Stuart G. Marcus

Activation of progelatinase A (MMP-2) by neutrophil elastase, cathepsin G, and proteinase-3: a role for inflammatory cells in tumor invasion and angiogenesis.

Gelatinase A (MMP‐2), a matrix metalloproteinase (MMP) involved in tumor invasion and angiogenesis, is secreted as an inactive zymogen (proMMP‐2) and activated by proteolytic cleavage. Here we report that polymorphonuclear neutrophil (PMN)‐derived elastase, cathepsin G, and proteinase‐3 activate proMMP‐2 through a mechanism that requires membrane‐type 1 matrix metalloproteinase (MT1‐MMP) expression. Immunoprecipitation of human PMN‐conditioned medium with a mixture of antibodies to elastase, cathepsin G, and proteinase‐3 abolished proMMP‐2 activation, whereas individual antibodies were ineffective. Incubation of HT1080 cells with either purified PMN elastase or cathepsin G or proteinase‐3 resulted in dose‐and time‐dependent proMMP‐2 activation. Addition of PMN‐conditioned medium to MT1‐MMP expressing cells resulted in increased proMMP‐2 activation and in vitro invasion of extracellular matrix (ECM), but had no effect with cells that express no MT1‐MMP. MMP‐2 activation by PMN‐conditioned medium or purified elastase was blocked by the elastase inhibitor α1‐antitrypsin but not by Batimastat, an MMP inhibitor, showing that elastase activation of MMP‐2 is not mediated by MMP activities. The PMN‐conditioned medium‐induced increase in cell invasion was blocked by Batimastat as well as by α1‐antitrypsin, showing that PMN serine proteinases trigger a proteinase cascade that entails proMMP‐2 activation: this gelatinase is the downstream effector of the proinvasive activity of PMN proteinases. These findings indicate a novel role for PMN‐mediated inflammation in a variety of tissue remodeling processes including tumor invasion and angiogenesis.

Optimal Management of the Pancreatic Remnant After Pancreaticoduodenectomy

ObjectiveThe authors evaluated methods of operative management of the pancreatic remnant after pancreaticoduodenectomy. Summary Background DataDespite reductions in mortality after pancreaticoduodenectomy, leakage from the pancreatic remnant still may cause significant morbidity. Patients with small, unobstructed pancreatic ducts or soft, friable pancreata are at particularly high risk. Although numerous surgical techniques have been described to avoid such complications, no single method is suitable for all patients. MethodsThe authors retrospectively reviewed the medical records of 114 consecutive patients who underwent pancreaticoduodenectomy. Sixty-nine patients were men (61%) and 45 were women (39%), with median age 66 years. Underlying disease was malignant in 87 (76%) and benign in 27 (24%). Patients were divided into groups based on risk for postoperative pancreatic fistula and on the operative management of the pancreatic remnant. Sixty-eight patients underwent end-to-side pancreaticojejunostomy, 13 of whom were high risk (group 1A) and 55 of whom were low risk (group 1B). Thirty-seven patients, all high risk, had either pancreatic duct closure by oversewing (N = 19, group 2) or end-to-end pancreaticojejunal invagination (N = 18, group 3). Nine patients underwent total pancreatectomy (group 4). Morbidity related to prolonged pancreatic drainage (PPD) of greater than 20 days was determined. ResultsOverall incidence of PPD was 17% and caused the only death. Patients considered high risk for postoperative pancreatic fistula had a 36% incidence of PPD compared with 2% in patients considered low risk (p < 0.0001). Prolonged pancreatic drainage frequency related to the method of pancreatic remnant management was as follows: group 1A, 15%; group 1B, 2%; group 2, 79%; and group 3,6% (p < 0.001 for group 2 vs. other groups). No serious sequelae followed PPD in 15 patients (79%); however, 4 patients required reoperation for pseudocyst or abscess drainage; one in group 1A (who died) and three in group 2. Multivariate analysis revealed that operative technique (oversewing of the pancreatic duct) and male sex were significant factors predisposing a patient to the development of PPD. ConclusionsAfter pancreaticoduodenectomy, pancreatic remnant management by end-to-side pancreaticojejunostomy appeared safe in low-risk patients. In high-risk patients, end-to-end

