Phase 1/1B trial to assess the activity of entrectinib in children and adolescents with recurrent or refractory solid tumors including central nervous system (CNS) tumors

10009

Background: Entrectinib is a CNS-penetrant oral inhibitor of TrkA/B/C, ROS1 and ALK tyrosine kinases. We report the efficacy of entrectinib in children with recurrent/refractory solid or CNS tumors. Methods: Patients ≤ 20y old with recurrent/refractory solid tumors were eligible. After determination of the recommended dose in all-comers, disease-specific expansion cohorts of CNS and solid tumors harboring target aberrations in NTRK1/2/3, ROS1 or ALK, and neuroblastoma (NBL), regardless of mutation spectrum, were enrolled. Response, assessed by Investigator, was classified as complete response (CR), partial response (PR), stable disease (SD) or progressive disease (PD) using RANO for CNS tumors, RECIST for solid tumors, and Curie score for NBL. Results: Between May 2016 and October 2018, 29 patients aged 4.9m–20y (median 7y) were enrolled and 28 were evaluated for response. Entrectinib was well tolerated. Dose limiting toxicities were elevated creatinine, dysgeusia, fatigue and pulmonary edema. The recommended dose was 550 mg/m2 daily. All responses occurred at doses ≥ 400 mg/m2. In CNS tumors (n = 6), all high-grade with gene fusions: 1 achieved a CR ( ETV6-NTRK3); 3 achieved a PR ( TPR-NTRK1, EEF1G-ROS1, EML1-NTRK2); 1 achieved an unconfirmed PR ( GOPC-ROS1); and 1 has yet to be evaluated ( KANK1-NTRK2). In extracranial solid tumors (n = 8), 6 had a fusion of whom 1 achieved a CR ( DCTN1-ALK) and 5 achieved a PR ( TFG1-ROS1, EML4-NTRK3, ETV6-NTRK3, KIF5B-ALK, ETV6-NTRK3). In NBL (n = 15): 1 achieved a CR ( ALK F1174L). Median duration of therapy was 85d (6–592d) for all patients; 56d (6–338d) for non-responders; and 281d (56–592d) for responders. Median time to response was 57d (30–58d). Conclusions: Entrectinib produced striking, rapid and durable responses in all children with refractory CNS and solid tumors harboring NTRK1/2/3, ROS1 or ALK fusions (11 out of 11) as well as in an ALK-mutated NBL. No responses were seen in tumors lacking aberrations in target kinases. These results support the continued evaluation of entrectinib as a targeted therapeutic in solid tumors with NTRK1/2/3, ROS1 and ALK fusions, especially in high-grade CNS neoplasms. Clinical trial information: NCT02650401.

Dinutuximab for the treatment of pediatric patients with neuroblastoma

Dinutuximab is a monoclonal antibody targeted at disialoganglioside (GD2), a tumor-associated antigen widely expressed in human neuroblastoma cells. The incorporation of dinutuximab into standard treatment regimens for patients with high-risk neuroblastoma has changed the landscape of neuroblastoma therapy. Dinutuximab has shown to be effective in prolonging survival for patients receiving standard multimodal treatment regimens and has now become standard of care during the final phase of treatment. More recently, it has also shown promising efficacy and tolerability in patients with relapsed or progressive neuroblastoma. The most effective way of incorporating dinutuximab into treatment protocols is still being explored, and is the focus of numerous ongoing clinical trials.

Factors impacting time to engraftment in patients with high-risk neuroblastoma following autologous stem cell transplant

