Preoperative endosonographic staging of cancer of the cardia.

BACKGROUND: To evaluate the diagnostic accuracy of endosonography (ES) in a prospective series of cancer of the cardia. METHODS: Thirty-five patients with cancer of the cardia were investigated by ES; 29 underwent surgery. ES staging for the surgery patients was compared with histopathologic findings. Tumors were staged according to the 1987 TNM classification. RESULTS: ES had a diagnostic accuracy of 79% for the T category, 79% for the N category, 89% for the M category, and 72% for prognostic TNM staging. CONCLUSION: ES is an excellent paraclinical modality for the staging of local-regional spread of cancer of the cardia and a useful complement to computed tomography for evaluation of these tumors.

[Evaluation of the "squamous cell carcinoma antigen" as marker of epidermoid cancer of the anal canal]. / Evaluation du "Squamous Cell Carcinoma Antigen" comme marqueur du cancer epidermoïde du canal anal.

The authors studied the value of Squamous Cell Carcinoma Antigen (SCC) in squamous carcinoma of the anal canal in 66 patients. Assays were made at the time of diagnosis, before any treatment and during follow-up. A total of 353 assays were made. The positive threshold was selected at 2 ng/ml. At the time of diagnosis, sensitivity of the marker was 44 per cent and its specificity 92 per cent. In our series, pre-treatment SCC levels were not correlated with T by the Papillon classification, but were correlated with lymph node involvement (p less than 0.05). They had no prognostic value at the time of the initial diagnosis. During follow-up, at the time of recurrence, SCC levels were 20.3 +/- 43 ng/ml. This rise was significant (p less than 0.01), the sensitivity of the marker being 77 per cent. In patients who had a recurrence, the outcome was correlated with SCC levels and the latter were of prognostic value (p less than 0.01). In conclusion, SCC levels should form part of the clinical monitoring of patients with a squamous carcinoma of the anal canal.

Assessment of "squamous cell carcinoma antigen" (SCC) as a marker of epidermoid carcinoma of the anal canal.

We measured squamous cell carcinoma antigen (SCC) in epidermoid carcinoma of the anal canal in 66 patients. Samples were taken at diagnosis, before treatment, and during follow-up; 353 samples were analyzed. The positive threshold was taken as 2 ng/ml. At diagnosis, the sensitivity of the marker was 44 percent and its specificity 92 percent. In our series, the pretherapeutic level of SCC does not correlate with T as in Papillons' Clinical Staging System, but it does correlate with nodal invasion (P less than 0.05). It is of no prognostic value at the time of diagnosis. During follow-up, at relapse the level of SCC is 20.3 +/- 43 ng/ml. This increase is significant (P less than 0.01): the sensitivity of the marker is 77 percent. In patients who have relapsed, development of the illness correlates with the level of SCC, which is of prognostic value (P less than 0.01). In conclusion, the level of SCC should be associated with the clinical follow-up of patients with epidermoid carcinoma of the anal canal.

[Conservative treatment of epidermoid cancer of the anal canal combining radiotherapy and curietherapy. Experience at the Antoine-Lacassagne Center]. / Traitement conservateur du cancer épidermoïde du canal anal par association de radiothérapie et de curiethérapie. Expérience du Centre Antoine-Lacassagne.

From 1973 to 1987, 33 patients aged from 46 to 86 years (25 female, 8 male) were treated for a tumour of the anal canal with radiotherapy and curietherapy. Tumour distribution was 7 T1, 19 T2, 7 T3, and 4 patients were N+. After treatment it was possible to assess 31 patients; 29 were in complete remission, remission was obtained in 2 others following surgery. Tolerance was comparable to other series but 4 patients developed necrosis of the anal canal; 2 patients died under general anesthesia and 1 patient had a radiation injury of the small intestine. The sphincter was conserved in 65 p. cent of cases. Relapse occurred in 8 patients within 6-92 months, and 6 patients developed metastases. Overall survival was 78 p. cent at 3 years and 74 p. cent at 5 and 10 years. Disease-free survival was 65 p. cent at 3 and 5 years and 52 p. cent at 10 years. Our results confirm those of other series using a similar treatment plan. This treatment is difficult to put into practice. Patients must be carefully selected preferably by a team including proctologist, surgeon and radiotherapist.

[Treatment of cancer of the anal canal with combination radiochemotherapy: apropos of 12 cases]. / Traitement des cancers du canal anal par association radio-chimiothérapie: à propos de 12 cas.

