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Despite the advances in pre-, peri- and post-operative medical care of colorectal carcinoma patients, the prognosis has improved only marginally over recent decades. Thus, additional prognostic indicators would be of great clinical value to select patients for adjuvant therapy. In previous studies we found that colorectal carcinomas have a marked increase of the urokinase-type of plasminogen activator (u-PA), and the inhibitors PAI-1 and PAI-2, whereas the tissue-type plasminogen activator (t-PA) is found to be decreased in comparison with adjacent normal mucosa. In the present study we evaluated the prognostic value of several plasminogen activation parameters, determined in both normal and carcinomatous tissue from colorectal resection specimens, for overall survival of 136 Dukes' stage B and C colorectal cancer patients, in relation to major clinicopathological parameters. Uni- and multivariate analyses indicated that a high PAI-2 antigen level in carcinoma, a low t-PA activity and antigen level and a high u-PA/t-PA antigen ratio in adjacent normal mucosa are significantly associated with a poor overall survival. A high ratio of u-PA antigen in the carcinomas and t-PA antigen in normal mucosa, i.e. u-PA(C)/t-PA(N), was found to be predictive of a poor overall survival as well. All these parameters were found to be prognostically independent of the clinicopathological parameters. Multivariate analysis of combinations of these prognostically significant plasminogen activation parameters revealed that they are important independent prognostic indicators and have in fact a better prognostic value than their separate components. Based on these combined parameters, subgroups of patients with Dukes' stage B and C colorectal cancer could be identified as having either a high or a low risk regarding overall survival. In conclusion, these findings emphasize the relevance of the intestinal plasminogen activation system for survival prognosis of patients with colorectal cancer and, in the future, might constitute a patient selection criterion for adjuvant therapy.

Objective: Comparison of an aggressive approach (including total mesorectal excision and combined modality adjuvant therapy) with a conventional approach in the treatment of primary rectal cancer. Design: Retrospective study. Setting: Memorial Sloan-Kettering Cancer Centre, New York (MSKCC) and University Hospital Leiden, the Netherlands (UHL). Subjects: One hundred and sixty-nine patients treated at MSKCC and 96 patients treated at UHL. Interventions: Total mesorectal excision (MSKCC) and conventional resection (UHL). Main outcome measures: Overall survival and local recurrence-free survival. Results: Five-year overall survival was 73% for MSKCC patients and 52% for UHL patients [ P P = 0.001). Relative risk of dying or developing a local recurrence was 3.37 and 2.61, respectively, for patients treated at UHL compared to patients treated at MSKCC ( P P = 0.008, respectively). Conclusions: These data suggest that an aggressive approach including total mesorectal excision and combined modality adjuvant therapy improves survival and local control compared to a conventional approach.

BACKGROUND. Patients with gastric cancer have a poor prognosis and can be cured by surgery only if the cancer is detected in an early stage. Extended surgery, down staging with chemotherapy before operation, and new postoperative treatments are recent approaches to increase survival rates. Categorizing patients' prognoses as good or poor by pathophysiologic markers, however, may be of great help in selecting therapies for these patients. For example, plasminogen activation (PA) parameters, that play an important role in tumor invasion and metastasis, have prognostic value for several human malignancies. METHODS. We evaluated the relation between several PA parameters in tissue with standard clinicopathologic parameters and with the overall survival of 50 consecutive patients with gastric carcinoma. RESULTS. Univariate analysis showed that a low tissue-type plasminogen activator (t-PA) activity in normal mucosa and in carcinomas and a high antigen level of inhibitor type-1 (PAI-1), and, to a lesser extent, of urokinase-type plasminogen activator (u-PA) receptor, in carcinomas are associated with a poor overall survival of the patients. In contrast, of the 14 clinicopathological parameters only the number of eosinophils in the tumors was associated with survival. Multivariate analysis revealed that the t-PA and PAI-1 levels are independently associated with survival. CONCLUSIONS. Plasminogen activation parameters in both normal and carcinomatous tissue of the stomach of patients with gastric carcinoma are of particular clinical interest because of their prognostic impact on overall survival.