e22008

Background: Neuroblastoma is the most common extra-cranial solid tumor of childhood, with overall survival for high-risk patients (HRNBL) near 50%. The outcomes of HRNBL have improved significantly with high dose chemotherapy followed by autologous stem cell rescue (ABMT). Data about factors influencing the rate of hematopoietic recovery following ABMT in HRNBL is lacking in the literature. Methods: This is a retrospective chart review of patients with HRNBL treated at Texas Children’s Hospital from October 2011 - November 2016. Neutrophil engraftment was considered the first of three consecutive days with post-transplant neutrophil count > 500 cells/uL. Red blood cell and platelet engraftment were considered at a hemoglobin > 8g/dL and platelets > 20,000/uL three days after the last transfusion. Race and conditioning regimen were analyzed using one-way ANOVA; amount of infused cells was analyzed using Pearson correlation coefficients; chemotherapy delay and bone marrow (BM) involvement after cycle 2 of induction chemotherapy were analyzed using independent sample t-tests. Results: The study included 17 males and 8 females with a median age at diagnosis of 3 years. 15 patients were Caucasian, 4 African-American, 5 Hispanic, and 1 Asian. The mean dose of infused CD34+ cells was 3.44x108cells/kg. 16 patients received conditioning therapy with carboplatin/etoposide/melphalan, 7 received busulfan/melphalan, and 2 received thiotepa/cyclophosphamide. Race was found to be significant for hemoglobin engraftment (p < 0.001). There were trends toward significance for conditioning regimen and neutrophil engraftment (p = 0.079), presence of delays in induction chemotherapy due to hematologic toxicity for platelet engraftment (p = 0.069) and BM involvement after cycle 2 of induction chemotherapy for hemoglobin engraftment (p = 0.12). Conclusions: Knowing the barriers for timely engraftment may help develop interventions for future patients. Race significantly impacted hemoglobin engraftment. Conditioning regimen, delays in induction chemotherapy, and BM involvement after cycle 2 of induction chemotherapy trended towards significance and need to be validated in a larger dataset.

Relapse prevention in serious and enduring mental illness: a pilot study

The purpose of the research was to ascertain whether coping knowledge and relapse outcomes are enhanced after 12 months following a programme of community-based relapse prevention (RP). Relapse to mental illness has high societal costs and this programme aims to lessen the likelihood of relapse by equipping service users with greater coping mechanisms by employing a quasi-experimental design with some controls. Participants are recruited from a day hospital in London. There are two groups: (1) experimental group (n = 10) and (2) control group (n = 10). The experimental group is given an 8-week RP programme, and the control group receives routine care. Both groups are then followed up at 1, 2 and 12 months. The research hypothesis was participants undergoing a programme of RP will have greater 12-month knowledge and superior relapse outcomes. The 52-week follow-up rates are 80% for experimental group and 70% for control group. There are no differences in the two groups in terms of relapse outcomes. Knowledge between baseline and 52 weeks is improved in the experimental group though most of the changes are observed during the first 12 weeks. We conclude that an 8-week RP programme resulted in improved knowledge but not relapse outcomes at 52 weeks. A randomized controlled trial should now be conducted to assess whether these results are replicated.

Sequential studies of sleep disturbance and quality of life in abstaining alcoholics

Previous studies in recently detoxified dependent alcoholics have shown severely disturbed sleep and impaired quality of life. Although this association has been found to predict short-term relapse to heavy drinking, no sequential studies have been conducted to monitor significant changes in sleep quality and quality of life in abstaining alcoholics. Fifty-seven inpatients at a voluntary sector 12-Step alcohol detoxification unit in South London were administered a series of questionnaires assessing sleep (Pittsburgh Sleep Quality Index, PSQI), Quality of Life (Euro-Qol) and Depression and Anxiety (Hospital Anxiety and Depression Scales, HADS). Questionnaires were administered at baseline and for 12 weeks at monthly intervals. At baseline, PSQI scores showed that 52 of the 57 participants suffered from impaired sleep. The scores, however, did not correlate significantly with any of the other measurements. All except two participants acknowledged impaired Quality of Life in at least one area. With respect to the follow-up measurements 23 (40%) participants completed the study. Quality of life and depression scores improved significantly over a 12-week period but sleep and anxiety scores did not. At 12 weeks the mean PSQI score was still above the cut-off point for 'sleep caseness'. Quality of life and depression show a significant improvement over a 3-month period of abstinence, although at this point the subjects are still experiencing difficulties with sleep and anxiety. This information could help in the planning of future rehabilitation and treatment programmes.