Expression of von Willebrand factor, an endothelial cell marker, is up- regulated by angiogenesis factors: A potential method for objective assessment of tumor angiogenesis

von Willebrand factor (vWF), a glycoprotein produced uniquely by endothelial cells and megakaryocytes, is routinely used to identify vessels in tissue sections. Vessel density in tumor specimens, as determined by immuno‐histochemical staining for vWF or other endothelial cell markers, is a negative prognostic factor for many solid tumors. vWF is heterogeneously distributed throughout the vasculature, transcriptional control in response to the tissue microenvironment being responsible for local variations in endothelial cell levels of vWF. Here, we report that fibroblast growth factor‐2 and vascular endothelial growth factor, potent angiogenesis inducers expressed in a variety of tumors, up‐regulate expression of vWF mRNA and protein in cultured endothelial cells with a synergistic effect. Our data support the measurement of vWF mRNA in tumors to detect activated endothelium or angiogenesis. For this purpose, we developed a semi‐quantitative RT‐PCR for vWF mRNA. Preliminary results obtained with specimens from colon carcinoma and the corresponding normal colonic mucosa showed higher vWF mRNA levels in most tumors than in their normal counterparts. The differences in vWF mRNA levels were much larger than the differences in vessel counts between a tumor and the corresponding normal mucosa, indicating that high vWF mRNA levels in tumors may indeed be an early sign of activation of the endothelium. The rapidity, objectivity, sensitivity and specificity of this technique make it suitable for routine clinical application to identify aggressive, highly angiogenic tumors. Int. J. Cancer 85:281–288, 2000. ©2000 Wiley‐Liss, Inc.

Endoscopic biliary drainage before pancreaticoduodenectomy for periampullary malignancies

Despite decreased operative mortality, pancreaticoduodenectomy (PD) remains a formidable operation with substantial morbidity. We have evaluated the influence of preoperative endoscopic biliary drainage (EBD) on morbidity after PD for malignant biliary obstruction by retrospectively reviewing the medical records of 182 patients undergoing PD between April 1985 and August 1996. Of 52 study patients with malignant obstructive jaundice, 22 underwent preoperative EBD, and 30 were not drained. Eighty-three patients were excluded for bilirubin levels less than 5 mg/dl, 43 had other biliary drainage, and 4 had jaundice with benign pathology. Preoperative, intraoperative, and postoperative factors were compared. The two groups were well matched for clinical presentation and operative characteristics except for lower preoperative values of liver chemistries in patients undergoing EBD. Length of postoperative hospitalization for patients undergoing EBD was 13.5 days, compared with 19 days for patients who were not drained (p = 0.02). Patients who were not drained tended to have more overall complications (p = 0.054). Multivariate analysis revealed time to regular diet (p < 0.0001) and no preoperative drainage (p = 0.04) to be independent factors significantly increasing the length of hospitalization. Endoscopic biliary drainage before PD significantly reduced the length of postoperative hospitalization and was associated with less postoperative morbidity. Further studies, including cost analysis, are warranted.

Topical Hepatic Hypothermia Attenuates Pulmonary Injury after Hepatic Ischemia and Reperfusion

BACKGROUND Prolonged periods of hepatic ischemia are associated with hepatocellular injury and distant organ dysfunction in experimental models. Neutrophils (PMN) and tumor necrosis factor (TNF)-alpha have been implicated, mostly because of their local deleterious effects on the hepatocyte after hepatic ischemia and reperfusion (I/R) injury. We hypothesize that topical hepatic hypothermia (THH) reduces ischemia and reperfusion-induced hepatic necrosis, PMN infiltration, TNF-alpha release, and consequent acute pulmonary injury. STUDY DESIGN Sprague-Dawley rats (250 to 300g) were evenly divided into three groups: 90 minutes of normothermic (37 degrees C) partial hepatic ischemia (normothermic I/R), 90 minutes of hypothermic (25 degrees C) partial hepatic ischemia (hypothermic I/R), and sham laparotomy (without ischemia). There were six animals in each experimental group per time point unless otherwise specified. Hepatic necrosis and PMN infiltration were evaluated and scored on hematoxylin and eosin-stained liver specimens 12 hours after reperfusion. Serum TNF-alpha levels were determined by ELISA at 0 minutes, 15 minutes, 30 minutes, 1 hour, and 12 hours postreperfusion. Pulmonary PMN infiltration and vascular permeability were measured by myeloperoxidase activity and Evans blue dye extravasation, respectively, to quantitate pulmonary injury 12 hours after reperfusion. RESULTS Normothermic I/R results in a significant increase in TNF-alpha at 15 and 30 minutes (p < 0.005), PMN infiltration (p < 0.001), and hepatic necrosis (p < 0.001), compared with sham. Institution of THH reduced peak serum TNF-alpha levels by 54% at 15 minutes (p < 0.005) and by 73% at 30 minutes (p < 0.001) postreperfusion compared with normothermic I/R. Similarly, hepatic PMN infiltration and necrosis at 12 hours were reduced by 60% (p < 0.05) and 47% (p < 0.05), respectively. Myeloperoxidase activity and Evans blue extravasation (measures of acute lung injury) were reduced by 42% and 39%, respectively, with institution of THH compared with animals undergoing normothermic I/R (p < 0.001). CONCLUSIONS These results demonstrate that THH protects the liver from ischemia and reperfusion-induced necrosis and PMN infiltration. In addition, THH reduces the serum levels of TNF-alpha and associated pulmonary injury. These data suggest that the ischemic liver is a potential source of inflammatory mediators associated with hepatic ischemia and reperfusion-induced pulmonary injury.

