with viral hepatitis complicated by cirrhosis of the liver and obstructive jaundice underwent MRC and dynamic MRI. Five patients received percutaneous transhepatic cholangiography and drainage; one of these patients also underwent resection of the left hepatic lobe. Another patient received MRC followed by thrombectomy and T-tube insertion. ERC and endoscopic nasobiliary drainage were performed in another patient for bile diversion.

RESULTS

Primary liver tumors and dilatation of biliary system were demonstrated in all patients. No capsule formation could be found in any primary liver tumors. MRI showed the simultaneous presence of an intraluminal tumor in the portal trunk and common hepatic duct in eight patients. Three different MRC features were found: (a) an oval defect in the hilar bile duct(s) with dilated intrahepatic ducts (n = 9), (b) dilated intrahepatic ducts with missing major bile ducts (n = 2), and (c) localized stricture of the hilar bile duct(s) (n = 2).

CONCLUSION

The presence of one or more of the following features in multiplanar MRI and MRC help to identify this rare, specific type of hepatocellular carcinoma: (a) the presence of an intraluminal tumor in both the portal trunk and the common hepatic duct, (b) enhancement of the intraluminal tumor in the common hepatic duct on the arterial phase, (c) type I MRC feature, and (d) hemobilia, blood clot within the gallbladder, and/or type II MRC feature.

Effective relief of obstructive jaundice in a patient with nonresectable icteric-type hepatocellular carcinoma by external beam radiation therapy: case report

We report on a 62-year-old woman with nonresectable icteric-type hepatocellular carcinoma who developed obstructive jaundice due to tumor thrombi in the common hepatic duct. External beam radiation therapy with total dose of 38 Gy was given in 10 fractions within 4 weeks. The serum bilirubin level progressively decreased from 30.0 to 1.7 mg/dl with a concomitant reduction of tumor size in the 2 months following radiotherapy. Serum alpha-fetoprotein level decreased from greater than 10,000 to 6540 ng/ml after radiotherapy but increased again due to new growth of tumors. The patient was subsequently treated by transcatheter arterial chemoembolization and was still alive 8 months after the diagnosis of nonresectable icteric-type hepatocellular carcinoma. This result suggests that external beam radiation therapy may be beneficial in some patients with nonresectable icteric-type hepatocellular carcinoma. When combined with other conventional therapies, radiation therapy may play an important role in the treatment of hepatocellular carcinoma.

Ultrasound guided puncture of the brachial artery for haemodialysis fistula angiography

BACKGROUND

Arterio-venous (a-v) fistulae of haemodialysis patients frequently require function assessment by angiography. The purpose of the present study was to determine the efficacy and safety of ultrasound-guided transbrachial catheterization when a-v fistulae were evaluated.

METHODS

Between July 1996 and December 1997, 208 dialysis patients, whose a-v fistulae (arterial inflow < 50 ml/min or venous pressure > 150 mm Hg in three consecutive HD sessions) were at the wrist or elbow, underwent transbrachial angiography using an ultrasound-guided 20-gauge IA needle to evaluate fistula function. Procedure-related symptoms or complications were noted in 28 patients and these were analysed.

RESULTS

No apparent cases of vessel spasm or thrombosis were noted. Reported symptoms in 28 patients (13.5%) included local arm pain (3.3%), transient paresthesia (0.9%), mild ecchymosis (10.6%) and haematoma (0.9%). All complications were minor and none required surgical intervention.

CONCLUSION

Ultrasound-guided puncture of the brachial artery is a safe, reliable and effective procedure in skilled hands and should be the preferred means of catheterization whenever haemodialysis angiography is performed.

Biliary hamartomas associated with biliary stones presenting as multiple microabscesses: case report

A 63-year-old men suffered from fever, jaundice, and right upper quadrant pain for 1 week. Biliary stones with biliary tract infection were diagnosed. He was treated with parenteral antibiotics. However, abdominal ultrasonography showed multiple hyperechoic lesions in both lobes, and infiltrating hepatocellular carcinoma was suspected initially. Numerous hypervascular nodular-enhancing lesions were revealed by computed tomography. Magnetic resonance imaging further disclosed numerous tiny cystic lesions with peripheral enhancement. Exploratory laparotomy was performed for biliary calculi and probable underlying malignancy. Cholecystectomy, choledocholithotomy, and liver wedge biopsy were done. The pathology revealed bile duct hamartomas with microabscess formation. The past literature about biliary hamartomas is reviewed.

