BACKGROUND:We wished to determine the role and significance of preoperative chemotherapy and radiotherapy in management of operable cancer of the esophagus.METHODS:Twenty-two patients with clinical stage I-II cancer of the esophagus were entered in a prospective study of preoperative chemotherapy (5-fluorouracil/cisplatin) and radiotherapy (3405 cGy) administered concomitantly during 21 days followed by restaging and total esophagectomy.RESULTS:Five patients did not complete the protocol (three had toxicity, one refused surgery, and one had interim distant metastasis). Seventeen patients underwent total esophagectomy with cervical anastomosis. Two postoperative deaths resulted from sepsis. Thirteen (76%) of 17 patients were considered to have complete clinical response (esophagoscopy and computed axial tomographic scanning) before surgery, but only 5 (29%) of 17 were free of cancer. The median survival was 18 months (median follow-up 57 months). No difference in survival was seen between complete and partial pathologic response.CONCLUSIONS:(1) Preoperative chemotherapy and radiotherapy did not result in increased survival compared with historic controls (surgery alone). (2) Preoperative chemotherapy and radiotherapy clinical staging overestimates the incidence of complete tumor response. (3) Combination chemotherapy is well tolerated, but until newly developed drugs show their efficacy for treatment, surgery should continue to be the major modality for local control and an integral part of clinical investigational trials.

BACKGROUND:Acalculous cholecystitis (ACC) is an uncommon disorder of the biliary tract, accounting for approximately 6% of acute cholecystitis cases. In this study, cholecystitis was seen in 8 of 770 bone marrow transplant recipients, with ACC occurring in five (63%).METHODS:Records of 592 allogenic and 150 autologous BMT patients were reviewed for risk factors associated with ACC.RESULTS:Only the number of blood transfusions administered and the use of total parenteral nutrition were associated with ACC development. ACC occurred in 4 of 42 (9%) allogeneic recipients who required exchange transfusion for ABO incompatibility. ACC developed in one autogolous recipient alongside venoocclusive disease of the liver. There was no association between ACC development and preparative regimen, cyclosporine usage, graft versus host disease, or cytomegalovirus infection.CONCLUSIONS:ACC occurs more frequently in patients after ABO incompatible BMT requiring exchange transfusion than in other transplant recipients.

From 1980 to 1991, 29 patients underwent complex reconstruction following extremity sarcoma resection. Soft tissue was the site of origin in 15 patients (52%) and bone was the site of origin in 14 patients (48%), with 20 sarcomas (69%) in the lower extremity. Resection consisted of the following procedures: extended anatomical soft-tissue resections (21 patients [72%]), bone resections (18 patients [62%]), and joint resections (14 patients [48%]). Reconstruction involved the following: myocutaneous flaps (20 patients [69%]), joint prosthesis (eight patients [28%]), and bone reconstruction (15 patients [52%]). There was no surgical mortality; one patient required an amputation owing to surgical complications. The site of the first failure was local (four [31%] of 13 patients), lung (five patients [38%]), others (four patients [31%]). At a median follow-up of 23 months, 18 patients (62%) had no evidence of disease, 27 (93%) had no local disease, 21 (72%) had good extremity function, three (10%) had major disabilities, and five (17%) underwent amputations. Local control improved when the margin of resection was larger than 10 mm. Disease-free survival was 67% at 3 years. Overall survival was 51% at 5 years. Tumor size was an independent predictor of overall survival. Local recurrence did not affect overall survival.

We report our experience with single-stage, primary reconstruction of the head and neck in 29 consecutive patients using parascapular free flaps. The commonest indications were for craniofacial defects (9), oropharyngeal soft tissue defects (10), and combined mandibular and soft tissue losses (4). Ablative surgery was performed for squamous carcinoma (22), melanoma (2), and malignant fibrous histiocytoma (2). Seven patients died of recurrent disease during a 3 1/2 year follow-up. Seven patients are alive with recurrence. Flap complications included total loss (2) due to unsalvageable microvascular thrombosis, wound breakdown with oropharyngeal fistula (2), mandibular osteomyelitis (1), trismus (2), neck contracture (1), and donor site wound dehiscence (1). The overall success of this reconstruction was 93%. Primary wound healing was the general rule with lower morbidity than with other reconstructive techniques. The flap is thin, pliable, and conforms well to three-dimensional defects. The lateral border of the scapula can be incorporated on the same vascular pedicle for single-stage mandibular reconstruction. No muscle is sacrificed, and the posterior donor defect is an added advantage. The parascapular flap is our first choice for reconstruction of major defects in the head and neck.

