Prolonged survival in selected patients following surgical resection for pulmonary metastasis from hepatocellular carcinoma

BACKGROUND: Pulmonary metastasis is the commonest site of extrahepatic spread from hepatocellular carcinoma (HCC). The aim of the present study was to evaluate the efficacy of surgical management in patients with solitary pulmonary metastases from HCC. METHODS: This was a retrospective study of patients with HCC admitted for hepatectomy from July 1972 to June 1995. The records of patients who had a pulmonary resection for histologically proven pulmonary recurrence after curative hepatectomy were selected for analysis. RESULTS: In the study interval, 380 patients with HCC underwent hepatectomy. Some 48 patients (12.6 per cent) developed pulmonary metastases documented pathologically or radiologically. Nine (seven men and two women) were suitable for curative pulmonary resection. The median disease-free survival between hepatectomy and appearance of the lung metastasis was 21 months. The median survival after pulmonary resection was 42 months, and the 1-, 2- and 5-year survival rates were 100, 78 and 67 per cent respectively. CONCLUSION: Pulmonary resection for metastases from HCC resulted in long-term survival in these highly selected patients.     

Surgical treatment of pulmonary metastasis of colorectal cancer. Prognostic survival factors

SURVIVAL RATES: Less than 5% of patients with pulmonary metastasis from colorectal carcinoma will survive at 5 years, but 30% will survive at 5 years after surgical treatment. MAIN PROGNOSTIC FACTORS: The number of nodules, presence of regional lymph node metastases, disease-free interval between treatment of the primary tumor and development of metastasis as well as serum CEA level are the main prognostic discriminants. INDICATIONS FOR SURGERY: An aggressive operative approach is indicated even when there are pulmonary and extra-pulmonary localizations. Repeat thoracotomy is warranted for recurrent disease.     

Long-term disease-free survival after isolated peritoneal metastasis from colonic cancer

We present the case of a 29-year-old female patient with an isolated peritoneal metastatic mass in the Douglas pouch, following ileocecal resection for a Dukes C2 colon cancer of the caecum. As initial treatment, four courses of continuous infusion with epiadriamycin were administered. The effect on the tumour size was marginal. Palliative radiotherapy (33 Gy) resulted in a reduction of the tumour size and subsequently a wide posterior exenteration could be performed. Five years after the initial diagnosis the patient is still in good health with no evidence of tumour recurrence. We sincerely believe that a maximum effort aiming for cure is warranted in selected patients with localized residual or metastatic peritoneal colon cancer, even if the initial prospects seem less favourable.     

Surgical treatment of pulmonary metastasis from renal cancer: analysis of 9 cases]

Nine patients with pulmonary metastasis from renal cancer were subjected to surgical treatment which included wedge resection (2 cases) and lobectomy (9). One case of multiple lesions in bilateral lungs was treated in the same time by cryosurgery and fulguration. The survival time after operation ranged from 5 to 90 months. In this series, four cases are still alive, others survived for 13 months, 20 months, 34 months, and 90 months, respectively. We suggest that the more active attitude should be taken for the surgical treatment of pulmonary metastasis.     

Prolonged disease-free survival by maintenance chemotherapy among patients with recurrent platinum-sensitive ovarian cancer

The aim of this prospective, randomized and double-blind study was to assess the effects of a high dose of the analgesic tramadol administered at the conclusion of surgery on extubation time, sedation, and post-anaesthetic shivering. Forty adult patients, ASA physical status I or II, underwent laparoscopic surgery of about 1 h duration and received a standardized anaesthesia that was maintained with isoflurane in O2/N2O. Tramadol 3 mg kg-1 (n = 20) was administered intravenously at the beginning of wound closure, and was compared with saline (n = 20). Post-anaesthetic shivering did not occur in any patient who received tramadol, whereas it occurred in 60% of the control group (P < 0.001). There were no adverse effects on time to extubation and sedation, and discharge-ready time was shorter in the tramadol group (P < 0.05 compared with control). Pain scores in the post-anaesthesia care unit (PACU) were statistically not different between the two groups, but significantly more supplemental medication was administered in the control group to treat shivering and/or pain. In conclusion, administration of a high dose of tramadol at the end of surgery prevents post-anaesthetic shivering without prolongation of extubation time, and shortens the PACU/discharge-ready time.     