The attitudes of forensic nurses to substance using service users

There is now a body of research that has shown that the attitudes of nurses towards substance misuse in the mentally ill are generally suboptimal and this has an impact on the quality of nursing care provided. Despite this, to date there have been no published studies that have examined the attitudes of forensic nurses towards substance misusing forensic service users. Sixty-three multiethnic registered forensic psychiatric nurses based on an inpatient unit in outer London were surveyed using the Substance Abuse Attitude Survey (SAAS). This has five subscores: Treatment Intervention, Treatment Optimism, Permissiveness, Non-Moralism and Non-Stereotypes. Only Permissiveness scores were at an optimum level and equivalent to other community mental health workers. The Treatment Intervention and Treatment Optimism subscores were well below those of a multidisciplinary group of community mental health workers. Three other findings were of note. Firstly, women had higher Non-Moralism scores than men. Secondly, staff nurses had higher Non-Stereotypes scores than other grades. Finally, Black nurses had higher Treatment Optimism scores than non-Black colleagues. In conclusion, the attitudes of forensic nurses towards substance misuse in forensic clients are more suboptimal than other groups of community mental health workers. Our findings also indicate that gender, staff grading and ethnicity are associated with suboptimal scores.

Quality of life, sleep, mood and alcohol consumption: a complex interaction

Socio-demographic information was collected from 52 (45 men, seven women) currently drinking moderately dependent alcohol misusers attending an outpatient clinic in South London for medical assessment and treatment. Assessments at baseline and 12-week follow-up included: (i) Severity of Alcohol Dependence (SADQ) (baseline only), (ii) Hospital Anxiety and Depression Scale (HADS); (iii) Nottingham Health Profile sleep subscale (NHP) and (iv) the EuroQoL (EQ-5D). The main outcome measure was drinking at a "sensible level" at 12-week follow-up as recommended by the Royal College of Psychiatrists. There were significant interactions between sleeping badly, lying awake at night and HADS depression scores. The Health-related Quality of Life (HrQoL) of this group was poor compared to general population norms. Lower EQ-5D index scores were associated with poorer educational attainment and lower EQ-5D Visual Analogue Scale (VAS) patient ratings with greater baseline alcohol consumption. Clinician ratings on the EQ-5D VAS were consistently lower than the patient ratings. The correlations between patient self-assessment and clinician ratings (EQ-5D VAS) were not significant. The forty-seven subjects (90%) who were successfully followed-up showed a significant reduction in the total amount of alcohol consumed. Ten (21%) subjects returned to sensible drinking levels at 12 weeks but there was not a corresponding improvement in HrQoL, sleep, or affective status scores or biochemical measures in these subjects.

Application of a quality of life measure, the life situation survey (LSS), to alcohol-dependent subjects in relapse and remission

BACKGROUND

Recent studies have shown that quality of life (QOL) is improved significantly when subjects do not relapse to heavy drinking, and QOL deteriorates significantly on prolonged relapse. This article further investigates these relationships using a QOL index, the Life Situation Survey (LSS).

METHODS

Eighty-two DSM-IV alcohol-dependent subjects admitted for alcohol detoxification were studied at baseline and 12 week follow-up. Sociodemographic data were collected, and severity of alcohol dependence (SADQ) and General Health Questionnaire (GHQ-12) were baseline indices only. The main outcome measure, the LSS, was administered at both time points.

RESULTS

Two subjects were lost to follow-up and one died during the study period. Thus, the relapse/ nonrelapse analysis related to 79 subjects. Fifty subjects (63%) had relapsed to heavy drinking at 3 months follow-up. There was a significant correlation between LSS and GHQ-12 scores. Significant changes occurred in total LSS scores as a result of relapse and nonrelapse. The improvement in LSS scores associated with nonrelapse was larger than the deterioration that accompanied relapse. In those subjects who did not relapse to heavy drinking, the mean follow-up score remained in the poor/borderline LSS range. Remission from heavy drinking was accompanied by significant improvements in appetite, sleep, and self-esteem. Relapse to heavy drinking coincided with a significant deterioration in mood/affect, public support, and work/life role scores.

CONCLUSION

QOL as assessed by the LSS in recently detoxified alcoholics is impaired significantly. In the nonrelapse group, there was a significant improvement in LSS scores after 3 months. Relapse was accompanied by a smaller deterioration in LSS scores. The LSS can play an important role in monitoring the clinical care and progress of alcohol-dependent subjects.

