Promoting sustainable responses to the US opioid epidemic with community-academic partnerships: qualitative outcomes from a statewide program

Background

Drug overdose deaths in the United States have continued to increase at an alarming rate. The Substance Abuse and Mental Health Services Administration (SAMHSA) distributed more than $7 billion between January 2016 and June 2020 to address the drug overdose crisis. The funds support evidence-based responses, including medications for opioid use disorder, and other prevention, treatment and recovery activities. Although the State Opioid Response (SOR) grants finance much-needed community level interventions, many of the services they support may not be sustainable, without ongoing assessment, evaluation and planning for continuation.

Methods

This paper describes a statewide effort to support local entities through SAMHSA’s SOR grants in Virginia. Community agencies across the state participated in detailed needs assessment exercises with VHEOC investigators, and developed requests for proposals (RFPs) to sustain their SOR programs. The RFPs were then distributed to prospective academic partners at the five VHEOC universities, based on the required subject matter expertise identified in the RFP. All responsive proposals were then provided to the local agencies who selected the proposal most likely to meet their needs. VHEOC investigators also conducted an inductive, three-phase content analysis approach to examine the RFPs submitted to the VHEOC to identify nominal categories of support requested of the VHEOC investigators.

Results

VHEOC Investigators received and coded 27 RFPs from ten community agencies representing four of five regions of the state. We identified six nominal categories of academic assistance with high inter-coder agreement. The six categories of support requested of the academic partners were program development and support, literature review and best practices, outreach and education, data analysis and interpretation, program evaluation, and grant writing assistance. Several RFPs requested up to three categories of support in a single project.

Conclusions

Our analysis of the requests received by the consortium identified several categories of academic support for SOR-grantees addressing the drug overdose crisis. The most common requests related to development and maintenance of supportive collaborations, which existing research has demonstrated is necessary for the long-term sustainability of SOR-funded services. In this way, the academic partners reinforced sustainable SOR-funded programs. As the state opioid response program is implemented nationally, we hope that other states will consider similar models in response to the opioid crisis.

A Formative Evaluation of Two FASD Prevention Communication Strategies

Aims

To evaluate the feasibility, acceptability and effectiveness of placing FASD prevention messages in the women's restrooms of establishments serving alcohol in Alaska and the Yukon, regions with high rates of FASD.

Methods

Our team placed an FASD educational poster, and posters affixed to a pregnancy test dispenser, in women's restrooms of bars and restaurants. We compared drinking behaviors and knowledge and beliefs about FASD among participants at baseline and at follow-up.

Results

Respondents consisted of 2132 women who completed a baseline survey and 1182 women who completed both a baseline and a follow-up survey. Women in both groups showed improvement in knowledge of FASD; the dispenser group scored higher than participants in the poster group on the FASD Health Belief questions at both baseline and follow-up. Forty-three women learned they were pregnant from our pregnancy tests and alcohol consumption among pregnant women was lower at follow-up than at baseline.

Conclusions

FASD prevention messages, particularly paired with pregnancy test dispensers, in the women's restrooms of establishments that serve alcohol can effectively promote informed alcohol consumption decisions among women who are, or may become, pregnant.

Short Summary

In this FASD prevention feasibility study, we found that FASD prevention messages, particularly paired with pregnancy test dispensers, placed in the women's restrooms of establishments that serve alcohol can effectively promote informed alcohol consumption decisions among women who are, or may become, pregnant.

Implementation of Care Management: An Analysis of Recent AHRQ Research

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Medical home implementation and trends in diabetes quality measures for AN/AI primary care patients

AIMS

Patient-centered medical home (PCMH) principles including provider continuity, coordination of care, and advanced access align with healthcare needs of patients with Type II diabetes mellitus (DM-II). We investigate changes in trend for DM-II quality indicators after PCMH implementation at Southcentral Foundation, a tribal health organization in Alaska.

METHODS

Monthly rates of DM-II incidence, hemoglobin A1c (HbA1c) measurements, and service utilization were calculated from electronic health records from 1996 to 2009. We performed interrupted time series analysis to estimate changes in trend.

RESULTS

Rates of new DM-II diagnoses were stable prior to (p=0.349) and increased after implementation (p<0.001). DM-II rates of HbA1c screening increased, though not significantly, before (p=0.058) and remained stable after implementation (p=0.969). There was non-significant increasing trend in both periods for percent with average HbA1c less than 7% (53 mmol/mol; p=0.154 and p=0.687, respectively). Number of emergency visits increased before (p<0.001) and decreased after implementation (p<0.001). Number of inpatient days decreased in both periods, but not significantly (p=0.058 and p=0.101, respectively).

CONCLUSIONS

We found positive changes in DM-II quality trends following PCMH implementation of varying strength and onset of change, as well as duration of sustained trend.

Assessing the social and physical determinants of circumpolar population health

INTRODUCTION

Systematic reviews of the social and physical determinants of health provide metrics for evaluation of programs to mitigate health disparities. Previous meta-analyses of the population health literature have identified several proximate social and physical determinants of population health in the circumpolar north including addiction, environmental exposures, diet/nutrition and global climate change. Proximate health determinants are most amenable to early detection and modification or mitigation through disease prevention or health promotion interventions.

DESIGN

There is a need for research to replicate these findings based on the latest science. This presentation describes a study applying Dahlgren and Whitehead's (1991) socio-ecological model of health determinants to identify the proximate social and physical determinants of health in the circumpolar north.

METHODS

The study consisted of a systematic review of recent studies that link determinants of health with the leading causes of mortality and morbidity in Alaska. Our search strategy employed a keyword search using the Circumpolar Health Bibliographic Database (CHBD) and 4 databases within the Web of Knowledge (WoK) data gateway. Keywords included various terms for the arctic, all relevant nations and territories within the region, as well as leading health outcomes.

RESULTS

Studies meeting the following inclusion criteria were reviewed: original research within a circumpolar population, published in English during 2011, and involving a rigorous demonstration of a link between a social determinant and selected health outcomes.

CONCLUSIONS

Study conclusions includes a list of determinants identified, their associated outcomes and the study designs implemented to assess that association.

Tribal implementation of a patient-centred medical home model in Alaska accompanied by decreased hospital use

Background

Between 1995 and 1998, tribally owned Southcentral Foundation (SCF) incrementally assumed responsibility from the Indian Health Service (IHS) for primary care services on the Alaska Native Medical Center (ANMC) campus in Anchorage, Alaska. In 1999, SCF began implementing components of a Patient-Centered Medical Home (PCMH) model to improve access and continuity of care.

Objective

To evaluate hospitalisation trends before, during and after PCMH implementation.

Design

Time series analysis of aggregated medical record data.

Methods

Regression analysis with correlated errors was used to estimate trends over time for the percent of customer-owners hospitalised overall and for specific conditions during 4 time periods (March 1996–July 1999: SCF assumes responsibility for primary care; August 1999–July 2000: PCMH implementation starts; August 2000–April 2005: early post-PCMH implementation; May 2005–December 2009: later post-PCMH implementation). Analysis was restricted to individuals residing in Southcentral Alaska and receiving health care at ANMC.

Results

The percent of SCF customer-owners hospitalised per month for any reason was steady before and during PCMH implementation, declined steadily immediately following implementation and subsequently stabilised. The percent hospitalised per month for unintentional injury or poisoning also declined during and after the PCMH implementation. Among adult asthma patients, the percent hospitalised annually for asthma declined prior to and during implementation and remained lower thereafter. The percent of heart failure patients hospitalised annually for heart failure remained relatively constant throughout the study period while the percent of hypertension patients hospitalised for hypertension shifted higher between 1999 and 2002 compared to earlier and later years.

Conclusion

Implementation of PCMH at SCF was accompanied by decreases in the percent of customer-owners hospitalised monthly for any reason and for unintentional injury and in the percent of asthma patients hospitalised annually for asthma. Increased accessibility to empanelled care teams may have contributed to decreased need for hospitalisation.

Initial findings from the implementation of a community-based sentinel surveillance system to assess the health effects of climate change in Alaska

Background

This report describes the results of a study to determine whether a community-based sentinel surveillance system can be developed and implemented to assess the health effects of climate change, and to contribute to local discussions to mitigate these health effects. The purpose of this report is to describe the process and outcomes of this innovative approach to identifying priority areas for adaptation investment. This report can be used to assist local, state and federal governments in determining how to develop actions and policies to promote adaptation to climate change.

