Primary nonampullary/periampullary adenocarcinoma of the duodenum

Primary duodenal adenocarcinoma not involving the ampullary region is rare. Our aim was to review the outcome of these patients and determine the factors that affect survival. We performed a retrospective review of all patients with primary, nonampullary duodenal adenocarcinoma at the Cleveland Clinic Foundation from January 1986 through December 1996. Twenty-six patients with primary, nonampullary duodenal malignancies were identified. There were 16 adenocarcinomas, 3 gastrinomas, 3 stromal tumors, 3 leiomyosarcomas, and 1 carcinoid tumor. Patients with adenocarcinoma had symptoms present an average of 6.1 months. Tumors were identified by upper gastrointestinal contrast study and esophagogastroduodenoscopy in 90 per cent and 87 per cent of patients, respectively. Twelve of 13 (93%) cancers found in the third or fourth portion of the duodenum were adenocarcinomas. Seven of the 16 adenocarcinomas were resectable on exploration. Those that were contained within the serosa have not recurred (mean, 6 years); one of the two patients with locally invasive adenocarcinoma remains disease free. The average survival for patients with unresectable disease was 6.7 months. The 5-year survival rates were: all adenocarcinoma, 38 per cent; resectable, 86 per cent; and unresectable, 0 per cent. All patients presenting with weight loss or obstructive symptoms died of disease; those with melena survived long term. Patients with tumors other than adenocarcinoma had a 90 per cent 5-year survival. We conclude that patients typically present with a long history of symptoms. Distal duodenal malignancies are most frequently adenocarcinomas. Upper gastrointestinal contrast study or endoscopy is often diagnostic. Patients with weight loss and/or obstructive symptoms had invasive disease and a morbid prognosis. Aggressive surgery is warranted, and most with resectable disease (86%) had long-term survival.     

Laser therapy of villous rectocolonic tumors. Evaluation of results by multivariate analysis

One hundred and twenty-four patients (mean age: 70 years) with a villous tumour of the rectum (n = 98) or the colon (n = 26) were treated by laser therapy from 1985 to 1991. Initial complete eradication was obtained in 93.5% of cases with a median time of 16 months. Using multivariate analysis, the tumor size (> 4 cm) only was predictive of eradication (P < 0.001). At 6 and 12 months, the actuarial eradication rates were 91 and 98% for small tumours versus 45 and 74% for larger tumours respectively. The actuarial recurrence rates were 10.5, 23, and 37% at 6, 12 and 24 months, and no longer increased after 3 years. No predictive factor of recurrence was isolated by multivariate analysis. Seven complications (5.6%) and 4 malignant transformations (3.4%) occurred. This study confirms the efficiency and low morbidity of laser therapy, especially in patients with small tumors, less than 4 cm in size.     

Design and evaluation of a portable rigid forced-air warming cover for prehospital transport of cold patients

Although villous lesions comprise only about 5 per cent of all adenomas, 40 per cent are premalignant. Complete colonic evaluation and resection of all villous lesions should be performed. The purpose of this study is to examine our experience with transanal excision and low anterior resection as treatment options for large villous adenomas of the rectum. A retrospective review of all cases of villous adenomas of the rectum at this institution from January 1991 to February 1997 was performed. A total of 16 patients were identified; fourteen underwent transanal excision and two underwent low anterior resection. The average lesion size was 5 cm, and 50 per cent extended proximal to 8 cm from the anal verge. Thirty-seven per cent (six patients) had villous lesions containing adenocarcinoma. Thirty-one per cent (five patients) have required treatment for residual disease noted within 6 months of resection. Twelve per cent (two patients) have received treatment for recurrent disease presenting 6 months after resection. The minor complications included two episodes of urinary retention. The serious complications included one perforation and one postoperative hemorrhage for a 12 per cent complication rate. In summary, large villous adenomas of the rectum can be removed by sphincter-preserving techniques with low morbidity and an acceptable recurrence rate.     

