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Objectives: The identification of hyperamylasaemia insufficient to confidently diagnose acute pancreatitis in patients with epigastric pain poses a clinical dilemma. The aim of this study was to identify a cohort of such patients and review their presentation, investigation and outcome., Design: Patients admitted through the emergency surgical intake during a 12-month period with serum amylase levels of 100-400 IU/L were identified and case notes reviewed to confirm those presenting with upper abdominal pain. Subsequent radiological and biochemical investigations were recorded., Participants: A total of 25 patients with non-diagnostic hyperamylasaemia., Setting: Ward patients in a University Hospital., Main Outcome Measures: Amylase level, eventual diagnosis, drug history., Results: Twenty-five patients were identified with a mean age of 46.7 years. The median serum amylase level was 230 IU/L (range 102-358 IU/L). Twenty-two patients underwent transabdominal ultrasound at presentation, with gallstones identified in nine cases. The remaining three had documented gallstones and were awaiting elective cholecystectomy. Of the 13 patients with no evidence of cholelithiasis, six were taking medications known to cause pancreatitis, seven patients underwent computed tomography (CT) scans that identified chronic pancreatitis in three, and were non-diagnostic in four cases. These four patients underwent endoscopic ultrasound (EUS) evaluation of the biliary tree identifying microlithiasis in one but no pathology in the remaining three cases., Conclusions: Patients with hyperamylasaemia not diagnostic of pancreatitis should be carefully investigated, as gallstones will be identified in at least 50%. An accurate drug history is also invaluable.

Background & Aims: The evidence in support of Early Enteral Nutrition (EEN) after upper gastrointestinal surgery is inconclusive. The aim of this study was to determine if EEN improved clinical outcomes and shortened length of hospital stay., Methods: Open, prospective multicentre randomised controlled trial within a regional UK Cancer Network. One hundred and twenty-one patients with suspected operable upper gastrointestinal cancer (54 oesophageal, 38 gastric, 29 pancreatic) were studied. Patients were randomised to receive EEN (n = 64) or Control management postoperatively (nil by mouth and IV fluid, n = 57). Analysis was based on intention-to-treat and the primary outcome measure was length of hospital stay., Results: Operative morbidity was less common after EEN (32.8%) than Control management (50.9%, p = 0.044), due to fewer wound infections (p = 0.017), chest infections (p = 0.036) and anastomotic leaks (p = 0.055). Median length of hospital stay was 16 days (IQ = 9) after EEN compared with 19 (IQ = 11) days after Control management (p = 0.023)., Conclusions: EEN was associated with significantly shortened length of hospital stay and improved clinical outcomes. These findings reinforce the potential benefit of early oral nutrition in principle and as championed within enhanced recovery after surgery programmes, and such strategies deserve further research in the arena of upper GI surgery., (Copyright © 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: The aims of this study were to assess the role of endoscopic ultrasound (EUS) in the evaluation of adenocarcinoma of the head of the pancreas in cases of diagnostic dilemma and to determine the strength of agreement between perceived pre-operative stage as determined by computerised tomography (CT) and EUS and histopathological stage., Methods: Patients undergoing pancreatic EUS were identified from a computerised radiology database. The strengths of agreement between the radiological and histopathological stages were determined by the weighted kappa (Kw) statistic., Results: Fifty-eight patients were identified. Of 37 patients with a pancreatic head mass on prior imaging, 32 had a diagnosis of adenocarcinoma confirmed by EUS, as did 11 of 21 patients with suspicious pancreatic head lesions. Twenty-five of 43 patients were deemed to have resectable carcinomas, and 2 patients had resectable mucinous lesions. In comparing CT and EUS in the 25 patients undergoing resection, the Kw for T and N stages was 0.250 (p = 0.05) and -0.080 (p = 0.288), respectively, for CT, compared with 0.738 (p = 0.0001) and 0.606 (p = 0.0001), respectively, for EUS., Conclusions: EUS was effective in assessing the resectability of pancreatic head adenocarcinomas. Furthermore, EUS held a significant 3-fold advantage over CT with regard to T stage and an even higher significant advantage with regard to N stage., (Copyright © 2011 S. Karger AG, Basel.)

