Leucine amino peptidase a better indicator of carcinoma of liver, biliary tract and pancreas.

Serum levels of leucine amino peptidase (LAP) was studied along with bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), gamma glutamyl transpeptidase (GGT), alkaline phosphatase (ALP) and the ratio of AST/ALT and GGT/AST in 25 healthy subjects and 52 patients with hepatobiliary malignancies of which 12 were with hepatocellular carcinoma, 12 with liver metastasis, 6 with obstructive jaundice, 9 with carcinoma of gall bladder, 6 with carcinoma of pancreas and 7 with periampullary carcinoma. 24 Of the 52 patients studied had jaundice and 28 were without jaundice.LAP as compared to the other enzymes AST, ALT, GGT, ALP and AST/ALT ratio and GGT/AST ratio showed 100% elevation in obstructive jaundice, carcinoma of gall bladder and pancreas and periampullary carcinoma, 91.7% elevation in hepatocellular carcinoma and 83.3% elevation in liver metastasis. On comparing the levels of these enzymes in non jaundiced and jaundiced groups, LAP was elevated in both jaundiced and non jaundiced groups in 95.8% and 92.9% cases respectively whereas the other enzymes AST showed increase from 67.9% to 100%, ALT from 21.4% to 83.3%, GGT from 71.4% to 95.4% and ALP from 82.1% to 100% in non jaundiced and jaundiced groups respectively indicating that LAP rises in hepatic dysfunction due to hepatobiliary malignancy whereas the other liver function enzymes showed increased hepatic dysfunction due to hepatobiliary malignancy with the onset of jaundice thereby indicating that LAP is a better indicator of hepatobiliary malignancy as compared to other enzymes.The quantitative methods used for determination are reliable, accurate, simple, rapid and cost effective and therefore have better application in a clinical setting.

The quality of swallowing for patients with operable esophageal carcinoma: a randomized trial comparing surgery with radiotherapy.

BACKGROUND: Surgery is considered the standard treatment for operable esophageal carcinoma, although there is no compelling evidence that surgery can achieve better results than radiotherapy. There has previously been no direct randomized comparison of these two modalities with survival or disease specific outcome end points. METHODS: Ninety-nine patients with operable squamous cell carcinoma of the esophagus were randomly allocated to surgery or radiotherapy after stratification for tumor length (< or = or >5 cm). Those randomized to surgery underwent transthoracic esophagectomy with limited lymphadenectomy, whereas those in the radiotherapy arm received 50 gray in 28 fractions followed by a 15-gray boost to the primary tumor. Disease specific outcome was assessed for 4 subgroups: 1) disease specific symptoms, 2) physical symptoms, 3) ability to work, and 4) social/family interaction and global perception of disease specific outcome. The questionnaire was given prior to treatment and posttreatment at 3-month intervals for 1 year. Death was a secondary end point. RESULTS: There was an overall improvement in the quality of swallowing in both treatment arms after treatment and with the passage of time. The swallowing status was better in the surgery arm than in the radiotherapy arm at 6 months after treatment (P = 0.03, Fisher's exact test). Logistic regression analysis showed randomization arm (P = 0.035), time since treatment (P = 0.003), and pretreatment swallowing status to be significant determinants of posttreatment swallowing status. Surgery was twice as likely to result in improvement in swallowing than radiotherapy after correction for time and pretreatment swallowing status. Overall survival was better in the surgery arm than in the radiotherapy arm (P = 0.002, log rank test) (OR = 2.74 with 95% confidence intervals 1.51-4.98; P < 0.009, Cox proportional hazards model). CONCLUSIONS: Both surgery and radiotherapy can improve the quality of swallowing significantly for patients with operable esophageal carcinoma. Surgery is marginally superior to radiotherapy in improving the quality of swallowing. In this trial, survival in the surgery arm was significantly better than in the radiotherapy arm, although the small number of patients is a limitation.

Pattern of recurrence after extended radical esophagectomy with three-field lymph node dissection for squamous cell carcinoma in the thoracic esophagus.

