Arterial line filtration protects brain microcirculation during cardiopulmonary bypass in the pig.

Microemboli in the brain may inhibit brain function during cardiopulmonary bypass, and in a previous study in pigs of normothermic nonpulsatile bypass we reported a significant decrease in cerebral glucose consumption secondary to interruption of the capillary flow, possibly caused by microemboli. In the present study we measured the regional cerebral glucose consumption and the regional capillary diffusion capacity (that is, the number of perfused capillaries) in 10 different brain regions in two separate groups of animals with and without an arterial filter during normothermic cardiopulmonary bypass. Inclusion of a 40 micron arterial filter in the bypass circuit increased the regional brain glucose consumption 27% (median; range -12% to 145%) and regional capillary diffusion capacity increased 123% (median; range 36% to 829%). No change in brain histologic features, the cerebrovascular permeability to serum proteins, or cerebral water content was observed. The arterial filter probably protects the cerebral microcirculation and prevents the decrease in cerebral glucose consumption otherwise seen during bypass.

[Does achalasia predispose to cancer of the esophagus?]. / Disponerer achalasia til esophaguscancer?

In a follow-up study of 147 patients with achalasia of the esophagus treated by myotomy, 146 patients were traced (58 female and 88 male patients aged 4 to 83 years; median 46 years). The living persons were contacted in writing or by telephone. The mean follow-up time after the operation was 23.2 years (range, six to 41 years). The cause of death was established for 71 patients. There were three postoperative deaths and two deaths following recurrence. In comparison with the Danish population, the 66 remaining patients were found to have a relatively higher cancer mortality (34.9% percent). Contrary to the expected less than one, ten of 23 patients who died of cancer had a malignant tumor in the esophagus. The mortality rate after 30 years was 66.1 percent, 11.9 percent of the deaths caused by esophageal cancer. It is concluded that there is a connection between achalasia and cancer of the esophagus that ought to be considered in the treatment and follow-up of patients with achalasia.

Brain damage following low flow cardiopulmonary bypass in pigs.

Reduction of pump flow during cardiopulmonary bypass (CPB) reduces the formation of microemboli and trauma to the blood components, reduces both rewarming of the heart and the noncoronary collateral flow, and improves surgical exposure. Recent studies indicate that a reduction in pump flow, even at normothermia, does not increase the incidence of postoperative cerebral dysfunction. We examined the cerebral consequences of 2 h of normothermic CPB in pigs carried out at pump flows of either 70 ml/kg per min or 50 ml/kg per min, and compared the results with those of a nonperfused control group. We measured the regional cerebral glucose metabolism and the regional capillary diffusion capacity simultaneously in ten different brain regions. Brain morphology, the blood-brain barrier permeability to serum proteins and the regional cerebral water content were also determined in the same animals. Glucose metabolism decreased significantly in both CPB groups (P < 0.001), and significant differences were found between the capillary diffusion capacities of the three groups (P < 0.05), with decreases in eight out of ten brain regions examined in the 50 ml/kg per min group. The results indicate that a reduction of pump flows from 70 ml/kg per min to 50 ml/kg per min is deleterious to the brain, and that a pump flow of 70 ml/kg per min itself has an injurious effect, when normothermic CPB is carried out for 2 h without the use of vasoactive drugs to maintain the blood pressure. Mean arterial blood pressure (MAP) rather than pump flow seemed to determine the adequacy of the cerebral perfusion.

Does achalasia predispose to cancer of the esophagus?

In a follow-up study of 147 patients with achalasia of the esophagus treated by myotomy, 146 patients were traced (58 female and 88 male patients aged 4 to 83 years [median, 46 years]). The living persons were contacted in writing or by telephone. The mean follow-up time after the operation was 23.2 years (range, 6 to 41 years). The cause of death was established for 71 patients. There were three postoperative deaths and two deaths following recurrence. In comparison with the Danish population, the 66 remaining patients were found to have a relatively higher cancer mortality (33.8 percent). Contrary to the expected less than one, ten of 23 patients who died of cancer had a malignant tumor in the esophagus. The mortality rate after 30 years was 66.1 percent, 11.9 percent of the deaths caused by esophageal cancer. It is concluded that there is a connection between achalasia and cancer of the esophagus that ought to be considered in the treatment and follow-up of patients with achalasia.

