[A patient with small-cell carcinoma of the esophagus with synchronous liver metastasis surviving 48 months after surgery]

Small-cell carcinoma of the esophagus is regarded as having a poor prognosis with frequent and early systemic metastasis. Recently, several reports have described small-cell carcinoma satisfactorily treated by chemotherapy and radiation therapy combined with surgery. We herein report a patient with small-cell carcinoma of esophagus with synchronous multiple liver metastasis who survived 44 months after surgery. A 70-year-old man was found to have a polypoid lesion at the abdominal esophagus by upper gastrointestinal endoscopy. A biopsy specimen of the lower esophagus demonstrated undifferentiated carcinoma of the esophagus. Ultrasonographic investigation demonstrated solitary SOL in the liver. The patient underwent a total gastrectomy and lower esophagectomy by an abdominal approach. As ultrasonographic evaluation during laparotomy revealed multiple liver metastases, a hepatic artery infusion catheter was inserted into the proper hepatic artery. A pathological study of the resected esophagus and a biopsy specimen of the liver revealed undifferentiated cell carcinoma of the esophagus (small-cell type). During hospitalization, hepatic artery infusion therapy (CDDP 20 mg/4 h and 5-FU 750 mg/5 h) was given for 4 days starting on days 14 and 28. After chemotherapy, liver metastasis could not be detected by ultrasonographic investigation. At the outpatient clinic bi-weekly hepatic artery infusion of 5-FU (1,500 mg/body/5 h) was continued for 30 months. The patient is alive 48 months after surgery without any evidence of recurrence.

[A case of advanced gastric cancer with multiple liver metastases partially responding to combination intra-arterial chemotherapy via the hepatic artery and abdominal aorta]

A 57-year-old female diagnosed with advanced gastric cancer with multiple organ metastases was treated by various intra-arterial chemotherapies. After surgical resection of the tumor, adjuvant chemotherapy was carried out. Continuously administered 5-fluorouracil of 250 mg/day made it possible to control the growth of the liver metastases. Extrahepatic metastases were kept under control by administering 30 mg of methotrexate, 750 mg of 5-fluorouracil and 30 mg of Leucovorin per/day/week, and 60 mg/day biweekly of cisplatinum via an abdominal artery infusion port. Owing to this multiple infusion route and chemotherapy regimen, the patient lived for 18 months after her first diagnosis of gastric cancer with multiple liver metastases. Although liver metastases may respond to hepatic arterial infusion chemotherapy, extrahepatic metastases lead to poor prognosis. Given the above results, intra-abdominal aorta chemotherapy may be effective for extrahepatic metastases since this method gives high concentration of the anticancer agents at tumor sites with a low incidence of side effects.

[Pharmacokinetic study of the intraperitoneal administration of CPT-11 for patients with peritoneal seedings of gastric and colonic cancers]

We studied the pharmacokinetics of the intraperitoneal administration of CPT-11 for four patients with peritoneal metastasis (2 gastric cancer cases, 2 colon cancer cases). CPT-11 was administrated in a dose of 40-60 mg and the intraperitoneal and serum levels of CPT-11, SN-38 and SN-38 glucuronized (SN-38 Glu) were measured periodically. Intraperitoneal therapy with CPT-11 was effective for the control of malignant ascites. No serious side effects were observed. The levels of CPT-11, SN-38 were no different 30 min afterwards the administration of CPT-11 either intraperitoneally or intravenously. The high concentration of CPT-11 was achieved with intraperitoneal therapy and a small fraction of CPT-11 changed into SN-38 in the abdominal cavity.

[Pharmacokinetics of "subselective" arterial infusion chemotherapy]

Arterial infusion chemotherapy is mainly used for lymph node and peritoneal metastases. Generally, it is said that the concentration of a drug in abdominal organs is higher with arterial infusion chemotherapy than that with systemic chemotherapy. In this study, the pharmacokinetics of arterial infusion chemotherapy for a patient who had an arterial infusion port for lymph node metastasis and peritoneal metastasis, and a hepatic arterial infusion port for liver metastasis, was evaluated. Sequential arterial infusion chemotherapy with methotrexate (MTX) and 5-FU was given. One hundred mg of methotrexate (MTX) was infused over 20 minutes into the aorta, followed by 750 mg of 5-FU over 10 minutes 2 hours later. Blood samples from a peripheral vein and hepatic artery were collected at 10, 20 and 125 minutes from the beginning of the arterial infusion chemotherapy. Then the serum concentration of MTX and 5-FU was examined. The serum concentration of MTX in the hepatic artery was 1.4 to 2.3 times higher than that in peripheral venous blood. The serum concentration of 5-FU in the hepatic artery was 4.9 to 6.0 times higher than that in peripheral venous blood. The serum concentration of drug in abdominal organ was higher with arterial infusion chemotherapy than with systemic chemotherapy. It would thus seem that the effect of arterial infusion chemotherapy is higher than that of systemic chemotherapy.

