Isolated fallopian tube metastasis from colorectal cancer: ultrasonographic features

We present here the first-reported case of tubal metastasis from colorectal cancer diagnosed by a preoperative pelvic ultrasound. A 53-year-old woman suffering from vaginal discharge was referred to us 2 years after she underwent a partial colectomy for adenocarcinoma. The pelvic ultrasound examination revealed a right pelvic mass of 52 × 24 × 38 mm, independent of the right ovary, which was apparently unaffected. A right salpingo-oophorectomy was performed and the definitive histopathology examination showed a recurrence of the initial adenocarcinoma with a right tubal metastasis. The eventuality of such an unusual site of metastasis should be remembered.

Delaying surgery to perform CT scans for suspected appendicitis decreases the rate of negative appendectomies without increasing the rate of perforation nor postoperative complications

PURPOSE

Negative appendectomies are costly and are embedded with unnecessary risks for the patients. A careful indication for surgery seems mandatory even more so, since conservative therapy emerges as a potential alternative to surgery. The aims of this population-based study were to analyze whether radiological examinations for suspected appendicitis decreased the rate of negative appendectomies without increasing the rate of perforation or worsening postoperative outcomes.

METHOD

This study is a retrospective analysis of a prospective population-based database. The data collection included preoperative investigations and intraoperative and postoperative outcomes.

RESULTS

Based on 2559 patients, the rate of negative appendectomies decreased significantly with the use of CT scan as compared to clinical evaluation only (9.3 vs 5 %, p = 0.019), whereas ultrasonography alone was not able to decrease this rate (9.3 vs 6.2 %, p = 0.074). Delaying surgery for radiological investigation did not increase the rate of perforation (18.1 vs 19.2 %; adjusted odds ratio (OR) 1.01; 0.8-1.3; p = 0.899). Postoperative complications (surgical reintervention, postoperative wound infection, postoperative hematoma, postoperative intra-abdominal abscess, postoperative ileus) were all comparable.

CONCLUSION

In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy. The delay induced by such additional imaging did not increase perforation nor complication rates. Abdominal CT scans for suspected appendicitis should therefore be more frequently used if clinical findings are unconclusive.

[Ultrasonographic features in the preoperative diagnosis of primitive fallopian tube carcinoma]

OBJECTIVES

To review the characteristic ultrasound features of primary fallopian tube carcinoma (PFTC) and its relationship to the clinical history in order to establish specific findings useful for the preoperative diagnosis.

METHOD

An extensive review of the current literature was done on Medline via PubMed by using the following keywords: "primary fallopian tube cancer", "tubal cancer", "adnexal malignancy mass" and "ultrasound".

RESULTS

PFTC corresponds to complex, sausage-shaped structures or cystic adnexal masses. A thick and an irregular capsule are in favour of a malignant lesion. Three-dimensional ultrasound is superior to 2D ultrasound for the detection of tubal wall irregularities such as papillary projections or pseudosepta who were suggestive of tubal malignancy and allows a better assessment of the extent of tumor infiltration through the capsule. Neovascularization with low resistance indices are typical of tubal malignancy. Three-dimensional power Doppler sonography acutely detected structural abnormalities of the malignant tumor vessels which are randomly dispersed within the papillary projections. Intra-uterine collection and peritumoral fluid are often found but ascite could be also an indirect proof of peritoneal carcinosis.

CONCLUSION

Sausage-shaped structures or cystic adnexal masses associated with imaging findings such as papillary projections and neovascularization with low resistance indices are in favour of PFTC. A standardized terminology, high-frequency and 3D power Doppler could improve diagnostic performance by allowing a better assessment of tubal wall and chaotic vessels architecture of these tumors.

Adenocarcinomas of the upper third of the rectum and the rectosigmoid junction seem to have similar prognosis as colon cancers even without radiotherapy, SAKK 40/87

PURPOSE

To investigate the prognosis of adenocarcinomas of the upper third of the rectum and the rectosigmoid-junction without radiotherapy.

