Unresectable Malignant Tumors Research Articles

Prospective randomized trial comparing Tannenbaum Teflon and standard polyethylene stents in distal malignant biliary stenosis

Background: Our aim was to compare the clinical efficacy of the Tannenbaum (TB) biliary prostheses, a recently designed Teflon stent without side holes, with the Cotton-Huibregtse (CH) polyethylene stent. Methods: Fifty-seven patients (26 men, mean age 75.5 years) with unresectable malignant tumors and distal biliary stenosis were included (38 pancreatic head cancer, 17 cholangiocarcinoma, 2 ampullary cancer). Patients were prospectively randomized to have a 10F, 7 cm long TB (29 patients) or CH (28 patients) stent inserted endoscopically. Four patients (2 TB and 2 CH) were excluded: 3 because of the failure of stent insertion and 1 because of a protocol violation. The patients were evaluated clinically and, if necessary, with biochemical tests every month until death or until they needed surgery for symptoms of gastric outlet obstruction. When occlusion or dislocation occurred, the stent was replaced with one of the same type. Cumulative stent patency and patient survival were estimated with the Kaplan-Meier life-table analysis and compared by log-rank chi-square test. Results: The two groups were comparable in mean age, gender, and diagnosis. The patients were followed for a mean of 145.5 days (range 24 to 613); by the end of the study 47 patients (81%) had died or developed symptoms of gastric outlet obstruction. Median survival was 88 days (range 24 to 613) in the TB group and 75.6 days (23 to 486) in the CH group. Stent exchange (occlusion 16, dislocation 3) was necessary for 5 patients in the TB group and 7 in the CH group. No statistical difference was found on comparing the mean duration of function of the first, second, and third stents (analysis of variance, p = 0.80). The median duration of stent function was 96 days (range 11 to 613) in the TB group and 75.5 days (range 23 to 323) in the CH group. No significant difference was found in either survival time ( p = 0.48) or stent patency ( p = 0.12). Conclusion: This study found no significant advantage of the Tannenbaum prostheses over the standard polyethylene stent in the palliation for patients with distal malignant biliary stenosis with regard to survival or length of stent patency. (Gastrointest Endosc 2000;51:23-7.)

Radiofrequency thermal ablation of hepatocellular carcinomas.

Although surgical resection remains the best option as potentially curative therapy for hepatocellular carcinoma, radiofrequency thermal ablation has begun to receive much attention as an effective minimally invasive technique for the local control of unresectable malignant hepatic tumors. Most recent radiofrequency devices equipped with a powerful generator and larger needle electrode permit larger thermal lesions, up to 5 cm in diameter, with a single ablation. In this article, the author reviews the technical developments and early clinical results obtained with radiofrequency ablation techniques.

Angiographically assisted helical CT of the liver.

T he sensitivity of CT in the detection of liver tumors is high when contrast material is directly delivered to either the liver parenchyma or the tumors using an angiographic technique I I , 2]. CT hepatic arteriography alone has not been established as a routine preoperative examination because of the high prevalence of perfusion abnormalities resulting from replaced or anomalous hepatic arteries or from hemodynamic changes caused by hepatic neoplasms or cirrhosis I 11. Researchers have described the usefulness OfCT during arterial portography (CTAP) in the preoperative workup of patients with suspected liver malignancy 121.Although the recent development of helical biphasic contrast-enhanced CT with IV bolus injection of contrast material has obviated the need for more invasive angiographically assisted CT in many patients with unresectable malignant tumors or benign lesions, we still believe that angiographic CT is indispensable in patients before potential liver resection. The superiority of CTAP to helical biphasic contrast-enhanced CT in the diagnosis of hepatocellular carcinoma (HCC) has been described [31. Angiographically assisted CT has the ability to show subtly altered vascularity in tumors, which is not satisfactorily shown with helical biphasic contrast-enhanced CT. However, CTAP has limitations, especially regarding detection of HCC in patients with cirrhosis. The accuracy of angiographically assisted CT for liver tumors is improved by the use of Cf arteriography and CTAP combined [4, 51This pictorial essay points out potential diagnostic pitfalls and shows findings of CT arteriography and CTAP combined for imaging various neoplastic processes ofthe liver.

