Multicentre study of the learning curve and surgical performance of cytoreductive surgery with intraperitoneal chemotherapy for pseudomyxoma peritonei

Background

The learning curves for cytoreductive surgery with intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei (PMP) were explored between international centres/surgeons to identify institutional or other factors that might affect performance.

Methods

Data from patients with PMP treated with the combined procedure across 33 international centres between 1993 and 2012 were analysed retrospectively. A risk-adjusted sequential probability ratio test was conducted after defining the target outcome as early oncological failure (disease progression within 2 years of treatment), an acceptable risk for the target outcome (odds ratio) of 2, and type I/II error rates of 5 per cent. The risk prediction model was elaborated and patients were evaluated sequentially for each centre/surgeon. The learning curve was considered to be overcome and proficiency achieved when the odds ratio for early oncological failure became smaller than 2.

Results

Rates of optimal cytoreduction, severe postoperative morbidity and early oncological failure were 84·4, 25·7 and 29·0 per cent respectively. The median annual centre volume was 17 (range 6–66) peritoneal malignancies. Only eight of the 33 centres and six of 47 surgeons achieved proficiency after a median of 100 (range 78–284) and 96 (86–284) procedures respectively. The most important institutional factor affecting surgical performance was centre volume.

Conclusion

The learning curve is extremely long, so centralization and/or networking of centres is necessary to assure quality of services. One centre for every 10–15 million inhabitants would be ideal.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal cancer

Peritoneal carcinomatosis (PC) arising from colorectal cancer (CRC) is generally considered a terminal condition with few treatment options. However, over the past few decades, new chemotherapeutic and biologic agents have improved the median overall survival of patients with unresectable metastatic disease up to 20 months. There has also been emergence of combining cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with PC. The literature supporting such an approach is significant, though not extensive, mainly consisting of small single-institution series, one international multicenter retrospective review, and one single-institution prospective randomized trial. Yet, there is remarkable homogeneity among the reported clinical outcomes, demonstrating 5-year OS rates of approximately 25-40% for patients undergoing a complete cytoreduction. These studies have fueled increasing interest in the use of CS and HIPEC for metastatic colorectal cancer over the past decade. However, despite the publication of a consensus statement on the role of CS and HIPEC for PC from CRC, there is still controversy regarding its appropriateness, effectiveness, safety, and application in this subset of patients. In this review we analyze the currently available scientific evidence supporting the clinical application of CS and HIPEC in the treatment of PC of colorectal origin.

Importance of gender in diffuse malignant peritoneal mesothelioma

BACKGROUND

Combined therapy involving cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy has been shown to improve survival outcomes for patients with diffuse malignant peritoneal mesothelioma (DMPM). The present study aims to investigate gender as a potential prognostic factor on overall survival.

PATIENTS AND METHODS

Over a period of two decades, 294 patients who underwent CRS and perioperative intraperitoneal chemotherapy were selected from a large multi-institutional registry to assess the prognostic significance of gender on overall survival.

RESULTS

Female patients were shown to have a significantly improved survival outcome than male patients (P < 0.001). Staging according to a recently proposed tumor-node-metastasis categorization system was significant in both genders. Older female patients had significantly worse survival than younger female patients (P = 0.019), a finding that was absent in male patients. Female patients with low-stage disease were found to have a very favorable long-term outcome after combined treatment.

CONCLUSIONS

Gender has demonstrated a significant impact on overall survival for patients with DMPM after CRS and perioperative intraperitoneal chemotherapy. An improved understanding of the role of estrogen in the pathogenesis of DMPM may improve the prognostication of patients and determine the role of adjuvant hormonal treatment in the future.

Reasons for choosing contralateral prophylactic mastectomies in women who test negative for the BRCA mutation: A retrospective questionnaire

192

Background: Determination of BRCA1and 2 mutation carrier’s status has become increasingly important. BRCA1/2 carriers are offered bilateral mastectomy (BLM) and prophylactic oophorectomy. Those who test negative typically do not undergo such extensive surgery. However, there is a cohort of women who still decide to have BLM at the time of their breast cancer diagnosis despite testing negative for the mutation. A questionnaire was sent to women who had prophylactic mastectomies to determine the reasons for their surgical choice.

Methods: Women who received BRCA1 and 2 testing and tested negative but chose bilateral mastectomies between January 2005- May, 2010 were sent a questionnaire. For those who expressed an opinion, a two-sided Fisher exact test was used to compare responses. Patient demographics, family history, reasons for choosing mastectomy, and satisfaction were recorded.

Results: A total of 35 surveys were mailed, and 28 were returned (80%). The mean patient age at diagnosis was 41.9 years. The majority of women were Caucasian, had some college to postgraduate education, and had children. 64% had a relative with breast cancer. Fear was the main reason why these women choose BLM. The majority had breast reconstruction and overall 71% were very satisfied with their surgical choice.

Conclusions: Increased rates of contralateral prophylactic mastectomies have been observed in women with negative BRCA results. In our study Caucasian, educated, married women were more likely to choose BLM. The main reason women gave for choosing BLM was fear of recurrence. Prospective studies are needed to examine factors effecting patient decision-making.

Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study

BACKGROUND

Evaluation of peritoneal metastases by computed tomography (CT) scans is challenging and has been reported to be inaccurate.

METHODS

A multi-institutional prospective observational registry study of patients with peritoneal carcinomatosis from colorectal cancer was conducted and a subset analysis was performed to examine peritoneal cancer index (PCI) based on CT and intraoperative exploration.

RESULTS

Fifty-two patients (mean age 52.6 ± 12.4 years) from 16 institutions were included in this study. Inaccuracies of CT-based assessment of lesion sizes were observed in the RUQ (P = 0.004), LLQ (P < 0.0005), RLQ (P = 0.003), distal jejunum (P = 0.004), and distal ileum (P < 0.0005). When CT-PCI was classified based on the extent of carcinomatosis, 17 cases (33%) were underestimations, of which, 11 cases (21%) were upstaged from low to moderate, 4 cases (8%) were upstaged from low to severe, and 2 cases (4%) were upstaged from moderate to severe. Relevant clinical discordance where an upstage occurred to severe carcinomatosis constituted a true inaccuracy and was observed in six cases (12%).