We present 12 patients (3 male, 9 female) aged from 53-88 years with squamous cell cancer of the anal canal treated with combined radiotherapy-chemotherapy (5 FU-mitomycin C); the distribution of the tumours was 2 T4, 6 T3, 3 T2, 1 T1). In 11 patients evaluated, complete remission was obtained in 8 with partial remission in 2 others. In spite of this good result with combined treatment, 4 patients had a recurrence between 9 and 26 months. Five patients survived and 2 died without disease (16-38 month), 3 patients died and one survived with disease. The small series confirms the efficacy of this combination which treated bulky tumours (T3-T4). It is necessary however to compare these results with radiation alone in a randomised trial.

Labeling index and labeling distribution in the colonic crypts: a contribution to definition of patients at high risk for colorectal cancer.

The labeling index (LI), representing the percentage of S-phase cells, was measured in the healthy colorectal mucosa of subjects without a personal or familial history of neoplasm as well as in persons with a positive history, and was compared to the LI in benign or malignant lesions in a total of 128 subjects. In the healthy mucosa, LI was lowest in control subjects; it rose progressively in patients with a personal history of adenoma, patients with non colorectal cancer, and colorectal cancer patients respectively. There was a significant increase in LI from healthy mucosa to adenoma to carcinoma. The pattern of labeling in the crypts was studied in 56 subjects with different familial and personal histories. Limitation of labeling to the deepest part of the crypts was observed in control subjects and to a lesser extent in the healthy mucosa of patients with adenoma. An upward shift of the proliferative zone was observed in patients with a personal or familial history of cancer; adenomatous lesions had an inverse labeling distribution: labeling decreased from the luminal aspect towards the deep segments. High LI values and a shift of the proliferative zone towards the surface of the crypt may identify individuals at high risk for cancer of the colon and rectum.

Relationship between systemic 5-FU passage and response in colorectal cancer patients treated with intrahepatic chemotherapy.

The study described herein was conducted to analyze the relationship between tumor exposure to 5-FU and clinical response. Six patients were placed on continuous 5-day intrahepatic 5-FU chemotherapy for colorectal cancer metastasized to the liver. The starting dose was 600-800 mg/m2 per day; cycles were repeated at 4-week intervals. The 5-FU dose was increased by 250 mg/day at each cycle. All six patients received 3 or more cycles, for a total of 37 cycles. Response was evaluated after each cycle by ultrasonography or computed tomography (CT). Pharmacokinetic data revealed a high individual cycle-to-cycle variability for all six patients in the 5-FU area under the curve (AUC day 1 to day 5) corrected for the dose. These variations in drug biodisposition, reflecting hepatic 5-FU uptake, were significantly related to measurable modifications in the tumor mass in 71% of cycles. The correlation between the reduction in local drug exposure and tumor regrowth was better than that between the increase in local drug exposure and tumor reduction. These findings constitute an original illustration in humans of the experimental concept of the drug exposure/tumor response relationship for 5-FU.

[Adriamycin in low weekly doses. Latest therapy of advanced cancer of the breast]. / L'adriamycine à faible dose hebdomadaire. Dernière thérapeutique du cancer du sein avancé.

Thirty-four patients with heavily pretreated advanced breast cancer received adriamycin in weekly doses of 12 mg/m2. Twenty-two patients (18 assessable) had a performance status greater than or equal to 3 (WHO scale). There were 5 (28%) partial responses, 7 (39%) minimal responses, 3 cases (17%) with no change and 3 (17%) with progressive disease; the mean duration of response was superior to 9 months (range: 3-12 months). In the remaining 12 patients, who had resisted a previous multidrug regimen containing adriamycin, there were 3 (25%) partial responses, 2 (17%) minimal responses, 4 cases (33%) with no change and 3 (25%) with progressive disease; the mean duration of response was superior to 5 months (range: 3-11 months). More than 600 weekly injections were administered with only minor blood and digestive tract toxicities. No alopecia was recorded. The total cumulative dose of adriamycin was superior to 900 mg/m2 in 8 patients; none had clinically evident cardiac toxicity. Adriamycin extravasation with subsequent tissue necrosis occurred on 10 occasions due to the frequency of administration; this problem was solved by the systematic installation of central venous catheters.

[Value of ultrasonics in diagnosing the onset of lymphomatous liver lesions]. / Valeur de l'échographie dans le diagnostic d'atteinte lymphomateuse hépatique.

