Stephen E. Hedberg

Preoperative irradiation for unresectable rectal and rectosigmoid carcinomas

The records of 25 patients with unresectable carcinoma of the rectum and rectosigmoid who received preoperative radiation therapy (RT) were reviewed. Twenty patients were considered to be resectable following RT (80%). Sixteen patients (64%) underwent curative resections. All patients with unresectable tumors following RT died with tumor within two and one half years (median survival, 11 months). For patients undergoing curative resection, the probability of two‐ and five‐year survival was 56% and 43%, respectively. In this latter group, five of seven patients with treatment failures (71%) had a pelvic component of disease. The incidence of pelvic recurrence was correlated with the pathologic stage, extent of resection and preoperative radiation dose. The need for more aggressive treatment for patients with these advanced tumors is emphasized. Future treatment alternatives are discussed.

Postoperative radiation therapy of rectal cancer

Beginning in December 1975, at the Massachusetts General Hospital (MGH) patients with rectal carcinomas thought to be at high risk of local recurrence after potentially curative surgical resection, were entered on a treatment protocol of high dose postoperative radiation therapy. Treatment was given with X rays of 10 MeV, generally using a four-field box technique to a dose of 4500 cGy with a boost to 5040 cGy or higher when the small bowel could be excluded from the reduced field. One-hundred sixty-five patients who began their radiation therapy between December 1975 and December 1982 were entered into the study. The median age was 65 years. The median follow-up in the survivors was 56 months, with a minimum follow-up of 17 months. All but 10 patients were followed for more than 2 years. Of the entire group, the actuarial 5-year survival was 53%, with survival of 71% in patients with Stage B-2, 39% in Stage C-2, and 17% in Stage C-3. Local failure was seen in 5/53 patients with Stage B-2 disease and 0/7 of patients with Stage B-3 disease. In patients with positive lymph nodes, local failure occurred in 2/10 (20%) of patients with Stage C-1, 16/77 (21%) of Stage C-2, and 8/15 (53%) of patients with Stage C-3 disease. Compared to previous series of surgery alone, the local failure rate has been decreased by more than one-half in all patients, except those with Stage C-3. Efforts to maximize the radiation doses in all stages should be made to minimize local failure. For Stage C-3, newer strategies such as intraoperative radiation therapy should be employed to decrease the continuing high incidence of failures.

Residual, unresectable or recurrent colorectal cancer: external beam irradiation and intraoperative electron beam boost ± resection

While combinations of external beam radiation (XRT) and surgery decrease pelvic recurrence and improve survival in the subgroups with residual disease (postop XRT) or initially unresectable disease (preop XRT), local recurrence is still unacceptably high, and survival could be improved. In view of this, pilot studies were instituted at Massachusetts General Hospital in which 32 patients received the standard previous treatment of external beam irradiation and surgery but in addition had an intraoperative electron beam boost of 1000-1500 rad to the remaining tumor or tumor bed. For the 16 patients who presented with unresectable primary lesions, the addition of intraoperative radiotherapy has resulted in a total absence of local recurrence with a minimum 20 month follow-up, and survival rates are statistically better than for the previous group treated with only external beam irradiation and surgical resection. In the group with residual disease, again there have not been any local recurrences in the 7 patients who received all treatment modalities versus 54% and 26% for the group with gross and microscopic residual treated with only external beam techniques. The remaining 9 patients presented with recurrent unresectable lesions--3 are alive (2 NED) at greater than or equal to 3 years.

Complications of intraoperative radiation therapy

The ability to demonstrate an improvement in therapeutic ratio is critical in assessing new treatment modalities; an evaluation of treatment complications is essential for this purpose. We have studied the severe complications occurring after treatment with intraoperative radiation therapy (IORT) in patients with locally advanced carcinoma of the rectum. Four groups of patients were compared: Group 1 (80 patients) had treatment with surgery alone for mobile and resectable tumors; Group 2 (23 patients) had treatment with high dose preoperative irradiation followed by surgical resection for tumors which were fixed to adjacent structures and initially unresectable for cure; Group 3 (24 patients, primary disease) and Group 4 (17 patients, locally recurrent disease) had locally advanced tumors as in Group 2 but were treated with IORT after preoperative irradiation and attempted surgical resection. All but 3 complications occurred within one year of therapy. Severe complications were seen in 16% of patients in Group 1, 35% in Group 2, 21% in Group 3 and 47% in Group 4 (32% in Groups 3 and 4 combined). There was a statistically insignificant increase (p = .10) in the complication rate in all irradiated patients (locally advanced tumors) compared to surgery alone (clinically mobile tumors). These data indicate no increase in severe complications with the use of IORT. If the ongoing studies continue to show improved local control with the use of IORT, expanded use of this modality may be warranted.

