Cephalad distribution of three differing volumes of new methylene blue injected into the epidural space in adult goats

Epidural anesthesia and analgesia are popular regional anesthetic techniques in many animal species. However, we have not found any reports of studies in animals that have investigated the extent of cephalad migration and level of sensory blockade achieved based only on the volume of drug injected into the epidural space. The purpose of this study was to determine if there is a relationship between the volume (mL/kg) of an injectate injected epidurally and the extent of its cephalad migration within the epidural space. Twelve adult goats were randomly assigned to three treatment groups based on the volume of 0.12% New Methylene Blue (NMB), 0.1, 0.2, or 0.3 mL/kg, injected into the epidural space. The site and speed of injection, animal position, and direction of needle bevel were held constant. All injections were performed at the lumbo-sacral space immediately following euthanasia. At necropsy, the vertebral columns were transected longitudinally. The extent of cephalad migration of dye within the epidural space was easily determined by staining of the dura. Measurements were rounded to the nearest intervertebral space to which the dye had migrated. The individual making assessments was blinded to all treatments. In goats treated with 0.1, 0.2, or 0.3 mL/kg NMB, the number of stained spinal segments was 3.5 +/- 0.6, 6.5 +/- 0.9, and 8.8 +/- 0.6, (mean +/- SEM), respectively. Linear regression performed on the data was significant (P < .05) with R2 = 0.86. There was a strong linear relationship between volume (mL/kg) of epidurally injected NMB and cranial migration, with the larger volumes producing more cephalad spread within the epidural space. These results provide evidence for the volume of epidural injectate needed to produce a desired level of sensory blockade in adult goats.

Retroperitoneal and abdominal wall emphysema after transanal excision of a rectal carcinoma

The use of transanal excision to remove rectal carcinomas is a relatively new application of this surgical procedure, which may require full thickness excision. Retroperitoneal and abdominal wall emphysema are potential complications of surgical procedures that breach the wall of the colon and rectum. Computed tomographic scans provide the clearest diagnostic picture of developing emphysema, and prompt diagnosis through accurate interpretation of the scans is essential to minimize morbidity and mortality. When the diagnosis is made early and no active infection accompanies the emphysema, the preferred approach to initial treatment is nonsurgical. This article presents a case in which local transanal excision was performed on a 70-year-old male to remove a superficial adenocarcinoma from the lower rectal wall. He developed postoperative retroperitoneal and abdominal wall emphysema. Conservative treatment is discussed.

Breast cancer in elderly women: presentation, survival, and treatment options

Recent data suggest that breast cancer in elderly women does not present as more advanced disease, nor is survival significantly inferior to that in younger women. Unfortunately, until recently, older women have been excluded from clinical trials that have determined survival benefit in both screening and treatment modalities. Unless co-morbid conditions adversely affect one's life expectancy or tolerance to therapy, older women should be treated with standard surgical procedures (including breast conservation, if so desired) for early-stage disease, as outcome is comparable to that in younger patients. Adjuvant tamoxifen therapy has proven survival benefit in women over 70 years of age with estrogen receptor-positive tumors and should be considered in all women with tumors greater than 1 cm in size. Older women may experience more chemotherapy-related toxicities. However, for those with a significant risk of recurrence due to tumor size or lymph node status, chemotherapy can be safely administered when factors such as age-related decline in creatinine clearance and co-morbid conditions are considered. Hormonal therapy (tamoxifen) is usually the first-line treatment option over chemotherapy for metastatic disease in the elderly unless the patient has an estrogen receptor-negative tumor, visceral-dominant disease, or significant disease-related symptoms. In the latter settings, chemotherapy can provide improved or more rapid response proportions but does not affect long-term survival.

The current role of prophylactic mastectomy

Prophylactic mastectomy has a role in preventing breast cancer in the woman at high risk. The rare indications for this operation are based on genetic and histologic factors that affect relative or cumulative risk. Evaluation of women at high risk must draw on multidisciplinary expertise, including genetic counseling. If prophylactic mastectomy is recommended, skin-sparing total mastectomy (not subcutaneous) with autogenous tissue reconstruction is the preferred approach.