For patients with gastric cancer deemed curable the only treatment option is surgery, but there is disagreement about whether accompanying lymph-node dissection should be limited to the perigastric nodes (D1) or should extend to regional lymph nodes outside the perigastric area (D2). We carried out a multicentre randomised comparison of D1 and D2 dissection. 1078 patients were randomised (539 to each group). 26 allocated D1 and 56 allocated D2 were found not to satisfy eligibility criteria (histologically confirmed adenocarcinoma of the stomach without clinical evidence of distant metastasis). Each of the remainder was attended by one of eleven supervising surgeons who decided whether curative resection was possible and, if so, assisted with the allocated procedure. Among the 711 patients (380 D1, 331 D2) judged to have curable lesions, D2 patients had a higher operative mortality rate than D1 patients (10 vs 4%, p = 0.004) and experienced more complications (43 vs 25%, p < 0.001). They also needed longer postoperative hospital stays (median 25 [range 7-277] vs 18 [7-143] days, p < 0.001). Morbidity and mortality differences persisted in almost all subgroup analyses. While we await survival results, D2 dissection should not be used as standard treatment for western patients.

Background/Aims: Human colorectal carcinogenesis was previously found to be associated with an increased urokinase-type plasminogen activator expression, both in antigen and activity, accompanied by simultaneously enhanced levels of plasminogen activator inhibitors type 1 and type 2. This increased proteolytic activity may contribute to invasive growth and metastasis of the tumors. Methods: In the present study, homogenates of liver metastases, primary colorectal carcinomas, and adjacent normal tissues were evaluated regarding the level and composition of urokinase, tissue-type plasminogen activator, and plasminogen activator inhibitors. Results: Concentrations of urokinase were significantly increased in primary carcinomas and liver metastases compared with normal tissues, whereas tissue-type plasminogen activator levels were significantly decreased. Liver metastases showed, in contrast to the carcinomas, hardly any activity of plasminogen activators, which could be attributed to the enhanced presence of the inactive proenzyme form of urokinase in combination with more complexes of plasminogen activators with inhibitors. Furthermore, liver metastases had an eightfold higher content of inhibitor type 1 compared with the primary carcinomas. The excess of inhibitors was confirmed by addition of plasminogen activators to metastasis homogenates, which resulted in increased complex formation. Conclusions: Colorectal cancer metastasis in the liver is associated with an inactivation of the enhanced urokinase cascade, which might allow tumor cells to settle in the liver.

Despite declining incidence and improved surgical care, gastric cancer remains associated with high mortality. Incidence and survival show remarkable geographic differences. Japanese patients have a much better chance of cure than Western patients. Whether biological differences between Japanese and Western patients are responsible for this remains unclear. Japanese surgeons, however, generally use a different surgical approach. The so-called R2 resection for gastric cancer has been investigated in a number of retrospective trials and, even in the West, evidence is accumulating that a more extensive resection of lymph nodes might positively influence stage dependent survival rates. Whether this approach indeed improves treatment and not just influences staging is currently being studied in a nation-wide, prospective randomized trial in the Netherlands. The design and the first results of this trial are presented here.

The choice of treatment for patients with cancer of the esophagus and cardia is controversial. Since overall survival is poor, the most important aim of treatment should be improvement of the main complaint: the inability to eat. In a retrospective analysis of 265 patients, referred to the University Hospital in Leiden, The Netherlands, comparisons were made between palliative effects of surgical resection (N = 92) and irradiation (N = 128). Several methods of comparing surgery with irradiation are possible: (1) all surgical patients vs. all irradiated patients; (2) only those surgical patients who survived the operation (N = 70) vs. all irradiated patients (N = 128); and (3) survivors after resection (N = 70) vs. only those irradiated patients treated with "curative" radiation (N = 62). Analysis of prognostic factors showed that in both surgical and irradiated patients, the only statistically significant factor was the (dis)ability to eat. Criteria to be considered to make individual recommendations for either treatment are presented.

Full clinicopathological details and clinical follow up of a case of malignant transformation within a tailgut cyst are presented. A 43 year old woman presented with signs and symptoms of an imminent threatened abortion. Routine examination identified a coincidental, asymptomatic retrorectal/presacral mass. Following imaging studies, surgical resection was carried out and an adenocarcinoma arising within a pre-existent tailgut cyst was identified by microscopy. Four years later the patient presented with neurological symptoms consistent with local recurrence of the tumour. Surgical biopsies confirmed this diagnosis and she was subsequently started on chemotherapy. She died soon after from a cause unrelated to the disease, after declining further active intervention. Differential diagnosis of such cases includes (cystic) teratoma, epidermal cyst, rectal duplication cyst, anal gland cyst and carcinoma, extension of local carcinoma, and metastatic disease. It is recommended that these lesions be completely excised when detected incidentally.

