腹腔镜手术意外胆囊癌的处理

目的探讨在腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中意外发现的胆囊癌的治疗方法。方法对17例LC时意外发现的胆囊癌者的临床资料进行回顾性分析。结果11例NevinⅠ，Ⅱ期患者行单纯LC；1例Ⅲ期和3例Ⅳ期患者行LC＋局部淋巴结清扫术；2例Ⅳ期患者行胆囊切除术。全组意外胆囊癌的发生率为0．6％。Ⅰ，Ⅱ期患者术后最长随访5年，未见复发；Ⅲ期1例术后1．5年复发，再次手术；而Ⅳ，Ⅴ期的病例预后较差，均于1年内死亡。结论Ⅰ，Ⅱ期的意外胆囊癌行LC可达到根治目的。Ⅲ期的需行胆囊癌根治术，如术中做到切缘镜下无瘤可望提高生存率。Ⅴ期应采用局部清扫＋肝脏楔形切除术进行治疗。     

Surgical treatment of patients with T2 gallbladder carcinoma invading the subserosal layer

BACKGROUND: Because T2 carcinoma of the gallbladder that invades perimuscular connective tissue without extension beyond serosa or into the liver has a hope for longterm survival, we attempted to clarify significant prognostic factors with respect to tumor- and surgery-related variables. STUDY DESIGN: Of 65 patients with gallbladder carcinoma who had undergone surgical resection from 1983 to 1999, 28 had T2 carcinoma histologically proved. The significance of variables for survival was examined by the Kaplan-Meier method and log-rank test followed by multivariate analyses using Cox's proportional hazard model. RESULTS: There were 17 patients with stage II carcinoma (T2 N0 M0), 6 with stage III (T2 N1 M0), and 5 with stage IVB. Lymph node metastasis was present in 11 patients (39%) and it reached to the peripancreatic head region (N2) in 5 of them. Lymphatic, venous, and perineural invasions were found in 68%, 57%, and 43%, respectively. With respect to tumor factors, the absence of perineural invasion (Odds ratio [OR] 16.77, 95% confidence interval [CI] 2.17-129.94, p = 0.0069), absence of lymph node metastasis (OR 15.00, 95% CI 2.08-108.33, p = 0.0073), and stage II (II versus III and IVB, OR 15.00, 95% CI 2.08-108.33, p = 0.0073) were significant factors related to good postoperative survival in the multivariate analysis. Surgical procedure (radical resection versus cholecystectomy, OR 4.31, 95% CI 1.34-13.82, p = 0.0142) and surgical margin (OR 7.41, 95% CI 2.19-25.13, p = 0.0013) were significant factors in the univariate analysis. Cancer-free surgical margins provided a significantly better survival (5-year survival rate, 62%); none with cancer-positive surgical margins survived for more than 27 months. In the multivariate analysis, surgical procedure was significant (OR 25.49, 95% CI 1.62-400.72, p = 0.021). Radical surgery, including extended cholecystectomy (resection of the gallbladder together with the gallbladder bed of the liver) and anatomic resection of liver segment 5 and of the lower part of segment 4, gave a significantly better 5-year survival rate than cholecystectomy (59% versus 17%). The 5-year survival rate after radical resection in patients with stage II was 75%; that in patients with stage III and IVB was 33%. CONCLUSIONS: Results suggest that radical surgery is the treatment of choice for patients with T2 carcinoma of the gallbladder. The presence of lymph node metastasis, perineural invasion, or both suggests the necessity of additional treatment after radical surgery.     

