New roles & responsibilities of hospital biomedical engineering

Over the last decade the changing healthcare environment has required hospitals and specifically Biomedical Engineering to critically evaluate, optimize and adapt their operations. The focus is now on new technologies, changes to the environment of care, support requirements and financial constraints. Memorial Sloan Kettering Cancer Center (MSKCC), an NIH-designated comprehensive cancer center, has been transitioning to an increasing outpatient care environment. This transition is driving an increase in-patient acuity coupled with the need for added urgency of support and response time. New technologies, regulatory requirements and financial constraints have impacted operating budgets and in some cases, resulted in a reduction in staffing. Specific initiatives, such as the Joint Commission's National Patient Safety Goals, requirements for an electronic medical record, meaningful use and ICD10 have caused institutions to reevaluate their operations and processes including requiring Biomedical Engineering to manage new technologies, integrations and changes in the electromagnetic environment, while optimizing operational workflow and resource utilization. This paper addresses the new and expanding responsibilities and approach of Biomedical Engineering organizations, specifically at MSKCC. It is suggested that our experience may be a template for other organizations facing similar problems. Increasing support is necessary for Medical Software - Medical Device Data Systems in the evolving wireless environment, including RTLS and RFID. It will be necessary to evaluate the potential impact on the growing electromagnetic environment, on connectivity resulting in the need for dynamic and interactive testing and the growing demand to establish new and needed operational synergies with Information Technology operations and other operational groups within the institution, such as nursing, facilities management, central supply, and the user departments.

Suitability of boron carriers for BNCT: accumulation of boron in malignant and normal liver cells after treatment with BPA, BSH and BA

Hepatocellular carcinoma remains widely prevalent in tropical Africa and south-east Asia. At present, there are no effective treatments for hepatoma and its prognosis is extremely poor unless the tumor was diagnosed in an early stage and resected before metastasis. Therefore, boron neutron capture therapy (BNCT) may provide an alternative therapy for treatment of hepatocellular carcinoma. In this study, the intracellular concentrations of L-boronophenylalanine (BPA), sodium borocaptate (BSH) and boric acid (BA) were examined in human hepatoma HepG2 and liver Clone 9 cell cultures. With the use of 25 microgB/mL media of BPA, BSH and BA, the intracellular uptake of boron in HepG2 and Clone 9 cells was compared. The suitability of BPA, BSH and BA were further evaluated on the basis of organ-specific boron distribution in normal rat tissues. BPA, BSH and BA were administered via intraperitoneal injection into rats with corresponding boron concentrations of 7, 25, and 25mg/kg body weight, respectively. The accumulation rates of BPA, BSH and BA in HepG2 cells were higher than that of Clone 9 cells. Boron concentration in BPA, BSH and BA treated HepG2 cells were 1.8, 1.5, and 1.6-fold of Clone 9 cells at 4h, respectively. In both HepG2 and Clone 9 cells, although the concentration of boron in BPA-treated cells exceeded that in BA-treated ones, however, cells treated with BPA had similar surviving fraction as those treated with BA after neutron irradiation. The accumulation ratios of boron in liver, pancreas and kidney to boron in blood were 0.83, 4.16 and 2.47, respectively, in BPA treated rats, and 0.75, 0.35 and 2.89, respectively, in BSH treated rats at 3h after treatment. However, boron does not appear to accumulate specifically in soft tissues in BA treated rats. For in situ BNCT of hepatoma, normal organs with high boron concentration and adjacent to liver may be damaged in neutron irradiation. BPA showed high retention in pancreas and may not be a good drug for BNCT of hepatoma. BSH had higher retention in liver but low level in pancreas and spleen appears to be a better candidate BNCT drug for hepatoma. These preliminary results provide useful information on future application of BNCT for hepatoma.

Iron-generated hydroxyl radicals kill retinal cells in vivo: effect of ferulic acid

Siderosis bulbi is vision threatening. An investigation into its mechanisms and management is crucial. Experimental siderosis was established by intravitreous administration of an iron particle (chronic) or FeSO4 (acute). After siderosis, there was a significant dose-responsive reduction in eletroretinogram (a/b-wave) amplitude, and an increase in •OH level, greater when caused by 24 mM FeSO4 than that by 8 mM FeSO4. Furthermore, the FeSO4-induced oxidative stress was significantly blunted by 100 μM ferulic acid (FA). Siderosis also resulted in an excessive glutamate release, increased [Ca++]i, and enhanced superoxide dismutase immunoreactivity. The latter finding was consistent with the Western blot result. Obvious disorganization including loss of photoreceptor outer segments and cholinergic amacrines together with a wide-spreading ferric distribution across the retina was present, which were related to the eletro-retinographic and pathologic dysfunctions. Furthermore, b-wave reduction and amacrine damage were respectively, significantly, dose-dependently, and clearly ameliorated by FA. Thus, siderosis stimulates oxidative stress, and possibly, subsequent excitotoxicity, and calcium influx, which explains why the retina is impaired electro-physiologically and pathologically. Importantly, FA protects iron toxicity perhaps by acting as a free radical scavenger. This provides an approach to the study and treatment of the iron-related disorders such as retained intraocular iron and Alzheimer disease.

Evolving technologies drive the new roles of Biomedical Engineering

Rapidly changing technology coupled with the financial impact of organized health care, has required hospital Biomedical Engineering organizations to augment their traditional operational and business models to increase their role in developing enhanced clinical applications utilizing new and evolving technologies. The deployment of these technology based applications has required Biomedical Engineering organizations to re-organize to optimize the manner in which they provide and manage services. Memorial Sloan-Kettering Cancer Center has implemented a strategy to explore evolving technologies integrating them into enhanced clinical applications while optimally utilizing the expertise of the traditional Biomedical Engineering component (Clinical Engineering) to provide expanded support in technology / equipment management, device repair, preventive maintenance and integration with legacy clinical systems. Specifically, Biomedical Engineering is an integral component of the Medical Physics Department which provides comprehensive and integrated support to the Center in advanced physical, technical and engineering technology. This organizational structure emphasizes the integration and collaboration between a spectrum of technical expertise for clinical support and equipment management roles. The high cost of clinical equipment purchases coupled with the increasing cost of service has driven equipment management responsibilities to include significant business and financial aspects to provide a cost effective service model. This case study details the dynamics of these expanded roles, future initiatives and benefits for Biomedical Engineering and Memorial Sloan Kettering Cancer Center.

Modulation of HER2 expression by ferulic acid on human breast cancer MCF7 cells

BACKGROUND

The molecular mechanisms underlying the mitogenic effect of ferulic acid (FA), an active compound derived from Angelica sinensis, have never been elucidated. It was the aim of this study to investigate the proliferative effect of FA on human breast cancer cell lines and to elucidate its modulation mechanism on HER2 expression in MCF7 line.

MATERIALS AND METHODS

By using MCF7 (oestrogen receptor-positive; ER+, HER2-low), BT474 (ER+, HER2-high), MDAMB231 (ER-, HER2-low) and SKBR3 (ER-, HER2-high) human breast cancer cell lines as in vitro models, the mitogenic effects of FA were assessed by trypan blue dye exclusion assay and DNA flow cytometry. Ferulic acid-modulated cell signalling and HER2 gene expression were evaluated in MCF7 line by Western blot and real-time RT-PCR analysis.

RESULTS

Ferulic acid ER-dependently stimulated cell proliferation on MCF7 cells in a concentration-dependent manner. The HER2 oncogene (one of the prognostic factors of breast cancer) and ESR1 gene (oestrogen receptor-alpha; ERalpha) transcription were markedly up-regulated by FA treatment. Besides, HER2 signalling and its downstream molecules such as AKT and ERK1/2 were involved in FA-modulated ERalpha and cyclin D1 synthesis. Addition of anti-HER2 antibody, trastuzumab, abrogated FA-enhanced proliferative effect on MCF7 cells, indicated a positive feedback control for the action of HER2 in this setting. The fact that the ER antagonist blocked most of the FA-up-regulated HER2 expression, and that trastuzumab down-regulated ERalpha gene expression, suggested a cross-talk between ERalpha and HER2 signalling on MCF7 cells.

