Adjuvant-antigen requirements for active specific immunotherapy of microscopic metastases remaining after surgery.

We studied the conditions required for eradication by immunization of occult lymph node metastases which remained after surgical removal of an intradermally transplanted cavian hepatoma. Guinea pigs that received no postsurgical treatment all died with progressively growing lymph node metastases. The growth of these metastases could be prevented in a significant proportion of the animals by postsurgical treatment with vaccines containing oil-in-water emulsions of Mycobacterium bovis strain Bacillus Calmette-Guérin (BCG) cell walls admixed with live or irradiated tumor cells. Vaccines containing living tumor cells cured most of the guinea pigs but produced tumors at the vaccine sites in a few animals. Irradiated tumor cell vaccines were not tumorigenic but required more tumor cells for successful therapy. Therapy was dependent both on the dose of tumor cells and on that of BCG cell walls. Microgram doses of BCG cell walls were required for a therapeutic effect; milligram doses of BCG cell walls inhibited the therapeutic response. Animals rendered tumor free by postsurgical vaccine therapy rejected an intradermal challenge with living tumor cells.

Metastasectomy for soft tissue sarcoma. Further evidence for efficacy and prognostic indicators.

Between 1982 and 1987, 74 patients (46 men and 28 women) had exploration for presumed metastases from high-grade soft tissue sarcoma of the head/neck, extremity, or trunk. Ages ranged from 11 to 75 years (median 38 years). Thirty (41%) had multiple procedures for recurrences (range two to six explorations). Median postthoracotomy time for the group of patients with histologically confirmed sarcoma (n = 63) was 20.3 months. Patients rendered free of disease at initial thoracotomy had significantly longer postthoracotomy survival times (26.8 months median) than those with unresectable metastatic disease (9 months median); p2 less than 0.0001). The prognostic significance of age, sex, location of primary tumor, disease-free interval, number of nodules on preoperative computed tomograms or conventional linear tomograms, number of metastases resected, and the use of postoperative chemotherapy were analyzed. In a univariate analysis, sex, age, and location of the primary tumor did not impact significantly on survival, nor did the use of postoperative chemotherapy. Initial disease-free interval of 1 year or less was associated with a significantly shorter survival time, and patients with five nodules or fewer on preoperative computed tomography had significantly longer survival times than patients with six nodules or more. Patients with three nodules or fewer on linear tomography had a longer postthoracotomy survival time than patients with four nodules or more. In patients whose malignant disease could be completely resected, the number of nodules resected at thoracotomy did not impact on long-term survival. According to proportional-hazards modeling, disease-free interval, sex, resectability, and truncal location were found to associate with length of survival after metastasis removal. We conclude that pulmonary metastasis resection in patients with soft tissue sarcoma is associated with long-term survival, and consistent indicators can define which patients may benefit from these interventions.

Chondrosarcoma: a case report with left atrial involvement and systemic embolization.

A 26-year-old white man underwent amputation of the right lower extremity for a chondrosarcoma of the distal femur. Eleven years later, after a long symptom-free interval, he was hospitalized for rapidly progressive dyspnea, pleuritic chest pain, and hemoptysis resulting from a large pulmonary metastasis that had extended directly to the left atrium via the pulmonary vein. Within 24 hours of hospitalization, obstruction of the left commom iliac artery by tumor embolus necessitated embolectomy. This represents the second report of a metastatic chondrosarcoma involving the left atrium. The case presented clinically as an atrial myxoma and disseminated via the systemic circulation with a rapidly downhill course therafter.

Surgery of malignant ovarian tumors.

As currently recognized, the essential aspects of ovarian carcinoma surgery are: (1) the search for occult metastases in tumors located in the lower pelvis, (2) the maximum tumor removal ("tumor-reductive surgery") in advanced ovarian carcinoma and (3) the exploratory laparotomy to confirm a complete clinical remission ("second-look operation").

The surgical management of multiple lung metastases.

From 1970 to June, 1976, 56 patients who had multiple metastatic tumors of the lung were treated by lung resection. Most of the bilateral lung lesions were removed through a median sternotomy so as to avoid staged bilateral thoracotomy. The surgical mortality was 1.8%. A total of 26 patients are alive at 7 to 69 months (estimated median survival, 20.7 months). Patients with tumor doubling time of less than 40 days had lower survival results (median, 9.5 months), compared to patients with tumor doubling time of more than 40 days (median not yet reached). The type of primary tumor, tumor-free interval, number of lesions removed, and presence of unilateral as opposed to bilateral lung metastases did not seem to affect the therapeutic results.