Symptomatic renal metastasis from testicular cancer

The clinical course of a patient who presented with a massive left renal metastasis from testicular carcinoma is described. Treatment with cisplatin-based chemotherapy produced a dramatic response. Symptomatic renal metastases from testicular cancer are rare and may be reflective of a high tumor burden or refractory disease.     

Determinants of survival following hepatic resection for metastatic colorectal cancer

Hepatic resection remains the only potentially curative treatment for metastatic colorectal cancer. This retrospective review study was undertaken in an attempt to identify factors that influence patient survival following hepatic resection for metastatic colorectal cancer. From January 1978 to December 1993, a total of 301 patients underwent a total of 345 planned hepatic resections for metastatic colorectal cancer. Of those, 245 patients had one resection, 44 had two resections, and 12 had three resections. For all patients the overall median survival was 20.6 months, operative mortality was 1.1%, and overall morbidity was 17.2%. Average hospital stay was 9 days. Statistical analysis included univariate analysis using log rank comparisons, Kaplan-Meier survival curves, and multivariate analysis using Cox proportional hazards regression. The statistically significant factors that influenced survival were distribution of liver metastases, unilobar versus bilobar (p = 0.0001), resected versus nonresected (p < 0.0001), and tumor-free surgical margins versus positive margins (p = 0.001). Surprisingly, the disease-free interval and the original stage of the primary tumor did not predict survival (p = not significant). Other factors that had no influence on survival were type of resection, size and number of liver metastases, ABO blood group, and the number of perioperative blood transfusions. For those patients who underwent resection of unilobar metastases with tumor-free margins, the 5-year survival rate was 29% with a median survival of 35 months and eight survivors > 7 years. In addition, one patient with bilobar disease had survival > 7 years and five patients who had resection of hepatic metastases and extrahepatic cancer simultaneously had survival > 3 years. Our data support the concept that patients with unilobar metastatic disease who undergo surgical resection with tumor-free surgical margins can be afforded a significant opportunity at long-term survival with acceptable morbidity, mortality, and hospital stay. Also, certain patients with bilobar or extrahepatic disease (or both) who undergo complete resection can enjoy a long-term survival. In these subgroups of patients resection should be considered on an individual basis.     

Bone metastasis from colorectal cancer in autopsy cases

The incidence of bone metastasis from colorectal cancer is reported to be 10.7% in autopsy cases. However, the characteristics of the primary cancers, as well as the patterns of bone metastasis, remain unclear. We analyzed the clinical and autopsy records of 118 patients with primary colorectal cancer treated either surgically or conservatively and eventually autopsied between 1970 and 1987 at Toranomon Hospital in Tokyo. Bone metastasis was detected in 23.7% (28/118). The average age of patients with bone metastasis was lower than that in patients without bone metastasis (P < 0.02). Cancers to the rectum and cecum were accompanied by bone metastasis more frequently than cancers of other portions of the colon. Signet-ring cell carcinoma showed a high incidence of bone metastasis (P = 0.041). Bone metastasis from colorectal cancer was associated with liver or lung metastases (P < 0.0001). These results indicated that bone metastasis from colorectal cancer is not as infrequent as previously described.     

Prolonged survival by 'early' salvage treatment of breast cancer patients: a retrospective 6-year study

Between 1977 and 1993, 384 breast cancer patients were followed up post-operatively every 4 or 6 months with a serum tumour marker panel (CEA-TPA-CA15-3) and the usual imaging techniques. Twenty-eight patients were treated 13.5 +/- 10 months (mean +/- s.d.) before the clinical and/or radiological occurrence of distant metastases that were suspected because of an increase in the tumour markers (patients treated 'early'). Their outcome was compared with that of 22 similar patients who were treated only after a definite radiological diagnosis was achieved (patients treated 'not early'). The median survivals from mastectomy and salvage treatment were also compared for the two groups. The groups were similar for all the major prognostic factors (menopause, staging, hormone dependency). In the group treated 'early', the lead time from the tumour marker increase to the clinical and radiological signs of metastases was significantly longer than that of the group not treated 'early' (13.5 +/- 10 vs 3.4 +/- 2.8 months respectively; P < 0.001 by unpaired t-test). For patients treated 'early', the survival curves up to 30 months after salvage treatment and up to 72 months after mastectomy showed greater survival than those for the patients treated later (42.9% vs 13.6% and 42.9% vs 22.7% respectively; P = 0.04 in both instances). These data suggest that treatment triggered by rising tumour markers before clinical and/or radiological appearance of distant metastases can be useful in prolonging both the asymptomatic interval and the duration of response of some relapsed patients. Randomized prospective trials must be encouraged to confirm these data and to better evaluate the effect on the disease-free survival (DFS) and overall survival (OS) of 'early' salvage treatment protocols.     