Tumor-associated antigen 43-9F is of prognostic value in squamous cell carcinoma of the lung. A retrospective immunohistochemical study.

BACKGROUND: Squamous cell lung carcinoma (SLC), the most frequent type of lung cancer, generally is treated surgically and its prognosis is poor. The only current clinically useful prognostic criterion is lymph node staging (TNM classification). Expression of a novel tumor-associated carbohydrate epitope Gal beta 1-3[Fuc alpha 1-4]GlcNAc beta 1-4[Fuc alpha 1-3]GlcNAc beta 1-3 Gal beta 1-4Glc identified by the 43-9F monoclonal antibody (MoAb) is associated with the growth pattern of SLC cell lines in athymic mice and in vitro. This implies that the 43-9F epitope may be related to tumor progression in patients with SLC and that, as such, it could be of prognostic value. METHODS: Primary tumor specimens from 231 patients with lung carcinoma (130 with SLC, 64 with adenocarcinoma, 10 with small cell carcinoma, 16 with large cell carcinoma, and 11 with adenosquamous carcinoma) were examined by immunohistochemical studies on formalin-fixed, paraffin-embedded tissue samples for immunoreactivity with an MoAb to the 43-9F antigen. Univariate and step-wise Cox regression analyses were used to compare survival time by histopathologic diagnosis, smoker status, TNM classification, and type of surgical treatment. RESULTS AND CONCLUSIONS: Patients with 43-9F epitope-positive SLC tumors had a significantly (P less than 0.01) better prognosis than patients with epitope-negative tumors. In contrast, no association was seen between 43-9F epitope expression and survival time for patients with lung adenocarcinomas. Further, the prognostic value of 43-9F expression in SLC was found to be superior to the N-classification with the added advantage that it requires access only to primary tumor tissue and thus is available before therapy.

Soluble interleukin-2 receptor and soluble CD8 antigen levels in serum from patients with non-resectable lung cancer.

In a preliminary longitudinal study two women with histologically verified adenocarcinoma of the lung, without simultaneous infectious or inflammatory conditions, were seen every 2 weeks until death. In one of the patients serum soluble interleukin-2 receptor (sIL-2R) levels rose progressively while the levels for the other patient increased during the second half of the observation period. Serum soluble CD8 antigen (sCD8 Ag) showed a pattern dissimilar to the one for sIL-2R. In a retrospective cross-sectional study circulating levels of sIL-2R and sCD8 Ag were measured before explorative thoracotomy in a total of 65 patients with histologically proven non-resectable carcinoma of the lung. The sIL-2R levels were significantly increased independently of histological subclassification while sCD8 Ag was increased only in patients with small-cell lung cancer. There was no correlation between pre-operative values and length of survival.

[Surgical treatment of cancer of the cardia and the esophagus]. / Kirurgisk behandling af cancer cardiae og cancer esophagi.

During the period 1977 to 1989, 379 patients with cancer cardiac and cancer esophagi were admitted. The ages ranged from 18-88 years with an average of 65 years. The treatment concept was basically unchanged during the study period. Resection as described by Ivor Lewis was employed as palliative or curative treatment when resection was considered possible. Intubation of the esophagus was employed when no other treatment was considered possible. Resection was employed in 251 patients, eight of these emergencies on account of perforation or haemorrhage. Bypass operations were employed in five patients, intubations in 63 and no surgical treatment was undertaken in 60 patients. The all over operative mortality for resections was 11.2% and for elective operations 9.9%. The operative mortality increased with the TNM stage of the tumour and was 3.2% for stages I + II, 8.2% for stage III and 24.4% for stage IV. The complication ration was 42%. 15% of the patients submitted to resection required reoperation. Anastomotic leaks were encountered in 18 patients and nine of these died. Pulmonary complications were the most frequent and resulted in ten early postoperative deaths. The mortality connected with intubations was 15%. The over all five-year survival rate after resections was 10.4%. In stages I + II this was 42% and 8% in stage III. None of the patients in stage IV survived for two years. The longest survival after intubation was less than one year.

