Intra-operative autotransfusion in radical cystectomy

OBJECTIVE

To assess the feasibility of intra-operative autotransfusion (IAT) as a method of decreasing or avoiding homologous blood transfusion during radical cystectomy.

PATIENTS AND METHODS

IAT was performed in 10 patients with bladder cancer who underwent radical cystectomy. The patients were divided into two groups: group 1 consisted of six patients without and group 2 of four patients with pre-deposited blood. Blood shed in the operative field was collected and processed with an IAT device.

RESULTS

In group 1, the intra-operative blood loss ranged from 1.08 to 2.67 L (mean 1.82) and homologous blood transfusion ranged from 0 to 1 L (mean 0.47). The amount of autologous blood processed and transfused by the IAT device ranged from 0.38 to 0.98 L (mean 0.64). Two patients did not require homologous blood transfusion. In group 2, the volume of pre-deposited blood ranged from 0.8 to 1.2 L (mean 0.9). The intra-operative blood loss ranged from 1.03 to 3.24 L (mean 1.8). The amount of processed autologous blood transfused ranged from 0.4 to 0.6 L (mean 0.45). None of the patients in group 2 required homologous blood transfusion.

CONCLUSION

Although there are theoretical risks with IAT, they were not substantiated by the clinical data. IAT seems to be a feasible method of reducing or avoiding homologous blood transfusion in radical cystectomy. These results suggest that IAT in combination with pre-deposited blood will abolish the need for homologous blood transfusion during radical cystectomy.

Assessment of the availability of intraoperative autotransfusion in urological operations

PURPOSE

Intraoperative autotransfusion in urological operations has the risks of reinfusing urine constituents, bacteria and cancer cells. We assessed the efficacy of intraoperative autotransfusion and leukocyte removal filters to separate red blood cells from these constituents.

MATERIALS AND METHODS

Concentrated red blood cells were mixed with urine, bacteria (Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumoniae) and tumor cells (KK47 and ACHN), and processed with the intraoperative autotransfusion device. Biochemical analyses of erythrocytes collected in reinfusion bags (collected erythrocyte solution) from the mixtures of concentrated red blood cells and urine (mixture 1), and cultures of collected erythrocyte solution from the mixtures of concentrated red blood cells and bacteria (mixture 2) were performed. Cytology was done on collected erythrocyte solution from the mixtures of concentrated red blood cells and tumor cells (mixture 3) and filtrates were passed through leukocyte removal filters.

RESULTS

Biochemical analyses of collected erythrocyte solution from mixture 1 indicated complete removal of urine constituents, while cultures from mixture 2 yielded bacterial growth. Tumor cells from both cell lines were found in the collected erythrocyte solution from mixture 3 although tumor cells were not found in filtrates through leukocyte removal filters.

CONCLUSIONS

Our results suggest that intraoperative autotransfusion is safe for urological operations in which bacteria and tumor cells are not present in the operative field. Our data also indicate that intraoperative autotransfusion may be safe for urological cancer operations if it is combined with leukocyte removal filters to prevent unexpected reinfusion of tumor cells.

Local treatment of rabbit VX2 rectal carcinoma with combined hyperthermia and intratumoral CDDP injection

The efficacy of combined use of hyperthermia and intratumoral cisplatin (CDDP) injection was investigated in rabbit rectal carcinoma models produced by VX2 carcinoma injection. Local hyperthermia was administered with a 13.56 MHz radiofrequency generator at 42-43 degrees C for 30 min. CDDP (3 mg) was injected into two sites within tumours. Temperatures in the VX2 rectal carcinomas reached 42-43 degrees C within 3 min following initiation of heating and remained stable. Tumour growth was inhibited markedly in rabbit undergoing combined treatment with intratumoral CDDP and hyperthermia, when compared with rabbit treated with hyperthermia or intratumoral CDDP alone. Histological examination further revealed that combined treatment resulted in more extensive tumour necrosis, when compared with hyperthermia or CDDP alone. Therefore, combined hyperthermia and CDDP intratumoral injection may be useful for neoadjuvant preoperative treatment of advanced rectal carcinomas as well as patients with recurrent rectal carcinoma.

Preoperative combined treatment with radiation, intraluminal hyperthermia, and 5-fluorouracil suppositories for patients with rectal cancer

A clinical trial of a novel modality consisting of preoperative irradiation and intraluminal hyperthermia therapy, with or without 5-fluorouracil (5-FU) suppositories, was conducted on 30 patients with rectal cancer. To create hyperthermia in rectal cancer, an intraluminal electrode connected to a radiofrequency system was devised. Patients were treated preoperatively with a total irradiation dose of 30 Gy, being 3 Gy every 2 days, and 5 applications of hyperthermia given twice a week, with or without 5-FU suppositories, given as 100 mg a day to a total of 2,000 mg. Twenty patients received irradiation, intraluminal hyperthermia, and 5-FU suppositories, being the three-combination treatment, and the remaining 10 received irradiation and intraluminal hyperthermia, being the two-combination treatment. Shrinkage of the rectal cancer was observed macroscopically in 26 patients, resulting in a flattened cancerous crater or shallow ulcer. Microscopic examination revealed a marked decrease in the number of cancer cells. In fact, three resected specimens showed no evidence of cancer cells microscopically. These striking reductions in cancer size enabled us to successfully perform super-low anterior resections in four patients, with anastomoses being made just above the dentate line with a sufficiently safe margin. No serious complications were encountered in this series.