Ultrasonographic findings and differentiation of benign and malignant focal splenic lesions

The purpose of this study was to analyse the sonographic findings of focal splenic lesions with an attempt to differentiate benign lesions from malignancies. The sonographic findings of 53 cases of verified focal splenic lesions, excluding post-traumatic haematomas and phleboliths, were retrospectively analysed. Of the 53 cases, 30 cases (57%) were benign and 23 cases (43%) were malignant. The malignancies included lymphoma (n=13), metastases (n=10); while the benign lesions included cysts (n=17), infarcts (n=3), and abscesses (n=5), and one case each of haemangioma, hamartoma, spontaneous rupture, tuberculosis, and lymphangioma. Significant differences were noted between the benign and malignant groups with respect to the presence of solitary lesions (p<0.0001), anechoic mass (p<0. 0001), lesions with highly echogenic foci due to gas or calcification (p = 0.0303), hyperechoic/mixed echoic lesions (p<0. 0001), presence of extrasplenic abdominal masses (p<0.0001), and nodules with the target sign (p<0.0001). Solitary lesions, anechoic mass, and lesions with highly echogenic foci due to gas or calcification each had a positive predictive value of 85%, 100%, and 100%, respectively, for the lesions to be benign. The multifocal/diffuse lesions, presence of extrasplenic abdominal masses, hyperechoic/mixed echoic lesions, and nodules with the target sign each had a positive predictive value of 70%, 100%, 70%, and 100%, respectively, for the lesions to be malignant. In summary, focal lesions with anechoic pattern or echogenic foci due to gas or calcification are suggestive signs of benign process. The sonographic observations of multifocal or diffuse solid lesions, especially those associated with target sign or extrasplenic abdominal masses are suggestive of malignancy.

Results of intraoperative mitomycin C application in dacryocystorhinostomy

AIMS

To evaluate the long term results of intraoperative mitomycin C application in dacryocystorhinostomy (DCR) surgery compared with results of the conventional procedure.

METHODS

In this prospective randomised controlled study, a total of 88 eyes diagnosed with acquired nasolacrimal duct obstruction were randomly divided into a conventional DCR group and a mitomycin C group in which mitomycin C was used during DCR surgery. The surgical procedures in both groups were exactly the same, except that in the patients in the mitomycin C group, a piece of neurosurgical cottonoid soaked with 0.2 mg/ml mitomycin C was applied to the osteotomy site for 30 minutes. The results of the DCR surgeries were evaluated by objective findings such as irrigation and the height of tear meniscus and subjective symptoms by asking patients the condition of tearing improvement.

RESULTS

Among the 44 eyes in the mitomycin C group, 95.5% of patients remained totally symptom free after 10 months of follow up; while in the conventional group, 70.5% of patients were reported to be symptom free and 18% of patients to have an improvement in their symptoms. There was a significant difference between these two groups. As far as objective findings were concerned, there were 41 eyes in the mitomycin C group classified as having a normal and one eye with moderate tear meniscus level, compared with 32 eyes and seven eyes, respectively, in the conventional group. There was also a significant difference between these two groups. The non-patency rate in the mitomycin C group is 4.5% compared with 11.4% in the conventional group. There were no complications such as abnormal nasal bleeding, mucosal necrosis, or infection except one patient with delayed wound healing.

CONCLUSIONS

Intraoperative mitomycin C application is effective in increasing the success rate of DCR surgery in standard nasolacrimal duct obstruction, and no significant complications resulted from its use.

Recurrent intracerebral hemorrhages in cerebral amyloid angiopathy: a case report

Cerebral amyloid angiopathy frequently causes recurrent intracerebral hemorrhages in elderly patients who do not have systemic hypertension. Surgery should be reserved for conditions which cannot be controlled by medical treatment. When surgery is needed, potential complications (such as bleeding near the operation site or remote area) should be kept in mind. A case study of a 66-year-old woman with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.

