Cisplatin, vinblastine, and mitoguazone chemotherapy for epidermoid and adenocarcinoma of the esophagus.

Thirty-six patients with adenocarcinoma or epidermoid carcinoma of the esophagus were entered into a phase II trial evaluating the combination of cisplatin 100 mg/m2 intravenously (IV) day 2, vinblastine 1.6 mg/m2 IV days 1 to 4, and mitoguazone (MGBG) 500 mg/m2 IV days 1 and 8. Twenty-nine patients (group A) were newly diagnosed with local-regional disease only and were candidates for transhiatal esophagectomy (THE). These patients received two courses of chemotherapy at 3-week intervals prior to surgery. Response was assessed by measuring changes in the primary tumor length and depth on serial biphasic contrast esophagrams and comparing this result with tumor measurements obtained from the surgical specimen. Complete (CR) and partial responders (PR) received three additional postoperative cycles. Seven patients had recurrent or metastatic disease (group B) and were treated every 4 weeks until disease progression. Of 34 patients evaluable for response, there was one pathologically confirmed CR and 15 PRs (47%). This consisted of 12 of 27 (44%) group A patients (seven of 11 epidermoid, five of 16 adenocarcinoma) and four of seven (57%) group B patients (two of four epidermoid, two of three adenocarcinoma). Toxicity included leukopenia in one third of treatment courses and thrombocytopenia in 21%. Nausea and vomiting occurred in 60% of patients, diarrhea in 18%, transient nephrotoxicity in 18%, peripheral neuropathy in 12%, and ototoxicity in 3%. Twenty-five group A patients underwent resection. Four chemotherapy nonresponders (NR) and one PR had known disease left at surgery; all others (80%) had gross total removal of their disease. The median survival time (MST) of the 29 group A patients was 14 months, with 21% alive at 36 months. The MST of group A chemotherapy responders was 15 months compared with 9 months for NRs (P = .032). Initial sites of recurrence in 14 patients were local-regional in six, distant only in six, both local-regional and distant in two. This regimen, administered in maximally tolerated doses, was active in epidermoid and adenocarcinoma histologies, recurrent disease and newly diagnosed patients. However, nearly all responses were PRs and the MST of resected patients was similar to a prior series of patients treated with esophagectomy alone. Observations from this pilot trial and those of others have led to a follow-up study, in progress, evaluating intensive preoperative chemotherapy and concurrent radiation therapy (RT).

Transient asymptomatic hydrothorax in pregnancy at term.

Two cases of transient asymptomatic hydrothorax during pregnancy are reported. In both cases the effusions resolved completely within a week of the termination of pregnancy. No apparent pathologic explanation could be found for this finding.

Evaluation of response to preoperative chemotherapy in esophageal and gastric cardia cancer using biphasic esophagrams and surgical-pathologic correlation.

Twenty-two patients with newly diagnosed carcinoma of the esophagus and gastric cardia were treated with combination chemotherapy prior to transhiatal esophagectomy. The clinical response to chemotherapy was determined by obtaining measurements of the vertical length of tumor, tumor depth, lumen size, and extent of ulceration on serial biphasic contrast esophagrams. Response was defined as a greater than 50% decrease in the sum of the products of the maximum vertical length and depth of the esophageal tumor mass. To obtain an assessment of the accuracy of the radiographically determined tumor measurements the esophagram results were correlated with surgical pathologic tumor measurements in 19 patients. The technique of esophagram and the determination of tumor measurements were standardized by having one radiologist perform and interpret all studies. All patients were clinically staged using the TNM classification system of the American Joint Commission on Cancer Staging. Three patients had T1 lesions, fifteen were classified as T2, and four as T3 lesions. Radiographic measurements of the tumor from the preoperative esophagram were correlated with the surgical pathologic specimen in five patients prospectively and 14 patients retrospectively. Response was seen in nine patients. The radiographically measured vertical length of the tumor was within 1 cm of the surgical specimen measurement in four of five (80%) prospectively evaluated patients and in nine of 14 (64%) retrospectively evaluated patients. These results suggest that chemotherapy-induced tumor regression can be objectively evaluated with a reasonable degree of accuracy using serial biphasic esophagrams.