CONCLUSION

The authors' conclude that FA causes human breast cancer cell proliferation by up-regulation of HER2 and ERalpha expression.

Design of an enterprise-wide physiological and clinical data solution

The deployment of new wireless and networked technology and advanced clinical applications has significantly increased the quality and the quantity of patient diagnostic and monitoring information throughout the patient care environment. Coupled with increasing workloads and reduced staffing, the difficulties in effectively prioritizing and handling this information have resulted in a rise in equipment-related errors, patient dissatisfaction, a potential for patient injury, and an increasing overall concern for patient safety. Concerns about this trend have prompted the Joint Commission to established seven patient safety initiatives geared to the patient environment of care, establishing methodologies and protocols to reduce the probability of errors, and to provide an enhanced level of communications. Planned deployment of advanced medical devices and supporting technologies coupled with our existing wired/wireless network infrastructure, need to consider the potential integrating clinical device, onto a unified network infrastructure providing advanced capabilities to share and effectively manage this key patient clinical information. Implementation of a biomedical device information network represents a significant advance in the management of clinical patient information, and enables device data, specifically critical patient alarms to be shared, coordinated, prioritized and sent directly to specific assigned care providers. The care giver utilizing a common hands-free wireless device can receive a prioritized audible (or a simulated voice) alarm message and utilize this same device for directed staff-to-staff or staff-to-patient communication. The Biomedical Information Network implementation identifies or associates patients with devices and consequently critical alarms, filters low priority or nuisance alarms, and eliminates the need for multiple costly communication devices. This implementation establishes an enhanced environment of care, providing increased patient safety, and a clear proactive response to the national patient safety initiatives.

Stage migration influences on stage-specific survival comparison between D1 and D3 gastric cancer surgeries

AIMS

We evaluate the influency stage migration in a randomised trial comparing D1 (N 1 lymphadenectomy) and D3 (N 1, 2 and 3 lymphadenectomy) dissections.

METHODS

Two hundred and thirteen curatively resected patients were analysed, with this TNM data.

RESULTS

After applying D3 patients' data according to simulated D1 staging, D3 resections were associated with up-staging to N2-3 levels in 8% of patients according to the N stage. The likelihood of N-status migration increased with increasing depth of invasion into the gastric wall. The increases in the calculated survival rate after stage migration on known 5-year survival rates were: 2% in stage IB, 1% in stage II, 4% in stage IIIA, and 1% in stage IIIB.

CONCLUSIONS

Stage migration secondary to meticulous lymph node dissection affects stage-specific survival rates. True therapeutic survival benefit of D3 resection can only be assessed in this context.

Antioxidant supplementation may improve renal transplant function: A preliminary report

Dysfunction of the renal graft may not only be due to rejection but also other causes such as ischemia and reperfusion injury and calcineurin inhibitor nephrotoxicity. Antioxidant free radical scavengers may decrease oxidative stress and lipid peroxidation. Previous animal studies suggest that vitamins C (ascorbic acid) and E (alpha-tocopherol) are both strong antioxidants, that decrease oxidative stress caused by ischemia-reperfusion injury and calcineurin inhibitor nephrotoxicity. But there have been only limited reports about clinical efficacy. We report five cases supplemented with vitamin C (500 mg per day), vitamin E (500 mg per day), or both. After a 1- to 3-month prescription, the serum creatinine level decreased more than 20% from the original value. Interestingly, one patient had this experience: he ceased vitamin E for 1 month due to noncompliance. The serum creatinine level increased more than 50%. When he took vitamin E again, his serum creatinine level declined and returned to the previous level. From our limited experience, antioxidant supplementation with vitamin C or E may improve renal transplant function, especially in grafts donated from marginal donors.

Alteration of the copy number and deletion of mitochondrial DNA in human hepatocellular carcinoma

Somatic mutations in mitochondrial DNA (mtDNA) have been detected in hepatocellular carcinoma (HCC). However, it remains unclear whether mtDNA copy number and mitochondrial biogenesis are altered in HCC. In this study, we found that mtDNA copy number and the content of mitochondrial respiratory proteins were reduced in HCCs as compared with the corresponding non-tumorous livers. MtDNA copy number was significantly reduced in female HCC but not in male HCC. Expression of the peroxisome proliferator-activated receptor γ coactivator-1 was significantly repressed in HCCs (P<0.005), while the expression of the mitochondrial single-strand DNA-binding protein was upregulated, indicating that the regulation of mitochondria biogenesis is disturbed in HCC. Moreover, 22% of HCCs carried a somatic mutation in the mtDNA D-loop region. The non-tumorous liver of the HCC patients with a long-term alcohol-drinking history contained reduced mtDNA copy number (P<0.05) and higher level of the 4977 bp-deleted mtDNA (P<0.05) as compared with non-alcohol patients. Our results suggest that reduced mtDNA copy number, impaired mitochondrial biogenesis and somatic mutations in mtDNA are important events during carcinogenesis of HCC, and the differential alterations in mtDNA of male and female HCC may contribute to the differences in the clinical manifestation between female and male HCC patients.

Reliability of contemporary radiology to measure tumour size of hepatocellular carcinoma in patients undergoing resection: limitations and clinical implications

BACKGROUND

Preoperative radiology has been widely used to detect and measure hepatocellular carcinoma (HCC). However, its accuracy and reliability are unclear. This study aimed to assess the ability of current radiology to measure tumour size in patients undergoing resection.

METHODS

We evaluated 212 HCC patients undergoing curative resection. Tumour size measured in the pathological examination was correlated with that obtained in preoperative ultrasound (US) and contrast-enhanced dynamic computed tomography (CT). Accuracy and association with tumour recurrence were investigated.

RESULTS

The mean size of the tumour was 4.5 +/- 2.6 cm and was accurate in both US and CT in only 6 (3%) patients. Cirrhosis (P = 0.015), absence of tumour stain (P = 0.002) and small (< or = 4 cm) tumour (P < 0.001) were the significant factors associated with size deviation using both US and CT. Ninety-four (44%) patients developed tumour recurrence within 17 +/- 11 months of resection. Recurrence rate was 52%, 52% and 67% in patients with underestimation in US (relative risk [RR]: 2.0, 95% confidence interval [CI]: 1.2-3.4, P = 0.01), CT (RR: 2.1, 95% CI: 1.1-4, P = 0.022) and both modalities (RR: 2.5, 95% CI: 1.4-4.2, P = 0.001), respectively, compared to 30% recurrence in patients with accurate estimation of tumour size.

CONCLUSION

The accuracy of radiology in measuring tumour size was poor, and may lead to inappropriate treatment. The finding that underestimation of tumour size was associated with a higher tumour recurrence rate is consistent with the hypothesis that HCC may recur from pre-existing tumour foci which could not be identified from the current imaging modalities.

IL-17 expression as a possible predictive parameter for subclinical renal allograft rejection

In the present study we have tried to establish the role of IL-17 in subclinical renal allograft rejection. In this animal model, renal grafts from BN (RT1n) were transplanted heterotopically into LEW (RT1l) rats. As controls, LEW grafts were transplanted into LEW rats. The histopathological examination demonstrated that the changes in the allograft kidney on day 2 were similar to those ranked as borderline changes according to the Banff classification scale. On day 2, the serum level of blood urea nitrogen (BUN) and creatinine were the same as on day 1. The examination of allograft cytokines mRNA showed that IL-17 mRNA expressed earlier on the second postoperative day, peaked at day 5, and then declined, becoming almost undetectable at day 9, when most rats died. IL-17 antigen was also proven, by histochemical staining, to be expressed early, however we could not find the same early appearance on other Th1/Th2 cytokines. In human renal biopsy samples, the IL-17 antigen could be found scattered around in the borderline changed rejected renal allografts without evidence of a serum creatinine increase, but was undetectable both in normal controls and in renal transplant tissue without signs of rejection. IL-17 mRNA was detected in the mononuclear cells of the urinary sediment of patients suffering from borderline subclinical rejection. From the above results we can hypothesize that IL-17 could serve as a predictive parameter for borderline subclinical renal allograft rejection in the future.

