Combined chemotherapy, radiation, and surgery for epithelial cancer of the anal canal.

Combined chemotherapy and radiation therapy have been reported to produce a high incidence of complete regression of epithelial cancer of the anal canal, resulting in prolonged disease-free survival. This modality has been advocated as an alternative to abdominoperineal resection as a primary treatment for this disease. Our group treated 19 patients between 1979 and 1985. Treatment included two infusions of 5-fluorouracil (1000 mg/m2/24 hours), one dose of mitomycin C (15 mg/m2), and simultaneous whole-pelvis radiation (3000 rad). The complete response rate was 88%. Three patients had anal cancer incompletely controlled by that therapy. They underwent abdominoperineal resections and are alive without disease at 10, 39, and 43 months, respectively. Actuarial disease-free survival at 40 months was 87.5 +/- 8.8 (% +/- standard error of the mean [SEM]). Complications included gastrointestinal, hematologic, and cutaneous toxicity. These results confirmed a high complete response rate to this therapy. Local treatment failures may occur, but these may be salvaged with abdominoperineal resection.

Multiple biochemical markers in patients with gynecologic malignancies.

Plasma levels of carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), and human chorionic gonadotropin (hCG) were measured in 253 patients with gynecologic malignancies and in 317 patients with benign gynecologic diseases. Plasma concentrations of each of these antigens were elevated in a significantly (p less than 0.001) greater number of patients with invasive gynecologic cancers than in the control population. Carcinoembryonic antigen was the most commonly elevated marker, followed by AFP and hCG. Prior to therapy, over 85% of patients with ovarian or cervical cancer had elevated plasma levels of one or more antigens. Specifically, CEA was most often elevated in patients with mucinous adenocarcinomas of the ovary and endocervix. Alpha-fetoprotein was most often increased in patients with germ cell or stromal tumors of the ovary and in patients with large-cell nonkeratinizing cervical cancers. In contrast, hCG concentrations were highest in patients with serious cystadenocarcinomas of the ovary and in patients with keratinizing squamous cell carcinomas of the cervix. Plasma antigen levels were directly related to tumor differentiation and stage of disease, and generally returned to normal eight to 12 weeks following therapy. Effective plasma and tumor antigen screening during initial evaluation of patients with gynecologic tumors should help to identify the most appropriate antigen for immunodetection procedures and for serial plasma determinations following therapy.

Incarcerated Spigelian hernia: ultrasonic differential diagnosis.

The gray scale ultrasonic findings in a case of incarcerated Spigelian hernia are presented. This hernia is uncommon, and the clinical diagnosis can be difficult. The appearance of the lesion is compared with others in and about the abdominal wall, including rectus sheath hematoma, seroma, abscess, peritoneal tumor implants, and pseudocyst at the end of a ventriculoperitoneal shunt. Clinical and sonographic differentiation is emphasized.

Palliation of inoperable head and heck cancer: combined intra-arterial infusion chemotherapy and irradiation.

Palliation of unresectable head and neck cancer remains a difficult problem. Because of excellent results reported by others with infusion of vinblastine, methotrexate, and 5-fluorouracil into the external carotid artery followed by irradiation before curative surgery, we applied this technic to 22 patients with advanced head and neck cancer. Fifteen patients from this group who had chemotherapy infusion followed by radiation therapy are compared with 21 patients who received radiation therapy alone. Both groups were similar in distribution of primary site, histology, and TNM stage. Of 15 patients, 14 (93%) had partial or complete tumor regression after both arterial chemotherapy infusion and irradiation, while 14 of 17 patients (82%) receiving primary irradiation had partial or complete response. Drug toxicity and complications related to infusion occurred in all patients. Most patients in both groups had short survivals (mean of 14.1 months in infusion chemotherapy and radiation vs 9.1 months in primary irradiation). One patient remains alive in the infusion group and two in the control group; however, all have recurrent disease. Results indicate a slight increase in survival time with the addition of infusionchemotherapy to irradiation in palliative treatment of head and heck cancer.

The use and abuse of CEA test in clinical practice.

