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The biochemical modulators PALA, an inhibitor of aspartate transcarbamylase which depletes uridine nucleotide pools, and 6-methylmercaptopurine riboside (MMPR) which inhibits purine metabolism, selectively potentiate the antitumor activity of 5-fluorouracil (5-FU) in preclinical models. Based on a phase I trial of this combination, we performed a phase II trial in patients with advanced pancreatic cancer. PALA 250 mg/m2 was administered i.v. on day 1, followed 24h later by MMPR 150 mg/m2 as a bolus i.v. injection, and 5-FU 2300 mg/m2 by 24h infusion. Treatments were repeated weekly. Seventeen patients, all previously untreated with chemotherapy, were entered, of whom 14 are evaluable for response. Toxicity > or = grade 2 included nausea (6/17), vomiting (4/17), diarrhea (3/17), stomatitis (5/17), and neurotoxicity (2/17). Among 14 evaluable patients there were no partial responses, and two patients with stable disease. Pretreatment with PALA and MMPR is insufficient to enhance the activity of 5-FU in pancreatic cancer.

Objective: The aims of this study were to quantify the amount of the residual carcinoma in re-excision lumpectomy specimens and retrospectively analyze the relationship between clinical parameters and the characteristics of the primary excision to these quantities of the residual tumor., Summary Background Data: Because complete gross surgical excision of the primary tumor is important in minimizing local recurrence in women undergoing breast conservation therapy, re-excision of the initial biopsy site is commonly practiced when the initial primary tumor excision shows inadequate or undeterminable margins. Several studies have reported a significant proportion of re-excision specimens to contain residual tumor (32% to 63%), but to the authors' knowledge, none have quantified the amount of residual tumor., Methods: The authors reviewed 192 re-excisions retrospectively to quantify the amount of residual carcinoma and correlate the quantities with the characteristics of the primary tumor resection., Results: No tumor was found in 105 (54.7%) specimens, 46 (23.9%) had minimal microscopic disease, 23 (12.0%) had extensive microscopic disease, and 18 (9.4%) had gross residual cancer. Characteristics significantly associated with the quantity of residual disease included clinical tumor stage (T stage), pathologic T stage, and the margin status of the primary excision. The majority (62.1%) of re-excision specimens containing residual carcinoma had an invasive component., Conclusions: It was concluded that re-excision lumpectomy yields an important number of patients with residual carcinoma and that characteristics of both the primary tumor and primary excision significantly predict the quantity of residual cancer in the specimen. In addition, these results support the policy of performing re-excision for patients with inadequate or undeterminable margins for the primary excision.

In order to determine whether preresectional chemoradiotherapy (CTRT) would influence resectability, local control, and survival of patients with localized pancreatic adenocarcinoma, a 5 1/2-year prospective study of 39 patients treated with preoperative radiation therapy, 5-Fluorouracil (5-FU), and Mitomycin C has been performed. Thirty patients had celiotomy after CTRT (1/39 died while receiving CTRT, one refused surgery, and seven had extrapancreatic disease progression). Seventeen (57%) had resections (seven total, two distal subtotal, and eight Whipple pancreaticoduodenectomies). All had clear margins of excision, and only one had any positive lymph nodes in the resected specimen. Eleven patients with resection had Stage I cancers (5 T1b, 6 T2), five had Stage II, and one had a Stage III lesion. Previous bypass surgery, age, clinical response to CTRT, and tumor size had no influence on resectability. Two patients died postoperatively (12%) early in the series. Three others suffered major morbidity (chylous ascites requiring peritoneovenous shunt, ARDS, and prolonged afferent loop obstruction leading to a fatal liver abscess 5 months after surgery). Two patients with resection are alive without recurrence at 48 months after tissue diagnosis, and six others are also alive without recurrence, after from 6 to 23 months. In summary, resectability is probably enhanced and nodal metastases and resection margins are downstaged by preoperative CTRT. Demonstration of an improved survival benefit awaits further observation and phase III trials.

