Survival of patients with initially unresectable colorectal liver metastases treated with FOLFOX/cetuximab or FOLFIRI/cetuximab in a multidisciplinary concept (CELIM study).

BACKGROUND: Initially, unresectable colorectal liver metastases can be resected after response to chemotherapy. While cetuximab has been shown to increase response and resection rates, the survival outcome for this conversion strategy needs further evaluation. PATIENTS AND METHODS: Patients with technically unresectable and/or ≥5 liver metastases were treated with FOLFOX/cetuximab (arm A) or FOLFIRI/cetuximab (arm B) and evaluated with regard to resectability every 2 months. Tumour response and secondary resection data have been reported previously. A final analysis of overall survival (OS) and progression-free survival (PFS) was carried out in December 2012. RESULTS: Between December 2004 and March 2008, 56 patients were randomised to arm A, 55 to arm B. The median OS was 35.7 [95% confidence interval (CI) 27.2-44.2] months [arm A: 35.8 (95% CI 28.1-43.6), arm B: 29.0 (95% CI 16.0-41.9) months, HR 1.03 (95% CI 0.66-1.61), P = 0.9]. The median PFS was 10.8 (95% CI 9.3-12.2) months [arm A: 11.2 (95% CI 7.2-15.3), arm B: 10.5 (95% CI 8.9-12.2) months, HR 1.18 (95% CI 0.79-1.74), P = 0.4]. Patients who underwent R0 resection (n = 36) achieved a better median OS [53.9 (95% CI 35.9-71.9) months] than those who did not [21.9 (95% CI 17.1-26.7) months, P < 0.001]. The median disease-free survival for R0 resected patients was 9.9 (95% CI 5.8-14.0) months, and the 5-year OS rate was 46.2% (95% CI 29.5% to 62.9%). CONCLUSIONS: This study confirms a favourable long-term survival for patients with initially sub-optimal or unresectable colorectal liver metastases who respond to conversion therapy and undergo secondary resection. Both FOLFOX/FOLFIRI plus cetuximab, appear to be appropriate regimens for 'conversion' treatment in patients with K-RAS codon 12/13/61 wild-type tumours. Thus, liver surgery can be considered curative or alternatively as an additional 'line of therapy' in those patients who are not cured. CLINICAL TRIAL NUMBER: NCT00153998, www.clinicaltrials.gov.

The influence of downstream arterial perfusion parameters on doppler pulsatility index and resistance index in an in-vitro perfusion model.

BACKGROUND: To investigate in vitro how downstream perfusion parameters influence pulsatility index (PI), resistance index (RI) and their constituting Doppler velocities. MATERIALS AND METHODS: We analyzed the influence of resistance, compliance, reflection coefficient and input impedance on PI and RI in an in-vitro model of arterial flow. RESULTS: The nominators of PI and RI were determined by resistance. The numerators were determined by compliance and by the reflection coefficient. There were close relationships of PI and RI with resistance under the condition of constant compliance, but not when compliance was variable. CONCLUSION: PI and RI consist of velocity terms which are independently influenced by different parameters of impedance: compliance, reflection coefficient and resistance. These findings explain the contradictory results reported for the relationship between the indices and peripheral resistance in studies where compliance and reflection effects were not considered.

Generation of survivin-specific CD8+ T effector cells by dendritic cells pulsed with protein or selected peptides.

