Effect of dietary nucleotides on the plasma fatty acids in at-term neonates

Non-protein nitrogen from human milk is presently being implicated in neonatal physiology. Human milk contains relatively high amounts of nucleotides which are practically absent in cow's milk and milk formulas. These compounds have been related to normal growth and cellular immunity in animals in early life. The aim of this study was to investigate the effects of dietary nucleotides on the plasma fatty acid pattern in term neonates during the first month of life. Twenty-six infants were fed human milk, 35 a milk formula and 23 the same formula supplemented with cytidine, adenosine, guanosine, uridine and inosine 5'-monophosphates in similar quantities to those determined in human milk. Plasma polyunsaturated fatty acids with more than 18 carbons of the omega 6 family were significantly increased in infants fed with the nucleotide-supplemented milk formula with respect to those fed the milk formula, whereas no differences could be detected between the human milk-fed and the nucleotide milk formula-fed ones. These results suggest that dietary nucleotides may be involved in the conversion of linoleic acid to longer chain polyunsaturated fatty acids during early life.

Surgical considerations after chemotherapy and radiation therapy for inflammatory breast cancer

Eighteen patients seen between 1974 and 1982 with the clinical diagnosis of inflammatory breast carcinoma underwent modified radical mastectomy after preoperative chemotherapy and radiation therapy. In 17 of the 18 patients (94%), residual carcinoma was detected in either the resected breast or the axillary nodes. All mastectomies were accomplished without major technical difficulty. Seven wound complications, including three infections, occurred. Local recurrence was noted in 29% (five of 17 patients) and distant metastasis was detected in 89% (16 of 18 patients). Only three patients are presently alive without evidence of disease 19, 21, and 21 months since the onset of symptoms. Eleven patients have died, the median survival being 23 months since the development of symptoms, and four are alive with distant metastasis. Modified radical mastectomy can be accomplished in patients with inflammatory breast cancer after preoperative chemotherapy and radiation therapy and may have a role in reducing local tumor burden.

Postoperative radiation therapy for epithelial ovarian cancer: the curative role based on a 24-year experience

We updated 152 cases of epithelial ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) stages I through III, treated at the Stanford Medical Center (Stanford, Calif) with irradiation as the only postoperative therapy. In 133 patients, radiation was directed only to those regions of known disease, while it was delivered to the whole abdomen and pelvis by the Martinez technique in 19 patients. Mean follow-up time was 6.8 years. The results were analyzed as freedom from relapse (FFR) at 15 years; overall, FFR constituted 44% of the patients. Statistically significant differences of FFR appeared between stages II (60%) and III (16%); among the histopathologic variants endometrioid (64%), serous papillary (45%), and undifferentiated (7%); between pathologic grades 2 (68%) and 3 (20%); between amounts of postoperative residual disease less than 2 cm (48%) and greater than 2 cm (16%); and between ages less than 40 (80%) and greater than or equal to 40 (38%). Considering all stages and grades together, FFR in the 54 cases with unfavorable residuum (greater than 2 cm) was 14%. Among the 98 with favorable residuum (none, or less than 2 cm) FFR was 62%; and 14 (39%) of the 36 relapses were in the untreated upper abdomen. Results in the favorable group support effectiveness of irradiation as postoperative therapy. These patterns of relapse suggest that whole-abdominopelvic irradiation would further increase FFR. We believe that, for favorable disease as defined such radiotherapy should be the standard for comparison.

Pelvic lymphadenectomy combined with transperineal interstitial implantation of iridium-192 and external beam radiotherapy for locally advanced prostatic carcinoma: technical description

Regardless of the treatment modality, control of locally advanced extracapsular prostatic cancer remains a therapeutic challenge. At the Mayo Clinic, we have recently developed a combined approach for surgically staged patients employing interstitial irradiation with 192 Iridium via a transperineal template. The Martinez Universal Perineal Interstitial Template (MUPIT-II) and moderate doses of external beam irradiation. The procedure consists of: 1) preoperative single dose external beam irradiation to decrease potential for tumor seeding or showering of malignant cells during MUPIT-II placement; 2) adequate surgical staging through a bilateral retroperitoneal lymphadenectomy; 3) transperineal interstitial implantation of the tumor and retropubic palpation of the needles to verify proper position; 4) intraoperative X rays are taken and used for documentation of needle position as well as for calculation and optimization of the implant dose distribution with the aid of a computerized system; 5) moderate doses of external beam irradiation postoperatively to the prostate with adequate margins. Our favorable preliminary results obtained in 18 patients treated with the above approach warrant the continuation of this trial. Details of this technique are presented.

Acute toxicity and preliminary therapeutic results of pelvic lymphadenectomy combined with transperineal interstitial implantation of 192IR and external beam radiotherapy for locally advanced prostate cancer

We have developed a combined modality approach for treatment of locally advanced prostate cancer consisting of: surgical staging with lymphadenectomy; transperineal placement of afterloading needles for a course of 192Ir brachytherapy; and a course of moderate-dose external beam irradiation to tight prostatic fields. The flexibility of the treatment permits adaptation of the dose to any tumor configuration. A total of 23 patients have been treated to date; 18 are available for treatment review and 14 for acute toxicity analysis. Significant morbidity has occurred in only 2 patients, 1 with a pelvic hematoma and 1 with hematoma in the wound. Local tumor response has been excellent in all but 1 patient. A good degree of symptomatic improvement was observed at the three-month follow-up. This approach appears to be safe and effective at this time. A brief review of the technique and the rationale for its use are also presented.