Ultrasound and anatomic findings were compared in 128 cases of lymphoma [87 non-Hodgkin lymphomas (NHL), 41 Hodgkin's disease (HD). Lymphomatous or other hepatic anomalies were observed in 40 cases (33 NHL, 7 HD). The 33 NHL lesions included 22 lymphomatous sites and 13 non-lymphomatous pathologies (in particular 5 biliary cysts and 4 cavernous liver hemangiomas). The 7 cases of hepatic anomalies in patients with HD included 6 specific disease sites and 1 cavernous hemangioma. For NHL, the sensitivity of ultrasonography in our series was 72.7% and the specificity 97%. In HD, the sensitivity was 66.6% and the specificity 100%. The value of ultrasound for the detection of lymphomatous liver lesions appears comparable to the results obtained with CT published in the literature; ultrasonography should thus be the first examination performed for subdiaphragmatic exploration during the investigation and follow-up of lymphomas.

[The CT scan coupled to the injection of lipiodol into the hepatic artery. Preliminary trial]. / La scanographie couplée à l'injection intra-artérielle hépatique de lipiodol. Expérience préliminaire.

A preliminary study of CT findings for 13 malignant liver tumors evaluated after intra-arterial hepatic lipiodol injection is presented. Comparison with ultrasound, conventional CT before and after contrast material injection, and arteriography revealed the superiority of intra-arterial lipiodol injection coupled with CT examination for both the detection of hepatomas and disease extension workups, thanks to the detection of small multifocal lesions. There is no lipiodol uptake by the tumor in cases of metastases or cholangiocarcinoma. The same technique can be applied to non-surgery patients for therapeutic hepatic artery injections of an extemporaneous lipiodol emulsion, hydrosoluble contrast materials and oncostatic drugs. A review of over 100 cases in the Japanese literature emphasizes the efficacy of this therapeutic approach.

Reevaluation of alkaline phosphatase measurement during Hodgkin's disease by electrophoretic isoenzyme separation.

Electrophoretic isoenzyme separation provides much more precise information than measurement of alkaline phosphatases (AP). Use of this technique for 83 patients with Hodgkin's disease revealed that the presence of the alpha 1 fraction (alpha 1 AP) was very significantly correlated with the stage of disease extension (P less than 0.01) and above all with the presence of general symptoms (P less than 0.001). Repeat measurements performed during patient follow-up demonstrated a close association between presence of alpha 1 AP and existence of progressive disease. While the mechanism of appearance of this abnormal alpha 1 AP fraction is not linked to Hodgkin-specific liver lesions, this test provides much more interesting data than classical measurement of total alkaline phosphatases (TAP).

Systemic blood levels after intra-arterial administration of microencapsulated mitomycin C in cancer patients.

Systemic delivery of mitomycin C (MMC) was studied in 6 patients administered microencapsulated MMC (MMC-mc) by an intra-arterial route (IA): 3 IA liver infusions, 3 IA pelvic infusions. Pharmacokinetic data revealed a lower blood MMC availability (peak plasma levels, AUC 0-4 hours) for the pelvis than for the liver; this was attributed to differences in the blood flow infusion rates at these two sites of administration. Direct comparison of systemic MMC exposure was possible for one patient, who received both IA liver MMC (10 mg in standard form, which served as the control) and IA liver MMC-mc (20 mg the day after). The 65% reduction in MMC-mc bioavailability observed for this patient indicates a quantitative local improvement in exposure to the drug and correlates well with the low incidence of systemic side effects noted in preliminary clinical studies.

Continuous 5-day regional chemotherapy by 5-fluorouracil in colon carcinoma: pharmacokinetic evaluation.

Eighteen patients with liver metastasis or locoregional recurrence of colon carcinoma received locoregional treatment by continuous 5-day infusions of 5-FU. 5-FU blood levels were measured by HPLC every day of the cycle at 8 am and 5 pm for a total of 87 cycles. Twelve patients were given the drug by an intra-arterial hepatic (i.a.h.) route, 3 by the portal vein (i.p.v.) and 3 by an intra-arterial pelvic (i.a.p.) route. These three routes were compared in respect of their relative pre-systemic drug uptake and the effect of dose escalation. Both the i.a.h. and i.p.v. routes, but not the i.a.p. route, resulted in a significant reduction in AUC 0-105 h compared to the i.v. route at the same dose range. Increasing the dose led to a modification in circulating 5-FU levels proportional to the dose for the i.v. and i.a.p. routes. By contrast, for the i.a.h. and i.p.v. routes, systemic drug delivery was significantly elevated, out of proportion with the dose, indicating a saturable process. For the i.a.h. route, increasing the 5-FU dose from 780 to 1000 mg m-2 day-1 caused a drop in hepatic extraction from 0.93 (0.90-0.95) to 0.44 (0.21-0.66). Liver saturation mechanisms were also evidenced by a mean increase of 2.6 times for the circulating drug level during the second part of the cycle as compared to the first part (P less than 0.001). The evolution of 5-FU AUC 0-105 h as a function of the dose was exponential (r = 0.75, P less than 0.001). Local extraction consecutive to i.a.p. was non-existent, implying that this route of drug administration has no potential advantage over classical i.v. infusion.