[Local injection of peplomycin adsorbed on activated carbon particles combined with 60Co radiation against inoperable advanced esophageal cancer--two long-term survivors]

We have developed a new dosage form, PEP-CH, consisting of peplomycin adsorbed onto small activated carbon particles. Ten patients with inoperable advanced esophageal cancer were treated with endoscopic local injection of PEP-CH combined with radiation using 60Co. Two of 5 patients who completed the treatment have survived over one year (19 and 23 months) now.

Endoscopic local injection of a new drug-delivery format of peplomycin for superficial esophageal cancer: a pilot study

BACKGROUND

A new drug-delivery format comprising activated carbon particles adsorbing peplomycin (PEP-CH) was developed for the treatment of superficial esophageal cancer.

METHODS

The drug distribution was measured in rats that received subcutaneous injections of PEP-CH or peplomycin aqueous solution. In 6 patients with superficial esophageal cancer, peplomycin as PEP-CH, 5-10 mg once a week for 4-10 weeks (total, 40-100 mg/patient) was injected endoscopically into primary lesions.

RESULTS

Rats given PEP-CH had significantly higher peplomycin levels in the regional lymph nodes and the injection site than rats given aqueous solution. Five patients have survived to the present or died without cancer after 27-72 months. The remaining patient has survived without cancer for 8 months after a second course of PEP-CH against recurrence.

CONCLUSIONS

PEP-CH therapy seems to have a good therapeutic effect on superficial esophageal cancer, although the present clinical study may have been biased by patient selection.

Pharmacologic effects of cisplatin microspheres on peritoneal carcinomatosis in rodents

BACKGROUND

A new drug-delivery formulation of cisplatin, whereby cisplatin was incorporated in lactic acid oligomer microspheres (CDDP-MS), has been developed in dosage form for peritoneal carcinomatosis and has been designed to release 70% of the incorporated cisplatin slowly during a period of 3 weeks. In this study, its pharmacologic effects were examined in rodents.

METHODS

CDDP-MS was tested to determine (1) tissue distribution of cisplatin after intraperitoneal administration of cisplatin at 3.0 mg/kg body weight to rats, (2) acute toxicity in mice when injected intraperitoneally, and (3) therapeutic effects on peritoneal carcinomatosis induced by transplantable M5076 tumors in mice.

RESULTS

These experiments revealed the following: (1) CDDP-MS resulted in a higher cisplatin concentration in tissues adjacent to the peritoneum for a longer period, and the concentration of cisplatin measured in the rest of the body was lower than that delivered by the cisplatin aqueous solution; (2) the 50% lethal dose value, determined by the Litchfield-Wilcoxon method, was 23.8 mg/kg body weight in CDDP-MS in terms of cisplatin, whereas in the cisplatin aqueous solution it was 13.5 mg/kg body weight; (3) CDDP-MS enhanced therapeutic effects when compared with the same toxicity dosage of cisplatin aqueous solution.

CONCLUSIONS

Intraperitoneal CDDP-MS releases cisplatin into the peritoneal cavity for a long time, and it results in less systemic toxicity and greater therapeutic effects on peritoneal carcinomatosis than does cisplatin aqueous solution.

Significant clinical response of activated carbon adsorbed-peplomycin against esophageal cancer: a pilot study

Activated carbon particle adsorbed-peplomycin (PEP-CH) was administered to three patients who had advanced esophageal cancer and its clinical usefulness was evaluated. The PEP-CH was injected endoscopically into the tumor or the adjacent normal esophageal tissue. Case 1 and case 3 were treated by topical injection of PEP-CH with or without surgery and case 2 was subjected to the PEP-CH treatment with radiation. The barium swallow and endoscopic examination exhibited a marked tumor reduction in all the patients at the end of the PEP-CH treatment. Although a marked clinical response was seen, case 1 died of postoperative complication. Two patients were capable of oral food intake after the treatment, which had been impossible before the treatment. There were no serious adverse side effects caused by the PEP-CH treatment in all the patients. PEP-CH should prove valuable as a new form of chemotherapy for the treatment of esophageal cancer patients.