Objective

To evaluate the health effects of climate change in rural Alaska.

Design

We conducted an iterative and participatory process to develop metrics, an instrument and a protocol to collect sentinel surveillance data on the health effects of climate change in 3 ecologically distinct regions of the state.

Results

We collected surveillance data from 91 study participants over the course of 12 months. These data were analyzed and categorized by frequency and association between specific health outcomes or health-related factors (such as food security) and reported exposure to environmental effects of climate change. We found significant associations between several health outcomes and health outcome mediators and reported exposures. We presented these data to study participants in community settings and moderated discussions of likely causal factors for these measured associations, and helped community residents to identify specific adaption measures to mitigate those health effects.

Conclusions

We conclude that community-based sentinel surveillance is an effective method for assessing health outcomes from exposure to environmental effects of climate change, and informing climate change health adaptation planning in Alaskan communities. We contend that it would be effective in other regions of the nation as well.

Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change

PURPOSE

We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors.

METHODS

Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context.

RESULTS

The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context.

CONCLUSIONS

These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation

PURPOSE

This study describes key elements of the transition to a patient-centered medical home (PCMH) model at Southcentral Foundation (SCF), a tribally owned and managed primary care system, and evaluates changes in emergency care use for any reason, for asthma, and for unintentional injuries, during and after the transition.

METHODS

We conducted a time series analyses of emergency care use from medical record data. We also conducted 45 individual, in-depth interviews with PCMH patients (customer-owners), primary care clinicians, health system employees, and tribal leaders.

RESULTS

Emergency care use for all causes was increasing before the PCMH implementation, dropped during and immediately after the implementation, and subsequently leveled off. Emergency care use for adult asthma dropped before, during, and immediately after implementation, subsequently leveling off approximately 5 years after implementation. Emergency care use for unintentional injuries, a comparison variable, showed an increasing trend before and during implementation and decreasing trends after implementation. Interview participants observed improved access to primary care services after the transition to the PCMH tempered by increased staff fatigue. Additional themes of PCMH transformation included the building of relationships for coordinated, team-based care, and the important role of leadership in PCMH implementation.

CONCLUSIONS

All reported measures of emergency care use show a decreasing trend after the PCMH implementation. Before the implementation, overall use and use for unintentional injuries had been increasing. The combined quantitative and qualitative results are consistent with decreased emergency care use resulting from a decreased need for emergency care services due to increased availability of primary care services and same-day appointments.

Demographic and contextual factors associated with inhalant use among youth in rural Alaska

Background

Abuse of harmful legal products that can be inhaled or ingested is a serious and growing problem in many rural Alaskan communities, and particularly so among preteens.

Methods

This study analyses data collected during baseline measurements of a 5-year NIH/NIDA-funded study entitled A Community Trial to Prevent Youth's Abuse of Harmful Legal Products in Alaska. Youth in 8 communities located throughout the state participated in a survey during the fall of 2009 to measure the prevalence and availability of harmful legal products (n=697). The goal of the analysis presented here is to compare the contextual factors of inhalant users and non-users in rural Alaskan communities.

Results

As reported in national surveys of substance use among youth, participants in this study indicated using alcohol more than any other substance. Inhalants were the second-most common substance abused, higher than either cigarettes or marijuana. Lifetime use varied among demographic factors such as age, gender and ethnicity as well as contextual factors including academic performance, parent employment, household living situation and income. When compared to non-users, significantly larger proportions of participants reporting lifetime inhalant use indicated easy availability of inhalants in their home, school and retail outlets. Users were also significantly more likely than non-users to have consumed alcohol.

Conclusion

Results of this study may inform the development of effective interventions in other rural communities.

Promoting prostate-specific antigen informed decision-making. Evaluating two community-level interventions

BACKGROUND

Most medical associations recommend that patients make informed decisions about whether to be screened for prostate cancer with the prostate-specific antigen (PSA) test. Studies assessing how to promote PSA informed decision-making (IDM) have been conducted almost exclusively in healthcare settings; there is a need for similar research in community settings.

METHODS

This paper describes the results of a 5-year study (2002--2007) in which two community-level interventions were developed, implemented, and evaluated in matched upper- and lower-SES comparison communities in Greensboro and Wilmington, North Carolina. Both interventions promoted PSA informed decision-making. One intervention (PSA-Only) consisted of educational information about prostate cancer and the PSA test, and the other (Men's Health) included additional information about recognizing and preventing heart attack, stroke, and colon cancer. Structured survey, semistructured interview, and structured observational data were combined to compare participating community residents' pre/post changes in knowledge, intentions, and behaviors related to PSA IDM.

RESULTS

The community-level interventions successfully engaged community participants in discussions, educated individuals, encouraged deliberation of information, and facilitated PSA test discussions with physicians. Men who participated in the PSA-Only educational sessions were more likely than those who attended the Men's Health educational sessions to discuss the PSA test with their physician (p=0.037).

CONCLUSIONS

When prospective SES-related confounding factors are matched across comparison communities, PSA IDM interventions can be shown to promote IDM. Framing the PSA test decision relative to less-ambiguous screening decisions does not appear to increase the likelihood of PSA IDM.

The impact of pre-therapy extraperitoneal surgical staging on the evaluation and treatment of patients with locally advanced cervical cancer

OBJECTIVE

The use of extraperitoneal surgical staging prior to treatment in patients with bulky or locally advanced cervical cancer allows the detection and treatment of disease beyond the standard pelvic radiation fields. This study was conducted to evaluate the impact of extraperitoneal surgical staging in the treatment and outcome of patients with locally advanced cervical cancer.

METHODS

51 patients with locally advanced cervical cancer treated between 1985 and 1998 were retrospectively reviewed. Information on morbidity, usefulness, and results of surgery and patterns of disease recurrence were obtained. Survival distributions were calculated by the Kaplan-Meier product limit method and compared with the log-rank test.

RESULTS

All 51 women were surgically staged by an extra-peritoneal approach. Preoperative CT scans (n=27) when compared with surgical findings showed sensitivity for pelvic and para-aortic lymph node metastasis of 39%, specificity of 88%, positive predictive value of 39% and negative predictive value of 88%. Lymph node metastases were found in 30/51 patients (59%). There were no significant treatment delays or surgical morbidity as a result of extra-peritoneal surgical staging. In 21 patients (41%), the highest level of involved nodes was in the pelvis and they were treated with pelvic radiation. The para-aortic nodes were involved in nine patients (18%) and were treated with extended field radiation. All patients also received concurrent radiosensitization with chemotherapy. The estimated survival for the entire group was 60% at 5 years. For node negative patients, estimated 5-year survival was 67% while it was 54% for all node positive patients (p=0.17). Analysis according to anatomic site of involved nodes showed that the estimated 2-year and 5-year survival for those with pelvic nodal involvement was 81% and 64%, respectively. However, in the group of nine patients with para-aortic nodal disease, the estimated 2-year survival was 44%. Five (56%) were dead of disease with a median time to death of 16.0 months and four patients (44%) were alive with a median duration of follow up of 16.1 months. There was a statistically significant difference in survival for the group of patients with positive pelvic nodes only compared to the group with positive para-aortic nodes (p=0.03). The estimated 5-year survival by FIGO stage was 80%, 70% and 51% for stages Ib, II, III, disease, respectively. Factors that did not significantly affect survival included age, histology and type of chemotherapy.

CONCLUSIONS

Pre-therapy extra-peritoneal surgical staging resulted in treatment modification in 18% of patients with locally advanced cervical cancer. The morbidity from surgery and subsequent radiation therapy was acceptable. The procedure is recommended to allow for individualization of treatment in patients with local-regional cervical cancer.

Pulmonary resection in metastatic uterine and cervical malignancies

OBJECTIVE

Although thoracotomy for removal of pulmonary metastasis is well documented in a wide variety of solid tumors, data are sparse regarding management of patients with gynecologic malignancies metastatic to the lung.

METHODS

We retrospectively reviewed the Roswell Park Cancer Institute experience between 1982 and 1999. Of 82 eligible patients with gynecologic tumors metastatic and confined to the lung, 25 underwent pulmonary resection.

RESULTS

There were 60 uterine and 22 cervix cancer patients with pulmonary metastases. Among patients with uterine cancer primaries undergoing pulmonary resection (n = 19) median survival was 26 months. Uterine cancer patients who underwent surgical resection for leiomyosarcomas (n = 11) had a median survival of 25 months compared to 46 months in patients with adenocarcinoma (n = 6, P = 0.02). Median survival in cervix cancer patients undergoing resection for pulmonary metastases (n = 6) was 36 months.

