Consensus guidelines from The American Society of Peritoneal Surface Malignancies on standardizing the delivery of hyperthermic intraperitoneal chemotherapy (HIPEC) in colorectal cancer patients in the United States

BACKGROUND

The American Society of Peritoneal Surface Malignancies (ASPSM) is a consortium of cancer centers performing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). This is a position paper from the ASPSM on the standardization of the delivery of HIPEC.

METHODS

A survey was conducted of all cancer centers performing HIPEC in the United States. We attempted to obtain consensus by the modified method of Delphi on seven key HIPEC parameters: (1) method, (2) inflow temperature, (3) perfusate volume, (4) drug, (5) dosage, (6) timing of drug delivery, and (7) total perfusion time. Statistical analysis was performed using nonparametric tests.

RESULTS

Response rates for ASPSM members (n = 45) and non-ASPSM members (n = 24) were 89 and 33 %, respectively. Of the responders from ASPSM members, 95 % agreed with implementing the proposal. Majority of the surgical oncologists favored the closed method of delivery with a standardized dual dose of mitomycin for a 90-min chemoperfusion for patients undergoing cytoreductive surgery for peritoneal carcinomatosis of colorectal origin.

CONCLUSIONS

This recommendation on a standardized delivery of HIPEC in patients with colorectal cancer represents an important first step in enhancing research in this field. Studies directed at maximizing the efficacy of each of the seven key elements will need to follow.

Is there a role for curative surgery for pelvic recurrence from rectal carcinoma in the presence of hydronephrosis?

BACKGROUND

The prognosis for patients with recurrent rectal adenocarcinoma is not uniformly fatal if one can safely and selectively reoperate on a subset of patients with resectable disease. Even with careful selection, many patients undergo exploratory laparotomy and do not have resectable disease. We have reported that the presence of hydronephrosis in the setting of recurrent rectal carcinoma portends a poor outcome because of invariable association with unresectable disease. The purpose of this study was to update our experience of patients presenting with unilateral or bilateral hydronephrosis and recurrent rectal cancer.

METHODS

A retrospective chart review of 142 patients with recurrent rectal cancer evaluated at our institution from January 1989 to December 1999 was performed.

RESULTS

Twenty-seven of 142 patients referred for the management of recurrent rectal cancer had unilateral or bilateral hydronephrosis. Fifteen (55%) of these patients had distant metastatic disease. Twelve patients (45%) with hydronephrosis and local recurrent disease on evaluation were analyzed. Six of the 12 patients underwent exploratory laparotomy, with none found to have resectable disease. Their mean survival after diagnosis of recurrent disease was 14 months.

CONCLUSIONS

Based on our results, the presence of hydronephrosis (unilateral or bilateral) in recurrent rectal adenocarcinoma portends a survival equivalent to the presence of distant metastasis. Therefore, we do not believe potential curative surgery has a role for patients with locally recurrent rectal adenocarcinoma in the presence of hydronephrosis.

Guidelines 2000 for colon and rectal cancer surgery

BACKGROUND

Oncologic resection techniques affect outcome for colon cancer and rectal cancer, but standardized guidelines have not been adopted. The National Cancer Institute sponsored a panel of experts to systematically review current literature and to draft guidelines that provide uniform definitions, principles, and practices.

METHODS

Methods were similar to those described by the American Society of Clinical Oncology in developing practice guidelines. Experts representing oncology and surgery met to review current literature on oncologic resection techniques for level of evidence (I-V, where I is the best evidence and V is the least compelling) and grade of recommendation (A-D, where A is based on the best evidence and D is based on the weakest evidence). Initial guidelines were drafted, reviewed, and accepted by consensus.

RESULTS

For the following seven factors, the level of evidence was II, III, or IV, and the findings were generally consistent (grade B): anatomic definition of colon versus rectum, tumor-node-metastasis staging, radial margins, adjuvant R0 stage, inadvertent rectal perforation, distal and proximal rectal margins, and en bloc resection of adherent tumors. For another seven factors, the level of evidence was II, III, or IV, but findings were inconsistent (grade C): laparoscopic colectomy; colon lymphadenectomy; level of proximal vessel ligation, mesorectal excision, and extended lateral pelvic lymph node dissection (all three for rectal cancer); no-touch technique; and bowel washout. For the other four factors, there was little or no systematic empirical evidence (grade D): abdominal exploration, oophorectomy, extent of colon resection, and total length of rectum resected.

CONCLUSIONS

The panel reports surgical guidelines and definitions based on the best available evidence. The availability of more standardized information in the future should allow for more grade A recommendations.

Safety and efficacy of arcitumomab imaging in colorectal cancer after repeated administration

In pivotal phase III clinical trials for detecting recurrent or metastatic colorectal cancer, most patients received a single arcitumomab injection. However, the early detection of postsurgical recurrence or metastases with arcitumomab will necessitate serial studies for surveillance. We present immunogenicity, safety, and imaging data supporting the use of multiple administrations of arcitumomab.

METHODS

Human antimouse antibody (HAMA) response, adverse events, clinical laboratory values, and diagnostic imaging results were evaluated in 44 patients (24 men, 20 women; age range, 2878 y) after repeated arcitumomab administration (44 second and 3 third injections). Most patients initially had Dukes' class B or C colorectal cancer and had known or occult disease recurrence and elevated serum carcinoembryonic antigen levels at the time of the repeated injection.