Inflammatory pseudotumor of the liver mimicking a malignancy: case report

Inflammatory pseudotumor (IPT) is a rare lesion of the liver that can be clinically indistinguishable from a malignant tumor. A 51-year-old woman was hospitalized for upper abdominal pain and a weight loss of 5 Kg in 2 months. Radiological examination showed a large heterogenous hypervascular mass in the left lobe of her liver, strongly in favor of hepatocellular carcinoma. However, an ultrasound-guided liver biopsy revealed the typical characteristics of IPT, which consist of plump spindle cells with dense inflammatory cell infiltration. A left lobectomy was performed. No microorganisms were found on stained sections. The markedly elevated eosinophil count reverted to normal postoperatively and she remained well on follow-up examination 8 months after discharge. This case exemplifies the difficulty in radiological diagnosis of hepatic IPT and underscores the importance of its histological differentiation from malignancy before laparotomy.

Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings

OBJECTIVE

We studied the efficacy of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of malignant perihilar biliary obstructions, with reference to endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 40 patients with malignant perihilar biliary obstructions, who underwent both MRCP (Magnetom Vision; Siemens, Erlangen, Germany; projection technique and multislice plus maximum intensity projection) and ERCP examinations, were studied. The study group included hilar cholangiocarcinoma (Klatskin tumor) in 26 patients, icteric hepatocellular carcinoma in four patients, gallbladder carcinoma in five patients, and metastasis from other than hepatobiliary origin in five patients. Axial and coronal magnetic resonance (MR) images were added simultaneously to the MRCP. The mean serum bilirubin level on admission was 11.5 mg/ml (range, 2.8-28.5 mg/ml). The presence and extent of malignant biliary obstruction were determined with both MRCP and ERCP following the known criteria: an abrupt and irregular character of a distal narrow segment, a proportionally dilated biliary tree proximally, and an irregularly shaped intraluminal filling defect. The efficacy of the MRCP examination in detecting the presence of biliary obstruction, its anatomical extent, and the underlying cause, respectively, was compared to that of ERCP.

RESULTS

MRCP examination was successfully performed on all patients, whereas ERCP examination was unsuccessful in two patients. Both MRCP and ERCP were very effective in detecting the presence of biliary obstructions (40 of 40 vs. 38 of 38, p = 1.0). MRCP was superior in its investigation of anatomical extent (34 of 40 vs. 24 of 38, p = 0.015) and the cause of the jaundice (31 of 40 vs. 22 of 38, p = 0.023) compared to ERCP. Specifically, the performance of MRCP is promising for the interpretation of cholangiocarcinoma (22 of 26) and gallbladder carcinoma (five of five), but is relatively ineffective for the interpretation of icteric HCC (two of four) and metastasis (two of five).

CONCLUSION

MRCP represented an ideal noninvasive diagnostic tool for the evaluation of malignant perihilar biliary obstructions with reference to ERCP.

Antral web--a rare cause of vomiting in children

Antral web is a rare cause of gastric-outlet obstruction. We report a case of gastric antral web with intermittent vomiting in a 10-year-old girl who received medical treatment for 6 months. The literature on this anomaly is reviewed with respect to differential diagnosis on the basis of upper gastrointestinal radiographic series, gastroscopy, and treatment planning.

Hepatic calcification by sequelae of chronic schistosomiasis japonica: report of four cases

Due to the elimination of intermediate hosts and the improvement of clinical care, most parasitic infections have been effectively controlled in developing countries. Recently, the increase of the worldwide tourism, especially to Mainland China, and the migration of overseas workers from endemic countries have led to more parasitic infections that should not be overlooked by physicians. Assessment of diffuse liver disease with physical examination and laboratory findings is notoriously inaccurate. Thus, physicians use liver biopsy for accurate diagnoses. We present 4 patients with hepatic schistosomiasis japonica which were diagnosed using imaging before liver biopsy. Hepatic schistosomiais japonica has a tendency to cause dystrophic calcification and fibrosis in the liver. According to the results, a combination of ultrasonography and computed tomography (CT), used to recognize characteristic calcification patterns, seem useful to physicians for accurate diagnoses. Thus, unnecessary biopsy procedures can be avoided.

