An improved technique for regional perfusion chemotherapy in the presence of a replaced right hepatic artery using a single implantable pump.

A new technique is described for regional perfusion chemotherapy in the presence of a replaced right hepatic artery. By anastomosis of the replaced right hepatic artery end-to-side to the left hepatic artery, a single implantable pump can be used to perfuse both lobes of the liver. This technique has the advantage of facilitating postoperative follow-up and substantially reducing the cost of the procedure.

Steroid pretreatment reduces interleukin-2 toxicity in sheep.

Recombinant interleukin-2 (rIL-2) has shown promise in the treatment of patients with advanced cancer. However, toxicity of this therapy remains a major problem with its use in some patients. In this study we examined whether steroids could reduce the adverse cardiopulmonary effects of rIL-2. Seven sheep were surgically prepared with vascular catheters and lung lymph fistulas. Each sheep received either a single dose of rIL-2 (100 micrograms/kg) or rIL-2 plus methylprednisolone (30 mg/kg) followed by the reverse treatment 1 week later. Lung lymph flow increased markedly after rIL-2 with a peak QL of 140% +/- 30% (above baseline). Steroid pretreatment significantly reduced this lymph flow increase with peak lung lymph flow being only 40% +/- 16% (p less than 0.004). The lymph/plasma protein ratio tended to increase after rIL-2, but these changes were not statistically significant. After rIL-2, cardiac output, heart rate, core temperature, and mean pulmonary artery pressure increased (p less than 0.05), whereas systemic vascular resistance and arterial PO2 decreased (p less than 0.05). These changes did not occur with steroid pretreatment. The results of this study demonstrate that steroids reduced the adverse cardiopulmonary effects of rIL-2. We believe that rIL-2 induces activation of arachidonic acid metabolism, which leads to the production of multiple inflammatory mediators that cause increased microvascular permeability and the adverse cardiopulmonary effects of rIL-2.

Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of patterns of recurrence.

The Registry of Hepatic Metastases has collected data on consecutive patients from 24 institutions who have undergone hepatic resection for colorectal carcinoma metastases. Patterns of recurrence were examined in a subgroup of 607 patients who had undergone curative resection of isolated hepatic metastases. Forty-three percent of these patient have had recurrences in the liver and 31% have had recurrences in the lung (either alone or in combination with other organs). A multivariate analysis showed that patients with positive pathologic margins or bilobar metastases were at an increased risk of having a recurrence in the liver (68% and 64%, respectively). We conclude that: hepatic resection effectively controls hepatic tumor in a substantial number of patients, adjuvant therapy after hepatic resection should be directed at both the lung and liver to significantly increase survival, and patients with positive pathologic margins or bilobar metastases are at an increased risk for hepatic recurrence.

Extrahepatic tumor deposits misdiagnosed as intrahepatic metastases.

Focal hepatic lesions seen on roentgenologic evaluation of the liver in patients with cancer are usually assumed to be caused by parenchymal metastases. In this report, liver imaging tests showed six patients with filling defects caused by peritoneal carcinoma indenting the liver parenchyma. Extrahepatic tumor deposits were misdiagnosed in all but one of these cases. The roentgenographic characteristics that can assist in the differentiation of intrahepatic and extrahepatic metastases are a lens-shaped defect, a defect adjacent to the hemidiaphragm, and a halo around the liver suggesting peritoneal carcinomatosis. A high index of suspicion for extra-hepatic tumor masses causing intrahepatic filling defects may help prevent unnecessary exploratory surgery for treatment of hepatic metastases. Angiography may occasionally be helpful in distinguishing intrahepatic from extrahepatic disease.

Resection of hepatic metastases from colorectal carcinoma. The registry data.

When liver metastases from colorectal carcinoma are detected, the surgeon must decide whether or not the patient is a candidate for resection. Even though long-term survival after resection is far from optimal, the relegation of patients to nonresective treatment means denying them the only chance for cure currently available. Better understanding of liver anatomy and improvement in resection techniques have decreased the morbidity and mortality. The RHM and the GITSG reports have better defined the prognostic factors for resections of colorectal liver metastases and allowed for a better understanding of the indications for resection. During the last decades, liver resection has been extended to older patients, patients with multiple liver lesions, and patients with larger solitary metastases. At the same time, anatomic rather than wedge resections are more common, and it is preferable to perform the colon and liver resection at different stages. The end result has been a marked increase in the number of hepatic resections performed for colorectal liver metastases during the last two decades.

Hepatoma registry of the Western world. Repeat Hepatic Resection Registry.

The western HCC registry comprised data from 322 patients who underwent hepatic resection for HCC over a 50-year period. The majority of patients had lesions > 4 cm and were symptomatic at presentation. Lesions were mostly unicentric. Cirrhosis was not a prevalent problem, unlike the East. In the most recent decade, 1980-1989, we noted a significant decrease in operative mortality from 19% to 10% overall, and 15% to 4% in the noncirrhotic group. We identified four variables that resulted in poorer postresectional outcome: cirrhosis, regional nodal disease, multicentric disease, and tumor-free resectional margin < 1 cm. Although these factors are associated with a poorer outcome after resection, whether they should serve as contraindications to surgery should be determined by individual surgeons, taking into account the patient's overall status, concomitant risk factors, and treatment objectives.