Brain histology, blood-brain barrier and brain water after normothermic and hypothermic cardiopulmonary bypass in pigs.

The effect of hypothermia during cardiopulmonary bypass (CPB) on cerebral histopathology, blood-brain barrier permeability to serum proteins and water content was evaluated. Pigs were subjected to non-pulsatile CPB for 2 h at either normothermia or hypothermia, and a group of anaesthetised pigs served as normothermic controls. The histopathology was assessed on paraffin embedded sections. The permeability of the cerebral vessels was studied by immunocytochemical demonstration of extravasated serum proteins. The cerebral water content was assessed by specific gravity measurements. The histological studies demonstrated hydropic degeneration of the brain parenchyma and perivascular swelling of the astrocytic endfeet throughout both white and gray matter in the normothermic CPB group. Similar changes were not encountered during hypothermic CPB, which suggests a beneficial effect of decreased temperatures on brain tissue during CPB. Neither normothermic nor hypothermic CPB induced significant changes in the cerebrovascular permeability or in the specific gravities.

Surgical management of thoracic anomalies in infants. Respiratory-tract malformations, congenital chylothorax and mediastinal masses.

The clinical presentation and surgical treatment of thoracic anomalies--developmental malformations of the respiratory tract, congenital chylothorax or mediastinal masses--in 15 infants are reported. The age range at operation was 2 weeks to 8 months. The diagnoses were lobar emphysema (3 cases), bronchogenic cyst (3), cystic adenomatoid malformation (1), enteric duplication (2), hyperplastic thymus (2), neuroblastoma (1), chylothorax (1), cystic lymphangiectasia (1) and tracheal stenosis (1). The most common symptom was respiratory embarrassment, with acute development in half of the cases. The diagnosis could be established or suspected from chest radiography in 14 of the 15 infants. All were submitted to thoracotomy. None died postoperatively, but three had major complications. At postoperative follow-up 13 of 14 patients were free from respiratory symptoms.

Brain microvascular function during cardiopulmonary bypass.

Emboli in the brain microvasculature may inhibit brain activity during cardiopulmonary bypass. Such hypothetical blockade, if confirmed, may be responsible for the reduction of cerebral metabolic rate for glucose observed in animals subjected to cardiopulmonary bypass. In previous studies of cerebral blood flow during bypass, brain microcirculation was not evaluated. In the present study in animals (pigs), reduction of the number of perfused capillaries was estimated by measurements of the capillary diffusion capacity for hydrophilic tracers of low permeability. Capillary diffusion capacity, cerebral blood flow, and cerebral metabolic rate for glucose were measured simultaneously by the integral method, different tracers being used with different circulation times. In eight animals subjected to normothermic cardiopulmonary bypass, and seven subjected to hypothermic bypass, cerebral blood flow, cerebral metabolic rate for glucose, and capillary diffusion capacity decreased significantly: cerebral blood flow from 63 to 43 ml/100 gm/min in normothermia and to 34 ml/100 gm/min in hypothermia and cerebral metabolic rate for glucose from 43.0 to 23.0 mumol/100 gm/min in normothermia and to 14.1 mumol/100 gm/min in hypothermia. The capillary diffusion capacity declined markedly from 0.15 to 0.03 ml/100 gm/min in normothermia but only to 0.08 ml/100 gm/min in hypothermia. We conclude that the decrease of cerebral metabolic rate for glucose during normothermic cardiopulmonary bypass is caused by interruption of blood flow through a part of the capillary bed, possibly by microemboli, and that cerebral blood flow is an inadequate indicator of capillary blood flow. Further studies must clarify why normal microvascular function appears to be preserved during hypothermic cardiopulmonary bypass.

Glycoproteins distinguishing non-small cell from small cell human lung carcinoma recognized by monoclonal antibody 43-9F.

