Surg Today (2003) 33:448–453
Long-Term Survival Following Treatment with Antineoplastons for Colon Cancer with Unresectable Multiple Liver Metastases: Report of a Case Yutaka Ogata1, Hideaki Tsuda2, Keiko Matono1, Tsutomu Kumabe3, Hideki Saitsu1, Hiroshi Hara1, Yoshito Akagi1, Yasumi Araki1, Michio Sata4, and Kazuo Shirouzu1 Departments of 1 Surgery, 2 Anesthesiology, 3 Radiology, and 4 Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
Abstract We report a case of survival for nearly 8 years after treatment of unresectable multiple liver metastases from colon cancer, using microwave ablation and the nontoxic antitumor agent, the antineoplastons. A 72year-old man diagnosed with adenocarcinoma of the ascending colon and 14 bilateral liver metastases underwent a right hemicolectomy combined with microwave ablation of six metastatic liver tumors. We also decided to give antineoplastons to inhibit metastatic tumor growth and recurrence. Antineoplaston A10 was given intravenously, followed by oral antineoplaston AS2-1. Computed tomography scans done 1 and 4 years after the initial diagnosis showed recurrent tumors in S4 and S7, respectively. The patient underwent a second and a third microwave ablation of the recurrent tumors, and has survived for nearly 8 years without suffering any serious adverse effects. He is currently free from cancer. This case report demonstrates the potential effectiveness of the nontoxic antitumor agent, the antineoplastons, for controlling liver metastases from colon cancer. Key words Antineoplaston · A10 · AS2-1 · Colon cancer · Liver metastasis · Microwave coagulation necrosis therapy
Introduction Colorectal cancer is one of the most common malignancies. The surgical therapeutic outcome of colorectal cancer is relatively good, with a 5-year survival rate exceeding 60% in Dukes’ C patients after curative re-
Reprint requests to: Y. Ogata Received: March 4, 2002 / Accepted: November 19, 2002
moval of the tumor. Even in patients with liver metastasis, the 5-year survival rate is favorable, at 30%–40%, if the metastatic tumors can be resected.1–3 However, when unresectable multiple hepatic metastases are involved, the outcome is usually poor. Wagner et al. reported that only a small percentage of patients with synchronous multiple hepatic metastases from colon cancer survive for 2 years.4 We report a patient with colon cancer and synchronous multiple unresectable liver metastases who has survived for nearly 8 years following treatment with microwave ablation and the nontoxic antitumor agent, the antineoplastons. Our findings may help clarify how to control unresectable metastatic tumors in the liver, originating from colon cancer. The possible mechanism of this treatment is discussed in relation to the clinical course of this patient, and in reference to related studies.
Case Report A 72-year old man was diagnosed with well-differentiated adenocarcinoma of the ascending colon, 6 ⫻ 3 cm in size, with multiple liver metastases. An arterial port graphic computed tomography (CT) scan also showed 14 metastastic tumors ranging in size from 1 to 3 cm in the bilateral lobes of the liver (Fig. 1). The clinical course of the patient is summarized in Fig. 2. A right hemicolectomy was performed 1 month later, combined with ablation by microwaves on the six metastatic liver tumors (three in S4, one each in S5, S6, and S8) that had been detected by intraoperative ultrasonography (US). Histological examination confirmed well-differentiated adenocarcinoma of the colon, Dukes’ D with N1 lymph node invasion. Immunohistochemistry using antihuman p53 (Dako, Carpinteria, CA, USA) and antihuman p21 (Dako, Glostrup, Denmark) antibodies showed that p53 and p21 proteins tended to coexpress in the colon tumor cells (Fig. 3).
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Fig. 1. Preoperative arterial port graphic computed tomography (CT) scan showed 14 metastastic tumors ranging in size from 1 to 3 cm in the bilateral lobes of the liver
Fig. 2. Clinical course of the patient. The number in parentheses represents the number of foci treated with microwave coagulation necrosis therapy (MCN). UFT, 1 : 4 tegafur ⫹ uracil; po, orally; iv, intravenously; CEA, carcinoembryonic antigen
a
b Fig. 3a,b. Immunostaining for p53 and p21 in primary colon cancer tissue. The deparaffinized thin sections from the primary colon cancer were incubated with 0.3% (v/v) of H2O2/ methanol for 20 min to block endogenous peroxidase activity. After blocking the nonspecific binding, the sections were incubated with the primary antibodies for p53 and p21 overnight at 4°C. After washing, the sections were incubated with biotinylated second antibody for 30 min at room temperature.