Management of non-resectable liver metastases from colorectal cancer.

Among patients who develop recurrent cancer following resection of the colorectal primary, 60-80% develop liver metastases. For such patients, liver resection is the only treatment that offers the potential for cure. Patients with four or fewer liver metastases and no apparent extrahepatic disease should be considered for resection. Patients with non-resectable liver metastases who are asymptomatic may prefer to receive no treatment until such time as symptoms occur. Those with symptomatic or rapidly progressive disease may be offered a variety of treatment approaches: Systemic chemotherapy (20% response rate); hepatic artery infusion; portal vein infusion; intraperitoneal chemotherapy; hepatic resection plus regional chemotherapy; hepatic artery ligation; hepatic artery ligation plus portal vein chemotherapy, and others. The advantages and disadvantages of each are discussed.

Management of recurrent and metastatic colorectal carcinoma.

When metastatic or recurrent disease from colorectal carcinoma is detected, the surgeon must decide whether a patient is a candidate for resection. Although long-term survival after resection is not optimal, the relegation of patients to nonresective treatment means denying them the only chance for cure currently available. When isolated disease involving the liver, lung, or region of the primary carcinoma is documented, curative resection must be considered. Symptomatic patients may also obtain maximal palliation from resection, diversion, or a bypass procedure. Chemotherapy for the treatment of recurrent disease is palliative and probably should be considered only within clinical trials. Future alternative methods of treatment or new chemotherapeutic regimens need to be studied to improve survival and quality of life.

Controversies in the treatment of ductal carcinoma in situ.

In summary, certain subgroups of DCIS appear not to require radiation. Corroboration of these results from retrospective reviews and prospective trials is necessary to confirm the safety and efficacy of individualized treatment strategies. Even though the current standard of treatment is (1) lumpectomy with radiation therapy, (2) mastectomy, or (3) mastectomy with reconstruction, it is possible in the future to say that patients with low-grade DCIS (the exact criteria to be defined) may be eligible for breast conservation without radiation, and all patients with high-grade DCIS or perhaps low-grade DCIS with necrosis would be treated best by lumpectomy plus radiation. It is possible that a small subgroup of patients may be best treated by mastectomy, or perhaps, as the results of B-24 become available, by radiation therapy plus tamoxifen. The use of tumor markers such as c-erbB-2, cathepsin D, and NM 23 may help us to better define these subgroups, but much study is necessary before a definite treatment strategy is reached.

Multidisciplinary care for patients with breast cancer.

Breast cancer management requires a multidisciplinary approach that is tailored to the patient's stage at presentation, desire for breast conservation or reconstruction, estimation of risk of recurrence, and assessment of the benefits and toxicities of potential adjuvant therapies. At the Lahey Clinic Medical Center, breast surgeons, plastic surgeons, radiation oncologists, and medical oncologists staff the Breast Cancer Treatment Clinic, and work closely together to formulate treatment plans that will optimize the likelihood for cure with an acceptable cosmetic result. This involves careful preoperative work-up, surgical axillary staging, breast irradiation in the setting of breast conservation, and selection of chemotherapy or hormonal therapy if appropriate. Newer aspects of breast cancer care, including sentinal lymph node biopsy, postmastectomy radiation therapy, expanded use of hormonal therapy in younger women, new agents and chemotherapy combinations, and autogenous reconstruction techniques, have become an essential part of the multidisciplinary clinic approach.

Common operative problems in hepatobiliary surgery.

The pace of change in hepatobiliary surgery requires a sound foundation in basic surgical principles. Further reductions in morbidity and mortality rates and appropriate use of alternative therapies require careful attention to preoperative risk assessment and patient selection. To operate safely and successfully on the liver and bile ducts, the surgeon must be well versed in normal and variant hepatobiliary anatomy, understand the underlying disease and therapeutic alternatives, and known techniques of reoperative biliary surgery. Surgeons who operate on the gallbladder must be prepared to confront a host of unexpected and difficult operative problems. Bile duct injuries must be repaired properly at the first attempt. Complex biliary operations require a great level of technical expertise and judgment to obtain successful results and should only be undertaken by experienced hepatobiliary surgeons. As proficiency with the more routine procedures improves, increasingly complex and extensive procedures become possible. We must constantly police ourselves to be certain that these more extensive procedures truly benefit our patients.

Special considerations when treating breast cancer in the elderly.

The growing aging population of the U.S. will lead to an absolute and proportional increase in elderly women with breast cancer. While the underlying biologic characteristics of the disease will not likely change, the health status and life expectancy of the patients will improve. Our decisions regarding therapy must take into account not just the disease we are treating, but the characteristics of the host as well.

The relationship between violent trauma and nonemployment in Washington, DC.