RESULTS

At the repeated injection, in no patient did elevated HAMA titers develop, hematology and serum chemistry changes were clinically insignificant, and only 1 adverse event (eosinophilia) was judged at least possibly related to arcitumomab. Arcitumomab imaging results at the second injection were comparable with those obtained in phase III trials after a single injection of arcitumomab, having a 78% per-lesion concordance with CT in the abdomen and pelvis and a 73% sensitivity and 94% specificity based on 9 patients with cancer confirmed surgically at 11 anatomic sites and excluded at 16 sites.

CONCLUSION

These data indicate that at least 2 injections of arcitumomab can be given safely to patients with colorectal cancer, without increased immunogenicity and with imaging efficacy equivalent to the first administration.

A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum: a progress report of National Surgical Breast and Bowel Project Protocol R-03

PURPOSE

National Surgical Adjuvant Breast and Bowel Project Protocol R-03 was designed to determine the worth of preoperative chemotherapy and radiation therapy in the management of operable rectal cancer.

METHODS

Thus far, 116 patients of an eventual 900 with primary operable rectal cancer have been randomized to receive multimodality therapy to begin preoperatively (59 patients) or identical therapy beginning after curative surgery (57). All patients received seven cycles of 5-fluorouracil (FU)/leucovorin (LV) chemotherapy. Cycles 1 and 4 through 7 used a high-dose weekly FU regimen. In Cycles 2 and 3, FU and low-dose LV chemotherapy was given during the first and fifth week of radiation therapy (5,040 cGy). The preoperative arm (Group 1) received the first three cycles of chemotherapy and all radiation therapy before surgery. The postoperative arm (Group 2) received all radiation and chemotherapy after surgery. Primary study end points included disease-free survival and survival. Secondary end points included local recurrence, primary tumor response to combination therapy, tumor downstaging, and sphincter preservation.

RESULTS

Overall treatment-related toxicity was similar in both groups. Although seven preoperative patients had events after randomization that precluded surgery, eight events occurred during an equivalent follow-up period in the postoperative group. No patient was deemed inoperable because of progressive local disease. Sphincter-saving surgery was intended in 31 percent of Group 1 patients and 33 percent of Group 2 patients at the time of randomization. Such surgery was actually performed in 50 percent of the preoperatively treated patients and 33 percent of the postoperatively treated patients. The use of protective colostomy in patients undergoing sphincter-sparing surgery and the development of perioperative complications in all surgical patients were similar in both groups. There was evidence of tumor downstaging in evaluable patients undergoing preoperative therapy, with 8 percent of Group 1 patients having had a pathologic complete response.

CONCLUSION

These data do suggest that the preoperative chemotherapy and radiation therapy regimen used are, at least, as safe and tolerable as standard postoperative treatment. There is presently a trend to tumor downstaging and sphincter preservation in the preoperative arm. Whether this arm will have greater or lesser survival and long-term toxicity awaits the completion of this relevant study.

Role of mitomycin in combination with fluorouracil and radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study

PURPOSE

Definitive chemoradiation (CR) has replaced radical surgery as the preferred treatment of epidermoid carcinoma of the anal canal. To determine the importance of mitomycin (MMC) in the standard CR regimen and to assess the role of salvage CR in patients who have residual tumor following CR, a phase III randomized trial was undertaken by the Radiation Therapy Oncology Group (RTOG)/Eastern Cooperative Oncology Group (ECOG).

PATIENTS AND METHODS

Between August 1988 and December 1991, 310 patients were randomized to receive either radiotherapy (RT) and fluorouracil (5-FU) or radiotherapy, 5-FU, and MMC. Of 291 assessable patients, 145 received 45 to 50.4 Gy of pelvic RT plus 5-FU at 1,000 mg/m2/d for 4 days, and 146 received RT, 5-FU, and MMC (10 mg/m2 per dose for two doses). Patients with residual tumor on posttreatment biopsy were treated with a salvage regimen that consisted of additional pelvic RT (9 Gy), 5-FU, and cisplatin (100 mg/m2).

RESULTS

Posttreatment biopsies were positive in 15% of patients in the 5-FU arm versus 7.7% in the MMC arm (P = .135). At 4 years, colostomy rates were lower (9% v 22%; P = .002), colostomy-free survival higher (71% v 59%; P = .014), and disease-free survival higher (73% v 51%; P = .0003) in the MMC arm. A significant difference in overall survival has not been observed at 4 years. Toxicity was greater in the MMC arm (23% v 7% grade 4 and 5 toxicity; P < or = .001). Of 24 assessable patients who underwent salvage CR, 12 (50%) were rendered disease-free.

CONCLUSION

Despite greater toxicity, the use of MMC in a definitive CR regimen for anal cancer is justified, particularly in patients with large primary tumors. Salvage CR should be attempted in patients with residual disease following definitive CR before resorting to radical surgery.

Human lung tumor cell secretion of interleukin-2 for protection against tumor engraftment

BACKGROUND

Lung cancer continues to claim large numbers of human lives each year despite advances made in conventional therapies. The use of biologic response modifiers to modulate the immune system against human tumors is an alternate form of immunotherapy. Interleukin-2 (IL-2), or T-cell growth factor, is an important modulator of activated T cells. We show here that tumor cells transduced with human IL-2 cDNA provide protective immunity against engraftment of IL-2-secreting, as well as parental non-IL-2-secreting, tumor cells in vivo.