CONCLUSIONS

Pulmonary resection may provide a survival advantage for selected patients with uterine and cervical malignancies with metastases isolated to the lung.

Soluble 2-substituted aminopyrido[2,3-d]pyrimidin-7-yl ureas. Structure-activity relationships against selected tyrosine kinases and exploration of in vitro and in vivo anticancer activity

In continuing our search for medicinal agents to treat proliferative diseases, we have discovered 2-substituted aminopyrido[2,3-d]pyrimidin-7-yl ureas as a novel class of soluble, potent, broadly active tyrosine kinase (TK) inhibitors. An efficient route was developed that enabled the synthesis of a wide variety of analogues with substitution on several positions of the template. From the lead structure 1, several series of analogues were made that examined the C-6 aryl substituent, a variety of water solublizing substitutents at the C-2 position, and urea or other acyl functionality at the N-7 position. Compounds of this series were competitive with ATP and displayed submicromolar to low nanomolar potency against a panel of TKs, including receptor (platelet-derived growth factor, PDGFr; fibroblast growth factor, FGFr;) and nonreceptor (c-Src) classes. Several of the most potent compounds displayed submicromolar inhibition of PDGF-mediated receptor autophosphorylation in rat aortic vascular smooth muscle cells and low micromolar inhibition of cellular growth in five human tumor cell lines. One of the more thoroughly evaluated members, 32, with IC50 values of 0.21 microM (PDGFr), 0.049 microM (bFGFr), and 0.018 microM (c-Src), was evaluated in in vivo studies against a panel of five human tumor xenografts, with known and/or inferred dependence on the EGFr, PDGFr, and c-Src TKs. Compound 32 produced a tumor growth delay of 14 days against the Colo-205 colon xenograft model.

Pericardial catheter sclerosis versus surgical procedures for pericardial effusions in cancer patients

BACKGROUND

Approximately 21% of patients with advanced malignancies have cardiac or pericardial involvement with tumor. Controversy exists regarding the optimal approach to the pericardial space when hemodynamic compromise due to effusions occurs.

METHODS

A six-year retrospective review of 59 cancer patients with pericardial effusions.

RESULTS

Thirty-six patients had subxiphoid pericardial window (SXPW) alone (Group A), 5 had pericardial catheter drainage (PCD) followed by a SXPW (Group B), 10 had PCD with sclerosis (Group C), 5 had PCD alone (Group D), 2 had PCD with pericardial-pleural window (Group E), and one had pericardial-peritoneal window (Group F). The method of procedure, complications, number of hospital and ICU days, cytological or pathologic evidence of malignancy, solid versus hematological tumors, and survival were analyzed. The median survival for those patients in group C was one month compared to 4 months for Group A and 6 months for Group B. Essentially, results were similar regardless of method performed with the exception that professional and hospital charges averaged $4830 for SXPW compared to $1625 for PCD.

CONCLUSIONS

Pericardial catheter drainage and sclerosis provides a viable option for the treatment of pericardial effusions in selected cancer patients at markedly reduced cost and patient discomfort.

Risk factors for nodal recurrence after lymphadenectomy for melanoma

BACKGROUND

The risk and outcome of regional failure after elective and therapeutic lymph node dissection (ELND/TLND) for microscopically and macroscopically involved lymph nodes without adjuvant radiotherapy were evaluated.

METHODS

Retrospective melanoma database review of 338 patients (ELND 85, TLND 253) from 1970 to 1996 with pathologically involved lymph nodes.

RESULTS

Regional recurrence occurred in 14% of patients treated with ELND (n = 12) and 28% of patients treated with TLND (n = 72; P = .009). Risk factors associated with nodal recurrence were advanced age, primary lesion in the head and neck region, depth of the primary lesion, number of involved lymph nodes, and extracapsular extension (ECE). For each nodal basin, the ELND group had a lower incidence of recurrence than the TLND group. The TLND group had larger lymph nodes, greater number of involved lymph nodes, and a higher incidence of ECE. The 10-year disease-specific survival was 51% vs. 30% for ELND and TLND, respectively (P = .0005). Nodal basin failure was predictive of distant metastasis, with 87% developing distant disease compared with 54% of patients without nodal recurrence (P < .0001). Of six patients who underwent a second dissection after isolated nodal recurrence, five patients have had a median disease-free interval of 79 months.

CONCLUSIONS

After ELND or TLND, patients who have a large tumor burden (thick primary melanoma, multiply involved lymph nodes, ECE), advanced age, and a primary lesion located in the head and neck have a significantly increased likelihood of relapse and a decreased survival. Few patients present with an isolated nodal recurrence, but the majority can be salvaged by a second dissection.

3-(3,5-Dimethoxyphenyl)-1,6-naphthyridine-2,7-diamines and related 2-urea derivatives are potent and selective inhibitors of the FGF receptor-1 tyrosine kinase

A series of 3-aryl-1,6-naphthyridine-2,7-diamines and related 2-ureas were prepared and evaluated as inhibitors of the FGF receptor-1 tyrosine kinase. Condensation of 4,6-diaminonicotinaldehyde and substituted phenylacetonitriles gave intermediate naphthyridine-2,7-diamines, and direct reaction of the monoanion of these (NaH/DMF) with alkyl or aryl isocyanates selectively gave the 2-ureas in varying yields (23-93%). For the preparation of more soluble 7-alkylamino-2-ureas, a number of protecting groups for the 2-amine were evaluated (phthaloyl, 4-methoxybenzyl) following selective blocking of the 7-amine (trityl), but these were not superior to the (required) 2-tert-Bu-urea group itself. Direct alkylation of the anion of the (unprotected) 7-amino group with excess 4-(3-chloropropyl)morpholine in DMF gave low (10%) yields of the desired product, but alkylation of the 7-acetamido anion, followed by mild alkaline hydrolysis, raised this to 64%. 3-Phenyl analogues were nonspecific inhibitors of isolated c-Src, FGFR, and PDGFR tyrosine kinases, whereas 3-(2,6-dichlorophenyl) analogues were most effective against c-Src and FGFR, and 3-(3,5-dimethoxyphenyl) derivatives showed high selectivity for FGFR alone. A water-soluble (7-morpholinylpropylamino) analogue retained high FGFR potency (IC(50) 31 nM) and selectivity. Pairwise comparison of the 1, 6-naphthyridines and the corresponding known pyrido[2,3-d]pyrimidine analogues showed little differences in potency or patterns of selectivity, suggesting that the 1-aza atom of the latter is not important for activity. A 7-acetamide derivative inhibited the growth of FGFR-expressing tumor cell lines and was particularly potent against HUVECs (IC(50) 4 nM). This compound was also a very potent inhibitor of HUVEC microcapillary formation (IC(50) 0.01 nM) and Matrigel invasion (IC(50) 7 nM) and showed significant in vivo antitumor effects in a highly vascularized mammary adenocarcinoma 16/c model at nontoxic doses. The compounds are worthy of further evaluation as antiangiogenesis agents.

p53 tumor suppressor gene mutations predict decreased survival of patients with sporadic colorectal carcinoma

BACKGROUND

Mutations of the p53 tumor suppressor gene play an integral role in sporadic colorectal carcinogenesis but prior studies have failed to show their prognostic significance consistently.

METHODS

Fifty-six consecutive sporadic colorectal tumors were analyzed for their p53 status. Polymerase chain reaction amplification with primers for exons 5-9 was conducted and these products were subjected to single strand conformation polymorphism analysis. Suspected mutations were confirmed with DNA sequencing. p53 status was entered into a colorectal clinical database and these patients then were followed prospectively. Patient status with regard to disease recurrence and survival was updated every 6 months. Survival and disease free survival were calculated according to the method of Kaplan and Meier. The association between p53 status and clinical and pathologic factors with survival and recurrence was statistically determined using univariate analysis and the Cox proportional hazards model for multivariate analysis.

RESULTS

p53 mutations were detected in 28 of 56 patients (50%). The median follow-up time was 45 months (range, 3-72 months). There were 33 patients (59%) who were alive at last follow-up. Fifteen of the 23 patients who died (65%) had p53 mutations and 8 (35%) had wild-type p53. Thirteen patients developed a disease recurrence, 9 of whom (69%) had tumors with p53 mutations. Overall 4-year survival rates for patients with wild-type p53 and mutant p53 were 71% and 54%, respectively (P = 0.05). The 4-year disease free survival rates for patients with wild-type p53 and mutant p53 were 83% and 62%, respectively (P = 0.09). p53 status and stage were found to be independent significant predictors for survival (p53 negative: P = 0. 02; stage: P = 0.0002.) Stage was found to be the sole significant predictor for disease free survival (P = 0.006).

