The continuing problem of carcinoma of the pancreas

The courses of 208 patients with adenocarcinoma of the pancreas were reviewed. The lesion was located in the head of the pancreas in 142 patient, (68%) and of these, in 22 patients the diagnosis was confirmed histologically at postmortem examination; 21 patients underwent laparotomy and biopsy with a 33% operative mortality and a 3.4-month average survival; 89 patients underwent biliary and/or gastric bypass with a 24% mortality and 4.8-month average survival; 10 patients underwent pancreaticoduodenectomy with a 20% mortality and 14.6-month average survival. The lesion was located in the body or tail of the pancreas in 77 patients (32%); and, of these, 15 patients had histologic confirmation of clinical diagnoses at postmortem examination; 19 patients underwent biopsy of extra-abdominal metastases and survived an average of 1.4 months; 27 patients underwent laparotomy and biopsy with a 26% operative mortality and 3.5-month average survival; 4 patients underwent gastric and/or biliary bypass with a 50% mortality and 4.5-month average survival; one patient underwent noncurative distal pancreatectomy and survived 1 month postoperatively. No patient was cured of his disease. Of the 55 operative survivors of biliary bypass alone for carcinoma of the head of the pancreas, 5 (9%) required subsequent gastroenterostomy for duodenal obstruction.     

Extended resection for pancreatic adenocarcinoma

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.     

Favourable prognosis of cystadeno- over adenocarcinoma of thepancreas after curative resection

This report details nine patients after curative surgical resection of histologically proven mucinous cystadenocarcinomaof the pancreas and compares the prognosis with ductal adenocarcinomas. Cystadenocarcinomas represented 2.1% (10/ 466) of a total of 466 patients who underwent surgical exploration and 5.5% of all curatively resected carcinomas of the exocrine pancreas at Hanover Medical School from 1971 to 1994. Forty per cent of adenocarcinomas and 90% of cystadenocarcinomas were resectable. A curative R0 resection was possible in all patients with cystadenocarcinoma and 85% with adenocarcinoma. Six of the patients with cystadenocarcinoma were female and three were male. Their median age was 54±12 years (range: 44 to 81 years). Four cystic neoplasms were located in the head, one in the head and body, three in the tail, and one in the body and tail of the pancreas. There was no hospital mortality in this group. The prognosis after resection of cystadenocarcinomas was significantly better compared to ductal adenocarcinomas of the pancreas. The Kaplan-Meier survival was 89% vs 52% after 1 year, and 56% vs 13% at 5 years. Our results indicate the favourable prognosis of cystadeno- over ductal adenocarcinomas of the pancreas in a cohort of patients with curative tumour resection.     

Subtotal duodeno-pancreatectomy for carcinoma of the head of the pancreas. Preliminary report of an alternative operation to total pancreatectomy

For ductal carcinoma of the head of the pancreas and large periampullary carcinoma with wide infiltration into the head of the pancreas a subtotal duodeno-pancreatectomy with preservation of the pancreatic tail and spleen is introduced as an alternative to total pancreatectomy. A preliminary report of 38 operations shows a mortality of only 3% and a low morbidity. Diabetes mellitus increased from 17% preoperatively to 40% postoperatively, therefore, in 60% a normal carbohydrate metabolism was preserved. At present 5 of 20 patients (R0) with ductal cancer are alive and free of recurrence 18 to 55 months after the operation with a median survival of 12 months for all curatively resected patients. No negative influence on median survival time can yet be recognized. Subtotal duodeno-pancreatectomy was performed with a much lower operative risk than total pancreatectomy and seems to be as effective as total organ removal.     