Comments on safe operation of ultracentrifuge

A review of 400 consecutive patients with retinoblastoma disclosed that 103 tumors in 103 eyes were treated with solitary plaque radiotherapy. The tumors were from 1 to 16 mm (mean, 7 mm) in basal diameter and from 1 to 8 mm (mean, 4 mm) in thickness. Thirty-one tumors were treated with plaque radiotherapy as initial treatment, whereas 72 tumors were treated with plaque radiotherapy as secondary treatment after failure of other methods. Of the 102 tumors on which adequate follow-up data were available, all responded initially to plaque radiotherapy with tumor regression. Over the mean follow-up of 38 months (range, six to 192 months), 89 tumors (87%) showed persistent regression and 13 (13%) showed tumor recurrence. The recurrence occurred at a mean interval of five months (range, one to 11 months) after plaque radiotherapy. A statistical analysis of tumor size, tumor location, tumor proximity to the optic disk and foveola, presence of vitreous seeds, radioactive plaque diameter, plaque shape, radioisotope, and primary or secondary treatment disclosed no important predictors of tumor recurrence. Carefully selected retinoblastoma, even juxtapapillary and macular tumors and those with localized vitreous seeds, can be successfully treated with plaque radiotherapy.     

Microsurgical treatment of intramedullary spinal cord tumors

Eighty patients with intramedullary spinal cord tumors were treated by microsurgical methods between 1988 and 1996. Twenty-nine patients were diagnosed with astrocytoma, 36 with ependymoma, five with metastasis, four with lipoma, three with dermoid or epidermoid tumor, two with neurofibroma, and one with neuroma. Vascular and infectious lesions (such as abscesses and hemangioblastomas) were excluded. After laminectomy, total removal of the lesion was achieved in 68 of 80 patients and subtotal removal in 12. Postoperative radiation therapy was performed in 13 of 80 patients. The follow-up period ranged from 12 to 92 months (mean 42.2 months). All patients underwent preoperative and postoperative magnetic resonance imaging at intervals ranging from 3 months to 5 years postoperatively. Four patients showed clinical and radiological evidence of local tumor recurrence during the follow-up period. Four patients died 5 months to 15 months postoperatively from the re-expansion of their primary metastatic disease. The operative results at long term (after the 6th postoperative month) were better than the results at short term (before the 6th postoperative month) and revealed clinical improvement in 63, no change in 10, and deterioration in seven patients. We recommend early radical surgery, whenever possible, to be performed when the patient's neurological status is still good. Subtotal removal and irradiation are better for malignant or metastatic tumors. Partial decompressive removal is best for large intramedullary lipomas. Plastic laminotomy with preservation of the intervertebral joints is especially recommended in young or middle-aged patients.     

NM23 gene product expression does not predict lymph node metastases or survival in young patients with colorectal cancer

PURPOSE: To develop a hepatic artery embolization protocol and investigate its efficacy in a prospective study treating patients with hereditary hemorrhagic telangiectasia and predominant hepatic involvement. MATERIALS AND METHODS: One man and four women with hereditary hemorrhagic telangiectasia presented with symptoms of high-output heart failure, abdominal angina, or severe portal hypertension. The hepatic arteries were embolized in stages in three to five sessions at 1- to 15-week intervals. After peripheral embolization with polyvinyl alcohol particles, proximal arteries were embolized with coils. Computed tomography and assessment of cardiac output were performed before and after therapy and at the end of follow-up (median, 25 months; range, 12-55 months). RESULTS: After embolization, analgesics and antiemetics were necessary for a median of 5 and 2 days, respectively. Other than ischemic cholangitis (one patient), no complications were observed. The mean cardiac output decreased significantly (P < .05) from 14.2 L/min to 8.0 L/min. Symptoms of high-output heart failure, abdominal angina, and portal hypertension resolved in all patients. Seven months after embolization, one patient died of postoperative sepsis after an unsuccessful surgical attempt to create a portacaval shunt. Delayed recurrence of symptoms was not noted in the other patients. CONCLUSION: In symptomatic patients with hereditary hemorrhagic telangiectasia and predominant hepatic involvement, embolization of the hepatic arteries in stages is well tolerated by the patients and results in good clinical improvement at midterm follow-up.     