Locoregional recurrence after treatment for rectal cancer may be largely prevented by wide pelvic surgical margins, adjuvant radiotherapy, and chemotherapy. Approximately half of these recurrences will present with recurrence only at the surgical site; one third to one half will be resectable with conventional surgical procedures, but the rest will require extended resections, including sacrum and hypogastric vessels, to achieve clean margins. Only a small fraction of those treated will be cured. There is no proof that radiotherapy or chemotherapy added to surgical excision afford better results, since no trials have been or are likely to occur, given the rarity of the situation. However, best results seem to follow multimodality therapy using complete surgical resection and radiotherapy (IORT or brachytherapy with or without teletherapy) with chemopotentiation. Yet, there is no multimodality series with a sufficient number of patients and follow-up period to be able to distinguish the actual value of the treatment and which patients are most likely to benefit. It is important to note that there will be some patients with second LRR who can be further aided by aggressive locoregional therapy.

Background: Low resectability rate and high locoregional recurrence are major factors contributing to the failure of surgical treatment for localized pancreatic adenocarcinoma. A Phase II study involving preoperative 5-fluorouracil (5-FU) and mitomycin C and radiation therapy was evaluated., Methods: Thirty-one patients with biopsy-proven carcinoma (24, head of pancreas; 2, body; 5 duodenum) were treated with preoperative radiation therapy, 5040 cGy (180 cGy/fraction, 5 days/week), concurrent with 5-FU, 1000 mg/m2/day continuous infusion (days 2-5, 28-32) and mitomycin C 10 mg/m2 bolus (day 2). Ten patients had previous laparotomy or bypass surgery and were deemed unresectable; 21 had percutaneous, endoscopic retrograde choleangiopancreatic, or transhepatic stent biopsies., Results: Toxicity included neutropenic fever (2 patients), biliary sepsis (2 patients), and nausea and vomiting requiring total parenteral nutrition. One patient died of biliary sepsis before completion of chemoradiation and 11 patients showed evidence of metastatic disease (clinical or occult). Resectability rate was 38% (10/26) for pancreatic carcinoma and 80% (4/5) for duodenal carcinoma. Pathology of the resected specimens revealed extensive necrosis and hyalinization with clear margins in all cases. Lymph node metastases were found in one case of pancreatic carcinoma. The four resected duodenal carcinomas contained no residual tumor in the specimens. At a median follow-up of 29 months, the median survival time for those with pancreatic carcinoma was not yet reached in the resection group and was 8 months in the nonresection group. The corresponding actuarial 5-year survival rates were 58% and 0%, respectively., Conclusions: Neoadjuvant chemoradiation therapy was given safely to patients with pancreatic and duodenal carcinoma. It facilitated complete resection in 38% of patients with pancreatic carcinoma and 80% of those with duodenal carcinoma. A significant downstaging of positive margins and regional lymph nodes occurs as a result of preoperative chemoradiation.

The patient who presents with evidence of a recurrent soft-tissue sarcoma of the extremity should have a complete history and physical examination. A diagnostic biopsy, either fine-needle or open biopsy, should be performed to confirm recurrence. Liver-function tests, complete blood cell count, electrolytes, and chest X-ray should be performed. If preliminary evaluation confirms local recurrence and is negative for regional or distant disease, a CT scan of the chest to better exclude metastases, as well as a CT or MRI of the local recurrence, should be performed. If neurovascular structures appear at risk on noninvasive scanning, an arteriogram is performed to exclude major vascular involvement. In selected circumstances, arterial and/or venous reconstruction may be indicated to allow complete gross removal of tumor. Complete removal of tumor should be combined with radiotherapy for all sarcomas with close margins and for any high-grade lesion regardless of margin status. Brachytherapy can often be used even when the patient has had prior teletherapy to the site. Complete tumor removal combined with adjuvant radiotherapy is the best way to prevent subsequent local recurrence and provide long-term survival.