Balloon dilatation for anastomotic stricture after upper gastro-intestinal surgery

We report our study on the correlation between the types of anastomosis and the incidence of anastomotic stricture formation in the upper gastro-intestinal tract. Our experience with balloon dilatation is also reported. We examined the incidence of stricture formation among patients who had an anastomosis between the esophagus and stomach following subtotal esophagectomy for esophageal cancer, and esophagojejunostomy following proximal or total gastrectomy for gastric cancer in the past 17 years. Among 283 patients undergoing esophagojejunostomy, 7 cases of stricture (excluding 3 cases of cancer recurrence) were observed (conventional anastomosis 1.8%; stapling anastomosis 4.6%). There were 17 cases of stricture among 56 patients who had anastomosis between the esophagus and stomach following subtotal esophagectomy (conventional anastomosis 28.6%; stapling anastomosis 50.0%). One month or more after the operation, the diameter of the esophagojejunostomy was estimated using a barium study. The mean diameter of the anastomosis using the stapling method was 11.9 +/- 2.9 mm, whereas the mean diameter of serosubmucosal single layer hand-sewn anastomosis (Jourdan's) was 19.8 +/- 2.2 mm, and that of vertical mattress hand-sewn anastomosis was 19.0 +/- 2.0 mm. Balloon dilatation was used in 29 patients with anastomotic stricture of the upper gastro-intestinal tract (esophageal cancer, 19 patients, gastric cancer, 10 patients). With repeated dilatation, we were able to obtain satisfactory efficacy for benign strictures and there were no severe complications. We believe that balloon dilatation is an easy, safe and effective therapy for anastomotic stricture of the upper gastro-intestinal tract.

Prophylaxis with carbon-adsorbed mitomycin against peritoneal recurrence of gastric cancer

Attempts to prevent peritoneal carcinomatosis after surgery for gastric cancer by intraperitoneal administration of anticancer drugs have not been successful, largely because the drugs are not retained in the peritoneal cavity. We have assessed the prophylactic efficacy of a delayed-release preparation--mitomycin adsorbed onto activated charcoal (M-CH). 50 patients with gastric cancer and serosal infiltration were randomly assigned intraperitoneal treatment with M-CH (50 mg mitomycin intraoperatively) or no anticancer prophylaxis (control). Survival rates for the 3 years of follow-up were significantly higher among the 24 M-CH recipients (1 was lost to follow-up) than among the 25 controls (p less than 0.01). There were significant differences in survival between the groups at 1.5 years after randomisation (difference 34.6% [95% confidence interval 8.5-60.8%]; p less than 0.01) and at 2.0, 2.5, and 3.0 years (41.7% [14.2-69.1%]; p less than 0.005). The concentration of mitomycin was significantly higher in peritoneal exudate than in plasma for 24 h after drug administration. Side-effects were slight and well tolerated. Thus, peroperative intraperitoneal treatment with M-CH seems to improve survival after gastrectomy for gastric cancer, presumably by a prophylactic effect on peritoneal recurrence.

The prognosis of patients with gastric cancer possessing sex hormone receptors

Estrogen receptors (ER) and progesterone receptors (PgR) were immunohistologically investigated in 107 patients with gastric cancer who underwent curative resection. Both ER and PgR were detected only in the cancer cell nucleus. The ER positive rate was 27.7% for males and 31.0% for females, while the PgR positive rate was 9.2% for males and 11.9% for females. Clinicopathologically, the ER positive rate was slightly higher in young females and in cases of poorly differentiated gastric cancer. When cumulative survival rates were analyzed in relation to the presence or absence of receptors, the 10-year cumulative survival rate after surgery was significantly lower in the ER positive cases, being 15.7% cent, than in the ER negative cases, being 62.7%, and also significantly lower in the PgR positive cases, being 18.2%, than in the PgR negative cases, being 48.3%. The coexistence of ER and PgR in gastric cancer tissues suggests that the ER is physiologically active, or that ER positive gastric cancer is hormone-dependent. The poor prognosis of patients with receptor positive gastric cancer suggests that gastric cancer with these receptors is highly malignant.

Characterization of estrogen receptor in human gastric cancer

Estrogen receptors (ER) were examined in cytosol, nuclear potassium chloride (KCl) extractable fraction, and nuclear KCl unextractable fraction by the dextran-coated charcoal adsorption method in various gastric cancer tissue. The overall ER-positive rate in the cytosol and nuclear fraction was 19.2%. The maximum binding site (Bmax) was 36.0 to 175.0 fmol/mg of protein, and the dissociation constant (Kd) was 0.6 to 1.6 X 10(-9) in cytosol fraction. In the nuclear fraction, Bmax was 7.5 fmol/mg of DNA and Kd was 2.3 X 10(-9). Estrogen receptors were characterized in cytosol protein. In cytosol, the estrogen (E2)-ER complex was sedimented at approximately the 5S and 8S regions by 5% to 20% linear sucrose gradient centrifugation. A steroid specificity study of ER showed the presence of an binder in gastric cancer tissue. In conclusion, these results that gastric cancer tissue has E2 binding sites with the same biochemical characteristics as in breast cancer and endometrial cancer strongly suggest the hormonal dependency of gastric cancer.