The purpose of this study was to determine the association of violent trauma with nonemployment status of victims and whether victims who knew their assailants were associated with a higher nonemployment rate than victims who did not know their assailants. Data were collected for 585 patients between 18 and 65 years of age. Patients were residents of Washington, DC, who presented with violent injuries to the emergency department at DC General Hospital between November 1989 and November 1990. Study participants were divided into two groups: those who knew their assailants (Group 1, n = 329) and those who did not know their assailants (Group 2, n = 256). The overall nonemployment rate for the sample population was 51% versus 29% for residents in the hospital catchment area (comparison population based on census data) (P < .001). Of patients in Group 1, 61% were nonemployed compared with 38% in Group 2 (P < .0001). Of male patients in Group 1, 55% were nonemployed compared with 33% in Group 2 (P < .0001). Of female patients in Group 1, 71% were nonemployed compared with 69% in Group 2 (P < .80). Results indicate that there is a significant association between victimization from violent trauma and nonemployment of the victim. In addition, male victims familiar with their assailants had a higher nonemployment rate than victims who did not know their assailants. We conclude that nonemployment seems to contribute to the violence in this population.

Evaluation of plasma and buffy coat ascorbic acid concentrations in dogs before and after a 24-hour fast.

Samples of blood were taken from 15 female and 15 male research laboratory Beagles before and after they were fasted for 24 hours. The mean buffy coat ascorbic acid concentration was significantly higher in dogs after they were fasted than that before they were fasted. In contrast, the mean plasma ascorbic acid concentration was significantly lower in dogs after they were fasted than that before they were fasted. The mean buffy coat ascorbic acid concentrations in blood samples of both fasted and nonfasted female Beagles was significantly greater than those of male Beagles, whereas the mean plasma concentrations of both fasted and nonfasted female Beagles was significantly lower than those of male Beagles. It was observed that whenever there was a decrease in plasma ascorbic acid concentration, there was an increase in buffy coat ascorbic acid concentration, regardless of fasting stress or sex difference.

Etiology of the obstructive pattern in hepatobiliary imaging.

The records of all patients undergoing hepatobiliary imaging at our hospital from January 1980 to March 1983 were reviewed and 29 scans met the criteria for a pattern consistent with complete biliary tract obstruction. Biliary tract obstruction (due to choledocholithiasis, primary or secondary carcinoma involving the common bile duct, and pancreatitis) was documented in 24 of these patients. However, the remaining five patients had a patent common bile duct, and the etiologic factor was intrahepatic cholestasis secondary to sepsis in four and peritonitis in one. A classification of altered biliary dynamics in hepatobiliary imaging, which is based on the classification of jaundice, is proposed.

Effects of nonadherent dressing materials on the healing of open wounds in dogs.

Four types of nonadherent dressing materials (rayon/polyethylene dressing, cotton nonadherent film dressings, fine mesh gauze petrolatum dressings, and commercial petrolatum emulsion dressings) were applied on small full-thickness skin defects on the backs of 12 Beagles. At 7 days, the wounds treated with the petrolatum-containing dressings had more contraction than wounds dressed with cotton nonadherent film dressings and wounds dressed with rayon/polyethylene dressings. However, by days 14 and 21, there was little difference in the amount of contraction of any of the wounds. At 7, 14, and 21 days, the wounds dressed with petrolatum-containing dressings had less epithelialization than wounds dressed with cotton nonadherent film dressings and rayon/polyethylene dressings. The uniform open mesh of the commercial petrolatum emulsion dressings allowed the best absorption of exudate and bacteria into the secondary overlying bandage.

Methods of arterial site skin preparation and dressing.

Before an arterial line is inserted, the skin at the site is prepped typically with the traditional iodophor-based preps. The arterial site is then covered with an occlusive dressing. When arterial lines are maintained for even a few days, it is not uncommon that some form of complication develops at the arterial site, such as redness, inflammation, positional problems, or even infection. Unfortunately, due to the nature of this traditional preparation and dressing method, the site is obscured constantly and complications are not always detected before a resulting infection occurs. This prospective study was designed to examine the efficiency and effectiveness of a new transparent prep, used with a transparent dressing at the arterial site. Sixty patients' arterial line sites were evaluated to determine the incidence of complications of the two arterial site prep and dressing methods. The effectiveness that the dressings may serve in securing the arterial lines in place was also evaluated. There were no complications in this study directly related to either skin preparation or dressing method, thus, there were no statistically significant differences. However, the transparent prep and transparent dressing method provided constant visual access to the arterial site and required fewer steps, clearly significant advantages not provided by the traditional method.

Breast cancer in the nineties.

Breast cancer is the most common cancer in women and is the second (after lung cancer) leading cause of cancer deaths in women. Knowledge of breast cancer and its epidemlology, natural course, and response to treatment continue to evolve, making the survival rates for patients with breast cancer more optimistic. Women with breast cancer must decide, in partnership with expert physicians and nurses, what their options are for screening, diagnosis, and treatment. This article provides an overview of options available to women diagnosed with breast cancer.