Radical pancreatectomy for ductal cell carcinoma of the head of the pancreas

Seventy-four patients were treated with a radical or a nonradical pancreatectomy for ductal cell carcinoma of the head of the pancreas. Their survival rates and the selection of the operative procedure were evaluated. In 32 patients, a radical pancreatectomy was attempted where there was sufficient clearance of regional or juxta-regional lymph nodes beyond the group of suspected metastatic nodes, as well as a resection of a greater margin of soft tissue around the pancreas. These patients' cumulative 5-year survival rate was 33.4%. In 14 Stage I or Stage II patients, the cumulative 5-year survival rate was 46.4%. In 18 Stage III or Stage IV patients, the cumulative 5-year survival rate was 20.7%. For 42 patients treated with a nonradical pancreatectomy with the dissection of lymph nodes adjacent to the pancreas or of regional lymph nodes but with insufficient clearance of the soft tissue around the pancreas, the cumulative 2-year and 3-year survival rates were 5.4% and 0%, respectively. In seven patients with Stage II carcinoma, the survival rate was 16.7% after 2 years and 0% after three years. In 35 Stage III or Stage IV patients, the survival rate was 3.2% after 2 years and 0% after 3 years. Thus, the survival rates were significantly higher in patients treated with radical operation than in patients who had nonradical operation. These results indicate that a radical pancreatectomy with sufficient lymph node clearance with the surrounding connective tissue around the pancreas is indispensable to cure patients with ductal cell carcinoma of the pancreas.     

Pancreatic resection for metastatic tumors to the pancreas

We report 3 cases of resectable pancreatic metastasis. CASE 1: A 76-year-old woman was followed after nephrectomy for renal cell carcinoma for 13 years. CT examination demonstrated a high vascular lesion in the pancreatic body and tail. We conducted distal pancreatectomy and diagnosed with metastatic tumor from renal cell carcinoma. She died of liver metastasis 8 years after pancreatic resection. CASE 2: A 64-year-old man, who had undergone right lower lobectomy for lung cancer a year ago, was found to have a mass in the pancreatic tail. We performed distal pancreatectomy and diagnosed with metastatic tumor from lung cancer. He died of lung metastasis 12 months after pancreatic resection. CASE 3: A 62- year-old woman, who had undergone left nephrectomy for renal cell carcinoma 3 years ago, was found to have a mass in the pancreatic body. With a diagnosis of metastatic pancreatic tumor from renal cell carcinoma, distal pancreatectomy was done. She died of liver and lung metastases 15 months after pancreatic resection. Long-term survival can be achieved in patients undergoing a pancreatic standard resection including lymphadenectomy for isolated metastasis from nonpancreatic sites.     

Major pancreatic resections for suspected cancer in a community-based teaching hospital: lessons learned

BACKGROUND: The literature reports 4-10% mortality rate, 30-60% morbidity rate, and 9-29% anastomotic leak rate after pancreaticoduodenectomy (PD) performed for periampullary tumors. These data demonstrate a linear relationship between surgical volume and outcome. METHODS: The objective of this study was to evaluate the experience of a high-volume hospital with low-volume pancreatoduodenectomy for suspected cancer. The study was designed as a retrospective review of medical records of all patients who underwent pancreatoduodenal resection or total pancreatectomy for a suspected periampullary carcinoma between January 1994 and December 2003. The setting of the study was a community-based teaching hospital with a general surgery residency training program. RESULTS: A total of 63 patients underwent pancreatoduodenal resection or total pancreatectomy. All procedures were performed by a total of 15 different surgeons; however, 27 operations were performed by one surgeon. Pre-operative diagnosis in most cases was either a known malignancy-27 cases (43%) or a tumor of the head of the pancreas, suspicious for malignancy-36 cases (57%). One patient underwent a total pancreatectomy. In 62 patients a pancreatoduodenal resection (Whipple procedure) was performed. Post-operative 30-day mortality was 4.7% (three patients). Overall in-hospital mortality was 9.5% (six patients). Ten (16.1%) had a leak of the pancreato-jejunal anastomosis, six of which resolved with non-operative management. Of the remaining four patients, three died from peritonitis or consequences of erosive hemorrhage. CONCLUSIONS: Post-operative leak of the pancreatic anastomosis represents a technical challenge. Although most of the leaks can be treated non-operatively, those that lead to peritonitis or erosive hemorrhage warrant operative intervention. Major pancreatic resections can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at a low-volume community-based teaching hospital.     