Anatomical study of a posterior cerebral lesion producing dyslexia.

After an "occipital lobectomy" that resulted in a severe dyslexia and a moderate dysgraphia-dyscalculia, anatomical study showed damage to the posterior extremity of the angular gyrus and degeneration in the posteroinferior pulvinar. This is in contrast to an earlier case that had degeneration in the anterosuperior pulvinor associated with a small anterior temporoparietal infarct and a well-documented receptive-expressive aphasia. However, the role of the pulvinar in speech function remains uncertain. The surgeon should be aware of the short distance between the angular gyrus and both the midline and the occipital pole because a lesion here during an "occipital lobectomy" produces a distressing and durable speech impairment.

Surgical treatment of single brain metastasis. Evaluation of results by computerized tomography scanning.

From July, 1977, through December, 1978, a series of 33 patients with solitary brain metastases underwent surgical resection and postoperative radiation therapy at Memorial Sloan-Kettering Cancer Center. Sequential computerized tomography (CT) scanning was performed to determine the incidence of local recurrence and new brain metastases. The cause of death was identified by clinical follow-up study. The median survival for the entire group was 8 months, with a 1-year survival of 44%. Of the patients with no evidence of systemic cancer at the time of craniotomy, 81% lived 1 year. Local recurrence was noted in one patient known to have subtotal removal of tumor, and three patients developed carcinomatous meningitis. Of the 20 patients who died, four died within 30 days folowing surgery; three died of causes related to the central nervous system ((CNS); and 13 (65%) succumbed to systemic cancer. These data show that recurrence in the CNS following surgery and radiation therapy for single brain metastasis is low, and that serial CT scanning provides a much better measure of the effectiveness of treatment of this complication of cancer than survival times. It is suggested that results of CT and neurological examination be used as indices when comparing different modes of therapy for brain metastases. Significant furhter improvement in survival of these patients is dependent on control of systemic cancer.

Control of the Zollinger-Ellison syndrome by excision of primary and metastatic tumor.

In a patient with Zollinger-Ellison syndrome, control of the peptic ulcer diathesis was attempted by excision of a small duodenal gastrinoma and removal of three lymph nodes containing metastases. The patient has been asymptomatic for 2.5 years with basal achlorhydria, a normal serum gastrin level and a negative gastrin response to secretin. Our experience with this patient emphasizes the fact that the presence of metastatic disease does not preclude the possibility of long-term control of hypergastrinemia by resection of the tumor. Attempts to cure the Zollinger-Ellison syndrome by tumor resection alone, however, should only be made in patients whose hypersecretion is adequately controlled by antisecretory drugs.

The open jejunum: a patch for large duodenal defects.

A practical solution is presented for the difficult problem posed by a large duodenal defect in a very sick patient. A segment of jejunum opened along its antimesenteric border was applied as a mucosally lined patch, with a favorable result.

Impact of mammography on breast surgery in a small community hospital.

The impact of mammography on breast surgery at a small community hospital was evaluated by comparing the stage of cancer at diagnosis in a 5 year period before mammography with that in a 5 year period after its introduction. During both periods approximately the same number and stage of palpable carcinomas were diagnosed and treated. However, in the 5 year period after introduction of mammography, in addition to the 35 palpable carcinomas 11 additional nonpalpable occult carcinomas were diagnosed. These 11, with an average size of 8 mm and all in patients with negative nodes, would fit into the category of minimal breast cancer, which is associated with a 10 year disease-free interval of over 90 percent.

Cerebral metastasis without known primary tumour: a retrospective study.

A retrospective study was made of 19 patients who underwent operation for an intracerebral metastasis of an unknown primary tumour. Most patients survived for a few months only, with 2 remarkable ecceptions. In only 8 of them, the primary tumour became manifest in the further course of the illness.

Pulmonary resection for sarcoma metastases.

We use pulmonary resection in patients with metastatic disease confined to the lungs when the primary disease is controlled, when the tumor doubling time of metastases is longer than 40 days, and when there is no evidence of metastases to other viscera. A staged bilateral thoracotomy should be performed when necessary. The size of the lesions and the number of lesions are not contraindications for resection. Pneumonectomy has been performed with gratifying long term results. Treatment in patients who have rapidly progressive metastatic lesions (tumor doubling time less than 40 days) or who have other metastatic disease must be considered experimental. Chemotherapeutic regimens used as adjuncts to pulmonary resection may produce extreme toxicity in this group of patients. This form of therapy must be administered and followed by experienced personnel in a medical center with facilities for close supervision.