METHODS

In an attempt to increase the antigen-induced proliferation and cytotoxicity T cells within the vicinity of tumor antigen, we have transduced human lung tumor cell lines (generated from whole tumor specimens obtained fresh from the operating room) with a vector containing the IL-2 gene. Cell lines secreting 0.5-20 Cetus units/ml of IL-2 were generated. Control cell lines were similarly established using the same retroviral vector containing the gene for adenosine deaminase (ADA). The growth of tumor xenografts of the vector-modified cell lines was observed in severe combined immunodeficient (scid) mice.

RESULTS

Using C.B-17 scid mice, we have observed that the local secretion of IL-2 by these human lung tumor cell lines will prevent engraftment of that tumor into scid mice. The parental tumor as well as the tumor containing the ADA gene grow aggressively in the scid mouse. Growth arrest also correlated strongly with the amount of IL-2 secreted by the tumor cells. The local secretion of IL-2 by the transduced cell line will abrogate the tumorigenicity of the parental cell line as well as an allogeneic tumor. The inhibition of growth occurs only when the tumors are placed in close proximity to each other. After gamma irradiation, transduced tumor cells will continue to secrete IL-2.

CONCLUSION

These results indicate that (a) human lung tumor cell lines can be transduced with IL-2-containing retroviral vectors; (b) local and sustained release of IL-2 will induce an antitumor response by the host against the IL-2-secreting as well as the control tumor cells; (c) secretion of IL-2 continues after the cells are irradiated. This study suggests that cytokine-secreting human lung tumors may be used in vaccination protocols for cancer patients.

Immunochemical versus guaiac occult blood stool tests: results of a community-based screening program

This study was designed to investigate two guaiac-based and one immunochemical faecal occult blood test in a community screening program. A total of 39,000 test kits consisting of Hemoccult II, Hemoccult Sensa and HemeSelect were distributed and of these 8933 (23%) were returned for testing. Follow-up contact with 1165 individuals who tested positive on at least one of the nine test slides was successful in 1076 cases (92.4%). Physician verification in 631 individuals revealed 25 patients (4%) diagnosed with colorectal cancer and 145 (23%) with polyps, of which 120 (82.7%) were adenomatous. The percentage of smaller adenomatous polyps detected relative to the percentage of large polyps (> 1 cm) was: Hemoccult II 31% versus 60%, Hemoccult Sensa 73% versus 80% and HemeSelect 34% versus 57%, respectively. The proportion of adenomatous polyps greater than 2 cm detected by individual tests was even more striking with Hemoccult II positive for 83%, Hemoccult Sensa for 100% and HemeSelect for 75%. Of the 25 patients diagnosed with cancer, 17 (68%) were diagnosed with early-stage disease. A statistically significant trend (P < 0.001) was observed with positive predictive values ranging from 3.3% for individuals with only one positive test to one approaching 40% for individuals with 7 or more positive tests. In this study, the most sensitive predictor of colorectal cancer was found to be the combination of Hemoccult II/HemeSelect. While there was no increase in the positive predicted value for adenomatous polyps < or = 1 cm, there was a direct linear increase for adenomatous polyps > 1 cm.

Initial clinical (phase I) trial of TLC D-99 (doxorubicin encapsulated in liposomes)

A liposome-encapsulated form of doxorubicin (TLC D-99), which was shown in preclinical toxicology to be less toxic to the gastrointestinal tract and myocardium than free doxorubicin, was administered by constant infusion (1.00-1.80 h) to 38 patients in single doses of 20, 30, 45, 60, 75, and 90 mg/m2 every 3 weeks and daily for 3 days at doses of 20, 25, and 30 mg/m2/day. The dose-limiting toxicity was leucopenia: the maximum tolerated doses were one at 90 mg/m2 and three at 25 mg/m2/day. Nausea, vomiting, and stomatitis were minimal or absent at each dose; alopecia was minor. Fever and chills were noted at most of the doses, and malaise was seen in some patients, especially at the higher doses. No hepatic, renal, or other organ toxicities were observed. Clinical cardiac toxicity was not observed in any patient; however, the cumulative doxorubicin dose was greater than 400 mg/m2 in only one patient. There was large variation among patients in estimated pharmacokinetic parameters and profiles. Higher plasma levels and dose intensities were achieved with TLC D-99 than were predicted for free doxorubicin. Liposome-encapsulated doxorubicin was well tolerated and produced less nausea, vomiting, and stomatitis than would be expected with free doxorubicin administered at equally myelosuppressive doses.

Utility of an oral examination in a surgical clerkship

To evaluate the utility of the oral examination in a surgical clerkship, we designed a prospective and randomized study to relate the subjective impressions of experienced examiners with an objective measure of cognitive knowledge. The examiners were asked to score the student's performance as honors, high satisfactory, satisfactory, or unsatisfactory, according to their subjective impression of the student's ability. Student performance was grouped according to oral examination performance. The cognitive performance in the honors group was significantly better than that of the other groups (Student's t-test, p = 0.05). There was a significant difference in cognitive performance for oral examination groups throughout the rotations (analysis of variance, p = 0.000; Kruskal Wallis, p = 0.05). The oral examination is useful to identify a high level of cognitive achievement but cannot discriminate between groups of median to low competence. It should be used for educational feedback, career counseling, residency recommendations, and professional development.

