Blood-borne spread of a benign giant cell tumor from the radius to the soft tissue of the hand

A unique case of giant cell tumor of the distal epiphysis of the radius that spread to the soft tissue of the hand after an en bloc excision is reported. Three months after the excision, 27 cutaneous-subcutaneous tumoral nodules, ranging from 0.3 to 1.5 cm in diameter, were observed spreading from wrist to fingers on both hand aspects. Microscopically, the tumor tissue displayed the pattern of a benign giant cell tumor. Multiple tumor tissue emboli were lodged in venules of the soft tissue between nodules and in a small vein. The findings suggest that the tumor emboli arrived at the hand through a mechanism of retrograde embolism through the superficial veins.

Analysis of failure following curative irradiation of gallbladder and extrahepatic bile duct carcinoma

Twenty patients with carcinoma of the gallbladder (GB-4 patients) or extrahepatic bile ducts (EHBD-16 patients) received radiation therapy with curative intent between January, 1980 and December, 1982. All 20 received 4500-5000 rad in 180-200 rad fractions to the tumor and regional lymph nodes. A 1000 to 1500 rad external beam boost was delivered in 180-200 rad fractions in 10 patients who received external beam alone or concomitant 5-Fluorouracil (5-FU). Three of the four GB and 5 of the 16 EHBD patients received a transcatheter boost with 192-Iridium (192Ir) to a dose of 2000-2500 rad calculated at a 0.5-0.1 cm radius. An additional 2 patients with EHBD lesions received an intraoperative electron (IORT) boost of 1500-2000 rad in one fraction calculated to the 90% isodose. Survival and patterns of failure were analyzed by site and treatment method. All four patients with GB carcinoma are dead of disease at 5 1/2, 6, 9 and 10 months from the date of diagnosis respectively. Three of the four developed diffuse peritoneal carcinomatosis. Five of the 16 patients with EHBD carcinoma are alive with a median follow-up of 18 months (range 6-23 months). Four of the 5 patients received a transcatheter 192Ir or IORT boost and all are without evidence of disease. Four of 9 patients who had a subtotal resection with transection of tumor, dilatation of the bile ducts with probes or curettement of the bile ducts developed either diffuse peritoneal carcinomatosis (3 patients) or a recurrence in the surgical scar (2 patients). Local failure was documented in 3 of the nine patients treated with external beam alone +/- 5-FU, and has been documented in one of the seven patients who received an IORT or transcatheter 192Ir boost. Further experience is necessary to determine whether this aggressive treatment will result in long-term disease-free survival in these patients.

Intraoperative radiation therapy for bladder cancer

The combination of intraoperative radiation therapy and external beam irradiation, a new treatment modality, has been added to the therapeutic armamentarium in the management of patients with bladder cancer. Encouraging results are seen when this combination is utilized for patients with superficial (Tis, T1, T2) bladder cancer. With more experience, the specific indications of this combined treatment modality will be identifiable.

Intraoperative and external beam irradiation with or without resection: Mayo pilot experience

At our institution, intraoperative radiation therapy (IORT) with an electron beam has been administered as a single boost dose of 1,000 to 2,000 cGy (rad) in combination with 4,500 to 5,000 cGy (rad) of fractionated external beam irradiation. From April 1981 to July 1983, 50 patients received such treatment, and results are analyzed in detail in this article. All patients had locally advanced disease (initially unresectable for cure, residual after resection, or recurrent), and the main disease sites were gastrointestinal (pancreatic, colorectal, and biliary tumors) and soft tissue (sarcomas). Disease-free survival to date has been excellent in our colorectal and biliary subsets of patients. Although local progression has not been a major problem in patients with unresectable pancreatic lesions, failures in the liver and peritoneal cavity have been excessive, and treatment strategies have been altered in an attempt to decrease the frequency of such failures. Although both short-term and long-term morbidity are acceptable, pilot trials with use of radiation-dose modifiers are planned to determine whether the therapeutic ratio of local control to associated complications can be improved even further.