IL-17 expression as a possible predictive parameter for subclinical renal allograft rejection

In the present study we have tried to establish the role of IL-17 in subclinical renal allograft rejection. In this animal model, renal grafts from BN (RT1n) were transplanted heterotopically into LEW (RT1l) rats. As controls, LEW grafts were transplanted into LEW rats. The histopathological examination demonstrated that the changes in the allograft kidney on day 2 were similar to those ranked as borderline changes according to the Banff classification scale. On day 2, the serum level of blood urea nitrogen (BUN) and creatinine were the same as on day 1. The examination of allograft cytokines mRNA showed that IL-17 mRNA expressed earlier on the second postoperative day, peaked at day 5, and then declined, becoming almost undetectable at day 9, when most rats died. IL-17 antigen was also proven, by histochemical staining, to be expressed early, however we could not find the same early appearance on other Th1/Th2 cytokines. In human renal biopsy samples, the IL-17 antigen could be found scattered around in the borderline changed rejected renal allografts without evidence of a serum creatinine increase, but was undetectable both in normal controls and in renal transplant tissue without signs of rejection. IL-17 mRNA was detected in the mononuclear cells of the urinary sediment of patients suffering from borderline subclinical rejection. From the above results we can hypothesize that IL-17 could serve as a predictive parameter for borderline subclinical renal allograft rejection in the future.

Preconditioning somatothermal stimulation on right seventh intercostal nerve territory increases hepatic heat shock protein 70 and protects the liver from ischemia-reperfusion injury in rats

Hyperthermic preconditioning attenuates the heat-induced cellular response to a subsequent severe heat challenge. However, it is impractical to perform whole-body hyperthermia in humans. This study was designed to test the hypotheses that hepatic heat shock protein 70 (Hsp70) could be induced by local somatothermal stimulation (LSTS) on right seventh intercostal nerve territory and that preconditioning the rats with LSTS protects the liver from subsequent ischemia-reperfusion injury. LSTS was brought about by application of a heating rod above right seventh intercostal nerve territory in male Sprague-Dawley rats. Hepatic gene expression of Hsp70 was assessed by Western blot and reverse transcription polymerase chain reaction (RT-PCR). Finally, serum ALT and AST and the lipid peroxidation product malondialdehyde (MDA) were evaluated in ischemic-reperfused rats preconditioned by application of LSTS on right seventh intercostal nerve territory. The results showed that hepatic gene expression of Hsp70 was upregulated in rats treated with LSTS. When animals were preconditioned with LSTS, followed by subsequent ischemia-reperfusion injury of the liver, there were significant decreases in liver enzymes (ALT/AST) and MDA formation in rats pretreated with one dose of LSTS (LSTS-1 group) as compared with those not treated with LSTS (control group) or treated with three doses of LSTS (LSTS-3 group). We conclude that mild local heat stress (one dose) on right seventh intercostal nerve territory upregulates hepatic gene expression of Hsp70 and protects the liver from subsequent ischemia-reperfusion injury. This might provide an easily applicable method for those patients facing ischemia-reperfusion challenge of the liver, as in liver resection and liver transplantation.

Randomized trial of gastrojejunostomy with duodenal partition versus antrectomy in unresectable periampullary cancer

BACKGROUND

A newly-designed gastrojejunostomy with duodenal partition was hypothesized to be a relatively easier and safer gastric bypass procedure in interrupting the "food reentry", as compared with antrectomy, for patients with unresectable periampullary cancer.

METHODS

Thirty patients with unresectable periampullary malignancy were randomized to receive gastrojejunostomy with either duodenal partition or antrectomy, in addition to biliary bypass, to compare surgical risk and efficacy of the gastric bypass between these two groups.

RESULTS

Gastrojejunotomy with either duodenal partition or antrectomy could significantly shorten the gastric emptying time 6 weeks after operation. There was no significant difference between these two groups in gastric outlet obstruction (GOO) symptoms, gastric emptying time, and time for resuming oral diet intake after operation. The median operation time was shorter in the duodenal partition group (180 min) than in the antrectomy group (240 min), p < 0.01. The median blood loss was less in the duodenal partition group (250 ml) than in the antrectomy group (400 ml), (p = 0.01). Complications occurred in 3 (20%) patients with duodenal partition and in 7 (47%) patients with antrectomy, (p = 0.25). One duodenal stump leakage occurred in antrectomy group. Surgical mortality occurred in 2 patients with antrectomy.

CONCLUSIONS

Duodenal partition, with shorter operation time and less blood loss, had similar efficacy with antrectomy in correction of GOO. Therefore, duodenal partition could be a relatively easier and safer alternative to antrectomy in interrupting the "food reentry" in gastrojejunostomy for patients with unresectable periampullary cancer.

Clinicopathologic and prognostic differences between patients with hepatitis B- and C-related resectable hepatocellular carcinoma

BACKGROUND AND PURPOSE

Hepatitis B and C viral infections are important factors in the development of hepatocellular carcinoma (HCC). This study examined the clinicopathologic and prognostic differences in patients with hepatitis B- and C-related resectable HCC.

METHODS

A total of 270 HCC patients who underwent hepatic resection were enrolled. Among these patients, 211 were positive for hepatitis B surface antigen (HBsAg) and 59 were positive for anti-hepatitis C virus antibody (anti-HCV). The clinical manifestations, pathologic features, and treatment outcomes were compared between the HBsAg-positive and anti-HCV-positive groups.

RESULTS

Compared to anti-HCV-positive patients, HBsAg-positive patients were significantly younger, had a higher familial incidence of HCC, larger tumor size, and a higher incidence of multiple tumors. HCC patients who were anti-HCV positive had worse liver function and a higher incidence of history of blood transfusion. DNA flow cytometric analysis revealed significantly more proliferative activity in the non-tumor part of the liver in HBsAg-positive HCC patients. The 1-, 3-, and 5-year overall survival rates of HBsAg-positive patients were 79%, 57%, and 48%, respectively, and for anti-HCV-positive patients were 91%, 75%, and 62%, respectively. HBsAg-positive patients had a significantly lower overall survival rate than anti-HCV-positive patients (p = 0.018).

CONCLUSIONS

HBsAg-positive patients with resectable HCC had a less favorable survival rate after tumor resection than anti-HCV-positive HCC patients. This survival difference might have been related to the relatively advanced stage of disease and the higher proliferative activity of the non-tumor part of the liver in HBsAg-positive HCC patients.

A highly aggressive primitive mesenchymal tumor with a translocation (1;19)(q12;q13.2)

Soft tissue sarcomas constitute a heterogeneous group of malignant tumors of mesenchymal origin, the classification of which may present a diagnostic challenge. We present here the cytological, histopathological, immunohistochemical, and cytogenetic findings of an unusual case of a highly aggressive sarcoma. Based on the morphology and the immunohistochemical profile, this primitive tumor and its metastases could not be conclusively classified as any of the defined subtypes of sarcomas, although the findings were suggestive of a variant of rhabdomyosarcoma. Cytogenetic characterization using G-banding, SKY, FISH, and CGH revealed almost identical chromosomal compositions of the primary tumor and the metastasis. The hypertetraploid karyotype was characterized by numerical imbalances as well as by an unbalanced translocation t(1;19)(q12;q13.2), which has not been previously reported.