Surgical resection of 48 patients with malignant disease of the pancreas and periampullary region

Fourty-eight patients with malignant disease of pancreas and periampullary region treated by surgery from Jan. 1966 to June 1985 are analyzed. Of these patients, 44 underwent pancreaticoduodenectomy, 2 had resection of the body and tail of pancreas, 1 had total pancreatectomy and 1 had tumor resection only. The operative mortality was 12.5%. The overall 5-year survival rate was 48.2%. The 5- and 10-year survival rates of the 44 patients by pancreaticoduodenectomy were 46.4% and 37.5%, respectively. Experience and technique on the postoperative complications were analyzed. The prevention of massive bleeding during operation were suggested. Apart from the cigarette drain to the pancreaticoduodenal bed, an easy and effective method for draining the digestive juice from the lumen near anastomosis of the pancreaticojejunostomy and choledochojejunostomy is suggested.     

The prognostic significance of malignant pleural effusion at the time of thoracotomy in patients with non-small cell lung cancer

Surgery is usually not indicated for malignant pleural effusion (PE) due to its poor prognosis. However, PE is first detected at thoracotomy, and it is difficult to judge an appropriate mode of resection. Forty-nine patients with lung cancer were first diagnosed as PE and/or pleural dissemination (PD) at thoracotomy. The histological types were 36 adenocarcinoma, ten squamous cell carcinoma and three large cell carcinoma. Sixteen patients had only PE, 17 had only PD, and 16 had both PE and PD. Ten patients underwent only exploratory thoracotomy, seven partial resection, 27 lobectomy and five panpleuropneumonectomy. The overall survival rate was 26.7% at 3 years. The patients with PE and/or PD seemed to have a poorer survival compared to our previous study. The patients with only PE showed a significantly better prognosis than the patients with only PD (P=0.0001) or with PD+PE (P=0.019). The patients who underwent exploratory thoracotomy showed poor survival. There were significant differences in the survival in relation to the extent of the primary tumor. In conclusion, the patients with T1-2 of primary tumor and only a small amount of PE without PD can be expected to show long-term survival after tumor resection.     

A case report of port-site metastasis of pancreatic cancer after laparoscope assistted distal pancreatectomy

Laparosopic port-site metastasis is rare, but a well recognized outcome following surgery in gastroenterological surgery for gastric cancer, colon cancer and gallbladder cancer with its etiology was not clearly understood. We report a port-site metastasis of pancreatic cancer diagnosed by position emission tomography( PET). A 49-year-old man was diagnosed as splenic tumor with pancreatic tail invasion due to malignant lymphoma, and received a laparoscope assisted distal pancreatectomy. Unsuspected pancreatic cancer was discovered with histological result of moderate differentiated invasive ductal adenocarcinoma of the pancreas infiltrating spleen. Systemic chemotherapy with 1,000 mg/m2 of gemcitabine (GEM) was performed for six months. Unfortunately, our patients relapsed one year after the surgery with multiple lesions in the peritoneum, abdominal wall, as well as a laparoscopic port-site metastasis. He was started on 100 mg/body of S-1 daily, subsequently, combined chemotherapy with GEM( 80 mg/m2) and S-1( 80 mg/body) was also performed. Furthermore, he underwent palliative radiation therapy( 40 Gy) to care the pain. Fortunately, a long-term survival of 3 years was elicited by these systemic treatments and radiography. Laparoscopic port-site metastases are associated with presence of advanced cancer. Therefore, we should carefully precede a laparoscopic resection against pancreatic cancer.     

Treatment of hepatic tumors by transcatheter chemo-embolization with gelatin sponge

Transcatheter chemo-embolization is a technique for achieving a marked antitumor effect by embolizing the hepatic artery with a gelatin sponge immediately after infusion of adriamycin 60 mg into the same artery. Chemo-embolization was performed in 212 cases of hepatocellular carcinoma and 23 cases of metastatic liver cancer, a total of 235 patients. Of this population, 19 patients with hepatocellular carcinoma underwent hepatectomy, and in 7 of them, complete necrosis of tumors having thick capsules and less than 4 cm in diameter was confirmed. The cumulative survival rate of patients with unresected hepatocellular carcinoma was 75.6% at 6 months, 52.6% at 1 year, and 20.3% at 2 years. The longest survival time was 3 years and a half, and this patient is now living. As regards metastatic liver cancer, complete necrosis could be achieved in 1 of 2 patients undergoing resection, whereas the cumulative survival rate of unresected cases was 55% at 6 months and 44% at 1 year: only two patients survived for more than 1 year. Technically, the use of a balloon catheter (7F) resulted in the virtual elimination of unsuccessful cases and the prevention of adverse effects due to migration of the gelatin sponge.     

