Pericardial and Pleural Effusion after Central Venous Line Insertion

A large volume of fluid collected in the pericardium and left pleural space following central venous catheter insertion for total parenteral nutrition in a 35-year-old man. This did not cause fatal hemodynamic compromise and was successfully diagnosed and treated.

Electroejaculation With a Foley Catheter in the Bladder

Electroejaculation has been successfully used for sperm procurement in anejaculatory men desiring fertility. The electroejaculation procedure begins with complete catheterization of the bladder and instillation of an insemination medium into the bladder as a buffer. This step can minimize possible detrimental effects of urine on any retrograde ejaculate. The catheter is then removed. After the collection of the antegrade ejaculate, the bladder is catheterized again. Our objective was to evaluate the possibility of performing electroejaculation while the Foley catheter is instilled in the bladder. Eleven men with anejaculation underwent 22 procedures of rectal probe electroejaculation. Each patient underwent electroejaculation twice, once without the catheter instilled in the bladder (standard method) and once with it. The 2 methods, with and without the catheter, showed no significant differences in volume, concentration, motility, count, and total motility of the antegrade ejaculate. In retrograde ejaculate, there were no significant differences in the count, motility, and total motility. In addition, there was no difference in the total count and the total motility of both fractions in the 2 methods. In this study, we show that ejaculation can be achieved while the Foley catheter is instilled in the urethra without any detrimental effect on the sperm. Therefore, we recommend not removing the Foley catheter while performing electroejaculation.

Resection margins in ultrasound-guided breast-conserving surgery

BACKGROUND

Few published studies have shown the benefits of intraoperative ultrasound in avoiding inadequate margins in breast-conserving surgery. The aim of this study is to quantify intraoperative ultrasound margin size and assess its relationship to tumor size, multifocality, palpability, histology, and presence of intraductal component.

METHODS

Patients with breast cancer undergoing breast-conserving surgery in whom the operating surgeon visualized the tumor by ultrasound were included. Ultrasound margins measured intraoperatively were prospectively recorded and compared with pathology margins.

RESULTS

Forty-five patients with 48 tumors were included. Twenty five patients (56%) had palpable tumors. Pathologic mean tumor size was 1.9 cm [95% confidence interval (CI) 1.6-2.2 cm, range 0.5-4.8 cm]. There was good correlation between closest margins recorded by ultrasound and pathology margins (r = 0.4674, P < 0.0008). Fourteen patients (31%) had margins re-excised intraoperatively, 12 of them in the direction of the closest pathological margin. Three patients (7%), all of whom had intraoperative re-excision, had a second operation for involved margins without residual cancer on pathological examination of the reoperative specimens. Ultrasound margins ≥0.5 cm achieved adequate pathology margins of ≥0.2 cm in 95% of margins. Overestimation of pathology margins by ultrasound measurement was significantly affected by multifocality (P = 0.0473). Tumor size, palpability, invasive lobular histology, and presence of ductal carcinoma in situ (DCIS) did not cause significant overestimation of pathology margins by ultrasound.

CONCLUSIONS

Intraoperative ultrasound may help maintain a low level of reoperation after breast-conserving surgery. Ultrasound margins <0.5 cm should be re-excised intraoperatively. Reliability of ultrasound in predicting the closest pathology margins was diminished in patients with multifocal tumors.

Comparison between the first and the second electroejaculate qualities obtained from neurologically intact men suffering from anejaculation

BACKGROUND

Electroejaculation is an artificial method used to procure semen from neurologically intact men suffering from anejaculation that have failed other treatments. In order to establish the consistency of semen parameters in repeated electroejaculations, we compared retrospectively the quality of the first and the second electroejaculates of anejaculatory men who were not suffering from any known neurological problems.

METHODS

Between 1995 and 2004, 59 neurologically intact men suffering from anejaculation underwent multiple electroejaculations. Sperm quality of the first and the second ejaculates was compared.

RESULTS

A significant difference of 0.33 +/- 0.16 ml in the volume of the antegrade portion was found (P = 0.023). The results showed no significant difference in the concentration, motility, count and total motile count of the antegrade ejaculates. In retrograde ejaculates there were no significant differences in the count, motility and total motile count. Neither was there any difference in the total count and the total motile count of both fractions.

CONCLUSIONS

Electroejaculation is a reliable method for semen procurement in men suffering from anejaculation. Since semen parameters are consistent, repeated procedures are not justified for improving the sperm quality in anejaculatory, neurologically intact men.

Preoperative and postoperative levels of interleukin-6 in patients with acute appendicitis: comparison between open and laparoscopic appendectomy

BACKGROUND

Cytokine interleukin-6 (IL-6) is an early marker of systemic inflammatory response and tissue damage. This study aimed to evaluate the levels of IL-6 after open and laparoscopic appendectomy to compare the degree of surgical stress associated with these procedures.

METHODS

The levels of IL-6 were measured pre- and postoperatively in the plasma of 37 consecutive patients with a diagnosis of acute appendicitis. After preoperative randomization, 22 patients underwent open appendectomy, and 15 patients underwent laparoscopic appendectomy.

RESULTS

The preoperative concentrations of IL-6 were 7.2 +/- 5.6 pg/ml in the open appendectomy group, as compared with 12.1 +/- 9.7 pg/ml in the laparoscopic appendectomy group (p < 0.05). The postoperative levels were 16.9 +/- 15.7 and 23.2 +/- 19.4 pg/ml, respectively. The mean postoperative to preoperative ratio of IL-6 was slightly higher for open (2.7 +/- 2.4) than for laparoscopic (2.3 +/- 1.6) appendectomy, but the difference did not reach statistical significance.