CONCLUSIONS

In this group of colorectal carcinoma patients, p53 mutations were a significant negative prognostic indicator for overall survival. This finding holds prognostic and therapeutic implications for the management of colorectal carcinoma patients.

Outcome of patients with proximal gastric cancer depends on extent of resection and number of resected lymph nodes

BACKGROUND

Studies have shown that the survival of patients with gastric adenocarcinoma is related to the number of regional lymph nodes with metastases. The probability of identifying node-positive cancers increases with the number of lymph nodes resected and examined. It has been recommended that at least 15 lymph nodes be removed and examined for adequate staging. Prospective randomized studies have shown the lymph node yield is much greater with the D2 resection than the D1. This study evaluated the relative contribution of both the number of resected lymph nodes and the extent of gastric resection (D1/D2) on the outcome of patients with proximal gastric cancer.

METHODS

The medical records of 114 patients with adenocarcinoma of the proximal stomach, who underwent a curative gastric resection, were reviewed. Patients were stratified into four groups, i.e., two groups, D1/D1.5 and D2/D2.5, based on the extent of resection, and two groups based on the number of lymph nodes removed, fewer than 15 lymph nodes and 15 or more lymph nodes. Survival was determined by the method of Kaplan-Meier and differences compared by the log-rank test. Multivariate analysis was performed by using the Cox model.

RESULTS

The number of resected lymph nodes had no effect on the survival of the group as a whole. A significant improvement in survival was noted for patients with a D2 or greater resection. The median survival of patients with 15 or more lymph nodes resected improved from 25 months to 42 months when treated with an extended resection, (D2 or D2.5). Resection of 15 or more lymph nodes alone, or combined with an extended resection, resulted in a statistically significant improvement in survival for patients in American Joint Committee on Cancer Staging (AJCC) stage II.

CONCLUSIONS

Both resection of 15 or more lymph nodes and extended lymphadenectomy contributed to the survival advantage observed in patients with AJCC stage II gastric cancer. The D2 gastric resection prolonged the median survival time and improved the 5-year survival rate for patients with 15 or more resected lymph nodes.

Clinical importance of late recurrence in soft-tissue sarcomas

BACKGROUND AND OBJECTIVES

Soft-tissue sarcomas (STS) represent a diverse histologic group of malignancies at risk for local and distant failure. We studied the impact of late (5 or more years) vs. early recurrence (less than 5 years) on subsequent outcome.

METHODS

Four hundred sixty-eight patients with STS treated between 1962 and 1992 were evaluated for late (n = 39; 8%) or early (n = 253; 54%) recurrence. Clinical and pathologic factors were reviewed. Survival data were analyzed by the Kaplan-Meier method and the log-rank test.

RESULTS

Of the 39 patients with a late recurrence (median follow-up 156 months), 18 patients had local recurrence, 7 patients developed distant recurrence, and 14 patients had local and distant recurrence. Thirty patients with late local and/or distant recurrence underwent complete or wide excision (n = 16), amputation (n = 4), or local resection (n = 10). The overall 5-year survival rate following late recurrence was 61%. The 5-year overall survival rate was statistically better for patients with a late local recurrence alone than for patients with distant failure, 94% vs. 36%, respectively (P = 0.003). Neither the site of the primary STS, age, primary margin status, nor histology had any effect on subsequent local or distant failure and subsequent survival.

CONCLUSIONS

These data suggest that an aggressive approach is appropriate in patients who present with late recurrence (more than 5 years) following treatment of the primary STS. Impressive survival rates can be achieved in the treatment of local recurrences.

Treatment and local control of primary extremity soft tissue sarcomas

BACKGROUND AND OBJECTIVES

Modern series of adult extremity soft tissue sarcomas utilize combinations of modalities in all patients. Remaining questions: 1) is it necessary to strive for wide margins in the multimodality era; 2) to use adjuvant therapy in every high-grade sarcoma? 3) Does previous partial or marginal resection seriously interfere with the definitive resection?

METHODS

In a retrospective review of 194 extremity soft tissue sarcomas (1977-1994), limb preservation was possible in 181/194 (93%) of cases. Patients with narrow margins received adjuvant radiation. Some patients were referred after partial (n = 39) or "complete" (n = 63) excision.

RESULTS

Local recurrence was observed in 181/141 (13%) of patients treated with wide or compartmental resection, and in 10 of 42 (24%) of those treated with conservative resection plus radiation (P = 0.14). The 5-year survival rate for grade III, >/=5-cm sarcomas was not significantly different (P = 0.82) with adjuvant (46%) or without (48%) adjuvant systemic chemotherapy. Five-year survival varied (P = 0.0001) according to grade. Patients referred with partial, or "complete" (63%, 38/63, had residual tumor at reoperation) excision had a local recurrence rate of 8% and 6%, and 5-year survival rates of 75% and 84%, respectively.

CONCLUSIONS

1) It is important to strive for wide margins even when adjuvant radiation is intended. 2) When a wide margin is possible, adjuvant radiation may not be necessary. 3) Adjuvant systemic chemotherapy may be considered for high-grade tumors, preferably within a prospective protocol. 4) A partial or "complete" excision of the tumor before referral to a tertiary center does not appear to compromise the limb preservation, local control, or survival rates of these patients.

Decreased immunoexpression of prostate inhibin peptide in prostatic carcinoma: a study with monoclonal antibody

Prostate inhibin peptide (PIP) is a follicle-stimulating hormone (FSH) regulating peptide produced by the prostate. The mechanism of its endocrine role in regulating prostate growth is believed to be androgen-independent but FSH-dependent. Previous studies using polyclonal antibody proposed PIP as a prostatic-specific marker in cancer diagnosis. However, the recently available monoclonal antibody has not yet been evaluated. Paraffin sections of 72 prostatectomy specimens for prostate cancer with or without hormonal blockage therapy and 10 nonneoplastic prostate tissues from autopsy were stained by using PIP monoclonal antibody (clone: 4A6A6) with the avidin-biotin complex method. PIP reactivity was semiquantitatively estimated in prostatic carcinoma (PCA), prostatic intraepithelial neoplasia (PIN), benign prostatic hyperplasia (BPH) and normal tissue in each case when ever present. Statistical analyses were performed accordingly. PIP expression is predominantly cytoplasmic. Urothelium, seminal vesicles, inflamed prostatic glands, basal cells, and squamous metaplasia were negative for PIP. Average percentage of cells expressing PIP was significantly decreased in PIN (40%) and PCA (14%) when compared with BPH (81%) and normal tissue (68%). There was no correlation of tumor PIP level with patient's age, tumor size, Gleason score, tumor stage, or the usage of preoperative hormonal blockage therapy. PIP monoclonal antibody should be used with caution as a prostate-specific marker in surgical pathology. The mechanism for this alteration and the effect of PIP on prostatic tumor growth, particularly in patients under a variety of hormonal therapies, needs further study.

Operation and photodynamic therapy for pleural mesothelioma: 6-year follow-up

BACKGROUND

Conventional therapy for pleural mesothelioma has met with disappointing results.

METHODS

From 1991 to 1996, 40 patients with malignant pleural mesothelioma were treated with surgical resection followed by immediate intracavitary photodynamic therapy.

RESULTS

The series included 9 women and 31 men with a mean age of 60 years. Morbidity and treatment-related mortality rates for the entire series, pleurectomy, and extrapleural pneumonectomy were 45% and 7.5%, 39% and 3.6%, and 71% and 28.6%, respectively. Median survival and the estimated 2-year survival rate for the entire series, stages I and II patients (n = 13), and stages III and IV patients (n = 24) were 15 months and 23%, 36 months and 61%, and 10 months and 0%, respectively. Multivariate analysis identified stage, length of hospital stay, photodynamic therapy dose, and nodal status as independent prognostic indicators for survival.

CONCLUSIONS

Surgical intervention and photodynamic therapy offer good survival results in patients with stage I or II pleural mesothelioma. For patients in stage III or IV, better treatment modalities need to be developed. Improvements in early detection and preoperative staging are necessary for proper patient selection for treatment.

