Claude Merrin

The surgical management of multiple lung metastases.

From 1970 to June, 1976, 56 patients who had multiple metastatic tumors of the lung were treated by lung resection. Most of the bilateral lung lesions were removed through a median sternotomy so as to avoid staged bilateral thoracotomy. The surgical mortality was 1.8%. A total of 26 patients are alive at 7 to 69 months (estimated median survival, 20.7 months). Patients with tumor doubling time of less than 40 days had lower survival results (median, 9.5 months), compared to patients with tumor doubling time of more than 40 days (median not yet reached). The type of primary tumor, tumor-free interval, number of lesions removed, and presence of unilateral as opposed to bilateral lung metastases did not seem to affect the therapeutic results.

Treatment of advanced bladder cancer with cis-diamminedichloroplatinum (II NSC 119875): a pilot study.

A pilot study was done using 19 patients with bladder cancer to test the efficacy of cis-diamminedichloroplatinum as a single agent to treat transitional cell carcinoma. Fourteen patients had stage D lesions, 3 patients had stage C and 2 patients had stage B tumors. The patients received 1 mg./kg. cis-diamminedichloroplatinum mixed with 2,000 cc dextrose 5 per cent in one-third normal saline solution, 37.5 gm. mannitol and 40 mEq. potassium chloride. The mixture was given in a slow infusion lasting 6 to 8 hours every week for the first 6 weeks and every 3 weeks thereafter. In the patients with stage D disease 1 complete clinical remission, 7 partial clinical remissions, 1 minimal objective response and 1 subjective response were observed. Four patients did not respond to the treatment. In the 3 stage C patients no response to the drug was observed. In the stage B patients 1 partial remission and 1 minimal objective response were seen. A total objective response (complete remission and partial remission) was seen in 9 of the 19 patients (47 per cent). The duration of the responses varied from 2 to 10 months, with an average of 4.8 months. These promising results seem to indicate the high degree of effectiveness of cis-diamminedichloroplatinum against transitional cell carcinoma of the bladder.

Treatment of advanced carcinoma of the prostate (stage D) with infusion of cis-diamminedichloroplatinum (II NSC 119875): a pilot study.

A study was done on 21 patients who had advanced carcinoma of the prostate (stage D) treated with 1 mg./kg. cis-diamminedichloroplatinum per week for 6 weeks. The infusions were then spaced every 3 weeks thereafter. One patient had never been treated previously and 20 patients were failures of previous therapy with estrogens and/or radiotherapy and/or chemotherapy. A partial objective clinical remission was seen in 9 of the 21 patients (43 per cent). This response lasted from 3 to 14 months, with an average of 5.8 months. The responses were evidenced by a 50 per cent or more decrease of lesions in the liver (2 patients), recalcification of a bone lytic lesion (1 patient), disappearance of positive lymph nodes in the neck (2 patients), disappearance of pleural effusion (1 patient), disappearance of lymphatic block of lower extremities (2 patients) and disappearance of lung metastases and ureteral obstruction (1 patient). Six patients (28.5 per cent) had a complete disappearance of the bone pain and became ambulatory and asymptomatic, 2 patients (9.5 per cent) with bony metastases remained asymptomatic and apparently stable and 4 patients did not respond to treatment and showed progression. Cis-diamminedichloroplatinum seems to be the most effective drug available to date for the treatment of advanced carcinoma of the prostate.

The clinical value of lymphangiography: are the nodes surrounding the obturator nerve visualized?

Twenty-five patients subjected to pelvic node dissection for urologic malignancies underwent bilateral pedal lymphangiography preoperatively. Postoperatively, 50 samples of the nodes selectively removed from the regions surrounding the obturator nerve were radiographed. All 50 samples revealed the presence of radiopaque dye. The lymph nodes surrounding the obturator nerve represent the first point of lymphatic metastases in carcinoma of the prostate and the bladder. Their visualization by lymphangiography emphasizes the importance of such a diagnostic study for the correct clinical staging of these diseases. The lymphatic anatomy of the pelvis is reviewed and compared to the radiological findings in lymphangiography.

Treatment of estrogen-resistant stage D carcinoma of prostate with cis diamminedichloroplatinum

Forty-five patients with rapidly progressive, estrogen-resistant Stage D adenocarcinoma of the prostate were treated with infusions of cis diamminedichloroplatinum (cis platinum) (1 mg./Kg./week) for six weeks initially and every three weeks thereafter. A partial objective response was observed in 13 of 45 patients (29 per cent). This response lasted from two to sixteen months with an average of six months. Eighteen patients (40 per cent) had a significant decrease or disappearance of bone pain and became ambulatory. Six patients (13 per cent) remained stable, and 8 patients (18 per cent) did not respond to treatment and showed progression of their disease. The toxicity of the treatment was mild to moderate. Most of the patients were treated in the outpatient department. Cis platinum appears to be the most effective drug available to date for the treatment of advanced carcinoma of the prostate.

