Exophytic condyloma: are they as benign as we think?

AIM

As the understanding of anal dysplasia continues to develop, controversy remains regarding treatment of these lesions. The purpose of this study was to evaluate lesion type (flat vs exophytic) and the association between morphology and dysplasia.

METHODS

This was a single-centre retrospective analysis of a prospectively collected pathological database of patients > 17 years old who underwent operative excision/biopsies for presumed anal condyloma or dysplasia from 2009 to 2018. The analysis includes comparisons between patient factors, phenotype and grade of dysplasia.

RESULTS

Sixty-nine patients had 423 lesions. The mean age of the study population was 48.2 years. 62.3% were men and 46.4% of patients were black. 47.8% of patients were human immunodeficiency virus (HIV) positive and 39.1% were men who have sex with men (MSM). There were 176 (41.6%) flat lesions and 234 (55.3%) exophytic lesions. Exophytic lesions were 2.5-fold more likely to be associated with a higher grade of dysplasia than flat lesions (OR 2.63, 95% CI 1.09-6.32). Neither lesion type nor dysplasia severity was associated with human papillomavirus, lesion location or patient characteristics, including race, MSM or HIV status.

DISCUSSION

Exophytic lesions were more than twice as likely to have advanced dysplasia compared with flat lesions. A clearer understanding of the association between gross lesion appearance and dysplasia will allow more appropriate counselling of patients and the development of better screening and treatment guidelines for anal condylomata and dysplasia.

Is sarcopenia a better predictor of complications than body mass index? Sarcopenia and surgical outcomes in patients with rectal cancer

AIM

Sarcopenia, or a reduction of lean muscle mass, is associated with poorer outcomes in cancer patients. Few previous studies have examined this potentially correctable risk factor in patients with locally advanced rectal cancer.

METHOD

Skeletal muscle mass index was measured retrospectively on initial staging CT scans of patients undergoing chemoradiation followed by radical resection for rectal cancer for the period 2007-2013. Patients were categorized as sarcopenic or nonsarcopenic and differences in terms of demographics, pre-, peri- and postoperative outcomes were examined.

RESULTS

Forty-seven patients were included; their mean age was 59.3 (36-82) years and 61.7% were men. We considered that 55.2% of men and 44.4% of women were sarcopenic; the overall prevalence of sarcopenia was 51.1%. Age, preoperative haemoglobin and albumin were significantly related to sarcopenia. Body mass index (BMI) and obesity (BMI > 30 kg/m² ) were not associated with sarcopenia. Blood transfusions were more frequent in sarcopenic patients (P = 0.001). Although readmissions and length of stay were not increased, overall postoperative complications were significantly higher in sarcopenic patients (P = 0.03). Neither BMI nor obesity was associated with postoperative complications.

CONCLUSION

Sarcopenia was present in over 50% of patients with locally advanced rectal cancer at diagnosis. It was associated with a higher incidence of both blood transfusion and postoperative complications. BMI did not correlate with these negative outcomes. Sarcopenia may be a better predictor of surgical outcomes than BMI or obesity.

Leflunomid reduziert den Angiogenesescore und das Tumorwachstum subkutan implantierter Kolonkarzinomzellen im Mausmodell

BACKGROUND

The inhibition of tumorangiogenesis may be of importance in the additive treatment of various cancers. Leflunomide, a drug which has been approved in Germany for the therapy of rheumatoid arthritis, inhibits the activity of several growth factors in vitro. The aim of this study was to investigate the effects of the drug on tumor angiogenesis in a nude mouse model.

MATERIALS AND METHODS

A total of 40 nude mice were injected with human colon carcinoma cells. Following randomization in 4 groups, therapy started on day five. Group 1 was treated daily with orally administered Leflunomide (35 mg/kg) dissolved in 1.5% Carboxymethylcellulose (CMC). Group 2 served as a control group and received 1 ml CMC orally per day. The animals of group 3 were treated daily with 35 mg Leflunomide/kg KG and 500 mg Uridine/kg dissolved in 1 ml Nacl 0.9% intraperitoneally. The 4th group again served as a control group and received only 500 mg Uridine/kg intraperitoneally each day. The main outcome criterion was the angiogenesis score (AS). In addition, the tumor volume and tumor weight were also assessed. The AS was determined by immunohistochemistry using an antibody against factor VIII related antigen.

RESULTS

All animals tolerated the procedure well. In the Leflunomide and the Leflunomide/Uridine group the angiogenesis score (p < 0.01), the tumor volume (p < 0.01) and the tumor weight (p < 0.01) were lower compared to the respective control groups.

CONCLUSION

The administration of Leflunomide leads to a significant reduction of tumor weight and tumor volume following subcutaneous injection of human colon carcinoma cells in a nude mouse model. This could be due to the reduction of tumor angiogenesis. Following further experimental and clinical studies, Leflunomide may come to play a role in the additive treatment of colonic carcinoma.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery, or TEM, is a technique that can be used for the treatment for early staged rectal cancer. This technique utilizes carbon dioxide insufflation through a 40 mm rectoscope to create better endoscopic visualization of the operative field. TEM has been praised for its access to middle and upper-third rectal cancers. However, one limitation of TEM is its inability to address local lymph node involvement. Therefore, an adequate preoperative assessment is crucial before using TEM as a curative modality. TEM can be used to remove virtually any benign lesion that can be brought into view. In addition, there are several studies that have shown TEM is a safe and effective way to treat T1 cancers and may have a role in the treatment of T2 and T3 cancers when combined with radiation and chemotherapy. TEM has lower recurrence rates, faster recovery, and fewer complications when compared to other local excision techniques and radical surgeries. The future of TEM is growing in acceptance as more surgeons learn to master this technique.

