Placenta previa total acreta complicada con ruptura prematura de membranas pretérmino: reporte de un caso / Total placenta praevia accreta complicated with preterm premature rupture of membranes: A case report

Resumen ANTECEDENTES La incidencia de acretismo placentario se ha elevado en países industrializados debido al incremento en la tasa de cesáreas. La ruptura prematura de membranas pretérmino se asocia con complicaciones en 3% de todos los embarazos. En la actualidad no existen publicaciones que documenten la atención médica de ambas alteraciones en conjunto. CASO CLÍNICO Paciente de 31 años, en curso del segundo embarazo (30.2 semanas de gestación), que acudió al servicio médico por salida de líquido transvaginal. Se confirmó la ruptura prematura de membranas pretérmino por cristalografía y determinación de microglobulina alfa 1 placentaria por tira reactiva Amnisure®. La valoración de los médicos del servicio de Medicina Materno-Fetal fue: placenta previa total, con lagunas placentarias y flujo turbulento, grosor miometrial menor de 1 mm y pérdida de la interfase deciduomiometrial. Después de comprobar el bienestar fetal se inició el tratamiento conservador de la ruptura prematura de membranas pretérmino. Se decidió finalizar el embarazo a las 31 semanas, debido a que se confirmó el inicio del trabajo de parto y actividad uterina normal; se efectuó cesárea-histerectomía sin complicaciones maternas. CONCLUSIÓN La placenta previa total con datos de acretismo, concomitante con ruptura prematura de membranas pretérmino, es una complicación poco común. Estas pacientes deben recibir tratamiento conservador y adecuada vigilancia materno-fetal. A pesar de los buenos resultados obtenidos en este caso, se requiere mayor evidencia para indicar el tratamiento conservador en estas pacientes.

Abstract BACKGROUND The incidence of placental accreta has increased in industrialized countries, due to the increase in the rate of cesarean sections. On the other hand, the premature rupture of membranes (PPROM), complicate approximately 3% of all pregnancies and is associated mainly with neonatal complications related to prematurity. At present, there is no documented evidence in the medical literature of the approach of both pathologies together. CLINICAL CASE 31-year-old woman at 30.2 weeks' gestation in her second pregnancy is admitted to the hospital with vaginal discharge. PROM is confirmed by fern-type crystallization and quantification of placental alpha macroglobulin-1 (PAMG-1) microglobulin by Amnisure® test strip. Medical assessment is performed by the maternal-fetal specialists, finding complete placenta praevia with the presence of vascular lacunae with turbulent lacunar flow, myometrium thickness < 1mm and loss of the clear space. Fetal well-being is confirmed and conservative management of PPROM is initiated. Obstetric delivery is conducted at 31 weeks of gestation with Caesarean section - Hysterectomy without complications. CONCLUSIONS The premature rupture of membranes in presence of placenta accreta is a rare complication. In this patients, conservative management is a suitable alternative, with an appropriate maternal and fetal surveillance. More evidence is required to indicate the conservative treatment in these patients.

Tasa de hemorragia, histerectomía obstétrica y muerte materna relacionada / Rate of obstetric hemorrhage, obstetric histerectomy and related maternal death in Hospital Central Ignacio Morones Prieto

RESUMEN ANTECEDENTES: la hemorragia obstétrica sobreviene en 3% de los nacimientos y en Estados Unidos es responsable de 18% de las causas de muerte obstétrica. En 2012 fue la segunda causa de muerte materna en México. La predicción del riesgo de hemorragia es compleja porque solo 40% de las pacientes tiene algún factor de riesgo identificado. La conducta activa del tercer periodo del trabajo de parto es la única medida útil demostrada por diferentes estudios para prevenir la hemorragia. OBJETIVO: determinar la tasa de hemorragia e histerectomía obstétricas y muertes maternas relacionadas. MATERIALES Y MÉTODOS: estudio retrospectivo y descriptivo efectuado mediante el análisis de los expedientes clínicos de pacientes atendidas de parto o cesárea en el Hospital Central Ignacio Morones Prieto de San Luis Potosí, SLP, entre los meses de enero de 2011 a octubre de 2015, y que tuvieron hemorragia o histerectomía obstétricas. Criterios de inclusión: pacientes con diagnóstico de hemorragia e histerectomía obstétricas y muerte materna en este hospital. Criterios de exclusión: hemorragias o histerectomías efectuadas en otros hospitales y expedientes incompletos. RESULTADOS: se atendieron 27,158 nacimientos; de estos 19,569 por parto y 7,589 por cesárea (28%). Se registraron 657 casos de hemorragia (tasa 2.4) y 58 histerectomías obstétricas. Las principales causas de la hemorragia obstétrica fueron: atonía uterina (36.2%), acretismo placentario (32.7%) y placenta previa más acretismo placentario (12%). Hubo 125 ingresos a la unidad de cuidados intensivos por hemorragia obstétrica y una muerte materna relacionada. CONCLUSIONES: la tasa de hemorragia obstétrica de 2.4 es indicativa del incremento en el número de cesáreas y la consecuente asociación con el acretismo placentario que reemplazó a la atonía uterina como primera causa de histerectomía obstétrica.

