William H. Kern

The Role of Adjuvant Chemotherapy Following Cystectomy for Invasive Bladder Cancer: A Prospective Comparative Trial

We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional cell carcinoma of the bladder (with or without squamous or glandular differentiation) to adjuvant chemotherapy or to observation after radical cystectomy and pelvic lymph node dissection. For most patients chemotherapy was planned as 4 courses at 28-day intervals of 100 mg./M.2 cisplatin, 60 mg./M.2 doxorubicin and 600 mg./M.2 cyclophosphamide. A significant delay was shown in the time to progression (p = 0.0010) with 70% of the patients assigned to chemotherapy free of disease at 3 years compared to 46% in the observation group. Median survival time for patients in the chemotherapy group was 4.3 years compared to 2.4 years in the observation group (p = 0.0062). In addition to treatment groups, important prognostic factors included age, gender and lymph node status. The number of involved lymph nodes was the single most important variable. We recommend adjuvant chemotherapy for patients with invasive transitional cell carcinoma after definitive surgical resection.

Malignant fibrous histiocytoma of the lung

Two malignant fibrous histiocytomas arising primarily in the lung are described. The first was a large tumor of the right lower lobe in a 53‐year‐old man. The other tumor was found incidentally on routine roentgenograms in a 25‐year‐old woman and involved the left main pulmonary artery. The lesions could be resected but both patients developed early cerebral metastases. The neoplasms were predominantly fibroblastic, had a characteristic storiform pattern, and included large histiocytes with bizarre nuclei and a vacuolated cytoplasm. The ultrastructure of the cells in the fibroblastic areas was characterized by irregular nuclei and a cytoplasm with a well‐developed endoplasmic reticulum and dilated cisternae. Some cells lacked the prominent endoplasmic reticulum of fibroblasts and others were characteristic histiocytes with numerous cytoplasmic lysosomes. The cases appear to be the first reported primary malignant fibrous histiocytomas of the lung.

The grade and pathologic stage of bladder cancer

One hundred fourteen cases of bladder cancers treated during a 3‐year period by cystectomy were uniformly reclassified, graded, and pathologically staged. One hundred thirty‐one cases treated during the same period by transurethral or segmental resection were similarly reclassified and checked for muscle invasion. Sixty‐one percent of the cystectomy cases were nonpapillary and 69% of the conservatively treated cases were papillary transitional cell carcinomas. In the pathologically staged cystectomy group, all poorly differentiated (grade III and IV) carcinomas were invasive. Nonpapillary tumors were more aggressive and 79% of the high grade tumors in these categories extended into the outer portions of the muscularis or into perivesical tissues. Muscle invasion could also be demonstrated in 74% of the 23 high‐grade nonpapillary carcinomas in the conservatively treated cases. Lymph node and pelvic wall metastases were found in 17% of the cystectomies and were present only in tumor grades III and IV and a pathologic stage of P‐3B or higher. None of the well differentiated (grade I) papillary carcinomas were invasive and invasion was superficial in most moderately differentiated (grade II) papillary tumors. The findings confirm that pathologic classification and grading of bladder carcinomas correlate closely with the stage of the disease. Cancer 53:1185‐1189, 1984.

The clinical course and treatment results of patients with postresection locally recurrent lung cancer

Of 1018 patients with lung cancer seen in the division of radiation therapy between 1963 and 1976, forty‐six patients (4.5%) presented with postresection local recurrence and no documented distant metastasis. The median time to recurrence was thirteen months. Most patients had central recurrence with hilar or mediastinal lymph node metastasis, parenchymal consolidation, main stem nodule or bronchial stump tumor. There was a propensity for these tumors to remain limited to the site of origin. Death was most often from local/regional disease rather than distant metastasis. In this clinical setting the effectiveness of radiotherapy was observed in terms of palliation and improved survival. Strong determinants to survival were cell type, tumor dose and tumor response. The median survival was eleven months. Cancer 42:2478–2482, 1978.

well differentiated adenocarcinoma of the prostate

One hundred and one adenocarcinomas of the prostate that over a five‐year period had been classified as being “well differentiated” or “grade 1” were reviewed and reclassified. Thirty‐eight of the cases met strict criteria for such a classification. Twenty‐six patients died of prostatic carcinoma. Seventy‐five patients (74%) survived for five years, including 87% of the patients with clearly well differentiated carcinomas and 67% of those with somewhat less differentiated tumors. Forty‐six percent of all patients including 22 of the 38 well differentiated review cases (58%) are now alive 7–11 years after prostatectomy without evidence of residual disease. Grading appears to be useful and the prognosis of well differentiated carcinomas is better than average but some cases even if focal and incidentally found will terminate with disseminated disease, usually more than five years after the original diagnosis.

The pathology of surgically excised aortocoronary saphenous vein bypass grafts.

The pathologic features of 60 surgically excised failed aortocoronary saphenous vein bypass grafts from 40 patients were reviewed. In 23 cases the grafts were occluded by intimal fibrosis. In five this was associated with thrombotic occlusion of the remaining lumen. The histologic findings in some of these cases indicated that thrombosis preceded intimal fibrosis. Seventeen patients had graft failure caused by advanced arteriosclerosis. In 13 this was associated with thrombotic occlusion, often due to rupture of atheromatous plaques. The average duration of these grafts was 6–7 years compared to an average duration of 3 years for graft failure caused by occlusive intimal fibrosis, and 7 months for those associated with fibrosis and organizing thrombosis.Vein grafts in the arterial circulation are susceptible to atherosclerosis; this becomes a significant problem after approximately 5 years. The pathologic changes closely resemble coronary arteriosclerosis.

Pathology of bronchogenic carcinoma in long‐term survivors

The pathologic features of 94 cases of bronchogenic carcinoma in patients who survived for 5 years or longer after resection are reviewed. The incidence of squamous cell carcinoma is 56% and parallels that for the entire group of 358 resected cases. There were no survivors with oat cell carcinoma but bronchiolo‐alveolar cell carcinomas were found frequently and more than half of the tumors were located peripherally or in an intermediate zone. One of the long‐term survivors had a characteristic giant cell carcinoma which had metastasized to regional lymph nodes and appears to represent the first such case recorded in the literature. Metastasis to lymph nodes was recorded in 28% of the cases. All slides were examined on six occasions, leading to considerable discrepancy in the classifications. Problems arose especially in the definition of adenocarcinomas versus bronchiolo‐alveolar cell carcinomas but also in the classification of squamous cell and undifferen bated carcinomas.

Seminoma with elevated human chorionic gonadotropin: The case for retroperitoneal lymph node dissection

An elevated serum level of human chorionic gonadotropin (HCG) in a patient whose primary tumor histologically appears to be a pure seminoma implies the presence of syncytiotrophoblastic giant cells either detectable by careful step sectioning of the primary tumor or present in metastatic disease. Inasmuch as the malignant potential and radioresponsiveness of syncytiotrophoblastic giant cells are unknown and the serum elevation of HCG may signal metastatic embryonal carcinoma, retroperitoneal lymph node dissection with adjuvant chemotherapy dependent on pathologic staging should be considered for patients with seminoma and postorchiectomy elevated HCG levels. An illustrative case is herein reported.