CONCLUSIONS

The actual clinical impact of inaccuracies of CT-PCI was modest. CT-PCI will remain as a mandatory imaging tool and may be supplemented with other tools including positron emission tomography scan or diagnostic laparoscopy, in the patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Adjuvant gemcitabine and concurrent radiation for patients with resected pancreatic cancer: a phase II study

The safety and efficacy of gemcitabine and concurrent radiation to the upper abdomen followed by weekly gemcitabine in patients with resected pancreatic cancer was determined. Patients with resected adenocarcinoma of the pancreas were treated with intravenous gemcitabine administered twice-weekly (40 mg m⁻²) for 5 weeks concurrent with upper abdominal radiation (50.4 Gy in 5½ weeks). At the completion of the chemoradiation, patients without disease progression were given gemcitabine (1000 mg m⁻²) weekly for two cycles. Each cycle consisted of 3 weeks of treatment followed by 1 week without treatment. Forty-seven patients were entered, 46 of whom are included in this analysis. Characteristics: median age 61 years (range 35–79); 24 females (58%); 73% stage T3/T4; and 70% lymph node positive. Grade III/IV gastrointestinal or haematologic toxicities were infrequent. The median survival was 18.3 months, while the median time to disease recurrence was 10.3 months. Twenty-four percent of patients were alive at 3 years. Only six of 34 patients with progression experienced local regional relapse as a component of the first site of failure. These results confirm the feasibility of delivering adjuvant concurrent gemcitabine and radiation to the upper abdomen. This strategy produced good local regional tumour control.

The influence of radiation therapy on survival among Medicaid-enrolled breast cancer patients treated with breast conserving surgery

609

Background: A growing body of evidence indicates that breast cancer patients treated with breast conserving surgery (BCS) without radiotherapy (RT) have a greater risk of cancer recurrence and mortality compared to those receiving BCS plus RT. Most of the research to date has not included or accounted for women with lower socioeconomic status. Methods: Using cancer registry, Medicaid claims, and Social Security death index data, we evaluated receipt of RT and mean 6-year overall and cancer-specific survival among Medicaid-enrolled breast cancer patients treated with BCS (n=230). Logistic regression was used to assess predictors of RT. The Kaplan-Meier method was used to determine survival by RT status and a multivariate Cox proportional hazards regression model was used to evaluate the role of RT on overall and cause-specific survival while controlling for demographic, clinical, and comorbid factors. Results: 65% of women received RT. Overall, 82% of the sample survived the 5–6 year study period, with death rates of 16% compared to 51% among those who did and did not receive RT, respectively (p<.001). Among the 24 individuals who died from cancer, 8 (33.3%) received radiation and 16 (66.7%) had not. After controlling for demographics, clinical factors, and comorbidity, use of RT was associated with a statistically significant decrease in all-cause mortality (hazard ratio = 0.42, 95% CI 0.21–0.85) and cancer-specific mortality (hazard ratio = 0.22, 95% CI −0.09–0.57). Conclusions: We found under-use of radiation following BCS in this Medicaid-enrolled population of breast cancer patients. Furthermore, omission of RT was associated with a greater than two-fold increased risk of death and almost a five-fold increase in cancer-specific death. Measures to improve RT use among poor women receiving BCS need to be implemented.

No significant financial relationships to disclose.

Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study

PURPOSE

The three principal studies dedicated to the natural history of peritoneal carcinomatosis (PC) from colorectal cancer consistently showed median survival ranging between 6 and 8 months. New approaches combining cytoreductive surgery and perioperative intraperitoneal chemotherapy suggest improved survival.

PATIENTS AND METHODS

A retrospective multicenter study was performed to evaluate the international experience with this combined treatment and to identify the principal prognostic indicators. All patients had cytoreductive surgery and perioperative intraperitoneal chemotherapy (intraperitoneal chemohyperthermia and/or immediate postoperative intraperitoneal chemotherapy). PC from appendiceal origin was excluded.

RESULTS

The study included 506 patients from 28 institutions operated between May 1987 and December 2002. Their median age was 51 years. The median follow-up was 53 months. The morbidity and mortality rates were 22.9% and 4%, respectively. The overall median survival was 19.2 months. Patients in whom cytoreductive surgery was complete had a median survival of 32.4 months, compared with 8.4 months for patients in whom complete cytoreductive surgery was not possible (P <.001). Positive independent prognostic indicators by multivariate analysis were complete cytoreduction, treatment by a second procedure, limited extent of PC, age less than 65 years, and use of adjuvant chemotherapy. The use of neoadjuvant chemotherapy, lymph node involvement, presence of liver metastasis, and poor histologic differentiation were negative independent prognostic indicators.

CONCLUSION

The therapeutic approach combining cytoreductive surgery with perioperative intraperitoneal chemotherapy achieved long-term survival in a selected group of patients with PC from colorectal origin with acceptable morbidity and mortality. The complete cytoreductive surgery was the most important prognostic indicator.

Surgical and ablative treatment for metastatic adenocarcinoma to the liver from unknown primary tumor

Metastatic adenocarcinoma to the liver from an unknown primary tumor (UPT) carries a poor prognosis, with a median survival of 5 months. Chemotherapy has not significantly improved outcome, and effective treatment is yet to be established in these patients. We examined our experience with surgical resection and ablation of this disease to determine clinico-pathologic characteristics and treatment outcomes. We undertook a retrospective chart review of 157 patients who were treated for metastatic disease to the liver with resection or radiofrequency ablation (RFA) between 1999 and 2003. Seven patients were identified with unknown primary malignancy. Evaluation of the seven patients included complete history and physical examination, complete blood count, routine chemistries, stool Hemoccult test, chest radiograph, and computed tomography (CT) of the abdomen and pelvis. In addition, the three female patients had breast examinations and mammography. Adenocarcinoma histology was determined via CT-guided liver biopsy in all patients. Other diagnostic tests, including whole-body positron emission tomography to the measurement of various serum tumor markers, were performed in the majority of the patients. There were nine total lesions treated; six with RFA and three with hepatic resection. Median diameter of the lesions was 5.4 cm (range, 1.3-15). Two patients were treated with adjuvant and three patients with neoadjuvant and adjuvant chemotherapy. Extrahepatic sites of metastases, adrenal and skeletal, were discovered in 1 patient prior to treatment. With a median follow-up of 9 months, 1 patient is currently alive with no evidence of disease, 4 patients are alive with disease, and 2 patients died of disease. Median disease-free-interval following treatment was 6.5 months. To date, optimal treatment for metastatic adenocarcinoma to the liver UPT remains unclear. Localized treatment involving RFA or hepatic resection may be a promising addition to chemotherapy in the management of this disease.

Cystic changes in hepatic and peritoneal metastases from gastrointestinal stromal tumors treated with Gleevec

BACKGROUND

Tyrosine kinase inhibitor (Gleevec or STI-571) must be considered the treatment of choice for metastatic gastrointestinal stromal tumors (GISTs). The purpose of this article is to address and illustrate a long-term follow-up of computed tomographic (CT) radiologic findings in patients with metastases from GIST after Gleevec treatment.

METHODS

We performed a retrospective review of seven patients (four male, three female) with unresectable metastases from GIST who were treated with STI-571 in a 1-year period. Patients were followed every 2-4 months by contrast-enhanced CT for up to 12 months. The size and attenuation of hepatic and peritoneal metastases on CT were measured and correlated.

RESULTS

Hepatic metastases from GISTs showed significant decreased attenuation from a mean of 60 HU to a mean of 32 HU (p < 0.01) in the first 2 months and continued decreasing attenuation to 23 HU at the 12-month follow-up. These metastases superficially resembled simple cysts. Most metastases became smaller, with more defined borders, after treatment. Histologic examination in a resected specimen revealed hepatic cyst with no residual tumor cells, regression of omental lesions, and extensive necrosis.