Six patients underwent translumbar amputation (TLA), a life-saving procedure, after standard modalities of therapy failed to control the progression of the disease. The primary diagnoses were as follows: pelvic arterial-venous (A-V) malformation, 1; sacral chordoma, 3; giant cell tumor of the sacrum, 1; and paraplegia with squamous cell cancer arising in intractable decubitus, 1. There were no operative deaths. The following postoperative complications developed in five patients: urinary fistulae, 2; small bowel obstruction, 1; intraabdominal bleeding, 1; hypertension, 2; small bowel fistula, 1; and dehiscence of skin closure, 1. Two patients died with distant metastases (24 months) and distant metastases with local recurrence (6 months). The remaining four patients were alive and well 72, 56, 48, and 18 months after the surgical procedure. All of these patients have reached the rehabilitation goals.

The ability of perioperative cefazolin to reduce the incidence of postoperative wound infection in patients undergoing ablative surgical treatment for carcinoma of the breast was tested in this prospective, randomized, double-blinded study. From May 1983 until December 1985, 118 women were divided into two groups at random. Group 1 consisted of 59 patients and received cefazolin and group 2 was made up of 59 patients who received a placebo. The groups were similar with respect to age, operative procedure, operative time and time to discharge after operation. Three infections occurred among those in group 1 and five among those in group 2 (p = 0.72). The time to onset of infection was delayed in the patients in group 1 versus those in group 2 (17.7 days versus 9.6 days, p = 0.04). Six of eight infections occurred in patients in whom an interval between biopsy and definitive surgical treatment was present. Prophylactic antibiotics in mammary operations did not reduce postoperative wound infections in this study.

The use of subcutaneously implanted, Dacron cuffed, central venous silastic catheters (Hickman/Broviac catheter [HC/BC]) has not eliminated catheter related-central venous thrombosis (CR-CVT). HC/BC related CR-CVT was identified and followed in 15 oncology patients. Median time period to CR-CVT was 155 days (range 15-638). No correlation was established to patient age, sex, diagnosis, coagulation status, use, longevity, technique, or site of placement. Fourteen patients were treated with anticoagulation and/or thrombolytic therapy. Of seven patients treated with HC/BC in situ, one required HC/BC removal to achieve CR-CVT resolution. Median follow-up post-CR-CVT was 362 days (range 34-1622). No patient suffered untoward long-term sequelae. Nine patients had 11 catheters placed following resolution of CR-CVT. None had repeat thrombosis. CR-CVT incidence in a single 12-month period was 3.7% (7/190). The placement of HC/BC in an oncology population is an acceptably safe method for long-term venous access.

Two hundred twenty-eight patients were included in a retrospective study to evaluate the morbidity and feasibility of early discharge after mastectomy. Group I (early discharge, n = 75) patients were given pre- and postoperative instruction related to wound and drain care. Group II (concurrent control, n = 44) was given similar postoperative instruction, but received no preoperative teaching. Group III (historical controls, n = 109) underwent surgery during a period of more liberal hospitalization and discharge policies. The groups were similar in age, cultural background, operations performed, and pathologic diagnosis. Length of stay for groups I, II, and III was 5.5 +/- 0.4, 3.5 +/- 0.2, and 8.6 +/- 0.3 days, respectively. Groups I and II had a significantly shorter stay than group III. There was no difference among the groups for the presence of wound erythema, rate of primary healing, seroma formation, or wound infection. The practice of same-day admission and early discharge to limit length of stay for patients undergoing mastectomy is safe and effective.

Tumor DNA content was measured in patients with colorectal carcinoma in order to determine whether tumor ploidy was a prognostic indicator independent of standard clinical and pathologic characteristics. One hundred forty-seven patients were analyzed who had their primary resectable colorectal carcinomas resected with curative intent from 1974 to 1981. Aneuploid colorectal cancers (i.e., tumors with abnormal DNA content) tended to be less well-differentiated, to invade the serosa or extend beyond, and to have lymph node metastases rather than diploid tumors (i.e., tumors with normal DNA content). A significantly increased rate of recurrent disease was demonstrated in patients with aneuploid tumors as opposed to those with diploid tumors (46.7% vs. 4.8%, respectively [p less than 0.001]). In addition, patients with aneuploid tumors exhibited a significantly decreased disease-free and overall survival in comparison with patients with diploid colorectal carcinomas. A Cox regression analysis demonstrated that tumor DNA content was the single most important factor in predicting recurrence or death from colorectal carcinoma.

