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From: Sultan Bin Sulayem To: Jeffrey Epstein leevacation@gmail.com> Subject: Fuss hospital china pioneers cancer treatment Date: Tue, 08 Nov 2011 06:32:05 +0000 put In the keywords for Search IFearth I Number ol freeze-Maw cycles There is some evidence that a double freeze-than cycle induces a higher percentage of tissue elesbuction within a given lesion. thus improves uniformity of cell death. Kollman(20' using a porcine model. studied ?inuatiepatic cryolesons induced by freezing the hepatic tissue for a total of 15 mins. Additional animals underwent a double freeze-than cycle of 7.5 mins each (DF). Seven days after freeong. OF did not change the volume of the env:lesion compared to SF. however. resulted in enhanced destrudion of hepatocyle nuclear morphology. Ile showed that double freezing may improve uniformity of truancy* nuclear destruction wthn the margin of the lesion due lea more pronounced shutdown of microvascular perfusion. resultng in irevernble iv:herrn (21.22). In addition. as it is well known that thawing is a more Overlent mechanism of cell death than cooling (231. the application of a double thaw cycle in double freezing may account for he more complete marghal hepatocyte nuclear destruction. Rolinson(24] showed that for bone cryostspery. the difference of the viability of targeted cells between one freezing cycle and two freezing cycles was Nghly signficanL But the viability blowing three freezing cycles was similar to that alter two freezing cycles (Fore 18.10). Also. after a singe cycle of freezing, most specimens were necrotic. some were still viable. to contrast. there were no specimens that had viable cells following two freezing cycles (Figure 1-8.11). Figure 1-8-10. Average viability 8 standard deviation of tumor morsels (expressed as optical density per 100 mg wet weir t) From Rolinson7 ef W. Crycebioloa 44 0 Vw ; El.; A Figure 1-8-11.7 A. Cell recluses following a single freezing cycle is not atiform (Aldan blue stain. origiral magnification 3200). B. Cell necrosis following two freezing cycles appears uniform (Akien due slain. original magnification 3200). From Robinson? D. of at Cryobiology 2001.414-10 Interestingly. Ktillmans study indicates a marked reduction of leukocyte nfiltration after double freezing compared to single freezing(201 This may be die to the fact that the double freeze procedure provides a more dstind micoarascular shutdown at he neigh of the cryolesion compared to be single freeze procedure(21.25). which can prevent rapid marginal tissue infiltration by leukocytes derived from the blood stream. The distinct OalinOphite :libation in marginal zone of ayokson was mire pronounced after debate freezing compared with single freezing, and thus inverse to leukocyte (mainly neutrophil) influation. This may indcate a specific immune response after double freezing. which remains to be elucidated in further studies. Adouble freeze thaw cycle was shown to produce significant increases in cel desbuction for every set of thermal parameter investigated. This finding is also in agreement with the two fact. theory. Al high cooling rates a double freeze thaw cycle should increase the statistical protablib of intracelblar ice formation and cell damage. At lower cooling rates he effect of a double freeze thaw cycle a to increase the amount of time cels exposed to the hypertonic condfions. and thus increase the degree of osmotic njuy(8). Selective vascular inflow occlusion Selective vascular inflowa:anion during the application of a SniSe freeze-thaw cycle effectively enhances marginal cell destruction. additionally. significantly messes the overall volume of the lesion. In clinical practice. additional Pringle maneuver (vascular occlusion) was introduced with the idea to increase the volume and effectiveness of the cryosurgcal proceduie(28.27). In a sheep model of cryosurgery. Delley(27) reported that the rate of increase of iceball diameter is significantly greater after vascular 'stow occlusion. and that the necrosis as a mean percentage of initial