Rabbit sex hormone-binding globulin: expression in the liver and testis during postnatal development and structural characterization by truncated proteins

Although sex hormone binding globulin (SHBG) is found in the blood plasma of adult humans and rabbits and the gene is expressed in their livers, it is not detected in the plasma of adult rodents nor is it expressed in adult rodent livers. Thus the rabbit represents a good model to study the metabolism and function of SHBG in the blood. We have used a cloned rabbit SHBG cDNA to detect mRNA expression in rabbits during the postnatal period, and to construct truncated SHBG proteins for structure/function analysis. The SHBG mRNA appeared in the testis as early as 3 days after birth. The level increased gradually in abundance throughout postnatal development, and attained a maximum at 12 weeks of age when the gonads were fully matured. In contrast, SHBG mRNA in the livers of male and female animals increased to a maximum by 4 weeks of age, and were maintained at this level until 12 weeks before subsiding to the initial levels. The increase and decrease in SHBG mRNA levels in the liver were accompanied by similar changes in serum SHBG. This suggests that SHBG in the blood circulation comes from the liver and this might also provide a source of SHBG for the male reproductive tract before formation of the blood-testis barrier. To elucidate the minimal sequence of rabbit SHBG responsible for steroid-binding, a panel of 13 truncated SHBG proteins was constructed, expressed in Escherichia coli, and biochemically purified for study. It was shown that the complete protein sequence of rabbit SHBG was important for maintaining a stable steroid-protein complex. Unlike human SHBG for which a truncated protein of the first 206 residues of the 373 amino acid protein can still bind steroid, removal of 43 or more residues from the C-terminus of rabbit SHBG completely abolished steroid-binding.

Ischaemic change of the human intestine after total portal occlusion during liver resection

This is a clinical study of the use of several monitoring techniques to evaluate the effect of total hepatic inflow occlusion on intestinal ischaemia during liver resection. A total of 8 patients was studied. Parameters measured included intestinal oxygen extraction ratio, portal venous and arterial lactate levels and intestinal intramucosal pH (pHi), measured by an intraluminal tonometer. When venous outflow of the intestine was occluded, intestinal oxygen extraction ratio increased and portal venous lactate increased significantly, but arterial lactate did not increase significantly until after 60 minutes of occlusion. Intestinal pHi decreased significantly after 60 minutes. Following release of the occlusion, oxygen extraction and pHi returned to normal in 7 out of 8 patients. The 1 patient who had a persistent decrease in pHi died postoperatively. These findings indicate that a marked drop in pHi after total portal occlusion and persistent low pHi following the release of a portal occlusion are associated with the development of complications and mortality during liver resection.

Transforming growth factor-beta3 perturbs the inter-Sertoli tight junction permeability barrier in vitro possibly mediated via its effects on occludin, zonula occludens-1, and claudin-11

Throughout spermatogenesis, inter-Sertoli tight junctions (TJs) that create the blood-testis barrier in the rat must be disassembled and reassembled to permit the timely passage of preleptotene spermatocytes from the basal to the adluminal compartment of the seminiferous epithelium. However, the mechanism(s) and the participating molecules that regulate this event are largely unknown. Although there is no in vitro model to study the event and regulation of inter-Sertoli TJ disassembly, primary cultures of Sertoli cells in vitro can be used to study junction assembly. In this study, we sought to investigate whether cytokines are involved in the inter-Sertoli TJ assembly in vitro. Sertoli cells isolated from 20-day-old rats were cultured at a density of 0.5-1.2 x 10(6) cells/cm(2) on Matrigel-coated dishes or bicameral units for 8-9 days. The steady-state messenger RNA levels of basic fibroblast growth factor (bFGF), transforming growth factor (TGF)-beta2, and TGF-beta3 at different time points were assessed by semiquantitative RT-PCR. In selected experiments, the assembly of inter-Sertoli TJs was monitored by transepithelial electrical resistance measurement. It was found that there was no change in the expression of basic fibroblast growth factor throughout the entire culture period. However, there was a 2-fold reduction in the expression of TGF-beta2 and TGF-beta3 at the time inter-Sertoli TJs were being assembled. On days 5-8, after the inter-Sertoli TJs had been assembled, the Sertoli cell steady-state messenger RNA levels of TGF-beta2 and TGF-beta3 increased by as much as 3- and 6-fold, respectively, when compared with Sertoli cells on days 1-3 when TJs were being assembled. Also, it was found that recombinant TGF-beta3 added to Sertoli cells cultured in vitro at 1.2 x 10(6) cells/cm(2) on Matrigel-coated bicameral units perturbed the inter-Sertoli TJ permeability barrier dose-dependently. Moreover, the presence of TGF-beta3 also inhibited the transient and/or basal expression of several TJ-associated proteins, which include occludin, zonula occludens-1, and claudin-11 when inter-Sertoli TJs were being assembled in vitro. These results suggest that TGF-beta plays a crucial role in regulating the complicated biochemical events of junction assembly in the testis.

Tie-1 tyrosine kinase is an independent prognostic indicator for invasive breast cancer

Receptor tyrosine kinases are known to be involved in the growth, progression and metastasis of solid tumors. We investigated the relationship between tie-1 expression and progression of invasive ductal breast carcinoma with immunohistochemical analysis. Tie-1 protein was detected in the microvessel endothelial cells and cytoplasm of tumor cells. The tumor size and stage were significantly associated with the expression of tie-1, which portends a worse 5-year disease-free status (39.3% v 59.2%, p = 0.07) and overall survival rate (67.3% v 93%, p = 0.02) than those without tie-1 expression. Multivariate analysis demonstrated that larger tumor size, presence of lymph node metastasis and tie-1 expression were independent prognostic parameters, both in 5-year disease-free survival and overall survival. Patients with lymph node metastases and tie-1 expression had the worst 5-year disease-free survival (0%) and overall survival (42.4%) compared to those without tie-1 expression (50.2%, 85%). In lymph node negative patients, those without tie-1 expression had better 5-year disease-free survival and overall survival (72.9%, 100%) compared to those with tie-1 expression (65.5%, 87.7%). We conclude that tie-1 expression is an independent prognostic factor for invasive ductal breast carcinoma, adversely affecting survival of breast cancer patients with positive nodes to a significant extent.

Sonographic features of breast abscesses with emphasis on "hypoechoic rim" sign

BACKGROUND

There are only limited reports on the ultrasound (US) features of breast abscess. The purpose of this paper is to review the US features of breast abscess with emphasis on "hypoechoic rim" sign which is more commonly seen in chronic abscess.

METHODS

In a period of 10 years, 20,998 patients were referred for breast US examinations. Medical records identified 204 patients in whom breast abscess was diagnosed. All patients were examined using high-resolution real-time US scanners. The initial ultrasound reports and hard copy images were all carefully reviewed. The grading of the echogenicity of the abscess was classified from grade 0 to grade 5. The contours of the lesions were described as smooth, macrolobulated, microlobulated, irregular, zigzag, spiculate or indistinct. The wall thickness was measured to document the presence of "hypoechoic rim" which denoted a wall thickness greater than 2 mm. The associated findings and other acoustic phenomena related to the lesion were recorded.

RESULTS

One hundred and thirty-six patients (136/204) having specific aspiration and/or biopsy/histopathological results were included in the study. All of the 136 patients showed abnormal US findings (100%). Most lesions showed grade 1 or grade 2 echogenicity (117, 86%). The contour of the abscess was usually smooth (42, 31%), macrolobulated (42, 31%), or irregular (22, 16%). A hypoechoic rim was noticed in 18 lesions (13%). Focal skin thickening was chiefly noticed in 91% of superficial abscesses (39/43) and 17% of intramammary abscesses (14/84). Diffuse skin thickening was exclusively evident in the breasts coexisting with mastitis. Hypoechoic interstitial streaks were not a common finding (7%), occurring in acute abscesses. The other findings included surrounding hypoechoic amorphous tissue (26%), posterior wall enhancement (71%), distal enhancement (60%) and lateral shadows (57%).

