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.

Perioperative factors as predictors of operative mortality and morbidity in pneumonectomy.

Pneumonectomy for lung cancer is associated with significant morbidity and mortality. Risk factors for the morbidity and mortality have been reported, but consistent conclusive data are undetermined. Current accepted 30-day mortality rates for pneumonectomy range from 7 to 11 per cent. The objective of this study is to determine whether various perioperative factors can serve as predictors of morbidity and mortality in pneumonectomy patients and to review outcome data on patients undergoing pneumonectomy for lung cancer. A total of 105 patients undergoing pneumonectomy for lung cancer from 1988 through 1998 are studied in a retrospective chart review. The main outcome measure is the 30-day operative mortality and morbidity. Complications occurring in 10 per cent or more of the patients included atrial fibrillation (33.3%), respiratory failure (23.8%), pneumonia (21.9%), and bronchopleural fistula (12.4%). The 30-day mortality rate was 10.5 per cent (11 deaths). By Fisher's exact test for Chi-square only three statistically significant mortality factors were identified: respiratory failure (P < 0.021), sepsis (P < 0.008), and male sex (P < 0.031); respiratory failure, sepsis, and sex were predictors of death. Significant correlation could not be made to predict postoperative morbidity. Overall long-term clinical outcome for pneumonectomy as lung cancer treatment was poor. Clinical judgment remains an essential factor when considering pneumonectomy as an option for lung cancer treatment.

Five-year experience with the "four-before" laparoscopic ventral hernia repair.

Between 1993 and 1998, we performed a linear study of laparoscopic ventral hernia repair performed in a standard fashion using expanded polytetrafluoroethylene on 49 patients. Eighteen patients had recurrent hernias and 30 patients were morbidly obese with a body mass index >30. Conversion to open procedure was required in two patients. Patients were observed a mean of 27 months. Three patients died of unrelated causes during the observation period. Three patients developed recurrent hernias. By a follow-up survey, we found that 90 per cent of patients were "satisfied" with their operation and results. Because of decreased complications, postoperative pain, hospital stay, and hernia recurrence, the "four-before" laparoscopic repair is our preference for ventral hernias. It has been particularly useful for obese patients and patients with recurrent ventral hernias.

Inadequate documentation and resection for gastric cancer in the United States: a preliminary report.

Patients entered into Southwest Oncology Group gastric adjuvant protocol INT 0016 (SWOG 9008) after a "curative" gastric resection were assessed to determine practice patterns of more than 300 surgeons nationwide who performed "curative" gastric resections for 453 gastric cancer patients. The most common gastric resection performed was distal in 256 patients, proximal in 118, and total in 79. Extragastric organs resected were omentum (285), spleen (59), pancreas (18), and bowel (17). The extent of lymphadenectomy as staged by Japanese rules was 246 (54.2%) D0 resections, 173 (38.1%) D1 resections, 28 (6.2%) D2 resections, and 7 (1.5%) D3 resections. Staging of the cancer was poorly documented, with no statement made regarding the status of the primary cancer in 6 per cent, liver in 10 per cent, lymph nodes in 17 per cent, and omentum in 17 per cent. The greater the lymph node clearance, the greater the chance of resecting to a level of negative lymphatics, given that 45 per cent of nodes were involved when 10 or less were removed, whereas only 17 per cent were positive when more than 40 were cleared. The lack of adequate clearance of lymph nodes and poor documentation of tumor stage suggests that a more regimented surgical approach to this uncommon cancer is required.

Treatment decision making and adjustment to breast cancer: a longitudinal study.

This study monitored women (N = 76) with breast cancer from diagnosis through 1 year, and tested constructs from subjective expected utility theory with regard to their ability to predict patients' choice of surgical treatment as well as psychological distress and well-being over time. Women's positive expectancies for the consequences of treatment generally were maintained in favorable perceptions of outcome in several realms (i.e., physician agreement, likelihood of cancer cure or recurrence, self-evaluation, likelihood of additional treatment, partner support for option, attractiveness to partner). Assessed before the surgical decision-making appointment, women's expectancies for consequences of the treatment options, along with age, correctly classified 94% of the sample with regard to election of mastectomy versus breast-conserving procedures. Calculated from the point of decision making to 3 months later, expectancy disconfirmations and value discrepancies concerning particular treatment consequences predicted psychological adjustment 3 months and 1 year after diagnosis.

