Months For Stage Research Articles

The International Staging System for Multiple Myeloma is Applicable in Symptomatic Waldenstrom's Macroglobulinemia

Several studies have indicated that age, hemoglobin and serum albumin are among the most important prognostic factors for survival of patients with Waldenstrom's macroglobulinemia (WM). Furthermore, recent data indicate that serum b2-microglobulin may be also significant. The recently proposed International Staging System (ISS) for multiple myeloma is based on serum albumin and b2-microglobulin. We designed a study to assess this model in patients with WM. Our analysis included 83 previously untreated patients with WM who required systemic treatment and in whom pretreatment values for both serum albumin and b2-microglobulin were available. Based on these variables the patients were stratified into three ISS stages. Stage I: albumin > or = 3.5 g/dl and b2-microglobulin < 3.5 mg/dl, stage II: albumin < 3.5 g/dl and b2-microglobulin < 3.5 mg/gl or b2-microglobulin 3.5-5.5 mg/dl and stage III: b2-microglobulin > 5.5 mg/dl. Low albumin (< 3.5 g/dl) and high b2-microglobulin (> or = 3.5 mg/dl) were recorded in 45% and 52% of patients respectively. The distribution of patients in the three ISS stages was: stage I: 30%, stage II: 43% and stage III: 27%. The median overall survival from the date of treatment initiation was 115 months. The median survival according to ISS was not reached for stage I, 116 months for stage II and 54 months for stage III (P = 0.02). Our analysis indicated that the recently proposed ISS for multiple myeloma could stratify the patients with WM into three distinct subgroups with significantly different survival times. If this model is validated in independent series, it could provide a new staging system for WM based on readily available and reproducible variables.

Serous carcinoma of the ovary, fallopian tube, or peritoneum presenting as lymphadenopathy.

The clinicopathologic features of 35 cases of serous carcinoma of the ovary, fallopian tube, or peritoneum presenting as lymphadenopathy are described. The cases were retrieved from the files of the Department of Pathology at the University of Texas M. D. Anderson Cancer Center from a 20-year period (1982-2002). The following parameters were evaluated: patient age at diagnosis, lymph node involved, primary tumor site, tumor histology, peritoneal disease status, and survival. The patients ranged in age from 30 to 85 years (mean, 59 years). The lymph nodes involved were inguinal, 20 cases; supraclavicular, 11 cases; axillary, 2 cases; cervical, 1 case; and retroperitoneal, 1 case. Primary tumor sites included 20 ovarian, 10 peritoneal, and 2 fallopian tube. In 2 patients, total abdominal hysterectomy/bilateral salpingo-oophorectomy and complete staging showed no additional tumor, and in 1 patient with a previous history of total abdominal hysterectomy/bilateral salpingo-oophorectomy for a benign condition, imaging studies did not identify a primary site. The carcinoma was high grade in 30 cases and low grade in 4 cases. In one case, the diagnosis was made on cytology material and the tumor could not be graded. Peritoneal disease status was known in 33 patients and was as follows: omentum with gross disease, 16 cases; and omentum without gross disease, 17 cases. Follow-up was available in 33 patients and ranged from 4 to 204 months, with a median survival of 36 months for stage III patients and 29 months for stage IV patients. Patients with adenopathy and minimal peritoneal disease (grossly negative omentum) had a median survival of 120 months compared with 24 months for those with bulky peritoneal disease (grossly positive omentum). Serous carcinoma of the ovary, fallopian tube, or peritoneum presenting as a lymph node metastasis is uncommon. In rare cases, a primary site may not be found. The median survival of the patients for stage is not appreciably different from those patients presenting in the usual fashion, suggesting that this atypical presentation does not adversely affect survival. Patients with minimal peritoneal disease and extra-abdominal lymph node metastases survive longer than those with bulky peritoneal disease

