Extended operations after induction therapy for stage IIIb (T4) non-small cell lung cancer

Twenty-three patients with stage IIIb (T4) non-small cell lung cancer received induction chemotherapy (median, 2 cycles) with (n = 12) or without (n = 11) radiation (median, 45 Gy) before operation. Nine tumors involved the carina (n = 8) or lateral tracheal wall (n = 1), 11 were located centrally and invaded the proximal pulmonary artery (n = 6), veins (n = 3), or both (n = 2), three were apical tumors involving T4 structures, and six were associated with histologically diseased mediastinal nodes. Five complete and 18 partial responses were observed after induction treatment. Resection of all residual tumor at the primary site and involved vestiges was possible in 21 patients (91%); in two apical tumors, tumor was left behind. Nine right tracheal sleeve and 11 intrapericardial pneumonectomies and three resections of apical tumors were performed; 11 patients (48%) had radical mediastinal lymph node dissection. Complete sterilization of the primary tumor was observed in 3 patients (13%). Mean operating time was 209.3 +/- 86.8 minutes, and mean blood loss was 896.9 +/- 1031 mL. Major postoperative complications occurred in 6 patients (26%), including hemothorax requiring drainage (n = 1) or reoperation (n = 1), acute distress syndrome (n = 2), and bronchopleural fistula (n = 2), and their incidence was significantly higher (p = 0.0003) among patients receiving induction chemoradiation than among those receiving chemotherapy alone (42 versus 9%). Early (< 1 month) postoperative mortality was 8.6% (n = 2). With a median follow-up of 25 months (range, 12 to more than 39 months), the projected 3-year overall survival was 54%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extended radical pancreatectomy for carcinoma of the head of the pancreas

BACKGROUND/AIMS: Pancreatic cancer has a poor prognosis, which is, in part due, to the unfortunately advanced stage, in which the tumor is diagnosed. Since 1973, we have utilized a unique method of extended radical pancreatectomy, using the translateral retroperitoneal approach (TRA) to facilitate combined portal resection. The advantages of this operation are described herein, for patients with carcinoma of the head of the pancreas. In addition, the problems associated with this operation are discussed. METHODOLOGY: Survival was calculated based on type of resection, degree of invasion of the retroperitoneal tissues, degree of lymph node involvement, and cancer stage. Extensive surgery has been performed for pancreatic carcinoma 216 patients. Of these, 14 patients had carcinoma of the head of the pancreas. There were 58 patients who underwent macroscopically curative resections. RESULTS: Only 39 patients were microscopically curative. Ten of the patients who underwent microscopically curative resections, survived for 5 years (34.0%). There were no statistically significant differences in survival based on tumor size. However, there was a significant difference in survival based on extent of invasion of the anterior capsule of the pancreas, extent of invasion of the retroperitoneal tissue, extent of lymph node involvement, cancer stage, and extent of invasion at the surgical margin of resection. CONCLUSION: The results suggest that extended radical pancreatectomy may be indicated for the treatment of cancer of the head of the pancreas.     

Extended lymphadenectomy in carcinoma of the right colon

The Authors report on a retrospective study concerning 49 patients treated for a modified Dukes' stage B, C or D right colon cancer. A potentially curative right hemicolectomy with extended lymphadenectomy was performed. Locally advanced disease was treated by "en bloc" resection. Two (4.1%) patients died after surgery, in other 2 (4.1%) cases major postoperative complications were registered. Microscopic examination of the surgical specimens showed lymph node metastases in 44.9% of the cases: in this subgroup a metastatic involvement of the main (III level) nodal groups was detected in 22.7% of the patients. The Authors conclude that extended lymph node dissection does not increase postoperative complications and may play a role in the treatment of right colon cancer. A not negligible group of patients may be understaged or receive inadequate surgical treatment when submitted to traditional right colectomy.     

Extended field radiation and cisplatin for stage IIB and IIIB cervical carcinoma

BACKGROUND: Monitoring health targets is often undertaken using questionnaire surveys of lifestyle risk factors. Non-response bias is recognized but rarely quantified. METHODS: Following a questionnaire survey on a random sample of 6009 residents of Somerset with a response rate of 57.6 per cent, a telephone survey was undertaken on a random sample of 400 non-responders. A small number of the more important questions from the questionnaire were put to the non-responders over the phone. RESULTS: Fifty-nine per cent of the sample were contacted and agreed to participate. Statistically significant differences between responders and non-responders to the original questionnaire were detected for current smoking, hazardous alcohol consumption and lack of moderate or vigorous activity. CONCLUSIONS: Lifestyle questionnaire surveys need to include an assessment of the non-response bias.     

