Good outcome associated with a standardized treatment protocol using selective postoperative radiation in patients with clinical stage I adenocarcinoma of the endometrium.

In 1982, a treatment protocol was instituted for the management of patients with clinical stage I adenocarcinoma of the endometrium. All pertinent historical, operative, and pathologic findings were reviewed by a multidisciplinary committee and 384 patients were prospectively assigned to either high- or low-risk categories. Patients were excluded from the study if they had clinically apparent extrauterine disease, clear cell or serous histologies, or microscopic ovarian metastasis. Patients were considered high-risk if they had one or more of the following factors: grade 3 tumor differentiation, myometrial invasion > 50% of the total wall thickness, pathologic cervical involvement, or adenosquamous histology. Two-hundred twenty-seven (59%) low-risk patients were followed without further treatment after surgery, while pelvic radiation was recommended for 157 (41%) high-risk patients. The 5-year relapse-free survival rates in the low- and high-risk groups were 95 and 81%, respectively. There were no treatment-related deaths. Severe or life threatening chronic radiotherapy complications occurred in 6 (5%) patients. Multivariate Cox analysis identified the following significant prognostic factors: grade, myometrial invasion, cervix involvement, and age. This treatment protocol represents a safe and effective method of managing patients with carcinoma of the endometrium and spares the need for radiation therapy in the low-risk patient.

[Abdominal rectopexy (Orr-Loygue) in rectal prolapse: celioscopic approach or conventional surgery]. / La rectopexie au promontoire (Orr-Loygue) dans le prolapsus rectal: approche coelioscopique ou chirurgie conventionnelle.

One of the treatment modalities for rectal prolapse is abdominal rectopexy, a comparison of the Orr-Loygue procedure, performed by laparotomy and by laparoscopy was done. From June 1981 and May 1993, 31 females and 3 males, with an average of age of 58.8 were operated. Twelve patients were operated by laparoscopy (group I) and 22 patients by laparotomy (group II). Two patients (16.7%) in group I were converted to a laparotomy due in one to operative hemorrhage and in the other to adhesions. Seven patients in group I and 18 in group II had had previous abdominal surgery. Average operative time was 2.56 hours and 2.25 hours for groups I and II respectively. A reduction in post operative hospital stay (5 vs 8.3 days) as well as in intramuscular analgesic requirements (5.5 vs. 14.1 doses) was observed in group I vs. group II respectively. Time to oral intake and cessation of intravenous fluids were also reduced in group I compared to group II (1.0 vs. 3.9 days and 2 vs. 5.8 days respectively). No mortality and minimal morbidity was observed in both groups. No recurrence of prolapse was noted in either group with an average of 12.6 mouths follow-up (2.8 to 17 months). We concluded that rectopexy by laparoscopy is technically feasible and has undeniable advantages over laparotomy.

Survival of breast-cancer patients with previous or subsequent neoplasms.

The authors reviewed retrospectively 1510 patients with breast cancer operated on between 1960 and 1980. They compared 1353 patients who had an isolated breast cancer (group 1) with 157 patients who also had breast cancer but had other cancers either previously or subsequently (group 2). The mean age of patients in group 2 was 2 years more than that of patients in group 1. Group 2 patients had fewer T3 tumours, more T1 tumours (TNM classification), a lower incidence of lymph-node involvement and clinically less advanced tumours than group 1 patients. Hormonal status, histologic type of tumour and surgical and adjuvant treatment were identical in both groups. The 10-year survival rate (considering death from breast cancer) was 54.6% in group 1 versus 78.1% in group 2. The overall survival rate (considering death from breast cancer or from the other cancer) was 54.1% in group 1 versus 64.5% in group 2. Survival was also better in group 2 for each clinical stage. The authors conclude that patients who have another cancer before or after the development of their breast cancer have a better survival rate than those who have isolated breast cancer with no previous or subsequent neoplasms.

Cancer of the breast: a study of 1520 consecutive patients operated on between 1960 and 1980.