Radiotherapy combined with transarterial infusion chemotherapy and concurrent infusion of a vasoconstrictor agent for nonresectable advanced hepatic hilar duct carcinoma

BACKGROUND: The treatment of patients with advanced hepatic hilar duct carcinoma is a challenging problem. The current study was performed to evaluate the outcome of patients with advanced hepatic hilar duct carcinoma who received external beam radiotherapy (EBRT) combined with transarterial chemotherapy and infusion of a vasoconstrictor. METHODS: Between April 1993 and December 2002, 23 patients with histopathologically confirmed hilar duct carcinoma entered the study. The median total dose of EBRT was 41.4 grays (Gy). Transarterial chemotherapy was performed twice during EBRT. It was comprised of an infusion of a cocktail of 20 mg of epirubicin, 10 mg of mitomycin C, and 500 mg of 5-fluorouracil and was administered 1 minute after injection of epinephrine via a catheter introduced in the hepatic arteries. After the combined treatment, the patients underwent biliary endoprosthesis after evaluation of the initial response to treatment by percutaneous transhepatic cholangiography (PTC). The initial responses based on PTC were classified into four categories: CR, no stenosis; PR, relief of stenosis/obstruction; NC, no change; and PD, progressive stenosis/obstruction. The outcome parameters were survival rates and time, as well as frequency and type of complications. RESULTS: Excluding 1 patient who discontinued the treatment, the initial responses of 22 patients were 1 CR (5%), 8 PR (36%), 11 NC (50%), and 2 PD (9%). The response rate was 41%. The overall survival rates at 1 year, 2 years, and 3 years after treatment were 59%, 36%, and 18%, respectively. CONCLUSIONS: The combination of radiotherapy, transarterial infusion chemotherapy, and concurrent infusion of a vasoconstrictor can be delivered safely with good efficacy for patients with advanced hilar duct carcinoma.     

Carcinoma of the pancreas: a retrospective review

Eighty-five patients with adenocarcinoma of the pancreas were reviewed in order to evaluate the efficacy of our methods of diagnosis and treatment. The most useful diagnostic test was percutaneous transhepatic cholangiography (PTC) with a diagnostic rate of 96%. Pancreaticoduodenectomy (Whipple procedure) and total pancreatic resection were performed in 13 and 2 patients, respectively. The remaining 50 patients underwent various palliative drainage procedures. Twenty patients did not undergo operation for various reasons. The primary tumor was found in the head of the pancreas in 50 patients (59%), the body in 6 patients (7%), and in the tail in 8 patients (9%). Postoperative complications, including sepsis, bleeding, intra-abdominal abscesses, and anastomotic leaks, occurred in 37% of the patients. There were one operative and 9 postoperative deaths. The average survival for those patients undergoing surgical intervention was 6 months. There were no 5-year survivors.     

Pancreas cancer -- duct cell adenocarcinoma: survival in relation to site, size, stage and type of therapy.

The records of 508 patients with cancer of the pancreas admitted to Memorial Hospital in New York from 1949 through 1972 were examined. Ten distinctive morphological types were delineated and the pathological features and response to various modes of therapy of the most common type -- duct adenocarcinoma -- were studied in 380 patients. Median survival was related to: the site of the cancer -- it was longer with tumors of the head than those of the body or tail; the size of the tumor -- cancers smaller than 3 cm were associated with over twice the survival of those with large tumors; the stage -- stage I patients had over twice the survival of those of stages II and III; and the type of therapy employed. Actuarial survival rate at one year was: with no specific therapy, 0%; with chemotherapy, 1%; after palliative by-pass surgery, 3%; following radiation therapy, 9%; and after all types of "surative" surgery, 21%. The only survivors at five years were in the "curative" surgery group, but these represented only 1% of all patients. Revolutionary changes in diagnosis and therapy will have to occur if significant increase in survival rate is to be achieved.     