Multidisciplinary Approach to Wilms' Tumor: 10 Years Experience of NCI, Egypt

8544 Background: This is a retrospective study of 140 nephroblastoma patients newly diagnosed and treated at the National Cancer Institute between January 1991 and December 2000. The aim was to report results of combined modality treatment and to investigate the impact of biopsy, presence of blastema and preoperative chemotherapy on outcome Methods: Chemotherapy consisted of Vincristine 1.5mg/m2 and Actinomycin-D 45μg/kg for stage I and stage II favorable. Doxorubicin 40mg/m2 was added in alternation with Actinomycin-D to stage II unfavorable and stages III-V. Duration of therapy was 6 months for stage I and stage II favorable, 12 months for stages II unfavorable, III-V favorable and 18 months for stages III-V unfavorable. Rhabdoid tumors were given Etoposide 150mg/m2×3days and Carboplatin 500mg/m2 day1 alternating with Ifosfamide 1800mg/m2×5days and Doxorubicin 75mg/m2 day1. Postoperative radiotherapy was given to tumor-bed (10–27Gy) in stage II unfavorable, stages III-V and to metastatic lung site (12Gy). Preoperative chemotherapy was employed in massive or bilateral tumors or presence of metastases Results: Using NWTS staging system 21.4%, 36.4%, 20.7%, 15.7% and 5.7% were stages I-V respectively. Histology was favorable (FH) in 93 (67%) patients [31/93 showed blastema] and unfavorable (UH) in 46 (33%). Preoperative chemotherapy resulted in down staging of 30/54 (55.6%) patients to stages I and II, of which only 4 relapsed. Local recurrence was reported in 4/32 patients (12.5%) with core biopsy, 0/15 fine needle biopsy and 10/93 (10.75%) without biopsy. With median follow up of 63 months, overall 5-year survival and disease free survival (DFS) were 72.3±4% and 69±3.9% respectively. For FH, 5-year DFS was 78.2±4.3% [stages I-V being 92%, 74.3%, 74%, 60%, 80%] and 51.4±7.9% for UH (p= .0007, log rank test) [stages I-V being 75%, 72.7%, 63.6%, 8.3%, 33.3%] Within FH, 5-year DFS was 76.6% for blastema versus 83.3% for non blastema (p= .46, log rank) Conclusions: This study suggests that biopsy and down staging after preoperative chemotherapy did not lead to increased risk of recurrence. Presence of blastema had adverse impact on outcome; however it needs to be studied on larger scale No significant financial relationships to disclose.

Multidisciplinary Approach to Wilms' Tumor: 10 Years Experience of NCI, Egypt

8544 Background: This is a retrospective study of 140 nephroblastoma patients newly diagnosed and treated at the National Cancer Institute between January 1991 and December 2000. The aim was to report results of combined modality treatment and to investigate the impact of biopsy, presence of blastema and preoperative chemotherapy on outcome Methods: Chemotherapy consisted of Vincristine 1.5mg/m2 and Actinomycin-D 45μg/kg for stage I and stage II favorable. Doxorubicin 40mg/m2 was added in alternation with Actinomycin-D to stage II unfavorable and stages III-V. Duration of therapy was 6 months for stage I and stage II favorable, 12 months for stages II unfavorable, III-V favorable and 18 months for stages III-V unfavorable. Rhabdoid tumors were given Etoposide 150mg/m2×3days and Carboplatin 500mg/m2 day1 alternating with Ifosfamide 1800mg/m2×5days and Doxorubicin 75mg/m2 day1. Postoperative radiotherapy was given to tumor-bed (10–27Gy) in stage II unfavorable, stages III-V and to metastatic lung site (12Gy...

The costs of managing patients with stage 3 and 4 colorectal cancer and the influence of patient factors at presentation

3656 Background: The costs of managing stage 3 and 4 colorectal cancer patients were determined and correlated with baseline patient characteristics. Methods: All patients presenting with stage 3 or 4 colorectal cancer at our institution between January 1986 and December 1993 were identified. Patients without pathologic confirmation or treated elsewhere for colorectal cancer were excluded. Ten patients were randomly selected from each of six categories based on disease site and stage, and resource utilization, clinical and demographic data were abstracted for each patient from hospital records. Unit costs obtained from a simultaneous fully allocated costing model and provincial billing data were attached to each resource. Average costs were determined, and univariate and multivariate regression analyses performed to estimate the influence on costs of baseline demographic and clinical variables. Results: Of 573 patients identified, 340 had colon cancer, 111 rectosigmoid cancer, and 122 rectal cancer. Of the 60 patients in the sample, 54% were men, and mean ages at presentation were 67.9 years for men and 69.9 years for women. Overall survival was 39 months for stage 3 and 11 months for stage 4 patients. Patient management in each category was described. Mean total costs per patient in each category varied from $13,075 (Canadian) to $21,853. Most costs were incurred during the first (71.3%) and second (21.1%) years following presentation. The ten most important cost categories were: number of admission days, surgical and operating room charges, clinic visits, medical imaging, inpatient physician charges, radiotherapy, laboratory tests, intensive care, medical specialist consultations, and surgical procedures. A multivariate regression model predicting total costs based on gender, disease site, stage at presentation, age, and comorbidity explained 33% of the variation in costs between patients. Conclusions: The cost components for stage 3 and 4 colorectal cancer were identified, and a multivariate regression model showed that baseline patient characteristics could explain one-third of the variation in health care costs. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Pharmacia Hoffmann-La Roche

