Should ruptured liver haemangioma be treated by surgery or by conservative means? A case report.

Spontaneous rupture of a liver haemangioma is a rare but life-threatening acute clinical situation following haemorrhage within the liver, the subcapsular space and the peritoneal cavity in cases of capsular rupture. Rupture of a liver haemangioma has been reported to occur spontaneously in the majority of cases. In the past, prompt surgical treatment was recommended but was associated with high morbidity and mortality. Currently, conservative management and, in cases of recurrent haemorrhage, delayed surgery may be proposed. We report a case of spontaneous rupture of hepatic haemangioma treated by arterial embolisation and conservative means. The literature is also reviewed.

[Treatment of peritoneal carcinomatosis from colorectal and appendiceal cancer by extensive cytoreductive surgery combined with hyperthermic intraoperative intraperitoneal chemotherapy]. / Traitement a visée curative des carcinoses péritonéales d'origine colorectale et appendiculaire par chirurgie maximaliste et chimiothérapie hyperthermique intrapéritonéale peropératoire.

Peritoneal carcinomatosis (PC) from colorectal cancer is a dreadful situation characterized by a rapid and mortal evolution (median survival of 5 to 7 months amongst the series published in the literature). The classical treatment includes systemic chemotherapy whether or not associated with palliative surgery. Since the early nineties, locoregional treatments combining extensive cytoreductive surgery with intraperitoneal hyperthermic chemotherapy have been developed, affording some patients a cure and yealding a 5-year survival as high as 30 to 40% in some series. However, it is associated with high morbidity and mortality rates.

Treatment of advanced digestive non-colon cancer with a weekly 24-h infusion of high-dose 5-fluorouracil modulated by folinic acid and cisplatin: an easy-to-use and well-tolerated combination.

The combination of 5-fluorouracil (5-FU) modulated by folinic acid (FA) and cisplatin is commonly used in advanced digestive non-colon cancers (ADNCC). In order to simplify treatment administration by avoiding cisplatin-related hydration, we investigated a weekly regimen of 5-FU/FA/cisplatin. Patients with ADNCC were treated with 5-FU 2.0 g/m2, FA 500 mg/m2 and cisplatin 25 mg/m2 day 1, for 6 weeks with a 2-week rest, and were assessed for toxicity, tumor response and disease-free survival. Forty-three patients with measurable ADNCC were treated with this weekly regimen. Primary tumor sites were mainly esophagus (n = 17), stomach (n = 12) and pancreas (n = 9). Results were as follows. Toxicity was mostly hematological, with 16% grade 3/4 neutropenia (seven of 43) and 4% febrile neutropenia (two of 43). Objective response (OR) was observed in 19 of 43 (44%) patients including four complete responses (9%) and 15 partial responses (35%). Another 18 patients (42%) experienced stable disease. Time to progression was 6.5 months. The median response and stable disease durations were 4.3 (range 3-34) and 5 (range 2-16) months, respectively. We conclude that weekly administration of 5-FU/FA/cisplatin is an active and well-tolerated regimen. Toxicity is manageable and allows chemotherapy on an outpatient basis without hydration program as required when cisplatin is used at the dose of 50 mg/m2.

[Surgical resection for gastrointestinal metastatic melanoma]. / Traitement chirurgical des métastases digestives de mélanome.

AIM: Metastases of melanoma are frequent. On the gastro-intestinal tract, commonest localizations are small bowel, stomach and colon. Surgical treatment of digestive metastases from melanoma is not well known and its value is still debated. PATIENTS AND METHODS: Medical records of 10 patients (six female and four male) operated for metastatic melanoma to gastro-intestinal tract were reviewed to determine results of surgery. RESULTS: Gastro-intestinal metastases were symptomatic in eight patients (abdominal pain in three, bowel obstruction in three, abdominal mass and obstructive jaundice in one each). Two patients had anemia. Diagnosis has been suggested by imaging in seven patients and endoscopy in three. All patients were operated on by laparotomy for resection of metastases located on small bowel in four patients, gallbladder in two, stomach in two and colon in two. Complete resection suppressed symptoms in nine cases. In one patient, resection was incomplete but provided satisfying symptomatic relief. One patient died at day 3; in other patients, median survival was 18 months (range: 3-120). CONCLUSION: In a patient with previous history of melanoma, digestive symptoms indicate morphological explorations due to suspicion of metastases to gastro-intestinal tract. Surgical treatment of these metastases is usually palliative but, in some cases, allows long-term survival.