Postoperative results of 48 patients who underwent anterior resection using the EEA-stapler were evaluated. In all but 2 cases the indication for surgery was colorectal carcinoma. In 24 patients an anastomosis was created above the 5 cm level (above the anal verge: colorectal anastomosis) and in 24 at the 0-5 cm level (coloanal anastomosis). There was no perioperative mortality. The only complication observed in the colorectal anastomosis group was one case of late anastomotic stenosis. In the coloanal anastomosis group there were 4 cases with early anastomosis leaks, 3 cases with late stenosis and 5 cases with various degrees of late fecal incontinence, ultimately resulting in a permanent diverting stoma in 5 (10.4%) patients. We conclude that for rectal tumors the EEA-stapled anterior resection provides excellent functional results in most cases. Stapled coloanal anastomoses more often demonstrate various (early and late) complications. Nevertheless in spite of chronic discomfort, many patients still prefer their complaints to a permanent stoma.

From 1964 to 1988, 231 patients underwent local excision as the single treatment of melanoma with a thickness of less than or equal to 1.5 mm. We investigated the prognostic value of several factors on cancer-specific survival and cancer-specific disease-free survival, from time of excision on, by performing life-table analysis on 206 evaluable patients. Recurrence developed in 11 patients; local recurrence occurred in four patients, hematogenic spread in three patients and lymph node metastases in another four patients. Six patients died as a result of the disease. Tumors with a thickness of less than or equal to 1.5 mm have an excellent prognosis regardless of the localization of the melanoma. At 15 years cancer-specific survival was 92.3% and cancer-specific disease-free survival was 86.9%. Recurrence was successfully treated with hope for cure in 4 patients. This figures does not justify aggressive follow-up for all patients.

Osteogenic sarcomas of the breast are extremely rare and need to be distinguished from a variety of breast lesions producing metaplastic bone. A 50 year old patient presented with a painless lump in her right breast after twice previously having undergone local excision of a phyllodes tumour at this site. Following radiological and cytological investigation, excision was advised. Histology showed focal remnants of the previously excised phyllodes tumour in continuity with areas of widespread differentiation towards a telangiectatic osteosarcoma. So far this is a unique morphological endpoint.

Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial.Hartgrink HH, van de Velde CJ, Putter H, Bonenkamp JJ, Klein Kranenbarg E, Songun I, Welvaart K, van Krieken JH, Meijer S, Plukker JT, van Elk PJ, Obertop H, Gouma DJ, van Lanschot JJ, Taat CW, de Graaf PW, von Meyenfeldt MF, Tilanus H, Sasako M.Department of Surgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands. h.h.hartgrink@lumc.nlPURPOSE: The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years. PATIENTS AND METHODS: Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years. RESULTS: A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P

Urinary and sexual dysfunction are common problems after rectal cancer surgery, and the likely cause is damage to the pelvic autonomic nerves during surgery. In recent years, attention has been focused on preserving the autonomic nerves through a technique which is usually combined with total mesorectal excision or radical pelvic lymphadenectomy. The autonomic nerves consist of the paired sympathetic hypogastric nerve, sacral splanchnic nerves, and the pelvic autonomic nerve plexus. We will demonstrate the anatomy of the pelvic autonomic nerves and the relation of these nerves to the mesorectal fascial planes, and review the medical literature on sexual and urinary dysfunction after rectal cancer surgery with and without autonomic nerve preservation.