Factors responsible for recurrence of esophageal cancer were investigated in 90 patients who underwent extended radical esophagectomy with three-field dissection for a squamous cell carcinoma in the thoracic esophagus. The initial tumor recurrence was grouped as either locoregional (site of the primary tumor, anastomotic site, or lymph nodes) or as distant (distant organs, pleura, or peritoneum). Nineteen patients (21%) developed a locoregional recurrence, and 19 (21%) developed a distant recurrence. One (1%) developed both recurrences simultaneously and was classified as a distant recurrence. The locoregional recurrence was correlated with the stage factors, particularly the number of metastasis-positive nodes. For the distant recurrence, vascular invasion was found to have been the most important prognostic factor. Our findings suggested that locoregional recurrence was due to tumor progress related to the extent of lymph node metastasis, whereas distant recurrence was due to the oncologic behavior of the tumor. Locoregional recurrence in patients with limited disease may be reduced by extended radical esophagectomy with three-field dissection. Distant recurrence cannot be controlled by surgery. Adopted postoperative adjuvant therapies showed no effect on recurrence.

Historical control bias: adjuvant chemotherapy in esophageal cancer.

UNLABELLED: Conclusion based on historical controls are known to be fallible in assessing efficacy of treatment due to selection bias. Historical controls have been repeatedly used in investigating efficacy of newer treatment avenues in esophageal cancer. The aim of the study was to assess the efficacy of adjuvant chemotherapy in esophageal cancer after correction for an historical control bias. PATIENTS AND METHODS: The database of 433 patients treated surgically for cancer of the esophagus at our institute between 1980 and 1989 was analyzed. The analysis was carried out using the Cox model for known prognostic factors without any correction for historical bias. Database was reanalysed after introducing registration year as a variable in the model to correct for historical control bias, which was further examined by carrying out a case-control study comparing chemotherapy (n = 83) vs contemporary control (n = 164) matched for lymph-node status, age and sex randomly selected from the same database. RESULTS: The analysis without correction for historical control bias showed lymph-node metastasis (P = 0.000), female sex (P = 0.002), depth of invasion (P = 0.001) and adjuvant chemotherapy (P = 0.03) as significant predictors of survival. On introduction of registration year as a variable, lymph-node metastasis, sex and depth of invasion continued to be significant factors but chemotherapy was replaced by registration year (P = 0.02). The database with contemporary control showed lymph-node metastasis (P = 0.000), depth of invasion (P = 0.008) and female sex (P = 0.001) as significant factors. Chemotherapy had no effect on survival. CONCLUSION: Results from historical controls are unreliable in detecting modest treatment benefits. Adjuvant chemotherapy in esophageal cancer should be tested within the tenets of randomized controlled trials with adequate-sample size to ascertain its efficacy.

Modified method for determination of serum beta-glucuronidase: A comparative study using P-nitrophenyl glucuronide and phenolphthalein glucuronide as substrate in gastrointestinal tract carcinomas.

Serum beta-glucuronidase activity was estimated by our modified method using two substrates phenolphthalein glucuronide and p-nitrophenyl glucoronide in 49 healthy subjects and 94 patients with gastrointestinal tract (GIT) carcinoma. The correlation coefficient using the two substrates was found to be r=0.8383. The method of Gabor Szasz was modified wherein the incubation time was decreased from 5 hours to 2 hours and the incubation temperature was increased from 25°C to 37°C. The increase in beta-glucuronidase activity in GIT carcinoma appears to be a good biochemical marker in patients with such type of carcinomas, a finding not reported in literature to-date.The modified quantitative method used for estimation of beta-glucuronidase is reliable, accurate, simple and rapid.

Intrathoracic anastomosis after oesophageal resection for cancer.

Cervical anastomosis has been advocated to avoid the pulmonary complications and life-threatening anastomotic disruptions following intrathoracic oesophagogastric anastomosis. This is a retrospective review of 111 oesophageal resections followed by an intrathoracic anastomosis. These resections were performed between September 1993 and August 1994 within a residency training program. The left thoracoabdominal approach was used for distal tumours and the Ivor Lewis technique for more proximal tumours. Squamous cell carcinoma accounted for 72% patients (n = 80), adenocarcinoma for 25% (n = 28), and others for 2.7% patients (n = 3). Of the patients, 69% had pathologic Stage III tumours. Operative mortality rate was 1.8% (two patients). Perioperative complications occurred in 39 patients, including anastomotic leak in 10 patients and myocardial infarction in 2 patients. In the absence of a leak, there were no major pulmonary complications requiring intensive care or ventilatory support. Of those patients with anastomotic disruption, 80% were salvaged by early clinical diagnosis and appropriate treatment. We conclude that transthoracic oesophagectomy with an intrathoracic anastomosis is a safe procedure that can be performed with low mortality and acceptable morbidity.

