The role of the community teaching hospital in surgical undergraduate education.

BACKGROUND: Significant changes in surgical practice have resulted in a reexamination of surgical undergraduate education. The increasing emphasis toward ambulatory procedures positions the community hospital as an excellent alternative site for surgical education. This study compares the quality of one medical school's surgical education at a principal teaching hospital to that of affiliated teaching hospitals. METHODS: Surgical undergraduate education offered through four programs was evaluated for 1993 to 1997. Students' performance was objectively rated by the National Board Examination in surgery, an oral examination, and a clinical appraisal. A subjective appraisal was determined via students' clerkship evaluation. RESULTS: There was a significant difference (P <0.01) in National Board Examination scores and clerkship evaluations that favored some affiliated teaching hospitals over the principal teaching hospital. CONCLUSION: The quality of surgical undergraduate education, documented by objective testing and subjective perception, indicated that the education obtained at the affiliated hospitals was at least equivalent to the principal teaching hospital.

Cancer conferences. Can they be improved?

PURPOSE: Cancer conferences are required for hospital cancer program approval by the American College of Surgeons. These conferences are important educational and clinical opportunities and can influence the management of patients with cancer. Nationally, they represent an enormous expenditure of time and effort by physicians, associated healthcare personnel, and tumor registrars. The educational aspects of cancer conferences have been previously reviewed. The purpose of this investigation was to evaluate the clinical aspects of cancer conferences. DESCRIPTION OF STUDY: A questionnaire, inquiring about various elements of cases presented at six consecutive cancer conferences, was sent to 93 Illinois hospitals. These elements included presentation at conference (presenter, time of presentation), clinical aspects (symptoms, history, physical examination, and laboratory tests), pathology (TNM stage and markers), therapeutic options, and quality-of-life issues. RESULTS: The person (or persons) presenting the case was most frequently the attending physician (n = 805, 52%); followed by the pathologist (n = 427, 28%); the cancer committee chairperson (n = 318, 21%); the resident (n = 138, 9%); and other members of the multidisciplinary healthcare team (n = 525, 34%), such as the nurse practitioner or radiation therapist. Of the 1547 cases reviewed, history, physical examination, and diagnostic tests were discussed in 93%, 91%, and 93% of conference presentations, respectively. However, staging by the required TNM system, tumor markers, and quality-of-life issues were discussed in only 28%, 34%, and 38% of presentations, respectively. CLINICAL IMPLICATIONS: Although clinical characteristics were adequately documented and discussed at the cancer conferences studied, other important parameters, such as TNM staging, tumor markers, and quality-of-life issues, were less often discussed. The former topic frequencies are expected, the latter unacceptable. Although cancer conferences currently enhance patient care, these findings indicate that there is potential for improvement through discussion of TNM staging, tumor markers, and quality of life.

A phase III randomized prospective trial of external beam radiotherapy, mitomycin C, carmustine, and 6-mercaptopurine for the treatment of adults with anaplastic glioma of the brain. CNS Cancer Consortium.

PURPOSE: This study was designed to evaluate strategies to overcome the resistance of anaplastic gliomas of the brain to external beam radiotherapy (ERT) plus carmustine (BCNU). Patients were > or = 15 years of age, had a histologic diagnosis of malignant glioma, and a Karnofsky performance status (KPS) > or = 60%. METHODS AND MATERIALS: In Randomization 1, patients were assigned to receive either ERT alone (61.2 Gy) or ERT plus mitomycin C (Mito, IV 12.5 mg/m(2)) during the first and fourth week of ERT. After this treatment, patients went on to Randomization 2, where they were assigned to receive either BCNU (i.v. 200 mg/m(2)) given at 6-week intervals or 6-mercaptopurine (6- MP, 750 mg/m(2) IV daily for 3 days every six weeks), with BCNU given on the third day of the 6-MP treatment. Three hundred twenty-seven patients underwent Randomization 1. One hundred sixty-four received ERT alone, and 163 received ERT + Mito [average 52.7 years; 63% male; 69% glioblastoma multiforme (GBM); 66% had a resection; 56% KPS > or = 90%]. Step-wise analysis of survival from Randomization 1 or 2 indicates that survival was significantly diminished by: (a) age > or = 45 years (b) KPS < 90%; (c) GBM/gliosarcoma histology; (d) stereotactic biopsy as opposed to open biopsy or resection. Median survival from Randomization 1 in both arms (ERT + Mito) was 10.8 months. Median survival from Randomization 2 was 9.3 months for BCNU/6MP vs. 11.4 months for the BCNU group (p = 0.35). Carmustine/6-MP showed a possible survival benefit for histologies other than GBM/GS. Two hundred and thirty-three patients underwent Randomization 2. The proportion of patients in the ERT group who terminated study prior to Randomization 2 was significantly less in the ERT group than in the ERT + Mito group (20 vs. 37%, p < 0.001). CONCLUSIONS: (a) The addition of Mito to ERT had no impact on survival; (b) patients treated with ERT + Mito were at greater risk of terminating therapy prior to Randomization 2; (c) there was not a significant survival benefit to the addition of 6-MP to BCNU.

