Predictive value of AMES scoring system in selection of extent of surgery in well differentiated carcinoma of thyroid.

The extent of surgical resection continues to be controversial for treatment of well-differentiated thyroid carcinoma (WDTC). It has been proposed that age, distant metastases, extent, and size (AMES) are prognostic indicators for WDTC. In this retrospective study, the role of AMES in selection and extent of surgical resection was evaluated. A total of 155 patients with WDTC treated between 1970 and 1990 at this institution were reviewed. The mean follow-up was 9 years. Patients were divided into low risk (Group A), and high risk (Group B) based on AMES. Group A had 141 patients, and Group B had 14 patients. Ninety-eight patients underwent total or subtotal thyroidectomy; 87 of these were in Group A and 11 in Group B. Fifty-seven patients had lesser surgical resection (53 lobectomy and isthmusectomy, three excision of nodule, and one needle biopsy). Five of the 11 in Group B who had more extensive surgery and none of 3 who had lesser surgery have died of their disease. Three patients in Group A have died of WDTC, of which two had total thyroidectomy and one had lobectomy with isthmusectomy. This study suggests that conservative resection is an adequate treatment in low risk patients based on AMES. This treatment may be enough for high risk patients, although the number of patients is small to make definitive recommendations.

Malignant melanoma in children: its management and prognosis.

Malignant melanoma is rare in children, representing 1% to 3% of all pediatric malignancies. Thirty-three children with malignant melanoma were treated at St Jude Children's Research Hospital from 1967 to 1988. Their ages ranged from 1 day to 20 years (median, 12 years); 23 were boys and 10 were girls; and 5 of the 33 (15%) were black. Four of the 33 children had been treated for a previous malignancy. In 3, melanoma arose within a bathing trunk nevus. The extremity was the most common site (13), followed by the trunk (9), head and neck (7), and perineum (1). In 3 patients the primary site could not be determined. Upon initial presentation to St Jude Hospital, 17 patients had localized disease (stage I), 10 had regional node involvement (stage II), and the remaining 6 patients had disseminated disease (stage III). Using both Clark's level and Breslow's thickness as indicators, the incidence, initial stage, prognosis, and survival were compared. By Clark's level, 7 patients, (6 of whom were stage I) were level II or III, and 22 patients were level IV or V. Though 16 of 22 level IV and V patients were initially stage I, 10 patients eventually developed progressive disease. Similar observations were noted when using Breslow's thickness to evaluate the primary. In 5 of 27 evaluable patients, Breslow's depth of invasion was less than 1.5 mm. All 5 of these patients were diagnosed with stage I disease and have not shown progressive disease.

Colon carcinoma in children and adolescents. A review of 30 cases.

Carcinoma of the large bowel is rare in persons under the age of 30, and generally presents with advanced stages of disease. From 1964 to 1984, 30 patients presented with nonfamilial large bowel malignancies. Seventeen patients were male, and 13 female (age range, 8-25 years). In 15 patients the primary was in the right transverse colon. In 26 patients the lesion was above the peritoneal reflection. Classification by Dukes' staging demonstrated Stage B in 3 patients, Stage C in 7 patients, and Stage D in 20 patients. Twenty-five patients had a mucinous variety of adenocarcinoma. Surgery at initial laparotomy consisted of biopsy (10 patients), palliative segmental resection (7 patients) and complete resection (13 patients; survival in each of these groups ranged from 1 to 15 months (median, 6 months), 6 to 36 months (median, 8 months) and 7 months to 14 years (median, 6 months), respectively. The only long-term survivors are three patients who had complete resection, two of whom are surviving free of disease after 5 and 15 years, respectively. Common sites of abdominal recurrence were the omentum (6 patients) and ovaries (7 patients). All patients received chemotherapy. In 16 of 24 evaluable patients, responses lasting 3 to 18 months were observed. Five patients also received radiation therapy. Follow-up of these patients included computed tomographic scans, ultrasound, and determination of carcinoembryonic antigen (CEA) levels. The CEA level in 9 of 23 patients did not correspond with the presence of either residual disease or progression of disease. Chemotherapy combined with a second-look surgical procedure in selected cases may improve the proportion of patients surviving and the duration of survival.

Adenocarcinoma of the colon and rectum in patients less than 40 years of age.

Sixty-two patients less than 40 years of age were admitted with adenocarcinoma of the colon and rectum between 1967 and 1981 at the Methodist Hospitals of Memphis. These represented 3.2 per cent of a total of 1909 patients with the disease during the same time period. Eighty-one per cent presented less than 6 months after onset of symptoms; pain and bleeding being the most common complaints. Inflammatory bowel diseases and polyposis were uncommon. Fifty-eight per cent of the lesions were within reach of the sigmoidoscope. Localized disease was present in 37.9 per cent, with one-third presenting with distant metastases. Sixty-five per cent were considered curable at initial laparotomy. Only 2 per cent of the lesions were well differentiated, and mucin production was noted in 32.3 per cent of the specimens compared to 8.6 per cent in the total group. Vascular invasion was noted in 24 per cent and perineural invasion in 11 per cent. Five-year survival was only 17.6 per cent, although this increased to 33 per cent in those undergoing curative resection. Survival in the total group of 1909 patients was 35.5 per cent at 5 years. The poorer survival in the young patients does not seem to be on the basis of delay in diagnosis, premalignant states, or distribution of lesions, but rather it reflects an inherently more virulent lesion. This impression is supported by a greater incidence of mucinous tumors (a poor prognostic indicator) and higher incidence of advanced disease, especially in the second and third decades.

Limb salvage procedures for children with osteosarcoma: an alternative to amputation.

