Maurizio Valente

Adjuvant treatment of stage I lung cancer with high-dose vitamin A.

PURPOSE Vitamin A and retinoids are strong inhibitors of epithelial cancer promotion and progression in experimental carcinogenesis. This study examined whether they may prevent the occurrence of upper aerodigestive cancer in subjects heavily exposed to tobacco smoking, such as patients already cured of an early-stage lung cancer. PATIENTS AND METHODS The adjuvant effect of high-dose vitamin A was tested on 307 patients with stage I non-small-cell lung cancer. After curative surgery, patients were randomly assigned to either a group prescribed retinol palmitate administration (orally 300,000 IU daily for 12 months) or a control group prescribed no treatment. RESULTS After a median follow-up of 46 months, the number of patients with either recurrence or new primary tumors was 56 (37%) in the treated arm and 75 (48%) in the control arm. Eighteen patients in the treated group developed a second primary tumor, and 29 patients in the control group developed 33 second primary tumors. A statistically significant difference in favor of treatment was observed concerning time to new primary tumors in the field of prevention (P = .045, log-rank test). The treatment difference in terms of disease-free interval was close to statistical significance (P = .054, log-rank test) and just significant when adjusted for primary tumor classification (P = .038, Cox regression model). CONCLUSION Daily oral administration of high-dose vitamin A is effective in reducing the number of new primary tumors related to tobacco consumption and may improve the disease-free interval in patients curatively resected for stage I lung cancer. The impact of such a treatment on survival needs to be further explored.

The contribution of salvage surgery to the management of childhood osteosarcoma.

Between January 1970 and December 1988, 174 consecutive patients under the age of 20 years with curatively resected primary osteosarcoma were treated at our institute; 72 in the years of 1970 to 1981 and 102 in the years 1982 to 1988. In the latter period, adjuvant chemotherapy was replaced by neoadjuvant programs, and new criteria were adopted for the management of lung metastases, consisting in early bilateral surgical staging and lung resection through median sternotomy for all patients with purely intrathoracic relapse. Follow-up was updated in December 1989. During the last period, the overall 5-year survival improved significantly from 35% to 58% (P less than .001). The disease-free survival rose from 38% to 45% at 5 years, with median values of 15 months versus 33 months, while the frequency of isolated lung metastases dropped from 58% to the actuarial 48%. The proportion of patients who underwent complete resections of their pulmonary metastases rose from 17% (seven of 42) to 55% (27 of 49), without operative mortality. Due to such a high proportion of patients eligible for salvage surgery, the overall survival from detection of lung metastases improved from 0% to 28% at 5 years (P less than .001). Contralateral occult metastases were resected in three of 15 subjects with monolateral clinical lesions, and five patients underwent subsequent lung resections. These data indicate that systematic bilateral pulmonary resection plays an important role in improving the final cure rate of childhood osteosarcoma, beyond the benefit resulting from neoadjuvant chemotherapy.

Perioperative blood transfusion and prognosis of resected stage Ia lung cancer

Based on the experience of blood-related immunosuppression in kidney transplants, some retrospective studies have reported an adverse relationship between blood transfusion and survival after curative resection for cancer. In order to confirm these findings, we have retrospectively evaluated our population of resected stage Ia non-small cell lung cancers (years 1974-79). Two hundred and eighty-three patients were included in this analysis: 65 underwent pneumonectomy (23%), 205 lobectomy (72%) and 13 sublobar resections (5%). Patients submitted to perioperative blood transfusions were 157 (55%), without major differences according to surgery or tumour extent. The cumulative survival at 8 yr was 40% for transfused patients and 41% for nontransfused, relapse-free survival was respectively 36% and 34%; no differences were detectable stratifying for the amount of blood transfused or the extent of operation. Our experience does not support the hypothesis of an adverse prognosis related to perioperative blood transfusion.