Renal cell carcinoma: tumor size, stage and survival. Members of the Cancer Incidence and End Results Committee.

In an attempt to define the relationship among tumor size, stage and survival, the Cancer Incidence and End Results Committee of the American Cancer Society, Illinois Division, Inc. reviewed the records of 2,473 patients with a histological diagnosis of renal cell carcinoma. Tumor size was related to stage and survival. Larger tumors were generally associated with an increased stage (p < or = 0.0005) as well as poorer survival (p < or = 0.005). For Robson stages II, III and IV, tumor size may contribute additional prognostic information for patient survival.

An analysis of radiotherapy data from the CNS cancer consortium's randomized prospective trial comparing AZQ to BCNU in the treatment of patients with primary malignant brain tumors. The CNS cancer consortium.

The CNS Cancer Consortium has conducted a phase III study comparing diaziquone (AZQ) with carmustine (BCNU) in the treatment of adults with primary anaplastic glial brain tumors. Patients eligible for this study were 18 years of age or older at the time of biopsy, subtotal resection, or gross total resection of an anaplastic glial brain tumor. Within 3 weeks of surgery, patients received whole brain radiotherapy at 1.7 to 2 Gy per fraction to a total whole brain dose of 42-48 Gy. This was followed by a boost to the tumor bed as ascertained by computed tomography (CT), angiography, and/or magnetic resonance imaging (MRI) of 1.7 to 2 Gy per fraction to a dose of 12-19 Gy. The recommended cumulative dose to the tumor bed was therefore 55-61 Gy. At 8 weeks following radiotherapy, patients were randomized to receive either AZQ at 15 mg/day for 3 days i.v. every 4 weeks or BCNU at 200 mg i.v. every 8 weeks. Chemotherapy was continued for at least 1 year unless death occurred, treatment failure was declared, or toxicity necessitated alteration of therapy. In the 249 randomized patients, there was no difference between the AZQ- and BCNU-treated patients in age, sex distribution, race, tumor histology, type of surgical resection, or Karnofsky performance status (KPS). Age and KPS at the initiation of therapy and tumor histology were the best overall predictors of survival. The type of chemotherapy (AZQ vs BCNU) was not predictive of survival. Two-year Kaplan-Meier survival was 22% in the AZQ-treated patients and 25% in BCNU-treated patients. In an analysis of radiotherapy administered we found that, within the range of doses required for this study, there was no influence of whole brain dose, boost dose, total dose, or size of the boost field on survival. The institution providing radiotherapy (teaching hospital vs nonteaching facility) did not influence survival.

Achieving local control for inflammatory carcinoma of the breast.

A single institution, retrospective study of 28 patients with inflammatory carcinoma of the breast treated from 1984 to 1990 was performed. Patients received two to four cycles of cyclophosphamide, doxorubicin and 5-fluorouracil (CDF) and were then evaluated for mastectomy. Mastectomy was accomplished in 26 patients after CDF. In 21 patients, the breast was resectable after the initial doses of chemotherapy and modified radical mastectomy was done. Radiation therapy was given to 16 of the 21 patients after six to nine cycles of postoperative chemotherapy. The remaining five of 26 patients had a marginal response to CDF and underwent preoperative radiation therapy. Local recurrence occurred in four of five patients receiving preoperative radiation, in three of 16 receiving postoperative radiation and in one of five receiving mastectomy without radiation therapy. The overall observed five year survival rate was 18 percent, with a median of 34 months. Neither dermal lymphatic invasion nor estrogen receptor status were statistically significant variables when analyzing patients for local recurrence or survival. Despite poor long term survival results, the combination of induction CDF, mastectomy and postoperative radiation achieved local control in 81 percent of patients.

Hospital variables associated with quality of care for breast cancer patients.