Liver resection for colorectal cancer: liver metastases in the aged

The purpose of this study was to determine the morbidity and mortality in elderly patients undergoing liver resections for metastatic colon cancer and compare them with those of a control group of younger patients. The charts of all patients undergoing liver resection for colon cancer were retrospectively reviewed. Patients less than 70 years of age (Group A) were compared with patients 70 years of age or older (Group B). Between 1971 and 1995, 167 liver resections were performed for metastatic colorectal cancer. Of these, 41 patients were in Group A and 126 patients were in Group B. The mean age of Group A was 74.5 years, and that of Group B was 57 years. American Society of Anesthesiologists (ASA) classification was similar for both groups (Groups A and B were 75.6% and 81.1% ASA class II, respectively). Anatomic resections were performed in 49 per cent and wedge resections in 51 per cent of patients in Group A, and 68 and 32 per cent in Group B, respectively. Estimated blood loss was slightly less for Group A (1575 vs 1973 cm3), as was operative time (4.0 vs 4.7 hours). In-hospital mortality rate was 7.3 per cent for Group A and 2.4 per cent for Group B. The major morbidity rates were 29 and 17.5 per cent, respectively. Intensive care unit care was necessary in 73 per cent (mean length of stay 3.9 days) for Group A and 62.6 per cent (mean length of stay 2.0 days) for Group B. The average length of hospitalization was 13.1 days for Group A and 16.6 days for Group B. The recurrence rates were similar for the two groups [56% (Group A) vs 66% (Group B)], but mean survival was longer for younger patients (22.9 vs 33.5 months). We conclude that liver resection for colorectal cancer liver metastases in properly selected patients older than 70 years of age can be performed with acceptable morbidity and mortality rates. The long-term survival for older patients is less than that for younger patients, but is still a significant length of time. Therefore, we conclude that age alone is not a contraindication to liver resection for colorectal cancer metastases in patients older than 70.

Do angiogenesis and growth factor expression predict prognosis of esophageal cancer?

A retrospective study of surgically resectable esophageal cancers was undertaken to determine the relationship between angiogenesis score and growth factor expression with tumor size, histology, degree of differentiation, depth of invasion, nodal disease, and the presence of Barrett's esophagus. The office and hospital charts of 27 patients who had esophageal resection for carcinoma between 1990 and 1995 at Rush-Presbyterian-St. Luke's Medical Center were reviewed. Data collection included patient demographics, survival, tumor size, histology, differentiation, depth of invasion, nodal metastases, and the presence of Barrett's esophagus. The pathology specimens were immunostained for von Willebrand factor (factor VIII-related antigen). Immunostaining was also performed for vascular endothelial growth factor and transforming growth factor alpha. Twenty normal esophageal specimens served as controls. Angiogenesis score was determined by counting vessels under conventional light microscopy at x200 magnification, and growth factor expression was graded on a scale of 1 to 4. Cancers had higher angiogenesis and growth factor expression than controls (P = 0.01). Patient age, tumor size, histology, differentiation, depth of invasion, and Barrett's esophagus did not correlate with angiogenesis score or tumor growth factor expression. Lymph node status did correlate with both angiogenesis score and growth factor expression (P < or = 0.02). We conclude that high angiogenesis score and growth factor expression correlate with the presence of lymph node metastases. This may help select patients for preoperative radiation and chemotherapy or determine the extent of surgery performed for esophageal carcinoma.

In vitro and in vivo antitumor activity of a novel immunomodulatory drug, leflunomide: mechanisms of action

Leflunomide, a novel immunomodulatory drug, has two biochemical activities: inhibition of tyrosine phosphorylation and inhibition of pyrimidine nucleotide synthesis. In the present study, we first showed that A77 1726 [N-(4-trifluoromethylphenyl-2-cyano-3-hydroxycrotoamide)], the active metabolite of leflunomide, was more effective at inhibiting the tyrosine kinase activity of platelet-derived growth factor (PDGF) receptor than that of epidermal growth factor (EGF) receptor, and had no effect on the tyrosine kinase activity of the fibroblast growth factor receptor. In the presence of exogenous uridine, A77 1726 was more effective at inhibiting the PDGF-stimulated proliferation of PDGF receptor-overexpressing C6 glioma than the EGF-stimulated proliferation of EGF receptor-overexpressing A431 cells. In vivo studies demonstrated that leflunomide treatment strongly inhibited the growth of the C6 glioma but had only a modest effect on the growth of the A431 tumor. Uridine co-administered with leflunomide did not reverse the antitumor activity of leflunomide on C6 and A431 tumors significantly. Quantitation of nucleotide levels in the tumor tissue revealed that leflunomide treatment significantly reduced pyrimidine nucleotide levels in the fast-growing C6 glioma but had no effect on the relatively slow-growing A431 tumor. Whereas uridine co-administration normalized pyrimidine nucleotide levels, it had minimal effects on the antitumor activity of leflunomide in both tumor models. Immunohistochemical analysis revealed that leflunomide treatment significantly reduced the number of proliferating cell nuclear antigen-positive cells in C6 glioma, and that uridine only partially reversed this inhibition. These results collectively suggest that the in vivo antitumor effect of leflunomide is largely independent of its inhibitory effect on pyrimidine nucleotide synthesis. The possibility that leflunomide exerts its antitumor activity by inhibition of tyrosine phosphorylation or by a yet unidentified mode of action is discussed.

Evolving trends in the treatment of anorectal diseases

During the first half of this century, the safe and effective treatment of benign anorectal disorders perhaps did more to establish our specialty as a viable and distinct entity than anything else. A thorough understanding of anorectal anatomy and physiology, improved methods of local anesthesia, and an appreciation of proper postoperative care made the care of patients with diseases of the rectum and anus the domain of true specialists. Hirschman stated, "It is the action of the profession itself which has created the special field of proctology--the anus and rectum being organs peculiar to themselves and being subject to many medical and surgical diseases in the same way as the eye, the ear, the nose, the genital and urinary organs; and call for just as much special medical and surgical care. The general surgeon knows nothing about, and cares less for, the medical treatment of these organs; and the general practitioner who is able to treat the medical conditions is not, as a rule, properly equipped to do so. Thus, the proctologist came into existence--a man who, by special study of this particular region of the body, is able to give special care of either a surgical or medical nature, and often both in the same case, as may be required."

Aminothiol WR-1065 protects endothelial cell morphology against alterations induced by lipopolysaccharide

In septic patients, lipopolysaccharide (LPS) damages the vascular endothelium, which manifests as tissue edema and impaired healing. This pathology occurs when LPS distorts endothelial cell morphology partly by generating free radicals. A radioprotector that scavenges free radicals, the aminothiol WR-1065 ([N-2-mercaptoethyl]-1-3-diaminopropane) was found in a prior study to normalize the morphology of irradiated endothelial cells (Mooteri SN, Podolski JL, Drab EA, et al: Radiat Res 145:217-224, 1996). The aim of this study was to determine whether WR-1065 also normalized endothelial cell morphology following exposure to LPS. For this aim, portions of bovine aortic endothelial cell cultures were denuded and exposed to LPS at 1 ng/mL. After 30 min, the apical membrane expressed increased integrin receptor to fibronectin, alpha5beta1. After 5 h, the morphology of the cells at the leading edge was distorted, and cell-cell contact was lessened. Also, filamentous actin-containing stress fibers were dissipated; however, filamentous actin content per cell was unchanged. Treatment with 2 mM WR-1065 for 2 h prior to LPS exposure attenuated the increased expression of alpha5beta1 and promoted cell-cell contact in the migrating endothelial cells. WR-1065 also promoted the retention of stress fibers and actin cytoskeletal shape in cells treated with LPS. Thus, LPS distorted endothelial cell morphology after increasing apical membrane expression of alpha5beta1 and dissipating stress fibers, effects prevented by WR-1065.

