Low maruyama index surgery for gastric cancer.

BACKGROUND: Japanese definitions and treatment guidelines have dominated extent-of-surgery concepts in gastric cancer for over 4 decades, despite the fact that such definitions/guidelines have changed considerably over time, and the fact they have largely failed to improve survival in prospective, randomized clinical trials. AIM: To briefly review lessons from previous surgical trials in gastric cancer, and, more specifically, to review data validating the concept of "low Maruyama Index surgery" as a data-driven guide to surgical treatment. METHODS: Review of results from blinded multivariate analyses of two separate, prospective, randomized clinical trials: (a) the Macdonald Trial of adjuvant postoperative chemo-radiation, Intergroup 0116, conducted in North America; and (b) the Dutch D1-D2 Trial. RESULTS: Blinded univariate and multivariate analysis of both trials establish "Maruyama Index of Unresected Disease" (MI) <5 as a strong independent predictor of better disease-free and overall survival in gastric cancer. Moreover, a strong "dose response" effect for MI versus survival is apparent. CONCLUSIONS: In contrast to surgery focused on achievement of a particular Japanese-defined D-level, "low Maruyama Index surgery" is associated with increased disease-free and overall survival. Further, the dose-response effect suggests MI can be used to quantify the adequacy of lymphadenectomy for a given patient. Low MI surgery can be prospectively planned by using the Maruyama Computer Program pre-operatively or intraoperatively.

Low Maruyama index surgery for gastric cancer: blinded reanalysis of the Dutch D1-D2 trial.

A quantitative estimate of residual nodal disease after gastric cancer surgery, the Maruyama index of unresected disease (MI), proved to be a strong independent predictor of survival in a large U.S. adjuvant chemoradiation study in which surgical undertreatment was frequent. Data from the Dutch D1-D2 Lymphadenectomy Trial permit an opportunity to assess the prognostic value of this variable in a cohort with lower-stage disease treated with minimum D-1 lymphadenectomy and no adjuvant chemoradiation. Blinded to survival, and excluding those cases with missing information, the MI was calculated for 648 of the original 711 patients treated with curative intent. Survival was assessed by log-rank and multivariate Cox regression analysis. All patients have been followed for a minimum of 11 years. Overall Dutch trial findings were not affected by the absence of 63 cases with incomplete data. As expected, the median MI was 26, much lower than in the previous U.S. study. In contrast to the D level, MI < 5 proved to be a strong predictor of survival by both univariate and multivariate analysis. The MI was an independent predictor of both overall survival [P = 0.016; hazard ratio (HR) = 1.45; 95% confidence interval (CI) 1.07-1.95] and relapse risk (P = 0.010; HR = 1.72; 95% CI 1.14-2.60). A strong dose-response reaction with respect to the MI and survival was also observed. We conclude that in this trial low-MI surgery is associated with enhanced survival, whereas outside of certain subgroups routine D2 lymphadenectomy is not. This observation suggests that surgeons might have more of an impact on patient survival by achieving a low-MI operation than a particular D level. A compelling dose-response effect reveals that the MI is a quantitative yardstick for assessing the adequacy of lymphadenectomy in gastric cancer.

Changing gastric cancer treatment in the United States and the pursuit of quality.

The low incidence of gastric cancer in the US presents various quality challenges. For most US practitioners, individual experience is inadequate. Accrual to clinical trials testing new treatments can be daunting. However, through the use of nationally available clinical trials sponsored by many trial groups working in concert, and the use of national registries for treatment and outcome surveillance, a path to increased gastric cancer survival has been charted. Moreover, systems for continuous quality improvement at the institutional level are in place. Quality assurance is an increasing concern of both private and governmental groups. In this article, we summarize recent national US clinical trial findings concerning gastric cancer treatment, highlight national assessment systems for cancer outcomes, and describe what these systems tell us about the current status of gastric cancer care in the US, highlighting challenges and areas for potential improvement.

Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction.