Factors in improved survival from paediatric cancer

OBJECTIVES: The cost of providing services is the traditional criteria used by payers in making selective contracting decisions regarding home care providers in general, and home infusion therapy (HIT) vendors specifically for this analysis. This approach assumes comparable health outcomes, for which adequate measures often are unavailable. In practice, poor quality can result in a need for remedial services. The objective of this research is to develop a method to use health insurance claims data to incorporate the hidden costs of adverse outcomes into an analysis of the costs of a vendor's HIT. METHODS: The Home Infusion Therapy/Relative Benefit Index (HIT/RBI) model incorporates measures of both the cost of providing HIT services as well as the cost of remedial treatment for the adverse outcomes that may result from HIT care, eg, emergency room visits. The data source for the analysis is the health care claims for a sample of managed care patients of national insurer for the period 1990 to 1994. RESULTS: The analysis confirms that adverse clinical outcomes can lead to additional demand for remedial health care with resultant negative financial consequences. When the cost of the adverse outcomes is incorporated into the analysis, vendors who appeared to be low cost on the basis of HIT services, in fact were higher cost vendors, whereas vendors with a high cost of services but with few adverse events were low cost vendors. CONCLUSIONS: Payers should consider both the clinical and economic consequences of providing care into account in selecting vendors. The HIT/RBI model is a useful tool for incorporating the cost of adverse outcomes into a comprehensive comparison of the cost multiple vendors of HIT services.     

Solitary cerebral metastasis from ovarian carcinoma: report of 4 cases

Four cases of solitary cerebral metastasis from ovarian carcinoma are reported. Although systemic metastases from this type of tumor are frequent, they rarely affect the nervous system. From the 4 cases presented and a review of the literature, it appears that a better outcome may be obtained by a combined treatment of the cerebral metastasis, comprising surgery, radiotherapy and chemotherapy.     

Racial differences in survival from gynecologic cancer

OBJECTIVE: To determine whether survival from gynecologic cancer is different between African-American and white patients at an inner-city hospital with both a large clinic and a private service. METHODS: We studied 538 patients (89 African American, 449 white) diagnosed with cervical, uterine, or ovarian cancer at a single institution from January 1, 1989 through December 31, 1993. Information was obtained on age, stage, site of disease, histology, and type of health insurance (public or commercial). Insurance coverage was used as a proxy for socioeconomic status. Overall survival was estimated by the method of Kaplan and Meier and compared by the log-rank test. Cox proportional hazard modeling was used to evaluate the effects of multiple factors on survival. RESULTS: African-American patients were significantly older and were more likely to have cervical cancer and public insurance than white patients. Overall survival was worse for African-American patients than for white patients (P < .05). However, stage for stage, there was no significant difference in survival between the groups. There was also no difference when patients were grouped by insurance status. African Americans had a significantly worse survival for cervical cancer than whites, and African-American patients older than 65 years had a worse survival than whites of similar age. On multivariate analysis, only stage and insurance coverage were significant predictors of survival. CONCLUSIONS: African-American patients with gynecologic cancer at our institution have worse overall survival than white patients. The survival difference seems to be due predominantly to differences in socioeconomic status and stage at diagnosis.     

Prognosis of hepatic metastasis from colorectal cancer following hepatic resection and arterial infusion chemotherapy--assessment from the percentage of tumor involved area

Prognosis of hepatic metastasis from colorectal cancer following hepatic resection and arterial infusion chemotherapy was studied from the percentage of tumor involved area (PTIA). The PTIA was calculated by the following formula: sigma S'/sigma S, with S' as the tumor area and S as the liver area on each CT slice. The subjects were 25 cases of hepatic resection (HR), and 31 cases of hepatic arterial infusion chemotherapy (HAI). The PTIA of the cases of HR and that of HAI was 1.5 to 25.9% and 0.8 to 31.3%, respectively. For comparison, all cases were divided into group A, which was not more than 10% of the PTIA, and group B, which was more than 10% of the PTIA. In the cases of HR, the prognosis of group A was significantly better than that of group B (p < 0.05). In the cases of HAI, the prognosis of group A was better than that of group B. Even in group A, the prognosis of the cases of HR was significantly better than that of HAI (p < 0.05). These results suggest that the PTIA in the cases of HR and HAI for metastasis from colorectal cancer is important factor which reflects the prognosis.     

