Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma

BACKGROUND

Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series.

METHODS

One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months.

RESULTS

Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 +/- 14.9 months) than in nonreoperated cases (3.2 +/- 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively).

CONCLUSIONS

Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Transaxillary access to perform hepatic artery infusion (HAI) for secondary or primitive hepatic tumors

There is a renewed interest in locoregional chemotherapy for hepatic tumors; trials in progress are experimenting with new therapeutic protocols with an approach combining different systems of infusion (HAI and systematic) or with the use of HAI as adjuvant or neoadjuvant of the surgical treatment or cryosurgical treatment of the hepatic metastases from colo-rectal cancer. However, HAI is practicable principally with the implantation of a catheter in the hepatic artery (port of Infusaid) by laparotomic access. This intervention limits wide-scale use of the infusion method, traditionally less toxic and more efficient in terms of results than systemic treatment. Limited experience of percutaneous access for HAI required more catheterisation with repeated puncturing of the artery and later necessity of surgery in cases of HAI with continuous spraying. Motivated by the first experience of certain authors from Chiba University, we have devised a system of catheterisation of the hepatic artery with transcutaneous access, with subcutaneous port that allows the use of HAI without recourse to the usual intervention. Access is made through the left axillary artery; the positioning of the catheter is in the hepatic artery with possible embolization of the collateral or abnormal hepatic artery that could hamper complete diffusion of the drug to the liver, or increase to toxicity of the method. The implantation is done in day-surgery. In the cases performed up to now there have been no complications regarding the method and the catheters function all perfectly thanks to the collaboration of ematologists to avoid possible thrombosis of the catheters.

[Advances in the treatment of gastroesophageal reflux. Intraoperative calibration of posterior fundoplication]

Posterior partial fundoplication can be as effective as total fundoplication in the long-term control of gastroesophageal reflux if the gastric fundus valve is encircled around the distal esophagus for no less than 270 degrees to obtain effective pressures in the newly built sphincter. In order to minimize the adverse effects, to reach constant results and to guarantee the reproducibility of the technique we have modified the 270 degrees posterior fundoplicatio (formerly described by Lind) according to the following principles: 1) the length of the gastric valve must be limited to 3 cm for each side of the esophagus; 2) the gastric valve must be fixed to the right and left side of the hiatal orifice by a single stitch; 3) the gastric valve must be calibrated with an intraoperative manometry, this allowing the standardization of the valve pressure to an average value of 35 mmHg by varying its wrapping angle; 4) the hiatal orifice must not be closed unless it is large enough for thoracic migration of the gastroplasty. Since 1984 to 1991 43 patients with proven gastroesophageal reflux not controlled by medical treatment were submitted to surgery. Twelve Nissen procedures (NP) and 31 posterior calibrated fundoplications (PCF) were performed; PCF seemed to be superior to NP in terms of postoperative mobility. After two years 20 patients treated with PCF were evaluated clinically, manometrically and by 24-hour pH monitoring. No dysphagia was reported; in two patients a pH-metric, asymptomatic relapse was observed, while one patient complained mild and occasional heartburn.(ABSTRACT TRUNCATED AT 250 WORDS)

[Villous adenoma of the rectum. Review of the literature and personal experience]

Potential malignancy of rectal villous adenomas is referred as varying from 20 to 30%; an appropriate surgical excision is required in order to insure an effective cancer prophylaxis and to improve the accuracy of the pathologic assessment. The Authors review their series concerning 15 patients with one or more polyps of villous type, located at the lower third of the rectum and with precise indications for transanal excision. In 13 cases histology demonstrated the presence of an adenoma with different grade of dysplasia, which simply entered a follow-up together with a case of an adenoma with carcinoma in situ. The latter, because of the presence of invasive carcinoma, underwent radical surgery. No postoperative morbidity was observed. Recurrence rate was 8%. After an accurate review of the Literature, a radical management of the rectal villous tumour performed on routine basis seems unjustified. The Authors suggest the indication for a modern proceeding.

[Evaluation of the effect of flunitrazepam on the lower esophageal sphincter in man with intraluminal manometry]

The effect of Flunitrazepam on the human lower oesophageal sphincter is evaluated. Pressure in the LOS and GOR using the Acid Reflux Test was evaluated in 22 surgical cases at rest (after ingestions of a placebo and Flunitrazepam). The results obtained indicate that the LOS pressure variations induced by flunitrazepam significantly increase the probability of GOR.

[Retrosternal thyroid cancers. Considerations on 25 cases]

Intrathoracic thyroid cancer is an unusual finding, and few reports are available on this item. Literature data have been reviewed, and some considerations on epidemiologic characteristics of the disease and on its treatment were gained from an analysis of reports based on the files of I Surgical Clinic of the University of Turin, Surgical service of the Oncological Department of the S. Giovanni Battista Hospital and II Pathological Anatomy Service of the University of Turin. No correlation was found between previous thyroid disease, sex, histological findings, previous radiotherapy and incidence of the disease. Older age at the onset and recurrent laryngeal nerve lesions are frequently associated with intrathoracic thyroid cancer; papillary carcinoma is rarely found. Intrathoracic situation is not likely, in Author's opinion, to affect the long term prognosis more than usual risk factors.

Presence and characterization of prolactin receptors in human benign breast tumours

Prolactin receptors have been determined in 64 benign breast tumours. A specific binding of 0.5% or more (with a range of 0.5-3.3%) was found in 34.4% of the cases and was considered prolactin-receptor-positive. The binding was found to be specific only for lactogenic hormones. By Scatchard analysis the dissociation constant was 2.55 X 10(-10) mol/l and the binding capacity was 4.6 fmol/mg protein.

