White epidermoid cyst transformation after stereotactic radiosurgery: illustrative case

BACKGROUND

White epidermoid cysts (WECs) are a rare type of epidermoid cyst with atypical radiological features. The epidemiological aspects and mechanisms of their onset remain unknown. Herein, the authors report a unique case of WEC transformation from a typical epidermoid cyst after stereotactic radiosurgery (SRS), confirmed by radiological and pathological findings.

OBSERVATIONS

The case involved a 78-year-old man with a history of 2 surgeries for a left cerebellopontine angle typical epidermoid cyst 23 years earlier and SRS using the CyberKnife for recurrent trigeminal neuralgia (TN) 14 years earlier. The tumor with high intensity on T1-weighted imaging, low intensity on T2-weighted imaging, without restriction on diffusion-weighted imaging had gradually enlarged after SRS. Therefore, a salvage surgery was performed via a left suboccipital craniotomy, and the intraoperative findings showed a cyst with a brown, viscous liquid component, consistent with those of WECs. Histopathologically, keratin calcification and hemorrhage were identified, leading to a diagnosis of WEC. The postoperative course was uneventful, and the TN resolved. No tumor recurrence was recorded at 2 years postoperatively.

LESSONS

To the best of the authors' knowledge, this is the first world case of WEC transformation from a typical epidermoid cyst after SRS, confirmed by radiological and pathological findings. Radiation effects could have been involved in this transformation.

Hemodynamic Analysis of Cerebral AVMs with 3D Phase-Contrast MR Imaging

BACKGROUND AND PURPOSE

The hemodynamics associated with cerebral AVMs have a significant impact on their clinical presentation. This study aimed to evaluate the hemodynamic features of AVMs using 3D phase-contrast MR imaging with dual velocity-encodings.

MATERIALS AND METHODS

Thirty-two patients with supratentorial AVMs who had not received any previous treatment and had undergone 3D phase-contrast MR imaging were included in this study. The nidus diameter and volume were measured for classification of AVMs (small, medium, or large). Flow parameters measured included apparent AVM inflow, AVM inflow index, apparent AVM outflow, AVM outflow index, and the apparent AVM inflow-to-outflow ratio. Correlation coefficients between the nidus volume and each flow were calculated. The flow parameters between small and other AVMs as well as between nonhemorrhagic and hemorrhagic AVMs were compared.

RESULTS

Patients were divided into hemorrhagic (n = 8) and nonhemorrhagic (n = 24) groups. The correlation coefficient between the nidus volume and the apparent AVM inflow and outflow was .83. The apparent AVM inflow and outflow in small AVMs were significantly smaller than in medium AVMs (P < .001 for both groups). The apparent AVM inflow-to-outflow ratio was significantly larger in the hemorrhagic AVMs than in the nonhemorrhagic AVMs (P = .02).

CONCLUSIONS

The apparent AVM inflow-to-outflow ratio was the only significant parameter that differed between nonhemorrhagic and hemorrhagic AVMs, suggesting that a poor drainage system may increase AVM pressure, potentially causing cerebral hemorrhage.

Integrating 3D Rotational Angiography into Gamma Knife Planning

3D rotational angiography provides remarkable spatial resolution for cerebrovascular disorders; however, it cannot be integrated directly into gamma knife planning due to the discrepancy of DICOM "tag" information, and most physicians still cannot benefit from 3D rotational angiography. Here, we describe a simple and easy technique to enable the integration of 3D rotational angiography.

Abstract P5-16-24: Prognostic factors after neoadjuvant chemotherapy in breast cancer: Surgery type as a new prognostic factor

Background: Pathological complete response (pCR) after neoadjuvant chemotherapy (NAC) is not necessarily linked to long-term survival. Response to chemotherapy and outcomes after NAC differ among breast cancer subtypes, so we analyzed prognostic factors by subtype.

Methods: We retrospectively analyzed 451 patients treated with anthracycline and taxane-based NAC between 2007 and 2015. Trastuzumab was added for human epidermal growth factor receptor (HER)-2-positive breast cancer. pCR was defined as no residual invasive breast carcinoma; noninvasive residuals and infiltrated lymph nodes were allowed. In our institute, mastectomy was performed in patients in whom the breast could not be preserved, such as patients with large residual tumors and diffusely spread tumors throughout the breast after NAC. Kaplan–Meier and univariate and multivariate cox regression analyses were used to evaluate disease-free interval (DFI) and DFI prognostic values, respectively.

Results: Median follow-up was 43 months; median age was 56 (range, 23–88) years. The 3-year DFI and OS were 82.1% and 94.4%, respectively. In total, 85 patients had recurrence (18.8%) and 31 patients died (6.9%). Response rate (RR) was 93.4% (421/457).pCR rate was 26.2% (118/451) in all cases: 0% (0/82), luminal A; 10.9% (14/128), luminal B HER2(−); 43.1% (31/71), luminal B HER2(+); 59.4% (38/64), HER2; and 34% (36/106), triple negative (TN). For all subtypes, patients who achieved pCR had a non-significantly higher DFI.

Multivariate cox regression showed these associations with DFI: surgery type and Ki-67 &gt; 30% for all cases and luminal B HER2(-); ypN (lymph node status after NAC), luminal B HER2(+);ypN and menopausal status, HER2; and age, surgery type, and clinical lymph node status (cN), TN.

Kaplan–Meier analysis showed that surgery type was strongly associated with DFI after NAC. Mastectomy patients had significantly poorer prognoses than partial mastectomy patients for all subtypes except HER2. For all cases, the median DFI in mastectomy patients was 73 months, but DFI was not reached in partial mastectomy patients (p &lt; 0.0001). Compared with partial mastectomy patients, mastectomy patients had more advanced disease in terms of tumor size, lymph node status, and stage and showed lesser clinical and pathological responses to NAC and effects on ypN. Furthermore, first recurrences in mastectomy patients were often distant metastases, leading to poor prognosis.

Moreover, we analyzed the prognostic factors in 118 patients who achieved pCR. Univariate Cox regression analysis showed the association of the following with DFI: age (≤40, &gt;40), cN, stage, surgery type, and ypN for all cases; decreasing Ki-67 values after NAC, luminal B HER2(−); clinical tumor size (cT), cN, surgery type, and luminal B HER2(+); ypN and HER2; age (≤40, &gt;40), cN, stage, surgery type, and TN. In multivariate cox regression analysis, age (≤40, &gt;40), surgery type, and ypN were independent predicting factors for all cases.