Redo hepatic resection for recurrent colorectal metastasis was performed in eight patients. There was no operative mortality; major morbidity occurred in 25% and minor morbidity in 13% of patients. Four patients are alive and disease-free at 9, 23, 39, and 49 months, respectively, after their repeat hepatic resection. Four patients have died of recurrent disease, with a median time to recurrence of 6 months and median survival of 15 months. Patterns of failure include hepatic failure alone in two patients and pulmonary and hepatic failure in two. Repeat liver resection can be performed safely and may be beneficial in some patients with recurrent metastases confined to the liver after previous hepatic metastasectomy.

The role of surgery in the management of intra-abdominal recurrence of colon cancer has not been clearly determined. We reviewed the charts of 28 patients operated upon at our institution for nonhepatic intra-abdominal recurrence of carcinoma of the colon and followed for a median of 10.5 months after reoperation. Total resection of gross disease was possible in 15 patients, who had a median overall actuarial survival of 25.5 months and a disease-free survival of 13 months. Within this group, disease-free survival was significantly prolonged when time to first recurrence was greater than 16 months and when patients had not had a prior operation for recurrent disease (P < 0.05). Six patients having a partial resection and seven patients having only a bypass or ostomy had significantly shorter survivals than those in the totally resected group, with median survivals of 8 and 3.5 months, respectively (P < 0.05). Operative management of recurrent colon cancer may prolong survival when disease can be eradicated, and palliative operations appear more successful when tumor is resected rather than bypassed.

Intraoperative radiation therapy (IORT) has been used successfully in the treatment of malignancies, alone and as an adjunct to surgical resection. This study examined a single institution's experience with combined IORT and surgical resection in the treatment of advanced cancer. The records of 41 consecutive patients undergoing intraoperative radiation therapy (IORT) at the Fox Chase Cancer Center, from July 1987 through March 1990, were retrospectively reviewed. All patients had locally advanced disease, of whom 73% had failed previous multimodality therapy and 44% had undergone prior radiation therapy (XRT). The 2-year actuarial survival for the entire cohort was 72%. Disease-free survival was 47% at 1 year and 5% at 2 years. The only important prognostic factor predicting outcome was status of the surgical margin. Positive surgical margins decreased the 2-year actuarial survival from 100% to 59%, and increased the local failure rate from 21% to 52%. Margin status had no effect on the later development of metastatic disease. Higher IORT doses, field sizes > 7 cm, and multiple IORT fields were used for larger tumors and larger amounts of residual disease. These parameters alone did not correlate with improved local control. This analysis suggests the usefulness of aggressive surgical resection with IORT in extending survival for locally advanced or recurrent cancer. Negative margin status is the best predictor of a favorable outcome and should be used to select patients who may benefit from IORT. The use of radiation sensitizing agents should be explored in patients with positive margins, since in-field failure continues to be the major pattern of failure. IORT in conjunction with aggressive surgical resection should continue to be studied in prospective randomized clinical trials.

Purpose: Many techniques and devices have been used in an attempt to minimize gastrointestinal morbidity of pelvic irradiation. The value of a temporary intrapelvic tissue expander to displace small bowel from pelvic radiotherapy fields was analyzed by comparing volumetric treatment parameters of patients with and without such a device., Methods and Materials: Between 1983 and 1991, 77 patients with a diagnosis of endometrial (n = 35), colorectal (n = 41), or anal carcinoma (n = 1) received adjuvant postoperative radiotherapy after undergoing treatment planning simulation with the use of small bowel oral contrast medium. Fourteen of these patients underwent surgical placement of a temporary intrapelvic tissue expander prior to radiotherapy, and 63 patients did not. Small bowel volume within the treatment portals was measured for both initial pelvic and conedown fields for all cases, and compared between the two patient groups., Results: The volume of small bowel within the initial pelvic fields receiving full dose irradiation was significantly less among patients with a tissue expander. For patients with a tissue expander, mean volume receiving full dose irradiation was 25 cm3 (median 0 cm3, range 0-297 cm3), whereas the corresponding volume was 239 cm3 (median 181 cm3, range 0-943 cm3) without a tissue expander (p < .0001). A similar reduction of irradiated small bowel volume was noted in the conedown fields with the use of a tissue expander (p = .07). Volumes receiving less than full dose irradiation were also less within the initial pelvic (p = .0001) and conedown (p = .002) fields with a tissue expander. Multivariate analysis of patient and treatment-related parameters showed the use of a tissue expander to be the only factor correlated with decreased small bowel volume within the treatment field (p = .003). Morbidity related to placement and removal of the tissue expander was acceptable. Acute radiation-related morbidity was significantly less in patients irradiated with a tissue expander in place (p < .001)., Conclusions: Placement of an intrapelvic tissue expander was correlated with decreased small bowel volume within the radiotherapy treatment field. Diminished radiation-induced acute gastrointestinal morbidity was noted with use of a tissue expander.