Background: CA19-9 is a carbohydrate tumor-associated antigen which is frequently upregulated in pancreatobiliary neoplasia. However, it may also be elevated in patients with jaundice in the absence of a tumor due to biliary obstruction, and in other non-hepato-pancreatico-biliary conditions. This study aimed to evaluate whether CA19-9 levels could accurately differentiate between benign and malignant pancreatobiliary disease., Methods: All patients referred to a single surgeon for investigation of pancreaticobiliary disease in 2003 in whom a firm diagnosis had been established were included. For malignant disease, a histological diagnosis was required but for benign disease a firm radiological diagnosis was deemed adequate. The patients were divided into 4 categories: pancreatic adenocarcinoma (PCa); cholangiocarcinoma (CCa); chronic pancreatitis (CP) and biliary calculous disease (Calc). Bilirubin and alkaline phosphatase levels corresponding to the point of assessment of CA19-9 were also noted., Results: Final diagnoses were made of pancreatic adenocarcinoma (PCa, n=73), cholangiocarcinoma (CCa, n=19), ampullary carcinoma (Amp, n=7), neuroendocrine carcinoma (Neu, n=4), duodenal carcinoma (Duo, n=3), chronic pancreatitis (CP, n=115), and biliary calculous disease (Calc, n=27). Median CA19-9 levels (U/ml) were: PCa, 653; CCa, 408; Duo, 403; Calc, 27; CP, 19; Neu, 10.5; Amp, 8 (reference range: 0-37). The CA19-9 levels were significantly greater for malignant than for benign disease, could differentiate PCa from CCa/Duo, and were significantly higher in unresectable than in resectable PCa. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for CA19-9 were 84.9%, 69.7%, 67.7% and 86.1%, respectively. A ROC analysis provided an area under the curve for CA19-9 of 0.871 (0.820-0.922), giving an optimal CA19-9 of 70.5 U/ml for differentiating benign from malignant pathology. Using this cut-off, the sensitivity was 82.1%, while specificity, PPV and NPV improved to 85.9%, 81.3% and 86.5%, respectively. When standard radiology was included (US/CT/MRCP) in the decision process, the results improved to 97.2%, 88.7%, 86.6%, and 97.7%. For benign disease, the CA19-9 correlated directly with the serum bilirubin, but for malignant disease, CA19-9 levels were elevated independent of the bilirubin level., Conclusions: CA19-9 is useful in the differentiation of pancreatobiliary disease and when using an optimized cut-off and combining with routine radiology, the diagnostic yield is improved significantly, thus stressing the importance of a multi-disciplinary approach to pancreatobiliary disease.

Context: There are classical radiological features for the diagnosis of chronic pancreatitis when utilising endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT), however, not all patients exhibit these features despite convincing clinical histories, which may result in diagnostic delay., Objective: The aim of this study was to assess the use of endoscopic ultrasound (EUS) in the diagnosis of chronic pancreatitis when other imaging modalities had not yielded a diagnosis., Methods: All patients undergoing pancreatic EUS between January 1996 and December 2004 were identified from the radiology computerised database. Sixteen patients with a clinical diagnosis of chronic pancreatitis (10 males, 6 females; mean age 53+/-4 years) underwent EUS after normal conventional imaging. Patients were then followed clinically until December 2007., Results: Thirteen patients exhibited features of chronic pancreatitis not identified by other modalities, which included duct dilatation (n=8), calcification (n=7); parenchymal change (n=6), irregular undilated ducts (n=2), pancreatic ductal calculi (n=1), and fine calcification (n=1). Of the remaining 3 patients, a diagnosis of autoimmune pancreatitis was made in one, in another there was a pancreatic duct stricture of uncertain origin that was stented, and in only one case was no diagnosis established. All 13 patients with an EUS diagnosis of chronic pancreatitis subsequently underwent a repeat CT scan for surveillance of their disease and in all cases, the CT scans subsequently demonstrated evidence of chronic pancreatitis indicating radiological progression. No new pancreaticobiliary diagnoses were established during this period., Conclusions: EUS is a useful diagnostic tool confirming the diagnosis of chronic pancreatitis in 13 of 16 cases where histories were suspicious of chronic pancreatitis, and providing an alternative diagnosis in another two cases. EUS should be considered an important tool for diagnosis of chronic pancreatitis and should be used when cross-sectional imaging is non-diagnostic.

Objective: The aim of this study was to investigate the role of EUS where other investigative techniques had failed to identify the cause of biochemically proven acute pancreatitis., Setting: All biliary EUS examinations performed between January 2000 and December 2004 were identified from the radiology computerised database., Patients: Forty-two patients (25 male, 17 female; mean age: 53+/-3.2 years) with negative prior radiological investigations underwent EUS., Main Outcome Measures: Prior and later radiological investigations, hospital readmission, and the need for further surgical intervention were also analysed., Results: EUS was normal in 17 patients (40.5%) and demonstrated signs of recent acute pancreatitis but no other aetiological factor in 8 patients (19.0%). Cholelithiasis or microlithiasis was identified in 9 patients (21.4%), combined gallstones/microlithiasis and choledocholithiasis in was seen in 6 patients (14.3%). In one patient (2.4%), calculi were seen in the common bile duct but not the gallbladder. In a further case with recurrent acute pancreatitis (2.4%), chronic pancreatitis was diagnosed on EUS. All patients with common bile duct stones underwent ERCP and sphincterotomy, and stones were universally confirmed. One patient with gallbladder calculi alone required an ERCP after developing jaundice whilst awaiting cholecystectomy., Conclusions: EUS provided additional diagnostic information in 17 of the 42 patients (40.5%). Moreover, exclusion of gallstones/microlithiais is also important as it facilitates a search for other causes of pancreatitis. In conclusion, most cases of cholelithiasis can be diagnosed with standard imaging modalities but when these fail to identify a cause, EUS has an important role to play.

