Small bowel exclusion from the pelvis by a polyglycolic acid mesh sling.

Radiation enteritis is seen in patients receiving radiation therapy for various pelvic malignancies. Attempts to prevent this have included various surgical as well as nutritional approaches with little success. The use of a polyglycolic acid mesh sling sewn above the pelvic inlet has prevented small bowel descent into the true pelvis in rats and in humans. The technique has been successful in both with no attendant morbidity during an 11-month follow up. Several patients have received additional doses of radiation therapy that would not have been given if the small bowel were not removed from the area to be irradiated.

Therapeutic and clinical course of deep vein thrombosis.

We have reviewed our experience with the treatment of 250 patients with deep vein thrombosis diagnosed by contrast venography. The level of thrombosis was recorded according to the anatomic level to which it extended. A third of the patients had cancer, and the most common clinical findings were swelling and pain. The risk of the development of pulmonary embolism, based on the anatomic level of initial deep vein thrombosis, revealed the following: 12 of 115 patients (10 percent) with level I (calf) deep vein thrombosis developed pulmonary embolism, as did 2 of 27 patients (7 percent) with level II (popliteal) disease, 5 of 60 (8 percent) with level III (thigh) disease, 1 of 19 patients (5 percent) with level IV (groin) disease, and 2 of 26 patients (8 percent) with level V (iliac) disease. Based on our favorable experience with heparin we believe that heparin is the treatment of choice for deep vein thrombosis regardless of the anatomic level. The incidence of pulmonary embolism does not appear to be influenced significantly by the level of the deep vein thrombosis.

Clinical experience with vena caval filters in high-risk cancer patients.

Our experience with the placement of intracaval filter devices in patients with malignancies, is reviewed. Seventy patients had either a Mobin Uddin or Greenfield Umbrella Filter placed since 1971. The indications for caval interruption in our series included contraindications to anticoagulant therapy, bleeding with anticoagulant therapy, and recurrent pulmonary embolism with anticoagulant therapy. Of the 70 patients, 47 had a diagnosis of deep vein thrombosis, 15 had the diagnosis of pulmonary embolus, and eight had the diagnosis of both deep vein thrombosis and pulmonary embolus. The types of malignancies that were present in our patients included breast carcinoma, gynecologic tumors, colon tumors, pancreatic carcinoma, and hematologic malignancies. We report no operative mortality and a low operative morbidity of 7% utilizing this method of caval interruption. The late morbidity of stasis sequelae following caval interruption was present in 14% of the patients. Based on a favorable experience with this method of vena cava interruption in high-risk patients with advanced malignancies, the authors suggest a more liberal indication for caval interruption in this group of patients.

Role of endocrine function tests in the evaluation of transsphenoidal hypophysectomy for advanced breast cancer.

Forty-three women underwent transsphenoidal hypophysectomy for metastatic breast cancer. Endocrine tests (luteinizing hormone, follicle-stimulating hormone, thyrotropin, prolactin and growth hormone) were done in 28 patients to evaluate the completeness of the procedure. Response of the metastatic breast cancer and duration of survival after hypophysectomy were determined and statistically compared with the posthypophysectomy hormone levels. Only one patient had an endocrinologically complete hypophysectomy, but the objective remission rate (32 percent) is comparable to the 30 to 40 percent objective remission rate reported in other studies that claim to have achieved complete hypophysectomy. No statistically significant associations were found between the levels of the hormones measured and the type of response (objective, subjective or none) to hypophysectomy. However, objective responders survived longer than nonresponders (p = 0.01). When analyzing the associations of the various hormone levels with the duration of survival after hypophysectomy, a positive correlation (p less than 0.05) of peak thyrotropin levels with duration of survival was found. Our data indicate that the clinical benefit advanced breast cancer patients received from an endocrinologically incomplete hypophysectomy is probably as great as that received from an endocrinologically complete hypophysectomy. It appears that a nonspecific disturbance of the hormonal milieu may adversely affect the growth of breast cancer. More studies are needed to elucidate the nature of the endocrine disturbance produced by hypophysectomy and its effects on hormone-sensitive tumors.

Leptomeningeal spread of breast cancer: report of case and review of the literature.

Leptomeningeal metastasis--so-called "meningeal carcinomatosis"--of breast carcinoma has become a problem of some magnitude in recent years, in part a result of the increasing use of combination chemotherapy in the treatment of this disease. Early clinical diagnosis, based on the recognition of multifocal neurologic dysfunction, and aggressive therapy combining irradiation to severely symptomatic sites with intrathecal chemotherapy are considered primordial in order to improve the poor prognosis of the untreated lesion. This is especially true in view of the fact that meningeal metastasis often occurs as the sole site of recurrence in an otherwise asymptomatic patient. Hence, relief of neurologic symptoms can provide meaningful palliation and an occasional long-term survivor. If meningeal metastasis continues to increase in breast cancer patients, prophylactic CNS treatment may become a consideration.