CONCLUSIONS

CT findings of unresectable hepatic and peritoneal metastases from GIST displayed decreasing, near cystic attenuation and size as an effective regression in response to STI-571 treatment.

PROGINS Alu insertion and human genomic diversity

A polymorphic Alu element belonging to the young Ya5 subfamily of Alu repeats located in the progesterone receptor gene has been characterized. Using a polymerase chain reaction (PCR)-based assay, the genetic diversity associated with the PROGINS Alu repeat was determined in a diverse array of human populations. The level of insertion polymorphism associated with PROGINS suggests that it will be a useful marker for the study of human evolution. In addition, we determined the distribution of the PROGINS Alu insertion in two groups of women from greater New Orleans, LA with breast cancer. The PROGINS Alu insertion was not associated with breast cancer in the populations tested.

Prospective trial for the treatment of malignant peritoneal mesothelioma

Malignant peritoneal mesothelioma (MPM) is a rare and often rapidly fatal disease with median survival of 5 to 12 months for untreated cases and 16 months reported after multimodality treatment. We report a prospective clinical treatment study using cytoreductive surgery combined with intraoperative intraperitoneal heated chemotherapy (IPHC) perfusion using mitomycin C for MPM. Twelve patients (11 male with a mean age 51 years) were treated. Seven patients presented with bulky disease and seven with ascites. All underwent exploratory laparotomy with histologically confirmed diagnosis of MPM. Surgical debulking as feasible was performed. Complete gross tumor removal was possible in only one patient. Cytoreduction was followed by a 2-hour closed low-volume IPHC using mitomycin C. One patient died 50 days postoperatively from complications relating to small bowel perforation. Hematologic toxicity of the procedure was minimal. Ascites was controlled in all patients and permanently in 86 per cent of patients presenting with ascites. To date median survival is 34.2 months with median follow-up of 45.2 months. One patient was re-explored for ventral hernia 2 years post-IPHC, had negative peritoneal biopsies, and remains disease-free at 5 years. Given the dismal prognosis associated with MPM the results of treatment with cytoreductive surgery combined with IPHC perfusion are encouraging. The rarity of MPM makes appropriately powered prospective randomized trials unlikely. Therefore, we now offer this approach off protocol; however, further study of this combined modality therapy is warranted.

Chest wall metastasis from recurrent meningioma

Meningiomas are generally considered benign lesions. A minority, however, are capable of metastasis. The ones most likely to do so are commonly recurrent or frankly malignant in nature. The optimal management of such metastases is unclear. This is the first reported case of meningioma presenting as an isolated metastasis to the chest wall. This case involves a 64-year-old woman without significant medical or family history who underwent resection of a meningioma of the right cerebral hemisphere. She was treated 10 years later for recurrence by stereotactic radiosurgery. Three years after that, the patient's family noticed a mass on the left chest wall. A CT scan revealed destruction of the ninth rib laterally and subpleural extension. The patient subsequently underwent resection of full-thickness chest wall for a presumed soft-tissue sarcoma. Further pathologic evaluation including electron microscopy and immunohistochemistry revealed metastatic meningioma. The patient received adjuvant radiation to the chest wall and is currently free of disease at the chest wall one year after surgery. This case illustrates the difficulty in establishing an accurate diagnosis of metastatic meningioma. Consequently in selected patients with a history of the disease the diagnosis of metastatic meningioma must at least be considered. Resection of an isolated metastasis in this setting appears warranted.

Paraneoplastic hypercalcemia in a patient with adenosquamous cancer of the colon

Hypercalcemia is a well-known manifestation of paraneoplastic syndromes associated with a variety of malignancies. However, colon cancer has only rarely been associated with hypercalcemia of malignancy. We present the case of a patient with recurrent adenosquamous carcinoma of the ascending colon found to have hypercalcemia. The patient is a 76-year-old white woman who initially presented with colon cancer in the cecum and underwent a right hemicolectomy. All lymph nodes and surgical margins were free of tumor. Pathological examination at that time revealed adenosquamous carcinoma of the colon. Eight months later she complained of dizziness, anorexia, and constipation and was found to have a calcium level of 13.6 mg/dL. CT scan revealed a mass measuring 10.5 to 12.7 cm in the right hepatic lobe, and a bone scan was normal. Her intact parathyroid hormone (PTH) level was 6 pg/mL (normal 12-72) and her PTH-related protein (PTHrP) level was 25.7 pmol/L (normal <1.3). She then underwent a hepatic resection. The serum PTH, calcium, and PTHrP levels normalized after resection. Hypercalcemia of malignancy in colon cancer is rare and has an association with adenosquamous histology. The hypercalcemia is attributed to PTHrP, and here we demonstrate this in the serum and tumor specimens. The effects of PTHrP are shown to be short-lived postoperatively. We find only 14 other cases in the literature of hypercalcemia related to a colonic neoplasm, and this is the only patient reported to be surviving. The diagnosis of a paraneoplastic syndrome mediated via PTHrP should be considered when hypercalcemia is encountered in the setting of metastatic colon carcinoma.

Incidental thyroid carcinoma identified by positron emission tomography scanning obtained for metastatic evaluation

Positron emission tomography (PET) scanning is an emerging technology with substantial implications for patients with solid tumors. PET is useful in identifying sites of metastatic disease as well as primary malignancy and evaluating suspicious findings found via other imaging modalities. PET is becoming a standard modality for metastatic evaluation of a variety of malignancies. However, this imaging is not limited by histology and may reveal clinically occult second lesions. We present five cases of a clinically occult thyroid cancer found in patients who underwent PET scanning for metastatic evaluations. The principal diagnoses included two patients with malignant melanoma, one each with gastric, rectal, and colonic adenocarcinoma. None of the cases had findings on physical examination. Increased uptake in the region of the thyroid was evident on the PET scan, and fine-needle aspiration biopsy indicated papillary carcinoma of the thyroid in all five cases. Although evaluation of metastatic disease is the primary purpose for PET in this setting the discovery of occult thyroid malignancy is an additional benefit of such imaging. This emphasizes the importance of investigating suspicious areas found by PET and not simply assuming that these are all sites of metastatic disease. Furthermore incidental findings of uptake in the region of the thyroid make consideration of a primary carcinoma mandatory.

