May 1980, Volume 30, Issue 5

News and Notes

SURVIVAL UP FOR PRIMARY CANCER OF LIVER; OUTLOOK WITH METASTASIS STILL GRIM

There are now glimmers of hope for patients with hepatic malignancies, according to Dr. Joseph G. Former of Memorial Hospital, New York.
Actuarial survival for those with rare primary liver tumors has more than doubled in the past decade, although the outlook for patients with hepatic metastases from cancer of other organs remains grim, he said.
Since 1970, an 89% three-year survival has been achieved for patients at Memorial Hospital with stage I primary tumors; a 27% three- year survival is associated with stagell or III disease. The overall survival among 41 patients was 48%, compared to a 23% survival among similar patients treated before 1970.
Tempering the news of improved survival after liver surgery was the acknowledgement that most hepatic tumors are inoperable at the time of diagnosis. Among 65 patients evaluated at the Medical College of Virginia, Richmond, resection could be considered in 33, and only seven ultimately proved to be treatable by surgery, Dr. Walter Lawrence, Jr., said.
At Memorial Hospital also most patients were not subjects for surgery. The 132 surgical patients evaluated came from a series of 405 patients seen since 1970.
More Benign Tumors in Women
Surgery for benign tumors provided the second glimmer of hope. "We\'re going to cure cancer in noncirrhotic women by going in after (what appears to be) a benign tumor," said Dr. James H. Foster of the Hartford (Conn.) Hospital. The distinction of noncirrhotic women is relevant; about 60% of liver cancer occurs in patients with cirrhosis, and none of these survive five years after surgery.
Most resectable liver tumors occur in women, who are also more likely to have benign tumors. The malignancy may then be detected during surgery for the benign disease. An open biopsy is best for patients with these benign tumors, because it enables sufficient tissue to be removed to rule out malignant disease. Needle biopsies will give a picture of cirrhosis in nodular hyper-plasis or of normal liver in adenoma, he said.
Dr. Ronald A. Malt, of Massachusetts General Hospital, Boston, advised against biopsying hyperplastic lesions, because of the extensive vascularity of the mass and the slight possibility that it may obscure a malignancy.
Instead, the entire lesion should be taken out at elective surgery at some later time. This type of tumor often looks malignant on gross pathology, although it is not, he said.
Drs. Foster and Malt agreed that a conservative approach to benign hepatic tumors is justi­fied. "You don\'t want to do a hepatectomy if you can avoid it," Dr. Malt said. Dr. Foster had several patients with benign lesions that were only partially excised or simply biopsied; in none of these cases did the residual tumor mass lead to a later recurrence, he said.
GAY BOWEL SYNDROME TRACED TO MULTIPLE ENTERIC INFECTIONS
Recent reports from here and New South Wales have drawn attention to venereally trans­mitted amebic proctocolitis-"gay bowel syndrome"-among male homosexuals who have not recently travelled outside of the area.
In the first report, Dr. J.Y. Kang and colleagues of the Royal North Shore Hospital, describe a 45-year-old salesman who presented with a one-year history of passing blood and mucus from the rectum up to 30 times a day. During this time, he had been seen at another hospital and treated with sulphasalazine for idiopathic colitis, but his condition worsened.
Sigmoidoscopy done at North Shore Hospital showed extensive mucosal ulceration of the rectum and sigmoid colon. When mucus, obtained at sigmoidoscopy, was examined under a light microscope, Entamoeba histolytica was seen. Culture of the mucus grew Neisseria gonorrhoeae, and biopsy confirmed the diagnosis of amebic proctocolitis. The patient improved after a course of metronidazole followed by procaine penicillin.
In the second report, Dr. John Goldbaum of Crow\'s Nest, New South Wales, and a col­league say they have recently identified and treated four male homosexuals with amebic proctocolitis.
"Gay bowel syndrome," characterized by multiple enteric infections, occurring concur­rently or sequentially, has also been reportedly seen among homosexuals in New York, London and San Francisco. The patient at Royal North Shore Hospital had amebic proctocolitis and gonococcal proctitis.
Dr. Goldbaum has come across a combination of gonococcal proctitis with herpes simplex virus type II proctitis, a condition which he reported confirmable by viral culture.
The importance of identifying infections of proctocolitis is that most of the organisms are readily treatable, Dr. Kang said, and treatment with corticosteroids, which may be appropriate for noninfectious proctocolitis only worsen the infectious types.
FUNCTION TESTS MAY MISS KIDNEY DAMAGE
Classical kidney function tests do not necessarily pick up damage that is occurring, Dr. Louis J. Merle, a former Visiting Fellow at the Cornell University Medical College, said at the annual meeting of the American Society for Pharmacology and Experimental Therapeutics.
Measurement of two enzymes, N-acetyl-B-glucoaminidase (NAG) and leucine aminope-ptidase, indicated early problems in rheumatoid arthritis patients, which were not shown by such standard tests as BUN, creatinine and determination of proteinuria.
