Decio M. Rangel

Validation of lymphatic mapping in colorectal cancer: in vivo, ex vivo, and laparoscopic techniques.

Background:The use of lymphatic mapping (LM) is being investigated to improve the staging of colorectal cancer (CRC) and thereby identify patients who might benefit from adjuvant chemotherapy. This study evaluated in vivo, laparoscopic, and ex vivo approaches for the ultrastaging of CRC.Methods:Seventy-five CRC patients were enrolled in a study of LM with peritumoral injection of isosulfan blue dye. LM was undertaken during open colon resection (OCR) in 64 patients, during laparoscopic colon resection (LCR) in 9 patients, and after specimen removal (ex vivo) in 2 patients. Ex vivo LM was also undertaken in 6 patients after unsuccessful in vivo LM. All nodes were examined by hematoxylin and eosin (H&E) staining; in addition, sentinel lymph nodes (SNs) were multisectioned and examined by immunohistochemical staining with cytokeratin (CK-IHC).Results:At least one SN was identified in 72 patients (96%). In vivo LM identified SNs in 56 of 64 (88%) patients undergoing OCR and in 9 of 9 (100%) patients undergoing LCR. Ex vivo LM was undertaken as the initial mapping procedure in 2 cases of intraperitoneal colon cancer and after in vivo LM had failed in 6 cases of extraperitoneal rectal carcinoma; an SN was identified in 7 of the 8 cases. Focused examination of the SN correctly predicted nodal status in 53 of 56 OCR cases, 9 of 9 LCR cases, and 6 of 7 ex vivo cases. Multiple sections and CK-IHC identified occult micrometastases in 13 patients (17%), representing 10 OCR, 1 LCR, and 2 ex vivo cases.Conclusions:LM of drainage from a primary CRC can be accurately performed in vivo during OCR or LCR. Ex vivo LM can be applied when in vivo techniques are unsuccessful and may be useful for rectal tumors. During LCR, colonoscopic injection can be used to mark the primary tumor and define the lymphatic drainage so that adequate resection margins are obtained. These LM techniques improve staging accuracy in CRC.

Serum sialic acid elevations in malignant melanoma patients

Elevated membrane sialic acid (n‐acetyl neuraminic acid) concentration may be a general phenomenon associated with malignant or transformed cells. In this study, sera from 30 normal persons and 25 melanoma patients were examined to determine first, if serum sialic acid elevations were associated with malignant melanoma, and second, if there was a relationship between tumor burden and serum sialic acid level. Significantly elevated sialic acid concentrations were found in the melanoma patients (p < 0.005), and levels tended to be greater in those with a large tumor burden (p < 0.05). Thus, increased serum sialic acid could prove to be a valuable clinical monitor of change in tumor burden as a result of therapy or change due to recurrence of disease following treatment.

Colonic diverticulitis in patients under age 40: Need for earlier diagnosis

Abstract Despite a clinical presentation and physical findings consistent with diverticulitis, this diagnosis was considered only in one third of 37 patients under age 40. Barium enema was particularly valuable and presented no risk to the patients with an incorrect diagnosis of acute appendicitis. In the medically treated group, 7 of 17 patients required subsequent operation. Those who had emergency surgery had a high wound infection rate. The need to consider the diagnosis in patients under age 40 years is stressed.

Multimodality cancer therapy in man: A pilot study of adriamycin by arterial infusion

Adriamycin was given by an infra‐arterial route as part of a planned program of combined modality therapy in 10 patients with regionally advanced neoplasms. Doses ranged from 45–107 mg/m2 given as a continuous infusion over 1.5–3.0 days. Adriamycin was followed by radiation therapy and/or radical surgical excision of the tumor in most cases, making long‐term evaluation of response difficult. However, 4 of 7 evaluable patients had prompt partial responses prior to subsequent treatment. We conclude that adriamycin can be administered by the intra‐arterial route and that it may be useful as part of a program of combined modality therapy in selected patients. Cancer 33:1485–1490, 1974.

Carcinoma of the gastroesophageal junction: A ten year experience with esophagogastrectomy

Eighty-six patients with carcinoma of the gastroesophageal junction were treated between 1966 and 1976. Adenocarcinoma was present in 62 patients and squamous cell carcinoma in 24. Surgical exploration was performed on 68 patients (79%) and 52 lesions (60%) were resected by combined midline laparotomy and right thoracotomy. There were 6 deaths (11%), 2 due to anastomotic leak. The mean survival for all resected patients was 2.1 years with a 22% three year life table survival (10/52). Five of 14 patients with negative nodes are alive more than five years. Palliative resection in 17 patients resulted in a mean survival of 10.5 months and no five year survivals. Esophagogastrectomy utilizing the Lewis technic reduces operative mortality and extends survival for patients with carcinoma of the gastroesophageal junction.

The hepatic response to endotoxin shock; Hemodynamic and enzymatic observations

Abstract In order to evaluate the role of the liver in endotoxin shock, purified endotoxin was injected into the portal vein or into the systemic circulation in dogs. Systemic administration of endotoxin produces a more severe hypotension than does injection into the portal vein, which suggests that endotoxin may be removed from the circulation and detoxified by the hepatic RE system. When the liver was excluded from the circulation, profound hypoglycemia followed administration of endotoxin and death soon occurred. Circulating SGOT, SGPT, and alkaline phosphatase levels increased greatly after administration of endotoxin in dogs with normal hepatic circulation, but the blood LDH levels were higher in dogs in which the hepatic inflow was excluded, which suggests an extrahepatic origin of the LDH isoenzymes. Although the present studies suggest that the liver exerts a protective effect during the initial phase of endotoxin shock, it is believed that with progression of shock the liver deteriorates and hepatic intracellular metabolites may be released into the circulation to accelerate the irreversibility of shock.

Pre- and transoperative localization of nonpalpable breast lesions

Percutaneous needle localization should be performed before biopsy of a nonpalpable breast lesion, thereby eliminating the need for blind biopsy. With small cancers, transoperative localization is just as important to confirm excision of the lesion and ensure that representative sections are obtained from the area in question for histologic study.

Resection of rectal mucosa without proctectomy as an adjunct to abdominoperineal resection for nonmalignant conditions

Summary An operative procedure consisting of excision of the rectal pouch and sigmoid end colostomy was performed in each of ten dogs to evaluate the fate of the rectal pouch. In each of the chronic survivors the lumen of the rectal pouch became obliterated within six to eight weeks, and abscess did not occur. Because of the frequent morbidity associated with abdominoperineal resection, it is believed that the described operation may warrant clinical trial in selected patients with ulcerative colitis and certain other nonmalignant conditions involving the rectum.