Accuracy of colonoscopy for the detection of colorectal polyps

The findings at colonoscopy were compared with the pathologic findings of the surgical specimen in 235 patients who underwent a colon resection for a primary colorectal neoplasm from January 1980 to December 1987 at Roswell Park Cancer Institute. Seven patients (3 percent) were found to have synchronous primary colon carcinomas, and 100 patients (43 percent) were found to have synchronous adenomatous polyps identified by colonoscopy and/or pathology. In patients with polyps 10 mm or greater in diameter, the findings on colonoscopy agreed with the pathology report 96 percent of the time. When polyps of all sizes were included, with many less than 5 mm in diameter, colonoscopy agreed with the pathology in 89 percent of patients. When only the area of the colon resected was used to determine the ability of colonoscopy to locate polyps, 58 percent of polyps of all sizes were located. The majority of the missed polyps were adjacent to a carcinoma. One cecal carcinoma was not seen by colonoscopy because of technical inabilities to reach the cecum. A second carcinoma (20 mm x 17 mm) was not seen at the splenic flexure.

Phase II trial of fluorouracil and recombinant interferon alfa-2a in patients with advanced colorectal carcinoma: an Eastern Cooperative Oncology Group study

In a pilot clinical trial, treatment of patients with advanced colorectal carcinoma with the combination of fluorouracil (5FU) and recombinant interferon alfa-2a (IFN) resulted in objective tumor regression in 62% of patients. To confirm these findings in a multiinstitutional setting, a phase II clinical trial was initiated by the Eastern Cooperative Oncology Group (ECOG) in 1989. The treatment regimen was identical to that used in the earlier study: 5FU 750 mg/m2/d for 5 days as a continuous infusion followed by weekly outpatient bolus therapy and IFN 9MU subcutaneously beginning day 1 and administered three times per week. Doses were modified for gastrointestinal, hematologic, and neurologic toxicity and for fatigue, similarly to those used in the previous pilot trial. Thirty-eight patients were registered; 36 are evaluable for response (one lost to follow-up and one with nonmeasurable disease). All patients had metastatic or locally recurrent disease beyond the scope of resection; 31 of 38 had liver metastases, and 20 of 38 had two or more sites of involvement. Eight patients had grade 4 toxicities, including sepsis (nonneutropenic) (one), watery diarrhea (two), and granulocytopenia (six). Grade 3 neurologic toxicities were observed in two (5%) patients and included slurred speech and gait disturbance. Objective response was 42% (95% confidence interval [Cl], 27% to 58%), including one clinical complete responder and 14 partial responders. Among the responding patients, the median time to treatment failure was 8 months. Two patients remain on treatment at 10+ and 16+ months: median survival has not been reached. The results of this multiinstitutional trial suggest that the addition of IFN to 5FU enhances the objective response rates achieved in patients with advanced colorectal carcinoma and that the toxicities of this regimen are acceptable.

Morbidity and survival of liver resection for colorectal adenocarcinoma

Sixty-two patients underwent hepatic resection for isolated colorectal metastases from 1963 to 1988. The numbers of hepatic resections were: lobectomy, 24 (39 percent); wedge resection, 23 (37 percent); and segmentectomy, 15 (24 percent). The median number of intraoperative blood transfusions was 3.0 units (range, 0-16 units). The median number of days in the hospital following hepatic resection was 13 (range, 4-51 days). There were 19 patients (30 percent), who developed a total of 23 complications. Surgery was required for complications in nine patients. Surgical mortality occurred in 5 of 62 (8 percent) patients. The estimated median survival in 56 patients with one to three metastases was 26 months, with a 28 percent estimated 5-year survival. The median size of the metastases was 4.0 cm (range, 0.7-13 cm). The estimated median survival in 27 patients with metastases less than 4 cm in diameter was 26 months, with a 24 percent estimated 5-year survival. The estimated median overall survival from the time of hepatic resection was 25 months.

Laser palliation for colorectal carcinoma

A review was conducted of 27 patients with colorectal carcinoma treated palliatively with endoscopic neodymium:yttrium-aluminium-garnet (Nd:YAG) laser. There were 25 rectal carcinomas and 2 primary invasive sigmoid colon carcinomas. Of the 25 rectal carcinomas, there was 1 carcinoma in situ, 16 primary cancers, and 8 recurrent rectal carcinomas. The level of the lesions from the anal verge ranged from 0 to 25 cm, with a mean of 7.2 cm. The length of the lesions ranged from 1.5 to 8.5 cm, with a mean of 5 cm. The mean number of Nd:YAG laser treatments was three, with a range from one to nine. The duration of the treatments ranged from 30 to 90 minutes, with a mean of 40 minutes. Four of 27 patients (15%) developed complications. The success rate in terms of the relief of symptoms was established in 23 of the 27 patients.