ABSTRACT BACKGROUND: Obstetric hemorrhage occurs in 3% of births. It is responsible for 18% of causes of death in US. In 2012 was the second leading cause of maternal death in Mexico. There is difficulty in predicting the risk of bleeding because only 40% of patients have some risk factor identified. Active management of the 3rd period of labor has been the only useful measure demonstrated by different studies to prevent obstetric hemorrhage. OBJECTIVE: The aim was to determine the rate of obstetric hemorrhage, obstetric hysterectomy and maternal deaths related to our hospital. MATERIALS AND METHODS: A retrospective study conducting search of medical records of Central Hospital Ignacio Morones Prieto in San Luis Potosi, of women who childbirth attended or cesarean section from January 2011 to October 2015, which presented obstetric hemorrhage, and as hysterectomy for uterine atony. Having as inclusion criteria patients diagnosed with obstetric hemorrhage and obstetric hysterectomy performed in this hospital between the above dates. And searching the number of direct maternal deaths. Exclusion criteria hysterectomies performed in other hospitals and incomplete records. RESULTS: From January 2012 to December 2015 a total of 21.648 births were 19,569 births, 7,589 Caesarean sections, were treated a total of 657 obstetric hemorrhage were presented, with a rate of 2.4 obstetric hemorrhage during the study time. There were 53 obstetric hysterectomies. It is the main cause obstetric hemorrhage: 36.2% uterine atony, 32.7% placenta accreta, and 12% placenta accreta plus placenta praevia. There were 125 income Intensive Care Unit for Obstetric Hemorrhage and 1 maternal death related to it. CONCLUSIONS: The rate of obstetric hemorrhage HCIMP is 2.4 during the study time. The increase in the number of cesareans and subsequent association with acretism has been replacing the uterine atonia as first causa of obstetric hysterectomy in our hospital.

Preoperative chemoradiation therapy and anal sphincter preservation with locally advanced rectal adenocarcinoma.

Preoperative irradiation has been used to produce tumor regression and allow complete resection of rectal cancer with a sphincter-saving procedure. To evaluate the associated toxicity, the response in the primary tumor, and the postsurgical morbidity in a group of patients with locally advanced rectal cancer treated with preoperative chemoradiation therapy and low anterior resection, 120 patients were treated with 45 Gy of preoperative radiotherapy and a bolus infusion of 5-fluorouracil 450 mg/m2 on days 1 to 5 and 28 to 32 of radiotherapy. Four to six weeks later, 16 lesions were found unresectable; 36 patients underwent abdominoperineal resection or pelvic exenteration, and in the remaining 68 a low anterior resection was performed. For the purpose of this study only the latter group was included. There were 38 men and 30 women, with a mean age of 54.7 +/- 13.1 years. Gastrointestinal and hematologic acute toxicity grade 3 to 4 occurred in 12 and 7 patients, respectively. The mean distance of the tumor above the anal verge was 8.2 +/- 2.6 cm. In 10 patients the surgical resection included neighboring pelvic organs; 16 patients (23.5%) required a temporary diverting colostomy. The main causes of surgical morbidity were clinical anastomotic leakage in seven (10%), abdominal wall infection in five (7.4%), anastomotic stenosis in three (4.5%), and intraabdominal abscess in one (1.5%). No operative deaths occurred. The postsurgical stages were as follows: no tumor in the specimen, 17 (25%); T1, 4 (6%); T2, 12 (17%); T3, 17 (25%); T4, 5 (7%); any T with N+, 9 (13%); and any T, N with M+, 4 (6%). The median and mean follow-ups were 30.0 months and 37.4 +/- 25.0 months, respectively. The local recurrence rate was 2.9%, and the distant recurrence rate was 17%. The administration of preoperative chemoradiation therapy for locally advanced rectal cancer is associated with tolerable toxicity, a high rate of response in the primary tumor that allowed anal sphincter preservation, and a low rate of local recurrence.