OBJECTIVE: To determine the degree of compliance with clinical standards among hospitals for care of breast cancer patients and account for variations in compliance. DESIGN: Analysis of cancer registry data submitted to the American Cancer Society, Illinois Division, Chicago, for a concurrent prospective descriptive study of breast cancer, supplemented by other hospital data from public sources. SETTING: Ninety-nine Illinois hospitals evenly distributed among rural counties, counties with small cities outside the Chicago metropolitan area, exurban counties in the Chicago metropolitan area, suburban Cook County, and urban Chicago. PATIENTS: A total of 5766 newly diagnosed patients with histologically confirmed breast cancer in 1988, representing 84% of the estimated 6900 new cases in the state for that year. MAIN OUTCOME MEASURES: Descriptive statistics and multiple linear regression analyses of five dependent quality variables from clinical indicators related to early diagnosis, hormone receptor determination, adjuvant therapy, radiation therapy, and axillary lymph node dissection. RESULTS: At the hospitals studied, (1) late stage (IIb through IV) at diagnosis was associated with urban location, higher proportion of poorly insured patients, fewer breast cancer cases treated, and lower oncology charges (proportion of variance explained, R2 = .50, P less than .00001); (2) omission of hormone receptor test for stages II through IV was associated with urban location and higher proportion of poorly insured patients (R2 = .18, P less than .00003); and (3) omission of indicated radiation therapy was associated with urban location and fewer breast cancer cases (R2 = .21, P less than .00001). Omission of adjuvant therapy and omission of axillary lymph node dissection were not significantly associated with any of the hospital variables examined. CONCLUSIONS: The findings suggest that there is a group of urban hospitals, generally small and marginally reimbursed, where comprehensive diagnosis and treatment of breast cancer are not obtained.

Pancreatic cancer in Illinois. A report by 88 hospitals on 2,401 patients diagnosed 1978-84.

A retrospective study of survival results for pancreatic cancer was performed. The study had two objectives: 1) to relate the extent of disease and management to survival, and 2) to determine whether newer treatment combinations have altered prognosis. Cancer registrars from 88 Illinois hospitals reviewed original medical records and submitted standardized report forms on 2,401 patients diagnosed between 1978-84. Three-year survival time was longer after laparotomy/bypass plus radiation/chemotherapy than for laparotomy/bypass alone (P less than .02). But the difference in survival between resection versus resection, radiation, and chemotherapy was not significant (P = .16). After resection, the median survival for 78 Stage I patients was 12.5 months, whereas for 181 Stage I patients after laparotomy/bypass it was 6.8 months (P less than .00001). For patients without metastases, 3-year survival was significantly better for 249 patients in whom cancer was resected versus 568 unresected patients (P less than .001). Survival was longer for 568 unresected patients without gross metastases than for 954 patients with metastatic disease found at laparotomy (P less than .05). From this study the authors concluded that: 1) since 3-year survival results were higher than expected after resection for localized cancers, resection is still desirable when it can be done with acceptable complication risks, and 2) the use of multiple treatment modalities for pancreatic cancer warrants further study in organized trials.

Effects of treatment on long-term survivors with malignant astrocytomas.

We reviewed the records of 160 consecutive patients with glioblastoma and anaplastic astrocytoma to evaluate the long-term consequences of radiation therapy and chemotherapy. We defined long-term survivors as those patients with glioblastoma or anaplastic astrocytoma who lived at least 100% longer than median survival of historical controls, for example, 2 years for patients with glioblastoma and 4 years for patients with anaplastic astrocytoma. There were 9 (5.6%) long-term survivors. Three (30%) became demented and died without evidence of tumor recurrence. One, after survival of 10 years, died of tumor recurrence. Of the remaining survivors, 2 (22%) have significantly impaired short-term memory function and other neurological deficits such as gait apraxia. Three (30%) can function independently. It is likely but cannot be proved that it is radiotherapy and not chemotherapy that is the causal factor of this dismal therapeutic outcome. Our study suggests restraint in the use of radiotherapy for patients with brain tumors that have more favorable prognoses than glioblastomas and anaplastic astrocytomas, such as low-grade astrocytomas and oligodendrogliomas.

Technique and complications of reconstruction of the pelvic floor with polyglactin mesh.