BACKGROUND: Curative resection is the treatment of choice for gastric cancer, but it is unclear whether this operation should include an extended (D2) lymph-node dissection, as recommended by the Japanese medical community, or a limited (D1) dissection. We conducted a randomized trial in 80 Dutch hospitals in which we compared D1 with D2 lymph-node dissection for gastric cancer in terms of morbidity, postoperative mortality, long-term survival, and cumulative risk of relapse after surgery. METHODS: Between August 1989 and July 1993, a total of 996 patients entered the study. Of these patients, 711 (380 in the D1 group and 331 in the D2 group) underwent the randomly assigned treatment with curative intent, and 285 received palliative treatment. The procedures for quality control included instruction and supervision in the operating room and monitoring of the pathological results. RESULTS: Patients in the D2 group had a significantly higher rate of complications than did those in the D1 group (43 percent vs. 25 percent, P

To describe some personal, medical and financial consequences of moving up the discharge of patients from hospital after an operation because of breast carcinoma.Descriptive.Department of Oncological Surgery, Medical Centre, Leiden University, Leiden, the Netherlands.Thirty-five patients with breast cancer were operated during the period March to August 1997. Thirteen patients of this group were discharged sooner after operation, with the drain still in situ; the other 22 remained in hospital until after removal of the drain. Medical and financial consequences were investigated.The patient characteristics of the two groups were similar. In the group discharged earlier, the number of postoperative days in hospital on average was 4.5 days smaller. The number of postoperative complications in the two groups were similar; development of seroma after removal of the drain occurred less frequently in the group discharged earlier. The financial savings amounted to an average of Dfl. 2497.-per patient. The patients discharged earlier were very satisfied.The orientative study suggests that moving up discharge after a breast cancer operation is a policy that is safe, financially advantageous and satisfactory to the patients.

An obese woman aged 18 years had been suffering for several years from axillary hidradenitis suppurativa. Repeated incision and drainage never gave lasting results and the patient became socially isolated. Hidradenitis suppurativa is a chronic suppurative inflammation of skin areas containing apocrine glands: the skin of the axillae, of the breasts and of the anogenital region. Treatment in the first instance consists of general hygienic measures. Pharmaceuticals used include antibiotics, antiandrogens and oestrogens. Surgery is performed when the condition is at an advanced stage, with cellulitis and scarring; ample excision is necessary to reduce the risk of recurrence. CO2 laser therapy is a new method of treatment that shows good results in incipient and advanced lesions.

Patients with gastric cancer have a poor prognosis and can be cured by surgery only if the cancer is detected in an early stage. Extended surgery, down staging with chemotherapy before operation, and new postoperative treatments are recent approaches to increase survival rates. Categorizing patients' prognoses as good or poor by pathophysiologic markers, however, may be of great help in selecting therapies for these patients. For example, plasminogen activation (PA) parameters, that play an important role in tumor invasion and metastasis, have prognostic value for several human malignancies.We evaluated the relation between several PA parameters in tissue with standard clinicopathologic parameters and with the overall survival of 50 consecutive patients with gastric carcinoma.Univariate analysis showed that a low tissue-type plasminogen activator (t-PA) activity in normal mucosa and in carcinomas and a high antigen level of inhibitor type-1 (PAI-1), and, to a lesser extent, of urokinase-type plasminogen activator (u-PA) receptor, in carcinomas are associated with a poor overall survival of the patients. In contrast, of the 14 clinicopathological parameters only the number of eosinophils in the tumors was associated with survival. Multivariate analysis revealed that the t-PA and PAI-1 levels are independently associated with survival.Plasminogen activation parameters in both normal and carcinomatous tissue of the stomach of patients with gastric carcinoma are of particular clinical interest because of their prognostic impact on overall survival.

Total mesorectal excision with autonomic nerve preservation for rectal cancer is based on the anatomy of the mesorectum and of the pelvic autonomic nerves. Cadaver dissections were performed to describe the relationship between these structures. Between the rectum and the sacrum a retrorectal space can be developed, lined anteriorly by the visceral leaf and posteriorly by the parietal leaf of the pelvic fascia. The hypogastric nerve runs anterior to the visceral fascia, from the sacral promontory in a laterocaudad direction. The splanchnic sacral nerves originate from the sacral foramina, posterior to the parietal fascia, and run caudad, laterally and anteriorly. After piercing the parietal layer of the pelvic fascia, approximately 4 cm from the midline, the sacral nerves run between a double layer of the visceral part of the pelvic fascia. The relationship between the hypogastric nerves, the splanchnic nerves and the pelvic fascia was comparable in all six specimens examined.

