Differing uptake of emulsion triglyceride by the fed and fasted rat liver.

The recycling perfusion of a fasted rat liver with an apoprotein E-enriched synthetic triglyceride emulsion revealed a significantly greater hepatic uptake of both the apoprotein and the triglyceride than did the liver of a chow-fed animal. This greater hepatic triglyceride uptake by the perfused fasted liver in comparison to the fed was also noted for emulsions containing no added apoprotein or supplemented with both the E and CIII-1 proteins. However, no difference in the uptake of the triglyceride emulsion was seen for the fed and fasted livers when evaluated by a nonrecycling single pass perfusion. The isolated hepatocyte plasma membranes from fasted rats failed to demonstrate enhanced binding of apoprotein or lipid when compared to those from fed animals. If the residual E loaded triglyceride emulsion was recovered from the recycling perfusates of fed and fasted livers and evaluated in a non-recycling single-pass system, the emulsion from the fasted perfusion was cleared as facilely as previously, whereas that from the fed was less actively cleared. The emulsions retrieved from the perfusion of the fed liver contained significantly more protein than did the fasted; in particular apo C. This apparent alteration of emulsion apoproteins by the fed liver possibly results in a less active hepatic retrieval and may be important in downregulating the entry of lipoprotein triglyceride in the postabsorptive liver.     

Effect of apoproteins on hepatic uptake of triglyceride emulsions in the rat.

The addition of apoprotein E isolated from human very low density lipoproteins to both rat lymph chylomicrons and a triglyceride emulsion significantly increased the hepatic uptake of these particles in a nonrecycling isolated rat liver perfusion system. The cleared triglyceride was removed without apparent hydrolysis by the hepatocyte. When lymph chylomicrons were loaded with both Apo E and Apo C proteins by exposure to rat plasma, no increment in hepatic clearance was observed. Sequential evalutions of the influence of the C apoproteins on the hepatic clearance of both emulsions and chylomicrons revealed that the CIII (CIII-1) protein had a pronounced inhibitory effect on hepatic removal. The inhibition was observed for both Apo E-enriched chylomicrons and those containing little of this apoprotein.     

Delayed breast abscesses after lumpectomy and radiation therapy

The incidence of delayed breast abscess as a complication following the treatment of breast cancer has not been reported. A retrospective review of 112 patients (pts) undergoing lumpectomy and radiation therapy (RT) in our institution revealed a six per cent incidence of delayed breast abscess (range 1.5-8 months, median 5 months). Prophylactic antibiotics (P = 1.0), postoperative chemotherapy (P = 1.0), primary vs. re-excisional lumpectomy (P = 1.0), and different surgeons (P = 0.514) were not associated with increased risk of delayed abscess. All abscesses occurred in the first 32 pts of this series. The size of the lumpectomy cavity correlated with the incidence of infection (P = 0.0440). Since six of seven abscess cultures grew staphylococci (coagulase negative three pts, coagulase positive three pts), and four of these pts experienced prior biopsy site infection, skin necrosis or repeated seroma aspirations, a skin source for contamination was suggested. Treatment of the abscesses with antibiotics and immediate drainage produced acceptable but inferior cosmesis. We conclude that a small but significant subset of patients treated with lumpectomy and RT will develop delayed wound infections and that expeditious treatment affords satisfactory cosmesis.     

Therapeutic options in the management of incidental carcinoma of the prostate.

Incidental carcinoma of the prostate is a protean disease with a natural course which may be indolent or aggressive, with prognosis correlated with histologic grade and extent of disease. Treatment of this pathologic entity has varied over time and has been governed by institutional policy rather than randomized comparison of therapies. This report reviews the literature on incidental prostate cancer focusing on outcomes of patients as related to different therapeutic maneuvers. Observation alone with careful follow-up is appropriate therapy only for those patients with well differentiated disease of limited extent. Patients with diffuse or less differentiated disease required definitive therapy to prevent symptomatic progression. Hormonal manipulation alone has not been demonstrated to be of benefit. Radioactive implants have yielded poor disease-free survival. Radical prostatectomy by an experienced surgeon for patients with adequate health to tolerate the procedure has been associated with acceptable morbidity and excellent local control and survival. Radiation therapy has yielded similar excellent local control and survival and appears to be appropriate for a broader range of patients regardless of health or age.     