[Mass-screening for breast cancer using C-mode display ultrasonography]

In order to elevate the detection rate of breast cancer in mass-screening, we examined whether the C-mode display ultrasonography is useful for detection of breast cancer. 1) Diagnostic sensitivity of C-mode ultrasonography was 88.2%, specificity was 66.7% and predictive value was 58.8%, respectively. 2) The detection rate of C0mode ultrasonography was 100% for tumors more than 5.0cm, 87.5% for 2.0-5.0cm, 74.2% for less than 2.0cm. Especially, the diagnostic value of lesser than 1.0cm breast cancer was high, 66.7%. 3) In findings of C-mode ultrasonography, images characteristic of carcinoma can be obtained regarding their unclear margin (70.6%), heterogenous (88.2%) and hypoechoic (70.6%) internal echoes and malignant halo (61.8%). Our present data suggest that C-mode ultrasonography is very useful for the mass screening for breast cancer.

[Study on follow-up of patients with biopsy-proven breast disease]

Eight hundred forty-one patients with biopsy-proven benign breast disease were followed annually in prospective manner for 1-10 years to analyse breast cancer development at aspect of histologic features, age at entry and mammographic patterns by Wolfe. No association was found between patients who developed cancer and those who did not with respect to the initial histologic features. The rate of breast cancer development in patients in thirties was the highest. The breast cancer development was found most often in less than three years follow-up period. The breast parenchymal patterns at entry related to cancer development. In 10 cancer patients, 8 patients showed DY pattern and 2 showed P2 patterns. The present results demonstrate that the patients with biopsy-proven benign breast disease in thirties, in less than 3 years follow up period and have parenchymal patterns of P2 or DY should be followed carefully.

Immunohistochemical demonstration of estrogen, progesterone, CEA and ferritin in breast cancer and their clinical value for the prediction of early postoperative recurrence

The aim of this paper is to determine whether the incidence of estrogen-, progesterone-, CEA-, and ferritin- positive staining of primary tumors, by using the PAP method, is related to the prognosis of breast cancer status. A significantly higher incidence (71 per cent) of CEA-positive tumors was observed in patients who had a recurrence of breast cancer within 2 years after radical operation. Patients, whose tumors were positive in estrogen or negative in CEA, showed a relatively good prognosis, even after a recurrence of the disease. Distant metastases were seen in most of the patients positive in CEA (78 per cent). Before the recurrence of breast cancer, those patients positive in progesterone had a good prognosis. After the recurrence, however, there was no relationship between the prognosis of recurrent disease and the progesterone-staining of primary tumors. Our data suggest that the immunohistological staining of estrogen, progesterone and CEA might offer the effective prognostic indices in breast cancer patients.

[Endocrine therapy of scirrhous carcinoma of the stomach]

Tissue localization of endogenous estrogens (estrone; E1, estradiol; E2, estriol; E3) progesterone was examined in scirrhous type of gastric cancer by the peroxidase-antiperoxidase (PAP) immunoperoxidase method. Twelve of 47 specimens showed positive estrogen staining, and 4 of 47 showed positive progesterone staining. The incidence of positive staining for these 4 substances was higher in male patients than in female patients. The number of specimens with positive E2 staining was the highest among E1, E2 and E3 staining. Prognosis of patients who had undergone curative surgery with positive estrogen staining were better than that of patients with negative estrogen staining. The existence of estrogen receptor (ER) and progesterone receptor (PgR) was also shown in 3 specimens and one specimen, respectively, from another 15 specimens with scirrhous type of gastric cancer by the dextran-coated charcoal assay. In a clinical test, Tamoxifen administered patients with scirrhous carcinoma following curative or noncurative gastrectomy showed better prognosis than non-Tamoxifen administered those.

Peroxidase-antiperoxidase staining for estrogen and progesterone in scirrhous type of gastric cancer: possible existence of the estrogen receptor

Tissue specimens from patients with the scirrhous type of gastric carcinoma were stained using the peroxidase-antiperoxidase (PAP) method. Nine out of thirty-seven specimens (24 per cent) showed positive estrogen staining, and here tissues from male or older patients were usually stained. Cumulative survival rate in patients whose tissue showed a positive estrogen staining was higher than that in case of a negative estrogen staining. Four out of thirty-one specimens (13 per cent) stained positively for progesterone, all four patients being male. These results suggest that estrogen and progesterone may relate to the growth of the scirrhous type of gastric cancer.