Endoscopic ligation with elastic bands in the prevention of hemorrhage recurrence caused by esophageal varices. Study of 45 patients

The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence by esophageal varices. Forty-five patients without known hepatocarcinoma who had survived a hemorrhagic variceal episode were included in the study. Seventeen patients (38%) were Child-Pugh A, 22 (49%) B, and 6 (13%) C, with the hepatitis C virus and alcohol being the etiology of cirrosis in 55 and 20% of the cases, respectively. The first ligation session was performed between the third and fifth days after the hemorrhagic episode and the posterior sessions were carried out at intervals of 2-4 weeks. The ligation sessions were performed without antibiotic prophylaxis and with placement of an overtube. A mean of 4 +/- 2 bands were placed per session (range, 1-8) and the mean number of sessions required per patient to achieve erradication of the varices was 3.5 +/- 1.5 (range, 2-8). The rate of bleeding recurrence was 17.7% (9 episodes, five by variceal rupture and four by ulcer secondary to ligation). All the episodes of bleeding recurrence occurred between the sessions, with the mortality being 11% (5/45 patients). In the 40 remaining patients the varices were erradicated although 19 (47.5%) required one or two additional sessions of sclerotherapy. The accumulated percentage of patients free of bleeding recurrence was 82% during a mean follow-up of 10.2 +/- 6.7 months. Ten lesions of dislaceration of the esophageal mucosa caused by placement of the were observed overtube. In conclusion, endoscopic elastic band ligation is a useful technique for the erradication of esophageal varices an in the prevention of bleeding recurrence.     

Pheochromocytoma, a rare cause of hypertension: long-term follow-up of 55 surgically treated patients

Pheochromocytoma is a rare tumor that is found in only 0.1% of patients with diastolic hypertension. We analyze the results of our experience in management of pheochromocytomas and long-term results of its surgical treatment. From 1977 to 1996 we operated on 55 patients with a pheochromocytoma: 29 males and 27 females with an average age of 41 years (range 10-63 years). In 44 (80.0%) patients episodic hypertension or paroxysms were observed; 7 (12.7%) patients had permanent hypertension, and 4 (7.3%) had a normal arterial blood pressure (ABP). 131/123I-MIBG scintigraphy (33 patients) and magnetic resonance imaging (12 patients) showed 100% sensitivity and computed tomography (47 patients) 97.9% sensitivity. At operation five (9.1%) tumors were bilateral, five extraadrenal, and five multiple. In four (7.3%) patients an association with familial syndromes (three MEN-IIb, one von Recklinghausen disease) was observed. Five (9.1%) malignant tumors were discovered, and two patients are still alive 30 and 104 months after surgery, one of them with relapse. In 43 (78.2%) patients we preferred a flank incision, and no intraoperative deaths occurred. Mean follow-up was 88 months (6-232 months) with recurrence in only 1 (2.0%) of 50 patients without malignancy. In patients with benign pheochromocytomas the recurrence rate did not seem to be elevated in our series. Nevertheless, because the lifelong follow-up requires only annual 24-hour urinary catecholamine measurement (less than $40 per patient per year) and periodic ABP measurements, it is suggested for all patients who undergo surgery for pheochromocytoma.     

Radioiodine I-31 therapy in the management of thyroid cancer. A prospective study