Inflammatory breast cancer

Multimodal therapy with induction chemotherapy has improved significantly local disease control and overall survival in patients with IBC. This is now considered standard therapy for patients with this disease. Although survival has been improved, well over 50% of these patients will succumb to this disease. Ongoing and future investigations may better define the optimal approach for local control, the optimal duration of maintenance chemotherapy, and the possible role of biologic response modifiers and growth factors in further improving the outcome for patients with this disease.

Complete intraoperative small-bowel endoscopy in the evaluation of occult gastrointestinal bleeding using the sonde enteroscope

OBJECTIVE

To review our experience with intraoperative small-bowel Sonde enteroscopy in evaluating occult bleeding in the small intestine.

DESIGN

Retrospective study with 100% follow-up.

SETTING

University-affiliated, tertiary-care teaching hospital.

PATIENTS

Sixteen consecutive patients referred with occult gastrointestinal bleeding in whom esophagogastro-duodenoscopy , push enteroscopy, and colonoscopy had failed to identify the source of bleeding. Fourteen of the 16 patients had required one or more transfusions.

MAIN OUTCOME MEASURE

Completeness of visualization, diagnostic accuracy, and complications of the procedure and follow-up for recurrent bleeding.

RESULTS

In all 16 patients, intraoperative Sonde enteroscopy allowed visualization of the entire small bowel. In 14 of the 16, it revealed the cause of bleeding, which was ileal angiodysplasia in three patients, ileal ulcers in six patients, neoplasia in two patients, and ileal ulcers caused by Crohn's disease, small-intestinal enteropathy and varices caused by portal hypertension, and radiation stricture in one patient each. Two patients had normal small bowel mucosa. The patients with mucosal disease underwent small-bowel resection or oversewing of bleeding sites. Two surgical complications occurred: prolonged postoperative ileus (one patient) and small-bowel obstruction that resolved without surgery (one patient). Two of the patients with angiodysplasia had recurrent bleeding postoperatively.

CONCLUSIONS

Intraoperative Sonde enteroscopy is safe and effective in localizing small-intestinal bleeding sites, providing complete visualization of the small-bowel mucosa without enterotomy while avoiding the trauma that can be caused by push endoscopy. It is the diagnostic assessment of choice in selected patients with occult gastrointestinal bleeding of presumed small-bowel origin.

Salt-resistant hypertension in mice lacking the guanylyl cyclase-A receptor for atrial natriuretic peptide

Around half of all humans with essential hypertension are resistant to salt (blood pressure does not change by more than 5 mm Hg when salt intake is high), and although various inbred strains of rats display salt-insensitive elevated blood pressure, a gene defect to account for the phenotype has not been described. Atrial natriuretic peptide (ANP) is released from the heart in response to atrial stretch and is thought to mediate its natriuretic and vaso-relaxant effects through the guanylyl cyclase-A receptor (GC-A). Here we report that disruption of the GC-A gene results in chronic elevations of blood pressure in mice on a normal salt diet. Unexpectedly, the blood pressure remains elevated and unchanged in response to either minimal or high salt diets. Aldosterone and ANP concentrations are not affected by the genotype. Therefore, mutations in the GC-A gene could explain some salt-resistant forms of essential hypertension and, coupled with previous work, further suggest that the GC-A signaling pathway dominates at the level of peripheral resistance, where it can operate independently of ANP.

What is your diagnosis?

Images

Studies in transgenic mice reveal potential relationships between secretin-producing cells and other endocrine cell types

We have produced transgenic mice expressing fusion genes consisting of 1.6 kilobase pairs of the secretin gene 5' flanking region to direct the expression of human growth hormone (hGH) or simian virus 40 large T antigen to secretin-producing cells. Analysis of different mouse tissues for hGH transcripts revealed expression in each of the major secretin-producing tissues, namely the intestine and endocrine pancrease. Multiple label immunohistochemistry demonstrated that the transgene was correctly directed to secretin cells in the intestinal tract, including a previously unrecognized population of secretin cells in the colon of adult and developing mice. In the small intestine, subpopulations of hGH-containing cells frequently coexpressed substance P, serotonin, and cholecystokinin, whereas in the colon, cells expressing hGH frequently coexpressed glucagon, peptide YY, or neurotensin. Transgenic mice expressing large T antigen in secretin cells developed poorly differentiated neuroendocrine tumors of the small intestine, well differentiated colonic tumors containing glucagon-expressing cells, and insulin-producing tumors in pancreas. These studies indicate that the major cis-regulatory sequences necessary for secretin expression in enteroendocrine cells and fetal islets are localized with 1.6 kilobase pairs of the transcriptional start site. Coexpression of reporter transgenes with several gastrointestinal hormones suggests a potential relationships between secretin cells and other enteroendocrine cell types, as well as pancreatic beta cells.