A polyglactin mesh sling was used to reconstruct the pelvis in eight patients after colorectal or urologic resections in preparation for postoperative radiation therapy. There were three perioperative complications--a pelvic abscess requiring percutaneous drainage, a wound dehiscence and a herniation of the small intestine between the pelvic sidewall and mesh requiring small intestinal resection. There were two delayed complications, both partial small intestinal obstructions. One occurred just after the conclusion of radiation treatment and the other occurred five months after the conclusion of radiation therapy. Both obstructions responded to conservative management. None of the common acute radiation effects occurred during radiotherapy. One patient with delayed partial small intestinal obstruction had possible late radiation effects. The median follow-up period after radiation therapy was 12.5 months. Despite the complications described in this report, the use of a polyglactin mesh sling as an adjunct to resection of carcinoma of the pelvis has merit and should be studied further.

The use of cancer registry data to study preoperative carcinoembryonic antigen level as an indicator of survival in colorectal cancer.

A retrospective analysis of survival results for colorectal cancer patients in Illinois was performed by the Cancer Incidence and End Results Committee of the Illinois Division of the American Cancer Society. Cancer registry data on 1,774 patients from 63 hospitals were used to investigate whether the preoperative level of serum carcinoembryonic antigen (CEA) was a prognostic indicator of survival for cancers diagnosed between 1976 and 1978. A direct relationship was found between the preoperative level of serum CEA and both the thickness and stage of the tumor at initial diagnosis. For Stage B2/3 colorectal cancer, the actuarial survival curves corresponding to normal, elevated, and markedly elevated CEA levels were significantly different (p less than 0.0001). The five-year survival rates for these patients were 61, 50, and 32 percent, respectively. Similar trends for patients with Stage C2/3 cancer were observed (p = 0.0058). The corresponding five-year survival rates were 44, 30, and 26 percent, respectively. Using a statewide cancer registry system, the analysis suggested that the preoperative level of serum CEA was an indicator of survival in patients with colorectal cancer, independent of the stage of disease at diagnosis.

Treatment of plasma cell granuloma of the lung with radiation therapy. A report of two cases and a review of the literature.

Plasma cell granuloma is a rare, benign tumor that affects people at all ages and most frequently involves the lung, gastrointestinal tract, and salivary gland. They are the most common, isolated, primary lesion of the lung in children less than 16 years of age, and usually present as circumscribed, peripheral, parenchymal tumors, which may be static or increase slowly in size without causing symptoms. Whereas surgical excision is the treatment of choice, there are situations in which the lesion cannot be resected without significant morbidity because of direct extension into the mediastinum or lymph nodes. In these circumstances, radiation therapy may be a better therapeutic option. Two cases of plasma cell granuloma that could not be completely resected are described. The patients were treated with radiation therapy consisting of 4320 rad in 4.5 weeks and 4500 rads in 4.5 weeks, respectively, and both have been cured. Although surgery as the primary treatment for most patients is still recommended, especially in the young so the potential side effects of radiation therapy can be avoided, the authors believe that in rare cases where the lesion is locally aggressive and surgically unresectable or resectable only with major morbidity, radiation therapy can be an effective alternative. Currently, the recommended treatment is 4000 to 4500 rad given in 180 to 200 rad fractions, with the fields being carefully tailored to tumor volume in order to minimize the dose to the surrounding normal tissue.

The role of post-operative radiation therapy in the treatment of malignant tumors of the parotid gland.

Twenty-nine patients treated with postoperative radiotherapy for malignant tumors of the parotid gland were reviewed at the Joint Center for Radiation Therapy. Most patients were treated between 5,000 and 6,500 rad. All were treated because of microscopic residual disease, extra capsular extension, or tumor close to the facial nerve. The overall results showed one in-field failure, two marginal recurrences, and eight patients failed distantly. Poor prognostic factors included high-grade, extracapsular extension, and nodal involvement. We conclude that patients with malignant tumors of the parotid should be treated with postoperative radiation therapy if any of the bad prognostic signs are present. This may enable the surgeon to spare the facial nerve and obtain local control results equal to or better than more radical surgical procedures.

Fibro-optic study of pharyngeal airway during sleep in patients with hypersomnia obstructive sleep-apnea syndrome.

Pharyngeal airway during sleep was observed with help of Fibro-optic flexible bronchoscope and cineradiography in 10 adult patients with Hypersomnia Sleep-Apnea (HSA) syndrome. The results of the study suggest that the structures involved in production of airway obstruction in the patients with HSA syndrome are the muscles of velopharyngeal sphincter and tongue. The laryngeal airway was not obstructed during the episodes of apnea.