The Breslow or tumour thickness is the most important prognostic factor for survival from cutaneous melanoma. We studied the occurrence of melanoma in relation to tumour thickness and subsite in The Netherlands. Data on all newly diagnosed invasive cutaneous melanomas in the Netherlands Cancer Registry in 1989 and 1990 were used to estimate age and sex-specific incidence rates according to site and depth of tumour invasion. The incidence among women (9.5 per 100,000 person-years) was relatively high compared with other European countries. The predominant site was the trunk among men and the leg among women. After age 70, one-third of the melanomas were observed in the head and neck region. According to data from PALGA, the national computerized archive of Dutch pathology laboratories, 37% of the men and 29% of the women had a melanoma1.5 mm thick. Among persons younger than age 60, 26% had a melanoma1.5 mm thick, compared with 44% among those 60 years and over. In both registries the absolute and relative risks for a thicker melanoma increased with age, particularly for men. In The Netherlands, preventive measures for population groups with thicker melanomas should be targeted towards men and elderly persons.

Adjuvant chemotherapy for early breast cancer has been shown to offer an improvement in recurrence-free and overall survival, especially for younger women, but the acute toxic effects of this treatment discourage some physicians from prescribing it. The purpose of this analysis was to determine whether the benefit of 6 months of adjuvant CMF (cyclophosphamide, methotrexate, fluorouracil) treatment outweighs its costs in terms of toxic effects.A meta-analysis of quality-adjusted survival was performed based on data from 1229 patients, aged 49 years or younger, randomized in eight trials comparing CMF versus no adjuvant systemic therapy. The eight trials were included in the worldwide overview conducted by the Early Breast Cancer Trialists' Collaborative Group. The Q-TWiST method was used in a meta-analysis that provided treatment comparisons incorporating differences in quality of life associated with the amount of time patients spend with subjective toxic effects, after relapse, and without symptoms of relapse.Within 6 years of follow-up evaluation for patients with node-positive disease, the benefit in terms of increased relapse-free and overall survival balanced the costs in terms of acute toxic side effects. This was true even for the extreme case in which a zero value was assigned to all 6 months during which patients might receive adjuvant CMF chemotherapy. Within 10 years of follow-up evaluation, treated patients gained an average of 1.5 years of relapse-free survival time, almost 1 year of overall survival time, and 1 year of time without symptoms and toxicity.Adjuvant chemotherapy for younger women with node-positive breast cancer provided substantial amounts of quality-adjusted survival time, even after accounting for costs associated with toxic effects of the treatment. The Q-TWiST method represents a valuable tool for comparing treatments because it incorporates patients' perceptions of their quality of life for therapeutic decision-making.

PURPOSE To investigate whether treatment with prolonged low-dose adjuvant chemotherapy could improve survival of patients with axillary node-positive breast cancer. PATIENTS AND METHODS Four hundred fifty-two patients with axillary node-positive breast cancer who received postoperative irradiation were prospectively randomized in a trial (European Organization for Research and Treatment of Cancer [EORTC] 09771) that compared surgery followed by prolonged low-dose chemotherapy versus surgery alone. Chemotherapy was given for a period of 2 years and consisted of monthly courses of cyclophosphamide 50 mg/m2 orally on days 1 to 14, methotrexate 15 mg/m2 intravenously on days 1 and 8, and fluorouracil 350 mg/m2 intravenously on days 1 and 8 (CMF). RESULTS At a median follow-up time of 10 years, the overall survival duration was significantly prolonged in the chemotherapy arm (hazards ratio, 0.75; 95% confidence interval, 0.56 to 0.99; P = .04). Ten-year overall survival rates (+/- SE) were 59% (+/- 3.6%) for the chemotherapy arm and 50% (+/- 3.7%) for the control arm. Time to local relapse was significantly prolonged in the chemotherapy arm (hazards ratio, 0.63; 95% confidence interval, 0.42 to 0.94; P = .02). Patients with one to three positive axillary nodes and patients with estrogen receptor-negative tumors especially benefited from chemotherapy. Toxicity was observed in 93% of patients. CONCLUSION We conclude that prolonged low-dose adjuvant CMF can significantly prolong overall survival in patients with node-positive breast cancer. However, considering the fact that toxicity was still considerable despite reducing the dose of chemotherapy by 50%, we believe that conventionally dosed short-term regimens are preferable in the treatment of node-positive breast cancer.