A prospective evaluation of hepatic resection for colorectal carcinoma metastases to the liver: Gastrointestinal Tumor Study Group Protocol 6584

We report here the results of the first multiinstitutional prospective evaluation of patients considered to have potentially resectable hepatic metastases from colorectal carcinoma. One hundred fifty-six patients were enrolled from 15 institutions. Six patients were subsequently excluded. One hundred fifty patients underwent surgery and are evaluable for analysis (median follow-up time, 3.1 years; range, 4 months to 5.1 years). Curative resection could be performed on 46% of patients (69 of 150), noncurative resection on 12% (18 of 150), while 42% were found to be unresectable (63 of 150). Thirty-day surgical mortality and morbidity rates in patients with attempted resection were 2.7% and 13%, respectively. The curative resection group was observed to have an improved median survival (37.1 months) compared with the noncurative resection group (21.2 months) and the unresectable group (16.5 months) (P less than .01). Computed tomographic (CT) scan was a poor predictor for resectability, and age was not a contraindication to curative resection. Preoperative carcinoembryonic antigen (CEA) values were also a poor predictor for resectability. However, the median CEA value 61 to 180 days postsurgery was significantly higher in unresectable patients compared with median CEA levels in noncuratively and curatively resected groups (P less than .01). Our results imply that curative resection leads to an increase in median survival. Noncurative resection provides no benefit to asymptomatic patients, since unresectable and noncurative resection groups have similar life expectancies. Longer follow-up will be needed to demonstrate the ultimate impact of curative resection on survival.

A phase I study of cisplatinum plus 5-fluorouracil in modulation with citrovorum factor in metastatic colorectal carcinoma

A phase I study of 5-fluorouracil 600 mg/m2/week and folinic acid 500 mg/m2/week on day 1 and cisplatin administered weekly on day 2 was carried out on 30 patients with metastatic colorectal carcinoma of which 20 patients were pretreated with 5-fluorouracil. The first group of patients received cisplatin at the dose of 5 mg/m2/week. Cisplatin was then escalated to 10, 15, 20, 25, 30, and 35 mg/m2/week for subsequent groups of patients. Gastrointestinal side-effects were the dose-limiting toxicity. A therapy related death was seen at the dose of 35 mg/m2/week of cisplatin. The maximally tolerated dose of cisplatin in combination with 5-fluorouracil and citrovorum factor is 20 mg/m2/week. The optimally tolerated dose of 5-fluorouracil is 400 mg/m2/week in modulation with citrovorum factor 500 mg/m2/week. The recommended doses for a phase II study are cisplatin 20 mg/m2/week, 5-fluorouracil 400 mg/m2/week, and citrovorum factor 500 mg/m2/week.

Localization of endogenous beta-galactoside-binding lectin in human cells and tissues

A rabbit antiserum raised against the 14.5-kilodalton (kDa) subunit of human splenic galaptin was used to probe protein blots of several tissue extracts. For all tissues examined, the only immunoreactive species detected was a 14.5-kDa polypeptide. This antiserum and a rabbit antiserum raised against native lung galaptin were used in immunohistochemical assays to determine the localization of galaptin in selected tissues and cells. In normal colon, galaptin was found prominently in the basement membrane and in the stroma. The cytoplasm of epithelial cells stained lightly for galaptin whereas mucous granules and secreted mucin were uniformly negative for galaptin. Hemagglutination inhibition assays also failed to demonstrate an interaction between galaptin and mucin. Macrophages stained conspicuously for galaptin in colonic and cutaneous tissue as did some capillary walls. In cutaneous tissue, the extracellular matrix and hair follicle cells contained abundant galaptin. Galaptin was absent in basal cell carcinoma and associated stroma. Galaptin was found throughout the cytoplasm of carcinoma cells of gynecologic origin present in effusions. Protein blot analysis of extracts of extracellular matrix synthesized in vitro by endothelial cells confirmed the presence of galaptin in matrix. The results show that: (1) galaptin is variably expressed by different cells and tissues; (2) its cellular location is not restricted to the cell surface; (3) galaptin is not associated with normal mucin; (4) the extracellular matrix is a major site of galaptin deposition, and (5) some malignant tissue may be characterized by a deficiency of galaptin.

Familial adenomatous polyposis in association with thyroiditis. Report of two cases

The authors report two patients with familial adenomatous polyposis and thyroiditis. One patient was discovered at autopsy to have in addition, a follicular carcinoma of the thyroid and focal nodular hyperplasia of the liver. The other patient had a sister with familial adenomatous polyposis and a papillary carcinoma of the thyroid. The association between familial adenomatous polyposis and thyroiditis has not been previously reported.

The modulation of fluorouracil with leucovorin in metastatic colorectal carcinoma: a prospective randomized phase III trial. Gastrointestinal Tumor Study Group

A total of 343 patients with previously untreated metastatic measurable colorectal carcinoma were studied to evaluate the impact on toxicity, response, and survival of leucovorin-modulated fluorouracil (5-FU). A maximally tolerated intravenous bolus loading course regimen of 5-FU alone (500 mg/m2 x 5 days every 4 weeks with 25 mg/m2 escalation) was compared with a high-dose leucovorin regimen (600 mg/m2 of 5-FU with 500 mg/m2 of leucovorin weekly for 6 weeks with a 2-week rest) and with a similar low-dose leucovorin regimen (600 mg/m2 of 5-FU with 25 mg/m2 of leucovorin weekly for 6 weeks with a 2-week rest). The dose-limiting toxicity for the two 5-FU and leucovorin regimens was gastrointestinal, specifically diarrhea; severe diarrhea was seen frequently, and treatment-related toxicity was implicated in the demise of 11 of the patients (5%). Significant improvements in response rates were observed with a response rate of 33 of 109 (30.3%) on the high-dose leucovorin regimen (P less than .01 v control); 13 of 107 (12.1%) on the 5-FU control; and 21 of 112 (18.8%) on the low-dose leucovorin regimen. A trend toward longer survival in the 5-FU plus high-dose leucovorin regimen was observed. In this study, leucovorin was shown to significantly enhance the therapeutic effect of 5-FU in metastatic colorectal carcinoma.

