Dimitrios N. Papachristou

Myosarcomas of the stomach: Natural history, prognostic factors and management

A retrospective study was made of 41 patients treated for gastric myosarcoma to identify prognostic factors that influence results. The adjusted five‐ and ten‐year survival rates were 56% and 43% respectively, with no significant difference between leiomyosarcoma and malignant leiomyoblastoma. A histopathologic grade of malignancy could be assigned to each tumor according to the degree of hypercellularity, nuclear abnormality, mitotic rate and other characteristics. High histopathologic grade, large tumor size (<5 cm diameter) and invasion of adjacent organs adversely affected prognosis. Five‐year survival after curative treatment was: 100% (9/9) for small tumors, of which six were treated by wedge gastric resection; 67% (8/12) for large tumors, mostly after subtotal gastrectomy; and 0% for tumors that invaded adjacent organs, despite extended resections. It is concluded that the management of gastric myosarcomas can be planned according to these prognostic factors and that multimodal therapy of tumors with adverse factors warrants consideration.

Bilateral breast cancer. Biopsy of the opposite breast

The bilateral nature of breast cancer is becoming increasingly evident. Recently 455 patients treated by the extended radical mastectomy more than 10 years ago were reviewed. Nine percent of the original patients had developed a clinically apparent cancer in the second breast within that time interval; this corresponds to 15% of the surviving patients. Since the stage of disease at the time of primary surgical therapy is the most important prognostic factor, it is imperative to detect these lesions as early as possible when they are most apt to be localized to the breast. Although some simultaneous, second primary breast cancers can be diagnosed clinically or by mammography, the great majority are not detected by these methods at the time of primary therapy of the dominant primary cancer. We have performed contralateral breast biopsy at the time of primary surgery for a known breast cancer in one breast routinely for the last 12 years. Twelve and one half percent of the contralateral breasts biopsied contain carcinoma, most at the “minimal” stage. A total of 954 biopsies were performed in 1204 patients. In 28 cases, carcinoma was suspected in the second breast on the basis of positive preoperative physical and/or mammographic findings. Twenty of these lesions proved to be infiltrating cancers, two non‐infiltrating cancers, and six were benign. In 625 patients, equivocal thickenings or densifications were noted in the opposite breast; 74 carcinomas were found in these breasts after biopsy of the dominant thickening, with 30 infiltrating and 44 noninfiltrating cancers. In 301 patients, no abnormal findings were noted in the opposite breast, either by mammogram or physical examination. Twenty‐three cancers were detected in this group by contralateral biopsy, five infiltrating and 18 noninfiltrating. This gives a total of 119 cancers found in the second breast by 954 biopsies in 1204 patients: 12.5% simultaneous bilateral breast cancer in the patients whose second breast were biopsied, and 10% simultaneous bilateral breast cancer in the overall group. Furthermore, 10% of the benign biopsies of the second breast demonstrated atypical ductal or lobular hyperplasia, a precancerous lesion. Further follow up of these patients at 6 years demonstrates on 8.8% incidence of subsequent development of breast cancer. Biopsy of the contralateral breast at the time of initial mastectomy has detected a significant number of minimal breast cancers, most being detected before diagnosis was possible by careful physical examination or adequate mammographic examination. The technique of contralateral breast biopsy is described; when a suspicious area or dominant thickening is present in the second breast, this is excised widely. Otherwise, in the absence of any specific finding, a large segment of breast tissue, including 20 to 25% of the breast parenchyma, is excised from the tail of the breast, as well as the mirror image location of the dominant cancer, in order to afford sufficient material for adequate histopathologic examination. When bilateral breast cancers are diagnosed by positive preoperative physical or mammographic signs, the second primary lesion is not at a particularly early stage of development; 20 of 22 cancers found were infiltrating and 45% of them had positive axillary nodes. However, the occult cancer found by contralateral biopsy in the absence of positve preoperative findings were almost universally at a “minimal” stage: 60% noninfiltrating cancer, and only 8.5% of the infiltrating cancers had positive axillary nodes, usually of a minimal degree. Contralateral breast biopsy at the time of mastectomy for a known cancer represents an additional method for the early detection of carcinoma in a very high risk group.

Comparison of lymphedema following incontinuity and discontinuity groin dissection.