Transanal endoscopic microsurgery: a single surgeon's experience

OBJECTIVE

To evaluate a single surgeon's experience with transanal endoscopic microsurgery (TEM) with regard to incidence of complications, recurrence rate of benign and malignant lesions, and impact on the treatment of rectal cancer.

DESIGN

Prospective tumor registry.

SETTING

Tertiary care university hospital.

PATIENTS

Seventy-three patients undergoing TEM between January 1991 and November 1996.

MAIN OUTCOME MEASURES

Complications, recurrence rates, and use of this technique with respect to radical operations.

RESULTS

The arrival of TEM was associated with an increase in the number of operations for rectal cancer; however, the use of TEM remained constant relative to radical resections. Use of TEM resection alone is appropriate for all adenomas and cancers staged Tis and T1. Use of TEM alone is not an appropriate treatment for T2 cancers. Four patients (5%) experienced fecal soilage, which was long lasting in only 1 (1%).

CONCLUSIONS

Transanal endoscopic microsurgery is a safe technique and provides improved access to lesions in the middle and upper rectum. Thus far, it has not had a significant impact in the overall treatment of rectal cancer.

Endorectal ultrasound

Endorectal ultrasound is a very useful diagnostic adjunct for benign and malignant anorectal diseases. The only prerequisite in performing this test is that the examiner appreciate the impact that EUS has on the clinical management of patients. For example, the information obtained when scanning rectal cancer dictates whether local excision (i.e., sphincter preservation) or preoperative adjuvant therapy followed by radical resection is chosen. For benign disease, EUS helps direct therapy for patients with fecal incontinence and selects those patients most likely to benefit from reconstructive surgery.

Mechanical, histologic, and biochemical effects of canine rectal formalin instillation

Instillation of 4 percent formalin effectively treats radiation hemorrhagic proctitis; however, little is known regarding its side effects.

PURPOSE

The study contained herein was undertaken to determine rectal compliance and collagen content, mucosal and vascular histologic changes, and kinetics of formalin absorption following instillation.

METHODS

Fifteen mongrel dogs (50-60 pounds) were randomized into five experimental groups according to time elapsed from formalin treatment: control, acute, one week, two weeks, and four weeks. Formalin was instilled in 30-ml aliquots to a total volume of 400 ml. Rectal compliance (closed manometry system) was assessed pre-formalin and post-formalin at the designated time interval. Serum formalin metabolites were determined at time 0, 0.5, 1, and 3 hours. A segment of rectal wall was analyzed for collagen content, mucosal injury, and blood vessel density.

RESULTS

Serum formalin levels peaked within 30 minutes, returning to normal by 3 hours. With the exception of one dog, toxic levels were not reached at any time during the study. No dogs experienced sepsis, fever, or altered gastrointestinal function. Acute and one-week dogs showed mild diffuse proctitis and mucosal slough, which healed within two weeks. Rectal compliance and collagen content were unchanged. Mucosal blood vessels decreased in number early (P = 0.03).

CONCLUSIONS

Instillation of 4 percent formalin in sequential aliquots of a small volume that is kept in contact for a short period of time is safe. Serum formalin levels generally do not reach toxic levels, and the slight elevation in formalin concentration that was seen returns to normal within three hours. Formalin-induced proctitis heals within two weeks, and no long-term changes in rectal compliance or collagen content were seen.

Absorption kinetics of rectal formalin instillation

Formalin instillation has become an accepted treatment of radiation-induced hemorrhagic cystitis and proctitis since the initial report by Brown in 1969 (Med. J. Aust. 1:23, 1969). Although its use is widespread, no studies have been performed to determine the safest, volume or duration of formalin exposure. The purpose of our study was to determine the optimum technique for instillation and the safety margin regarding the maximum time that formalin can be in contact with the rectal mucosa without causing serum toxicity. In a pilot canine study, 4% neutral buffered formalin was instilled into the rectum in 30 ml aliquots for 60 seconds each after which each aliquot was withdrawn; a total volume of 400 ml was used. Our subsequent experiment involved rectal instillation of a single formalin bolus of 100 ml for 1 hour without removal during this time. Formalin metabolites were measured in the blood and urine to assess toxicity. Results indicate that with the latter technique serum formic acid reaches toxic levels within 15 minutes of instillation and may stay elevated for several hours. Metabolites in the urine similarly increase within 15 minutes, lagging only shortly behind the rise in serum levels. Performing formalin instillation in a series of 30 ml aliquots appears to be a safer treatment, as toxic serum levels were not reached and their slight rise above baseline returned to normal within 3 hours.

Intraoperative ultrasound in the management of liver neoplasms

The purpose of this study was to determine the impact of intraoperative ultrasound (IOUS) on the management of patients with neoplasms of the liver. Fifty-nine patients with liver neoplasms (primary, 6; metastatic, 53) and without pre- or intraoperative evidence of extrahepatic disease underwent laparotomy for possible liver resection. Preoperative imaging studies included external ultrasound (n = 12), magnetic resonance imaging (n = 11), and/or computed tomography (n = 57). Intraoperative evaluation on all patients included inspection, bimanual palpation, and ultrasonography. External ultrasound, magnetic resonance imaging, and computed tomography identified all intraoperatively confirmed liver neoplasms in 33, 45, and 67 per cent of cases, respectively. Unsuspected neoplasms were identified in 12 patients (20%) by inspection/palpation and in 19 patients (32%) by IOUS. In eight patients (14%), the occult neoplasms were identified only IOUS, and in one patient the neoplasms were identified only by inspection/palpation. Occult neoplasms identified by IOUS were characterized by small size (less than 2 cm). Findings from the intraoperative evaluation, such as unsuspected neoplasms and vascular proximity or invasion, altered the preoperative plan in 20 (34%) patients. Inspection, and particularly palpation, identifies a number of preoperatively unsuspected liver neoplasms. Intraoperative ultrasound, however, is the most sensitive method for detection of liver neoplasms and influences the operative management in a substantial number of patients.