Conclusions: Prognostic factors after NAC differ among subtypes. Surgery type was strongly associated with outcomes after NAC, so it could be an independent prognostic factor.

Citation Format: Fujihara M, Kin T, Yoshimura Y, Kajiwara Y, Ito M, Ohtani S. Prognostic factors after neoadjuvant chemotherapy in breast cancer: Surgery type as a new prognostic factor [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-24.

Abstract P3-01-04: Potential clinical application of mammography conducted immediately after contrast enhanced CT as contrast enhanced subtraction mammography

【Background】

Contrast Enhanced Subtraction Mammography (CESM) has gained worldwide popularity. It is said that CESM can not only identify tumors but also delineate high-density lesions of the mammary gland that are difficult to be identified by normal mammography (MMG), as well as intraductal progress, and tumor hemodynamics.

一In general, imaging is commenced two minutes after injection of the contrast medium, and is conducted in two directions, i.e., left to right craniocaudal view and mediolateral oblique view in the similar manner to the normal MMG.

【Subjects and purpose】

The study was performed upon the approval of the institutional review board, and included 70 patients who had undergone CESM during the nine-month period from August 2015 to April 2016 using the method that MMG was performed within 2-8 minutes after injection of the contrast medium during contrast enhanced computed tomography. The scan was performed as postoperative follow-up in 29 patients, and as preoperative testing in 41 patients. This method allowed us to obtain additional data with contrast imaging without placing financial burden on the patient, and we investigated whether this method was effective as CESM in the present study.

【Results】

Of the 41 patients who had undergone the scan as a preoperative test (bilateral scans in 3 patients, and 44 breasts), it was in 43 breasts (97.7 %) that lesions could be identified by MMG, and in 42 breasts (95.5 %) that lesions could be identified by CESM. Of the 44 breasts, three breasts showed high-density mammary glands, in two of which the mass was lateral to the margin of the mammary gland, and therefore could be identified by normal MMG; however, in one breast the mass was medial to the margin of the mammary gland and difficult to be identified by MMG, and could only be identified by CESM. The lesions in the two breasts that were difficult to be identified by CESM exhibited the histological type of DCIS, and the lesions were able to be identified as calcification with normal MMG.

The tumor diameter was compared using invasion size determined by CESM, contrast-enhanced MRI, and postoperative pathological specimen, respectively. The correlation coefficient for CESM and contrast-enhanced MRI was 0.9668, and the correlation coefficient for CESM and postoperative pathological specimen was 0.984887, with a strong correlation observed (Pearson's correlation coefficient test).

【Conclusion】

To the best of our knowledge, no reports of CESM in which MMG is performed immediately after contrast-enhanced CT have been published to date, and thus this is the world's first attempt of such method performed at our hospital. CESM ensures diagnosability without being invasive or placing financial burden on the patient. It was suggested that CESM can be clinically useful particularly for those who cannot undergo contrast-enhanced MRI due to hardware problems, financial difficulties, or metal embedded within the body.

Citation Format: Ohtani S, Yoshimura Y, Kin T, Fujihara M, Kajiwara Y, Ito M, Okada N, Urashima M. Potential clinical application of mammography conducted immediately after contrast enhanced CT as contrast enhanced subtraction mammography [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-01-04.

Islet product characteristics and factors related to successful human islet transplantation from the Collaborative Islet Transplant Registry (CITR) 1999-2010

The Collaborative Islet Transplant Registry (CITR) collects data on clinical islet isolations and transplants. This retrospective report analyzed 1017 islet isolation procedures performed for 537 recipients of allogeneic clinical islet transplantation in 1999-2010. This study describes changes in donor and islet isolation variables by era and factors associated with quantity and quality of final islet products. Donor body weight and BMI increased significantly over the period (p<0.001). Islet yield measures have improved with time including islet equivalent (IEQ)/particle ratio and IEQs infused. The average dose of islets infused significantly increased in the era of 2007-2010 when compared to 1999-2002 (445.4±156.8 vs. 421.3±155.4×0(3) IEQ; p<0.05). Islet purity and total number of β cells significantly improved over the study period (p<0.01 and <0.05, respectively). Otherwise, the quality of clinical islets has remained consistently very high through this period, and differs substantially from nonclinical islets. In multivariate analysis of all recipient, donor and islet factors, and medical management factors, the only islet product characteristic that correlated with clinical outcomes was total IEQs infused. This analysis shows improvements in both quantity and some quality criteria of clinical islets produced over 1999-2010, and these parallel improvements in clinical outcomes over the same period.

Islet oxygen consumption rate dose predicts insulin independence for first clinical islet allotransplants

BACKGROUND

Human islet allotransplantation for the treatment of type 1 diabetes is in phase III clinical trials in the U.S. and is the standard of care in several other countries. Current islet product release criteria include viability based on cell membrane integrity stains, glucose-stimulated insulin release, and islet equivalent (IE) dose based on counts. However, only a fraction of patients transplanted with islets that meet or exceed these release criteria become insulin independent following 1 transplant. Measurements of islet oxygen consumption rate (OCR) have been reported as highly predictive of transplant outcome in many models.

METHOD

In this article we report on the assessment of clinical islet allograft preparations using OCR dose (or viable IE dose) and current product release assays in a series of 13 first transplant recipients. The predictive capability of each assay was examined and successful graft function was defined as 100% insulin independence within 45 days post-transplant.

RESULTS

OCR dose was most predictive of CTO. IE dose was also highly predictive, while glucoses stimulated insulin release and membrane integrity stains were not.

CONCLUSION

OCR dose can predict CTO with high specificity and sensitivity and is a useful tool for evaluating islet preparations prior to clinical human islet allotransplantation.

Autologous islet transplantation after total pancreatectomy for renal cell carcinoma metastases

Pancreatic metastases from renal cell carcinoma (RCC) may have a chronic and highly indolent course, and may be resected for cure after considerable delay following treatment of the primary tumor, in contrast to other more common pancreatic tumors. Surgical resection is the treatment of choice, which may lead to postpancreatectomy diabetes mellitus in the case of extensive resection. We present a 70-year-old patient with multifocal pancreatic metastases from RCC causing obstructive jaundice. A total pancreatectomy was required to excise two distant tumors in the head and tail of the pancreas, together with a segment VI liver resection. An autologous islet transplant (AIT) prepared from the central, uninvolved pancreas was carried out to prevent postpancreatectomy diabetes. The patient was rendered insulin-free and remains so with excellent glycemic control for 1 year of follow-up, and there is no evidence of tumor recurrence. The patient has been treated with adjuvant sunitinib to minimize risk of further recurrence. In conclusion, AIT after pancreatectomy may represent a useful option to treat patients with metastatic RCC. A critical component of this approach was dependent upon elaborate additional testing to exclude contamination of the islet preparation by cancerous cells.

