Extended resection for locally advanced colorectal carcinoma.

BACKGROUND: The purpose of this study was to determine the therapeutic benefit of multivisceral resection (MVR) in patients with locally advanced colorectal carcinomas. METHODS: The study population was composed of 118 patients whose resection of the primary lesion included one or more adhesed adjacent secondary organs or structures (ASOS). Tumors were staged as B3 (T4,N0) and as C3 (T4,N1-3). Adhesions were classified as invasive (B3+,C3+) or inflammatory (B3-, C3-). RESULTS: Sixty-four patients were staged B3 and 54 C3. Eighty-one were classified B3+/C3+. Fifty-nine percent of patients had ASOS resected, 29% had two resected, and the remaining 12% had three or four resected. Actuarial 5-year survival rates were 62% and 38% (p = 0.017) for B3 and C3 lesions, respectively. The 5-year survival rates were 78% for patients with B3- tumors and 58% for those with B3+ tumors (p = 0.043), and 34% for patients with C3+ tumors and 64% for those with C3- tumors (p = NS). The 5-year survival rates were 71% for patients with B3-/C3- tumors and 47% for those with B3+/C3+ tumors (p = NS). The 5-year survival rates after resection of one ASOS, two ASOS, and three or four ASOS were 52%, 55%, and 38%, respectively (P = NS). CONCLUSIONS: There is no statistically significant difference in the 5-year survival rates when multiple ASOS are resected; therefore, an aggressive surgical approach is warranted.

Chemotherapy and low-dose radiotherapy in the treatment of HIV-infected patients with carcinoma of the anal canal.

PURPOSE: To determine the efficacy and tolerance of a standardized protocol of chemotherapy and low-dose radiotherapy in the treatment of anal cancer in human immunodeficiency virus (HIV)-infected patients. METHODS AND MATERIALS: Between 1987 and 1995, eight HIV-positive patients with squamous cell carcinoma of the anal canal, four of whom had acquired immunodeficiency syndrome (AIDS), received therapy at the Kaiser Permanente Medical Center. All patients were treated using a combined modality approach consisting of low-dose radiotherapy (30 Gy in 15 fractions delivered 5 days/week), and chemotherapy [1000 mg/m2 of 5-fluorouracil (5-FU) delivered on days 1-4 and 29-32 as a continuous infusion over 96 h, and 10 mg/m2 of mitomycin C delivered as a bolus injection on day 1]. Patients have been followed from 4 to 81 months (mean 41, median 38). RESULTS: All eight patients completed the therapy with minor variations to the protocol, and all have attained a clinical complete response. Four patients are alive and free of disease, and four died as a result of complications of AIDS, but remained free of anal carcinoma. There were no mortalities from the protocol and the morbidity was acceptable. Only one patient each was noted to have Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Grade 4 hematologic and gastrointestinal acute toxicity, and no Grade 4 skin toxicity was noted. CONCLUSION: This combined therapy is effective for HIV-infected patients and appears to be tolerable with acceptable toxicities. It is best applied to patients who are HIV positive, or who have AIDS without concurrent major opportunistic infections. This approach is reasonable and affords patients a reasonably good chance at sphincter preservation by avoiding abdominoperineal resection. The optimal therapy for HIV-positive patients with advanced AIDS remains less well defined.

Massive gastrointestinal hemorrhage from AIDS-related Kaposi's sarcoma confined to the small bowel managed with radiation.

A > 50% incidence of Kaposi's sarcoma (KS) of the gastrointestinal tract has been seen in acquired immunodeficiency syndrome (AIDS) patients with cutaneous KS. Although gastrointestinal Kaposi's sarcoma (GIKS) is usually asymptomatic, hemorrhages from the oral cavity, esophagus, stomach, and large bowel have occurred in this disease. We describe a patient with acute, massive gastrointestinal hemorrhage from GIKS confined to the small bowel who was treated with chemotherapy, surgery, and radiation. To the best of our knowledge, this is the first reported case of AIDS-related GIKS limited to the small bowel. Although chemotherapy is generally used successfully to palliate diffuse GIKS, we report that radiation was an effective modality that rapidly resulted in resolution of considerable local bleeding and could be used in such cases as an alternative to surgery. Details of this case history, including radiographs, are presented.