Sentinel lymph node mapping for carcinoma of the colon: a pilot study

Sentinel lymph node (SLN) mapping has evolved into the standard of care for melanoma and may replace routine node dissection in the treatment of breast cancer. There are few data evaluating sentinel node mapping in patients with cancer of the colon. This trial represents our initial experience with SLN mapping for carcinoma of the colon. SLN mapping was performed in 22 patients most of whom had biopsy-proven adenocarcinoma of the colon. One milliliter of isosulfan blue was injected with a 25-gauge needle into the subserosa at four sites around the edge of the palpable tumor. The SLN was identified visually and excised. A standard lymphadenectomy was then performed. The SLN was analyzed with standard hematoxylin and eosin evaluation. Immunohistochemical techniques for carcinoembryonic antigen and cytokeratin (Imm) were performed if the H&E was negative. The mapping added approximately 5 minutes to the total operative time and no adverse reactions to the dye occurred. A SLN was identified in 20 of 22 cases. In cases with negative lymph nodes the SLN was predictive of all the regional nodes by both H&E and Imm (14 of 14). In patients with positive lymph nodes the SLN was predictive in all cases (six of six). In one case the only node with disease was the SLN, and in this case the diease was identified by only Imm; thus this patient was upstaged. SLN mapping is feasible and safe and can readily be performed in patients with colonic cancer. In conjunction with SLN mapping, Imm techniques may upstage a subset of patients likely to be at increased risk for metastatic disease. Consequently SLN mapping of colon cancer should be evaluated in large prospective trials.

Radiation-induced gastrointestinal stromal sarcoma of the esophagus

Esophageal sarcoma is an uncommon tumor, sporadically reported in the literature. Radiation therapy is frequently employed in the treatment of carcinoma of the esophagus, and the increased risk of development of sarcoma arising in irradiated fields is well known. However, to our knowledge, the occurrence of radiation-associated sarcoma of the esophagus after radiation therapy for carcinoma of the esophagus has not been reported. We therefore report the case of a 43-year-old female who developed a gastrointestinal stroma sarcoma 9 years following radiation therapy for esophageal squamous cell carcinoma. The patient underwent resection of her gastrointestinal stromal sarcoma by transhiatal esophagectomy with cervical anastomosis and is doing well 18 months later. The increasing use of radiation therapy for esophageal carcinoma suggests that radiation-associated sarcoma of the esophagus may be seen more frequently in the future.

A prospective study of seeding of the skin after core biopsy of the breast

BACKGROUND

The number of core biopsies done for breast abnormalities is increasing. The risk of skin seeding resulting from core biopsy is unknown.

METHODS

Consecutive patients diagnosed with breast cancer were studied. The skin and subcutaneous fat surrounding the site of core needle penetration were excised and studied by routine histologic staining. Findings were correlated with other clinical variables.

RESULTS

Eighty-nine consecutive patients were studied. Thirty-one had stereotactic core biopsies, 23 had vacuum-assisted biopsy, 8 had multiple-puncture biopsy, and 58 had ultrasound-guided core biopsy. Two patients who were biopsied using multiple-puncture biopsy were found to have nests of cancer cells in the dermis. One of these patients had recurrence in the skin biopsy site at 34 months.

CONCLUSION

Skin seeding may be important in light of increasing use of image-directed biopsy, and particularly for cases in which the biopsy puncture site is outside the index quadrant and in which no radiation is anticipated.

Current role of scapulectomy

Tumors of the scapula are an unusual clinical challenge. Partial or complete resection of the scapula, with its attached musculoaponeurotic tissue, is a seldom used technique for the treatment of primary bone and soft tissue tumors, as well as selected metastatic involvement of the scapula. Scapulectomy may allow wide margins of resection without amputation. The purpose of this study is to review our recent experience with scapulectomy. This study describes the recent experience with scapulectomy by the Section of Surgical Oncology and the Department of Orthopedics at Louisiana State Medical Center (New Orleans, LA). Between 1994 and 1998, 12 patients (between 16 and 79 years of age) underwent a resection of the scapula. Eleven of these patients had soft tissue tumors; one had a metastasis from a thyroid carcinoma. Six of these patients underwent a scapulectomy as a primary treatment, five for recurrence. Six patients also received postoperative radiation and/or chemotherapy. The follow-up ranged from 6 months to 4 years. There was no mortality or wound infection associated with scapulectomy. All patients had normal hand and wrist function after surgery. Three distant recurrences occurred, with no local or regional failures encountered during the follow-up period. Scapulectomy can result in excellent local tumor control. Whereas some loss of active shoulder motion may occur, hand, wrist and elbow function is preserved. Although maintenance of shoulder function should not take precedence over adequacy of resection, scapulectomy remains an excellent procedure for malignant disease that preserves hand, wrist, and elbow function.

Influence of erythropoietin on transfusion requirements in patients receiving preoperative chemoradiotherapy for rectal cancer

PURPOSE

Perioperative homologous blood transfusion has been suggested to have an adverse effect on survival in patients undergoing resection of colorectal cancers. Preoperative therapy is being increasingly used for rectal cancer patients and has an adverse effect on erythropoietic capacity. The objectives of this study were to evaluate the feasibility and safety of administration of recombinant human erythropoietin to patients receiving preoperative therapy for rectal cancer and to assess the impact of such treatment on blood transfusion requirements.

METHODS

The study was an open-label, Phase I and II, nonrandomized, two-center trial. All patients received 50.4 Gy of irradiation with 5-fluorouracil infusions. Ten patients diagnosed with rectal cancer received 250 U/kg of recombinant human erythropoietin subcutaneously three times per week during preoperative radiation and chemotherapy. Oral iron was given to patients receiving erythropoietin. Ten contemporaneously treated patients who received both radiation and chemotherapy were used as controls.

RESULTS

Of the 20 patients 13 were males; mean age was 64 years. Surgical procedures that patients underwent were abdominoperineal resection (14 patients), low anterior resection (4 patients), coloanal anastomosis (1 patient), or none (1 patient). There were no significant differences between groups in age, gender, stage or hemoglobin levels before therapy. No adverse reactions to erythropoietin were encountered. Hemoglobin levels were significantly higher in the treatment group during Weeks 1, 3, and 5 (P < 0.02 for each). Transfusion requirements were significantly decreased in patients who received erythropoietin (0.4 vs. 3.7 units; P < 0.0003).

CONCLUSIONS

The data showed that use of erythropoietin during preoperative therapy can prevent the decline in hemoglobin that commonly occurs during therapy. Further, this was not associated with adverse events and significantly decreased the need for perioperative blood transfusions. This suggests that the use of erythropoietin in support of a preoperative chemoradiotherapy regimen for patients with rectal cancer is safe and should be considered. Whether such transfusion avoidance will translate into a survival benefit in this setting will require a large, prospective, clinical trial.

Prognostic factors in soft tissue sarcoma

The ability to accurately define the prognosis for patients with soft tissue sarcoma is a continuing challenge. Classically, this has been accomplished through assessments of tumor size, histologic grade, location, and the presence of nodal or distant metastases. These criteria are the basis of the currently utilized American Joint Commission on Cancer (AJCC) staging system. However, several other markers have been identified which have prognostic value. These newer markers are useful additions to the AJCC system. Such markers may not only improve our ability to prognosticate at diagnosis, but may also prove useful in selecting high-risk soft tissue sarcoma patients who could benefit from adjuvant therapy. This review will focus upon prognostic factors for patients with soft tissue sarcomas (STS). First, the components of the current AJCC staging system will be discussed; second, a summary of clinical prognostic factors which are not part of the staging system; and third, a discussion of newer and potential prognostic factors for STS patients.

