Search

Background: Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery., Methods: The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs < or =5 operations/year), hospital's annual caseload (>26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status., Results: Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055)., Conclusions: High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials.

This retrospective study concerns 683 consecutive patients operated for primary non-small cell lung cancer between 1977 and 1989 (581 men and 102 women with a mean age of 60.3 years). Histology was as follows: squamous in 422 (62%), adenocarcinoma in 207 (30%), broncho-alveolar in 24 (4%) and large-cell in 30 (4%). According to the TNM classification, 304 tumors were graded as stage I (45%), 130 as stage II (19%), 157 as stage IIIA (23%), 62 as stage IIIB (9%) and 19 as stage IV (3%). Surgery consisted of lobectomies in 337 (49%), pneumonectomies in 210 (31%), segmentectomies and wedge resections in 42 (6%), bilobectomies in 41 (6%) and exploratory thoracotomies in 53 (8%). It was curative in 513 cases (75%) and palliative in 170 (25%). 49 patients died within 2 months of the operation (7.2%), while 209 suffered postoperative complications (31%). Mediastinal lymph node dissection was not routinely performed to in this series. However global outcome (30% 5 years survival and 18% at 10 years), compared favorably with that reported by centres that perform mediastinal lymphadenectomy systematically.

Cephalic duodenopancreatectomy is certainly the operation of choice in cases of adenocarcinoma of the pancreatic head. We evaluated the results of this operation in order to justify its indication and to pinpoint the factors that have an influence on the patients' prognosis after the operation. From 1982 to 1992, 386 patients were hospitalized in our department with the diagnosis of pancreatic cancer, all histological types included. Of these, 21 men and 18 women, mean age 65 years, underwent cephalic duodenopancreatectomy for adenocarcinoma. Associated with these operations were 3 liver metastasis excisions, 2 vascular resections, 1 colectomy and 1 splenectomy. All the tumors were operated on whenever technically possible, except those associated with distant metastasis. Postoperatively, only one patient died (on the 29th day, of viral meningitis). Postoperative morbidity was 51% with 23% local complications. There was one leakage of the anastomosis. Age, weight loss, history of pancreatitis or cirrhosis, anesthetic risk (ASA) and tumor staging were not found to be factors increasing the risk of postoperative complications. Survival after 1 year was 34% and after 5 years 6%. The degree of histological differentiation was the only factor that had any significant influence on the postoperative survival rate in our study. We conclude that cephalic duodenopancreatectomy is the treatment of choice which is capable of improving the quality, and to a lesser extent the length, of survival of patients suffering from pancreatic cancer, with acceptable postoperative mortality and morbidity rates.

The possible occurrence of multiple synchronous or metachronous malignant lesions in patients with carcinoma of the colon and rectum is a well known event. In this population-based study in the Geneva area from 1970 to 1986, the frequency of synchronous colorectal carcinomas was 1.1% and that of metachronous carcinomas 1%. The relative risk of metachronous colorectal carcinoma is higher than in the general population (colon after rectum 1.2, colon after colon 1.7 and rectum after rectum 1.4). A high association of adenomatous polyps with multiple colorectal carcinoma was observed. The 5-year actuarial survival in case of curative resection was 87% for metachronous carcinomas, 35% for single carcinomas and 33% for synchronous carcinomas. We conclude that complete preoperative colonoscopy, whenever possible, should be performed to screen patients with synchronous carcinomas. Finally, a lifelong follow-up of the residual colon or rectum should be planned to detect metachronous lesions.

The possible occurrence of multiple synchronous or metachronous malignant lesions in patients with a carcinoma of the colon and rectum is a well known event. In this population-based study in the Geneva area from 1970 to 1986, the frequency of synchronous colorectal carcinomas was of 1.1% and that of metachronous carcinomas of 1%. The relative risk of metachronous colorectal carcinoma is higher than in the general population (colon after rectum 1.2, colon after colon 1.7 and rectum after rectum 1.4). A high association of adenomatous polyps with multiple colorectal carcinomas was observed. The 5-year actuarial survival in case of curative resection was of 87% for metachronous carcinomas, 35% for single carcinomas and 33% for synchronous carcinomas. We conclude that complete preoperative colonoscopy, whenever possible, should be performed to screen patients with synchronous carcinomas. Finally, a lifelong follow-up of the residual colon or rectum should be planned to detect metachronous lesions.