Alteration of adenosine deaminase levels in peripheral blood lymphocytes of patients with gastric cancer

The present study was undertaken to determine the adenosine deaminase (ADA) activity of peripheral lymphocytes in patients with gastric cancer, with respect to the cancer progression, the effect of surgery and/or immunotherapy. The gastric cancer patients showed lower lymphocyte ADA activity than did the normal control. The lymphocyte ADA activity did not decrease with the cancer progression. There was a significant correlation between lymphocyte ADA activity and blastogenesis of lymphocyte by phytohemaglutinin or concanavalin A. Six months following gastrectomy, the lymphocyte ADA activity was increased, as compared with the preoperative value. The ADA activity of patients on post-operative OK-432 showed a greater increase, as compared to that of patients not given this treatment. In conclusion, decreased lymphocyte ADA activity in gastric cancer patients might be due to either the cancer bearing status or to the immunological suppression.

Detection of gastric cancer by a combination of tissue polypeptide antigen (TPA), lipid-bound sialic acid (LBSA) and carcinoembryonic antigen (CEA)

In this study, the clinical significance of the tumor markers, tissue polypeptide antigen (TPA) and lipid-bound sialic acid (LBSA) in conjunction with carcinoembryonic antigen CEA, was tested in 52 gastric cancer patients. The incidence of elevated serum levels of these 3 markers was as follows: 63% (33/52) for TPA; 40% (21/52) for LBSA; 21% (11/52) for CEA. In a combination assay using all three tumor markers, 37 out of 52 gastric cancer patients (71%) showed a positive combination assay, while 5 out of 20 normal subjects (25%) showed a positive combination assay. In a discriminant analysis of the resulting data, 18 out of 52 gastric cancer patients (35%) were classified correctly based on an analysis of CEA alone. Furthermore, 25 out of 52 gastric cancer patients (48%) and all 20 normal subjects (100%) were classified correctly based on an analysis of all three variables. Our data suggest that TPA and LBSA are more sensitive than CEA as markers of gastric cancer, and that the simultaneous measurement of TPA and LBSA in conjunction with CEA is more useful in cancer detection than the measurement of CEA alone.

Manometric study and prolonged pH monitoring of esophagus in patients with hiatus hernia before and after operation

The pathophysiology of the lower esophagus in 18 patients with hiatus hernia and 15 normal controls was investigated by esophageal manometry and prolonged pH monitoring. Thirteen patients with symptoms of severe gastroesophageal reflux had lower than normal pressures at the gastroesophageal junction. In 5 patients without symptoms, the pressure was normal. Nine of the 13 patients were inadequately controlled by conservative measures and underwent Nissen or Dor-Nissen fundoplication. All were free of esophageal symptoms postoperatively. Fundoplication resulted in a significant increase in the lower esophageal pressure. Prolonged esophageal pH monitoring showed significant improvement in all indices. Hiatus hernia and gastroesophageal reflux are related etiologically. However, further observations are needed to explain the association between reflux esophagitis and hiatus hernia. Nissen and Dor-Nissen fundoplications restored competence to the gastroesophageal junction as judged by esophageal manometry and prolonged pH monitoring.

Correlation between carcinoembryonic antigen in gastric cancer tissue and survival of patients with gastric cancer

Gastric cancer specimens obtained from 162 patients who had undergone radical surgery with the routine postoperative administration of both mitomycin C and 5-fluorouracil were stained for carcinoembryonic antigen (CEA) by the unlabeled antibody enzyme technique. The CEA (-/+) group (92 cases) consisting of the negative and weakly positive staining cases had a significantly better survival rate over a period of 5 years than the CEA (++) group (70 cases) which comprised only strongly positive cases. The CEA (-/+) group with differentiated adenocarcinoma had the best prognosis and the 5-year survival rate was significantly higher than those of the other three groups. Among stage II and III carcinomas, the postoperative survival rate was significantly better in the CEA (-/+) group than in the CEA (++) group. Among the patients with lymph node metastasis, the postoperative survival rate was low, especially in the CEA (++) group. The present data suggest that staining for CEA in tissue sections of stomach carcinoma may be helpful in differentiating among tumors that appear similar by conventional histological methods, thus providing a new means for obtaining more precise prognostic information.

Comparative study of CEA staining in gastric and colorectal cancer tissues

Expression of CEA was studied in tissue sections from 140 cases of gastric and 54 cases of colorectal carcinoma by the immunoperoxidase technique. In some cases of gastric cancer, the intensity of CEA staining was compared with the CEA concentration by radioimmunoassay, and the intensity of the CEA staining was related to CEA concentration. CEA was more strongly positive in colorectal carcinomas than in gastric carcinomas. The intensity of the CEA staining was stronger in differentiated gastric and colorectal carcinomas than in anaplastic ones. No relationship was seen between the expression of CEA and the extent of disease in gastric or colorectal carcinoma. The CEA expression was related to the location of tumors in colorectal carcinomas, but not in gastric carcinomas.