Intraoperative gamma detection of 125I-lanreotide in women with primary breast cancer

BACKGROUND

Somatostatin receptors are present in most human breast cancers. We performed a pilot trial of intraoperative tumor-gamma detection using the radiolabeled somatostatin analog 125I-lanreotide in 13 women with 14 primary breast carcinomas.

METHODS

All patients were given 125I-lanreotide intravenously before surgery. Patients underwent lumpectomy, and postresection margins were evaluated with the gamma probe. Axillary dissection specimens were evaluated ex vivo.

RESULTS

Seven of 13 women had gamma probe-positive or clinically suspicious margins re-excised at the time of lumpectomy. Four of six probe-positive margins were histologically positive, and two of six probe-positive margins were histologically negative; a single clinically suspicious margin was histologically positive. A total of 270 axillary lymph nodes were evaluated ex vivo by gamma probe and histology. McNemar's contingency tests demonstrated a highly statistical correlation between histology and gamma probe counts (P < .0001).

CONCLUSIONS

The overall accuracy of nodal evaluation with 125I-lanreotide/intraoperative gamma detection was 77%; the negative predictive value of this technique was 97%, however. This technique predicted the presence of tumor in 20% of axillary lymph nodes that were negative by routine histology. This technique appears safe and is able to detect positive tumor resection margins and accurately predict axillary lymph node negativity. Further trials of this technique are required to validate its utility.

Pancreaticoduodenectomy for melanoma metastatic to the duodenum: a case report and review of the literature

Although melanoma accounts for fewer than 5 per cent of cutaneous malignancies, it is responsible for more than 75 per cent of skin cancer deaths. Metastasis generally proceeds from regional lymph nodes to visceral organs, with the lungs, liver, brain, and bowel being most commonly affected. Herein, we report a case of malignant melanoma metastatic to the ampulla of Vater treated with a pancreaticoduodenectomy.

A 60 kd MDM2 isoform is produced by caspase cleavage in non-apoptotic tumor cells

The MDM2 oncogene product is a regulator of the p53 tumor suppressor. MDM2 is cleaved by Caspase 3 (CPP32) during apoptosis after aspartic acid-361, generating a 60 kd fragment. Here we report that human tumor cell lines often express high levels of a 60 kd MDM2 isoform (p60) in the absence of apoptosis. We demonstrate that p60 is a product of caspase cleavage of full length MDM2 after residue 361. The protease that cleaves MDM2 in non-apoptotic cells appears to be distinct from the apoptosis-specific Caspase 3, since Caspase 3 substrate poly(ADP-ribose) polymerase (PARP) is not cleaved in cells producing p60. The p60 form of MDM2 is a significant fraction of the p53-bound MDM2 protein in certain tumor cells, suggesting that it functions in the regulation of p53. p60 is also detected in breast tumors overexpressing MDM2. These observations suggest that MDM2 is regulated by caspase processing in non-apoptotic cells, and may account for the MDM2 proteins of similar mobility seen in tumors and other cell lines.

Extended hemipelvectomy in a Jehovah's Witness with erythropoietin support

The care of patients refusing blood transfusion who require major ablative surgery for malignancy is a continuing challenge. The use of recombinant human erythropoietin is clearly efficacious in patients with renal disease and may be useful in anemic patients who refuse transfusion. Herein, we report a successful extended hemipelvectomy in a Jehovah's Witness using recombinant human erythropoietin support.

Altered composition and increased endothelial cell proliferative activity of proteoglycans isolated from breast carcinoma

BACKGROUND AND OBJECTIVES

Proteoglycans of the extracellular matrix are vital to the growth and evolution of malignant neoplasms. The present study determined the composition of proteoglycans isolated from paired specimens of normal breast and adenocarcinoma of the breast harvested from each patient (n = 8). The proteoglycans were then tested for their ability to stimulate endothelial cell proliferation.

METHODS

Proteoglycans were isolated by extraction with 4 M guanidine hydrochloride and purified by CsCl density-gradient centrifugation. The proteoglycans were characterized and tested for their ability to simulate endothelial cell proliferation.

RESULTS

In each case, the total proteoglycan content of the tumor was significantly greater than that of the corresponding normal tissue. The proteoglycans isolated from the carcinoma contained 32.2% (13.7/42.5) more chondroitin sulfate, 18.5% (5.6/30.2) less dermatan sulfate, and 29.6% (8.1/27.3) less heparan sulfate than did the proteoglycans of normal breast tissue. Proteoglycans from normal tissue did not stimulate endothelial cell proliferation, whereas those from malignant tissue stimulated proliferation by 1.3- to 1.5-fold.

CONCLUSIONS

These results indicate that malignant breast tissue exhibits both qualitative and quantitative changes in proteoglycan composition, which, in turn, may stimulate endothelial cell proliferation.

Recurrent malignant acrospiroma. Treatment by chest wall excision

Malignant acrospiroma is an uncommon tumor of the eccrine sweat gland. In contrast to its relatively more common benign counterpart, malignant acrospiroma is highly invasive, often with significant lymphatic and distant metastasis. The establishment of this diagnosis is difficult on both clinical and histopathologic grounds. After diagnosis, wide surgical excision is warranted to completely extirpate these lesions. We report the case of a 66-year-old female with a recurrent malignant acrospiroma. This patient's tumor was removed by wide radical resection, including chest wall excision, followed by reconstructive surgery and radiotherapy. After 16 months there is no evidence of local recurrence or distant metastasis.

Early gastric cancer and Helicobacter pylori: 34 years of experience at Charity Hospital in New Orleans

Good survival rates have been reported for resected early gastric adenocarcinoma (EGC) in patients found via screening procedures. However, the prevalence of Helicobacter pylori in EGC in unscreened populations is unclear. The major purpose of this investigation was to analyze the clinical experience and incidence of H. pylori in unscreened patients presenting with EGC at Charity Hospital over a 34-year period. From 1963 through 1997, the tumor registry at Charity Hospital compiled data on 2497 patients evaluated for gastric carcinoma. Of these patients, 26 (1%) had lesions that were confined to the mucosa or submucosa, i.e., T1N0M0 (American Joint Commission on Cancer classification). Pathology specimens and medical records were retrieved for confirmation of diagnosis and retrospective analysis for H. pylori. H. pylori was analyzed by Steiner staining and immunohistochemistry using a polyclonal antibody. EGC was detected in 12 men and 14 women with a mean age of 62 years. Upper gastrointestinal X-ray studies were performed on 19 of the 26 patients and failed to conclusively demonstrate a lesion in any case. Endoscopy was performed on 22 patients, and preoperative biopsies were positive in 95 per cent of these. Operative procedures included 2 local excisions and 22 subtotal and 2 total gastrectomies. No extended nodal dissections were performed. Microscopic evaluation revealed lesions limited to the mucosa in 63 per cent of cases and involving the submucosa in 37 per cent of the cases. Of the 14 patients evaluable of H. pylori, 79 per cent were positive for the bacterium. The status of 2 patients is unknown, and only 1 patient died of the original gastric cancer, for a disease-free survival of 96 per cent. The 5-year and 10-year overall survival rates were calculated to be 50 per cent and 21 per cent, respectively, when all causes of death were taken into consideration. Median follow-up of the survivors was 64 months. Resection of early gastric carcinoma in unscreened patients without extended lymphadenectomy yielded excellent results. H. pylori was present in 79 per cent of cases. These data suggest an association between H. pylori and EGC. Whether H. pylori infection is an etiologic factor in gastric cancer remains an area of active research.

