The treatment of some cancer patients has shifted from traditional, non-specific cytotoxic chemotherapy to chronic treatment with molecular targeted therapies. Imatinib mesylate, a selective inhibitor of tyrosine kinases (TKIs) is the most prominent example of this new era and has opened the way to the development of several additional TKIs, including sunitinib, nilotinib, dasatinib, sorafenib and lapatinib, in the treatment of various hematological malignancies and solid tumors. All these agents are characterized by an important inter-individual pharmacokinetic variability, are at risk for drug interactions, and are not devoid of toxicity. Additionally, they are administered for prolonged periods, anticipating the careful monitoring of their plasma exposure via Therapeutic Drug Monitoring (TDM) to be an important component of patients' follow-up. We have developed a liquid chromatography-tandem mass spectrometry method (LC-MS/MS) requiring 100 microL of plasma for the simultaneous determination of the six major TKIs currently in use. Plasma is purified by protein precipitation and the supernatant is diluted in ammonium formate 20 mM (pH 4.0) 1:2. Reverse-phase chromatographic separation of TKIs is obtained using a gradient elution of 20 mM ammonium formate pH 2.2 and acetonitrile containing 1% formic acid, followed by rinsing and re-equilibration to the initial solvent composition up to 20 min. Analyte quantification, using matrix-matched calibration samples, is performed by electro-spray ionization-triple quadrupole mass spectrometry by selected reaction monitoring detection using the positive mode. The method was validated according to FDA recommendations, including assessment of extraction yield, matrix effects variability (<9.6%), overall process efficiency (87.1-104.2%), as well as TKIs short- and long-term stability in plasma. The method is precise (inter-day CV%: 1.3-9.4%), accurate (-9.2 to +9.9%) and sensitive (lower limits of quantification comprised between 1 and 10 ng/mL). This is the first broad-range LC-MS/MS assay covering the major currently in-use TKIs. It is an improvement over previous methods in terms of convenience (a single extraction procedure for six major TKIs, reducing significantly the analytical time), sensitivity, selectivity and throughput. It may contribute to filling the current knowledge gaps in the pharmacokinetics/pharmacodynamics relationships of the latest TKIs developed after imatinib and better define their therapeutic ranges in different patient populations in order to evaluate whether a systematic TDM-guided dose adjustment of these anticancer drugs could contribute to minimize the risk of major adverse reactions and to increase the probability of efficient, long lasting, therapeutic response.

Introduction: Surgery for symptomatic aortic abdominal aneurysms (sAAA) is associated with an increased mortality and morbidity compared to asymptomatic aortic aneurysms (aAAA). With the advent of endovascular therapy, an alternative therapeutic modality has become available. Endovascular therapy, however, depends on certain morphologic criteria, whereas open surgery can be performed on any type of AAA. The purpose of this study was to analyse our data of surgical treatment of non ruptured AAA and to identify the amount of patients in whom endovascular therapy would have been possible.Methods: Retrospective analysis of the medical data of all patients operated upon non ruptured AAA in our department by 3 responsible vascular surgeons from 1995-1999.Results: 225 consecutive patients with a median age of 65 (42-95) years were included in the study. There were 184 (82 %) male and 41 (18 %) female patients with 143 (63.5 %) aAAA and 82 (36.5 %) sAAA. Patients with sAAA underwent emergency aneurysm repair and had a significantly increased aneurysm diameter compared to the aAAA, who underwent elective surgical aneurysm repair (6.9 ± 1.6 cm vs. 6 ± 1.2 cm; p = 0.002). A total of 11 (4.9 %) patients had an inflammatory AAA. Smoking was found to be the only significant increased preoperative risk factor in the group of sAAA compared to aAAA (91 vs. 35 patients; p = 0.008). Morbidity was significantly increased in the patients with sAAA compared to the aAAA (55 % vs. 31.5 %; p = 0.041) The mortality however did not differ significantly in the two groups (2 vs. 3 patients; p = 0.691). Considering morphological criteria of the AAA, endovascular therapy would have been possible in 59 (26 %) patients. However, in 24 (11 %) of the 59 patients, endovascular therapy was not feasible because of aortic kinking, heavy calcification of the aneurysm neck, a patent inferior mesenteric artery or atherosclerotic diseased iliac arteries. Consequently, only 35 (15 %) patients would have qualified for an endovascular therapy.Discussion: Surgical therapy can be performed in patients with asymptomatic and symptomatic AAA with an equal low mortality. This finding underlines the fact, that surgical therapy still remains the standard therapy for AAA. In addition, in our study only a relative small amount of patients would have qualified for an endovascular therapy.