Pulmonary metastasectomy for soft tissue sarcomas: is it justified?

The role of pulmonary metastasectomy for metastatic soft tissue sarcomas is examined by reviewing the recent (1978-1994) English language literature. There are no prospective studies that contain an appropriate control group, and only one retrospective study contains a matched control group. In those few studies that provide greater than 5-year survival data, the survival curve still has a steep slope and few patients are alive at 7 years. In most studies only one or two patients are at risk at 5 years or more. Projected survival is therefore statistically questionable. It is currently impossible to know what is the impact of the surgical procedure over and above the natural history (biology) of the tumor. A randomized, prospective study, as suggested a decade ago, is still needed. While there may be some merit to pulmonary metastasectomy in highly selected patients, aggressive pulmonary metastasectomy does not seem justified by the available data.

A comparison of two surgical techniques for performing mastectomy.

Most surgeons performing mastectomy (MRM) use either the scalpel or electrocautery for developing flaps and performing node dissection. We report a retrospective analysis of all MRM performed over a five-year period by two surgical oncologists. One-hundred-and-ninety-six cases met criteria for inclusion into the study. There are 110 patients in the electrocautery (EC) group and 86 patients in the scalpel (Scpl) group. Mean patient age, mean specimen weight and mean number of lymph nodes removed were not significantly different for the two groups. The incidence of complications was similar for the two groups. Mean estimated blood loss was 134.1 cc for the EC group and 331.6 cc for the Scpl group (P < 0.001). Estimated blood loss ranged from 25 to 475 cc for EC group and from 88 to 1350 cc for the Scpl group. One patient in the Scpl group required transfusion. Mean operating time was less for the Scpl group, 111.0 vs 93.5 minutes (P < 0.009). Multiple regression analysis revealed that technique was the strongest predictor of estimated blood loss (standardized coefficient 0.61). Operating time, age, number of nodes removed and specimen weight were less predictive (standardized coefficient 0.21, 0.17, 0.11 and 0.09, respectively).

Small bowel cancer: a 30-year review.

BACKGROUND: Small bowel cancer is a relatively rare tumor with an incidence of 2,700 new cases and 900 deaths per year. The influence of stage on survival has been reported only once previously. Patterns of recurrence are unreported. METHODS: All cases of small bowel cancer treated at our hospital over a 30-year period (1960-1989) were reviewed. RESULTS: The site of most cancers was the duodenum (46%), followed in frequency by the jejunum (33%) and the ileum (21%). Adenocarcinoma was the most common histology (63%), followed in frequency by lymphoma (15%), leiomyosarcoma (13%), carcinoid tumors (6%), and miscellaneous (3%). Analysis of stage distribution by site showed a decrease in stages I and II with more distal locations. Associated cancers occurred in 11%, but none were seen in the group with carcinoid tumors. Actuarial 10-year survival rates were 24% for those with adenocarcinoma (all stages) 75% for stage I, 25% for those with stage II, and 0% for stage III. A subgroup of 10 patients who underwent a pancreaticoduodenectomy (one stage I, seven stage II, two stage III) had a 30% 10-year survival rate. Those patients with lymphoma had a 12% 10-year survival rate, and those with leiomyosarcoma had a 20% 10-year survival rate. A 100% 10-year survival rate was observed in those with carcinoid tumors. Peritoneal carcinomatosis was the most common failure pattern (33%), followed in frequency by local recurrence in 23% and abdominal wall recurrence in 15%. CONCLUSIONS: A correlation exists between the pathologic stage and the survival rate for adenocarcinoma. The most common recurrence pattern for adenocarcinoma was carcinomatosis, followed in frequency by abdominal wall recurrence. Leiomyosarcoma preferentially metastasizes to the liver.

Cancer of the anal canal: treatment with chemotherapy and low-dose radiation therapy.