Tumour angiogenesis is a critical step in the growth, metastatic spread and regrowth of colorectal cancer. Angiogenesis specific to tumour is a complicated process, the mechanisms of which remain unclear. Metastasis of colorectal cancer may result from passive entry into the circulation secondary to the effect of angiogenic factors. The survival and growth of colorectal tumour and thus their metastases are dependent on the balance of endogenous angiogenic and anti-angiogenic factors such that the outcome favours increased angiogenesis. Angiogenesis has become an attractive target for anticancer drug development, based on its important roles in tumour growth, invasion and metastasis. Several growth factors have been identified that regulate angiogenesis in colorectal cancer; the most important of these are vascular endothelial growth factors (VEGF), and of the several angiogenic factors, VEGF expression at the deepest invasive site of tumour is the most statistically significant prognostic indicator in advanced colorectal carcinoma. In this review article, we provide an overview on angiogenic factors and their receptors, and discuss the role of newly identified tumour endothelial markers (TEMs) that are involved in tumour-associated angiogenesis in colorectal cancer.

Background: Leiomyosarcoma of the inferior vena cava is a rare tumor that presents in an insidious manner with non-specific symptoms. Given its rarity, there are no consensus guidelines to its management. The aim of this study was to report the clinical experience in the management of patients presenting to our institution during a 12 year period., Patients and Methods: Four patients with leiomyosarcomas of the inferior vena cava were managed at our institution during the period reviewed. Patient details were identified through a search of the pathology department computerized database, and case notes were retrospectively reviewed to obtain details of presentation and management., Results: There were 3 females and 1 male with a mean age of 59 years. All tumors were identified within 2 months of first symptoms. Three of the 4 had localized tumors whilst 1 patient had lung metastases at presentation. The three patients with resectable tumors underwent radical surgical excision of the tumor, and two patients had postoperative radiotherapy. One patient died of recurrence at 7 months, and another at 30 months. The third patient is currently well and disease free at 16 months. The fourth patient with metastatic disease was treated with chemotherapy alone and survived 36 months., Conclusion: Leiomyosarcoma of the inferior vena cava is an uncommon tumor that presents with non-specific symptoms. At the time of presentation, tumors are usually large and resection is challenging but probably offers the best opportunity for long-term survival.

Background and Aims: Tumour endothelial marker-8 (TEM-8) has been found to be selectively up regulated in tumour-associated endothelial cells, it is implicated in tumour specific angiogenesis, but its mechanism in angiogenesis is not defined., Methods: A ribozyme transgene (TEM-8) was cloned into a suitable mammalian expression vector (pc DNA 3.1-GFP-NT) and transfected into HECV cells. Various domains of TEM-8 were designed and cloned into pEF6/V5-His TOPO TA vector and transfected into Chinese Hamster ovarian cells (CHO), which do not form tubules and do not express TEM-8 in general (CHO(vW), CHO(TM), CHO(vW/TM), CHO(AE), CHO(AC), CHO(IC), and CHO(FL) domains, respectively). The effect of TEM-8 knocked out HECV cells was tested (by angiogenesis and migration assays), and the effect of each cleavage domain of TEM-8 was tested by microtubule formation assay., Results: TEM-8 stable transfectants (HECV(DeltaTEM8a)) manifested a complete loss of TEM-8 gene expression at mRNA and protein levels. In contrast, control GFP plasmid (HECV(pControl)) and wild-type HECV cells (HECV(WT)) had similar levels of TEM-8 expression. TEM-8 transfected cell (HECV(DeltaTEM8a)) significantly decreased the micro-vessels formation compared with controls (HECV(pControl)) (mean+/-SE, 20.3+/-4.03 microm; p=0.0086 vs. control 39.5+/-10.1 microm), and migration (38.52+/-2.17; p<0.05 vs. control 80.23+/-3.19), and micro-vessel formation of HECV(DeltaTEM8a) cell was also reduced compared with wild-type (HECV(WT)) (mean+/-SE, 20.3+/-4.03 microm; p=0.0078 vs. wild-type 42.5+/-9.1 microm) and migration (38.52+/-2.17microm; p<0.05 vs. wild-type 82.4+/-4.45 microm). vW together with transmembrane domains of TEM-8 (CHO(vW/TM)) and full-length CHO(FL) showed formation of tubule-like structure in CHO cells, whereas the other domains showed no effect., Conclusion: Targeting the TEM-8 gene by way of a hammerhead ribozyme knocks out TEM-8 cells, and is an effective way to reduce the micro-vessel formation or migration potential in tumour-associated endothelial cell through its vW domain. These results suggest that the vW domain together with the transmembrane domain of TEM-8 may play an important biological role in TEM-8 related tubule formation.

Aim: Tumor endothelial markers (TEMs) are a newly discovered family of endothelial markers associated with tumor specific angiogenesis. This study sought to examine the levels of expression (qualitatively and quantitatively) for TEMs in human colon cancer., Methods: Human colorectal cancer tissues (n = 48) and normal background tissues (n = 31) were obtained after surgery. RNA was extracted from frozen sections for gene amplification. The expression of TEMs (TEM-1 to TEM-8) was assessed using RT-PCR and their transcript levels were determined using real-time-quantitative PCR (Q-RT-PCR)., Results: TEM-1 (P = 0.01), TEM-7 (P = 0.04), TEM-7R (P = 0.03), TEM-8 (P = 0.001) significantly raised in colon cancer tissues compared with the levels detected in normal background tissues. The expressions of TEM-2 and TEM-6 were found to be not significantly different between tumor tissues and normal tissues (P > 0.05). Patients who had cancer penetrating into and through the muscularis propria of the bowel wall and developed nodal involvement (Dukes C) exhibited significantly higher levels of TEM -8 compared to patients who were node negative (P < 0.05). TEM-7 and TEM-7R showed high level of transcripts in Dukes C, but they were not statistically significant., Conclusion: The level of the expression of TEM-1, TEM-7, TEM-7R and TEM-8 (but not TEM-2 and TEM-6) were associated with both nodal involvement and disease progression, and may therefore, have a prognostic value in colorectal cancer.

