Deborah G. Rose

Longer time interval between completion of neoadjuvant chemoradiation and surgical resection does not improve downstaging of rectal carcinoma

AbstractPURPOSE: An interval of six to eight weeks between completion of preoperative chemoradiation therapy and surgical resection of advanced rectal cancer has been described. Our purpose was to determine whether a longer time interval between completion of therapy and resection increases tumor downstaging and affects perioperative morbidity. METHODS: Forty patients with advanced adenocarcinoma of the rectum underwent preoperative chemoradiation on a prospective trial with irinotecan (50 mg/m2), 5-fluorouracil (225 mg/m2), and concomitant external-beam radiation (45–54 Gy) followed by complete surgical resection of the tumor with total mesorectal excision. The time interval between completion of chemoradiation and surgical resection ranged from 28 to 97 days. The patients were divided into two groups with 33 eligible patients: Group A (4-week to 8-week time interval; 28–56 days) and Group B (10-week to 14-week interval; 67–97 days). Tumor downstaging was compared between these two groups. The number of patients downstaged by at least one T stage, those downstaged by at least one N stage, those with pathologic complete responses, and those with only residual microscopic tumor foci were compared. Postoperative length of stay, estimated blood loss, perioperative morbidity, and sphincter-sparing procedures were also compared. Chi-squared tests and Student’s t-test were calculated. RESULTS: Group A had 19 patients, and Group B had 14 patients. Patient demographics were comparable. Mean age was 52 years, and 70 percent of patients were male. There were no deaths. There were no statistical differences in perioperative morbidity, with three anastomotic leaks in Group A. Tumors were downstaged in 58 percent of patients in Group A and 43 percent of those in Group B (P = 0.61). Nodal downstaging occurred in 78 percent of Group A and 67 percent of Group B (P = 0.9). The pathologic complete response rate was 21 percent in Group A and 14 percent in Group B (P = 0.97), and a residual microfocus of tumor was found in 33 percent of patients in Group A and 42 percent of those in Group B (P = 0.90). These differences were not statistically significant. CONCLUSIONS: Perioperative morbidity is not affected by longer intervals. A longer interval between completion of neoadjuvant chemoradiation and surgical resection may not increase the tumor response rate of advanced rectal cancer in this cohort.

Human Microvessel Endothelial Cell Isolation and Vascular Graft Sodding in the Operating Room

We have evaluated multiple factors inherent to an operating room-compatible endothelial cell procurement and sodding procedure. Microvessel endothelial cell isolations have been performed on fat tissue obtained from over 140 patients with a 100% success rate. Liposuction-derived fat was optimal with respect to cell yield, and isolation time. The devices and equipment used were acceptable to the operating room and the complete cell procurement procedure was successful even in the hands of personnel with minimal training. Fat digestion was achieved using crude clostridial collagenase, with an average cell yield of 1 x 10(6) microvessel endothelial cells/gm of fat. Evaluation of this procedure with canine fat using an operating room acceptable procedure resulted in a 100% procurement success rate requiring 1.5 hours (+/- .5 hrs) for completion of the fat isolation, and cell isolation procedure. Microvessel EC could subsequently be used in graft seeding or sodding techniques to establish endothelial cell monolayers on vascular grafts. Our results indicate that one person with minimal cell isolation background can reproducibly isolate large quantities of sterile autologous endothelial cells in the operating room for immediate use in endothelial cell seeding/sodding procedures.

Thrombus-free, human endothelial surface in the midregion of a Dacron vascular graft in the splanchnic venous circuit--observations after nine months of implantation.