Cell lines derived from human squamous lung carcinoma release large amounts of a soluble glycoprotein into the culture media, having very high molecular weight (greater than 2 X 10(6] and mucin-like properties. A monoclonal antibody called 43-9F has been generated that recognizes a carbohydrate epitope on the glycoconjugate. The epitope is also present on a diverse set of smaller glycoproteins (Mr 50,000-200,000) distributed primarily on the surface of the squamous lung carcinoma cells. A sensitive assay using the 43-9F antibody in a dot blot procedure has been devised that is able to detect an amount of antigen less than that possessed by a single squamous lung carcinoma cell. This assay, and also conventional immunofluorescence and immunohistochemical assay procedures, have been used to screen different normal cells, normal tissues, cancer cells, and tumor biopsy specimens for the antigen. In the normal lung the 43-9F antigen is found only on cells of some of the seromucous glands. In the normal digestive system it is associated in certain organs only with a limited population of mucosal epithelial cells. Other organ systems lack any reactive cells. The cells of most human non-small cell lung carcinomas and their released glycoconjugates have large amounts of the 43-9F epitope, while small cell lung carcinomas and the glycoconjugates released by small cell lung cancer cells lack the epitope. The oligosaccharide recognized by the 43-9F antibody may therefore provide a useful marker to distinguish the different lung carcinomas and for investigating the different cells of origin of these tumors.

Survival in small cell lung carcinoma after surgery.

In a retrospective study of long term survival in patients with small cell carcinoma of the lung who had been treated purely by surgery, 1820 patients with lung cancer seen during the 15 years 1962-77 were reviewed and reclassified histologically and according to the TNM system. Of these patients, 924 had had resections and 284 exploratory thoracotomies. Cancer chemotherapy was not used in this period and radiotherapy was given only occasionally as palliative treatment. Seventy seven of the patients having pulmonary resections had small cell carcinoma (8.4%), and there were six survivors among the 71 with T1-2, N0-1, M0 tumours. The five and 10 year survival rates were both 12%. The histological specimens from these six patients with a small cell carcinoma who survived more than 10 years were re-evaluated and confirmed as small cell by an independent group of pathologists. It seems justified to conclude that a selected group of patients with small cell carcinoma should be treated by surgery alone without adjuvant chemotherapy, which might reduce the long term survival.

Regulatory peptides in the lower esophageal sphincter of man.

Smooth muscle specimens were taken from the lower esophageal sphincter of patients suffering from achalasia or hiatus hernia with gastro-esophageal reflux. The specimens were analysed for neurohormonal peptides using immunochemistry and immunocytochemistry. Control specimens were obtained from patients subjected to esophageal resection because of esophageal cancer. The concentration of vasoactive intestinal polypeptide (VIP) was higher and the VIP nerve supply greater in patients with hiatus hernia than in control patients. The VIP nerve supply and the content of this peptide was lower in patients with achalasia than in controls. The same tendency was observed for substance P and enkephalin although the changes in their concentrations were not statistically significant. Enkephalin fibers were few, both in specimens from control patients and from patients with hiatus hernia; they could not be detected in specimens from patients with achalasia. Never fibers containing somatostatin or gastrin/cholecystokinin could not be detected in any of the groups and somatostatin and gastrin/cholecystokinin could not be measured in extracts of the lower esophageal sphincter. We propose that changes in the concentration of neuropeptides may at least contribute to manifestations of achalasia and of decreased lower esophageal sphincter pressure and gastro-esophageal reflux.

Modulatory effects of 5-azacytidine, phorbol ester, and retinoic acid on the malignant phenotype of human lung cancer cells.