Is the capacity for lymph node-mediated distant dissemination the same for all nodal groups in malignant melanoma?

This study addresses two hypotheses: (1) that the inherent potential of melanoma metastatic to regional nodal groups for lymph-mediated distant dissemination may not be the same for all nodal groups; and (2) that the risk of distant metastases in patients with clinically involved nodal metastases is higher than in patients with clinically occult nodal metastases. It involved a retrospective chart review of patients with histologically involved axillary or inguinal nodes treated at Roswell Park Cancer Institute (RPCI) (244 patients) or at the participating institutes from the Intergroup Surgical Trial (IST) (108 patients). The distant recurrence rates of 623 melanomas with axillary or inguinal drainage from the IST data were also reviewed. In the RPCI data there was a significant difference in the overall and disease-free survival (P=0.0001) between patients with microscopic versus palpable involvement of the regional nodes in the axilla, while no such difference was observed for patients with groin metastases (P=0.30 and 0.36, respectively). The same trend was noted in the IST data. In the latter data the distant recurrence rate for melanomas drained via the axilla was significantly higher (P=0.026) than for those drained by the groin. In conclusion, lymph-mediated distant dissemination may be more aggressive from the axilla than from the groin in melanoma.

2-Substituted aminopyrido[2,3-d]pyrimidin-7(8H)-ones. structure-activity relationships against selected tyrosine kinases and in vitro and in vivo anticancer activity

While engaged in therapeutic intervention against a number of proliferative diseases, we have discovered the 2-aminopyrido[2, 3-d]pyrimidin-7(8H)-ones as a novel class of potent, broadly active tyrosine kinase (TK) inhibitors. An efficient route was developed that enabled the synthesis of a wide variety of analogues with substitution on several positions of the template. From the lead structure 2, a series of analogues bearing variable substituents at the C-2 position and methyl or ethyl at N-8 was made. Compounds of this series were competitive with ATP and displayed submicromolar to low nanomolar potency against a panel of TKs, including receptor (platelet-derived growth factor, PDGFr; fibroblast growth factor, FGFr; epidermal growth factor, EGFr) and nonreceptor (c-Src) classes. One of the more thoroughly evaluated members was 63 with IC50 values of 0.079 microM (PDGFr), 0.043 microM (bFGFr), 0.044 microM (EGFr), and 0.009 microM (c-Src). In cellular studies, 63 inhibited PDGF-mediated receptor autophosphorylation in a number of cell lines at IC50 values of 0.026-0.002 microM and proliferation of two PDGF-dependent lines at 0.3 microM. It also caused inhibition of soft agar colony formation in three cell lines that overexpress the c-Src TK, with IC50 values of 0.33-1.8 microM. In in vivo studies against a panel of seven xenograft tumor models with known and/or inferred dependence on the EGFr, PDGFr, and c-Src TKs, compound 63 produced a tumor growth delay of 10.6 days against the relatively refractory SK-OV-3 ovarian xenograft and also displayed activity against the HT-29 tumor. In rat oral bioavailability studies, compound 63 plasma concentrations declined in a biexponential manner, and systemic plasma clearance was high relative to liver blood flow. Finally, in rat metabolism studies, HPLC chromatography identified two metabolites of 63, which were proved by mass spectrometry and synthesis to be the primary amine (58) and N-oxide (66). Because of the excellent potency of 63 against selected TKs, in vitro and in vivo studies are underway for this compound in additional tumor models dependent upon PDGFr, FGFr, and c-Src to assess its potential for advancement to clinical trials.

Anterior compartment resection of the thigh in soft-tissue sarcomas

AIMS

Soft-tissue sarcomas of the anterior thigh present technical problems due to the proximity of the femoral vessels, and the disability caused by a standard anterior compartment resection.

METHODS

We treated 44 consecutive patients with primary sarcomas in the anterior thigh with wide resection (n = 15), and modified (n = 26) or standard (n = 3) compartment resection. No patient had amputation as primary treatment.

RESULTS

The overall rate of local recurrence was 6/44 (14%). Local recurrence was observed in 1/3 patients with standard anterior compartment resection and 5/41 (12%) of those with wide excision or modified compartment resection. It was noted in 1/6 (17%) patients with adjuvant radiation and 5/38 (13%) of those treated with surgery alone. One of six patients with local recurrence required amputation. The 5-year survival rate was 66% varying significantly according to grade.

CONCLUSIONS

Limb preservation was possible in 98% of patients. Wide resection or modified compartment resection was feasible in the majority (93%) of patients resulting in improved function.

Soft tissue sarcomas of the hand and foot: management and survival

BACKGROUND

Soft tissue sarcomas of the hands and feet present a challenge for limb-preserving resections.

METHODS

A retrospective review of 19 patients with sarcomas of the hand or foot was done. Wide or local excision was performed in 14 patients (74%), and amputation in 5 patients (26%). Of the latter group, three amputations involved a digit or toe, and two (10%) were major amputations (one Syme amputation and one below-knee amputation). When the minimum surgical margin was narrow (1 to 2 mm), adjuvant radiation was given postoperatively (n = 4).

RESULTS

Local recurrence was observed in four patients (21%). Two of these required an amputation for local control. Local recurrence was observed in one of four patients (25%) treated with marginal resection and radiation and three of 15 (20%) of those with resection alone.

CONCLUSIONS

A sizable percentage (37%) of patients with soft tissue sarcomas of the hand and foot ultimately required an amputation, although often the amputation was a minor one involving only a toe or a digit. Limb preservation was successful in the majority of patients (63%). The local recurrence rate was 21%, which may be improved with more frequent use of adjuvant therapy. The 5-year survival rate was 82%, which is better than that usually quoted for overall extremity soft tissue sarcomas.

Intraoperative determinants of unresectability for patients with colorectal hepatic metastases

BACKGROUND

Intrahepatic and extrahepatic factors are utilized by the surgeon in the decision-making process for the performance of hepatic resection for patients with colorectal metastases. Accurate preoperative and intraoperative staging are mandatory to avoid unnecessary surgery. In this report the intraoperative determinants of hepatic unresectability were evaluated.

METHODS

This was a retrospective review of medical records from January 1985 to March 1996 of 62 patients with colorectal hepatic metastases who at the time of exploratory laparotomy were deemed to have unresectable disease based on intrahepatic or extrahepatic factors. The stage of the primary tumor, disease free interval, preoperative carcinoembryonic antigen, computed tomography portography, intraoperative ultrasound, and assessment of intrahepatic and extrahepatic tumor extension were evaluated.

RESULTS

Intraoperative determination of the extent of required hepatic resection, including trisegmentectomy (9 patients; 15%) and total hepatectomy (10 patients; 16%), accounted for the majority of unresectable patients. Patients with > 4 metastases (8 patients; 13%) and satellitosis (6 patients; 10%) accounted for 23% of unresectable patients. Four patients had extensive nonmalignant hepatic parenchymal disease precluding resection. Thorough abdominal exploration revealed extrahepatic disease in 13 of 62 patients (21%). Routine periportal/celiac lymph node biopsies revealed metastases in an additional 12 patients (19%), 7 of whom (11%) had only periportal/celiac lymph node metastases.

CONCLUSIONS

A meticulous abdominal exploration prior to hepatic resection for patients with colorectal metastases is essential to identify those patients with extrahepatic disease. Periportal and celiac lymph nodes commonly are involved by tumor. Therefore, routine periportal/celiac lymph node biopsies should be performed in the absence of other extrahepatic disease.

Five-year survival after second-line cisplatin-based intraperitoneal chemotherapy for advanced ovarian cancer

BACKGROUND

To evaluate the 5-year survival rates of second-line intraperitoneal chemotherapy in advanced-staged ovarian cancer.

MATERIALS AND METHODS

Between August 1985 and September 1991, 63 patients with advanced epithelial ovarian cancer received intraperitoneal cisplatin and cytarabine chemotherapy as second-line treatment.

RESULTS

The median survival from the time of initiation of intraperitoneal chemotherapy (IPC) was 29.1 months. A significant advantage in 5-year survival (40%) and 5-year progression-free survival (37%) was observed among 21 patients who demonstrated a response to first-line and second-line treatment compared to those who demonstrated a response to first-line treatment only (6 and 0%, respectively) (P < 0.0001). No patient (n = 13) who failed to respond to either first-line or second-line treatment survived for 5 years. Among 42 patients with < or = 5 mm residual disease at the time of initiation of IPC, 5-year survival was 36% and 5-year progression-free survival was 31%, while no patient (n = 21) with residual disease measuring > 5 mm at the initiation of IPC survived 5 years (P < 0.0001).