METHODS

Patients from a multicenter randomized controlled trial from 1987-1993 on adjuvant chemotherapy for R0-resected colorectal cancers with stage I-III disease were retrospectively allocated: cancers of the lower two-thirds of the rectum (11 cm or less from anal-verge, Group A, n = 205), of the upper-third of the rectum and rectosigmoid-junction (>11-20 cm from anal-verge, Group B, n = 142), and of the colon (>20 cm from anal-verge, Group C, n = 378). The total mesorectal excision (TME) technique had not been introduced yet. The adjuvant chemotherapy turned out to be ineffective. None of the patients received neoadjuvant or adjuvant radiotherapy.

RESULTS

The patients had a regular follow-up (median, 8.0 years). The 5-year disease-free survival (DFS) rate was 0.54 (95%CI, 0.47-0.60) in Group A, 0.68 (95%CI, 0.60-0.75) in Group B, and 0.69 (95%CI, 0.64-0.74) in Group C. The 5-year overall survival (OS) rate was 0.64 (95%CI, 0.57-0.71) in Group A, 0.79 (95%CI, 0.71-0.85) in Group B, and 0.77 (95%CI, 0.73-0.81) in Group C. Compared with Group C, patients in Group A had a significantly worse OS (hazard ratio [HR] for death 2.10) and a worse DFS (HR for relapse/death 1.93), while patients in Group B had a similar OS (HR 1.12) and DFS (HR 1.07).

CONCLUSIONS

Adenocarcinomas of the upper third of the rectum and the rectosigmoid-junction seem to have similar prognosis as colon cancers. Even for surgeons not familiar with the TME technique, preoperative radiotherapy may be avoided for most rectosigmoid cancers above 11 cm from anal-verge.

Ground-level ozone differentially affects nitrogen acquisition and allocation in mature European beech (Fagus sylvatica) and Norway spruce (Picea abies) trees

Impacts of elevated ground-level ozone (O(3)) on nitrogen (N) uptake and allocation were studied on mature European beech (Fagus sylvatica L.) and Norway spruce (Picea abies [L.] Karst.) in a forest stand, hypothesizing that: (i) chronically elevated O(3) limits nutrient uptake, and (ii) beech responds more sensitively to elevated O(3) than spruce, as previously found for juvenile trees. Tree canopies were exposed to twice-ambient O(3) concentrations (2 × O(3)) by a free-air fumigation system, with trees under ambient O(3) serving as control. After 5 years of O(3) fumigation, (15)NH(4)(15)NO(3) was applied to soil, and concentrations of newly acquired N (N(labelled)) and total N (N(total)) in plant compartments and soil measured. Under 2 × O(3), N(labelled) and N(total) were increased in the bulk soil and tended to be lower in fine and coarse roots of both species across the soil horizons, supporting hypothesis (i). N(labelled) was reduced in beech foliage by up to 60%, and by up to 50% in buds under 2 × O(3). Similarly, N(labelled) in stem bark and phloem was reduced. No such reduction was observed in spruce, reflecting a stronger effect on N acquisition in beech in accordance with hypothesis (ii). In spruce, 2 × O(3) tended to favour allocation of new N to foliage. N(labelled) in beech foliage correlated with cumulative seasonal transpiration, indicating impaired N acquisition was probably caused by reduced stomatal conductance and, hence, water transport under elevated O(3). Stimulated fine root growth under 2 × O(3) with a possible increase of below-ground N sink strength may also have accounted for lowered N allocation to above-ground organs. Reduced N uptake and altered allocation may enhance the use of stored N for growth, possibly affecting long-term stand nutrition.

Combining sap flow and eddy covariance approaches to derive stomatal and non-stomatal O3 fluxes in a forest stand

Stomatal O3 fluxes to a mixed beech/spruce stand (Fagus sylvatica/Picea abies) in Central Europe were determined using two different approaches. The sap flow technique yielded the tree-level transpiration, whereas the eddy covariance method provided the stand-level evapotranspiration. Both data were then converted into stomatal ozone fluxes, exemplifying this novel concept for July 2007. Sap flow-based stomatal O3 flux was 33% of the total O3 flux, whereas derivation from evapotranspiration rates in combination with the Penman-Monteith algorithm amounted to 47%. In addition to this proportional difference, the sap flow-based assessment yielded lower levels of stomatal O3 flux and reflected stomatal regulation rather than O3 exposure, paralleling the daily courses of canopy conductance for water vapor and eddy covariance-based total stand-level O3 flux. The demonstrated combination of sap flow and eddy covariance approaches supports the development of O3 risk assessment in forests from O3 exposure towards flux-based concepts.