The addition of an endothelial cell lining to a prosthetic vascular graft may reduce the thrombogenicity of the blood-contacting surface. An endothelialized mesoatrial graft was implanted in a patient with Budd-Chiari syndrome caused by a primary inferior vena caval leiomyosarcoma. During the initial surgery a Dacron vascular graft was preclotted with plasma and then lined with microvascular endothelial cells derived from the patients subcutaneous adipose tissue. The patient did well initially but 9 months later required resection of a mechanical stricture of the graft that occurred as it passed beneath the costochondral junction. Grossly, the luminal surface of the resected graft was free of thrombus, with a smooth, glistening, white surface. Light microscopy demonstrated a surface layer of cells morphologically consistent with an endothelial cell monolayer, a subendothelial layer composed of extracellular matrix and spindle-shaped cells, and granulation tissue around the Dacron fabric. Immunohistochemistry and electron microscopy confirmed the presence of vascular endothelium on the luminal surface. This report documents the successful achievement of a human endothelial cell monolayer that persisted for 9 months in the midportion of a Dacron vascular graft.

Origin of endothelial cells that line expanded polytetrafluoroethylene vascular grafts sodded with cells from microvascularized fat

PURPOSE Cell transplantation onto prosthetic vascular grafts remains an attractive technique to reduce the thrombogenicity of polymeric materials. In this study we evaluated whether autologous cells isolated from falciform ligament fat and transplanted onto the lumenal surface of 4 mm expanded polytetrafluorethylene grafts were the same cells present on the surface of these grafts when they were explanted from canine carotid arteries 3 weeks after their implantation. METHODS The fluorescent dye PKH-26 was used to label transplanted cells to evaluate their fate after implantation of grafts as carotid artery replacements. This fluorescent dye homogeneously labeled all cells in the primary cell isolate. RESULTS In vitro studies indicated that dye labeling was nontoxic, as evidenced by the normal growth characteristics of fluorescently labeled cells compared with nonlabeled cells. Immunocytochemical analysis of microvascularized fat before cell isolation determined that approximately 90% of the cells stained positive for von Willebrand factor2. At the time of explant, seeded grafts exhibited a nonthrombogenic lumenal cell lining as evidenced by the lack of adherent platelets or fibrin. Cells on the lumenal surface of grafts exhibited PKH-26 fluorescence emission. In addition, these cells expressed von Willebrand factor and actively sequestered DiI-acetylated low-density lipoprotein. CONCLUSIONS We conclude that sodding of prosthetic grafts with autologous microvascularized fat-derived cells results in the formation of an endothelial cell lining on the lumenal flow surface. These endothelial cells are the same cells placed on the lumenal surface of the graft at the time of initial cell transplantation. Finally, a confluent monolayer forms after high-density cell sodding by the process of cell adherence and spreading, without the need for cell proliferation.

Origin of cells that line damaged native blood vessels following endothelial cell transplantation

Endothelial cell (EC) transplantation has been proposed as a method to reduce the thrombogenicity of both vascular grafts as well as injured native blood vessels. While techniques have been developed to establish EC monolayers on these surfaces, a major question that remains is whether the cells that exist on the blood flow surface are the same cells placed on the surface at the time of transplantation. We have developed an intravital fluorescent staining technique that permits isolated, autologous, fat-derived microvascular endothelial cells (MVEC) to be labeled and subsequently detected following their transplantation. In our study, rat abdominal aortas (AA) were injured with a 3F embolectomy catheter, and the injured surfaces were immediately treated with fluorescently labeled MVEC. Five days after transplantation, AA were evaluated by both scanning electron and fluorescence microscopy. Results of scanning electron microscopy showed the existence of nonthrombogenic regions in the areas of injury, and fluorescence microscopy of the identical areas established that these cells contained fluorescent dye. Our results indicate that the cells that line these injured areas of native vessels are the same cells that were originally transplanted. Our intravital fluorescence technique provides a method to trace the origin and disposition of transplanted cells on the vascular surfaces.

CARBOHYDRATE REGULATED TRANSENDOTHELIAL TRANSPORT OF PROTEINS

The study of vascular permeability has been focused in part on the structure of endothelial cells which line the vascular system. The importance of endothelial cell junctions, fenestra and vesicles in the regulation of vascular permeability is now well established. Newer ultrastructural techniques such as immuno-gold labelling1 and rapid freezing2 have confirmed numerous earlier studies which established that endothelial cell structure regulates the transendothelial transport of solutes.