Charts of 437 patients having plasma carcinoembryonic antigen determinations during the period January 1, 1976 through April 30, 1976 were reviewed to determine whether CEA results led to clinical decisions altering management patterns. Data analysis disclosed that CEA test results did not result in any change in management in 167 patients with non-neoplastic disease. Most had single determinations. In 270 patients with neoplastic disease, CEA results led to changes in management in one patient with lung cancer and two patients with colon cancer, which may have altered prognosis. In a fourth patient, CEA results led to discovery of unresectable pancreatic cancer at laparotomy. Cost benefit analysis indicated a CEA test cost of $5,047.50 per patient benefitted in 299 patients eligible for analysis. We conclude that maximal benefit to the patient results from serial CEA test use in follow-up of colon cancer patients after curative therapy.

Squamous cell carcinoma of the common bile duct.

Squamous cell carcinoma of the common bile duct in a young woman was treated with pancreatoduodenectomy and chemotherapy. She died eight months after diagnosis. Clinical presentation and aggressiveness of the tumor are similar to adenocarcinoma. Radical resection is the treatment of choice, particulary in young patients.

Usefulness of serial carcinoembryonic antigen (CEA) determinations in monitoring chemotherapy.

Serial carcinoembryonic antigen (CEA) levels were measured during chemotherapy for metastatic cancer in 94 patients. Criteria for chemotherapy responses were those used by the Central Oncology Group. Patients were classified according to changes in CEA levels and response to chemotherapy. Four categories represented a positive correlation: (1) increasing abnormal CEA with progressing disease, (2) decreasing abnormal CEA with disease regression, (3) unchanged abnormal CEA with stable disease, (4) change from normal to abnormal CEA with progressive disease. Positive correlation of serial CEA levels with clinical responses occurred in 71% of patients with GI cancer, 51% with breast cancer, 42% with sarcoma, 50% with respiratory cancer, and 25% with melanoma. These data indicate that serial CEA determinations may be of value as an additional parameter of response to chemotherapy in gastrointestinal cancer.

Analysis of the causes of mortality from appendicitis.

An analysis of 944 cases of acute appendicitis treated at the University of Kentucky Medical Center from 1966 to 1973 is presented. There were 12 deaths in this series, a mortality rate of 1.3 per cent, and the clinical presentation, operative and autopsy findings are discussed. It is significant that seven of the 12 patients had other serious illnesses that influenced the decision for operation and that operation was delayed over 48 hours in 50 percent. It is stressed that the need for early exploration in the patient suspected of having appendicitis is even more imperative in the individual with concomitant disease. Adequate but immediate preoperative preparation with fluids and electrolytes antibiotics and stabilization of renal, pulmonary and cardiac status is mandatory.

Carcinoembryonic antigen in intraepithelial neoplasia of the uterine cervix.

Carcinoembryonic antigen (CEA) was elevated (greater than 2.5 ng. per milliliter) in 29 of 100 patients with cervical intraepithelial neoplasia (CIN). CEA concentration was related to the amount of intraepithelial neoplasia and to the presence of glandular extension. Lymphoplasmacytic infiltration of tumor cells was unrelated to CEA levels. CEA values returned to normal within 8 weeks following surgery in 77 per cent of patients. A persistently elevated (greater than 5.0 ng. milliter) plasma CEA value following conization was associated with residual CIN in the cervix. These results suggest that sequential CEA determinations may be of value in the follow-up of those cervical cancer patients who initially have high plasma antigen levels.

Carcinoembryonic antigen and skin test reactivity in tumor radiotherapy.

Serial carcinoembryonic antigen (CEA) levels were obtained from 122 cancer patients. In a random selection, the levels in 67 of these patients were compared with clinical response to radiotherapy. Skin tests were also performed for histoplasmin, tuberculin and mumps. CEA levels, skin-delayed hypersensitivity reaction (DHR) and clinical tumor response were evaluated and correlated. Clinical response of tumors to radiotherapy was more often seen in patients with positive skin tests, but no correlation was observed between skin test reactivity and CEA response curves.

Membrane filters. Additional safety for intra-arterial infusions.

The addition of a 0.45mu in-line membrane-filter to the delivery system for intra-arterial infusion therapy is a simple and inexpensive means of providing additional safety. The filter decreases particulate and microorganism infusion by removing all measurable particles and most bacterial and fungal organisms. Since air will not pass through the filter, air embolism is prevented. In addition, in the event of set disruption, the filter will prevent bleeding via red blood cells clogging the membrane.