Primary anastomosis vs Hartmann's procedure in patients undergoing emergency left colectomy for perforated diverticulitis

OBJECTIVE

Comparison of primary anastomosis (PA) and Hartmann's procedure (HP) in perforated diverticulitis is biased as the patient groups are different in age, comorbidity and severity of disease. Still, PA has been advocated as the procedure of choice. The aim of this study was to compare the two surgical procedures after eliminating this selection bias using a propensity score model.

METHOD

Sixty-five HP and 46 PA patients who underwent emergency laparotomy for perforated diverticulitis were analysed. Multivariate logistic regression using the Mannheim peritonitis index, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, Charlson comorbidity index and Hinchey score was performed to determine the propensity score.

RESULTS

Patients with HP had significantly higher scores, median age and were more often on immunosuppressive medication. Unadjusted logistic regression for outcome showed a significant risk of HP vs PA for nonsurgical morbidity (odds ratio 3.25, 95% CI: 1.26-8.43; P = 0.015), but not for mortality and surgical morbidity. After adjusting for the propensity score, outcome was not significantly different. Patients with PA had a clinical leak rate of 28% and none of the patients with leakage had a protective ileostomy. Patients with PA and leak had higher Charlson scores whereas all other scores were similar to nonleak patients.

CONCLUSION

The theory that PA is generally superior to HP cannot be supported. HP remains a safe technique for emergency colectomy in perforated diverticulitis, especially in elderly patients with multiple comorbidities. If PA is performed, a protective ileostomy must be considered.

Usefulness of routine intraoperative staging of suspicious adnexal tumours: illustration by two cases of adult granulosa cell tumour

Granulosa cell tumours (GCTs) account for less than 3% of all ovarian malignancies but are among the most common sex cord-stromal tumours. They may develop at any age. Symptoms related to oestrogen production by the tumour may occur. Because GCTs are uncommon and cannot be diagnosed preoperatively, their management is challenging. Surgery with salpingo-oophorectomy and painstaking staging is mandatory. Adjuvant chemotherapy is required in some patients. We report two cases of adult GCTs that illustrate the usefulness of extensive abdominal exploration in every patient with a suspicious ovarian mass, to obviate the need for a second staging procedure. With this strategy, the prognosis is excellent, although the possibility of late recurrences requires prolonged follow-up.

Adjuvant perioperative portal vein or peripheral intravenous chemotherapy for potentially curative colorectal cancer: long-term results of a randomized controlled trial

BACKGROUND AND AIMS

The perioperative use of a single course adjuvant portal vein infusion chemotherapy in patients with potentially curable colorectal cancer has been shown to significantly improve overall survival but did not reduce the occurrence of liver metastases (SAKK 40/81) [Swiss Group for Clinical Cancer Research (SAKK) Lancet 345(8946):349-353, 1995]. The objective of the present prospective, three-arm randomized multicenter trial was to assess whether peripheral venous administration of adjuvant chemotherapy regimen based on 5-fluorouracil (5-FU) and mitomycin C decreases the occurrence of liver metastases as well as prolongs disease-free and overall survival.

MATERIALS AND METHODS

Stages I-III colorectal cancer patients (n = 753) were randomized to receive either surgery alone (control arm), surgery plus postoperative portal venous infusion of 5-FU 500 mg/m(2) plus heparin given for 24 hours for seven consecutive days plus mitomycin C 10 mg/m(2) given on the first day (arm 2), or surgery and the same chemotherapy regimen administered by peripheral venous route (arm 3).

RESULTS

The 5-year disease-free survival for the three treatment groups were 65% (control group), 60% (portal vein infusion, hazard ratio 1.18, p = 0.23), and 64% (intravenous infusion, hazard ratio 1.04, p = 0.76); the 5-year overall survival was 72% (control group), 69% (portal vein infusion, hazard ratio 1.21, p = 0.2), and 74% (intravenous infusion, hazard ratio 1.03, p = 0.86), respectively. A significant accumulation of early deaths were observed in the portal vein infusion group (p = 0.015).