Galectin-8 expression decreases in cancer compared with normal and dysplastic human colon tissue and acts significantly on human colon cancer cell migration as a suppressor.

BACKGROUND AND AIMS: Galectins are beta-galactoside binding proteins. This ability may have a bearing on cell adhesion and migration/proliferation in human colon cancer cells. In addition to galectins-1 and -3 studied to date, other members of this family not investigated in detail may contribute to modulation of tumour cell features. This evident gap has prompted us to extend galectin analysis beyond the two prototypes. The present study deals with the quantitative determination of immunohistochemical expression of galectin-8 in normal, benign, and malignant human colon tissue samples and in four human colon cancer models (HCT-15, LoVo, CoLo201, and DLD-1) maintained both in vitro as permanent cell lines and in vivo as nude mice xenografts. The role of galectin-8 (and its neutralising antibody) in cell migration was investigated in HCT-15, LoVo, CoLo201, and DLD-1 cell lines. METHODS: Immunohistochemical expression of galectin-8 and its overall ability to bind to sugar ligands (revealed glycohistochemically by means of biotinylated histochemically inert carrier bovine serum albumin with alpha- and beta-D-galactose, alpha-D-glucose, and lactose derivatives as ligands) were quantitatively determined using computer assisted microscopy. The presence of galectin-8 mRNA in the four human colon cancer cell lines was examined by reverse transcriptase-polymerase chain reaction. In vitro, cellular localisation of exogenously added galectin-8 in the culture media of these colon cancer cells was visualised by fluorescence microscopy. In vitro galectin-8 mediated effects (and the influence of its neutralising antibody) on migration levels of living HCT-15, LoVo, CoLo201, and DLD-1 cells were quantitatively determined by computer assisted phase contrast microscopy. RESULTS: A marked decrease in immunohistochemical expression of galectin-8 occurred with malignancy development in human colon tissue. Malignant colon tissue exhibited a significantly lower galectin-8 level than normal or benign tissue colon cancers; those with extensive invasion capacities (T3-4/N+/M+) harboured significantly less galectin-8 than colon cancers with localised invasion capacities (T1-2/N0/M0). The four experimental models (HCT-15, LoVo, CoLo201, and DLD-1) had more intense galectin-8 dependent staining in vitro than in vivo. Grafting the four experimental human colon cancer models onto nude mice enabled us to show that the immunohistochemical expression of galectin-8 was inversely related to tumour growth rate. In vitro, galectin-8 reduced the migration rate of only those human experimental models (HCT-15 and CoLo201) that exhibited the lowest growth rate in vivo. CONCLUSIONS: Expression of galectin-8 correlated with malignancy development, with suppressor activity, as shown by analysis of clinical samples and xenografts. In vitro, only the two models with low growth rates were sensitive to the inhibitory potential of this galectin. Future investigations in this field should involve fingerprinting of these newly detected galectins, transcending the common focus on galectins-1 and -3.

Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction.

OBJECTIVE: The aim was to identify the prognostic factors which relate to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with an occlusion. METHODS: The files of 109 patients with a neoplasm who were operated on for occlusion between 1990 and 2000 have been re-examined. The prognostic factors studied were age, sex, the location of the primary tumour, the extension of the cancer at the time of the operation, and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of transit and the return home. RESULTS: The median survival was 64 days and the peroperative mortality was 21%. The quality of life of patients has been improved in 65% of cases. The only factors clearly correlating to survival and the success of the operation are the aetiological diagnosis of the occlusion (local recurrence better than carcinomatosis) and the type of procedure it was possible to carry out (resection better than bypass). CONCLUSION: Palliative surgery can, in a certain number of cases, improve the quality of life of patients, but it has not been possible for us to demonstrate prognostic factors which would allow the selection of patients who could benefit the most from such surgery.

[Intestinal obstruction in cancer patients: results of palliative surgery]. / Occlusions intestinales chez le patient cancéreux: résultats de la chirurgie palliative.