Outcome after in-patient detoxification for alcohol dependence: a naturalistic comparison of 7 versus 28 days stay

Research has tended to show that the gains of residential rehabilitation are short-term and cost-inefficient. This study compares the outcomes of two samples, one group staying at a non-statutory sector alcohol detoxification unit for < or =7 days (short stay: SS) with a second group also admitted for detoxification but who stayed at the Unit for a further 8-21 days (long stay: LS). Allocation was not at random: the longer stay was either at the request of the client, referring or treatment agency itself and then had to be approved by an external funding agency. Sixty-four DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) alcohol-dependent subjects were studied. Baseline data included socio-demographic information, illicit drug use during the past 12 months, severity of alcohol dependence, alcohol problems, physical/psychological symptoms, depression and indices of quality of life. At baseline, LS subjects reported more recreational cannabis use than SS subjects. Sixty-two (97%) subjects were re-interviewed 12 weeks after baseline assessment. During follow-up, equal proportions of each group relapsed (> or =21 units/7 day period fo males; > or =14 units/7day period for females). There was a trend for SS clients to have consumed less alcohol in total than the LS clients. The trend was towards improvement in the study measurements for the SS group, though none of the changes was significant. In the LS group, all variables tended towards a deterioration in health status. The longer stay did not appear to confer any extra benefit to the LS group. Cannabis use and illicit drug use at baseline, while commoner in the LS group, did not predict drinking or social adjustment in the follow-up period in this sample and thus could not be used to explain the lack of a better outcome in the LS group.

Quality of life measures and outcome in alcohol-dependent men and women

A sample of 82 (41 men 41 women) DSM IV alcohol-dependent inpatients admitted for detoxification was studied at baseline and followed-up 12 weeks thereafter. The following questionnaires were administered 4-5 days after admission for detoxification: Socio-demographic information, Severity of Alcohol Dependence Questionnaire (SADQ), Alcohol Problems Questionnaire (APQ), Rotterdam Symptoms Checklist (RSCL), Life Situation Survey (LSS), Beck Depression Inventory (BDI), General Health Questionnaire (GHQ 12), and Nottingham Health Profile (NHP). All indices other than socio-demographic data, the SADQ, and APQ were administered at 12-week follow-up. After controlling for confounding factors at baseline, women were more likely to be in a higher social class, prescribed anti-depressants during the previous 12 months, drink fewer units of alcohol in a typical week, and have a higher level of psychiatric caseness scores (GHQ-12). A total of 80 subjects (97%) were successfully followed-up. Difference between gender did not significantly impact upon any of the 12-week outcome measures. There was no significant difference in the study relapse rates or time taken to relapse between men and women. The only significant total sample change was a reduction in the amount of alcohol consumed in a typical week. This was significantly related to changes in the following Quality of Life (QoL) measures, NHP emotional reaction sub-scores, LSS, and BDI scores.

Measurement of quality of life in alcohol-dependent subjects by a cancer symptoms checklist

There are few studies of Quality of Life measures (QoL) in alcohol-misusing patients. The present study addresses this deficiency. The sample consisted of 60 (39 men, 21 women) alcohol dependent subjects defined by DSM-IV criteria (American Psychiatric Association, 1994). At baseline (4-5 days after admission and detoxification) sociodemographic data were collected, and three questionnaires were administered: the Rotterdam Symptoms Checklist (RSCL), the Severity of Alcohol Dependence Questionnaire (SADQ), and Alcohol Problems Questionnaire (APQ). QoL scores for dependent alcoholics both for physical and psychological measures were significantly worse (higher) than those reported for a variety of cancer patients. Psychological symptom scores were higher than physical symptoms at baseline. Correlations of RSCL scores to both SADQ and APQ were greater for RSCL physical compared to psychological symptom scores. The subjects were followed up at 12 weeks when the RSCL was re-administered and relapse status ascertained. Fifty-eight (97%) subjects were successfully contacted at 12 weeks of whom 36 (62%) had relapsed. After a repeated measures ANOVA psychological and physical symptom subscores were statistically significantly improved as a result of not relapsing to heavy drinking. There was no significant change in scores in the relapse group when baseline and week 12 scores were compared. The RSCL measure is a useful QoL assessment tool in alcohol-dependent subjects.

Impaired sleep in alcohol misusers and dependent alcoholics and the impact upon outcome

BACKGROUND

There is very little work that has investigated the self-reported sleep status of alcohol misusers. This study addressed that imbalance.

METHODS

The study consisted of two parts: 1) the outpatient study, a sample of DSM-IV alcohol-dependent subjects who were referred to an outpatient clinic and were given a series of questionnaires, including the Pittsburgh Sleep Quality Index (PSQI); and 2) the inpatient study, a group of DSM-IV alcohol-dependent subjects whose sleep was assessed by the Nottingham Health Profile (NHP) sleep subscore at the start of the study and again at the 12-week follow-up. Both the PSQI and NHP are self-report indices whereby higher scores indicate a poor sleep quality.

