Biomedical subjects
G Bonfanti
Publications and source records attributed to G Bonfanti.
Intrahepatic chemotherapy for unresectable hepatocellular carcinoma.
From 1976 to 1983, 28 patients (24 male and four female) with unresectable hepatocellular carcinoma (HCC) were treated by intraarterial chemotherapy at the Istituto Nazionale Tumori of Milan, Milan, Italy. Tumors were retrospectively classified by a previously proposed staging system. Two patients were classified as Stage I and 26 as Stage II. Liver cirrhosis was present only in the males (in 50% of them). Nineteen patients were treated with doxorubicin (Adriamycin [Adria Laboratories, Columbus, OH]) and nine with 5-fluorouracil. Systemic toxicity was mild, but the treatment induced hepatic toxicity (ascites, clinical jaundice, or biochemical impairment) in 18% of noncirrhotic and 66% of cirrhotic patients. Clinical reduction of hepatomegaly was observed in 50% of noncirrhotic versus 16% of cirrhotic patients. Doxorubicin was effective in 66% of noncirrhotic patients and 20% of cirrhotic patients, with an overall response rate of 42%. 5-fluorouracil was effective only in patients without cirrhosis, with an overall response rate of 22%. Overall median actuarial survival was 3.5 months, with a significant difference between noncirrhotic and cirrhotic patients (6 versus 2 months, respectively). Overall median survival of patients who responded to the treatment was 13 versus 2 months for nonresponders (P less than 0.001). Liver cirrhosis was the most important prognostic factor in terms of liver toxicity, response rate, and survival. This study emphasized the negative impact of the treatment on cirrhotic patients. Also, the real value of intraarterial administration of doxorubicin was investigated.
Prognosis of patients after palliative surgical procedures for carcinoma of the stomach.
From 1965 to 1980, 294 (33 per cent) of 885 patients admitted to the Istituto Nazionale Tumori of Milan with carcinoma of the stomach did not undergo a radical operation. Forty-eight patients were not considered suitable for operation due to their poor general status and spread of disease. One hundred and five patients underwent simple exploratory laparotomy, 80 underwent bypass procedure and 61, noncurative resection, and the operative mortality rate was 4.7, 10.0 and 11.5 per cent, respectively. Median survival time was 2.4 months for patients who did not undergo an operation, 2.8 months after exploratory laparotomy and 3.5 months after bypass procedures. Median survival time after nonradical resections was 8.0 months and 6 per cent of these patients survived for more than five years. To perform the analysis within relatively homogeneous groups, patients with different treatments were further stratified into three groups according to the spread of disease: local, distant and local plus distant spread. It is noteworthy that the benefit after bypass procedures in comparison to exploratory laparotomy was limited to those patients with local spread of disease; the advantage of nonradical resection was apparent in all groups. Survival time was finally analyzed with reference to the extent of liver involvement in patients with metastatic disease confined to the liver. The data suggest that a limited sporadic survival time is possible only after gastric resection in patients with liver involvement of less than 50 per cent.
Subtotal versus total gastrectomy for cancer of the lower two-thirds of the stomach: a new approach to an old problem.
Many surgeons favour total gastrectomy (TG) 'de principe' in the treatment of gastric cancer, but final demonstration of its advantage over subtotal gastrectomy (SG) is still lacking. We analysed survival after curative TG or SG within groups of patients stratified according to the main prognostic variables as found in multivariate analysis, i.e., nodal status, degree of invasion of the gastric wall, patient age and sex. Our series consisted of 361 patients treated by curative SG and 41 by curative TG, admitted to the Istituto Nazionale Tumori of Milan between 1965 and 1979. In patients with lymph node involvement survival appeared to be significantly better (P = 0.0005) after SG. However, stratifying for age it was found that the benefit was limited to patients over 60 years old. No significant difference in survival was found in the group without nodal involvement (N -) and invasion of the wall to the serosa or beyond. No statistical comparison was possible in N - groups with invasion confined to mucosa, submucosa or muscularis propria because of the small number of such patients who underwent TG. We conclude that SG still represents the standard reference operation for gastric carcinoma provided that a safe proximal margin of resection is guaranteed.
