Carcinoma Obstructing

Targeting of anti-inflammatory and anti-fibrotic drugs to the proximal tubular cell may prevent tubulointerstitial inflammation and scarring secondary to systemic and glomerular infection and proteinuria. Furthermore, tubular drug dehvery may be beneficial during shock, renal transplantation, ureter obstruction, diabetes, proteinuria, renal carcinoma and some tubular defect diseases such as Fanconi and Bartter s s5mdrome. 

The rate of resectability is only 15-20% for proximal bile duct carcinomas but up to 70% for distal lesions. In addition, there is little benefit to preoperative decompression of the biliary tree in patients having obstructive jaundice (65,66). However, this procedure is frequently practiced. For proximal cancers, local excision is often possible. In particular, hepatic resection is indicated for upper bile duct cancers with quadrate lobe invasion or unilateral intrahepatic ductal or vascular involvement, and distal and midductal lesions may require pancreatoduodenectomy. Also, biliary-enteric continuity... 

Greiner R, Skaleric C, Veraguth P. The prognostic significance of ureteral obstruction in carcinoma of the bladder. Int J Rad Oncol Biol Phys 1977 2 1095-1100. 

Carboxyhemoglobinaemia Chronic obstructive airways disease Pulmonary hypoventilation syndrome Right-to-left cardiac shunt Absolute - physiologically inappropriate Ectopic erythropoietin production Renal carcinoma and cysts Hepatoma... 

Possible increase in serum conjugated bilirubin Obstruction of bile flow commonly due to common bile duct stone or pancreatic carcinoma Failure of bile secretion Extrahepatic cholestasis Intrahepatic cholestasis... 

Other enzymes are also useful indices of liver pathology. Serum alkaline phosphatase is often a useful indicator of liver and bone disease. The alkaline phosphatases are a diverse group of enzymes that catalyze reactions in which a phosphate is removed from a phosphate ester, especially at an alkaline pH. Physicians don t care about this. They do care that serum alkaline phosphatase levels often rise with bone breakdown (as in tumor infiltration) and in liver disease, especially where tliere is obstruction of the bile duct. Acid phosphatase is particularly rich in the prostate. A rise in its serum levels provides a test as to the presence of prostate carcinoma. This test has largely been replaced by assay for Prostate Specific Antigen (PSA), a serine protease that is elevated in prostatic carcinoma. 

An elderly gentleman with obstructing carcinoma of the oesophagus who was a keen gardener. He remained at home, free from pain, attended a garden show on Saturday, worked in his garden on Sunday, and died on Monday. ... 

Extrahepatic obstructive jaundice is caused by stenos-ing processes. The region of Vater s papilla is particularly affected, for example by inflammations, stones, duodenal diverticula, carcinoma, parasites, cicatricial stenosis or adenomatosis. In this respect, special mention should also be made of carcinoma, cicatricial strictures and gallstones (s. figs. 8.14, 8.15 32.1, 32.15), compression of the common bile duct due to a cystic duct stone (= Mirizzi syndrome), haemobilia, and various parasites - such as Ascaris lumbricoides (s. fig. 25.8 ). All of these disorders can be found in the area of the extrahepatic bile ducts. (9, t9)... 

A 62-year-old woman with invasive ductal carcinoma of the breast was treated with epirubicin and cyclophosphamide. She rapidly developed swelling and necrosis of the tongue and consequent airway obstruction necessitating tracheostomy. After excision of the necrosis, the swelling of the tongue and the airway obstruction resolved. 

Dilute solutions of 1-10% formalin have been instilled into the bladder to treat inoperable profusely bleeding tumors or intractable hemorrhagic cystitis. Anuria was a severe complication. This was due either to edematous obstruction of the ureter or to tubular or papillary necrosis, probably caused by systemic absorption. Bladder perforation with intraperitoneal spillage, peritonitis, and finally death was described in an elderly patient with a carcinoma of the uterine cervix (SEDA-11, 476). 

A 68-year-old man with chronic obstructive pulmonary disease underwent CT examination of the abdomen with intravenous infusion of iomeprol for suspected hepatocellular carcinoma and 2 hours later developed severe dyspnea. A chest X-ray showed bilateral diffuse shadowing of the lungs and the heart shadow was not enlarged. A diagnosis of non-cardiogenic pulmonary edema was made and he improved with glucocorticoids. 

Suramin was not effective in one phase II study in advanced renal cell carcinoma, in which it was given in a fixed dose plus hydrocortisone to 22 patients (19 men, three women, aged 30-74 years) (11). Three patients had grade 4 toxicity (hypersensitivity, urethral obstruction, hypotension, and neutropenic sepsis). Eleven developed grade 3 toxicity, mainly abdominal pain, anemia, diarrhea, erythema, dyspnea, fatigue, and fever. 