Total pelvic exenteration. A 50-year experience at the Ellis Fischel Cancer Center

OBJECTIVE

To review a 50-year experience with total pelvic exenteration for treatment of advanced pelvic cancer.

DESIGN

Retrospective study with 100% follow-up.

SETTING

Cancer hospital.

PATIENTS

Two hundred thirty-two patients referred for treatment of advanced pelvic cancer who underwent total pelvic exenteration.

MAIN OUTCOME MEASURES

Rates of operative mortality, complications, recurrence, and 5-year survival.

RESULTS

The morbidity rate was 45%. The operative death rate was 14% during the 50-year period, but decreased from 16.8% in the first three decades to 10% thereafter. Eighty-nine patients (38%) had recurrences. The overall 5-year survival rate was 42%.

CONCLUSIONS

Operative mortality and morbidity have declined over 50 years, largely because of proper patient selection, increasing experience, and advances in perioperative care. Exenteration has a major role in the treatment of advanced pelvic cancer.

Multidisciplinary treatment of biliary tract cancers

Ninety-six patients referred for radiation therapy to Washington University affiliated institutions with tumors of the extrahepatic biliary tree form the basis of this report. Patients were examined with regard to demographic factors, tumor primary site, presenting symptoms, methods of diagnosis, and methods of management. The median survival of all 96 patients in this series was 11 months. There was no significant difference between patients with gallbladder cancer and patients with cancer of the biliary ductal system. There was a statistically significant improvement in survival in those patients undergoing resection as management or as a component of the management of their tumors (P = 0.02). Patients receiving > 4,000 cGy of radiation therapy had an improved survival compared to those patients receiving < or = 4,000 cGy of radiation therapy (P = 0.003). While surgical resection improved survival for those patients undergoing removal of all gross tumor, this effect was noted especially in patients with gallbladder cancer.

Nutritional support and prognosis in patients with head and neck cancer

We retrospectively studied the relationship between nutritional status as indicated by the presence or absence of the cutaneous delayed hypersensitivity response and treatment-related morbidity, disease recurrence, and survival at 2 years in 67 consecutive patients with head and neck carcinoma. Serial nutritional assessments were conducted throughout the course of combined initial antineoplastic treatment and nutritional support. The presence of cell-mediated immunity at the end of treatment was associated with a 2-year survival rate of 100%, whereas patients who were anergic at the end of treatment had a 2-year survival rate of 48% (P < 0.01). Morbidity due to surgical therapy and tumor recurrence rates were also higher in the anergic group (P < 0.01). Prognosis in head and neck cancer is based on many factors, but vigorous nutritional support during initial treatment may have some effect on morbidity, tumor recurrence, and survival time.

Role of extended resection in the initial treatment of locally advanced colorectal carcinoma

The focus of this review is the role of extended resection in the initial treatment of primary colorectal carcinoma. About 10% of patients with newly diagnosed colorectal cancer will have locally advanced disease without evident distant or discontiguous intraabdominal metastases. En bloc resection of such tumors, including attached tissues or organs, provides a 5-year survival rate of about 40%, if the microscopic margins are tumor free. As many as 60% of these large tumors are node negative; in this circumstance the 5-year survival rate approaches 70%. These results are achievable when there is a meticulous preoperative and intraoperative search for metastases, a wide anatomic resection, including en bloc lymphadenectomy, is performed, and tumor manipulation is minimized. Blunt separation of structures adherent to the primary tumor should be avoided because adhesions will be neoplastic in about 50% of cases, and cancer recurrence is virtually certain when tumor is transected. The mortality from multivisceral resection, including total pelvic exenteration, should be 10% or less. We emphasize the importance of including these patients in prospective trials to define their optimal adjuvant therapy. There is a disturbing recurring theme in published series, failure to extend the scope of resection in potentially curable patients. The management of these locally advanced lesions typically receives but cursory notice in otherwise highly detailed reviews or textbook chapters. In the present era of emerging multimodality treatment for colorectal cancer, the adequacy of the one most important treatment component--surgical resection--is seldom emphasized. Furthermore, our perusal of the recent literature disclosed no diminution in the incidence of inadequate resection, suggesting that this subject requires more emphasis in postgraduate surgical education.