Intractable oesophageal variceal bleeding caused by splenic arteriovenous fistula: treatment by transcatheter arterial embolization

We describe a rare case of splenic arteriovenous fistula and venous aneurysm which developed after splenectomy in a 40-year-old woman who presented with epigastralgia, watery diarrhoea, repeated haematemesis and melaena caused by hyperkinetic status of the portal system and bleeding of oesophageal varices. It was diagnosed by computed tomography and angiography, and obliterated with giant Gianturco steel coils.

Genetic manipulation to identify limiting steps and develop strategies for high-level expression of penicillin acylase in Escherichia coli

We have identified the bottleneck steps limiting expression of penicillin acylase (PAC) through comparison of the expression performance for various PAC-expression vectors constructed by genetically modulating the efficiencies of transcription and/or translation of the pac gene. To our knowledge, this is the first report demonstrating that expression of PAC could be limited by various steps, such as transcription, translation, and post-translational steps (i.e. translocation and periplasmic processing), depending on the host/vector systems. Results also indicate that the structure of the wild-type pac gene might not be optimal for direct use in production of PAC using recombinant DNA technology. To improve the gene expression, transcription was enhanced by manipulating certain DNA bases in the pac regulatory region, whereas translation was enhanced by enlarging the spacing between the ribosome binding site and the ATG initiation codon to increase the initiation efficiency. The information is useful in terms of developing genetic strategies for overproduction of recombinant PAC in Escherichia coli.

Effect of SecB chaperone on production of periplasmic penicillin acylase in Escherichia coli

The effect of SecB chaperone on production of periplasmic penicillin acylase (PAC) in Escherichia coli was investigated. It appears that formation of PAC required the function of SecB chaperone and the amount of SecB required was at a basal level. The secB mutant was defective in production of PAC, and the impairment could be complemented by extrachromosomally supplementing SecB in trans. The function of SecB might be primarily stabilizing the cytoplasmic PAC precursors. Overproduction of SecB chaperone usually resulted in an increase in the amount of PAC precursors without enhancing PAC activity. In addition, most of the PAC precursors were located in the periplasm, suggesting that formation of active PAC was likely limited by periplasmic processing steps.

Manipulation of carbon assimilation with respect to expression of the pac gene for improving production of penicillin acylase in Escherichia coli

A strategy of genetically manipulating carbon assimilation with respect to expression of the pac gene was employed for overproduction of recombinant penicillin acylase (PAC). Two expression plasmids of pCLL2902 and pCLL3201, which contain the pac coding region but differ in the pac regulatory region, were constructed for the production experiments. Expression of the pac gene was subjected to phenyl acetic acid (PAA-) induction and glucose catabolite repression for pCLL3201, whereas it was subjected to neither of the two transcriptional regulations for pCLL2902. The specific PAC activity for strains harboring pCLL2902 was significantly higher than that for strains harboring pCLL3201 due to an improved transcription efficiency. In addition, no inclusion bodies were observed upon production of PAC using the current expression systems. The results suggest that using the native pac promoter instead of a strong promoter such as tac for regulation is a feasible approach for production of PAC. The impact of the current expression systems is also significant from a process viewpoint since, using strains harboring pCLL2902, not only could glucose replace PAA as a carbon source of Escherichia coli cultures for production of PAC but also the volumetric PAC activity was highly improved.

Value of magnetic resonance cholangiopancreatography in demonstrating major bile duct injuries following laparoscopic cholecystectomy

BACKGROUND

Conventionally, recognition of bile duct injuries after laparoscopic cholecystectomy largely relies on endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). However, these invasive procedures are not without risk. Preliminary experience with use of magnetic resonance cholangiopancreatography (MRCP) to identify these injuries is reported.

