Background. The benefits of preoperative chemotherapy and radiation for esophageal carcinoma are under investigation. A pilot study was undertaken to determine if pathologic assessment of tumor regression correlated with disease free survival. Methods. Ninety‐three resected specimens from patients treated with cis‐dichloro‐diamino cisplatin and irradiation before surgery were examined on semiserial sections. Patients selected for surgery were all Status 1 according to the World Health Organization (WHO) classification. Histologic typing was based on the WHO classification. Tumor regression grade (TRG) was quantitated in five grades: TRG 1 (complete regression) showed absence of residual cancer and fibrosis extending through the different layers of the esophageal wall; TRG 2 was characterized by the presence of rare residual cancer cells scattered through the fibrosis; TRG 3 was characterized by an increase in the number of residual cancer cells, but fibrosis still predominated; TRG 4 showed residual cancer outgrowing fibrosis; and TRG 5 was characterized by absence of regressive changes. Survival curves were estimated according to the Kaplan‐Meier method. A quantification of the relationship between treatment failure and confounding variables (age, tumor location, tumor size, esophageal wall involvement by residual cancer and/or regressive changes, histology, treatment, adequacy of surgery, pathologic lymph node status, and tumor regression grade) was done using Cox's proportional hazards model. Results. Forty‐two percent of specimens were TGR 1–2; 20%, TGR 3; and 33%, TGR 4–5. Univariate analysis found that tumor size, pathologic lymph node status, tumor regression grade, and esophageal wall involvement were highly correlated with disease free survival (P > 0.05). After multivariate analysis, only tumor regression (i.e., TRG 1–3 versus TRG 4–5) remained a significant (P > 0.001) predictor of disease free survival. Conclusions. This study highlights the importance of tumor regression in the survival of patients with esophageal carcinoma treated with preoperative chemoradiotherapy. These findings suggest that tumor regression grade should be considered when evaluating therapeutic results. Cancer 1994; 73:2680–6.

Objective: Whether lymph-node dissection (LND) influences the lymph-node recurrence (LNR) risk in patients with papillary thyroid cancer remains controversial. The prognostic impact of macroscopic and microscopic lymph-node involvement at diagnosis is also an unresolved issue. A retrospective study was conducted to assess the influence of various LND procedures and to search for LNR risk factors. Methods: Overall 545 patients without distant metastases prior to surgery and main tumour R10 mm were included. A total thyroidectomy was performed in all patients with either no LND (Group 1, nZ161), bilateral LND of the central and lateral compartments (Group 2, nZ181) or all other dissection modalities (Group 3, nZ203). Post-operative radioiodine was given to 496 (91%) patients. The 10-year cumulative probability of LNR was assessed and a prognostic study using multivariate analysis was performed. Results: Macroscopic lymph-node metastases were present in 118 patients, 57 diagnosed before surgery and 61 only at surgery (including 81% in the central compartment). Overall, the 10-year cumulative probability of LNR was 7%. Macroscopic lymph-node metastases (PZ0.001), extra-thyroidal invasion (PZ0.017) and male gender (PZ0.05) were independent risk factors, while bilateral LND of the central and lateral compartments was protective (PZ0.028). In patients with macroscopic lymph-node metastases, the 10-year probability was lower in Group 2 than in Group 3 (10% vs 30%, P!0.01). In patients without macroscopic lymph-node metastases (nZ427), no significant differences were observed between the three LND groups. Conclusions: Patients with macroscopic, but not microscopic, lymph-node involvement have a major LNR risk and need an optimal LND at primary surgery.