Neoadjuvant therapy for locally advanced breast cancer improves disease control, but the complications of treatment are not well established. The aim of this study was to assess the operative morbidity in 20 consecutive patients with locally advanced, noninflammatory breast cancer treated with preoperative chemotherapy and radiation. Patients received preoperative cyclophosphamide, methotrexate, 5-fluorouracil, prednisone, and tamoxifen (CMFPT) to maximum response followed by concurrent chemotherapy and radiation to the involved breast and regional lymph nodes. Following modified radical mastectomy, chemotherapy was continued for a total of 10 cycles. Disease progressed in 3 of 20 patients (15%). Seventeen patients underwent mastectomy, 4 (24%) of whom demonstrated a pathologic complete response to chemoradiotherapy. Seven patients (41%) developed wound infections, 2 (12%) necrosis, 5 (29%) delayed healing, 2 (12%) upper extremity lymphedema, and 8 (47%) seromas. Postoperative chemotherapy was delayed in 4 (24%) patients. There was no mortality, and hospitalization was for less than 1 week. Only one patient required readmission. Although this treatment regimen is aggressive with attendant morbidity, complications are easily managed and generally do not delay therapy. Treatment modification to further reduce complications may be indicated.

Increasingly effective systemic chemotherapy has improved responses in patients with previously unresectable colorectal hepatic metastases. In the future, response to chemotherapy may define a new population of patients that may benefit from hepatic resection. A retrospective review to determine the safety and effectiveness of potentially curative hepatic resection of metastatic colorectal carcinoma after systemic chemotherapy identified 11 such patients with resections between July 1987 and October 1991. Five patients had unresectable disease confined to the liver, two had hepatic and limited extrahepatic metastases, two had hepatic recurrences after previous hepatic metastasectomy, and two had initially resectable liver metastases. These patients were resected after a mean of 8 months of systemic chemotherapy. Complications, usually minor, occurred in five patients (45%). There were no deaths. Three patients are disease free at 15, 18, and 31 months (mean 21) after hepatic resection. Eight patients have recurred with a median time to recurrence of 8 months. Five patients have subsequently died of recurrent disease. This study suggests that hepatic resection following systemic chemotherapy can be performed safely and may benefit selected patients.

A 46-year-old female who had been experiencing severe diarrhea and marked weight loss underwent exploratory laparotomy because of a mass near the tail of the pancreas noted on CT scan. Pathologic examination revealed a mucinous cystadenoma of the pancreas occurring in heterotopic pancreatic tissue. This is the second reported case of mucinous cystadenoma occurring in heterotopic pancreatic tissue.

Long-term therapy of oncology patients has been facilitated by permanent indwelling central venous catheters, but catheter-related infections remain a serious complication of their use. Using a retrospective matched cohort design, we compared the risk of catheter-related infection in 47 adult solid tumor patients with right atrial Hickman catheters and 94 patients with totally implanted port catheters. Patients were matched for primary solid tumor, presence of metastases, age, gender, and date of catheter insertion. Seven of 47 patients with Hickman catheters developed catheter-related infection (1.8 infections/1,000 catheter days at risk) compared with 10 of 94 patients with implanted port catheters (0.4/1000 catheter days, P less than 0.0002). Hickman catheters were used more often for terminally ill patients than were port catheters which was a potential source of bias, but results were unchanged after stratifying patients on lifespan. Our study suggests that there are fewer infections in port than in Hickman catheters in adult patients with solid tumors, but prospective randomized studies are needed.