Surgical treatment of pancreatic cancer

An experience with 16 radical operations for cancer of the pancreatic body and tail is analysed. The increased resectability and reduced mortality was gained by elaborating and introducing into clinical practice some new original methods of surgery: an extensive left-sided resection of the pancreas, performed in 5 patients with one case of mortality, and the combined left-sided pancreatectomy, performed in 3 patients without lethal issues. A 3-year survival was noted in 3 patients, a 5-year survival--in 1.     

Synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites.

PURPOSE: The present study presents the experience at the University of Florida with synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites. PATIENTS AND METHODS: This study included 1,112 patients with squamous cell carcinomas of the oropharynx, hypopharynx, and supraglottic larynx treated with radiation therapy with curative intent from 1964 to 1997. All patients had follow-up for at least 2 years. No patients were lost to follow-up. RESULTS: The overall survival rate was 45% and the disease-specific survival rate was 67% at 5 years after initial diagnosis of carcinoma of the head and neck mucosal sites. Seventy-seven patients (7%) presented with synchronous carcinomas of the head and neck mucosal sites and 103 patients (9%) developed metachronous carcinomas of the head and neck mucosal sites at 0.6 to 21.7 years (median, 3.6 years). The overall survival rate was 31%, and the disease-specific survival rate was 50% at 5 years after metachronous carcinomas of the head and neck mucosal sites. Seven patients (1%) developed metachronous carcinomas of the thoracic esophagus at 1 to 11.1 years (median, 2.8 years), 15 patients (1%) presented with synchronous carcinomas of the lung, and 83 patients (7%) developed metachronous carcinomas of the lung at 0.6 to 17.6 years (median, 3.5 years). CONCLUSION: Development of synchronous and metachronous squamous cell carcinomas of the head and neck mucosal sites are in part responsible for failure to improve overall survival rates for patients with squamous cell carcinomas of the head and neck mucosal sites, justifying rigorous follow-up and studies on chemoprevention.     

An appraisal of pancreatectomy for advanced cancer of the pancreas based on survival rate and postoperative physical performance.

The follow-up results of surgical procedures for cancer of the pancreas at three affiliated hospitals during the past 15 years (1974-1989) were retrospectively analyzed to evaluate the merit of pancreatectomy in surgical treatment of advanced stages of this disease. Included were 4 cases of stage I, 14 cases of stage II, 19 cases of stage III, 43 cases of localized stage IV, and 35 cases of generalized stage IV. Pancreatectomy was performed in 67 cases; 100%, 92.9%, 89.5%, 67.4%, and 11.4% of the stage I, II, III, localized IV, and generalized IV cases, respectively. For the localized stage IV cases, in which the cancerous lesions were advanced but limited to the peripancreatic region, 29 pancreatectomies, 12 bypass operations, and 2 exploratory laparotomies were performed. This group included 17 curative and 12 noncurative pancreatectomies. The 50% survival periods were 257 days after curative pancreatectomy, 226 days after noncurative pancreatectomy, 120 days after bypass operation, and 33 days after exploratory laparotomy. The difference in overall survival rate between curative and noncurative pancreatectomies was not significant. The overall survival rates after both curative and noncurative pancreatectomies were significantly higher than the rate after bypass operation. The postoperative physical performance status after pancreatectomy was significantly better than after the palliative procedures. No significant difference in the status was found between patients after standard and extended pancreatectomies. There was no significant difference in the survival rates or the physical performance status between the pancreatectomy group and the palliative surgery group for the generalized stage IV cases, in which the cancerous lesions extended beyond the peripancreatic region. On the basis of these findings, it is concluded that pancreatectomy extends the postoperative survival period without impairment of the physical performance status in patients with advanced cancer of the pancreas. Even when the pancreatectomy proves to be a noncurative resection, this aggressive surgical approach may be of benefit to this group of patients. It should be noted, however, that pancreatectomy is not beneficial to patients whose lesions have already become generalized.     