Breast carcinoma presents a decade earlier in Mexican women than in women in the United States or European countries.

BACKGROUND: In Mexico, breast carcinoma is the second most frequent malignancy, representing 10.6% of all cases and 16.4% of all cancers in women, with an increase in breast carcinoma mortality rates from 3.6 per 100,000 women in 1985 to 6 per 100,000 women in 1994. Most of the tumors are diagnosed in advanced stages with little chance of cure. METHODS: To determine the age of patients in Mexico at presentation of breast carcinoma, the authors analyzed the cases registered from 1993 to 1996 from the database of the Histopathological Registry of Malignant Neoplasms in Mexico. RESULTS: There were 29,075 cases of breast carcinoma. The median age of Mexican women with breast carcinoma is 51 years, and 45.5% of all breast carcinomas develop before patients reach age 50 years. The most frequently affected age group is that of 40-49 years (29.5%), whereas the groups from 30 to 39 and from 60 to 69 years of age have a similar percentage (14%) of frequency. This contrasts with women from the United States, as well as with women from European countries, where the median age at presentation is 63 years, and only one-fourth of the patients are younger than 50 years of age, and three-fourths are postmenopausal. Similar to Mexico, in Venezuela and in Japan nearly one-half of women with breast carcinoma are younger than 50 years of age, and this resembles rates in many Latin American countries. CONCLUSIONS: It is necessary to change the guidelines of breast carcinoma screening in Mexican women, to increase the possibility of early diagnosis and better survival.

Morbidity and mortality following abdominoperineal resection for low rectal adenocarcinoma.

BACKGROUND: Abdominoperineal resection (APR) has been the standard treatment of low rectal cancer, but it is associated with significant morbidity and mortality. AIM: To analyze the morbidity and mortality rates associated with this surgical procedure performed at a tertiary-level cancer center. MATERIALS AND METHODS: From 1995-1999, 137 patients with rectal cancer located between 0 and 8 cm from the anal verge underwent APR. Covariates were analyzed mean chi 2 and those favorable or adverse covariates affecting the perineal infection and recurrences were analyzed by logistic regression analysis. RESULTS: There were 78 males and 59 females, with a mean age of 57.4 +/- 14.6 years. Mean intraoperative hemorrhage was 739 +/- 547 mL; 51 (37.2%) patients received blood transfusion. Seventy-two patients received preoperative radiotherapy (PRT): 22, postoperative chemo-radiation therapy; 21, PRT + chemotherapy, and 22, APR only. Seventeen patients (12.4%) had major complications and 47 (34.3%) had minor complications. Twenty patients (14.6%) developed perineal wound infection. The main factors influencing these complications were administration of PRT +/- chemotherapy and age over 55 years. Operative mortality was 0.7%. Median follow-up was 32 months. Twelve patients (8.8%) had local recurrence and 35 (25.7%) had distant recurrence. Overall five-year survival was 75%. CONCLUSIONS: APR is a surgical procedure associated with significant morbidity but low postoperative surgical mortality. The main cause of morbidity was perineal would infection influenced by administration of PRT +/- chemotherapy and age over 55 years. However, this treatment association is linked with low rate of local recurrence.

Specific c-K-ras gene mutations as a tumor-response marker in locally advanced rectal cancer treated with preoperative chemoradiotherapy.