Patterns of recurrence for advanced colon cancer modified by whole abdominal radiation and chemotherapy.

Abdominal failure for colonic carcinoma patients following curative resection has been high in patients with advanced disease stage, particularly when increased numbers of lymph nodes are involved. Surgeons desire curative treatment for their patients, but they interpret local and regional lymph node recurrence as a failure of surgical resection. The effect of current adjuvant treatment protocols on modifying patterns of relapse, particularly in the abdomen, has not been well studied and is of interest to surgeons. We analyzed reported patterns of failure of patients with Stage C2 colon cancer from two colon cancer adjuvant treatment studies; 5-FU plus levamisole (SWOG 8591) and 5-FU, whole-abdominal radiation, and tumor boost. The total number of recurrences in SWOG 8591 at all sites was reduced. The percent of lung relapses was reduced from 34 per cent to 20 per cent in the treatment group, but the percentage of local relapse increased from 20 per cent in the observation group to 27 per cent in the 5-FU plus levamisole group. Similarly, the number of first relapses was fewer at a local site in the 5-FU plus levamisole group, but the percent of relapses at the local site was not reduced (18 vs. 22%). Advanced C2 patients who received regional treatment on 5FU and whole-abdominal radiation produced the lowest percent of local relapse (12%), suggesting a benefit for regional treatment. Further study of patterns of relapse after resection and adjuvant treatment in high risk C2 patients may lead to further progress in control of advanced, curative colon carcinoma.

Squamous cell carcinoma of the esophagus.

The role of surgery as primary treatment for patients with squamous cell carcinoma of the esophagus (SCCE) has been challenged by an improved response rate for radiotherapy that is made possible by adding radiosensitizing chemotherapy. The purpose of our study was to review our institution's treatment results for SCCE and to compare results of radiation versus surgery as primary treatment of early stage disease. A retrospective chart review was done on 241 patients who were treated with SCCE at Kansas University Medical Center and affiliated hospitals between 1970 and 1990. Patients were divided into five groups based on treatment received: (A) No Treatment; (B) Surgery Only; (C) Surgery plus Adjuvant Chemoradiotherapy; (D) Radiation Therapy Only; and (E) Chemoradiotherapy. Surgical treatment groups B and C had the best overall survival of all groups. To reduce any bias due to stage differences in groups, survival of groups was assessed only for early stage disease patients (Stage I, IIa, IIb). For Stage I and II patients receiving surgery as primary treatment (groups B and C), 29 per cent had a survival at 5 years compared to patients receiving primary radiation treatment (groups D and E) who had a combined survival of only four per cent. Although attempting comparison of risk groups is always a problem in nonrandomized studies, it is significant that only one 5-year survivor was in the nonresection radiation treatment groups D and E. Surgical resection for SCCE had the best survival in our study, especially in patients with early stage disease.

Acute cholecystitis treated urgently by nonselective laparoscopic cholecystectomy.

Beginning in 1990, all patients encountered by the author requiring cholecystectomy were attempted by laparoscopy. This study reports the results of 83 patients with acute cholecystitis who were urgently treated, nonselectively, by laparoscopic cholecystectomy. Acute cholecystitis was diagnosed clinically by the presence of right upper quadrant peritoneal pain, gallbladder phlegmon and fever, and/or increased white blood cell count. In addition, a confirming pathology report and/or elevated white blood cell count was present in all 83 patients. Age ranged from 18 to 82 years with an average of 39.4 years. Fifteen patients were male and 68 female. Insufflation was obtained in all patients without a complication. Discharge occurred by postoperative Day one for 24 patients, Day two for 66 and by Day three for 75 patients (range 19-300 hours). No patient had common duct stones. Most patients had stones impacted in the cystic duct, including one patient who had Mirizzi's syndrome. Operative time ranged from 28 to 300 minutes, with an average of 106.3 minutes. No conversion to open cholecystectomy was required. Complications included bile spillage in five patients, stone spillage in ten, and ileus in three patients. One patient with Mirizzi's syndrome required a postoperative radiological procedure for removal of a cystic duct stone remnant that was not completely removed at the time of operation. The high complication rate initially associated with laparoscopic cholecystectomy probably resulted from violating cardinal principles of surgery, not from the inappropriateness of laparoscopy. In conclusion, it is recommended that urgent laparoscopy is an appropriate initial approach for patients with acute cholecystitis.