The role of pediatric surgery in the medical school curriculum

In most medical schools, exposure to pediatric surgery is presented as a subspecialty elective. We have offered it as an integral part of the surgical clerkship for 10 years in the belief that it provides an excellent educational environment. To confirm this concept, the quizzes (Q), final examinations (FE), and grades of students assigned to the pediatric surgical service were prospectively studied. All students (N = 139) in the surgical clerkship entered the study. Thirty-two students were randomly selected and assigned to the surgical service of a major pediatric hospital (P-Surg) for 50% of their clerkship. The other students (N = 107) were assigned to a variety of adult surgical services (G-Surg) and served as the control group. All students attended the same seminars, used the same educational materials, were examined with the same test items, and were evaluated by the same oral examiners. Test items were electronically scored and the database was analyzed on an IBM computer. The statistical analysis was performed using a Student's t test and chi 2 analysis. There was no significant difference in the demonstrated cognitive performance and grades awarded to the two groups of students. We conclude that a pediatric surgical service provides an atmosphere that is educationally comparable to the adult general surgical service.

Phase I trial of a new nitrosourea, CGP 6809, given every 2 weeks

A phase I study was carried out on a new water-soluble nitrosourea, 6-deoxy-3,5 di-O-methyl 6-(3 methyl-3-nitrosoureido)-alpha-D-glucofuranoside (EDMN, CGP 6809), given every 2 weeks. A total of 18 patients received doses of 1, 2, 3, and 3.75 g/m2 as a 2- to 5-h infusion. Toxicity principally involved nausea and vomiting, hepatotoxicity, and abdominal pain. There was no evidence of cumulative toxicity. The dose of 3.75 g/m2 was not exceeded because in a previous phase I study, 4.5 g/m2 every 6 weeks was not tolerated; the recommended dose for phase II studies is 3.75 g/m2 every 2 weeks.

In vivo determinations of labelling index of metastatic colorectal carcinoma and normal colonic mucosa using intravenous infusions of bromodeoxyuridine

In vivo determination of the labelling index of metastatic colon carcinoma was performed in 14 patients following intravenous infusion of bromodeoxyuridine (BrdU), at doses of 100 and 50 mg/M2. No toxicity was seen. Labelled cells were detected by an immunohistochemical technique using a monoclonal antibody to BrdU. Labelling was uniform and highly specific with good preservation of morphology. Labelling index values ranged from 15.0-40.6% for metastatic lesions and 3.6%-20% for normal colonic mucosa, with mean values of 24% and 11%, respectively. This represents a useful new method for in vivo labelling index determination in solid tumors.

Ornithine decarboxylase activity in hepatic and extrahepatic metastases from colorectal cancer

The values of ornithine decarboxylase (ODC) activity in hepatic and extrahepatic metastases from primary colorectal cancer were studied. Adjacent noninvolved tissue was used as a control. Liver metastases had significant elevated ODC levels over surrounding liver (0.271 vs. 0.065, respectively, P less than .008). Results similar to those found in liver metastases were noted in extrahepatic metastases (median value, 0.271). This study discusses the possible reasons for these elevations and emphasizes that these differences may have potential roles in the areas of diagnosis, staging, monitoring of the disease, and therapeutic interventions in colorectal cancer and its hepatic and extrahepatic metastases.

Expression of an unusual isozyme of lactate dehydrogenase in the serum of cancer patients and comparison with carcinoembryonic antigen

Two studies reported here demonstrate a statistically significant association between metastatic cancer and the appearance of the k isozyme of lactate dehydrogenase in serum of affected patients. The first study included 190 coded samples from three types of cancer patients and matched controls; the second included 155 preoperative and 200 postoperative colorectal cancer patients. In the second, plasma carcinoembryonic antigen was compared with serum k isozyme of lactate dehydrogenase as an indicator of the presence of metastatic cancer. This comparison showed that both markers were independently useful for assessing patient status and predicted that a combination of the two should be a better discriminator for the presence of metastases than either marker alone.

A prospective randomized trial of 5-fluorouracil versus 5-fluorouracil and high-dose leucovorin versus 5-fluorouracil and methotrexate in previously untreated patients with advanced colorectal carcinoma

Seventy-four previously untreated patients with metastatic colorectal adenocarcinoma were prospectively randomized into one of three treatment regimens: (1) 5-fluorouracil (5-FU) 450 mg/m2 as an intravenous (IV) bolus daily for five days or toxicity, then 200 mg/m2 IV bolus every other day for six doses; (2) methotrexate (MTX) 50 mg/m2 in normal saline by IV infusion over four hours followed by an IV bolus of 5-FU 600 mg/m2. This was administered weekly for 4 weeks and then every 2 weeks. (3) Leucovorin 500 mg/m2 in a two-hour IV infusion of normal saline with 5-FU 600 mg/m2 as an IV bolus one hour after the Leucovorin began every week for 6 weeks. The combined complete and partial response rates in the three regimens were 11%, 5%, and 48%, respectively (P = .0009). The median duration of response in the 5-FU and Leucovorin regimen was 10 months. There was no statistically significant difference between the treatment regimens with respect to survival time (P = .6). Toxicity in the 5-FU and Leucovorin regimen was predominantly diarrhea (13 of 30 patients, 40%). In this regimen, eight of 13 patients (52%) who developed diarrhea not only required a dose reduction of 5-FU, but also hospitalization for IV hydration. The predominant toxicity in the 5-FU alone regimen and the 5-FU and MTX regimen was leukopenia. One drug-related death occurred in each regimen.