Unlike in Japan, autoimmune pancreatitis is uncommon in the Western world, particularly in Europe. We report the first case of a Caucasian male with typical features of autoimmune pancreatitis in the UK. Recognizing autoimmune pancreatitis as a new clinical entity in Europe will change the management of many patients who have been labelled as having acute or chronic pancreatitis.

Background and Aims: Tumour endothelial marker-8 (TEM-8) is endothelial cell surface marker that may be specific to tumour endothelial cells. This study examined the role of TEM-8 in human colon cancer and its correlation with tumour prognosis., Methodology: Specimens of colorectal tissue (normal and cancer) were stained immunohistochemically with an anti-TEM-8 antibody, newly developed in our laboratory, and with anti-vonWillebrand Factor antibody. RNA was extracted from frozen sections for gene amplification. The anti-TEM-8 antibody specificity tested by using slot blotting with irrelevant antibody, and western blotting with different cell lines. The expression of TEM-8 was assessed using RT-PCR, and the level of TEM-8 was quantified using real-time-quantitative PCR (Q-RT-PCR)., Results: TEM-8 staining was primarily seen in endothelial cells. TEM-8 identified more micro-vessels in colon tumour tissue, than in normal colon tissues, (p=0.002). Whereas, fewer vessels were stained positive for TEM-8 in normal tissues stained positive for vonWillebrand Factor (factor-8), (p=0.008). Malignant cells in tumour tissues were found to be stained strongly positive for TEM-8 compared with the epithelial cells in normal colon tissues. The level of TEM-8 expression was significantly higher in the tumour tissues compared to the normal colon mucosa (p=0.001). TEM-8 mRNA expression was also found to be more elevated in patients with advanced tumour, Dukes C (Dukes A vs. Dukes C, p=0.01)., Conclusion: TEM-8 is a marker that identifies tumour associated micro-vessels in colon cancer. The levels of expression of TEM-8 in invasive colon cancer are linked to disease progression. This suggests that TEM-8 has significant prognostic and therapeutic values in colon cancer.

Tumour endothelial marker-8 (TEM-8) has been found to be selectively upregulated in tumour-associated endothelial cells and is implicated in tumour specific angiogenesis. Specific factors, indigenous to tissues and tumours that regulate the TEM-8 mechanism in angiogenesis are not defined. We report for the first time that interleukin-1beta induces the expression of TEM-8 in endothelial cells. Human vascular endothelial cells (HECV), which strongly express IL-1beta receptor (as revealed by RT-PCR, Western blotting), increased the level of TEM-8 expression following stimulation with IL-1beta (as revealed by conventional and quantitative RT-PCR). Using a newly developed antibody to human TEM-8, we have further demonstrated that IL-1beta significantly raised the level of TEM-8 at the protein level, as revealed by Western blotting. In vitro tubule forming assay, revealed that IL-1beta significantly induced the formation of capillary-like tubules from the HECV cells, accompanied by an increase in TEM-8 expression. It is concluded that IL-1beta is a powerful regulator of the expression of TEM-8 in vascular endothelial cells. Our results suggest an important pathway through which IL-1beta regulates tumour-associated angiogenesis.

Objective: It has been suggested that patients with chronic pancreatitis have antioxidant deficiencies. It is unclear whether these antioxidant deficiencies also occur in patients with recurrent acute pancreatitis and whether this condition represents an intermediate state between normality and chronic pancreatitis. The aim of this study was to determine the antioxidant profiles of patients with pancreatitis (recurrent acute and chronic) and to compare their profiles with a control population., Methods: The antioxidant profiles of patients with chronic pancreatitis (n = 27) and recurrent acute pancreatitis (n = 11) were determined and compared with the antioxidant profiles of control subjects (n = 19). The following parameters were measured in blood: trace elements (selenium, copper, zinc), vitamins A and E, and carotenoids (alpha-carotene, beta-carotene, xanthine, beta-cryptoxanthine, lycopene)., Results: Patients with chronic pancreatitis had significantly lower plasma concentrations of selenium, vitamin A, vitamin E, beta-carotene, xanthine, beta-cryptoxanthine, and lycopene compared with both control subjects and patients with recurrent acute pancreatitis (p < 0.05). There were no significant differences between the antioxidant profiles of patients with chronic pancreatitis due to alcohol excess and patients with idiopathic chronic pancreatitis, or between the antioxidant profiles of patients with recurrent acute pancreatitis and control subjects., Conclusions: Patients with chronic pancreatitis had evidence of multiple antioxidant deficiencies. The antioxidant profiles of patients with recurrent acute pancreatitis did not differ from those of control subjects, discounting the hypothesis that recurrent acute pancreatitis represents an intermediate state between normality and chronic pancreatitis.

