Biomedical subjects
Publications and source records attributed to W G Kraybill.
We present four patients who developed posthemipelvectomy hernias. Identified etiologic factors include infection at the time of hemipelvectomy, radiation therapy, and excessive weight gain. Two patients were reconstructed using local tissues, and two required prosthetic materials. There were no hernia recurrences, although two patients died of recurrent cancer.
Second malignant neoplasms (SMN) in late childhood or young adulthood in individuals who have been successfully treated for an initial malignancy have emerged as a late effect of therapy in survivors of childhood cancer. Although radiation therapy is frequently implicated, chemotherapy with alkylating agents and antimetabolites has also been associated with SMN. Soft tissue sarcomas are among the most frequent primary malignancies complicated by a SMN and account for a majority of nonhematolymphoid SMN. We present the clinical and pathologic findings in a patient who had a peripheral neuroepithelioma (primitive neuroectodermal tumor, PNET) of the soft tissues diagnosed at 17 years of age, was treated with high-dose irradiation and multidrug chemotherapy, and developed an angiosarcoma 14 years later. This case represents an uncommon combination of mesenchymal malignancies in a young patient with an unusually favorable clinical course following the diagnosis of PNET.
Between 1974 and 1989, 49 patients with histologically confirmed malignant fibrous histiocytoma received postoperative radiotherapy at the Mallinckrodt Institute of Radiology for primary (41) or recurrent (8) disease. Median age of the patients was 63 years, and the median follow-up period was 41 months. Patients were grouped according to the 1988 AJC staging classification: stage IA (one patient), stage IIA (4 patients), stage IIB (9 patients), stage IIIA (15 patients), stage IIIB (18 patients), and stage IVA (2 patients). Eight tumors (16%) were in the pelvis, 8 (16%) in the trunk, 4 (8%) in the head and neck, and 29 (60%) in the extremities. Primary surgical procedures included incisional biopsy (4 patients), excisional biopsy (19), narrow margin excision (14), wide local excision (9), and removal of the entire compartment (3). Based on pathology reports, the margins of resection were classified as positive in 23 (5 gross, 18 microscopic), 5 close, 11 negative, and 10 unknown. Patients were irradiated with shrinking field technique; the median radiation dose was 6000 cGy, with more than 95% of patients receiving at least 4500 cGy. In addition, seven patients received postoperative chemotherapy. The 5-year overall survival rate was 62%, disease-free survival 64%, local control 68%, and freedom-from-distant metastasis 85%. Thirteen patients had local recurrences, with greater than 75% recurring within 3 years. Sites of local recurrence were as follows: trunk (3), pelvis (3), lower extremities (4), and head and neck (3). There appears to be a correlation of local failure with positive surgical margin: of 23 patients with positive margins, 9 (39%) had local recurrences, whereas 1 of 11 patients (9%) with negative margins had local recurrence. Three of 13 patients with persistent or recurrent disease were salvaged by additional treatment, rendering ultimate local control in 80% (39/49). Thirty-four of 36 patients with local control obtained good to excellent function. Two patients were found to have grade 3 complications: 1 patient had edema of the extremity, and the other developed necrotic skin ulcer that was successfully treated with hyperbaric oxygen. Five patients developed distant metastases, with 80% occurring within 2 years. In summary, adequate but conservative surgery with postoperative radiotherapy for malignant fibrous histiocytoma can achieve local tumor control as well as preservation of functional limbs with acceptable morbidity in a large proportion of patients.
The management of soft tissue sarcomas has undergone and continues to undergo important changes. The purpose of this report is to review the presentation, diagnosis, and natural history of soft tissue sarcomas. In so doing, the importance of a careful and rigorous method of evaluation will be emphasized. Furthermore, the results of multidisciplinary treatment, with a goal towards limb salvage, will be reviewed. With appropriate and timely intervention, selected patients with pulmonary metastases may still experience long-term survival. Throughout this review, the importance of early and continuing multidisciplinary treatment and evaluation will be emphasized.