[Interventional radiology in chemotherapy. Percutaneous arterial route and and embolization with microspheres]. / Radiologie interventionnelle en chimiothérapie. Voie artérielle percutanée et embolisation de microsphères.

The authors present their experience with interventional radiological techniques employed for chemotherapy: 205 intra-arterial chemotherapy (IAC) cycles were administered to 67 patients (lesion sites were: liver 20, pelvis 35, unknown 12). Catheters were left in place for 5 days in 89% of cases. The positions of the end of the catheter was checked by CT scan, with concomitant arterial opacification in the case of pelvic pathologies; this allowed evaluation of the tumor volume treated. Serious radiological complications of IAC included: 2 surgical thrombectomies and 2 surgical removals of broken catheters (2% complication rate for IAC). 15 embolizations with microcapsules of mitomycin were performed for 11 patients, using the technique of Kato. Venous blood samples revealed the persistence of mitomycinemia for up to four hours. three instances of pain were noted in the 24 hours following embolization. These two techniques have a low rate of serious complications; the therapeutic efficacy observed in certain cases warrants the use of these methods for cancers impossible to treat by radical procedures.

Colonic and rectal lymphomas. A report of six cases and review of the literature.

In connection with six cases of colorectal lymphomas, including five cases of non-Hodgkin lymphomas (3 primary, 2 secondary), and one case of Hodgkin's disease, the authors review the literature concerning the general features and radiological aspects of these pathologies. The radiological signs observed during barium enemas for non-Hodgkin lymphomas are as follows: a small nodular pattern, frequently with multiple lesions (45.7% of cases), a diffuse or infiltrating pattern (25.4%), a filling defect (22.9%), endo- and exo-luminal images (17.8%), ulcerating patterns (3.4%) and a pure mesenteric form (0.8%). Thus, associated radiological forms are present in 16% of cases. The preferential site is the caecum (52.5% of cases), followed by the rectum (21.2%). Colonic or rectal involvement by Hodgkin's disease is extremely rare. From a radiological viewpoint, the most frequently described pattern in the literature is an infiltrating lesion which may or may not cause stenosis; the most frequent site is the caecum.

[Adenocarcinoma of the small intestine. Current state of diagnosis and treatment. A study of 27 cases and a review of the literature]. / L'adénocarcinome de l'intestin grêle. Etat actuel du diagnostic et du traitement. Etude de 27 cas et revue de la littérature.

On the basis of 27 personal cases of adenocarcinoma of the intestine and a review of the literature, the authors discuss present-day knowledge about this pathology from both radiologic and therapeutic viewpoints. This study, which excludes papillary tumors, reveals that, on a para-clinical level, barium follow-through examinations allow correct diagnosis in 85% of cases. Arteriography does not provide any special data, and more recent techniques such as ultrasound and C.T. do not appear suited for use in initial investigations. From a therapeutic standpoint, surgery is the only effective solution, but long-term survival had not increased for forty years. This rare form of cancer, with an especially insidious clinical course, has thus not benefited from recently introduced diagnostic and therapeutic technics.

Assessment of nutritional proteins during the parenteral nutrition of cancer patients.

Albumin, prealbumin, retinol-binding protein, and transferrin were all measured on the sera of 39 cancer patients before and during parenteral nutrition (PN). At the outset of PN, the concentrations of all of these proteins were low, as compared to reference values, and thus quantitatively reflected the degree of malnutrition. Prealbumin proved to be the most interesting parameter during PN: (1) during an initial period it rapidly reflects the nutritional input, and (2) after two weeks of PN it allows differentiation of patients whose prealbumin level rises regularly during PN and will survive from those patients whose prealbumin level drops after the initial period and will die during or within the month following PN. Prealbumin thus offers a means for biochemical monitoring of PN as well as having a prognostic value.

[The liver masses in ultrasonography. Report on 400 cases (author's transl)]. / Les masses hépatiques en échographie. A propos de 400 cas.

On the basis of 400 cases of liver masses, the authors have drawn conclusions that can be used to orient etiological investigations: --one or more well demarcated transsonic formations always correspond to a cystic etiology: --a hyperechoic metastatic liver points towards a primary cancer of the digestive tract whereas a hypoechoic metastatic liver is only rarely caused by such a cancer. The authors also propose a strategy for the exploration and surveillance of isolated hyperechoic or transsonic nodules of no more than 3 cm.