Trends in clinicopathologic characteristics and prognostic predictors of survival outcome in black patients with gastric carcinoma: a single institution's experience.

BACKGROUND: Age, gender, and ethnic group-related differences influence the outcome of gastric cancer. Our aim was to analyze the trends and association of clinicopathologic characteristics and prognostic factors of gastric cancer in black patients over a period of 28 y. METHODS: A retrospective analysis of all black patients treated for gastric cancer from 1979 to 2007 at Howard University Teaching Hospital. This period was divided into two time frames, 1979-1993 and 1994-2007. RESULTS: Of 286 patients in our study, there were 160 (55.9%) males versus 126 (44.1%) females. For the period 1979-1993, there were a total of 169 (59.1%) patients versus 117 (40.9%) for 1994-2007. A significant increase in the incidence of cardia/fundus tumors and stage IV tumors was noted between the two periods (P<0.02, P<0.004), 8.9% versus 12% and 71.4% versus 50.8%. The median survival time for the period 1979-1993 was 30.5 mo versus 39.2 mo for 1994-2007. The median survival time for males was 35.7 mo versus 34.9 mo for females. Significant independent predictors of a shorter gastric cancer-specific survival include tumor stage IV (HR 8.4 95% CI 2.0-35.0, P<0.003), female gender (HR 2.3 95% CI 1.0-4.9, P<0.02). CONCLUSION: Increased incidence of cardia/fundus tumors and stage IV disease may contribute to the sustained higher gastric cancer-specific mortality observed amongst black patients. Female gender emerged as an independent predictor of a shorter survival time.

Sclerosing lobular hyperplasia manifesting as a palpable mass of the breast in young black women.

Sclerosing lobular hyperplasia is defined as a lesion of the breast characterized solely by prominent hyperplasia of the lobules and sclerosis of the intralobular stroma. The extra-lobular connective tissue may or may not be fibrosed. To ascertain the frequency of this condition, the histologic sections of all benign breast lesions diagnosed at Howard University Hospital between January 1, 1980, and June 30, 1982, were reviewed. The patient population of the hospital is almost entirely black. Among a total of 590 benign breast lesions, 18 cases of sclerosing lobular hyperplasia were found. The mean age of the patients was 28.3 years. The patients generally complained of a painless or slightly tender lump in the breast, of one or two month's duration. The masses appeared finely nodular and varied in size from 0.8 X 1.2 cm to 3.5 X 5.0 cm. Some microscopic sections from patients with sclerosing lobular hyperplasia revealed incipient (lobule-sized) fibroadenoma. On re-examination of the available sections of 101 fibroadenomas, 47 (46.5 per cent) were found to be surrounded by breast tissue exhibiting focal sclerosing lobular hyperplasia. Apparently, sclerosing lobular hyperplasia is often overgrown by fibroadenoma, and the presenting symptoms are those of the dominant tumor rather than those of the preceding condition.

Progress in cancer.

Definite progress has been made against cancer since the National Cancer Act was passed in 1971. Physicians are giving increased attention to cancer prevention. The exciting changes in molecular biology provide increased knowledge about basic mechanisms in tumor growth and metastases. Detailed discussions of two common solid cancers--breast and colorectal--attest to continuing advances in cancer diagnosis and treatment. All of these augur well for further progress in oncology. Continued research, basic and clinical, is mandatory.

Claude H. Organ, Jr. Honorary/Sandoz Nutrition Lectureship. Ethics in research and surgical practice.

The topic "Ethics in Research and Surgical Practice" appears most appropriate for the 1997 Claude H. Organ, Jr. Honorary Sandoz Nutrition Lecture. With the increasing numbers of ethical problems facing clinicians today, greater emphasis on ethics is demanded. This lecture focuses primarily on the clinical applications of basic science and ethics certainly plays a major role in this regard. Ethical principles espoused by the American College of Surgeons and the American Medical Association will be emphasized. Further, the results of the deliberations of the Advisory Committee on Human Radiation experiments will be discussed. Certainly, the Tuskegee experiment debacle will be mentioned. Ethics remains important if we are to give our patients the best care. We must always keep in the vanguard of our thinking that the welfare of our patients comes first. High ethical principles emphasize our obligations and responsibilities to our patients.