Inhibition of matrix metalloproteinases reduces local and distant organ injury following experimental acute pancreatitis.

BACKGROUND Pulmonary complications from pancreatitis involve parenchymal destruction via proteolytic enzymes. Matrix metalloproteinases (MMPs) may play an important role in pulmonary injury following acute severe pancreatitis. We hypothesized that local and distant organ injury would be decreased by the presence of an MMP inhibitor (Batimistat; BB-94) following severe acute pancreatitis (AP). METHODS Eighteen male rats were randomized into two groups: BB-94 (AP + 40 mg/kg/24 h BB-94 ip x three doses) or control (AP + 20 ml/kg/24 h normal saline ip x three doses). Necrotizing AP was induced by retrograde infusion of 5% sodium taurocholate (1.5 ml/kg) into the pancreatic duct. Twenty additional animals were randomized into BB-94 and control groups for the survival study. Serum was evaluated for amylase and MMP activity. Pancreatic sections were graded for edema, necrosis, neutrophil infiltrate, and hemorrhage. Myloperoxidase (MPO) activity was used to determine PMN infiltration in the lung. Evans Blue dye extravasation was used to quantify vascular permeability. RESULTS Animals in the BB-94 group had decreased amylase levels (1086.0 +/- 61.7 U/L vs 2232.7 +/- 309.9 U/L; P < 0.05), decreased cellular infiltrate (1.4 +/- 0.2 vs 2.3 +/- 0.2; P < 0.02), and decreased necrosis (4.1 +/- 0.3 vs 6.1 +/- 0.4; P < 0.005) compared to the control group. Lung tissue following pancreatitis in the BB-94 group demonstrated decreased MPO activity (41.5 +/- 2.4 units vs 57.3 +/- 2.9 units; P < 0.05) and decreased vascular permeability (18.3 +/- 2.8 mg/100 g vs 30.1 +/- 4.6 mg/100 g; P < 0.05). Animals treated with BB-94 had 100% survival compared to 50% survival in control at 72 h. CONCLUSIONS Pancreatitis results in increased local and distant MMP activity. Pulmonary and pancreatic injury following AP can be abrogated by treatment with an MMP inhibitor (Batimistat; BB-94) which may result in decreased morbidity and mortality.

Perforated Duodenal Diverticulitis: A Report of Three Cases

Background: Duodenal diverticuli are present in up to 22% of the population. However, perforation of a duodenal diverticulum with spillage of enteric contents into the retroperitoneum is rare. Methods: We report three cases of perforated duodenal diverticulitis. Results: Clinical presentations varied widely from patients with acute abdominal findings and generalized sepsis to a patient with mild symptoms of abdominal discomfort. CT scanning was the imaging modality used to make an accurate diagnosis. Treatment approaches for the most stable patient included nonoperative management with antibiotics, bowel rest and parenteral alimentation, while the less stable patients underwent definitive surgery with complete diversion of gastric contents and biliary flow from the affected area of duodenum. Conclusions: This report highlights the salient issues in the presentation, diagnosis and modern management of patients with this potentially catastrophic disease.

Magnetic resonance cholangiopancreatography accurately predicts the presence or absence of choledocholithiasis