Studies on effect of carcinoembryonic antigen on leucocyte migration inhibition test in patients with colorectal cancer

Leucocyte migration inhibition test (LMIT) is a useful method to detect tumor associated antigens (TAA) in cancer patients. Carcinoembryonic antigen (CEA) is one of the best tumor markers for gastrointestinal cancer, and especially for colorectal cancer patients, who show high plasma CEA level frequently. In this study, we performed LMIT in 71 colorectal cancer patients with 3 M KCl extracts of cancer tissues and measured concentration of CEA in the plasma and the extracts of cancer tissue simultaneously. Although CEA in colorectal cancer extracts was individually varied from low to high in concentration, the levels of CEA had no relation to LMI reactivity. In addition, the LMI reactivity of colorectal cancer patients did not relate to the plasma CEA level of the corresponding patient. The results suggest that some antigens which induce leucocyte migration inhibition factor (LMIF) to lymphocytes from colorectal cancer patients might be different substances from CEA.

Anal sphincter function and rectal reservoir after sphincter saving operations for carcinoma of the rectum

Anal sphincter function and rectal reservoir were studied in 27 patients after low anterior resection, in 6 after Welch or Turnbull type pull-through surgery and in 3 after Bacon type pull-through surgery. Sixteen patients who had undergone right hemicolectomy served as a control group. Anal sphincter function immediately after low anterior resection was diminished, but improved during the following 6 months. Rectal capacity was much reduced immediately after surgery, but increased with time, and the neorectum could to some extent adapt to its new role as a reservoir. After pull-through operations, anal canal pressure and rectal compliance were significantly lower than after low anterior resection or right hemicolectomy. These findings may explain the increased frequency of bowel action after pull-through operations.

Immunoassessment of patients with gastric cancer. Using leukocyte migration inhibition (LMI) test

Leukocytes from patients with gastric, colorectal or benign gastrointestinal disease, as well as those from normal control subjects, were tested by the leukocyte migration inhibition test (LMIT), using five different allogeneic 3 M KCl extracts of gastric cancer extracts. In LMIT with a single tumor extract, a pathological MI was found in 48% of 79 gastric cancer patients, a significantly higher figure than in the three other groups of patients (4-21%). In the panel mode of LMIT, that is, testing each blood sample with five different tumor extracts, 62/79 (79%) of patients with gastric cancer showed a positive reaction. Positive reactivity was significantly higher in patients with gastric cancer than in patients in the other groups and the frequency was higher in stage IV cases than in stage I-III cases, although the differences were not significant. In addition, the frequency of the positive reaction was unrelated to the degree of differentiation in adenocarcinoma. Positive reactivity increased in inverse proportion to the degree of nuclear grade (NG) (84% in NG I, 80% in NG II and 64% in NG III), but the correlation was not statistically significant.

Immunoreactive carcinoembryonic antigen in gastric juice in patients with gastric cancer

To clarify the significance of immunoreactive carcinoembryonic antigen in gastric juice (gastric CEA) from gastric cancer patients, we studied the gastric CEA in comparison with cancer progress, histologic types of tumors, staining for CEA and extent of intestinal metaplasia. The gastric CEA levels from patients with other gastric diseases, i.e., gastric ulcer, duodenal ulcer and chronic gastritis were also investigated. The mean gastric CEA level from gastric cancer patients was significantly higher than from gastric or duodenal ulcer patients, but there was no significant difference between levels in patients with gastric cancer and in those with chronic gastritis. The gastric CEA levels from cancer patients increased with progression of the cancer. The differentiated carcinomas showed significantly higher gastric CEA levels than the poorly differentiated carcinomas. Positive CEA tumors showed significantly higher gastric CEA levels than did the negative CEA tumors. The tumors with diffuse intestinal metaplasia revealed high gastric CEA levels. Determination of gastric CEA levels is considered to be useful for screening of gastric cancer.

Conservative surgery for regional lymphadenectomy in the treatment of early gastric carcinoma

The relationship between lymph node metastases and postoperative prognosis in 209 patients with early gastric cancer was studied. As to the postoperative prognosis in relation to the extent of lymph nodes dissection, no significant difference was observed among the age-corrected 5-year survival rates following three surgical procedures in patients with early gastric cancer. Age-corrected 5-year survival rates were 0.92 +/- 0.44 R1-resection, 0.95 +/- 0.44 in R2-resection, and 1.00 +/- 0.06 in R3-resection, respectively. In addition, in 71 patients including 33 with early gastric cancer and 38 patients with advanced but relative early gastric carcinoma, the relationship between the immunostatus and postoperative prognosis was investigated. Postoperative age-corrected 5-year survival rate (0.904 +/- 1.153) of the optimal responders with good immunostatus was significantly higher than that (0.582 +/- 1.153) of the suboptimal responders with impaired immunostatus (P less than 0.01). Thus, conservative surgery for regional lymphadenectomy may be an effective procedure for cure of early gastric carcinoma, particularly in cases of a carcinoma limited to the mucosal area of the stomach.