Chemotherapy for carcinoma of the esophagus: a comparison of evidence from meta-analyses of randomized trials and of historical control studies.

BACKGROUND: Chemotherapy (CT) has been used as an adjunct to local treatment (surgery or radiotherapy) in esophageal carcinoma. A meta-analysis of all published randomized clinical trials and historical control studies which have used cisplatinum-based combination CT was carried out to asses the effect of chemotherapy on survival for esophageal cancer. MATERIALS AND METHODS: A computer-based literature search was performed for the period from January 1988 to March 1995 using the index terms "Esophageal neoplasms' and "Chemotherapy'. The frame of reference was further narrowed to include only cisplatinum-based combination chemotherapy. Twelve randomized clinical trials (RCT) and eight historical control (HC) studies were included in the meta-analysis. RESULTS: In the overview of HC studies a highly significant reduction in odds of death with CT was observed (68% +/- 8% OR = 0.32, 95% CI 0.24-0.42). On the other hand, the overview of RCTs showed a relative reduction in odds of death for the CT group of 4.2% +/- 23.7% (OR = 0.96, 95% CI 0.75-1.22). CONCLUSIONS: There was a gross overestimation of treatment effect in the studies using HC as compared to RCTs, despite the use of cisplatinum-based chemotherapy in both groups. The meta-analysis of RCTs reveal no significant survival benefit from cisplatinum-based adjuvant/neoadjuvant chemotherapy in esophageal cancer.

Impact of age and sex on survival after curative resection for carcinoma of the esophagus.

BACKGROUND: The impact of age and sex-related changes in the endogenous hormonal milieu on survival after curative resection for esophageal epithelial cancer is explored. Adami et al. have suggested that the event of puberty has a favorable impact on survival after treatment of epithelial cancers. METHODS: The database consisted of 469 patients with esophageal cancer treated surgically with an intent to cure (without any gross residual disease at the end of the primary treatment) at Tata Memorial Hospital between 1980 and 1989. RESULTS: Life-stable analysis revealed a significantly better 5-year survival for women younger than 49 years (35%, CI 24-48) compared with men of the same age (16%, CI 8-27) (P < 0.008). There was no difference in survival between men (17%, CI 12-23) and women (26%, CI 16-37) older than 49 years (P = 0.08). A Cox proportional hazard model showed sex to be the second most significant determinant of survival (P = 0.002) after lymph node metastasis (P < 0.0001). CONCLUSION: The finding that the survival benefit is confined to women younger than 49 years is consistent with the hypothesis that the endocrine milieu in premenopausal women may prevent the establishment of micrometastases and thus improve the prognosis for esophageal epithelial cancer.

Solid and cystic papillary neoplasm of pancreas--a report of seven cases.

OBJECTIVE: To study the clinico-pathological features of patients with solid and cystic papillary neoplasm of the pancreas. METHODS: The clinico-pathological features of solid and cystic papillary neoplasm of the pancreas were studied in seven fully documented and confirmed cases presented during the last seven years. RESULTS: All the patients were women with a median age of 18 years (range 12-40). Four presented with epigastric pain and three had a painless abdominal lump. The median duration of symptoms prior to presentation was 3 months (range 1-6). The tumor size ranged from 6-16 cm (mean 10 cm). Preoperative diagnosis was established by fine needle aspiration cytology in three patients. All the seven underwent resection. Pericapsular adhesions were found in two patients. All the patients were free of disease on follow-up ranging from 3-60 months (median 16 mo). CONCLUSION: Occurrence in young females, solid and cystic areas on imaging, resectability in spite of large size, and good prognosis are the important features of this tumor.

Palliative segment III biliary bypass (left cholangio-jejunostomy) in malignant block at porta hepatis.

Segment III cholangio-enteric anastomosis was performed in 17 patients with obstructive jaundice due to unresectable malignancies at the porta hepatis. The operative mortality was 6% (1/17) and morbidity 30% (5/17). More than 50% fall in bilirubin level with symptomatic improvement in pruritus was seen in 13 patients. Three patients had 25%-50% fall in bilirubin level. This procedure is safe and effective in palliation of unresectable hilar obstruction.

Carcinoma in the third testis in a case of polyorchidism and persistent müllerian structure syndrome.

Polyorchidism is a rare anomaly and neoplasia arising in a supernumerary testis is even rarer. We herein describe a case of tumor in a supernumerary abdominal testis in an adult male with unrecognized persistent müllerian structure syndrome.