Amputation remains the standard surgical management for patients with osteosarcoma. However, in carefully selected patients, eradication of the primary tumor can be achieved by En-Bloc resection of the affected bone preserving both anatomical and functional status. Our criteria for limb salvage procedures are that patients must: (1) be age 12 years or older, (2) have no angiographic or clinical evidence of neurovascular involvement, (3) have low-grade osteosarcoma and/or good response to preoperative chemotherapy, and (4) be compliant. Between November 1980 and October 1982, 32 patients with osteosarcoma of an extremity were seen. Eight patients ranging in age from 13 to 21 years underwent limb salvage procedures. Five of these had Tikhoff-Linberg procedures for upper extremity lesions, two had En-Bloc resections for distal femur lesions, and one patient had a segmental arthrodesis for a distal tibial lesion. Of these eight patients, two had low-grade parosteal osteosarcoma. Follow-up ranged from 10 to 28 months (median 16 months). The two patients with parosteal osteosarcoma received no further therapy, while the other six patients received multiple agent chemotherapy. One patient died at 18 months with bilateral pulmonary disease. None have had local recurrences. Two of the eight patients had minor skin necrosis, requiring revision subsequently. Three patients have had transient nerve palsy. All have had good functional results. With careful selection of patients by rigid criteria, limb salvage procedures can be a viable alternative to amputation.

Use of tumor colony assay in clinical oncology.

We have evaluated the usefulness of the tumor colony assay in predicting chemotherapeutic drug response in our cancer patient population. We found that a wide variety of human tumors will produce clonal growth in this in vitro assay. Low growth rates in many of the common human tumors, however, severely restrict the utility of this assay in a large number of cancer patients. A retrospective analysis using the assay to predict anticancer drug response revealed a true-positive predictive rate of 63% and a true-negative predictive rate of 96%. We conclude that if growth stimulants can be developed to enhance clonal growth without altering the predictability of the assay, the tumor colony assay could prove to be extremely useful in selecting appropriate chemotherapy for individual cancer patients.

Neoplasia of the extraperitoneal rectum and anus. The perineal dilemma.

A retrospective analysis was undertaken of 113 patients with biopsy-proven neoplasia of the extraperitoneal rectum and anus occurring between 1970 and 1975. Common initial symptoms included bleeding, constipation, and diarrhea; colon obstruction was the initial symptom in only ten cases. Adenocarcinoma occurred in 90 per cent of cases while lesions such as epidermoid cancer, carcinoid, and melanoma were encountered rarely. Operative treatment consisted of abdominoperineal resection (APR) in 60 cases, colostomy alone in 26 cases, anterior resection 13 cases, and electrocoagulation in four cases. Ten patients refused operative therapy. Of patients undergoing APR, 7 per cent died in the perioperative period. Postoperative morbidity included infection, impotence, bladder dysfunction, and perineal complications. The single most important factor contributing to this high morbidity was perineal wound management: 34 patients managed by the open method sustained a 47 per cent complication rate while the 26 patients with closed and adequately drained wounds had only a 15 per cent complication rate.

The role of surgery in the management of gastric lymphoma.

With the development of more effective combination chemotherapy and radiation, the role of surgical resection in the management of gastric lymphoma is reappraised. A retrospective review of 32 patients with gastric lymphoma, diagnosed and treated during the period between 1966-1979, is presented in an attempt to evaluate the relative effectiveness of the various modalities of diagnosis and treatment. Preoperative gastric barium x-ray studies were abnormal in 28 patients but were infrequently diagnostic of lymphoma. Endoscopy was employed in 15 patients with washings and biopsy. The biopsies were reported: four nondiagnostic; three suspicious of tumor; three carcinomas; and in only five patients was a clear diagnosis of lymphoma established. Fifteen patients were treated on the basis of biopsy via gastroscopy, or were explored and not resected and were treated with chemotherapy and/or radiation therapy. Fourteen of the nonresected patients have died with disease; one patient is surviving with disease at 20 months. Surgical resection was accomplished in 17 of the 32 cases, with seven patients (41%) surviving from 2-12 years. Aggressive primary chemotherapy with four-drug combination (CAOP) without surgical resection has resulted in massive upper gastrointestinal hemorrhage in four of five patients thus treated. This required emergency surgery for patients with depressed leukocyte and platelet counts. No perforation of the stomach was seen with primary chemotherapy as reported by other authors. In this series surgical exploration was necessary to establish a definite histologic diagnosis in 27 of the 32 patients. Exploration was an essential step in establishing the extent of disease to plan therapy. The only long-term survivors free of tumor were those which had been surgically resected. Resection of the gastric lymphoma prevented the complication of hemorrhage and perforation associated with chemotherapy and radiation therapy.

Gastrointestinal carcinoids: extrahepatic metastases and symptomatology following resection.

Of 49 patients with midgut and hindgut carcinoids, second primary distinct carcinomas occurred in 12. The most aggressive carcinoids were the 24 that arose in the distal small bowel and cecum. Of the patients affected, 15 had lymph node metastases and eight had liver metastases at the time of diagnosis. That only five patients were completely relieved of symptoms following resection was partially explained by autopsy findings in 15 patients, six of whom had metastatic extra-abdominal carcinoid without liver metastases (most commonly, bone metastases).

Inflammatory fibrous polyp (pseudotumor) of ileum, a rare cause of intestinal obstruction.

Inflammatory fibrous polyp of the ileum is a rare condition. This report adds one patient to the 11 previously reported. These lesions usually involve intermittent, colicky abdominal pain, often of several weeks duration and occasionally as a cause of acute intestinal obstruction. X-rays usually show small bowel obstruction or intussusception, but may be completely normal. The pathological diagnosis is seldom made before microscopic examination of resected specimens. They are clinically interpreted to be neoplasm and treated by segmental resection. No recurrences have been reported after treatment. Etiology is unknown.