Development of extrahepatic arterial blood supply to the liver during hepatic arterial infusion chemotherapy

The aim of this study was to evaluate the correlation of development of the collateral circulation to the liver during hepatic arterial infusion chemotherapy (HAIC) with the presence of hepatic tumours adjacent to the hepatic surface, and with pretreatment occlusion of aberrant hepatic arteries. In 102 patients with unresectable malignant hepatic tumours treated with HAIC using an implantable port system, development of collaterals to the liver was assessed with CT arteriography using the implantable port and pre- and postoperative angiography. Aberrant hepatic arteries, if present, were occluded prior to treatment for hepatic arterial redistribution. Collaterals to the liver were seen in 29 patients, who had 35 areas with collateral perfusion: 22 areas were in the right posterosuperior area, 6 in the left peripheral area and 7 in the right or left lobar area. Collaterals were revealed more frequently in patients with hepatic tumours adjacent to the hepatic surface than in those without hepatic tumours in peripheral areas in the liver (p < 0.0001). In addition, collaterals developed more frequently in patients with an aberrant hepatic arterial anatomy compared with those with conventional anatomy (p = 0.0007). Our results indicated that patients with hepatic tumours adjacent to the hepatic surface and with pretreatment occlusion of aberrant hepatic arteries had the potential to develop collaterals to the liver during HAIC.

A comparison of laser therapy, plastic stents, and expandable metal stents for palliation of malignant dysphagia in patients without a fistula

Background: Many options are available for palliation of inoperable malignant stenoses of the esophagus. We report our experience with different modalities of endoscopic therapy. Methods: From 1986 to 1996, we treated 125 patients with dysphagia caused by unresectable malignant tumors with endoscopic therapy. Seventy patients were treated with laser therapy, 34 with a plastic endoprosthesis, and 21 with an expandable prosthesis. Therapeutic outcome and complication rates were analyzed for the three groups. Results: Mean dysphagia score decreased in the same manner in all three groups. Major and minor complications were significantly more common in the plastic endoprosthesis group and in the metallic stent group compared with the laser therapy group. Therapy and patient survival were not significantly different among the three groups. Conclusions: Plastic and metal stents carry a high complication rate for a short period of palliation. Endoscopic laser therapy, in contrast, has a low complication rate. Laser therapy should be the first choice for palliation in malignant dysphagia in patients with a short life expectancy. Stents might be used when laser therapy fails, in the presence of fistulas, or in patients with a reasonable life expectancy. (Gastrointest Endosc 1998;48:383-8.)

Primary cardiac tumors

Primary cardiac tumors are infrequent, and few cardiac surgeons have extensive experience in treating them. The majority of the tumors are benign. As noninvasive diagnostic imaging of cardiac masses continues to improve, the number of these tumors that are seen by clinicians will increase. More of the malignant tumors may be curable if detected at an earlier stage. A retrospective review was conducted of all patients with primary cardiac tumors managed by a university teaching center over a period of 40 years, using hospital medical records and a Provincial cardiovascular surgery database. Seventy-one patients (25 males and 46 females) with primary cardiac tumors were identified. Fifty-seven (80%) were benign masses and 14 (20%) were malignant masses. Twenty-eight percent of the tumors in men were malignant (7 of 25) compared with only 15% in women (7 of 46). Seventy-two percent of the masses were located in the left atrium. Forty-three percent of tumors in the right atrium were malignant (6 of 14) compared with only 14% in the left atrium (7 of 51). Complete resection was possible for 50 of 52 benign atrial tumors (96%) but for only 5 of 14 malignant tumors (36%). There was one perioperative death (1.4%). Three patients had no surgery because of their poor medical condition. Two of the patients with unresectable malignant tumors were still alive at last follow-up. The remaining 12 patients with malignancy have all died of their disease. Primary cardiac tumors are uncommon. Most patients present with symptoms of congestive heart failure. The second most common presenting symptom is embolization. Improvement in noninvasive diagnostic technology has increased the number of patients identified with a primary cardiac tumor and has also increased the number referred for surgical resection. The majority of left atrial tumors were benign, whereas up to one-half of tumors found in the right atrium were malignant. A greater proportion of malignant primary tumors were found in men than in women. Malignant cardiac tumors tend to be diagnosed after they have become extensive and the patients already have a very grave prognosis.