The two enzymes are found in the proximal tubule of the kidney along with beta-2-microglo-bulin, which is filtered through the glomeruli and normally absorbed through the proximal tubule. Their measurements permit a more accurate determination of kidney phenomena, he said.
"I think that by monitoring the kidney function repeatedly, one could find an easy way to predict more serious renal damage, so that you know whether to stop the treatment or to continue. I think this could be done routinely now," because the assay for NAG is easy and very reliable, said Dr. Merle.
In addition to 36 rheumatoid arthritis patients on chronic gold therapy, he studied urine samples from 18 healthy subjects and nine hospitalized patients with skeletal disease. While NAG values ranged from around 23 to 38 in healthy and hospitalized patients, 28 rheumatoid arthritis patients had at least one such value of over 100, and 11 patients of the 36 had at least one such value of over 300 nmoles/ product/hr/mg creatinine, indicating renal tubular injury.
MONITORING WORKADAY VENTRICULAR FUNCTION
Continuous monitoring of left ventricular function during everyday activities is promised by this 12-pound electronic vest, developed at Massachusetts General Hospital and successful in trials.
Dr. William Strauss, leader of the developing team, says that the vests\'s cadmium tellurite detectors carry electric charges that vary in response to radiation intensities from injected erythrocyte-binding technetium isotope. The charge reflects the LV volume curve and is recorded on six-hour minitape cassette.
HEPATITIS B DELTA ANTIGEN TAGS THE CLINICALLY AFFLICTED
A mysterious antigen, found only in certain persons with hepatitis B surface antigen, is reported to be almost invariably associated with pathology. "The delta antigen, as it is called, appears to be associated with a transmissible particle distinct from the hepatitis B virus," Dr. Robert Purcell told the Gustav Stem Symposium on Perspectives in Virology. "However, it is only found in the presence of marker antigens for hepatitis B virus (HBV), and, therefore, seems to be defective, requiring HBV synthesis for its propagation".
According to Dr. Purcell, who heads the hepatitis virus section of the laboratory of in­fectious diseases of the National Institute of Allergy and Infectious Diseases, it is too early to make any firm clinical predictions based on what is known about delta antigen. But, he adds, it is "interesting" that virtually all those who have the delta antigen have clinical illness, although persons with chronic HBV infection may or may not have clinical illness.
World-wide Distribution
In animal studies, those "that had chronic hepatitis with no evidence of illness for many years, developed transaminase elevations and other indications of pathology after being infected with delta antigen."
The delta antigen has a world-wide distribution, but appears to be most common in southern Italy and parts of Scandinavia and is most frequently associated with high-risk groups for hepatitis, including persons who have undergone multiple transfusions, illicit drug users and male homosexuals. The antigen was first discovered in 1977 by an Italian investigator, Dr. Mario Rizzetto of the Hospital San Giovanni in Turin. Since then, he has been continuing his investigations in the U.S. in collaboration with Dr. Purcell and others.
So far, the attempts to characterize the antigen as it occurs in the sera of infected in­dividuals have revealed that it is associated with a 35-37 nanometer particle and a piece of low-molecular-weight RNA. The particle also appears to be encapsulated by hepatitis B surface antigen, leading Dr. Purcell to speculate that this could represent a piece of encapsulated messenger RNA from the hepatitis virus or a unique species of host RNA that has been "kidnapped".
Though the delta antigen seems to require hepatitis virus for its synthesis, it, in turn, inhibits the multiplication of the virus. "At this point," Dr. Purcell said, "the research on the antigen is raising more questions than it answers, but it promises to be highly significant."
PHLEBITIS RISK LINKED TO TEFLON CATHETERS
The use of small-bore Teflon catheters was associated with an increased risk of phlebitis in two hospitals in Boston.
In a randomized, prospective study comparing complications resulting from insertion of 466 Teflon catheters and 489 steel needles for 72 hours, investigators at Beth Israel Hospital and the Children\'s Hospital Medical Centre found that phlebitis occurred twice as often with Teflon catheters, but that infiltration was twice as common with steel needles.
The researchers, Drs. J.L. Tully, G.H. Friedland and D.A. Goldmann, found that infiltration occurred in 39.9% of patients who had needles inserted and in 18.2% of patients with catheters. Phlebitis occurred in 18.7% of patients who had catheters inserted compared with 8.8% in those with needles.
The risk of phlebitis was reported to increase each day after the first day in patients who had catheters.
The investigators concluded that while both needles and catheters are associated with low rates of microbial colonization and infection, steel needles are associated with a reduced per-day risk of phlebitis but infiltrate more readily.
Their report was given at the International Congress of Chemotherapy.
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