CONCLUSIONS

The present prospective randomized multicenter trial provides compelling evidence that short-term perioperative chemotherapy does not improve disease-free and overall survival in patients with potentially curative colorectal cancer. In contrary, the chemotherapy regimen administered in the present investigation seems to have potentially harmful effects, a finding which should be carefully considered in the planning of future trials. Postoperative short-term administration of 5-FU plus mitomycin C either through portal infusion or a central venous catheter is not recommended for routine use in patients with potentially curable colorectal cancer.

Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial

BACKGROUND

Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections.

MATERIALS AND METHODS

Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea.

RESULTS

One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups.

CONCLUSION

Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.

Evaluation of critical incidents in general surgery

Background

The analysis of adverse events is a central step in critical incident reporting, but has not been described in a surgical setting. The aim of this study was to develop an evaluation protocol and assess its feasibility.

Methods

All incidents were analysed by a multidisciplinary team. A coding system based on three published theories was used to assess all incidents and their underlying causes. A risk analysis was also conducted.

Results

Between July 2004 and December 2005, 9785 inpatients were treated and 139 critical incidents reported. Classification of active errors revealed 47·7 per cent to be execution failures and 45·9 per cent knowledge-based errors. The distribution of medical errors was 12·9 per cent diagnostic, 46·0 per cent treatment, 17·3 per cent preventive and 23·7 per cent other. Some 282 latent failures were identified among the 139 incidents. Risk analysis revealed a severe incident rate of 21·6 per cent.

Conclusion

This study has shown the feasibility of an evaluation protocol based on a combination of three classification systems and a risk analysis. It allows a thorough assessment of critical incidents, identification of priorities and tailored countermeasures.

[Investigation on smoking during pregnancy in the Versailles suburbs]

OBJECTIVE

To investigate active and passive smoking during pregnancy in the Versailles suburbs before workshops for smoking cessation.

MATERIALS AND METHODS

Descriptive investigation of 1006 pregnant women in the perinatal community of the Versailles suburbs based on autoquestionnaire. The variables analysed included the characteristics of the mother during pregnancy, the presence of a smoking spouse and a professional exposition to passive smoking, the perception of risk linked to smoking, and the help for smoking cessation.

DISCUSSION AND CONCLUSION

An assistance to stop smoking could be suggested to smoking pregnant women and their spouses.

Performance of office hysteroscopy and endometrial biopsy for detecting endometrial disease in women at risk of human non-polyposis colon cancer: a prospective study

The objective of this study was to report the value of diagnostic hysteroscopy and endometrial biopsy for the detection of complex atypical hyperplasia or cancer in asymptomatic human non-polyposis colon cancer (HNPCC) patients. The secondary objective was to evaluate the accuracy of hysteroscopy, using endometrial biopsy as a gold standard. Consecutive patients at risk of HNPCC evaluated between January 1, 1999, and June 30, 2006 were included if they underwent diagnostic hysteroscopy at least once. Patients with a history of hysterectomy and those unwilling to undergo diagnostic hysteroscopy were not included. Yearly follow-up evaluations included diagnostic hysteroscopy, with endometrial biopsy. Hysteroscopic and histologic findings were recorded and compared. We included 62 patients, of whom 13 had mismatch repair gene mutations and 49 met Amsterdam II criteria. Of 125 attempted hysteroscopies, 11 (8%) failed. Hysteroscopy showed normally appearing mucosa in 46 cases, nonmalignant lesions in 65 cases, and possibly malignant lesions in 3 cases with abnormal uterine bleeding. Endometrial biopsy was attempted in 116 cases and failed in 12 (10%). Three cases each of simple hyperplasia and of cancer were diagnosed. No preinvasive or invasive lesions were found in asymptomatic women. When compared to endometrial biopsy, sensitivity of hysteroscopy was 100% for the detection of hyperplasia or cancer. No cases of cancer were diagnosed in asymptomatic patients in our study. However, diagnostic hysteroscopy ensured the diagnosis of endometrial adenocarcinoma in HNPCC women with bleeding. Nevertheless, usefulness and optimal modalities of screening remain to be determined.