The therapeutic value of I-131 ablation therapy following thyroidectomy for thyroid cancer was evaluated in 54 patients in a prospective study of 25 years. Thirteen (24%) patients had follicular, 24 (44%) papillary, 13 (24%) mixed papillary-follicular, two (4%) Hurthle cell and two (4%) had undifferentiated cell type tumor. Twenty-four (44.5%) patients had metastases at the time of I-131 therapy mainly to cervical and mediastinal lymph nodes, and less frequently to bone, brain, lung, and liver. After surgical thyroidectomy, the mean cumulative dose of I-131 required to achieve therapeutic ablation of functioning post-surgical remnants or tumor metastases was 163.4 mCi. The recurrence rate for patients with metastases was 56% and those without metastases was 25%. Ten patients showed recurrence of I-131 accumulating tissue five to 10 years after initial total ablation. The total mean cumulative dose of I-131 administered for both followup diagnostic studies, and initial and follow-up therapy was 245.3 mCi. Seven deaths were attributable to thyroid cancer, five with differentiated and two with anaplastic cell type tumors. Three of the four patients with differentiated cell type tumors had metastases to brain or bone. Their response to therapy was similar to those patients with anaplastic cell type tumors. In contrast, there were no deaths due to thyroid cancer when total ablation was achieved and maintained. After ablation, all patients were maintained on maximum tolerated doses of thyroid extract or thyroxin. No significant complications attributable to the therapeutic doses of I-131 employed in this series were noted.     

Gorlin's syndrome: the role of the carbon dioxide laser in patient management

The treatment of multiple basal cell carcinomas in patients with Gorlin's syndrome presents a therapeutic challenge. The carbon dioxide laser presents a unique treatment option due to increased surgical speed, a bloodless operating field, reduced postoperative pain and discomfort, and acceptable scars. Six patients with Gorlin's syndrome have been treated with the carbon dioxide laser. Between 14 and 110 lesions were treated in one session under local anesthesia. Pre- and postlaser biopsies of the lesions confirm complete eradication of the tumors. Mean follow-up is 20 months. No local recurrence has been observed.     

Uveal metastasis from carcinoid tumor. Clinical observations in nine cases

BACKGROUND: Carcinoid tumor is a low-grade malignancy that usually arises in the gastrointestinal tract or bronchus and rarely metastasizes to the eye. Metastasis of carcinoid tumor to the uvea can be confused clinically with other primary and metastatic uveal tumors. METHODS: The authors reviewed the records of 410 consecutive patients with uveal metastases referred to the Ocular Oncology Service at Wills Eye Hospital to identify those in whom carcinoid tumor was the primary neoplasm. The authors evaluated the clinical features of these metastases. RESULTS: Of 410 consecutive patients with uveal metastases, the primary neoplasm was a carcinoid tumor in 9 (2.2%). There were four men and five women. The mean age at ocular diagnosis was 50 years. In five patients (56%), the primary tumor was undiagnosed at ocular presentation. In the other four patients, the mean time interval from diagnosis of the primary carcinoid tumor to uveal metastasis was 89 months (range, 55-180 months). The site of the primary carcinoid tumor was the bronchus in seven patients, the esophagus in one, and the thymus in one. The site of intraocular metastasis was the choroid in six patients, the ciliary body in two, and the iris in one. All choroidal tumors had a characteristic orange color. Initial ocular treatment included external beam radiotherapy in five patients, plaque radiotherapy in two, argon laser photocoagulation in one, and local resection in one. Ocular tumor control was achieved in each patient. After a mean follow-up of 34 months, four patients (44%) are still alive. Five patients have died, with a mean survival of 34 months (range, 2-104 months) after the diagnosis of uveal metastasis. CONCLUSIONS: Uveal metastasis from carcinoid tumor is rare and tends to arise from the bronchus. Clinically, it has a distinctive orange color and may be associated with a longer systemic survival, compared with uveal metastasis from other primary sites.     

Surgical experience with intracardiac myxomas: long-term follow-up

BACKGROUND: Myxomas are the most common benign intracardiac tumors. This report summarizes our 20-year experience with these tumors. METHODS: Sixty-six patients (25 male) with a median age of 39 years (range, 6 to 70 years) underwent surgical excision of primary or recurrent intracardiac myxomas during the years 1976 to 1996. Symptom duration ranged from 2 to 8 months. There were 55 left atrial myxomas, 10 right atrial myxomas, and 1 biatrial myxoma. Three of the patients were in one family. The surgical approach comprised complete wide excision. RESULTS: There were two early deaths. Late follow-up is 89% (57/64) complete. There was one late death, which was not due to a cardiac cause. Echocardiography at a mean follow-up of 66.9 months (range, 7 to 241 months) showed no recurrence of sporadic myxomas. However, 2 of the 3 patients with familial myxomas had recurrence. CONCLUSIONS: Surgical excision of atrial myxoma gives excellent short-term and long-term results leading to eventual cure of nonfamilial myxomas. However, familial myxomas retain a strong tendency to recur even 20 years after excision.     

