Morbidity and mortality after surgery in patients with disseminated or locally advanced cancer receiving systemic chemotherapy

All postoperative complications and mortality were analyzed in a diverse group of patients operated upon by the authors during a ten-year period. These patients shared only two common factors: 1) known locally advanced or disseminated cancer, and 2) systemic chemotherapy within three weeks (either pre- or postoperatively) of major surgery. One hundred eighty-six operations were performed on 175 patients. The overall mortality in this series was 2.2% (four patients), with a complication rate of 5.9% (11 patients). Despite the known detrimental effects of widespread cancer and cytotoxic agents on wound healing, appropriate surgical intervention can be accomplished with an acceptable mortality and morbidity in patients with locally advanced or disseminated cancer who are receiving systemic chemotherapy.

Dose response of 1,2-dimethylhydrazine and methylazoxymethanol acetate in the F 344 rat

Weanling male and female F 344 rats were given various doses of 1,2-dimethylhydrazine (DMH) or methylazoxymethyl acetate (MAMAc), and were then held for 46-64 weeks in an effort to determine a dose response and establish a dose level which would produce a low level of intestinal neoplasia with a minimal number of tumors in other organs. DMH proved superior to MAM in this respect, although liver lesions were still observed with both compounds at the lowest carcinogenic intestinal dose.

Foley catheter hysterosalpingography: a simplified technique for investigating infertility

A simplified technique for hysterosalpingography, based on over 5,000 studies, is described. This method is quickly and easily performed. Patient acceptance is high.

Influence of supernatants from polymorphonuclear leucocytes on blastogenesis of syngeneic and allogeneic murine splenocytes

Supernatant was produced from activated peritoneal polymorphonuclear leucocyte-rich cell populations from different strains of mice. These supernatants were studied for their ability to modify spontaneous and mitogen-induced blastogenesis of syngeneic and allogeneic splenocytes. Our results indicate that polymorphonuclear leucocyte-rich cell cultures from two strains of mice, A/J and BALB/c, produced a supernatant that could enhance PHA-induced blastogenesis of syngeneic and allogeneic splenocytes. Cells from a third strain C57B1/6, did not produce an active supernatant. In general, the response by splenocytes from these three strains paralleled the production of active supernatant that we observed. The response to the active supernatant was dependent upon the mitogen stimulation of the splenocytes, the mitogen dilution and the supernatant activity. These functions are believed to be genetically determined.

Rehabilitation profile of kidney transplant patients

The rehabilitation of 132 patients with functioning grafts six months to ten years post transplantation was examined by review of self-report questionnaires. The patients were divided into three groups according to when they underwent transplantation. Results showed 62 per cent of patients in group A (transplant received between July 1, 1973 and December 31, 1973), 69 per cent in group B (transplant received between January 1, 1971 and June 30, 1973), and 90 per cent in group C (transplant received between January 1, 1964 and December 31, 1970) were productively active in July 1974. Nearly all attained productively active rehabilitation scores by twelve months, but one-third reported they were functioning at a lower level than before their illness, and a significant number of patients with physically strenuous jobs before illness acquired sedentary jobs post transplantation.

Preoperative and follow-up bone scans in patients with primary carcinoma of the breast

We have attempted to evaluate the role of preoperative and postoperative bone scans in patients with localized carcinoma of the breast. The yield of positive preoperative scans in patients with Stages I and II disease is low and confounded by a relatively high percentage of false-positive results. Conversely, 16 per cent of patients with Stage III disease had evidence of bony metastasis at the time of operation. Positive bone scans were found three times as frequently in patients with axillary node involvement than in those without. Thirty per cent of those observed for varying times up to 41 months had evidence of bony metastases. Again, there was a correlation with initial clinical staging with 3.6 to 8.0 times more conversions in patients with Stage II or III disease than in those with Stage I disease. It appears that the majority of metastases to the bone become apparent within the first years. This observation deserves further study to elaborate the natural history of metastatic carcinoma of the breast.

An aggressive multimodality approach to locally advanced carcinoma of the breast

In a series of patients who were not candidates for mastectomy because of locally advanced disease or distant metastases, or both, excellent local control was obtained by radiation therapy and systemic therapy in the form of oophorectomy-adrenalectomy and chemotherapy. Local control was obtained in 12 of 15 patients with metastatic disease by systemic therapy without radiation. The median disease-free survival time for patients with advanced Stage III carcinoma of the breast was significantly prolonged from 9.5 to 15 months by oophorectomy-adrenalectomy with chemotherapy, although there was no definable difference in the over-all survival period for the two groups.