Angiodysplasia clinical presentation and colonoscopic diagnosis

: Angiodysplasia is a recently recognized important cause of lower intestinal bleeding in older patients. Although angiography is an established procedure for the diagnosis of angiodysplasia, colonoscopy is being used increasingly for evaluation of lower intestinal bleeding. In order to define the nature of bleeding due to angiodysplasia and the appropriate role of colonoscopy, 80 patients diagnosed by angiography, pathology, or colonoscopy were reviewed. Bleeding attributable to angiodysplasia varied from acute life-threatening hemorrhage to occult blood in stools. Thirteen patients with angiodysplasia had no bleeding and were identified incidentally by colonoscopy performed for other indications. Eighty-nine percent of the lesions were located in the right colon and there was a mean of 1.5 angiodysplastic lesions per patient. The sensitivity of colonoscopy compared to angiography and pathology was 68% overall and 81% when the colon was completely examined and lesions were located in the colon. The predictive value of a positive colonoscopic diagnosis was 90% in this population. Colonoscopy should be employed as an initial study in patients with chronic or mild acute rectal bleeding.Angiodysplasia is a recently recognized important cause of lower intestinal bleeding in older patients. Although angiography is an established procedure for the diagnosis of angiodysplasia, colonoscopy is being used increasingly for evaluation of lower intestinal bleeding. In order to define the nature of bleeding due to angiodysplasia and the appropriate role of colonoscopy, 80 patients diagnosed by angiography, pathology, or colonoscopy were reviewed. Bleeding attributable to angiodysplasia varied from acute life-threatening hemorrhage to occult blood in stools. Thirteen patients with angiodysplasia had no bleeding and were identified incidentally by colonoscopy performed for other indications. Eighty-nine percent of the lesions were located in the right colon and there was a mean of 1.5 angiodysplastic lesions per patient. The sensitivity of colonoscopy compared to angiography and pathology was 68% overall and 81% when the colon was completely examined and lesions were located in the colon. The predictive value of a positive colonoscopic diagnosis was 90% in this population. Colonoscopy should be employed as an initial study in patients with chronic or mild acute rectal bleeding.

Objective evaluation of ampullary stenosis with ultrasonography and pancreatic stimulation

Ultrasonography can detect changes in pancreatic and bile duct sizes after pancreatic stimulation by secretin or morphine and prostigmine. The effects of the two pharmacologic regimens on pancreatic duct dilatation were comparable and correlated with papillary stenosis determined at surgery, but the morphine and prostigmine combination produced more false-positive responses than did secretin. After administration of intravenous secretin (1 unit/kg), the pancreatic duct dilated in 83 percent of 12 symptomatic patients found at surgery to have a stenotic sphincter of Oddi and in 72 percent of 17 symptomatic patients found to have a stenotic accessory papilla associated with the pancreas divisum anomaly. Comparable dilatation occurred in 14 percent of 14 control subjects without suspected ampullary disease and in none of 10 patients with surgically disproved stenosis (p less than 0.001). The morphine and prostigmine combination produced more false-positive results in both the pancreatic duct and bile duct. Concomitant elevation of the serum amylase level and reproduction of pain were found to be of no discriminatory value. In patients whose pancreatic duct dilated preoperatively during secretin stimulation, dilatation did not occur after surgical sphincteroplasty. A positive test result was associated with a 90 percent success rate in preventing recurrent pancreatitis and ameliorating pain. A negative test result was associated with a 29 percent success rate. Ultrasonography of the pancreatic duct with secretin stimulation may provide objective criteria to supplement clinical judgment in selecting patients for sphincteroplasty to treat stenosis of either the sphincter of Oddi or the accessory papilla in pancreas divisum.

Injection sclerotherapy of esophageal varices using ethanolamine oleate

Fifty-three patients with upper gastrointestinal bleeding and proven esophageal varices were treated by intravascular injection sclerotherapy of the varices using a mixture of ethanolamine oleate, bovine thrombin and cephalothin. An intraesophageal balloon was used to impede craniad flow during the injection. Except in three patients who failed to stop bleeding from nonvariceal lesions, sclerotherapy was 94 percent successful in controlling bleeding. The mortality rate in sclerotherapy patients with ascites was 25 percent compared with 54 to 75% reported elsewhere. There has been no rebleeding from varices after the third treatment week in patients followed up for up to 14 months.

Experience with gastrointestinal stapling at the Massachusetts General Hospital.

The article describes the reintroduction of the use of stapling devices for intestinal suture at Massachusetts General Hospital in 1976, and reviews the results. Tabulated data of a large number of procedures performed are presented in detail and discussed.

ENDOSCOPIC DIAGNOSIS OF UPPER GASTROINTESTINAL HEMORRHAGE.

Records of 186 patients with upper gastrointestinal bleeding seen at Massachusetts General Hospital over a two year period were studied to determine the accuracy of diagnostic methods employed and to evaluate results of gastrointestinal endoscopy. Of 177 endoscopic diagnoses, 152 were correct, 11 falsely negative, and 14 incorrect. Of 191 x-ray diagnoses, 89 were correct, 34 falsely negative, and 68 incorrect. The combination of x-ray and endoscopy yielded correct preoperative diagnoses in 97 per cent of 86 patients operated on.Results obtained in this series indicate that endoscopy is a safe and accurate diagnostic method in upper gastrointestinal bleeding.

Endoscopy in gastrointestinal bleeding. A systematic approach to diagnosis.

The place of endoscopy in bleeding from the lower gastrointestinal tract has yet to be defined. The discussion concentrates on those methods that relate specifically to endoscopy, on the endoscopic techniques themselves, and on the system by which the proper timing and selection of endoscopic techniques can be made.