Twelve years of experience with cytotoxic therapy in malignant tumors of the neck and head

Since 1968 we have treated with antiblastic drugs 164 malignant tumors recurrent or incurable by surgery or radiotherapy in 151 cases. Different therapeutic methods were employed. Today we have the possibility of selecting alternative options with incipient or relatively delimited carcinomas, principally the substitution of radical surgery by initial associated physical and chemical treatment, so that if there is a cure the consequences of radical surgery can be avoided. We emphasize the curve of two primary cancers of the uvula with 300 mg bleomycin exclusively and the results observed in oropharyngeal and laryngeal carcinomas by using three intermittent Schabel cycles and 4,000 rad Telecobalt, avoiding a radical surgery.

[Late arrhythmias in the operated interatrial communication. Analysis of sinus node function and the conduction pathways by His bundle electrocardiography]

Four hundred patients with atrial septal defect treated surgically were reviewed. Thirty five (8.7%) developed arrhytmias post-surgery which persisted for over a year. Sinus bradycardia was found in 10 patients, nodal rhythm in 21, and atrial fibrilation and flutter in 4 patients. Thirty five per cent of the patients with late arrhythmias developed related symptomatology. In 14 patients the function of the sinus node was studied with electrical stimulation of the atrium and with His registry. The interatrial conduction time, AV node and His Purkinje were analized employing various stimulation frequencies. All the cases studied had normal intra-atrial conduction; the response of the atrio-ventricular node to increasing frequencies was normal, an the intraventricular conduction remained constant. In 8 patients (52%), alterations of the sinus node were found; these consisted of prolonged post-stimulation pauses, Wenckebach's type sinoatrial block and suppression of sinus automatism employing vagal procedures or through electrical stimulation. A patient with severe bradycardia detected by dynamic electrocardiography had to be treated with a permanent pacemaker. We confirm that these arrhytmias are not produced by lesions of the internodal tracts, and that an alteration of the sinus node is frequent without a concomitant lesion of the intraventricular pathway. The lesion to the nutrient artery could be due to trauma and/or surgically induced. The response to anticholinergic drugs was good. Prolonged observation of these patients could increase the morbility of these arrythmias and raise doubts of the surgical indications in cases with moderate hemodynamic repercussion.

[Apical hypertrophic myocardiopathy. Report of the first case identified on the American continent]

What appears to be the first case of hypertrophic apical myocardiography described in the western hemisphere is presented in this report. The diagnosis was confirmed by angiocardiography and echocardiography. The electrocardiogram showed the characteristic giant T waves. It is of interest that the coronary radioangiography suggested alterations in the microcirculation which could explain the striking electrocardiographic pattern of subepicardial ischemia seen in these patients.

[Hemodynamic effects of atrial overstimulation in patients with ischemic heart disease]

Auricular over-stimulation is used by some researchers to study patients under suspicion of coronary heart disease. In this paper we discuss the changes in telediastolic pressure of the left ventricle (PT-DVI), stimulating the right auricle with increasing frequencies sent through an external pacemaker. When the ventriculography and coronarography were over, the Sones catheter was left into the left ventricle. An electrode-catheter was introduced through vein in the right auricle, the distal end being very close to the sinusal node, where the electric catch as accomplished. Through this stimulator the cardiac frequency was increased in 20 heart beats more than the basal cardiac frequency and the PTDVI was simultaneously measured every 3 minutes. Through the coronarographic study, the patients were classified in: normal, bi-vascular and tri-vascular. The increase and decrease of PTDVI was calculated in relation to the results obtained during the last minutes of over-stimulation compared with the basal figures. Most of the patients showed a decrease in PTDVI no matter what the vascular engagement was. Our results show there is no difference between the response and the coronary obstruction degree so, this evidence is of no value to judge the functional situation of the left ventricle.