Background: It has been suggested that antioxidant deficiency may play a role in the pathogenesis of chronic pancreatitis. The aim of this review was to analyse the evidence for this relationship and to consider the role of antioxidant supplementation in the treatment of chronic pancreatitis., Methods: Medline review of all English language publications for the years 1966-1998., Results and Conclusions: There is evidence that patients with chronic pancreatitis have enhanced levels of free radical production, cytochrome P450 induction and antioxidant deficiencies, in particular selenium. The limited published literature in this field suggests that dietary antioxidant supplementation may ameliorate the pain associated with chronic pancreatitis, diminish the frequency of acute exacerbations and reduce the requirement for pancreatic surgery. These findings await confirmation by a large prospective placebo-controlled study.

Desmosomes are key structures in cell-cell adhesion. In this study we examined the effect of n-6 essential fatty acids on the expression of desmoglein (Dsg), desmosomal cadherin and the formation of desmosomes in E-cadherin negative human breast, colon and lung cancer cells and melanoma cells. Electron microscopy revealed that cells cultured with gamma linolenic acid (GLA) showed increased cell-cell adhesion together with an increase in the formation of desmoglein-containing desmosomes. Western blotting studies of cellular proteins demonstrated that, following culture with fatty acids, Dsg expression was modified, with the greatest increase seen after GLA treatment. Other fatty acids increased Dsg expression, but to a lesser extent. It is concluded that GLA regulates desmosome-mediated cell-cell adhesion in human cancer cells, particularly in cells without E-cadherin.

Patients with obstructive jaundice have an increased perioperative complication rate. Sepsis, bleeding, wound problems, renal and liver malfunction are all seen in these patients. Assessment of immune function has been an active research area in these patients. This review will examine various aspects of immune functions in obstructive jaundice, discuss the recent research results and controversies and then go on to discuss the relevant mediators of immune function and some possible implications for treatment.

The c-met proto-oncogene product is a receptor tyrosine kinase that mediates the effects of the multifunctional cytokine hepatocyte growth factor/scatter factor (HGF/SF). We have studied the expression of both the c-met receptor and HGF/SF at both the protein and message level in colorectal cancer tissues of varying disease stage. All of the tumors displayed an overexpression of the c-met mRNA compared to their normal tissue counterparts while 16 of 21 tissues (75%) displayed up-regulation of c-met protein. No HGF/SF mRNA or protein could be detected in either tissue type. Viable tumor cells extracted from cancer tissue exhibited increased motility in response to HGF/SF stimulation demonstrating that c-met was functionally active. No correlation between expression of c-met and tumor stage or degree of differentiation was observed. HGF/SF is known to be a potent stimulator of tumor cell motility and invasion, two cellular properties essential for the metastatic development of cancers. The overexpression of the HGF/SF receptor in colorectal cancers may result in an increased sensitivity to HGF/SF, which may confer an enhanced metastatic potential to the cancer cells within the tumor body.

The effect of n-6 fatty acids, particularly gamma-linolenic acid (GLA), on the oxidase response and neutrophil priming by tumour necrosis factor alpha and interleukin 8 was studied in both normal volunteers and patients with obstructive jaundice. GLA inhibited the neutrophil respiratory burst at concentrations higher than 50 mummol/l, but abolished cytokine priming at concentrations as low as 1 mummol/l. Inhibition was not the result of either cytotoxicity to the neutrophils or alteration in cytosolic free calcium homoeostasis. It is concluded that GLA is a potential inhibitor of neutrophil priming by cytokines and of the oxidative response.

Patients with obstructive jaundice have an increased incidence of peri-operative complications and immune dysfunction. This study was to investigate interleukin (IL)-12 (a cellular immunity stimulant), levels in jaundiced patients. 23 jaundiced patients and 17 controls were studied. There was significantly increased monocyte IL-12 production in jaundice, as measured by an ELISA, compared with that in controls (p < 0.01 by Mann-Whitney U test). A similar increase is seen in both benign and malignant jaundice. There was no difference between plasma IL-12 levels in the two groups. It is concluded that in jaundice, monocytes have a significantly increased capacity to release IL-12. This suggests that IL-12 may play a role in the immune dysfunction in jaundiced patients.

Some monocytic cytokines are important immune regulators. We have investigated cytokine production by monocytes and the blood levels of IL-1 beta, IL-6, TNF alpha, and TGF beta, in patients with obstructive jaundice. The supernatant from LPS stimulated monocytes from jaundiced patients released significantly increased quantities of TNF alpha by both bioassay and radioimmunoassay (RIA) (12.4 +/- 2.5 fmol/mL and 32.6 +/- 8.3 fmol/mL, respectively, for jaundice, compared with 1.6 +/- 0.3 fmol/mL and 2.4 +/- 0.5 fmol/mL respectively for controls, and also of IL-6 (54.8 +/- 5.0 fmol/mL in jaundice compared with 35.6 +/- 5.0 fmol/mL for controls). The production of IL-1 beta and TGF beta by stimulated monocytes was unchanged. Jaundiced patients had significantly higher plasma TGF beta, but TNF alpha and IL-1 beta were below the limits of detection. The highest monocyte TNF alpha and IL-6 levels were seen in malignant disease patients, especially those with a poor immediate prognosis. We conclude that the production of some cytokines by monocytes is up-regulated in patients with obstructive jaundice.