High dose N-acetylcysteine to prevent pulmonary complications in partial or total transthoracic esophagectomy: results of a prospective observational study

Cancer of the esophagus has a poor long-term prognosis and a high peri-operative morbidity in which pulmonary complications play a major role. The combination of the surgical approach, pre-existing pulmonary disorders, poor nutritional status and the release of pro-inflammatory cytokines may be contributing factors. N-acetylcysteine ((NAC) has been shown to have oxygen scavenging abilities. In severe sepsis and acute respiratory distress syndrome, positive effects of NAC on morbidity and mortality were discovered. In this observational study peri-operative high dose NAC was administered in 22 patients. The effects of this treatment on respiratory function, morbidity and survival were studied. These prospectively collected data were compared with data of a matched, retrospective group without NAC treatment. There were no significant differences between the groups in terms of socio-demographic data, preoperative pulmonary function, intra-operative course and oncologic characteristics. The oxygenation indices at the postoperative hours 2 (P = 0.019), 4 (P < 0.001), 8 (P = 0.035), 12 (P = 0.035) and 24 (P = 0.046) were significantly higher in the NAC group. After 36 h, the difference between groups was no longer significant (P = 0.064). NAC-treated patients showed significant lower overall pulmonary morbidity, 45.5% versus 81.8% (P = 0.027). Surgical morbidity, intensive care unit and hospital stay were not significantly different between groups, mortality was zero. Kaplan-Meier curves showed no significant difference in survival 12 months postoperatively. These data indicate that postoperative oxygenation can be improved and rate of overall pulmonary complications is reduced using peri-operative high dose NAC in transthoracic esophagectomy.

Response evaluation with endoscopic ultrasound (EUS) measuring maximum tumor thickness to predict pathological response after neoadjuvant chemoradiation therapy (CRT) in patients with locally advanced esophageal cancer (EC)

15009

Background: EUS does not accurately assess T-stage after neoadjuvant CRT due to inflammation, necrosis and fibrosis. We evaluated whether maximum tumor thickness (MTT) can predict pathological response (tumor regression grade, TRG) after CRT. Methods: Patients (pts) with resectable, locally advanced EC, were treated with 2 cycles of docetaxel/cisplatin (DC) q3w followed by CRT (DC weekly x5 with concomitant 45 Gy radiation therapy) and surgery. Radial scan EUS (7.5MHz) measured MTT at baseline and 3–5 weeks after CRT completion. We prospectively hypothesized that MTT =6mm in the second EUS predicts complete and subtotal pathological response (TRG1 and 2), tested by logistic regression. The effect of >50% reduction of MTT was analysed as well. Results: 66 pts from 11 institutions were treated; median age 61y (35–70y); adenocarcinoma (AC) 53%; squamous cell carcinoma 46%; 40 pts were eligible for the EUS project (10 no surgery, 10 tumor stenosis prohibiting EUS, 5 MTT not measured, 1 intolerant to EUS). Initial EUS staging: 9 uT2N1, 3 uT3N0, 27 uT3N1, 1 uT3Nx; Siewert-type-1 in 13 of 22 AC. Reduction of MTT to =6mm correctly predicted TRG1/2 with sensitivity (sens) 45%, specificity (spec) 90%, negative predictive value (NPV) 62%, and positive predictive value (PPV) 82%, the Iogistic regression model showed a trend predicting response only (OR 0.80; C.I. 0.62–1.03; p=0.082). Reduction of MTT >50% predicted TRG1/2 with sens 40%, spec 75%, NPV 56% and PPV 62%. Conclusions: The absolute value of maximum tumor thickness =6mm in the second EUS correctly predicts a good response to CRT in 82% (spec 90%) - rather than the relative reduction of MTT >50% -, but does not identify all responders. Feasibility in this multicenter setting was limited by exclusions due to tumor stenosis and incomplete measurements.

[Table: see text]

No significant financial relationships to disclose.

Performance of laparoscopy in identifying malignant ovarian cysts

BACKGROUND

Peroperative identification of malignancy is crucial to management planning for ovarian cysts. The aim of this study was to evaluate the performance of laparoscopy in identifying malignant ovarian cysts.