A retrospective study was carried out of 1520 consecutive patients with breast cancer operated on at the Hôpital Notre-Dame in Montreal between 1960 and 1980. Age and hormonal status of the patient, and duration, size, location, histologic type and stage of the tumour were studied. The authors grouped the patients according to four types of surgical treatment: radical (487 patients), modified radical (497 patients) and simple (220 patients) mastectomies and conservative procedures (316 patients). Adjuvant treatments included radiotherapy in 60%, hormone therapy in 4.7% and chemotherapy in 6.7% of patients. Overall survival at 5, 10 and 15 years was 71.3%, 58.7% and 51.1%; in patients with stage I disease, survival rates were, respectively, 86%, 78% and 72%; rates for patients with stage II disease were 74%, 62% and 53%. The population characteristics and survival rates were similar to those reported by others. The four types of treatment did not produce significantly different survival rates in patients with stage I lesions. However, this was not the case in patients with stage II and III lesions in whom simple mastectomy (McWhirter procedure) was associated with significantly worse results. Finally, this study confirmed the prognostic importance of stage, size of the tumour and degree of axillary lymph-node involvement.

[Selective galactophorectomy for mono-orificial nipple discharge without associated mass: technique and results. Apropos of seventy-three cases]. / La galactophorectomie sélective pour l'écoulement mammaire uniorificiel sans masse associée: technique et résultats. A propos de soixante-treize cas.

A single duct mammary discharge is a sign of an underlying disease: inflammatory, benign proliferative disease or even cancer. Selective resection of a ductolobular tree insures appropriate diagnosis and causative and definitive treatment of the discharge. Mammogram is essential. Galactography is quite usefull and reliable but may be unindicated or contraindicated. Surgery includes catheterization of the hole, methylene blue dye staining of the duct, circumareolar or radial incision, dissection, pyramidal resection of the whole galactophoric tree and closure with a retracting suture of the nipple. Woman's age, color of the discharge, pre-operative galactography suggest the diagnosis which has been in our series of 73 cases an inflammatory process in 53.4% of cases, a benign proliferative in 42.5% of cases and an epithelioma in situ in 4.1% of cases. The 46 cases of serous, serosanguinous or sanguinous discharge were due to an inflammatory process in 15 cases (32.6%), a benign proliferative in 28 cases (60.9%) and an in situ carcinoma in 3 cases (6.5%).

Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader.

Spontaneous perforation of the esophagus (Boerhaave syndrome) is an emergency that requires early diagnosis if death or serious prolonged illness is to be averted. The cases of three patients with spontaneous esophageal perforation simulating other primary diagnoses are described. The respective referral diagnoses were pericarditis, lung abscess, and pancreatitis. Each case was characterized by severe illness, and by delay in diagnosis despite multiple consultations. Two patients died. The literature is reviewed and the causes of delay in diagnosis are analyzed. More than 40 years after the first report of successful surgical repair, spontaneous esophageal perforation is insufficiently considered in diagnostic hypotheses, yet may be confirmed or excluded by simple methods. All clinicians need to be alert to this lethal disease, and to be aware of its frequent atypical presentations.

Adverse effect of blood transfusions on patient survival after resection of rectal cancer.

Studies have shown that the number of units of blood transfused perioperatively in patients operated on for colonic cancer has a progressively strong negative influence on survival. The present study, involving 198 patients with rectal cancer, was done to determine if perioperative blood transfusions had any prognostic significance. Multivariate regression analysis was applied to these patients, operated for cure of Dukes' stage A, B or C disease. Other variables analysed were age, sex, preoperative hemoglobin, albumin and lymphocyte values and the timing of transfusion. Perioperative deaths, pre- and post-operative immunodepression, neoplasia in situ, nonresections and stage D disease were excluded. It was found that the number of units of blood transfused perioperatively had a negative effect on patient survival, that was independent of the other analysed variables. It is suggested that blood transfusion perioperatively exerts an immunosuppressive effect on patients with rectal cancer.

Effects of maternal oral salbutamol therapy on neonatal endocrine status at birth.

Cord blood concentrations of insulin, growth hormone (GH), triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) from 20 patients treated with oral salbutamol were compared with those of 18 matched patients who had not received any betamimetic agents. No significant difference was found in circulating insulin, T3, T4, and TSH between both groups. However, GH levels were significantly higher in the treated group (36.5 +/- 17.4 ng/mL) than in the control group (17.4 +/- 6.6 ng/mL; P less than .001). The unexpected increase in GH levels in the treated group could reflect either fluctuating fetal blood glucose in response to episodic betamimetic administration or direct fetal pituitary production through adrenergic stimulation.