Abdominal mass in a 19-year-old with neurofibromatosis

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Radiation injuries of the gastrointestinal tract

Although radiation has proven itself valuable in the treatment of a variety of pelvic malignancies, it is not without serious morbidity. This article has outlined the incidence of acute and chronic injury, ways to prevent the occurrence of complications, and the use of new medical and surgical treatments.

Angiogenesis in colorectal cancer

Angiogenesis is a complicated multistep process involving the breakdown of the endothelial cell basement membrane, digestion of the extracellular matrix, proliferation and migration of endothelial cells toward the angiogenic stimulus, and formation of functioning capillaries. This neovascular network not only provides nutrients for an expanding tumor mass but also a means of dissemination to sites far removed from the primary tumor site. The entire process is mediated by cytokines or growth factors released either by the tumor cells themselves or by endogenous cells within the microenvironment surrounding the tumor. The literature has conclusively shown that those lesions with high angiogenesis scores or microvessel densities are associated with a higher risk of metastases, recurrence, and early patient death. This is especially so for colorectal cancer. Antiangiogenesis therapy holds promise for the future and, in the adjuvant setting, has many theoretical advantages over conventional cytotoxic chemotherapy.

Transanal endoscopic microsurgery

Traditional methods of excising adenomas and selected carcinomas of the distal rectum provide adequate exposure and acceptable cure rates. Recurrence rates after locally excising adenomas, however, are 12% to 25%, possibly because the limited exposure has led to less than adequate resection margins. Whether or not TEM can yield lower recurrence rates remains to be seen, but this perhaps is not the main reason one should include TEM in his or her armamentarium. Rather, it is the improved exposure, the superior optics, and the opportunity to address lesions in the upper rectum that set TEM apart from conventional instrumentation. One should also keep in mind that these "inaccessible" lesions have been treated heretofore with either a transsacral or transabdominal approach, both of which are accompanied by a lengthy hospital stay and potential morbidity. When considering TEM excision of rectal cancers, proper patient selection cannot be overemphasized. Endorectal ultrasonography can help to determine depth of penetration preoperatively, and TEM can be used with curative intent for those lesions with minimal involvement of the rectal wall. TEM can also be used as a means to palliate the primary tumor of those patients with incurable, disseminated disease. Minimal-access surgery is here to stay. TEM may gain acceptance in this arena, marking a new technology for the treatment of a number of rectal conditions. The considerable skill necessary to perform this operation, combined with the relatively infrequent nature of the pathology addressed, however, will make TEM the domain of only a few surgeons.

Brain metastases from colorectal cancer

PURPOSE

We wished to determine the time interval before diagnosis of brain metastases from a colorectal origin, typical neurologic presentation, overall survival, and impact of type of treatment and metastatic growth patterns (solitary, location, etc.) on prognosis.

METHODS

Between 1980 and 1994 we retrospectively identified 19 patients with metastatic colorectal cancer to the brain. Data were collected with regard to patient characteristics, location and stage of primary tumor, and extent and location of metastatic disease. Statistical analyses were performed with STATISTICA for Windows.

RESULTS

Mean patient age was 66 (43-87) years. Primary tumor location was distributed throughout the colon; 58 percent had disseminated disease when first diagnosed. All patients were symptomatic. Lesions were solitary in 63 percent, unilateral in 89 percent, and cerebral in 53 percent. Overall median survival was 2.8 months; 1-year survival was 0 percent. Survival was longer following craniotomy (4.1 months) compared with radiation (2.8 months); however, survival was not affected by number or location of metastatic lesions or whether the brain was the sole site of metastatic disease.

CONCLUSIONS

Brain metastases from colorectal cancer are infrequently the sole site of metastatic disease, and because survival is dismal regardless of form of therapy chosen, craniotomy is rarely indicated. Exception is the rare patient who has minimum neurologic impairment, a long disease-free interval, a solitary metastasis, and no extracranial disease.

Intestinal anastomotic healing at varying times after irradiation

The use of preoperative and intraoperative irradiation as surgical adjuncts in cancer management has led to concerns regarding post-operative wound healing. The optimum time to construct an intestinal anastomosis after irradiation has not been determined. The aim of this study was to evaluate anastomotic wound healing at varying times after irradiation. One hundred eighty-seven male Sprague-Dawley rats were randomized into seven experimental groups. Group I (control) had a sutured anastomosis and no irradiation. Groups II-VII received a single dose of 20 Gy intraoperatively. In group II, a sutured anastomosis incorporating irradiated bowel was performed immediately after irradiation. Groups III-VII underwent a second laparotomy to undergo a sutured anastomosis with irradiated bowel at 2 days, 1 week, 2 weeks, 3 weeks, and 4 weeks after irradiation. The rats were sacrificed 7 days after the anastomosis was created and the segment of terminal ileum containing the anastomosis was harvested. Tensile strength, hydroxyproline content, and modified Black irradiation damage scores were determined: [table: see text] The increasing modified Black scores reflect the progressive nature of irradiation damage over time. Increasing hydroxyproline content is seen after irradiation but this does not imply increasing wound strength. There was a return of tensile strength to normal levels by 2 weeks. These findings suggest that normal wound healing can be expected if a minimum of 2 weeks elapses between irradiation and intestinal anastomosis.

WR-1065 and radioprotection of vascular endothelial cells. II. Morphology

Although the aminothiol WR-1065 protects normal tissues, its direct effect on the damage and restoration of the vascular endothelium is not clear. In endothelial cells, WR-1065 attenuates both the DNA damage and the G1-phase arrest induced by radiation. After the destruction of nearby endothelial cells, the survivors rearrange their cytoskeleton, migrate and replicate. To determine the effect of radiation on morphology and migration, portions of bovine aortic endothelial cell cultures were denuded with a pipette tip and irradiated (137Cs gamma rays). The following observations were noted after 5 Gy: within 10 min, there was increased formation of protein-mixed disulfides including actin-mixed disulfide; after 30-min, alpha 5 beta 1, the integrin receptor for fibronectin, was up-regulated on the apical membrane surface. Within 5 h, actin-containing stress fibers reorganized, although there was no change in the total filamentous (F-)actin content within the cells. Compared to controls after 24 h, the irradiated cells had migrated 15% farther (P < 0.01), and at the leading edge covered twice the surface area (P < 0.0001). The addition of 2 mM WR-1065 for 2 h before 5 Gy inhibited the increased expression of alpha 5 beta 1, promoted retention of stress fibers and prevented the enhanced cell migration and spreading. These results indicate that WR-1065 prevents radiation-induced morphological responses. This effect appears to be mediated by an impact on both adhesion molecule expression and cytoskeletal reorganization.

Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients

PURPOSE

Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safety, ability to stop bleeding, and complications associated with therapy.

METHODS

Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient.

RESULTS

In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month.

CONCLUSIONS

Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.

Tumor angiogenesis as a predictor of recurrence and survival in patients with node-negative colon cancer

OBJECTIVE

The authors' objective was to quantitatively assess angiogenesis or neovascularity within node-negative colon cancers and to determine if increased angiogenesis correlated with higher recurrence and lower survival rates.

SUMMARY BACKGROUND DATA

Neovascularization promotes rapid tumor growth by facilitating nutrient and metabolite exchange. Recent work with breast and nonsmall cell lung cancers has shown that low angiogenic activity imparts a lower risk of recurrence and metastasis. Although adjuvant therapy is beneficial for patients with node-positive colon cancers, no such benefit has been demonstrated for patients with node-negative lesions. Nevertheless, up to 30% of this latter group will experience recurrence. We sought to identify a subset of patients with node-negative colon cancers at high risk for recurrence who might benefit from such therapy.

METHODS

One hundred five node-negative colon cancers were immunostained for endothelial cell factor VIII-related antigen. Blood vessels within three microscopic fields at 100X magnification were counted, the mean calculated, and an angiogenesis score assigned. A subjective angiogenesis grade (1-4) was assigned after each slide was surveyed in its entirety. Score and grade were then assessed with respect to cancer recurrence and patient survival.

RESULTS

Mean patient age was 71 years (range, 41-90 years) and mean tumor size, 5.6 cm (range, 2-12 cm). Mean follow-up was 6.5 years; mean angiogenesis score, 27.9 (range, 4-50); and mean grade, 2.0 (range, 1-4). Patients living 5 years had significantly lower angiogenesis scores than did nonsurvivors (22.8 vs. 43.2, p = 0.0004). Each 10-vessel increase in score imparted a 2.0-fold greater hazard of death and a 2.7-fold greater hazard of recurrence. The probability of surviving 5 years is estimated by: [formula: see text] and the probability of recurrence is estimated by: [formula: see text]

CONCLUSIONS

Angiogenesis within colon cancer is an important predictor of tumor behavior and may identify patients at higher risk for recurrence and early death.

Four-contrast defecography: pelvic "floor-oscopy"

PURPOSE

This study was designed to determine the accuracy of physical examination (as judged by four-contrast defecography) for women with pelvic floor relaxation disorders.

METHODS

Sixty-two women (mean age, 59 years) who had obstructed defecation or constipation, vaginal prolapse, urinary difficulty, or pelvic pain underwent four-contrast defecography. Oral, vaginal, bladder, and rectal contrast were administered selectively and fluoroscopy was performed. Radiographic findings were compared with physical examination diagnosis.

RESULTS

Four-contrast defecography changed the diagnosis in 46 patients (75 percent); 26 percent of presumed cystoceles, 36 percent of enteroceles, and 25 percent of rectoceles were not present on defecography. Defecography also revealed unsuspected coexisting defects in addition to known abnormalities detected on physical examination. In contrast, when physical examination was negative for these defects, 63 percent of patients were found to have cystoceles, 46 percent to have enteroceles, and 73 percent to have rectoceles on four-contrast defecography. The discovery of Grade 2 or 3 unsuspected abnormalities was significant, especially so for enteroceles. For posterior vaginal eversions extending to or past the introitus, physical examination was accurate in only 61 percent. Physical examination of large anterior defects was more accurate, with 74 percent of patients being correctly diagnosed.

CONCLUSIONS

Physical examination diagnosis of pelvic floor relaxation disorders is frequently inaccurate, especially for large vaginal eversions. Four-contrast defecography improves diagnostic accuracy, helps to identify all pelvic floor defects before surgery, and can assist with planning the correct operative approach.

Tumor angiogenesis and rectal carcinoma

PURPOSE

This study was designed to determine whether those rectal cancers that demonstrated increased vessel ingrowth or angiogenesis behave in a different fashion.

METHODS

The paraffin blocks of 48 rectal cancers removed by low anterior or abdominoperineal resection were recalled and immunostained with a monoclonal antibody specific for endothelial cell Factor VIII. The intense reddish brown color imparted to blood vessels facilitated their quantification which was undertaken at x100 and x200 magnification. Vessel counts within three microscopic fields were averaged and the relationships between angiogenesis score and tumor size, depth of invasion, incidence of lymph node or distant metastases, and survival were assessed.

RESULTS

Significantly higher angiogenesis scores were seen in tumors with transmural penetration (at x100, P = 0.002; at x200, P = 0.002) and in patients dying before five years (at x100, P = 0.013; at x200, P = 0.034). Although higher angiogenesis scores were seen in patients with larger tumors and metastases, these trends were not statistically significant.

CONCLUSIONS

Our results suggest that the growth of rectal cancer is dependent on the ingrowth of new blood vessels, and that increased vascularity promotes dissemination and adversely affects survival.

Peritoneovenous shunts for palliation of the patient with malignant ascites

METHODS

This study evaluated the effectiveness and morbidity associated with 116 peritoneovenous shunts inserted into 89 patients for symptomatic malignant ascites between 1981 and 1991. All patients had previously failed standard medical therapy of salt and fluid restriction, diuretics, and intermittent peritoneal aspirations.

RESULTS

Symptoms from the ascites included discomfort, impaired mobility, early satiety, and dyspnea. The study population was composed of 31 men and 58 women whose ages ranged from 24 to 81 years (mean 56). Primary tumors originated from the following sites: breast, 17; ovary, 17; pancreas, 13; gastrointestinal or related organs, 21; and other sites, 21. Mean shunt patency was 83 days; however, only 31% of the patients studied maintained a patent shunt and lived for > 2 months. Symptomatic relief was achieved in only 57 patients (62%). Forty-four patients (49%) developed one or more complications related to shunt placement. The deaths of 12 patients (13%) within 30 days of surgery were directly related to a complication of shunt placement. Overall, 30- and 60-day mortality rates were 43% and 61%, respectively.