Desmoid tumor arising in a laparoscopic trocar site

Desmoid tumors are fibrotic neoplasms of low metastatic potential. These tumors have long been associated with major laparotomy incisions. However, to the best of our knowledge, they have not been previously associated with laparoscopic trocar placement. This report involves the case of a patient who developed a desmoid tumor at a trocar site. A 35 year-old premenopausal woman presented with an enlarging infraumbilical mass 10 years after a laparoscopic tubal ligation. The mass was immediately subjacent to the skin incision for the laparoscopic procedure. It was approximately 6 cm in diameter and fixed to the underlying abdominal wall. It was evaluated with sonographic and CT imaging, which revealed a solid mass arising from the fascia with no associated hernia. A biopsy of the mass confirmed a diagnosis of a desmoid tumor. This was subsequently excised with a wide margin and reconstructed with Marlex mesh. The patient is without recurrence 2 years following surgery. This case represents what we believe to be the first report of a desmoid tumor arising from a incision made for the placement of a laparoscopic port. Rapidly increasing laparoscopic applications make it likely that these lesions will increase in frequency. In this setting, resection with wide margins remains the mainstay of treatment for desmoid tumors.

Initial clinical experience with colonic stent placement

BACKGROUND

The purpose of this study is to review initial experience with a colonic stent as an alternative to colostomy in patients with colonic obstruction.

METHODS

Ten patients diagnosed with acute colonic obstructions from both benign and malignant causes underwent stent placement. Self-expandable metallic stents were deployed using fluoroscopic guidance. Patients were followed up clinically until removal of the stent or death.

RESULTS

Nine of the 10 patients who underwent colonic stent placement achieved clinical decompression within 6 hours. Six patients underwent standard mechanical bowel preparation and elective resection of obstructing lesions. The other 4 patients received stent placement for palliative purposes. Complications included 4 cases of migration and 1 death. Migrated stents in the rectum were easily retrieved and replaced using fluoroscopic techniques. There were no perforations.

CONCLUSION

Placement of self-expandable metallic stents for acute colonic obstructions may allow patients to undergo elective surgical resection avoiding possible colostomy.

Successful treatment of in-transit metastases from Merkel's cell carcinoma with isolated hyperthermic limb perfusion

Merkel's cell carcinoma is an uncommon neuroendocrine cutaneous neoplasm. An unusual mode of dissemination of this tumor is the phenomenon of in-transit metastases. We report complete resolution of in-transit metastases from a Merkel's cell carcinoma in response to treatment with isolated hyperthermic limb perfusion with melphalan. Limb perfusion appears to be a promising modality for such lesions.

Preoperative chemotherapy for locally advanced breast carcinoma at Charity Hospital, New Orleans, Louisiana

Despite increased screening and public education efforts, there continues to be a subset of patients with breast carcinoma who do not seek medical attention until their lesions are locally advanced. Recently, there has been increasing interest in administering preoperative chemotherapy to these patients. The purpose of this study was to evaluate the Charity Hospital experience with preoperative chemotherapy for locally advanced breast carcinoma. Thirty-three poor urban women with T3 or T4 breast lesions were treated with preoperative chemotherapy before surgical resection, between 1987 and 1995. Their charts and pathology were reviewed and analyzed. Local treatment was in the form of radical mastectomy (n = 3), modified radical mastectomy (n = 26), or lumpectomy with axillary dissection (n = 4). After preoperative chemotherapy, 4 patients had a complete histologic response (12%), 19 had a partial response (58%), and 10 had no response (30%). After a mean follow-up of 40.6 months, stage IIIA (n = 16) and stage IIIB (n = 12) patients were found to have 5-year survival rates of 50.2 and 26.7 per cent, respectively. Stage IV (n = 5) patients had a median survival of 23.1 months with no survivors at 3 years. Patients who had a complete or partial response to chemotherapy had a median survival of 43.0 months versus 23.1 months for the nonresponders. We conclude that our response rate, for poor urban women with locally advanced breast carcinoma, to preoperative chemotherapy, is comparable with that found in the literature. Furthermore, the initial response to this chemotherapy may be an important indicator of ultimate prognosis.

The effect of clenbuterol and recombinant erythropoietin on tumor growth and the anemia caused by the Walker 256 carcinosarcoma

In patients with advanced cancer, anemia is a common complication indicative of a poor prognosis. Attempts to alleviate this have met with mixed success and interventions including erythropoietin often fail to elicit an appropriate response. We have used rats implanted with the Walker 256 carcinosarcoma as a model of non-responsive anemia. This study demonstrates that the provision of recombinant erythropoietin in the presence of clenbuterol, a beta2 agonist, attenuates both the cancer induced anemia and the growth of the tumor in this model. We hypothesize that this treatment relieves the tumor induced inhibition of hematopoiesis, which allows for not only an increase in hematocrit but an increased immunosurveillance resulting in tumor suppression.

Leiomyosarcoma: a 45-year review at Charity Hospital, New Orleans

Approximately 2 to 9% of all soft tissue sarcomas are leiomyosarcomas (LMS). LMS arises nearly exclusively as tumors in adults, with peak incidence occurring in the fifth and sixth decades. The purpose of this study was to analyze disease-specific survival and define prognostic factors in patients with this disease who were treated and followed at a single institution. Fifty-eight cases of LMS were identified in the Tumor Registry of the Medical Center of Louisiana at New Orleans (charity Hospital) from 1950 to 1995. Charts were reviewed and tissue blocks reexamined to confirm the diagnosis. Follow-up information was available for 56 of 58 (96%) patients. Univariate and multivariate analyses were performed to analyze which factors predict outcome. The median survival time was 138 months. Univariate analysis identified age (> 48 years), location (retroperitoneal vs other sites), and extent of disease as prognostic factors. Multivariate analysis revealed that only age and the extent of disease at presentation are independent prognostic indicators. Race, sex, and adjuvant therapy were not significant prognostic factors. Surgical resection remains the therapeutic mainstay for patients with LMS. The value of other treatment modalities is largely limited to surgical failures. The data show that the age of the patient and the extent of disease at presentation are the best predictors of long-term survival. LMS has a good prognosis when complete resection of localized lesions can be achieved.

