Between 1977 and 1984, 92 patients with clinical Stage II non-seminomatous germ-cell testicular tumours were treated by primary chemotherapy, with surgery reserved for the excision of persisting masses. Eighty patients (87%) are alive and disease-free: 96% for Stages IIA and IIB and 74% for Stage IIC. Of 43 Stage IIA, B and C patients treated with bleomycin, etoposide and cisplatin (BEP), 40 (93%) are disease-free. For the whole group there was a significant difference between the outcome of treatment in patients with retroperitoneal masses greater than 8 cm in transverse diameter compared with those in whom masses were less than 8 cm, the disease-free rates being 54 and 97% respectively. Primary histology did not influence the outcome of treatment. However, whereas 51% of patients with teratocarcinoma had masses resected after chemotherapy, only 26% of embryonal carcinoma patients came to surgery. The results obtained in this series are as good as those obtained when lymph node dissection is employed as the initial form of treatment. The avoidance of surgery with preservation of ejaculatory function in 78% of Stage IIA and IIB patients argues in favour, of an initially non-surgical approach to management.
Thirty-seven patients with advanced non-Hodgkin's lymphoma who were treated by total-body irradiation (TBI) at the Royal Marsden Hospital are reviewed. Twenty-four patients had received no previous therapy; 13 patients were in relapse. The overall response rate was 73% for nodular lymphomas and 80% for those with diffuse disease. THe duration of complete response ranged from two to 41 months (median 12 months). Subsequent chemotherapy was given successfully except in patients with prolonged thrombocytopenia which appeared to be related to an initially involved bone marrow. Hemibody irradiation (HBI) was the least myelosuppressive form of TBI and is now being used in complete remission following chemotherapy.
Abstract A series of 310 patients with Hodgkin's disease having a staging laparotomy under the care of one surgeon (J-C. G.) between October 1969 and June 1980 is presented. A total of 51 per cent had positive laparotomy findings, and 30 per cent had their staging altered, but there was a low incidence of positive laparotomy findings when performed within 2 months of initial treatment by chemotherapy. None of the investigations used to determine possible splenic or hepatic involvement preoperatively was found to be of any value, and their routine use is not recommended. Bipedal lymphography was found to give an accurate assessment of iliac and lower para-aortic nodal involvement, and so the laparotomy protocol since 1975 has not included biopsy of these nodes. The incidence of minor complications was 31 per cent and of major complications 4 per cent. One patient died. Staging laparotomy has played an important part in the management of Hodgkin's disease over the past decade, but it is likely to assume a less prominent role in the 1980s as the role of chemotherapy in early Hodgkin's disease expands. In non-bulky clinical stage I and II Hodgkin's disease, when radiotherapy alone is curative, then a staging laparotomy is justifiable because it will detect occult abdominal disease, especially in the lymphogram-negative patient, which may require the addition of chemotherapy or more extensive radiotherapy. Laparotomy is essentially an operation to remove the spleen and to obtain adequate liver biopsy specimens in order to ascertain possible involvement of these two organs. Non-opacified nodes at the porta hepatis and coeliac axis should also be sampled, as should a node from the poorly opacified upper paraaortic area. Routine oophoropexy is not recommended.
Thirty-three patients with malignant testicular teratomas and para-aortic metastases exceeding 2 cm in diameter have been treated with radiotherapy, chemotherapy (vinblastine and bleomycin, with or without cis-platinum) or both, followed by surgical excision of the residual para-aortic mass. Removal of a poorly functioning ipsilateral kidney was necessary in 7 cases (21%) and a segment of vena cava was resected in 2 (12.5%) of 16 patients with primary right-sided tumours. Removal was incomplete in only one patient, who had femoral nerve root involvement, and he subsequently died of secondary haemorrhage (operative mortality 3%). Undifferentiated tumour was found in 8 (61%) of 13 patients (Group 1) after radiotherapy, compared with only 2 (15%) of 13 (Group 2) after chemotherapy and radiotherapy, and 4 (57%) of 7 (Group 3) who had chemotherapy only prior to surgery; however, 3 of the Group 3 patients were referred because of evidence of activity in the para-aortic region.
Summary— Forty‐one patients with advanced non‐seminoma germ cell testicular tumours were treated by chemotherapy, with or without radiotherapy, followed by excision of residual para‐aortic lymph node masses. All para‐aortic metastases were initially greater than 2 cm, 35 were larger than 5 cm, and 9 were over 10 cm in diameter. Seven patients also had nodal deposits above the diaphragm and 1 8 had distant metastases. The residual masses were excised completely in all except 3 cases. Residual malignancy was found in 7 (1 8%) of 38 operable cases; of these 7, only 2 remain alive and disease‐free. In contrast, 28 (90%) of 31 operable cases with necrosis and fibrosis, or with fully differentiated teratoma, are alive and disease‐free. Elevated serum markers were found in 6 of 9 cases with respectable or unrespectable residual malignancy, but in only 1 of 32 who were tumour‐free. Residual malignancy was found in 3 (9%) of 34 cases with normal marker levels. Malignancy was not found in any residual mass less than 4 cm diameter. We conclude that excision of para‐aortic lymph node masses should be electively delayed until seium markers become normal and until shrinkage of the mass has ceased. The presence of residual malignancy in the excised tissue then provides a clear indication for further chemotherapy.
A curriculum in oncology for medical students in Europe is proposed. The proposals are presented with the unanimous approval of the deans of undergraduate medical schools and oncologists from 17 European countries who attended an EC/EORTC Workshop in Bonn in May 1988. The proposals arise as a response to the recognised deficiency of undergraduate cancer education in many medical schools and the pressing need to ensure that newly qualified doctors possess the necessary skills and knowledge to participate in cancer prevention, early diagnosis and curative and palliative management. The proposals concern both basic science and clinical practice, stressing the need for bedside teaching, instruction in the multi-disciplinary nature of cancer care and the elimination of bias towards particular disciplines. To achieve the objectives it is proposed that each medical school shall have an undergraduate teaching programme in oncology. A detailed prescription for an undergraduate curriculum is not attempted but rather a frame-work provided that should be adopted regardless of national and local differences in medical educational practice.
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