Percutaneous Lymph Node Aspiration Biopsy and Tumor Grade in Staging of Prostatic Carcinoma

ONCOLOGY AND CI-IEMOT:dERi\PY

A lower midline abdominal incision is extended to the groin on the involved side. The ipsilateral rectus muscle and inguinal ligament are divided, exposing the femoral vessels. Ligation and division of the inferior epigastric vessels along with dissection underneath the incised inguinal ligament allow elevation of the lower abdominal walL With this approach, proximal control of the common iliac vessels and distal control of the femoral vessels are achieved easily. Exposure of the femoral and obturator nerves, and the internal iliac vessels is excellent. D. K. M. 10 figures, 4 references

Tumors of the Appendix M. WOLFF, Department of Surgical Pathology, Morristown Memorial Hospital, Morristown, New Jersey N. Y. State J. Med., 84: 291-292 (June) 1984 A patient who presented with acute appendicitis and a mass in the right lower quadrant had carcinoid and microglandular adenocarcinomas. Microglandular adenocarcinoma may escape detection, since the cells are pale on staining and are inconspicuous, especially if the appendix is inflamed acutely. Nonetheless, this tumor has true malignant capability. In this particular case microglandular carcinoma was shown not to be related to the carcinoid tumor. This finding is of more than academic interest in that carcinoid tumors metastasize only rarely, while microglandular carcinomas require a more radical operation owing to their malignant potential. G. W. K. 14 references

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the effects of radiation. At the conclusion of radiotherapy mitomycin C is added to the regimen. D. K. M. 1 figure, 7 tables, 22 references

A Unique Surgical Approach for Massive Retroperitoneal Tumors T. MOLT, M. SHAFIR AND A. H. AUFSES, JR., Department of Surgery, Mount Sinai Medical Center and the Mount Sinai School of Medicine (CUNY), New York, New York J. Surg. Oncol., 26: 168-171 (July) 1984 A 28-year-old man with von Recklinghausen's disease had a large left retroperitoneal malignant schwannoma. With the patient in the left lateral decubitus position an inverted U incision was made, which permitted elevation of the posterolateral and anterolateral abdominal walls. The incision was begun in the posterior midline at L5 and extended upward to Ll, and then was curved along the course of the 12th rib, which was resected subperiosteally. The incision then was continued anteriorly in an oblique fashion, much as a standard flank incision. The authors believe that this unique approach offers greater resectability for selected retroperitoneal tumors. D.K.M. 7 figures, 3 references

Detection of Metastatic Tumoir in Normal-Sized Retroperitoneal Lymph Nodes Monoclonal-Antibody Imaging

P. J. Treatment of Advanced Invasive Cervical Cancer: Changing Times and T:rends M. YOONESSI, Department of Gynecology-Obstetrics, School of Medicine, State University of New York at Buffalo, Buffalo, New York

J. Surg. Oncol., 26: 161-167 (July) 1984 A retrospective review was done on 140 patients with advanced (stage HB or more) invasive cervical carcinoma treated from 1962 through 1982. Results achieved in 96 patients treated early who did not undergo surgical staging were compared to those of patients treated later who underwent transperitoneal or extraperitoneal (18) surgical staging. Treatment consisted of external radiation followed by intracavitary radiation and by systemic cwcmuc,1t1 in some patients. In patients who did not have surgical staging the 5-year survival rates were 56 per cent for those with stage HB, 37 per cent with stage III and 16 per cent with stage IV disease. Transperitoneal surgical staging in a later group revealed that many patients had a greater extent of disease than was judged by clinical staging. However, transperitoneal surgical staging before treatment did not increase survival, and there was in creased morbidity and mortality with this approach. The extraperitoneal approach allowed accurate pre-treatment staging and reduced markedly the incidence of gastrointestinal radiation complications. The author currently recommends laparoscopy to detect gross extrapelvic visceral metastases. Saline peritoneal washing is done to detect malignant cells at the time of this examination. If visceral metastases are absent retroperitoneal lymphadenectomy and para-aortic node sampling are performed. After staging, radiation therapy is given along with chemotherapy (hydroxyurea, vincristine and bleomycin) designed to