Prognostic factors in advanced cancer patients: evidence-based clinical recommendations--a study by the Steering Committee of the European Association for Palliative Care.

PURPOSE: To offer evidence-based clinical recommendations concerning prognosis in advanced cancer patients. METHODS: A Working Group of the Research Network of the European Association for Palliative Care identified clinically significant topics, reviewed the studies, and assigned the level of evidence. A formal meta-analysis was not feasible because of the heterogeneity of published studies and the lack of minimal standards in reporting results. A systematic electronic literature search within the main available medical literature databases was performed for each of the following four areas identified: clinical prediction of survival (CPS), biologic factors, clinical signs and symptoms and psychosocial variables, and prognostic scores. Only studies on patients with advanced cancer and survival < or = 90 days were included. RESULTS: A total of 38 studies were evaluated. Level A evidence-based recommendations of prognostic correlation could be formulated for CPS (albeit with a series of limitations of which clinicians must be aware) and prognostic scores. Recommendations on the use of other prognostic factors, such as performance status, symptoms associated with cancer anorexia-cachexia syndrome (weight loss, anorexia, dysphagia, and xerostomia), dyspnea, delirium, and some biologic factors (leukocytosis, lymphocytopenia, and C-reactive protein), reached level B. CONCLUSION: Prognostication of life expectancy is a significant clinical commitment for clinicians involved in oncology and palliative care. More accurate prognostication is feasible and can be achieved by combining clinical experience and evidence from the literature. Using and communicating prognostic information should be part of a multidisciplinary palliative care approach.     

Bile duct carcinoma. Diagnosis and treatment.

Fifty-three patients were evaluated for carcinoma of the extrahepatic bile ducts at the University of Virginia from 1951 to April 1984. This population was retrospectively reviewed and 33 preoperative and postoperative variables were analyzed to evaluate the predictors of increased survival. No preoperative data, including symptoms, admitting laboratory data, or tumor location, predicted increased survival. Whipple resection yielded a median survival of 12 months; palliative resections, 1.5 months; and laparotomy, only 5.5 months; these differences were not statistically significant. Experience with six patients treated with internal radiation (iridium-192), plus as much as 4000 rads of external beam irradiation, suggests that this combination of radiation treatment may aid palliation.     

Comparison of pathologic and clinical evaluation of lymph nodes in prostate cancer: implications of RTOG data for patient management and trial design and stratification.

RTOG 77-06 and 75-06 were studies of nodal irradiation in prostate cancer, for which the status of nodes was determined by lymph node dissection (LND), lymphangiography (LAG), or computer assisted tomography (CT) based on investigator preference. Actuarial 5 year endpoints of survival, NED survival, local recurrence and distant metastasis have been determined by stage for 805 eligible patients with a comparison of pathologic vs clinical (imaging test) determined nodal status. Patients with pathologically negative lymph nodes show significantly improved 5 year survival (Stage T-2 (B) 84% vs 77%, Stage T-3,4 (C) 82% vs 65%) and NED survival (Stage T-2 (B) 72% vs 63%, Stage T-3,4 (C) 64% vs 44%) compared to patients clinically negative. Free of metastasis rates are increased in Stage T-3,4 (C) pathologic negative patients compared to imaging negative patients (75% vs 60%). A comparison of clinical positive versus clinical negative patients shows no difference in survival, NED survival or rate of metastasis, while a similar comparison of pathologic positive versus pathologic negative shows significant difference for all three endpoints (survival: Stage T-2 (B) 84% vs 61%, Stage T-3,4 (C) 82% vs 66%, NED survival: Stage T-2 (B) 72% vs 32%, Stage T-3,4 (C) 64% vs 32%; free of metastasis: Stage T-2 (B) 82% vs 64%, Stage T-3,4 (C) 75% vs 44%). The clinical determination of nodal status, therefore, has no prognostic value in contrast to pathologic determination and should not be used for stratifying patients in clinical trials. The CT scans often used to evaluate nodal status are more useful if delayed until they can be done as part of the treatment planning process where the CT has value. When imaging tests suggest positive lymph nodes in prostate cancer patients, the imaging finding is confirmed by biopsy.