Bleeding lipomas of the upper gastrointestinal tract. A diagnostic challenge.

Submucosal lipoma of the upper gastrointestinal tract is a rare benign tumor. However, it may present as both a diagnostic problem and as a life threatening lesion due to exsanguinating hemorrhage. The authors report four patients with significant upper gastrointestinal bleeding due to ulcerating lipomas. In two patients the lesions were gastric and in two patients the lesions were duodenal in origin. In no instance could the diagnosis of lipoma be accurately established short of operative intervention because of unusual morphologic features. Surgical extirpation was necessary to stop the bleeding and establish the histologic diagnosis of the tumor.

Intussusception in adults.

A review of 25 adult patients with intussusception is reported. Intussusception in adults constituted 16.6% of 150 intussusception cases observed during 1956-1985. The underlying pathologic processes were identified in 23 patients (92%). Etiologically, adult intussusception could be categorized into four groups: (1) tumor-related (13 cases, 52%); (2) postoperative (nine cases, 36%); (3) miscellaneous--Meckel diverticulum (one case, 4%); and (4) idiopathic (two cases, 8%). The tumor-related intussusceptions were caused by benign tumors in five and malignant tumors in eight patients. Postoperative intussusceptions were related to various factors including suture lines, ostomy closure sites, adhesions, long intestinal tubes, bypassed intestinal segments, submucosal edema, abnormal bowel motility, electrolyte imbalance, and chronic dilatation of the bowel. The sites of involvement of intussusception were jejunogastric (one), jejunojejunal (seven), ileoileal (four), ileocolic (10), and colocolic (three patients). Four patients had synchronous multiple (ileoileal and jejunojejunal), four had compound (ileoilealcolic), and two had recurrent intussusceptions. When an intussusception is encountered in adults, an underlying pathologic process usually can and should be determined for proper management.

Barrett carcinoma of the esophagus: clinical and radiographic analysis of 34 cases.

Review of 34 cases of pathologically proved Barrett-type adenocarcinoma of the esophagus seen at the University of Michigan during 1962-1983 revealed that it constituted 5% of all carcinomas of the esophagus and 20% of all adenocarcinomas involving the esophagus during that period. Despite many similarities to conventional squamous cell carcinoma and gastric cardiac carcinoma, certain distinguishing features were identified. Radiologically, diagnosis of Barrett carcinoma should be suggested when a patient with a longstanding history of gastroesophageal reflux, chronic esophagitis, and hiatus hernia with or without features of Barrett esophagus demonstrates a long vertical segment of esophageal involvement by an infiltrating or varicoid-appearing lesion. This review analyzes the clinical and radiologic distinguishing features of Barrett carcinoma and compares those of gastric cardiac carcinoma and conventional squamous cell carcinoma of the esophagus.

Esophageal involvement in Zollinger-Ellison syndrome.

Review of 18 patients with Zollinger-Ellison syndrome (ZES) revealed pathologic evidence of esophageal disease in six (33%). Four patients manifested varying degrees of esophagitis, ranging from mild to severe ulcerations and stricture formation. In two patients, symptomatic Barrett esophagus was detected 4 and 6 months after total gastrectomy, respectively. It is postulated that due to longstanding gastroesophageal reflux, Barrett esophagus was present in these two patients before total gastrectomy, and esophageal symptoms became only apparent after more compelling symptoms of gastric peptic ulceration were controlled by definitive surgery. Esophageal involvement occurs with greater frequency in patients with ZES; the previously held notion that esophageal disease due to gastroesophageal reflux in ZES patients is uncommon is contrary to the results of this study. It is recommended that all patients with ZES irrespective of symptom-complex should be routinely evaluated for the presence or absence of esophageal disease because of its important bearings on adequate surgical management.

Recurrent laryngeal nerve paralysis: a laryngographic and computed tomographic study.