BACKGROUND: Forty percent of patients with colorectal cancer develop mutations in the K-ras gene. OBJECTIVE: Our objective was to evaluate whether the presence of c-K-ras gene mutations is a useful tumor-response marker in patients with locally advanced rectal cancer treated with preoperative chemoradiotherapy. MATERIAL AND METHODS: Thirty seven patients with locally advanced rectal cancer were treated with preoperative chemoradiotherapy. Four to six weeks later, surgery was performed. Specimens were classified according to the UICC-AJC classification. A segment of the tumor was obtained to analyze specific c-K-ras gene mutations. Restriction fragment length polymorphism (RFLP) and single strand confirmation polymorphism (SSCP) techniques were used with a set of probes to detect specific c-K-ras mutations in codons 12, 13, and 61. The 37 patients were divided into Group A (with mutations) and Group B (without mutations). RESULTS: All 37 patients completed the scheduled treatment. Group A consisted of 12 patients, whose tumors were classified and specific c-K-ras mutations were located as follows: eight in codon 12, two in codon 13, and one in codon 61. Group B consisted of 25 patients. The tumors were classified and there were more early-stage tumors in Group A, whereas in Group B there were more advanced-stage tumors (P = .05, respectively). The mean follow-up was 36.2+/-18.3 months. All Group A patients survived, whereas 8 of the 25 patients in Group B died due to progressive metastatic disease. Survival in Group A was 100%, whereas in Group B it was 59% (P = .03). CONCLUSIONS: The presence of specific c-K-ras mutations is an indicator of tumor response in patients with locally advanced rectal cancer treated with preoperative chemoradiotherapy and surgery. Therefore, responding patients may be more amenable to less radical surgical procedures based on c-K-ras mutations.

Prognostic factors in patients with locally advanced rectal adenocarcinoma treated with preoperative radiotherapy and surgery.

Preoperative radiation therapy (PRT) prior to potential curative resection for rectal adenocarcinoma is not widely accepted. This report evaluates the prognostic factors affecting local recurrence and 5-year survival. This is a retrospective study of 214 patients with primary rectal adenocarcinoma treated from January 1986 to December 1994. A PRT dosage of 45 Gy in 20 fractions was administered to patients with clinically tethered or fixed tumors, and 4 to 8 weeks later surgery was performed (group I). Patients with clinically mobile tumors were treated by surgery alone (group II). There were 130 men and 84 women. The median age was 58 years (range 19-85 years). There were 111 patients in group I: 7 patients had no microscopic residual tumor, 80 had Dukes' A and B, and 24 had Dukes' C. There were 103 patients in group II: 70 patients were classified as Dukes' A and B and 33 as Dukes' C. The mean follow-up of the entire cohort was 62 months (range 2-132 months). Local recurrence was seen in 17% of patients in group I and 35% in group II (p = 0.002). Distant recurrence in patients with metastatic lymph nodes was seen in 79% of group I and in 34% of group II (p = 0.001). The favorable prognostic factors for local control were the administration of PRT and well differentiated cancer. The favorable prognostic factors for survival were age < 50 years and the absence of lymph node metastasis. The administration of PRT diminishes the risk of local recurrence. The presence of metastatic lymph nodes in the postirradiated specimen is an ominous prognostic factor for survival. Therefore such patients should be considered for adjuvant chemotherapy.

Inguinal lymph node metastases from rectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: The prognosis of patients with inguinal lymph node metastases from rectal adenocarcinoma is poor. The purpose of this study is to analyze the clinical behavior and response to different therapies in a group of these patients. MATERIALS AND METHODS: The medical records of 32 patients with inguinal lymph node metastases from rectal adenocarcinoma, diagnosed between January 1985 and December 1996, were retrospectively analyzed. The cohort was divided into: Group A (synchronous), and Group B (metachronous), according to the time of diagnosis. RESULTS: There were 17 males and 15 females, with a mean age of 53.5+/-13.8 years. Bilateral inguinal lymph node metastases were diagnosed in 17 patients, and unilateral in 15 patients. Fourteen of 18 patients in Group A (78%) and 13 of 14 patients (93%) in group B, respectively, had concomitantly extrapelvic metastatic disease. Seventeen patients in Group A treated with colostomy + chemoradiotherapy (45 Gy/20 fractions to the pelvis and groin area + 5-fluorouracil 450 mg/m2/weekly) had a progressive metastatic disease; the remaining patient was lost to follow-up after an abdominoperineal resection plus superficial groin dissection. Median survival was 8 months (range, 4-30 months). Overall 5-year survival was 0%. Ten patients in Group B were treated with chemoradiotherapy (50 Gy/25 fractions + 5-fluorouracil 450 mg/m2 + leucovorin 30 mg/m2); three patients received supportive care only, and one patient was treated with a groin dissection. All of them died of disseminated metastatic disease at a median of 13 months (range, 6-57 months). Overall 5-year survival was 0%. CONCLUSION: The presence of inguinal metastases in patients with rectal cancer heralds systemic disease and, due to a poor response to the different therapies, only palliative treatment should be indicated.