Advanced prostatic adenocarcinoma: biological aspects and effects of androgen deprivation achieved by castration or agonistic analogues of LHRH

Twenty-nine patients with advanced prostatic adenocarcinoma were evaluated clinically, biochemically and radiologically and randomly assigned either to orchiectomy or to medical treatment. The latter consisted of the chronic administration of an LHRH agonistic analogue by parenteral and/or intranasal routes. Plasma testosterone levels fell to castrate values and remained so for as long as the follow-up lasted (24 months); estrogen levels fell as well. No change in basal cortisol, thyroxine or prolactin levels was noticed. A decrease in prostate size and improvement in prostatism occurred in all. Bone pain and radiology conventionally or by isotopic scanning, did not parallel the improvement seen in the primary disease locus. Similarly, the changes in alkaline phosphatase were minimal when compared to that of prostatic acid phosphatase. Both enzymes increased prior to or concurrently with relapse of the disease. The longest remission and survival was seen in patients with low enzyme levels, non diffuse bone metastases and high degree of tumor differentiation. Chronic use of agonistic analogues of LHRH induces effective castration in men with prostatic carcinoma and can replace orchiectomy or estrogen administration. The quantitative analysis of androgen receptors (AR) in subcellular fractions of tumor cells; the use of techniques to enhance the number of AR in the cytosol; and the determination of the type II/I regulatory subunit of protein kinase may be used to identify hormone independent clones and spare patients of unnecessary procedures.

The current status of drug development of hypoxic cell radiosensitizers and their potential role in gynecologic oncology

Both laboratory and clinical data suggest that hypoxia contributes to the failure of radiotherapy to achieve local control of bulky gynecologic tumors. As part of a Phase I trial of hypoxic cell radiosensitizers, 19 women at Stanford University with advanced (n = 6) or recurrent (n = 13) pelvic neoplasms were treated with radiotherapy plus desmethylmisonidazole. Complete or partial response occurred in 42% of patients with some patients achieving local control for over 1 year. It is unknown if the sensitizer added to the results of radiotherapy alone. A Phase I trial of a theoretically superior sensitizer, SR-2508, is soon to begin. It is anticipated that the dose-limiting neurotoxicity seen with misonidazole and desmethylmisonidazole will either be eliminated or will occur at a much higher total dose of drug. Many patients with gynecologic tumors could potentially benefit from participation in the new drug trials.

Normal reference-intervals for 20 biochemical variables in healthy infants, children, and adolescents

We determined normal reference values from data on sera of 2099 outpatient children (ages one week to 14 years) at our institution. Using a continuous-flow instrument (SMAC, Technicon), we determined the following analytes in each serum sample: glucose, creatinine, uric acid, inorganic phosphorus, sodium, potassium, chloride, total CO2, iron, cholesterol, triglycerides, total protein, albumin, total bilirubin, creatine kinase, lactate dehydrogenase, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and calcium. The resulting data were coded and subsequently processed in an IBM 370 computer, and the reference values (3rd and 97th percentiles) were defined for each analyte. A two-way analysis of variance was also done to determine the influence of age and sex on results of these 20 biochemical tests.

Normal reference-intervals for 20 biochemical variables in healthy infants, children, and adolescents

We determined normal reference values from data on sera of 2099 outpatient children (ages one week to 14 years) at our institution. Using a continuous-flow instrument (SMAC, Technicon), we determined the following analytes in each serum sample: glucose, creatinine, uric acid, inorganic phosphorus, sodium, potassium, chloride, total CO2, iron, cholesterol, triglycerides, total protein, albumin, total bilirubin, creatine kinase, lactate dehydrogenase, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and calcium. The resulting data were coded and subsequently processed in an IBM 370 computer, and the reference values (3rd and 97th percentiles) were defined for each analyte. A two-way analysis of variance was also done to determine the influence of age and sex on results of these 20 biochemical tests.

A multiple-site perineal applicator (MUPIT) for treatment of prostatic, anorectal, and gynecologic malignancies

Recently, transperineal interstitial-intracavitary applicators have been used to treat locally limited and advanced perineal and gynecologic malignancies. We have developed a single afterloading applicator, referred to as the "MUPIT" (Martinez Universal Perineal Interstitial Template), which with its prototypes has been utilized to treat 78 patients with malignancies of the cervix, vagina, female urethra, perineum, prostate, and anorectal region. The device basically consists of two acrylic cylinders, an acrylic template with a predrilled array of holes that serve as guides for trocars, and a cover plate. Some of the guide holes on the template are angled outward to permit a wide lateral coverage without danger of striking the ischium. The cylinders have an axial hole large enough to pass a central tandem or a suction tube for the drainage of secretions. Thus, the device allows for the interstitial placement of 192Ir ribbons as well as the intracavitary placement of either 137Cs tubes or 192Ir ribbons. In use, the cylinders are placed in the vagina and rectum and then fastened to the template, so that a fixed geometric relationship among the tumor volume, normal structures, and source placement is preserved throughout the course of the implantation. Hollow, closed-end, stainless steel trocars are then inserted through the guide holes that produce optimal coverage of the treatment volume. Appropriate computer programs also have been developed on a minicomputer for the corresponding dose-rate computations. These programs run with sufficient speed that they may be used for both the planning of the source placement beforehand and the computation of the actual dose-rate distribution obtained. The advantages of the system are (1) greater control of the placement of sources relative to the tumor volume and critical structures owing to the fixed geometry provided by the template and cylinders, and (2) improved dose-rate distributions obtained by means of computer-assisted optimization of the source placement and strength during the planning phase.

