Hypomagnesemia after cisplatin combination chemotherapy.

Sixty-six patients receiving a five-drug combination chemotherapy regimen containing low-dose cisplatin were studied for the presence of hypomagnesemia. Thirty-eight (76%) of 50 patients receiving treatment every four weeks became hypomagnesemic during treatment. The incidence increased with the cumulative cisplatin dose, ranging from 41% after a single course to 100% of patients receiving six cycles of therapy. The incidence seemed lower in patients receiving the combination with a greater interval (eight weeks v four weeks) between cycles. We report the incidence and severity of hypomagnesemia to be dose dependent. The cause of the higher incidence of hypomagnesemia observed in this series compared with others is unknown but may be related to an interaction of cisplatin with another drug contained in this regimen.

Melanoma of skin of the breast: therapeutic considerations based on six cases.

Melanomas of the skin of the breast are uncommon lesions which are amenable to cure with standard mastectomy techniques, even when lymphatic spread has occurred. Of six patients treated at the University of Iowa, two have died of metastatic melanoma, one treated by wide excision and subsequent axillary dissection and the other by radical mastectomy initially. Of the remaining patients, one with positive axillary nodes at the time of mastectomy died 28 years following operation of unrelated causes, one with axillary nodes involved is 5 years without evidence of recurrence, and two who have been followed for less than 2 years, are without evidence of recurrent disease in spite of having had positive nodes at the time of initial treatment. All six patients had had pigmented lesions of the skin of the breast for many years, suggesting that such lesions in this location should be considered premalignant.

Treatment outcome in recurrent head and neck cancer.

One hundred cases of recurrent oral, pharyngeal, or laryngeal squamous cancer were reviewed to determine the contribution of retreatment of such lesions to overall survival. Thirty percent (8/27) of locally recurrent T1-2 primary lesions and 4% (1/28) of recurrent T3-4 lesions were cured by retreatment. Forty-five percent (5/11) of patients with conversion of N0 necks were salvaged, while no cures of neck recurrence after an earlier elective (four) or therapeutic (22) neck dissection were seen. Three of eight patients with isolated lung recurrence were salvaged. Patients benefiting most from retreatment were those with local recurrence of small primary lesions, conversion of a previously N0 neck, or isolated lung disease. Those with other types of recurrence were helped much less.

Accuracy and cost of needle localization breast biopsy.

The success and cost of needle localization biopsy (NLB) performed with local anesthesia in an outpatient procedure room (81 biopsies, group 1) or under general anesthesia in an operating room (36 biopsies, group 2) were compared in a longitudinal study. Only 78% of operations in group 1 successfully removed the target breast lesion; definite failure occurred in 17%, and results were indeterminate in 5%. Among lesions sought by group 2 procedures, 92% of lesions were removed successfully, 5% were missed, and 3% were indeterminate. The incidence of carcinoma in breast specimens was 17% in group 1 and 22% in group 2. Wound infection occurred after 6% of group 1 biopsies. The total cost of NLB was $775 in group 1 and $1960 in group 2. The difference in cost represented by the use of general anesthesia was $1260. The added expense of NLB done in an operating room under general anesthesia can be justified by a high rate of success in removing the breast lesion, by patient comfort, and by technical ease.

Acid and gastrin levels following pyloric-preserving pancreaticoduodenectomy.

Acid and gastrin production after pyloric-preserving pancreaticoduodenectomy was evaluated in six patients. Five patients had low-normal basal and stimulated acid output; the sixth patient was achlorhydric. Fasting gastrin levels were less than 90 to 105 pg/mL (normal range) in five patients, three of whom had stimulated gastrin levels that remained below this range. Two patients had stimulated gastrin levels of 510 pg/mL and 205 pg/mL, respectively, within 15 minutes of eating; however, both levels returned to normal by 120 minutes' time. The sixth patient had mildly elevated fasting (105 pg/mL) and stimulated gastrin levels (160 to 200 pg/mL) throughout the test period. The results suggest that pyloric-preserving pancreaticoduodenectomy does not lead to either gastric hyperacidity or persistent hypergastrinemia.

Endoscopic cholangiography and stone removal prior to cholecystectomy. A more cost-effective approach than operative duct exploration?

Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85,526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.

Hemicorporectomy for intractable decubitus ulcers.

A hemicorporectomy was successfully employed for control of intractable decubitus ulcers, osteomyelitis, and low-grade epidermoid cancer in a 55-year-old man marked reduction in pulmonary functions. Strict attention to postoperative fluid balance was associated with a smooth convalescence. The operation may be more applicable to paraplegic patients with intractable pelvic decubiti than to those with advanced pelvic tumors. In view of the increased number of paraplegics who may be at risk for developing this problem, more frequent consideration of the procedure seems warranted.

Prearterial reversed midgut rotation. A rare congenital anomaly.