[Comparative study of coronariography and radiocoronariography in ischemic cardiopathy. Preliminary report]

25 patients with ischemic heart disease were studied by selective coronariography and radiocoronariograpy with 3mCi of human albumin macroaggregates labeled with 99mTc, injected selectively into each coronary artery. Gammagraphic images were then obtained. 17 cases (68%), had coronary obstructions and 8 patients (32%), had a normal coronary angiogram. Of all patients studied, 23 (92%), had areas of hypoperfusion. Patients with coronary obstructions had corresponding image defects. 6 cases with normal coronary angiography had areas of hypoperfusion and finally 2 cases had normal images in both studies. All patients wit EC6 necrosis had abnormal radiocoronariography. The macrocirculation is studied by coronary angiography, while the microcirculation is visualized by radiocoronariography. Both technique are complementary. We conclude that radiocoronariography should be performed routinely after coronary angiography in the study of ischemic heart disease, with special emphasis in cases with normal angiograms.

Preliminary results of chemo-radiotherapy followed or not by active immunotherapy of stage III and IV lymphosarcoma and reticulosarcoma. Correlation of the results with WHO categorisation

We treated 101 patients with advanced (stage III and IV) lymphosarcoma and reticulosarcoma at first presentation of the disease or in relapse according to a protocol combining initial chemotherapy, complementary radiotherapy on icebergs, supplementary chemotherapy, and, finally, active immunotherapy. The overall complete remission rate was about 79% for lymphosarcoma and 73% for reticulosarcoma. About 50% of the patients were still in remission in each of the two diseases at 2 years; 60% of lymphosarcoma and 44% of reticulosarcoma patients achieved 2-year survival. This study shows the prognostic value of the WHO classification for lymphosarcoma and reticulosarcoma: the prognosis of prolymphocytic (centrofollicular) lymphosarcoma is far better than that of the lymphoblastic type, which is in turn better than that of the very poor prognosis of the immunoblastic type. The prognosis of reticulosarcoma is intermediate between that of the best-prognosis and that of the poorest-prognosis type of lymphosarcoma.

Preliminary results of chemoradiotherapy followed (or not ) by active immunotherapy of stage III and IV lymphosarcoma and reticulosarcoma: correlation of the results with WHO categorization

One hundred and one patients with advanced (stage III and IV) LS and RS at the first presentation of the disease or on relapse were treated with a regimen combining initial chemotherapy, complementary radiotherapy on "icebergs," supplementary chemotherapy, and finally, active immunotherapy. The overall complete remission rate was about 79% for LS and 73% for RS. About 50% of the patients were still in remission for both diseases after 2 years; 60% with LS were still alive after 2 years and 44% with Rs. This study shows the useful prognostic value of the WHO classification for LS and RS: the prognosis of prolymphocytic (centrofollicular) LS is far better than that of the lymphoblastic type, which is itself better than that of the very poor prognostic immunoblastic type. The prognosis of RS is intermediate between that of the best prognostic type and that of the poorest prognostic type of LS.

[Correlation between exercise test and coronariography]

In order to evaluate the sensibility and specificity of the maximal treadmill exercise-stress test, a correlation was made, in fifty patients, of the resus of the test and the findings at selective coronary arteriography. None of the patients had received cardioactive drugs previous to the study. Among twenty-nine patients with proven coronary disease, three had false negative exercise tests. The remaining twenty-six cases had positive tests. The sensitivity of the method (reliability in identifying the presence of disease) was 89.7%. Twelve of twenty-one subjects with normal coronary arteries had negative exercise tests. In eight patients without coronary artery lesions, the exercise test was positive (false positive tests). An additional patient had an equivocal response and is included among the false positive responses. These nine-patients form a special group since they had severe heart disease, even though it was not due to atherosclerosis of the major coronary vessels. The specificity of the test (reliability in identifying the absence of disease) was 57.1%. However, in the absence of other heart disease, none of the subjects with normal coronary arteries had a false positive response. An analysis is made of the possible causes of these false negative and false positive responses. It was also shown in this study that the patients with coronary artery disease and positive treadmill tests had a definite functional aerobic impairment as well as a significant reduction in such indices of myocardial oxygen consumption as the heart rate and the double product (pressure-pulse), when compared to the subjects with normal coronary vessels and negative tests. In the group of patients with false positive responses, these parameters were not significantly different from the normals. The exercise-stress test protocol used in this study appears to have an adequate sensibility and an acceptable specificity.