METHODS

Patients undergoing laparoscopy for ovarian cysts from 1998 to 2001 were enrolled prospectively. Physical findings, Doppler ultrasonography, and serum CA 125 served to compute two risk-of-malignancy indexes (RMI-1 and RMI-2), and laparoscopy findings served to categorize lesions as benign, possibly malignant, or malignant. Frozen sections were examined as needed. Final histology was the reference.

RESULTS

Of 313 patients, 294 had benign cysts, six borderline lesions, and 13 malignancies. Sensitivity and specificity were respectively 84 and 93% for RMI-1, 92 and 80% for RMI-2, 100 and 99% for laparoscopy, 91 and 100% for frozen sections, and 100 and 100% for laparoscopy plus frozen sections, which had 100% negative predictive value. Six (1.8%) adverse events occurred.

CONCLUSIONS

Laparoscopy reliably identifies ovarian cancer and borderline disease. Morbidity is low compared to oncologic surgery.

Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis?

OBJECTIVES

To determine which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings, and to determine if the use of logistic regression models for calculation of individual risk of malignancy would improve the diagnostic accuracy in difficult tumors.

METHODS

In a prospective, international, European multicenter study involving nine centers, 1066 women with a pelvic mass judged to be of extrauterine origin underwent transvaginal ultrasound examination by an experienced ultrasound examiner before surgery. A standardized examination technique and predefined definitions of ultrasound characteristics were used. On the basis of subjective evaluation of ultrasound findings, the examiner classified each mass as being certainly benign, probably benign, unclassifiable, probably malignant or certainly malignant. Even when the examiner found the mass unclassifiable (i.e. difficult mass) he or she was obliged to state whether the mass was more likely to be benign or malignant. Borderline tumors were classified as malignant.

RESULTS

There were 90 (8%) unclassifiable masses. Multiple logistic regression analysis showed papillary projections, >10 locules in a cyst without solid components, low-level echogenicity of cyst fluid, and moderate vascularization as assessed subjectively at color Doppler examination to be ultrasound variables independently associated with unclassifiable mass. Borderline malignant tumors (n = 55) proved to be most difficult to assess with only 47% being correctly classified (i.e. classified as malignant), 29% being incorrectly classified (i.e. classified as benign) and 24% being unclassifiable vs. 90% of non-borderline tumors being correctly classified, 3% being incorrectly classified and 8% being unclassifiable (P < 0.0001). Papillary cystadeno(fibro)mas, myomas and cases of struma ovarii were also more common among the unclassifiable masses than among the classifiable ones (5.6% vs. 1.1%, P = 0.008; 4.4% vs. 0.9%, P = 0.02; 4.4% vs. 0.2%, P = 0.0006). No ultrasound variable or clinical variable (including CA 125) entered a logistic regression model to predict malignancy in difficult masses. A model could be constructed for difficult masses containing papillary projections but this model performed no better than subjective evaluation of the ultrasound image. Sensitivity and specificity of subjective evaluation with regard to malignancy in the group of unclassifiable masses were 56% (14/25) and 77% (50/65) vs. 91% (220/241) and 97% (712/735) in the classifiable masses.

CONCLUSIONS

Borderline tumors cause great diagnostic difficulties, but so do papillary cystadeno(fibro)mas, struma ovarii and some myomas. Logistic regression models do not solve the diagnostic problem in difficult pelvic masses.

[The osteosynthesis of fractures of distal radius with the AO/ASIF Titanium Pi Plate]

The AO/ASIF Titanium Pi Plate has been developed for dorsal plating of fractures of the distal radius. It is designed by reflection of the anatomy, to ensure stability of the angle using a juxtaarticular band and to minimize tissue reaction by low profile design. The aim of this study was to evaluate the subjective and objective outcome of 61 consecutively operated patients after a minimum of 12 months (12-29 months) postoperatively. There were 3 A2, 23 A3, 1 B1, 12 C1 and 22 C2 fractures (AO-Classification). The subjective results were good to very good. The range of motion showed over 80% compared to the uninjured side. Overall, there were no ruptures of tendons and 18% irritations. Extension, ulnar abduction and force were significantly better in patients in which the plate has been removed. In this collective the tendon irritations were only 3.8%. With the AO/ASIF Pi Plate good subjective and objective results can be achieved. The indication for removal of the plate should be given generously.