Repair of stricture in Crohn's disease: treatment of choice?

Strictureplasty has become one of the surgical options available for skip-lesions and for duodenal, multiple small bowel or anastomotic strictures caused by Crohn's disease. Over a sixteen-year period, 44 patients underwent strictureplasty for 269 symptomatic strictures associated with Crohn's disease. After a median follow-up of 50 months (range 18-89) a second additional operation for symptomatic recurrence was performed in 10 patients, two of whom developed new symptomatic strictures after 3 and 36 months, requiring a third operation. Of all the strictures present at surgery, 174 were treated performing strictureplasties (156 were closed transversely using Heineke-Mickulicz, 16 in a side-to-side Finney fashion and 2 in the manner of Jabolay) and 88 with synchronous resection. Furthermore, 7 other strictures were treated with a side-to-side ileocolic (5 strictures in 3 patients) or ileoileal (2 strictures in one patient) anastomosis. No operative mortality was recorded and there were no septic complications due to anastomotic leak. The mean follow-up period was 47.8 +/- 42.4 months (range 3-132). Symptomatic restrictures of previous strictureplasty sites requiring surgery occurred in 8.8% of cases. Furthermore, no statistically significant difference (Kaplan-Meier) was observed in the reoperation rate among patients affected respectively by skip lesions or multiple strictures or among patients treated only by strictureplasty or with an associated resection. We concluded that strictureplasty is a valuable adjunct to resection in the treatment of Crohn's strictures.     

Has the impact of Helicobacter pylori therapy on ulcer recurrence in the United States been overstated? A meta-analysis of rigorously designed trials

OBJECTIVE: The aim of this study was to assess the effect of H. pylori eradication on ulcer recurrence in North American duodenal ulcer patients by examining only treatment studies that met rigorous methodologic criteria. METHODS: Data sources were computerized bibliographic searches from 1983, review of reference lists, communication with companies that manufacture medications used for H. pylori therapy in the U.S., and H. pylori investigators, review of open presentations to the Food and Drug Administration, and review of abstracts from annual scientific meetings. Criteria for study inclusion were double blind, randomized North American trials of H. pylori therapy for duodenal ulcer, scheduled endoscopic follow-up exams for > or = 6 months, and H. pylori cure documented > or = 4 wk after completion of therapy by at least two endoscopic biopsy tests. Seven relevant trials were identified. Data were abstracted independently and disagreement was resolved by consensus. We obtained missing data and identified erroneous assessments through contact with an author or sponsor of all studies. RESULTS: The common odds ratio for ulcer recurrence was 0.20 (95% CI, 0.13-0.31) and 2.8 patients would need to be successfully treated to prevent one ulcer recurrence at 6 months. The pooled ulcer recurrence rate at 6 months in patients with H. pylori eradication was 20%. CONCLUSION: Results of North American studies of highest methodological quality confirm that H. pylori eradication markedly decreases ulcer recurrence. Nevertheless, 20% of patients in these studies had ulcer recurrence within 6 months, despite successful cure of infection and no reported use of NSAIDs. Non-H. pylori, non-NSAID ulcers may be more common in the U.S. than previously believed.     

Reconstitution of squamous epithelium in Barrett's oesophagus with endoscopic argon plasma coagulation: a prospective study