RESULTS

In the outpatient study, the PSQI scores were significantly higher in the alcoholics (n = 31) compared with the controls (n = 49). There were no differences in the PSQI scores among mildly (n = 11), moderately (n = 10), and severely (n = 11) dependent drinkers. The PSQI total scores correlated with the Beck Depression Index but not with severity of dependence or alcohol problem scores. Sleep latency emerged as the most significant predictor of relapse, and sleeping badly was associated with poor outcome at the 12-week follow-up in the inpatient study.

CONCLUSION

Self-reported sleep disturbance can provide clinicians with information to plan better treatment for alcohol misusers.

Quality of life in alcohol-dependent subjects--a review

Although alcohol misuse is a major cause of morbidity and mortality and an important health care burden, the Quality of Life (QoL) of alcohol misusing subjects has been little studied to date. For example, only 5 out of 442 accepted abstracts at a recent international QoL conference concerned alcohol-dependent subjects. This paper reviews the ongoing and published work in the area focusing upon QoL characteristics of alcohol-dependent subjects, the link between QoL comorbidity and alcoholism, QoL alcohol dependency and social environment, changes in QoL status as a result of abstinence, minimal or controlled drinking, QoL as a predictor of relapse to heavy drinking and the importance of using a QoL measure when assessing treatment outcomes together with some of the present difficulties with existing measures. The main conclusions from the review were that the QoL of alcohol-dependent subjects is very poor but improved as a result of abstinence, controlled or minimal drinking. The important factors in the QoL of alcohol-dependent subjects are psychiatric comorbidity, social environment and disturbed sleep.

Resection for cure of adenocarcinoma of the head of the pancreas: the greater Hartford experience

BACKGROUND

Nationally, the results of pancreaticoduodenectomy for adenocarcinoma of the pancreas have improved. Therefore, we examined our experience with this operation.

METHODS

A retrospective review of tumor registry data from four greater Hartford, Connecticut, hospitals identified 51 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas between 1982 and 1992.

RESULTS

The 30-day operative mortality rate for the group was 4%. Life table survival analysis revealed a five-year survival rate of 15% and a median survival of 15 months. Twelve patients had postoperative radiation therapy and chemotherapy. The median survival in this group was 36 months, significantly longer than that of the nonadjuvant therapy group (13 months, P < .02). No difference in operative mortality or ultimate survival was seen between the hospital with the largest experience and the three other hospitals.

CONCLUSIONS

Pancreaticoduodenectomy can be performed safely at hospitals with relatively low pancreaticoduodenectomy volume. Survival rates are longer than in past reviews.

Overview and future prospects

At present, resection affords highly selected patients with limited liver cancer their only choice for cure. Palliation with currently available agents and techniques often is not successful, but recent advances promise a brighter future.

The malignant transformation of liver cell adenomas

OBJECTIVE

To investigate clinical experience with the apparent malignant transformation of benign liver cell adenomas.

DESIGN

Retrospective review of personal experience and literature.

SETTING

University hospital and affilated community hospitals.

PATIENTS

All patients diagnosed with liver cell adenomas over a 30-year period.

INTERVENTIONS

Liver resection and/or tumor biopsy.

MAIN OUTCOME MEASURES

Gender, age, drug associations, alpha-fetoprotein levels, response to treatment, and survival.

RESULTS

Thirteen patients from personal experience and 26 patients from the reports of others had liver cell adenomas that were not resected. Five of these patients subsequently developed hepatocellular carcinoma.

CONCLUSIONS

Malignant transformation of a liver cell adenoma is a rare phenomenon, but it does occur. Alpha-fetoprotein levels may be more helpful in diagnosis than expected from previous reports. Solitary benign adenomas should be resected whenever possible. Patients with diffuse multiple tumors should be observed closely over a long period.

Hyperbaric oxygen therapy: Contraindications and complications

The literature is replete with references regarding the use of hyperbaric oxygen (HBO) therapy to treat various human maladies. However, the oral and maxillofacial surgery literature is lacking in information regarding patient selection criteria and possible contraindications to HBO therapy, as well as possible risks and/or complications of such therapy. This article details patient selection criteria, discusses relative and absolute contraindications to HBO therapy, and describes the potential risks and complications of this therapy.

