Integration of surgery in multimodality therapy for esophageal cancer.

BACKGROUND: While adding chemotherapy to radiation for the treatment of esophageal cancers has been shown to be beneficial, surgery usually follows treatment or is omitted. In either case, regional control remains problematic. The purpose of this study was to test the feasibility of using chemotherapy and radiation following surgery in the treatment of of esophageal cancer and to assess the impact of this approach on regional control and survival. PATIENTS AND METHODS: Twenty-five patients with esophageal cancer were treated in a phase I pilot protocol consisting of initial esophagectomy with gastroesophagostomy and subsequent combined chemotherapy and radiation. Chemotherapy consisted of cisplatin given on day 1 and 5-fluorouracil (FU) on days 1-5 by continuous infusion. Radiation therapy was administered in varying fractionation schedules of once or twice daily concomitantly with the chemotherapy. Treatment was repeated every other week for two to four cycles. Median follow-up was 42 months. RESULTS: Acute toxicities (mucositis and cytopenias) were common but not worse than grade 3. Higher doses of 50 Gy with 2 Gy b.i.d. hyperfractionation caused late complications in four of 10 patients, (two lethal). Control of local disease for all patients was excellent with only two known and two possible local recurrences (16%) but distant metastases were common (46%). Disease-free survival was 58 and 30% at 1 and 2 years, respectively. Survival was 58 and 32% at 1 and 2 years, respectively (median survival, 19 months). CONCLUSION: The local control rate and survival were better than those in our historical experience with cisplatin and 5-FU chemotherapy and radiation given prior to surgery. A dose-fractionation schedule of < 2 Gy up to a total of 50 Gy b.i.d. is recommended to avoid late adverse effects. The role of surgery will be defined by randomized studies. Better systemic therapy is needed to impact on systemic failure.

Patterns of breast and cervical cancer screening at three public health centers in an inner-city urban area.

In an effort to examine breast and cervical cancer screening patterns among poor African-American urban women, medical records were abstracted at three public health centers located in the inner city of Chicago. The proportions of eligible women at these three centers who received Pap smears, breast examinations, and mammograms were computed. These proportions were notably low and differed significantly among the three centers. Because the literature is now suggesting that an appropriate sequence best defines adequate screening, sequences of screenings were also determined and were found to be lacking. All of these screening histories fall far below the screening objectives set by the National Cancer Institute for the year 2000. This information suggests that interventions are needed that will help health centers serving poor women to deliver more frequent cancer screening.

An urban community-based cancer prevention screening and health education intervention in Chicago.

Most types of cancer are disproportionately present in black populations. Among all ethnic and racial groups, black people have the highest incidence of all types of cancer combined, experiencing the highest mortality and the worst survival rate. A major intervention effort has begun in Chicago, targeting women living in 10 south side community areas whose populations are almost all black and among the poorest in the city. The purposes of the intervention are to develop and evaluate ways to reduce morbidity and mortality from breast and cervical cancer. Three outcome measures are being used, the proportion of women who receive Papanicolaou smears, breast examinations, and mammograms; the scores derived from a knowledge, attitudes, and practices survey; and the stage of diagnosed cancer. The results are being evaluated in three locations, the 10 target community areas, a Chicago Health Department clinic located in the community, and Fantus Clinic at Cook County Hospital. The intervention consists of reducing barriers to care at both public clinic sites and delivering education and information within the community. Public health outreach workers who are culturally sensitive to the population bring word of the program to places frequented by women, including local businesses (such as beauty shops, grocery stores, pharmacies, and currency exchanges), public housing developments (one being the largest in the country), and facilities belonging to city services programs. The intervention was developed to permit its ready adoption in similar environments should the evaluation results prove its usefulness.

Bilateral trephine bone marrow biopsy for staging non-Hodgkin's lymphoma--a second look.

Several reports have suggested that bilateral bone marrow biopsy is better than unilateral biopsy in staging non-Hodgkin's lymphomas. Therefore since 1975, bilateral iliac crest bone marrow biopsy has been part of our standard initial staging investigation of non-Hodgkin's lymphomas. The present study is to determine the relative value of bilateral marrow biopsy compared to the unilateral procedure. We studied 176 patients who had evaluable adequate bilateral biopsies and tumor histology. Among 57 patients with low-grade lymphoma, 7 (12%) were unilaterally positive for lymphoma and 25 (44%) were bilaterally positive. Among 119 patients with intermediate and high-grade lymphoma, 6 biopsies (5%) were unilaterally positive and 10 (8%) were bilaterally positive for lymphoma. Doing the second (contralateral) biopsy changed the disease stage as assessed by bone marrow biopsy in 6.1% of patients with favorable histologies and in 2.5% of patients with unfavorable histologies. These changes are small. Moreover, treatment would not have been significantly altered in the majority of patients as a result of the changes. We conclude that the routine use of bilateral trephine biopsy in initial staging of non-Hodgkin's lymphomas needs to be reappraised. We believe that its use should be limited to selected patients in whom the finding of bone marrow involvement may influence the choice of treatment.

Metabolic emergencies in cancer medicine.

This article describes the many metabolic complications encountered in the management of cancer patients. Pathogenetic mechanisms and therapy are discussed, with special emphasis on hypercalcemia, the most common of these disorders.

Burkitt cell acute lymphoblastic leukemia with partial expression of T-cell markers and subclonal chromosome abnormalities in a man with acquired immunodeficiency syndrome.

A 45-year-old white male, bisexual, with a 2-year history of acquired immunodeficiency syndrome (AIDS) prodrome, developed a Burkitt cell-like acute lymphoblastic leukemia (ALL). Marker studies of marrow blasts show an unusual and possibly unique pattern, in that an unequivocal monoclonal B cell leukemia, having K-IgM with HLA-DR and B cell subset antigen (BA-1) expression, was superimposed with a mature suppressor T cell marker profile (pan-T, mature T, and suppressor/cytotoxic T antigens). The leukemic blasts were totally negative for terminal deoxynucleotidyl transferase (TdT), human T cell leukemia-lymphoma virus (HTLV) p19 antigen, and other immunoglobulin isotypes. Chromosome analysis of marrow cells disclosed that 70% of the cells had 47,XY, + 12,t(8;14)(q24;q32) chromosome complement, and 30% of the cells had a 47,XY, + 12,dup1q + (q22-31),t(8;14)(q24;q32). The consistent finding of the specific chromosome rearrangement (8/14 translocation) in all abnormal cells suggests that the cells were derived from a common precursor. With regard to the partial T cell marker expression, the significance of these markers in B cell leukemia is unclear, as is their relation to the additional chromosome abnormalities that apparently developed in the process of clonal evolution.