Ezrin is a member of the TERM family and is a key protein in cytoplasmic membrane-cytoskeleton interactions. This study showed that hepatocyte growth factor/scatter factor (HGF/SF), a cytokine known to regulate motility, morphogenesis and growth of cells, stimulated the tyrosine phosphorylation of ezrin in a human colon epithelial cell line, HT115. After HGF/SF stimulation, ezrin translocated from the cytosol and generalised membrane to the areas of ruffled membrane as visualised by indirect immunofluorescent and immunogold electron microscopy. This effect was inhibited by genistein, a tyrosine kinase inhibitor. It is concluded that HGF/SF induces ezrin translocation by stimulation of its tyrosine phosphorylation and that this plays a key role in HGF/SF induced membrane ruffling.

Catenins (alpha, beta, and gamma) are a group of proteins linking E-cadherin with the cytoskeleton. Reduced expression of alpha catenin has been shown in some cancer lines and tissues and is related to the invasive nature of tumour cells. This study examined the effects of n-6 PUFAs on the expression of catenins in a range of human cancer cells by Western blotting. Although most of the cell lines expressed similar levels of beta and gamma catenins, a number of cell lines expressed low levels of alpha catenin. Treatment of cells with gamma linolenic acid (GLA) increased alpha catenin expression in most cell lines, while beta catenin levels were reduced, and gamma catenin expression was unchanged. Linoleic acid and arachidonic acid had not significant effects. We conclude that in human cancer cell lines, the expression of alpha and beta catenins can be regulated by gamma linolenic acid.

E-cadherin is a cell to cell adhesion molecule which acts as a suppressor of metastasis. This study examined the effect of gamma-linolenic acid (GLA), a n-6 polyunsaturated fatty acid, on the expression of E-cadherin in human cancer cells. Western blotting studies demonstrated that treatment of cells with GLA for 24 h increased the expression of E-cadherin in lung, colon, breast, melanoma, and liver cancer cells, but not in endothelial cells and fibroblasts. The results were confirmed by immunocytochemistry. In contrast, two other n-6 fatty acids, linoleic acid and arachidonic acid, failed to induce these changes. The increased expression of E-cadherin was correlated with reduced in vitro invasion and increased aggregation, indicating that the increased E-cadherin expression induced by GLA was biologically active. These data add GLA to the short list of E-cadherin up-regulatory factors. The up-regulation of E-cadherin expression in human cancer cells may contribute to the anticancer properties of GLA.

HGF/SF (0.5-100 ng/ml) induced rapid membrane ruffling, formation of microspikes, and increased motility of HT115 cells within 5 min of addition. These effects were not accompanied by any change in cytosolic free Ca2+ concentration. However, ATP (0.5-10 mM) induced a transient rise in cytosolic free Ca2+ concentration in HT115 cells from a resting concentration of 100 nM to a peak of 400 nM before returning to baseline within 3 min. The addition of ATP to cells treated with HGF/SF inhibited both membrane ruffling and cell movement. The effect of ATP was attributed to the transient rise in cytosolic free Ca2+ concentration, because cytosolic BAPTA, which prevented the rise in cytosolic free Ca2+ concentration, also abolished the inhibitory effect of ATP. Raising cytosolic free Ca2+ concentration with ionomycin and ADP also inhibited membrane ruffling. It was thus concluded that transiently raised cytosolic free Ca2+ concentration inhibited HGF/SF-induced membrane ruffling of HT115 cells.

Tumour cell motility and attachment are crucial requirements in the formation of metastatic lesions. These properties are affected by a number of cytokines including hepatocyte growth factor/scatter factor (HGF/SF) and several immunoregulatory proteins, including interleukin-12 (IL-12). Although IL-12 has been reported to exhibit potent anti-tumour effects in vivo, a direct effect of IL-12 on cancer cells has not been reported. We show here that IL-12 directly inhibited the attachment of the human colon cancer cell lines HRT18, HT29 and HT115 to Matrigel, HGF/SF-stimulated cell motility and HGF/SF-induced cell invasion through a reconstituted basement membrane. IL-12 did not affect the growth of these cell lines. Flow cytometry, Western analysis and immunohistochemistry revealed an up-regulation of E-cadherin cell-surface adhesion molecules. These direct effects of IL-12 on colon cancer cells suggest a potentially important role for IL-12 in metastasis.

Tumour tissues are frequently seen with monocyte/macrophage infiltration. This study was to establish the role of monocytes on the motile and invasive behaviour of human cancer cells. By using a co-culture technique, we have shown that both human peripheral blood monocytes and a monocytic cell line, U937, stimulated colon and breast cancer cell colony scattering, motility, and invasion into a basement membrane (Matrigel). This effect was enhanced when monocytic cells were stimulated by a particulate stimulus. IL-4 and IL-10 reduced these effects of monocytes. We conclude that monocytic cells enhance the motility and invasion of tumour cells. These effects can be regulated by inhibitory cytokines of monocytes.