[Treatment of cancer of the lung. Considerations on a current problem]. / Trattamento del cancro del polmone. Considerazioni su di un problema di attualità

In spite of its limitations, surgery is still the only effective means of treating lung cancer, particularly in cases where an early diagnosis has been made. Reference is made to various points associated with diagnosis, indications and treatment. It is felt that surgical management should be conducted on a radical basis, provided the patient is left with an acceptable degree of respiratory function.

[Bilateral carcinoma of the breast]. / Alcune considerazioni sul carcinoma bilaterale della mammella.

In the light of literature and personal experience the Authors analyse the problem of bilateral breast cancer. Distinction between primary cancer (synchronous or metachronous) and metastasis in the second breast is made on the bases of clinical and histological criteria. Lobular cancer, either in situ of infiltrating, has a higher incidence of bilaterality. Aethiology, incidence, prognostic significance of the second cancer are briefly discussed; particularly, it is emphasized that there is a "high risk" group of patients in which the incidence of primary contralateral cancer is much higher. The Authors stress the importance of clinical examination of the other breast at the time of initial mastectomy for a proven breast cancer. The risk of metachronous cancer may be prevented by prophylactic contralateral mastectomy in the "high risk" patients or by random biopsy of the opposite breast in all the patients undergoing surgical therapy for cancer in the first breast. It is opinion of the Authors that early diagnosis may be also obtained if the patients are carefully followed by regular physical examinations and by diagnostic aids (mammography, ultrasonography, thermography).

[Late ileal metastases from a skin melanoma with mainly hemorrhagic symptoms. Report of one case (author's transl)]. / Métastases iléales tardives d'un mélanome cutané périphérique. Manifestations hémorragiques prédominantes. A propos d'un cas.

Intestinal metastase from a malignant melanoma are rare and raise difficult diagnostic problems especially when far from the initial tumour. Although acute intussusception is the usual clinical presentation, one should recognise the possibility of atypical symptoms: e.g. repeated digestive hemorrhage or resistant anemia. A sutdy of past history may lead to the discovery of a malanoma. Treatment is unfortunately surgical and palliative to releave the complication.

[Jejuno and ileo-ileal invaginations revealing mutiple melanic metastases of the small intestine. Case report]. / Invaginations jéjuno- et iléo-iléales révélatrices de multiples métastases mélaniques de l'intestin gréle. présentation d'une observation

The authors report the case of 60 year old man with multiple jeuno-ileal metastases from a malignant melanoma of the skin revealed by jejuno-jejunal intussusceptions. In the light of this case, the authors emphasize the frequency and preferential localisation of these metastases at the level of the jejunum and ileum, the usual mildness of their symptoms until the day where acute obstruction requires laparotomy. The multiple lesions, their diversity and their very rapid course.

[Surgery of 19 bilateral simultaneous pulmonary metastases]. / A propos du traitement chirurgical de 19 métastases pulmonaires bilatérales et simultanées.

19 patients with bilateral simultaneous pulmonary metastases were operated on between 1954 and april 1976 at the Marie-Lannelongue surgical centre. Sarcomas were twice as common as carcinomas. In 10 cases the thoracotomy was only unilateral, either because thoracotomy was not attempted on the other side owing to the diffuse nature of the lesions (8 cases) or because prior chemotherapy had permitted complete reduction of the metastases on the opposite side (2 cases). This thoracotomy remained exploratory in 47 p. cent of cases, radical removal of all the tumour nodules was possible in 53 p. cent of cases (10 patients). Peripheral resections of the lesions were the rule. But in 4 cases, lobectomy was carried out on one side. 7 of the 9 bilateral operations were performed during the same stage. There were no operative deaths. The late results are encouraging considering the number of sarcomas in which the prognosis is usually poor. Bilateral lesions are thus not an absolute contra-indication, provided one remains within reasonable anatomical and functional limits, in the fields of well-conducted anti-cancer strategy.

[Effect of high-power pulse laser radiation on experimental tumor metastasis]. / Vliianie moshchnogo impul'snogo lazernogo izlucheniia na metastazirovanie éksperimental'nykh opukholei.

Under study was the effect of the energy density and pulse duration of laser radiation on metastasization of Lewis carcinoma and melanoma B16. It was shown that laser irradiation of blastomas, the energy density of the former not exceeding 400 joule/cm2 and the pulse duration being 1 msec, not only fails to contribute to tumor proliferation but, on the contrary, somewhat reduces the number of pulmonary metastases. The phenomenon of such kind is observed in simultaneous rise of the energy density up to 800 joule/cm2 and lengthening of the pulse up to 6 msec.