iceball diameter after 1 morel is more pronounced alter double versus sitgle freezing. Kollman(201 used a porcine model lo study whether selective vasctiar inflow occlusion can achieve complete hepatic tissue destruction. Resifts showed that it the single freeze-thaw cycle was applied during selective vascuter inflow occlusion. the volume of the cryoleson was significantly naeased compared to single freeze-Caw cycle (SF) and amble freeze-thaw cyde(DF). More detailed analysis of the transition zones of the crvolesions of each group revealed destruction of the intralobilar kabecdar architecture in zone 1. which was stighUy more pronounced in VO.SF-treated livers compared to Dr-livers. Importantly. destruction of Musics-se nuclear morphology n zone 1 was not complete in SF-heated livers, but was evident OF and VCSSF heated hepatic tissue. Accordingly. within the tranSilion zone 1 OF. and VO-SF Weis showed a significantly higher score of destruction of hepatocyte nuclear morphologycompared to SF-heated tissue. In zone 2. VO.SF restated in comparable leukocyte infiltration as observed after SF, while DF was assooated with a significanUy reduced leukocyte infiltrative response. In zone 3. bile duct poitetabon was associated with apoplotic cell death and eceinophific infiltration. Bib duct proliferation was comparable in all fivee groups. Moreover. VO.SF•treated ben showed more pronounced apopfettc cell death. while OF. treatment hereased the infiltration of aninophin cells. The pendia bleedings at the tranfilico to the norms hepatic tissue in zone a did not differ in severity between the three different treatment goozops(Figere 1-8-12). EFTA00661247 --11 an. Figure 143-12. Histonarphological Characteristics 7 days after ayourgery.Nere the bile dud proliferation (A. after Slagle "reeze-thaw cycle of 15 mins), the aCOondalion of apostolic rolls (B. after single freeze haw cycle of 15 mitts dud.° selective vascular intim oodusion (VO'SF)). and the infiltration of eoshophiro cells (C. alter dotale freeze- raw tide of 2X7.5 mins) in zone 3 of the transitional area within the margin of the crydesica. In addtion. within the transilka from zone 3 to the normal hepatic tissue of zone 4. petechial bleedings are observed (a after VO'SF). From KoNntan O. el at Cfyohiceogy 2004; 48.263-272 kLala(28) studied the effect of vascular Mow =roman for Crydesiceis in pgs during hepatic freezing. leftbal volume was estimated by intraoperabve magnetic resonance imaging. Rastas shaved that the macron volume of cryolesicasmade during adieuoccasion was 195% larger than cryolesions induced without occlusion. The geometry of the ieeballs was mere regular if produced Bring allow occasion then if noL Seifert) 10.29) showed that using 8 ripticryoprobes in vivo placed in the pig fiver. a 20 mins single freeze cycle with additional Pringle manoeuvre, resulted in a safety margin of about 15-16 mm. KOWeVer, a significant ischaemia-reperfusion injury may resift in addition lo the liver injury caused by erinye manoeuvre. For this reason hepatic inflow occlusion during era:therapy should be 'rated to special situations requiring this tedinque (for example lesions >3 cm in difficult locations close to large vessels. which do not allow the placement of maple probes) and net recommended as a routne procedure. The higher effectiveness achieved by in0ow vascular occlusion has to be attributed to the abrogation of the "heal sink effect' due to the lack of mictovascular perfusion/ 1.8). Antifreeze proteins tt have been shown that antifreeze proteins can enhance the destructionof eels frozen. Al the AFPs. including AFP-I. share the ablity to depress the freezing point of body fluids netroollgatively. When the fuids eventually freeze, these proteins modify the SeuCture of the ice crystak(31). A more comprehensive study on antifreeze protein adjawnl cryosurgery for prostate. breast and liver cancer was performed. Over 30 control studies compared the viabitty of prostate cancer cells. breast cancer cells. and hepaccytes. To show that antifreeze proteins are effective during cryosurgery in