Between 1977 and 1986, 101 patients underwent surgical bypass for periampullary carcinoma. The hospital mortality rate was 18 per cent and the morbidity rate 43 per cent. Mortality was not influenced by the extent of the tumour. Survival rates at 1,2 and 3 years were 28, 9 and 4 per cent, respectively. The median survival time was 17 months for localized tumours, 10 months for those that had invaded surrounding tissues, 6 months in the presence of lymph node involvement and 3 months with distant metastasis. The quality of survival was good for most patients with localized tumours but poor for those with parenchymal metastasis, in whom palliation was transient for 85 per cent and effective for less than half of their survival time for 60 per cent. These results suggest that patients with distant metastasis but without impending duodenal obstruction should undergo palliation by endoscopic or percutaneous routes while those with less advanced disease or with duodenal involvement remain candidates for surgical bypass.

We have performed 33 pylorus-preserving duodenopancreatectomies. Twenty patients presented with severe chronic pancreatitis and 13 with periampullary adenocarcinoma. We have no postoperative mortality and a 24% rate of morbidity. Complications include anastomotic leaks (2), surgical bleeding (1), anastomotic ulceration (1), and others (4). We have complete follow-up for all cases. In the tumor group, 8 (62%) patients are alive with a mean survival time of 20 months (range: 2-46). In the pancreatitis series, all patients are alive after a mean of 34 months (range: 4-66). We have observed 5 cases (15%) of anastomotic ulcerations responsible for stenosis (2) and acute perforation with peritonitis (2) occurring after a mean interval of 18 months. Four cases have been confirmed histologically after resection. The short- and long-term beneficial effects of the pylorus-preserving operation on patient well-being and nutritional status were confirmed and compared with the results achieved after a Whipple procedure performed in a series of 18 consecutive patients.

Our experience with the use of mammography as a diagnostic aid in symptomatic women with breast complaints has been presented. One-third of all cancers were found in women 50 years of age and under. The detection of cancer by mammography in the younger age group was similar to that experienced in the older age group. Radiation exposure by mammography has diminished markedly during the last 15 years--only one-third to one rad per exposure with modern technique. Recent hysterical criticism of the use of mammography in women under 50 years of age is unwarranted in the light of current findings. This diagnostic modality should be utilized when indicated in all age groups over 30. It is probable that screening clinics should include all women over 35 years of age.

A retrospective study was made of 38 myosarcomas of the small and large intestines (34 leiomyosarcomas and 4 malignant leiomyoblastomas). Endoenteric, small, and noninvasive tumors were successfully treated by simple wedge excision, cautery snare removal, or segmental bowel resection with a high 5-yr cure rate of 86% (12/14). Exo-enteric tumors often invaded adjacent structures or perforated into the peritoneal cavity. Extensive resection procedures, including pancreaticoduodenectomy, abdominoperineal resection, and pelvic exenteration salvaged only 13% (2/16) of these patients. Three clinicopathologic factors adversely affected prognosis: i) tumor size greater than 5 cm in diameter, ii) extra-intestinal invasion or free perforation, and iii) high histopathologic grade of malignancy. The presence of none, one, two, or three of these adverse factors gave decreasing 5-yr survival rates of 100, 44, 31, and 0%, respectively. These observations suggest use of a multimodal treatment program that may minimize treatment failure from local as well as distant disease.

In 500 consecutive modified radical mastectomies (MRM) performed for clinically early (T1 N0) breast carcinomas between 1975 and 1982, the interpectoral lymph nodes (IPN) were separately sampled at the end of the operative procedure. Among the patients consistently sampled (1979-1982), lymph nodes were found in 73%. Interpectoral lymph node metastases were found in 2.6% of all patients, 3% of patients with infiltrating cancers, and 4% of patients sampled. A total of 8.2% of axillary node positive and 0.5% of axillary node negative patients had IPN disease. Among the 13 patients with positive IPN, there were no differences in tumor size or location from the entire group. The two patients whose only nodal metastases were to the IPN are currently disease-free without having received systemic adjuvant therapy. These data suggest that for early breast cancers treated by MRM, routine excision of the IPN is of potential therapeutic or prognostic benefit in very few cases. However, as MRM is increasingly applied to patients with more locally advanced disease (T2-3, N1b-N2), metastases in unexcised IPN may become a more significant source of local or systemic treatment failure.

