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208 cases of rectal cancer after curative or palliative surgical treatment are reported. Postoperative lethality, early complications and late follow-up prognosis are discussed. After curative surgical treatment 5-year-survival runs to 53%. In suitable cases palliative removal of the tumor is justifiable.
Electrocoagulation as a primary curative method for the treatment of carcinoma of the rectum is of proved merit. The continuation of abdominoperineal resection as the acceptable standard routine for treatment will deny many patients the choice of a proved alternative curative procedure with less risk, a better survival rate and a better quality of life. To confirm or negate the reported efficacy of electrocoagulation in the treatment of carcinoma of the rectum, the initiation of universal prospective studies in its use is warranted.
Two hundred patients with a previously untreated carcinoma of the thoracic portion of the esophagus and who underwent curative or noncurative resection were retrospectively evaluated. The patterns of recurrence were compared with the pathologic findings at operation. In 30 of 90 (33.3 per cent) patients in the curative resection group and 68 of 110 (61.8 per cent) of those in the noncurative resection group, there was a recurrence. Hematogenic recurrence was most frequent in instances of blood vessel invasion of the carcinoma detected at the time of the operation, and death occurred during the early postoperative period. Lymph node recurrence was most frequent in instances of lymphatic invasion or blood vessel invasion, or both, and the postoperative survival time in such patients was double that seen in those with a hematogenic-related recurrence.
Computed tomography and ultrasonography of the liver were performed during the immediate postoperative period in 35 consecutive patients undergoing apparently curative resection for colorectal carcinoma. On the basis of these investigations, occult hepatic metastases were detected and confirmed by sequential imaging in 11 patients. All patients were followed for a minimum of 3 yr. Of these 35 patients, 2, 10, and 23 were allocated to the traditional Dukes' stages A, B, and C, respectively. The corresponding 3-yr survival was 100%, 70%, and 57%. The 11 patients with occult hepatic metastases at the time of surgery were allocated to the Dukes' B group in 2 cases and the Dukes' C group in 9 cases. When these 11 patients are excluded from the traditional Dukes' staging, the corrected survival of the A, B, and C groups was 100%, 88%, and 86%, respectively. Only 1 of the patients with occult hepatic metastases survived 3 yr. These results show that the presence of occult hepatic metastases predominantly explains the pattern of early death after apparently curative resection for colorectal carcinoma.
Advanced disseminated leukemia can be successfully eradicated by treatment with a combination of noncurative nonlethal chemotherapy plus adoptively transferred immune cells. The time course of tumor elimination following such therapy was examined by bioassay for tumor of peripheral blood and spleen cells from treated mice. Curative treatment with adoptive chemoimmunotherapy did not immediately eliminate all leukemia. Bioassay of cells from treated mice, rather, demonstrated that, following the initial tumor lysis mediated by the chemotherapy and immune cells, a period of tumor regrowth lasting several weeks preceded ultimate tumor eradication. This transient tumor regrowth detectable by bioassay never became clinically evident in the treated mice. However, immunosuppression of mice two weeks after treatment with adoptive chemoimmunotherapy resulted in recurrence of lethal tumor. The results suggest that tumor elimination following curative adoptive chemoimmunotherapy is biphasic and that the efficacy of therapy may be subject to positive and/or negative influences over a prolonged time period.
Although epilepsy may be successfully managed with appropriate medication, in Africa epileptics are often vilified, sometimes because of traditional beliefs about the illness. We investigated the strength of beliefs which 112 rural Malawians held regarding traditional and medical explanations for the cause, treatment and cure of epilepsy. Those who believed in traditional causes of epilepsy also endorsed traditional treatment for it, though they did not see such treatment as curative. Those who believed in a medical treatment, did however see such treatment as curative. Knowledge of a local medical facility for the treatment of epilepsy was also positively related to the belief that epilepsy is curable. The ability of people to simultaneously hold medical and traditional beliefs about epilepsy was noted.