Nutritional support in patients with cancer of the esophagus: Impact on nutritional status, patient compliance to therapy, and survival

Aims and background The multimodal approach to patients with esophageal squamous cell carcinoma often includes poly-chemotherapy combined with radiation therapy. Cancer dysphagia and drug-related anorexia, mucositis and vomiting can all lead to malnutrition. The aim of this study was to analyze the impact of the administration of enteral nutrition (EN) on the patients nutritional status, tolerance of chemotherapy and radiotherapy, and final oncological outcome. Methods Fifty esophageal cancer patients who were to be submitted to chemotherapy (days 1-4 5-fluorouracil (FU) 1 g/m2/day and cisplatin (CDDP) 100 mg/m2/day 1) for two cycles plus radiotherapy (31 Gy) were referred to the Nutrition Support Unit prior to any therapy due to their malnourished status. Twenty-nine dysphagic patients received nutrition via tube (37 kcal/kg/day + 2.0 g proteins/kg/day for 34 days), while 21 others who were not dysphagic were given a standard oral diet (SD). The patients who received EN had a more severe weight loss than the SD patients (16.8% vs 12.8%, P <0.02). Results The dose of administered EN represented 86% of the planned support, and 70% of the nutritional therapy was administered in the home setting. Administration of EN support resulted in stable body weight and unchanged levels of visceral proteins, while SD patients had a decrease in body weight, total proteins and serum albumin (P <0.01). There was no difference between the two groups in terms of tolerance and response to cancer therapy, suitability for radical resection and median survival (9.5 months). Conclusions EN in patients with cancer of the esophagus undergoing chemotherapy and radiotherapy is well tolerated, feasible even in the home setting, prevents further nutritional deterioration and achieves the same oncological results in dysphagic patients as those achieved in non-dysphagic patients.

Safety of high-dose vitamin A : randomized trial on lung cancer chemoprevention

The paper reports on the efficacy and side effects of high-dose vitamin A, administered as adjuvant treatment for resected stage I lung cancer in a randomized clinical trial. After a median follow-up

Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space

BACKGROUND The management of postoperative leaks into the mediastinum or pleural cavities after esophageal surgery yields unsatisfactory results. A recently described method, drainage of the mediastinum or pleural cavity through suture line defects, has been used in our department with eight patients. METHODS A suction tube was advanced over an endoscopically placed guide wire into the abscess from inside the esophagus, and gentle aspiration was used to remove saliva and secretions. Intravenous antibiotics and total parenteral nutrition were also given. RESULTS The sepsis was rapidly controlled, and the abscess cavity progressively collapsed in all cases. Seven patients recovered and were discharged 34 to 61 days after operation; one died of concomitant complications. CONCLUSIONS This method seems promising for the management of intrathoracic esophageal leaks.

Lung resection as salvage treatment for metastatic osteosarcoma.

Resection of pulmonary metastases has achieved a central role in the overall management of osteosarcoma, since a number of studies have demonstrated that salvage surgery is able to cure 20 to 40% of all relapsing patients. This paper presents the results of surgical management of 27 consecutive cases of pulmonary metastases from osteosarcoma, who underwent complete resection at the Istituto Nazionale Tumori of Milan between 1975 and 1986. In the present series, overall actuarial survival at 3 years from the first thoracotomy was 47%, with a median survival of 28 months and no operative mortality. Better results were observed in patients with single lesions (68% survival) or when the interval to lung metastases exceeded 12 months (60% survival). These data support the concept of pulmonary metastasectomy as effective salvage therapy for metastatic osteosarcomas whose distant spread is confined in the lungs.

Effect of chronic cardiopulmonary disease on survival after resection for stage Ia lung cancer.