History of liver surgery

Although battle surgeons had débrided small bits of liver protruding through wounds since ancient times, formal entry into the peritoneal cavity to staunch hemorrhage due to trauma or to remove tumors or drain cysts had to await the advent of general anesthesia and antisepsis. After a burst of pioneering activity from 1880 to 1910, little progress was made until after World War II. In the last 40 years, remarkable advances have been made in the techniques of liver resection, our understanding of liver diseases requiring operation, and our ability to support patients through major resections. Liver transplantation epitomizes the challenges that can now be accepted, and its success augurs well for an increase in liver operations in the future.

Surgical treatment of metastatic liver tumors

Liver resection for limited amounts of metastatic cancer should be recommended to highly selected patients. It will provide a significant chance for "cure" for patients with metastases from colorectal cancers and may provide palliation for a few others with very slow-growing tumors or hormone symptoms from endocrine tumors. The results of resection are compared with those of chemotherapy, radiation, arterial ligation, and other treatments. Selection criteria, none of which is absolute, include number of metastases, stage of primary tumor, interval between resection of primary tumor and discovery of liver metastasis, and proximity to vital structures. The presence of extrahepatic metastasis, even if resected, carries with it a grim prognosis and should probably preclude liver resection.

Liver resection techniques

Liver resection can be safely accomplished using techniques based on a thorough knowledge of anatomy and the use of readily available tools. Preoperative studies can determine resectability in most cases. An aggressive attitude toward resection of localized primary and secondary malignancies is justified by a 5-year survival rate of 25 to 35 per cent in selected patients. If the possibility of carcinoma has been ruled out, most asymptomatic benign tumors can be watched.

Evaluation of asymptomatic solitary hepatic lesions

Clinical judgment and noninvasive radiologic imaging are the keystones to decision-making in the management of most patients with asymptomatic liver lesions. A knowledge of the natural history of the common lesions suggests a conservative approach to those that are benign and an aggressive approach to those that are malignant and still localized.

Resection of the liver for colorectal carcinoma metastases. A multi-institutional study of long-term survivors

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to 1-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primary carcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

The blue scrotum sign of Bryant: a diagnostic clue to ruptured abdominal aortic aneurysm

A 73-year-old man presented to the emergency department twice with nonspecific abdominal pain. He was diagnosed as having mild diverticulitis and was discharged. Four days later he presented to the emergency department in severe abdominal pain with scrotal and penile ecchymoses. After an initial urologic consultation the correct diagnosis of ruptured abdominal aortic aneurysm was made. We discuss the pathogenesis of the genital discoloration and make the correct historical attribution of this sign to John Henry Bryant, a turn-of-the-century physician at Guy's Hospital.

Temporomandibular joint dysfunction in infancy

Temporomandibular joint (TMJ) dysfunction describes a pain-dysfunction phenomenon that usually afflicts persons in their 4th or 5th decade. The syndrome can be produced by a variety of etiologic factors including occlusal disharmony, articular disorders, and muscle imbalance. It may cause severe otalgia and refer pain to the temple, occiput, nape of neck, and shoulders. Often, associated joint clicking or popping, aural fullness, vertigo, tinnitus, subjective hypoacusis, and nausea occur. As it has not been previously reported in infants, we would like to describe our experience with this disorder in an 11-month-old boy who was referred to our clinic with a presumed diagnosis of otitis media. The embryology of the temporomandibular joint is reviewed and appropriate treatment with anti-inflammatory analgesics, warm compresses, orthodontics, and external brace appliances is discussed. Because of referral patterns in the infant age group, the pediatric otolaryngologist should be similar with this entity and its presentation in children.

Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of patterns of recurrence

The Registry of Hepatic Metastases has collected data on consecutive patients from 24 institutions who have undergone hepatic resection for colorectal carcinoma metastases. Patterns of recurrence were examined in a subgroup of 607 patients who had undergone curative resection of isolated hepatic metastases. Forty-three percent of these patient have had recurrences in the liver and 31% have had recurrences in the lung (either alone or in combination with other organs). A multivariate analysis showed that patients with positive pathologic margins or bilobar metastases were at an increased risk of having a recurrence in the liver (68% and 64%, respectively). We conclude that: hepatic resection effectively controls hepatic tumor in a substantial number of patients, adjuvant therapy after hepatic resection should be directed at both the lung and liver to significantly increase survival, and patients with positive pathologic margins or bilobar metastases are at an increased risk for hepatic recurrence.