In 1985 we presented results of a randomized trial involving 1843 women followed for five years that indicated that segmental breast resection (lumpectomy) followed by breast irradiation is appropriate therapy for patients with Stage I or II breast cancer (tumor size, less than or equal to 4 cm), provided that the margins of the resected specimens are free of tumor. Women with positive axillary nodes received adjuvant chemotherapy. Lumpectomy followed by irradiation resulted in a five-year survival rate of 85 percent, as compared with 76 percent for total mastectomy, a rate of survival free of distant disease of 76 percent, as compared with 72 percent, and a disease-free survival rate of 72 percent, as compared with 66 percent. In the current study, we have extended our observations through eight years of follow-up. Ninety percent of the women treated with breast irradiation after lumpectomy remained free of ipsilateral breast tumor, as compared with 61 percent of those not treated with irradiation after lumpectomy (P less than 0.001). Among patients with positive axillary nodes, only 6 percent of those treated with radiation and adjuvant chemotherapy had a recurrence of tumor in the ipsilateral breast. Lumpectomy with or without irradiation of the breast resulted in rates of disease-free survival (58 +/- 2.6 percent), distant-disease-free survival (65 +/- 2.6 percent), and overall survival (71 +/- 2.6 percent) that were not significantly different from those observed after total mastectomy (54 +/- 2.4 percent, 62 +/- 2.3 percent, and 71 +/- 2.4 percent, respectively). There was no significant difference in the rates of distant-disease-free survival (P = 0.2) or survival (P = 0.3) among the women who underwent lumpectomy (with or without irradiation), despite the greater incidence of recurrence of tumor in the ipsilateral breast in those who received no radiation. We conclude that our observations through eight years are consistent with the findings at five years and that these new findings continue to support the use of lumpectomy in patients with Stage I or II breast cancer. We also conclude that irradiation reduces the probability of local recurrence of tumor in patients treated with lumpectomy.

The trapezius musculocutaneous flap based on the descending branch of the transverse cervical vessels has been used to reconstruct a variety of large and complex defects in the head and neck region. Forty-three flaps were performed in 41 patients over a period of 26 months. Excellent reconstruction was achieved in 37 patients. Six total and nine partial flap failures were noted. There were 8 deaths during this time, 2 attributable directly to flap failure. Patient positioning during surgery and the tedious dissection are disadvantageous. The advantages of this flap are its thinness, long reach, and a posterior donor defect. These attributes are ideally suited for certain complex reconstructive endeavors in the head and neck.

The records of 130 patients with soft tissue and bone sarcomas were retrospectively analyzed to identify the subgroups of patients that would benefit from tomographic studies for pulmonary metastasis. Sixty‐six of 96 patients with a normal conventional chest roentgenogram (CXR) had tomography to diagnose pulmonary metastasis. Of the 53 patients who had primary disease and a normal CXR followed by tomography, only 1 (1.9%) had metastases identified on tomograms. Of the 13 patients who had locally recurrent sarcoma and a CXR plus tomographic studies, 2 (15%) had metastases detected on tomogram only. Tomographic studies detected significantly more sarcoma patients with pulmonary metastasis in the group with locally recurrent disease than in the group with primary disease ( P < 0.05).

Nutritional support is an important consideration in the management of the head and neck cancer patient. In our series, characteristics significantly associated with the need for long-term postoperative nutritional support included stage IV cancers, primary pharyngeal tumors, combined treatment utilizing surgery and radiotherapy, and preoperative weight loss of more than 10 pounds. In planning nutritional support, nasogastric tube feeding is appropriate for short-term use. In contrast, gastrostomy tube feeding is preferable for those head and neck cancer patients with a high probability of requiring long-term nutritional support postoperatively.