Synchronous primary cancers of the endometrium and ovary: a single institution review of 84 cases

Objectives. Synchronous primary cancers of the endometrium and ovary are found in 10% of women with ovarian cancer and 5% of women with endometrial cancer. The purpose of this study was to characterize patients diagnosed with synchronous primary cancers of the endometrium and ovary with an emphasis on risk factors. Methods. Between 1989 and 2002, 84 patients with synchronous primary cancers of the endometrium and ovary were identified. Patients with uterine papillary serous carcinoma were excluded. Clinical and pathologic information was obtained from medical records. Parametric methods were used to compare clinical and pathologic features. Kaplan–Meier survival analyses were performed and compared using the log rank test. Results. Median age at diagnosis was 50 years. Median body mass index (BMI) was 28 kg/m 2. Fifty-one percent (43/84) of the women were premenopausal and 33% (28/84) were nulliparous. The most common presenting symptom was abnormal vaginal bleeding; in those women with abnormal vaginal bleeding, 69% had stage I ovarian cancer. Ovarian cancer was an incidental finding in 48% of these patients. Sixty-eight percent of patients (57/84) had endometrioid histology of both their endometrial and ovarian cancers. Patients with early stage ovarian cancer tended to have a more favorable prognosis than those with advanced stage disease (median survival not reached in stage I and II versus 66 months in stage III and IV, P = 0.06). Patients with concordant endometrioid histology had a favorable prognosis (median survival 119 versus 48 months in all other groups, P = 0.02). Conclusions. In this large series of patients, women with synchronous primary cancers of the endometrium and ovary were young, obese, nulliparous, and premenopausal. Patients with concordant endometrioid tumors of the endometrium and ovary had a favorable prognosis, with median survival approaching 10 years.

Laparoscopic resections for colorectal cancer: Does conversion survival?

This purpose of this study was to examine whether survival is affected when laparoscopic resections for colorectal cancer are converted to open surgery. A prospective database of 377 consecutive laparoscopic resections for colorectal cancer performed between November 1991 and June 2002 was reviewed. The TNM classification for colorectal cancer and the Kaplan-Meier method were used to determine survival curves for each group. Conversion to an open procedure was required in 46 cases (12.8%). Converted and laparoscopic groups were similar in age, sex, comorbidities, and location and size of tumor. The converted group had a significantly higher weight (75 kg vs 69 kg, p = 0.013) and conversion score (2.18 vs. 1.87, p = 0.005). Patients with stage IV disease were significantly more likely to be converted than those with stage I-III disease (23.0% vs 11.2%, p = 0.04). There was no difference in the conversion rate between patients with stage I (14%), II (8%), or III (13%) colorectal cancers. Median follow-up was 30.5 months for stage I-III and 10.8 months for stage IV cancers. There were 190 patients followed at least 2 years and 73 patients followed at least 5 years. Survival curves demonstrate significantly lower 2-year survival after converted procedures as compared to laparoscopic (75.7% vs 87.2%, p = 0.02), with a trend toward lower 5-year survival (61.9% vs 69.7%, p = 0.077). Survival rates at 2 and 5 years are lower for patients in the converted group compared to patients with LR. This finding could have serious impact on the treatment of patients with colorectal cancer. Further confirmation is required.

Indications et modalités de la chimiothérapie adjuvante des cancers du côlon

Within the past 12 years, many progresses have been performed in adjuvant chemotherapy of colon cancer. 5FU + levamisole was first considered as standard treatment in the early 1990s, then FUFOL and later LV5FU2. More recently, FOLFOX4 achieves a better disease-free survival at 3 years as compared to LV5FU2, and should now be considered as a standard treatment. Adjuvant chemotherapy is recommended for 6 months for stage III patients. It is an option for stage II patients. Elderly patients could be treated according to the same modalities as younger patients, based on physiological age and relative contra-indications from associated diseases.