CONCLUSIONS

Due to the brief and only fair relief of symptoms with a high associated morbidity and mortality, we believe peritoneovenous shunts are of very limited usefulness in the palliation of malignant ascites and suggest that alternate methods should be considered to manage these patients.

Neuroendocrine cancers of the colon and rectum. Results of a ten-year experience

PURPOSE

Our goal was to define the incidence of neuroendocrine carcinomas of the colon and rectum, the patterns of neuroendocrine expression, and the cellular subtype within neuroendocrine tumors. We attempted to determine whether differences in neuroendocrine expression or specific cell type influenced survival.

METHODS

Over a ten-year period, 988 patients had resections for colorectal cancer. Using immunohistochemical staining methods specific for neuroendocrine markers, 39 (3.9 percent) neuroendocrine cancers were identified retrospectively. Tumors were also stained with monoclonal antibody A-80 which is specific for exocrine differentiation. In this way we were able to determine the extent of neuroendocrine differentiation such as pure neuroendocrine, predominant neuroendocrine, and equal neuroendocrine-exocrine expression.

RESULTS

Average patient age was 65.5 (range, 28-89) years; there were 25 males and 14 females. Nineteen tumors were located in the right colon, 11 in the left, and 9 were in the rectum. Three histopathologic patterns were identified: pure neuroendocrine (n = 11), predominantly neuroendocrine (n = 17), and cancers with equal exocrine and neuroendocrine differentiation (n = 7). Three cellular subtypes were seen: small-cell (n = 15), intermediate-cell (n = 15), and well-differentiated neuroendocrine cancers (n = 5). There was one Dukes A cancer, 7 Dukes B, 16 Dukes C, and 15 patients had metastases to distant sites at the time of diagnosis. As a group, neuroendocrine tumors have a poor prognosis: six-month survival was 58 percent, three-year survival was 15 percent, and five-year survival was 6 percent. Survival statistically correlated with tumor stage (P = 0.01) but not with age, sex, tumor location, histopathologic pattern, or neuroendocrine subtypes. Median survival for pure neuroendocrine carcinomas was seven months and for predominantly neuroendocrine carcinomas was five months. Tumors with equal neuroendocrine and exocrine differentiation had a median survival of 22 months (P = 0.3). Small-cell neuroendocrine carcinomas had a median survival of five months, intermediate-cell had 11 months, and well-differentiated had a median survival of 22 months (P = 0.1).

CONCLUSIONS

Neuroendocrine differentiation is found in at least 3.9 percent of colon and rectal cancers. Many of these tumors were initially diagnosed as "carcinoids," the diagnosis was changed to "neuroendocrine carcinoma" after immunohistochemical staining. Overall survival is poor especially for small-cell and pure neuroendocrine carcinomas.

Predicting lymph node metastases in rectal cancer

For properly selected rectal cancers, local excision is a sphincter-saving alternative to abdominoperineal resection. If histologic assessment of a locally excised tumor reveals ominous features, further treatment with radical resection or irradiation may be necessary to treat potential lymph node metastases.

PURPOSE

We wished to determine which features, if any, were predictors of nodal metastases.

METHODS

Nine histologic and morphologic features of 62 radically excised rectal cancers were reviewed to determine which factors, if any, were associated with nodal disease.

RESULTS

Using a chi-squared analysis, we found worsening differentiation (P = 0.0001), increasing depth of penetration (P = 0.026), a microtubular configuration of 20 percent or more (P = 0.023), and the presence of venous (P = 0.001) or perineural invasion (P = 0.002) to significantly influence nodal disease. Lymphatic invasion was witnessed too infrequently to determine significance but, when present, was associated with nodal metastases in every case. Exophytic tumor morphology, mitotic count, and tumor size were not significant predictors. An analysis of variables determined that, of all factors or combination of factors examined, Broder's classification was the strongest predictor of nodal disease.

CONCLUSIONS

If a rectal cancer is accessible and of small size to facilitate local excision, an in-depth histologic assessment is needed to determine if nodal metastases are likely on a statistical basis.

Immunohistochemical detection of mutant P53 protein and human papillomavirus-related E6 protein in anal cancers

PURPOSE

The wild-type P53 protein, a product of the P53 gene, is a normal growth controlling protein. Mutation of the P53 gene generates a mutant P53 protein which promotes tumor formation through loss of growth suppression. Some of the agents responsible for P53 gene mutation are known, one of which may be tumorigenic human papillomavirus (HPV) infection. Anal cancers are demonstrating a changing trend in the affected population, from older females in the older reported series to younger males more recently. This may be a reflection of infection with tumorigenic HPV types 16 and 18. The E6 oncoprotein of these viruses inactivates the growth-controlling wild-type P53 protein. In this study, our purpose was to determine the incidence of mutant P53 and HPV-16 and 18-related E6 protein and their coexpression in anal cancers.

METHODS

We examined 29 anal cancers immunohistochemically for mutant P53 protein, HPV 16 and 18 E6 protein, and coexpression of the two.

RESULTS

Mutant P53 protein was present in 58.6 percent of anal cancers overall and in 85.7 percent of anal adenocarcinomas. E6 oncoprotein was present in five cases (17.2 percent), all of which were squamous-cell carcinomas. Coexpression of both mutant P53 and E6 proteins was seen in only three cases (10.3 percent).

CONCLUSION

Although tumorigenic HPV may be an important cause for P53 gene mutation in anal cancers, perhaps other mutagenic factors play a predominant role.

Thoracotomy for colon and rectal cancer metastases

Between 1978 and 1990, 23 patients underwent 35 thoracotomies for metastatic colorectal cancer. The pulmonary disease was diagnosed within an interval of 0 to 105 (average, 33.4) months after colon resection. Fifteen patients underwent a single thoracotomy; 12 patients had solitary lesions, and three patients had multiple nodules. Eight patients underwent multiple thoracotomies. The median survival following thoracotomy was 28 months; three-year survival was 45 percent, and five-year survival was 16 percent. Factors that had no significant bearing on survival included origin and stage of the primary tumor and patient age and sex. An interval before thoracotomy of three years had an impact on survival approaching statistical significance (P = 0.17). Patients who underwent multiple thoracotomies had a significantly prolonged survival (P = 0.04). Patients who underwent a single thoracotomy for a solitary lesion had a significantly prolonged survival compared with patients who had a single thoracotomy for multiple metastases. After thoracotomy, 14 patients eventually developed recurrent disease, which was confined to the lung in only four patients. Of these 14 patients, 11 subsequently died of cancer. We conclude that thoracotomy for metastatic disease should be considered when the primary tumor is controlled, the lungs are the only site of metastatic disease, and there is adequate lung reserve to withstand surgery. Survival following thoracotomy may be influenced by the interval before diagnosis, the number of pulmonary nodules, and the number of thoracotomies performed.