Gallium-67 scanning for carcinoma of the lung

Gallium-67 citrate scanning was prospectively evaluated in 55 patients who had lung lesions suspected to be primary carcinoma on chest x-ray films and in whom subsequent histologic diagnosis was obtained. Of 47 patients with histologically proved carcinoma of the lung, 44 (94 per cent) had a positive 67Ga scan. No patient with a positive scan had a benign lesion, so that the positive scan accuracy rate was 100 per cent. All 8 patients with a benign lesion and 3 patients with a malignant lesion had negative scans, for a negative scan accurary rate of 72 per cent for benign lesions. These results give statistical validity for the usefulness of the 67Ga scan in diagnosing carcinoma of the lung (p less than 0.001). Tumor cell type had little effect on the sensitivity of 67Ga scan. The 67Ga scan was equally useful in the evaluation of peripheral and central lesions. There was little difference amount T1, T2, and T3 classified lesions in their ability to take up 67Ga. The 67Ga scan was competitive with mediastinoscopy in assessing mediastinal lymph node metastases and provides a noninvasive method of assessing hilar lymph node metastases. There was a good correlation between the clinical staging of patients with lung cancer based on a chest x-ray film and 67Ga scanning and the staging after surgical treatment based on the histology of the resected specimens.     

Combined lung resection for advanced thoracic esophageal carcinoma

We performed lung resection together with esophagectomy in 2 patients with advanced thoracic esophageal cancer. Both patients survived more than 2 years with no evidence of disease. The first case was a 60-year-old man who had a cancer lesion in middle of the intra-thoracic esophagus (Im) and the right lower lobe of the lung was involved. In March 1989, right lower lobectomy of the lung was performed with esophagectomy. Pathologic examination showed well differentiated squamous cell carcinoma invading the lung parenchyma and intrapulmonary lymph node. Postoperatively, 44 Gy of radiation and Peplomycin cancer chemotherapy was performed. The patient survived 51 months after surgery and died of chronic myelogenous leukemia. The second case was a 60-year-old man who underwent thoracic esophagectomy with resection of the involved pericardium and right lung in February 1992. Pathologic examination showed N3 lymph node metastasis. Postoperatively, the patient received 48 Gy of radiation and was free from cancer after 30 months. In conclusion, better surgical results are expected in cases of advanced thoracic esophageal cancer with lung involvement which can be completely resected en bloc with the primary tumor even in a3 cases than in those with aortic or tracheobronchial involvement.     

Second primary lung carcinoma

Ffity-five patients suffering from second primary lung carcinoma, 10 synchronous and 45 after resection for lung carcinoma (metachronous), have been observed from 1400 resections. The first manifestation of a second carcinoma in this series has always been the appearance of a new shadow in the follow-up radiograph. In our experience, second primary lung carcinoma is a disease affecting only heavy cigarette smokers. Heavy cigarette smokers suffering from squamous-cell carcinoma are at special risk. The results of re-operation, the significance of the time interval between the original operation and the appearance of the second primary carcinoma, and the slow growth rate of some second primaries are briefly discussed. No clear-cut methods exist for distinguishing a second primary from a metastasis from the original carcinoma.     

Bronchioloalveolar carcinoma of the lung

Iodine-123-iodobenzamide (IBZM) is a specific antagonist of dopamine D2 receptors and usually is used to study neuropsychiatric disorders. It also has a substantial affinity for malignant melanomas. This has been attributed to specific dopamine D2 receptor binding on melanoma cells because melanocytes and dopaminergic neurons share the same ectodermal origin and are both able to produce melanin. However, IBZM binding to melanoma metastases occurs predominantly 24 hr after injection, which is much later than maximal specific D2 receptor binding is expected. Furthermore, IBZM binding is not consistent in melanoma patients. This points to another mechanism of IBZM binding to melanoma cells. The aim of this study was to characterize IBZM-binding metastatic melanoma patients clinically and histologically to shed light on the nature of this mechanism. METHODS: Twenty-one patients with proven or suspected metastases of a malignant melanoma entered this prospective study after surgical removal of the primary tumor. Whole-body scans, planar scintigrams and SPECT scans were performed 2-5 hr and 1 day after intravenous injection of 185 MBq IBZM. RESULTS: The suspected diagnosis of metastatic cancer was later confirmed in 17 patients by histology, clinical follow-up, x-ray, CT or other radiologic methods. Four patients were free of tumor tissue at the time of investigation and remained stable for 2 yr thereafter. Twelve of the 17 patients had a melanotic and 5 had an amelanotic subtype of the tumor. Iodine-123-IBZM accumulation occurred in the metastases of 10 of the 12 patients with melanotic melanoma and in 0 of the 5 patients with the amelanotic tumor type (p < 0.01; chi-square test). Furthermore, IBZM accumulation occurred in 0 of the 11 amelanotic metastases but in 20 of the 25 melanotic metastases (p < 0.001). The sensitivity is, thus, 83% for the detection of melanotic melanoma metastases on a patient basis and 80% on a lesion basis. Iodine-123-IBZM scintigraphy demonstrated one previously unknown metastasis. Six initially suspected lesions were not due to melanoma metastases and were IBZM-negative. No false-positive IBZM accumulations occurred in our patients. CONCLUSION: Iodine-123-IBZM binds to melanotic malignant melanomas with high specificity and moderate sensitivity but not to amelanotic melanomas. Our data suggest that the tracer does not bind to membrane dopamine receptors of the tumor but is built in or closely bound to intracellular melanin.     