Indications for prophylactic mastectomy

This article reviews the current state of knowledge regarding factors which put women at highest risk for developing breast cancer and identifies that population we consider as potential candidates for prophylactic mastectomy. Specifically, we focus on the concept of cumulative predisposition and the relative risk assigned to more significant factors that increase a woman's chances of developing breast cancer: family history, proliferative breast histology, and previous cancer in one breast. In addition to outlining the results of reconstruction, the article also examines the controversy surrounding the issue of whether any mastectomy can be truly prophylactic. We conclude with advice to physicians who must counsel women concerned about their breast cancer risk so they can help their patients make fully informed choices.

Pathology and treatment of impalpable breast lesions

With the increasing use of mammography, more needle-localized breast biopsies (NLBB) are being done. The purpose of this study was to analyze the pathology of impalpable breast lesions and the impact of NLBB on treatment strategies. From 1985 to 1990, 1,605 NLBB were performed, of which 321 (20%) were malignant. Twenty-five percent of malignant biopsies demonstrated in situ disease only. The average size of all lesions detected was 16 mm, and, for invasive cancer, 12 mm. Eighteen percent of invasive cancers had metastasized to the axillary lymph nodes. Surgical management consisted of mastectomy in 74% of patients and breast conservation treatment (BCT) in 26%. No significant difference in surgical management for women 50 years of age or younger compared with those older than 50 years of age was noted. Although the use of BCT for eligible women is recommended by the National Institutes of Health, it is not widely practiced, possibly reflecting less physician acceptance of BCT. These observations suggest that the detection of smaller, impalpable breast cancers has had no impact on treatment strategies.

Effects of dantrolene on myoplasmic free [Ca2+] measured in vivo in patients susceptible to malignant hyperthermia

Malignant hyperthermia (MH) is a genetic disease characterized by hypermetabolism in skeletal muscle following a triggering stimulus and can be reversed or pretreated with dantrolene sodium. The myoplasmic free [Ca2+] was measured, using Ca2+ selective microelectrodes in vivo in the superficial fibers of the sartorius muscle of eight MH-susceptible and eight control subjects. Both groups received continuous epidural anesthesia with chloroprocaine 3%. In both the control and MH muscle fibers, the myoplasmic free [Ca2+] was measured before and after the intravenous administration of a cumulative dantrolene dose of 0.5, 1.5, and 2.5 mg/kg. The mean resting myoplasmic free [Ca2+] was 0.112 +/- 0.004 microM (mean +/- SEM n = 32) in the control and 0.485 +/- 0.022 microM (n = 33) in the MH subjects. In the MH subjects, dantrolene induced a dose-dependent reduction in myoplasmic free [Ca2+]. The 0.5-mg/kg dose reduced it to 0.326 +/- 0.017 microM (n = 22), the 1.5-mg/kg dose to 0.233 +/- 0.015 microM (n = 25), and the 2.5-mg/kg dose to 0.092 +/- 0.008 microM (n = 26). In controls, dantrolene also reduced resting myoplasmic free [Ca2+] but to a lesser extent. The 0.5-mg/kg dose reduced it to 0.096 +/- 0.004 microM (n = 22), the 1.5-mg/kg dose to 0.077 +/- 0.003 microM (n = 23), and the 2.5-mg/kg dose to 0.068 +/- 0.002 microM (n = 27). The results of the study extend our previous findings in humans and swine and demonstrate that it is possible to measure myoplasmic free [Ca2+] in vivo in humans.(ABSTRACT TRUNCATED AT 250 WORDS)