[Initial immunologic evaluations in breast and thyroid cancer]

In evaluating pre- and post-operative immunological status of 15 patients with malignant breast and thyroid tumors and of 9 patients with benign breast and thyroid lesions, rosette E test, CEA, cortisol, immunocomplexes and determination of circulating leukocytes, B lymphocytes and immunoglobulins was employed. The obtained data were not significative to show a lack of immune response in tumor bearing patients. Among the reexamined parameters, CEA was the only one that apparently correlated with prognosis; its serum levels, being at a high rate in a high percentage of malignancies, tended to fall down after surgical treatment.

[Cytostatic therapy of metastatic breast cancer]

As complete as possible a picture of the current state of cytostatic chemotherapy in the treatment of metastatic breast carcinoma is offered. Attention is therefore mainly concentrated on application modalities of this form of therapy in relation to the clinical stage of the disease and to the use of other treatment possibilities. Methods and results of cytostatic therapy are then considered. The present situation is reviewed and the pharmacological and toxic aspects of prolonged antiblastic treatment are assessed. After outlining a number of special problems relating to the treatment of CNS and pleural metastases, the personal series is presented and results, which do not differ from other reported series, reported. In conclusion, stress is laid on the importance and effectiveness of cytostatic therapy in the treatment of metastatic breast carcinoma, but extended, controlled studies are also recommended.

[Antiprolactin therapy in the treatment of benign lesions of the breast. Comparison of bromocryptine and methergoline]

The Authors have treated 11 patients with benign breast diseases (fibroadenosis or fibrocystic disease) with two prolactin inhibitor drugs -- metergoline and bromocriptine -- at the dose of 8 mg/die and 7,5 mg/die respectively for sixty days with a 30 days interval from one to the other. All patients, except one, had normal serum prolactin levels before the trial; during the treatment with metergoline no long-term changes in serum prolactin levels were observed; on the contrary, bromocriptine reduced significantly prolactin values for the whole duration of the therapy. Negative clinical results were obtained with the first drug, while bromocriptine allowed to reach an 80% of positive results at the end of the trial. Coming from previous experience, the Authors conclude that the positive therapeutic effect of bromocriptine treatment is connected with the maintenance of prolactin reduction.

Treatment of benign breast disease with bromocriptine

23 women with benign breast disease (fibrocystic disease or fibroadenosis) were treated for three months consecutively with a prolactin inhibitor drug, bromocriptine, at the dose of 2.5 mg every eight hours. Serum prolactin levels were normal before treatment; during treatment prolactin concentrations were significantly suppressed all the day long. 21 out of 23 patients receiving bromocriptine showed marked relief to pain and mammary tension after a few days of treatment; adenomatous of cystic nodules became smaller and softer, often with disappearance of the smaller ones. Two patients failed to respond to treatment. In all positive cases the improvement persisted for at least six months after the end of treatment. No important side effects were observed during the therapy. Our results do not allow any conclusion on the real mechanism of action of bromocriptine in benign breast disease, nevertheless they indicate the possible usefulness of this drug in treating patients with benign breast disease.

[Preliminary results of treatment of hormone-dependent metastatic carcinoma of the breast with the bromocriptin-medroxyprogesterone acetate combination]

A brief account of the concept of hormone dependence in breast neoplasia is followed by the presentation of results obtained with an association of medroxyprogesterone acetate (MAP) and 2-bromo-alpha-ergocriptine (CB 154) in 14 women with metastatic cancer of the breast, hormone dependent due to the presence of the cytoplasmic receptor for 17-beta-oestradiol. All patients, in fertile or premenopausal stage, were subjected to prior surgical ovariectomy. MAP was given i.m. at a dose of 1 g/day for 30 days and then 150 mg/day. In the same time 2.5 mg CB 154 were administered every 6 hr per os. Evaluation in accordance with the criteria proposed by the Coop Breast Cancer Group showed that rapid improvement was obtained in all cases, persisting (at the time of writing) for a minimum of 6 months to a maximum of 2 yr of observation. In addition, rapid disappearance of pain was noted, particularly in subjects with secondary bone lesions. Side-effects were in all cases of slight consequence and suspension of the treatment was never necessary. The mechanism of the two drugs and the advantages of their association are discussed.

[Computer study of the anatomo-clinical characteristics of breast carcinoma. II]

Data relating to the major and minor clinical features of breast cancer were examined in 200 cases and correlated to obtain an overall picture of the objective picture. The classic pattern was present in most cases. Some data, such as patient occupation and the extent of lymph node invasion expressed different meanings, while various parameters led to dubitative conclusions.

[A roentgenologic study on metoclopramide in the vagotomized rat]

After a brief description of the central pharmacodynamic action of metoclopramide, the results of an investigation in two groups of rats of the same age, sex, and weight are reported. The first group was subjected to vagotomy, whereas the second consisted of normal animals. The experiment consisted of two stages. During the first part of the experiment control roentgenograms were taken at fixed intervals after a barium solution had been introduced into the stomach of the animals (both normal and vagotomized). Later, the experiment was repeated after the intravenous or intramuscular administration of 5 mg of metoclopramide. A positive action of Plasil on the gastro-intestinal motility was confirmed in the normal rat, as was the negative action of the drug in the vagotomized animal. An effective action of the drug on the gastro-intestinal system thus depends on the integrity of the efferent parasympathetic paths; this is probably also related to species differences.