Second-look operation in ovarian carcinoma: postchemotherapy

One hundred and three patients with advanced ovarian cancer underwent a second-look operation following chemotherapy. Patients should have ten or more courses of chemotherapy before second-look operation. Those patients with no evidence of disease at second laparotomy should discontinue their chemotherapy. Patients who continued chemotherapy after the second-look operation did better than those who were treated with radiation after surgery. Only patients with clinical remission benefit from the second-look procedure. Advantages of second-look operations following chemotherapy are discussed.     

Results of surgical treatment of T3 lung carcinoma according to the combined resection of involved organs

A new TNM staging system was decided last year by UICC, consequently T3N0M0 was transferred from stage IIIA to stage IIB. Although T3 is defined to include tumors with direct invasion to adjacent organs. Those are chest wall, parietal pleura, diaphragma and pericardium, however results of surgical treatment according to the combined resection of involved organs described above have not been investigated yet enough. Eighty-nine cases with T3 from 1996 were divided into two groups, patients from 1986 to 1990 and from 1994 to 1998. In the former phase 46 cases were resected and its 5-year survival rate was 15.6%. Better prognosis with significant difference was shown in patients between N0 (5-year survival: 25.1%) and N1 + N2 (5-year survival: 4.0%). In the latter phase 43 cases underwent surgery and its 3-year survival was 24.0%. In the prognoses according to the involved adjacent organs, patients with combined resection of parietal pleura showed the best survival in comparison with patients of chest wall resection and pericardial resection, but there was no significant difference in these 3 groups. Two patients with combined resection of diaphragma are well alive.     

Extended vertical partial laryngectomy for treatment of the glottic cancer with T3 category]

From June 1981 to December 1992, 32 patients of glottic cancer with T3 category were treated by extended vertical partial laryngectomy, i.e. vertical laryngectomy plus the resection of the arytenoid and part of the cricoid plate. The laryngeal defect was reconstructed by an osteomuscular flap. The 3- and 5-year survival rates were 78.1% and 73.9% respectively. The decannulation rate was 81.3%. The voice was satisfactory in 84.3%. All patients resumed mouth-food-taking. The authors conclude that selective glottic cancer of T3 category treated with extended vertical partial laryngectomy, which preserves the functions of the larynx and improves the quality of the life, is feasible and acceptable.     

Appleby operation for carcinoma of the body and tail of the pancreas

Long-term survival of carcinomas in the body and tail of the pancreas after surgery is still rare. One of the major reasons for unresectability is cancerous invasion to major vessels, such as the common hepatic and splenic arteries. Resection of the involved arteries can increase resectability and thus might increase post-operative survival. The aim of this study was to clarify the importance of the Appleby operation for carcinoma of the body and tail of the pancreas. A Case Report was carried out with a 54 year-old man, had suffered back pain and loss of body weight for six months. Imaging procedures such as US, CT or angiography showed a carcinoma in the body of the pancreas, about 3 cm in size, and both the common hepatic and splenic arteries were invaded by the tumor. The Appleby operation was used for this patient, since firstly there was no invasion to the head of the pancreas, secondly neither the proper hepatic artery nor the SMA was involved, thirdly the root of the CA was free of carcinoma, and finally because clear pulsation of the proper hepatic artery could be felt one or two minutes after occlusion of the CHA, which indicated that resection of the CHA would not lead to hepatic ischemia. The postoperative course was uneventful. His appetite recovered well and his body weight increased to the level before the disease. The patient was relieved from back pain and has returned to work 18 months after the operation, although he had a local recurrence eight months after the operation. In addition, eleven cases with carcinoma of the body and tail of the pancreas were used for a literature review. The average survival time after the Appleby operation is 6.6 months, and four patients are still alive. One patient has survived 13 years after the operation. It was concluded that although the prognosis after Appleby procedure is still not satisfactory that this operation can at least offer patients a better quality of life.     