Toxic megacolon. An analysis of 70 cases.

The clinical features and outcome of 70 patients treated for toxic megacolon between 1970 and 1984 in five university-affiliated hospitals were determined. There were 35 women and 35 men with a mean age of 39 +/- 0.2 years. Toxic megacolon occurred at the initial episode of colitis in 43 patients (61 percent). Only five patients had a specific colitis: salmonellosis, two; ischemic, two; and pseudomembranous, one. Of the 65 remaining patients with nonspecific colitis, six had to be operated on without delay because of peritonitis. In the remaining 59 patients, toxic megacolon was cured with intensive medical management in nine (15 percent), improved temporarily in 14 (24 percent), and remained unchanged in 36 (61 percent). The postoperative mortality rate was 11 percent for all patients (6/56), 4 percent for patients without perforation (2/50) compared with 27 percent for patients with perforation (4/15). None of the patients who underwent surgery within five days of medical treatment died. When toxic megacolon was complicated by hemorrhage (nine patients) or peritonitis (eight patients), the mortality rate increased to 33 percent and 27 percent, respectively. A one-stage proctocolectomy was performed in 19 patients (32 percent). Of 32 patients in whom the rectum was retained, successful restoration of continuity was possible in only seven (22 percent) within 12 months after surgery. In well-selected patients, a plea is made for rectal preservation to offer an alternative to permanent ileostomy.

Blood transfusions and survival after colectomy for colorectal cancer.

This study was carried out to determine the effect of perioperative blood transfusions on the survival of patients operated on for colorectal cancers. Cox's regression analysis was applied to 281 patients operated for cure of Dukes' stage A, B or C disease. Other variables studied were age, sex, tumour location, and preoperative hemoglobin, lymphocyte and albumin values. Perioperative deaths, pre- and postoperative immunodepression, neoplasia in situ, nonresections and stage D disease were excluded. It was found that the number of units of blood transfused had a strong influence on the prognosis of patients with colorectal cancer, particularly colonic cancers, but the effect could not be demonstrated when rectal cancers were studied separately, perhaps because of the small number of cases. The mechanism of action of blood transfusions seems to be independent of the other analysed variables. The authors suggest that perioperative blood transfusions may have an immunomodulatory effect in patients with colonic cancer, as already shown in recipients of transfused kidney allografts.

[Complications of the treatment of cervix neoplasms by radiotherapy]. / Les complications du traitement du cancer du col utérin par radiothérapie.

Of 939 patients treated by radiotherapy for carcinoma of the cervix at the hôpital Notre-Dame in Montreal, between 1979 and 1981, 275 (29.3%) had digestive, urologic, gynecologic, vascular, osseous and cutaneous complications. Surgery was necessary to treat 73 complications in 55 patients (5.9%): 42 digestive (25 occlusions, 13 fistulas and 4 perforations); 22 urologic (16 occlusions, 5 fistulas, 1 hemorrhage); 6 gynecologic (3 hemorrhage and 3 uterine necrosis); 1 cutaneous, 1 vascular and 1 osseous necrosis. No direct correlation was found between the incidence of the complications and certain predisposing factors such as the type of radiotherapy, patients' age, stage of the disease and gynecologic surgery before radiotherapy. However, there was a strong correlation between the incidence of complications and the dose of radiotherapy and the need for gynecologic surgery after radiotherapy. High morbidity was observed in the 55 patients treated surgically: they had to undergo a mean of 2.36 operations each, 2.98 general anesthetics, 1.81 hospitalizations (mean duration 75.7 days); 21 had one or more definitive stomas. The death rate was 5.45%. Surgical treatment was individualized. Limited resections were performed for occlusions, fistulas and perforations whenever it was technically feasible to treat digestive and urologic complications. A bypass procedure was used when resection would have been too extensive or dangerous. The majority of rectal lesions were treated by colostomy and a Hartmann procedure.

Radiographic differences between two subtypes of bronchioloalveolar carcinoma.