Cloned human cell lines of squamous-cell lung carcinoma and small-cell lung carcinoma were treated with 5-azacytidine (5-azaC), 12-0-tetradecanoyl-phorbol-13 acetate (TPA), retinoic acid (RA), or a combination of these drugs, and the effects on cellular morphology, in vitro growth properties, antigenicity, tumorigenicity and metastatic activity in nude mice were studied. Antigenicity was measured by the expression of major histocompatibility antigens (MHC) and of lung-tumor-associated antigens. 5-AzaC treatment resulted in subclones with shorter population doubling times (from 40-50 hr down to 14-20 hr) and increased cloning efficiencies (from less than 1% to 5-50%). TPA and RA induced loss of proliferative activity in vitro and tumorigenicity in vivo of both lines. This was morphologically associated with the appearance of an abundance of large vaculated cells which by DNA-analysis were all found to be in G0-G1 phase. However, 2 of the 5-azaC-treated subclones were insensitive to both TPA and RA, whereas the remaining subclones (20) all responded like untreated lines to TPA and RA. One of the sublines insensitive to TPA and RA formed metastases in nude mice in contrast to all the other lines used. The density of lung-tumor-associated antigens was significantly reduced by TPA-RA treatment, whereas the expression of MHC antigens was unaffected. In contrast, 5-azaC resulted in some cases in increased density of MHC antigens. The effects of 5-azaC on cellular phenotypes were not directly correlated to the total genomic content of 5-methylcytosine. The data suggest that this experimental system is suitable for studies of phenotypic features of malignant cells as related to cellular differentiation.

Intratumoral phenotypic diversity of cloned human lung tumor cell lines and consequences for analyses with monoclonal antibodies.

Cloned cell lines and a number of subclones from these lines were established in vitro from biopsies of small cell lung carcinomas and squamous cell lung carcinomas. The cloned cultures, including the cloned subclones, were analyzed in respect to morphology, karyotype, growth rates, clonogenicity in semisolid agar medium, and tumorigenicity in nude mice. A remarkable biologic diversity was found in respect to most of these biologic features. In addition, four murine monoclonal antibodies with high specificity for lung tumor cells were generated. Their reactivity pattern to clonogenic cells was for some clones different as compared to the nonclonogenic cells. Subclones of tumor cells not binding the antibody were identified for each monoclonal antibody. It is concluded that intratumoral phenotypic diversity may have a severe negative impact on the use of monoclonal antibodies in cancer diagnosis/therapy. The work also indicates that a mixture of antibodies may be more useful in tumor diagnosis than individual antibodies and perhaps even therapy, particularly if they bind to the clonogenic part of a cell population.

Resection of acquired tracheal stenosis in childhood.

In a series of 74 tracheal resections, six were performed in boys aged 2 to 13 years. One patient was intubated shortly after operation because of bulbar paralysis with swallowing difficulties. He died 5 months later of traumatic hydrocephalus. Another patient was reintubated because of an accompanying nondiagnosed glottis stenosis which later was treated successfully. Four patients have been followed up from 4 to 10 years. In these patients tracheoscopy and x-ray examination have shown that the anastomosis has grown at the same rate as the rest of the trachea. It is concluded that operation can be performed in children at any age provided that swallowing is normal and accompanying laryngeal stenosis is excluded.

Resection of congenital stenosis of the trachea in an infant.

A case of congenital stenosis of the distal trachea in a 4-week-old boy with severe respiratory distress was treated with circular resection of the trachea. At follow-up, more than one year after operation, the condition of the patient was normal.

Congenital chylothorax: management by ligature of the thoracic duct.

Congenital chylothorax in a male infant persisted for 10 weeks despite repeated thoracocenteses and dietary regimens which included total parenteral nutrition for 37 days and a peroral semielementary diet with medium-chain triglyceride content for 19 days. Thoracotomy disclosed a small leak in the thoracic duct. The duct was ligated above and below the leak, as attempted repair was unsuccessful. There was no recurrence of pleural effusion after the operation and no distal lymphoedema was observed.

Lack of vasoactive intestinal polypeptide nerves in esophageal achalasia.

Vasoactive intestinal polypeptide-containing nerves were examined in the lower esophagus of control and achalasia patients. The smooth muscle in patients with achalasia had conspicuously fewer vasoactive intestinal polypeptide-immunoreactive nerve fibers than specimens from control patients. Also the concentration of vasoactive intestinal polypeptide in the lower esophagus was much reduced in achalasia. In view of the potent smooth muscle relaxing effects of vasoactive intestinal polypeptide, it is suggested that the reduced number of vasoactive intestinal polypeptide fibers in the achalasic esophagus causes or at least contributes to the incomplete relaxation and the increased resting tone of the lower esophageal sphincter characteristic of this disease.