Accurate common bile duct (CBD) imaging in patients with biliary calculi is an important determinant of specific therapy. Noninvasive methods to evaluate calculi in the CBD have limited accuracy and rely mainly on ultrasonography and computed tomography. Magnetic resonance cholangiopancreatography (MRCP) is a new noninvasive modality available to evaluate the biliary system. This study was undertaken to assess the accuracy of MRCP in predicting the presence or absence of CBD stones in patients at increased risk for choledocholithiasis. The medical records of 48 patients with a final diagnosis of biliary calculous disease undergoing MRCP between November 1995 and April 1997 were retrospectively reviewed. Three groups were identified: choledocholithiasis (n = 19), gallstone pancreatitis (n = 11), and uncomplicated cholelithiasis (n = 18). In all patients the presence or absence of CBD calculi, as determined by MRCP, was correlated with the final diagnosis obtained from endoscopic retrograde cholangiopancreatography (ERCP) (n = 19), intraoperative cholangiography (n = 6), CBD exploration (n = 13), or clinical follow-up (n = 10). Sensitivity, specificity, and accuracy of MRCP were determined. The major clinical indications for MRCP in the 48 patients ware abnormal liver function tests followed by hyperamylasemia. Twenty patients were diagnosed with CBD stones and 28 were not. MRCP correctly predicted the presence of CBD stones in 19 of 20 patients and failed to detect CBD stones in one patient with gallstone pancreatitis. MRCP incorrectly predicted the presence of CBD stones in 3 of 28 patients ultimately found to have gallstones and no CBD stones. MRCP correctly predicted the absence of CBD stones in the other 25 patients including 10 patients with gallstone pancreatitis. Overall, MRCP had a sensitivity of 95%, a specificity of 89%, and an accuracy of 92%. MRCP is an accurate, noninvasive test for evaluating the CBD duct for the presence or absence of calculi in patients suspected of having CBD stones. Our data support the use of MRCP in the preoperative evaluation of these patients as findings may influence therapeutic decisions.

Neoadjuvant chemotherapy with CPT-11 and cisplatin downstages locally advanced gastric cancer

We examined the role of neoadjuvant therapy in downstaging locally advanced gastric cancer. Preoperative staging was performed with a combination of CT scans, endoscopic ultrasonography and/or laparoscopy, and laparoscopic ultrasonography. Patients with T ⋝3 tumors and/or node-positive disease by preoperative clinical staging were eligible for entry. Neoadjuvant therapy consisted of two cycles of CPT-11 (75 mg/m2) with cisplatin (25 mg/m2) weekly four times every 6 weeks. This was followed by resection with D2 lymph node dissection and two cycles of intraperitoneal chemotherapy with floxuridine and cisplatin. Twenty-two patients were entered into the study (4 with T3N0 disease and 18 with T3N1 disease). Induction chemotherapy was well tolerated with major toxicities being neutropenia and diarrhea. A median of 78%/75% of the planned dosage of CPT-11/cisplatin was delivered. Two patients withdrew consent during the first cycle and were lost to follow-up. One patient progressed to stage IV disease during induction chemotherapy and did not undergo surgery. Nineteen patients underwent surgery. One patient had undetected stage IV disease (liver) and underwent a palliative R2 resection. Of the 18 remaining patients, 17 had curative R0 resections and one had a palliative R1 resection. A median of 21 lymph nodes (range 1 to 121) were examined histologically. There was one postoperative death. Surgical morbidity did not appear to increase after the neoadjuvant regimen. The median postoperative length of hospital stay was 9 days (range 3 to 75 days). Postoperative pathologic staging yielded 16% T3 lesions compared to 85% before treatment based on clinical staging; postoperative American Joint Committee on Cancer staging yielded 37% stage IIIA disease compared to 70% stage IIIA before treatment. With a median follow-up of 15 months, median survival has not yet been reached. We conclude that CPT-11-based neoadjuvant therapy downstages locally advanced gastric cancer. Further follow-up is necessary to determine the ultimate impact of this combination therapy on recurrence and survival.

Magnetic resonance imaging with magnetic resonance cholangiopancreatography accurately predicts resectability of pancreatic carcinoma

Accurate preoperative staging of pancreatic malignancy aids in directing appropriate therapy and avoids unnecessary invasive procedures. We evaluated the accuracy of magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) in determining resectability of pancreatic malignancy. Twenty-one patients with suspected pancreatic malignancy underwent dynamic, contrast-en-hanced breath-hold MRI with MRCP prior to surgical evaluation. Results of this study were correlated with operative results and pathologic findings. The sensitivity, specificity, and accuracy of MRI with MRCP in detecting a mass, determining the nature of the mass, and predicting lymph node involvement and resectability were determined. MRI with MRCP correctly identified the presence of a pancreatic mass in all 21 of these patients. Following pathologic correlation, it was determined that MRI with MRCP was 81 % accurate in determining the benign or malignant nature of the pancreatic mass and 43% accurate in predicting lymph node involvement. In predicting resectability, MRI with MRCP had a sensitivity of 100%, specificity of 83%, positive predictive value of 94%, negative predictive value of 100%, and accuracy of 95%. MRI with MRCP is an accurate, noninvasive technique in the preoperative evaluation of pancreatic malignancy. Information obtained from MRI with MRCP including identification of a mass and predicting tumor resectability may be of value in staging and avoiding unnecessary invasive diagnostic procedures in patients with pancreatic cancer.