Management of Unresectable Malignant Tumors at the Skull Base Using Concomitant Chemotherapy and Radiotherapy with Accelerated Fractionation

Between January 1988 and June 1992, 20 patients with unresectable malignant tumors at the skull base were treated. Eleven had T4 lesions of the paranasal sinus/cavity complex, and 9 had T4 nasopharynx cancer. All patients had stage IV disease by the American Joint Committee on Staging Criteria. The histology was squamous cell cancer in 15 patients and other minor salivary gland histologies in 5. There was brain and/or dural invasion in 11 patients and orbital invasion in 9. All patients received radiation therapy with accelerated fractionation to a total of 70 Gy in 6 weeks. Concomitant cisplatin (100 mg/m(2)) was given on days 1 and 22 of radiation. Seven patients received mitomycin C (7.5 mg/m(2)) on days 1 and 22, plus adjuvant chemotherapy with cisplatin and vinblastine. Median follow-up was 11 (range: 1 to 43) months. At 2 years, local progression-free survival was 94%, distant metastases-free survival was 57%, and overall survival was 80%. Complications occurred in 20% and caused the death of 1 patient. Treatment of this group of patients with aggressive chemotherapy and radiation therapy produced excellent local control in our early experience, but longer follow-up is needed. There is a high rate of distant failure. Future strategies are outlined.

Metallic biliary endoprostheses.

In patients with obstructive jaundice caused by unresectable malignant tumors, biliary endoprostheses inserted percutaneously or endoscopically can provide excellent palliation. Conventional plastic stents are associated with a relatively high rate of occlusion caused by biliary sludge. Migration is another significant problem. Self-expandable, metallic stents can be inserted percutaneously via a small transhepatic track but expand to achieve a relatively large internal diameter. This minimizes the problem of occlusion due to encrusted bile and reduces the rate of reintervention. Migration rarely occurs. Metallic stents have also been employed in the management of recurrent benign biliary strictures unsuitable for surgery. In those patients in whom the frequency of radiological intervention is unacceptably high, such endoprostheses can provide a means of preventing restenosis.

Orthotopic liver transplantation in primary liver tumors.

Among 283 orthotopic liver transplantations made during the last 6 years at our institution, 22 (7.77%) were done on 19 patients with unresectable hepatic malignant tumors [hepatocellular carcinoma (17), angiosarcoma (1), and cholangiocarcinoma (1)]. None of them showed extrahepatic invasion, and only one had lymph node involvement. Cyclosporin A, corticosteroids, and azathioprine were administered for 3 months after the procedure, and maintenance therapy involved the first two drugs. Acute rejection rate and hospital stay were not significantly different compared with non-tumoral grafted patients. Three patients were retransplanted, one with uncontrolled acute rejection and two with chronic rejection. Intraoperative mortality was zero. Eight patients (42.1%) were alive at a mean follow-up of 31 months (range, 6-74). Four 22.2%) died with tumor recurrence, three of sepsis, two of respiratory insufficiency, one of hepatitis recurrence with cirrhosis, and one of primary lung neoplasia. If adequately selected, primary liver tumor patients may benefit from liver transplantation. Future research with adjuvant therapies will improve the results.

Conversion of Unresectable Malignant Tumors or liver to Resectable by Treatment of Trancatheter Hepatic Artery Embolization and Histopathological Study of the Specimens

Conversion of Unresectable Malignant Tumors or liver to Resectable by Treatment of Trancatheter Hepatic Artery Embolization and Histopathological Study of the Specimens

CLINICAL STUDY OF PTCD IN 76 CASES OF OBSTRUCTIVE JAUNDICE

A retrospective study of 76 patients undergone PTCD (included 11 cases of PTGBD) in our clinic for the past seven years was conducted to determine the efficacy of PTCD and benefits of different operative treatments. Fifty-seven patients with malignant tumor (either bile duct, pancreas head, or gallbladder cancer) were divided into three treatment groups: Group I, curative operation (9 patients); Group II, palliative operation such as internal drainage (15); and Group III, PTCD alone (33). Seventeen of 19 benign cases with PTCD were suffered from choledocholithiasis and cholangitis. Both total serum bilirubin prior to PTCD and the drainage time to attain the normal range (less than 3.0 mg/dl as serum total bilirubin level) were significantly low in the benign group compared to the malignant group (p<0.01). The survival rates in the malignancies tended to be lowered from bile duct, pancreas head, to gallbladder cancers in this order. Group I patients showed the best survival, whereas the median survival period in group II patients was 125 days which did not differ from that in group III (PTCD alone) (116 days). From these findings, the significance of adequate selection of palliative surgical treatments such as by-pass operation should be emphasized to reduce hyperbilirubinemia in the patients with unresectable malignant tumor.

