Intracranial pressure in single-suture craniosynostosis

To assess changing patterns of treatment for chronic anal fissure, a retrospective analysis of treatment for chronic anal fissure within one hospital between January 1990 and December 1996 was undertaken. A total of 221 patients received treatment for a chronic anal fissure in this period, of whom 209 had a surgical procedure. Manual dilatation of the anus was performed in 21 patients (10%) and has not been performed since 1995. Lateral internal sphincterotomy was performed in 183 patients (88%) and continues to be the mainstay of treatment. Five female patients (2%) were identified as having a sphincter defect by anal manometry combined with endoanal ultrasound and were treated by an anal advancement flap. From 1996 onwards, 15 patients (7%) were treated by topical glyceryl trinitrate (GTN) paste as the first line of treatment. Of these patients, nine have experienced healing of their fissure, and three have had relief of pain without healing of the fissure. Three have gone on to have a lateral internal sphincterotomy. Lateral internal sphincterotomy remains the primary form of treatment for chronic anal fissure. GTN cream has increasingly been offered as preliminary treatment over the last 12 months. Perioperative use of endoanal ultrasound allowed identification of patients who may be at high risk of postoperative incontinence from a sphincterotomy. An anal advancement flap has been used as an alternative surgical approach for these patients.     

Early postoperative morbidity after hemorrhoidectomy using the Milligan-Morgan technic. A retrospective studies of 1,134 cases

Milligan and Morgan's procedure is commonly used for the surgical management of haemorrhoids. The aim of our study was to evaluate short term postoperative morbidity. Between 1975 and 1990, 1,134 patients were operated on. Two patients died after operation. The most frequent complications were pain (71%) and urinary retention (16.4%). Hemorrhages (7.6%) resulting in a re-operation occurred in 1% of cases. Other complications were rare and always cured by a specific treatment (stenosis: 2.9%, anal fissure: 0.5%, abscess: 0.6%, fistula in ano: 1.2%). Two patients had anal incontinence partially improved by biofeedback. Hemorrhoidal was 2%. Short term postoperative morbidity is generally low after Milligan and Morgan hemorrhoidectomy, with careful supervision in a surgical department and repeated postoperative care.     

Retama raetam W: a poisonous plant of North Africa

A through-the-scope endoscopic balloon dilatation technique and acid-reducing medication was used in 46 consecutive patients (median age, 55; range, 21-88 years) with benign gastric outlet obstruction. In five patients, dilatation was not technically possible. In 41 patients, 122 dilatations (median, 2; range, 1-9 per patient) were performed without morbidity. Ninety-four procedures were successful (77%) at the initial attempt (able to pass a 12-mm endoscope into the duodenum at the end of the procedure). Median follow-up in the 41 patients was 19 (range, 1-78) months. Thirteen patients (32%) required subsequent surgery; 8 had delayed operation for persistent symptoms (1-28 months after the first dilatation), 1 had surgery during the initial hospital admission, and 4 required emergency surgery for other ulcer complications (3 perforation, 1 bleeding). Of the 28 patients who had only balloon dilatation and medical therapy, 11 are asymptomatic (4 with active ulceration), 9 have mild symptoms (Visick 2), and 3 have persistent symptoms (Visick 3). One patient was lost to follow-up and four patients have died (one from an ulcer-related complication). Balloon dilatation and sustained acid-reducing therapy with regular endoscopic surveillance should be first-line treatment of peptic pyloroduodenal strictures, because the procedure is safe and is likely to be successful in half of the patients in whom dilatation is technically possible.     

Benign anal lesions, inflammatory bowel disease and risk for high-risk human papillomavirus-positive and -negative anal carcinoma