[An 85-year-old patient with recurrent episodes of confusion and absences]

Verwirrte Patienten sind in Klinik und Praxis häufig. Ihre Behandlung erfordert eine sorgfältige klinische Evaluation, um auch seltenere Ursachen zu erfassen. Differentialdiagnostisch sollte stets an die Hypoglykämie gedacht werden, die selten einmal durch ein Insulinom verursacht wird. Charakteristisch für das Insulinom sind neuroglykopenische Symptome wie Verwirrung, Seh- und Sprachstörungen, ungewöhnliches Verhalten, Agitation, Krampfanfälle, Koma und fokale neurologische Symptome. Diese treten bei einem Blutzucker unter 2.5 mmol/l auf. Bei nicht weniger als 20% der Patienten werden die Symptome als neurologische oder psychiatrische Erkrankung verkannt. Vor allem bei älteren Menschen wird die Diagnose des Insulinoms oft erst verzögert gestellt. Diagnostisch ist ein inadäquat hohes Serum-Insulin während einer spontanen Hypoglykämie oder im Fastentest.

Perioperative detection of disseminated tumour cells is an independent prognostic factor in patients with colorectal cancer

BACKGROUND

The objective of the present investigation was to assess the prognostic significance of disseminated tumour cells in peritoneal lavage, and peripheral and mesenteric venous blood in patients undergoing curative resection of colorectal cancer.

METHODS

The prognostic impact of perioperative cytological and immunocytochemical detection of disseminated colorectal cancer cells was evaluated prospectively. Peritoneal lavage fluid, and peripheral and mesenteric venous blood from 53 consecutive patients undergoing curative surgery for colorectal cancer were analysed. The dichotomous results (positive versus negative) from the cytological and immunocytochemical analysis were used as a predictor along with other co-variates in proportional hazard regression models of disease-free and overall survival.

RESULTS

Disseminated colorectal cancer cells were found in 13 of 53 patients (25 per cent) using cytology (CYT) and/or immunocytochemistry (ICC). The median follow-up at the time of the analysis was 37 months. In multivariate proportional hazard regression models CYT/ICC status was a significant predictor for disease-free (P = 0.002) and overall (P = 0.006) survival.

CONCLUSION

Disseminated tumour cells detected by CYT and ICC represent an independent prognostic factor in patients undergoing surgery for colorectal cancer and may identify patients at high risk of recurrence.

[Solitary duodenal diverticulum with enterolith as a rare cause of acute abdomen]

Diverticula of the duodenum are not rare and in the most cases without any symptoms. The incidence of duodenal diverticula in autopsies is known to be 20-22%. Only in a very small number of cases, they are complicated and therefore clinically presented by diverticulitis, perforation, hemorrhage, pancreatitis, or biliary obstruction. The most uncommon complication is the enterolith formed within the diverticulum. In all reported cases, the enterolith--formation was associated with small bowel obstruction or perforation. Complications of duodenal diverticula have a high mortality rate (33-48%) that could be due to difficulties in diagnostics and the adequate surgical procedure. In our case report, a patient presented at our institution with symptoms of an acute abdomen caused by an enterolith inside a solitary duodenal diverticulum "ante perforationem". The ultrasound and the CT scan of the abdomen showed free intraabdominal fluid beside the duodenum, the exact diagnosis however was not made. The indication for laparotomy was given by the clinical signs. The dicerticula was resected and ligated.