MOLDOFSKY, H. F. SEARS, C. B. MULHERN, JR., N. D. HAMMOND, J. POWE, R. A. GATENBY, Z. STEPLEWSKI AND H. KOPROWSKI, Fox Chase Cancer Center and Winstar In-

stitute, Philadelphia, Pennsylvania

New Engl. J. Med., 311: 106-107 (July 12) 1984 Computerized tomography (CT), bone and liver/spleen scans, and chest x-ray in a patient with adenocarcinoma of the colon demonstrated metastatic disease confined to the liver. An immunoglobulin G2a monoclonal antibody with specificity for noncirculating human colorectal carcinoma cell surface antigen was treated by pepsin cleavage to produce F(ab') 2 fragments. Then, 96.2 MBq. 131iodine-labeled F9(ab')z fragments were injected intravenously, and scintigraphic images of the abdomen were obtained at 48 and 144 hours after injection. At 144 hours there vvas an accumulation of activity near the midline at the level of the left renal hilus. This area was normal on the CT scan. At laparotomy the nodes in this area were normal in appearance but were removed for study. Histological examination demonstrated foci of adenocarcinoma confirmed to be colonic in origin immunoperoxidase staining for 108317- lA colorectal carcinoma antigen. This case demonstrates the ability of monoclonal imaging techniques to identify metastatic deposits that are normal by all other parameters, including visual inspection. G. F. S. 1 figure, 12 references

Percutaneous Lymph Node Aspiration Biopsy and Tumor G:rade in Staging of Prostatic Carcinoma F. PISCIOLI, E. LEONARDI, A. REICH AND L. LUCIANI, Institute of Anatomic Pathology, Division of Urology, and S. Chiara Hospital, Trento, Italy Prostate, 5: 459-468, 1984

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PREOPERATIVE AND POSTOPERATIVE THERAPY

The authors compared percutaneous fine needle aspiration biopsy of pelvic lymph nodes to pelvic lymphadenectomy in 31 patients with biopsy proved, previously untreated, clinically localized prostatic carcinoma. The lymph nodes were visualized by pedal lymphography and aspirations were performed with fluoroscopic guidance via a long beveled, side-holed, modified Chiba needle. A maximum of 3 aspirations per nodal chain was made routinely to provide sufficient material. A total of 107 nodes was biopsied in 31 patients. Aspiration results were positive in 25 nodes and negative in 82. Of the patients with negative aspirations 10 per cent had histologically demonstrable small metastases on excision of the nodes. There were no false positive biopsies. The over-all accuracy of fine needle aspiration biopsy was 89.7 per cent, sensitivity was 72.4 per cent and specificity was 100 per cent. Fine needle aspiration biopsy established the presence of metastatic disease in 45 per cent of the patients, compared to 51.6 per cent for pelvic lymphadenectomy. External iliac metastases were most common. The authors believe that the combination of pelvic lymph node fine needle aspiration biopsy and Gleason grading permits the limitation of lymphadenectomy to a select group of patients. If aspirations are positive lymphadenectomy is unnecessary. If the Gleason grade is less than 5 and the aspirations are negative, the disease may be considered localized and patients in this category do not require further staging. In patients with a Gleason score of more than 7 pelvic lymph node dissection is necessary because aspiration does not exclude the possibility of metastases. In patients with Gleason scores of 5 to 7 negative cytology findings can be accepted as definitive. G. W. K. 8 figures, 1 table, 33 references

The Differential Diagnosis of Routinely Processed Anaplastic Tumors Using Monoclonal Antibodies K. C. GATTER, C. ALCOCK, A. HERYET, K. A. PULFORD, E. HEYDERMAN, J. TAYLOR-PAPADIMITRIOU, H. STEIN AND D. Y. MASON, Nu/field Department of Pathology, John Radcliffe Hospital, Department of Radiotherapy and Oncology, Churchill Hospital, Oxford, Department of Histopathology, St. Thomas' Hospital, London, and ICRF Laboratories, Lincoln's Inn Fields, London, United Kingdom