A central role in anal carcinogenesis of high-risk types of human papillomaviruses (hrHPV) was recently established, but the possible role of benign anal lesions has not been addressed in hrHPV-positive and -negative anal cancers. As part of a population-based case-control study in Denmark and Sweden, we interviewed 417 case patients (93 men and 324 women) diagnosed during the period 1991-94 with invasive or in situ anal cancer, 534 patients with adenocarcinoma of the rectum and 554 population controls. Anal cancer specimens (n = 388) were tested for HPV by the polymerase chain reaction. Excluding the 5 years immediately before diagnosis, men, but not women, with anal cancer reported a history of haemorrhoids [multivariate odds ratio (OR) 1.8; 95% confidence interval (CI) 1.04-3.2] and unspecific anal irritation (OR 4.5; CI 2.3-8.7) significantly more often than controls. Women with anal cancer did not report a history of benign anal lesions other than anal abscess to any greater extent than controls, but they had used anal suppositories more often (OR 1.5; CI 1.1-2.0). Patients with hrHPV in anal cancer tissue (84%) and those without (16%) reported similar histories of most benign anal lesions, but anal fissure or fistula was more common among hrHPV-positive cases. Ulcerative colitis and Crohn's disease, reported by <1% of study participants, were not associated with anal cancer risk. The higher proportion of hrHPV-positive anal cancers among case patients with anal fissure or fistula suggests that such mucosal lesions may provide direct viral access to basal epithelial layers. Since risk associations with benign anal lesions in men may be confounded by unreported sexual behaviour, and since risk associations in women were generally negative, it seems unlikely that benign anal lesions act as promoters in hrHPV-associated anal carcinogenesis. Moreover, benign anal lesions appear not to be linked to an alternative, hrHPV-unassociated causal pathway to anal cancer. Ulcerative colitis and Crohn's disease were not supported as causal factors for anal cancer.     

Pneumatic dilatation is effective long-term treatment for achalasia

Although pneumatic dilatation (PD) has been an established treatment for achalasia for decades, there is limited information on its long-term clinical efficacy. We have followed up the clinical status of patients having PD with a 30- or 35-mm balloon by one of us (D.O.C.) over a 25-year period. Of 144 patients whose initial records were available for review, 31 could not be contacted. Of the remaining 113 patients, 72 (64%) responded to a questionnaire assessing swallowing status and patient satisfaction, and this forms the basis of this report. There were 32 men and 40 women, with mean age 46 years (range: 17-78); mean length of follow-up since PD was 6.5 years (range: 10 months to 25 years). Success was primarily defined by the need for no additional therapy for achalasia other than one or two PD's. PD was effective long-term treatment in 61/72 patients (85%); only four of these required a second PD over this time interval. There was no significant difference in any of the following parameters between patients with a treatment success or failure: age, sex, size of pneumatic dilator, and duration of symptoms prior to PD. Response was significantly better (P < 0.05) in patients having no prior dilatation (43/47; 91%) than in those in whom another physician had performed prior dilatation (18/25; 72%). In response to the question of whether they would select PD again, 68 patients (94%) responded positively. In conclusion, pneumatic dilatation performed using a consistent technique by an experienced physician is effective long-term therapy for achalasia patients of all ages. Most patients require only one dilatation.     

Topical nitroglycerin in the management of anal fissure: an explosive outcome!

Anal sphincter spasm is a common finding in patients with anal fissure disease. It is postulated that spasm impedes mucosal blood flow and impairs healing. Topical nitroglycerin (NTG), a nitric oxide donor compound, has been shown to cause relaxation of the anal sphincter and may have treatment efficacy in the management of anal fissure. The purpose of this study was to assess the usefulness of NTG for anal fissure. We performed a retrospective review of patients with anal fissure treated with various concentrations of topical NTG ointments over an 18-month period ending July 1997. Of the 81 patients studied, 44 (54%) were male. There were 42 acute and 39 chronic fissures. NTG preparations included 1 per cent isosorbide (n = 37), 0.2 per cent NTG (n = 38), and 0.5 per cent NTG (n = 6). Healing with NTG therapy occurred in 29 acute (69%) and 21 chronic fissure (54%) patients. There was no difference in the incidence of healing of acute or chronic fissure between the various NTG treatment preparation groups. When acute and chronic fissure therapy was subdivided by time of NTG treatment (immediate versus post-conservative therapy failure (PCF)), 14 (74%) of acute PCF and 5 (42%) of chronic PCF patients healed. We conclude that no single formula was superior. When patients were subdivided into a PCF group, NTG therapy demonstrated a significant salvage rate, thus avoiding surgery.     

Around the sphincter: problems of continence in surgery of the large intestine

Anatomy and physiology of anal continence and incontinence are described. The surgeon's first main task is the prevention of incontinence, e.g. in the treatment of the small and mobile carcinoma of the rectum, the wide pedunculated papilloma, the fistula in ano, haemorrhoids and anal fissure. The second main task is the reconstruction of continence of rectal prolapse, ectropion, third grade rupture of the perineum and perineal injuries. The possibilities for reconstruction, reinforcement and replacement of the sphincter are described.     