In order to evaluate the significance of postoperative adjuvant chemotherapy for colorectal carcinoma, the Colorectal Cancer Chemotherapy Study Group, from 140 leading hospitals in Japan, conducted a prospective, randomized, controlled trial on patients who had undergone curative resections for colorectal carcinomas during the period from February 1984, to December 1985. The regimens for colon cancer were, Arm I: mitomycin C [intraoperative portal vein bolus (12 mg/m2) + postoperative, twice weekly and then three times bimonthly for six months intermittent i.v. bolus (6 mg/m2)] + 5-fluorouracil (5-FU) 200 mg/body/day p.o. for six months; Arm II: postoperative twice weekly and then three times bimonthly intermittent i.v. bolus mitomycin C (6 mg/m2) for six months + 5-FU 200 mg/body/day p.o. for six months; Arm III: surgery alone. The regimens for rectal cancer were, Arm IV: same as Arm I, with superior rectal artery infusion of the same mitomycin C dose instead of portal vein infusion; Arm V: same as Arm II; Arm VI: same as Arm III. Of 2001 collected cases, 1805 eligible cases (899 colon cancers and 906 rectal cancers) were analyzed. Significant differences in five-year survival rates were found between Arms IV and V and Arm VI [Arm IV: 70.7% (95% confidence interval (C.I.): 65.6-75.8%), P = 0.004 vs Arm V: 73.6% (68.5-78.7%), P = 0.000 vs Arm VI (control): 60.2% (54.5-65.9%)]. No significant difference in overall survival rate was found in the colon cancer patients [Arm I: 80.4% (75.7-85.1%), not significant (N.S.) vs Arm II: 82.1% (77.8-86.4%), N.S. vs Arm III (control): 79.5% (74.6-84.4%)]. When stratified into Dukes classes, however, Dukes C patients in Arm II showed a significantly improved survival rate compared with that of those in Arm III [Arm I: 72.6% (64.8-80.4%), N.S. vs Arm II: 75.0% (67.9-82.1%), P = 0.012 vs Arm III (control): 61.0% (51.4-70.6%)]. We conclude the adjuvant use of long term oral 5-FU and intermittent mitomycin C (i.v.) to improve the survival rate of patients with curatively resected rectal cancer. Further comparative study is, however, recommended to confirm the effectiveness of 5-FU alone and the combination of 5-FU and mitomycin C. Regional chemotherapy made no contribution to reducing an hepatic recurrence of colon cancer or a local recurrence of rectal cancer.
The indication for curative radical prostatectomy in a patient with prostatic cancer clinically confined to the prostate (stage T1, T2) and the absence of any detectable metastases, is associated with a postoperative recurrence rate of 24 to 51% after a mean follow-up of 3 years. Certain preoperative criteria allow the selection of patient groups in which the risk of postoperative tumour recurrence is higher: presence of more than 4 positive biopsies out of 6 systematized biopsies associated with a Gleason score greater than or equal to 7 and a PSA higher than 15 ng/ml (normal value for monoclonal test < 4 ng/ml). The indication for curative radical prostatectomy is doubtful in this group of patients.
A familiar medical contrast is presented as part of a modern medical problem. The problem it reflects is the relative importance of preventive and curative services for medical practitioners, which is already, or will shortly resolve itself into, a dilemma of whether medical men should stress preventive medicine to the possible detriment of curative medicine. It is submitted that the solution to both problem and dilemma should be sought against the background of history and philosophy, where they are seen to be expressions of an eternal paradox--that of the relative value of the individual in relation to the family, group, or community. If the submission is valid, then the answer to the problem is not a purely medical exercise, nor is the dilemma purely a 'doctor's dilemma'. The paradox, being eternal, is not soluble in our time, but the community must, on the urging of the medical profession, find a general solution to the problem--'a public consensus for out time'. This must be followed by public demand for a parliamentary solution--'decision-making ex consensus'. It is argued that although the latter programme does not come easily to democracy, it can be achieved through public consensus if action is taken by the leaders of thought in appropriate categories. Initiative must be exercised by the medical profession, but public consensus can only be achieved in consultation with the leaders of all learned professions, civil servants and legislators. It must then be presented fairly and without bias to the public. In the meantime, the medical profession must formulate its own 'medical consensus' and the doctor must resolve his personal dilemma according to formulated law, public or medical consensus or, in the last resort, according to his conviction and conscience. This method of solving a problem will almost certainly be applicable to other and more recent medical problems such as the population explosion, selective abortion and euthanasia.
BACKGROUND: Correlation between erbB-2 expression, histologic type of gastric carcinoma, and survival after curative resection was evaluated. METHODS: Paraffin-embedded specimens from 120 patients who underwent curative resection of gastric carcinoma were analyzed immunohistochemically for the expression of erbB-2. RESULTS: Enhanced erbB-2 expression correlated with tumor stage and depth of invasion. Well-differentiated adenocarcinomas had a higher incidence of erbB-2 expression than did poorly differentiated carcinomas. Survival rates of 33 patients with erbB-2-positive carcinomas were significantly lower than those of 87 with erbB-2-negative carcinomas (p < 0.001). Survival rates of patients with well-differentiated adenocarcinomas that were erbB-2 positive were significantly lower than those that were erbB-2 negative (p < 0.001). However, the presence of erbB-2 was not associated with altered survival in 46 patients with poorly differentiated carcinomas. Multivariate analysis of all 120 patients revealed that independent predictors of recurrent disease include nodal involvement (p = 0.003) and erbB-2 expression (p = 0.0051). CONCLUSIONS: Our results suggest that erbB-2 expression is a new marker associated with poor prognosis in well-differentiated gastric adenocarcinomas.
