Extrapelvic colon--areas of failure in a reoperation series: implications for adjuvant therapy.

A total of 230 patients had planned single or multiple reoperative procedures following "curative" resection of colorectal cancer at the University of Minnesota. The site of the primary lesion was extrapelvic in 91, and later evidence of cancer was found in 58 patients (64%) at re-operation and/or other follow-up. Eight of the 58 (14%) were converted to disease-free status. Incidence and patterns of failure were correlated with initial operative-pathologic extent of disease (87 of the 91 at risk had initial tumor extension beyond the bowel wall, involved nodes or both) and comparisons were made with the previously analyzed rectal reoperation patients. While a component of local-regional failure was more common with rectal lesions (48/74 at risk, 65%), it was not uncommon with extrapelvic primaries (44/91-48%). The incidence of hematogenous metastasis (DM) was equal, but the pattern of initial DM differed (extrapelvic colon--primarily liver; rectum--liver and lung). Peritoneal seeding was a more common component of failure with the extrapelvic primaries (19/91--21% vs 3/74-4%). Since surgery alone is inadequate treatment for many patients with colon as well as rectal cancer, the rationale of adjuvant radiation and systemic therapy, alone or in combination, is discussed.

Adenocarcinoma of the stomach: areas of failure in a re-operation series (second or symptomatic look) clinicopathologic correlation and implications for adjuvant therapy.

Following initial "curative" operative procedures for gastric carcinoma, 107 patients had planned single or multiple re-operations at the University of Minnesota. Later evidence of cancer was found in 86 patients at re-operation and/or other follow-up. Initial operative-pathologic extent of disease was correlated with incidence and patterns of failure. Distant metastasis (DM) alone was uncommon, but was found as a new component in 25.6% of the failure group. Nearly half of the peritoneal failures (PS) were localized, and when diffuse, were usually accompanied by a moderate sized local-regional failure. Local recurrence and/or regional lymph node metastasis (LF-RF) occurred as the only failure in 53.7% of the failure group if localized peritoneal failures were included, and as any component of failure in 87.8% (67.3% of the total 107 patients). Operation alone yields inadequate results for the majority of patients with gastric carcinoma. The rationale of adjuvant radiation and systemic therapy alone or in combination is discussed.

Lymphography as a guide during laparotomy in Hodgkin's and non-Hodgkin's lymphomas.

Lymphography of 123 newly diagnosed patients with lymphoma was followed by staging laparotomy without intra-operative abdominal roentgenography. These patients were retrospectively evaluated for residual abnormal nodes with postoperative abdominal roentgenography. Sixteen patients with pathologically normal nodes at laparotomy had residual lymphographically abnormal nodes at postoperative roentgenography. Nine patients received less extensive irradiation than they would have if the remaining abnormal nodes had been biopsied and found to contain tumor. Two had shortened survivals as an apparent consequence.

Management of focally malignant pedunculated adenomatous colorectal polyps.

A hospital record review identified 59 patients whose sole colorectal pathology was a pedunculated, adenomatous polyp with a focus of malignancy confined to the head of the tumor. Thirty-one patients had polyps with in-situ carcinoma, and 28 patients had foci of invasive carcinoma. Sixteen patients who had lesions in situ underwent laparotomy, and not a single instance of metastasis was found. Twenty patients who had carcinoma in situ received only local treatment, and 15 are alive and well. None of the patients treated locally has developed subsequent colorectal cancer, and 12 have survived at least five years following treatment. Of the 28 patients who had invasive carcinoma confined to the head of an adenoma, 19 are alive and well, and 17 have lived five years or more following treatment. There was one instance of lymph-node metastasis, which occurred in a patient who had a malignant lesion extending to the neck of the tumor and tumor cells in the lymphatics in the head of the polyp. All of the eight patients treated locally are alive and well, and five have lived at least five years following treatment. The results of this study, coupled with the rarity of reported metastasis from focally malignant, pedunculated, adenomatous colorectal polyps, strongly suggest that local treatment is sufficient for the vast majority of these lesions. Evidence from the literature suggests that resective therapy should be considered when 1) lymphatics within the head of the polyp contain tumor cells; 2) the cancer is highly undifferentiated; 3) the pedicle is extremely short and malignant changes extend to the neck of the adenoma.