A single midnight serum cortisol measurement distinguishes Cushing''s syndrome from pseudo-Cushing states

PURPOSE: We report stage specific followup guidelines based on our evaluation of the pattern of recurrence in 286 patients treated for local N0 or Nx renal cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of 286 patients with pT1 to pT3N0 or Nx renal cell carcinoma who underwent nephrectomy at our center between February 1985 and December 1994. In cases of later metastases the median interval to first metastasis, site of metastasis and method of diagnosis were correlated with the primary lesion stage. RESULTS: Metastases developed in 68 patients a median of 23 months after nephrectomy. Eight of the 113 patients with pT1 disease had metastases (median time to diagnosis 38 months), while 17 of 64 with pT2 disease and 43 of 109 with pT3 disease had metastases (medians 32 and 17 months, respectively). Of the 92 metastases 59 (64%) were asymptomatic, including 44 detected on routine chest x-rays (32) and blood tests (12). Isolated asymptomatic intra-abdominal metastases were diagnosed by surveillance computerized tomography in only 6 patients (9%). The remaining patients with metastases had associated clinical symptoms and/or abnormal results on interval tests that prompted further diagnostic studies. CONCLUSIONS: We confirmed that the risk of metastatic renal cell carcinoma is stage dependent. Therefore, surveillance protocols should be based on the pathological stage of the primary tumor. We recommend an annual chest x-ray, and serum liver function and alkaline phosphatase level tests for patients with pT1 disease. These studies are indicated beginning at 6 and 3 months for pT2 and pT3 disease, respectively, continuing every 6 months for 3 years and then annually. Surveillance computerized tomography should be performed at 24 and 60 months in patients with pT2 and pT3 disease or earlier when the results of any routine study are abnormal or clinical symptoms are present. Bone and brain surveillance studies should be prompted by site specific symptoms, elevated alkaline phosphatase levels or the diagnosis of metastasis at another site.     

Chronic anal fissure: results of the surgical treatment of 220 patients

Since results from non-surgical procedures designed for treatment of chronic anal fissure are still controversial, sphincterotomy remain as the "state of the art" therapy for this condition. In a retrospective basis, the authors intend to review results from treatment of chronic anal fissure in 220 patients who underwent surgical procedure between 1984 and 1995. Data from chart review included age, sex, location of the lesion at the canal anal, associated anorectal disease, delivered surgical technique and complications. Seventy per cent of the patients were male. Mean age was 37.1 years. Fissure was located at the posterior midline in 86.1%. Associated anorectal conditions occurred in 41.4%. Fissurectomy plus posterior sphincterotomy was the treatment of choice in 84.1%. Complications occurred in 5 (2.3%) cases. There were no incontinent patients. Mean follow-up was 2.6 years. The authors conclude that partial internal anal sphincter section produces excellent results in treatment of chronic anal fissure. Posterior sphincterotomy may persist effective and safe since continence impairment was not identified in the present study.     

Idiopathic constipation in childhood is associated with thickening of the internal anal sphincter

This study was undertaken to search for a rational basis for the use of anal dilatation and internal sphincterotomy as the treatment for chronic intractable constipation in children. Sixteen children, age 5 months to 13 years, who had constipation resistant to conservative treatment were compared with 39 age-matched controls. History and current symptoms were assessed using a standard questionnaire. Internal and external and sphincter morphology was assessed on clinical examination and by anal endosonography, using a 10-MHz rotating endoprobe to provide accurate measurement of the various components of the anal canal. The control group showed a linear correlation between the thickness of the internal anal sphincter and both age and weight, increasing from 0.4 mm in infancy to 0.9 mm in adolescence. Children who had constipation displayed significant thickening of the internal sphincter (range, 0.5 to 1.9 mm, P = .005) which was independent of the length of the history (P = .103). There was no difference in the morphology of the external anal sphincters between the groups. The finding of a hypertrophied internal anal sphincter could provide a rational basis for anal dilatation and internal sphincterotomy as treatment for idiopathic constipation.     