Clinicopathological features and management of gallbladder cancer in Pakistan: a prospective study of 233 cases.

Gallbladder cancer is common in Pakistan and has an extremely poor prognosis. Treatment is primarily surgical. Chemotherapy is frequently used in patients with advanced disease. This study was performed to evaluate and compare the clinicopathological features and management of gallbladder cancer in Pakistani patients, with particular emphasis on factors that influence survival. Two hundred and thirty-three patients with histologically proven gallbladder cancer were studied. Information was prospectively collected on demographic features, clinical and laboratory findings at the time of presentation, influence of therapy, and survival. Data were analyzed to evaluate variables that influenced survival. Kaplan-Meier analysis was used to calculate survival. Most patients were women (77%). Mean age was 55 years (+/-11 years). Fourteen per cent of females were nulliparous. Twenty-six per cent had five or more children. Only 4% of patients had a documented history of typhoid fever. The majority (69%) had a history of symptomatic gallbladder disease. The commonest presenting symptom was pain (89%), followed by nausea and vomiting (52%), weight loss (42%), and jaundice (33%). One-quarter of patients had a palpable abdominal mass. Most had abnormal hepatic function tests and 58% had elevated carcinoma embryonic antigen levels. Stage (P < 0.001), jaundice (P = 0.01) and palpable mass (P = 0.02) were statistically significant variables. However, on multivariate analysis, tumor node metastases (TNM) stage was the only factor influencing survival. Median survival of the patients was 44 months for patients with stage I disease, 23 months for stage II, 17 months for stage III and 6 months for stage IV. These data are comparable with those reported from other developing countries. Most patients presented at an advanced stage of disease and had an extremely poor prognosis. Systemic therapy did not provide any survival benefit. The TNM stage remains the most important factor influencing survival.

A population-based study of tumor-node relationship, resection margins, and surgeon volume on gastric cancer survival

Background Gastric cancer surgery literature is conflicting. Two European level I randomized controlled trials refute Asian lesser level evidence promoting more radical resections. Population-based study evidence is undefined. Methods Using this study design we examined the overall survival, the tumor-node relationship, margins, and surgeon volume on gastric cancer survival in a Canadian province. Results Between 1991 and 1997, 577 (71 ± 13 years 60% male) gastric adenocarcinomas were diagnosed in Northern Alberta (population 1.7 million). Respectively, median survival in months for stage I (n = 67) was 77, stage II (n = 55) 75, stage III (n = 155) 12, stage IV (n = 235) 3, and 65 unstaged (n = 65) 4. Five-year survival for T1N0 (n = 28) was 68% versus T1N1 (n = 7) 71% ( P = 0.80); for T2N0 (n = 29) 58% versus T2N1 (n = 19) 58% versus T2N3 (n = 7) 29% ( P = 0.08); for T3N0 (n = 33) 57%, versus T3N1 (n = 98) 9% versus T3N2 (n = 47) 0% versus T3N3 (n = 8) 0% ( P < 0.0001). Median gastrectomy survival (months) in stage III was 15 months margin negative versus 8 months margin positive versus 6 bypass and 5 for no surgery ( P = 0.0004). In stage IV it was margin positive 8 versus margin negative 6 (nonsignificant), bypass 3 versus no surgery 2. Five-year survival for surgeons doing fewer than 20 gastrectomies (n = 196 patients) was 29% (median 1.4 years) versus 35% (median 2.3 years; n = 72 patients) for surgeons doing 20 or more (n = 4; P = 0.325). Conclusions From these population data we conclude that (1) few patients present with “curable” gastric cancer, (2) node negative or small gastric cancer survival is not influenced by nodal stage, (3) positive margin resection survival is better than bypass or no surgery in stage IV but not stage III disease, and (4) surgeon volume does not appear to influence patient survival.