Reports of the results of clinical trials on adjuvant chemotherapy for curatively resected gastric cancer were reviewed. All but two trials did not show its efficacy. In spite of this, understanding some results of subset analysis as definite proof, a consensus was achieved in Japan on its efficacy due to lack of proper knowledge of medical statistics among surgeons. Recently it has been recognized that this consensus was groundless and that evaluation of adjuvant chemotherapy should be carried out again. The results of the trial of JCOG, comparing adjuvant chemotherapy versus control (surgery alone) are therefore awaited. For the moment, all clinical trials on adjuvant chemotherapy for curatively resected gastric cancer should have an arm of surgery alone as control.
A retrospective study of gastric adenocarcinoma treated with surgery as curative attempt was performed at the Oncology Service, in the Hospital Regional 20 de Noviembre, ISSSTE. Morbidity and mortality of the surgical procedures were evaluated, the significance of several risk factors and the survival impact of adjuvant chemotherapy with 5-fluorouracil (5-FU) and mitomycin C (MMC). In the period from 1975 to 1991 a total of 483 new cases were seen. In only 54 patients (11.2%) was it possible to undertake a curative resection. The patients were assigned to three groups of treatment: surgery alone (14 cases), surgery + 5-FU (19 cases), and surgery + 5-FU+MMC (21 cases). Three different types of surgical techniques are regularly performed in our service for gastric cancer treatment: Billroth II distal gastrectomy, total gastrectomy with Roux-En-Y reconstruction, and esophagogastrectomy with esophagogastrostomy. Surgical morbidity and mortality was low, with 9% of duodenal stump fistulas and 27% with partial stenosis of esophagojejunostomy; the operative mortality was zero. Chemotherapy toxicity was transient and low, no related deaths were recorded. The prognostic factors associated significantly with survival were lymph node status and tumor penetration. The histologic differentiation as well as the tumor location and type of surgery had no significance. The estimated 5-year survival of the patients treated with surgery alone was 62%, while that of the patients treated with surgery plus chemotherapy was 38%. These groups were not comparable, however, because of important differences in their prognostic factors. The groups treated with 5-FU alone or in combination with MMC had no survival difference between them.(ABSTRACT TRUNCATED AT 250 WORDS)
The recovery of colony-forming cell numbers after curative treatment for leukemia and severe aplastic anemia (SAA) was studied. We examined 191 patients (85 acute myeloid leukemia [AML], 48 acute lymphocytic leukemia [ALL], 32 chronic myeloid leukemia [CML], 17 SAA, and nine myelodysplastic syndrome [MDS]) who were in hematologic remission 6 months to 13 years after either curative chemotherapy (n = 69) or allogeneic bone marrow transplantation (BMT) (n = 122) by culturing their precursor cells from bone marrow (BM) (n = 548) and peripheral blood (PB) (n = 529) in methylcellulose. Thirty-six BM donors and 25 PB donors served as controls. BM colony-forming cell numbers were abnormally low in all patients (p < 0.002) irrespective of underlying disorder and type of treatment (chemotherapy or irradiation). These numbers did not normalize with time--colony-forming cells were still strongly reduced up to 10 years after therapy, whether or not the patient had received an allogeneic bone marrow graft (p < 0.002). We also compared patients who remained in stable hematologic remission with those who later relapsed (6 months to 2 years after treatment). BM colony-forming cell numbers were significantly lower in patients who subsequently relapsed (p = 0.004). In contrast to BM cultures, we found normal colony-forming capacity by PB precursors in all patients. We conclude that (1) after chemotherapy or BMT, colony-forming cell numbers of BM in culture are permanently reduced; (2) this defect is probably due to a dysfunction of the BM environment rather than to a numerical reduction of the precursor cell pool; and (3) very low colony-forming capacity may be related to relapse.
Mice infected with Friend Leukemia Virus (FLV) rapidly develop erythroleukemia and severe immune deficiency which resembles human AIDS. We have reported that mice infected with a lethal dose of FLV can be 100% cured by 150 cGy total body irradiation (TBI). This curative effect was associated with restoration of cellular immunity which was compromised by the virus. This restoration may result from activation of the IFN-gamma system and IL-2 production. Our research work further demonstrated that no spleen focus-forming virus (SFFV) specific mRNAs, no 6.0kb SFFV fragments and SFFV envelope glycoproteins were detectable in FLV-infected mice treated with low dose TBI. Predicated on our report, del Regato has initiated clinical trials to treat AIDS patients with low dose TBI. The preliminary results are encouraging and the study is continuing. We have also studied the effects of low dose TBI on the expression of the P53 gene. The results show loss or inactivation of P53 tumor suppressor genes in FLV-infected mice, but P53 expression was restored in FLV-infected mice treated by low dose TBI. It is intriguing to speculate that in the curative effect of low dose TBI on mice infected with retrovirus, the P53 tumor suppressor gene may play an important role. It would be of interest to see if this type of treatment, which was well tolerated by mice, would be beneficial in other types of virally induced disease, including AIDS.