Circulating immune complexes in patients following clinically curative resection of colorectal cancer

Sixty-nine patients have been followed prospectively after curative resection of Dukes-Kirklin B-2 or C colorectal cancer. Serial plasma samples were studied in selected patients to determine changes in circulating immune complex concentrations (CIC) following primary tumor resection, and to compare serial plasma CIC and carcinoembryonic antigen (CEA) levels. CIC was determined in an average of seven serial samples per patient by inhibition of antibody-dependent cell-mediated cytotoxicity (ADCC). CEA assays were performed by the Hanson Z-gel method. Two distinct patterns of serial CIC have emerged. In seven patients with no known tumor recurrences, serial CEA levels and CIC oscillated regularly and were inversely related. In seven of eight patients whose tumors recurred, both CEA and CIC rose together. In three patients with elevated plasma CEA levels due to inflammatory bowel disease, serial Ag-Ab complex concentrations did not vary, nor did separated Ag or Ab fractions inhibit ADCC. These data suggest that, in patients following curative resection of colorectal cancer, serial changes in circulating immune complexes may discriminate between transient CEA elevations which occur despite no known tumor recurrence and tumor recurrence which is beyond the capacity of adequate host antitumor defense.

In pursuit of the unknown primary

The case histories of sixty-seven patients were reviewed to evaluate the contribution made by various x-ray and laboratory studies to the diagnosis and treatment of systemic metastases from unknown primary tumors. When used as screening procedures, radiographic contrast studies were rarely helpful unless the test was indicated by appropriate symptoms. The large number (8 of 27) of misleading ultrasonic scans rendered that study a major source of confusion. Inadequate tissue samples were another cause of confusion and delay. Even with adequate tissue samples, a definitive pathologic diagnosis could be assigned to only forty-five of the sixty-five patients who underwent biopsy. After extensive diagnostic evaluations, only thirty-one of the sixty-seven patients received chemotherapy for specific diagnoses. Objective remissions were seen in four of thirty-one recipients of specific chemotherapy and one of five patients treated without a primary diagnosis. The same patients would have received the same therapy had the diagnostic workup been limited to x-ray studies of symptomatic systems, adequate tissue sampling, and appropriate pathologic examinations followed by treatment of the "most treatable" disease.

Inhibition of lymphoma cell proliferation by supernatant from fibrosarcoma cultures: preliminary evidence that the inhibitory material is prostaglandin E

Supernatants obtained from mouse fibrosarcoma cultures 48 hr after the addition of fresh medium contained dialyzable material which inhibited the proliferation of syngeneic lymphoma cells in vitro, as measured by 3H-thymidine incorporation. Three lines of evidence indicate that the supernatant inhibitory material is probably prostaglandin (PG) E. First, the supernatant and dialysis of the supernatant contained a substance with the same characteristics as PGE1 or PGE2 as detected by thin layer chromatography. Second, PGE2-treatment of lymphoma cells mimicked the inhibition of proliferation observed with supernatant inhibitory substance. Third, indomethacin, treatment of fibrosarcoma cultures reduced the amount of supernatant inhibitory substance present.

Calyceal-cutaneous fistulae in renal transplant patients

Calyceal-cutaneous fistula is a serious sequela of renal transplantation occurring in approximately 3% of allografts. This complication occurred in 12% of allografts with multiple renal arteries. A localized area of poor parenchymal perfusion involving less than one-eighth of the kidney was noted at the time of transplantation in only one-third of the kidneys developing fistulae. Attempts of surgical correction of the fistulae in the presence of serious wound and urinary tract sepsis were usually unsuccessful, with the ultimate loss of 7 of 8 kidneys and the death of 3 patients from sepsis. One individual underwent successful partial resection and closure of the fistula with a muscular graft and survives with adequate function. This experience would suggest that if an initial aggressive surgical attempt at repairing a calyceal-cutaneous fistula fails, transplant nephrectomy should be performed.