PURPOSE: To determine the efficacy of a standardized protocol of chemotherapy and low-dose radiation therapy in treatment of patients with anal canal cancer. MATERIALS AND METHODS: Forty-two consecutive patients with anal canal cancer were treated with 15 fractions of 30-Gy photon beam radiation therapy administered anteroposterior-posteroanterior in conjunction with chemotherapy with 5-fluorouracil and mitomycin C. Survival analysis was performed with the lifetest procedure. RESULTS: In patients with stage T1 and T2 tumors, 26 of 29 (90%) were free of disease after chemotherapy and radiation therapy and had no recurrent tumors. In patients with stage T3 and T4 tumors, five of 13 (38%) were free of disease after therapy and had no recurrences. CONCLUSION: This therapy is effective for epidermoid cancers of the anal canal that are smaller than 5 cm regardless of nodal status. Tumors larger than this or that invade adjacent structures are not adequately controlled with this protocol.

Results using the biofragmentable anastomotic ring for colon anastomosis.

The Biofragmentable Anastomotic Ring (BAR) (Valtrac, Davis & Geck, Inc.) is a newly approved device intended for colonic anastomosis. We have used the device in 47 patients to date. These patients were studied to determine the effectiveness, uses and limitations of this new device. The BAR is similar in concept to the older Murphy "Button" used circa World War I, but it's constructed of polyglycolic acid rather than metal. Anastomosis is effected by placing the two bowel lumens over the device, tying the purse-string sutures snugly, and "clicking" the device closed. The BAR fragments and is passed 2 to 3 weeks postoperatively. The patients ranged from 14 to 82 years of age. Thirty-nine patients were operated on for cancer, four for diverticulitis, and four for colostomy closure. One transverse colectomy (THC), 15 left hemicolectomies (LHC), 23 sigmoid colectomies (SC), two low anterior resections (LAR), four colostomy closures, and two right hemicolectomies were performed. There were no anastomotic leaks and no complications. We found that because of the need to have access distally to "click" the device closed, BAR anastomosis after LAR is rarely feasible. Because of the small lumenal size of the distal ileum, the BAR is seldom usable for ileocolonic anastomosis after right hemicolectomy (RHC). The newly approved 25-mm BAR may change this. We found that the time required to perform an anastomosis with the BAR is equivalent to stapled techniques. At our hospital, the cost of the device is equivalent to one intestinal stapler. Since multiple staplers are used in most colon anastomotic techniques, there is a modest cost advantage for the BAR.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective comparison of transanal surgery and endocavitary radiation for the treatment of 'early' rectal adenocarcinoma.

OBJECTIVE: To compare two techniques for the local treatment of "early" rectal adenocarcinoma. DESIGN AND STUDY PARTICIPANTS: A retrospective comparison of 27 patients who underwent transanal disk excision and fulguration (group A) and 38 patients who underwent transanal endocavitary radiation (group B). SETTING: Inpatient and outpatient. INTERVENTION: Group A patients had rectal adenocarcinoma treated with disk excision and fulguration. Group B patients received 100 to 125 Gy in four to five fractions using the Phillips RT-50 unit. MAIN OUTCOME MEASURES: Survival and local recurrence. RESULTS: The median follow-up for group A was 68 months; for group B, 38 months. The mean tumor diameter was 2.5 cm, all were grade 1 or 2. The local recurrence rate was 7.4% for group A and 21% for group B. Local recurrence was not correlated with tumor grade, location, or size but did correlate with tumor ulceration. CONCLUSION: For selected early rectal cancers, surgical excision and fulguration offers better local control than endocavitary radiation therapy, while survival was similar.

Myocardial infarct death, the population at risk, and temperature habituation.

Daily myocardial infarct deaths from Brisbane, 29 degrees 28' S, and Montreal, 45 degrees 30' N, were used to derive a "pool of susceptible individuals". Pool size had no effect on the minimum death temperature but large pools increased the value of the acceleration temperature in Brisbane and the maximum death temperature in Montreal. Moderately sized pools in Montreal appeared to produce reduced death rates in cold conditions from both cold avoidance and habituation. A generalized relationship between temperature and myocardial infarct death is postulated.