CONCLUSIONS

US plays an important role in confirmation of the clinical diagnosis of breast abscess and aids significantly in the management of inflammatory breast diseases. Presence of the hypoechoic rim surrounding a fluid space or a central area of low-level echoes (i.e., grade 1 to grade 3) is indicative of a chronic abscess.

Reappraisal of surgical risk and prognosis for periampullary lesions after pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy remains a high-risk and formidable challenge to many surgeons. This study reappraised the surgical risk and prognosis for periampullary lesions in patients undergoing pancreaticoduodenectomy before and after 1990.

METHODS

Data on 308 patients with periampullary lesions undergoing pancreaticoduodenectomy were analyzed. The surgical risk was assessed by a variety of factors. Prognoses for periampullary cancers were determined and compared.

RESULTS

The overall surgical mortality, morbidity and pancreatic leakage were 12.7%, 47.7% and 14.9% respectively. Surgical morbidity (43.5% vs. 51.6%) and pancreatic leakage (12.9% vs. 16.8%) did not change significantly before 1990 and after 1990. Surgical mortality significantly decreased from 17.1% before 1990 to 8.7% after 1990 (p = 0.043). Surgeons having more experience in performing pancreaticoduodenectomy (count > 20) made significantly lowest rates of surgical mortality, pancreatic leakage and bile leakage, as compared with those having performed this surgery with medium count (10-20) or low count (< 10). Statistically, pancreatic leakage was highly associated with operative mortality, (p < 0.001). As analysed by multivariate logistic regression, the most independent risk factor of surgical mortality after pancreaticoduodenectomy was pancreatic leakage (odds ratio = 12.1), followed by date of operation (odds ratio = 2.5). The 5-year survival rate for overall periampullary cancers was 23.0%, with the highest in ampulla of Vater cancer (32.7%), followed by duodenal cancer (18.0%), distal common bile duct cancer (12.3%) and pancreatic head cancer (5.5%) (p < 0.001).

CONCLUSIONS

Surgical morbidity following pancreaticoduodenectomy remains high and unchanged while surgical mortality has significantly reduced. Pancreatic leakage is the most independent risk factor of surgical mortality. Patients with periampullary lesions appear to benefit from the experience of surgeons. The overall 5-year survival is most favorable for ampulla of Vater cancer and worst for pancreatic head cancer.

Sonography of acute right side colonic diverticulitis

BACKGROUND

To describe the prevalence and sonographic findings and ultrasound diagnostic accuracy of the right side colonic diverticulitis in patients having right lower abdominal pain with indeterminate nature.

METHODS

A total of 934 patients with acute right lower abdominal pain of clinically indeterminate nature were referred for ultrasound examination (US). US studies were performed with 3.5 to 7.0 (or occasionally 10) MHz transducers using graded compression method. Twenty-three patients were finally diagnosed to have an uncomplicated acute diverticulitis of the right colon. The gray-scale sonographic images were reviewed. A retrospective study was undertaken to evaluate diagnostic contribution of US.

RESULTS

The prevalence of acute right side colonic diverticulitis was 2.5% in patients with clinically indeterminate acute right lower abdominal pain. Locations of the inflamed diverticula include cecum in 6 patients, proximal ascending colon in 15 patients, and distal ascending colon in only 2 patients. Sonography detected 21 inflamed diverticula with 1 false positive and 2 false negative results. The most typical sonographic feature of an inflamed diverticulum of right side colon was a rounded or oval-shaped hypoechoic or nearly anechoic structure (52%) protruding out from the segmentally thickened colonic wall. Some of them might contain strong echoes representing gas or feces (43%), or stone in the lumen (5%). Regional pericolic or peridiverticular fat thickening was noted in 57% of patients, and segmental colon wall thickening in 38%. US examination yielded a sensitivity of 91.3%, a specificity of 99.8%, an overall accuracy of 99.5%, a positive predictive value of 95.5%, and a negative predictive value of 99.7%. A positive sonogram made the likelihood of acute right side diverticulitis 456.5 times greater compared with the pretest clinical impression. US differentiated acute right side colonic diverticulitis from acute appendicitis with a 100% accuracy.

CONCLUSIONS

Ultrasound can be extremely useful in diagnosing acute right side colonic diverticulitis. Careful ultrasound evaluation of the right colon and the cecum may facilitate a correct diagnosis and help differentiate from acute appendicitis, and steer the surgeon to a more effective management.

Long-term outcome of kidney transplantation in patients with hepatitis C virus infection

BACKGROUND/AIMS

The impact of HCV (hepatitis C virus) infection on the long-term outcome of kidney transplant patients is controversial.

METHODOLOGY

Eighty-four renal allograft recipients who were seronegative for hepatitis B surface antigen and had been screened for antibody to hepatitis C virus (anti-HCV) were included. The outcome and survival were compared between anti-HCV-positive (n = 30, group 1) and anti-HCV-negative (n = 54, group 2) kidney transplant patients. Group 1 patients were further compared to 52 anti-HCV-positive end-stage renal disease patients (group 3) who were on chronic dialysis.

RESULTS

Group 1 patients had a higher prevalence of chronic hepatitis than group 2 and group 3 patients did (67% vs. 2% and 31%). Liver-related complications and deaths between group 1 and group 2, and group 1 and group 3 patients were not significantly different. The comparisons of the long-term survival between these groups showed no significant differences, despite group 3 patients had a higher overall mortality rate. Cox regression analysis confirmed that age more than 45 years was the only independent factor that affected survival in anti-HCV-positive end-stage renal disease patients with or without kidney transplantation.

CONCLUSIONS

HCV infection is not a contraindication to kidney transplantation. For anti-HCV-positive end stage renal disease patients, survival is better in younger patients, and is not influenced by kidney transplantation or continuing dialysis.

Comparison of the UICC/AJCC 1992 and 1997 pN categories for gastric cancer patients after surgery

BACKGROUND/AIMS

UICC/AJCC 1997 classification changes pN category. We evaluated its prognostic impact.

METHODOLOGY

A total of 710 patients who underwent a > or = D2 gastrectomy were recruited. Among them, the data of 319 patients who had involved regional lymph nodes and no evidence of distant metastases were used for comparing the 1992 and 1997 pN categories.

RESULTS

For 1997 category, 201 patients (64%) were pN1, 75 (23.5%) pN2, and 43 (13.5%) pN3. For 1992 category, 143 patients (44.8%) were pN1, and 147(46.1%) pN2. 29 patients (9.1%) with lymph node metastasis to the hepatoduodenal ligament were distant metastasis. The 1997 pN category was a more powerful prognostic discriminant (relative risk: 2.086) than the 1992 category. Compared to the 1992 stage classification, the 1997 one had a skewed distribution of patients with marked shift of patients of stage IIIA (105-126 patients), IIIB (116-58 patients), and IV (100-122 patients). The survival difference between stage IIIA and IIIB for the 1997 stage classification is narrower than for 1992.

CONCLUSIONS

The 1997 pN category allows for estimation of prognosis superior to the 1992 category.

Arginine modulated cyclosporine-induced immune suppression in rats transplanted with gastric cancer cells

BACKGROUND

The incidence of cancer is significantly increased in kidney transplant patients receiving cyclosporine treatment. It has been reported that arginine can modify cyclosporine-induced nephrotoxicity in rats. Whether arginine interfered with cyclosporine-induced immune suppression in tumor transplant is not clear.

MATERIALS AND METHODS

Male Wistar rats were inoculated subcutaneously with human gastric cancer SC-M1 cells and separated into 4 groups; control, cyclosporine, cyclosporine plus arginine and cyclosporine plus glycine groups. The growth of SC-M1 tumor was monitored on 4, 7, 10, 14 and 21 days after tumor implant. In another set of experiments, the rats were separated into control, cyclosporine, arginine and cyclosporine plus arginine groups. After treatment for one week, mononuclear cells were collected and stained with anti-rat CD3 antibody followed by flowcytometric analysis. On the other hand, splenocytes from each group of rats were stimulated with phyto-hemaglutinin (PHA) to determine their DNA synthesis by 3H-thymidine uptake assay.