Doxorubicin is an antineoplasic agent active against sarcoma pulmonary metastasis, but its clinical use is hampered by its myelotoxicity and its cumulative cardiotoxicity, when administered systemically. This limitation may be circumvented using the isolated lung perfusion (ILP) approach, wherein a therapeutic agent is infused locoregionally after vascular isolation of the lung. The influence of the mode of infusion (anterograde (AG): through the pulmonary artery (PA); retrograde (RG): through the pulmonary vein (PV)) on doxorubicin pharmacokinetics and lung distribution was unknown. Therefore, a simple, rapid and sensitive high-performance liquid chromatography method has been developed to quantify doxorubicin in four different biological matrices (infusion effluent, serum, tissues with low or high levels of doxorubicin). The related compound daunorubicin was used as internal standard (I.S.). Following a single-step protein precipitation of 500 μl samples with 250 μl acetone and 50 μl zinc sulfate 70% aqueous solution, the obtained supernatant was evaporated to dryness at 60°C for exactly 45 min under a stream of nitrogen and the solid residue was solubilized in 200 μl of purified water. A 100 μl-volume was subjected to HPLC analysis onto a Nucleosil 100–5 μm C18 AB column equipped with a guard column (Nucleosil 100–5 μm C6H5 (phenyl) end-capped) using a gradient elution of acetonitrile and 1-heptanesulfonic acid 0.2% pH 4: 15/85 at 0 min→50/50 at 20 min→100/0 at 22 min→15/85 at 24 min→15/85 at 26 min, delivered at 1 ml/min. The analytes were detected by fluorescence detection with excitation and emission wavelength set at 480 and 550 nm, respectively. The calibration curves were linear over the range of 2–1000 ng/ml for effluent and plasma matrices, and 0.1 μg/g–750 μg/g for tissues matrices. The method is precise with inter-day and intra-day relative standard deviation within 0.5 and 6.7% and accurate with inter-day and intra-day deviations between −5.4 and +7.7%. The in vitro stability in all matrices and in processed samples has been studied at −80°C for 1 month, and at 4°C for 48 h, respectively. During initial studies, heparin used as anticoagulant was found to profoundly influence the measurements of doxorubicin in effluents collected from animals under ILP. Moreover, the strong matrix effect observed with tissues samples indicate that it is mandatory to prepare doxorubicin calibration standard samples in biological matrices which would reflect at best the composition of samples to be analyzed. This method was successfully applied in animal studies for the analysis of effluent, serum and tissue samples collected from pigs and rats undergoing ILP.

Objective: Prospective analysis of the morbidity and outcome of the sentinel lymph node (SLN) technique in a consecutive series of patients with early-stage melanoma. Methods: Between 1997 and 1998, 60 patients with stage IB-II malignant melanoma underwent SLN dissection. Preoperative dynamic lymphoscintigraphy with mapping of the lymph vessels and lymph nodes and location of the sentinel node was performed the day before SLN dissection. SLN was identified by use of the blue dye technique. SLN was assessed for histopathological and immunohistochemical examination. Postoperative morbidity and mortality were recorded. Follow-up consisted of repetitive clinical examination with lymph nodes status, laboratory and radiologic findings. Results: Tumor-positive SLN was observed in 18% of the patients and stage II disease was found in 91% of the patients with positive SLN. Breslow thickness was the only significant factor predicting involvement of a SLN (p = 0.02). In 36% of the positive SLN, metastases could be assessed only by immunohistochemical examination. Postoperative complications after SLN dissection were observed in 5% in comparison with 36% after elective lymph node dissection. After a mean follow-up of 32 months, recurrence was observed in 3% with a mean disease-free survival of 8 months. Overall survival was 82% and 90% in patients with positive and negative SLN, respectively. Overall mortality was 15%, due to distant metastases in 78% of the cases. Conclusions: Staging of early-stage melanoma with the SLN dissection by use of the blue dye technique combined to lymphoscintigraphy and immunohistochemistry is reliable and safe, with less morbidity than elective lymphadenectomy. Long-term follow-up is mandatory to establish the exact reliability of SLN dissection.