vivo. Pham(31Iperromed experiments with human prostate adenocardnoma grown subcutaneously in rude mice. Prior to cryosurgery. the tumors of test mix were injected interstitially win AFRI. In control mice, the tumors were injected with PBS in a sirnlar manner or with no injection al all. The results shaved (Figure 1413) the tissue frozen withAFPs has completely last its structural integrity. The eel membranes are not intadi the nuclei have become distorted. and. in particular, the connective tissue surrandag the cells appears to be sheared. There is no continuity between the cells. nuniefOuS lacunae are evident between the cells. Vw c. \..t Figure 1.8-13. Typical micrographs of the prostate cancer tissue before (a) and after cryosurgery (b) and (e) b. Obtained from prostate cancer tumors that were injected with pheSphate.buffeled saline solution IMO( to freezing: ?O.? Obtained from tumors that were injected with a solution of PBS containing 10 nftftmlAFRI. The staining shows the cell nuclei. a Illustrates the rand shape of the nuclei in prostate cancer tutors and the flannel tissue Structure: b. Shows that after freezing some of the nuclei have become distorted and have darkened while others (marked with arrays) appear intact. c. Shows that after freezing with AFP the nuclei are dislorled and irregular in site. Fixthermore. there are numerous lacunae in the tissue. Scale bar l0mm From Prom L. of al.Cfralhdlogy 1999;38:169.175 Muldreur32)had a similar study. He used subcutaneous tumors of Cunning AT-1 rat prostate eels grown in Copenhagen rats to de aid adjuvant effect of AFP I for cryosurgery, and the ayoinjury was assessed with the dame blue indicator of metabolic activity. Results showed that a double-freeze procedure with AFP? was land to give significunly better ablation than 3 double-freeze without AFP or a singletreeze with or without AFP. The mechanism by which AFPs destroy cells and tissue was not yet understand. There is a pthiarbility that AFFs modify the skydive of ice crystals. The destruction occurs regardless of the thermal conditions during freezing and appears to be related only to theobserved formation of the needlelike ice crystals. Histology suggests that this mode of freezing is associated with severe disruption of the cellular and ccnnective structures. including the nuclei mernbrane.A possible explanation for the damaging effect of the antifreeze proteins is mechanical. The small needle-like ice crystals propagate through the tissue in the drediCel of the temperature gradients and may shear the cell and nudei membrane and the connective tissue as they propagate through the tissue. Formation of the spicUes is concentration dependent(32). Regardess of the mechanism by whiro antifreeze proteins produce they destruction, the demonstration of the effectiveness of the AFPs in cryosurgery in vivois important for Girder/ practice. Turner neurosis favor.. (TNF.a) The cytokine TNF-a. while systemically toxic. has shown benefit When kcally administered to tumors. This adjuvant is known to promote inftammatiert endothelial injury and apoptosis. a addition to being cytotoxic 10 cancer cells and generally harmful to tumor microvasculatute. Because of the role of TriFft in cellular (apoputic and necrotic cell death) as well as vascular mechanisms of idiocy related to endothelial cell activation and intiammation. Tftfta may enhance cryosurgical lesion in Avol83-35). Chao(36) examined the effect of TroF-a on cryosurgery of an in vivo microvascular preparation in a nude mouse. A aroparison of injwy data to a thermal model indicated that the minimum ternparatise after moderate rooting. thawing. and hold time reguked for causing necrosis. shows? that the local use of TNF'a can dramatically inCreaSe the threshold temperature of CryOdeStruClion by more than 107C ( Niro 148.14) . EFTA00661248 Figure 1.8-14. The minimum tempeateres required to cause necrosis in deferent tissues Mowing moderate coaling. thawing and hold time. 'Normal Skin- denotes normal skin tissues horn Copenhagen rah (n -6: while column). nude mice (n .9: tight gray). or inflamed skie tissues from nude mice after 7AF-a treatment (n - 4: dark gray). 