International advances in surgical oncology最新文献

As sensitive radioimmunoassays for the detection of polypeptide hormones are developed, the exciting discovery of a diffusely distributed system of interrelated endocrine cells has begun a new era of endocrinology. This system, although anatomically disassociated, is bound together by a number of common features such as its biosynthetic mechanism, histochemical and ultrastructural features, and embryologic origin (Table I). The most prominent feature, however, is their biosynthetic pathways for hormone production, from which the acronym APUD has been derived. These are the capacity for Amine Precursor Uptake such as DOPA and then subsequent Decarboxylation, resulting in the synthesis of bioactive amines or polypeptide hormones. Hyperplasias or neoplasms of these cells are defined as apudomas. In the last ten years a great deal of research has rapidly altered the original concepts of this system, especially in terms of its embryologic origin, physiologic interrelationships, classification, as well as the addition of many new APUD cell members. These will be reviewed, and the origin, diagnosis, and treatment of each recognized apudoma will be synthesized in light of its membership within the APUD system.

Most of the patients diagnosed as having cancer of the breast in an early stage survive for a longer period and deserve to be socially rehabilitated by reconstruction. The main obstacle for primary reconstruction is delay in discovery of local recurrence. Standard, radical mastectomy with primary reconstruction by a distant thick flap or free myocutaneous gluteal flap is justified, because modified radical mastectomy has been an accepted method and permits primarily the local thick flap cover or the pectoral major muscle. We have done primary reconstruction in two cases (secondary in one case) with success, utilizing the microvascular surgical technique. This autogenous tissue transfer is the most physiological method and we believe that it is the procedure of choice. Postoperative follow-up studies by muscle biopsy, xerography and thermography have shown the satisfactory results without local recurrence.

The technique of the Turnbull-Cutait pullthrough procedure as performed at the Cleveland Clinic for carcinoma of the rectum and other conditions is described. The results in 127 patients are reported. Eighty-four patients were operated upon for cancer of the rectum and 47 for miscellaneous benign conditions. The average distance of tumors from the anal margin was 7.6 cm. The average margin of resection was 4.1 cm. The overall operative mortality was 1.2% in the cancer group. Ischemic necrosis occurred in 1.2% of the cancer patients, and minor pelvic sepsis occurred in 7.1%. The five-year survival in Dukes' A, B and C carcinoma of the rectum was 100%, 57% and 53%, respectively. The incidence of pelvic recurrence of the tumor at 6% was within acceptable limits. The quality of bowel function following the pullthrough procedure is discussed. It is concluded that this pullthrough procedure has a significant role in the management of carcinoma of the rectum and other conditions.

Prolactin secreting adenomas are the most frequently (50%) occurring pituitary adenoma. They occur more commonly in women than in men (4:1). Impairment of gonadal function accounts for the predominant symptoms in both sexes. Forty females and ten males with prolactin secreting adenomas were treated with selective adenoma removal by transsphenoidal surgery. Duration of symptoms varied from two months to 25 years. Twenty percent of the women and 100% of the men had invasive adenomas, a tumor that is difficult or impossible to eradicate. The chances of surgically correcting hyperprolactinemia in the female patient was 75% if the preoperative basal prolactin was 200 ng/ml or less, or 71% if the adenoma was non-invasive. The men were more difficult to treat because they all had invasive adenoma. In 50% of the men, prolactin was normalized by surgery. Early recognition of these patients before the adenomas become invasive is needed.

A review of experimental studies of chemotherapeutic agents and wound healing has demonstrated impairment of healing by a wide variety of agents. The extent of impairment by several agents (corticosteroids, Adriamycin, methotrexate, and cyclophosphamide) is dependent upon the interval between administration and wounding. If given within three to four days of wounding significant impairment results, but beyond that interval, impairment is minimal. Studies in animals with some agents (adriamycin, nitrogen mustard, cyclophosphamide, and methotrexate) have shown a dose-dependent impairment of healing, but extrapolation of these doses to regimens employed in man is impossible. Information regarding complications of chemotherapeutic agents in wound healing in man is available from adjuvant studies. No increased frequency of complications from nitrogen mustard, thio-TEPA, or cyclophosphamide occurred, even when these agents were given in the immediate perioperative period. Increased wound complications occurred with 5-fluorouracil when a 60 mg/kg dose was begun seven days after surgery but not when it was begun 14 days after surgery. These results stress the need for continued attention to wound complication occurring in adjuvant studies, and suggest that delay of treatment until seven days after surgery should produce minimal impairment.

Over 1,500 patients at our institution have received intravenous hyperalimentation (IVH) as nutritional support for nutritional rehabilitation prior to and/or during oncologic therapy. Stimulation of tumor growth has not been identified, and septic and metabolic complications of this technique have been minimal. Nutritional repletion resulted in return of immunocompetence and was associated with a reduction in sepsis, proper wound healing, and an apparent increase in tumor response to chemotherapy. If these observations were related as cause and effect, then a method of restoring and maintaining adequate nutrition should be added to the armamentarium of the oncologist. The use of IVh allowed specific oncologic therapy to be administered to a group of malnourished patients who otherwise might not have been acceptable candidates for intensive antineoplastic therapy.