B and T lymphocytes in Hodgkin's disease. Analysis at diagnosis and following therapy.

B and T lymphocytes were studied in the blood and lymph nodes of fifty patients with Hodgkin's disease. At diagnosis, most patients (77%) had normal percentages of circulating B and T lymphocytes. Most patients (60%) also showed normal percentages of B and T lymphocytes in involved lymph nodes. Splenectomy had no effect on circulating B and T lymphocytes in four of five patients studied 2 weeks postoperatively. Seventeen patients were studied before and after treatment to determine the effect of therapy. Very high percentages of B lymphocytes were found in patients studied following radiotherapy. It appears that the known defects in cell-mediated immunity in Hodgkin's disease are not expressed as significant abnormalities in B-or T-lymphocyte ratios in blood or lymphoid tissues at diagnosis. The proliferation of B lymphocytes following radiotherapy could represent a compensatory mechanism to cell-mediated deficiency or a loss of normal suppressor activity of T lymphocytes.

Reflux gastritis: the consequences of intestinal juice in the stomach.

The consequences of exposure of the intact stomach to intestinal contents were examined in six dogs. Diversion of duodenal contents through the stomach lead to the following changes: histologic gastritis in both antrum and corpus, increase in resting and postprandial serum gastrin levels, increased parietal cell density in four of six animals, and enhanced maximal acid secretory capacity in three of six animals. No significant changes were seen in insulin-stimulated acid secretion, insulin-stimulated pepsin secretion, antral gastrin levels, or G cell numbers. We conclude that chronic exposure of the intact stomach to duodenal contents results in gastritis and an amplified gastrin response to food. Parietal cell numbers and maximal acid secretory capacity are increased in some animals.

B and T cell lymphomas. Analysis of blood and lymph nodes in 87 patients.

B and T cell populations were studied in blood and neoplastic tissues from 64 untreated and 23 treated patients with non-Hodgkin's lymphoma. This study was undertaken primarily to evaluate the relation of B and T cell markers in various lymphomas to the currently accepted morphologic classifications and to determine the utility of various tissues in defining the cell of origin of a lymphoma. When histologically involved blood, bone marrow, lymph nodes or body fluids were studied, a B or T cell origin of the lymphoma was identified in 26 of 28 (68 per cent) patients. A B cell origin was found in 17 adults classified as having nodular (N) or diffuse (D) poorly differentiated lymphocytic lymphoma (PDLL). One lymphoma of T cell origin was observed in an adult with poorly differentiated lymphocytic lymphoma-diffuse (PDLL-D). In contrast, all cases of PDLL-D in children were T cell in origin. The origin of American Burkitt's (stem cell) lymphoma in two children was the B cell. When histologically involved blood was studied, a B or T cell origin was demonstrated in 10 of 21 (48 percent) adults. Evidence of a monoclonal proliferation of B lymphocytes in the blood was found two adults with more than 7 per cent lymphoma cells in Wright-Giemsa stained blood smears. When neoplastic lymph nodes were studied, the diagnosis of a B cell lymphoma was made in 8 of 12 (67 per cent) adults. Study of surface markers on malignant cells in cerebrospinal or serosal fluids frequently revealed a B or T cell origin of the lymphoma. B and T lymphocyte numbers in the blood did not correlate with immunoglobulin or skin test abnormalities. Abnormalities in circulating B or T cell percentages at diagnosis were a poor prognostic sign in patients with PDLL-D.

Metastasis from a pedunculated adenomatous colonic polyp with focally invasive carcinoma: report of a case.

A patient who had metastasis from a focus of invasive carcinoma confined to the head of an otherwise benign pedunculated adenomatous polyp of the sigmoid colon is described. That only 20 such cases have been reported previously attests to the rarity of this phenomenon. Because the morbidity and mortality of radical surgery far outweigh the liklihood of metastasis from such foci of invasive carcinoma in pedunculated adenomatous colonic polyps, local removal is recommended.