Distinct and opposing roles for the phosphatidylinositol 3-OH kinase catalytic subunits p110α and p110β in the regulation of insulin secretion from rodent and human beta cells

AIMS/HYPOTHESIS

Phosphatidylinositol 3-OH kinases (PI3Ks) regulate beta cell mass, gene transcription, and function, although the contribution of the specific isoforms is unknown. As reduced type 1A PI3K signalling is thought to contribute to impaired insulin secretion, we investigated the role of the type 1A PI3K catalytic subunits α and β (p110α and -β) in insulin granule recruitment and exocytosis in rodent and human islets.

METHODS

The p110α and p110β subunits were inhibited pharmacologically or by small hairpin (sh)RNA-mediated knockdown, and were directly infused or overexpressed in mouse and human islets, beta cells and INS-1 832/13 cells. Glucose-stimulated insulin secretion (GSIS), single-cell exocytosis, Ca(2+) signalling, plasma membrane granule localisation, and actin density were monitored.

RESULTS

Inhibition or knockdown of p110α increased GSIS. This was not due to altered Ca(2+) responses, depolymerisation of cortical actin or increased cortical granule density, but to enhanced Ca(2+)-dependent exocytosis. Intracellular infusion of recombinant PI3Kα (p110α/p85β) blocked exocytosis. Conversely, knockdown (but not pharmacological inhibition) of p110β blunted GSIS, reduced cortical granule density and impaired exocytosis. Exocytosis was rescued by direct intracellular infusion of recombinant PI3Kβ (p110β/p85β) even when p110β catalytic activity was inhibited. Conversely, both the wild-type p110β and a catalytically inactive mutant directly facilitated exocytosis.

CONCLUSIONS/INTERPRETATION

Type 1A PI3K isoforms have distinct and opposing roles in the acute regulation of insulin secretion. While p110α acts as a negative regulator of beta cell exocytosis and insulin secretion, p110β is a positive regulator of insulin secretion through a mechanism separate from its catalytic activity.

The voltage-dependent potassium channel subunit Kv2.1 regulates insulin secretion from rodent and human islets independently of its electrical function

AIMS/HYPOTHESIS

It is thought that the voltage-dependent potassium channel subunit Kv2.1 (Kv2.1) regulates insulin secretion by controlling beta cell electrical excitability. However, this role of Kv2.1 in human insulin secretion has been questioned. Interestingly, Kv2.1 can also regulate exocytosis through direct interaction of its C-terminus with the soluble NSF attachment receptor (SNARE) protein, syntaxin 1A. We hypothesised that this interaction mediates insulin secretion independently of Kv2.1 electrical function.

METHODS

Wild-type Kv2.1 or mutants lacking electrical function and syntaxin 1A binding were studied in rodent and human beta cells, and in INS-1 cells. Small intracellular fragments of the channel were used to disrupt native Kv2.1-syntaxin 1A complexes. Single-cell exocytosis and ion channel currents were monitored by patch-clamp electrophysiology. Interaction between Kv2.1, syntaxin 1A and other SNARE proteins was probed by immunoprecipitation. Whole-islet Ca(2+)-responses were monitored by ratiometric Fura red fluorescence and insulin secretion was measured.

RESULTS

Upregulation of Kv2.1 directly augmented beta cell exocytosis. This happened independently of channel electrical function, but was dependent on the Kv2.1 C-terminal syntaxin 1A-binding domain. Intracellular fragments of the Kv2.1 C-terminus disrupted native Kv2.1-syntaxin 1A interaction and impaired glucose-stimulated insulin secretion. This was not due to altered ion channel activity or impaired Ca(2+)-responses to glucose, but to reduced SNARE complex formation and Ca(2+)-dependent exocytosis.

CONCLUSIONS/INTERPRETATION

Direct interaction between syntaxin 1A and the Kv2.1 C-terminus is required for efficient insulin exocytosis and glucose-stimulated insulin secretion. This demonstrates that native Kv2.1-syntaxin 1A interaction plays a key role in human insulin secretion, which is separate from the channel's electrical function.

Anakinra potentiates the protective effects of etanercept in transplantation of marginal mass human islets in immunodeficient mice

Anti-inflammatory agents are used routinely in clinical islet transplantation in an attempt to promote islet engraftment. Infliximab, and more recently etanercept, is being used to neutralize tumor necrosis factor alpha, but this tenet is based on limited preclinical data. One group has promoted the potential of combined etanercept with an IL-1 receptor antagonist, anakinra in a small clinical study, but without strong preclinical data to justify this approach. We therefore sought to evaluate the impact of combined anakinra and etanercept in a marginal islet mass transplant model using human islets in immunodeficient mice. The combination of anakinra and etanercept led to remarkable improvement in islet engraftment (control 36.4%; anakinra 53.9%; etanercept 45.45%; anakinra and etanercept 87.5% euglycemia, p < 0.05 by log-rank) compared to single-drug treated mice or controls. This translated into enhanced metabolic function (area under curve glucose tolerance), improved graft insulin content and marked reduction in beta-cell specific apoptotis (0.67% anakinra + etanercept vs. 23.5% control, p < 0.001). These results therefore strongly justify the combined short-term use of anakinra and etanercept in human islet transplantation.

Late cytomegalovirus transmission and impact of T-depletion in clinical islet transplantation

The epidemiology of cytomegalovirus infection (CMV) in islet transplantation (IT) is not well defined. This study defines incidence, transmission and clinical sequelae of CMV reactivation or disease in 121 patients receiving 266 islet infusions at a single institution. The donor (D)/recipient (R) serostatus was D+/R- 31.2%, D+/R+ 26.3%, D-/R+ 13.2% and D-/R- 29.3%. CMV prophylaxis with oral ganciclovir/valganciclovir was given in 68%. CMV infection occurred in 14/121 patients (11.6%); six had asymptomatic seroconversion and eight others had positive viremia (six asymptomatic and two with CMV febrile symptoms). Median peak viral loads were 1755 copies/mL (range 625-9 100 000). Risk factors for viremia included lymphocyte depletion (thymoglobulin or alemtuzumab, p < 0.001). Viremia was more common in D+/R+ versus D+/R- (p = 0.12), occurring mostly late after transplant (median 306 days). Presumed transmission from IT occurred in 8/83 of D+/R- procedures (9.6%). Of the two cases of CMV disease, one resulted from islet transmission from a CMV positive donor (D+/R-); the other was due to de novo exogenous infection (D-/R-). Therefore, CMV transmission presents rarely after IT and with low incidence compared to solid organ transplantation, but occurs late posttransplant. The use of lymphocyte depleting therapies is a primary risk factor.