[Angiographic diagnosis of congenital abnormalities of the coronary vessels]

A new classification for congenital anormaleis of the coronary vessels is presented. The fundamentals of pathophysiology in each entity, are discussed.

[Treatment of supraventricular paroxysmal tachycardia and auricular flutter by auricular stimulation]

Although the management of supraventricular tachycardias (SVT) and atrial flutter (AF1) with drugs or cardioversion is usually effective, their use in the high risk patient commonly digitalized, may be dangerous. Since the availability of an alternate therapeutic method is desirable, the usefulness of atrial pacing was evaluated in 31 episodes of tachyarrhythmia in 31 patients with varied heart conditions. The arrhythmia diagnosis and the stimulation were done through a right atrial electrode. In most cases the rate of stimulation was higher than that of the atria (up to 400 stimuli per min). Of 17 cases with SVT (four with preexcitation syndrome), pacing led to sinus rhythm (SR) in all, even though it was transient in two. SR was obtained in six of eleven cases of AF1, through a short lasting atrial fibrillation (AF) in three of them. Four patients with paroxysmal atrial tachycardia with A-V block changed to AF. SR was achieved shortly after termination of the procedure in two of the latter. It is concluded that atrial pacing is a valuable therapeutic method since it is effective, it has very low risk specially in digitalized patients, its does not require anesthesia and because it may be used repeatedly in case of recurrence. The technique of atrial pacing permits, in some cases, the identification of the mechanism responsible for the arrhythmia.

[Hemodynamic evaluation in acute myocardial infarct. Application to the treatment of contractile insufficiency syndromes of the left ventricle]

Even though the coronary care units have reduced to a minimum the mortality due to arrhythmias, the syndromes of left ventricular failure are responsible for the greatest part of hospital deaths in patients with acute myocardial infarction. The poor results depend upon the extensive destruction of left ventricular mass. The management in these cases should be directed to improve the performance of viable muscle as well as to preserve thejeopardized ischemic myocardium that is potentially viable. These goals may be adequately pursued by continuous hemodynamic characterization of left ventricular function. The experience of the Coronary Care Unit of the Instituto Nacional de Cardiología de México in the study of 30 of these patients is presented. Hemodynamic evaluations were performed by means of a Swan-Ganz catheter and cardiac output determinations by the thermodilution technique. The studies may be performed with a minimum of risk. Central venous pressure measurements do not adequately indicate the status of the left ventricle. Its function may be evaluated by the use of end diastolic pulmonary artery pressure which reflects, quite accurately, the left ventricular filling pressure in these patients. Continuous hemodynamic monitorization facilitates the proper manipulation of the determinants of ventricular performance (preload, afterload, cardiac rate and contractility) and permits an attempt to improve the balance between available oxygen and myocardial oxygen requirements. Hemodynamic studies and ventricular function curves are presented in selected patients with acute myocardial infarction. The mortality due to left ventricular failure and cardiogenic shock in patients with acute myocardial infarction remains extremely high. However, it is only through the early recognition by continuous hemodynamic monitorization and the aggressive management of the patient with incipient left ventricular failure that the number of survivors may be increased.