Breast biopsy for nonpalpable lesions: a worthwhile endeavor?

The purpose of this study was to determine our yield of carcinoma in patients with a nonpalpable mammographic abnormality and to identify which mammographic criteria will most likely yield a positive biopsy. We conducted a review of all patients with nonpalpable mammographic abnormality who underwent needle-localized breast biopsy at our institution from 1988 to 1991. Charts of 295 patients who underwent 332 needle-localized breast biopsy were reviewed for age, family history, cancer history, mammographic findings, operative time, volume of excised breast tissue, and histology. Mammographic abnormalities were categorized as suspicious (clustered) microcalcification, stellate mass, ill-defined mass, well-circumscribed mass, developing density, or asymmetric density. The overall yield of cancer positive biopsies was 48 of 332 (14.5%). The frequency of diagnosed cancers was DCIS (8), LCIS (1), Stage I (31) and Stage II (8). The frequency that each single mammographic criteria resulted in a cancer diagnosis was: suspicious calcification (12%), stellate mass (22%), ill-defined mass (14%), well-circumscribed mass (11%), developing density (9%) and asymmetric density (0%). However, patients with both a stellate mass and microcalcifications formed the highest risk subgroup, with cancer detected 66 per cent of the time (P = 0.03).

Pelvic exenteration: a treatment for failed rectal cancer surgery.

Local-regional recurrences of the pelvis occur as an isolated event in 4 to 24 per cent of rectal cancer patients. While radiation therapy may provide temporary relief of pain due to recurrence, only a salvage pelvic exenteration offers hope of cure in these patients. We identified and reviewed 16 rectal cancer cases with local-regional recurrence who underwent salvage pelvic exenteration for cure. There were eight men and eight women. The primary cancer was treated by AP resection (3), low anterior resection (6), Hartman's resection (6), or local excision (1). Tumor at primary resection was Stage I for two patients, II for five patients, and nine patients were Stage III. Adjuvant radiation had been given to nine patients. The type of exenteration required for curative resection was anterior (3), posterior (6), total (4), or total-sacral (3). One patient died postoperatively. Survival calculations were from time of salvage exenteration until death or last follow-up. Only six deaths have occurred with a 5-year survival of 49 per cent. Mean survival for the total group was 31 months. Salvage pelvic exenteration should be given high priority in managing local-regional recurrences of the pelvis and provides worthwhile survival.

Role of herniography in the diagnosis of occult hernias.

Twenty-two patients with groin or incisional pain and normal physical examinations underwent herniography. Eight patients were found to have 11 unsuspected hernias. Seven were direct, two indirect, and two incisional. Six of nine groin hernias were recurrent. Exploration confirmed the herniographic findings in all patients. Follow-up evaluation of patients undergoing herniorrhaphy revealed resolution of symptoms. Ten of the 14 patients with normal herniograms were asymptomatic 3 months after herniography. In these 22 patients, herniography resulted in a savings of $31,000. We conclude that herniography is cost-effective and useful in patients with abdominal wall pain of obscure etiology.

Advanced gastric leiomyosarcoma.

This is a retrospective review of twenty-two patients surgically treated for leiomyosarcoma. All but two patients had an advanced tumor of at least 8 cm size or involving contiguous structures. The most commonly performed operation was subtotal gastrectomy. The gastric resection required en bloc resection of contiguous structures in 10 patients. Fifteen patients with curative resection had a three year survival of 58 per cent. The overall group had a three year survival of 35 per cent. Advanced gastric leiomyosarcomas present a surgical challenge to complete resection, but when the procedure is accomplished the patient has a reasonable curative potential.

Traumatic trochanteric bursitis.

The trochanteric bursa is anatomically quite susceptible to traumatic injury. However, specific reports of traumatic trochanteric bursitis in the literature are lacking. This may be due to failure to recognize this condition and to differentiate it from other pain syndromes involving the hip. This case report demonstrates the clinical presentation and management of traumatic trochanteric bursitis.