CONCLUSION

The operative stress in open as compared with laparoscopic appendectomy is not reflected by circulating levels of IL-6.

Validation of a new classification system for curatively resected colorectal adenocarcinoma

BACKGROUND

The parameters within which colorectal adenocarcinoma is currently staged are often insufficient for decisions regarding therapy after potentially curative surgery. Consequently, oncologists make frequent use of additional prognostic indicators when assessing individual prognosis and selecting patients for adjuvant systemic treatment. Follow-up programs are generally uniform for all patients, regardless of disease stage and prognosis. As a result, patients with a favorable prognosis are needlessly subjected to stressful, costly follow-up too early and too frequently. This study was conducted to validate a new classification system that is a superior predictor of individual prognosis following curative surgery and may serve as a guide for personalized, cost-effective postoperative management and follow-up.

METHODS

A total of 231 American colorectal carcinoma patients who underwent curative resection were retrospectively staged according to a new classification (containing 4 stage-groups) for curatively resected colorectal adenocarcinoma. This classification is based on statistical analysis of the impact on prognosis of numerous characteristics of 363 consecutive Israeli colorectal carcinoma patients who underwent curative resection. All the patients in both cohorts had had surgery at least 5 years previously. The new classification is based on three histologic variables (venous invasion, depth of primary tumor penetration, and regional lymph node status) and a scoring system that correlates higher numeric score with worse prognosis. In both cohorts, the new classification was compared with the Dukes, Astler-Coller, and TNM staging systems for patient distribution and survival (both disease free and cancer-related survival).

RESULTS

In both cohorts, the 4 stage-groups of the new classification differed significantly in both the rate of and the time to first recurrence and cancer-related death, with progression from Group 4 to Group 1. Groups of high risk lymph node negative patients were defined, and lymph node positive patients were subdivided according to prognosis. It is suggested that, by using this new classification as a guide, selection for adjuvant systemic treatment may be refined, and postoperative follow-up may be personalized and therefore more cost-effective.

CONCLUSIONS

The new classification for curatively resected colorectal adenocarcinoma, based on an analysis of the Israeli cohort and validated in the American cohort, is superior to the Dukes, Astler-Coller, and TNM staging systems as a predictor of individual prognosis, most probably because it incorporates the microscopic forerunner of distant, hematogenous spread (i.e., venous invasion) with the locoregional parameters of extent of disease (i.e., T and N values). It is suggested that the new classification may serve as a guide for more refined selection of patients for adjuvant systemic treatment and for individualized and more cost-effective postoperative follow-up. The new classification is simple and easy to use, requires no sophisticated equipment or tests, and can be applied in any health care system worldwide.

New approach to the substaging of node-positive colorectal adenocarcinoma

BACKGROUND

Future developments in adjuvant modalities may require substaging of node-positive colorectal adenocarcinoma that is accurately indicative of individual prognoses, upon which therapeutic decisions (e.g., choice of agents and intensity of treatment) may be based. This study compares substaging of node-positive colorectal cancer by venous invasion with substaging by three currently used methods, with respect to the ability of each method to define patient subsets that differ significantly in both disease-free and cancer-related survival rates.

METHODS

A total of 171 patients with node-positive colorectal cancer, who had undergone potentially curative resection at least 5 years earlier, were retrospectively substaged by the tumor, node, metastasis (TNM) N1/N2, Astler-Coller C1/C2, Gastrointestinal Tumor Study Group (GITSG) C1/C2, and venous invasion (positive/negative) methods. Disease-free and cancer-related survival curves were calculated (by the Kaplan-Meier method) and compared for statistical significance (using the log-rank test).

RESULTS

The separation of disease-free and cancer-related survival curves using the four methods of substaging node-positive colorectal cancer was as follows: TNM, P = .16 (not significant) and P = .12 (not significant); Astler-Coller, P < .01 and P = .006; GITSG, P = .067 (not significant) and P = .03; venous invasion, P = .016 and P = .007, respectively.

CONCLUSIONS

Numerical substaging of node-positive colorectal cancer (TNM and GITSG methods) is an inferior predictor of prognosis, compared with substaging by the T value (Astler-Coller) or venous invasion methods. We think that the latter method is the method of choice, because it separates patients who have only lymphatic metastasis from patients who display microscopic hematogenous spread as well. This separation obviously has biological/oncological significance, and it may have practical therapeutic implications in the future.

Efficacy of the topical anesthetic cream, EMLA, in alleviating both needle insertion and injection pain

To assess the efficacy of the topical anesthetic cream, EMLA, in alleviating the pain produced by infiltration of local anesthetic prior to surgical skin biopsies, a randomized, double-blind, placebo-controlled study was performed on 54 patients undergoing 162 excisional biopsies. Both pain induced by needle insertion and pain induced by local injection were significantly diminished after topical application of EMLA cream. However, part of the effect was placebo, because the placebo ointment (Vaseline) also produced significant pain alleviation.

Plasma and tumor prolactin in colorectal cancer patients

Fifteen consecutive patients with recently diagnosed colorectal cancer were studied for plasma and tumor tissue prolactin content. In eight patients (four men and four postmenopausal females), preoperative high plasmatic prolactin was found (mean 1553 nmol; range 516-3677 nmol). In three of them, prolactin was also present in the tumor cells. All plasma prolactin levels returned to normal after tumor resection and remained so during a three-month follow-up. The tumor stage by Duke distribution was similar for both high and normal plasmatic prolactin patients. The role of prolactin in the pathogenesis of colorectal cancer, and as a marker of the tumor, remains to be established. This is the first time that prolactin has been detected in human colon cancer.