57Co-bleomycin scanning dates from the early 1970s, when the first results were presented by Renault et al. Since then there have been numerous publications concerning the high sensitivity of this type of study in the detection of pulmonary or cerebral neoplasms. In the region below the diaphragm, however, sensitivity was poor due to hyperactivity of the kidney, liver and bladder. To eliminate this problem the authors have used single photon emission computerized tomography (SPECT), and their department is currently investigating the sensitivity of this technique for the detection of neoplasms. Two typical cases are described which illustrate the value of this method in the detection of cancer.

Sera of normal individuals or patients with lung cancer were assayed for Forssman-like antibody by a quantitative and specific method using ethylenediaminetetraacetate-containing buffer to inactivate complement in the test serum. It was shown that although Forssman-like antibody levels were distributed widely, (a) the levels of young (20 to 45 years of age) normal subjects of Blood Groups A and AB were lower than those of Blood Groups O and B, (b) the levels of old (60 to 80 years of age) normal subjects were lower than those of young normal subjects of Blood Groups O and B, and (c) the levels of old lung cancer patients were lower when compared to age-matched normal individuals of their blood group.

We analysed 55 exploratory thoracotomies undertaken in the Thoracic Surgery Service of the Geneva University Hospital between 1977 and 1987, to determine the preoperative examinations to prevent exploratory thoracotomy, a gesture that brings no benefits at all for the patients. We concluded that the most helpful preoperative examination is the CT-scan.

Malignant tumors are a frequent problem in gerontologic medicine; moreover, the number of geriatric patients is increasing. Surgical treatment is often proposed for solid tumors, even in patients over 80 years of age. 183 cases observed over the last 15 years in the Digestive and Thoracic Clinics of the University Hospital, Geneva, are reviewed. The affected organs were, in order of frequency, 1. large bowel, 2. breast, 3. stomach, and, more rarely, biliary tract, pancreas, esophagus and liver. Postoperative survival was satisfactory in this series. Analysis by organ shows that, in the case of the large bowel, one-stage resection-anastomosis provides the best results. For the breast, the classic procedures under general anesthesia are recommended. For the stomach, resection of the tumor prolongs survival. Postoperative mortality within 30 days is not increased by this type of intervention. Classification of evaluation of operative risk, as proposed by the American Society of Anesthesiologists, corresponds favourably with the postoperative mortality rate. For nearly 60% of our patients the quality of life is the same postoperatively as before. In this group, 78% have a Karnofsky index of 100%. It can therefore be stated that surgery for solid tumors is well tolerated by geriatric patients.

All type C retroviruses are lysed by human serum in apparently antibody-independent, complement-mediated reactions. In contrast, we have now determined that the mouse mammary tumor virus (MMTV), a type B retrovirus, is not disrupted by normal human serum. MMTV was lysed, however, when rabbit antibody to whole MMTV was added to the serum. By taking advantage of this dependence of MMTV lysis on specific antibody, a virolytic assay was developed, based on the measurement of reverse transcriptase released from disrupted virions, to search for evidence of antibodies to MMTV in human sera. Significantly greater virolytic activity was detected in the sera of patients with breast cancer than in sera of patients with benign disease (P less than 0.001) or colorectal cancer (P less than 0.001) or in sera from apparently healthy individuals (P less than 0.002). This assay thus appears to be able to detect a unique attribute, possibly the presence of an antibody crossreacting with MMTV, in serum in patient with breast cancer.

Between 1981 and 1986, 140 patients over 80 years of age were operated on for a gastrointestinal tract tumor in our service. There were 24 gastric, one small-bowel, 91 colonic, and 24 rectal cancers. Only 40% of the patients were preoperatively free of any systemic disorder other than tumor. We performed surgical procedures with a curative intent for 90 (64%) of them. Our mean overall postoperative mortality was 17%, but this rate could be decreased by performing elective operations on well-prepared patients. Over 80% of the deaths were related to systemic organ failures. Eighty-three percent of the survivors (96 patients) returned to their homes; 82% (94 patients) had normal activities for their age. The actuarial survival curve showed a 50% survival rate at three years, all tumoral stages included. These results support the view that surgery is a safe, valid option in the face of gastrointestinal tract tumors in the elderly.