OBJECTIVE: The study aim was to investigate predictive factors related to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with intestinal obstruction. METHODS: A total of 109 patients already treated for a neoplasm were operated on for intestinal obstruction between 1990 and 2000. The investigated prognostic factors were age, sex, location of the primary tumour, extension of the cancer at the time of the operation and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of intestinal transit and the return home. RESULTS: The median survival rate was 64 days and the postoperative mortality rate 21%. The quality of life was improved in 65% of the patients. The only factors clearly correlated with survival and the success of the operation were the aetiological diagnosis of the intestinal obstruction and the type of procedure which was possible to carry out. CONCLUSION: Palliative surgery may improve the quality of life of a certain number of patients, but it was not possible to demonstrate predictive factors for the selection of patients who could have the larger benefits of such surgery.

[Development of surgical treatment of primitive and metastatic rectal cancer]. / Evolution du traitement chirurgical du cancer du rectum primitif et métastatique.

There are many ways by which the surgeon can optimize curative resection for rectal cancer. Appropriate margins with total mesorectal excision, should be the goals for tumors in the lower two-thirds of the rectum. Reconstruction should be performed, whenever technically possible, by a colonic J-pouch. Preservation of pelvic autonomic nerves is possible in most cases, reducing the risk of postoperative sexual and urinary dysfunction. New techniques increase the frequency of curative treatments of metastatic disease. Towards either the primary or the metastatic disease, the new therapeutic strategies offer an hope of cure, and a better quality of life, to an increasing number of patients.

Peritoneovenous shunt in malignant ascites. The Bordet Institute experience from 1975-1998.

BACKGROUND/AIMS: This is the review of our experience in the treatment of malignant ascites using Le Veen and Denver peritoneovenous shunt. METHODOLOGY: From 1975-1998, 24 peritoneovenous shunts were inserted in 22 patients with malignant ascites. RESULTS: All patients benefited from the procedure. The principal cause of failure was shunt occlusion (n = 5). CONCLUSIONS: This study permits us to conclude that a preoperative appropriated selection of patients, should decrease failure rate. Patients should be sent to surgery as soon as the diagnosis of recalcitrant ascites is confirmed, to obtain a longer and more comfortable quality of life with terminal cancer.

Metastatic involvement of ceco-appendicular segment: a diagnosis of right lower quadrant abdominal pain in patient receiving chemotherapy.

Metastases are a common feature during the evolution of breast cancer. However, gastrointestinal metastases, and especially ceco-appendicular ones, are very rare. Melanoma however frequently metastasize in the gastrointestinal tract. Ceco-appendicular metastases do not display any specific signs in cancerous patients. These rare metastases must be considered in the diagnosis of right lower quadrant pain in cancerous patients. The main differential diagnosis includes neutropenic enterocolitis, acute appendicitis, malignant intestinal obstruction and perforation of the bowel. The morbidity of gastrointestinal complications in patients with metastatic cancer receiving chemotherapy is significant and surgery is often the only chance of survival. The major clinical decision is whether or not to operate.

Grading dysplasia in colorectal adenomas by means of the quantitative binding pattern determination of Arachis hypogaea, Dolichos biflorus, Amaranthus caudatus, Maackia amurensis, and Sambucus nigra agglutinins.

The current study deals with the setting up of a new tool that enables the benign versus the malignant nature of colorectal adenomas to be determined accurately. The 2 objectives are to determine (1) whether adenomas should, or should not, be included in a 2- or a 3-tier grading system, and (2) whether severe dysplasias and carcinomas in situ share common or different biological characteristics. The levels of expression of different types of glycoconjugates were characterized in a series of 166 colorectal specimens, including 14 normal, 90 dysplastic, and 62 cancerous cases. The glycoconjugate expressions were demonstrated for 5 lectins, namely, Arachis hypogaea (PNA), Dolichos biflorus (DBA), Amaranthus caudatus (ACA), Maackia amurensis (MAA) and Sambucus nigra (SNA). The glycoconjugates demonstrated by these 5 lectins belong to the family of the Thomsen-Friedenreich antigens. The binding patterns of the 5 lectins were quantitatively determined by means of computer-assisted microscopy. The quantitative data were submitted to discriminant analyses. Our results show that the specific glycochemical staining patterns could be identified unambiguously and without misclassification between benign (normal and low dysplasia) and malignant (ie, either as moderate/severe dysplasia, carcinoma in situ, or cancer) cases. The data also strongly suggested that (1) dysplasias seem to be distinguishable in 2 instead of 3 groups, that is, low versus moderate/severe (high); and (2) moderate/severe dysplasias are biologically distinct from carcinomas in situ. The methodology developed can be applied directly in routine diagnosis to identify moderate/severe dysplasia specimens already exhibiting features common to carcinomas, and which therefore should be treated consistently in view of the fact that our data strongly suggest that most moderate/severe dysplasias are still benign, whereas carcinomas in situ are real carcinomatous lesions.