Human islet distribution program for basic research at a single center

The Clinical Islet Laboratory at the University of Alberta/Alberta Health Services distributes human islets for basic research when islet preparations fail to meet defined release criteria for transplantation. This report highlights our islet distribution activity for diabetes research over a 3-year period. Shipments of the acinar-enriched fraction for research were not included in this report. In 2010, we distributed 6.3 million islet equivalents (IEQs) of islets through 127 shipments to 8 researchers, locally, nationally, and internationally. The number of preparations for research use was stable over the 3-year period (26, 23, and 29 preparations in 2008, 2009, and 2010, respectively). Islet yield distributed for research per isolation was 201, 212, and 218 × 10(3) IEQs, respectively. The number of basic researchers was stable as well, although there were only 2 researchers before 2007. Recently, each researcher has received fewer islets per shipment (49,820 IEQs in 2010 vs 75,635 IEQs in 2008) but more frequently (21.5 in 2010 vs 11.2 times per year in 2008). This paradigm shift would be desirable for researchers, because in our experience, most require <30,000 IEQs per shipment, and more frequent islet shipments results in a larger sample size for experimentation. After an initial expansion in the number of researchers requesting islets, our islet distribution activity has remained stable over the years in terms of total productivity of islets utilized for research. The current supply-versus-demand ratio in our program appears to be appropriate.

Coexistence of Ramsay Hunt syndrome and varicella-zoster virus encephalitis

We describe a patient with Ramsay Hunt syndrome and varicella-zoster virus encephalitis. The coexistence of these conditions is rare and to our knowledge has not been clearly documented in the English-language literature. We summarize the clinical characteristics of our patient and seven similar patients described in previous reports, including those published in Japanese. Although concomitant diseases such as diabetes and chronic renal failure may lead to an aggressive course, all patients described in detail have had good outcomes.

Enhancing the success of human islet isolation through optimization and characterization of pancreas dissociation enzyme

A major obstacle to successful human islet isolation has been the variability of the enzymatic digestion phase. The aim of this study was to define optimal enzyme activity ranges normalized by the pancreas weight and to identify valid parameters for the optimal selection of successful lots of collagenase enzyme blends. Our results from 251 islet isolations showed that optimization of thermolysin dosage based on Caseinase unit/g pancreas contributed considerably to islet isolation outcome but that collagenase dosage measured by the manufacturer (Wünsch unit/g pancreas) was not a major determinant of islet isolation outcome. We also found that lot-to-lot inconsistency of enzyme performance was not explained by the activity values provided by the manufacturer, but rather by an in-house assay of class I collagenase (CI) and class II collagenase (CII); using a lot with a lower CII/CI resulted in a higher success rate. The odds of successful isolation was 8.67 times higher when a vial with CII/CI ratio <0.204 was used than when a vial with CII/CI >or=0.204 was used, suggesting that CII/CI ratio may be a strong predictor to distinguish potential lot success. This study provides a framework for improved enzymatic digestion in human islet isolation.

Global and region-specific analyses of apparent diffusion coefficient in dentatorubral-pallidoluysian atrophy

BACKGROUND AND PURPOSE

Dentatorubral-pallidoluysian atrophy (DRPLA) is an autosomal dominant spinocerebellar ataxia. Techniques for the quantitative assessment of neurodegenerative lesions remain to be established in this disease. We attempted to quantify global and region-specific neurodegeneration in DRPLA using analysis of apparent diffusion coefficient (ADC) maps.

METHODS

Diffusion-weighted images (b = 1000 s/mm(2)) by echo-planar sequences were obtained with the use of a 1.5T clinical scanner. Whole-brain histogram and region of interest (ROI) analyses of ADC values as well as conventional MR imaging studies were performed in 6 patients with genetically confirmed DRPLA.

RESULTS

Histograms demonstrated significantly higher mean ADC values in the patients than in age- and sex-matched control subjects (P < .01). ROI analysis revealed that the patients had significantly higher ADC values in the cerebellum and globus pallidus, preferentially affected regions (P < .05), but not in the thalamus, the region relatively spared in this disease. ADC values in the white matter were higher only in patients with adult-onset disease. Histogram analyses could more sensitively identify abnormalities than ROI analyses, because the former avoided errors associated with setting ROIs and thus had smaller P values on statistical analysis than the latter.

CONCLUSIONS

Histogram ADC analyses were more sensitive for the detection of neurodegeneration in DRPLA than ROI analyses, whereas ROI analyses revealed regional alterations reflecting the distribution of pathologic changes. Thus, histogram and ROI analyses complement each other and may permit the sensitive, quantitative evaluation of neurodegeneration in DRPLA, especially that involving the globus pallidus showing normal T2 signals.

Prevention of bleeding after islet transplantation: lessons learned from a multivariate analysis of 132 cases at a single institution

Islet transplantation is being offered increasingly for selected patients with unstable type 1 diabetes. Percutaneous transhepatic portal access avoids a need for surgery, but is associated with potential risk of bleeding. Between 1999 and 2005, we performed 132 percutaneous transhepatic islet transplants in 67 patients. We encountered bleeding in 18/132 cases (13.6%). In univariate analysis, the risk of bleeding in the absence of effective track ablation was associated with an increasing number of procedures (2nd and 3rd procedures with an odds ratio (OR) of 9.5 and 20.9, respectively), platelets count <150,000 (OR 4.4), elevated portal pressure (OR 1.1 per mm Hg rise), heparin dose > or =45 U/kg (OR 9.8) and pre-transplant aspirin (81 mg per day) (OR 2.6, p = 0.05). A multivariate analysis further confirmed the cumulative transplant procedure number (p < 0.001) and heparin dose > or =45 U/kg (p = 0.02) as independent risk factors for bleeding. Effective mechanical sealing of the intrahepatic portal catheter tract with thrombostatic coils and tissue fibrin glue completely prevented bleeding in all subsequent procedures (n = 26, p = 0.02). We conclude that bleeding after percutaneous islet implantation is an avoidable complication provided the intraparenchymal liver tract is sealed effectively.