The effect of postoperative and primary radiation therapy on delivered dose of adjuvant Cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemotherapy in breast cancer

The dose of adjuvant chemotherapy for breast cancer may be an important factor in the success of the treatment program. In a retrospective analysis, the authors determined whether patients who were irradiated either postoperatively (N = 29) or as part of primary treatment (N = 13) received a lower dose of adjuvant cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemotherapy than patients who were not irradiated (N = 42). The 84 evaluable patients received either cyclical or weekly CMF. Radiation therapy included the chest wall or breast and regional lymph nodes. The mean percentage of maximum chemotherapy dose delivered (59.9% versus 73.5%; P less than 0.001), mean percent prescribable or theoretical maximum dose (83.1% versus 91.3%; P less than 0.001), and mean leukocyte count (3.9 versus 4.5; P less than 0.01) during therapy were statistically significantly lower in irradiated patients. The lower delivered chemotherapy dose in irradiated patients was not related to the radiation dose to the thoracic spine. The authors conclude that radiation therapy to the chest wall or breast and regional lymph nodes reduces the dose of adjuvant CMF that can be delivered.

Analysis of cosmetic results and complications in patients with stage I and II breast cancer treated by biopsy and irradiation

Between May, 1973 and December, 1980, 78 Stage I and II breast carcinomas in 76 patients were treated by biopsy and radiotherapy with curative intent. With a maximum follow-up of 10 years, a minimum of 2 1/2 years and a median follow-up of 3 1/2 years, a loco-regional control rate of 97% was obtained. Cosmetic results and treatment complications were studied. Patient characteristics, tumor size, excisional biopsy technique, axillary staging procedure and radiotherapy techniques were analyzed and all found to be important factors affecting cosmesis and complications. The most common complications included transient breast edema observed in 51% of patients, breast fibrosis (usually mild) seen in 23% of the population, axillary hematoma or seroma formation in 15%, mild arm edema in 14% and basilic vein thrombosis in 10% of patients. The causes of these and other less frequent complications are discussed. The overall cosmetic result was excellent in 78%, satisfactory in 18% and unsatisfactory in 4% of patients. Recommendations for improving cosmetic results minimizing complications are made. In our prospective trial, the high loco-regional control and good cosmesis supports the use of excisional biopsy and radiation therapy in patients with Stages I and II breast carcinoma.

The use of para-aortic radiation therapy based on lymphangiogram interpretation in uterine cervical carcinoma

From January, 1965, to June, 1979, 79 nonrandomized patients with carcinoma of the uterine cervix had a bipedal lymphangiogram (LAG) prior to radiotherapy at the Stanford University Medical Center. In 32 patients the LAGs were interpreted as normal. Of the remaining 47 patients, 28 had LAGs interpreted as positive for metastatic involvement of pelvic nodes alone, 11 as positive for pelvic and para-aortic (PA) metastasis, and 8 as positive in PA nodes alone. Five-year survival and freedom from relapse (FFR) were found to be similar for patients with LAGs interpreted as normal or positive in pelvic nodes only (all stages combined). The addition of elective PA irradiation in those patients with positive pelvic nodes alone (median 5000 rad/5 weeks) did not enhance either survival or FFR in this group. The 19 patients with positive PA nodes had significantly worse survival and FFR when compared with the other groups. Survival was not enhanced by the addition of therapeutic PA irradiation (median 5000 rad/5 weeks) and the 7 patients in this group so treated appeared to have a reduced FFR when compared to the 12 untreated patients. Irrespective of the location of nodal abnormality on LAG and regardless of stage, the majority of relapses (16/23) occurred either centrally or at the pelvic sidewalls. It is concluded that the LAG is a good predictor of subsequent relapse and survival, but that the addition of either elective or therapeutic PA radiotherapy based on LAG interpretation does not affect survival of FFR and should, therefore, be considered for investigational or palliative use only.

