Management of isolated recurrence after surgery for pancreatic adenocarcinoma.

BACKGROUND: Recurrence of pancreatic cancer after primary pancreatectomy occurs in the vast majority of patients. The role of surgical treatment for recurrent pancreatic cancer is not well established. METHODS: Patients who underwent primary pancreatectomy with curative intent from 2000 to 2014 at a single large-volume centre were evaluated retrospectively. CT or PET was used to select patients with an isolated recurrence. The clinicopathological features and survival outcomes were compared according to treatment modalities. RESULTS: Of the 1610 patients with pancreatic cancer who underwent resection, 1346 (83·6 per cent) were diagnosed with recurrent pancreatic cancer. Recurrence was locoregional in 366 patients (27·2 per cent), distant multifocal in 251 (18·6 per cent), distant isolated in 188 (14·0 per cent), locoregional plus distant in 153 (11·4 per cent) and peritoneal seeding in 388 (28·8 per cent). Of the 1346 patients with recurrence, 197 (14·6 per cent) had isolated recurrence; of these, 48 (24·4 per cent of all isolated recurrences; 3·6 per cent of all recurrences) underwent resection. Median survival of the 197 patients after diagnosis of isolated recurrence was 14·7 months; it was longer in patients who underwent surgical resection than among those treated non-surgically (23·5 versus 12·0 months; P = 0·014). Multivariable analysis showed that chemotherapy and resection for recurrence were associated with better prognosis. Median survival after recurrence was longest in the 23 patients with isolated pulmonary recurrence (33·3 months). Survival after recurrence was better in patients who underwent resection of isolated recurrence in the remnant pancreas (median 28·0 versus 12·0 months, P = 0·010) and lung (median 36·5 versus 9·5 months; P = 0·010) than in those who did not undergo resection. CONCLUSION: Surgical resection may be considered an option for treatment of patients with isolated recurrent pancreatic cancer.

Kaurane diterpenes from Isodon japonicus inhibit nitric oxide and prostaglandin E2 production and NF-kappaB activation in LPS-stimulated macrophage RAW264.7 cells.

A methanolic extract of the whole plant of Isodon japonicus (Labiatae) showed potent inhibition on the LPS-induced nitric oxide (NO) and prostaglandin E2 (PGE2) production in RAW264.7 cells. Four known kaurane diterpenes were isolated by activity-guided fractionation and their structures were identified as kamebanin (1), kamebacetal A (2), kamebakaurin (3), excisanin A (4). All compounds also inhibited the LPS-induced NF-kappaB activation as assessed by NF-kappaB reporter assay and electrophoretic mobility shift assay (EMSA). Compounds 2-4 showed comparable inhibitory effects on the LPS-induced production of NO and PGE2, and activation of NF-kappaB without affecting cell viability. These results suggest that kaurane diterpenes could exert their inhibitory effects on the production of NO and PGE2 through the suppression of NF-kappaB activation, and be partially responsible for the anti-inflammatory activities of the genus Isodon.

Antioxidant benzoylated flavan-3-ol glycoside from Celastrus orbiculatus.

A new flavan-3-ol glycoside, (-)-epicatechin-5-O-beta-D-glucosyl-3-benzoate (1), and two known compounds, (-)-epicatechin and (-)-epiafzelechin, were isolated from an EtOAc extract of Celastrus orbiculatus aerial parts that exhibited significant antioxidant effect in a 1,1-diphenyl-2-picrylhydrazyl (DPPH) free radical assay. The structure of 1 was elucidated by spectroscopic analyses, and compound 1 and its aglycon, (-)-epicatechin-3-benzoate (2), were found to be moderately active as antioxidants in the DPPH assay.

Inhibition of type A monoamine oxidase by coptisine in mouse brain.

The inhibitory effects of coptisine, a protoberberine isoquinoline alkaloid, on type A and type B monoamine oxidase (MAO-A and MAO-B) activities in mouse brain were investigated. Coptisine showed an inhibitory effect on MAO-A activity in a concentration-dependent manner using a substrate kynuramine, but coptisine did not inhibit MAO-B activity. Coptisine exhibited 54.3% inhibition of MAO-A activity at 2 microM. The values of Km and Vmax of MAO-A were 151.9 +/- 0.6 microM and 0.40 +/- 0.03 nmol/min/mg protein, respectively (n=5). Coptisine competitively inhibited MAO-A activity with kynuramine. The Ki value of coptisine was 3.3 microM. The inhibition of MAO-A by coptisine was found to be reversible by dialysis of the incubation mixture. These results suggest that coptisine is a potent reversible inhibitor of MAO-A, and that coptisine functions to regulate the catecholamine content.