CONCLUSION

Given the limitation that this is not a randomized trial, the data appear to indicate that salvage platinum-based intraperitoneal chemotherapy results in significant 5-year survival and progression-free survival in selected patients who initiated therapy with small (< or = 5 mm) tumor burden. These survival rates as second-line therapy approach those achieved by first-line platinum-based intravenous chemotherapy in patients with advanced-stage ovarian cancer with similar small residual disease at the initiation of therapy.

Intraperitoneal chemotherapy in disseminated abdominal sarcoma

BACKGROUND

There is no information in the literature concerning the use of cytoreductive surgery with intraperitoneal chemotherapy for sarcomas disseminated intraabdominally.

METHODS

A prospective study was initiated of exploratory laparotomy, removal of all macroscopic tumor when feasible, and intraperitoneal chemotherapy with cis-DDP 100 mg/m2 every 4 weeks. Patients were to be explored in 6 months or earlier for detectable tumor recurrence. Twenty-eight consecutive patients enrolled in the study.

RESULTS

Complete resection of all macroscopic tumor was possible in 79% of patients. Survival rates at years 1-5 were 54%, 21%, 7%, 7%, and 7%, respectively. Of the two long-term survivors, one was found to be disease free at the second-look operation with a catheter free of adhesions, whereas the other had recurrent disease and all her lesions were resected. Of 20 patients who underwent a second-look procedure, the Tenkhoff intraperitoneal catheter was found to be densely surrounded by adhesions in 19. In the 19 patients with adhesions, there was no tumor around the catheter for a radius of 15-20 cm, but the rest of the peritoneal cavity contained multiple tumor nodules.

CONCLUSION

Removal of all macroscopic tumor is possible in 79% of the patients with sarcoma disseminated in the abdominal cavity. Intraperitoneal chemotherapy with cis-DDP after cytoreductive surgery resulted in a 5-year survival rate of only 7%.

Tourniquet infusion chemotherapy for extremity in-transit lesions in malignant melanoma

BACKGROUND

Perfusion remains the standard of regional chemotherapy for extremity in-transit lesions from melanoma. However, there is an interest in other forms of intraarterial chemotherapy due to the simplicity and feasibility of repeat administration of the latter.

METHODS

Review of 51 patients with extremity in-transit lesions from melanoma treated with the tourniquet infusion (TI) method on the basis of a prospective protocol. Drugs used were either Adriamycin (group A) or Dacarbazine (DTIC) + cisDDP (group B). The median number of courses was two. Lesions were resected at the same time as TI (n = 27) or after a month or more of observation in the absence of complete regression.

RESULTS

There was no significant difference in response rates between groups A and B. The overall objective response rate in 24 evaluable patients was 75%, being complete in seven (29%), partial (> 50%) in 11 (46%), minor (< 50%) in three (12.5%), and progression of disease in three (12.5%). At a mean follow-up time of 40 months, no recurrence was observed in the treated extremity in 18 patients (35%), but further recurrences were noted in 31 patients (61%). The 5-year survival rate was 30%.

CONCLUSION

TI provides an objective response rate of 75% for in-transit lesions, but after TI and resection of in-transit lesions as needed, the recurrence rate in the treated extremity is high (61%). Further work is needed with higher drug doses, local hyperthermia, or the administration of suitable doses of new regimens that are more successful with perfusion.

Survival benefit of extended D2 resection for proximal gastric cancer

BACKGROUND

The long-term survival of patients with adenocarcinoma of the proximal stomach remains dismal. Despite its increasing frequency and poor prognosis, a general consensus has not been reached on the extent of surgical resection. The significance of extended lymph node dissection (D2 gastrectomy) for the surgical treatment of patients with proximal gastric cancer was evaluated.

METHODS

Sixty-two patients who underwent a potentially curative total or proximal gastric resection were retrospectively divided by extent of lymphadenectomy into two groups: the extended resection group (D2,D2.5) and limited resection group (D1,D1.5). Survival rates were estimated by the method of Kaplan and Meier [J Am Stat Assoc 53:457-486, 1958] and the differences compared by the log rank test. Multivariate analysis of prognostic parameters was performed using the Cox proportional hazard model.

RESULTS

The median overall survival time for the extended resection group (D2,D2.5) was 34 months compared to 18 months for patients treated by a more limited resection (D1,D1.5). Patients treated with extended resection had an estimated 5-year overall survival rate of 37% compared to 21% for patients treated with limited resection. This difference was statistically significant with a P value of 0.04. The median disease-free interval for the extended resection group was 31 months compared to 17.6 months for patients in the limited resection group. The 5 year disease-free survival rate for both groups was 37% and 17%, respectively (P = 0.09). Extent of lymphadenectomy and stage of disease were found to be independent predictors of overall and cancer-free survival.

CONCLUSIONS

Patients treated with an extended lymph node dissection (D2 gastrectomy) were more likely to survive 5 years, had longer disease-free intervals, and prolonged median survival times (particularly patients with T1-3,N0-1,M0 cancers) as compared to those patients treated with a more limited lymph node dissection (D1,D1.5). These differences reached or approached statistical significance.

Survival benefit of extended D2 resection for proximal gastric cancer

BACKGROUND

The long-term survival of patients with adenocarcinoma of the proximal stomach remains dismal. Despite its increasing frequency and poor prognosis, a general consensus has not been reached on the extent of surgical resection. The significance of extended lymph node dissection (D2 gastrectomy) for the surgical treatment of patients with proximal gastric cancer was evaluated.

METHODS

Sixty-two patients who underwent a potentially curative total or proximal gastric resection were retrospectively divided by extent of lymphadenectomy into two groups: the extended resection group (D2,D2.5) and limited resection group (D1,D1.5). Survival rates were estimated by the method of Kaplan and Meier [J Am Stat Assoc 53:457-486, 1958] and the differences compared by the log rank test. Multivariate analysis of prognostic parameters was performed using the Cox proportional hazard model.

RESULTS

The median overall survival time for the extended resection group (D2,D2.5) was 34 months compared to 18 months for patients treated by a more limited resection (D1,D1.5). Patients treated with extended resection had an estimated 5-year overall survival rate of 37% compared to 21% for patients treated with limited resection. This difference was statistically significant with a P value of 0.04. The median disease-free interval for the extended resection group was 31 months compared to 17.6 months for patients in the limited resection group. The 5 year disease-free survival rate for both groups was 37% and 17%, respectively (P = 0.09). Extent of lymphadenectomy and stage of disease were found to be independent predictors of overall and cancer-free survival.

CONCLUSIONS

Patients treated with an extended lymph node dissection (D2 gastrectomy) were more likely to survive 5 years, had longer disease-free intervals, and prolonged median survival times (particularly patients with T1-3,N0-1,M0 cancers) as compared to those patients treated with a more limited lymph node dissection (D1,D1.5). These differences reached or approached statistical significance.

Rectal cancer risk in hereditary nonpolyposis colorectal cancer after abdominal colectomy. International Collaborative Group on HNPCC

OBJECTIVE

The authors analyzed the incidence of rectal cancer in patients with hereditary nonpolyposis colorectal cancer (HNPCC) after an abdominal colectomy.

SUMMARY BACKGROUND DATA

The treatment of choice for a newly diagnosed patient with HNPCC with colon cancer is an abdominal colectomy. The incidence of rectal cancer after abdominal colectomy in HNPCC is not known.

MATERIALS AND METHODS

A questionnaire was mailed to all International Collaborative Group on HNPCC members to identify patients in whom rectal cancer developed after total, subtotal or completion colectomy. Statistics were performed using the log-rank test, Kaplan-Meier method, and Cox's proportional hazards model.

RESULTS

Rectal cancer developed in 8 (11%) of 71 patients a median of 158 months (range, 38-282 months) from their primary procedure. Of these eight patients, adenomas in the rectal mucosa developed in five at risk either before (4) or synchronous (1) with the diagnosis of rectal cancer. At the time of diagnosis of rectal cancer, six of eight patients were being observed. Age at first procedure and whether the patient was under surveillance were the only significant variables (p < 0.05) in the multivariate analysis in terms of rectal cancer risk. The risk of developing rectal cancer was estimated to be 3% every 3 years after abdominal colectomy for the first 12 years.