BACKGROUND: Surgical resection of adenocarcinoma of the stomach is curative in less than 40 percent of cases. We investigated the effect of surgery plus postoperative (adjuvant) chemoradiotherapy on the survival of patients with resectable adenocarcinoma of the stomach or gastroesophageal junction. METHODS: A total of 556 patients with resected adenocarcinoma of the stomach or gastroesophageal junction were randomly assigned to surgery plus postoperative chemoradiotherapy or surgery alone. The adjuvant treatment consisted of 425 mg of fluorouracil per square meter of body-surface area per day, plus 20 mg of leucovorin per square meter per day, for five days, followed by 4500 cGy of radiation at 180 cGy per day, given five days per week for five weeks, with modified doses of fluorouracil and leucovorin on the first four and the last three days of radiotherapy. One month after the completion of radiotherapy, two five-day cycles of fluorouracil (425 mg per square meter per day) plus leucovorin (20 mg per square meter per day) were given one month apart. RESULTS: The median overall survival in the surgery-only group was 27 months, as compared with 36 months in the chemoradiotherapy group; the hazard ratio for death was 1.35 (95 percent confidence interval, 1.09 to 1.66; P=0.005). The hazard ratio for relapse was 1.52 (95 percent confidence interval, 1.23 to 1.86; P<0.001). Three patients (1 percent) died from toxic effects of the chemoradiotherapy; grade 3 toxic effects occurred in 41 percent of the patients in the chemoradiotherapy group, and grade 4 toxic effects occurred in 32 percent. CONCLUSIONS: Postoperative chemoradiotherapy should be considered for all patients at high risk for recurrence of adenocarcinoma of the stomach or gastroesophageal junction who have undergone curative resection.

Ultrasound-guided radiofrequency thermal ablation of liver tumors: percutaneous, laparoscopic, and open surgical approaches.

Only 10% to 20% of patients with primary and colorectal metastatic liver tumors are candidates for curative surgical resection. Even after curative treatment, tumors recur commonly in the liver. As a less invasive therapy, radiofrequency thermal ablation (RFA) of primary, metastatic, and recurrent liver tumors was performed under percutaneous, laparoscopic, or open intraoperative ultrasound guidance. The safety and local control efficacy of RFA were investigated. RFA was performed mostly in patients with unresectable hepatomas or metastatic liver tumors. Patients with large tumors, major vessel or bile duct invasion, limited extrahepatic metastases, or liver dysfunction were not excluded. An RFA system with a 15-gauge electrode-cannula with four-pronged retractable needles was used. All patients were followed for more than 8 months to assess morbidity and mortality, and to determine tumor recurrence. Sixty RFA operations were performed in 46 patients: 11 patients underwent repeat RFA once or twice. A total of 204 tumors were treated: 70 hepatomas and 134 metastatic tumors. Tumor size ranged from 5 mm to 180 mm (mean 36 mm). RFA was performed in 29 operations for 81 tumors percutaneously, in seven operations for 14 tumors laparoscopically, and in 24 operations for 109 tumors by open surgery. Combined colorectal resection was carried out in five operations and combined hepatic resection was carried out in three operations. There was one death (1.7%) from liver failure, and there were three major complications (5%): one case of bile leakage and two biliary strictures due to thermal injury. There were no intra-abdominal infectious or bleeding complications. The length of hospital stay ranged from 0 to 2, 1 to 3, and 4 to 7 days for percutaneous, laparoscopic, and open surgical RFA, respectively. During a mean follow-up period of 20.5 months, local tumor recurrence at the RFA site was diagnosed in 18 (8.8%) of 204 tumors. The risk factors for local recurrence included large tumor size and major vessel invasion: recurrence rates for tumors less than 4 cm, 4 to 10 cm, and greater than 10 cm, and for those with vessel invasion were 3.3%, 14.7%, 50%, and 47.8%, respectively. Ten of 18 tumors recurring locally were retreated by RFA, and eight of them showed no further recurrence. Ultrasound-guided RFA is a relatively safe, well-tolerated, and versatile treatment option that offers excellent local control of primary and metastatic liver tumors. The appropriate use of percutaneous, laparoscopic, and open surgical RFA is beneficial in the management of patients with liver tumors in a variety of situations.

Current practice of radioiodine treatment in the management of differentiated thyroid cancer in Germany.

This prospective, observational study of a cohort of thyroid cancer patients in Germany focusses on the "real-world" practice in the management of thyroid cancer patients. This report includes data from 2376 patients with primary differentiated thyroid carcinoma first diagnosed in the year 1996. The study reveals considerable differences in actual practice concerning surgery and radioiodine treatment. The results indicate that consensus is lacking with respect to the multimodality treatment approach for differentiated thyroid carcinoma. Our analysis represents the most current and comprehensive national assessment of presenting patient characteristics, diagnostic tests, treatment and complications for thyroid cancer.