RESULTS

The SC-M1 tumors in the cyclosporine-treated rats were larger than that of the arginine plus cyclosporine group. Although SC-M1 tumors were eventually rejected in Wistar rats, the duration of detectable SC-M1 tumors in cyclosporine-treated rats was longer than that of rats treated with arginine plus cyclosporine. More infiltrating inflammatory cells were detected at an early stage of tumor rejection in rats treated with arginine plus cyclosporine than in cyclosporine-treated rats. In vitro analysis of PHA-stimulated splenocyte proliferation showed that arginine activated lymphocyte proliferation while cyclosporine inhibited lymphocyte proliferation. Arginine significantly interfered with cyclosporine-induced growth inhibition of PHA stimulated lymphocytes (p = 0.0039).

CONCLUSION

Using a tumor transplant model, we have found that dietary supplements of arginine interfered with cyclosporine-induced immunosuppression in rats. The antagonistic effect between arginine and cyclosporine on immune suppression is worthy of further investigation in organ transplant patients.

Male predominance in hepatocellular carcinoma: new insight and a possible therapeutic alternative

Hepatocellular carcinoma is one of the most common cancers in the world. The male to female ratio is 3-6 to 1 in patients with hepatocellular carcinoma. Although steroid hormones and receptors have been examined extensively for their role in the growth regulation of hepatocellular carcinoma, the direct stimulation of hepatocellular carcinoma by steroid hormones still awaits elucidation. On the other hand, clinical trials using antagonists for steroid hormones to treat hepatocellular carcinoma were found to be mostly ineffective. Recently it has been found that 2-methoxyestradiol - an estrogen metabolite - is effective in growth inhibition of various tumor cells as well as in angiogenesis inhibition. Since estrogen is metabolized in the liver, it is conceivable that females with menstruation cycles have more estrogen metabolized in their liver, consequently more 2-methoxyestradiol produced which could inhibit tumor growth in situ. We propose that the low incidence and mortality of hepatocellular carcinoma found in females may have resulted from the high levels of 2-methoxyestradiol produced in the liver during their reproductive years. Consequently, the growth of hepatocellular carcinoma in females is delayed significantly as compared to males. The potential of using 2-methoxyestradiol for treatment of patients with hepatocellular carcinoma after resection of tumor should be explored.

Comparison of 2-methoxyestradiol-induced, docetaxel-induced, and paclitaxel-induced apoptosis in hepatoma cells and its correlation with reactive oxygen species

BACKGROUND

Previously, the authors observed that paclitaxel treatment of hepatoma cells resulted in differential cytotoxicity. Whether other antimicrotubule agents (docetaxel and 2-methoxyestradiol) are more effective than paclitaxel is not clear. Moreover, whether the modulation of reactive oxygen species (ROS) is involved in the drug-induced growth inhibition of hepatoma cells is not known.

METHODS

The authors examined the effects of 2-methoxyestradiol, paclitaxel, and docetaxel on HepG2, Hep3B, HA22T/VGH, and Hepa1-6 hepatoma cell lines. The parameters examined included cell viability, cell membrane permeability, cell cycle distribution, DNA fragmentation, and ROS generation.

RESULTS

Docetaxel and paclitaxel inhibited the growth of hepatoma cells at submicromolar concentrations, whereas that of 2-methoxyestradiol was within a micromolar range. This drug-induced growth inhibition was cell cycle dependent. 2-Methoxyestradiol-treated (10-50 microM) cells resulted in G2/M block prior to apoptosis. High dose (0.1 microM) docetaxel- and paclitaxel-treated cells resulted in a G2/M arrest followed by generation of polyploidy or apoptosis; however, low dose (0.01 microM) treatment induced apoptosis without G2/M arrest. The low dose effect was more significant in docetaxel-treated cells than in paclitaxel-treated cells. Although these antimicrotubule agents increased the formation of ROS, antioxidant treatment did not block drug-induced cell cycle and growth inhibition effects.

CONCLUSIONS

The current results suggest that the growth inhibition of hepatoma cells induced by 2-methoxyestradiol, paclitaxel, and docetaxel was mediated through G2/M-phase arrest, caspase activation, and DNA fragmentation. The drug-induced apoptosis was independent of ROS formation. Docetaxel was more effective than paclitaxel in killing hepatoma cells. The potential of using 2-methoxyestradiol and docetaxel for the treatment of patients with hepatoma is worthy of further study.

Prognostic significance of heat shock protein-27 expression in hepatocellular carcinoma and its relation to histologic grading and survival

BACKGROUND

The expression of heat shock protein-27 (HSP-27) has been detected in some human tumors. In this study the authors investigated HSP-27 expression in patients with hepatocellular carcinoma (HCC) and examined its prognostic significance.

METHODS

Expression of HSP-27 was studied in 58 HCC and adjacent noncancerous liver tissues by immunohistochemical stain. The relation between its expression and eight known prognostic factors was evaluated.

RESULTS

Of the 58 HCC tissues studied, the presence of HSP-27 was demonstrated in 45 tissues (77.6%); low expression (</= 25%) was demonstrated in 17 tissues and high expression (> 25%) was demonstrated in 28 tissues. A significantly higher distribution of HSP-27 expression in HCC tissues compared with adjacent noncancerous liver tissues was obtained (P < 0.0001). Patients with high HSP-27 expression had a significantly higher histologic tumor grade than those with low HSP-27 expression (P = 0.001). The 5-year disease free survival rate of patients with high HSP-27 expression was 21.4% versus 59.3% for patients with low HSP-27 expression (P < 0.001). A similar relation was observed with overall survival (33.3% vs. 64. 8%; P = 0.009). HSP-27 expression was also identified to be a significant and powerful prognostic indicator for disease free survival (odds ratio = 2.25; P = 0.034) and for overall survival (odds ratio = 2.72; P = 0.015).

CONCLUSIONS

The current study data suggest that HSP-27 expression is a powerful prognostic indicator and is related to histologic grade and survival of patients with HCC.

Prognostic significance of heat shock protein-27 expression in hepatocellular carcinoma and its relation to histologic grading and survival

BACKGROUND

The expression of heat shock protein-27 (HSP-27) has been detected in some human tumors. In this study the authors investigated HSP-27 expression in patients with hepatocellular carcinoma (HCC) and examined its prognostic significance.

METHODS

Expression of HSP-27 was studied in 58 HCC and adjacent noncancerous liver tissues by immunohistochemical stain. The relation between its expression and eight known prognostic factors was evaluated.

RESULTS

Of the 58 HCC tissues studied, the presence of HSP-27 was demonstrated in 45 tissues (77.6%); low expression (</= 25%) was demonstrated in 17 tissues and high expression (> 25%) was demonstrated in 28 tissues. A significantly higher distribution of HSP-27 expression in HCC tissues compared with adjacent noncancerous liver tissues was obtained (P < 0.0001). Patients with high HSP-27 expression had a significantly higher histologic tumor grade than those with low HSP-27 expression (P = 0.001). The 5-year disease free survival rate of patients with high HSP-27 expression was 21.4% versus 59.3% for patients with low HSP-27 expression (P < 0.001). A similar relation was observed with overall survival (33.3% vs. 64. 8%; P = 0.009). HSP-27 expression was also identified to be a significant and powerful prognostic indicator for disease free survival (odds ratio = 2.25; P = 0.034) and for overall survival (odds ratio = 2.72; P = 0.015).

CONCLUSIONS

The current study data suggest that HSP-27 expression is a powerful prognostic indicator and is related to histologic grade and survival of patients with HCC.