Multi-lot analysis of custom collagenase enzyme blend in human islet isolations

INTRODUCTION

Variability currently in Liberase HI from lot to lot limits the ability to effectively isolate islets with consistency. Roche Diagnostics Inc (Indianapolis, Ind, USA) has developed a Custom Collagenase enzyme blend in hopes that producing collagenase II and I and thermolysin separately will eliminate variability. In this study we examined the variability in Custom Collagenase lots in respect to isolation results and isolation success rates and compared those to Liberase HI.

METHODS

We retrospectively analyzed records from 68 islet isolations where either Liberase HI (lot A: n = 23, Lot B: n = 20) or Custom Collagenase blend (Lot C: n = 10, Lot D: n = 15) was employed. Human islets were isolated from cadaveric pancreata using standardized methods performed in a controlled islet isolation facility.

RESULTS

Analysis of Liberase HI and Custom Collagenase using Student t test showed no difference between the two groups. Comparison of the two Custom Collagenase lots using the t test showed a statistical difference between undigested pancreas weight and pancreas digestion times. Using chi-square test, no statistical significance was found in isolation success rates from lot to lot.

CONCLUSION

Although the Custom Collagenase blend is comparable to Liberase HI in its ability to isolate human islets, variability still exists from lot to lot when used conventionally as Liberase HI is. The ability to predetermine doses is beneficial, and as techniques to manipulate the activity levels prior to isolations improve so to will the enzymes' ability to isolate islets on a consistent basis.

The standardization of pancreatic donors for islet isolation

INTRODUCTION

Islet transplantation has proven to be a successful treatment for insulin-dependent diabetes mellitus (IDDM). The aim of this study was to establish an algorithm by which the combination of the donor quality and pancreas quality was given a numerical score from 0 to 100 for use in determining the quality of a pancreas for islet isolation.

METHODS

In this study we retrospectively analyzed 326 pancreata and the outcomes of their respective isolations. Specific donor variables and physical characteristics were identified and weighted according to their influence on the success of the isolation. For each variable, ranges and point weightings were established based on our laboratory experience and literature review.

RESULTS

Analysis of the data showed a strong association of the donor point with isolation outcome. Pancreata with lower donor point scores had lower transplant success rates, while higher donor point scores in turn produced higher transplant rates.

CONCLUSION

This scoring system has proven to be effective in assessing the potential of pancreata for a favorable isolation outcome. By analyzing the final score of the pancreas, a standardized decision can be made on whether to accept or decline the pancreas. Another benefit of the scoring system is that it is a quick and efficient way to trend the quality of donor organs.

Resuscitation of the ischemically damaged human pancreas by the two-layer method prior to islet isolation

A two-layer cold storage method (TLM) allows sufficient oxygen delivery to pancreata during preservation and resuscitates the viability of ischemically damaged pancreata. This study determined the effect of additional preservation of ischemically damaged human pancreata by the TLM before islet isolation. Human pancreata were procured from cadaveric organ donors and preserved by the TLM for 3.2 +/- 0.5 hours (mean +/- SEM) at 4 degrees C after 11.1 +/- 0.9 hours of cold storage in University of Wisconsin solution (UW) (TLM group), or by cold UW alone for 11.0 +/- 0.3 hours (UW group). Islet isolations of all pancreata were performed using the Edmonton protocol. Islet recovery and in vitro function of isolated islets were significantly increased in the TLM group compared with the UW group. In the metabolic assessment of human pancreata, ATP levels were significantly increased after the TLM preservation. This study showed that additional short-term preservation by the TLM resuscitates the viability of ischemically damaged human pancreata before islet isolation, leading to improvements in islet recovery and in vitro function of isolated islets.

Serine-protease inhibition during islet isolation increases islet yield from human pancreases with prolonged ischemia

BACKGROUND

Islet isolation from the pancreatic tissue matrix remains highly variable. Recent evidence suggests that intrinsic human pancreatic proteases, including trypsin, may inhibit effective collagenase enzymatic activity during islet isolation, thereby impairing the isolation success. In this study we have hypothesized that serine protease inhibition applied during pancreatic digestion, could improve yield and/or functional viability of islets isolated from human pancreases.

METHODS

Twelve organ donor pancreases with 12.9+/-0.6 hr cold storage (mean+/-SEM) were perfused via their ducts with Liberase-HI enzyme in the presence (n=6) or absence (n=6) of 0.4 mM Pefabloc. All were then gently dissociated and their purified islets separated with Ficoll density gradient centrifugation.

RESULTS

Donor-related factors (age, gender, cold storage time, body mass index, and pancreas weight) did not differ significantly between the two experimental groups. Pefabloc supplementation did not affect the digestion time, islets remaining trapped in exocrine tissue, or final islet purity. Islet recovery was increased in the Pefabloc-treated group (mean+/-SEM yield 323.8+/-80.8 x 10(3) islet equivalents vs. 130.8+/-13.6 x 10(3) islet equivalents, P<0.05). Cellular composition, DNA and insulin content, and insulin secretory activity of the isolated islets was similar.

CONCLUSIONS

Inhibition of intrinsic protease activity within pancreases after prolonged cold storage improves isolation of viable islets.

Clinical outcomes and insulin secretion after islet transplantation with the Edmonton protocol