CONCLUSIONS

The risk of rectal cancer in patients with HNPCC after an abdominal colectomy is approximately 12% at 12 years. Age at first surgical procedure and surveillance correlated with rectal cancer risk. Aggressive endoscopic surveillance of the rectum should be performed after abdominal colectomy.

Lack of improved survival plus increase in thromboembolic complications in patients with clear cell carcinoma of the ovary treated with platinum versus nonplatinum-based chemotherapy

BACKGROUND

This study was conducted to evaluate survival rates for patients with clear cell ovarian carcinoma who had platinum-based chemotherapy versus nonplatinum-based chemotherapy and the risk of thromboembolic complications.

METHODS

One hundred and eleven evaluable patients with clear cell ovarian carcinoma who underwent primary surgery and postoperative therapy were retrospectively evaluated. Median follow-up was 21.3 months (range, 3-280 months). Patients treated with platinum-based chemotherapy and nonplatinum-based chemotherapy were evaluated according to stage, age, grade, extent of surgery, and development of thromboembolic complications. Patient populations were compared using the chi-square test. Estimated 5- and 10-year survivals for each group were calculated using the method of Kaplan and Meier. Differences in survival rates were calculated using the log rank test. The frequency of thromboembolic complications in the clear cell ovarian carcinoma group was compared with its frequency in a matched-control group of 109 patients with epithelial nonclear cell ovarian carcinoma.

RESULTS

Seventy-one patients were treated with nonplatinum-based chemotherapy and 40 patients were treated with platinum-based chemotherapy. There was no statistically significant difference in the characteristics of patient populations treated with platinum-based chemotherapy or nonplatinum-based chemotherapy. The estimated 5-year survival for clear cell ovarian carcinoma patients treated with platinum-based chemotherapy did not differ significantly from the estimated 5-year survival for patients with clear cell ovarian carcinoma treated with nonplatinum-based chemotherapy (36% vs. 32%; P = 0.23). Twelve patients with clear cell ovarian carcinoma developed thromboembolic complications remote from primary surgery, whereas in a matched-control group of patients with nonclear cell ovarian carcinoma treated with platinum-based chemotherapy, no patients developed a thromboembolic complications (P = 0.0004). Eight of 40 patients (20%) with clear cell ovarian carcinoma treated with platinum-based chemotherapy developed thromboembolic complications, whereas 4 of 71 patients (6%) treated with nonplatinum-based chemotherapy developed thromboembolic complications (P = 0.03). Multivariate logistic regression analysis demonstrated that the development of a thromboembolic complication was significantly related to clear cell ovarian carcinoma and platinum-based chemotherapy and had a significant (P = 0.009) negative impact on survival.

CONCLUSIONS

Platinum-based chemotherapy did not appear to improve survival compared with nonplatinum-based chemotherapy of patients with clear cell ovarian carcinoma. The combination of platinum-based chemotherapy and clear cell ovarian carcinoma significantly increases the risk for thromboembolic complications and has a significant negative impact on survival.

Complications and outcome of external hemipelvectomy in the management of pelvic tumors

BACKGROUND

Although the technique of external hemipelvectomy has been adequately described, little is known about its complications and late results.

DESIGN

Retrospective review of 68 external hemipelvectomies performed at our Institute between 1973 and 1994.

MATERIALS AND METHODS

Eleven patients had bone tumor; 39 patients, soft-tissue sarcoma; seven patients, melanoma; 10 patients, squamous cell carcinoma; and one patient, giant neurofibroma. In 48 (71%) patients, the intent was curative. In 17 cases, the hemipelvectomy was extended.

RESULTS

Postoperative complications occurred in 36 (53%) patients, including flap necrosis in 11 (16%), wound infection in 24 (35%), and other complications in 12 (18%). Four (6%) patients died postoperatively. The average hospital stay after curative versus palliative resection was 39 versus 24 days. Only three (5%) patients were able to use a prosthesis, whereas 55 (81%) used crutches, six (9%) remained wheelchair bound, and four patients (6%) spent most of the time in bed. Local recurrence occurred in 35% of the patients. The estimated 5-year survival for curatively resected patients was 21%.

CONCLUSIONS

External hemipelvectomy is a procedure with considerable morbidity and is indicated for only a minority of far-advanced tumors. It offers a chance of palliation and possibly cure when lesser surgical options have been exhausted.

Local recurrence and survival in soft-tissue sarcomas

BACKGROUND

There is a continuous interest in the literature concerning the management and survival after treatment of local recurrence in sarcomas because it is one of the most common types of recurrence.

DESIGN

We retrospectively reviewed 93 patients treated for local recurrence from soft-tissue sarcoma.

METHODS

We evaluated prognostic parameters (grade, tumor size, location) and the effect of treatment on survival.

RESULTS

Resection of all the gross tumor at first visit to our Institute for local recurrence was accomplished in 88 patients (95%). Of the 59 patients with extremity tumors, six (10%) required an amputation. At a mean follow-up of 66 months, further local recurrence was noted in 27%. The estimated 5-year survival rate was 100% for patients with grade I tumors (n = 16), 77% for grade II (n = 31), and 45% for grade III tumors (n = 46) (p = 0.0002). This value was 78% for tumors < or = 5 cm and 57% for those > 5 cm (p = 0.03).

CONCLUSIONS

Local recurrence is resectable and limb preservation is possible in the majority of patients. The overall 5-year survival rate was 65%. Survival after treatment of local recurrence is determined mainly by the grade and secondarily by the size of the tumor as for primary sarcomas.

Positive deep nodes in the groin and survival in malignant melanoma

A review of 48 consecutive patients with positive deep nodes in the groin and positive inguinal nodes from malignant melanoma was carried out. The deep nodes were enlarged (>2 cm) in 60% of the patients. The estimated 5-year survival rate following dissection of the deep nodes was 34%, 31% for those with palpable nodes (n=40) and 50% for those with non-palpable (n=8) inguinal nodes (P=0.13). The overall 10-year survival rate was 25%. Involvement of the deep (iliac or obturator) nodes in malignant melanoma does not indicate systemic dissemination for all patients, as an appreciable percentage attains long-term survival after a thorough dissection of these nodes.

Major vessel resection during limb-preserving surgery for soft tissue sarcomas

There is uncertainty in the literature as to whether major vessel involvement in extremity soft tissue sarcomas constitutes an indication for amputation. This retrospective review includes 21 patients who underwent major vessel resection in the context of limb preservation for soft tissue sarcomas. Resected vessels were the common iliac in one, external iliac and common femoral in six, common and superficial femoral in five, superficial femoral in six, distal superficial and popliteal in two, and subclavian vessels in one. Wound infection occurred postoperatively in five patients (24%). One Gore-tex and one vein graft became exposed, but the wounds healed by secondary intention with routine wound care. Three patients (14%) manifested local recurrence, of which one required an amputation. The estimated 5-year survival rate is 63%. Involvement of major vessel(s) by soft tissue sarcomas of the extremities is not in itself an indication for amputation, as with en bloc resection of major vessels the local recurrence and 5-year survival rates parallel those of patients with soft tissue sarcomas not requiring major vessel resection.

Resectability and survival in retroperitoneal sarcomas

BACKGROUND

Retroperitoneal sarcomas historically have presented difficulties in their management due to a high rate of unresectability, which affects the survival of these patients.

METHODS

We retrospectively reviewed the charts of 87 consecutive patients with retroperitoneal sarcomas treated in the period 1977-1994.

RESULTS

The resectability rate was 100% for the primary tumors (n = 55) and 87% for the locally recurrent tumors (n = 32). The 5-year survival rate was 63% (66% for the primary tumors and 57% for those with local recurrence). The 10-year survival rate was 46% (57% for primary tumors and 26% for those referred with locally recurrent tumor). The overall local recurrence rate was 31% (25% for the primary tumors and 41% for those referred with local recurrence); it was 56% after local excision and 15% after wide resection (p = 0.0003). The 10-year disease-free survival of patients with local excision (n = 25) was 7%, and that of patients with wide resection (n = 54) 59% (p = 0.0001).

CONCLUSIONS

The overall resectability rate of retroperitoneal sarcomas was 95%. Wide resection produced a significantly higher survival rate compared with that of local excision. The survival rate for the primary tumors, varying significantly with the histologic grade, approached the rate reported for primary soft-tissue sarcomas of the extremity.