Sputum cytology for the detection of pulmonary metastases from colorectal carcinoma

Twenty-two patients with pulmonary metastases from adenocarcinoma of the colon and rectum had sputum samples examined for cytology. All patients had lesions demonstrated on chest roentgenography and eight patients also underwent bronchoscopy. Three or more sputum samples were examined for eight patients, two samples for seven patients, and seven patients had one sample only examined. In five of 22 patients, the sputum samples were reported to be unsatisfactory for cytodiagnosis. Of the remaining 17, nine patients had at least one positive result for metastatic adenocarcinoma and in two additional cases the sample showed atypical cells. The result was therefore positive or atypical in 11 of 17 patients (65 percent). The positive cytology rate reported (79 percent for multiple pulmonary metastases) represents an improvement compared with previously published work. In this study 14 patients had either one or two samples collected for cytology and it is likely that the positivity rate would have been higher if three samples had been collected.

Phase I clinical trial of ethyl 6-deoxy-3,5-di-O-methyl 6-(3 methyl-3-nitrosoureido)-alpha-D-glucofuranoside (CGP 6809)

A phase I study of single i.v. doses of a new sugar containing nitrosourea 6-deoxy-3,5 di-O-methyl 6-(3 methyl-3-nitrosoureido)-alpha-D-glucofuranoside (CGP 6809, EDMN) has been carried out in 47 patients with advanced solid tumors. Nine dose levels between 200 and 4500 mg/m2 were examined. Nausea and vomiting were seen in most patients but were controlled with antiemetics. Myelosuppression was minimal. The dose-limiting toxicity was hepatotoxicity, occurring early (peak at days 2-4) and resolving rapidly. No cumulative toxicity was seen with an every 6 weeks schedule. Other toxicities were abdominal pain, diarrhea, arm pain, restlessness, and headache. Pharmacokinetic studies in 20 patients using an HPLC assay and in 5 patients using [14C]EDMN showed a short half-life, rapid plasma clearance, rapid metabolism, and minimal excretion of unchanged drug. There was one partial response in a patient with colon carcinoma. The recommended dose for phase II studies in 3750 mg/m2 every 6 weeks.

Pediatric infiltrating lipomas: case report and review of the literature

A case of pediatric infiltrating lipoma and a collected literature review of four pediatric patients with well-documented infiltrating lipomas are presented. These lesions tend to recur after resection but there are no reported incidences of distant metastases or degeneration into frankly malignant lesions. Treatment consists of excising the lesion with a margin of normal muscle.

Causes of death in patients with familial polyposis coli (FPC)

Autopsy reports from patients with familial polyposis coli were obtained from the Roswell Park Memorial Institute Registry as well as clinical data on patients with familial polyposis coli with regard to their causes of death. Although the latter group did not undergo autopsy they were the subject of a close follow-up. From this data it is clear that diagnosis at an early age may not diminish the chances of the patient with familial polyposis to develop cancer. Removal of the colonic mucosa does not provide absolute assurance that patients with this condition will be cured, as these patients remain at considerable risk for developing other benign and malignant lesions of the gastrointestinal tract and perhaps also of other organs. Close follow-up of FPC patients who have had surgery for colorectal polyps or cancer is necessary. Other proliferative abnormalities of FPC patients include an abnormal fibroblastic response, tendency to develop adhesions, and the propensity for developing desmoids. Desmoids may follow a slow but unrelenting course with a lethal outcome. Autopsy findings support the view that there should be no distinction between familial polyposis coli and Gardner's syndrome.

The morbidity of perineal wounds following abdominoperineal resection for rectal carcinoma

The clinical charts of 44 patients who underwent an abdominoperineal resection for adenocarcinoma of the rectum at Roswell Park Memorial Institute were retrospectively reviewed. The morbidity of an open perineal wound versus the closed perineal wound were evaluated. All of the patients received a Nichol's bowel preparation and following the abdominal portion of the dissection reperitonealization of the pelvic floor was performed. The overall morbidity for the open perineal wounds was 21% compared to a morbidity of 63% for the perineal wounds that were closed primarily. The mean length of hospitalization from the time of abdominoperineal resection was 21 days for the open perineal group and 22 days for the closed perineal group. The inclusion of wound sinus tracts in our morbidity assessment may explain the higher complication rate of the closed wound group than previously reported in the literature. This retrospective review emphasizes that the morbidity of the open perineal wound following abdominoperineal resection has been overemphasized. One is trading a potentially increased incidence of septic wound complications in the closed perineum for a protracted wound closure in the open perineum.

Does more intense palliative treatment improve overall survival in metastatic breast cancer patients?

A retrospective review of 483 women who had metastatic breast cancer and were treated between 1942 and 1975 was carried out to examine the effects of improving and aggressive palliative modalities on patient survival. There was a steady increase in the proportion of patients treated by chemotherapy and/or hormonal ablative therapy. Additive hormonal therapy, irradiation, and surgery for palliation decreased in frequency during the same period. Survival time from the first recurrence did not appear to increase in these patients over the period of this study. In spite of increasingly sophisticated palliative therapies, the survival time of patients with metastasis did not appear to be significantly prolonged.

