William H. Knapper

Metastatic melanoma of unknown primary

A retrospective study of 166 patients with metastatic melanoma of unknown primary was performed. These were selected from 3805 cases of melanoma in Memorial Sloan‐Kettering Cancer Center from 1949 through 1975 (an incidence of 4.4%). There were 109 male and 57 female patients, 75 with Stage II disease and 91 with Stage III. The site of predominant involvement in Stage II patients was the axilla (47%). Five‐ and ten year survival rates of Stage II patients were 46% and 41%, respectively. The only factor that was shown to influence their survival was the delay (three months or more) of radical lymphadenectomy after initial histologic diagnosis. As expected, the prognosis of Stage III patients was very poor. Our study showed that patients with metastatic melanoma of unknown primary followed a similar clinical course as the Stages II and III patients with overt primary lesion. Stage II patients could expect a reasonable survival, the treatment of choice being prompt radical regional lymphadenectomy.

Embryonal rhabdomyosarcoma in adults

A series of 54 cases of embryonal rhabdomyosarcomas in adults were studied. The neoplasms were classified according to anatomic site, size, histologic pattern, age, and sex of the patients and modality of treatment. The major anatomic sites were the extremities (21 cases), genitourinary organs (13 cases) and the trunk (nine cases). The overall five‐year survival rate was 21% but 79% of the patients were dead at an average time of 17 months after the primary diagnosis was made. On the other hand, 80% of the patients with Stage II disease (tumor size < 5 cm) survived five years. In general, patients who were treated with surgery only or surgery and radiation or chemotherapy did much better than patients treated with chemotherapy and/or radiation therapy only. When the rate of recurrences, metastasis and time of death due to spread of neoplasm was compared in cases diagnosed between 1950‐1969 and 1970‐1978, patients in the last nine years had fewer recurrences, less metastases and better survival than those who had their neoplasm diagnosed and treated between 1950 and 1969.

Regional isolated limb perfusion of melanoma intransit metastases using mechlorethamine (nitrogen mustard).

Forty-two patients with intransit metastases of melanoma in a limb were treated by isolated regional perfusion chemotherapy using mechlorethamine (nitrogen mustard). Group 1 (n = 12) underwent treatment at low dose, less than 0.35 mg/kg, or low temperature, less than 38 degrees C. Group 2 (n = 30) received higher doses, 0.35 to 0.6 mg/kg, plus heat at 38 degrees C to 41 degrees C. No patient had evidence of disease outside the limb at the time of perfusion. The median follow-up time was 48 months (range, 1 to 9 years). Of the 42 patients, 29 had measurable lesions that responded as follows: group 1, complete response (CR) in two of ten and partial response (PR) in none; group 2, CR in six of 19 and PR in six of 19. The combined CR and PR rate of 12 of 19 in group 2 was significantly higher than that of group 1 (P less than .05). CR lasted only 2 months in the two patients of group 1, but persisted in the six patients of Group 2, four of whom are still alive free of disease at 16, 21, 33, and 40 months. Relapse-free control of disease in the limb was achieved in 36% of the patients in group 2 at 24 months, compared with 0% in group 1 (P less than .05). An overall survival of 74% at 48 months was observed in group 2, significantly higher than that of 64% for group 1 (P less than .05). The status of the regional lymph nodes (RLN) and the number of metastases did not affect tumor response. However, 77% of RLN-negative patients survived 48 months, in contrast to only 38% of RLN-positive patients (P less than .05). One patient died postoperatively of myocardial infarction. No serious systemic toxicity developed. Two patients who underwent repeat salvage perfusions developed a reversible peripheral neuropathy in the limb. Limb function was good after treatment, and dramatically improved in patients who had advanced satellitosis that responded to treatment. These results suggest that heated limb perfusion using mechlorethamine at an adequate dose can offer long-term control of intransit metastases in approximately one third of these patients, with preservation of good limb function and possible prolongation of survival.

Case report: Antemortem diagnosis of central nervous system strongyloidiasis.

Strongyloidiasis is usually a benign illness confined to the gastrointestinal tract. However, dissemination (hyperinfection syndrome) may occur, particularly in patients with impaired cell-mediated immunity. The diagnosis of hyperinfection syndrome is often made postmortem, and mortality is high, even when the disease is recognized during life. Central nervous system involvement with Strongyloides stercoralis has previously been recognized in only a few cases at postmortem examination, and in one case antemortem. We describe a patient with disseminated strongyloidiasis in whom central nervous system involvement was diagnosed antemortem. This patient developed multiple bacterial and fungal systemic and central nervous system infections as a complication of disseminated strongyloidiasis. The natural history of the disease in man, factors predisposing to dissemination, immunologic aspects of helminthic infection, and treatment modalities are discussed.

Pseudo-obstruction of the colon (Ogilvie's syndrome)

Pseudo-obstruction of the colon is an acute abdominal problem that can occur from a variety of causes and multiple organ failures. It is characterized by massive colonic dilatation and a clinical picture suggestive of mechanical large-intestinal obstruction, without any organic obstruction. Decompression should be cautiously attempted with proctoscopy and, possibly, colonoscopy; if these fail, then surgical decompression, usually by a cecostomy, is indicated.

Laparoscopic diagnosis of suspected liver neoplasms

To study the efficacy of standard blood tests of liver function (LFTs) and technetium-99m liver scan followed by laparoscopy in the diagnosis of solid malignant tumors of the liver, 100 consecutive patients were evaluated who had these tests because of clinical suspicion of liver neoplasm. Malignant liver tumors were present in 65 of the 100 patients. Laparoscopy diagnosed 60 of the 65, and the neoplasms were documented pathologically by directed biopsy (92% sensitivity, 100% specificity). In 8 patients, hepatoma was diagnosed and staged for possible resection. A negative “blind” biopsy had been performed in 23 of the 60 patients with liver neoplasms diagnosed at laparoscopy. LFTs and liver scans together were good screening tests (95% sensitivity) but had low specificity (46%). Liver scans also provided information as to probable tumor location in the liver, guiding the insertion site for the laparoscope, and directing deep-needle biopsies if no surface lesions were seen.