125I vicryl suture implants as a surgical adjuvant in cancer of the head and neck

Sixty-four intraoperative 125I seed implants using absorbable suture (Vicryl) carriers were performed in 53 patients with head and neck cancers at Stanford between 1975 and 1980. In previously untreated patients, local control in the implanted volume or in all head and neck sites was obtained in 79 and 71%, respectively. Five of these patients (40%) remained NED. Of 34 patients with recurrent carcinomas, local control was obtained in the implant volume in 20 (59%), while 38% had no recurrence post-implantation in any head and neck site. The incidence of complications is correlated with 125I radiation doses, total millicuries inserted, seed strength used, and tissue volume implanted for both untreated patients and those with local recurrences. Guidelines for the optimal use of the above 4 parameters are also presented. We conclude that 125I seed Vicryl intraoperative suture implants are an effective surgical adjuvant in the treatment of advanced, previously untreated or recurrent head and neck cancers.

Combination of external beam irradiation and multiple-site perineal applicator (MUPIT) for treatment of locally advanced or recurrent prostatic, anorectal, and gynecologic malignancies

We have devised a single after-loading applicator, the Martinez Universal Perineal Interstitial Template (MUPIT), which has been used in combination with external beam irradiation to treat 104 patients with either locally advanced or recurrent malignancies of the cervix, vagina, female urethra, prostate, or anorectal region. Twenty-six patients treated for prostate cancer are excluded because of their short follow-up. Local failure developed in 13 of the 78 remaining patients (16.6%)--major complications developed in 4 patients (5.1%). Follow-up has been 1 year to 7 1/2 years; 60/78 patients have been followed for more than 2 years. All local recurrences and complications occurred before 18 months. The device consists of two acrylic cylinders, an acrylic template with an array of holes that serve as guides for trocars, and a cover plate. In use, the cylinders are placed in the vagina and/or rectum or both 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. Appropriate computer programs have been developed to calculate the dose from these implants. The advantages of the system are (a) greater control of the placement of sources relative to the tumor volume and critical structures, as a result of the fixed geometry provided by the template and cylinders, and (b) improved dose-rate distributions obtained by means of computerized optimization of the source placement and strength during the planning phase. We conclude that the local control rate (83.4%) with low morbidity (5.1%) achieved with the combination of external beam irradiation and MUPIT applicator in these patients with locally advanced malignancies represents an improvement over previous published results with other applicators.

Management of malignant airway obstruction: clinical and dosimetric considerations using an iridium-192 afterloading technique in conjunction with the neodymium-YAG laser

Fourteen patients with malignant airway obstruction have had 21 placements of a flexible nylon catheter for afterloading Iridium-192 using the flexible fiberoptic bronchoscope. Prescribed therapy was completed in 13 patients (18 courses). All patients had prior full-dose external irradiation, and no effective surgical or chemotherapeutic options remained. While many have had a trial of neodymium-YAG (yttrium-aluminum-garnet) laser therapy alone, eight patients received laser treatment one to three weeks prior to planned brachytherapy to provide immediate relief of symptoms and/or facilitate access and safe catheter placement. Most patients (64%) had recurrent squamous cell lung cancer. A dose of 3000 cGy is currently specified to 5 mm and 10 mm in the bronchus and trachea, respectively. Nine of the 13 treated patients have had follow-up bronchoscopy at approximately three months post-treatment with improvement documented in seven and progression in two patients. One patient was clinically improved without follow-up bronchoscopy, and three patients have had insufficient follow-up. A single patient treated with laser and 6000 rad at 5 mm developed a bronchoesophageal fistula. No other complication has been observed. The technique is simple and safe with the use of laser therapy when needed and appears to offer effective palliation in most patients even when standard therapy is exhausted.

Intra-arterial infusion of radiosensitizer (BUdR) combined with hypofractionated irradiation and chemotherapy for primary treatment of osteogenic sarcoma

Combined modality treatment was given in nine patients of osteogenic sarcoma wherein the tumor was unresectable because of location or amputation was refused. This alternative to massive surgery comprised hypofractionated irradiation, intra-arterial infusion of the radiosensitizer 5'-bromodeoxyuridine (BUdR) and adjuvant systemic chemotherapy. Local control was achieved in seven of the nine patients. Four survived, all without evidence of disease at 6, 7.1, 8.8, and 10.5 years after completion of irradiation. Pulmonary metastases developed in six patients--of whom one survives, following high-dose pulmonary irradiation and additional chemotherapy. Significant soft-tissue injury occurred in five patients. On the basis of our experience, we believe that new approaches using modifications of external beam irradiation with different fractionation schedules or better radiosensitizing compounds may hold promise for patients with non-resectable osteosarcoma.

Transient idiopathic subpleural cysts in the newborn: an observation in two patients

We present two cases of transient idiopathic cystic formations in the subpleural region in full-term newborns, that do not fit into any known cystic process to our knowledge. The features of the cystic formations, their subpleural location, their spontaneous regression, the histopathological study, as well as the absence of a clear etiology, have led us to propose the name of "Transient Idiopathic Subpleural Cysts in Full-term Newborns", for this process.

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.