Analysis of medical-decision making and the use of standards of care in oncology.

Guidelines in medicine have been proposed as a way to assist physicians in the clinical decision-making process. Increasingly, they form the basis for assessing accountability in the delivery of healthcare services. However, experiences with their evaluation, as the most important step in the continuous guidelines process, are rare. Patient Care Evaluation Studies have been developed by the Commission on Cancer in the United States. As they reflect the "real-world" medical practice they are helpful in evaluating the quality of diagnosis, therapy and follow-up of tumor diseases in hospitals and cancer center and the compliance with current standards of care. In this context, they can provide an infrastructure for the analysis of the decision-making process.

Patterns of care for patients with primary differentiated carcinoma of the thyroid gland treated in Germany during 1996. U.S. and German Thyroid Cancer Group.

BACKGROUND: To determine current patterns of care and disease characteristics for patients with thyroid carcinoma, a Patient Care Evaluation Study was initiated in 1996 in the U.S. and Germany. This project addresses ongoing concerns with respect to the diagnostic evaluation and treatment of patients diagnosed with thyroid carcinoma and raises questions concerning how physicians are interpreting current standards and acting on the basis of these recommendations. METHODS: Patients with primary thyroid carcinoma were entered into a prospective multicenter observational study with free choice of treatment (no control group) between January 1, 1996 and December 31, 1996 in Germany. This resulted in a total of 2537 cases under observation and analysis; 1685 patients had papillary carcinoma (66.4%), 691 had follicular carcinoma (27.2%), 70 had medullary carcinoma (2.8%), and 91 had anaplastic carcinoma (3.6%). The 2376 patients with carcinoma of either papillary or follicular histology were included in the current analysis. RESULTS: The major symptoms reported for patients with papillary and follicular thyroid carcinoma was neck mass (reported in 76% and 79%, respectively) followed by dysphagia (reported in 25% and 27%, respectively), stridor (reported in 9% and 14%, respectively), and neck pain (reported in 7% and 8%, respectively). Greater than 50% of the patients with papillary thyroid carcinoma were reported to have American Joint Committee on Cancer/International Union Against Cancer Stage I disease. Between 37-39% of the follicular carcinoma patients had Stage I and Stage II disease. Only slight differences in the diagnostic approach to patients with papillary or follicular carcinoma were noted. The majority of patients underwent an ultrasound of the thyroid region (78.1%), which was suggestive of carcinoma in only 39% of the cases. A thyroid scan was performed on 76.6% of patients, and the results were suggestive of carcinoma in 44.8% of the individuals. In contrast, fine-needle aspiration biopsy of the thyroid is highly recommended in the current Clinical Practice Guidelines (CPG) but results were obtained in only 27.4% of the patients. Total thyroidectomy without lymph node dissection was the most commonly used surgical procedure in the treatment of patients with papillary and follicular thyroid carcinoma. Only approximately 2% of patients at low risk in the group with Stage I disease were treated with a lobectomy. In 80% of the patients with Stage I papillary thyroid carcinoma and approximately 90% of those patients diagnosed with Stage II, III, and IV disease treating physicians chose to utilize radioiodine as adjuvant treatment after disease-directed surgery. External beam radiation was added to the treatment regimen for many patients diagnosed with Stage III and IV disease (30% in patients with papillary thyroid carcinoma and 33% in patients with follicular thyroid carcinoma). CONCLUSIONS: To the authors' knowledge no single effective diagnostic test for thyroid carcinoma currently is available and in the majority of cases a combination of ultrasound, thyroid scan, or fine-needle aspiration biopsy together with the clinical findings (e.g., thyroid mass) led to a diagnosis of carcinoma. The authors suspect that the high prevalence of concomitant pathologic findings such as goiter, even in the healthy population in Germany, reduces the accuracy of all diagnostic test methods and may account for the frequent use of imaging techniques. The majority of patients underwent a total or near-total thyroidectomy. Total thyroidectomy with radical lymph node dissection was used very frequently in those patients with papillary thyroid carcinoma (22%). German physicians tend to surgically treat early stage thyroid carcinoma somewhat more radically than recommended in the CPG. With respect to other treatment options employed as part of the first course of treatment, radioiodine appears to play the most important role. [See commentary o

Initial results from a prospective cohort study of 5583 cases of thyroid carcinoma treated in the united states during 1996. U.S. and German Thyroid Cancer Study Group. An American College of Surgeons Commission on Cancer Patient Care Evaluation study.