To assess the subjective value that patients with cancer place on regular follow up after operation; to see what effects regular follow up visits have on the patient's physical and psychological wellbeing; and to find out which variables influence patients wellbeing and attitudes to follow up.Survey by questionnaire.University Hospital Leiden, the Netherlands.127 Patients who had been operated on for cancer.67 Patients were assessed one month before a routine follow up visit, and 60 on the day of the follow up; 46 of the second group were assessed again two weeks later.Answers to questions about physical and psychological wellbeing.Most patients were in favour of regular follow up visits at the hospital, and thought that the advantages outweighed the disadvantages. There were more reports of psychological than physical distress one month beforehand, but these were significantly less two weeks after the appointment compared with one month before (p = 0.003) and on the day of the appointment (p0.001). Regular follow up visits do not temporarily increase physical or psychological distress; rather there is a temporary decrease, less fear of recurrence, and less perception of any disadvantages. Women in general, and those with breast cancer in particular and patients with a lower educational standard in particular, had significantly more psychological complaints.Regular follow up visits are in general welcomed by patients who have had operations for cancer.

Thirty-five patients with oesophageal cancer were treated with external beam irradiation (50–60 Gy) followed by a boost-dose of 15–20 Gy by means of low dose rate intraluminal brachytherapy. Of the 35 patients treated 17 (48%) were pretreated with laser therapy or dilation alone. Although the intraluminal application time was long (up to 36 h) the treatment was feasable with minor acute toxicity. The palliative effect of the combined treatment was excellent; at 6 weeks post-treatment 32 of the 35 patients were able to eat solid food. Late complications were seen in six patients (17%), of which only one was severe and probably treatment-related. The median survival was 11 months; the 1- and 2-year survival were 42% and 10% respectively. The survival was strongly dependant on local control. Distant metastases became evident in 23% of patients. The interval between external radiotherapy and brachytherapy seemed to be critical. The results were compared with 68 historical controls. A significantly better survival was observed at 6 months. It is concluded that low dose rate intraluminal brachytherapy is a useful and feasable technique to increase the total dose for obtaining a better local control. The shortcomings are discussed and ideas for further improvement are mentioned.

In a retrospective study 678 patients who underwent (modified) radical mastectomy between 1970 and 1986 were analysed. By comparing the groups of patients who experienced local recurrence, regional recurrence or distant metastasis during follow-up with patients who remained free of disease, we have tried to gain some insight into the significance of local recurrence. By looking at the prognostic factors and the disease-free period there is hardly any difference between the patients with either a local, regional or distant recurrence. Actuarial survival of patients with local recurrence is slightly better than the survival of patients with distant metastasis (P = 0.009). From our results and from the literature we conclude that an isolated local recurrence after mastectomy for breast cancer is, in most cases, a first manifestation of metastatic disease. Probably only a minority of the local recurrences is caused by tumour cells left behind in the operation field.

A series of 83 patients with incurable cancer of the pancreatic head were analysed. Obstructive jaundice required surgical intervention in all of them. Different biliary decompression operations, either single or with concomitant prophylactic gastro-enterostomy were constructed in different ways. From our study we conclude: a single bypass, using the gallbladder and anastomosed with the jejunum is preferred in those cases where life expectation is estimated to be less than 3 months. Delayed gastric emptying after gastro-enterostomy is a frequent complication. Double bypasses are recommended only in those cases where duration of life is estimated at more than 3 months.

In a retrospective study we performed an analysis of the sexual (dys)function in 26 men operated in the University Hospital Leiden, the Netherlands, for rectosigmoid carcinoma. Nine patients (mean age 59.8 years (45-67)) underwent abdomino-perineal resection and 17 (mean age 59.5 years (43-75)) underwent (low) anterior resection. All men were sexually active before surgery. Following abdomino-perineal resection only 2 patients are sexually active, five are unable to achieve an erection and seven have no orgasms. Three patients only achieve an incomplete erection. One patient has a retrograde ejaculation. Following anterior resection 12 of 17 patients are sexually active, four are unable to achieve an erection or orgasm. Four patients only achieve an incomplete erection. Five patients have a retrograde ejaculation. It is concluded that sexual disorders occur frequently after surgery for rectosigmoid carcinoma, and following abdomino-perineal resection in practically all cases, while the nature of the disorder varies greatly. It is very important to inform the patient before surgery.