Lack of effect of corticosteroids and tamoxifen on suramin protein binding and in vitro activity

Stout and colleagues [Proc Am Assoc Cancer Res 1993, 34, p. 298] previously reported that both hydrocortisone and tamoxifen increased the free fraction of suramin in human plasma. We examined several corticosteroids as well as tamoxifen for their effects on suramin protein binding and also evaluated hydrocortisone for its ability to modulate suramin activity in PC-3 and MCF-7 cells. Greater than 99% of the suramin was protein bound in undiluted human plasma. However, the free fraction of suramin was increased with the reduced plasma protein levels and increased suramin concentrations. At concentrations ranging from 1 to 30 microM, neither tamoxifen, hydrocortisone, prednisone nor dexamethasone had any effect on the binding of suramin to human plasma, regardless of protein concentrations. Similar results were observed with fetal calf serum. Hydrocortisone also had no effect on suramin activity against PC-3 and MCF-7 cell in vitro. We conclude from these studies that neither corticosteroids nor tamoxifen affect suramin protein binding or its cytotoxic activity.

Resectability of retroperitoneal sarcomas: a matter of surgical technique?

The management of retroperitoneal sarcomas has been hampered by the difficulty in complete resection, the resectability rate in the literature being about 53%. In a review of the last 88 consecutive patients with retroperitoneal sarcomas the resectability rate was 95%. At a mean follow-up of 48 months, the local recurrence rate was 17% following wide resection and 59% following local excision (P = 0.0002). For patients with minimum follow-up of 5 years, the local recurrence rate was 39% for those with primary tumours and 57% for those referred with local recurrence. Local recurrence diminished the rate of long-term survival. The 5- and 10-year survival rates for the primary retroperitoneal sarcomas (n = 55) were 66% and 57% and for those referred with locally recurrent sarcoma (n = 33) 57% and 26%, respectively. The 5-year survival rate varied significantly with the grade of the tumour, from 88% for Grade I to 44% for Grade III tumours (P = 0.006). In conclusion, with modern surgical techniques the resectability rate of retroperitoneal sarcomas is about 95%, and the survival rate of the primary tumours approximates that of the primary soft tissue sarcomas of the extremities.

Cisplatin, adriamycin, etoposide, megestrol acetate versus melphalan, 5-fluorouracil, medroxyprogesterone acetate in the treatment of endometrial carcinoma

Fifty consecutive patients with documented advanced or recurrent endometrial carcinoma from 1978 through 1985 were prospectively treated with melphalan, 5-fluorouracil, medroxyprogesterone acetate (MFP) as first-line chemotherapy. From 1987 through 1993, 50 consecutive patients with documented advanced or recurrent endometrial carcinoma were prospectively treated with cisplatin, Adriamycin, etoposide, megestrol acetate (PAV-M) as first-line chemotherapy. Response rates for MFP versus PAV-M, 2- and 5-year survival, median survival, 2- and 5-year progression-free survival, and median progression-free survival were not statistically different. However, there was a significant improvement favoring PAV-M in 2-year (45 versus 14%), 5-year (30 versus 5%), and median survival (22.3 versus 8.7 months) (P = 0.008) compared to MFP in patients with primary advanced endometrial adenocarcinoma. Moreover, there was a significant improvement in 2- and 5-year and median survival (55 and 15% and 26.7 months) for PAV-M compared to MFP (7 and 0% and 7.3 months) (P = 0.002) for the more aggressive other adenocarcinomas (adenosquamous, clear cell, papillary serous, undifferentiated) compared to the more common endometrioid adenocarcinoma. The current data suggest that cisplatin- and adriamycin-based chemotherapy results in some long-term survival benefit for patients with primary advanced endometrial adenocarcinoma and the more aggressive nonendometrioid adenocarcinoma histologies.

Retroperitoneal sarcomas and their management

BACKGROUND

Retroperitoneal sarcomas historically have presented difficulties in their management due to a high rate of unresectability.

OBJECTIVE

To determine prognostic parameters, resectability, and survival of these patients in a more recent period.

DESIGN

Retrospective review, with a mean follow-up of 47 months.

SETTING

Tertiary care cancer institute.

PATIENTS

The charts of 90 consecutive patients with retroperitoneal sarcomas treated in the period from 1977 to 1995. No patient referred with a localized retroperitoneal sarcoma was excluded from this review.

RESULTS

The resectability rate was 100% for the primary tumors (n = 57) and 88% for the tumors initially presenting as local recurrence (n = 33). The 5-year survival rate was 63% (66% for patients with primary tumors and 57% for those with local recurrence). The 10-year survival rate was 46% (57% for patients with primary tumors and 26% for those referred with local recurrence). The local recurrence rate was 25% for primary tumors and 39% for tumors initially presented as local recurrence (overall rate, 30%); it was 56% after local excision and 16% after wide or radical resection (P < .001). The 5- and 10-year survival rates were 72% and 61%, respectively, for those with wide resection and 55% and 23%, respectively, for those with local excision (P = .01).

CONCLUSIONS

With modern surgical techniques, the overall resectability rate of retroperitoneal sarcomas is 96%. The ensuing survival, affected significantly by the histologic grade, approaches that for the extremity sarcomas.

Various types of hemipelvectomy for soft tissue sarcomas: complications, survival and prognostic factors

Fifty-three hemipelvectomies were performed for primary or recurrent soft tissue sarcomas with fixation to the pelvis or peripelvic tissues. Resection was carried out in the absence of distant metastases in 70% of the cases. The hemipelvectomy was posterior in 66%, anterior in 6% and internal in 28%. Post-operative complications included wound edge necrosis in 19% and infection in 43% of cases. The mortality rate was 5.7%. Margins were macroscopically clear in 76% and marginal in 24% of cases. Tumours were high grade in 92%; their mean diameter was 16.5 cm. Local recurrence occurred in 19% and distant recurrence in 66% of patients. Overall survival was 39% at 2 years and 10% at 5 years. Pelvic soft tissue sarcomas have a poor prognosis. However, in the absence of other effective therapy, hemipelvectomy provides local control with acceptable morbidity in the majority of patients, with a small percentage (10%) surviving 5 years or longer.

Use of a mesh for musculoaponeurotic defects of the abdominal wall in cancer surgery and the risk of bowel fistulas

BACKGROUND

Enterocutaneous fistulas resulting from mesh reconstruction of full-thickness musculoaponeurotic abdominal defects in benign conditions is a relatively infrequent, but serious complication.

STUDY DESIGN

In the period 1977 to 1986, 26 patients with abdominal wall defects due to ablative surgery for carcinoma had repair with prosthetic material without any special effort to interpose tissue between bowel loops and the mesh. In the period 1986 to 1992, 30 patients with similar defects had tissue interposition between the bowel loops and the mesh (four patients had a free peritoneal patch). In an experimental study, 11 rabbits had an abdominal wall defect repaired with mesh alone, and 14 other rabbits had the abdominal wall defect repaired with the mesh plus a free peritoneal patch sutured underneath.

RESULTS

In the first group of patients, six (23 percent) of 26 had enterocutaneous fistulas develop, in the second group zero (zero percent) of 30 had a fistula develop (p = 0.007). In the experimental study, the first group (ten of 11 rabbits) had dense adhesions develop between bowel loops and the mesh. In the second group, none of the 14 rabbits had adhesions develop (p < 0.0001).

CONCLUSIONS

In full-thickness abdominal wall defects, omentum, muscle flap, or a peritoneal patch sewn under a mesh prevent fistula formation.

Partial and complete internal hemipelvectomy: complications and long-term follow-up

BACKGROUND

The complications and long-term follow-up results of internal hemipelvectomy are not well documented.

STUDY DESIGN

We reviewed 32 internal hemipelvectomies performed between 1976 and 1994.

RESULTS

The pathologic diagnoses were soft tissue sarcoma in 15 cases, bone tumor in 14 cases, melanoma in two cases, and carcinoma in one of the cases. In 24 cases, the intent of surgery was curative; in 22 cases, the procedure was modified. Average blood loss was 3.2 L; the procedure took on average 7.5 hours. Complications included skin flap necrosis in four cases, infection in 15 cases, and various other complications in five cases. Three mortalities (9 percent) occurred. Thirty-four percent of the patients ambulated without any assistance, 59 percent ambulated with crutches, while 7 percent remained wheel-chair bound. The survival rate after resection for cure was 45 percent at ten years compared with 29 percent at two years for palliative resections.

CONCLUSIONS

Internal hemipelvectomy is a complex procedure that is functionally and cosmetically superior to external hemipelvectomy and, when done with curative intent, results in considerable long-term survival rates.