BACKGROUND: The American College of Surgeons Commission on Cancer (CoC) has conducted national Patient Care Evaluation (PCE) studies since 1976. METHODS: Over 1500 hospitals with CoC-approved cancer programs were invited to participate in this prospective cohort study of U.S. thyroid carcinoma cases treated in 1996. Follow-up will be conducted through the National Cancer Data Base. RESULTS: Of the 5584 cases of thyroid carcinoma, 81% were papillary, 10% follicular, 3.6% Hürthle cell, 0.5% familial medullary, 2.7% sporadic medullary, and 1.7% undifferentiated/anaplastic. Demographics and suspected risk factors were analyzed. Fine-needle aspiration of the thyroid gland (53%) or a neck lymph node (7%), thyroid nuclear scan (39%), and ultrasound (38%) constituted the most frequently utilized diagnostic modalities. The vast majority of patients with differentiated thyroid carcinoma presented with American Joint Committee on Cancer Stage I and II disease and relatively small tumors. For all histologies, near-total or total thyroidectomy constituted the dominant surgical treatment. No lymph nodes were examined in a substantial proportion of cases. Residual tumor after the surgical event could be documented in 11% of cases, hypocalcemia in 10% of cases, and recurrent laryngeal nerve injury in 1.3% of cases. Complications were most frequently associated with total thyroidectomy combined with lymph node dissection. Thirty-day mortality was 0.3%; when undifferentiated/anaplastic cancer cases were eliminated, it decreased to 0.2%. Adjuvant treatment, probably underreported in this study, consisted of hormonal suppression (50% overall) and radioiodine (50% overall). CONCLUSIONS: In addition to offering information concerning risk factors and symptoms, the current PCE study compliments the survival information from previous NCDB reports and offers a surveillance snapshot of current management of thyroid carcinoma in the U.S. Identified opportunities for improvement of care include 1) more frequent use of fine-needle aspiration cytology in making a diagnosis; 2) more frequent use of laryngoscopy in evaluating patients preoperatively, especially those with voice change; and 3) improved lymph node resection and analysis to improve staging and, in some situations, outcomes.

The National Cancer Data Base Report on poor survival of U.S. gastric carcinoma patients treated with gastrectomy: Fifth Edition American Joint Committee on Cancer staging, proximal disease, and the "different disease" hypothesis.

BACKGROUND: A high proportion of U.S. patients with gastric carcinoma do not receive surgical treatment. To sharpen staging criteria and facilitate comparisons with surgical series, an analysis of patients whose treatment included gastrectomy was undertaken. In addition, to evaluate the "different disease" hypothesis as an explanation for superior Japanese results, outcomes for Japanese Americans were examined. METHODS: Data were obtained from National Cancer Data Base (NCDB) reports of 50,169 gastric carcinoma cases diagnosed during the years 1985-1996 and treated with gastrectomy. In addition to demographic and treatment information, 5-year and 10-year relative survival rates are presented, with stage defined according to fifth edition American Joint Committee on Cancer (AJCC) staging procedures. RESULTS: Stage-stratified 5-year and 10-year relative survival rates were as follows: Stage IA, 78%/65%; Stage IB, 58%/42%; Stage II, 34%/26%; Stage IIIA, 20%/14%; Stage IIIB, 8%/3%; and Stage IV, 7%/5%. Stage-stratified survival for Japanese Americans was higher. Males had a poorer prognosis than females, and the male-to-female ratio for Japanese Americans was lower. Proximal tumors were associated with a worse prognosis than distal tumors; the proportion of Japanese Americans with proximal disease was less than in the overall patient group. Japanese Americans underwent resection of adjacent organs less frequently. In this series, adjuvant therapy did not substantially affect survival. Overall, 20% were 10-year survivors; of these, 67% were lymph node negative and 98% had /= 15 lymph nodes analyzed. Stage migration was evident in cases with

Two hundred eighty-six cases of parathyroid carcinoma treated in the U.S. between 1985-1995: a National Cancer Data Base Report. The American College of Surgeons Commission on Cancer and the American Cancer Society.