Significance of tubulitis in chronic allograft nephropathy: a clinicopathologic study

PURPOSE: To investigate the diagnostic accuracy of faecal occult blood test (FOBT) for anal diseases and to evaluate the relationship of this disorder to the results of FOBT. METHODS: In a hospital-based retrospective study, FOBT using faecal samples collected on two consecutive days was performed on patients with anal disease, such as internal as well as external haemorrhoids and anal fissure, patients with colorectal cancer and healthy subjects to evaluate the diagnostic accuracy of FOBT. In a screening-programme-based cross-sectional study, the subjects who underwent colorectal cancer screening by FOBT using the 2-day method were divided into two groups according to the results of a questionnaire on anal diseases; the positive rate of FOBT as well as the predictive value for colorectal cancer were determined in the two groups. RESULTS: Among 300 cases, including 100 anal diseases, 100 colorectal cancers and 100 healthy subjects, the test was positive in 12 anal diseases, 82 colorectal cancers and six healthy subjects. The sensitivity to anal diseases and colorectal cancer was calculated to be 12% and 82%, respectively, and the specificity was 95%. A significant difference was noted in the sensitivity between anal diseases and colorectal cancer (P < 0.001). Among 21,724 subjects, who underwent colorectal cancer screening, 2395 subjects were positive for anal diseases, and 19,329 subjects were negative. The positive rate of FOBT was 7.2 for the anal diseases group and 6.8 for the non-anal diseases group, and the predictive value for colorectal cancer was 2.9 and 3.0, indicating no substantial difference between the two groups. CONCLUSIONS: These results reveal that FOBT is inferior for the diagnosis of anal diseases, and anal diseases have little relationship to the results of FOBT.     

Intermittent androgen suppression with leuprolide and flutamide for prostate cancer: a pilot study

OBJECTIVES: To affirm the feasibility of using intermittent androgen suppression in patients with hormone-naive prostate cancer. METHODS: Leuprolide and flutamide were administered for 9 to 12 months and then discontinued until prostate-specific antigen (PSA) levels reached a threshold value determined by the baseline PSA value. This constituted one cycle of treatment. Androgen suppression was then administered intermittently as described until there was evidence of androgen independence. RESULTS: Twenty-two patients with PSA failure after primary therapy with surgery and/or radiation and untreated early or Stage D2 disease were treated. Twenty-one patients completed androgen suppression during cycle 1, with a median time to PSA nadir of 3.5 months (range, 2 to 12). Fifteen patients completed cycle 1 with a median time off treatment of 6 months (range, 2 to 19) or 38% (range, 17% to 64%) of a treatment cycle. Six patients continued off treatment during cycle 1 for 1+ to 31+ months. During cycle 2, 12 patients achieved a PSA nadir in a median time of 3.5 months. Two patients completed cycle 2 with a median time off treatment of 10 months (51%). Median follow-up for all patients is 26 months (range, 10 to 51). While off treatment, all patients reported a reduction of symptoms associated with androgen suppression. CONCLUSIONS: Intermittent androgen suppression is a feasible alternative to continuous androgen suppression for treatment of prostate cancer, and quality of life is improved while off treatment.     

A critical appraisal of pathogenesis and morbidity of surgical treatment of chronic anal fissure

Preoperative and postoperative manometric findings and the results of lateral internal sphincterotomy were analyzed in 44 consecutive patients affected with chronic anal fissure. Preoperatively, resting anal pressure was increased in 32 patients. At one month postoperatively, 23 patients showed normal pressures, whereas 14 were still hypertonic and seven, hypotonic. Only three patients still had a weak sphincter six months postoperatively. The overall morbidity rate was 31.8 percent. Minor complications occurred in 11 patients. Major complications affected three patients. Overall, impaired continence was recorded in eight patients, although only two complained of persistent, albeit lesser, defects of continence not requiring the use of pads. Nonoperative treatment should be reserved for few selected patients with recent, acute fissures. As for chronic and fissures, compared with other operative or nonoperative modalities of treatment, lateral internal sphincterotomy is a highly successful procedure and its minimal morbidity is well accepted by the patient.     

Percutaneous transvenous balloon dilatation of mitral valve stenosis

In this study, 42 consecutive symptomatic patients (median age 60 (30-78) years, 86% females) with mitral valve stenosis (57% had severely deformed and/or calcified mitral valves) were treated with (Inoue) balloon dilatation during the period August 1989-June 1994. Mitral valve area and cardiac output increased by 67 and 25%, whereas the transmital gradient as well as pulmonary artery pressure fell by 45% and 21%, respectively, after the dilatation. Follow-up at a mean of 16 (1-46) months revealed a total mortality of 12% (cardiac mortality of 7%). Five patients developed significant' mitral regurgitation after the treatment and four of these had subacute mitral valve replacement. A further four patients received an artificial valve during the follow-up period. During the follow-up period the increase in valve area remained unchanged, and accordingly 97% of the patients were in New York Heart Association functional class I-II. Balloon dilatation was an acceptable treatment in the described elderly population with significant mitral stenosis and deformed valves.     