Between 1986 and 1990, 16 patients were enrolled in a prospective Phase I/II study of transanal local excision and combined preoperative and postoperative radiation therapy (RT). All patients had biopsy-proven adenocarcinoma extending to within 6 cm of the anal verge and involvement of at least one third of the rectal circumference with tumor. Five of 16 patients (32%) had T3 tumors, and only two patients had T1 tumors. Patients received a single 500 cGy fraction of RT to the pelvis within 24 hours before surgery and underwent transanal excision followed by postoperative RT (median dose, 5040 cGy). With a median follow-up of 33 months, overall 3-year actuarial survival was 94%. Two patients had isolated local recurrences (both successfully salvaged), and four had distant metastases but maintained local control. The 3-year actuarial rates of continuous freedom from any relapse, continuous local control, and no evidence of disease at last follow-up were 53%, 80%, and 71%, respectively. Only three of 16 patients required colostomy, resulting in a 3-year actuarial colostomy-free rate of 77%. There was a trend toward a higher rate of relapse (P = 0.066) in patients with T3 tumors than those with T1 and T2 tumors. Sphincter-preserving therapy for low-lying rectal carcinomas using local excision and combined preoperative and postoperative RT is feasible, although improved local and adjuvant therapy is needed for patients with T3 lesions.

The charts of 44 women who underwent 47 immediate postmastectomy prosthetic breast reconstructions (IPMPBR) with subpectoral prostheses (long-term implant, long-term expandable implant or tissue expanders followed by long-term prosthetic placement) were retrospectively reviewed. Follow-up was from 3 to 49 months (median 18 months). Patient ages ranged from 31 to 77 years (median 42) but 82 per cent were under 60 years old. Indications for mastectomy were infiltrating cancer in 30 patients, intraductal cancer in 11, lobular carcinoma in situ in two and prophylaxis in one. There were 11 patients with pathologic Stage I, 15 with Stage II, three with Stage III and one with Stage IV breast cancer. Adjuvant chemotherapy (CTX) was given to 17 women, adjuvant hormonal treatment to nine, and radiation therapy (RT) to five. One patient had prosthesis extrusion and removal. Two patients had late periprosthetic infections (PPI) with consequent prosthesis removal. CTX did not have a significant association with PPI (two of 14 with CTX vs 0 of 29 without, P = 0.1). However, fill port migrations, prosthesis deflations, and greater than 1 complication were significantly associated with these infections (two of three vs 0 of 38, P = 0.004; two of two vs 0 of 45, P = 0.001; two of four vs 0 of 43, P = 0.006). Skin flap cellulitis and postoperative seroma were also associated with PPI (P less than 0.003 and less than 0.006, respectively). These factors were all also significantly associated with involuntary prosthesis loss (n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective neoadjuvant trial utilizing chemotherapy (CTX) and radiotherapy (XRT) prior to pancreatectomy was established to determine the feasibility of resection after aggressive pretreatment and its effect on survival. Fifteen patients with pancreatic cancer (14 head, 1 body) and 1 patient with duodenal cancer, (with paraaortic adenopathy), were subjected to combination treatment with infusional 5-FU, bolus injection of mitomycin-C, and XRT (4 patients were treated off the protocol). Patients were restaged 3 wk after XRT, and those deemed resectable underwent a pancreatic resection. Three patients did not undergo exploration after the neoadjuvant therapy, although two of these were deemed resectable by CT scan. The remaining 13 patients underwent exploration and 10 underwent resection. Three did not undergo resection because of extrapancreatic disease, although their primary tumors were resectable. One patient had no residual tumor in the specimen. The others had residual tumor with evidence of necrosis and hyalinization, but all margins were free of tumor. There were two perioperative deaths from sepsis. Of the remaining patients who underwent resection, one died of a myocardial infarction at 9 mo. One patient died with recurrent disease at 19 mo. The remaining patients are alive 40, 32, 11, 11, 10, and 4 mo since diagnosis and are currently free of disease. Aggressive neoadjuvant chemoradiotherapy can be performed safely, allows successful resection, and may yield long-term survival or curve.