Seven surgical exemplars and the College--lest we forget.

The Society of Black Academic Surgeons was founded, not to foster any measure of separatism or exclusivity, but rather to encourage and nurture black surgeons to pursue careers and participate fully in all phases of academic surgery. The Society meets annually with varied scientific presentations by its members. State-of-the-art lectures by nationally acclaimed surgical leaders remain an integral part of the program. On this occasion, it seems appropriate to recall the contributions of some of our colleagues and especially their relationship to the American College of Surgeons (the College, or ACS). We are well aware that progress in academic surgery did not begin with those of us currently on the scene but rather that our paths have been made smoother by those who have gone before us. To that end, I have chosen seven black surgeons who played major roles in these efforts. Owing to space constraints, only abbreviated accounts of their contributions will be given. Oral and written versions of their lives demonstrate a keenness of mind and strength of character that enabled them to confront various indignities while persevering to achieve their goals. Equally important was the demonstration of good will, justice, and fair play by some leaders in American surgery who afforded these seven stalwarts the opportunity to train, to develop, and to succeed. Both groups deserve our praise, tribute, and respect. Prudence dictates that no special mention be made of the living; thus, I will side with prudence and restrict my statements to the contributions of seven colleagues who have departed this vale. These seven surgical exemplars are Daniel H. Williams, Louis T. Wright, Frederick D. Stubbs, William H. Sinkler, Matthew Walker, Charles R. Drew, and Samuel L. Kountz.

Penetrating neck wounds.

Over a 15 year period 120 patients with neck injuries that penetrated the platysma were studied. Appropriate treatment was initiated in the emergency room. Sixty-one patients underwent exploration and 59 were observed. Two of the observed patients later required delayed operation. In 9.2 percent of the patients, two or more injuries were present within the neck, whereas in 30 percent the neck injury was only one of many bodily injuries. Length of hospital stay for the operative group of patients was 9 days and for the nonoperative group 5 days. There was one death. The complication rates in the operative and nonoperative groups were 2.5 and 1.7 percent, respectively. The major structures injured were within the venous system. The neck injuries were classified according to three zones defined by Saletta and Jones and their co-workers [4,5]. The majority were Zone II injuries. Our morbidity and mortality rates are slightly lower than those reported in most series. This review supports the concept that therapy for penetrating injuries to the neck should be individualized.

Asymptomatic pneumoperitoneum diagnostic and therapeutic dilemma.

The most common cause of pneumoperitoneum is iatrogenic postsurgical free air that enters the abdominal cavity during laparotomy. In these patients, pneumoperitoneum usually resolves within the first week of surgery and laparoscopic procedures. In patients who have not had recent laparotomy or laparoscopy, pneumoperitoneum indicates rupture of an intra-abdominal viscus in about 90 per cent of the time. Perforated gastric and duodenal ulcers account for the greatest number of these cases. The other 10 per cent are due to a variety of nonsurgical causes that can often be treated by supportive and non-operative measures. Lack of clinical awareness about these small but significant subset of patients who present with spontaneous benign pneumoperitoneum is a source of needless laparotomies that can at times lead to serious postoperative complications. Benign pneumoperitoneum can be categorized according to the source of the gas as suggested by Gantt. The thoracic cavity is by far the most common source, followed by the GI and female genital tracts and a host of other miscellaneous causes. We report here six patients who presented to Howard University Hospital with nonsurgical pneumoperitoneum. Four of these patients underwent negative laparotomies and one died postoperatively. The most common causes of benign pneumoperitoneum are discussed and a review of the literature is presented.

Gastric carcinoma in African Americans: a 10 year single center analysis.