One hundred cases of anal fissure treated with botulin toxin: early and long-term results

PURPOSE: Sphincterotomy still is considered the therapy of choice to eliminate sphincter spasm in the treatment of uncomplicated chronic anal fissure. The surgery is weighted with the possible surgical risk and the risk of subsequent fecal incontinence. This study reports the effect of botulin toxin injections within the first six months. PATIENTS AND METHODS: One hundred patients were treated (43 females; average age, 34.7 years). The injection of botulin toxin (2.5-5 units of Botox each) was done bilaterally to the fissure, thereby causing paresis of the sphincters for approximately three months. Patients were re-examined after one week and three and six months. RESULTS: Within the first week, 78 percent of patients were free of pain. In 82 percent of patients, complete healing of the fissure occurred within the first three months. Eight patients experienced relapses within the first six months of therapy, three of whom needed surgical intervention. The healing rate after six months was 79 percent. No healing occurred in 21 patients, and they had to undergo surgery. Transitory fecal incontinence resulted in seven cases. CONCLUSIONS: Injection of botulin toxin enables us to treat chronic, uncomplicated anal fissures with increased sphincter tone. It is well tolerated, can be administered on an outpatient basis, does not cause any lesion of the continence organ, and subsequently, does not lead to any permanent latent or apparent fecal incontinence.     

Polycythemia vera treated with pipobroman as single agent: low incidence of secondary leukemia in a cohort of patients observed during 20 years (1971-1991)

The 'gold standard' for the treatment of polycythemia vera (PV) is to date undefined. We performed a retrospective analysis to evaluate the outcome of a cohort of PV patients treated with pipobroman (PB) at a single institution during a period of 20 years (November 1971-October 1991). During this period, a total of 366 adult PV patients were diagnosed according to Polycythemia Vera Study Group (PVSG) criteria. Of these, only 199 (54%) were treated with PB: 92 were males and 107 females, median age was 63.0 years (range 25.2-87.3 years). Major clinical characteristics at onset were as follows: 34 (17%) patients had splenomegaly >3 cm below costal margin, 70 (35%) had platelets >600,000/mm3, 79 (40%) had white blood cells >12,000 mm3; 97 (49%) had hypertension, 83 (42%) had minor neurological symptoms (as vertigo, headache, paresthesias), 33 (17%) had pruritus and 27 (13%) had thrombotic features. All patients received PB at the dosage of 1 mg/kg/day until response was achieved (hematocrit value <50% in males and <45% in females). Thereafter treatment was given according to toxicity and maintenance of response. All patients were phlebotomized before starting treatment (mean number of phlebotomies performed: three, range 2-4) and 47 of them received PB when hematocrit value was already reduced at response levels: therefore, while all patients are evaluable for acute and long-term toxicity, only 152/199 (76.4%) patients are evaluable for response to PB. During a median time of 2 months, all these 152 patients achieved the response; as maintenance, 128/199 (64.3%) patients were managed with PB alone and 71/199 (35.7%) patients received phlebotomies occasionally. Sixty-one out of 199 (30.6%) patients developed disease-related complications (25 neurological symptoms, 21 thrombotic complications, 12 cardiovascular problems, three hepatic failures). Eleven (5.5%) patients developed acute myelogenous leukemia (AML) after a median time of treatment of 89 months (range 33-188 months), 11 (5.5%) patients developed myelofibrosis (median time from treatment 71 months, range 31-182 months) and in six (3%) patients cancer occurred (median time from treatment 85 months, range 13-118 months). The cumulative risk of leukemia in PV was 2% (95% CI: 0-4%) and 6% (95% CI: 1-11%) at 5 and 10 years respectively; the cumulative risk of myelofibrosis was 2% (95% CI: 1-5%) and 9% (95% CI: 3-15%) at 5 and 10 years, respectively. As of May 1996, 33 (16.6%) patients are lost to follow-up, 40 (20.1%) are dead and 126 (63.3%) are alive with a median overall survival of 191 months. In conclusion, this retrospective analysis confirms the efficacy and safety of PB in PV patients and its low leukemogenic role; prospective studies are needed to evaluate the real impact of PB in the treatment of PV.     