Adrenalectomy for a solitary adrenal metastasis from lung cancer

Intrathecal sufentanil provides approximately 2 h of excellent labor analgesia with minimal motor blockade. Epidural sufentanil has received less scrutiny but may provide the same benefits as intrathecal sufentanil. In this study, we compared epidural sufentanil 40 microg after a lidocaine with an epinephrine test dose with intrathecal (i.t.) sufentanil 10 microg with respect to onset and duration of analgesia, degree of motor block, side effect profile, and mode of delivery. Seventy ASA physical status I or II parturients in early labor (< or = 4 cm cervical dilation) were randomized to receive either i.t. sufentanil 10 microg with a combined spinal-epidural technique (CSE) or epidural sufentanil 40 microg (e.p.) after epidural catheter placement and testing with 3 mL of 1.5% lidocaine with epinephrine (15 microg). After the administration of analgesia, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. The study period was completed when the patients requested additional analgesia. All patients, except one, achieved adequate analgesia with the initial study dose and satisfactorily completed the study. There were no demographic differences between the two groups. Pain relief was rapid for all patients; pain scores were significantly lower at 5 and 10 min in the i.t. group versus the e.p. group. The mean duration of analgesia was similar between the e.p. group (127 +/- 40 min) and the i.t. group (110 +/- 48 min). No patient experienced any motor block. Side effects were similar between the two groups, except for pruritus-both the incidence and severity were significantly more profound at 5, 10, 15, 20, and 30 min in the i.t. group. There was no difference in time from analgesic to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 40 microg after a lidocaine test dose provides analgesia comparable to that of i.t. sufentanil 10 microg with less pruritus. Implications: We compared the efficacy and side effects of intrathecal sufentanil with epidural sufentanil with a local anesthetic test dose for analgesia during labor. Analgesia was equally good, although the intrathecal group experienced more itching.     

Surgical and medical management of patients with pulmonary metastasis from parathyroid carcinoma

BACKGROUND: The aim of this study was to characterize patients with pulmonary metastasis of parathyroid carcinoma and to evaluate the long-term effect of surgical and medical therapy. METHODS: Seven patients with pulmonary metastasis of parathyroid carcinoma were treated between 1980 and 1992. Six patients underwent resection of pulmonary metastases, and one patient has had long-term bisphosphonate therapy alone. Bisphosphonate was also given before or after operation to three patients. RESULTS: Two patients underwent a unilateral thoracotomy for a single pulmonary lesion, and four other patients with multiple lesions underwent staged bilateral thoracotomies. The postoperative serum calcium level returned to normal after each thoracotomy in three patients who were alive and well 3, 8, and 12 years after the first thoracotomy. Hypercalcemia persisted in the other three patients. In two of the patients, bisphosphonate therapy was also unable to control hypercalcemia. In one patient the serum calcium level has been maintained in the 13 mg/dl range by bimonthly bisphosphonate therapy alone for 3 years. CONCLUSIONS: The aggressive surgical approach to pulmonary metastasis of parathyroid carcinoma was shown to be effective for palliation in selected patients. Bisphosphonate therapy is an alternative to resection but has only a temporary calcium-lowering effect.     

The incidence of solitary pulmonary metastasis from carcinoma of the large intestine

Two hundred and two consecutive patients who underwent resection of an adenocarcinoma of the colon or rectum from January 1958 to December 1972 were evaluated for the development of a metastatic tumor in the lungs. In the 185 patients who survived the 30 day postoperative period, 30 malignant pulmonary lesions were subsequently recognized. Six of these were a solitary lesion and 24 were multiple lesions. Three of these malignant lesions were proved to be other than metastatic disease. Metastatic adenocarcinoma from the colon or rectum was proved to be present in 27 patients, an incidence of 14.5 per cent. Only four of these lesions were solitary, 14.8 per cent of the metastatic pulmonary lesions. The solitary metastatic tumors represented an incidence of 2.1 per cent in this patient population, but long term tumor-free survival was possible with appropriate pulmonary resection of the metastatic disease. It is suggested that periodic roentgenographic examination of the chest, every four to six months, be an integral part of the postoperative follow-up study carried out on these patients.