The primary antibody was detected using the avidin-biotin peroxidase complex (Vector Laboratories, Burlingame, CA, USA) and 3,3⬘-diaminobenzidine tetrahydrochloride as the chromogen. These thin sections were also counterstained with hematoxylin and mounted. The sections were heated in a microwave oven for 5 min twice prior to incubation with the primary antibody. Negative controls used all the reagents except for the primary antibody. a p53 (⫻25); b p21 (⫻25)
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Fig. 4. Serial changes in the liver metastases on CT scan. CT scans showed that untreated foci in S7 with microwave ablation (microwave coagulation necrosis therapy), disappeared during antineoplaston AS2-1 therapy (arrow)
Fig. 5. Follow-up CT scan showed a recurrent tumor in S7. This was the lesion that had disappeared during antineoplaston AS2-1 therapy, as shown in Fig. 4
The patient refused postoperative hepatic arterial infusion chemotherapy (HAI) because of the potential side effects. We decided to give him antineoplaston A10-I and AS2-1 capsules (0.5 g) to inhibit metastatic tumor growth and recurrence, because of their negligible side effects. Antineoplaston A10-I was administered intravenously, at 30 g/day, over 10 days for rapid saturation as induction, followed by oral antineoplaston AS2-1, 10 g/day. The patient also began to take UFT (1:4 tegafur ⍚ uracil) 450 mg/day. Abdominal US was done every month and CT scans were done every 3–6 months. No recurrence or tumor progression was detected until 9 months later, when a new lesion appeared in S4 (Fig. 4). The patient then underwent a second micro-
wave ablation of the recurrent tumor. He stopped taking UFT because of minor side effects, such as gastric discomfort and pruritis, but continued taking antineoplaston AS2-1. Because no further recurrence or any new lesions were seen in the next 2.5 years, the dose of antineoplaston AS2-1 was gradually decreased from 10 to 5 g/day. A CT scan done 2 years 8 months after the first recurrence showed a recurrent tumor is S7 (Fig. 5), and regular US examinations confirmed that it was growing rapidly. The patient underwent a third ablation immediately, and the dosage of antineoplaston AS2-1 was increased to 10 g/day. Since then, he has been doing well without limiting his usual activities and is still free of cancer. The results of blood cell counts and liver and
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renal function test indicate that the continuous administration of antineoplaston AS2-1 did not cause any serious problems. The patient has survived for 7 years 10 months since his initial diagnosis, with a good quality of life. No sign of recurrence or new lesions have been found on CT since the last recurrence, over 4 years ago.
Discussion Metastasis to the liver presents a major problem in the control of colorectal cancer. Although an aggressive surgical approach has been applied to improve survival, and favorable results have been reported,1–3 recurrence still develops in more than 50% of patients, even after curative hepatic resection.5 The postoperative infusion of anticancer drugs, such as 5-fluorouracil and floxuridine, into the hepatic artery has also been tried as adjuvant therapy for preventing hepatic recurrence; however, these agents have distressing side effects and may also produce more resistant cancer cells, which frequently metastasize to the lung. This may be one of the reasons why postoperative HAI contributes little to survival benefit. Nontoxic agents that can control neoplastic growth are crucial for the maintenance treatment of colon cancer. Antineoplastons are naturally occurring peptides and amino acid derivatives that control neoplastic growth, as first described by Burzynski in 1976.6 Antineoplaston A10-I, a mixture of the sodium salts of phenylacetylglutamine and phenylacetylisoglutamine in a ratio of 4 : 1, and AS2-1, a mixture of the sodium salts of phenylacetylglutamine and phenylacetic acid in a ratio of 1 : 4, are chemically identified and synthesized. These drugs have been tested, both experimentally and clinically, and their side effects found to be negligible.7,8 We previously demonstrated the apopotosis-inducing effect of antineoplaston AS2-1 in hepatocellular carcinoma cells9 and colon carcinoma cells (Matono et al., in preparation), and we are now conducting clinical trials on antineoplastons A10-I and AS2-1 in cancer patients, under the approval of the Ethics Committee of Kurume University. The patient in this report was enrolled in a phase I clinical trial on antineoplaston A10-I and AS2-1. We treated him for colon cancer with synchronous multiple liver metastases using hemicolectomy and microwave ablation of the liver tumors, then with antineoplastons A10-I and AS2-1, given by injection and capsule therapy, respectively. The patient has survived for nearly 8 years and has not complained of any serious adverse effects, despite the prolonged use of antineoplaston AS2-1. We have not yet clarified how the liver metastasis and extrahepatic metastasis were controlled, but no other patient with colon cancer and more