In order to establish the reliability of the assessment of tumour stage and hence of resectability of carcinoma of the pancreatic head by ultrasonography (US) and computed tomography (CT) a retrospective analysis was performed on 41 patients. Both direct imaging techniques were very accurate in detecting non-resectable disease, 100 and 85% respectively, but were much less accurate in predicting resectable cancer, 18 and 15% respectively. False-resectable results were established in 58% of US examinations and 42% of CT examinations. As demonstrated in this study, predicting resectability of carcinoma of the pancreatic head with US and CT is an inadequate method of assessing tumour stage and should be complemented by other techniques to ensure a reliable result.

A group of 46 patients, with stage-1 malignant melanoma of intermediate thickness and histologically proven negative regional lymph nodes, was retrospectively reviewed. The aim of our study was to determine whether the prognosis of these patients had been worsened by the regional lymph-node dissections. There was no influence on the survival or disease-free interval.

From 1964 to 1988, 231 patients underwent local excision as the single treatment of melanoma with a thickness of less than or equal to 1.5 mm. We investigated the prognostic value of several factors on cancer-specific survival and cancer-specific disease-free survival, from time of excision on, by performing life-table analysis on 206 evaluable patients. Recurrence developed in 11 patients; local recurrence occurred in four patients, hematogenic spread in three patients and lymph node metastases in another four patients. Six patients died as a result of the disease. Tumors with a thickness of less than or equal to 1.5 mm have an excellent prognosis regardless of the localization of the melanoma. At 15 years cancer-specific survival was 92.3% and cancer-specific disease-free survival was 86.9%. Recurrence was successfully treated with hope for cure in 4 patients. This figures does not justify aggressive follow-up for all patients.

Experimental and clinical studies on ifosfamide indicate that fractionated treatment regimens have a higher efficacy compared to a single short-term infusion. In addition, protracted continuous infusion, in general, is often less toxic without loss of antitumour activity. To study the toxicity of a 10-day continuous infusion at increasing dosages of ifosfamide and mesna, 24 patients with a variety of advanced cancers (colon 10, pancreas 5, adenocarcinoma with unknown primary 5, and 4 others) received a total of 60 cycles (range 1-6 cycles, median 2) at 3 to 4 week intervals. The ifosfamide and mesna doses ranged from 654 mg m-2 day-1 to 1562 mg m-2 day-1 for a total of ten doses. Twenty-two patients were chemotherapy-naive. Pharmacia-Deltec CADD-1 pumps and Port-a-Cath implantable venous access devices were used. The dose-limiting toxicity was leucopenia without thrombocytopenia. At a dose of 1300 mg m-2 day-1 in 30% of the cycles in 7 patients leucopenia of WHO grades 3 and 4 was observed, while at higher dosages this percentage increased to 73%. Haemoglobin values usually decreased during the infusion with a mean of 1 mmol/l (range 0.3-2.5 mmol/l), frequently with partial or full recovery by the next cycle. The next most disturbing side-effect was fatigue (50% of patients WHO grades 2 and 3), and nausea and vomiting requiring drug treatment in 75% of patients. Renal failure and haematuria did not occur. There were two catheter-related complications: thrombosis (1 patient) and mechanical obstruction (1 patient). One patient developed severe encephalopathy at day 6 (total dose 18 g ifosfamide) with complete recovery after cessation of the infusion. In summary, a tolerable ifosfamide dose using this regimen in this previously largely untreated patient group appears to be 1200-1300 mg m-2 day-1 for 10 days. Fatigue is a frequent complaint and might be explained as a kind of neurotoxicity. The treatment can be administered to outpatients.

The undescended testis carries an increased risk of cancer; however, the exact individual risk of a cryptorchist during his life to develop cancer is unknown. The risk of developing cancer can be calculated from three important figures: (a) the number of cryptorchists in the population; (b) the number of malignant testicular tumors found in undescended testicles; and (c) the number of testicular tumors per annum. In the literature, a 48 times increased chance to develop testicular cancer is accepted; it is a high risk which is contrary to the fact that a malignant cryptorchid testis is a very rare disease. Based on the estimated risk for the cryptorchist in the Netherlands to develop testicular cancer, this article criticizes the value of the figures that are generally used to calculate the individual risk; it is concluded that even today the exact risk is unknown. In giving advice concerning the management of undescended testis, one must appreciate not only the supposed cancer risk, but also take into consideration morbidity and mortality after prophylactic orchidectomy and improved cure rates after electively treated testicular tumors.