Multimodal Treatment of Advanced Testicular Tumor with Radical Reductive Surgery and Multisequential Chemotherapy with CIS Platinum, Bleomycin, Vinblastine, Vincristine and Actinomycin D

Advanced testicular tumors in 34 patients were treated by combination chemotherapy with bleomycin, vinblastine, vincristine, cis platinum and actinomycin D. The therapy was divided into 3 phases: 1) induction, 2) consolidation and 3) maintenance. Induction lasted 4 weeks and consisted of 420 mg. bleomycin, 0.2 mg./kg. vinblastine, 4 mg./kg. cis platinum, and 20 mg. prednisone daily. Consolidation lasted 6 weeks and consisted of 5 mg. actinomycin D, 6 mg. vincristine and 6 mg./kg. cis platinum. Maintenance therapy was achieved with 2.5 mg. actinomycin D every 6 weeks and 1 mg./kg. cis platinum every 3 weeks. A tumor reductive operation was done before induction of chemotherapy in 13 patients and after induction of chemotherapy in 12 patients. Nine patients were treated with chemotherapy alone. Three patients with brain metastases received concomitant radiotherapy to the brain (3,000 rads). A previous operation and chemotherapy had failed in 11 patients and previous radiotherapy had failed in 1 patient. All patients treated had at least 1 objective response (34 of 34 or 100 per cent). Partial clinical remission was achieved in 7 of 34 patients (21 per cent). A complete clinical remission was observed in 27 of 34 patients (79 per cent) and of this group 6 had a relapse. At present, 22 of 34 patients are free of disease from 4 to 24 months, with an average of 13 months (65 per cent). The toxicity consisted of nausea, vomiting, mucositis, alopecia, mild leukopenia and tinnitus. This approach seems to be effective in producing long clinical remissions in the majority of patients with advanced disease.

Adjuvant chemotherapy for bladder cancer with doxorubicin hydrochloride and cyclophosphamide: preliminary report.

We describe 25 patients with bladder cancer who received adjuvant chemotherapy with doxorubicin hydrochloride and cyclophosphamide after radical cystectomy. Two patients had stage A disease, 3 had stage B, 3 had stage C and 17 had stage D. The 2 patients with stage A tumors have been free of disease for 12 and 15 months, respectively, and the 3 patients with stage B tumors have been free of disease for an average of 25 months. Of the 3 patients with stage C tumors 2 have been free of disease for an average of 34.5 months. Of the 17 patients with stage D tumors 10 have been free of disease for an average of 1 year (59 per cent). These preliminary results seem to indicate the value of adjuvant chemotherapy with doxorubicin hydrochloride and cyclophosphamide in cases of bladder cancer.

Chemotherapy of Advanced Renal Cell Carcinoma with Vinblastine and CCNU

Forty-four patients with advanced renal cell carcinoma (stage IV) were divided into 3 groups. The 23 patients in group 1 received CCNU alone,the 6 patients in group 2 received CCNU and vinblastine and the 15 patients in group 3 received methyl CCNU and vinblastine. The over-all response, subjective and objective, was 30% in group 1, 60% in group 2 and 54% in group 3. These results are compared to other existing modalities of treatment and appear to be superior.

Malignant Fibrous Histiocytoma of the Retroperitoneum and Genitourinary Tract: a Clinicopathological Correlation and Review of the Literature

Malignant fibrous histiocytoma is an uncommon pleomorphic tumor of the soft tissues possibly arising from the histiocyte. A case of malignant fibrous histiocytoma in the retroperitoneal space is reported. Pathologic and clinical features of this lesion as they relate to the retroperitoneum and genitourinary tract are discussed and suggestions for therapy are presented.

Cancer reductive surgery: report on the simultaneous excision of abdominal and thoracic metastases from widespread testicular tumors.

Eighteen patients with advanced testicular tumors presenting metastases in the retroperitoneum, the abdomen, the mediastinum and the lungs underwent a simultaneous excision of their abdominal and thoracic metastases in preparation for chemotherapy. A midline incision from the symphysis pubis to the xiphoid process was first done allowing entrance into the abdomen and the retroperitoneal area. Excision of the lesions in these areas was first performed. The wound was then closed and the midline incision was extended to the base of the neck. The sternum was split in half longitudinally allowing entrance into the mediastinum. Both pleural cavities were then opened allowing exploration of the lungs and wedge resections of the pulmonary nodules bilaterally. Fifteen patients tolerated the surgery well. Two patients developed transient respiratory failure and recovered. One patient died in the postoperative period from respiratory insufficiency. The autopsy report indicated pulmonary fibrosis secondary to previous bleomycin therapy. At present, 9 out of 18 patients (50%) are alive with no clinical evidence of disease from 9 months to 39 months (average 26 months), respectively, 6 patients (39%) are dead, 6 patients (33%) died from their tumor several months after surgery, and 1 patient died in the postoperative period. The morbidity of such an approach will be analyzed and the rationale will be discussed. All the patients in this report received chemotherapy with various combinations of bleomycin, vinblastine, vincristine, platinum, adriamycin, cytoxan, and actinomycin D.