Automatic clip applier as an aid to liver resection

The use of an automatic clip applier greatly adds to the safety and speed of liver resection by reducing both operative manipulation and the amount of residual dead tissue and foreign bodies.

Acute fatty liver of pregnancy and diagnosis by computed tomography

A 39 year old woman was admitted to a maternity unit at 34 weeks' gestation with nausea, vomiting, and jaundice. Her condition deteriorated, and she was transferred to hospital, deeply unconscious and hypotensive. The diagnosis of acute fatty liver of pregnancy was initially suggested by the typical history of prodromal malaise and vomiting and the rapid onset of hepatic encephalopathy with profound hypoglycaemia and only small increases in transaminase activities. Computed tomography was performed: there was no enlargement of the liver or spleen, but the attenuation value over the liver indicated appreciable fatty infiltration of the liver, establishing the diagnosis of acute fatty liver of pregnancy. Computed tomography is of value in the diagnosis of liver disease of late pregnancy, and this technique may become the method of choice for the investigation of acute fatty liver of pregnancy.

Adriamycin and cisplatin for hepatoblastoma

Four consecutive infants and children with hepatoblastomas were treated with a combination of Adriamycin (doxorubicin) and cisplatin. Three patients had unresectable tumors and in each there was a dramatic decrease in tumor size and serum alpha-fetoprotein (AFP) levels. The tumors of two of these patients, including one with pulmonary metastases which cleared, were rendered resectable. The third patient's tumor remained unresectable but his AFP level returned to normal following radiotherapy. All three patients are disease-free, and both without metastases are off therapy from 9 to 24 months. A fourth child received the combination as adjuvant therapy following resection of an embryonal hepatoblastoma and he remains disease-free 7 months after its discontinuation. Therapy was tolerable in all patients and its principal toxicities were myelosuppression and magnesium wasting. Adriamycin and cisplatin in combination were very effective in these patients and deserve further trials, especially in unresectable and metastatic hepatoblastomas.

The effect of chemotherapy on hepatoblastoma

A 15-month-old girl had a case of mixed hepatoblastoma. The unresectable tumor became surgically resectable after treatment with doxorubicin hydrochloride and cisplatin, which was also continued postoperatively. This regimen had a remarkable necrotizing effect on the fetal epithelial component of the hepatoblastoma. The patient's high alpha-fetoprotein level and extreme thrombocytosis, which resolved with treatment, were used as indicators of the disease's activity. An unaffected mesenchymal component and a few microscopic foci of undisturbed embryonal hepatoblastoma were found. The finding of a mature intestinal epithelial island in this case is unique.

Operative management of renovascular hypertension. Results after a follow-up of fifteen to twenty-three years

From March 1960 through January 1968, 71 patients underwent operations for renovascular hypertension at our center. There were three operative deaths in 94 procedures. Primary nephrectomy was performed in 26 patients. Attempted revascularization of 62 kidneys was successful in 46 (74%). In 13 (87%) of the 15 cases considered operative failures, the patients underwent either secondary nephrectomy (11) or repeat revascularization (two). Based on the results of the final operation, initial blood pressure response (1 to 6 months postoperatively) in the surviving patients indicated 44% cured (30 patients), 40% improved (27), and 16% unchanged (11). The sequential clinical, functional, and anatomic follow-up evaluations to time of death or to date are available in 66 of the 68 patients (97%) who survived operation and form the basis of this report. Fifteen- to 20-year arteriographic follow-up in 16 patients revealed one late neointimal anastomotic stenosis and an additional three aortic suture line false aneurysms in Dacron aortorenal grafts. During this 15- to 23-year follow-up, 71% of atherosclerotic (AS) patients and 23% of fibromuscular dysplasia (FMD) patients died. Cardiovascular (CV) morbid events occurred in 77% of AS patients and in 19% of FMD patients. The cumulative incidence of death and CV morbid events during follow-up is examined by Kaplan-Meier life tables and Cox's proportional hazards regression analysis in these respective groups to identify preoperative markers predictive of longer event-free survival in relation to blood pressure benefit by operation (for example, focal vs. diffuse AS, presence of cerebrovascular disease, ischemic heart disease, left ventricular hypertrophy seen by electrocardiography, azotemia, smoking, diabetes, and hyperlipidemia).(ABSTRACT TRUNCATED AT 250 WORDS)