Objective: Bilateral lung volume reduction surgery (LVRS) has emerged as a palliative treatment option in patients with severe pulmonary emphysema. However, it is not known if a sustained functional improvement can be obtained using an unilateral approach. Methods: We hypothesized that a palliative effect can also be obtained by unilateral LVRS and prospectively assessed lung function, walking distance, and dyspnea before and 3, 6, 12, 18. 24 and 36 months after unilateral LVRS, Results: Twenty-eight patients were operated by the use of video-assisted thoracoscopic surgery (VATS) with a mean follow-up of 16.5 months (range 3-36 months). Forced expiratory volume in 1 s (FEV1) was significantly improved up to 3 months (1007 +/- 432 compared to 1184 +/- 499 ml, P < 0.001), residual volume up to 24 months (4154 +/- 1126 compared to 3390 +/- 914 ml. P < 0.01) dyspnea up to 12 months (modified Borg dyspnea scale 6.6 +/- 1.8 compared to 3.9 +/- 1.8. P = 0.01) and walking distance up to 24 months (343 +/- 107 compared to 467 +/- 77 m. P < 0.05) after unilateral LVRS compared to preoperative values. Overall, 25 of 28 patients reported a subjective benefit after unilateral LVRS. There was no 30-day mortality. Only two patients required surgery on the contralateral side after 4.5 and 6 months. respectively, both suffering from alpha -1-antitrypsin deficiency. Conclusions: Unilateral LVRS by the use of VATS results in a sustained beneficial effect. improving walking distance and dyspnea for up to 24 months in patients with severe emphysema. The preservation of the contralateral side for future intervention if required renders unilateral LVRS an attractive concept in this difficult palliative situation. (C) 2001 Elsevier Science B.V. All rights reserved.

Il est indiscutable que la veine est le meilleur materiel de remplacement pour les reconstructions peripheriques infragonales et surtout jambieres. Dans 10 a 40% des cas la veine saphene interne autologue a deja ete utilisee, a subi une transformation cicatricielle post-thrombotique, est variqueuse ou n'est plus presente. Materiel: dans une periode de 23 mois nous avons trouve parmi 249 reconstructions peripherique 89 cas dans lesquels la veine n'etait plus utilisable en totalite ou en partie 73% des 89 extremites (86 patients se trouvaient au stade III et IV. 7,8 % avaient une isehemie critique ou complete. La cause etait dans 56% des cas l'absence d'une veine saphene interne (by-pass peripherique 30%. by-pass coronaire 14 %, operation de varices 12 % ). ou qu'elle n'etait que partiellement utilisable III %. de calibre trop faible (10%), post-rthrombotique (10%), variqueuse (9%) et ectasique (3%). Dans 78% des cas des derivations infragonales. jambieres et du pied etaient necessaires qui ont ete effectuees dans 39 cas completement avec du materiel veineux present. dans 39 cas uniquement avec du PTFE et dans 11 cas avec des by-pass PTFE/veines composites. Resultats: le pourcentage perioperatoire global d'amputation et de mortalite se situait a 9 %.3 patients sont morts dans la periode perioperatoire. Une defaillance precoce du by-pass avec amputation consecutive est survenue surtout apres des derivations au PTFE. Conclusion: un probleme croissant des derivations peripheriques est le manque de materiel veineux ou son etat inacceptable. On rencontre de plus en plus frequemment des transformations cicatricielles parietales, des veines variqueuses, ectasiques ou de calibre insuffisant mais elles peuvent etre utilisees pour la mise en place d'un by-pass complet ou partiel. Il faut eventuellement preferer pour une derivation prothetique jambiere une veine partiellement normale mais avec une intima intacte.

