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In situ phosphorous MRS was employed to study the metabolites of normal and cancerous breasts, and the alterations of tumor response to therapy. In a group of 7 normal volunteers and 12 patients, the total mobile phosphate content of breast carcinomas was found to be at least two to three times higher than that of the normal breast measured off menstruation. The metabolite profiles of normal and tumorous breasts are coarsely similar. In both cases the intracellular pH (pHi) was either neutral or slightly alkaline (pH greater than 7.0). Prior to treatments, the metabolite levels of phosphoryl monoester-to-ATP ratio of breast neoplasms were higher than those of the controls and decreased after the patients received a few treatments while the pHi fluctuated at a value greater than 7.0. The phosphoryl diester-to-ATP ratio also demonstrated to a lesser extent a decreasing trend in response to therapy.

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Thirty-five human neoplasms from various sites and of various histologic types and stages were examined with phosphorus-31 magnetic resonance spectroscopy in situ. The tumors included 13 squamous cell carcinomas of the head and neck (lymph nodes), eight Hodgkin lymphomas, six non-Hodgkin lymphomas, four carcinomas of the breast, one melanoma, one sarcoma, one neuroblastoma, and one mucoepidermoid sarcoma of the salivary glands. Thirty-four of the neoplasms had normal to slightly alkaline pH before irradiation. During fractionated radiation therapy, the pH stayed in a range of from near neutral to alkaline and rose to 7.6-8.0 at several time points of radiation therapy for some tumors. These results suggest that most tumor cells in human neoplasms are well oxygenated and that only a negligible fraction are chronic hypoxic cells. The fluctuating alkaline pH during radiation therapy occurred regardless of the responsiveness of the treated tumors.

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Data on 126 consecutive patients with periampullary tumors resected at the Cleveland Clinic between January 1950 and December 1984 were reviewed. One hundred five patients underwent pancreatoduodenal resection, 10 patients total pancreatectomy, and 11 patients local resection of the tumor. The site of tumor was ampulla of Vater (59), head of the pancreas (30), duodenum (20), and distal common bile duct (11). Six patients had benign disease. The operative mortality rate for radical resection for the entire period was 7.8%; it has declined to 5.4% since 1974. The operative mortality rate for local resection was 9.1% (one patient). The overall 5-year survival rate for all malignant tumors of the periampullary area was 28% and 25.5% for invasive adenocarcinoma. Survival was affected primarily by location and histologic findings. The 5-year survival rate for adenocarcinoma of the ampulla of Vater was 37.2%, 27.5% for the duodenum, 16.7% for the distal common bile, and 4.3% for the pancreas (p = 0.0001). Papillary adenocarcinoma had a 5-year survival rate of 49.2% in contrast to 18.4% for nonpapillary ductal adenocarcinoma (p = 0.002). Patients with ampullary adenocarcinoma treated by local resection had a 5-year survival rate of 40.9%. These data justify continued use of a selective radical approach in the resection of most periampullary tumors with local resection for small tumors in high-risk patients.

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Pancreatic heterotopia is a developmental anomaly. When it produces complications, symptoms depend on the site of the lesion and may reflect the whole range of pathology affecting pancreatic tissue. In the ileum, pancreatic heterotopia is usually associated with a Meckel's diverticulum and may cause intestinal obstruction by intussusception. Isolated ileal pancreatic rests are rare and usually are discovered incidentally during surgery for other conditions. A case of a polypoid mass in the ileum containing aberrant pancreatic tissue that had been causing recurrent small bowel obstruction is described. Resection and primary anastomosis were curative.

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A retrospective study was performed on 89 patients who underwent total colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis between the years 1957 and 1977 in order to determine the risk of developing cancer of the rectum. The 30-day operative mortality rate was 0%. Of the 84 patients available for follow-up study, four patients, (4.8%) developed a carcinoma of the rectum. The risk of cancer per patient-year was zero in the first decade, 1/206 in the second decade, and 1/116 in the third decade. The cumulative risk of developing cancer was 0% at 10 years, 2.1% +/- 2.1% at 15 years, 5.0% +/- 3.5% at 20 years, and 12.9% +/- 8.3% after 25 years of disease. Patients with cancer or precancer in the colon at the time of colectomy appear to be at high risk for the later development of rectal cancer.

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An unusual case of systemic mastocytosis with splenomegaly, portal hypertension, and bleeding esophageal varices is presented. Arteriograms and liver biopsy suggested the mechanism of the portal hypertension was due to increased blood flow in the splenic vein, although splenic arteriovenous shunting secondary to histamine release and increased intrahepatic resistance secondary to mast cell infiltration might have played a role. The portal hypertension was relieved by splenectomy.

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Three patients with pancreatic fistulae were given parenteral 10% fat emulsion (Intralipid) to study the effect of intravenous fat on pancreatic fistula output. Each patient received nutritional support with isovolumetric, isonitrogenous, and isocaloric solutions containing either hypertonic dextrose and amino acids, or hypertonic dextrose, amino acids, and a fat emulsion. Measurements of fistula volume, fistula amylase, lipase, and chloride concentrations, and fistula trypsin activity were performed. The patients were studied for periods of 10 to 26 days. No significant increases in any of the above parameters were noted during the periods when the fat emulsions were infused. In one patient the fistula closed spontaneously. We conclude that intravenous fat emulsions may be used to provide nutritional support for patients with pancreatic fistula without increasing pancreatic juice volume or enzyme content.

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The history and current status of home total parenteral nutrition are reviewed. Patients without a functional intestinal tract are able to lead a relatively normal life, infusing their essential nutrients through a Silastic central venous catheter while they sleep at night. The average catheter life is nine months. Suspected sepsis and obstruction of the catheter were the leading causes for catheter removal.

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Home hyperalimentation is now recognized as a technique which allows patients with severe short bowel syndrome or inflammatory bowel disease to return to a near normal life style. The success of this program is dependent on the longterm use of a catheter through which intravenous fluids are infused. In the past 20 months, we have inserted 32 catheters into 22 patients for purposes of home parenteral nutrition. In a 1 to 20-month follow-up, the average duration of catheter insertion was 6 months, the longest has been 19 months in 2 patients. One patient with superior vena cava thrombosis has had a catheter inserted via a femoral vein which has been functioning well for 5 months. Thirteen catheters have been removed: 3 for obstruction, 2 for sepsis, 1 due to breakage of the catheter, 4 for slippage (3 were pulled out by the patient, and 1 was removed because of inability to psychologically accept the presence of the catheter). The removal of 6 of these 13 catheters was necessitated by breaks in the proper techniques of catheter care, which include daily dressing changes and heparinization of the catheter at least once daily. Techniques of catheter insertion and catheter care will be presented

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In a patient with nonpalpable carcinoma of the breast, the diagnosis from a metastalic axillary node was made by measuring estrogen receptor protein (ERP). The specificity of the technique makes it useful as a diagnostic aid in a patient with mammogram negative for tumor.

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