[Adjuvant short-term continuous hepatoarterial infusion of 5-FU for advanced colorectal cancer using a removable hepatoarterial catheter]

We devised a removable hepatoarterial catheter which we then implanted in patients during colorectal operations, after first making sure this system worked well in an experiment with rabbits. We have applied this devise in 21 advanced colorectal cancer patients. The procedure to place the hepatoarterial catheter followed the resection of the colorectal cancer. A 16 G 30 cm TPN catheter was inserted into the gastroduodenal artery. This artery was ligated at two points with a double loop of elastic rubber threads (Elastik, Matsuda Suture, Tokyo). The catheter was fixed with Vicryl RAIDE (4-0). After the operation, 5-FU was continuously infused through the catheter for 2 weeks. We could remove the arterial catheter without any complications or bleeding after the chemotherapy was completed.

[Preoperative chemotherapy for advanced colorectal carcinomas--comparison of histological effect between 5'-DFUR + leucovorin tablet and 5'-DFUR alone]

The authors analyzed the histological effect of preoperative chemotherapy for 62 advanced colorectal cancer patients using resected specimens. Thirty-one patients in the 5'-DFUR + LV group received 800 mg/day of 5'-DFUR and 30 mg/day of leucovorin for 10-14 days just before the operations. Thirty-one patients in the 5'-DFUR group received 5'-DFUR 800 mg/day during the same period. None of the patients in either group developed any side effects. The results of the histological examination showed the number of Grade 1a and 1b cases in the 5'-DFUR + LV group was 22 (66.7%) and 5 (15.2%), respectively, and in the 5'-DFUR group 21 (65.6%) and 5 (15.6%). In the 5'-DFUR + LV group, 3 lesions showed Grade 2 histological degeneration, while there were no such lesions in the 5'-DFUR group. However, our results did not demonstrate any statistical difference between the two groups (p = 0.25, U test).

[Hepatic arterial injection therapy (HAI) for metastatic liver tumor from gastric cancer]

The results and problems of hepatic artery infusion therapy (HAI) for gastric carcinoma with synchronous liver metastasis were evaluated. The response rate of HAI with CDDP and 5-FU for metastatic liver tumor was 55% (1 CR + 5 PR/11). The median survival time for responders was 16.5 months, which was statistically longer than that of non-responders at only 5.5 months. Histologically, most responder cases were with AFP producing tumors and NSE positive tumors without distant lymph node involvement. Non-responder cases developed marked distant lymph node involvement besides the liver metastasis. Most of responder patients died of lymph node recurrence or distant metastasis other than liver tumor. It may be concluded that additional therapy to HAI is needed to improve the prognosis of gastric cancer patients with multiple liver metastases.

[Experimental study on CPT-11 intraperitoneal chemotherapy--metabolism of CPT-11 in malignant ascites]

The metabolism of CPT-11 in malignant ascites of gastric cancer patients with peritoneal seedings was studied in advance of the intraperitoneal chemotherapy of CPT-11 in humans. Malignant ascites and blood were drawn from gastric cancer patients. CPT-11 solution (20 mg/ml; 0.2 ml) was added into 3.8 ml ascites or plasma under 37 degrees C and CPT-11, SN-38 and SN-38GLU concentrations were measured with HPLC at times of 5, 30 and 60 minutes after addition of CPT-11. The change from CPT-11 to SN-38 was minimal not only in plasma, but also in malignant ascites. SN-38 GLU concentration was below the limit of measurement. This study showed that in malignant ascites, the enzymes such as carboxyesterase that convert CPT-11 to SN-38 were not present or minimal.

[Pharmaco-dynamic study of methotrexate (MTX) during intraperitoneal MTX/5-FU sequential therapy after gastric surgery]

A pharmaco dynamic study of Methotrexate (MTX) during intraperitoneal MTX/5-FU sequential therapy was carried out after gastric surgery. A comparative study of the route of MTX administration and its dose was also done. 1) Comparative study of the serum concentration of MTX between i.p. and i.v. administration revealed a similar MTX concentration except immediately after administration. 2) A comparative study of the serum concentration of MTX administered i.p. between patients with and without malignant ascites was conducted. Immediate elevation of the serum concentration of MTX was observed in patients without malignant ascites. On the other hand, the MTX concentration was slowly elevated and washed out in patients with malignant ascites. 3) The MTX concentration in the intraperitoneal fluid was compared between patient with and without malignant ascites. In patients without malignant ascites, MTX disappeared quickly from the intraperitoneal fluid. However, the MTX concentration lasted long in the malignant ascites cases. These results were similar with a low-dose MTX (30 mg/body) or moderate dose (100 mg/body). MTX/5-FU sequential i.p. therapy can thus be an effective treatment for patients after gastric surgery, though clearance of MTX was slow in cases with malignant ascites.

