Huei Jyh Fahn

Prognostic significance of HER-2/neu overexpression in stage I adenocarcinoma of lung.

BACKGROUND Even with early diagnosis and adequate resection, the 5-year survival rate for stage I lung cancer patients is around 60% to 70%. Overexpression of HER-2/neu protein is associated with poor prognosis in lung cancers. In this study, we evaluated the expression of HER-2/neu in cancer cells of lung and assessed their clinicopathologic and prognostic significance. METHODS From 1986 to 1995, clinical data on 42 consecutive patients who underwent complete surgical resection for stage I lung adenocarcinoma were collected. Expression of HER-2/neu in paraffin-embedded tumor samples was determined by immunohistochemistry and scored with a semiquantitative method. RESULTS Twenty-one of 42 patients were positive for HER-2/neu overexpression in tumor. Compared with patients with low HER-2/neu expression, patients with HER-2/neu overexpression had a significantly higher incidence of early tumor recurrence (p = 0.014). Survival was also significantly better in patients without HER-2/neu overexpression than in those with HER-2/neu overexpression (p = 0.0047). By univariate analysis, HER-2/neu overexpression and poor cell differentiation are two important factors correlated with poor prognosis. CONCLUSIONS Expression of HER-2/neu oncoprotein in stage I lung adenocarcinoma can predict the tumors aggressiveness. Early tumor recurrence was frequently detected in patients with HER-2/neu overexpression. We recommend an individualized therapeutic strategy based on the level of HER-2/neu oncoprotein in the tumor cells.

Management of Primary Chest wall Tuberculosis

Primary tuberculosis of the chest wall is rare and its clinical presentation may resemble pyogenic abscess or tumour. The diagnosis is difficult, since smears or cultures of aspirate frequently fail to show tubercle bacilli. Seven cases of primary chest-wall tuberculosis treated between 1973 and 1992 are described. All presented with a progressively enlarging mass. The diagnosis was based on bacteriologic and histologic findings, but definitive diagnosis was obtained before treatment in only two cases. Satisfactory results were obtained with surgical debridement and specific chemotherapy in six cases and with chemotherapy alone in one case. From this limited experience, we suggest that primary chest-wall tuberculosis should initially be treated with a combination regimen of antituberculous chemotherapy, which should take more than 9 months. If the lesion progressively enlarges or secondary infection occurs, however, adequate surgical debridement is also required.

Tumor recurrence in long-term survivors after treatment of carcinoma of the esophagus

To evaluate the status of tumor recurrence and the possible factors relevant to tumor recurrence among patients who survived more than 5 years after subtotal esophagectomy for the treatment of squamous cell carcinoma of the esophagus, a total of 104 patients who received treatment between 1959 and 1986 were reviewed. In 18 of these 104 patients, local or distant tumor recurrence developed, for a tumor recurrence rate of 17.3%. Eleven (61.1%) of these 18 patients eventually died of carcinomatosis despite further radiotherapy or chemotherapy, or both, and 4 patients with the disease are still alive. Three patients continue to survive after aggressive therapy was instituted for control of the locally recurrent tumor. Sixty-nine of the 104 patients are alive without tumor recurrence after the initial esophagectomy, and the remaining 17 patients died of miscellaneous causes. Tumor recurrence appears to be the most important factor affecting the prognosis in long-term survivors with resectable esophageal carcinoma. Among the 11 patients who died of tumor recurrence, 10 died within 5 to 9 years of their esophagectomy. The incidence of various modes of tumor recurrence among these 18 patients was as follows: blood-borne metastasis, 61%; lymph node recurrence, 33%; and locoregional organ recurrence, 33%. Factors that may be pertinent to a higher tumor recurrence rate include male sex, moderate to poor tumor differentiation, the presence of lymph node metastasis, and late stage of disease (stage IIb or worse). However, we could not find any statistical significance among these possible factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Management for patients with advanced T4 epidermoid carcinoma of the esophagus