A patient with a right-sided descending colon, left-sided ascending colon, and transverse colon in front of the superior mesenteric artery is described. We believe that this is only the second case of "prearterial" reversed midgut rotation existing with normally situated stomach and liver. The best explanation for these relationships seems to be (a) anomalous positioning of the primitive midgut-hindgut junction right of midline; (b) ensuing midgut rotation in a reversed, or clockwise, direction.

Iatrogenic liver abscesses. A complication of hepatic artery ligation for tumor.

The use of hepatic artery ligation, with or without placement of an indwelling infusion catheter for the instillation of chemotherapy, became widely employed in the late 1960s. This was a natural outgrowth of observations that it was reasonably well tolerated in man if certain precautions were followed and that tumors in the liver, whether primary or metastatic, received the major portion of their blood supply by that vessel. As tumor necrosis following ligation was the anticipated result, it followed that undrained collections of nonviable tumor might well be expected to develop in a certain number of patients and that such collections would form intrahepatic abscesses. It appears that development of the complication does not adversely affect the result of the procedure, and this must certainly only be true because of recognition and proper therapy directed to the complication.

Controlled open drainage of severe intra-abdominal sepsis.

Controlled open drainage of the abdomen (gauze in plastic intestinal bag/surgical glove packing of abscesses; wound closure only to the degree needed to prevent evisceration) was compared with closed drainage (soft rubber or sump drains; complete fascial closure) in 31 patients with severe intra-abdominal sepsis. Three (23%) of 13 patients died after open drainage vs eight (44%) of 18 after closed drainage. The difference was attributable to a lower incidence of recurrent abscesses in the former group (one recurrence) than in the latter (six recurrences). Thus, controlled open drainage may improve survival in this highly lethal condition.

A prospective study of incisional time, blood loss, pain, and healing with carbon dioxide laser, scalpel, and electrosurgery.

Carbon dioxide laser incisions are reported to be less painful, less bloody, and less prone to seroma formation and to heal better than scalpel or electrosurgical incisions. We compared all three modalities in a prospective randomized study of cholecystectomy incisions. Time required for the incision and incisional blood loss was less with electrosurgery than with the carbon dioxide laser or scalpel. Postoperative pain and wound healing, however, were the same for all three techniques. The carbon dioxide laser appears to offer no advantage over conventional means of making a standard incision.

Pelvic and sacropelvic exenteration for locally advanced or recurrent anorectal cancer.

Postirradiation "fixed" anorectal tumors are often considered incurable. Since 1980, we have carried out 12 pelvic and seven sacropelvic exenterations for this problem (adenocarcinoma, 18; squamous cancer, one). Nine tumors were primary; ten were recurrent (five after an anterior resection and five after an abdominoperineal resection). Prior irradiation ranged from 3000 to 12,000 rad (30 to 120 Gy). Four patients had synchronous distant metastases; three died of disease (one with local recurrence), and the fourth patient has been living with disease (distant metastasis). Fifteen patients (four with B2 tumors and 11 with Astler-Coller C2 disease) had no extrapelvic disease. One patient died of postoperative complications; two others died free of disease. Three of the 15 patients died of disease (all with local recurrence), and one has been living with disease (local recurrence). Eight (53%) of 15 patients have been living free of disease 12+ to 53+ months. The results suggest that many patients with fixed postirradiation anorectal tumors may be salvaged by aggressive surgery.

Papillomavirus found in anorectal squamous carcinoma, not in colon adenocarcinoma.

We used polymerase chain reaction DNA amplification methods for the detection and typing of genital human papillomaviruses in paraffin-embedded tissue sections of five patients with anorectal squamous cell carcinoma and 22 patients with colonic adenocarcinoma. The cases were further tested by in situ hybridization with biotin-labeled probes specific for human papillomavirus types 6/11, 16/18, and 31/33/35. By polymerase chain reaction, human papillomavirus DNA was demonstrated in all of the cases of anorectal squamous cell carcinoma and in none of the cases of colonic adenocarcinoma for which analyzable DNA was available. Tumor cell nuclei stained for human papillomavirus DNA by in situ hybridization in four of the five cases of squamous cell carcinoma and in none of the cases of colonic adenocarcinoma. We conclude that human papillomavirus types usually associated with malignant transformation are uniformly present in anorectal squamous cell carcinoma but are absent from adenocarcinoma of the colon.

Permanent control of massive tumor bleeding with intraluminal balloon catheters.

Proximal ligation usually controls bleeding from a tumor-eroded carotid artery. When this maneuver failed, two intraluminal balloon catheters were passed distally into the vessel, after which they were inflated and left in place for six weeks. The patient had no neurologic sequelae or further bleeding before succumbing to tumor progression 10 months later.

Preoperative chemo-radiotherapy in advanced head and neck cancer.