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than four synchronous nonresectable multiple liver metastases in bilateral lobes, treated at our hospital, has lived longer than 28 months, regardless of the type of treatment. There was a significant difference in the treatment of this patient from that of other patients with a similar condition. First, he chose antineoplastons A10I and AS2-1 as induction and maintenance therapy, respectively; and second, microwave ablation had been applied to control metastases and recurrence. Chemotherapeutic agents may effectively kill the recurrent or metastatic cancer cells in the liver; however, the surviving cancer cells often gain resistance. Holbrook and Fornace reported a dramatic change in cellular gene expression induced by chemotherapeutics and irradiation.10–12 Chemotherapy may weaken the immune response to cancer, making cancer growth more aggressive. The frequent use of chemotherapeutics may cause genetic mutations in surviving cancer cells, leading to aggressive disease progression. When chemotherapeutics attack the malignant cells they may injure them. These injured malignant cells die by apoptosis if normal (wild-type) p53 is present, but the mutant p53 gene gives them a chance to recover and gain more aggressive genetic potential after chemotherapy.13,14 The malfunction of the p53 protein is thought to be at least partly due to conformational change in structure by the binding of DNA viral oncoproteins or endogenous cellular proteins such as MDM2.13 Small stable molecules of antineoplastons A10-I and AS2-1 can insert themselves into large DNA molecular structures and proteins and change their conformations, leading to modification of their functions. Bruzynski showed that phenylacetylglutamine in A10-I and AS2-1 increased p53 protein.6 It was recently shown that a lowmolecular-weight compound, PRIMA-1, can restore the tumor suppressor function to mutant p53.15 Therefore, it is possible that antineoplastons activate the p53 tumor suppressor gene through activation of the genes and proteins, which counteract the wild or mutant p53 gene, or both, and protein in colon cancer. Antineoplaston AS2-1 also interrupts signal transmission in the ras oncogene pathway by blocking farnesylation and methylation of the p21ras protein.16 Antineoplaston AS2-1 has shown a cell differentiation effect in many malignant cells such as human erythroleukemic cells (K562)17 and human hepatocellular carcinoma cells (KIM-1).18 These findings suggest the diverse effects of antineoplaston AS2-1 on the genes controlling cell differentiation. The microwave ablation applied in this patient coagulated cancer tissue using heat. This technique may be beneficial because its local control of liver metastases is thought to be similar to that of hepatic resection.19 Although this technique may leave some of the tumor cells alive, the activated or restored p53 function, or both,
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caused by antineoplastons A10-I and AS2-1 may induce apoptosis of those malignant cells and nonapoptosis of noninjured normal hepatocytes. Of 14 metastatic tumors, 6 were coagulated by microwaves during the initial operation, and the remaining ones that were not detected clearly by intraoperative US disappeared later. Our patient experienced recurrence of liver metastasis twice, suggesting that the malignant cells may have remained alive despite long-term continuous administration of antineoplaston AS2-1. The second recurrence was found after the dose of antineoplaston AS2-1 was decreased, suggesting that antineoplaston AS2-1 at a dose of 10 g/day was arresting malignant cell growth, but not killing all the malignant cells. It is considered that a higher dose of antineoplastons is better, because the antineoplaston level in urine is reportedly lower in cancer patients than in healthy controls,20 and because the treatment strategy of antineoplastons is a supplement of the deficiency. The highest dose of AS2-1 that patients could tolerate was found to be 12 g/day,8 but we are still not sure about the most appropriate dose and duration of AS2-1 to effectively treat colorectal metastases to the liver. Antineoplaston AS2-1 is essentially not chemically reactive, and is excreted by the kidneys. Therefore, it does not accumulate in the body even during longterm administration. Small stable molecules of antineoplaston AS2-1 can enter the large molecular structures of protein and DNA and change their conformations, leading to modification of the protein’s function. This may be why antineoplaston AS2-1 is nontoxic and high dosages, such as 10 g/day, are needed to exert the effect. Liau et al. reported that high methyltransferase activity of nucleic acid in cancer cells was returned to the normal range by the active components of antineoplastons.21 The normal methylation status of DNA brought on by the conformational change of this DNA methyltransferase would enhance the gene expression being silenced by hypermethylation of the promoter. In cancer cells, methyltransferase is activated by binding of the protein, proliferating cell nuclear antigen (PCNA), and the WAF1 gene is activated by antineoplaston AS2-1. The p21WAF1 protein produced binds to this methyltransferase/PCNA complex and reverses the methyltransferase activity to normal. The deactivated p53 gene in cancer cells may then become normalized. Activation of the p53 tumor suppressor gene and deactivation of the ras oncogene by the simple components of antineoplastons A10-I and AS2-1 give us a rational reason to use antineoplastons as a maintenance agent to prevent recurrence or metastasis in colon cancer treatment. In reference to the p53 status in this patient, the p53 protein expressed in the primary colon cancer cells was thought to be wild-type and to have some conforma-
tional changes because of its tendency of coexpression with p21, whereas the majority of p53 immunoreactivity is reportedly mutant. The antineoplastons might have activated p53 more aggressively and p53, in turn, induced p21WAF1. In conclusion, we successfully treated a 72-year-old man with colon cancer and multiple liver metastases, using antineoplastons A10-I and AS2-1, after hemicolectomy and microwave ablation of metastatic and recurrent tumors. This patient has survived for 7 years 10 months without any serious side effects. Thus, the administration of antineoplastons A10-I and AS2-1 after surgery, with or without ablation therapy, should be considered as adjuvant therapy, in addition to conventional chemotherapeutic agents, in patients with colon cancer.
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