Effect of anular repair on the healing strength of the intervertebral disc: a sheep model

STUDY DESIGN

The intervertebral disc, in a sheep model, was used to assess the effect of directly repairing three different anular incisions on the subsequent healing strength of the intervertebral disc.

OBJECTIVES

To assess whether directly repairing an anular defect, made at the time of lumbar discectomy, could influence the healing rate and strength of the anulus fibrosus.

METHODS

Twenty-four sheep underwent a retroperitoneal approach to five lumbar disc levels. An anular incision, followed by partial discectomy was done at each exposed level. Anular incisions used in this study consisted of 1) a straight transverse slit, 2) a cruciate incision, and 3) a window or box excision. Healing strength was measured at three time intervals: 2 weeks, 4 weeks, and 6 weeks. Each anular incision type was performed on 30 lumbar discs, 10 discs in each time interval. Five discs in each time interval underwent direct repair, and five discs were left unrepaired to heal as controls. The sheep were killed at 2, 4, and 6 weeks after surgery. The lumbar spines were removed en bloc, and the intervertebral discs were subjected to pressure-volume testing to assess the anular strength of repaired versus unrepaired disc injuries at each time interval.

RESULTS

Statistical analysis was performed to evaluate the effects of healing time, incision technique, and repair on the pressure-volume characteristics of the involved discs. Pressure-volume testing showed trends of stronger healing for repaired discs, but at no time interval was any significant difference found between repaired and nonrepaired anular strength. Of the nonrepaired discs, the box incision was only 40 to 50% as strong as the slit or cruciate incised discs during early healing.

CONCLUSION

Direct repair of anular incisions in the lumbar spine does not significantly alter the healing strength of the intervertebral disc after lumbar discectomy.

Tumor necrosis factor gene polymorphism and septic shock in surgical infection

OBJECTIVES

To evaluate the relationship of the genotype distribution of the tumor necrosis factor (TNF)-alpha polymorphism with regard to the plasma TNF-alpha concentration and the development of septic shock as well as mortality of infected patients in a surgical intensive care unit (SICU).

DESIGN

A total of 112 postoperative critically ill infected patients were prospectively enrolled.

SETTING

SICU of a tertiary university-affiliated medical center.

PATIENTS

Patients who were consecutively admitted to the SICU because of surgical infection with sepsis.

INTERVENTION

Blood sampling.

MEASUREMENTS AND MAIN RESULTS

Blood sample was obtained 24 hrs after intensive care unit (ICU) admission or within 2 hrs after the onset of septic shock to determine the plasma TNF-alpha level and to analyze the genotype of the biallelic polymorphism of the TNF-alpha.

RESULTS

The allele frequency of the TNF2 in our infected ICU patients was 12%. Forty-two (37.5%) patients admitted fulfilled the criteria of septic shock during their ICU stay. Patients carrying the TNF2 allele were not more likely to develop septic shock, nor did they have a higher mortality rate. In the patients with septic shock, those carrying the TNF2 allele had a significantly higher mortality rate than those with the homozygous TNF1 genotype (92% vs. 62%, p < .05). In those who developed septic shock, the TNF2 allele was significantly associated with higher TNF levels.

CONCLUSION

In patients admitted to SICU with surgical infection, the frequency of TNF2 allele was higher than in the general population. SICU patients with TNF2 allele did not show a higher incidence of developing septic shock, nor was there a higher baseline TNF-alpha level after infection. However, once septic shock had developed, the mortality rate was higher in those patients carrying the TNF2 allele.

Splenic abscess--a changing trend in treatment

Fifteen patients with splenic abscesses were evaluated between 1985 and 1995. The most common predisposing factors were remote infection, diabetes mellitus and heart disease. Common clinical presentations included leucocytosis, fever, left upper quadrant abdominal pain and left pleural effusion. Four patients with splenic abscesses smaller than 4 cm in diameter were treated with antibiotics alone, and 1 in this treatment group died. Among the 10 patients with splenic abscesses larger than 4 cm in diameter receiving percutaneous drainage, 9 (90%) were successfully cured, including 8 with unilocular abscesses and 1 with multilocular abscesses. Two patients underwent splenectomy. In conclusion, percutaneous drainage using ultrasound or computed tomography guidance may be recommended as the treatment of choice for splenic abscess larger than 4 cm in diameter. Antibiotics alone may sometimes be considered for splenic abscesses smaller than 4 cm in diameter. Splenectomy is reserved for those cases where medical treatment has failed.

Concomitant chemoradiation treatment in the management of patients with extrahepatic biliary tract recurrence of gastric carcinoma

BACKGROUND

The aim of this study was to determine the role of concomitant chemoradiation in the alleviation of obstructive jaundice in patients with extrahepatic biliary tract metastases from gastric carcinoma.

METHODS

Thirteen patients with good performance status who had obstructive jaundice resulting from extrahepatic biliary metastases after gastrectomy for gastric carcinoma were treated with palliative intent. Treatment consisted of insertion of a percutaneous transhepatic choledochal drainage (PTCD) catheter followed by external radiation up to a total dose of 40-60 grays in combination with chemotherapy (cisplatin 20 mg/m(2)/day, 5-fluorouracil 600 mg/m(2)/day, and leucovorin 90 mg/m(2)/day for 96 hours during the first and fifth weeks) on an outpatient basis.

RESULTS

The concomitant chemoradiation produced a good palliative effect in all 13 patients. Hyperbilirubinemia continued to improve after treatment, patients' clay-colored stool resolved within an average of 4 weeks (range, 2-6 weeks), and bilirubin levels returned to normal. The PTCD catheter could be removed after treatment was completed (the seventh week); the mean duration of PTCD placement was 2 months. The entire treatment course was performed on an outpatient basis; hospital admission was necessary only for PTCD insertion and chemotherapy. Ten patients died of their disease, with an average survival of 14.4 months (range, 4-31 months) from the time of PTCD insertion. Three patients are still alive at 16, 21, and 8 months. Biliary tract patency was maintained until death. No serious treatment-related complications occurred, and no endoprothesis or intraluminal brachytherapy was needed in this study.

CONCLUSIONS

Satisfactory palliation can be achieved by concomitant chemoradiation for patients with obstructive jaundice resulting from extrahepatic biliary metastases from gastric carcinoma, providing an alternative treatment choice for these patients.

Variations of the cystic artery in Chinese adults

The origin and course of the cystic artery related to the Calot triangle were studied in 72 autopsies. The cystic artery arises from many possible origins; the right hepatic artery is the most common origin (76.6%). The Calot triangle (hepatocystic triangle), which is an important imaginary referent area for biliary surgery, is bounded by the common hepatic duct (CHD), the cystic duct, and the cystic artery. Of all the cystic arteries, 86.1% coursed through the Calot triangle, and 100% of the cystic arteries originating from the right hepatic artery coursed through the Calot triangle. However, only 54% of the cystic arteries that originated from the left, bifurcation, proper, and common hepatic arteries ran through the triangle. None of the cystic arteries that originated from the gastroduodenal, celiac, superior mesentery, or superior pancreaticoduodenal arteries passed through the triangle. Furthermore, 72.7% of the cystic arteries that originated from the right hepatic artery ran beneath the CHD as they entered the Calot triangle; the others ran anterior to the CHD. Of the cystic arteries that arose from locations other than the right hepatic artery, 29.4% ran posterior to the CHD, and 11.8% ran anterior to the CHD. The current study provides detailed information about anatomic variance in Chinese adults that may help avoid injury during open or laparoscopic cholecystectomies.

Prognostic significance of heat shock protein-27 expression in hepatocellular carcinoma and its relation to histologic grading and survival

BACKGROUND

The expression of heat shock protein-27 (HSP-27) has been detected in some human tumors. In this study the authors investigated HSP-27 expression in patients with hepatocellular carcinoma (HCC) and examined its prognostic significance.

METHODS

Expression of HSP-27 was studied in 58 HCC and adjacent noncancerous liver tissues by immunohistochemical stain. The relation between its expression and eight known prognostic factors was evaluated.