BACKGROUND: In combination with other Commission on Cancer programs, the National Cancer Data Base (NCDB), a national electronic registry system currently capturing > 60% of incident cancers in the U. S., offers a working example of voluntary, accurate, cost-effective "outcomes management" on a both a local and national scale. In addition, it is proving to be of particular value in capturing clinical information concerning rare cancers. METHODS: For accession years 1985-1995, the NCDB captured prospectively collected demographic, stage, treatment, and outcome information for a national hospital-based sample of 286 parathyroid carcinoma cases (0.005% of the total NCDB cancer cases). This report describes clinical and demographic features as well as patterns of care and 5-year and 10-year relative survival rates. RESULTS: The NCDB's 10-year accrual of parathyroid carcinoma cases exceeded the cumulative number reported in the English literature though 1991. Gender distribution was equal. The authors were unable to detect any disproportionate clustering by race, income level, or geographic region. Treatment overwhelmingly was surgical. The data from the current study suggest that neither tumor size nor lymph node status are significant prognostic factors. Overall relative survival at 5 years and 10 years was 85.5% and 49.1%, respectively. CONCLUSIONS: At 5 years of follow-up, and possibly beyond, neither tumor size nor lymph node status were found to be significant prognostic factors and basing a staging system on them would be useless. Although complete, en bloc resection of all tumor represents the best opportunity for cure, a substantial proportion of patients fail to receive such treatment. The authors speculate that the rarity of this condition and late intraoperative recognition occasionally prevent optimal treatment. [See editorial on pages 378-80, this issue.]

Confronting actual practice with practice guidelines in oncology.

Improving health care quality requires the availability of data to identify and eliminate unnecessary variations in the care process. Variations can be caused by an ineffective implementation of research findings or by obstacles to the translation of research into clinical practice. The analysis of current patterns of care by the use of routine data from electronic patient records or clinical registries may help highlight these deficiencies in actual care. The growing infrastructure of information technologies and the knowledge about clinically relevant variations of routine practice may help us understand the mechanisms that are impeding the translation of research into practice. There is a need to scrutinize these variations of practice and the barriers to guideline implementation. We think that an understanding and open discussion of such reasons may help, to continuously improve the quality of patient care. This process facilitates efforts and strategies to implement evidence-based medicine in the daily routine.

Perspective: National Cancer Institute summary report about estimated exposures and thyroid doses received from iodine 131 in fallout after Nevada atmospheric nuclear bomb tests.

Environmental 131I contamination from atmospheric nuclear bomb tests conducted at the NTS from 1951 to 1958 exposed Americans nationwide to a cumulative average dose of 1 to 4 rad to the thyroid gland. By comparison, 10 years of exposure to natural background sources of thyroid radiation results in a cumulative dose of 1 rad. Americans living in certain high-deposition areas received an average cumulative thyroid dose of as much as 16 rad. Individual dose rates vary considerably as a function of age at the time of exposure, site of residence, and dietary habits with respect to milk consumption. The individual cumulative thyroid dose for persons born between 1945 and 1958 may be significantly higher than the reported averages for their locale. The NCI report contains voluminous data tables permitting detailed calculations of individual dose. Additionally, color-coded dose maps allow one to approximate individual dose conveniently. Translation of cumulative thyroid dose attributable to 131I to predictions of increased rates of thyroid cancer appears problematic and is the subject of further study. In contrast to studies of patients receiving external thyroid irradiation, existing studies of patients treated with 131I for diagnostic and therapeutic medical purposes do not document increased rates of thyroid cancer. An Institute of Medicine task force is expected to issue a report on this subject in September 1998. This review also briefly summarizes the evaluation, diagnosis, and treatment of patients with papillary and follicular thyroid cancers. Data from 53,856 patients with thyroid cancer accessioned to the NCDB from 1985 to 1995 document extremely high survival rates for patients in the United States with papillary and follicular thyroid cancer.

A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-1995 [see commetns].