BACKGROUND: Barrett's oesophagus is a premalignant condition. Recent reports have suggested that laser coagulation or photodynamic therapy combined with acid suppression may induce reconstitution of squamous mucosa. However, a high percentage of residual glands remain in cases treated with both techniques. Argon plasma coagulation (APC) appears to be an attractive alternative to other thermoablative techniques. The aim of this study was to investigate the reconstitution of squamous epithelium in Barrett's oesophagus after APC. METHODS: Fifteen patients with histologically proven Barrett's oesophagus were included in a prospective study. After base-line documentation by videotaping and biopsies, Barrett's epithelium was treated by repeated APC at intervals of 4-6 weeks until complete squamous restoration was achieved. All patients were kept under high-dose proton pump inhibitor therapy. RESULTS: In 13 patients complete reconstitution of squamous epithelium was achieved. Buried glands after squamous restoration were detected transiently in only one case after the first session. As side effects seven patients had mild retrosternal discomfort. One patient reported severe retrosternal pain for 1 week. He then refused further APC sessions. Another patient was excluded because of noncompliance. During the follow-up period (6-13 months) recurrence of Barrett's epithelium was observed in one patient. CONCLUSIONS: APC is a suitable technique for achieving squamous restoration in Barrett's oesophagus. The rare occurrence of remaining buried glands may result from the homogeneous coagulation achieved by the ionized argon gas beam.     

Reconstruction of the biliary tract using biliary-duodenal interposition of a defunctionalized jejunal limb

Interposition of a defunctionalized limb of jejunum between the confluence of the hepatic ducts and the duodenum seems to have some advantages. Biliary-jejunal anastomosis can be performed in a wider diameter, if necessary; duodenal function is kept almost normal, and the isolated segment of jejunum prevents the duodenojejunal reflux from getting to the biliary tract. The records of 19 patients upon whom hepatico-jejuno-duodenostomy was performed were reviewed. Seventeen patients had iatrogenic lesions and benign strictures of the common bile duct. Two patients had malignant tumors of the common bile duct. The postoperative follow-up period ranged from six months to five years. The average postoperative time was ten days. Two transient bile leaks were observed. Two patients had postoperative episodes of cholangitis. In both, the hepatico-jejunostomy was narrow, and stones were found in the intrahepatic position. A new and wider cholangiojejunostomy was performed. All of the patients were investigated roentgenographically after contrast material was given orally. Only two of the patients were found to have an enteric-biliary reflux which partially filled the intrahepatic biliary branches, but this was only observed at the time the abdomen was compressed.     

Superselective vagotomy. Preliminary results

Twelve patients suffering from an intractable duodenal ulcer are included in this review. Eleven were treated by superselective vagotomy without drainage, one had a selective vagotomy with pyloroplasty. A peroperative control of the gastric acidity after pentagastrin stimulation was used in all cases and permitted section of forgotten nerve fibers. Short-term results are satisfactory: after 2-6 months the clinical state of the patients is excellent (Visick I and II), basal acidity is decreased by 58 to 66% of preoperative value, the Hollander tests are negative except two. After more than 6 months, the few available results are satisfactory except one case of recurrent ulcer. The one case with a 1 year follow-up is excellent, clinically and as to acid secretion.     

Adrenocortical carcinoma: surgery and mitotane for treatment and steroid profiles for follow-up

Adrenocortical carcinoma (ACC) is a rare disease with a poor prognosis. It has been difficult to establish a strict treatment program for ACC, and better treatment alternatives and diagnostic tools must be sought. Even though surgery is the treatment of choice, the role of surgery in advanced disease has been questioned. Eighteen consecutive patients were treated at our unit over a 22-year period (1975-1997). All patients underwent surgery and were followed by our protocol, which includes urinary steroid profiles, clinical examinations, analysis of steroid hormones, and radiologic investigations. Twelve patients received mitotane with drug concentration measurements to deliver an effective, nontoxic dose. The median duration of mitotane treatment was 12 months. Few side effects were observed. Four patients with low-stage tumors underwent second-look operations with no pathologic findings. Five patients were subjected to repeat operations, and the mean duration of the disease-free interval before repeat surgery for these patients was 59 months. There was a significant positive correlation between the disease-free interval and the observed survival after repeat surgery. Eleven patients with intentionally curative surgery had their urinary steroid profiles tested several times postoperatively. For five patients preoperative urine samples were also available. Steroid profiles indicated recurrent disease despite normal radiologic findings in two of these five patients. The follow-up ranged from 6 weeks to 24 years. The predicted 5-year survival was 58% according to the Kaplan-Meier method. We conclude that monitoring serum concentrations of mitotane makes long-term treatment possible with few side effects; steroid profile analysis can be used for early detection of tumor recurrence; and repeat surgery for recurrence is of value for patients with long disease-free intervals.     