RESULTS

Of the 58 HCC tissues studied, the presence of HSP-27 was demonstrated in 45 tissues (77.6%); low expression (</= 25%) was demonstrated in 17 tissues and high expression (> 25%) was demonstrated in 28 tissues. A significantly higher distribution of HSP-27 expression in HCC tissues compared with adjacent noncancerous liver tissues was obtained (P < 0.0001). Patients with high HSP-27 expression had a significantly higher histologic tumor grade than those with low HSP-27 expression (P = 0.001). The 5-year disease free survival rate of patients with high HSP-27 expression was 21.4% versus 59.3% for patients with low HSP-27 expression (P < 0.001). A similar relation was observed with overall survival (33.3% vs. 64. 8%; P = 0.009). HSP-27 expression was also identified to be a significant and powerful prognostic indicator for disease free survival (odds ratio = 2.25; P = 0.034) and for overall survival (odds ratio = 2.72; P = 0.015).

CONCLUSIONS

The current study data suggest that HSP-27 expression is a powerful prognostic indicator and is related to histologic grade and survival of patients with HCC.

Clinical significance of microscopic tumor venous invasion in patients with resectable hepatocellular carcinoma

BACKGROUND

Tumor venous invasion in patients with resectable hepatocellular carcinoma (HCC) is frequent and can be macroscopic and microscopic or microscopic alone. Although macroscopic invasion is a well-established prognostic indicator, the clinical significance of microscopic invasion remains unclear.

METHODS

There were 322 patients enrolled who had undergone curative resection for HCC. The clinicopathologic factors and prognostic significance associated with macroscopic and microscopic venous invasion were analyzed.

RESULTS

Macroscopic invasion was observed in 50 patients (15.5%) and microscopic invasion in 190 (59.0%). The larger the tumor, the more the incidence of venous invasion. There were 140 patients with microscopic invasion only (Group 1). Patients with macroscopic invasion (Group 2, n = 50) also had microscopic invasion. Compared with patients without venous invasion (Group 3, n = 132), Group 1 had a higher alpha-fetoprotein level, a larger tumor size, and more tumors without encapsulation. For group 1, the 1-, 3-, and 5-year disease-free survival rates were 65.6%, 41.6%, and 30.8%, respectively. The 1-, 3-, and 5-year overall survival rates were 87. 8%, 60.0%, and 52.7%, respectively. The survival rates of group 1 were lower than those of group 3 and higher than those of group 2 (P <.05). Multivariate analysis indicated that microscopic and macroscopic venous invasion, surgical margin, indocyanine-green retention, and tumor size and number were significant predictors of postresectional survival.

CONCLUSIONS

In HCC patients, microscopic venous invasion is frequent and related independently to postresectional outcome.

Prospective case-controlled trial of adjuvant chemotherapy after resection of hepatocellular carcinoma

Recurrence of hepatocellular carcinoma (HCC) after curative hepatic resection is frequent and is an important factor adversely influencing long-term survival. The role of postoperative chemotherapy in the reduction of tumor recurrence rate is still controversial. During the period of 1992-1995 a series of 49 patients who underwent curative resection of HCC and had at least one risk factor of tumor recurrence were followed in this prospective study. Patients were allocated to adjuvant chemotherapy and control groups. Twenty-four patients received a combination of low dose intravenous epirubicin (20 mg/m2) and mitomycin (5 mg) monthly for seven courses starting 5 to 6 weeks after surgery. Twenty-five patients had no adjuvant treatment. The disease-free and overall survivals were compared for the two groups. A total of 154 courses of chemotherapy were given to the 24 patients. The chemotherapy-related side effects were mild and tolerable with no mortality. At a median follow-up of 39 months (range 9-71 months), 9 patients in the adjuvant chemotherapy group and 16 patients in the control group developed tumor recurrence. The respective 1-, 2-, 3-, and 5-year disease-free survival rates were 75%, 67%, 63%, and 63% for patients in the adjuvant chemotherapy group and 68%, 42%, 37%, and 32% for patients in the control group (p = 0.0575). The 1-, 2-, 3-, and 5-year overall survival rates were 100%, 96%, 77%, and 72% in the adjuvant chemotherapy group and 92%, 67%, 63%, and 51% in the control group (p = 0.0746). In conclusion, postoperative adjuvant chemotherapy using the present regimen has a tendency to reduce tumor recurrence rate and may improve long-term survival for high risk patients.

Perioperative safety and prognosis in hepatocellular carcinoma patients with impaired liver function

BACKGROUND

The benefits of liver resection for hepatocellular carcinoma (HCC) patients with concomitant impaired liver function were often considered questionable because of poor postoperative prognosis. This study will clarify whether an acceptable operative risk exists and whether limited resection will compromise the outcomes of these patients.

STUDY DESIGN

Between July 1991 and December 1996, a total of 168 patients with HCC who underwent hepatectomies were enrolled and divided into normal (group A) and impaired (group B) liver function groups according to the value of indocyanine green retention rate at 15 minutes. Clinical features, surgical related features, pathologic features, and disease-free and overall survivals were compared between the groups.

RESULTS

Operative morbidity and mortality in group A were 27.3% and 1.6%, and in group B were 40.0% and 2.5%, respectively (p = 0.129 and 0.506). Disease-free survival and overall survival at 5 years in group A were 43.2% and 59.6%, respectively, and in group B they were 30.6% and 56.8%, respectively (p = 0.607 and 0.378).

CONCLUSIONS

Limited liver resection is safe and provides favorable prognosis in HCC patients with concomitant impaired liver function.

Preferentially deleted chromosome region 9p21 in large hepatocellular carcinomas

The role of somatic deletions in chromosome 9 and chromosome 22 loci in hepatocellular carcinomas (HCC) was studied. Twenty-one paired HCC and adjacent tumor-free liver tissue samples were examined for loss of heterozygosity at six chromosome 9 and ten chromosome 22 loci. Among informative cases, the highest LOH rates were observed at 9p21 (40% or 4/10 at IFNA) and 9q23 (23% or 3/13 at D9S318). Our observed LOH rate at 9p21 was significantly higher than the background level previously reported for the same tumor type. Clinical data indicate that chromosome 9p21 deletions occurred preferentially in larger tumors (>5 cm diameter). However, a sequence analysis of the MTS1 gene coding region in cases of 9p21 LOH did not reveal any change, suggesting another tumor suppressor gene as the LOH target.

Telomerase activity correlates with cell cycle regulators in human hepatocellular carcinoma

AIMS/BACKGROUND

Mutation in cell cycle genes is the most common genetic change in malignant tumor cells. Telomerase activation, considered as essential in the immortality of cancer cells, is found in most cancers, where there may be an association with an active cell cycle.

METHODS

In this study study we used the TRAP assay to determine telomerase activity in liver tumor specimens from 25 cases of hepatocellular carcinoma (HCCs) as well as in corresponding non-cancerous liver tissue in each patient. The expression of cyclin D1, cdk2, and cdk4 protein was also examined by Western blot.

RESULTS

Twenty-one of the 25 cases of HCC were found to have increased telomerase activity, whereas only five out of the 25 non-cancerous liver samples were found to have weak telomerase activity. Telomerase activity was not found to be related to tumor size, HBsAg, HBeAg, anti-HCV, transaminase, or alpha-fetoprotein serum titer. Furthermore, three out of the 25 cases of HCC showed cyclin D1 overexpression, whereas 15 of the 23 cases of HCC showed decreased cyclin D1 expression. Down regulation of cyclin D1, cdk2, cdk4 protein correlated with telomerase activity (p<0.004, p<0.013, and p<0.001 respectively).

CONCLUSION

The results indicate that genetic defects in HCC facilitate the reactivation of telomerase activity, a process which may be dependent on cyclin D1 with its cyclin dependent kinase (cdk) partner defect.