The occurrence of gastric cancer (GCa) has been declining in the U.S. over the past years. The reasons for this decline, though unclear, may not hold true for minorities. In fact, data on the occurrence, presentation and determinants of survival in African Americans still remains sketchy. In an attempt to rectify this problem, we retrospectively analyzed accumulated data at the Howard University Cancer Center between 1985 and 1994. There were 115 patients with GCa, 53 females and 62 males. The age range was 26-88 years, with most patients being over 50 years of age (84%). Eighty seven out of the 115 patients were completely staged and thus formed the population base for the analysis. There was a progressive decline in the frequency of diagnosis of GCa between the 1985-1989: 63% cases (55/87) and 1990-1994: 37% cases (32/87). In analyzing this group, we found no gender difference on presentation. Seventy percent of the patients (61/87) presented with the advanced disease (stages III & IV). Eighty eight percent (77/87) underwent surgery: 50/77 surgery alone; 9/77 surgery and chemo; 18/77 surgery and other forms of therapy (radiotherapy and chemotherapy). Seventy one percent of the patients who presented with late stage disease, died within 12 months. The predominant histologic type was adenocarcinoma (85%), while lymphoma and leiomyosarcoma accounted for five and three percent respectively. In conclusion, our data suggest that most patients in our minority population presented at a late stage of GCa, and stage was an important determinant of survival. Also, our findings are in agreement with the declining trend of GCa in the U.S.

Colorectal cancer in young black patients.

A higher percentage of young black patients are discovered with a more advanced stage of colorectal cancer than is reported for white patients. To evalute this phenomenon, various prognostic factors in young colorectal cancer patients at Howard University Hospital were studied.

Massive upper gastrointestinal bleeding in a patient with a duodenal diverticulum: a case report and review of the literature.

Diverticula of the duodenum occur in approximately 2% to 5% of individuals who have had upper gastrointestinal (GI) series; the majority of these patients are asymptomatic. These diverticula occasionally result in the obstruction of the biliary and pancreatic ducts, which leads to jaundice and pancreatitis. Other complications such as hemorrhage, perforation, sepsis, and death can occur. This article reports a case of upper GI bleeding in a patient who was found to have duodenal diverticula by upper GI series and endoscopy. Diverticulectomy was performed, and microscopic examination of the specimen showed dilated blood vessel suggestive of angiodysplasia.

Primary malignant small bowel tumors: an atypical abdominal emergency.

Primary malignant tumors of the small bowel are uncommon in the United States. They comprise less than 1% of all gastrointestinal malignancies, with an incidence of 2200 cases per year. The clinical presentation of small bowel tumors is frequently insidious and often overlooked by physicians. The low incidence and lack of pathognomonic symptoms are the reasons that the early diagnosis of malignant small bowel tumor is uncommon. To better understand the clinical presentation, diagnostic evaluation, management, and outcome, a review of Howard University patients with primary malignant small bowel tumors between 1970 and 1990 was conducted. Our experience concurs with the reported literature and supports the conclusion that a high index of suspicion is necessary. The diagnosis of a malignant small bowel tumor should be considered in patients with vague chronic abdominal complaints.

Breast ductal carcinoma with osseous metaplasia.

The case of an elderly patient with one of the rarest forms of breast carcinoma is reported. Histomorphologic aspects and theories as to its origin are discussed.

Is there a genetic basis for the differences in cancer incidence between Afro-Americans and Euro-Americans?

The data of the Third National Cancer Survey show for many cancer types, large differences in cancer incidence between Euro-Americans and Afro-Americans.(1) As in other racial studies, it is difficult to separate environmental and genetic factors. For the cancers which are more frequent among Afro-Americans, environmental factors seem to be primarily responsible. However, among the cancers less frequent in Afro-Americans, there are some for which the racial differences have a genetic basis. This is clearly the case for skin and lip cancers caused by the ultraviolet B of the sun. Genetic factors are probably also responsible for the racial differences in the incidence of malignant melanomas, testis cancers, astrocytomas, and Ewing's sarcomas. Perhaps there is also a genetic basis for some of the racial differences in the incidence of malignant lymphomas and leukemias. For all these cancers, Afro-Americans are less susceptible. The only cancer to which Afro-Americans appear more susceptible on the basis of genetic makeup, is fibrosarcoma. This is in accord with the high frequency of keloids, a benign counterpart of fibrosarcoma in Afro-Americans.

Superior mesenteric vein thrombosis: a case report.