[Determination of the real value of the ventricular volume using angiographic methods]

The developing of cuantitative angiographic procedures for evaluating the left ventricular efficiency have displaced most of the simple hemodynamic methods. The calculation of the left ventricular volume by usual ventriculography yields, as a rule, magnified values. The purpose of this paper is to determine the equation of the regression line means of which the real left ventricular volume can be calculated. A series of 12 normal hearts obtained from accidentaly deceased adult individuals (this necropsy material was afforded by the Forensic Medicine Department of México City). Previously measured amounts of a contrast substance were injected into the left ventricular cavity. The heart was filmed in a position equivalent to the chest RAO. The volume of the left ventricle was calculated using monoplane Sandler and Dodge cineventriculographic method. The results were submitted to statistic analysis. Confrontation of calculated and real values rendered a significative "r" (0.7374) and a non-significant "p" (0.001) the regression equation obteined was: y=36.97 + (0.39 x) in which: y=real left ventricular volume. x=calculated left ventricular volume.

[Value of the electrocardiogram to predict the pattern of left ventricular contraction in ischemic cardiopathy]

A correlative electrocardiographic and ventriculographic study was performed in a series of 100 patients with clinical and electrocardiographic diagnosis of ischemic heart disease. The analysis was focused on the possibility of predicting ventricular contraction pattern (VCP) disturbances, through electrocardiographic signs of coronary insufficiency. Two main groups were separated on the basis of the presence of necrosis. There were 66 cases with necrosis, and 34 without it. The type of VCP was calssified in accordance with the criterion of Herman et al. in: asyneresis, akinesis and dyskininesis. The degree of coronary narrowing was arbitrarily evalued as less than 50%, between 50 and 75%, and over 75% of the lumen.

Myocardial ultrastructural changes during extracorporeal circulation wtih anoxic cardiac arrest and its prevention by coronary perfusion. Experimental study

This experimental work has been carried out with the aim of studying the ultrastructural myocardial changes caused by prolonged anoxic cardiac arrest during cardiopulmonary bypass, and their prevention by means of two different techniques of coronary perfusion--systemic-pressure continuous and low-pressure intermittent perfusion. After 30 minutes of cardiac anoxia, the ultrastructural changes of the myocardial cell were reverted to normal by coronary perfusion; when anoxic cardiac arrest was prolonged up to 60 minutes there was severe myocardial damage, with marked mitochondrial changes and dehiscence of intercalated discs, which persisted in spite of restoring coronary flow. These morphological data were in accordance with the fact that no dog which underwent anoxic cardiac arrest for 60 minutes recovered. Both intermittent and continuous coronary perfusion were effective in preventing anoxic damage; cardiac muscle cells were better preserved by low-pressure intermittent perfusion than by systemic-pressure continuous perfusion, which caused intracellular and intramitochondrial oedema.

[Supravalvular aortic stenosis. Report of clinical findings in 5 patients]

Five cases of supravalvular aortic stenosis (SAS) diagnosed by heart catheterization were studied in the Instituto Nacional de Cardiologia of Mexico. The clinic and laboratory data of interest of the differential diagnosis with other forms of obstruction of the left ventricle as follows: 1. Three cases had mental retardation and "elfin" face (SAS with specific psychophysical syndrome), the rest had a normal psyco-physical state without family antecedents (sporadic SAS). 2. The aortic focus was the epicenter of the expulsion murmur. In the phoncarodiographic study, two patients had protosistolic click and another had, in addition, a descending protodiastolic murmur (Int. I-IV). In the radial sphigmograms, one case had an amplitude difference in favor of the right side. 3. All had serum calcium figures within normal limits. 4. A chromosomatic analysis of preperipheral blood was performed on two patients, with normal results. 5. In the electrocardiogram, one case had right ventricular enlargement secondary to pulmonary arterial hypertension, due to stenosis of the main pulmonary arteries. 6. The radiologic study did not show dilatation of the ascending aorta and aortic bud in any case. 7. The angiocardiography showed: stenosis directly above the Valsalva sinuses; absence of dilatation or hypoplasia of the aorta above the stenosis; and the coronary network, indirectly opaqued, showed no abnormalities. One case had aortic coarctation and abnormal implantation of the right sublaviar artery, and another, stenosis of the right and left branch of its origen of the truncus of the pulmonary artery. The literature up to the present is reviewed and an anatomo-functional classification is proposed with the objective of including new varieties.