Our purpose in this study was to determine whether tumor DNA content is a prognostic factor independent of other standard clinical and histologic parameters in squamous cell carcinoma (SCC) of the head and neck region. Tumor DNA content was determined in 76 patients with primary resectable SCC of the oral cavity, larynx, or pharynx who were treated from 1978 to 1984 at the City of Hope. In addition, we measured various clinical and pathologic parameters in all patients. In comparison to patients with diploid SCC, those with aneuploid SCC had significantly decreased relapse-free and overall survival rates (p less than 0.001 for both). A Cox regression analysis demonstrated that tumor DNA content was a prognostic factor independent of all clinicopathologic features examined. By regression analysis, it was the single most important prognostic factor in determining relapse and death from SCC (p less than 0.001 for both).

The incidence of morbidity and mortality in 365 consecutive patients with a mean age of 60 years who underwent intraabdominal operation for a variety of cancers involving different organ systems over a recent 2-year period was analyzed. The primary tumor sites were the esophagus (21 patients), gastroduodenum (33 patients), liver and gallbladder (6 patients), pancreas (15 patients), colorectum (101 patients), lymphoproliferative disorders (35 patients), abdominal carcinomatosis (45 patients), genitourinary and gynecologic systems (94 patients), and other sites (15 patients). One hundred eighty-two patients (49 percent) had 1 or more complications (grouped as gastrointestinal, septic, cardiopulmonary, and nonseptic) and 47 patients died (12.9 percent). The 145 patients who underwent a palliative procedure had the highest morbidity and mortality rates (41 percent and 21 percent, respectively). In the 168 patients who had curative resection, the morbidity and mortality rates were 39 percent and 9 percent, respectively, and in 51 patients with a diagnostic laparotomy, 20 percent and 4 percent, respectively. Age was not a contributory factor. The 177 malnourished patients had a significantly higher incidence of complications (72 percent) and postoperative death (23 percent) than the well-nourished patients (29 percent and 4 percent, respectively; p less than 0.001). These differences also existed with each form of complication. Of those patients without complications, the majority resumed consuming 60 percent of their caloric requirements by postoperative day 9. In the majority of patients with complications, resumption of adequate oral intake occurred by postoperative day 20.

Thirty-six patients underwent resection of the thoracic esophagus without a thoracotomy for the management of cancer of the cervical esophagus (2 patients), middle third and lower third of the esophagus (4 patients and 23 patients, respectively), and the gastroesophageal junction (17 patients). In addition to a total esophagectomy, two patients required a laryngectomy and seven patients had a total gastrectomy. Intraoperative bleeding occurred in three patients. Postoperative complications included subphrenic abscess (Candida) (2 patients), diaphragmatic hernia (1 patient), and salivary fistula (11 patients). Three patients died in the postoperative period from necrosis of interposed colon, pneumonia, and liver failure due to liver metastasis. The average blood loss was 1,300 ml, the duration of surgical procedure was 5.3 hours, and the hospital stay was 21 days. The survival rates at 1, 2, and 3 years were 80 percent, 50 percent, and 33 percent, respectively. Transhiatal esophagectomy can be considered a sound alternative to transthoracic esophagectomy in the management of tumors involving the cervical and lower esophagus. Small lesions of the middle third should also be considered for this procedure, however, bulky lesions of the upper esophagus are better removed by thoracotomy.

Patients with primary and/or metastatic colorectal cancer who had been scheduled for operative intervention were injected intravenously with 200 μg of a high‐affinity anti‐carcinoembryonic antigen (CEA) monoclonal antibody labeled with 2 mCi of 111‐indium (Indacea). Patients were imaged by gamma camera at 24 and 48 hours. Primary tumors were identified in 3/10 cases and were not visualized in 3/10 cases. Four scans were considered equivocal. Hepatic metastases were identified as image defects in 5/13 cases and were not visualized in 8/13 cases. All tumors contained CEA by immunoperoxidase staining. In all cases, the primary tumor uptake (5.44 ± 1.07% ID/kg) was much higher than the uptake of the adjacent fat (0.18 ± 0.04% ID/kg). There was a direct correlation between tumor CEA content, tumor radioactivity, and the imaging of primary tumor by Indacea. High liver uptake (30.3 ± 3.0% ID/kg), seen when scanning all patients, was the main limitation of imaging and led to photopenic visualization of hepatic metastases. These results suggest that selection of patients with colorectal carcinoma on the basis of tumor CEA content will lead to improved rates of tumor imaging by Indacea in post‐surgical scanning.