Adenocarcinoma of the endometrium. Analysis of 256 cases with disease limited to the uterine corpus: treatment comparisons

Between 1959 and 1975, 256 patients with pathologic Stage I uterine adenocarcinoma were treated at Stanford University Hospital, Stanford, California. One hundred ninety-three patients were initially treated with surgery, and 63 received preoperative radium, reflecting different treatment philosophies of physicians operating at Stanford. Relapse rates for the two treatment groups were 9% (17 of 193) and 14% (9 of 63), respectively (P = 0.24). In both groups of patients, relapse rates were correlated with grade, although for those treated with initial surgery myometrial invasion was a much better predictor of relapse. Only one of the 127 patients without demonstrable myometrial invasion suffered a possible relapse. Sixteen of 66 patients with myometrial invasion (24%) relapsed after treatment. A review of the histologic material revealed 26 of 256 cases with a special histologic variant termed uterine papillary serous carcinoma, which was associated with a high relapse rate (50%) and a marked tendency for upper abdominal spread. It was found that the use of preoperative intracavitary radium was not demonstrated to be of value. Histologic information obtained from the hysterectomy specimen can be used to determine patients at high risk for relapse who may benefit from adjuvant treatment based on our understanding of the natural history of endometrial carcinoma.

Survival, prognostic factors, and relapse patterns in uterine cervical carcinoma

Between 1965 and 1979, 295 evaluable patients were treated with radiotherapy and/or surgery for invasive cervical carcinoma at the Stanford University Medical Center. The records of these patients were analyzed retrospectively with regard to survival, possible prognostic factors of freedom-from-relapse, and relapse patterns. Survival for the entire population at 5 years was 67%, with a median follow-up of 5 years. Five-year freedom-from-relapse (FFR) rates for stages I-IV were 88%, 61%, 33%, and 11%, respectively. Eighty-eight percent of all relapses occurred within 5 years. Several possible prognostic factors of FFR--including stage, histology, tumor differentiation, lymphangiogram status, treatment modality, age, presence of cervical stump, and initial serum hemoglobin value--were evaluated with a multivariate analysis. Stage was the best predictor of FFR, and lymphangiogram (LAG) status was the next most important covariate: 13 of 19 patients who showed involvement of paraaortic nodes on LAG relapsed within 1 year. There was no difference in survival or FFR between adenocarcinoma or squamous cell histologies. FFR in stage IB patients was independent of treatment modality; i.e., radiotherapy alone, surgery alone, or combined therapy. Initial serum hemoglobin (less than 12 vs. greater than 12) was not predictive of FFR or survival. Stage for stage, patients over 57 years of age tended to have better FFR than younger patients. The majority of relapses occurred centrally or at the pelvic sidewalls (58%), and future attempts to improve local control rates will rely more heavily on the individualized use of interstitial template applicators.

Fat necrosis of the breast simulating recurrent carcinoma after primary radiotherapy in the management of early stage breast carcinoma

Between March 1973 and December 1980, 76 patients with Stage I or II breast carcinoma were treated by biopsy and definitive radiation therapy at Stanford University Medical Center. There were 78 treated breasts since two patients had bilateral carcinomas at presentation. During a median follow-up period of 29 months, eight patients developed discrete masses in the treated breast. In four of these patients biopsied tissue revealed recurrent carcinoma yielding a local control rate of 95%. Four additional patients had lesions which were clinically indistinguishable from recurrent cancer. Biopsy specimens, however, revealed fat necrosis of the breast. The clinical and pathologic features of this entity are described. It is imperative that clinicians be aware of this treatment sequelae so that conservative diagnostic procedures may be used and breast deformity minimized. If postirradiation fat necrosis is considered, mastectomy for suspected persistent or recurrent disease may be avoided.

Irradiation as an alternative to mastectomy for early breast cancer

Between May 1973 and December 1980 there were 76 patients (78 breasts) with clinical stage I or II breast carcinoma treated by biopsy and definitive radiotherapy at Stanford University Medical Center. Local-regional control has been achieved thus far in 76 of 78 cases (97 percent) with a median follow-up time of 26 months. Transient lymphedema of the breast, arm edema and breast fibrosis were the most commonly noted complications. The cosmetic result was analyzed and scored as excellent in 78 percent, satisfactory in 18 percent and unsatisfactory in 4 percent. The three unsatisfactory results occurred in patients in whom severe fibrosis developed as a result of suboptimal radiation techniques. Interdisciplinary cooperation among surgical, medical and radiation oncologists is important. The 97 percent local-regional control and the 96 percent excellent-to-satisfactory results support the use of primary radiotherapy in early stage breast carcinoma.