Surgery for gastric cancer.
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Chondrosarcoma--55 unreported cases: epidemiology, surgical treatment and prognostic factors.
Fifty-five cases of chondrosarcoma, seen at the Istituto Nazionale Tumori of Milan, were reviewed to collect epidemiological data in order to verify therapeutic effects and the validity of possible prognostic factors. Epidemiological data according to sex and age distribution and skeletal location were in accordance with the literature (male:female ratio, 1.8; mean age, 37 years, 62% of lesions located in the pelvic or scapular girdle). Of 52 cases operated on with the intent of radicality, 5 were intralesional operations, 20 marginal and 27 radical. The local recurrence rate was dependent upon the degree of surgical radicality (60%, 35% and 11% respectively for intralesional, marginal and radical surgery). Age, site, type of first symptom and pathological grading were significant as prognostic factors. The type of the first symptom was directly correlated to the site of the tumour. Sex, tumour size and degree of surgical radicality were not relevant.
A multifactorial approach for the prognosis of patients with carcinoma of the stomach after curative resection.
This study was done to define the prognostic role of some clinical and pathologic variables in patients with carcinoma of the stomach who underwent a curative subtotal gastrectomy for cancer located at the lower two-thirds of the stomach. An univariate and multivariate analysis, according to Cox's regression model, was retrospectively performed upon 361 patients operated upon at the Istituto Nazionale Tumori of Milan from 1965 to 1979 by a curative subtotal gastrectomy. Data were stored by an IBM 4331 computer. Several factors were taken into consideration: age, sex, site and size of tumor, gross appearance, histologic type, invasion of the gastric wall, nodal status and symptoms. Of six variables selected by the univariate analysis, only four (sex, age, lymph node status and degree of invasion in the gastric wall) were validated by the multivariate evaluation, whereas tumor size and symptoms lost their prognostic relevance. The most important variables were nodal status and the degree of invasion in the gastric wall. The influence of age had a different impact on survival time, depending upon nodal status. In fact, patients with positive nodes who were less than 60 years old had the worst prognosis; the same age group with negative nodes had the best prognosis. Multifactorial analysis, according to the automatic interaction detection procedure, showed that prognosis worsened progressively beginning with female patients with negative nodes at pT1 or pT2 (91.6 per cent five year survival rate), male patients with negative nodes at pT1 or pT2 (76.3 per cent five year survival rate), female patients with negative nodes at pT3 or pT4 (62.4 per cent), male patients with negative nodes at pT3 or pT4 (40.0 per cent), patients more than 60 years old with negative nodes (36.8 per cent) and patients less than 60 years old with positive nodes (20.8 per cent). In our opinion, these parameters should be taken into consideration when stratification of patients as candidates to undergo adjuvant treatment after surgical treatment is planned.
[Immediate and long-term results of mechanical anastomoses in surgery of cancer of the rectum].
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Indoor dose in Milano (Italy).
This work is related to the problem of providing a more careful evaluation of the population exposure to natural radiation background, and was carried out in connection with the ENEA programmes on the assessment of indoor exposure doses in Italy. A large number of works in recent years have pointed out the main contribution of the indoor dose to the natural dose received by the members of the general population, and the large contribution of radon daughter inhalation. Different building materials and techniques lead to different exposure doses. In Milano such materials can be quite different in kind (bricks, concrete, gypsum by-products, tile-stone, paving-tile, etc.) and origin (national and foreign). For this reason, a collection of indoor doses in Milano is not only complementary to analogous investigations carried out in other Countries of the European Communities, but the obtained information can be compared with other large European towns. As agreed, a large number of various dwellings in Milano were investigated to evaluate the external gamma-ray exposure rate, and measurements of indoor radon concentrations were performed for some of them. Various typical building materials used in Lombardia were also analysed by means of gamma-ray spectrometry.