The role of chronic cardiopulmonary disease as a risk factor for immediate and late mortality was evaluated retrospectively in a consecutive series of 116 patients who had had resections for stage Ia non-oat-cell lung cancers. The presence of chronic cardiopulmonary disease was diagnosed on the clinical history and preoperative assessment of lung and heart function by traditional means. Patients with chronic cardiopulmonary disease showed a lower five-year survival rate than controls--35% versus 53% (p less than 0.08). The difference increased and became significant if besides having cardiopulmonary disease the patient was over 60 years of age or had had a pneumonectomy--30% versus 52% (p less than 0.025). A higher operative mortality was the main reason for the lower observed survival. Nevertheless, survival of patients at risk exceeded 30% in each subgroup, being 33% for patients over 60 undergoing pneumonectomy. In our series the benefits of resection of lung cancer in patients with impaired cardiopulmonary function were greater than the risks of perioperative and later death even in the groups with a poorer prognosis.

Growth characteristics of human colorectal and non-small cell lung tumors xenografted into nude mice: possible correlation with prognosis.

Specimens from human colorectal tumors and from non-small-cell lung tumors obtained at surgery were subcutaneously implanted as xenografts in athymic Swiss mice of both sexes to investigate to what extent the properties of the original tumors were maintained. A successful take was obtained in 5 of 9 colorectal tumor and 6 of 11 non-small-celll lung tumor xenografts. Moreover, 44% and 45% of the respective tumors could be established as tumor lines. Neither metastases nor local tumor invasion was observed in tumor-bearing mice. Seven of 9 serially transplantable tumors had a short latency period (14-30.5 days) when first xeno-grafted. No significant changes in tumor histopathology were noted after growth into nude mice. Tumor take was partially related to clinical stage and prognosis of patients. In fact, 8 of 12 specimens from NO patients failed to grow, whereas 7 of 8 tumors from patients with nodal invasion and/or metastasis grew in nude mice. Moreover, for the group of patients whose tumor was « take – », the one-year survival was 85%, compared to 40% for the « take + » group (p < 0.05).

Reverse flap of distal latissimus dorsi for diaphragm reconstruction in the adult: specification of the technical procedure and report on six cases.

autograft rather than other valve prostheses in children, some specific reasons were present in this special situation. Resection of the aneurysmal aortic root was necessary and the relatively difficult access to the aortic root made the choice of a homograft less preferable in view of the inevitable reoperation. The operation turned out to be straightforward. The anterior placement of the pulmonary trunk made its harvesting easy. Coronary artery problems were not encountered. Transposition may, however, be combined with coronary artery patterns that make harvesting of the pulmonary trunk more difficult, especially a right coronary artery crossing the right ventricular outflow tract. No important mismatch between the diameters of the pulmonary trunk and aortic anulus existed, which further encouraged us to choose the pulmonary autograft for aortic root replacement. In conclusion, the Ross procedure is technically feasible after an arterial switch operation and may be a particularly attractive alternative for this special population. This may be even more true because it is the original aortic valve that is used to replace the insufficient neoaortic valve. R E F E R E N C E S 1. Gittenberger-de Groot AC, Sauer U, Oppenheimer-Dekker A, Quaegebeur JM. Coronary arterial anatomy in transposition of the great arteries: a morphological study. Pediatr Cardiol 1983;4(suppl 1):15-24. 2. Klautz RIM, Ottenkamp J, Quaegebeur JM, Buis-Liem TN, Rohmer J. Anatomic correction for transposition of the great arteries: first follow-up (38 patients). Pediatr Cardiol 1989;10: 1-9. 3. Yamaguchi M, Hosokawa Y, Imai Y, Kurosawa H, Yasui H, Yagihari T, et al. Early and midterm results of the arterial switch operation for transposition of the great arteries in Japan. J Thorac Cardiovasc Surg 1990;100:261-9. 4. Ungerleider RM, Gaynor JW, Israel P, Kanter RJ, Armstrong BE. Report of neoaortic valve replacement in a ten-year-old girl after an arterial switch procedure for transposition. J Thorac Cardiovasc Surg 1992;104:213-5. 5. Serraf A, Roux D, Lacour-Gayet F, Touchot A, Bruniaux J, Sousa-Uva M, et al. Reoperation after arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;110:892-9.