Amer. J. Clin. Path., 82: 33-43 (July) 1984 Anaplastic tumors present a problem of differential diagnosis, since subsequent treatment is different for lymphoma compared to carcinoma. The authors studied 38 unselected anaplastic tumors with monoclonal antibody immunohistological labeling. In 30 cases reactivity with monoclonal antibodies against the leukocyte common antigen led to the diagnosis of lymphoma, while in 7 reactivity with antibodies against epithelial constituents was diagnostic for carcinoma. The biopsy was unreactive with all antibodies in only 1 case. These techniques can be applied to routinely fixed and paraffin-embedded biopsies, and frequently will yield a definitive diagnosis that may alter the treatment of individual patients significantly. D. K. M. 5 figures, 2 tables, 21 references

ment of Pathology, Albert Einstein School of Medicine, New York, New York J. Surg. Oncol., 26: 183-186 (July) 1984 The apocrine nevus is a proliferation containing mature apocrine glands. To date only 3 or 4 cases have been reported. The authors report on a 32-year-old man with a neck nodule that proved to be an apocrine nevus containing mature and immature apocrine structures. Carcinoembryonic antigen staining was positive intracellularly in the smaller luminal structures. D. K. M. 4 figures, 10 references

Safety and Efficacy of Continuous Intravenous Morphine for Severe Cancer Pain M. L. CITRON, A. JOHNSON-EARLY, B. E. FOSSIECK, JR., S. H. KRASNOW, R. FRANKLIN, S. V. SPAGNOLO AND M. H. COHEN, Sections of Medical Oncology and Pulmonary Dis-

eases, Veterans Administration Medical Center, Washington, D. C. Amer. J. Med., 77: 199-204 (Aug.) 1984 Continuous intravenous morphine was administered to 13 consecutive patients with a histologically proved diagnosis of cancer and severe pain not relieved by conventional methods of narcotic administration. Respiratory rate, pulse, blood pressure, arterial blood gas values, pain intensity, pain relief and mental status were monitored at baseline and during the study interval. A dosage of 2 to 5 mg. morphine was given by bolus intravenous injections every 10 minutes until pain was relieved. Within the next hour continuous intravenous morphine was infused, with the hourly dose equal to the cumulative bolus dose. The majority of patients had major to complete relief of pain during treatment. Other patients with slight to moderate relief underwent palliative radiotherapy, nerve blocks and neurosurgical procedures. Pulse rates and systolic blood pressures did not change from the baseline values during treatment. There was a decrease in arterial oxygen pressure and/or an increase/ in arterial carbon dioxide pressure of more than 20 per cent of baseline values during the first 24 hours of infusion. Despite increases in morphine dose during infusion, blood gases tended to remain at or return toward baseline values. Respiratory rate tended to decrease during continuous morphine infusion without deterioration of mental status. Bradypnea with marked somnolence was a cause for dose reduction. There were 4 deaths (3 of cancer and 1 of sepsis). No patient died directly of morphine infusion. Continuous intravenous morphine is safe and effective in the treatment of severe cancer pain. F. T. A. 2 figures, 2 tables, 10 references

PREOPERATIVE AND POSTOPERATIVE THERAPY Ejaculatory Failure After Chemical Sympathectomy A.

The Polymorphic Apocrine Nevus: A Study of a Unique Tumor Including Carcinoembryonic Antigen Staining R. A. SCHWARTZ, R. ROJAS-CORONA AND W. C. LAMBERT, Department of Dermatology and Pathology, New Jersey Medical School (UMDNJ), Newark, New Jersey and the Depart-

D. BAXTER AND B. A. O'KAFO, Departments of Anesthesia and Surgery, Health Sciences Center, St. John's, Newfoundland, Canada

Anesth. Anal., 63: 770-771 (Aug.) 1984 A 32-year-old man with Buerger's disease who was a heavy smoker underwent bilateral lumbar sympathectomy with good