Anal lesions complicating Crohn disease

Of 503 patients with Crohn disease seen at the New York Hospital-Cornell Medical Center, 138 (28%) developed an anorectal abscess, anal fissure, or anal fistula during the course of their disease. In 9.3% of patients the anal lesion preceded the onset of intestinal symptoms by two weeks to 12 years. Patients in our series with large bowel disease were twice as likely to develop an anal lesion as were patients with small bowel disease. Likewise, patients with large bowel disease were twice as likely to have had an anal lesion as a presenting symptom. A patient with an anal lesion, however, was more apt to develop small bowel disease simply because the small bowel was a far commoner site of Crohn disease in this series. The cause of the anal lesions is still not clear. Specific evidence of Crohn disease was not found in histological examination of material from any of the patients.     

Long term follow-up and late complications of 2-chlorodeoxyadenosine in previously treated, advanced, indolent non-Hodgkin's lymphoma

BACKGROUND: The aim of this study was to determine the long term outcome and toxicities after the administration of 2-chlorodeoxyadenosine (2-CdA) to patients with previously treated, advanced, indolent non-Hodgkin's lymphoma (NHL). METHODS: Twenty-two patients (median age, 55 years) with relapsed or refractory low grade NHL (median disease duration, 2.8 years) were treated with 2-CdA by continuous infusion at 0.1 mg/kg/day over 5 or 7 days every 28 days, for a maximum of 6 cycles. RESULTS: The overall response rate was 45%. Two patients (9%) achieved a complete response (CR), 8 patients (36%) achieved a partial response, and 12 patients (55%) had no response. The two patients achieving CR have remained in CR for 46 and 38 months, respectively. Freedom from treatment failure at 24 months was 32%. Overall survival at 24 months was 59%. Three patients developed second malignancies: acute myelogenous leukemia (AML), myelodysplastic syndrome, and a cutaneous lymphoproliferative disorder. Fourteen patients have died after a median follow-up of 28 months (range, 3.9-49.2 months) due to progressive NHL (11 patients), infection (2 patients), and AML (1 patient). CONCLUSIONS: 2-CdA is an active agent for patients with previously treated, advanced, indolent NHL and may result in lasting remissions. Late complications following treatment may include delayed bacterial, fungal, or viral infection. Determination of whether the second malignancies that occurred in three patients reported herein were related to treatment with 2-CdA will require further study.     

Anal and urinary incontinence after obstetric anal sphincter rupture]

The aim of the study was to assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence, and identify factors to predict patients at risk. In 94 consecutive women who had sustained an obstetric anal sphincter rupture, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months post partum was performed. A questionnaire regarding incontinence was sent between two to four years post partum. Forty-two percent of responders had anal incontinence, 32% had urinary and anal incontinence. Overall, 56% of the women had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies > 2.0 milliseconds and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Thirty-eight percent of the women with incontinence wanted treatment, but only a few had sought medical advice.     

Preferences for chemotherapy in patients with advanced non-small cell lung cancer: descriptive study based on scripted interviews

OBJECTIVE: To determine how patients with lung cancer value the trade off between the survival benefit of chemotherapy and its toxicities. DESIGN: Scripted interviews that included three hypothetical scenarios. Each scenario described the same patient with metastatic non-small cell lung cancer with an expected survival of 4 months without treatment. Subjects were asked to indicate the minimum survival benefit required to accept the side effects of chemotherapy in the first two scenarios (mild toxicity and severe toxicity). In the third scenario, subjects were asked to choose between chemotherapy and supportive care when the benefit of chemotherapy was either to prolong life by 3 months or to palliate symptoms. SUBJECTS: 81 patients previously treated with cis-platinum based chemotherapy for advanced non-small cell lung cancer. MAIN OUTCOME MEASURE: Survival threshold for accepting chemotherapy. RESULTS: The minimum survival threshold for accepting the toxicity of chemotherapy varied widely in patients. Several patients would accept chemotherapy for a survival benefit of 1 week, while others would not choose chemotherapy even for a survival benefit of 24 months. The median survival threshold for accepting chemotherapy was 4.5 months for mild toxicity and 9 months for severe toxicity. When given the choice between supportive care and chemotherapy only 18 (22%) patients chose chemotherapy for a survival benefit of 3 months; 55 (68%) patients chose chemotherapy if it substantially reduced symptoms without prolonging life. CONCLUSIONS: Patients' willingness to accept chemotherapy for the treatment of metastatic lung cancer varies widely. Many would not choose chemotherapy for its likely survival benefit of 3 months but would if it improved quality of life. The conflict between these patients' preferences and the care they previously received has several explanations, one being that some patients had not received the treatment they would have chosen had they been fully informed.