Treatment of carcinoma of the gallbladder in Japan

Clinical records of 2567 patients (1717 female and 850 male) with primary carcinoma of the gallbladder in Japan, during the past 19 years, were collected by questionnaires sent out to the main 100 surgical institutes in Japan. Eighty-seven per cent of the patients were over fifty years of age. Gallstones were found in 58.8% of 1496 patients. About 50% of the patients with gallstones had cholesterol group stones. Of the 2269 patients who underwent surgical interventions, radical operations were performed in 467 patients (20.6%). Of the 467 patients, a correct preoperative diagnosis was made in only 77 patients (16.3%). Patients in Nevin's Stages I and II, whose lesions had been confined to the muscle layer, showed a good survival rate with only simple cholecystectomy or extended cholecystectomy, while the patients in Stages III, IV and V, whose lesions had spread beyond the muscle layer, showed poor results even with more aggressive surgical approaches. The poor prognosis of the lesions in Stages III, IV and V might be due to inappropriate aggressive procedures. For the lesions involving all the layers of the gallbladder wall, radical resection, such as extended cholecystectomy plus pancreatoduodenectomy, or extended right lobectomy plus pancreatoduodenectomy, might be recommended. Presented at the 13th Congress of the Japanese Gastroenterological Society, Kumamoto, Japan 1980, by Dr. I. Yokoyama, the Chairman of the Congress.     

误诊为胆囊良性疾病的胆囊癌二次根治术

目的探讨误诊为胆囊良性疾病的胆囊癌二次手术方式以及对预后的影响。方法对于1995年6月-2002年12月因误诊为胆囊良性疾病而切除胆囊,因术后病理证实为胆囊癌而二次行胆囊癌扩大根治术的41例患者进行回顾性分析。41例患者中,男12例,女29例,平均年龄51岁,均因胆囊炎(41例)或并发胆囊结石(32例)、胆囊息肉或腺瘤(9例)在第一次手术时行单纯胆囊切除。术后病理：胆囊腺癌32例,鳞癌6例,鳞腺癌3例;Nevin Ⅰ期6例,Ⅱ期16例,Ⅲ期17例,Ⅳ期2例,Ⅴ期0例。二次手术距一次手术间隔时间为6—30d。二次手术均行以改良的Glenn根治性胆囊癌切除术为标准的胆囊癌根治术式。结果二次手术时发现14例患者有淋巴结转移,14例患者有胆囊床转移,6例患者有胆管转移,2例患者有胰腺转移;Nevin Ⅳ期14例,Ⅴ期9例,无Ⅰ、Ⅱ、Ⅲ期者。二次手术后1年后存活率100％(41例),3年存活率53、8％(22例),5年存活率17．5％(7例)。结论扩大根治术是治疗误诊为胆囊良性疾病的胆囊癌的重要方法之一。     

An appraisal of the surgical management of stage I and II cancers of the pancreas

During the period between 1966 and 1984, 65 patients with duct cell cancer of the head of the pancreas underwent pancreatectomy. Among the 15 cases with tumors less than 2 cm in size, 27% were in stage I, 53% in stage II and 20% in stages III and IV, suggesting that small pancreatic cancer is not compatible with early cancer. Prognosis of cancer of the pancreas was mainly dominated by the stage of the cancer and radicality of the operation. The 5-year survival rate in patients with curative resection in stages I and II was 60%, and prognosis was particularly satisfactory in cases with no, So, Rpo and Vo. In cases of tubular adenocarcinoma of the pancreas, the prognosis was also influenced by the lymphatic, venous, perineural and connective tissue infiltrations. These results substantiate the concept that extended radical pancreatectomy is an indispensable procedure for cancer of the pancreas even in stages I and II.     

Is Carcinoma of the Gallbladder a Curable Lesion?