Available data concerning the treatment of patients with advanced T4 esophageal carcinoma are limited. A consecutive series of 42 patients with advanced T4M0 epidermoid carcinoma of the esophagus were studied from June 1987 to July 1992. The aim of this study was to evaluate the efficacy of various therapeutic modalities, and further evaluate the therapeutic options. The various therapeutic modalities included the following: Group I, feeding jejunostomy or endoesophageal intubation, 6 patients; Group II, palliative subtotal esophagectomy only, 8 patients; Group III, bypass procedures without tumor resection, 9 patients; Group IV, nutritional support and then treatment with irradiation (n = 8) or concurrent radio‐chemotherapy (n = 4), 12 patients; Group V, subtotal esophagectomy, followed by aggressive concurrent radiochemotherapy, 7 patients. The total prescribed irradiation dose was 60 Gy (10 Gy/5 fractions/week). A combination regimen of chemotherapy consisted of cisplatin, 5‐fluorouracil, and leucovorin (PFL regimen).

Surgical Management of Substernal Goiter

Seventeen cases of large substernal goiter are reviewed. The commonest clinical features were frequent upper respiratory tract infections, dyspnea and a cervical mass. Five of the patients had previous thyroidectomy. The substernal goiter was located in the right chest in 11 cases, the left chest in five and bilaterally in one case. On computed tomograms it was pretracheal or prevascular in ten cases and retrovascular in seven. Tracheal deviation was present in 15 cases, causing tracheal compression or stenosis in 14. Thyroidectomy was performed on all 17 patients (8 subtotal, 9 total) through a low transverse collar incision. The recommended technique for substernal goiter extending from the neck to a level below the subcarinal region includes concomitant finger dissection and upward traction of the cervical thyroid through the subcapsular plane, with obliteration of the postresection substernal dead space by sutures. Follow-up radiography showed that all the deviated tracheas had resumed near normal position 2-3 months postoperatively and the average diameter of the compressed tracheas had increased significantly.

Primary Pulmonary Malignant Hemangiopericytoma Associated With Coagulopathy

A 34-year-old woman with a massive pulmonary malignant hemangiopericytoma and coagulopathy as a paraneoplastic syndrome is reported. Although coagulopathy may appear as a paraneoplastic syndrome and cause treatment to be more complicated and difficult, it can also be a useful marker to monitor the results of operation and tumor recurrence. This unusual case shows that primary pulmonary malignant hemangiopericytoma deserves aggressive surgical intervention with complete resection even under the circumstances of coagulation abnormality.

Flow-cytometric DNA content analysis of oesophageal carcinoma. Comparison between tumour and sequential non-tumour mucosae

The DNA content in oesophageal carcinoma and in sequential non-tumour mucosa was evaluated in 35 patients with oesophageal carcinoma, to explore the hypotheses that DNA distribution pattern and S-phase fraction can reflect malignant potential and that DNA aneuploidy can provide an early-warning signal of developing cancer. DNA flow cytometry was performed on 129 specimens from the tumours and on 119 specimens from non-tumour mucosa. Control specimens from gastric fundus had normal diploid DNA content and low S-phase fraction. Aneuploidy was found in 94.3% of the carcinoma specimens and intratumoral heterogeneity in 54.3%. Of the non-tumour specimens, 43.7% showed aneuploidy and none multiple aneuploidy. Pattern III distribution was present in 8.6% of the tumour specimens but not in non-tumour mucosa, where the incidence of aneuploidy rose with closeness to the tumour (p < 0.001). S-phase fraction was smaller in non-tumour than in tumour specimens (p < 0.0001). The study indicated that histologically tumour-free oesophageal mucosa may have a high malignant potential in patients with oesophageal carcinoma. The relative instability of such mucosa, with aneuploid cells and low S-phase fraction, may facilitate transition to abnormally proliferating cells in response to environmental signals. Cigarette smoking and alcohol may increase the risk of multicentric cancer development.