Cecal infarct: report of a case.

PURPOSE: The purpose of this article is to present a case of an uncommon opportunistic fungal infection that appears in immunologically or metabolically compromised patients and is usually fatal. METHOD: A 54-year-old woman with an acute lymphoblastic leukemia had acute abdominal pain with peritoneal symptoms during her hospital stay. A laparotomy was performed and a cecal infarct firmly adherent to about 30 cm of infiltrated jejunal loop was discovered. RESULTS: Microscopic studies revealed an infiltration of the jejunal wall by abnormal lymphocytes. The cecal and ileal walls were infiltrated by leukocytes. Blood vessels were invaded by giant cells and large, unseptated, right-angle branching hyphea. CONCLUSIONS: These findings were considered typical of invasive mucormycosis of the cecum and the terminal ileum.

Adjuvant portal-vein infusion of fluorouracil and heparin in colorectal cancer: a randomised trial. European Organisation for Research and Treatment of Cancer Gastrointestinal Tract Cancer Cooperative Group, the Gruppo Interdisciplinare Valutazione Interventi in Oncologia, and the Japanese Foundation for Cancer Research.

BACKGROUND: There is conflicting evidence on the efficacy of regional adjuvant chemotherapy, via portal-vein infusion (PVI), after resection of colorectal cancer. We undertook a randomised controlled multicentre trial to investigate the efficacy of PVI (500 mg/m2 fluorouracil plus 5000 IU heparin daily for 7 days). METHODS: 1235 of about 1500 potentially eligible patients were randomly assigned surgery plus PVI or surgery alone (control). The patients were followed up for a median of 63 months, with yearly screening for recurrent disease. The primary endpoint was survival; analyses were by intention to treat. FINDINGS: 619 patients in the control group and 616 in the PVI group met eligibility criteria. 164 (26%) control-group patients and 173 (28%) PVI-group patients died. 5-year survival did not differ significantly between the groups (73 vs 72%; 95% Cl for difference -6 to 4). The control and PVI groups were also similar in terms of disease-free survival at 5 years (67 vs 65%) and the number of patients with liver metastases (79 vs 77%). INTERPRETATION: PVI of fluorouracil, at a dose of 500 mg/m2 for 7 days, cannot be recommended as the sole adjuvant treatment for high-risk colorectal cancer after complete surgical excision. However, these results cannot eliminate a small benefit when PVI is used at a higher dosage or in combination with mitomycin.

Vascular access problems.

Vascular access is one of the most commonly used techniques in the care of the patient with cancer. Often treated as a routine matter, venous access can have serious consequences which can be maintained at a very low level providing there is strict adherence to a regimented protocol of surgical technique and of catheter care.

Isolated limb perfusion with tumor necrosis factor and melphalan for limb salvage in 186 patients with locally advanced soft tissue extremity sarcomas. The cumulative multicenter European experience.