[Identification of sentinel lymph node with patent blue V in patients with cutaneous melanoma]. / Identificación del ganglio centinela con azul patente V en pacientes con melanoma cutáneo.

Regional lymphadenectomy in patients with cutaneous malignant melanoma in stages I-U AJC/UICC has not demonstrated improvement either in loco-regional control or in survival. The results of the lymphatic mapping technique have demonstrated that on identifying the sentinel node, the group of patients with microscopic nodal metastases can be selected for regional treatment. We performed the intraoperative lymphatic mapping technique with 1 ml of blue patent V by intradermal injection just around the primary melanoma; after injecting the dye we incised the nodal skin region, identifying the sentinel node by its blue color. The histologic examination, by frozen section of this node, determines whether or not to proceed with a formal lymphadenectomy. We calculated the sensitivity of the dye for the identification of the sentinel node and the Pearson's test was performed between the intraoperative histologic study and the definite pathological result. Thirty one lymphatic mappings were performed in 29 patients with stages I-II malignant cutaneous melanoma. The sentinel node was found in 26/31 explored lymphatic zones, and in 5, it was not found, sensitivity of 84%; 23/26 sentinel nodes were negative and only 3/26 were metastatic in frozen section. The Pearson's test result was 0.78 with a predictive value of 92%. The blue patent V intraoperative lymphatic mapping technique in patients with malignant cutaneous melanoma provided a great sensitivity to identify the sentinel node and allows the identification of patients with high risk of microscopic nodal metastases.

Colorectal sarcoma: analysis of failure patterns.

BACKGROUND AND OBJECTIVES: Colorectal sarcomas (CRS) are rare and their treatment remains controversial, especially for those located in the rectum. The aim of this paper is to evaluate our experience, with special emphasis on the failure pattern after surgical therapy alone or combined with postoperative radiotherapy. MATERIALS AND METHODS: The medical records and histological slides of 13 CRS patients treated between 1986 and 1996 were reviewed retrospectively. RESULTS: The patients included eight males and five females, with a median age of 54 years; nine of their primary tumors were located in the rectum, and four in the colon. The histologies were leiomyosarcoma in nine cases and malignant fibrous histiocytoma in four cases. Surgical treatment consisted of anatomical colectomy (four); local excision (three); abdominoperineal resection (APR)(two); low anterior resection (LAR)(two); LAR en bloc with the prostate (one), and total pelvic exenteration (one). One operative death occurred. The median size of the tumors was 8 cm (range, 5-40). The tumors were graded as low, three, and high, ten. The median follow-up was 24 months. Eight patients in the overall group developed recurrences as follows: local, three; local and distant, three, and distant, two. Five out of nine patients with rectal sarcoma received adjuvant postoperative radiotherapy (PRT). Local recurrence occurred in 20% (1/5) of those who received PRT, and in 100% (3/3) of those who did not. The overall 5-year survival was 40%, and the 5-year survival for patients with low-grade tumors was 66%, as compared with 22% for those with high-grade tumors. CONCLUSIONS: The patterns of failure in CRS are combined in both local and distant sites. However, our results suggest that in rectal sarcoma, the use of surgery + PRT may reduce the local recurrence rate; in selected patients, it may allow for anal sphincter preservation.

Partial laryngectomy as salvage surgery for radiation failures in T1-T2 laryngeal cancer.

BACKGROUND: Radiotherapy is the treatment of choice for early glottic carcinoma. Thirteen percent to 24% of patients require salvage surgery. To evaluate time of recurrence, site, and locoregional control, we retrospectively reviewed 29 patients treated from 1981 to 1996. METHODS: There were 28 men and 1 woman. Mean age was 63 years. Twenty were T1 (69%) and 9 were T2 (31%). Median time of recurrence was 14.5 months. In 14 patients (52%), a partial laryngectomy was done, and 13 patients had a total laryngectomy. Two refused surgery. RESULTS: One patient relapsed after salvage surgery. Five-year survival after salvage surgery was 92%, with no difference between partial and total laryngectomy (p = 0.2). CONCLUSIONS: Recurrences after failure to radiotherapy in T1-T2 glottic carcinoma could be salvaged with partial laryngectomy in 52% of patients, preserving laryngeal function, with adequate tumor control and acceptable morbidity. The selection of the surgical procedure is based on the tumor extension.