Renal transplantation: a twenty-five year experience

Boston has played a significant role in the development of renal transplantation. In Boston was performed the first successful isograft between identical twins (1954) the first successful allograft between fraternal twins (1959) and the first successful allograft from a cadaveric donor (1962). An immunosuppressive drug was also described in Boston by hematologists Schwartz and Dameschek (1959) and modified for renal transplantation in dogs (1961) and used for the first time in a human recipient in March 1962. By 1965 renal transplantation had become a clinical reality. Three hundred and ninety-eight of 589 recipients (68%) since 1950 are still alive, a remarkable figure considering that it includes all the earliest experimental transplants. One hundred and ninety-five of 295 (68%) with living-related donor transplants still have functioning allografts; 104/265 (39%) with cadaveric donor transplants have functioning grafts currently. Since 1968 transplants from living-related donors have an 80% one year survival whereas cadaveric donor transplants have approximately a 50% one year survival. Seventy-nine per cent of all one year survivors have had excellent psycho-social rehabilitation.

The role of effector cells and antiserum in the inhibition of cell-mediated cytotoxicity of allogeneic tumor cells

Previous experiments in this laboratory demonstrated a progressive decrease in cell-mediated cytotoxicity (CMC) against allogeneic tumor cells by immune spleen cells from mice repeatedly immunized with those tumor cells. In the present study, immune spleen cells, obtained at specified intervals during the course of multiple immunizations of BALB/c mice with EL-4 lymphoma cells, were tested for CMC against EL-4 target cells pretreated with anti-EL-4 serum which had been obtained from singly or repeatedly immunized animals. Cytolysis of EL-4 cells was measured by a 51Cr-release assay. The results indicate that blocking of CMC in an allogeneic tumor model may occur by two pathways. First, antigen or antigen-antibody complexes present in the immunized animal may bind in vivo to the antigen receptor sites of of sensitized effector cells that are used in the in vitro CMC assay, thereby blocking their interaction with tumor cells. Second, immune serum that is added to the in vitro CMC assay may contain highly avid antibodies, as well as antigen-antibody complexes, that bind to tumor cells and thereby block interaction with sensitized effector cells. The identification of these elements may be of prognostic significance in certain clinical situations.

Familial male breast cancer

Infiltrating ductal carcinoma of the breast occurred in a total of six men from two families. In one family specimens from three men who had prophylactic mastectomies revealed focal intraductal hyperplasia, suggesting a familial tendency toward proliferation of mammary-duct epithelium. In the other family, benign and malignant breast lesions also developed in several women. Preliminary data suggest elevated urinary oestrogen excretion in three men from these families, implicating a defect in oestrogen production or metabolism in the pathogenesis of male breast neoplasms.

Using celioscopy to determine stages of intra-abdominal malignant neoplasms

From January 1973 through June 1974, 23 patients underwent celloscopy to assess the extent of intra-abdominal malignancy. Of the 23 patients in the study, eight were spared a needless exploratory procedure. Three patients had potentially curative surgery after intrahepatic neoplasm suggested by liver scintiscan was excluded by celloscopy. The therapies of eight patients were greatly altered after the extent of hepatic or peritoneal disease was de-ermined. Four patients had no change in treatment as a result of celloscopy. Three additional patients underwent celloscopy to determine the cause of an intra-abdominal mass. No complications occurred in these patients. We conclude that celloscopy prior to a major operative procedure may assist in determining the stage of intra-abdominal malignant disease and may lead to notable changes in patient management.

Secondary hyperparathyroidism in human kidney transplant recipients

76 kidney transplant recipients who were up to 4 years post transplant, were studied to assess the incidence of secondary hyperparathyroidism. All patients had good renal function with a mean serum creatinine of 1.4 mg/100 ml. Secondary hyperparathyroidism, as evidenced by increased serum parathyroid hormone levels, was present in 53 of the 76 patients (66%) and radiologic bone disease in 26 of the 76 patients (34%), while hypercalcemia (serum calcium greater than 11.0 mg/100 ml) occurred in only 6 patients (8.5%). The incidence of secondary hyperparathyroidism decreased slightly with time following transplantation, but the degree of secondary hyperparathyroidism as indicated by the levels of serum parathyroid hormone at various times following renal transplantation was essentially similar. The causes for the persistence of this condition are not totally known, but it was found that its incidence was related to the duration of dialysis prior to transplantation.

