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Ninety-two patients with histologically confirmed bronchogenic carcinoma treated by surgical resection of the tumour were subsequently given immunotherapy with BCG (Glaxo). The patients were randomly allocated into three groups. Twenty-nine patients received multipuncture BCG (50 to 250 X 10(6) viable units), and twenty-six patients intradermal BCG (0.4 to 0.9 X 10(6) viable units), treatment being given at 1, 2, 6, 9, 13, 26, and 52 weeks after operation. Thirty-seven control patients did not receive any BCG immunotherapy; two patients in the control group were lost to follow-up. The overall five-year survival in all groups was 37%. Favourable prognostic features were squamous carcinoma (45% five-year survival), the absence of involved mediastinal nodes at operation (46%), and lobectomy (45%), but even the presence of involved mediastinal nodes was associated with a 19% five-year survival. There were no statistically significant differences between the survival of the control group and either group treated by immunotherapy considered individually or in combination. The influence of the presence of positive mediastinal lymph nodes and the extent of surgical resection on survival was not affected by immunotherapy. No serious side-effects of immunotherapy were encountered. [ABSTRACT FROM AUTHOR]

Summary: Phaeochromocytoma, a rare neuroendocrine tumour of chromaffin cell origin, is characterised by catecholamine excess. Clinical presentation ranges from asymptomatic disease to life-threatening multiorgan dysfunction. Catecholamine-induced cardiomyopathy is a dreaded complication with high lethality. While there is lack of evidence-based guidelines for use of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) in the management of this condition, limited to case reports and small case series, V-A ECMO has been reported as 'bridge to recovery' therapy, providing circulatory support in the initial period of stabilisation prior to surgery. We report on two patients presenting with catecholamine-induced cardiomyopathy and circulatory collapse who were successfully treated with V-A ECMO for 5 and 6 days, respectively, providing initial haemodynamic support. After stabilisation and introduction of alpha-blockade, both cases had favourable outcomes, with successful laparoscopic adrenalectomies on days 62 and 83 of admission, respectively. Our case reports provide further support for the use of V-A ECMO in the treatment of such gravely ill patients., Learning Points: Phaeochromocytoma should be considered in the diagnosis of patients presenting with acute cardiomyopathy. Management of catecholamine-induced cardiomyopathy is complex and requires multidisciplinary specialist input. Pre-operative management of phaeochromocytoma involves alpha-blockade; however, haemodynamic instability in the setting of cardiogenic shock can preclude alpha-blockade use. Veno-arterial extracorporeal membrane oxygenation is a life-saving intervention which may be considered in cases of acute catecholamine-induced cardiomyopathy and cardiogenic shock in order to provide the required haemodynamic support in the initial phase of treatment, enabling the administration of traditional pharmacological agents, including alpha-blockade.

Aims: To critically review the available transcatheter aortic valve implantation techniques and their results, as well as propose recommendations for their use and development., Methods and Results: A committee of experts including European Association of Cardio-Thoracic Surgery and European Society of Cardiology representatives met to reach a consensus based on the analysis of the available data obtained with transcatheter aortic valve implantation and their own experience. The evidence suggests that this technique is feasible and provides haemodynamic and clinical improvement for up to 2 years in patients with severe symptomatic aortic stenosis at high risk or with contraindications for surgery. Questions remain mainly concerning safety and long-term durability, which have to be assessed. Surgeons and cardiologists working as a team should select candidates, perform the procedure, and assess the results. Today, the use of this technique should be restricted to high-risk patients or those with contraindications for surgery. However, this may be extended to lower risk patients if the initial promise holds to be true after careful evaluation., Conclusion: Transcatheter aortic valve implantation is a promising technique, which may offer an alternative to conventional surgery for high-risk patients with aortic stenosis. Today, careful evaluation is needed to avoid the risk of uncontrolled diffusion.

Circadian rhythms in the Syrian hamster can be phase advanced by arousal during the mid-rest period. Similar phase shifts are induced by 5-HT(7) receptor activation in vivo and in vitro. Shifts in vitro are dependent on mobilization of intracellular cyclic AMP (cAMP), and can be blocked by melatonin, which opposes cAMP accumulation. If phase shifts to arousal in vivo are also dependent on cAMP, then these shifts may also be attenuated by melatonin. Hamsters were confined to a novel running wheel for 1.5 or 3 h in the mid-rest period. Melatonin (1 mg/kg i.p.) as a single bolus did not induce phase shifts, and single or multiple doses did not affect shifts to arousal. These data suggest that stimulation of cAMP by 5-HT(7) receptor activation is not necessary for clock resetting by behavioral arousal.