(-)-Epiafzelechin: cyclooxygenase-1 inhibitor and anti-inflammatory agent from aerial parts of Celastrus orbiculatus.

An inhibitor of cyclooxygenase (COX)-1 activity of prostaglandin H2 synthase was isolated from aerial parts of Celastrus orbiculatus Thunb. (Celastraceae), an oriental folk medicine for rheumatoid arthritis by activity-guided column chromatographic methods. The COX inhibitor was identified as (-)-epiafzelechin, a member of flavan-3-ols by the structural analysis with HR-EI-mass, 1H-NMR and 13C-NMR spectral data. The compound exhibited a dose-dependent inhibition on the COX activity with an IC50 value of 15 microM. (-)-Epiafzelechin exhibited about 3-fold weaker inhibitory potency on the enzyme activity than indomethacin as a positive control. (-)-Epiafzelechin exhibited significant anti-inflammatory activity on carrageenin-induced mouse paw edema when the compound (100 mg/kg) was orally administrated at 1 h before carrageenin treatment.

Pregnane glycoside multidrug-resistance modulators from Cynanchum wilfordii.

The methanol-soluble extracts of the roots of Cynanchum wilfordii showed a significant multidrug-resistance-reversing activity, and four known pregnane glycosides were isolated by bioassay-directed fractionation and separation. Their structures were identified as gagaminin 3-O-beta-D-cymaropyranosyl-(1-->4)-beta-D-oleandropyranosyl- (1-->4)-b eta-D-cymaropyranosyl-(1-->4)-beta-D-cymaropyranoside (1), wilfoside K1N (2), wilfoside C1N (3), and cynauricuoside A (4). In particular, compound 1, at a concentration level of 1 microM, was found to completely reverse the multidrug-resistance of KB-V1 and MCF7/ADR cells to adriamycin, vinblastine, and colchicine.

Acetophenones from the roots of Cynanchum wilfordii H(EMSLEY)

Two acetophenones, cynandione A (1) and cynanchone A (2), were isolated from the roots of Cynanchum wilfordii. Their structures were identified by comparison of their physicochemical and spectral data with reported values.

Intrapulmonary thrombin generation and its relation to monomethylmethacrylate plasma levels during hip arthroplasty.

Frequent peroperative sampling of arterial and mixed venous blood was undertaken in eight consecutive patients during cemented hip arthroplasty to obtain a sequential picture of thrombin-antithrombin (TAT) and methylmethacrylate monomer (MMA) concentrations. TAT, detected neo-antigenically, reached its maximum levels after bone preparation, prior to introduction of cement and prosthesis. Furthermore, TAT values were higher in arterial than in mixed venous blood, indicating generation and inactivation of thrombin when blood is passing the lung. MMA concentration, measured by high pressure liquid chromatography, increased very rapidly and declined within 1 min following socket as well as shaft implantation, reaching the highest mean value of 3599 ng/ml only 30 s after femoral impaction of cement. MMA concentration was higher in mixed venous than in arterial blood, indicating elimination of the monomer during lung passage. This study confirms our previous observation that coagulation is activated prior to the implantation of bone cement and prosthesis into the femoral shaft; in addition, it provides further evidence of the thrombin-generating potential of the pulmonary capillary bed. Very frequent sampling was necessary to reveal the sharp rise in MMA levels following impaction of cement. Further investigations are needed to establish whether interaction between activated coagulation and MMA may predispose to cardiovascular complications.

Elliptinium acetate in metastatic breast cancer--a phase II study.

Thirty-five patients with metastatic breast cancer who had received one or two prior chemotherapeutic regimens were treated with elliptinium acetate at a dose of 80 mg/m2 for 3 days every 3 weeks. Of the 33 patients evaluable for response, 1 patient achieved complete remission, 4 achieved partial responses (15% overall objective response with 95% confidence interval of 5-32%), and 6 achieved minor response. Toxicity of the treatment was xerostomia, diarrhea, and nausea and vomiting. The drug was not myelosuppressive. Three patients showed evidence of elliptinium antibody, and treatment was discontinued. No episodes of hemolysis were observed. Elliptinium acetate showed modest antitumor activity in previously treated patients with metastatic breast cancer.

Pirarubicin in combination chemotherapy for metastatic breast cancer.