The most promising developments in the field of isolated limb perfusion have centred around the use of the recombinant cytokine tumour necrosis factor-alpha (rTNF-alpha) in combination with melphalan. While the results of clinical trials are impressive, the exact antitumour mechanisms of rTNF-alpha and its role in combination with melphalan remain unclear. Our aim was to study the antitumour activity of human rTNF-alpha with or without the combination of melphalan in a nude mouse human melanoma xenograft system. In a first attempt to define the maximal tolerated single dose of rTNF-alpha in this setting, 15 animals were exposed to increasing doses of rTNF-alpha (60-2500 microg/kg intraperitoneally). All but one animal survived and tumour growth was not influenced by these single dose applications of rTNF-alpha even at the very high doses. Anti-tumour activity of repeated application of melphalan (three times 9 mg/kg in group 2 and three times 6 mg/kg in group 3), of rTNF-alpha alone (nine doses of 50 microg/kg in group 4), and of rTNF-alpha in combination with melphalan (nine doses of 50 microg/kg rTNF-alpha and three times 6 mg/kg melphalan in group 5) was further compared with non-treated animals (group 1). Tumour growth was significantly inhibited in all animals treated with melphalan (group 2, 3 and 5), but was not decreased in animals treated with rTNF-alpha alone (group 4). Mean final tumour volumes and mean tumour weight were not different in group 2 (789 +/- 836 mm3, 0.38 +/- 0.20 g), group 3 (1173 +/- 591 mm3, 0.55 +/- 0.29 g) and group 5 (230 +/- 632 mm3, 0.37 +/- 0.29 g), but significant lower than group 1 (3156 +/- 1512 mm3, 2.35 +/- 0.90 g) and group 4 (3228 +/- 1990 mm3, 2.00 +/- 1.16 g). There were no significant differences between high and low dose melphalan treatment and between melphalan treatment in combination with rTNF-alpha. Histological examination did not show differences between treated and non-treated animals besides slightly inhibited mitotic activities of tumour cells in melphalan-treated animals. While tumour growth of human xenotransplanted melanoma in nude mice could be inhibited by melphalan, we failed to demonstrate any antitumour effect of rTNF-alpha. The combination of melphalan and rTNF-alpha did not enhance the antiproliferative effect of melphalan alone. Human xenotransplanted tumours on nude mice might not be the ideal experimental setting for studies of potential direct antineoplastic activity of rTNF-alpha, and these results support the concept that TNF-alpha exerts its antitumour activity indirectly, possibly by impairing the tumour vasculature and by activating the immune system.

The role of video-thoracoscopy (VT) as an invasive diagnostic procedure for mediastinal lesions not reachable by cervical mediastinoscopy (CM) has still to be defined, particularly with regard to parasternal mediastinotomy (PMT). Diagnostic efficiency and morbidity of the three methods were assessed and compared in a consecutive series over a 18 months-period after determination of a new diagnostic strategy. Among 77 interventions in 73 patients the following distribution of the methods referred was achieved: 42 CM (paratracheal and anterior subcarinal biopsies), 17 PMT (biopsies of anterior mediastinal lesions) and 18 VT (3 paratracheal, 3 posterior subcarinal, 3 anterior, 5 aortico-pulmonary window, 4 posterior biopsies or resections). All procedures were performed in general anesthesia for VT the double-lumen technique was used. Drains could be removed not later than the second postoperative day. In 7/17 cases of PMT the pleural space was opened and drained. Mean operation time (incl. waiting period for intraoperative frozen section and complete resection in a few cases) was 77 (45-100) min for VT, 49 (10-180) min for PMT and 41 (20-105) min for CM. Histological diagnosis of biopsy specimens were conclusive in all VT cases, in 15/17 PMT (88 %) and in 37/42 CM (88 %). Two major complications occurred: one recurrent nerve palsy following VT-resection of a neurinoma originating from the recurrent nerve itself; in a second patient submitted to mediastinoscopic biopsy, venous bleeding had to be managed by surgical sternotomy. CM as the most approved method for paratracheal and anterior subcarinal biopsies has not lost its importance. PMT as a simple and usually extrapleural intervention can further be advocated for anterior mediastinal lesions. VT turns out to be rather a complementary than a competitive invasive mediastinal diagnostic procedure and is regarded as method of choice for diagnostic approach to posterior, posterior subcarinal and aorticopulmonary lesions.

The role of video-thoracoscopy (VT) as an invasive diagnostic procedure for mediastinal lesions not reachable by cervical mediastinoscopy (CM) has still to be defined, particularly with regard to parasternal mediastinotomy (PMT). Diagnostic efficiency and morbidity of the three methods were assessed and compared in a consecutive series over a 18 months-period after determination of a new diagnostic strategy. Among 77 interventions in 73 patients the following distribution of the methods referred was achieved: 42 CM (paratracheal and anterior subcarinal biopsies), 17 PMT (biopsies of anterior mediastinal lesions) and 18 VT (3 paratracheal, 3 posterior subcarinal, 3 anterior, 5 aortico-pulmonary window, 4 posterior biopsies or resections). All procedures were performed in general anesthesia for VT the double-lumen technique was used. Drains could be removed not later than the second postoperative day. In 7/17 cases of PMT the pleural space was opened and drained. Mean operation time (incl. waiting period for intraoperative frozen section and complete resection in a few cases) was 77 (45-100) min for VT, 49 (10-180) min for PMT and 41 (20-105) min for CM. Histological diagnosis of biopsy specimens were conclusive in all VT cases, in 15/17 PMT (88%) and in 37/42 CM (88%). Two major complications occurred: one recurrent nerve palsy following VT-resection of a neurinoma originating from the recurrent nerve itself; in a second patient submitted to mediastinoscopic biopsy, venous bleeding had to be managed by surgical sternotomy. CM as the most approved method for paratracheal and anterior subcarinal biopsies has not lost its importance. PMT as a simple and usually extrapleural intervention can further be advocated for anterior mediastinal lesions. VT turns out to be rather a complementary than a competitive invasive mediastinal diagnostic procedure and is regarded as method of choice for diagnostic approach to posterior, posterior subcarinal and aorticopulmonary lesions.