The incidence of delayed breast abscess as a complication following the treatment of breast cancer has not been reported. A retrospective review of 112 patients (pts) undergoing lumpectomy and radiation therapy (RT) in our institution revealed a six per cent incidence of delayed breast abscess (range 1.5-8 months, median 5 months). Prophylactic antibiotics (P = 1.0), postoperative chemotherapy (P = 1.0), primary vs. re-excisional lumpectomy (P = 1.0), and different surgeons (P = 0.514) were not associated with increased risk of delayed abscess. All abscesses occurred in the first 32 pts of this series. The size of the lumpectomy cavity correlated with the incidence of infection (P = 0.0440). Since six of seven abscess cultures grew staphylococci (coagulase negative three pts, coagulase positive three pts), and four of these pts experienced prior biopsy site infection, skin necrosis or repeated seroma aspirations, a skin source for contamination was suggested. Treatment of the abscesses with antibiotics and immediate drainage produced acceptable but inferior cosmesis. We conclude that a small but significant subset of patients treated with lumpectomy and RT will develop delayed wound infections and that expeditious treatment affords satisfactory cosmesis.

This report describes the case of a 42-year-old man with malignant lymphoma, diffuse large non-cleaved cell type, who developed cutaneous malakoplakia in the left groin. The patient had widespread lymph node involvement, including a left inguinal mass which was clinically thought to represent recurrent lymphoma. The inguinal mass failed to regress after chemotherapy and irradiation, although lymphoma in other sites responded to chemotherapy. A skin biopsy of the area showed an ulcer and an abscess involving the dermis and subcutaneous tissue. Microscopically, a diffuse infiltrate of foamy histiocytes was seen with numerous intracellular and extracellular, round and laminated bodies. Some of these bodies had a "targetoid" appearance, stained strongly with von-Kossa's calcium stain and showed the typical appearance of Michaelis-Gutmann bodies by electron microscopy. Cultured monocytes from the peripheral blood of the patient showed ultrastructural features similar to their tissue counterparts, suggesting a systemic involvement of the monocyte macrophage lineage. This case represents an unusual presentation of malakoplakia of the skin associated with relapsing malignant lymphoma in a patient on immunosuppressive drugs.

Five pancreatic cutaneous fistulas were treated by subcutaneous administration of a long-acting synthetic analog of somatostatin, SMS 201-995. Patients included four men and one woman who ranged in age from 52 to 77 years. The fistulas developed after drainage of a pancreatic abscess, biopsy of a pancreatic mass, splenectomies for idiopathic thrombocytopenic purpura and Felty's syndrome, and operative trauma, respectively. Fistula output consisted of 1,000 ml/day of amylase- and lipase-rich fluid in the patient with a pancreatic biopsy. The other four patients had low-output fistulas (100 to 250 ml/day) that had been draining for 1 to 12 months. Direct communication with the pancreatic duct was demonstrated by endoscopic retrograde cholangiopancreatography, sinography, or both in four of the five patients. Fistula output decreased from 340 +/- 376 ml/day to 63 +/- 36 ml/day on the first day of therapy with two daily doses of 0.05 mg SMS 201-995 (p less than 0.03) and to 13 +/- 19 ml/day on the seventh day of therapy (p less than 0.03). Two patients had prompt closure of their fistulas and one closed in 3 months. One patient with chronic pancreatitis and a duct stricture and one patient with recurring infection did not achieve permanent fistula closure with SMS 201-995. Because of its safety, ease of administration, and efficacy in decreasing fistula output, we believe somatostatin analog therapy is beneficial in hastening closure of pancreatic fistulas.