Quality control in planning and technique of radiotherapy with cobalt-60 for T1 glottic cancer increase local control and organ preservation.

BACKGROUND: In order to evaluate whether individualized technique and dosimetry of radiotherapy increase local control, organ preservation, and survival of patients with T1 glottic cancer, we reviewed 76 cases treated from 1979 to 1993. METHODS: Group A included 32 patients treated from 1979 to 1989 with different techniques, based on clinical aspects. Group B included 44 patients treated from 1990 to 1993 with individualized technique according to tumor extension and patient's anatomy. RESULTS: Five-year local control with radiotherapy alone was achieved in 53% of group A versus 91% of group B (P > 0.005). Survival was similar in both groups with rescue surgery (90% versus 96%). Five-year survival with larynx preservation was 65% in group A versus 88% in group B (P = 0.02). Most recurrences (78%) appeared within 24 months of follow-up. CONCLUSION: Adequate staging, individualized technique, computing planning using simulation and use of immobilization devices during cobalt-60 radiotherapy significantly increase local control and organ preservation in T1 glottic cancer.

Patterns of recurrence following pelvic exenteration and external radiotherapy for locally advanced primary rectal adenocarcinoma.

BACKGROUND: Local recurrence remains the main site of failure after pelvic exenteration for locally advanced primary rectal adenocarcinoma. This is a report on the patterns of recurrence in a group of such patients treated with pelvic exenteration and radiotherapy. METHODS: Between 1980 and 1992, we treated 49 patients. Thirty-one received preoperative radiotherapy (pre-RT), 4,500 cGy. Six weeks later, we performed posterior pelvic exenteration (PPE) in 21 patients, and total pelvic exenteration (TPE) in 10. Nine patients received postoperative radiotherapy (post-RT), 5,000 cGy after a PPE. Nine patients had surgery only, PPE (n = 7) and TPE (n = 2). RESULTS: Surgical mortality occurred in 16% of those patients who received pre-RT. The median follow-up was 52 months. Recurrences occurred in 23% of those patients who received pre-RT (local, one; local/distant, one; distant, four); in 88% of those patients treated with surgery only (local/distant, four; distant, four); and in 11% of those treated with post-RT (distant, one). The 5-year survival for patients who received radiotherapy was 66 versus 44% for those treated with surgery only. CONCLUSION: Local control of locally advanced primary rectal adenocarcinoma requiring a pelvic exenteration is improved by the addition of radiotherapy. When recurrences do occur they are predominantly at extrapelvic sites.

Anorectal malignant melanoma.

BACKGROUND: Great controversy exists with regard to the best surgical therapy for anorectal malignant melanoma. MATERIALS AND METHODS: Between 1980 and 1996, 15 patients with anorectal malignant melanoma were treated. The recurrence pattern after therapeutic intervention and their survival were evaluated. RESULTS: There were nine females and six males, their mean age was 66.3 years. At diagnosis their disease stages were: I (n=7), 11 (n=3) and III (n=5). Patients with stage I disease were treated with abdominoperineal resection (APR) (n=6) and local excision (n=1); their average tumour size and thickness were: 4.7 cm and 6.4 mm respectively; their median follow-up and disease-free survival were 11 months and 7 months respectively; their recurrence pattern was: local (n=6), inguinal (n=4) and distant (n=6). Those patients with stage II and III disease were treated with transverse colostomy (n=6); two of them received 50 Gy of radiotherapy and local excision plus interferon alpha-2b (n=2), all had progressive distant disease. Patients with stage I disease had a median survival of 12 months compared with 5 months for those with stages II and III (P=0.10). The overall 5-year survival was 0%. CONCLUSION: The recurrence pattern in anorectal malignant melanoma is mainly at distant sites. The role of APR in maintaining local control over tumours larger than 4 cm or thicker than 5 mm remains elusive.

Modified clearing technique to identify lymph node metastases in post-irradiated surgical specimens from rectal adenocarcinoma.