Bronchioloalveolar carcinoma has two light-microscopic, morphologic types, the alveolar type which has cuboidal cells resembling Type II pneumocytes, and the bronchiolar type in which these cells are of the tall columnar variety. To determine if these two different cellular patterns are associated with different clinical or radiologic patterns of disease, we compared the anthropometric, demographic and past medical history, the presenting symptoms, signs, radiographic changes and survival of patients with these two diseases. Clinical records, chest radiographs and pathologic specimens were reviewed by individuals blinded to the hypothesis. Of 30 patients reviewed, we found only one purely alveolar pattern, one predominantly alveolar, 13 mixed, 12 predominantly bronchiolar, and three purely bronchiolar. For analysis we combined the alveolar and the mixed groups and compared them to the purely and predominantly bronchiolar groups. Anthropometric and historical data were similar. The radiographs were different; the most striking difference was the presence of air bronchograms only in the bronchiolar group (p less than 0.0001). Of those who had previous chest films, 80% in the alveolar-mixed group were abnormal, whereas none of those in the bronchiolar group were (p = 0.02). All the initial films in the bronchiolar group had a lesion with definable borders, whereas only two-thirds of the mixed alveolar group did (p = 0.02). Some of the radiographic changes of bronchioloalveolar carcinoma depend on the histologic subtype.

Increases in choline levels in rat brain elicited by meclofenoxate.

Meclofenoxate, the p-cholorophenoxyacetic acid ester of deanol, was found to dramatically elevate choline (Ch) levels in the rat CNS. In the hippocampus, this elevation in choline was accompanied by a new elevated steady state level in acetylcholine (ACh). No such coupling was observed in the striatum or parietal cortex. Deanol also elevated choline levels in the CNS but was about half as potent as meclofenoxate; p-chlorophenoxyacetic acid was inactive in this respect. Lesions of striatal neurons with kainic acid and of hippocampal cholinergic nerve endings with surgical section of the fimbria indicated that the changes in choline levels were mainly extraneuronal. In spite of the changes in choline and ACh levels, no consistant alterations in ACh turnover were measured. In summary, meclofenoxate induced dramatic alterations in CNS choline metabolism and may, therefore, be a useful therapeutic tool for potentiating depressed cholinergic neurons.

Differentiating bronchioloalveolar carcinoma from adenocarcinoma.

The recognition of bronchioloalveolar carcinoma (BAC) as distinct from adenocarcinoma of the lung, is controversial. Using strict pathologic criteria, 43 consecutive patients with BAC were matched by year of diagnosis and compared with a similar number of patients with adenocarcinoma, and for contrast, with those with squamous and oat cell carcinoma of the lung. We demonstrated that BAC is not sex related, and is not as smoking related as the other neoplasms. Unlike epidermoid carcinoma, BAC does not show a predilection for those occupations requiring manual labor. Also, BAC is frequently distinguishable radiologically from the other three by being smaller and peripheral. A pleural tag and an air bronchogram in a mass are rather specific, and BAC is less likely to have large airway involvement and adenopathy. The percentage of patients who were free of tumor after 2 yr was greater in the BAC group than in the others, but the overall survival rate between the BAC group and the adenocarcinoma group was not. Based on inter-observer variability, there is some overlap pathologically between these 2 groups. However, when the overlap between the adenocarcinoma and the BAC groups is compared with that between the adenocarcinoma and the squamous cell carcinoma groups, the difference is not significant. We conclude that BAC should be considered a distinct clinical entity.

[Cancerous Peutz-Jeghers syndrome with disseminated metastases]. / Syndrome de Peutz-Jeghers cancérisé avec métastases disséminées.

This report of a patient with Peutz-Jeghers syndrome is unusual in a number of ways: the patient, a 49-year-old woman, was first seen with deep thrombophlebitis of the leg which appeared to be part of a paraneoplastic syndrome. The patient had an adenocarcinoma originating in a hamartoma of the terminal ileum, with ovarian and lymph-node metastases. During the course of the disease the patient was found to have metastatic disease in the cervical lymph nodes which responded, temporarily, to chemotherapy. The authors review the literature on metastatic Peutz-Jeghers syndrome. Although the rate of metastatic disease is low, they believe that all patients with Peutz-Jeghers syndrome deserve a close long-term follow-up.