Physiologic status of the anorectum following sphincter-saving resection for carcinoma of the rectum

The physiologic status of the anorectum after low anterior resections or pull-through operations of the rectum was evaluated clinically and by manometric studies. It was demonstrated that the presence of a normal anal resting pressure and an anorectal reflex were important to achieve postoperative continence after sphincter-saving operations. In patients with anastomotic leaks and poor function, a marked high-pressure zone in the anal canal and an anorectal reflex were not found, but as local inflammation resulting from the anastomotic leak disappeared, these parameters returned to normal. A normal anorectal reflex was found in one of three patients after Bacon-type pull-through operations, but the remaining two showed an increase of anal canal pressure during colonic distention. These results indicate that an elevation of anal-canal pressure in response to colonic distention plays a significant role in fecal continence at the time of "a sense of urgency" if internal sphincter function is impaired.

[Follow-up study of preoperative oral administration of an antineoplastic agent as an adjuvant chemotherapy in stomach cancer]

Based on the propensity of fat emulsion to be absorbed mainly into lymphatic capillaries and regional lymph nodes, preoperative oral administration of 5-FU emulsion was attempted as an adjuvant chemotherapy to surgery for gastric carcinoma. In our previous studies, it was demonstrated that the mean 5-FU level in the regional lymph nodes was higher in patients who received the 5-FU solution. Since 1974, we have administered 5-FU emulsion preoperatively to 167 patients with gastric cancer (500 mg X 10 days) and examined histologically the effect of this regimen on the metastatic foci in the lymph nodes. A positive change, such as marked necrosis or marked degeneration, was found in 58% of the metastatic lesions. Sixty-four patients with advanced cancer who received the preoperative 5-FU emulsion also received a curative resection between 1974 to 1977 in addition to postoperative chemotherapy (MMC 40 mg and 5-FU more than 5000 mg) (Group A). Their survival rate was compared with that of the curatively operated advanced cancer patients from 1959 to 1973 who received the same postoperative chemotherapy only (Group B, N = 59) and with that of patients, from 1959 to 1970, who received no chemotherapy (Group C, N = 222). The 5 year survival rate of Group A was 0.53 +/- 0.07, which was higher than that (0.49 +/- 0.07) of Group B and that (0.40 +/- 0.10) of Group C. Comparing the 5-year survival rates of the 3 groups from several points of view, such as a stage of cancer progress absence of serosal invasion, the 5-year survival rate of group A was higher than that of other groups. Although these differences between Group A and B were not statistically significant, but those between Group A and B were significant. From these results it is suggested that preoperative oral 5-FU emulsion might be effective as an adjunct to surgery for gastric cancer.

Reactivity of gastric cancer patients in leucocyte migration inhibition tests to 3M KCl extracts from gastric tumor

Leucocytes from patients with gastric cancer and other malignant and non-malignant diseases of the gastrointestinal tract as well as from healthy controls were tested for leucocyte migration inhibition test (LMI) using five different, allogeneic 3M KCl soluble extracts from gastric cancer tissues. The normal range of migration index (MI) was considered to be between 0.77 and 1.18 by calculating the mean MI +/- 2SD of ten healthy controls with cancer extracts. MIs out of this range were considered to be pathologic. In LMI test with a single tumor extract, pathologic MI was found in 48% of 79 gastric cancer patients, such being significantly higher than in those (4-21%) of three other groups of patients. In the panel mode of LMI, i.e., testing each blood sample with five different tumor extracts, 79% (62/79) of patients with gastric cancer were reactive, while 25% (5/20) of colorectal cancer patients showed "positive" reaction and no "positive" reactivity was observed in two other groups of patients. Thus, the "positive" reactivity in patients with gastric cancer was observed significantly higher than those in the other 3 groups of patients. Gastric cancer extracts had a wide range of cross-reactivity when compared with colorectal tumor extracts which showed a relatively restricted cross-reactivity. Thus, the LMI tests, particularly when tested by a panel mode, seems to express cell-mediated immunity against tumor associated antigens of gastric cancer.

Studies on cell-mediated immunity in patients with colorectal cancer: leucocyte migration inhibition test using allogenic 3M KCl extract

Leucocytes from patients with colorectal and other malignant and non-malignant gastrointestinal diseases as well as those from normal subjects were tested by the leucocyte migration inhibition test (LMT), employing the method of Clausen, using five different allogenic 3M KCl soluble extracts of colorectal cancer tissue. The normal range of migration index (Ml) was found to be greater than 0.82 and less than 1.20 by calculating the mean Ml +/- 2SD of ten normal subjects with cancer extracts. Mls out of this range were considered to be pathological. In LMIT with a single tumour extract, a pathological Ml was found in 46% of 50 colorectal cancer patients, a significantly higher figure than found in the three other groups of patients (4% to 16%). In the panel mode of LMIT, that is, testing each blood sample with five different tumour extracts, 40/50 (80%) of patients with colorectal cancer were reactive, while 2/15 (13%) of gastric cancer patients showed a "positive" reaction; no positive reactivity was observed in the other two groups of patients. Thus "positive" reactivity was significantly commoner in patients with colorectal cancer than in patients belonging to the other groups. The frequency of "positive" reactivity was higher in patients with Dukes C carcinoma than in those with Dukes A or B carcinomas, though differences were not significant. In the follow-up study, marked depression of reactivity was seen 10 to 14 days after curative resection. In patients without recurrence, leucocyte migration was found to be in the normal range during the two four weeks after surgery. "Positive" reactivity reappeared in patients with local recurrence. Thus the LMIT, particularly when tested by a panel mode, by demonstrating cell-mediated immunity against tumour-associated antigens of colorectal cancer, provides a method of monitoring colorectal cancer activity.