Twenty patients with advanced pelvic malignancy and secondary hydronephrosis underwent percutaneous nephrostomy between July 1982 and October 1986. Improvement in renal function occurred in 17 patients (85 percent), and survival ranged from 4 days to 2 years. Median survival was 13 weeks, and 55 percent of the patients required multiple hospitalizations for urosepsis. In addition, 55 percent required multiple tube changes. Thirty-five percent of the patients never left the hospital and an additional 35 percent spent less than 6 weeks at home before they died. Median survival for eight patients with primary cancers most frequently associated with carcinomatosis was 7 weeks, and 63 percent of these patients died during hospitalization. The factors of limited survival, significant morbidity, in-hospital mortality, and poor quality of life should be considered before recommending percutaneous nephrostomy in patients with advanced cancer.

An increased risk for regional enteritis patients of small bowel adenocarcinoma to develop has been suspected but unproved. We have analyzed 49 cases reported since 1957 and two additional ones of our own. These have been compared with a current group of small bowel adenocarcinomas not associated with regional enteritis. The Crohn-associated cancers differed from adenocarcinomas not associated with Crohn disease in that (1) mean age at cancer discovery was less (46 vs 64 years), (2) more cancers arose in the ileum (76% vs 27%), (3) diagnosis and cure were less successful, and (4) they occurred more frequently. The 32 cases reported in the past five years were compared with the expected 0.1 to 5 cases. Regional enteritis patients were found to have an increased risk for the development not only of small bowel adenocarcinoma, but one that is more occult and lethal than that in individuals wihtout Crohn disease.

Soft tissue infections were seen in 25 patients with underlying malignancy and immunosuppressive disease. The primary disease included leukemia, lupus, aplastic anemia, lymphoma, carcinoma and myeloma. Infectious sites included the perianal area, gluteal, chest wall, extremity and the vulva. Eighty per cent of the infectious episodes occurred in patients who were granulocytopenic. Initial presentation was of local tenderness and redness. Fluctuation and discoloration were present in nine patients who were also hypotensive. Local drainage in five patients resulted in the death of two (20%). Overall, the mortality was 3/25 (12%). Wide debridement and drainage and appropriate antibiotic therapy resulted in the death of 1/20 (5%) patients. Hypotension, discoloration and fluctuation were found to be late signs in these patients. Soft tissue infections in the compromised host present subtly and progress to death if treatment is delayed. Temperature elevation and localized tenderness and erythema are indications for broad spectrum antibiotics and extensive intraoperative drainage and debridement.

Ultrasound has proven invaluable in detecting and evaluating pancreatic pseudocysts, and it is now a standard test to rule out complications of pancreatitis. In reviewing the authors' experience with 122 patients treated surgically for a pancreatic pseudocyst, five patients were identified in whom an ultrasound demonstrated a pseudocyst that was associated with an unexpected cancer at the time of operation. A sixth patient, with a pseudocyst documented by ultrasound, died prior to surgery and was found at autopsy to have metastatic common bile duct carcinoma. There was little difference in presenting symptoms, age, frequency of alcoholism, or physical findings compared with patients with pseudocysts secondary to pancreatitis. In two patients, pseudocysts were found in the tail of the pancreas at operation, in addition to carcinoma. In the other three patients, no pseudocyst was found; however, a subcapsular splenic hematoma was present in one. Five patients had metastatic disease, three from pancreatic adenocarcinoma, one from islet cell carcinoma, and one from a common bile duct carcinoma. One patient with a pancreatic adenocarcinoma confined to the head underwent a Whipple procedure and has no evidence of disease 6 months later. Malignancy may cause or coexist with pancreatic pseudocysts. Ultrasound is often not helpful in distinguishing pseudocysts associated with malignancy from those associated with pancreatitis. Biopsy should be performed to rule out malignancy when operating for pancreatic pseudocysts.