Squamous cell carcinoma of the anal canal

Between 1979 and 1988, 33 patients with squamous cell carcinoma of the anal canal were treated with chemoradiation. There were 24 women and 9 men, from 37 to 90 years of age (median: 63 years). Complete tumor regression occurred in 29 of the 33 patients (88%), only one of whom later developed recurrence. In the other four patients, there was persistent tumor after 3 months; three of these patients died within 2 years; and one is alive with distant metastases 2 years later. During the first 5 years of the study, seven patients with complete tumor regression underwent planned abdominoperineal resection following chemoradiation. Four of the abdominoperineal resection specimens were free of tumor, but three were not. These three patients, who had abdominoperineal resection within 3 months of chemoradiation, are disease-free. Ten of the 29 patients who had complete tumor regression had biopsies of the primary site 3 months after treatment. All biopsies were negative for residual carcinoma. At present, 26 patients (79%) are alive and disease-free from 2 to 10 years post-treatment (median: 4 years). Two patients died of unrelated causes, four of cancer, and one is alive with cancer. Complications of the chemoradiation required surgical intervention in two patients, and two others developed severe hematologic toxicity, for a complication rate of 12% (4 of 33 patients). There was no treatment-related mortality. These results support the efficacy of chemoradiation treatment for carcinoma of the anal canal. They suggest that abdominoperineal resection no longer need be part of the planned initial management, and that posttreatment biopsy of the primary site is unnecessary, unless palpable or visible abnormalities are present 3 months after treatment.

Multimodal therapy in locally advanced breast carcinoma

Among 879 patients treated for breast cancer between 1975 and 1984, advanced disease was found in 125 (14%). A subgroup of 34 (4%) presented with untreated locally advanced disease without demonstrable distant metastases at the time of diagnosis (stage IIIB = T4abed, NX-2,MO). During the first 5 years (1975 through 1979), 17 patients were treated primarily with sequential radiotherapy and chemotherapy (Group A). From 1980 to 1984 (Group B), the management consisted of four courses of induction multi-drug chemotherapy followed primarily by mastectomy and additional chemotherapy. The mean follow-up for the most recent group (Group B) is 48 months. Follow-up was complete. While the local disease control rate was the same for both groups (76%), the survival was remarkably different. Group A patients experienced a median survival of 15 months, and only one survived 5 years. In Group B, the median survival was 56 months with nine patients (53%) alive between 40 and 76 months, seven (41%) of whom are 5-year survivors. While the overall mortality of patients with inflammatory breast cancer was greater in both groups when compared with the group with noninflammatory disease, the survival of patients in Group B was better than in Group A for both inflammatory and noninflammatory cancers (p less than 0.01). Estrogen receptor, nodal, and menopausal status did not influence survival. These data suggest that neoadjuvant chemotherapy improves survival for patients with stage IIIB breast carcinoma and delays the establishment or progression of distant metastases. Mastectomy is an important component in the treatment of this disease.

Long-term results of surgical resection of locally advanced colorectal carcinoma

This study was undertaken to review the long-term results of multivisceral resection of locally advanced colorectal carcinoma. Between 1964 and 1980, 1042 patients underwent exploratory surgery for colorectal cancer. Of these, 58 patients (5.5%) underwent curative multivisceral resection for suspected contiguous invasion by the primary tumor. Follow-up was complete for all patients. The primary tumors were located in the rectum (38 patients), sigmoid (9 patients), left colon (6 patients), and right colon (5 patients). En bloc resection of other viscera included uterus, adnexa, bladder, vagina, small intestine, abdominal wall, liver, stomach, kidney, and ureter. The operative morbidity and mortality rates were 31% and 1.7%, respectively. Resection margins were free of tumor in 54 patients. In the four patients with tumor-positive resection margins, recurrence of disease was evident between 8 and 22 weeks after surgery (mean survival time, 8.2 months). Carcinomatous invasion of the resected contiguous organ was confirmed in 49 patients (84%). The mean survival time for patients without lymph node metastases was 100.7 months, but it was only 16.2 months (p less than 0.01) for patients with lymph node metastases. Actuarial 5-year disease-free survival rate for patients without lymph node metastases was 76% (36 of 47 patients). None of the patients (0 of 11) with lymph node metastases survived for 5 years. Three of 36 of the 5-year survivors experienced recurrence of disease before the seventh postoperative year; no cancer-related deaths occurred between 7 and 25 years. These data suggest that survival in locally advanced colorectal carcinoma is more dependent on lymph node status than on the extent of local invasion. Effective disease control associated with survival in the long term can be achieved by multivisceral resection.

Current management of primary breast cancer. Part II: Adjuvant therapy and management of stage III disease and in-situ carcinoma

In the second of two parts, the authors discuss adjuvant therapy, treatment of locally advanced breast cancer, and management of carcinoma in situ. In last month's issue, the aspects of screening, staging, diagnosis, and treatment of early breast cancer were presented.