Carcinoma of the gallbladder is an uncommon, but not rare tumor that is associated with a 5% five-year survival rate after resection and this rate has not appreciably improved over the last decades in most series. Nevin et al.²⁰ however have reported that favorably staged gallbladder cancers (according to histologic grade and depth of invasion) have a relatively good prognosis. They quoted an overall five-year survival of 21% in 66 patients. Most of the surviving patients (11) were in the favorably staged category: Stage I (intramucosal cancer) and Stage II (invasion of mucosa and muscularis). The remaining few were in Stage III (invasion of all layers), Stage IV (cystic node metastases), or Stage V (extension of metastases to the liver or distant sites). Our data has been analyzed to determine whether microstaging of the primary cancer will select out a subgroup with a favorable prognosis, and whether there are survival benefits according to the type of surgical resection. A clinical and pathologic review was done of 100 patients treated at the University of Virginia Hospital from 1930 to 1978. There were 77 women and 23 men, with an average age of 65 years (range 21-89). Gallstones were described in 78% of the patients. Surgical procedures included cholecystectomy alone (23 patients), cholecystectomy with biliary drainage (17 patients), cholecystectomy and resection of the hepatic bed (8 patients), and exploration with biopsy or bypass (44 patients). Autopsy only was done in eight patients. There were only three long-term survivors (6 years, 11 years, and 24 years). Median survival was six months with cholecystectomy alone, five months with cholecystectomy and bypass, 14 months after partial liver resection, and 2.0 months after laparotomy/bypass/biopsy. The five-year survival rate was 5% after cholecystectomy alone or with bypass, and 13% (1/8) after cholecystectomy and partial liver resection (p = 0.07). Microstaging of the primary cancers showed no prognostically favorable subgroup. Of 46 patients with microstaged lesions, only 13% were in the very favorable Stage I and II groups (only one of six survived), 46% were Stage III (1/21 survived), and the remaining 41% were in the highly unfavorable Stage IV and V groups (1/19 survived). Most patients showed progression of disease either primarily or secondarily that was locoregional (liver and nodes). Although longterm survival may accompany cholecystectomy alone for a favorable early-staged cancer, this is still uncommon. There may be theoretical, although not proven, merit for resection of the hepatic bed and regional node dissection in the selected patient, possibly complimented by adjuvant therapy. Future advances in chemotherapy and radiation will be needed to augment the current poor cure rate of this disease.     

Gallbladder cancer: the role of laparoscopy and radical resection

OBJECTIVES: We assess how laparoscopy has altered the presentation of patients with gallbladder cancer and determine whether radical resection in patients with gallbladder cancer is beneficial. SUMMARY BACKGROUND DATA: The widespread adoption of laparoscopic cholecystectomy has led to an increased frequency of incidentally discovered gallbladder carcinoma. Little data exist to guide surgeons in the optimum management of patients with gallbladder cancer, particularly with respect to the potential advantages of radical resection. METHODS: Records of 107 patients with gallbladder cancer admitted to a tertiary academic medical center between 1995 and 2004 were reviewed. Gallbladder cancer was found incidentally in 53 patients (50%). Fifty-two of these patients underwent a routine laparoscopic cholecystectomy and were found to have gallbladder cancer intraoperatively or following the operation by subsequent pathologic evaluation of the specimen. Gallbladder cancer had been diagnosed preoperatively by radiology in the other 54 patients (50%). These patients did not undergo laparoscopic cholecystectomy and were explored electively. RESULTS: The median age at presentation was 67 years and 66% were female. Patients who were found to have gallbladder carcinoma incidentally at laparoscopic cholecystectomy had a significant increase in survival when compared with those who were admitted electively with a known diagnosis (P < 0.001). All patients who presented with a known diagnosis had stage II or greater disease, and 36% of these were stage IV carcinomas. However, 82% of those patients who were found incidentally were stage I or II. The overall 5-year survival for all patients was 15%; those discovered incidentally at laparoscopic cholecystectomy had a 5-year survival of 33%. This difference was significant among patients with stage II carcinomas. In the laparoscopic group, there was no difference in survival between the patients who were immediately converted to an open resection when identified to have gallbladder cancer intraoperatively (n = 6) and those who had a completed laparoscopic cholecystectomy and were re-explored at a later point when found to have gallbladder cancer by subsequent pathology (n = 33). There was a significant improvement in survival in 50 patients (47%) who underwent some form of radical resection (P < 0.001). Stage for stage comparison showed that this was significant in stage II disease. Patients who underwent hepatic resection along with lymphadenectomy and extra hepatic biliary resection had similar survival compared with those who had hepatic resection and lymphadenectomy alone. CONCLUSIONS: Laparoscopic cholecystectomy appears to have resulted in the earlier discovery of gallbladder cancer in some patients, resulting in increased probability of survival. Patients discovered with gallbladder carcinoma during a laparoscopic cholecystectomy do not have to be converted immediately to an open resection and should be referred to a tertiary care center for further exploration. Adjunctive radical surgical resection, either at the time of cholecystectomy or subsequently, increases survival significantly in early stage disease.     