Among 879 patients treated for breast cancer between 1975 and 1984, advanced disease was found in 125 (14%). A subgroup of 34 (4%) presented with untreated locally advanced disease without demonstrable distant metastases at the time of diagnosis (stage IIIB = T4abed, NX-2,MO). During the first 5 years (1975 through 1979), 17 patients were treated primarily with sequential radiotherapy and chemotherapy (Group A). From 1980 to 1984 (Group B), the management consisted of four courses of induction multi-drug chemotherapy followed primarily by mastectomy and additional chemotherapy. The mean follow-up for the most recent group (Group B) is 48 months. Follow-up was complete. While the local disease control rate was the same for both groups (76%), the survival was remarkably different. Group A patients experienced a median survival of 15 months, and only one survived 5 years. In Group B, the median survival was 56 months with nine patients (53%) alive between 40 and 76 months, seven (41%) of whom are 5-year survivors. While the overall mortality of patients with inflammatory breast cancer was greater in both groups when compared with the group with noninflammatory disease, the survival of patients in Group B was better than in Group A for both inflammatory and noninflammatory cancers (p less than 0.01). Estrogen receptor, nodal, and menopausal status did not influence survival. These data suggest that neoadjuvant chemotherapy improves survival for patients with stage IIIB breast carcinoma and delays the establishment or progression of distant metastases. Mastectomy is an important component in the treatment of this disease.
This study was undertaken to review the long-term results of multivisceral resection of locally advanced colorectal carcinoma. Between 1964 and 1980, 1042 patients underwent exploratory surgery for colorectal cancer. Of these, 58 patients (5.5%) underwent curative multivisceral resection for suspected contiguous invasion by the primary tumor. Follow-up was complete for all patients. The primary tumors were located in the rectum (38 patients), sigmoid (9 patients), left colon (6 patients), and right colon (5 patients). En bloc resection of other viscera included uterus, adnexa, bladder, vagina, small intestine, abdominal wall, liver, stomach, kidney, and ureter. The operative morbidity and mortality rates were 31% and 1.7%, respectively. Resection margins were free of tumor in 54 patients. In the four patients with tumor-positive resection margins, recurrence of disease was evident between 8 and 22 weeks after surgery (mean survival time, 8.2 months). Carcinomatous invasion of the resected contiguous organ was confirmed in 49 patients (84%). The mean survival time for patients without lymph node metastases was 100.7 months, but it was only 16.2 months (p less than 0.01) for patients with lymph node metastases. Actuarial 5-year disease-free survival rate for patients without lymph node metastases was 76% (36 of 47 patients). None of the patients (0 of 11) with lymph node metastases survived for 5 years. Three of 36 of the 5-year survivors experienced recurrence of disease before the seventh postoperative year; no cancer-related deaths occurred between 7 and 25 years. These data suggest that survival in locally advanced colorectal carcinoma is more dependent on lymph node status than on the extent of local invasion. Effective disease control associated with survival in the long term can be achieved by multivisceral resection.
Twenty-five patients with measurable metastatic breast cancer and assays for estrogen receptor (ER) were studied. Of the 16 ER positive patients on anti-estrogen therapy, one had complete disappearance of all tumor for seven months and seven patients had more than 50% reduction in their measurable tumor for an average duration of 8.8 months. Seven other ER positive patients had stabilization of their tumors for an average interval of 8.4 months. Only one of the 16 ER positive patients progressed promptly. Conversely there was only one partial response in the nine ER negative patients and only two ER negative patients had stabilization of disease. Six out of nine ER negative patients progressed promptly. Correlation existed between the duration of response and absolute estrogen receptor level of the tumor. There may be a positive correlation between the response to antiestrogen therapy and response to endocrine ablation but prospective studies must be done to further define the role of antiestrogens in this regard.
Twenty-six member institutions of the Central Oncology Group entered 154 patients in this two-armed, phase III study comparing the effects of adriamycin, bleomycin, and CCNU against a variety of squamous cell carcinomas. The combination of adriamycin and bleomycin produced a 43% overall response rate in primary tumors of the head and neck, which included two complete responses. This compares favorably to the results obtained with methotrexate and other agents previously reported. The combination of adriamycin and bleomycin will probably be the most useful for induction chemotherapy because both drugs have cumulative toxicities and the duration of response to this combination is short.
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Forty patients with otherwise untreatable advanced carcinomas received arterial infusions of adriamycin. Significant responses were seen in five of nine tumors of the bladder, two of five hypernephromas, two of two islet cell tumors, three of five sarcomas and one of two metastatic tumors of the breast. One patient with advanced transitional cell carcinoma of the bladder had no tumor at the time of a subsequent resection. There were no responses seen in two oat cell tumors metastatic to the liver, one seminoma of the retroperitoneal space metastatic to the liver, one squamous cell tumor metastatic to the liver, one squamous cell of the vulva, one carcinoma of the cervix uteri and one cloacogenic carcinoma. these responses in advanced tumors are exciting. The use of this technique to reduce tumor bulk prior to operation, irradiation, adjuvant chemotherapy and immunotherapy may allow a significant breakthrough for such tumors as sarcomas, hypernephromas and transitional cell carcinomas of the bladder. Further studies will be pursued using this concept.
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