Myocardial infarct death and temperature in Auckland, New Zealand.

Daily myocardial infarct deaths for Auckland (36 degrees 51'S, 20 m above sea-level) show an increase in mortality rate with decreasing temperatures over the entire thermal range. Parallel studies in Brisbane and Montreal predicted a minimum death temperature between 21 and 24 degrees C, but no such point was apparent. Lack of temperatures above 21 degrees C, together with the small overall thermal range, is thought responsible.

An analysis of the results of mammographically guided biopsies of the breast.

Three hundred and fifty-three women underwent 358 biopsies of the breast for nonpalpable mammographic lesions during a five year period. Cancer was identified in 95 (27 per cent). Mammographic findings in the patients with cancer were calcifications only (54 per cent), a mass (27 per cent), a mass with calcifications (15 per cent), an asymmetric distortion (1 per cent) and an asymmetric distortion with calcifications (3 per cent). Cancer was identified in 29 per cent of the biopsies done for calcifications, 20 per cent of those done for a mass with calcifications, 6 per cent of those done for an asymmetric distortion and 38 per cent of those done for an asymmetric distortion with calcifications. Forty-nine per cent of the mammographically suspicious calcifications were cancer, while 100 per cent of the indeterminate calcifications were benign. Forty-five per cent of the spiculated masses were cancerous, while only 3 per cent of the circumscribed masses were malignant. For those patients with carcinoma undergoing axillary lymph node dissection, 13 per cent had one or more positive nodes. A strategy for increasing the effectiveness of mammographically guided biopsies of the breast is presented.

Case report 700: Primary intracortical osteosarcoma of femur, sclerosing variant, grade 1 to 2 anaplasia.

We report a case of intracortical OS of the mid-femur in a 43-year-old man. The patient is the oldest reported to date. Histologically, the tumor was a sclerosing variant of OS with extensive "normalization" of nuclei. This is the most common histological subtype of intracortical OS. The patient was treated by en bloc resection without preoperative or systemic chemotherapy and is without evidence of disease with 15 months' follow-up.

Sacral resection. Operative technique and outcome.

Tumors involving the sacrum are difficult to treat. These include both primary tumors of the sacrum and locally invasive colorectal carcinomas. Sacral resection is often the only effective alternative for meaningful palliation or cure of sacral tumors. A review of 20 cases of sacral resections for primary sacral tumors (8) and locally invasive anorectal cancers (12) is presented. The mortality (0%) and morbidity (35% urinary complications, 25% wound disruptions, 1600-mL median blood loss) compare favorably with reports in the literature. Long-term survival was achieved with primary tumors of the sacrum. Local control of disease was achieved in the majority of patients with rectal cancer, with good palliation of preoperative pain. Long-term survival, however, is rare in this group. Surgical resection of sacral tumors can be undertaken with acceptable morbidity and mortality in selected patients.

Fine-needle aspiration biopsy of the pancreas complicated by pancreatic ascites.

A case is reported of a patient with pancreatic carcinoma who developed pancreatic ascites after intraoperative fine-needle aspiration cytology (FNAC) biopsy. This complication of FNAC has not previously been reported to the authors' knowledge. The literature is reviewed, and FNAC is shown to be the safest method of pancreatic biopsy, the present report not withstanding.

Congenital metastatic cervical teratoma: diagnostic and management considerations.

Cervical teratomas in the newborn are uncommon and difficult management problems, as their natural history and prognosis are not well defined. Existing or potential airway obstruction is usually the main concern in acute management of these patients. Total excision is essential to avoid local recurrence in benign lesions, and a small but present risk of malignancy can result in death from metastatic lesions which appear later. A unique case of neonatal malignant cervical teratoma with large congenital metastatic lesions present in liver, lung, and buttocks was successfully managed. Magnetic resonance imaging (MRI) was invaluable, both in delineating these lesions and in planning a four-stage curative resection of all macroscopic disease. Such a case has not been reported previously.

Extended resection for primary colorectal carcinoma involving adjacent organs or structures.