术前新辅助化疗治疗浸润性膀胱癌疗效观察

目的:观察术前新辅助化疗治疗浸润性膀胱癌的临床疗效。方法:对27例平均年龄68岁、有全膀胱切除指征而无法耐受或不愿接受膀胱全切的浸润性膀胱癌患者行骼内动脉化疗并栓塞联合手术治疗,观察膀胱保留率、降级降期率、肿瘤复发率,Kaplan-Meier 法计算总生存率、无瘤生存率,并绘制生存曲线。结果:髂内动脉化疗、栓塞后,22例患者膀胱肿瘤缩小约81.5% ,无变化5 例;肿瘤临床分期降低21例（有效率77.8%）,无变化6 例;病理分级降低12例（降级率44.4%）,分级不变15例。共24例患者得以保留膀胱,其中21例行经尿道膀胱肿瘤切除术（transurethral resection of the bladder ,TURB）,3 例行膀胱部分切除术（膀胱保留率88.9%）。 3 例接受根治性膀胱全切术。术后1、2、3、5 年分别复发4 例（14.8%）、7 例（25.9%）、11例（40.7%）、14例（51.9%）。 2 例随访11个月和23个月发现肿瘤远处转移后死亡,1 例膀胱切口种植转移,局部切除后再发,带瘤生存,术后3 年死于肿瘤进展,2 例腺癌5 年内死于肿瘤进展。至随访截止日期,死于术后肿瘤进展共5 例。27例患者1、2、3、5 年无瘤生存率分别为88.9% 、73.6% 、58.1% 、41.4% ,5 年总生存率66.0% 。结论:有选择地对部分浸润性膀胱癌患者施行术前髂内动脉灌注化疗、栓塞,联合手术等综合性治疗措施以保留功能性膀胱确实可行,但合理评价其在浸润性膀胱癌治疗中的应用价值尚需要进一步研究证实。      

52例胰体尾癌的外科诊治分析

  目的  探讨胰体尾癌的诊断与临床治疗。  方法  回顾性分析天津医科大学附属肿瘤医院从2008年1月至2012年12月收治的52例胰体尾癌患者的临床资料, 包括诊断、治疗等。应用Kaplan-Meier方法计算中位生存期。Log-rank检验分析临床病理参数对预后的影响。  结果  38例行手术探查, 手术切除24例, 基本术式为胰体尾及脾切除术; 胰腺癌TNM分期: Ⅰ期5例（13.16%）, Ⅱ期19例（50%）, Ⅲ期5例（13.16%）, Ⅳ期9例（23.67%）; 根治术后胰体尾癌的中位生存时间为（18.0±1.23）个月, 接受姑息治疗、辅助治疗及无特殊治疗患者的中位生存时间为（10.0±2.71）个月。根治性切除者生存期明显长于非根治性切除者（P < 0.01）。  结论  早期诊断是获得长期生存的关键因素, 根治性切除是提高外科治疗效果的重要环节。      

A comparison of bone marrow transplantation with maintenance chemotherapy for patients with acute nonlymphoblastic leukemia in first complete remission

Twenty patients treated with maintenance chemotherapy for acute nonlymphoblastic leukemia after achieving complete remission were compared with 13 patients who underwent bone marrow transplantation from an HLA-identical sibling. The median age was 27 years for both maintenance chemotherapy patients (range 17-42 years) and for patients undergoing bone marrow transplantation (range 16-42 years). The 1-year survival for maintenance chemotherapy was 80% vs. 54% with bone marrow transplantation (p = NS). Complete remission durability was 70% at 1 year for maintenance chemotherapy (34% projected for 5 years) compared with no relapses in the first year with bone marrow transplantation (p = 0.01). Patients on maintenance chemotherapy were hospitalized for an average of 22 days (range 0-171 days) during the first 12 months of treatment. Patients undergoing bone marrow transplantation were hospitalized for an average of 82 days (range 41-113 days) in the same time period. Severe hematologic toxicity was seen in 13/13 bone marrow transplantation patients and 6/20 maintenance chemotherapy patients. Chronic graft-vs.-host disease occurred in 3/7 surviving bone marrow transplantation patients. Maintenance chemotherapy had an average first year cost of +3,076.00 for patients who did not relapse and +48,827.00 for patients that relapsed. The first year costs for bone marrow transplantation averaged +84,102.00. Thus, maintenance chemotherapy was associated with a better early survival, less toxicity, and lower cost than bone marrow transplantation in the first year after initiating therapy. However, fewer relapses with bone marrow transplantation suggest that it will yield a higher long-term survival rate.