Pirarubicin is an anthracycline with broad antitumor activity, and without significant cardiotoxicity in preclinical and early clinical trials. We treated 40 evaluable patients with metastatic breast cancer and no prior exposure to chemotherapy with 5-fluorouracil, pirarubicin, and cyclophosphamide at 21-day intervals until reaching cumulative doses of 800 mg/m2 of pirarubicin, or the development of progressive disease. The median age was 56 years and the median performance status, 1. Seventeen patients had prior hormone therapy and 12 had prior radiotherapy. The median number of metastatic sites was three, with 11 patients having less than three sites. Twelve patients were premenopausal. The median disease-free interval was 6 months. Four patients achieved a complete remission and 21 a partial remission, for an overall response rate of 63%. The median response duration was 8 months and the median time to progression for all patients was 9 months. The median survival has not been reached, but will exceed 13 months. Gastrointestinal toxicity was minimal to moderate, whereas myelosuppression was severe. Complete hair loss was observed by only 58% of patients. There were two episodes of mild congestive heart failure at high cumulative doses of pirarubicin; both were controlled with medical treatment. This three-drug combination containing pirarubicin is effective in treating metastatic breast cancer, with less severe toxicity than other anthracycline-containing combinations.

c-erbB-2 amplification in node-negative human breast cancer.

c-erbB-2 gene analysis by Southern and DNA dot blot methods was done in 66 tumor samples from patients with histologically node-negative breast cancer. The c-erbB-2 gene was amplified 2- to greater than 8-fold in 13 tumors (20%). None of 59 tumors that were examined by the Southern method showed c-erbB-2 gene rearrangement. c-erbB-2 amplification was analyzed in relation to other prognostic factors. The c-erbB-2 gene was amplified in five of 36 (14%) diploid and eight of 30 (27%) aneuploid tumors. Thirteen of 54 (24%) tumors with nuclear Grade 1 or 2 displayed c-erbB-2 amplification, whereas none of 12 tumors with nuclear Grade 3 did. No correlation was observed with estrogen receptor content, tumor size, histological type, or age of patients. The median follow-up date for these patients was 85+ mo. Of 13 patients whose tumors showed c-erbB-2 amplification, six patients (46%) developed recurrence, and five patients (38%) died of metastatic disease. In contrast, of 53 patients whose tumors did not show c-erbB-2 amplification, 15 patients (28%) developed recurrence, and seven patients (13%) died of disease. In conclusion, our results show that c-erbB-2 gene amplification was more frequent in aneuploid tumors and tumors with poor nuclear grade. c-erbB-2 amplification may be considered a possible prognostic factor in node-negative breast cancer.

A monoclonal antibody cocktail for detection of micrometastatic tumor cells in the bone marrow of breast cancer patients.

We investigated whether monoclonal antibodies (MoAbs) reactive against both acidic and basic cytokeratins alone were sufficient to detect minimal numbers of contaminating epithelial tumor cells in the bone marrow of breast cancer patients. Monoclonal anti-cytokeratin antibodies (AE1 and AE3) were used to stain 14 breast carcinomas by the avidin-biotin-peroxidase technique. Nine tumors (64.3%) showed high reactivity and five (35.7%) showed low or moderate reactivity. Nine MoAbs that proved to be unreactive to light density bone marrow cells by immunoalkaline phosphatase histochemistry were screened for reactivity to breast carcinomas having only low or moderate positivity to cytokeratin antibodies. Three of nine MoAbs showed high percentages of positivity and were selected to supplement the anti-cytokeratin antibodies for immunohistochemical detection of minimal marrow disease in breast cancer patients. A MoAb cocktail was prepared, further tested for reactivity to another five breast carcinomas, and compared with cytokeratin staining alone. The cocktail labeled 100% of carcinoma cells in all the examined specimens. To determine the sensitivity of this panel for detecting minimal numbers of contaminating tumor cells in bone marrow, in vitro mixing experiments were performed. T47D breast carcinoma cells were mixed with bone marrow mononuclear cells at ratios from one tumor cell per 10 bone marrow cells up to one tumor cell per 1 x 10(6) marrow cells, and cytospin preparations were subsequently stained with the MoAb cocktail by the immunoalkaline phosphatase method. Our approach could detect one tumor cell in 1 x 10(5) hematopoietic cells.

Reduction to homozygosity at the SIS/PDGF-2 locus in human mesenchymal tumors.

Enhanced expression of the human SIS/PDGF-2 gene has been reported in a number of human cell lines, sarcomas, and glioblastomas. We have analyzed the SIS/PDGF-2 gene for structural alterations in fresh human tumors. DNA samples from 79 patients with solid tumors (63 mesenchymal tumors, 12 lung carcinomas, 4 breast carcinomas) were examined and compared with DNA samples from 50 leukemia patients and 14 unrelated individuals without malignant neoplasms. When DNA samples were digested with a HindIII restriction endonuclease, Southern blot analysis demonstrated two distinct bands (21kb and 18kb) after hybridization to the SIS/PDGF-2 gene probe. A pedigree analysis of a 43-member family indicated that these allelic variants segregated in a Mendelian fashion. There was, however, tumor specific allele loss in 18% of the mesenchymal tumors analyzed, which may indicate a common etiology for this tumor type.