Immunomorphologic study of regional lymph nodes in cancer: response of regional lymph node cells from gastric and colorectal cancer to PHA stimulation

To obtain information regarding the immunologic capacity of uninvolved regional lymph nodes (RLNs) draining tumor, the in vitro response of regional lymph node cells (RLNCs) to PHA was investigated in lymph nodes from 55 patients with gastric or colorectal cancer, and gastric ulcer. Evaluation of data relative to cancer progress demonstrated that, in gastric cancer patients, the response of stimulated RLNCs from patients with middle stage carcinoma was significantly higher compared with those of cells from patients with early or late stage carcinoma, such being similar to the response of RLNCs from control patients with gastric ulcer. The results from colorectal cancer patients were also similar to those from patients with gastric cancer. Our results suggest that RLNs without metastasis contain cells capable of responding to PHA despite the presence of growing tumors in these cancer patients. In the results of PHA stimulation in relation to the lymph node morphology, we observed in both groups of patients with gastric or colorectal cancer that, regardless of the extent of the cancer lymph nodes with lymphocyte predominance there was a high PHA response while lymph nodes with lymphocyte depletion and unstimulated nodes exhibited a low PHA response. These results show a close relationship between this lymph node morphology and immunologic status of nodes.

Comparative studies on absorption patterns of the drug after intrarectal administration of 5-FU emulsion and 5-FU solution

Intrarectal administration of 5-fluorouracil (5-FU) emulsion was compared experimentally with that of 5-FU solution as to the degree of absorption and tissue distribution. For the 5-FU levels in the rectal wall, the levels in the emulsion group remained at high levels during the 6 hour period after administration while the levels in the solution group decreased rapidly. For the 5-FU levels in the lymph nodes, those in the emulsion group were significantly higher (more than four times) and remained at relatively high levels for a longer period than those in the solution group. In the thoracic lymph, 5-FU levels in the emulsion group remained more than two times higher throughout the experimental period. The results suggest tha preoperative intrarectal administration of 5-FU emulsion may be effective as an adjunct to surgery for rectal cancer with lymph node metastasis, because of the long duration of high concentration resulting in the rectal lymphatics and rectal wall.

Clinical studies of intrarectal administration of 5-FU emulsion as an adjunct to surgical treatment of rectal cancer

Preoperative intrarectal administration of 5-FU emulsion was attempted as an adjuvant chemotherapy to surgery for rectal cancer. The drug concentrations of resected specimens were determined and histological examinations of them were carried out in order to evaluate the effect of anticancer drugs on the metastatic lymph nodes as well as on the primary tumors. 5-FU levels both in the regional lymph nodes and primary tumors of 18 patients with rectal cancer, who were given with the 5-FU emulsion (emulsion group) or 5-FU suppository (suppository group) intrarectally two hours before surgery, was found to be much higher in emulsion group than in suppository group. 46 patients with rectal cancer were treated preoperatively with intrarectal administration of 5-FU emulsion (25 cases) or 5-FU suppositories (21 cases) for a period of 10 days before surgery, and the histological effect of this regimen on the metastatic lesion in the lymph nodes, as well as in the primary tumor was examined. No detectable difference was found in the primary lesions between the emulsion group and the suppository group. In the metastatic lesions, however, the rate of effectiveness was higher in the emulsion group than in the suppository (68 percent versus 33 percent).

Regional lymphadenectomy and tumor curability in C3H/He mice transplanted with MH 134

In order to elucidate the effect of surgical removal of the regional nodes on the immunological defence of the host against the tumor, as well as on the cure rate of C3H/He mice transplanted with MH 134, three separate experiments were carried out, and the following results were obtained: 1) The cure rates of mice treated by removal of the primary tumor with regional lymph nodes were significantly lower than that of mice treated by simple amputation without regional lymphadenectomy. 2) It was demonstrated by a bioassay of the regional node that viable tumor cells presented in the nodes prior to the operation disappeared after removal of the primary tumor, whereas in 60-Co irradiated mice prior to the tumor inoculation, such phenomena were not observed. 3) Observation utilizing in vivo neutralization revealed that regional lymph node cells were capable of interfering with growth of tumor cells. These findings suggest that removal of the regional nodes impairs the restraint to the growth of residual tumor after the removal of the primary tumor, and this is probably due to a derangment of the immunologic response of the host.