Predictors of hepatic steatosis in living liver donors

780) for compensated cirrhosis308.8&145.2 (84-660) for decompensated cirrhosis, 238.4&125.3 (48-480) for HCC and 221.6&133.9 (17-550) for ALT normal CH. Analysis of CH patients revealed different durations of development of CH as 200.0&129.5 (11-504) months in stage 1 and 311.9&145.7 (48-780) in stage 4. The difference in duration of HCV infection between stage 1 and 4 was statistically different (p<O.OOl). The mean time to develop CH and cirrhosis in this HCV genotype lb dominant population is 16 years and 26 years respectively. The development of stage 4 CH takes 25 years while this duration for stage 1 disease is 15 years. The results have confirmed previous knowledge about duration of HCV infection to develop CH and cirrhosis.

Outcomes and patterns of failure in bronchial carcinoid tumors

Purpose : To clarify the natural history, prognosis, and treatment failure patterns for bronchial carcinoid tumors according to their clinical and histopathologic features. Methods : The charts of 241 patients from our institution with bronchial carcinoid tumors were reviewed. Thirty-four patients had no follow-up, yielding a study population of 206. Of the 206 patients, 62 had atypical carcinoid (AC) and 144 had typical carcinoid (TC) tumors. Results : The 5-, 10-, and 20-year disease-specific survival rates were lower in patients with AC (60.1%, 36.8%, and 28.1%, respectively) than in those with TC (79.0%, 62.9%, and 38.8%, respectively; p = 0.0002). Predictors of poor outcome included more advanced stage ( p <0.00001), male gender ( p = 0.019), symptoms at presentation ( p = 0.013), and age ≥60 years ( p = 0.02). Stage I AC was associated with a median disease-free survival of 96 months compared with 222 months for Stage I TC ( p = 0.0002) and had an actuarial 22% locoregional failure rate 5 years after surgery compared with 6% for Stage I TC ( p = 0.022). The disease-free survival for Stage II and III AC was worse than that for Stage II or III TC, but the difference did not reach statistical significance ( p = 0.15). Locoregional failure was also prominent in Stage II and III AC. Second malignancies were common in patients with bronchial carcinoids (56 of 206 patients). Conclusion : Stage-for-stage, the outcome is worse for patients with AC than for those with TC. Locoregional failure is common after curative resection, even for early-stage AC. Second cancers are common in patients with carcinoid tumors.

Elevated mia serum levels are predictors of poor prognosis after surgical resection of metastatic malignant melanoma

The secreted MIA protein is upregulated in melanocytic tumors and expression parallels the progressive malignancy of melanoma cells. Recent reports suggest MIA as a diagnostic tumor marker that may also serve as an indicator of tumor progression. In this study we evaluated the association between pre- and post-treatment serum levels of MIA and survival in 70 patients with advanced melanoma. Elevated (> or = 8.8 ng/ml) pre-treatment levels of MIA predicted a poor prognosis in these patients. Overall median survival in stages III and IV was 13 months in MIA positive patients, compared to 28 months in patients with negative pre-treatment MIA levels. The staging-related analysis showed a median survival of 14 months in MIA positive patients, versus 28 months in MIA negative patients in stage III, and 12, versus 19, months in stage IV melanoma, respectively. In addition, there was a trend towards a poorer survival in patients where MIA serum levels remained high after surgery. Therefore, determination of pre- and post-treatment serum MIA levels could be useful for the management and prognosis of metastatic melanoma patients.

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Pancreatic cancer has a poor response to conventional chemotherapy and radiotherapy. Inhibition of matrix metalloproteinase activity involved in tumour invasion and metastases is a novel biological approach for cancer treatment. This multicentre phase II clinical trial assessed marimastat, an oral matrix metalloproteinase inhibitor, in patients with advanced pancreatic cancer. A total of 113 patients received marimastat for 28 days at 100 mg b.d. (n = 9), 25 mg o.d. (n = 90) or 10 mg b.d. (n = 14). Patients with a response to treatment could continue marimastat beyond 28 days. Of 113 patients, 90 (80%) completed the 28-day study and 83 (73%) continued treatment. The principal side effect was arthralgia in 14 (12%) patients at 28 days and 33 (29%) patients over the whole study. There were 31 patients (27%) who required dose modification. Of 76 patients with evaluable CA19-9 levels, 23 (30%) showed no increase or fall in CA19-9. Of 83 patients with radiologically assessable disease, 41 (49%) had stable disease. The median survival was 245 days for those with a stable or falling CA19-9 level 128 days in those with rising CA19-9. The overall survival was 3.8 months. 5.9 months for stage II, 4.7 months for stage III and 3 months for stage IV disease. Of 90 patients, 46 (51%) had stabilization or reduction in pain, mobility and analgesia scores. Further development and clinical evaluation of matrix metalloproteinase inhibitors for the treatment of pancreatic cancer is warranted. © 2001 Cancer Research Campaign http://www.bjcancer.com