OBJECTIVE: The objective of the study was to achieve limb salvage in patients with locally advanced soft tissue sarcomas that can only be treated by amputation or functionally mutilating surgery by performing an isolated limb perfusion (ILP) with tumor necrosis factor (TNF) + melphalan (M) as induction biochemotherapy to obtain local control and make limb-sparing surgery possible. SUMMARY BACKGROUND DATA: To increase the number of limb-sparing resections in the treatment of locally advanced extremity soft tissue sarcoma, preoperative radiation therapy or chemotherapy or a combination of the two often are applied. The ILP with cytostatic agents alone is another option but rarely is used because of rather poor results. The efficacy of the application of TNF in ILP markedly has changed this situation. METHODS: In 8 cancer centers, 186 patients were treated over a period of almost 4.5 years. There were 107 (57%) primary and 79 (43%) recurrent sarcomas, mostly high grade (110 grade III; 51 grade II; and 25 very large, recurrent, or multiple grade I sarcomas). The composition of this series of patients is unusual: 42 patients (23%) had multifocal primary or multiple recurrent tumors; median tumor size was very large (16 cm); 25 patients (13%) had known systemic metastases at the time of the ILP. Patients underwent a 90-minute ILP at 39 to 40 C with TNF + melphalan. The first 55 patients also received interferon-tau. A delayed marginal resection of the tumor remnant was done 2 to 4 months after ILP. RESULTS: A major tumor response was seen in 82% of the patients rendering these large sarcomas resectable in most cases. Clinical response rates were: 33 complete response (CR) (18%), 106 partial response (PR) (57%), 42 no change (NC) (22%), and 5 progressive disease (PD) (3%). Final outcome was defined by clinical and pathologic response: 54 CR (29%), 99 PR (53%), 29 NC (16%), and 4 PD (2%). At a median follow-up of almost 2 years (22 months; range, 6-58 months), limb salvage was achieved in 82%. Regional toxicity was limited and systemic toxicity minimal to moderate, easily managed, with no toxic deaths. CONCLUSIONS: In the setting of isolated limb perfusion, TNF is an active anticancer drug in patients. The ILP with TNF + melphalan can be performed safely in many centers and is an effective induction treatment with a high response rate that can achieve limb salvage in patients with locally advanced extremity soft tissue sarcoma.

Hepatic morphonuclear alterations following portacaval shunt in the rat.

Portacaval shunt (PCS) induced major biochemical alterations to rat liver. We characterized the chromatin status in the rat hepatocyte at various times after this surgical procedure. The samples studied were from histological imprint smears of liver tissue. Nuclear assessments were computed on Feulgen-stained nuclei by means of a cell-image processor. We described the distribution values of the ploidy, of the percentage of diploid and tetraploid cells per case, of the size of nuclei, and of the chromatin pattern. At the 18th hr post-PCS we observed a complete inversion in the ratio of diploid and tetraploid cells. The size of nuclei increased after PCS and returned progressively to normal values at the 72nd hr post-PCS. The chromatin pattern revealed a mirror image between the small and large dense chromatin clumps (SRL and LRL parameters). Twenty-four hours postsurgery, we observed the minimum value for SRL together with the maximum value for LRL, and these two parameters remained to the normal values within 72 hr post-PCS. Our results show that chromatin organization level is changed during portacaval shunt. They also suggest that the value of SRL and LRL parameters are important in the description of normal or neoplasic cells.

Contribution of molecular oncology in the detection of colorectal carcinomas.

The development of effective screening tests for colorectal tumors is essential given the high frequency of these cancers in the general population, and more especially in various groups at risk. Sporadic and hereditary colorectal cancers result from the accumulation of mutations in oncogenes, such as ras, myc, neu/HER2, and in tumor suppressor genes such as apc, dcc, p53. The detection of ras or p53 mutations in DNA extracted from stool has been shown to be feasible and might be useful for the development of new screening tests. Many mutations in these genes can also be used as new prognostic factors. Identification of mutation in the apc gene responsible for familial polyposis, or its indirect detection through the study of polymorphism in such families, is completely changing the previously recommended medical attitude for the screening of this disease, and therefore may decrease or even avoid major medical follow-up. These changes are also true for the nonpolyposis hereditary colorectal tumors, also called Lynch syndrome, since the responsible hMSH2, hMLH1, hPMS1 and hPMS2 genes have recently been cloned. Mutations in these genes do not seem to be limited to families with Lynch syndrome, and could account for a predisposition of some patients to develop colorectal or other tumors.

Survival of patients with radiation enteritis of the small and the large intestine.

We reviewed the clinical and survival data of 108 consecutive patients who presented with radiation enteritis between 1965 and 1981. One hundred and two (94%) had been irradiated for carcinoma of the cervix uteri. The median follow-up was of 11 years. The median time of occurrence of severe radiation-induced lesions (obstruction, perforation) after radiotherapy was of 18 months, against 10.5 months for mild symptoms (e.g., tenesmus) and 9 months for rectal bleeding (p < 0.001). Cox survival analysis taking into account the stage of the cancer and the age at diagnosis showed that rectal bleeding is a factor with a prognosis significantly poorer than the mild symptoms (p = 0.05), equivalent to that of the severe complications. We conclude that in the evaluation of patients who underwent radiotherapy for abdominal or pelvic tumours, rectal bleeding should be considered as a sign of serious radiation-induced complication.