METHODS

The medical records of five patients who had undergone laparoscopic cholecystectomy and had suspected major bile duct injuries were reviewed. All five patients underwent MRCP, followed by conventional cholangiography: either ERCP or PTC, or both. The findings of MRCP and conventional cholangiography were compared.

RESULTS

Four patients had proven bile duct injuries. The remaining patient had gallstones dislodged into the common bile duct (CBD) during laparoscopic cholecystectomy, which presented as transient jaundice mimicking a bile duct injury. The MRCP images were of higher diagnostic value than conventional cholangiographic images in four patients with frank bile duct injury. For these patients, ERCP showed only the cut-off sign of the CBD, and PTC was needed to visualize the upper biliary system. MRCP, however, demonstrated the entire biliary system proximal and distal to the amputated or stenotic sites simultaneously. In the remaining patient with dislodged gallstones, the two techniques yielded similar diagnostic information.

CONCLUSION

This preliminary study suggests that MRCP is an ideal diagnostic test whenever bile duct injury following laparoscopic cholecystectomy is suspected.

Dacryocystorhinostomy with intraoperative mitomycin C

PURPOSE

To observe the effect of intraoperative mitomycin C on the size of the osteotomy site after dacryocystorhinostomy.:

METHODS

A total of 15 eyes of 14 patients diagnosed with primary acquired nasolacrimal duct obstruction were assigned randomly to either a mitomycin C group or a control group. The surgical procedures in both groups were exactly the same, except that in the patients in the mitomycin C group, a piece of neurosurgical cottonoid soaked with 0.2 mg/ml mitomycin C was applied to the osteotomy site and then after 30 minutes was removed transnasally. Nasoendoscopic findings were recorded at the completion of the surgery and at 1 month, 3 months, and 6 months after surgery for the two groups. A computer-aided digitizer was used to calculate the surface area of the osteotomy site, and a Student's t test was used to compare the difference between the two groups.

RESULTS

All patients in the mitomycin C group remained symptom free after removal of their silicone tube (100% success), and there was one patient in the control group who had recurrent epiphora (87.5% success). Septo-osteotomy adhesion was found in two patients in the control group (25%), but there was no such adhesion found in the patients in the mitomycin C group. In the mitomycin C group, the average final surface area of the osteotomy at the end of the sixth postoperative month was 27.10 +/- 5.78 mm2, whereas that of the control group was only 10.83 +/- 3.37 mm2. Although the immediate postoperative surface area of the osteotomy showed no significant difference between the two groups, a statistically significant difference was noted at 6 months.

CONCLUSION

Intraoperative mitomycin C is effective in maintaining a larger osteotomy size. This modification may possibly improve success rates over the traditional dacryocystorhinostomy procedure.

[Changing seroepidemiology pattern of hepatitis B virus infection among elementary and junior high school children in Keelung, Taiwan, 1988]

A large-scale seroepidemiologic study of 20816 (35.6% of total) elementary and junior high school children (grades 1-9) in Keelung, Taiwan was conducted in April-May 1988. The study was to investigate the current status of hepatitis B virus (HBV) infection and to plan the extension of the present HBV prevention program to other age groups. Two HBV markers, hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs), were determined by enzyme immunoassay. The overall seropositivity rates of HBsAg and anti-HBs were 19.0% and 25.6%, respectively. Only 0.4% of the children studied were concurrently positive for both HBsAg and anti-HBs and 55.8% of them were negative for these two markers. It is noteworthy that the seropositivity rate of HBsAg increased with increasing age, from 15.4% in grade 1 (ages 6) to 23.7% in grade 9 (ages 15). This rate of HBsAg was not higher than the 1986 findings (14.0-25.5%) screened from children (4-13 years old) in Keelung, by comparing each age cohort strata, even though the age of study population was two years older. These data indicate that the current hepatitis control strategies have resulted in the reduction of the hepatitis B carrier rate among children from more than 20% to 15% at age 6 (grade 1) in Keelung, but the reduction is still higher than in Taipei children (10%). The seropositivity rate of anti-HBs was also increased with increasing age, from 13.5% (grade 1) to 44.1% (grade 9) and was similar to previous findings in Taiwan.(ABSTRACT TRUNCATED AT 250 WORDS)