Superior mesenteric vein thrombosis is an abdominal emergency that is rarely diagnosed early. Abdominal pain, vomiting, fever, and hematochezia are the characteristic presenting complaints. Tenderness, distension, and diminished intestinal sounds were the prominent abdominal physical findings in this case and were often associated with tachycardia and hypotension. This is a case that demonstrates all the nonspecifics, and one in which the patient survived beyond all others reported in the literature to date.

Hyperparathyroidism in black patients: an update.

Cervical exploration with removal of the pathologic gland or glands is effective treatment for parathyroid adenomas and hyperplasia. This article reports the results of a retrospective study of 41 patients who underwent elective cervical exploration for primary hyperparathyroidism at Howard University Hospital between 1974 and 1989. Preoperative localization studies for primary neck exploration consisted of an ultrasound of the neck. Removing the diseased gland/glands resulted in the resolution of the patients' symptoms and the return of calcium levels to normal. Complications included transient hypocalcemia, a wound hematoma, and a postoperative death.

Colorectal carcinoma in young persons: experience at Howard University Hospital, 1955--1977.

Case records of all patients 30 years of age and under with a proven pathological diagnosis of colorectal cancer at Howard University Hospital between January 1955 and December 1977 were reviewed. Over this 23-year period, 14 cases were documented. All patients were black. This study reaffirms the poor prognosis which accompanies colorectal carcinoma in the young, particularly in those patients with mucinous carcinoma.

Crohn's disease in black patients.

Crohn's disease is less prevalent in blacks than in whites. However, when it does occur, it is associated with a high degree of morbidity and is frequently unrecognized at initial presentation. Forty-three patients with Crohn's disease presented to Howard University Hospital between 1965 and 1987. There were 156 hospital admissions, 47 emergency room visits, and 76 clinic visits over this 22-year period. Twenty-eight patients were female and 15 were male. The age of presentation for males ranged from 18 to 63 years and for females, 12 to 74 years. Crohn's disease should be considered in black patients who present with chronic abdominal pain and diarrhea. With correct diagnosis and appropriate medical therapy, patients should have an enhanced quality of life with less morbidity.

Preliminary survivorship report on combined intraoperative radiation and hyperthermia treatments for unresectable pancreatic adenocarcinoma.

Five patients with unresectable pancreatic adenocarcinoma were treated with simultaneous intraoperative radiotherapy and intraoperative hyperthermia. Postoperative survivorship averaged 15.8 months, which compares favorably to a previous study in which 19 patients receiving intraoperative radiotherapy without intraoperative hyperthermia survived an average of 6.05 months. Three of the five patients following the experimental protocol of intraoperative radiotherapy and intraoperative hyperthermia with additional external beam radiotherapy are still alive, which may result in average postoperative survivorship exceeding 15.8 months.

Chylothorax: an omnipresent reality in thoracic surgical procedures.

Loss of integrity of the thoracic duct will produce a chylous thoracic effusion. latrogenic chylothorax occurring during an intrathoracic surgical procedure in the vicinity of the thoracic duct is an omnipresent reality. The fluid is characteristically milky in appearance, sterile, and high in fat content.There seems to be a general agreement that initial management be conservative, namely, dietary control and adequate drainage. The success of conservative management will depend on collateral lymphatic channels developing. If conservative measures fail, thoracotomy for ligation of the duct is indicated. When to terminate nonoperative therapy and opt for operative is controversial.

The effect of citrate and polyamines on human benign prostate in organ culture.

A technique for short-term cultivation of slices of human benign prostate tissue in an organ culture environment is described. Minimum essential medium utilized was supplemented with 10 percent fetal bovine serum and 25 mg/mL of citrate, spermine, and spermidine. Spermine in the presence of testosterone in the culture medium induced morphological changes, enhancing the morphology of the tissue. The epithelium was well preserved morphologically. Citrate or spermidine together with testosterone does not enhance any morphological change. After seven days of culture, necrosis was developed. The spent culture medium showed a pattern of prostatic acid phosphatase production. When treated with spermine, the maximum level was reached at four days, after which it decreased. With spermidine or citrate, the maximum level is reached at two days of culture. Tissue ß-glucuronidase activity was enhanced by either spermidine, spermine, or citrate together with testosterone. The biochemical studies suggested that explants of human benign prostate can be well maintained in organ culture for a few days.