[Intrabiliary administration of doxorubicin for pancreaticobiliary cancer]

The effect and drug absorbtion of intrabiliary chemotherapy with Doxorubicin for pancreaticobiliary cancer with PTCD was investigated. Doxorubicin (DXR: 20 mg) was administered intrabiliary for 3 hours by PTCD catheter. Radiographic evaluation of the bile duct before and after chemotherapy and measurement of DXR concentration in the serum and bile were carried out.

RESULTS

Intrabiliary administration of DXR was completed without any significant complications other than epigastric pain. Radiographic study of the bile duct of a patient with pancreatic cancer who could successfully complete DXR administration showed improvement of bile duct passage. The placement of biliary stent could be achieved. Concentration of DXR in the serum after administration was below the lowest determinable level while those in the bile maintained a considerably high concentration 4 hours after the administration. With negligible absorption from bile, intrabiliary chemotherapy with DXR was thought to be an acceptable palliative treatment for pancreaticobiliary cancer.

One-point measurement of the peak-to-peak pulsatility index as an indicator for evaluation of infrainguinal bypass procedures

While duplex scanning has been advocated as the most accurate modality for postoperative graft surveillance, it is time-consuming for evaluating the entire graft. The aim of the present study was to determine which parameter predicts graft failure most simply and precisely, by examining 62 men and 1 woman who collectively underwent 71 infrainguinal arterial bypasses. A total of 212 scannings were obtained using a duplex scanner, and the peak systolic velocity (PSV), PSV ratio, and peak-to-peak pulsatility index (PPI) were analyzed. This analysis revealed 7 occlusions, 9 stenoses, and 1 arteriovenous fistula. When a PSV < 45 cm/s and/or a PSV ratio > 2.0 was defined as graft failure the sensitivity was 84.0% and the specificity was 81.8%: however, a PPI < 7.0 at the midgraft, indicating graft failure, showed a sensitivity of 100% and a specificity of 83.3%. The PPI exhibited better sensitivity and specificity than the PSV, even though the PPI needs only to be measured at the midgraft whereas the PSV should be measured at at least two points. Thus, we believe that the PPI could be the most useful and simple parameter to assess infrainguinal bypass grafts.

Chlamydia trachomatis peritonitis: report of a patient presenting spontaneous regression of ascites

A 36-year-old Japanese woman complained of right hypochondralgia followed by ascites. Paracentesis showed a turbid, straw-colored sterile exudate. Computed tomography and magnetic resonance imaging of the abdomen revealed a left periuteric mass and ascites. The mass and ascites spontaneously regressed within a month with no specific treatment. Later, after the patient had been discharged from hospital, immunofluorescence antibody titers for Chlamydia trachomatis were successfully determined using stored ascitic fluid and serum. Though the number of cases of Chlamydia trachomatis peritonitis has increased, few cases with ascites have been reported, and spontaneous regression of the ascites is also rare.

[The effect of the elastase on aminonucleoside nephrosis]

In this paper, we studied the effect of elastase on aminonucleoside (AN) nephrosis which is considered a model of focal glomerular sclerosis (FGS). Elastase is an enzyme which disintegrates elastin, discovered by Balo, and used in the treatment of arteriosclerosis and hyperlipidemia. It has also been known to improve metabolism of acid mucopolysaccharides, so, this study focused on metabolic improvement. Three groups of male Sprague-Dawley rats were studied and observed at regular intervals; 30, 60, 90 days. The ANE group (AN + elastase) was administered one shot of AN (10 mg/100 g B.W.) during the test interval, while elastase (5 mg/kg B.W.) was injected 5 days/week for the entire test interval. The AN group was administered one shot of AN only. The third group was a control (C). The following results were observed: (1) Focal segmental hyalinosis and sclerosis (FSHS); ANE group was weaker than AN group. (2) Other significant qualifying glomerular changes (vacuolar change and hyaline droplets of the epithelial cells, adhesion, and foam cells); ANE group was weaker than AN group. (3) Anion loss in GBM was shown by a lack of colloidal iron staining under light microscopy, and by a lack of PEI particles under electron microscopy; there was significantly less anion loss with ANE group, than with AN group. The findings suggest that elastase has an affect on the metabolism of acid mucopolysaccharide and collagen in sclerotic lesion, and may restrain the progress of amino-nucleoside nephrosis.