125Iodine implants as an adjuvant to surgery and external beam radiotherapy in the management of locally advanced head and neck cancer

125Iodine seeds either individually placed or inserted into absorbable Vicryl suture carriers were utilized in conjunction with surgery and external beam radiotherapy in an attempt to increase local control rates in patients with (1) advanced oropharyngeal and laryngopharyngeal cancers (T3-T4, N2-N3), (2) massive cervical lymphadenopathy (N3) and an unknown primary site and (3) locally recurrent head and neck cancers. Forty-eight patients were treated with 55 implants. The carotid artery was implanted in 15 patients, while seven patients had seeds inserted into the base of the skull region, and another three patients had implants near cranial nerves. Eighteen of the 48 patients were treated for cure. The actuarial survival at five years in this subgroup was 50%. The overall local control in the head and neck area was 58%. In this group no patients to date have had a local failure in the implanted volume. Seventeen patients with comparable stage of disease treated prior to 1974 with curative intent without 125I implants were analyzed retrospectively for comparison with the implanted patients. The actuarial survival of these patients was 18% and the overall head and neck control was 21%. These differences are statistically significant at a P value of 0.01 and 0.007, respectively. Seventeen patients received implants for local recurrence. The local control in the head and neck area was 50%; however, the 2.5 year actuarial survival was only 17%. The complication rate was 11% (six of 55 implants). The improved survival, the high local control, and the minimal complication rates in this series makes the intraoperative implantation of 125I seeds and effective adjunctive treatment to surgery and external beam irradiation.

Interstitial therapy of perineal and gynecological malignancies

Thirty-five patients, 38 to 88 years of age, were treated with 125-Iodine or 192-Iridium interstitial implants at Stanford University Medical Center between July 1974, and December, 1978. There were 25 primary epithelial malignancies, eight extensions from intrapelvic organs and two metastatic tumors (hypernephroma and Hodgkin's disease). The involved sites were: urethra (6 patients); vulva (9 patients); vagina (8 patients); anus (7 patients); cervix (5 patients). Implantation was usually performed to treat evident or microscopic disease in conjunction with external beam pelvic treatment with or without local excision. Computerized implant preplanning was used. 125-Iodine seeds were inserted either directly or within absorbable suture Polyglactin 910; 192-Iridium in nylon carriers was placed by suture or transperineal template. Two patients were lost to follow-up leaving 33 patients, 27 of whom are alive and free of local disease from 37 to 76 months. The overall local control rate was 88%, or 29/33 patients. All four local recurrences appeared before 24 months. Minor complications included: 10 patients with transient mucositis, four with superficial ulcers, and one patient with infection at the implanted site. Two major complications occurred: a necrotic rectal ulcer requiring a colostomy and a contracted, painful bladder necessitating a urinary diversion. We conclude that in selected cases interstitial irradiation provides good local control of perineal and gynecological malignancies with low morbidity in this elderly and quite often fragile group of patients.

Nuclear alterations induced by cadmium chloride and L-canavanine in HeLa S3 cells. Accumulation of perichromatin granules

The effects of L-canavanine and cadmium on the ribonucleoprotein constituents of HeLa S3 cells have been analyzed. Both chemicals induce a similar pattern of alterations in different RNP structures as well as in both RNA and protein synthesis. Pulse and chase autoradiographic experiments reveal that both canavanine and cadmium induce a preferential inhibition of nucleolar RNA synthesis and a slowdown in the transport or processing of nucleolar and extranucleolar RNA. Nucleoli become round and compact. Accumulation of perichromatin granules and fibrils occurs, there is a depletion of interchromatin fibrils, and nuclear formations appear which seem to be involved in the morphogenesis of perichromatin granules accumulated during the treatments. The appearance of clusters of 29- to 35-nm granules might be related with a deficient assembling of constituents of perichromatin granules. The effects of different inhibitors of the transcriptional processes on the accumulation of perichromatin granules suggest that these granules represent a particular subpopulation of hnRNP.