Involvement of adjacent organs by colorectal cancer has been associated historically with poor local control and survival. This can be improved by en bloc extended resection. A retrospective review was done of 58 patients who underwent this procedure. The operative mortality was 5%. Cases were divided into Gunderson-Sosin Stages B3 and C3. Five-year survival was markedly better for Stage B3 (64% versus 11%). Regardless of stage, local recurrence was increased, and 5-year survival decreased for those cancers with carcinomatous adhesions. At surgery, lesions cannot be staged accurately into C3 or B3 cancers. All such lesions should be resected. The B3 patients have a significant chance for cure, and C3 patients will have good local control despite their dismal 5-year survival.

Liver mass in a four-year old child: current considerations for diagnosis and treatment.

A case is presented of an embryonal sarcoma of the liver in a young child. The differential diagnosis of liver masses in children is reviewed, as well as the implications of diagnostic imaging studies for diagnosis, prognosis, staging, and the choice of treatment. The use of diagnostic imaging for guiding interventional diagnostic procedures and certain palliative approaches is also discussed.

Arterial infusion of dacarbazine and cisplatin for recurrent regionally confined melanoma.

We treated nine patients who had metastatic malignant melanoma confined to one extremity (8/9) or the vulva (1/9) with arterial dacarbazine and cisplatin at respective doses of 800 and 90 mg/sq m. We percutaneously introduced catheters into the extremity or regional artery under fluoroscopy by the Seldinger technique, removed them at the end of the infusions, and repositioned them at four-week intervals for repeated treatment cycles. One patient achieved a complete remission, three patients had partial remissions, and five patients' disease was stable. The group median survival will exceed 19 months. Three patients with stable disease died 6, 18, and 19 months after treatment initiation, respectively. The toxic effects were primarily nausea and vomiting, pain in the infused extremity, and local erythema. Arterial dacarbazine and cisplatin offer a more effective and less toxic alternative to higher-dose single-agent arterial cisplatin for locally advanced malignant melanoma.

Epidermoid cancer of the anorectum.

The optimal treatment for squamous and cloacogenic tumors of the anorectum is controversial. Radical surgery, limited surgery, and radiotherapy (XRT) are all potentially curative. This study was undertaken to determine which patients are candidates for each type of treatment and which would benefit from combined treatment. The records of 192 patients treated at this institution between 1954 and 1979 with the diagnosis of squamous or cloacogenic carcinoma of the anorectum were retrospectively reviewed. A subgroup of 132 patients undergoing abdominal perineal resection (APR) was analyzed to determine prognostic factors for these tumors. No survival difference was observed between the two histologic types (P = 0.51). Prognostic variables significant at P = 0.05 or better were sex, size, nodal status, and level of invasion. A new staging system is proposed that utilizes tumor size, invasion, grade, and nodal status. Actuarial 10-year survival was 100%, 76%, 29%, and 0% for Stages A, B, C and D, respectively (P values 0.22, 0.0007, and 0.01, respectively). Twelve patients undergoing APR received postoperative XRT; when compared by stage with APR alone no survival difference can be shown, although there is a trend towards fewer local recurrences. Of 26 patients (14 Stage B, 12 Stage C) receiving preoperative XRT (average 4000 R) before APR, 10 had inoperable tumors prior to XRT. All became operable. Eight patients had negative surgical margins and survival was equivalent stage for stage to the operable group (Stage B 78%, 5-year survival; Stage C 43%, 5-year survival). Eleven patients had no demonstrable primary tumor after XRT, although three had nodal metastasis. Five-year survival was 83% for this group. Thirty-one local recurrences were retreated for cure by surgery, XRT, or combination. Actuarial 5-year survival after retreatment was 38%. Thirty metachronous inguinal metastases were seen, 20 were retreated for cure, 18 by inguinal lymphadenectomy. Actuarial 5-year survival was 42%. Using a new staging system based on analysis of prognostic parameters for this disease, the outcome of combined surgery and XRT is compared. The efficacy of preoperative XRT for inoperable tumors is demonstrated. An appreciable salvage rate for local or inguinal recurrence was observed.