Successful short-term modification of hyperacute renal allograft rejection in the primate. Intrarenal effects of phenoxybenzamine and methylprednisolone combined with heparin

Inhibition of renal vasoconstriction during hyperacute rejection by phenoxybenzamine or methylprednisolone combined with either the antiplatelet agent pyridinolcarbamate or heparin was evaluted in primates. Phenoxybenzamine plus pyridinolcarbamate did not prolong kidney survival. Phenoxybenzamine plus heparin uniformly prolonged low rates of venous flow to 180 minutes and delayed secondary C3 consumption, sequestration of erythrocytes and platelets, coagulation, and fibrinolysis; neutrophil sequestration and vascular injury and obstruction were more marked than with heparin alone. Host pretreatment with methylprednisolone plus heparin also prolonged the low rates of venous flow to 180 minutes, further reduced secondary alterations, and resulted in the least vascular injury. When intact donor kidneys were also pretreated with methylprednisolone, persistently normal rates of venous flow were achieved. Despite marked consumption of Factor XII, the consumption of C3, other coagulation factors, prekallikrein, and sequestration of formed elements was minimal, and the histology appeared compatible with even more prolonged survival.

A twenty year survey of arterial complications of renal transplantation

The significant arterial complications of renal transplantation are hemorrhage, infarction, stenosis and aneurysm formation. Hemorrhage is often associated with sepsis and may be lifethreatening. Large infarcts may be secondary to multiple small vessels or intraoperative hypotension with inadequate perfusion of the organ. Nephrectomy is invariably indicated in these situations. Renal artery stenosis with resultant hypertension may occur secondary to stenosis at the anastomosis, atherosclerotic plaque formation or intimal fibrosis of the renal artery. Operative reconstruction if the anastomotic site may relieve hypertension is selected patients but places the transplanted kidney greatly at risk. Aneurysm formation is often mycotic and is associated with multiple operations and wound sepsis. The iliac artery may be ligated without loss of limb, while the resultant claudication may be relieved by a surgical bypass procedure.

The immune response of mice repeatedly injected with allogeneic tumor cells

The development and kinetics of cell-mediated cytotoxicity (CMC), antibody-mediated complement-dependent cytotoxicity (C'DC), and antibody-dependent cellular cytotoxicity (ADCC) were studied in an allogeneic model. Using microcytotoxic assays of 51Cr release from labeled EL-4 tumor cells, C'DC, ADCC, and CMC were measured at 14 intervals during the 77-day course of the experiment. The results obtained demonstrate the oscillating nature of the immune response. The rise and fall of activity was almost synchronous for the three functions studied. A generalized trend of increasing antibody-dependent functions and a simultaneous dampening of CMC was noted.

Treatment of chronic renal failure by transplantation and dialysis: two decades of cooperation

The overall transplant experience at the Peter Bent Brigham Hospital which extends over twenty years has been reviewed; the course of all patients was updated to a followup of at least one year (through October 1973). A total of 388 patients received 427 renal isografts and allografts between March 1951 and October 1972. Of these, 58% were still alive at the end of the followup period, 50% with a functioning graft. The results of patient and allograft survival early (1959-1968) and later (1968-1973) in the experience have been compared. The significant decline in patient mortality, especially among recipients of cadaver allografts, demonstrates improved treatment of complications and increased availability of dialysis. The improvement of allograft function during the two time periods is less striking but still significant. Overall social and work rehabilitation following transplantation was evaluated in 284 patients, 86% of whom became at least as well adjusted as they had been prior to the development of renal failure. The incidence and individual causes for mortality and complications of transplantation have been compared to results from the National Dialysis Registry, figures comparable to those of the dialysis program at this institution. Transplantation and dialysis must be used conjointly and in a complimentary manner as part of the total treatment for those with end-stage renal failure.

Listeroisis in immunosuppressed patients. A cluster of eight cases

Bactermia due to listeria monocytogenes developed in eight patients who were receiving immunosuppresive medications during a 15 month period at one hospital. Seven survived. Meningitis was documented in only the four who received kidney transplants. Their neurologic signs were minimal, indicating a need to treat any immunosuppressed patient with Listeria bacteremia for meningitis. During this period the incidence of Listeria bactermia in immunosuppressed patients greatly exceeded that previously observed in this hospital or reported elsewhere, but the incidence of infection with other opportunistic agents was not increased. As with previously decreased listeria outbreaks in nonimmunosuppressed patients, no source or mechanism of spread could be identified. Thus, disease due to L. monocytogenes may occur focally among immunosuppressed populations, a pattern which also appears to be emerging for other opportunistic agents. A patient's exposure to different opportunistic agents may be as important as the kind of immunosuppressive therapy he recieves in determining which opportunistic infection he will acquire or even whether any infection will occur.