Patients with progressive Stage D carcinoma of the prostate resistant to conventional endocrine therapy were evaluated for their symptomatic response to bilateral adrenalectomy, hypophysectomy, combination hypophysectomy and adrenalectomy, or chemotherapy with a new oral steroidal-alkylating agent, Estracyt (estramustine phosphate). Good, long-term palliative responses were achieved with bilateral adrenalectomy, hypophysectomy, and Estracyt. Because of its ease of administration, effectiveness, and lack of toxicity, oral Estracyt may be considered the method of choice in some cases for failures following conventional hormonal therapy.

A group of 127 patients with esophageal cancer treated with radiotherapy at different dose levels was retrospectively analysed. It was found that 70.5% of the patients showed improvement of dysphagia and that 54% remained palliated with respect to food passage until their death. The two major prognostic variables with respect to the palliative effect on dysphagia as well as survival were the passage score and the radiation dose. Patients with severe dysphagia (PASS 0 or 1) had a median actuarial DFI and SURV of 3.7 and 6.4 months, respectively, in contrast to 16.0 and 8.7 months for patients who were able to use (semi)solid food (PASS 2 and 3). The median actuarial DFI and SURV of patients treated with a relatively low dose (less than 50 Gy in 5 weeks) were 2.5 and 4.8 months, respectively, compared to 10.1 and 8.3 months, respectively, for patients treated with a relatively high dose.

From 1976 through 1984 46 patients with locally advanced breast cancer were treated by either radiotherapy alone or by combination of surgery and postoperative radiotherapy. Eleven of the 21 patients treated by radiotherapy alone had a local or regional recurrence, while no recurrences occurred in the combined treatment group. From this study it was concluded that “locally advanced” breast cancer is a heterogeneous disease and that further study concerning the role of surgery is justifiable for a selected subgroup of patients with non-inflammatory resectable tumours (meeting the criteria of “locally advanced” breast cancer).

From 1960 to 1982, a total number of 216 patients with Stage I melanoma underwent local excision as the single treatment. Life-table analysis was performed on 211 evaluable patients to investigate the prognostic value of several factors on survival as well as disease-free survival. The influence of sex, age, localization of the tumor, and margin of the excision on prognosis was not statistically significant. The Clark level and Breslow thickness were important factors to predict the prognosis. Local recurrence occurred in only one patient; in most cases tumor growth close to the original site of excision indicates early manifestation of hematogenic spread. Lymph node metastases developed in 31 patients; ten of them remained free of disease after node dissection. Six patients died from hematogenic metastases without nodal involvement. Tumors with thickness less than 1.5 mm have excellent prognosis regardless of the location of the melanoma or the margin of the excision. With increasing thickness of the tumor, prognosis is proportionally worse. By performing wide excisions the final outcome can not be improved.

All patients (N = 41) who participated in a randomized clinical trial in the Leiden University Hospital comparing mastectomy to tumorectomy have been studied with respect to their quality of life 11 months (+/- 5) after surgery. The body image of patients is more severely impaired after mastectomy than after tumorectomy (P less than .01). The studied groups did not differ, as has been suggested, with respect to fear of recurrence and death. These fears, however, turned out to be inversely related to the age of the patients (r = -.34, P = .02).

The distinction between affect and cognition was studied in a sample of early breast cancer patients. As assumed by Mckennell (1978) the change experienced led to a level of affect that was lower than the level of cognition and an increased discrepancy between these two components of quality of life within the first year after surgery. Cognition was stable over time, whereas affect improved (p

The importance of the mechanical cleansing of the bowel in relation to surgery of the colon is well understood. This article provides practical remarks concerning the technique of irrigation. Technical details are given on transforming a Bremshey hospital bed into a 'whole-gut irrigation bed'. The clinical procedure of the irrigation is described. We recommend irrigation by nasograstric tube with large amounts of fluids to all our patients when the bowel needs to be cleansed. Our specially designed whole-gut bed provides excellent comfort to our patients.