A combined treatment program for the management of locally recurrent breast cancer following chest wall irradiation.

Locally recurrent breast cancer involving the previously irradiated chest wall and skin is a difficult but manageable problem. A detailed oncological evaluation is initially undertaken to determine the extent of local and systemic disease. Local infection, if present, is controlled by topical therapy with 0.5% silver nitrate in conjunction with well-planned, aggressive radiotherapy to the areas of tumor recurrence. Concomitant, hormonal, and/or cytotoxic chemotherapy is administered if evidence of systemic involvement is detected. Biopsies of the ulcer margin are performed with surgical excision and débridement as indicated, followed by sequential skin grafting. Seven patients are presented in whom circumferential ulcer biopsies, radiation therapy, skin grafting, and topical silver nitrate therapy were carried out with control and resolution of local symptoms in all cases. It is not essential to have initial tumor control in order to insure graft take. This program has particular application to the poor risk surgical patient, with or without evidence of systemic disease.

Retroperitoneal fibrosis with ureteral obstruction secondary to Actinomyces israeli.

A case of Actinomycosis israeli causing retroperitoneal fibrosis and ureteral obstruction is presented. This rare occurrence followed direct extension of the infectious process from intra-abdominal abscesses to the retroperitoneum, resulting in dense fibrosis. Diagnosis is most commonly established by histologic identification of sulfur granules obtained at abdominal exploration. The pathogenesis and treatment of genitourinary as well as retroperitoneal actinomycosis is discussed.

Pelvic exenteration as palliation of malignant disease.

It has been traditional to exclude patients with radiation-recurrent carcinoma of the uterine cervix or other pelvic neoplasms, incapacitating pelvic pain, postirradiation fistulas, hemorrhage, or malodorous draining tumor necrosis from pelvic exenteration if cure of the malignant disease is not achievable. This negative attitude is a direct result of the reported high morbidity, prohibitive mortality, and low salvage rate previously associated with pelvic exenteration, the only acceptable surgical approach to these diseases. A recent experience with eighteen patients who underwent pelvic exenteration for advanced primary or recurrent carcinoma of the cervix, urinary bladder, or rectum has led us to challenge several traditional concepts regarding this operative procedure. We have observed but one operative death and our morbidity has been minimal. This may reflect our belief that an aggressive pelvic lymphadenectomy in those patients with direct visceral involvement from radiation-recurrent carcinoma of the pelvic viscera is not advantageous since no significant survival has ever been documented for patients with pathologic visceral involvement and positive lymph nodes. In addition, significant morbidity has always been associated directly with pelvic lymphadenectomy in the irradiated pelvis, and elimination of this phase of the operation in selected patients with radiation-recurrent carcinoma is indicated. Moreover, the considerable decrease in morbidity and the minimal mortality observed have led us to adopt a very liberal attitude toward preoperative selection criteria, and we regularly now use pelvic exenteration not only for cure but as intentional palliation in selected patients. We strongly believe that elimination of pain, fistulas, pelvic sepsis, hemorrhage, and malodorous areas of tumor necrosis are important for improving the quality of life for both the patient and family.

New look at pelvic exenteration.

Our experience with 18 patients undergoing pelvic exenteration for advanced primary or recurrent pelvic malignancies is presented. Only one postoperative death was noted, and morbidity was minimal despite the advanced age and high incidence of radiotherapy failures seen in our patients. Although no improvement in cure of malignancy has been seen in this small series, appreciable periods of symptom-free life have been achieved in patients who were previously incapacitated by extensive pelvic pain, fistulas, sepsis, hemorrhage and urinary-fecal incontinence. Because of the symptomatic palliation obtained in our experience, with minimal morbidity and mortality, we have developed a liberal attitude toward the use of pelvic exenteration in the management of selected patients with extensive pelvic malignancy, even when cure is not anticipated.

Preneoplastic changes in rabbit pancreatic duct cells produced by dimethylhydrazine.

Permeation catheters containing 40% dimethylhydrazine (DMH) were implanted into the main pancreatic duct of New Zealand white rabbits. The catheters were constructed of silicone polycarbonate with a 4- to 10-day carcinogen release rate. Rabbits implanted with catheters containing DMH showed pancreatic ductal cell hyperplasia, metaplasia and dysplasia with periductal cell infiltration, adenosis and adenoma formation. These changes began approximately 9 to 12 weeks after implantation and persisted for 75 to 80 weeks. Specificity of the delivery system appeared to be excellent in that pathologic effects were observed only in the pancreatic and peripancreatic tissues. Moreover, these effects were probably directly related to the implanted carcinogen since similar maintained effects were not observed in control animals.