In this study we have determined the effects of the n-6 essential fatty acid gamma-linolenic acid (GLA) on the motility and invasive/metastatic nature of the human colon cancer cell lines HT115, HT29 and HRT18. Cell motility was induced by hepatocyte growth factor/scatter factor (HGF/SF) and measured by both colony scattering and dissociation from carrier beads. Invasiveness was measured in vitro by cellular invasion into extracellular matrix. At concentrations up to 100 microM (which had no effect on cell growth over the duration of the experiments) both cell motility and invasion induced by HGF/SF were markedly reduced by GLA and its lithium salt. The attachment of these cells to the extracellular matrix components (Matrigel and fibronectin) was also inhibited. There were also changes in the cell-surface E-cadherin, but not fibronectin receptor at similar concentrations. It is concluded that n-6 essential fatty acids have the ability to inhibit both motility and invasiveness of human colon cancer cells, perhaps by modifying cell-surface adhesion molecules.

Changes in fatty acid patterns may explain many of the observed abnormalities found in obstructive jaundice. This study looked at fatty acids in plasma cholesterol esters, in a group of patients with obstructive jaundice and a matched group of controls. Significant abnormalities were demonstrated, most importantly a fall in essential fatty acids, in the jaundiced group. Overall the saturation of this fraction, as assessed by double bond index, rose. The essential fatty acids are important as factors in membrane function and as precursors of eicosanoids. The abnormalities found in this study provide further evidence of the significance of EFA in patients with obstructive jaundice.

In the past decade significant advances in establishing the underlying biological mechanisms of tumour invasion and metastasis have been made. Some of the triggering factors and genes relevant to metastatic spread have been identified. Advances have also been made in understanding the signal transduction pathways involved in invasion and metastasis. This increased comprehension of the malignant metastatic process has enabled new antimetastatic strategies to be devised. This review summarizes progress in these areas and discusses the implications for the treatment of metastasis.

The poor outcome in patients with extrahepatic cholestatic jaundice seems in some way related to reticuloendothelial dysfunction. Similar dysfunction can be caused by abnormal tissue phospholipid fatty acid patterns. Little is, however, known about such patterns in extrahepatic cholestatic jaundice. The phospholipid fatty acid patterns in 42 controls were compared with 42 patients with extrahepatic cholestatic jaundice. Many abnormalities were found. The general pattern was of a fall in polyunsaturated fatty acids and a rise in monounsaturated fatty acids, with a consequent fall in the double bond index (mean number of double bonds per fatty acid) showing an overall rise in saturation. All three major substrates for eicosanoid production were reduced in the jaundiced group. The changes seemed to be associated with jaundice itself, rather than the cause of the jaundice. The central roles of fatty acids in the determination of membrane function and in the provision of substrates of eicosanoid production, mean that these changes may explain some of the reticuloendothelial dysfunction found in extrahepatic cholestatic jaundice.

Patients with obstructive jaundice frequently suffer postoperative complications. We have investigated the relationship of obstructive jaundice to the neutrophil oxidase response and the "priming" of the response by the cytokines TNF alpha, interleukin-1 (IL-1), IL-6, and IL-8. On stimulation with f-met-leu-phe (fmlp), the respiratory burst in neutrophils from jaundiced patients was greatly increased compared with controls (p < 0.01), jaundiced patients having the highest respiratory burst levels were those with the poorest prognosis. Neutrophils from controls were primed by all the cytokines tested, whereas "jaundiced" cells were primed only by IL-1, and not by TNF alpha, IL-6, or IL-8, which in fact produced slight inhibition. We conclude that neutrophils from obstructive jaundiced patients have raised oxidative responses which may be due to "pre-priming" in vivo by cytokines, such as IL-6, IL-8, or TNF alpha. This exaggeration of the oxidative response in circulating neutrophils may contribute to the peri-operate complications of patients with obstructive jaundice.

Hepatocyte growth factor (HGF) is the most potent stimulator of hepatocyte growth and DNA synthesis identified; it is now known to be the same molecule as scatter factor, which increases the motility of a variety of cell types. HGF is becoming recognized as one of the most important factors in the regulation of liver regeneration after surgical resection or chemical damage. HGF is produced by several tissues, including neoplasms; it can therefore provide a stimulus for increased motility of malignant cells by both a paracrine and autocrine mechanism. The receptor for HGF has been identified as the product of the oncogene c-met, raising the possibility that this gene plays a key role in facilitating cellular invasion. HGF may therefore be important not only for liver cell growth but also in metastasis. This article summarizes the current position of research on HGF, and presents both clinical and scientific evidence that strongly implicates this factor in liver regeneration and cancer invasion and metastasis.

Monocyte hydrolases are harmful when secreted inappropriately. In this study we have investigated the levels of one of the hydrolases. beta-hexosaminidase in patients with obstructive jaundice. These patients showed markedly elevated plasma levels, and their monocytes show increased spontaneous secretion and total enzyme content. The plasma enzyme levels correlate with monocyte enzyme content as well as bile salt, and bilirubin levels, the high levels may also reflect Kupffer cell damage, as these cells clear the enzyme. Compared with controls monocytes from jaundiced patients show reduced enzyme secretion after PMA stimulation, in vitro, and unchanged secretion after zymosan stimulation. There is a difference between plasma enzyme levels in benign and malignant patients but this does not provide a clear distinction between the two groups. We conclude that patients with obstructive jaundice have increased blood level of beta-hexosaminidase, and that activated monocytes partly contribute to this change.