An analysis of the isoenzymes of creatine phosphokinase and lactic dehydrogenase in the esophagus

Surgical manipulation of muscular organs can cause alterations of the serum isoenzymes of creatine phosphokinase (CPK) and lactic dehydrogenase (LDH), which are frequently used to confirm the diagnosis of myocardial infarction (MI). Since the content of these enzymes and their isoenzymes has not been established for the esophagus, an experiment was conducted to evaluate and compare the enzymes in postmortem specimens from humans and fresh canine specimens. One gram transmural esophageal sections were taken from specimens having no demonstrable disease. All samples were homogenized individually in Ringer's lactate solution and centrifuged, and the supernatants were analysed for the respective isoenzyme distributions by agarose gel electrophoresis. From the study we drew the following conclusions: (1) all three isoenzymes of CPK (including CPK-MB, the myocardialisoenzyme) are present in the esophagus; (2) LDH, the isoenzyme of LDH most prevalent in myocardium, is the least common of the five isoenzymes of LDH in the esophagus; (3) the dog is an appropriate model for studying changes of these isoenzymes after operation; and (4) any potential confusion in diagnosing postoperative MI due to esophageal CPK-MB in the serum can be resolved, theoretically, by analyzing LDH serum isoenzymes. In myocardial infarction, LDH becomes the predominant isoenzyme, whereas esophageal injury should be associated, theoretically, with a serum LDH isoenzyme pattern in which LDH is the least prevalent isoenzyme.

Hepatocellular carcinoma. Polygonal cell type with fibrous stroma--an atypical variant with a favorable prognosis

Hepatocellular carcinoma, even when treated with operative resection, is generally regarded as uniformly fatal. Isolated reports of an unusual histologic variant characterized by polyglonal cells with a fibrous stroma (PCFS) suggest a more favorable outcome. Twelve cases of PCFS, representing the largest reported group, are presented. The mean age of the patients at the time of onset was 23.1 years and the male to female ratio was 1:2. Successful operative resection of the primary neoplasm and metastatic foci has resulted in a significant percentage of long-term survivors with a mean survival time of 68 months and two- and five-year survival rates of 82% and 63%, respectively. The variant shows cytologic similarity to differentiated hepatocellular carcinoma with a unique stromal appearance suggesting a pattern of fibrosis associated with focal nodular hyperplasia. Focal nodular hyperplasia is noted occasionally in the liver adjacent to PCFS. The possibility that PCFS represents an intermediate stage between focal nodular hyperplasia and the more malignant variants of hepatocellular carcinoma is discussed.

Hepatocellular carcinoma. Polygonal cell type with fibrous stroma--an atypical variant with a favorable prognosis

Hepatocellular carcinoma, even when treated with operative resection, is generally regarded as uniformly fatal. Isolated reports of an unusual histologic variant characterized by polyglonal cells with a fibrous stroma (PCFS) suggest a more favorable outcome. Twelve cases of PCFS, representing the largest reported group, are presented. The mean age of the patients at the time of onset was 23.1 years and the male to female ratio was 1:2. Successful operative resection of the primary neoplasm and metastatic foci has resulted in a significant percentage of long-term survivors with a mean survival time of 68 months and two- and five-year survival rates of 82% and 63%, respectively. The variant shows cytologic similarity to differentiated hepatocellular carcinoma with a unique stromal appearance suggesting a pattern of fibrosis associated with focal nodular hyperplasia. Focal nodular hyperplasia is noted occasionally in the liver adjacent to PCFS. The possibility that PCFS represents an intermediate stage between focal nodular hyperplasia and the more malignant variants of hepatocellular carcinoma is discussed.

Hypertension secondary to complete occlusion of the renal artery

In summary, we feel the results of this study support an aggressive approach toward the diagnostic evaluation and operative management of patients with renovascular hypertension secondary to complete occlusion of the renal artery. Further, the frequent presence of contralateral disease and the progressive nature of renal artery occlusions represent a significant threat to renal function. Since renal function is frequently compromised but potentially retrievable by revascularization, nephrectomy should be employed only when hypertension is difficult to control, revascularization is impossible, and excretory function in the affected kidney is minimal.