A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma

Background: Surgical resection of malignant pleural mesothelioma is reported to have up to an 80% rate of local recurrence. We performed a phase II trial of high-dose hemithoracic radiation after complete resection to determine feasibility and to estimate rates of local recurrence and survival. Methods: Patients were eligible if they had a resectable tumor, as determined by computed tomographic scanning, and adequate cardiopulmonary function for extrapleural pneumonectomy or pleurectomy/decortication. After complete resection, patients received hemithoracic radiation (54 Gy) and then were followed up with serial computed tomographic scanning. Results: From 1995 to 1998, 88 patients (73 men and 15 women; median age, 62.5 years) were entered into the study. The operations performed included 62 extrapleural pneumonectomies (70%) and 5 pleurectomies/decortications; procedures for exploration only were performed in 21 patients. Seven (7.9%) patients died postoperatively. Adjuvant radiation administered to 57 patients (54 undergoing extrapleural pneumonectomy and 3 undergoing pleurectomy/decortication) at a median dose of 54 Gy was well tolerated (grade 0-2 fatigue, esophagitis), except for one late esophageal fistula. The median survival was 33.8 months for stage I and II tumors but only 10 months for stage III and IV tumors (P =.04). For the patients undergoing extrapleural pneumonectomy, the sites of recurrence were locoregional in 2, locoregional and distant in 5, and distant only in 30. Conclusion: Hemithoracic radiation after complete surgical resection at a dose not previously reported is feasible. This approach dramatically reduces local recurrence and is associated with prolonged survival for early-stage tumors. Stage III disease has a high risk of early distant relapse and should be considered for trials of systemic therapy added to this regimen of resection and radiation.

A single center experience with extrahepatic cholangiocarcinomas

Background. Few large Western series on cholangiocarcinoma have been reported in the literature. We reviewed 40 consecutive cases of extrahepatic cholangiocarcinomas referred to a single center. Methods. From 1992 until 2000, 40 patients with extrahepatic cholangiocarcinomas were evaluated. The charts of all patients were reviewed to evaluate predictors of survival. Survival was calculated with the Kaplan-Meier method. Results. Forty patients were referred for management of extrahepatic cholangiocarcinomas. Tumors were located in the distal common duct in 3 (7.5%), mid duct in 5 (12.5%), and at the bifurcation in 32 (80%). Surgical resection was attempted in 32 (80%) patients and was curative in 9 (22.5%), palliative in 11 (27.5%), and diagnostic in 12 (30%). Mean survival for all patients was 21.1 ± 5.1 months and on the basis of tumor stage was 71.4 ± 15.4, 39.7 ± 10.6, 19.2 ± 2.9, 3.9 ± 1.8, and 6.9 ± 1.3 months for stages I, II, III, IVA, and IVB, respectively. Mean survival was 51.1 ± 13.5 months versus 10 ± 1.8 months in those with curative and noncurative resections, respectively. The presence of a portal mass was associated with a reduction in mean survival from 28.4 ± 7.2 months to 6.0 ± 1.9 months. Conclusions. Extrahepatic cholangiocarcinoma remains a dismal disease with only a 22.5% chance of a curative surgical resection, achieving a 5-year survival rate of 44.4%. Only the absence of a portal mass was predictive of a possible curative resection and long-term survival. (Surgery 2001;130:584-92.)