Successful preservation of the first ray was achieved in a diabetic patient with a penetrating ulcer with underlying osteomyelitis of the first metacarpophalangeal joint and arterial insufficiency. Resection of the joint followed by stabilisation using an external fixator for four weeks resulted in permanent control of infection and preservation of the toe without recurrence of osteomyelitis or ulceration. Since preservation and correct alignment of the first ray is essential for foot stability, this technique may be beneficial in young and active diabetic patients suffering from this difficult complication of their disease.

OBJECTIVE:To assess the power of operative flow measurements in the prediction of outcome after infrainguinal bypass operations for critical ischaemiaDESIGN:Open studySETTING:University department of vascular surgerySUBJECTS:197 patients operated on for critical ischaemia between 1 January 1982 and 31 December 1989 under the care of one surgeon.INTERVENTIONS:Standard operative angiography and measurement of flow of distal runoffMAIN OUTCOME MEASURES:Patency and limb salvageRESULTS:All patients were followed up prospectively until 31 March 1991 or death. The estimated 5 year rates of primary patency and limb salvage were 0.75 and 0.86, respectively. Multivariate analysis showed that flow measurement was the most powerful predictor of graft patency (p = 0.0003) and limb salvage (p = 0.004) of all factors studied, including angiography. Irrespective of the site of distal anastomosis no polytetrafluoroethylene (PTFE) graft remained patent if the flow was less than 50 m/minute, whereas vein grafts remained patent if the flow was as little as 10 ml/minute.CONCLUSIONS:Flow is easy to measure and is a better predictor of outcome than angiography. Decisions about grafting should rely on flow measurements if there is any doubt about patency or limb salvage, particularly if a PTFE graft is going to be used.

The levels of several potential indicators of drug resistance were measured in tumor and corresponding normal tissue of 55 untreated patients with lung cancer. The resistance parameters include glutathione (GSH) level, activities of the enzymes glutathione transferase (GST), glutathione peroxidase (GPx) and O6‐alkylguanine‐DNA alkyltransferase (ATase), as well as expression of P‐glycoprotein (Pgp). Median values of GSH, GST and GPx were significantly higher in tumor than in normal tissue of non‐small‐cell lung cancer (NSCLC) or of small‐cell lung cancer (SCLC), whereas ATase was elevated in tumor tissue of NSCLC only. Pgp expression as determined by Western blotting was significantly lower in tumor than in normal tissue of NSCLC. Resistance‐parameter expression did not correlate with stage of disease or age of the patients. We found a negative correlation between smoking intensity and GSH level in normal tissue. Our findings indicate that the fundamental differences in chemo‐sensitivity between SCLC and NSCLC cannot be explained by differences in the GSH‐system or in the expression of Pgp. However, the level of ATase activity may be one of the factors responsible for the difference in chemosensitivity.

A procedure for the extraction and high performance liquid chromatographic (HPLC) determination of the photodynamic therapeutic agent 5,10,15,20-tetra(m-hydroxyphenyl)chlorin in human, rat and mouse tissues following intravenous administration of the drug is described. The tissue (tumour, skin, muscle and liver) was homogenized and extracted into a mixture of methanol:dimethyl sulphoxide:water (32:8:1 by vol.) containing, 5,10,15,20-tetra(p-hydroxyphenyl)chlorin as the internal standard. The precipitated proteins were removed by centrifugation and the supernatant was separated by reversed phase HPLC on a Hypersil-ODS column with 77% (v/v) acetonitrile in 0.1% trifluoroacetic acid as the mobile phase. The solute was detected with high sensitivity and specificity by a UV-VIS detector set at 423 nm.