Islet transplantation offers the prospect of good glycemic control without major surgical risks. After our initial report of successful islet transplantation, we now provide further data on 12 type 1 diabetic patients with brittle diabetes or problems with hypoglycemia previous to 1 November 2000. Details of metabolic control, acute complications associated with islet transplantation, and long-term complications related to immunosuppression therapy and diabetes were noted. Insulin secretion, both acute and over 30 min, was determined after intravenous glucose tolerance tests (IVGTTs). The median follow-up was 10.2 months (CI 6.5-17.4), and the longest was 20 months. Glucose control was stable, with pretransplant fasting and meal tolerance-stimulated glucose levels of 12.5+/-1.9 and 20.0+/-2.7 mmol/l, respectively, but decreased significantly, with posttransplant levels of 6.3+/-0.3 and 7.5+/-0.6 mmol/l, respectively (P < 0.006). All patients have sustained insulin production, as evidenced by the most current baseline C-peptide levels 0.66+/-0.06 nmol/l, increasing to 1.29+/-0.25 nmol/l 90 min after the meal-tolerance test. The mean HbA1c level decreased from 8.3+/-0.5% to the current level of 5.8+/-0.1% (P < 0.001). Presently, four patients have normal glucose tolerance, five have impaired glucose tolerance, and three have post-islet transplant diabetes (two of whom need oral hypoglycemic agents and low-dose insulin (<10 U/day). Three patients had a temporary increase in their liver-function tests. One patient had a thrombosis of a peripheral branch of the right portal vein, and two of the early patients had bleeding from the hepatic needle puncture site; but these technical problems were resolved. Two patients had transient vitreous hemorrhages. The two patients with elevated creatinine levels pretransplant had a significant increase in serum creatinine in the long term, although the mean serum creatinine of the group was unchanged. The cholesterol increased in five patients, and lipid-lowering therapy was required for three patients. No patient has developed cytomegalovirus infection or disease, posttransplant lymphoproliferative disorder, malignancies, or serious infection to date. None of the patients have been sensitized to donor antigen. In 11 of the 12 patients, insulin independence was achieved after 9,000 islet equivalents (IEs) per kilogram were transplanted. The acute insulin response and the insulin area under the curve (AUC) after IVGTT were consistently maintained over time. The insulin AUC from the IVGTT correlated to the number of islets transplanted, but more closely correlated when the cold ischemia time was taken into consideration (r = 0.83, P < 0.001). Islet transplantation has successfully corrected labile type 1 diabetes and problems with hypoglycemia, and our results show persistent insulin secretion. After a minimum of 9,000 IEs per kilogram are provided, insulin independence is usually attained. An elevation of creatinine appears to be a contraindication to this immunosuppressive regimen. For the subjects who had labile type 1 diabetes that was difficult to control, the risk-to-benefit ratio is in favor of islet transplantation.

[A case of epithelial membrane antigen-positive leiomyosarcoma of the urinary bladder]

A 41-year-old woman was admitted with gross hematuria and pain on urination. Cystoscopy showed a huge and lobulated submucosal non-papillary bladder tumor. Pelvic computed tomography demonstrated a heterogeneous and enhanced lobulated mass, 8 cm in diameter, with extravesical invasion but there appeared to be no metastatic lesions. Transurethral biopsy revealed leiomyosarcoma pathologically. Total cystectomy and construction of an ileal conduit were performed. The tumor was histologically diagnosed as leiomyosarcoma. Immunohistochemical studies revealed the tumor to be positive for epithelial membrane antigen (EMA) and muscle actin but negative for desmin, and S-100. We reviewed 102 cases of vesical leiomyosarcoma reported in Japan. Among these 102 cases, there were no EMA-positive cases. Immunohistochemical and electromicroscopic evaluation should be performed to evaluate this disease.

[Treatment results of VIP (etoposide, ifosfamide and cisplatin) chemotherapy as a first-line therapy in metastatic germ cell tumors]

PURPOSE

We investigated the effectiveness and toxicity of VIP therapy as a first-line chemotherapy for patients with metastatic germ cell tumor.

PATIENTS AND METHODS

From March 1994 to October 1997, we treated 16 patients with VIP therapy consisting of etoposide (100 mg/m2), ifosfamide, (1.2 g/m2) and cisplatin (20 mg/m2), all of which were generally given daily for 5 consecutive days every 3 weeks. Of the 16 patients, 6 were classified into a good, 5 into an intermediate, and 5 into a poor prognostic group according to the International Germ Cell Consensus Classification.

RESULTS

Thirteen patients (81%) achieved complete response with VIP alone or VIP plus surgery. Three-year survival rate was 100% in good and intermediate prognostic group, while 40% in poor prognostic group. Although all patients had Grade 3 or higher myelosuppression, the treatment was well tolerated and no patient died of treatment-related complications.

CONCLUSIONS

VIP appears to be an effective and safe regimen as an induction chemotherapy for good and intermediate risk patients with germ cell tumor. However, more intensive regimen may be necessary for poor-risk patients.

Humoral human xenoreactivity against isolated pig pancreatic islets

It is widely believed that the hyperacute rejection of vascularized xenografts in the pig-to-human combination is triggered by the binding of human preformed natural antibodies (PNAbs) to the Galalpha.(1,3)Gal epitope in pig endothelium and the subsequent activation of complement. However, it remains poorly defined whether xenogeneic pig pancreatic islets are damaged by antibody and complement-mediated mechanisms. We examined the expression of Galalpha(1,3)Gal on isolated adult pig islets and the presence of PNAbs in normal human sera directed against islets, using immunofluorescence staining and confocal laser scanning microscopy. The pig islets were not stained with Galalpha(1,3)Gal-specific lectin GSIB4, however, the exocrine cells reacted strongly with GSIB4, indicating that the Galalpha(1,3)Gal epitope was highly expressed on exocrine cells, but not on islets. Human sera showed weak reactivity of IgM and IgG class PNAbs to the islets, but strong reactivity to the exocrine cells. Furthermore, we investigated the cytotoxic effect of human serum on pig islets using an in vitro model of pig-to-human islet transplantation. The incubation of pig islets with normal human sera for 45 min resulted in less than 10% specific lysis despite the binding of PNAbs, whereas exposure of porcine aortic endothelial cells to the same human sera caused 56% complement-mediated lysis, determined using a MTT cytotoxic assay. These results support the view that pig islets might not undergo early antibody and complement-mediated rejection in humans.

[Metastatic testicular tumor requiring inferior vena cava resection with polytetrafluoroethylene graft replacement: a case report]

A 31 year-old man with a biopsy-proved retroperiotoneal yolk sac tumor was referred to our clinic. Physical examination revealed a thum- tip sized left supra-clavicular mass, a huge right abdominal mass and a tiny hard mass of the right testis. On CT scan, the abdominal tumor, 13 cm in diameter, encircled the inferior vena cava. Serum levels of LDH, AFP and hCG-beta were 2,585 U/l, 19,922 ng/ml and 6.6 ng/ml, respectively. No visceral metastasis was found. Following the right high orchiectomy, 4 cycles of VIP chemotherapy consisting of ifosfamide, etoposide and cisplatin were given, which resulted in partial response of the retroperitoneal mass and complete regression of the supraculavicular node with normalization of all tumor markers. Thus, retroperitoneal lymph node dissection was carried out. Because of the marked adhesion to the tumor, the inferior vena cava was segmentally resected together with the tumor, which was followed by reconstruction of the vena cava using a 16 cm long polytetrafluoroethylene graft, since no collateral venous route was found on the pretreatment venacavography. Histologically, the tumor was nearly necrotic with mature teratoma in small part. Postoperative clinical course was uneventful except feeling of numbness at the right tip toe, and the inferior vena cava has been patent 18 months after the operation with no evidence of recurrence.