Vocal cord paralysis is a relatively common entity, usually resulting from a pathologic process of the vagus nerve or its recurrent laryngeal branch. It is rarely caused by intralaryngeal lesions. Fourteen patients with recurrent laryngeal nerve paralysis (RLNP) were evaluated by laryngography, computed tomography (CT), or both. In the evaluation of the paramedian cord, CT was limited in its ability to differentiate between tumor or RLNP as the cause of the fixed cord, but it yielded more information than laryngography on the structural abnormalities of the larynx and pre-epiglottic and paralaryngeal spaces. Laryngography revealed distinct features of RLNP and is the procedure of choice for evaluation of functional abnormalities of the larynx until further experience with faster CT scanners and dynamic scanning of the larynx is gained.

Radiologic diagnosis of Barrett's esophagus: critical analysis of 65 cases.

A recent increase in the number of Barrett's esophagus being diagnosed is probably directly related to a proportional increase in endoscopic biopsies of the esophagus and awareness of premalignant potential of Barrett's mucosa. While the endoscopist can detect Barrett's mucosa with fair degree of accuracy, the radiologic diagnosis of Barrett's esophagus still remains a diagnostic challenge despite several well established radiologic features. We reviewed 65 patients with pathologically proven Barrett's esophagus and found a wide spectrum of radiologic features. These include hiatus hernia in 49, gastroesophageal reflux in 38, strictures in 32, esophagitis in 20, and characteristic Barrett's ulcer in 12. In addition ascending or migrating strictures were found in 10, mucosal pattern simulating areae gastricae in 5, cricopharyngeal dysfunction in 4, and fixed spiral folds in 3 patients. This constellation of radiologic features, some of which have not been previously emphasized, should further assist radiologists in suggesting the diagnosis of Barrett's esophagus.

Secondary neoplasms of the esophagus.

A review of 62 cases of esophageal involvement by secondary neoplasms is reported. The common routes of esophageal involvement are by direct extension of the tumor from the contiguous or adjacent organs (45.2%), via mediastinal nodes (35.5%), and hematogenous spread from a distant primary (19.3%). In the first 2 modes of esophageal involvement, the diagnosis is usually obvious but hematogenous metastases to the esophagus usually pose a diagnostic challenge. Radiologically, hematogenous metastases show a spectrum of features consisting of a short segment of progressive stricture with normal to minimally irregular mucosa, a submucosal mass with or without ulceration, a polypoid mass or masses, and defects in esophageal motility including secondary achalasia. Since endoscopy and biopsy have limited diagnostic yield, radiologic diagnosis plays a key role in the diagnosis of secondary neoplasms of the esophagus irrespective of their mode of spread to the esophagus.

Duplex ventral pancreas.

Complete duplication of the ventral pancreatic ductal system in 2 patients is reported. Both patients, during evaluation for recurrent abdominal pain, underwent endoscopic retrograde cholangiopancreatography that revealed typical changes of chronic pancreatitis and pseudocysts confined to 1 ductal system with the other ductal system completely normal. Both ductal systems filled with contrast medium via a common opening at the major papilla. A rudimentary minor papilla was present, but cannulations were unsuccessful. This unusual anomaly of the ventral pancreas with its embryologic basis, diagnosis, and clinical implications is discussed.

Spontaneous resolution of acute pancreatic pseudocysts.

The statements to be given in this section summarize the conclusions drawn from this study. The accuracy of ultrasound in the early detection of pseudocysts is exceedingly high and corroborates the experiences of others. The incidence of pseudocysts complicating acute pancreatitis was 20 per cent. Seventeen patients had a single pseudocyst (85 per cent). Multiple pseudocysts were seen in three patients (15 per cent). Twenty-five per cent of the acute pseudocysts underwent uncomplicated spontaneous resolution. Serial ultrasound examinations play a major role in the early detection and demonstration of spontaneous resolution of acute pseudocysts. Therefore, serial ultrasonography should be the imaging modality of choice in the management of acute pseudocysts.