Concerns remain over the risk of cancer following differentiated thyroid carcinoma and its causes. Iodine-131 ((131)I) and external irradiation are known to have potential carcinogenic effects. Thyroid carcinoma is a polygenic disease which may be associated with other malignancies. We investigated the incidence of second cancer and its aetiology in a cohort of 875 patients (146 men, 729 women) with differentiated thyroid carcinoma originating from Basse-Normandie, France. Cancer incidence was compared with that of the general population of the Département du Calvados matched for age, gender and period. The cumulative proportion of second cancer was estimated using the life-table method. Factors that correlated with the risk of second cancer were studied using the Cox model. After a median follow-up of 8 years, 58 second cancers had been observed. Compared with general population incidence rates, there was an overall increased risk of second cancer in women [standardised incidence ratio (SIR)=1.52; P<0.01], but not in men (SIR=1.27; P>0.20). Increased risk related to cancers of the genitourinary tract (SIR=3.31; P<0.001), and particularly to cancer of the kidney (SIR=7.02; P<0.01). Multivariate analysis showed that age above 40 years (P<0.01) and a history of previous primary cancer (P<0.001) correlated with risk. In contrast, neither cervical irradiation nor cumulative activity of (131)I was related to the risk. These data confirm that women with differentiated thyroid carcinoma are at risk of developing a second cancer of the genitourinary tract and kidney. Only age and medical history of primary cancer before thyroid carcinoma are risk factors for second cancer. Common environmental or genetic factors as well as long-term carcinogenic effects of primary cancer therapy should be considered.

Elective laparoscopic sigmoidectomy for diverticulitis is feasible and is safe. The complication and mortality rates are similar to those observed after open procedures. For experienced surgical teams, laparoscopic colonic resection is a good approach for selected patients suffering from symptomatic diverticulitis.

We conducted a retrospective multicenter study by questionnaire to evaluate the results of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP). Between 1991 and 1998, 209 patients with a mean age of 41.2 years (range, 10-83) had a laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Preoperatively, 178 patients (85%) underwent medical treatment aimed at achieving a satisfactory platelet count. Twenty-nine patients were obese, with a body mass index greater than 30%, and 14% were HIV-seropositive. The so-called hanging spleen technique in the right lateral decubitus position was used most often. The average duration of surgery was 144 minutes (45-360). This was significantly longer in cases of conversion (170 minutes; P < 0.01). The factors influencing the duration of laparoscopy were operator experience and patient obesity (P < 0.01). A conversion was necessary in 36 cases (17.2%) because of hemorrhage. The conversion rate varied from 5.3% to 46.7%, depending on the surgical team. A multivariate analysis of factors disposing to conversion identified two causes: obesity and operator experience. One or more accessory spleens were found in 34 patients (16.2%). The average weight of the spleens was 194.2 g. There were no deaths. There were no complications in 187 patients (89.5%), with a mean hospital stay of 6.1 days. Patients who did not require a conversion had a significantly earlier return of intestinal transit, used less analgesic, and had a shorter length of hospitalization. Overall morbidity was 10.5% (22 cases), due to subphrenic collections (7 cases), abdominal wall complications (6 cases), re-intervention for actual or suspected hemorrhage or pancreatitis (3 cases), pneumopathology (2 cases) and others (4 cases). A multivariate analysis about morbidity shows a statistically significant difference in conversions (P < 0.05) but not in obesity or in surgeon's experience. Normal activity was achieved on average by the twentieth postoperative day--earlier if conversion was not required (18.4 versus 33.9 days). The average preoperative platelet count was 92.7 x 10(9)/L (range, 3 to 444). Twenty patients had a count of less than 30 x 10(9)/L and in this group the conversion rate was 30% (6 cases). Ninety-six patients were seen in the outpatient clinic, with an average follow-up time of 16.2 months (3 to 72 months), and the average platelet count was 242 x 10(9)/L (6 to 780). Eight patients (8.3%) were failures with a platelet count of <30 x 10(9)/L. In the 20 patients with a preoperative platelet count <30 x 10(9)/L, there were 3 early failures and 5 late relapses. There were 2 late deaths: chest infection at 3 months in an HIV seropositive patient and one case of pulmonary embolus at 6 months. Laparoscopic splenectomy constitutes a real alternative to conventional splenectomy for the treatment of idiopathic thrombocytopenic purpura. It is associated with fewer postoperative complications, a shorter duration of hospitalization and an earlier return to normal activity. The limiting ...