浸润深度局限在胆囊壁内的T1和T2期胆囊癌的预后分析

目的 探讨不同治疗方式对浸润深度局限于胆囊壁内的T1、T2期胆囊癌预后的影响。方法 对浸润深度局限于胆囊壁内的45例T1和12期胆囊癌患者的预后进行回顾分析。结果 Cox多因素分析显示肿瘤浸润深度（T）、胆囊癌根治术以及术后化疗是影响预后的三个独立的因素。在未用化疗的情况下T1a期、T1b期和T2期胆囊癌在单纯胆囊切除术后的5年生存率分别为100％、67％和0,T1b期与T2期两组生存差异有统计学意义。在未用化疗的情况下T2期胆囊癌在单纯胆囊切除和胆囊癌根治术后的5年生存率分别为0和63％。T2期胆囊癌在单纯胆囊切除术后使用化疗与未用化疗的生存差异有统计学意义。结论 T1期胆囊癌预后明显优于12期胆囊癌。T1a期和T1b期胆囊癌在单纯胆囊切除术后即可获得比较满意的5年生存率。胆囊癌根治术和化疗均可以改善T2期胆囊癌的预后。     

Controversy on early carcinoma of the gallbladder based on the results of surgical treatment

Seventy-two cases of carcinoma of the gallbladder removed surgically were retrospectively studied to evaluate the relationship between stage and prognosis, and to define early carcinoma of the gallbladder. These cases were staged according to general rules for surgical studies on cancer of biliary tract (Japanese Biliary Surgical Society). Stage I patients were 23, composed of 13 of mucosal carcinoma, 7 with involvement of the muscularis and 3 with microinvasion into the subserosa. Stage II and III were 14, and Stage IV 35. All patients with mucosal carcinoma were alive with the exception of the one case who died of other cause. Two cases of the remaining 10 Stage I died of recurrence of carcinoma 1.5 years and 2 years after surgery. Five-year survival rates were 100 percent in cases with mucosal carcinoma, 75 percent in cases with muscular involvement or subserosal microinvasion, 31.6 percent in Stage II and III cases. Stage IV was fatal and most of them died within 6 months after surgery. From our data, it may be rational that the early carcinoma of the gallbladder is defined as the carcinoma of which invasion is limited to the mucosa.     

Appraisal of surgical resection of gallbladder carcinoma with special reference to hepatic resection

Carcinoma of the gallbladder a gastrointestinal malignancy with an extraordinarily poor prognosis. However, aggressive surgery, with special reference to hepatic resection, may improve survival. To prove this, we performed a retrospective analysis over an 18-year period to investigate the experience of a center that began employing liver resection in patients with gallbladder cancer in 1978. The analysis was based on patients' documentation and regular follow-up to January 1996. The standard procedures were extended cholecystectomy (cholecystectomy with lymphadenectomy and wedge hepatic resection), anatomic segmentectomy of segments IVa and V, and extended hepatectomy. Significance was assessed by the log-rank test. Thirty-nine patients were resected, curatively in 41% (n = 22; group I) and palliatively in 31% (n = 17; group 2). In 28% (n = 15; group 3) a palliative or no operation was performed. Only curatively resected patients were analyzed and followed up to January 1996. No patients in group 1 died postoperatively. The actuarial 5-year survival rate of the patients with curative resection was 55%. Four patients had stage I, two had stage II, four had stage III, and two had stage IV disease according to TNM-classification. Six of the 16 patients without lymph node metastasis survived more than 5 years. A significant difference in long-term survival was recognised between stage II and stage IV patients and between stage (pT1a)- and (look table 1b) (pT1b)-patients (P < 0.01). Diagnostic efforts should focus on detecting early stages I and II gallbladder cancer. In advanced cases, aggressive surgery, particularly with hepatic resection, is the method of choice and is successful even in patients 70 years and older. Received for publication on July 31, 1997; accepted on April 1, 1998     