The aim of this study is to describe a modification of the original method of clearing lymph nodes in specimens from rectal adenocarcinoma and its yield in comparison to a control group whose specimens were studied by a manual technique. There were 32 consecutive patients with locally advanced rectal adenocarcinoma. All patients received preoperative radiation therapy (PRT) at doses of 45 Gy, concomitant with 5-fluorouracil at the doses of 450 mg/m2 IV bolus, days 1-5 and 28-33 of PRT; 4-8 weeks later radical surgery with a curative intent was performed. Twenty two specimens were studied by a manual technique consisting of fixation in 10% formalin. Ten specimens were studied with the modified clearing technique consisting of administration through the inferior mesenteric artery of methylene blue; fixation with 10% formalin plus 0.01% of methylene blue; clearing the fat with a sequence of 95% alcohol-100% acetone-100% xylene. In the 32 specimens, 413 lymph nodes were found. Using the manual technique 104 lymph nodes were found (average 4.7 lymph nodes per specimen); 309 lymph nodes by the modified clearing technique (average 30.9 lymph nodes per specimen), (p < 0.0001). Using the manual technique 23 out of 104 lymph nodes (22%) contained metastases. All metastatic lymph nodes measured > 5 mm; 18 out of 23 metastatic lymph nodes were located on the perirectal area (level 2); and five were located in the root of the inferior mesenteric artery (level 5). Using the modified clearing technique 278 out of 309 (89%) lymph nodes measured < 5 mm; 15 out of 309 (4.8%) lymph nodes contained metastases; 9 out of 15 (60%) measured > 5 mm and were located on levels 2 and 5; and six, located on level 5, measured < 5 mm. The modified clearing technique is a quick, easy and reproducible method for identifying lymph nodes in post-irradiated surgical specimens. In comparison to the traditional manual method of searching for lymph nodes, it improves in the detection of small lymph nodes (< 5 mm), allowing better staging in patients with rectal adenocarcinoma.

Sphincter-saving surgery with and without pre-operative radiation therapy as treatment for adenocarcinoma of the mid-rectum.

AIMS: To determine if pre-operative radiation therapy induces a local response in patients with complete tumour penetration into the rectal wall and allows for anal sphincter preservation, we compared the results from pathological specimens and local recurrences as measurable end-points in patients treated with pre-operative radiation therapy plus low anterior resection vs. those only treated with low anterior resection. METHODS: From January 1986 to December 1992, we treated 62 patients with mid-rectal adenocarcinoma (5-10 cm from the anal verge as determined by rigid proctosigmoidoscopy with the patient in the jackknife position). Pre-operative evaluation included: complete blood cell count, chemistry profile and the determination of carcinoembryonic antigen, chest X-ray, barium enema or colonoscopy and CT scan of the abdomen and pelvis. Only tumours potentially curative by resection in patients with performance status 0-2 (ECOG) were included. Twenty-one patients received pre-operative radiation therapy at a dose of 45 Gy delivered to the pelvis; 4-8 weeks later a low anterior resection was performed. Forty-one patients were treated with low anterior resection alone. Surgical specimens were classified according to the Astler-Coller modification of Dukes' classification. RESULTS: There were 36 males and 26 females, with a mean age of 56 years. The surgical specimens of those treated only with surgery were classified as: A, 5; B1, 4; B2, 15; C1, 2; and C2, 15. Postirradiated specimens: no residual tumour, 3; A, 4; B1, 4; B2, 7; C2, 3. One surgical death occurred in the group who underwent surgery alone. The median follow-up was 50 months in patients treated with surgery alone vs. 62 months in the combined approach group. Local recurrences occurred in 15/40 patients treated with surgery alone and in 2/21 of those treated with the combined approach (P = 0.043). Anal sphincter continence was classified as excellent by 24/40 patients treated with surgery only and by 18/21 patients treated with the combined approach. The 5-year survival period was 58% in the surgery only group and 82% in the group with combined treatment (P = 0.08). CONCLUSIONS: The use of pre-operative radiation therapy plus low anterior resection was associated with a lower rate of local recurrence and with a higher number of surgical specimens with no lymph node metastases. Thus, this combined treatment modality should be further evaluated as a possible treatment of mid-rectal cancers in good surgical candidates selected for sphincter-saving procedures.

Oral feeding after total laryngectomy for endolaryngeal cancer.