Growth delay effect of combined interstitial hyperthermia and brachytherapy in a rat solid tumor model.

The rat mammary AC33 solid tumor model was used to investigate the efficacy of interstitial hyperthermia and/or brachytherapy. Subcutaneous flank tumors were heated with an interstitial microwave (915 MHz) antenna to a temperature of 43 +/- 0.5 degrees C for 45 min for two treatments, three days apart, and/or implanted with Ir-192 seeds for three days (-25 Gy tumor dose). Following treatments, tumors were measured 2 to 3 times per week. Hyperthermia alone produced a modest delay in tumor volume regrowth, while brachytherapy was substantially more effective. The combination produced a improvement in tumor regrowth delay compared to brachytherapy alone.

Intraarterial chemotherapy and hyperthermia for pain control in patients with recurrent rectal cancer.

For the majority of patients with unresectable recurrence of rectal cancer, persistent pain is the most distressing problem. This brief study describes a method to control pain in 10 patients with unresectable rectal cancer confined to the pelvis after standard therapy failed. All of the patients had percutaneous placement of infusion catheters in both internal iliac arteries. A continuous intraarterial infusion of 800 mg/m2 of 5-fluorouracil per day was given for 7 days and 10 mg/m2 of mitomycin C was administered as a bolus injection on the seventh day only. Four patients also received whole body hyperthermia by way of a Erbotherm 434 mHz microwave generator on the second and fifth days of infusion. Relief of pain occurred in three of the six patients who received intraarterial chemotherapy only. All four patients who also received hyperthermia achieved prolonged pain relief when it was added. We have concluded that intraarterial chemotherapy may be beneficial in patients with uncontrolled pelvic pain due to recurrent rectal cancer. The addition of hyperthermia may augment the benefit.

Cisplatin plus 5-FU for the treatment of adenocarcinoma of the colon.

Cisplatin plus 5-FU appears to have significant additive activity in various tumors, such as head and neck carcinoma and esophageal cancer. A partial explanation for this may be drug synergism, which has been noted in the L1210 leukemia model. Based on these data, a prospective trial of weekly bolus 5-FU (15 mg/kg) and cisplatin (60 mg/m2) given every 3 weeks was initiated at Indiana University. Forty-one patients, of whom 38 are fully evaluable for response, were treated with these two drugs. Ten partial and one complete response (complete + partial response rate = 29%) were observed in the 38 evaluable patients. Thirteen additional patients had stable disease for greater than or equal to 3 months. The median durations of remission and survival time were 6 and 10.3 months, respectively. Myelosuppression was unusually severe, with granulocyte counts less than 1000/mm3 in 65% of patients, including four patients with granulocyte count nadirs less than 100/mm3. Three patients developed granulocytopenic fever, with two drug-related deaths (sepsis, hyperosmolar coma). Nearly all patients had nausea and vomiting, but this was not a treatment-limiting toxic effect in any patient. Although this combination suggests a higher response rate than usually seen with bolus iv 5-FU in colon cancer, a trial comparing 5-FU alone or with cisplatin to determine whether true synergy exists is currently underway.

Chemosurgical reports: myxoid dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is a fibroblastic tumor characterized by a high rate of recurrence following conventional surgical treatment. Several different histopathologic patterns exist, with the "cartwheel" pattern the most common. In this report, a patient with the unusual myxoid histopathologic pattern was successfully treated with Mohs surgery.

Late results of an extended devascularization procedure for patients with bleeding esophageal varices.

A procedure for control of variceal bleeding has been described that involves devascularization of the distal one-third of the esophagus and upper one-half of the stomach combined with a Nissen fundoplication performed through a left lateral thoracotomy and an incision in the left diaphragm. Transection of the truncal vagi is required to devascularize effectively the distal esophagus, and thus a pyloromyotomy or pyloroplasty is added. Twelve patients who were moderately high-risk candidates underwent this procedure for control of persistent hemorrhage. There were two postoperative deaths. Four late deaths occurred at 30, 32, 36, and 48 months in patients who continued drinking. Cause of death was uncontrolled esophageal bleeding (2) and liver failure (2). The six survivors have not rebled and are living and well at 24, 48, 54, 55, 55, and 92 months.