BACKGROUND/AIM: We studied the influence of alcohol abuse (ethanol intake > 80 gm/day for > 5 yr.) on recurrence in 81 patients with hepatocellular carcinoma who had undergone curative hepatic resection. Twenty-nine patients were positive for alcohol abuse [AA(+)] and 52 were not [AA(-)]. RESULTS: Recurrence of carcinoma within 2 and 27 postoperative months was observed in 45 (55.6%) of the 81 patients. The median disease-recurrence time was 12.0 mo in the AA(+) group and 24.1 mo in the AA(-) group (p<0.01). The patterns of recurrence were classified into the following 4 types: single-nodular type (intrahepatic single nodule); multi-nodular type (intrahepatic multiple nodules); whole liver type (diffuse recurrence over the whole remnant liver); and extrahepatic type (extrahepatic recurrence alone). Five (29.4%) of the 17 patients with recurrence in the AA(+) group demonstrated the whole liver type, compared with only 2(7.1%) of the 28 patients in the AA(-) group (p<0.05). CONCLUSION: Patients with alcohol abuse should be followed up particularly closely, even if they have received curative surgery, since alcohol abuse is strongly related to postoperative recurrence.
OBJECTIVE: The benefits of periodic colonoscopic surveillance after curative resection for colon cancer are controversial. We investigated the incidence, size, and time interval to the detection of recurrent adenomatous polyps in patients who have undergone resection of a colorectal cancer. METHODS: In this retrospective study, the records of 351 patients who underwent curative resection for colorectal carcinoma between 1967 and 1991 were reviewed. Sixty-one patients were excluded because of incomplete data. RESULTS: Eighty-seven patients (30%) were found to have had at least one adenoma. Twelve patients had more than five adenomas. The median time to diagnosis was 24 months. Forty-six patients of the 87 (52.9%) had polyp recurrences within 2 yr after cancer resection. CONCLUSION: This group of patients is at increased risk for the development of adenomatous polyps. Surveillance colonoscopy and polypectomy may reduce the incidence of metachronous colon cancer.
Over a period of ten years (1980-1989) 528 patients with colon cancer were treated at one institution. One hundred seventy nine (33.9%) were obstructed (O) and underwent emergency surgery, while 349 received elective (E) treatment; of these 363 had one-stage curative treatment. Operative mortality was 10.3% (O) and 3.5% (E) respectively (p < .0.5). Three hundred forty three patients survived surgery and entered follow-up: 96 were O (M:F, 54:42) and 247 E (M:F, 119:128, p = N.S.). Their mean age was 69.5 and 64.4 (p < .001), respectively. Dukes' stage and histological grading were evenly distributed within the two groups, but sites of the primary were not (p < .001). During the follow-up local recurrence occurred in 40 patients (13 O, 27 E, p = N.S.) and metastatic disease in 78 (28 O, 50 E, p < .05, Life Table Analysis) including liver recurrence in 17 O and 30 E (p = .063). Five year crude survival (51%) was significantly worse in obstructed patients. Multivariate analysis showed that Dukes' stage and obstruction were the only prognostic factors of recurrent disease, while survival was affected by the same variables and age over 70. When recurrent disease was introduced in the model survival depended on Dukes' stage, site of the primary and age over 70 and the variable obstruction disappeared as prognostic factor. Right sided tumours showed a better and those at the splenic flexure a worse prognosis. Despite one-stage curative treatment obstruction carries a significantly higher risk of developing metastatic disease, suggesting that obstruction enhances cancer cell dissemination. These patients might benefit from per-operative intra-portal and post-operative systemic adjuvant chemotherapy.
We have successfully treated 40 patients with early gastric cancer by using two different laparoscopic procedures since March 1992, which are laparoscopic wedge resection of the stomach using a lesion-lifting method (n = 25) and laparoscopic intragastric mucosal resection (n = 15). The indication is as follows; 1) mucosal cancer, 2) < 25 mm, if the lesion is protruded type, 3) < 15 mm and Ul(-), if the lesion is depressive type. All patients were discharged within 4-8 days uneventfully. The resected specimens were 66 +/- 16 mm and 48 +/- 8 mm in diameter respectively, and had a sufficient surgical margin horizontally (16 +/- 5 mm, 8 +/- 4 mm) and vertically. Histology revealed they were all curative surgeries except one case in whom an additional gastrectomy with lymph node dissection by lapalotomy was required one month after surgery because lymphatic invasion had been revealed by pathology. In conclusion, these laparoscopic procedures are curative and minimally invasive treatment for early gastric cancer.