Home parenteral nutrition for patients with advanced intraperitoneal cancers and gastrointestinal dysfunction.

The use of total parenteral nutrition (TPN) in patients with advanced, untreatable cancer is controversial. Occasionally, however, damage to bowel by tumor, radiation, or surgery renders these patients unable to eat and TPN may be indicated to prevent premature death from starvation. We have used Home Parenteral Nutrition (HPN) to support three patients with advanced, untreatable abdominal cancer and inability to eat. Morbidity was minimal and survival times were 24, 6 and 1.5 months. Payment was covered by third party agencies. All patients and their families were gratified by the ability to return home with nutritional support. HPN can be used to support terminal cancer patients with bowel obstruction and may afford them longer survival. Ideally, patients considered for this should be well motivated, with good support systems, and with survival estimated to be at least months.

Retransplantation of murine skin allografts: assessment of treatment effects on the allograft in the absence of effects on the host.

In transplantation techniques previously described it was impossible to separate the effects of immunosuppressive treatments on the host from the effects directed at the allograft itself. The skin allograft retransplantation technique described here allows one to assess changes in the immunogenicity of the allograft generated in the primary recipient but assessed on a second untreated host. The skin allograft is parked on a primary recipient and then retransplanted with a thin margin of recipient tissue to a second host. Data obtained from this model shows that passenger leukocytes do not influence skin allograft survival times. Enhancing alloantisera used in the primary host was shown to cause prolonged graft survival in the untreated second recipient. Using this model the effects of immunosuppressive or immunostimulatory treatments directed at the graft itself can be assessed.

Quality of life assessment of patients in extremity sarcoma clinical trials.

Twenty-six patients with soft tissue sarcoma who participated in a randomized controlled clinical trial were studied to compare the impact of treatments on quality of life. Patients were treated with amputation plus chemotherapy or with limb-sparing surgery plus radiation therapy plus chemotherapy. After completion of treatments, when the patients' physical status had stabilized, a "Quality of Life Assessment" was administered. It consisted of the Psychosocial Adjustment to Illness Scale, the Sickness Impact Profile, the Barthel Function Scale, the Katz Activities of Daily Living Scale, nd an economic assessment. In addition, clinical assessments of mobility, pain, sexual relationships, and treatment trauma were obtained. Analysis of these assessments indicated that our hypothesis that limb-sparing surgery plus irradiation would provide improved quality of life when compared to amputation was not substantiated.

Assessment of T cell function with a skin allograft assay.

The adoptive transfer of cytotoxic effector cells to induce accelerated skin allograft rejection in the normal murine host was used as an assay of lymphocyte function in vivo. Splenocytes sensitized in vivo caused specific accelerated skin allograft rejection when administered i.v. at a dose of 5 X 10(7) cells 1 day after grafting. Graft rejection was specific for the immunizing alloantigen and could not be transferred with freeze-thawed or irradiated cytotoxic cells. In this assay the i.v. and local routes of administering cytotoxic cells were effective whereas the i.p. and s.c. routes were not. T cells were necessary in that pretreatment of the cells with anti-Thy-1.2 plus rabbit complement abrogated this phenomenon. Immune cells from spleens of mice sensitized but no longer actively cytotoxic did not demonstrate in vivo activity. If hyperimmunized mice were challenged by i/p. allogeneic tumor, their spleen cells were highly cytotoxic by in vitro assay but acted as suppressor cells in vivo by prolonging skin graft survival. Adoptively transferred in vivo sensitized cells subsequently expanded in number by T cell growth factor did not demonstrate in vivo activity. This skin allograft assay may be used to demonstrate T cell activity in vivo by inducing accelerated allograft rejection, and immune suppression by prolonging graft survival. Also a comparison of in vivo and in vitro effects was possible.

Assessment of serial carcinoembryonic antigen (CEA) assays in postoperative detection of recurrent colorectal cancer.

Monthly serial postoperative CEA determinations, three-monthly system review plus physical examination, and a battery of six-monthly laboratory and radiologic tests were compared in order to evaluate each in detection of recurrent colorectal cancer. Twelve of the 33 patients studied prospectively developed recurrent disease. In this study CEA was found not to be a substitute for careful clinical follow-up, but if used in a serial manner it was a useful adjunct for detection of early recurrent cancer, especially intra-hepatic and retroperitoneal disease recurring in patients with elevated pretreatment CEA levels. The other laboratory and radiologic tests employed were often useful to confirm progressing disease, but they did not reveal any first evidence of recurrent disease.

Preoperative laparoscopy in diagnosis of acute abdominal pain.

During 1973, 56 patients on one of three general surgical services at the Peter Bent Brigham Hospital, Boston, Massachusetts, who were judged to require hospital admission for acute abdominal pain were dividied into two groups. This division was determined by whether or not the physician responsible thought a definite diagnosis could be established on clinical grounds. 27 patients were thought to have a definite diagnosis and underwent laparotomy without preoperative laparoscopy; at laparotomy, 6 of these patients (22%) had no operable lesion. An additional 29 patients had severe abdominal pain and required observation in hospital. An exact diagnosis could not be clinically established in these patients, and many would in the past have required exploratory laparotomy. These 29 patients underwent laparoscopy resulting in all but 1 (4%) having the presence or absence of intra-abdominal disease requiring operative intervention definitely established. At laparoscopy, diagnosis was made in 18 patients who did not require laparotomy while 11 had disease requiring laparotomy after laparoscopy. No complications resulted from laparoscopy. The difference in the median length of stay and hospital charges resulted in a saving of one and a half days in hospital and $87 when laparoscopy rather than explatory laparotomy determined that acute abdominal pain was caused by a condition not requiring surgical intervention.