Detection of K-ras mutations in resected primary leiomyosarcoma

Mutation of the K-ras oncogene occurs frequently in human malignancy. However, there are few reports concerning K-ras mutations in soft-tissue sarcoma, including leiomyosarcoma. We therefore designed a study to determine the prevalence of mutations in the first exon of K-ras in leiomyosarcoma and to evaluate its prognostic potential. Fifty-one leiomyosarcomas were reviewed, and their diagnoses were confirmed on pathological review. Tissue blocks were retrieved, and new sections were prepared for confirmation of diagnosis. Additional tissue sections were used for DNA isolation. PCR and denaturing gradient gel electrophoresis (DGGE) were used to detect K-ras mutations in the first exon of genomic DNA isolated from the specimens. Seven (14%) K-ras mutations were detected using DGGE. Subsequent sequencing of the K-ras gene from each of the mutated tumors confirmed the DGGE results in each case. The median survival for patients whose tumors did not contain mutations of K-ras was 42 months (n = 42) versus 25 months (n = 7) for those with mutations (P = 0.06). However, patients with stages I and II tumors had a median survival of 82 months (n = 28) compared to 28 months for those with stages III and IV disease (n = 20, P = 0.02). The results suggest that K-ras codon 12 mutations are uncommon in leiomyosarcoma; however, when such mutations are found, there is a trend toward worse survival. Furthermore, the data confirm that stage is a significant prognostic indicator.

Evaluation of newer prognostic markers for adult soft tissue sarcomas

PURPOSE

In addition to tumor size, grade, location, and the presence of metastases, other factors may be useful in prognostication for adults with soft tissue sarcoma (STS). This study examines the relationship of MDR-1 mRNA, p-glycoprotein (P-gp), Ki-67 expression, and DNA content expression to clinical outcome in adults with STS.

PATIENTS AND METHODS

Snap-frozen STS specimens from 65 patients were analyzed and compared with clinical outcomes. Immunohistochemistry was performed for the Ki-67 antigen and P-gp. DNA content was determined using the Feulgen reaction and quantitated using image analysis. MDR-1 mRNA expression was determined using a reverse-transcriptase polymerase chain reaction (RT-PCR)-based assay.

RESULTS

P-glycoprotein expression was found by immunohistochemistry in 48% of cases with 5-year overall (54% v 14%, P = .07) and disease-free survival rates (32% v 18%, P = .039) higher in high-grade tumors that did not express P-gp. MDR-1 mRNA was detected in 51% of cases and no patient with high levels of MDR-1 mRNA expression was a long-term survivor. Patients with diploid tumors had significantly better survival than those with nondiploid tumors (51% v 31%, P = .03). High levels of Ki-67 were associated with poorer overall survival (46% v 31%, P = .04). On multivariate analysis, American Joint Committee on Cancer (AJCC) staging, DNA content, Ki-67, and P-gp staining were significant prognostic factors for 5-year overall and disease-free survival.

CONCLUSION

P-gp expression, high-level Ki-67 expression, and nondiploid DNA content are independent prognostic indicators that correlate with poor outcomes in STS patients. However, MDR-1 mRNA was not found to be predictive of survival. These newer markers are useful additions to AJCC staging for prognostication for patients with STS. Such markers may be useful in selecting high-risk STS patients who could benefit from systemic adjuvant therapy.

Chest wall resection for extrapulmonary tumor

Despite progress in early detection of breast cancer, a minority of women continue to present with extensive disease which may necessitate chest wall resection. Between 1992 and 1996, 14 patients were treated by surgical resection of the chest wall and reconstruction by the LSU Sections of Surgical Oncology and Plastic Surgery. Indications included resection of primary tumor, resection of recurrent tumor, and resection of radiation therapy induced damage to the chest wall. We report chest wall excision and reconstruction with no operative mortality and minor surgical morbidity in 21% of cases. Local control was achieved in 13 of 14 cases. Additionally we report uniform success in the palliation of ulcerating, painful, or infected chest wall lesions. Approximately 25% of patients treated for breast cancer and followed up for more than 6 months have remained free of disease. Chest wall resection is a useful modality in selected patients with extensive disease.

Tumor specific Epstein-Barr virus infection is not associated with leiomyosarcoma in human immunodeficiency virus negative individuals

BACKGROUND

Recent studies have suggested that the Epstein-Barr virus (EBV) is associated with leiomyosarcoma in children with human immunodeficiency virus (HIV) and in organ transplant recipients. To determine whether EBV is associated with leiomyosarcoma in HIV negative patients, the authors examined resected leiomyosarcomas for EBV and HIV.

METHODS

Twenty-four leiomyosarcomas were studied and their diagnosis confirmed on pathologic review. From these specimens DNA was isolated. Tumor samples were analyzed for EBV and HIV using a polymerase chain reaction (PCR) technique followed by gel electrophoresis and Southern blot analysis. DNA from an EBV-infected human Burkitt's lymphoma cell line and peripheral blood from an HIV positive patient were used as positive controls for the presence of EBV and HIV, respectively. Immunohistochemistry was performed using an antibody to Epstein-Barr nuclear antigen.

RESULTS

HIV was not present in any of the patients analyzed. EBV DNA was detected in tumor tissue; however, 80 cycles of PCR were used before EBV sequences were detected. Therefore, the data indicate that tumor tissue was not infected with EBV. The positive results observed after 80 cycles of PCR were likely due to infiltrating lymphocytes. Immunohistochemistry confirmed the lack of active or latent EBV infection in tumor cells.

CONCLUSIONS

The results indicate that EBV is not associated with sporadic leiomyosarcoma in HIV negative patients. Therefore, the biology of leiomyosarcoma associated with HIV may be substantially different from the more common sporadic form.

Successful resection of multifocal hepatic adenoma during pregnancy

Hepatic adenoma is an unusual complication of pregnancy. Most of these lesions are solitary and associated with hormonal contraceptives. We believe ours is the first case of successful resection of multifocal hepatic adenoma during pregnancy in a patient with no history of oral contraceptive use.