[Two cases of giant testicular tumor with widespread extension to the spermatic cord: usefulness of upfront chemotherapy]

The first case was a 55-year-old man with biopsy-proven seminoma of the left inguinal undescended testis. The tumor, 10 x 9 x 9 cm in size, with a calculated weight of 520 g invaded the left spermatic cord up to the level of the renal hilum and metastasized to the retroperitoneal lymph nodes (13 x 10 cm). The serum level of lactate dehydrogenase (LDH) and beta human chorionic gonadotropin (beta-hCG) was 3,669 U/l and 1.3 ng/ml, respectively. The second case was a 38-year-old man with non-seminoma of the left testis. The testicular tumor, 32 x 28 x 28 cm in size, with a calculated weight of 7,000 g invaded the left spermatic cord up to the level of the aortic-bifurcation and metastasized to the retroperitoneal and the left supraclavicular lymph nodes. The serum level of LDH, alphafetoprotein (AFP) and beta-hCG was 2,040 U/l, 240 ng/ml and 5.6 ng/ml, respectively. Both patients were initially treated with VIP chemotherapy (etoposide, ifomide and cis-platinum), 4 cycles for the 1st case and 3 for the 2nd, and followed by high orchiectomy and retroperitoneal lymph node dissection. Histologic section of all resected specimens revealed only necrosis and fibrosis. The patients have been free of recurrence for 15 and 13 months, respectively, after the operation. In the Japanese literature, 42 cases of giant testicular tumor (> 400 g) including these two cases have been reported. To our knowledge, our second case is the largest among the non-seminomatous tumors. For giant testicular tumor with extensive invasion to the spermatic cord, initial chemotherapy followed by surgical resection appears to be a better management.

The serum interleukin 8 level reflects hepatic mitochondrial redox state in hyperthermochemohypoxic isolated liver perfusion with use of a venovenous bypass

BACKGROUND

We have recently developed a simple method of hyperthermochemohypoxic isolated liver perfusion (HILP) as a regional therapy for unrecognized liver micrometastases. However, little is known about the influence of HILP on cytokine production and liver function. We investigated the influence of HILP on interleukin 8 (IL-8) production and the hepatic mitochondrial function and assessed the relationship between these 2 parameters. We also measured the serum tumor necrosis factor-alpha (TNF-alpha) and interleukin 1 beta (IL-1 beta) levels to examine the involvement of HILP-induced cytokines in the tumor response.

METHODS

Sixteen patients with metastatic liver tumors were randomly assigned to undergo hepatectomy with HILP (group A, n = 9) or hepatectomy alone (group B, n = 7). The isolated liver was perfused for 30 minutes with Ringer's lactate solution containing chemotherapeutic agents warmed to 42 degrees C to 43 degrees C without oxygenation.

RESULTS

The serum IL-8 levels in group A were markedly increased, with peaks at 3 hours after reperfusion, which was significantly higher than levels in group B (P < .01). In group A the arterial ketone body ratio, which reflects the hepatic mitochondrial redox state, decreased during perfusion and was gradually restored to the preperfusion level 1 hour after reperfusion. However, in group B it decreased during hepatectomy but rapidly recovered 5 minutes after hepatectomy. There was a significant negative correlation between the peak serum IL-8 level and the initial velocity of arterial ketone body ratio recovery for the first 5 minutes after reperfusion r = -0.83, P < .001). The serum TNF-alpha and IL-1 beta were temporarily detected only in 3 of 9 patients in group A.

CONCLUSIONS

We have shown that HILP resulted in augmented IL-8 release but not TNF-alpha and IL-1 beta and that the serum IL-8 level reflects the hepatic mitochondrial redox state. These findings suggest that IL-8 production may be associated with hepatic mitochondrial impairment during ischemia. This work may contribute to new therapeutic strategies not only for hepatic ischemia reperfusion injury but also for metastatic liver tumors.

Double cancers of the lung and esophagus associated with a sarcoid-like reaction in their regional lymph nodes: report of a case

A case of double cancers of the lung and esophagus associated with a sarcoid-like reaction in their regional lymph nodes is reported. A 73-year-old man with hemosputum was found to have a mass in his right lower lung field on a chest X-ray. Based on a diagnosis of lung cancer, a right middle and lower lobectomy with a dissection of the lymph nodes was performed. Microscopically, a well developed granulomatous reaction was seen in the dissected mediastinal and hilar lymph nodes. Three years after the pulmonary resection, he was admitted to our hospital because of dysphagia. A diagnosis of lower esophageal cancer was made. A lower esophagectomy with a total gastrectomy was performed. A sarcoid-like reaction comprising epithelioid cells and giant cells was seen in the regional lymph nodes. No clinical findings indicative of systemic sarcoidosis were observed. This rare condition may therefore help to improve our overall understanding of the relationship between malignant neoplasms and sarcoid-like reactions in the regional lymph nodes.

[Successful management for chemorefractory testicular cancer with brain and lung metastases. A case report]

This is a report of successful management for a far advanced, chemorefractory testicular cancer patient. A 29-year-old male was referred to our hospital for the treatment of progressive lung metastases with elevated hCG level, which had recurred after complete remission following 3 courses of BEP chemotherapy and progressed after transient partial regression following 2 courses of intensified EP chemotherapy. In addition, a 3 cm in diameter, solitary brain metastasis was detected on CT. First, we performed wedge resection of bilateral pulmonary lower lobe for chemorefractory pulmonary metastases. Histological examination revealed viable embryonal carcinoma identical to the primary one. Thereafter, whole brain irradiation in combination with VIP chemotherapy (etoposide 100 mg/m2, cisplatin 20 mg/m2 and ifosfamide 1200 mg/m2 daily for 5 consecutive days) was carried out to treat brain metastasis. By 2 cycles of VIP therapy and irradiation (36 Gy), partial tumor regression and normalization of hCG level were achieved, leading to salvage surgery of the brain metastasis which histologically proved to be necrosis. Following an additional cycle of VIP therapy, the patient has been free of recurrence 24 months after completion of the treatment.

