Howard M. Spiro

Therapy of locally unresectable pancreatic carcinoma: a randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil), and high dose radiation + 5-fluorouracil: The Gastrointestinal Tumor Study Group.

One‐hundred‐ninety‐four eligible and evaluable patients with histologically confirmed locally unresectable adenocarcinoma of the pancreas were randomly assigned to therapy with high‐dose (6000 rads) radiation therapy alone, to moderate‐dose (4000 rads) radiation + 5‐fluorouracil (5‐FU), and to high‐dose radiation plus 5‐FU. Median survival with radiation alone was only 51/2 months from date of diagnosis. Both 5‐FU‐containing treatment regimens produced a highly significant survival improvement when compared with radiation alone. Forty percent of patients treated with the combined regimens were still living at one year compared with 10% of patients treated with radiation only. Survival differences between 4000 rads plus 5‐FU and 6000 rads plus 5‐FU were not significant with an overall median survival of ten months. Significant prognostic variables, in addition to treatment, were pretreatment performance status and pretreatment CEA level.

Medical and Surgical Management of Reflux Esophagitis

We compared the surgical and medical managements of reflux esophagitis in a prospective managements of reflux esophagitis in a prospective clinical trial. Patients wissigned to surgical (15 patients) and medical (16 patients) groups. A non-randomized medical group (20 patients) was also studied. Seventy three per cent of the surgical and 19 per cent of the medical group had an excellent to good response. A fair to poor response was observed in 81 per cent of medical and 27 per cent of surgical patients. Symptomatic improvement was accompanied by normal findings on acid infusion test and esophagoscopy. The histologic appearance of the squamous mucosa, however, remained abnormal in all but one patient. In patients who did well after operation there was improvement in resting lower-esophageal-sphincter pressures and absence of gastroesophageal reflux. The relative increases in pphincter pressure to graded increases in gastric pressure, however, remained abnormal in all but one patient.

Cancer of the pancreas. Diagnostic accuracy and survival statistics

We have reviewed the natural history, reliability of diagnosis, and survivorship of 100 patients with adenocarcinoma of the pancreas, in the context of a thorough review of the literature on survival after therapy for adenocarcinoma of the pancreas. There is 40‐62.5% error in the histologic confirmation of the diagnosis of pancreatic cancer. The error by inspection and palpation alone at the time of surgery may be as great as 25%. The absolute 5 year survival rate calculated from 61 clinical studies representing approximately 15,000 patients is 0.4%. The best series in the current literature has only 3% 5 year rate based upon the total population of pancreatic cancer patients. 12.3% of 5 year survivors from the world literature did not have curative surgery. This study shows the necessity for standardization of reporting methods. The same patients and survivors should not be used repeatedly in different reports. Some authors who claim the most effective palliation by pancreatic resection have the highest mortality rates. Cancer 42:2494–2506, 1978.

Treatment of Crohn's disease with azathioprine: a controlled evaluation.

To determine whether azathioprine is an effective drug in the treatment of Crohns disease a double-blind study was performed. Twenty-seven patients with involvement of either small or large intestine or both were randomized to either a treatment group (azathioprine 3 mg per kg of body weight) or a placebo group for 4 months. During the subsequent 4-month period, the treatment schedule of the two groups was reversed. Although some patients improved dramatically on azathioprine, others improved during the placebo period. This study does not provide evidence to support the effectiveness of azathioprine in the treatment of Crohns disease.

Amyloidosis and the gut

SummaryAmyloid involving the gastrointestinal tract may be deposited anywhere in the mucosa, the blood vessels, or in the muscular layers. It causes derangement of bowel function by direct infiltration or by producing secondary ischemic changes. Impaired motor activity, malabsorption, or infarction of the bowel may result.

Medical and Surgical Therapy in Diverticular Disease: A Comparative Study

The course of 132 patients with documented acute diverticulitis was analyzed: 99 patients treated medically and 33 patients treated surgically were followed for an average of 9.2 years. Seventy-three per cent of the medical group and 79% of the surgical group had no further symptoms or hospital admissions as a result of their diverticular disease once they were recovered from the acute episode. For three-quarters of the patients, therefore, acute diverticulitis occurred as a single episode that responded to either medical or surgical management. Considering the morbidity and cost to the patient, the treatment of the patient recovered from acute diverticulitis should be medical, with operation reserved for complications.

Glucagon Secretion in Acute and Chronic Pancreatitis

Plasma pancreatic glucagon concentrations were determined in the basal state and after the infusion of alanine in 10 patients with acute pancreatitis (5 in an initial episode of pancreatitis), in 10 patients with chronic pancreatic insufficiency, and in 21 healthy controls. In acute pancreatitis, basal glucagon levels were nine times normal but were higher during the initial attack than with a history of previous attacks. The glucagon response to alanine was also increased threefold to fourfold in initial attacks. In contrast, after recovery from the initial attack of acute pancreatitis, during acute episodes of pancreatitis in patients with a history of previous attacks, and in patients with pancreatic insufficiency, alanine failed to elicit a consistent rise in plasma glucagon. The data suggest that hyperglucagonemia may contribute to the hyperglycemia of acute pancreatitis, particularly during the initial episode. Loss of alpha cell responsiveness to alanine provides a sensitive index of previous pancreatitis.

Effects of radiation on the human gastrointestinal tract.

Radiation therapy directed at the abdomen may damage the digestive tract, the type and extent of injury depending on the dose of the radiation and the radiation sensitivity of the gut. Characteristic early changes are manifest in the mucosa of the gut: for later ulceration, changes in the collagen tissues and particularly in the vascular channels occur. This paper describes and characterizes injuries to the esophagus, stomach, small intestine and colon. It emphasizes the importance of recognizing radiation-induced damage to the gut which may occur early or late after radiation.

Randomized phase II clinical trial of adriamycin, methotrexate, and actinomycin-d in advanced measurable pancreatic carcinoma. A gastrointestinal tumor study group report

Sixty‐six patients with advanced pancreatic carcinoma were randomized to receive single agent chemotherapy with either adriamycin, methotrexate, or actinomycin‐D using conventional dose, route and schedule of administration. All patients had measurable lesions which were used for objective assessment of response. For adriamycin, 2 of 25 patients (8%) evidenced a partial response (2 of 15 (13%) previously untreated patients). One of 25 patients treated with methotrexate and one of 28 who received actinomycin‐D responded. The duration of responses ranged from 43–64 days for those patients with no chemotherapy prior to study entry. The median survival of patients who received adriamycin as initial treatment was 12 weeks compared to 8 weeks for methotrexate and 6 weeks for actinomycin‐D therapy.

Esophageal Motility in Neuromuscular Disorders

Excerpt One of the frequent problems in patients with neuromuscular disorders is swallowing dysfunction, often leading to a severe nutritional disturbance. Swallowing is a complex phenomenon compri...