The identification of tumor-associated antigens recognized by CD8+ cytotoxic T cells paved the way to new concepts in adjuvant anticancer therapy. However, the number of tumor-associated proteins found to be expressed in the majority of human cancers is still rather limited. Recently, the newly identified apoptosis inhibitor protein survivin has been recognized as a widely occurring tumor-associated protein. In the present study, we demonstrate that survivin is capable of inducing specific CD8+ effector T cells in vitro. T cells from healthy donors were subjected to several cycles of stimulation by autologous dendritic cells (DCs) pulsed with soluble recombinant survivin protein. Activation of CD8+ cytotoxic T cells by survivin-derived peptides cross-presented by DCs was demonstrated by lysis of autologous survivin-expressing B cell transfectants. Using a peptide-motif scoring system, two survivin peptides (ELTLGE-FLKL and TLPPAWQPFL) were predicted and proved to bind to the HLA-A*0201 molecule. Both peptides were shown to induce CD8+ effector T cells when presented on DCs; one peptide could be verified to result from natural intracellular processing of survivin. These findings recommend survivin as a new and widely applicable target for protein- and peptide-based immunotherapy of tumors.

Newcastle disease virus-infected intact autologous tumor cell vaccine for adjuvant active specific immunotherapy of resected colorectal carcinoma.

An active specific immunization (ASI) procedure with two types of autologous tumor cell vaccines (ATVs) is tested for adjuvant immunotherapy of resected colorectal carcinoma to provide preliminary information on local immunological skin responses, side effects, and 2-year survival rates. For vaccine preparation, the tumor-derived freshly isolated and cryopreserved cells were thawed, purified by Percoll density centrifugation, and depleted of tumor-infiltrating lymphocytes by immunomagnetic beads. After inactivation by 200 Gy, the cells of this ATV were either infected by Newcastle disease virus (NDV) or they were admixed with Bacillus Calmette Guérin (BCG) organisms. Vaccination was performed in the arm beginning 6-8 weeks after operation, three times at 2-week intervals. Of 57 patients that received ASI, 48 were treated by virus-infected ATV (ATV-NDV) and 9 were treated with the BCG-admixed vaccine (ATV/BCG). The mean value of delayed hypersensitivity skin reactions from ATV-NDV-treated patients was 18 mm for the first vaccination and 26 and 29 mm for the succeeding ones. Although the application of ATV-NDV was associated with only mild side effects, the ATV/BCG vaccine led to long-lasting ulcers and to more serious side effects. The 2-year survival rate obtained with ATV-NDV was 97.9%, whereas the survival rate with ATV/BCG was 66.7%. The mean survival of 661 patients from a historical control was 73.8%. These data suggest that the type and quality of the tumor vaccine for ASI treatment is important. The findings with ATV-NDV necessitate corroboration in a prospective, randomized controlled study.

New ELISA for quantitation of human urokinase receptor (CD87) in cancer.

The serine protease urokinase-type plasminogen activator (uPA), its inhibitor (PAI-1), and its receptor (uPAR; CD87) facilitate cancer cell invasion and metastasis. Whereas uPA and PAI-1 antigen levels determined in tumor tissue extracts of breast cancer patients correlate with disease recurrence and overall survival, the prognostic relevance of uPAR is still a matter of debate. We established two new sandwich-type enzyme-linked immunosorbent assay (ELISA) formats (HU/IIIF10-ELISA and HU/HD13-ELISA) using the epitope-defined monoclonal antibody (mAb) IIIF10 or the conformation-dependent mAb HD13.1, a polyclonal chicken antibody (HU277), and recombinant soluble uPAR (CHO-suPAR) as the standard. The lower detection limit of the assays was at 0.16 ng/ml, with a linear dose-response up to 5 ng/ml of uPAR antigen. Both ELISA formats showed good reproducibility and recovery. The intra-assay and the inter-assay variation coefficients were respectively 4.3% and 11.7% (HU/IIIF10-ELISA) and 4.0% and 10.7% (HU/HD13-ELISA). The recovery rate of uPAR in cell lysates spiked with CHO-suPAR was above 82% and 88%, respectively. With these new ELISA formats, uPAR antigen content in breast cancer tissue extracts and tumor cell lysates was determined and compared to a commercially available ELISA (ADI-ELISA). By all of the three uPAR ELISA formats CHO-suPAR and uPAR present in lysates of non-malignant epithelial cells and stimulated monocytes were quantified with similar sensitivity. Interestingly, in breast cancer cell lines of epitheloid origin a higher uPAR antigen content was determined by the HU/IIIF10-ELISA than the HU/HD13- or ADI-ELISA formats. In lysates of fibroblastic breast cancer cell lines similar uPAR values were obtained with the HU/IIIF10- and ADI-ELISA formats, whereas with the HU/HD13-ELISA significantly lower uPAR concentrations were determined. The prognostic relevance of tumor uPAR antigen was evaluated in 199 primary breast cancer patients with a median follow-up of 24 months. uPAR antigen values above the cut-off of 3.33 ng/mg protein as determined by the HU/IIIF10-ELISA were significantly correlated with short disease-free survival (p=0.025). Results obtained by the other two ELISA formats (HU/HD13-ELISA and ADI-ELISA) were not associated with prognosis. Our findings stress the need of well-characterized antibodies, which detect both uPAR of non-malignant and tumor cells, in setting up a uPAR-ELISA useful for assessing breast cancer patient prognosis.