Reassessment of the role of radiation therapy in the treatment of endocrine-inactive pituitary macroadenomas

OBJECTIVE: This prospective clinical trial was undertaken to assess the rate of tumor recurrence in patients with endocrine-inactive pituitary macroadenomas who underwent gross total surgical resection of their tumors and did not receive adjuvant radiotherapy. METHODS: Between December 1987 and July 1994, 45 patients with endocrine-inactive pituitary macroadenomas underwent transsphenoidal surgery. In 38 (84%) of these patients, gross total surgical resection was achieved and was confirmed by postoperative magnetic resonance imaging (n = 37) or computed tomography (n = 1). After receiving counseling from the neurosurgeon concerning the risks and benefits of radiation therapy, 32 of the 38 patients elected not to receive adjuvant radiotherapy. Patients were followed through March 1998 with radiographic imaging obtained every 6 months for the first 2 years, annually for postoperative Years 3 and 4, and then every 2 to 3 years thereafter. The study end point was defined as radiographic tumor recurrence or patient death. RESULTS: The mean follow-up duration for the study group was 5.5 years. During that time, 2 of 32 (6%) patients developed recurrence, at 18 and 24 months, respectively, after initial surgery. Both were successfully treated using radiation therapy, with one requiring additional surgery. Three additional patients died as a result of unrelated causes 9, 12, and 49 months, respectively, after initial surgery. Immunocytochemical analysis revealed 66% of the tumors to be weak gonadotroph cell adenomas, 22% to be null cell adenomas, 9% to be silent prolactinomas, and 3% to be silent corticotroph cell adenomas. CONCLUSION: This study demonstrates a 6% 5-year recurrence rate in patients with endocrine-inactive pituitary macroadenomas treated using gross total surgical resection alone. Reserving radiation therapy for the infrequent patient with recurrence and sparing the majority of patients the associated risks inherent in its use seems reasonable.     

Combined radiochemotherapy for organ preservation in head and neck cancer: review of literature and personal experience

Combined radiochemotherapy is the most common method aimed at improving the rate of clinical response in advanced head and neck cancer. Complete clinical remission may correspond to a significant percentage in organ and/or function preservation. In 1992 a protocol of concomitant radiochemotherapy with continuous infusion of carboplatin for 14 consecutive days at the daily dose of 30 mg/m2 and concomitant radiotherapy with conventional fractionation (1.8 Gy to a total 65-70Gy) was started. Over a 3-year period, 56 patients with advanced head and neck cancer, were treated. In view of organ preservation, 26 patients of this series, though with considerable extent of the disease at diagnosis, were considered candidates for radical surgery: oral cavity 9 patients; oropharynx 9 patients; larynx/hypopharynx 8 patients. A single patient was stage I (hypopharynx); most patients were stage III (7) and IV (17 = 65%); T4 20%, N3 23%. 17/20 patients (70%) showed complete clinical response, 6 partial clinical response with a single non responder (overall response 95%). A patient underwent total glossectomy followed by local recurrence and another patient underwent pharyngolaryngectomy also followed by recurrence. After a mean follow-up from 22 to 60 months, 9 patients were still free of disease (37.5%). Median duration of complete response was 25.6 months. Overall median survival was 26.7 months: 38 months in responders. 2-year survival of patients with complete response was 59%. As for organ preservation, at present 6 over 18 patients (33%) with tumor of the oral cavity or oropharynx and 3 patients with tumors of larynx/hypopharynx have preserved organ and function. As for complete responders, 54.5% of those with tumors of oral cavity or oropharynx and 50% of those with tumors of larynx/hypopharynx, have preserved anatomy and function after at least 2-year follow-up. To-date, in follow-up controls relevant late toxicity has not been observed, showing that to the positive anatomical result corresponds the functional preservation of single structures.