Surgical clinicopathologic study of malignant fibrous histiocytoma

Fifteen men and six women, ranging in age from 20 to 79 years, with malignant fibrous histiocytoma comprised this series. Amputation of the right lower extremity was performed in one patient, wide resection in 7 and marginal excision in 9, respectively. In the other 4 patients, a non-curative resection was carried out. Adjuvant chemotherapy was prescribed post-operatively for 12 patients. Histologic grade of the surgical specimens was Stage I in 3, II in 6, III in 8 and IV in 4. Among fourteen patients living from 10 months to 9 years and 9 months after the operation, the 7 subjected to a wide resection are all disease free. Seven patients died of a local recurrence or a distant metastases. The survival rate of the patients with Stages I, II is significantly higher than those with Stages III, IV. These results show that a wide resection is to be favored and that staging is useful to estimate the prognosis.     

Surgical clinicopathologic study of malignant fibrous histiocytoma

Fifteen men and six women, ranging in age from 20 to 79 years, with malignant fibrous histiocytoma comprised this series. Amputation of the right lower extremity was performed in one patient, wide resection in 7 and marginal excision in 9, respectively. In the other 4 patients, a non-curative resection was carried out. Adjuvant chemotherapy was prescribed post-operatively for 12 patients. Histologic grade of the surgical specimens was Stage I in 3, II in 6, III in 8 and IV in 4. Among fourteen patients living from 10 months to 9 years and 9 months after the operation, the 7 subjected to a wide resection are all disease free. Seven patients died of a local recurrence or a distant metastases. The survival rate of the patients with Stages I, II is significantly higher than those with Stages III, IV. These results show that a wide resection is to be favored and that staging is useful to estimate the prognosis.     

Extended cholecystectomy for carcinoma of the gallbladder

We evaluated extended cholecystectomy, wedge resection of the gallbladder bed, and regional lymphadenectomy for carcinoma of the gallbladder. Between 1971 and 1993 we treated 227 patients, 59 of whom were treated with simple cholecystectomy and 66 with extended cholecystectomy. The tumors were classified according to the stages proposed by the Japanese Society of Biliary Surgery. For Stage I and II discase extended cholecystectomy had a better result than simple cholecystectomy. For the extended cholecystectomy cases the cumulative 5-year survival rate was 78.9% for Stage I, 63.6% for Stage II, 44.4% for Stage III, and 8.3% for Stage IV. The survival of Stage I patients was excellent. For cases more advanced than Stage II (S3, N2, Hinf1, and Binf1), the prognosis was significantly worse. In these cases more aggressive surgery may be needed.

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Resumen Hemos estudiado el procedimiento de colecistectomía ampliada, resección en cuña del lecho vesicular y linfadenectomía regional en el tratamiento del carcinoma de la vesícula biliar. En el período 1971 a 1993, se trataron 227 casos, de los cuales 59 fueron sometidos a colecistectomía simple y 66 al procedimiento ampliado. Los tumores fueron clasificados de acuerdo con la estadificación propuesta por la Sociedad Japonesa de Cirugía Biliar. En los estados I y II, la colecistectomía ampliada demostró un mejor resultado que la colecistectomía simple. En los casos de colecistectomía ampliada, la tasa acumulada de sobrevida a 5 años fue 78.9% en el estado I, 63.6% en el estado II, 44.4% en el estado III y 8.3% en el estado IV. La tasa de sobrevida en el estado I fue excelente. En los casos con tumores más avanzados que el estado II, S3 N2 Hinf1 y Binf1, el pronóstico fue significativamente peor. En estos casos puede ser necesaria una conducta quirúrgica más agresiva.

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Résumé Nous avons évalué la choléystectomie étendue, c'est à dire combinée à une résection en coin du lit vésiculaire et une lymphadénectomie régionale, pour cancer de la vésicule biliaire. Entre 1971 et 1993, 227 cas de cancer de la vésicule ont été traités. Parmi ceux-ci, 59 ont eu une simple cholécystectomie et 66 ont eu une choléystectomie «étendue». Les tumeurs ont été classées par la Société Japonaise de la Chirurgie Biliaire. Dans les stades I et II, l'évolution après la chlécystectomie étendue a été meilleure qu'après la cholécystectomie simple. La survie cumulative à 5 ans a été, respectivement dans les stades I, II, III et IV, de 78.9%, 63.6%, 44.4%, et 8.3. La survie chez les patients stade I est excellente. Dans les stades II, III, et IV, S3, N2, Hinf1 et Binf1, le pronostic est nettement moins bon. C'est dans ces cas qu'une chirurgie plus agressive est indiquée.