Epidermoid carcinoma of the anal canal

The charts of 67 patients treated for epidermoid carcinoma of the surgical anal canal were reviewed. The clinical presentation, type of surgical procedure performed, lymph node status of the pararectal and inguinal nodes, time of recurrence, site of recurrence, and median survival from the date of primary surgery and from the date of recurrence were determined. There were 55 patients (82%) who had a minimum of 5 years' follow-up since initial treatment. Optimal surgical treatment requires an abdominoperineal resection with wide dissection of the ischiorectal fossa and perineum in all patients, as well as an en bloc excision of the posterior vaginal wall in women. Although excision of the posterior vaginal wall improves the disease-free interval, median survival is not altered, compared with the group without vaginectomy. The predominant sites of local recurrence in men are the pelvis and perineum, and in women, the pelvis and posterior vaginal wall. The status of the pararectal lymph nodes from the operative specimen can give accurate information about the relative risk of recurrence. The presence of inguinal lymph node metastases represents a poor prognosis because of a close association with systemic metastases.

Phase II study of combination bleomycin, vincristine and high-dose methotrexate (BOM) with leucovorin rescue in advanced squamous cell carcinoma of the anal canal

Fifteen patients with advanced squamous cell carcinoma of the anal canal were treated with a combination of bleomycin, vincristine, and high-dose methotrexate (BOM) with leucovorin rescue. Three out of twelve patients with measurable disease had objective responses of 1, 2, and 5 months. Five of the fifteen patients had severe or life-threatening complications as a result of this treatment regimen. The narrow therapeutic index of the BOM therapy makes it a less than ideal drug combination for the treatment of advanced squamous cell carcinoma of the anal canal.

Subcutaneous metastases without visceral metastases from an adenocarcinoma of the rectum

Skin metastasis from colorectal carcinoma without evidence of visceral metastases is exceedingly rare. However, it must be considered whenever a new skin growth appears in a patient with a history of carcinoma. A diagnostic biopsy is mandatory as the appearance of these metastases is not distinctive.

Metastasis to the parotid gland from colorectal adenocarcinoma

This manuscript presents only the fifth reported case in the literature of colorectal carcinoma with metastasis to the parotid gland. A 66-year-old white woman, referred to Roswell Park Memorial Institute, presented with a left parotid mass and a past history of undergoing right hemicolectomy for an adenocarcinoma of the ascending colon with synchronous liver metastases. The clinical presentation and treatment of the patient are discussed with a review of the literature.

Cavernous hemangioma of the anus

Vascular tumors of the large bowel can be divided into malignant and benign lesions. The benign lesions can be divided into capillary and cavernous hemangiomas. Large-bowel hemangiomas are rare lesions, with the majority of cases reported in the rectum and rectosigmoid regions. Few cases of isolated anal hemangiomas are found in the literature. A case of an asymptomatic anal cavernous hemangioma, palpable on routine rectal examination and subsequently removed at proctosigmoidoscopy, is described.

Long survival after ovarian and hepatic metastasis from carcinoma of the large bowel: report of a case

Herein we present the case of a woman who is now 19 years post abdominoperineal resection for a Dukes' C1 rectal carcinoma, 10 years post right hemicolectomy for a Duke's C1 carcinoma of the ascending colon and removal of a solitary hepatic metastasis and now 9 years post resection of an ovarian metastasis. She had 5-fluoracil, postoperatively. This is the ninth case reported in the literature of a 5-year survivor free of disease following oophorectomy for metastatic adenocarcinoma of the large bowel. The finding of ovarian and hepatic metastases from her colorectal carcinoma would have indicated a poor prognosis. We feel that those rare patients who have an unexpected long survival should be reported for accumulation of clinical data, illustration of their clinical management, and analyses of the applied therapeutic interventions.

Phase I-II trial of high-dose calcium leucovorin and 5-fluorouracil in advanced colorectal cancer

Twenty-six patients with metastatic colorectal adenocarcinoma were entered into a Phase I-II study of 5-fluorouracil (5-FUra)-high-dose leucovorin (CF). The starting dose of 5-FUra was 300 mg/sq m with escalation to 750 mg/sq m/week in 6 doses given by rapid i.v. injection midway during a 2-hr infusion of CF, 500 mg/sq m. Partial responses were seen in 9 of 23 patients (6 of 12 who had had previous 5-FUra). Complete normalization of liver enzymes was seen in two of these patients. Side effects were seen sporadically with 5-FUra doses up to 600 mg/sq m. At a 600-mg/sq m 5-FUra dose, 8 of 18 patients had diarrhea, and 2 of 18 had white blood cell counts less than 3000/microliter. At a 750-mg/sq m dose of 5-FUra, 6 of 11 patients had severe diarrhea and 6 of 11 had white blood cell counts less than 3000/microliter. Other toxicities were mild conjunctivitis and lacrimation, thinning of the nails, and alopecia. In bioavailability studies of CF p.o., no plasma CF could be detected. After CF i.v., mean plasma peak was 111.3 +/- 40.3 (S.D.) microM. 5-FUra-CF appears to be effective in patients clinically resistant to 5-FUra. This study is being extended to randomized trial of 5-FUra-CF versus 5-FUra alone.