'Tumor Tissues" denotes AT-1 Dunning rat prostate tumor (ri -8: white column). LNCaP Pro 5 human prostate cancer (n -8: light gray)• or inflamed LNCaP Pro 5 tissues after TNF-a treatment -4: dark gray). A previous results obtained using normal tissue and AT-1 rat prostate tumor in the Copenhagen rat are listed for comparison ( Hoffmann NE. Bischof J Biontech Eng 2001: 123:310-316 ) . Error bars are standard deviations Fran Chao BR. N al Cryonforogy 2004;49:10-27 However. neither normal nos tumor tissues shaved neaosis after TNF-a treatment without cryosurgery. suggesting local application of TNF-a by itself al this dosage would not damage tissue. There is the hypothesis that vascular-mediated injury is responsble for defining the edge of the cryolesian in rricrovascular.perfuned tissue. and therefore the inflammation induced by local use of Thlra augments cryoinjury. The effect may impact the montaing of cinical cryosurgery Dying cryosurgery of the prostate and other organs such as Peek kidney or brat,. ultrasound. CT or lMl can Le used to Ronda the extent of the cryosurgical iceball. However. this is not optimal with cryosurgery on some special sites such as prostate. since overfreeang into sensitive adjacent structures can cause complications. On the other hand. it the aspect+ endafreeze by keeping the Celan solely within the tenor. cancer existing al the periphery of the crydesion may not be Meagrely treated. which may lead to recurrence of disease. Local application of THE-a to targeted tissue in vivowould decrease as ayoinjury threshold. or increase its thermal threshold. to 3.503.91C under moderate freeze Arum conditions. which are close to the temperature at the edge of the ceball. Therefore. the canbinalion of cryosurgery and local inflammation halted byTAP-a may improve the ethical application of cryosurgery. specifically in the prostate but also in other organ systems. by increasing the abilityof abasound and other icebal-mcnilorhg leoMobgies to Menke and predict injury. subsequentlyracketing potential side effects from cryotherapyl57). CONCLUSION Main causes of tumor persistence or recurrence after cryosurgery at the site of ayoablation are incomplete destruction due to inaccurate procedural monitoring and inadequate criteria tor treatment adequacy. The optimization of cryostegery should consider crucial factors such as the time of freezing. freeze-thaw cycles, number of probes. probes sizes. the spatial position of the probes. and shape and Sze of the tumor. The selecctine occlusion of vascular inflow and addlion of molecular adjuvants. such as TNF-alpha. Can dramatically increase the threshold temperature of ayo• destruction. REFERENCES (1) Lam CM. Shim SA. Needle implantation ayoprobms: Biophysical and thermal characteristics. Semin Legatees Sing 1997:4:89-95. (2) Lam CM. Shim SA. Cuschieri A Ultrasonographic characterization of hepatic cryolesians. Arch Sure 1995;130:1068-1072. (3) Lam CM. Shim SA. Cuschieri A Thermal characteristics of a hepatic ayolesion famed in vitro by a 3 mmimplantable ayoprobe. 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Tumor production of angiostatin is enhanced alter exposure to TAW-alpha. Int J Cancer 2002;97:410-415. (34) Ruegg C. Yiknaz A. Bieler G. et al. Evidence for the invOlvernertl of endothelial cell irtegrin alphaVbeta3 in the &eruption of the tumor vasculahre induced by TNF and IFN-garnnia. Nat Med 1998:4:408-414. (35) Watanabe N. Nitsu Y. Wane H. et al. Toxic effect of tumor necrosis factor on tumor vasculakue in mice. Cancer Res 1988:48:2179-2183. (38) Oda BH. He X. BischaJC. Pre-treatment inflammation induced by TNF-o augments ayosiagical injury on human prostate cancer. Cryobiology 2004:49:1047. (37) Hoffmann NE. Bisect JC. Cryosurgery of normal and lunar tissue in dorsal skin flap chamber. Pali -injury response. J BiaMeCh Eng 2001:123: 310-318. Sent from my iPlione NOTE: This e-mail message is subject to the Dubai World Group disclaimer see http://www.dubaiworld.ae/email_disclaimer EFTA00661249