     

Clinical analysis of 1,000 patients with prostate cancer

OBJECTIVES: Treatment outcomes for prostate cancer in our hospital were reported. MATERIALS AND METHODS: We analyzed 1,009 patients with prostate cancer treated at Niigata Cancer Hospital between 1983 and 2003. RESULTS: As for the clinical stage, 20 cases belonged to Stage I, 367 cases to Stage II, 269 cases to Stage III and 353 cases to Stage IV. The overall 5-year survival rate of the all 1,009 cases was 59.0%, comprising 78.2% for stage I, 82.0% for Stage II, 76.0% for Stage III and 30.0% for Stage IV cases. Disease-specific 5-year survival rates for Stage I, II, III and IV were 100%, 96.8%, 89.3% and 41.1% respectively. In Stage III patients, the radiotherapy (with endocrine therapy) group showed longer cause-specific survival than the endocrine therapy group (p = 0.0056). CONCLUSIONS: Our result suggest that the radiotherapy with endocrine therapy is useful for Stage III prostate cancer.     

Ten-year survival rates in breast cancer using combination chemotherapy.

The outcome in 254 patients with all stages of breast cancer treated by combination chemotherapy is presented. All the patients were treated 10 or more years ago. The 10-year survival rate for Stages I and II combined is 60 per cent, in Stage III 19 per cent and in Stage IV 3 per cent. The combined rate in Stages I and II differed markedly according to hormonal status. In premenopausal patients the rate was 84 per cent compared with 42 per cent in postmenopausal patients.     

Resected cases of middle lobe primary cancer

Of 200 lung cancer lesions resected in our hospital, there were 15 cases (7.5%) with middle lobe origin. The histological types were adenocarcinoma in 13 patients (4 patients with alveolar cell carcinoma), squamous cell carcinoma in one and large cell carcinoma in one. These patients were classified into two groups according to the type of operation they received and each group was evaluated. Group I (resection of the middle lobe) included 8 patients. Each one of Stage IIIB and Stage IV received the operation to improve their symptoms. The six patients of Stage I received only middle lobectomy as absolute curable cases. Group II (resection of the middle and lower lobes) included 7 patients, who had preoperative diagnosis of stage III. Two of them were postoperatively found to be cases of Stage I and Stage II. Although it was still short-term, the follow-up evaluation proved that these patients survived without local recurrence and distant metastasis, except for two with pleural dissemination and one with cerebral metastasis, who had received lobectomy as palliative operation. No difference was observed between the two groups receiving different types of operation.     

Enoxaparin prevents progression of stages I and II osteonecrosis of the hip

In a prospective pilot study, we hypothesized that enoxaparin (60 mg/day for 12 weeks) would prevent progression of Stages I and II osteonecrosis of the hip associated with thrombophilia or hypofibrinolysis or both over > or = 108 weeks of followup versus untreated historic controls, with different treatment responses in primary versus corticosteroid-associated secondary osteonecrosis. Patients with one or more thrombophilic-hypofibrinolytic disorder and Ficat Stages I or II osteonecrosis of at least one hip were included. A blinded committee interpreted anteroposterior and frog-leg lateral radiographs at entry in the study and every 36 weeks to > or = 108 weeks. Maintenance of the disease at Stages I and II versus progression of the osteonecrosis to Stages III and IV requiring total hip replacement was the major end point. Sixteen patients had primary osteonecrosis (25 hips; 13 Stage I, 12 Stage II), and 12 had secondary osteonecrosis (15 hips; five Stage I, 10 Stage II). With no Enoxaparin-related complications, 19 of 20 hips (95%) with primary osteonecrosis were unchanged from Stages I and II osteonecrosis at > or = 108 weeks; 12 of 15 hips (80%) with secondary osteonecrosis progressed to Stages III and IV osteonecrosis. In primary osteonecrosis at > or = 108 weeks, survival of 95% hips, or 76% (19/25 hips, based on intent to treat), compared favorably with untreated historical controls (approximately 20% 2-year survival), comparable to 20% survival in secondary hip osteonecrosis. Enoxaparin may prevent progression of primary hip osteonecrosis, decreasing the incidence of total hip replacement. LEVEL OF EVIDENCE: Therapeutic study, II-1 (prospective cohort study).     