Surgical analysis for metastatic lung tumor from renal cell carcinoma

Metastatic lung tumor from renal cell carcinoma were studied in 29 cases. Eighteen patients were treated surgically, 11 were treated non-surgically. The overall 5-year survival rate with the patients of pulmonary resection was 53.5%, and that with those of conservative therapy was 0%, and this difference is statistically significant (p < 0.05). There was no significant difference in any characteristics such as sex, age, stage, grade, disease free interval, metastatic pattern and combination with or without interferon therapy. There was no significant difference in surgically treated patients with pulmonary metastasis in terms of any factors such as age, sex, stage, grade, disease free interval, pulmonary metastasis pattern, metastatic number, surgical procedure, combination with or without interferon therapy statistically. Analysis for the surgically treated patients with pulmonary metastasis from renal cell carcinoma shows no significant difference in prognosis with any characteristics. This result shows efficacy of surgery even if for the patients with synchronous bilateral multiple pulmonary metastasis from renal cell carcinoma.     

Long-term followup of all patients with muscle invasive (stages T2, T3 and T4) bladder carcinoma in a geographical region

PURPOSE: We studied the relationship between long-term survival and treatment of stages T2, T3 and T4 bladder carcinoma in an unselected patient population. MATERIALS AND METHODS: A total of 680 patients with the initial diagnosis of bladder carcinoma in 1987 to 1988 in Western Sweden was prospectively registered and followed until 1994. Of these patients 107 had stage T2 to T3 and 41 had stage T4 disease. RESULTS: Of the patients with stage T2 to T3 disease 30 (mean age 66) underwent radical cystectomy, 33 (mean age 75) full dose radiotherapy and 44 (mean age 81) nonradical therapy (mainly transurethral resection of the bladder). The 5-year crude survival rates were 33, 15 and 14%, respectively. Of the patients with stage T4 disease 6 (mean age 61) underwent radical cystectomy, 9 (mean age 73) full dose radiotherapy and 26 (mean age 81) nonradical therapy (mainly transurethral resection of the bladder). All except 1 patient died of disease within 4 years. CONCLUSIONS: More than 60% of the patients in the cohort were considered unsuitable for radical cystectomy and their survival was poor, whether treated with full dose radiotherapy or transurethral resection of the bladder alone.     

Long-term results following resection for T3 non-small cell lung cancer

Surgical intervention is routinely employed for non-small cell lung cancer, whenever no distant metastasis is found. However, its surgical results depend on the staging of the lung cancer, and surgery for stage III disease is less effective compared with stage I or II disease. For patients with stage III, some treatments such as induction chemotherapy have been tried to support the surgery. Recently, T3 lung cancer is divided in two category of staging, T3N0 is evaluated to be stage II B and T3N1-2 is stage III A. In this study, we classified T3 diseases by some factors, and examined long-term survival of each group. As a result, we concluded that mediastinal invasion and N2 involvement were risk factors to early failure. On the contrary, patients with adjacent lobe invasion and resection of two lobes led to the prolonged survival rather than lobectomy with partial resection of adjacent lobe.     

Extramedullary hematopoiesis mimicking metastatic lung carcinoma

Extramedullary hematopoiesis is a rare condition defined as the appearance of hematopoietic elements outside of the bone marrow, which occurs primarily in patients with chronic myeloproliferative disorders or congenital hemolytic anemias. We report a patient who presented with a left lower lobe lung carcinoma and right paravertebral and left pleural masses, initially thought most consistent radiographically with inoperable metastatic disease, until biopsies of the paravertebral and pleural masses established the presence of extramedullary hematopoiesis. The left lower lobe neoplasm was subsequently resected uneventfully.     

Long-term results of preoperative hyperthermo-chemo-radiotherapy (HCR) for patients with esophageal carcinoma invading neighboring structures (T4)

PATIENTS: A total of 180 patients with esophageal carcinoma invading the neighboring structures (T4) were surgically treated by esophagectomy and reconstruction in the Department of Surgery II, Kyushu University from January 1965 to April 1997. Any of these cases with distant node metastasis and demonstrating organ metastasis or a combined resection of adjacent structures were excluded from this study. As a result, twenty-six patients treated with preoperative hyperthermo-chemo-radiotherapy (HCR Group), 39 treated either with preoperative radiotherapy or preoperative chemo-radiotherapy (R or CR Group) and 23 non-treated patients (Non-tx Group) were thus entered in this study. RESULTS: The 3-year survival rates after esophagectomy in HCR Group, R or CR Group and Non-tx Group were 26.5%, 0% and 9%, respectively, while the 5-year survival rate of the HCR group was 15.9%. The group with preoperative HCR thus showed a significantly more favorable outcome than R or CR Group and Non-tx Group. (p < 0.05). DISCUSSION: The significant difference observed in the prognosis was thought to be due to the reinforced effect of local regulation due to hyperthermia. Our data thus suggest that preoperative HCR contributes to the prolonged post-operative survival for carcinoma of the esophagus invading the neighboring structures.