Multiple restriction fragment length polymorphisms of the human epidermal growth factor receptor gene.

We have examined the epidermal growth factor (EGF) receptor gene for structural alterations in fresh human tumors. DNA samples from 92 patients with solid tumors (lung cancer, 37; breast cancer, 24; head and neck cancer, 17; other tumors, 14) were analyzed and compared with those from 22 leukemia patients and 14 individuals without malignant neoplasms. When DNA samples were digested with HindIII restriction endonuclease, Southern blot analysis demonstrated 3 distinct polymorphic bands (9.8, 11, and 12 kilobases) after hybridization to the HER-A64-1 probe and another 2 distinct polymorphic bands (4.9 and 5.2 kilobases) after hybridization to the HER-A64-3 probe. Pedigree analysis of 43 members of a single family and comparative analysis of tumor and normal DNA samples from the same patients demonstrated that the variations in fragment size observed were due to 2 independent restriction fragment length polymorphisms in the region of the EGF receptor gene. Amplification of the EGF receptor gene was detected in 3 cases of breast cancer, but not in other tumors studied. We conclude that the human EGF receptor gene has multiple restriction fragment length polymorphisms and that in fresh human tumor samples rearrangement and amplification of the gene occur infrequently, if ever, within the region encompassed by the 2 complementary DNA probes used.

Global tests on coagulation and fibrinolysis in systemic and pulmonary circulation accompanying hip arthroplasty with acrylic cement.

Sudden cardio-respiratory collapse (CRC) within seconds after implantation of methylmethacrylate cement and femoral prosthesis during hip replacement surgery, accounted at our hospital among 315 patients for a mortality of 0.6%. This prompted our pathophysiological studies concentrating on the critical intraoperative period for this complication. This series of 6 patients with osteoarthrosis was followed with established parameters on coagulation and fibrinolysis in arterial and mixed venous blood withdrawn frequently during and after total hip arthroplasty. The surgical procedure induced activation in both systems as evidenced by a gradual and statistically significant drop in level of blood platelets, fibrinogen, vitamin K dependent clotting factors. At the end of operation soluble fibrin and moderately elevated concentrations of FDP/FRA were demonstrated. The results were similar in corresponding arterial and mixed venous blood specimens. The perioperative changes were not potentiated by the introduction of cement and the implantation of the prosthetic components. The postoperative changes had the same pattern and the same magnitude as those following other types of major surgery. The present results do not indicate marked alterations in coagulation and/or fibrinolysis in the critical period for CRC to develop.

Studies on coagulation, fibrinolysis, kallikrein-kinin and complement activation in systemic and pulmonary circulation during hip arthroplasty with acrylic cement.

This study was designed to evaluate the contribution of the plasma cascade systems to the cardiopulmonary complications, occasionally leading to sudden death during hip arthroplasty using acrylic cement. The intraoperative pattern following uneventful surgery was therefore investigated in 8 patients with osteoarthrosis with frequent sampling from the radial and pulmonary arteries. The following general findings emerged: A gradual consumption of coagulation factors (platelets, fibrinogen, factor VII, antithrombin III), fibrinolytic components (plasminogen, alpha-2-antiplasmin), kallikrein-kinin factors (prekallikrein, kallikrein inhibitor) and complement factors (C3c, C4) was observed. Some intrapulmonary proteolytic inhibition was noticed as evidenced by lower arterial than mixed venous blood levels of alpha-2-antiplasmin and kallikrein inhibitor. Insignificant changes occurred for factor VII-phospholipid complex. A rapid, massive and transient increase in fibrinopeptide A (FPA) values in the radial artery, as opposed to the moderate increase in the pulmonary artery, was found immediately after reaming and broaching of bone. This probably reflected intrapulmonary fibrinogen to fibrin conversion, reaching a maximum 15-20 minutes before the femoral implantation. As estimated from the FPA arterial peak values and the fall in fibrinogen concentrations, approximately 5-10% of the circulating fibrinogen molecules were devoided of FPA during this intraoperative phase. The marked a-v difference in FPA level supports earlier findings of intrapulmonary fibrin formation and deposition. This process, however preceded the critical period of cardiorespiratory collapse (CRC) by at least 15 minutes, and may thus predispose to this complication.