Neuroendocrine carcinomas of the stomach: a clinicopathologic evaluation

BACKGROUND

The purpose of this study was to determine by immunocytochemistry the relative incidence and clinicopathologic characteristics of neuroendocrine carcinomas of the stomach.

METHODS

Sections from paraffin blocks from 81 patients who had undergone resection of carcinomas of the stomach were immunostained with a battery of neuroendocrine differentiation markers and with A-80, a marker of exocrine differentiation. The clinical and pathologic data of the 12 patients diagnosed with neuroendocrine carcinomas of the stomach were analyzed.

RESULTS

The 10 men and two women ranged from 53 to 81 years of age (median, 69 years). Procedures performed included distal subtotal gastrectomy in eight patients and total gastrectomy in four patients. Pathologic stages were stage I, one patient; stage III, four patients; and stage IV, seven patients. Metastatic sites included regional nodes, 11 patients; liver, four patients; and bone, one patient. Adjunct treatment included multiagent chemotherapy plus radiotherapy, four patients; and only radiotherapy, one patient. Eleven patients died of disease 1 to 27 months after diagnosis with an overall median survival of 15 months. Three groups of neuroendocrine carcinomas were identified based on immunostaining patterns. These included pure neuroendocrine carcinomas, two patients; neuroendocrine carcinomas with occasional exocrine cells, three patients; and mixed neuroendocrine-exocrine carcinomas, seven patients.

CONCLUSIONS

(1) The relative incidence of neuroendocrine differentiation in carcinomas of the stomach is higher than is generally recognized. (2) Neuroendocrine gastric carcinomas behave aggressively and display numerous structural and functional similarities with their colonic, extrahepatic biliary tract, and pulmonary counterparts.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEM) has emerged as a minimally invasive means of resecting rectal tumors. Developed in Germany and now being used with increasing frequency in the United States, TEM utilizes a 40-mm operating rectoscope, which is sealed with an airtight facepiece. Carbon dioxide is constantly infused, thereby distending the rectum and maintaining visibility. A variety of instruments, such as tissue graspers, a high-frequency knife, suction, and needle holders, are inserted through the facepiece. Adenomas that are small, large, or even circumferential, as well as selected carcinomas up to 24 cm, can be removed with TEM instrumentation. The optics provide sixfold magnification, and this, combined with the constantly distended operative field, allows for a precise excision of the tumor as well as closure of the wound. For lesions in the mid and upper rectum, TEM is an alternative to a transsacral or transabdominal approach, with subsequently shorter hospital stay and fewer complications.

Variable expression of P-glycoprotein in normal, inflamed, and dysplastic areas in ulcerative colitis

Screening programs for the detection of cancer in ulcerative colitis are inexact and not always successful in finding early, curable cancers. P-glycoprotein is a membrane-based, energy-dependent protein found in varying degrees within normal human tissue. P-glycoprotein is overexpressed in malignant tumors, particularly colorectal cancer, and is known to convey resistance to certain anticancer drugs by acting as a membrane "pump." The purpose of this study was to determine the expression of this protein in inflamed and premalignant colonic epithelium, compare its expression with normal controls, and assess its potential use as a screening tool for high-risk patients with ulcerative colitis. Using immunohistochemical techniques, the colons of 21 patients (10 with dysplasia) with ulcerative colitis were stained with monoclonal antibody C-219 (MAbC219) specific for P-glycoprotein. P-glycoprotein was expressed in 38 percent of normal areas, 71 percent of inflamed areas (P = 0.0156), and 70 percent of dysplastic areas. Comparing the level of expression when progressing from normal to inflamed areas within a given patient, 11 patients (52 percent) showed increased expression, 8 (38 percent) showed equal expression, and only 2 (10 percent) showed decreased expression (P = 0.0225). Comparing expression when progressing from inflamed to dysplastic areas (10 patients), 7 showed equal expression and 3 showed increased expression (P = 0.25). Increasing duration of disease was associated with a significant increase in P-glycoprotein expression, but only in histologically normal areas. Duration of disease had no effect on P-glycoprotein expression in inflamed or dysplastic areas. Similarly, when surgery was performed for elective reasons, there was a significant overexpression of P-glycoprotein, but only in histologically normal areas. Our findings suggest that the increase in P-glycoprotein expression from normal to inflamed and dysplastic areas reflects the premalignant nature of ulcerative colitis and occurs early in the course of the disease. Further research needs to be done to determine its role in cancer surveillance.

Fibrin glue improves the healing of irradiated bowel anastomoses

Many surgeons are reluctant to construct a bowel anastomosis with irradiated intestine. Previous studies have demonstrated diminished tensile strength of rat small bowel anastomoses that have been irradiated intraoperatively. To determine whether fibrin glue, a known tissue adhesive, improves the healing of these anastomoses, 69 male Sprague-Dawley rats were randomized into three anastomotic groups: Group 1, sutured ileal anastomosis without radiation or fibrin glue; Group 2, irradiated sutured ileal anastomosis without fibrin glue; and Group 3, irradiated ileal anastomosis with fibrin glue added to the suture line. Groups 2 and 3 received a single dose of 2,000 R intraoperatively. At seven days, the rats were sacrificed and the anastomotic segment was tested for breaking (tensile) strength. Anastomotic collagen content was evaluated using a hydroxyproline assay. Tensile strength results demonstrated that Group 2 was significantly weaker than Groups 1 and 3 (P = 0.001) and that the hydroxyproline content of Group 3 was significantly greater than that of Group 2 (P = 0.015). These results show that the addition of fibrin glue to an intraoperatively irradiated small bowel anastomosis improves healing, as demonstrated by both tensile strength and hydroxyproline content studies.