Current management of primary breast cancer. Part I: Screening, diagnosis, staging and local treatment of stage I and II disease

In the first of two parts, the authors present an overview of screening, staging, diagnosis, and treatment of primary breast cancer. In next month's issue, the aspects of adjuvant therapy, treatment of locally advanced breast cancer, and management of carcinoma in situ will be presented.

Breast cancer detected by screening: the importance of long-term follow-up

This study updates a 10- to 15-year follow-up of 136 patients with breast cancer among 10,187 symptom-free participants in a screening program. Mammography was the sole detection modality in 76 (56%) patients. The combination of mammography and physical examination revealed 41 (30%) cancers, whereas 19 (14%) were detected on physical examination alone. There were 26 (19%) noninvasive and 110 (81%) invasive neoplastic lesions. Positive axillary nodes were found in 34 (25%) patients, and 102 (75%) patients had negative nodes. For the entire group 5- and 10-year survival rates were 84.5% and 75%, respectively. After a minimum follow-up of 10 years and a median of 13.5 years, 102 patients are alive; one of these has a recurrence of cancer. Among the 34 patients who are no longer living, 14 died of causes unrelated to breast cancer. Two patients in the group in which diagnosis was based on mammography alone died of breast cancer, for a breast cancer-related fatality rate of 2.6% (2/76). By contrast, the breast cancer-related mortality of patients whose tumors were palpable at the time of detection was 30% (18/60) (p = 0.00001). This study suggests that long-term survival of patients whose breast cancer is detected by screening is, in large measure, dependent on the ability to detect malignant lesions before they become palpable.

Carcinoma of the anal region

Preservation of anorectal function makes chemoradiotherapy attractive as the primary treatment in patients with squamous cell carcinoma of the anal region. Despite variations in techniques of chemoradiotherapy administration, the accumulated experience of a number of institutions indicates substantial improvement over previous approaches, which included surgery or radiation therapy individually. Although no longer providing the definitive therapeutic role in this disease, the surgeon is frequently asked to evaluate lesions suspected of being anal malignancies. In addition, it is the surgeon who most often performs the diagnostic biopsy, consults on local complications of chemoradiotherapy, and manages complications of local recurrence. In this context, optimal care includes early organization of the medical oncologist, radiation therapist, and surgeon to participate in the initial diagnostic evaluations, examinations with the patient under anesthesia, and follow-up during therapy. A complete response is often not evident until 2 to 3 months after treatment. We recommend a follow-up schedule of monthly visits for the first 6 months, examinations every 3 months for the next 2 years, and assessment every 6 months thereafter. Evaluation during early routine visits includes manual and proctoscopic examination of the perineum and rectum and review of the hemogram and liver enzyme levels in the serum. CT, MRI, or lower endoscopy procedures are performed only if clinical examination or studies suggest the possibility of recurrence or a second primary tumor. Patients with an incomplete response to therapy after 3 months often undergo examination under anesthesia with biopsy of suspect areas. Chronic inflammatory changes in the area of previous carcinoma may be interpreted as persistent disease. Thus histologic proof of recurrent malignancy must be obtained before considering surgical or chemoradiotherapy salvage treatment.

Primary carcinoma of the gallbladder: TNM staging and prognosis

In order to investigate the lethality of carcinoma of the gallbladder and several of the coexisting features, a retrospective analysis of 53 patients with this disease was undertaken. Abdominal pain, obstructive jaundice, and a right upper quandrant mass were present in approximately one-half of the patients. Laboratory and radiological data were frequently nonspecific and did little to identify the diagnosis. The most common preoperative diagnoses were cholelithiasis or chronic cholecystitis. Cholecystectomy was the most frequently performed procedure. Fifteen wedge liver resections were performed. No radical or extended liver resections were done. Eighty-one percent of the patients had sufficient data for staging. Five patients (11.6%) had stage I lesions, three patients (7.0%) had stage II lesions, while 17 (39.5%) and 18 (41.9%) patients had stage III and IV lesions, respectively. Mean survival was 6.4 months for the entire group. Three patients are still alive (two longer than 5 years and one at 2 years) for an overall survival of 5.7%. Both staging and grading of the tumor correlated well with patient survival. Those patients with stage I lesions survived significantly longer (23 months vs. 3 months) than those with stage IV tumors. Also, those with more favorably graded (well-differentiated) neoplasms lived an average of 13 months longer than patients with poorly differentiated lesions.