A comparison study of staging systems for bone sarcomas

A retrospective study of 250 patients treated at one institution was done to evaluate the prognostic significance of the new American Joint Committee on Cancer staging system compared with the Musculoskeletal Tumor Society staging system for patients with sarcomas of bone. Regarding the Musculoskeletal Tumor Society system, there were significant differences in survival among patients with Stage I, Stage II, and Stage III disease. There were no significant differences between patients with Stages I-A and I-B disease, nor between patients with Stages II-A and II-B disease. Similarly, regarding the new American Joint Committee on Cancer staging system, there were significant differences among patients with Stage I, Stage II, and Stage IV disease. No significant differences were seen between patients with Stages I-A and I-B disease, between patients with Stages II-A and II-B disease, nor between patients with Stages IV-A and IV-B disease. A significant advantage in the ability to predict prognosis for one staging system over the other staging system was not shown with the relatively small number of patients in this study.     

Transhiatal and transthoracic esophagectomy for adenocarcinoma of the esophagus.

Adenocarcinoma of the esophagus is no longer rare and is treated by resection. To determine whether the approach used for resection influences outcome, we studied 88 patients who underwent resection; 14 had stage I or II disease, 74 had stage III, and 40 had stage IV. One third of those with Barrett's esophagus were noted on screening endoscopy to have potentially curable disease; the others were diagnosed with stage III or IV disease. Transhiatal esophagectomy was performed in 63 patients; 24 patients underwent transthoracic esophagectomy. We found no difference in survival or morbidity between transhiatal and transthoracic esophagectomy. Overall 5-year survival for stage I and II disease was 86%. For stage III and IV disease, 5-year survival was 14.5%. Aggressive surveillance of Barrett's esophagus facilitates the discovery of early disease. Esophagectomy for adenocarcinoma can result in cure of early cancers and improved palliation of more advanced disease.     

The impact of delayed diagnosis of lung cancer on the stage at the time of operation

Objective: The purpose of this investigation was to study the correlation between diagnostic delay and the stage of the lung cancer at the time of operation. A second objective was to study differences in symptoms between the patients grouped according to stage. Methods: A total of 172 patients consecutively admitted for surgery between 1 January 1994 and 1 June 1995 at the Department of Thoracic and Cardiovascular Surgery of Rigshospitalet National Hospital of Denmark were included in the retrospective study. Two groups of patients were compared, one group with good prognosis (patients in Stages I and II) and one group with poor prognosis (patients in Stages III and IV). The time-spans studied were: (1) interval from the patient's perception of the first symptom to operation; and (2) the time from first contact with the healthcare-system to operation. The median delay between the patient-groups was compared using the Mann–Whitney U-test. To compare the symptoms which brought the patients in contact with the healthcare-system, the χ²-test was used. Results: In the time interval between appearance of the first symptom and operation, a significantly shorter median delay was found for patients with Stages I and II compared to Stages III and IV (P=0.037). Concerning the interval from first contact with the healthcare system to operation a significantly shorter median delay was found for the group of patients in Stage I and II compared to the patients-group in Stage III and IV (P=0.017). It was found that the cancer was an accidental finding, significantly more often in patients in Stages I or II compared to patients in Stages III or IV (P=0.0002). Conclusions: A few months delay before final treatment of a non-small-cell lung cancer seems to have an impact on the perioperative stage of the cancer, and thereby on the patients prognosis. A screening of asymptomatic risk-group patients will result in recognition of early lung cancer.