Intra-arterial adriamycin for limb sarcomas.
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Intra-arterial adriamycin followed by surgery for limb sarcomas. Preliminary report.
A multimodal treatment schedule for operable soft tissue sarcomas is ongoing in our institution. The main purposes are to achieve an easier radical surgery with limb preservation and to lower the risk of local relapses. Patients with documented untreated soft tissue sarcoma of the lower limb are given continuous intra-arterial regional infusion with adriamycin consecutively for 8 days up to a dose of 100 mg/m2. Radical surgery is performed by the fourth day after infusion. Preliminary data on 13 cases are available: after infusion only 6 patients presented reduction of the tumor diameters, but almost all postoperative histological examinations revealed wide areas of necrosis (up to 100%) of tumor tissue (in 9 cases greater than 50%). In 4 patients surgical treatment was completed with radiotherapy. In 2 cases the preliminary indication to disarticulation could be modified in wide excision after the postinfusional tumor reduction. The toxicity of adriamycin was typical and acceptable. Further data will be available after adequate follow-up and when more patients enter the study. These data document the feasibility of this multimodal treatment and its validity in terms of specific tumor tissue toxicity and improved surgical approach.
Prevention and treatment of central venous catheter sepsis by exchange via a guidewire. A prospective controlled trial.
A new approach for preventing and treating sepsis due to central venous catheter (CVC) has been devised at the Istituto Nazionale Tumori of Milan. A prospective protocol has been developed that includes the weekly exchange of the CVC via a guidewire as well as its exchange when a CVC-related sepsis is suspected. Growth of microorganisms on the tip of the CVC is defined as contamination if peripheral blood culture is negative and as sepsis if it is positive for the same microorganism. Colonization simply means growth of microorganism independently of the results of peripheral blood culture. Two hundred seven CVCs (64 polyvinyl chloride and 143 rubber silicone) were evaluated in 62 patients, for a total of 170 exchanges. The incidence of colonization and sepsis was 33.8% and 4.8%, respectively, a rate which is not significantly different from the values found in 81 historical controls (30.8% and 11.1%). However, it is noteworthy that the sepsis rate was reduced strongly during the first month of observation (0% vs. 11.9%; p = 0.01), whereas in the second month, it was similar in both groups (15% vs. 7.1%). Moreover, it should be noted that three-fourths of the colonized CVCs became negative after the first exchange, and virtually all were negative at the fourth exchange. All of the episodes of sepsis resolved spontaneously with the CVC exchange. The study, therefore, concludes that this procedure: 1) is without risk for CVC cross contamination, 2) is effective in the treatment of contaminated CVCs and of septic patients without any interruption of total parenteral nutrition, and 3) can reduce the incidence of CVC sepsis during the first month of total parenteral nutrition. One must be cautious about the possible onset of pulmonary embolism in patients with subclavian venous thrombosis, since a transient pulmonary embolism occurred in one of the patients. With the use of silastic CVCs, which are less thrombogenic than polyvinyl ones, the rate of pulmonary embolism due to blind exchange (without previous venography) is estimated to be 0.1% to 0.2%.
Delayed cutaneous hypersensitivity reaction to carcinoembryonic antigen in cancer patients.
The delayed cutaneous hypersensitivity reaction to carcinoembryonic antigen (CEA) was tested in 84 patients with different diseases including large bowel adenocarcinoma and breast carcinoma, with or without metastasis, liver cirrhosis and inflammatory or degenerative diseases. Positive skin test to CEA was observed in a small proportion (11%) of the patients tested. No difference in positive skin test reactions was observed in the 6 different groups of patients. Similar delayed cutaneous hypersensitivity reactions were found to various amount of CEA ranging from 0.5 to 25 micrograms. No correlation was seen between the results of skin test and blood CEA levels.
Results of extended surgery for cancer of the rectum and sigmoid.