Comparison of the ECL-cell frequency in the stomachs of 3 different rat strains.

Three different rat strains, Sprague-Dawley, Wistar and Fischer 344, were treated for 3 months with 2 doses (0.8; 4 mg/kg) of the gastric acid suppressing ATPase inhibitor pantoprazole. The gastrin levels were determined, the height of the mucosa measured and the number of enterochromaffin-like (ECL) cells counted. Because these cells were stained according to the method of Grimelius they were designated as GPC (Grimelius positive cells). Under 4 mg/kg, the gastrin levels were increased 8 hours after administration, but fell again after 24 h. The Fischer rats showed the highest value. Also the height of the mucosa was increased under 4 mg/kg. A trend towards an increased mucosal height was noticeable even at 0.8 mg/kg. The number of GPC was determined in 2 ways: 1) without taking the mucosal height into account, 2) taking the height into account. An increase in GPC was observed at 4 mg/kg with both methods.

Ultrastructural investigations of the enterochromaffin-like (ECL) cells in three different rat strains (Sprague-Dawley, Fischer 344, Wistar) after treatment with the H+,K(+)-ATPase inhibitor pantoprazole.

The purpose of the present study was the evaluation of ultrastructural characteristics of the enterochromaffin-like (ECL) cells in the fundic mucosa of three different rat strains without treatment and after treatment with the H+, K(+)-ATPase inhibitor pantoprazole. In the study, 20 one year old female Sprague Dawley (SD), Fischer 344 (F) and Wistar (W) rats each were treated orally for three months with 4 mg pantoprazole/kg/d or with the vehicle only. The control animals showed close conformity of ECL cell density and morphology in all three strains. Treatment with pantoprazole led to a significant increase in serum gastrin concentration and GPC density in all strains. However, the electron microscopically determined ECL cell density was markedly increased in the SD strain only. Ultrastructurally all treated rats showed activation of the ECL cells, and enhanced histamine release. The SD and F strains had an enhanced proportion of large ECL cell granules, with the F rats also showing an increased granule density. In contrast, the treated W rats were found to have a lower granule density and a higher proportion of small and medium sized granules compared to their controls.

[Pathophysiology and clinical aspects of ischemia-reperfusion damage to skeletal muscles]. / Pathophysiologie und Klinik des Ischämie-Reperfusions-Schadens an der Skelettmuskulatur.