Following concern over a suggested link between the implantation of silicone gel and connective tissue disease, the Medical Devices Directorate (MDD) of the Department of Health reviewed all available data for submission to a specially convened Expert Advisory Group. Animal studies indicated that silicones are unlikely to stimulate a specific antibody response or cell-mediated immunity, that they have no adverse effect on resistance to infection, and produce minimal effects in the presence of potent adjuvants but can act as adjuvants themselves. The connective tissue disease most commonly claimed to be associated with breast implants is scleroderma. Although one series of patients showed a significantly higher prevalence of this disease than expected, there is no clear indication that the incidence of scleroderma in women with breast implants is any higher than in the general population.

The optimal frequency of clinic follow-up after radical radiotherapy to early cervical cancer is not well established. A retrospective analysis was carried out of 392 patients with FIGO Stage IIA and IIB carcinoma of the cervix treated by radical radiotherapy who attended a radiotherapy clinic for follow-up. A total of 38 (43%) of the 87 locoregional and 25 (38%) of the 66 metastatic relapses were detected at routine clinic visits. There were 72 clinic visits per relapse detected. The majority of locoregional and metastatic relapses whether detected at routine or interval visits were symptomatic of the locoregional recurrences 78% (42/54) occurred in the first two years following treatment. The majority were advanced. 7% (4/54) of locoregional relapses occurred after 5 years. Only 17% (9/54) of patients with locoregional relapse underwent salvage surgery. More intensive follow-up in the first two years is recommended.

Two cases of extramedullary plasmacytoma of the rectum treated by radiotherapy are reported. In one patient local control of disease was achieved at 36 months. A second patient treated by a palliative course of radiotherapy had initial good local regression and control of symptoms at 3 months. In view of the radiosensitivity of this tumour, consideration should be given to treating extramedullary plasmacytoma of the rectum by primary radiotherapy.

The value of hospital follow-up in the detection of first locoregional or metastatic relapse was assessed in 276 patients with histologically confirmed FIGO Stage IB carcinoma of the cervix. All were treated by intracavitary and external beam irradiation. The maximum period of follow-up studied was 10 years (median follow-up was 55 months) during which 3190 routine and interval clinical visits were made. Fifteen (44%) of locoregional relapses (LRR) and eight (38%) of metastatic relapses were detected at routine visits (137 visits per relapse detected). Seventy-five per cent of relapses occurred within the first 5 years. Nine LRR occurred in the second quinquennium. Five (14.7%) of LRR underwent salvage surgery, three of whom were asymptomatic at the time of relapse. If routine visits had been stopped at 5 years the number of clinical visits would have been reduced by 15%, possibly at the cost of one patient whose asymptomatic LRR might not have been amenable to salvage surgery, had she not presented until she was symptomatic. Routine follow-up beyond 5 years is of dubious benefit in the detection of relapse.

Locally advanced carcinoma of the cervix has a poor prognosis with a high incidence of persistent or recurrent local disease contributing to distressing symptoms and poor survival. This has remained unaltered over the past 30 years in spite of the addition of other therapeutic modalities. Between 1983 and January 1986, 38 patients with locally advanced carcinoma of the cervix were treated with synchronous 5-fluorouracil, mitomycin-C, and radiotherapy. The results of this pilot study indicate both an improvement in pelvic control and in 3-year survival rate for the chemosensitized therapy compared to conventional radiotherapy alone (55% v 28%) using historical controls. Improved survival was only significant for bulky FIGO Stage IIb tumors. The toxicity of this combination was predominantly gastro-intestinal and led to modification of both radiation dose and technique with subsequent improvement in the incidence of side effects. The results suggest that the combination of synchronous chemotherapy with radiotherapy is an improved method of treatment for locally advanced carcinoma of the cervix and that a prospective randomized trial is now justified.

Seventy-one patients with intestinal injury secondary to pelvic irradiation had predominantly large bowel lesions. Seventeen cases were treated conservatively and 54 came to surgery, 28 patients having more than one operation. Following this essentially salvage surgery there were more ileal than colonic anastomotic leaks. Thirty-four patients died during the follow-up period (2-12 years), 19 from recurrent malignancy, and nine as a result of continuing radiation effects. Seventy per cent of the patients who had a radiation fistula died as a result of malignancy. Of 42000 cases of pelvic malignancy treated by irradiation over the decade 1972-1982, surgical referrals for complications constituted 1.7%, with an overall radiation-related mortality of 0.2%. It is our opinion that colostomy alone has little part to play in this condition, and a policy based on excisional surgery is suggested.