There is still no agreement about the beginning of oral feedings after total laryngectomy. Some authors begin routine feedings on the 3rd postoperative day, while others delay oral feedings until 12-14 days after surgery. The present study was devised as a prospective randomized clinical trial concerning beginning oral feedings on the 7th or 14th postoperative day in 35 patients following total laryngectomy as treatment for endolaryngeal cancer. There were no differences in risk factors present in either group. Only two pharyngocutaneous fistulae occurred in the overall series (5.7%), with both appearing in the 7-day group and developing on the 18th and 20th postoperative days respectively. There were no statistically significant differences in fistula formation between the two groups (P = 0.49). We conclude that it is not necessary to delay oral feedings more than 7 days in patients without suture line tension.

Risk of nodal metastases from malignant salivary gland tumors related to tumor size and grade of malignancy.

Indications for elective treatment of the neck are not well defined in salivary gland tumors. We retrospectively reviewed 153 cases of malignant salivary gland tumors treated from 1965 to 1985 at the Hospital de Oncología, Mexico City. There were 106 parotid cancers, 26 in the submandibular gland and 21 in minor salivary glands. Median follow-up was 48 months. In T1-2 tumors there was a 12% incidence of nodal metastases as compared with 27% in T3-4 cancers (P = 0.01). Thirty-six elective neck dissections were performed. Patients with high-grade tumors had an increased risk (50%) of occult node metastases, while no cases were found in low-grade carcinomas (P < 0.05). The risk of neck recurrence was higher in N+ (23.5%) than in N0 patients (3.2%). The 5-year actuarial survival was significantly better in low-grade tumors (78%), T1-2 tumors (85%) and negative nodes (63%) than in high-grade neoplasms (49%), T3-4 tumors (35%) and positive nodes (P = 0.001, P = 0.001 and P = 0.04, respectively).

Total intravenous anesthesia with propofol vs. propofol/midazolam in oncology patients.

The goal of this study was to determine dose requirements of propofol vs. propofol/midazolam in oncology patients during total intravenous anesthesia. The design of the study was a controlled clinical trial. The setting was the Oncology Hospital, National Medical Center, IMSS, located in Mexico City. Sixty patients were allocated randomly into two groups, patients in control group received propofol and fentanyl to induced and to maintain the anesthesia. Twenty nine patients in the experimental group received propofol and midazolam to induce anesthesia and to maintain propofol and fentanyl. The combination of propofol and midazolam to induce general anesthesia in oncology patients reduced the requirements in propofol and fentanyl in total intravenous anesthesia.

Morbidity and mortality following preoperative radiation therapy and total pelvic exenteration for primary rectal adenocarcinoma.

BACKGROUND: Pelvic exenteration, the standard treatment for patients with locally advanced rectal adenocarcinoma infiltrating neighbouring pelvic visceras, carried a significant morbidity and mortality rate. AIMS: The aim of this study was to determine the morbidity and mortality rates in a group of patients who were treated with preoperative radiation therapy and total pelvic exenteration. METHODS: Between January 1980 and January 1995, we treated 18 patients. Pretreatment staging was determined by clinical examination and computed tomography (CT) scan of the abdomen and pelvis. Each patient received preoperative radiation therapy of 45 Gy in 20 fractions delivered to the whole pelvis; approximately 6 weeks later total pelvic exenteration was performed. RESULTS: There were 17 males and 1 female, with a median age of 59 years. All patients underwent and completed the scheduled radiation therapy treatment. The main complaints related to radiotherapy were transient skin erythema in five patients and diarrhoea in four. Blood loss (estimated by the surgeon) ranged from 1000 ml to 4200 ml, with a mean loss of 2020 ml. Eight patients (44%) developed major complications: anastomatic leak from the uretero-intestinal suture line (n = 1); perineal wound infection (n = 2); abnormal wall infection (n = 1); haemorrhage from the right internal iliac vein (n = 1) and pneumonia (n = 1). Three patients required surgical reintervention for immediate postoperative haemorrhage from the sacral venous plexus (n = 1), small bowel obstruction (n = 1), and intra-abdominal and pelvic abscess (n = 1). There were two postoperative deaths (11%). The mean and median follow-up was 41 and 32 months, respectively. Two patients (12%) developed local recurrence at 5 and 8 months, and six developed distant recurrences (37%). The overall 5-year survival rate was 61%. CONCLUSION: Our treatment approach was associated with high morbidity and mortality rates, but was similar to previously published series based on total pelvic exenteration without prior radiation therapy. In addition, our therapeutic approach was associated with a low rate of overall local recurrences. Surgical Oncology 1995; 4: 295-301.