Cardiac tumors: Clinical spectrum and prognosis of lesions other than classical benign myxoma in 20 patients

Between 1961 and 1983, 20 patients underwent operation at the Texas Heart Institute for primary tumors other than classical benign myxoma. Total follow-up was 70.7 patient years (mean 3.5 years). There were 10 adults and 10 children under 12 years of age. There were two operative deaths and four late deaths. All of the pediatric patients had benign lesions (five fibromas, five rhabdomyomas), and only one patient in this group died (during the operation). All operative survivors are alive between 0.9 and 18 years postoperatively, although in three cases excision was incomplete. Of the 10 adult patients, five had benign lesions; all were completely excised. In the other five adult patients, unresectable malignant tumors were found, and all four operative survivors died of metastatic disease within 8 months. Benign cardiac tumors in childhood have an excellent prognosis when completely excised and appear to have a good short-term prognosis even when excision is incomplete. Although prognosis for benign tumors in adults is good, malignant tumors are associated with very poor survival.

Nd-YAG laser, a new palliative alternative in the management of esophageal cancer.

Ten patients with unresectable esophageal malignant tumor have been managed by Nd-YAG laser palliative therapy. Esophageal obstruction, and dysphagia, the most frequent symptoms, were relieved in all cases after periods ranging from 5 to 14 days. The mean total energy required was 26.121 watts sec-1. No serious immediate or late complication was encountered, except for one small transient bleeding without clinical repercussion. Two relapses of dysphagia were successfully managed by the same procedure. This new palliative approach has to be compared with the other available methods, surgical resection and bypass procedures, radiotherapy or endoscopic prosthetic intubation. Its high degree of effectiveness in providing rapid relief of dysphagia, and its low morbidity rate will give to laser therapy an important place in the future palliative management of esophageal cancer, either alone or in combination with other treatments.

Ten Years' Experience With Intra-Aortic Infusion Chemotherapy for Gastrointestinal Malignant Tumors

Ten years' experience with intra-aortic infusion chemotherapy for 114 patients with unresectable or recurrent gastrointestinal malignant tumors is described. A marked response (1-B in Karnofsky's criteria) was obtained in a type of simple peritoneal dissemination of stomach carcinoma and in a locally recurrent type of rectal carcinoma. However, the overall response rate was low and the duration of response was generally short for gastrointestinal malignant tumors. The rationale of chemotherapy by the intra-aortic route is to enhance the antitumor response and to reduce drug toxicity as compared with that by the intravenous route. The drug of choice is 5-fluorouracil (5-FU) in intraaortic continuous infusion. As far as 5-FU is concerned, no toxic manifestation was observed in most cases. However, the major complication. i.e.. aortic perforation at the level of an indwelling catheter tip, which is attributed to the chemical action of 5-FU, occurred in two cases. Cancer chemotherapy is discussed on the basis of our experience with intra-aortic infusion treatment with 5-FU. Our previous results suggest that the drug sensitivity of individual cancer tissues is the most important factor.

The Radiologic Investigation of Hepatic Tumors in Childhood

In hepatic tumors seen in children, treatment and prognosis differ from tumor to tumor and thus accurate determination of their extent and characteristics is important. Evaluation by gray scale ultrasonography, radionuclide imaging and angiography has produced definable characteristics for the various tumor types and often allows distinction from other intrahepatic processes. In addition, chemotherapeutic treatment of initially unresectable malignant hepatic tumors can be followed by nuclear imaging, ultrasound and angiography to determine therapeutic response.

Preoperative therapy for unresectable malignant tumors in children

Thirty-six children with initially unresectable malignant tumors were man-aged with pre- and postoperative therapy combined with reduction of primary tumor burden by total or subtotal resection. The proportion of patients achieving long-term tumor-free survival after surgery was 0.48 in the Wilms' tumor group and 0.60 among patients with other regionally unresectable malignant neoplasms. These results are encouraging in an otherwise high mortality situation.