Postoperative adjuvant chemoradiotherapy for rectal cancer: analysis of acute and chronic toxicity.

AIMS AND BACKGROUND: The aim of the study was to evaluate acute and chronic toxicity of combined postoperative standard radiation therapy to the pelvis and 5-fluorouracil plus levamisole in resectable rectal cancer. METHODS: Between July 1990 and September 1993, 58 patients with histologically confirmed adenocarcinoma of the rectum entered the prospective study. The schedule consisted of 5-fluorouracil, 450 mg/m2 i.v. for 5 days, and from day 28 5-fluorouracil, 450 mg/m2 i.v. weekly for 24 weeks, plus levamisole given orally at the dose of 150 mg every day for 3 days every 2 weeks for 6 months; radiotherapy (180 cGy/day) 5 days a week for a total dose of 45 Gy was administered from day 28. RESULTS: After the first cycle of chemotherapy (before radiotherapy), overall toxicity was mild. During chemoradiotherapy, dose-limiting toxicity was grade 3 diarrhea and proctitis, for which the combined treatment was interrupted for more than 7 cumulative days in 28 patients. During the 24 weeks of weekly 5-fluorouracil (after radiotherapy), no severe toxicity was reported. Three-year survival and progression-free survival were 65% and 50-55%, respectively. CONCLUSIONS: Although adjuvant chemoradiotherapy is usually feasible, in our study toxicity was severe in a substantial proportion of patients, probably due to the schedule applied. We are evaluating the feasibility and toxicity of a combined treatment which includes 5-fluorouracil in continuous chronomodulated infusion during radiotherapy.

Analysis of treatment failures in patients with early-stage uterine leiomyosarcoma.

This retrospective study aimed to investigate the treatment failures in 26 patients with stages I-II uterine leiomyosarcoma (> or = 10 mitoses per 10 high-power field (HPF) who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy +/- adjuvant external pelvic irradiation. Thirteen (50%) patients developed recurrent disease, after a median time of 10 months from surgery (range = 4-72 months). Recurrence was pelvic in 3 (23%) patients, extrapelvic in 9 (69%) patients, and both pelvic and extrapelvic in 1 (8%) patient. Disease-free survival was better for premenopausal than for postmenopausal patients (p = 0.002) and for patients with < 20 mitoses per 10 HPF than for those with > or = 20 mitoses per 10 HPF (p = 0.006). In conclusion, patients with early-stage disease who had undergone locoregional treatment experienced a high recurrence rate. Most of the treatment failures were extrapelvic. Multicentric randomized trials on the role of adjuvant chemotherapy are advocated.

The role of early flap coverage in the management of open fractures of both bones of the leg.

Sixty patients with type III injuries (open fractures) of the tibia were treated in a prospective fashion by combined orthopaedic and plastic surgical schemes based on the principles of early radical cleaning, a second-look operation, and early coverage of soft tissue defects with an appropriate local or distant flap. Stabilization of fractures was achieved by external fixation in most cases and patients were allowed to walk within 4-8 weeks (partial weight bearing). Bony union was achieved in 23.4 weeks. The mean hospital stay was 3.5 weeks. Limb salvage was achieved in all cases and there were no major complications.

Open reduction and fixation of proximal humeral fractures and fracture-dislocations.

Open reduction and internal fixation was employed in the treatment of 25 severely displaced fractures and fracture-dislocations of the proximal humerus. Our aims were accurate reduction and stable fixation to allow early mobilisation and to achieve full functional recovery. In 15 fractures an AO T-plate was used and in 10 a bent semitubular plate was employed as a blade plate. Excellent or satisfactory results were obtained in all six patients with two-part fractures involving the surgical neck; in four of the five patients with three-part fractures involving the surgical neck and tuberosities; in nine of the 11 patients with fracture-dislocation; and in two of the three patients with split fractures of the humeral head. Overall results were good or satisfactory in 21 of the 25 cases. Unsatisfactory results were associated with rotator cuff damage.

Surgery and radiotherapy in the treatment of early stage uterine sarcomas.

Twenty-three patients with early stage uterine sarcomas underwent surgery (5 patients) or surgery and pelvic irradiation (18 patients). Twelve (52%) of the patients developed a recurrence: relapsing disease was pelvic in 3 (25%) of them, extrapelvic in 8 (66.7%) and both pelvic and extrapelvic in one (8.3%). Out of the whole series the 2- and 5-year actuarial survival rates were 61% and 33% respectively. Among the patients with leiomyosarcoma the 2- and 5-year actuarial survival rates were 54% and 39% respectively. Among the patients with carcinosarcoma the 2- and 5-year actuarial survival rates were 66% and 23% respectively. The high incidence of extrapelvic recurrences after locoregional treatment seems to suggest the use of an adjuvant chemotherapy in the management of patients with early stage uterine sarcomas.

[2 cases of hairy cell leukemia]. / Osservazioni su due casi di tricoleucemia.

Two cases of tricholeukaemia are reported. In both, onset and course of the disease were dominated by infectious episodes of varying gravity. Diagnosis was based on the finding in the blood and bone marrow of mononucleate cells containing the characteristic cytoplasmatic projections, best recognised in the phase contrast microscope, and on the cytochemical finding of intense positivity of the acid phosphatase reaction, that a very serious septic state starting from a dental abscess was possible in a patients by associating infusions of paps of leucocyte concentrates with massive target antibiotic therapy. Splenectomy carried out in the same patient led to an increase in the number of circulating platelets and leukocytes. After operation, two episodes of cutaneous inflammation presented by the same patient were less serious than similar previous infectious episodes.

[Phallin syndrome. Reports on 28 cases]. / Sindrome fallinica. Osservazione su 28 casi.

28 cases of phallinic syndrome have been studied: 24 out of them were from amanita phalloides poisoning and 4 from amanita verna poisoning. After a lag phase lasting from 7 to 30 hours, symptomatology characterized by starting gastroenteric troubles as vomit, diarrhea, abdominal cramps, meteorism and pain following abdomen palpation. In one case the syndrome started with parasympathicomimetic crisis, probabily due to ingested amanita containing muscarinic type poison. Subsequent evolution of clinical picture included signs of hepatic and renal involvement. As far as laboratory diagnosis is concerned, high levels of serum aminotransferases were found and, less frequently, hyperbilirubinmia and high BUN levels occurred. In severe cases, in addition, lowered values for plasma prothrombine, fibrinogen and cholinesterase were found. Low therapeutic effect followed rehydration, equilibration of electrolytic unbalance and administration of thioctic acid, coagulants and so on. As a matter of fact 3 out or 28 patients, treated only with such therapy, died. On the contrary good therapeutic effect followed to peritoneal dialysis, in two cases coupled to exchange transfusion: 10 patients were treated in such a way and no one died but all of them quickly recovered. Forced diuresis also appeared greatly useful and practical in therapeutic treatment of phallinic syndrome: results compared favourably with those obtained by means of peritoneal dialysis. As a matter of fact 15 patients, 5 of them having ingested a great amount of amanita phalloides, were treated with forced diuresis and no one of them died. Finally, the need is stressed for a very quick therapeutic intervention (exchange transfusion; plasmapheresis; peritoneal dialysis; forced diuresis, and so on) in order to lower the plasma concentration of the toxins responsible for the phallinic syndrome. Only in such a way diffusion of toxins from blood to tissues is avoided.