Measurement of serum CHE activity can serve as a sensitive indicator of the synthetic capacity of the liver. In the absence of genetic causes or known inhibitors, any decrease in CHE activity reflects impaired synthesis of the enzyme by the liver. A 30% to 50% CHE decrease is observed in acute hepatitis and in chronic hepatitis of long duration. Decreases of 50% to 70% occur in advanced cirrhosis and carcinoma with metastases to the liver. CHE is essentially normal in obstructive jaundice except when the cause is malignant. Serial measurement of CHE has been promoted as an indication of prognosis in patients with liver disease and for monitoring liver function after liver transplantation. 

Obstruction of the pancreatic duct by a calculus or by carcinoma of the pancreas may increase serum LPS activity depending on the location of the obstruction and the amount of remaining functioning tissue. In patients with a reduced glomerular filtration rate, the serum LPS activity is increased. Thus care should be exercised in the interpretation of elevated serum LPS values in the presence of renal disease. Finally, investigation of the biliary tract by endoscopic retrograde pancreatography or treatment with opiates (which causes the sphincter of Oddi to contract) may increase serum LPS activity. 

Extrahepatic obstruction Stones Carcinoma Stricture Atresia... 

Abnormalities of Bile Acid Delivery to the Bowel. Decreased bile flow from intrahepatic cholestasis or extra-hepatic bUe duct obstruction caused by bUiary atresia, stricture, stone, or carcinoma will result in bile acid retention and regurgitation from the liver ceU into plasma and a decrease in delivery to the intestine. The ratio of plasma trUiydroxy to dihydroxy acids increases in cholestasis. 

Measurement of serum y-GT activity has clinical significance. The enzyme is present in all tissues, but the highest level is in the kidney however, the serum enzyme originates primarily from the hepatobiliary system. Elevated levels of serum y-GT are found in the following disorders intra- and posthepatic biliary obstruction (elevated serum y-GT indicates cholestasis, as do leucine aminopeptidase, 5 -nucleotidase, and alkaline phosphatase) primary or disseminated neoplasms some pancreatic cancers, especially when associated with hepatobiliary obstruction alcohol-induced liver disease (serum y-GT may be exquisitely sensitive to alcohol-induced liver injury) and some prostatic carcinomas (serum from normal males has 50% higher activity than that of females). Increased activity is also found in patients receiving phenobarbital or phenytoin, possibly due to induction of y-GT in liver cells by these drugs. 

Mechanical gastric outlet obstruction Peptic ulcer disease Gastric carcinoma Pancreatic disease Motility disorders Gastroparesis... 

Chronic inflammatory liver diseases Malignancies Carcinoma Lymphoma Leukemia Multiple myeloma Less common causes Alcoholic liver disease Congestive heart failure Thrombophlebitis Chronic obstructive lung disease Ischemic heart disease... 

Although once the most common type of NSCLC, squamous cell (or epidermoid) carcinoma now accounts for less than 30% of all lung cancers, and is distinguished histologically by evidence of squamous differentiation. This tumor tends to be central in origin, arising from metaplastic bronchial epithelium, and frequently extends into the bronchial lumen, resulting in obstruction. Squamous cell carcino-... 

Fig. 11. Partial obstruction of the bile passages (as in patients with cholan olar carcinoma or hepatic metastases) enhances alkaline phosphatase synthesis proximal to the site of obstruction. Such patients may have normal serum bilirubin values because the excretory processes in other parts of the liver are unimpaired.

Gullick (G27) studied 100 patients with carcinoma of the pancreas. Fifteen of 18 icteric patients had elevated serum alkaline phosphatase values, but there was no correlation between the severity of the hyperbilirubinemia and that of the hyperphosphatasemia. Among nonicteric patients, serum alkaline phosphatase elevation was usually associated with hepatic metastases (G27). The majority of patients with carcinoma of the pancreas without biliary obstruction have normal serum alkaline phosphatase activities (K32). 

Corticosteroids are used in clinical practice to relieve pressure symptoms caused by many tumor types, notably intracerebral tumors but also those causing airway or central venous obstruction. Their mode of action has been studied in animals (57) and humans (58), and is thought to involve first constriction of tumor vascular volume and then a reduction in water content. Reduced interstitial pressure should increase perfusion and extravascular diffusion rates, and high doses of steroids have been shown to increase blood flow in human colonic tumors transplanted into mice. Uptake of antibody into tumors has been assessed before and after administration of high-dose dexamethasone to decrease tumor interstitial pressure and thus increase antigen accessibility. Three patients with recurrent colorectal carcinoma had two antibody scans each, 72 h apart, and the injected dose was the same for all scans (20 mg). Dexamethasone was started 24 h before the second dose of antibody, with an initial iv dose of 10 mg followed by 4 mg four times daily orally for 48 h. 

Metastatic breast carcinoma is the most likely diagnosis in this case. The liver function tests indicate that there is little hepatocellular damage present and that bilirubin excretion is normal. These findings, however, do not exclude the possibility of hepatic metastasis, giving rise to localized areas of intrahepatic obstruction. 

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