Ischemia/reperfusion-injury of skeletal muscle--pathophysiology and clinical implications. Ischemia and reperfusion of skeletal muscle occurs in acute vascular occlusion and revascularisation, in elective vascular surgery, in orthopedic surgery by means of a tourniquet, and in transplantation of muscle-containing cutaneous flaps. The ischemia sets up a cascade of events, which fully develops not prior to the moment of reperfusion. The ischemia-reperfusion-cascade is comparable to an overwhelming inflammatory reaction out of control. Depending on the duration of ischemia it prompts an injury for the muscle itself, and in some cases for the whole body. The present review discusses the main mechanisms of ischemia/reperfusion-injury in terms of cellular metabolism, endothelial function, cytokine release, and leucocyte function. Release of toxic oxygen radicals by activated leucocytes plays the pivotal role in this reaction. In addition, the clinical manifestations of ischemia/reperfusion will be reviewed as well as some of the means proposed to control this harmful reaction.

[Peripheral aneurysm of the hepatic artery as the etiology of acute upper gastrointestinal hemorrhage]. / Peripheres Aneurysma der Arteria hepatica als Ursache einer akuten oberen Gastrointestinalblutung.

We report the case of a 64-year-old female with an intrahepatic aneurysm of the right hepatic artery. Initially uncharacteristic upper abdominal symptoms were followed by repeated upper gastrointestinal bleeding and, eventually, hemorrhagic shock. Finding the cause of severe hematemesis was challenging due to a previous Billroth-II gastric resection. Delayed diagnosis of hemobilia necessitated coeliacography, whereby an intrahepatic aneurysm of the right hepatic artery was found and, during the same session, super-selective embolization was achieved. If the cause of upper abdominal complaints remains unknown after routine diagnostic measures and the origin of bleeding in the upper gastrointestinal tract cannot be identified, aneurysms of abdominal arteries should be considered. Hemobilia of unknown etiology should always be an indication for coeliacography. The superselective angiographic embolization of intrahepatic aneurysms is a promising form of treatment with low risk.

[Clinical significance of cytokines Il-6, Il-8 and C-reactive protein in serum of patients with acute pancreatitis]. / Klinische Bedeutung der Cytokine IL-6, IL-8 und des C-reaktiven Proteins im Serum von Patienten mit akuter Pankreatitis.

The detection of cytokines may elucidate the pathophysiological mechanisms that produce early systemic complications in acute interstitial (i) or necrotizing (n) pancreatitis (AP). The increase in the level of cytokines in the blood of patients with AP may correlate with the severity of the disease. In a prospective clinical trial from October 1992 to August 1993, 23 patients with AP were recruited and blood samples taken for cytokine detection by commercially available Elisa kits and C-reactive protein (CRP) by laser nephelometry. Six of 11 patients with nAP died either early (n = 1) or of late septic complications. None died of iAP. The peak of cytokine and CRP level in the first 3 days of hospitalization was used for calculation. The IL-6 concentration in the blood reached up to 2600 pg/ml in the 1st few days, depending on the severity of AP, and dropped to almost zero in the next days, independently of the clinical course. The differentiation of i- versus nAP, using a cut-off line of 600 pg/ml, was correct in 20 patients [87%, sensitivity (SE): 82%, specificity (SP): 91%, P < 0.001]. The blood levels of IL-8 reached a maximum of 1381 pg/ml in the 1st few days, depending on the severity of AP, and showed a correlation with the clinical course in the following days. The peak of IL-8 blood levels indicated correctly the severity of AP in 18 out of 23 patients using a cutoff level of 200 pg/ml (accuracy: 78%, SE: 82%, SP: 75%, P < 0.01). The CRP levels increased up to a maximum of 535 mg/l and indicated the course of AP correctly in 18 out of 22 patients (SE and SP 82%, P < 0.01). There was no correlation between cytokine blood levels and mortality. In the blood samples of five patients with i- or nAP, no TNF-alpha was detectable. The blood levels of IL-6, and to a lesser extent of IL-8 and CRP, can predict the severity and early systemic complications of AP. The excessive rise in cytokines can be explained by the stimulation of immunological cells (macrophages, lymphocytes and endothelial cells) in the course of AP, inducing early systemic complications.

[Does selenium prevent peroxynitrite formation from NO in vascular surgery interventions? A clinical study]. / Verhindert Selen die Peroxynitritbildung aus NO bei gefässchirurgischen Eingriffen? Eine klinische Studie.