Repeat hepatectomy for recurrent colorectal metastases

Recurrence rates after hepatic resection in patients with colorectal metastases are reported to range from 47% to 80%. Hepatic recurrence is seen in 35% to 50% of patients. Aggressive surgical resection appears to be a worthwhile treatment in patients with recurrent hepatic metastases to promote longer patient survival because surgical resection remains the only curative therapy available. This is a retrospective review of our experience with 15 patients undergoing repeat hepatic resection culled from 67 patients undergoing initial hepatectomy for metastatic colorectal cancer. Of 67 patients who underwent hepatectomy for colorectal hepatic metastases, 33 developed hepatic recurrence at a median interval of 23 months (range 1-176 months) after the first hepatectomy. The second hepatectomy was performed in 15 patients 5 to 29 months after the first hepatectomy, with no mortality. The mean operating time and blood loss at the second hepatectomy were similar to those at the first hepatectomy. The mean hospital stay at the second hepatectomy was significantly shorter than that at the first hepatectomy. The cumulative survival rate for the 15 patients was 42.4% at 3 years and 21.2% at 5 years, respectively, which compared favorably with the survival rate of the 67 patients who underwent initial hepatectomy. Patients who underwent the second hepatectomy had significantly higher survival rates from the first hepatectomy than the 18 patients with unresectable hepatic recurrence. Repeat hepatectomy can be performed safely and provides long-term survival rates similar to those of first hepatectomies. In appropriately selected patients, repeat hepatectomy for colorectal metastases is a worthwhile treatment.

Examination of prognostic factors after resection of pulmonary metastasis of osteosarcoma by multivariate analysis

Prognostic factors for the case of pulmonary metastasis of osteosarcoma was examined using the multivariate analysis. 1) The 3-year survival rate after operation of primary focus in 23 cases was 34.8% and the 5-year survival rate was 30.4%. The 3-year survival rate after the first operation of pulmonary metastasis was 30.4% and the 5-year survival rate was 12.2%. No deaths attributed to operation were found. 2) Gender, age, histological type, solitary or multiple pulmonary metastasis, laterality, number of pulmonary metastatic tumors, TDT and DFI were examined, and the laterality, number of pulmonary metastatic tumors and DFI were considered to be useful prognostic factors. DFI among them was most closely associated with postoperative survival days. 3) A significant difference in the number of excised nodules was found between the DFI less than 90 days group and the DFI not less than 90 days group, and the number in the former group was significantly larger. 4) It was suggested that postoperative observation and close examination for pulmonary metastasis at about 3 months intervals after of primary focus are important, and also, positive or negative pulmonary metastasis as the time of examination, particularly, the number metastatic nodules of less than 5 or not less than 5, are reflected in the prognosis. 5) Expected survival time after the first operation pulmonary metastasis appeared possible to estimate as 3.0 x DFI days.

A case of pulmonary metastases of synovial sarcoma surviving for a long period after active surgery

The patient was a 24-year-old woman. She underwent marginal excision of synovial sarcoma originating in the right femoral soft tissue at the age of 18, followed by local radiation therapy and chemotherapy. At the age of 20, abnormal shadow was indicated in bilateral lungs on plain roentgenography of the chest, and she underwent open-chest surgery for excision of bilateral pulmonary metastatic tumors. She was subjected to bilateral thoracotony repeatedly thereafter for a total of 5 times, and all of the metastatic foci detected in each operation were resected. Consequently, she has been surviving for a long period of about 7 years. The therapeutic outcome of tumor of bone soft tissue is greatly affected by its pulmonary metastasis. Although the therapeutic outcome has recently been improved by large dose chemotherapy and active excision of metastatic foci in the lung, survival time in the case of synovial sarcoma, giant cell sarcoma and Ewing's sarcoma is not very long yet. In the present study, we observed a patient who had lung metastasis of synovial sarcoma of which prognosis is generally considered poor has been surviving for a long time of 7 years owing to active excision of pulmonary metastatic foci. The relation of the present prognostic factors to those in the past were compared.

Comparison of hemodynamic changes in two veno-venous bypass techniques modified at the portal cannulation site

Veno-venous bypass under total vascular exclusion is a useful technique to permit safer resection of hepatic malignancy. We describe here a retrospective study of two modified venous bypass techniques as alternatives to the conventional end-on portal cannulation technique. Portal decompression via inferior mesenteric vein access was performed in eight patients (group A), and portal decompression via a passive shunt between a branch of the mesenteric vein and the right saphenous vein was performed in a second group (group B; n = 8). Both techniques were used in hepatic resection for malignancy under total vascular exclusion. To assess the efficacy of these bypass techniques, we compared the hemodynamic changes in the two groups. There were no differences in the bypass flow between the two groups. Neither group showed any significant changes in hemodynamic parameters (including mean arterial pressure, cardiac index, systemic vascular resistance index, and pulmonary artery pressure) between the pre-bypass and bypass phases. The heart rate in the bypass phase was significantly increased compared to that in the pre-bypass phase in both groups. All hemodynamic parameters in each phase were similar in the two groups. We conclude that both techniques maintained adequate venous return and stabilized the hemodynamic changes during hepatic resection under total vascular exclusion, and that either technique can be selected according to the intraoperative situation.

Hyperthermo-chemo-hypoxic isolated liver perfusion for hepatic metastases: a possible adjuvant approach

As a possible intraoperative adjuvant approach to treating hepatic metastases we developed a method of hyperthermo-chemo-hypoxic isolated liver perfusion in combination with hepatic resection. This method was applied to 11 patients with colorectal hepatic metastases between 1992 and 1995. One patient died on postoperative day 14 of hepatic failure (9% mortality), the cause of which was live temperature that reached 42.9 degree C, which seems to be the maximum limit for thermal toxic effect on the human liver. The other 10 patients tolerated the perfusion well, with mild hepatic and non systemic toxicity after minor or even major hepatic resection; the serum aminotransferase and total bilirubin levels returned to normal levels by postoperative day 14. Only one of eight patients (13%) for whom cytotoxic drugs were added to the perfusate (mitomycin C 10 micrograms/ml or cisplatin 2 micrograms/ml) had hepatic recurrence by 19 months after the perfusion (mean follow-up 25.8 months; median 23 months; range 8-57 months). Two patients were alive with no evidence of disease at 13 and 57 months, respectively after the perfusion; the other five patients had postperfusion extrahepatic recurrences (median: 19 months; range 7-20 months). In contrast, hepatic metastases recurred 7 and 20 months after the perfusion, respectively, in the two patients not given a cytotoxic drug.