Detection of tyrosinase mRNA from the blood of melanoma patients

Surgical therapy for localized melanoma is highly successful. However, if melanoma spreads beyond its primary site, the results of treatment are poor. Therefore, early detection of circulating melanoma cells in the blood may be important. Currently, circulating melanoma cells are undetectable. Tyrosinase is an enzyme in the melanin synthetic pathway the expression of which is only found in melanin-producing cells. Because melanocytes are not normally found in the peripheral blood, we hypothesize that melanoma cells circulating in the peripheral blood could be detected by amplifying the tyrosinase mRNA using the reverse transcription-PCR (RT-PCR). The purpose of this study was to determine the sensitivity of a RT-PCR-based assay for tyrosinase mRNA from peripheral blood and evaluate correlations with tumor status in melanoma patients. RNA was isolated from the peripheral blood or tissue culture cells, and cDNA was prepared. DNA was amplified using RT-PCR with nested primers for tyrosinase and beta(2)-microglobulin. Serial dilution experiments using cells from the SK-MEL-28 cell line were performed in culture media and in whole blood. Twelve patients with melanoma, 10 healthy controls, and 15 patients with nonmelanoma malignancies were tested for tyrosinase expression in peripheral blood. The sensitivity of this assay was determined to be as low as 1 melanoma cell in 5 ml of whole blood. No tyrosinase was found in healthy subjects or other cancer control patients. Tyrosinase mRNA was detected in the blood of five melanoma patients (one stage II, two stage III, and two stage IV). Three of these tyrosinase-positive patients had biopsy-proven evidence of melanoma, whereas the other two had no clinical evidence of malignant disease after surgical resection. The remaining seven melanoma patients had no evidence of disease and tested negative for tyrosinase mRNA. This study suggests that a RT-PCR-based assay for the detection of tyrosinase mRNA in peripheral blood is feasible. Moreover, the presence of tyrosinase mRNA in the blood seems to correlate with the stage of melanoma. Further study and follow-up are needed to clarify the role of tyrosinase mRNA as a tumor marker for malignant melanoma.

The stability of estrogen and progesterone receptors in patients receiving preoperative chemotherapy for locally advanced breast carcinoma

The determination of estrogen (ER) and progesterone receptor (PR) content is routine in the management of carcinoma of the breast. Such data are commonly used to predict responses to endocrine therapy. Preoperative chemotherapy is often utilized in the treatment of patients with locally advanced carcinoma of the breast. However, little attention has been focused upon the effect of preoperative chemotherapy on hormonal receptor expression in that setting. The purpose of this study is to evaluate the effect of preoperative chemotherapy on ER and PR expression in patients with locally advanced breast carcinoma. Patients with T3 or T4 adenocarcinoma of the breast from Charity Hospital in New Orleans were studied. Levels of ER and PR were determined from tissue blocks obtained at diagnostic biopsy, as well as after the preoperative chemotherapy. The receptor levels were determined using immunohistochemistry and quantified using image analysis. We evaluated 21 locally advanced cancer patients who received at least three cycles of standard chemotherpay regimens. Of these patients, 11 achieved a partial response, with 3 achieving a complete response after preoperative chemotherapy. A total of 33 per cent of patients had a significant change in hormonal receptor content after preoperative chemotherapy. ER changed in 17%, PR in 22%, and both ER and PR in 6%. These data show that ER and/or PR expression changed in 33% of patients studied. Further, ER and PR status does not appear to predict or correlate with response to chemotherapy. This suggests that determination of ER and PR may best be performed from definitive resection specimens in patients who receive preoperative chemotherapy.

Forequarter amputation for soft tissue tumors

Forequarter amputation is a radical surgical procedure initially described for the treatment of traumatic injuries in 1908. This procedure has been used more recently in the treatment of soft tissue tumors. This report describes the experience in the Division of Surgical Oncology at the University of Illinois over a 20-year period. Between 1970 and 1991, 10 patients underwent forequarter amputations for malignant disease. Nine of these patients had soft tissue tumors and one a malignant melanoma. Four patients underwent amputation as primary treatment of their tumor, and six underwent the procedure as treatment for recurrent tumor. All patients are presently alive with a mean follow-up of more than 10 years. Three patients had recurrent tumor after the forequarter amputation. One local failure was salvaged with a chest wall resection, and two patients had distant failure. Forequarter amputation remains an effective procedure for local control of tumors of varying histology involving the shoulder girdle and upper arm. The most common indication for this procedure is a recurrent soft tissue tumor for which limb sparing procedures are not applicable. Forequarter amputation should remain a rarely used, but important, surgical option for the treatment of patients with soft tissue tumors.

Rosai Dorfman disease of soft tissue

Rosai Dorfman disease (RDD), or sinus histiocytosis with massive lymphadenopathy, is a well-described phenomenon in lymph nodes and other organs. However, it has only recently been described as a distinct entity in soft tissue. Here we present what we believe to be the first report of a case of multiply recurrent RDD occurring exclusively in the soft tissue. Recognition that RDD of soft tissues can be a pernicious locally recurrent lesion is important and suggests that an aggressive surgical approach to this lesion may be warranted.

Effects of recombinant human erythropoietin and interleukin-3 on erythropoietic recovery from acute anemia

The risks inherent in the use of homologous blood products have increased efforts toward identifying alternatives to transfusion. We have previously shown that the administration of recombinant human erythropoietin (rhEpo) enhances the erythropoietic response to acute blood loss. Recombinant human interleukin-3 (rh-IL-3) is a hematopoietic growth factor that has been shown to act synergistically with rhEpo in accelerating erythropoiesis in vitro. The purpose of this study in a primate model was to determine if the administration of rhIL-3 in combination with rhEpo could augment the erythropoietic response to acute blood loss more than rhEpo therapy alone. Twenty-four adult male baboons were randomized into four groups. The induction of acute normovolemic anemia to a hematocrit of 20% was accomplished via exchange-transfusion with 6% hetastarch. The groups were then treated for 7 consecutive days with the following growth factors: group I (n = 7), no growth factors; group II (n = 5), rhIL-3 alone (100 micrograms/kg/d); group III (n = 6), rhEpo alone (1000 U/kg/d); group IV (n = 6), rhEpo (1000 U/kg/d) plus rhIL-3 (100 micrograms/kg/d). All animals received folate, vitamin B12, and intravenous iron-dextran immediately following the exchange-transfusion. Response to therapy was monitored for 35 days. There were no adverse reactions following growth factor administration. The analysis of erythropoietic rates between study days 1 through 11, as determined via linear regression analysis, revealed that hematocrits increased significantly faster in the groups receiving rhEpo compared to controls. The administration of rhIL-3, however, did not increase the rate of erythropoiesis when compared to controls, nor did it augment response when added to the rhEpo regimen. The results of this study demonstrate that the administration of rhIL-3 alone had no significant effect on erythropoiesis in this setting of acute blood loss. Further, despite promising in vitro data, rhIL-3 provided no additional stimulation of erythropoiesis in animals receiving rhEpo. Nevertheless, the study confirms that the pharmacologic acceleration of erythropoiesis by rhEpo alone remains an attractive alternative to homologous transfusion.

Pediatric soft tissue sarcomas of nonmyogenic origin

Nonrhabdomyosarcoma soft tissue sarcomas (NRSTS) are relatively rare tumors, which nonetheless constitute 50% of the soft tissue sarcomas seen in the pediatric population. The prognosis for these tumors is good, with 92% of patients in our series alive and 61% free of their disease at 5 years follow-up. The most important prognostic factor among our 35 patients was the grade of the tumor. More than 70% of our patients with grade I or II lesions are disease-free at 5 years, compared to only 39% of patients with grade III lesions. The patients with the best outlook are those who can be treated with surgery alone as the definitive care for this disease. Resection remains the primary treatment modality in NRSTS, whereas, unlike the treatment of rhabdomyosarcomas, the value of radiation therapy and chemotherapy in treating NRSTS remains undefined.