Nitric oxide seems to play a protective role in the pathogenesis of arteriosclerosis. It appears to protect the tissue during reperfusion in vascular surgery. High values of NO show an inverse correlation to the severity of arteriosclerosis. In our opinion selenium should be substituted in order to enhance the activity of the glutathione peroxidase. This means an effective protection against the high production of peroxinitrite in patients with arteriosclerosis. A comparison of the corresponding redox pairs SeO3(2-)/SeO4(2-) and HOONO/HONO allows the conclusion that sodium selenite can be a direct antioxidant thereby.

Routine peri-operative management of the diabetic patient.

Many aspects of peri-operative management of the diabetic patient remain controversial, although there are a variety of approaches towards management. These patients are at risk for certain complications related to the severity and chronicity of the disease. The surgeon and the anaesthetist must be conversant with the management of diabetes in elective and emergency situations. Reasonable metabolic control can be achieved within a few hours pre-operatively and clinical assessment can be performed on an out-patient basis. Anaesthetic management consists of assessment of the control of the disease followed by evaluation of diabetic complications and their severity. Different views are expressed regarding tight control of blood glucose level (4-8 mmol/l) versus moderate control (8-12 mmol/l) when managing diabetic patients. The importance of guarding against factors favouring metabolic decompensation in the peri-operative period, is stressed. Minor or major surgery has important implications regarding the management of diabetes. All patients scheduled for major surgery should be treated with intravenous insulin. Blood sugar should be monitored at regular intervals to protect the patient against hypoglycaemia. Emergency surgery is usually associated with an infectious process. Pronounced hyperglycaemia, dehydration and metabolic derangement may be present. The underlying pathology may aggravate the diabetic state and surgery may actually improve the patient's condition. It is unnecessary to postpone surgery to treat ketosis fully, because this may need 12-24 hours. Extreme insulin resistance and greater insulin requirements are present during cardiopulmonary bypass, hypothermia and rewarming. Beware of severe hypoglycaemia after cardiopulmonary bypass.

Diabetic complications with special anaesthetic risk.

Diabetes mellitus leads to acute and chronic complications. Acute complications include hypoglycaemia, diabetic keto-acidosis, hyperglycaemic hyperosmolar non-ketotic syndrome and lactic acidosis. Chronic complications are neuropathies, nephropathy, retinopathy, peripheral arterial disease, cerebrovascular disease, coronary artery disease, cardiomyopathy, hypertension, infection, delayed wound healing and stiff joint disease. End-organ pathology is in part responsible for the increased morbidity and mortality seen in diabetic patients in the peri-operative period. A thorough pre-operative search for end-organ pathology is essential to optimise patient management. Relevant diabetic complications and their anaesthetic risk are discussed.

Matrix metalloproteinase 2 polymorphisms in a caucasian population with abdominal aortic aneurysm.

BACKGROUND: The formation of sporadic abdominal aortic aneurysm (AAA) is explained by remodeling of the extracellular matrix (ECM) and breakdown of structural components of the vascular wall. Matrix metalloproteinase 2 (MMP2) is one of the principal matrix-degrading proteases and is known to play a major role in the remodeling of the extracellular matrix in arterial vessels. Increased MMP2 expression in the extracellular matrix of the walls of AAAs has been shown in several studies. To investigate the possible impact of genetic variants of the MMP2 gene in the etiology of AAA, we conducted this case-control study. PATIENTS AND METHODS: We analyzed MMP2 single-nucleotide polymorphisms (SNPs) in 51 patients with AAA and 48 controls. Differences in genotype and allele frequencies of identified polymorphisms were determined after sequencing the entire coding region and three selected parts of the promoter. RESULTS: Eighteen polymorphisms were identified, 6 of which are newly described, with 3 located in the introns (c.IVS1+31C>G, c.IVS7-18G>A, c.IVS10+26C>T) and 3 located in the coding region (c.124G>A, c.1368C>T, c.1860C>T). There were no statistically significant differences in genotype or allele frequencies between the two groups. CONCLUSIONS: Our analysis of the entire coding region and three parts of the promoter of the MMP2 gene failed to show an association between genetic polymorphisms and AAA, suggesting that variations in the MMP2 gene do not contribute to the development of AAA.