BACKGROUND: The National Cancer Data Base (NCDB) represents a national electronic registry system now capturing nearly 60% of incident cancers in the U. S. In combination with other Commission on Cancer programs, the NCDB offers a working example of voluntary, accurate, cost-effective "outcomes management" on a both a local and national scale. In addition, it is of particular value in capturing clinical information concerning rare cancers, such as those of the thyroid. METHODS: For the accession years 1985-1995, NCDB captured demographic, patterns-of-care, stage, treatment, and outcome information for a convenience sample of 53,856 thyroid carcinoma cases (1% of total NCDB cases). This article focuses on overall 10-year relative survival and American Joint Committee on Cancer (AJCC) (3rd/4th edition) stage-stratified 5-year relative survival for each histologic type of thyroid carcinoma. Care patterns also are discussed. RESULTS: The 10-year overall relative survival rates for U. S. patients with papillary, follicular, Hürthle cell, medullary, and undifferentiated/anaplastic carcinoma was 93%, 85%, 76%, 75%, and 14%, respectively. For papillary and follicular neoplasms, current AJCC staging failed to discriminate between patients with Stage I and II disease at 5 years. Total thyroidectomy +/- lymph node sampling/dissection represented the dominant method of surgical treatment rendered to patients with papillary and follicular neoplasms. Approximately 38% of such patients receive adjuvant iodine-131 ablation/therapy. At 5 years, variation in surgical treatment (i.e., lobectomy vs. more extensive surgery) failed to translate into compelling differences in survival for any subgroup with papillary or follicular carcinoma, but longer follow-up is required to evaluate this. NCDB data appeared to validate the AMES prognostic system, as applied to papillary cases. Younger age appeared to influence prognosis favorably for all thyroid neoplasms, including medullary and undifferentiated/anaplastic carcinoma. NCDB data also revealed that unusual patients diagnosed with undifferentiated/anaplastic carcinoma before age of 45 years have better survival. CONCLUSIONS: The NCDB system permits analysis of care patterns and survival for large numbers of contemporaneous U. S. patients with relatively rare neoplasms, such as thyroid carcinoma. In this context, it represents an unsurpassed clinical tool for analyzing care, evaluating prognostic models, generating new hypotheses, and overcoming the volume-related drawbacks inherent in the study of such neoplasms. [See editorial on pages 2434-6, this issue.]

The National Cancer Data Base report on gastric carcinoma.

BACKGROUND: The National Cancer Data Base (NCDB) represents a national electronic registry system now encompassing almost 60% of incident cancers in the United States. In combination with other programs of the American College of Surgeons Commission on Cancer, the NCDB offers a working example of voluntary, accurate, and cost-effective "outcomes management" on a both a local and a national scale. METHODS: For the accession years 1985-1993, the NCDB has obtained information on demographics, patterns of care, disease stage, treatment, and outcome for a convenience sample of 57,407 gastric carcinoma cases (1.6% of total NCDB cases). In addition to describing trends, this report focuses on 5-year relative survival for a cohort of 1987-1988 cases staged according to the third edition of the American Joint Committee on Cancer's TNM classification, as well as patterns of care for a cohort of 1992-1993 cases. RESULTS: Stage-stratified 5-year relative survival for the 1987-1988 cohort was as follows: IA, 71%; IB, 56%; II, 37%; IIIA, 18%; IIIB, 11%; IV, 5%. Without noteworthy changes in stage distribution, demographics, or other factors, the proportion of patients treated by total gastrectomy is increasing slightly, but proximal gastrectomy for proximal cancers remains surprisingly popular. The proportion of cases receiving postoperative adjuvant treatment has declined slightly. Presumably because of advanced age and/or medical infirmity, a substantial proportion of U.S. patients with disease at every stage receive no treatment for cancer. CONCLUSIONS: This analysis of patterns of care has revealed unexplained variations in treatment and opportunities for improvement. Treatment of the elderly, infirm patient with gastric carcinoma appears problematic.

The National Cancer Data Base report on patterns of hospital reporting.