Effect of intraoperative radiation on the tensile strength of small bowel anastomoses

Increasing interest in the use of preoperative or intraoperative radiation therapy for cancer has led to concerns regarding tissue healing and integrity subsequent to treatment. This is especially so for intestinal anastomoses incorporating irradiated bowel, where poor healing may lead to anastomotic disruption and sepsis. One hundred thirty Sprague-Dawley rats were randomized into five groups as follows: both limbs, one limb, or neither limb of an anastomosis received 2,000 R of radiation intraoperatively. A fourth group had a segment of small bowel irradiated, with no anastomosis; a fifth group had the gut exposed by celiotomy. The control groups and all anastomoses underwent tensile strength measurements on the seventh postoperative day, with findings as follows: no anastomosis, no irradiation, 143.75 g; no anastomosis, irradiated, 114.50 g; anastomosis, no irradiation, 85.273 g; anastomosis, one limb irradiated, 78.100 g; anastomosis, both limbs irradiated, 59.00 g. There was no statistical difference in tensile strength of the anastomosis between when neither limb and when just one limb was irradiated. However, when both limbs were irradiated, the loss of strength was statistically significant (P = 0.002). Irradiation damage scores were assigned using Black et al.'s histologic scoring system. These scores were not significantly different between the irradiated segments. Inflammation and fibrosis scores for the anastomoses were also not significantly different. These results indicate that, in rats, anastomotic healing is impaired only when both limbs of the anastomosed intestine are irradiated. The normal strength of the anastomosis with only one limb irradiated cannot be explained by differences in inflammation, fibrosis, or radiation damage and is caused by an undetermined factor.

Laparoscopic removal of a large colonic lipoma. Report of a case

A 72-year-old white male was found to have a 6-cm submucosal mass at 35 cm on screening sigmoidoscopy. The lesion had all the characteristics of a submucosal lipoma. Instead of performing a laparotomy with its potential morbidity, the lesion was removed laparoscopically in its entirety without untoward operative sequelae. Laparoscopic techniques have had a profound impact on the treatment of patients with surgical disorders. This new technology can be applied to selected patients with colorectal diseases.

Appendiceal Kaposi's sarcoma: a cause of right lower quadrant pain in the acquired immune deficiency syndrome

These case reports describe two patients with acquired immune deficiency syndrome (AIDS) who presented with acute right lower quadrant pain. Appendiceal involvement with Kaposi's sarcoma accounted for the clinical presentation, and was confirmed histologically. This association emphasizes the diagnostic confusion that may be caused by acute abdominal conditions in the AIDS population. Abdominal pain may result from AIDS-related or unrelated processes; appropriate operative intervention requires recognition of the various diagnostic possibilities.

Relationship of the expression of the multidrug resistance gene product (P-glycoprotein) in human colon carcinoma to local tumor aggressiveness and lymph node metastasis

P-glycoprotein mediates classic multidrug resistance by functioning as an efflux pump that excretes lipophilic chemotherapeutic drugs from cancer cells. We now report an association of P-glycoprotein in colon carcinomas with another tumor property, i.e., enhancement of local tumor aggressiveness. P-glycoprotein was detected with monoclonal antibody immunohistochemistry in 65 of 95 primary colon adenocarcinomas, which were stage B1 or greater. In all but 1 of the 95 cases, solitary invading carcinoma cells were present at the leading edge of the tumor. This subpopulation of invasive carcinoma cells expressed P-glycoprotein (P-Gp+) in 47 of the 95 surgically resected colon specimens. Cases were grouped on the basis of the presence (Group 1, 47 cases) or absence (Group 2, 48 cases) of P-Gp+ invasive carcinoma cells. There was a significantly greater incidence of vessel invasion (P less than 0.001) and lymph node metastases (P less than 0.01) in Group 1 cases. Groups 1 and 2 did not differ with respect to tumor size, depth of invasion of the bowel wall, histological grade, maximum tumor size, mitotic index, mucin production, or presence of perineural invasion (P greater than 0.1). Our findings indicate that P-Gp+ invasive colon cancer cells may have an increased potential for dissemination, suggesting that P-glycoprotein may influence cell behavior.

Clean sweep of the colon. The use of intraoperative colonoscopy

Since 1982, intraoperative colonoscopy has been performed on 66 patients. Preoperative intent was to perform a colonoscopic polypectomy during an intra-abdominal procedure in 44 patients, localize lesions that might subsequently lead to either colon resection or colotomy and polyp excision in 13, localize bleeding sites in 4, determine the extent of inflammatory bowel disease in 2, survey the colon in 2 who did not have preoperative colon radiography, and assess bowel viability in 1. Surgery proceeded as planned in 54 patients; however, colonoscopic findings extended the resection to include additional segments of bowel in 4. In four patients, polypectomy or bowel resection was avoided as a result of the colonoscopic findings. Intraoperative colonoscopy was not possible in four patients. No complications were related directly to this procedure. Intraoperative colonoscopy is a useful adjunct for localizing lesions or "clearing" the colon. In some patients, colonoscopic findings may change the extent of resection performed.

Hormone receptor studies in axillary metastases from occult breast cancers

The authors describe 11 patients with occult breast carcinoma, who initially presented with axillary nodal metastases of unknown origin. In all 11 cases, physical examination and mammography results were normal. Steroid hormone receptor studies were done on tissue from all 11 axillary masses and 2 masses underwent lactalbumin staining as well. In 8 of the 11 patients these studies were positive, suggesting breast as the primary tumor site. Estrogen (30 to 445 fmol/g) or progesterone (30 to 1059 fmol/g) receptors, or both, were positive in seven cases. Although a breast carcinoma was subsequently found in all 11 patients, receptor studies on the primary tumor could not be done in every instance. The authors concluded that performing steroid hormone receptor assays on axillary metastases from occult tumors not only may provide information regarding the identity of the primary tumor but also may be the sole opportunity to determine its hormone receptor status.

The role of ultrasonography in the evaluation of primary hyperparathyroidism

Ultrasonography was used preoperatively in 21 patients with primary hyperparathyroidism in an effort to locate enlarged parathyroid glands. It indicated the presence of a solitary mass compatible with a parathyroid adenoma in 14 patients. At operation, adenomas were found at the location indicated by ultrasonography in 13 of the 14 patients (93 per cent). In seven patients, ultrasonography failed to reveal evidence of a mass of the parathyroid gland. At operation, three had diffuse parathyroid hyperplasia and four had a solitary adenoma. Of the four patients with adenomas undetected by ultrasonography, one patient had an adenoma which had undergone infarction and three had coexisting nodular thyroid gland disease. We concluded that ultrasonography is valuable in the preoperative assessment of patients with primary hyperparathyroidism. This is especially so in the absence of coexisting nodular thyroid gland disease. When positive, ultrasonography accurately locates adenomas, and when negative, it strongly suggests the presence of hyperplasia. This may have clinical application in limiting the extent of dissection and, thereby, reducing the morbidity of parathyroid gland exploration.