Granulomatous inflammation of the oropharyngeal cavity as a possible cause for unexpected high mortality in a Fischer 344 rat carcinogenicity study.

An unexpected, high, test-substance-unrelated mortality has been found predominantly in female Fischer 344 rats of a 2-year gavage carcinogenicity study, which is still in the active phase. Most of the dead animals (53%) had an impacted food or bedding bolus in the oropharyngeal cavity. Histologic evaluation of this area revealed a calcified, granulomatous inflammation of the sero-mucinous glands (60%), frequently accompanied by papillary projections (50%) into the lumen. Additionally, decentral islet formation of the tracheal cartilage was evident in all animals examined. We assume that the partial blockage of the oropharyngeal lumina was the cause of death, because other possible factors were ruled out. To detect a possible strain-related predisposition, Fischer 344 and Sprague Dawley rats that had been used for technician gavage training were studied. Granulomas and papillary projections, as well as the decentral islet formation in the tracheal cartilage, however, were found in gavaged Fischer 344 but not Sprague Dawley rats. We consider the high mortality to be related to three factors: a predisposition of the Fischer 344 rat strain, an unphysiological pH of the solvent (pH 10), and chronic irritation due to an inflexible, metallic gavage tube.

[Radiofrequency ablation of liver tumours]. / Hochfrequenz-Thermoablation bei Lebertumoren.

BACKGROUND: A variety of local treatment modalities exists for the palliative therapy of inoperable primary or secondary liver tumours. In this connection the promising use especially of thermal ablation methods has been reported recently. Numerous procedures and technical terms have been mentioned in this context giving us the opportunity of a review on this subject. METHODS: From the literature of the last five years (Medline/PubMed) including the lists of references physical principles and application techniques, indications and contraindications, possibilities of evaluation and results of high frequency thermotherapy (HFTT) respectively radiofrequency ablation (RFA) were investigated and compared to our own first experiences. Survival and recurrence rates were estimated from the study results. RESULTS: Most authors describe the HF-thermoablative treatment as a technically uncomplicated and relatively low-risk procedure. After a mean follow-up of about 10 months the mean survival rate was about 90 % and tumor recurrence was seen in approximately 30 % of the patients. The main problems occurred in view of the complete registration of all tumors with imaging techniques before RFA and the complete ablation, especially of larger tumours. CONCLUSIONS: In most of the clinical studies RFA promises an advantage of survival and improvement of quality of life compared to the known courses of untreated liver tumours. Therefore this method should be practiced on a larger scale in suitable patients. At the same time its efficacy must be proven by comparative studies.

[Management of abdominal stab injuries]. / Management abdomineller Stichverletzungen.

This is a retrospective study of 56 abdominal stab wounds analysed with reference to aetiology, pattern of injury, diagnostic and therapeutic procedures and indications for surgery. Indications for mandatory laparotomy were a manifest haemorrhagic shock (n = 20), evisceration (n = 13) and persisting presence of a weapon in the abdomen (n = 2). All patients who did not undergo immediate surgery were observed closely in repeated physical examination, in some cases complemented by ultrasound examination or peritoneal lavage. The indications for surgery were then based on the development of clinical signs. As a result of this selective approach, 31 patients underwent surgery immediately, 21 patients within 4 h and 4 patients more than 4 h after the initial assessment. The unnecessary laparotomy rate was 10.8%. The mortality rate was 3.5%, but in no case did death result from the selective approach.