BACKGROUND: Previous Commission on Cancer data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1993) data are described here. METHODS: Five calls for data have yielded a total of 3,700,000 cases for the years 1985 through 1993, including 477,679 cases for 1988, and 608,593 cases for 1993, from hospital cancer registries across the U.S. RESULTS: The most recent call for data for 1993 comprised 52% of the estimated new cases of cancer in the U.S. The country was comprised of 6 regions, with the Mountain and Southeast regions having the highest regional reporting of new cases of cancer (69% and 55%, respectively) and the Northeast and Pacific regions having the lowest (47% each). Approximately 96% of patients received their treatment at the reporting hospital. The 4 most common carcinomas were breast (15.7%), lung (14.6%), prostate (14.2%), and colon (7.5%) and comprised the majority of new cases. Trends in patterns of care for breast carcinoma were analyzed for possible bias in the 1988 and 1993 periods. When hospitals reporting only in 1988 or in 1993 were compared with hospitals reporting at both time points, the only differences were small differences in ethnic participation. These differences were less than 1.5% in the proportion of African Americans reported in the different time periods. There were no significant differences in the downstaging of breast carcinoma, or the role of conservative surgery or adjuvant radiation therapy. CONCLUSIONS: The NCDB is a cancer management and outcomes data base for health care organizations that presently comprises 52% of the estimated new cases in the U.S. This will increase to 80% as the approved hospitals of the Commission on Cancer are required to report to the NCDB. Comparison of breast carcinoma findings at two time periods appeared similar regardless of hospital reporting set (i.e., set of hospitals reporting for one period versus both periods).

Racial factors cannot explain superior Japanese outcomes in stomach cancer.

OBJECTIVE: To compare the stage-stratified survival of Japanese patients treated in Honolulu according to Western techniques with that of Japanese patients treated in Tokyo according to Japanese techniques, thus eliminating race as a potentially confounding variable. DESIGN AND PATIENTS: Of 312 Honolulu Japanese patients surviving Western-type gastric resection for neoplasm between 1974 and 1985, 279 were identified with invasive gastric adenocarcinoma unassociated with any second malignancy. This Honolulu cohort, treated by Western methods, was retrospectively compared with a similar, previously described cohort of 3176 Tokyo Japanese patients treated according to Japanese methods. MAIN OUTCOME MEASURES: American Joint Committee on Cancer/Union Internationale Contre le Cancer criteria for stage-stratified survival. RESULTS: Despite non-TNM prognostic factors favoring higher survival for the Honolulu Japanese patients, for every TNM stage, we observed higher survival for the Tokyo Japanese patients who were treated according to Japanese techniques. For stage I disease, the survival rates were 86% vs 96%, respectively (P < .001); for state II, 69% vas 77% (P = .15); for stage III, 21% vs 49% (P < .001); and for stage IV, 4% vs 14% (P < .001). CONCLUSIONS: Because all patients in this study are Japanese, race-related factors or the "different-disease" hypothesis cannot explain these results. Lymphadenectomy-related stage-migration and/or differing therapeutic efficacy seem more likely explanations.

Ischemic colitis after aortic aneurysmectomy.

A retrospective analysis was conducted to quantitatively assess eight suspected risk factors for the development of bowel ischemia after abdominal aortic aneurysmectomy. Eighteen patients were studied and compared with 100 randomly selected control subjects who underwent similar operations during the same time period in five Honolulu hospitals, but in whom the complication did not develop. Prolonged cross-clamp time, hypoxemia, ruptured aneurysm, hypotension, and arrhythmia (supraventricular and ventricular) occurred with significantly greater frequency among the patients with ischemia when compared with the control subjects. Age and other preexisting cardiovascular or gastrointestinal diseases did not significantly correlate with risk of postoperative colon ischemia. In addition, the technique of aortic grafting did not significantly influence the risk of development of ischemic colitis, but the number of patients in this study is too small to provide meaningful data on that point.

The spatial and temporal quantification of myofibroblasts.

The number and distribution of myofibroblasts in porcine excisional wounds have been measured over a 16-week period by immunoperoxidase labeling of the smooth-muscle antigen in the cytoplasm of the contractile fibroblasts. Changes in the number of myofibroblasts over time correlate with the rate of wound contraction, and the myofibroblasts were distributed throughout the granulation tissue. These findings support the proposal that the contractile fibroblast is the agent of wound contraction. Significantly fewer myofibroblasts are found near the base of the wound and a larger number of myofibroblasts are found in close proximity to inflammatory foci, suggesting a causal relationship between inflammation and the acquisition of contractile properties by the wound fibroblast. There is evidence of a slightly lower percentage of myofibroblasts in areas of rapid fibroblast replication, and the percentage of myofibroblasts does not vary with changes in the tension across a wound. The immunoperoxidase-staining technique permits the identification of individual myofibroblasts by light microscopy and will be a useful tool for further studies of myofibroblast activity and control.