Wide excision of primary malignant melanoma en bloc with regional lymphadenectomy decreases the incidence of regional recurrence as compared with a discontinuous dissection. The more extensive soft tissue defect of the incontinuity procedure is of concern since major lymphatics are often ablated from the ankle region up to the aortic bifurcation. This problem was studied in 81 currently living patients, all of whom had been operated upon for primary melanoma located below the distal thigh. Measurable lymphedema was found in 64% who had had the incontinuity procedure and 69% in the discontinuity group. The incidence of advanced lymphedema (greater than two inches) was 23% and 36%, respectively. All patients with advanced edema had been operated upon more than 3 years ago. Eighty per cent of patients operated upon more than 5 years ago had lymphedema. Wound complications had occurred in 41% of the patients in the incontinuity group and 42% in the discontinuity group, but this did not affect the incidence of edema. The clinical findings are readily explainable on the basis of lymphangiographic data.

Effect of postoperative wound infection on the course of stage II melanoma.

Microbial infections reportedly have a favorable effect on the course of certain malignant diseases. Intralesional inoculation of micro‐organisms can bring about tumor regression in certain clinical and experimental situations. In order to evaluate the influence of immediate postoperative wound infection on the course of Stage II melanomas, a retrospective study was undertaken of 211 patients who had undergone axillary or groin dissection. None had any antibiotic, steroid, chemoimmunotherapy, or cryosurgery and there was no history of a second primary neoplasm, pregnancy, immunodeficiency, or administration of immunosuppressive drugs. Forty of these patients developed significant postoperative wound infections. Although their representation according to sex, tumor location, number of nodes involved, and other parameters was comparable to that of the remaining 171 patients who did not develop wound infections, the incidence of local recurrence in the group with infections was significantly lower (p < 0.01). Patient survival and disease‐free interval following node dissection were not influenced by infection. Post‐operative infections in the groin or axilla offered only local protection from tumor recurrence; the ultimate course of the disease was not affected. Cancer 43:1106–1111, 1979.

Anastomotic failure complicating total gastrectomy and esophagogastrectomy for cancer of the stomach

Anastomotic failure complicated the postoperative course of 11 per cent of 350 gastric cancer patients who underwent total gastrectomy and esophagogastrectomy and was responsible for 33 per cent of all operative deaths. The extent of disease and the presence of tumor at the margin of resection did not prove to be significant factors in regard to the incidence of anastomotic failure. Gastrectomy combined with resection of other organs was associated with a significantly higher risk of failure. End-to-end esophagogastrectomy and esophagoduodenostomy appeared to be prone to failure, while Roux-en Y, jejunal pouch, and jejunal loop reconstructions were safer. Patients with severe intraabdominal or intrathoracic sepsis had a poor prognosis, and their management with surgical or conservative methods was ineffective. On the basis of these findings, alternatives to manual methods of visceral suturing should be considered.

Experimental use of a gastric flap on an omental pedicle to close defects in the trachea, pharynx, or cervical esophagus.

The use of local or regional skin flaps for repairs after head and neck cancer surgery often increases the deformity of the patient. We present a new procedure using a gastric flap on an omental pedicle. It has been successful in dog experiments where we transferred it to the head and neck region, to serve as a substitute for the standard skin flaps.

Prediction of intestinal viability by intra-arterial dye injection: A simple test

A vital dye solution injected intra-arterially stains only the viable parts in intestine of questionable viability. After various periods of ischemia, the viability of rat intestinal loops was assessed by three methods: on clinical basis; by detection of reactive hyperemia using an electronic thermometer; and by intra-arterial dye injection. The accuracy in viability prediction was 36, 69, and 84 per cent, respectively. The intraarterial dye injection method proved to be a simple, easy, and inexpensive way to accurately predict the viability of ischemic rat intestine.

Experimental use of free gastric flaps for the repair of pharyngoesophageal defects.

The repair of large pharyngoesophageal defects was accomplished experimentally in 16 dogs with revascularized free flaps from the greater curvature of the stomach. These flaps were based on the gastroepiploic vessels, and they were anastomosed to the carotid artery and external jugular vein in the neck. The procedure had a low mortality and did not lead to peptic ulceration or hyperchlorhydria in these animals.

A simple method of pancreatic transplantation in the dog.

Canine pancreatic organ transplantation can be performed without resection of adjacent structures or transection of major blood vessels. The graft consists of the entire gland except the distal tail and is based on the superior pancreaticoduodenal vessels. Devascularization of the duodenal loop does not result in ischemic necrosis. The duct-ligated graft is placed in the groin.