The clinical records of 61 patients who underwent extended surgery, including resection of parietes or other viscera, from 1965 to 1977 for cancer of the rectum and sigmoid were reviewed. Abdominoperineal resection was performed in 41 patients, anterior resection in 18 and Hartmann's resection in 2. The postoperative mortality rate was 8.2 per cent, the non-lethal morbidity rate 30.3 per cent, but 4 patients presented multiple complications. The 5-year survival rate was evaluated separately for patients with and without microscopic evidence of neoplastic involvement of the simultaneously excised structures; in the first group it was 32 per cent, in the second 75 per cent. Local or distant recurrence occurred in 66 per cent of patients with microscopic infiltration and in 24 per cent of patients without microscopic infiltration. These results compare favourably with those reported after ordinary resections of Dukes' C cancers of the rectum and sigmoid, and seem to justify the use of extended surgery when cancer of the rectum and sigmoid has invaded contiguous structures.
Adequacy of margins of resection in gastrectomy for cancer.
This study determines the infiltration rate of proximal and distal margins of resection in patients operated on for gastric cancer at the Istituto Nazionale Tumori of Milan. Two hundred and eighty-five proximal margins and 286 distal margins were reviewed, and the incidence of infiltration was related to the length of grossly tumor-free edge, the location, site, size and gross appearance of the tumor, degree of invasion of the gastric wall, histologic type, and status of perigastric lymph nodes. Infiltration occurred in 7.3% of oral margins of transection and in 2.6% of aboral margins. Except for the degree of invasion of the gastric wall, no correlation was found among the infiltration rate and the above parameters. In fact, the incidence of infiltration of the proximal edge was significantly higher (6.4+ vs. 0.8%, p less than 0.01) when the tumor penetrated the serosa or spread beyond it than when the lesion was confined to the mucosa, submucosa, or muscular layer. With reference to the length of margin of resection, it is noteworthy that no involvement was found when cranial distance between the lesion and line of transection was equal to or greater than 6 cm. Proximal or distal infiltration for a distance greater than 3 cm did not occur in patients with lesions confined to the mucosa, submucosa, and muscularis. This data should provide the surgeon with a rational basis for assessing the extent of resection when performing gastrectomy for cancer.
Microsphere angiography in hepatic artery infusion for cancer.
99mTc-human albumin microspheres were injected at a slow rate into the hepatic arteries of 24 patients before starting intraarterial chemotherapy for liver cancer. The distribution patterns of radiolabeled microspheres were significantly different from those obtained in contrast angiography in 13 of 22 patients. Liver uptake of slowly injected microspheres was greater than 75% in 16 of 24 patients and less than 25% in 4 of 24 patients. A significantly increased arterial blood supply to intrahepatic neoplastic regions was demonstrated in 12 of 20 patients. Microsphere examination allowed an easy evaluation of the relative perfusion of the liver and of the intrahepatic distribution of arterial blood flow in all patients.
Surgical treatment of recurrences following sphincter-saving procedures for cancer of the rectum.
Of 77 patients treated by sphincter-saving procedures (anterior or pull-through resection) for cancer of the rectum, 17 (22%) developed a local recurrence; 10 of them were submitted to abdominoperineal resection. The "rescue" operation was technically difficult, and major problems, including large blood loss and ureteral complications, were often encountered. At operation the recurrent malignancy was more extended than preoperative diagnosis suggested, and reoperation was not macroscopically radical in one case. All patients but one died for the disease after a mean period of 19.8 months. Causes of local failure are analyzed to interpret the rational of surgical approach related to the poor results observed; intensive follow-up programs are also discussed. It is concluded that surgical treatment of local recurrence after sphincter-saving procedures must be reserved only to selected patients, with limited malignancy, and adjuvant radiochemotherapy should also be employed.
[Clinico-statistical studies of the conditions of the masticatory apparatus and disorders of the digestive system in about a thousand aged subjects in the province of Ferrara].
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