A primate model of hyperacute renal allograft rejection

Hyperacute renal allograft rejection is initiated by primary immune injury to vascular endothelium and is propagated by secondary vasoconstriction, platelet aggregation and intravascular coagulation. Previous dissociation of these primary and secondary events, with graft survival in one human, suggested that the more usual graft failure was due to secondary injury. As a basis for further modification studies, this primate model most closely resembled its counterpart in man, as the onset and intensity of functional, morphologic and biochemical alterations were similar. Unmodified allografts failed within 5 minutes. The earliest and most abnormal finding was marked reduction in renal blood flow affecting all compartments. By 5 minutes, histologic changes of hyperacute rejection as well as antibody and faint C3 deposits were noted, but biopsies suggested that the initial flow reduction was more likely due to vasoconstriction, which was then followed by vascular obstruction. Glomeruli appeared most damaged, but at the highest antibody titer arterial injury was more prominent. Early red cell sequestration and stasis was marked, followed by progressive platelet clumping and neutrophil infiltration. While the decline in renal venous C3 levels was prompt, as in man, early intrarenal activation of the coagulation, fibrinolytic and kinin-forming systems could not be demonstrated, and fibrin formation was sparse by light and fluorescence microscopy. Qualitatively similar histologic and functional alterations were noted in autograft controls. While the initiating event was unclear and may have been accentuated by the arteriovenous shunts utilized, the final mechanism was probably marked vasoconstriction with renal ischemia. Intrarenal C3 consumption was an important finding and was not associated with tissue deposits of antibody or complement; it may provide a parallel with the progressive complement-mediated injury associated with acute myocardial ischemia noted by others. Endothelial injury was not seen in arteries, and all alterations were delayed in onset and progressed more slowly than in allografts. These findings may elucidate the mechanism of early malfunction of most autografts. Treatment of additional autografts with increasing doses of heparin progressively reversed these changes and even prevented the initial reduction in blood flow. Therefore, many alterations consistent with hyperacute rejection which are probably immediately responsible for graft failure can also be initiated by nonspecific, nonimmunologic events and, where injury is less intense, can be prevented pharmacologically. This model provides a means of dissecting the injurious events and subsequent evaluation of the effectiveness and interaction of various agents on the damaging secondary alterations which occur during hyperacute rejection.

Preoperative laparoscopy in diagnosis of acute abdominal pain

During 1973, 56 patients on one of three general surgical services at the Peter Bent Brigham Hospital, Boston, Massachusetts, who were judged to require hospital admission for acute abdominal pain were dividied into two groups. This division was determined by whether or not the physician responsible thought a definite diagnosis could be established on clinical grounds. 27 patients were thought to have a definite diagnosis and underwent laparotomy without preoperative laparoscopy; at laparotomy, 6 of these patients (22%) had no operable lesion. An additional 29 patients had severe abdominal pain and required observation in hospital. An exact diagnosis could not be clinically established in these patients, and many would in the past have required exploratory laparotomy. These 29 patients underwent laparoscopy resulting in all but 1 (4%) having the presence or absence of intra-abdominal disease requiring operative intervention definitely established. At laparoscopy, diagnosis was made in 18 patients who did not require laparotomy while 11 had disease requiring laparotomy after laparoscopy. No complications resulted from laparoscopy. The difference in the median length of stay and hospital charges resulted in a saving of one and a half days in hospital and $87 when laparoscopy rather than explatory laparotomy determined that acute abdominal pain was caused by a condition not requiring surgical intervention.

[Cellular immunity in actively conditioned recipients of renal allotransplants (author's transl)]

The presence of circulating "killer" cells was demonstrated in actively "conditioned" rats with permanently accepted renal allotransplants. Immunocompetant cells of these animals were able to develop a normal graft-versus-host reaction 100 and 200 days after the transplantation. The ability of these recipients simultaneously to accept secondary donor-specific skin transplants without demonstrable immunological rejection is compatible with the concept that the cytotoxic potential of these cells in vivo is inhibited by enhancing antibodies.