Non-Hodgkin’s lymphoma of the testis: A retrospective study of 84 patients treated in the French anticancer centres

Primary non-Hodgkin's lymphoma of the testicle is rare. We analysed cases treated in French anticancer centres from 1969 to 1995. All cases were reviewed and classified according to the R.E.A.L. Classification. Eighty-four cases were included in this study. The median age was 67 years (17-85). Disease was classified as stages I in 42 cases, stages II in 19 and stages III-IV in 23. Diffuse large B-cell lymphoma was diagnosed in 75% of cases. Treatment included orchidectomy and radiotherapy and/or chemotherapy. A complete response was obtained in 72.6% of the patient population and in 100%, 68% and 33% of stage I, II and III-IV disease respectively. Recurrence occurred in 32 cases and the most frequent site was the central nervous system: six of these patients presented stage I disease. Median overall survival was 32 months for the entire population, 52 months for stage I, 32 months for stage II, and 12 months for stage III-IV cases (P < 0.0001). Among patients presenting stage I disease, no difference was found between those treated with combined surgery and chemotherapy or surgery followed or not followed by radiotherapy. This study confirms that non-Hodgkin's lymphoma of the testicle carries a poor prognosis. Systemic adjuvant chemotherapy should be discussed because of the high recurrence rate. Inclusion of these cases in large co-operative prospective studies is recommended.

Laparoscopic retroperitoneal lymph node dissection.

Retroperitoneal lymph node dissection is the most sensitive and specific diagnostic modality for detecting occult lymph node metastases in clinical stage I testicular tumor. In stage II disease, residual tumors after chemotherapy have to be removed surgically. To reduce the morbidity of these procedures we have replaced open surgery by laparoscopy. Between August 1992 and December 1999 125 patients underwent laparoscopic RPLND (stage I: 76 pts., stage II: 49 pts.) Laparoscopic RPLND could be completed as planned in all but two patients in whom bleeding required conversion to open surgery. Once the learning curve had been overcome, mean operative time decreased significantly from 476 to 219 min for stage I and averaged 226 min in stage IIB disease. Only minor postoperative complications occurred such as asymptomatic lymphoceles (7 pts.) and chylous ascites (6 pts.). Mean post-op hospital stay was 3.3 and 3.5 days, respectively (stages I and II). Mean followup is currently 46 months for stage I and 35 months for stage II tumors. Over this period a single retroperitoneal recurrence was observed (stage I), which, however, was not due to surgical failure, but to false negative histologic findings. All other patients have remained free of relapse. Laparoscopic RPLND is a demanding procedure with a long and steep learning curve. It has proved feasible also after chemotherapy. The diagnostic accuracy of laparoscopic RPLND was as good as that of the open procedure, while the morbidity is significantly lower. Tumor control was not compromised by the laparoscopic approach.

Multimodality treatment of Merkel cell carcinoma: case series and literature review of 1024 cases.

Merkel cell carcinoma (MCC) is an unusual and potentially aggressive cancer of the skin. There is no consensus regarding the optimal therapeutic approach, and the relative roles of surgery, radiotherapy, and chemotherapy still are controversial The aim of this study is to analyze the roles of these therapeutic options. The medical records of 16 patients with a diagnosis of localized, primary MCC treated at the University of Alabama at Birmingham were reviewed. An extensive review of the English-language literature also was performed. The Kaplan-Meier method was used to develop the survival curves. Comparisons were made using Fisher's exact test. Significance was defined as P < .05. MCC presented primarily in Caucasians (98.3%) with a median age of 69 years. Immunosuppressive therapy appeared to play a role in the development of this cancer. In the UAB experience, 3-year actuarial survival was 31%. The only factor significantly associated with overall survival was the stage of disease at presentation: median survivals were 97 vs. 15 months for stages I and II, respectively (log-rank, P = .02). From the literature review, adjuvant radiotherapy was associated with a reduced risk of local recurrence (P < .00001). MCC is an aggressive cancer, with a high tendency for local recurrence and distant spread. Surgery and adjuvant radiotherapy appear to provide optimal local control. The role of chemotherapy remains to be defined.

The Supply and Demand for Eurosystem Deposits the First 18 Months

This paper describes the demand and supply factors affecting the amounts of deposits held by banks with the Eurosystem in the first 18 months of Stage Three of EMU and differences to the years before. paper starts from the methodology adopted in a recent study by James Hamilton on The supply and demand for Federal Reserve deposits. While the treatment of the autonomous liquidity factors is in principle similar, the modelling of open market operations and of the recourse to standing facilities diverge. These differences stem from different institutional settings, but also from somewhat different views on the accurate model. In a second part, the paper turns to prices by providing a simple econometric model capturing a large part of the variability of the difference between the EONIA rate (the price for daily funds) and the rate charged for the main refinancing operations.