Hepatocyte growth factor (HGF), also known as scatter factor, regulates both cell motility and the growth of some cell types. We have determined the effects of HGF on the motility and growth of human colon cancer cell lines (HT115, HT29, HRT18 and HT55). Cell motility, as measured by dissociation from carrier beads or by scattering of cell colonies, was greatly increased in all cell lines. The effects were completely blocked by anti-HGF antibody. In contrast, cell growth of HT115, HT29 and HRT18 cells was inhibited by a wide range of concentrations of HGF. HT55 cell growth was also inhibited but needed a prolonged culture period (> 5 days). The HGF receptor/Met protein is highly expressed in the membrane fraction of these cells as determined by Western blotting. It is concluded that HGF has an effect on both colon cancer cell motility and growth, which may be important in the control of the spread of colon cancer.

A number of cytokines have been reported to increase the cell motility (scatter) of cohesive cell colonies. We report here a novel scattering factor produced by human monocytes. Media from both stimulated and non-stimulated human monocytes or the monocytic cell line, U937, increased the cell motility of 2 human colon-cancer cell lines, HT115 and HT29, but not the canine epithelial cell line MDCK. Motility was assayed by cell dissociation from carrier beads and colony scattering. HT115 cells were strongly scattered by the conditioned media but not by interleukins IL-1, 2, 4, 6, 8, 10, TNF alpha, TGF beta, EGF, GM-CSF, IGF-I, PDGF, interferon-gamma. This factor is distinct from hepatocyte growth factor/scatter factor (HGF/SF), since the activity was not blocked by anti-HGF/SF antibody. The activity was reduced by treatment with acid, heat, trypsin and dithiothreitol; this, together with gel filtration, suggests that the factor is a protein (MW 40 to 60 kDa). This new factor, which is secreted from monocytes and the monocytic cell line, U937, has the ability to increase the motility of cancer cells and may be important in controlling the behaviour of tumours in vivo.

Several large series have been reported describing extensive surgery for gallbladder cancer; prolonged survival, however, has not been shown compared with more conservative treatment. Although in the case of bile duct tumors, excision of adjoining structures might confer some benefit and further improvement might be seen by the use of radiotherapy. Accurate preoperative imaging is beginning to be beneficial in the selection of patients for the different modalities of treatment.

Hepatic 'pseudotumours' are radiological abnormalities which give the appearance of tumour. They may be focal areas of disease such as fatty infiltration or areas of focal sparing in diffuse processes. We present four cases of hepatic 'pseudotumours' due to diffuse fatty infiltration with focal sparing and emphasise the need for further radiological assessment of focal lesions found on ultrasound scanning. Measurement of CT attenuation allows a confident diagnosis of fatty infiltration with focal sparing, thus preventing unnecessary investigation. Other forms of hepatic pseudotumour may require further investigation.

Hepatobiliary cystadenomas with mesenchymal stroma (CMS) are rare tumors. Two cases are reported that illustrate many features of CMS, including polypoid involvement of the common hepatic duct in one case. Both tumors were associated with elevated serum levels of the tumor-associated antigen CA 19-9 but normal levels of carcinoembryonic antigen and alpha-fetoprotein. Immunohistochemical analysis confirmed the presence of CA 19-9 in the epithelial component of the tumor. The implications of these findings are discussed, both in relation to the histogenesis of CMS and its preoperative diagnosis. A minimally elevated level of CA 19-9 was found in only one of five patients with hydatid disease of the liver, an important differential diagnosis in clinical management.

We demonstrate here that the recently defined cytokine hepatocyte growth factor (HGF) 'primes' human neutrophils. Recombinant human HGF over the concentration range 0.1-20 ng/ml increased the neutrophil response to f-met-leu-phe by up to 200%, and required only a short preincubation, 10 min producing the maximum effect. Priming was independent of changes in cytosolic-free calcium homeostasis. We conclude that HGF may be a physiologically important cytokine with 'priming' activity for neutrophils.

The U937 cell line has been shown to generate tumour necrosis factor alpha (TNF-alpha) in response to soluble stimuli such as PMA and LPS, but only after treatment with GM-CSF. We report here the generation of TNF-alpha from U937 cells following phagocytosis of opsonised zymozan particles without the need for pre-treatment with GM-CSF. The release of TNF-alpha from U937 cells was demonstrated by a specific radioimmunoassay, L929 cell killing and neutrophil 'priming'. The biological activities in the cell supernatant were inhibited by TNF-alpha antiserum. Phagocytosis was required for TNF-alpha production. Non-opsonised zymozan or latex particles which were not phagocytosed or pretreatment with cytochalasin B, which inhibited phagocytosis of opsonised zymozan particles, all failed to trigger TNF-alpha production. Phagocytosis failed to trigger detectable IL-1 generation, and production of IL-6 was insufficient to produce biological effects on neutrophils. The U937 supernatant thus provides a source of human TNF-alpha which can be generated conveniently and cheaply for experimental investigations.

Pig lymphocytes typed for products of the MHC were primed in vitro against allogeneic lymphocytes. When rechallenged with a panel of different cells, specific 'typing' responses were distinguishable which were not obscured by high non-specific responses or by a restimulator gene dose effect. A gene additive effect was observed in both primary MLR and in the primed lymphocyte test (PLT).