In a prospective evaluation, two preoperative courses of methotrexate, bleomycin, and cisplatin combined with 2,000 rad/10 fractions ("chemo-radiotherapy") yielded 78% responses rates in previously untreated advanced head and neck cancer. Similarly staged patients receiving preoperative irradiation of 5,000 rad alone had a 67% response rate. Treatment-related mortality in the chemo-radiotherapy patients was equal to that seen with standard combinations of surgery and preoperative or postoperative irradiation. At 24 months, disease-free survival is 47% with chemo-radiotherapy vs 33% with standard therapy; however, patients benefiting most from the former approach were those with T4 primary lesions or N3a neck nodes.

Mandibular reconstruction in irradiated patients utilizing myosseous-cutaneous flaps.

Myosseous-cutaneous flaps were used for mandibular reconstruction in 16 irradiated patients. Three of six sternomastoid-clavicle flaps failed (all in conjunction with a neck dissection), as did one of 10 pectoralis major-anterior-fifth rib flaps. One trapezius-scapular flap was used and it succeeded. We found the blood supply of the sternomastoid-clavicle flap too tenuous for use in conjunction with a neck dissection. The trapezius-scapular flap had too short an arc of rotation to be used for defects other than those in the horizontal ramus. In addition, this flap required a change of position and created an undesirable functional deformity. The pectoralis major-fifth rib flap, in contrast, could be used for a variety of defects, in conjunction with a neck dissection, and did not require a change of position during operation. We found it to be the most versatile and dependable of the flaps employed in this series.

Surgical management of complications of radiation-injured gut.

Radiation-injured bowel has been diagnosed in 5.1 per cent of 1,824 patients receiving pelvic or abdominal radiotherapy over the past ten years. Surgical intervention to manage these complications was required in 35 per cent. The type of procedure employed for large and small bowel complications has been evaluated to define guidelines for future therapy.

Modified radical neck dissection and postoperative radiotherapy in squamous cell head and neck cancer.

Between 1978 and 1982, 41 patients with clinically staged N1, N2, or N3b disease underwent unilateral or bilateral modified radical neck dissection. Five patients died free from their original disease with less than 24 months follow-up. Twenty-four patients with histologically positive nodes received postoperative radiotherapy with 2 (8 percent) neck recurrences. Another four patients with histologically positive nodes refused postoperative radiotherapy and had two (50 percent) neck recurrences. Three patients did not respond to radiotherapy at the time of their surgery and had no neck recurrences. The final five patients had histologically negative nodes, did not receive radiotherapy, and had no neck recurrences. These results suggest that modified radical neck dissection can be used in lieu of the classical radical dissection in many patients with clinically positive nodes who have squamous cell head and neck cancer without compromising survival.

A case-control study of late recurrence of malignant melanoma.

Late recurrence of malignant melanoma is uncommon but appears to be a growing problem. It is unclear whether late recurrence has a better prognosis than early recurrence. Since the answer may influence treatment, we compared recurrence sites and subsequent survival in 35 patients with disease-free intervals of 72 to 240 months (median: 127 months) with 35 case-controls who had relapse at 4 to 56 months (median: 26.7 months). The distribution of recurrence sites in early relapse was 66% in regional nodes or soft tissue and 34% in distant soft tissue or viscera. In late relapse, this distribution was 49% in regional nodes or soft tissue and 51% in distant soft tissue or viscera (no significant differences). Median survival for patients with early and late recurrences in regional nodes or soft tissue was 26 and 44 months, respectively (no significant differences); 5-year survival was 27% and 33%, respectively (no significant differences). Median survival was similar for early or late relapse in distant soft tissue or viscera (8 and 10 months, respectively), as was 5-year survival (0% and 6%, respectively). These results suggest that the metastatic pattern and survival after recurrence are similar for patients with early and late recurring melanoma.

Intrathyroidal parathyroid glands can be a cause of failed cervical exploration for hyperparathyroidism.

BACKGROUND: The incidence of intrathyroidal parathyroid glands remains controversial. The purpose of this study was to determine the incidence in a series of patients with hyperparathyroidism. METHODS: Three hundred nine patients underwent parathyroidectomy. Patients were divided into two groups: uniglandular disease versus hyperplasia. RESULTS: Eighteen of 309 patients (6%) had abnormal intrathyroidal parathyroid glands. The incidence was 3% (7 of 222) in patients with uniglandular disease versus 15% (11 of 73) in those with hyperplasia. With a mean follow-up of 54 months, 12 patients are eucalcemic, 5 have persistent hypocalcemia, and 1 has recurrent hypercalcemia. There were no recurrent laryngeal nerve injuries. CONCLUSIONS: These data suggest that an intrathyroidal adenoma is an uncommon cause of failure, whereas abnormal intrathyroidal parathyroid tissue may be a more common cause of failure in patients with hyperplasia.