Infrequent mutation of the tumour-suppressor gene Smad4 in early-stage colorectal cancer

Smad4 is a candidate tumour-suppressor gene identified recently on chromosome 18q21.1. Both alleles are inactivated in nearly one-half of pancreatic carcinomas, but its role in the tumorigenesis of other tumours is still unknown. The aim of this study was to investigate the potential involvement of the Smad4 locus in early-stage colorectal cancers (stages I-III) in tumour samples from a randomised multicentre trial. Of a large collection of DNA samples, 73 with a loss of one allele of the Smad4 gene were analysed for the presence of point mutations in the remaining gene. Patients, from whom biopsies were isolated, were part of a previous randomised multicentre study of the Swiss Group for Clinical Cancer Research on the benefit of adjuvant chemotherapy (SAKK study 40/81). Mutation analysis was restricted to the highly conserved C-terminal domain (exons 8, 9, 10 and 11) of Smad4, using PCR and single-strand conformational variant analysis. Two of the 73 patients (3%) with loss of one allele of Smad4 had a point mutation in the remaining allele. These results indicate that whereas Smad4 point mutations are prevalent in pancreatic carcinoma, they are infrequent in early stages (I-III) of colorectal cancer.

[Multiple recurrent perforated jejunal diverticulitis]

Jejunal diverticulitis is a very rare cause of acute abdomen. The treatment of choice in acute perforated jejunal diverticulitis is intestinal resection with primary anastomosis of the affected area. Data on long-term results, postoperative complications and the nature of this illness is limited. To our knowledge, a recurrent perforated jejunal diverticulitis has never have been reported in the literature. In this case,we present a patient who suffered from a recurrence of perforated jejunal diverticulitis 13 weeks after the initial intestinal resection. After the second intestinal resection (due to the recurrent infection), the patient suffered from a third period of jejunal diverticulitis.

[Hysterosonography]

Hysterosonography, which consists in the injection of some cc of saline in the uterine cavity during sonography, allows an exploration of the uterine cavity and of the endometrium. Accuracy of hysterosonography is similar to that of office hysteroscopy. Hysterosonography distinguishes normal cavities from pathologic ones, endometrial atrophy from mucosal anomalies, polyps from myomas. Conversely, endometrial biopsy is still necessary for diagnosis of hyperplasia or cancer. Hysterosonography can also be proposed for first trimester bleedings, trophoblast retention or ectopic pregnancy. In the near future it could be applied to therapeutic goals such as sonographic section of polyps.

Percutaneous minimal osteosynthesis of fractures of the proximal humerus in elderly patients

INTRODUCTION

The aim of this study was to evaluate the subjective and objective outcome of the percutaneous minimal osteosynthesis in elderly patients. Untreated, unstable and dislocated proximal humeral fractures show poor functional and subjective results. Reduction and fixation of the fragments is essential to achieve a good clinical outcome. Especially noted in elderly patients, the osteosynthesis is concurrent with the implantation of a prosthesis.

PATIENTS AND METHODS

We examined 31 patients with a mean age of 72 years (51-87) after an average follow-up period of 15.8 months (9-31). To assess the functional and subjective results, we used the Constant Score as well as an adapted version of the Oxford Shoulder Score. Radiographs in two planes displayed the anatomical situation, the healing of the fracture, and the evidence or absence of avascular necrosis.

RESULTS

There were no local complications such as hematomas or wound infections. The results of the Constant Score showed an average of 63.5 Pts. (18-82 Points) and adapted to age and gender by 90.2% (28.1-118.8%). Compared with the uninjured arm with an average of 77.1 Points (20-89 Points) and 109.5% (29-129%) respectively, we achieved an average functionality of 82.6%, operated versus non-operated side. All but one fracture, that showed signs of avascular necrosis with disintegration of the humeral head, were fully consolidated. The subjective results were very good in 18 patients, good in 7, satisfying in 3 and poor in 3 patients.

CONCLUSION

Our data indicate that the percutaneous minimal osteosynthesis is a valuable method for the fixation of proximal fractures of the humerus in elderly patients. The technique has a very low rate of complications and the time of convalescence is short. If closed reduction fails or a stable percutaneous fixation of the fracture by K-wires is not possible, the change to open reduction and internal fixation or the implantation of a prosthesis is required.

Prophylactic surgery in families with familial adenomatous polyposis (FAP) and in colitis

Colorectal cancer is the second most common cause of death from malignant tumors in western countries with approximately 3800 new cases/year in Switzerland. For individuals known to be at high risk for the development of colorectal cancer, screening, chemoprevention and/or prophylactic surgery are the only tools to avoid unnecessary premature death from this disease. With modern molecular and/or genetic testing the risk of developing colorectal cancer can be more precisely estimated on an individualized basis. These individuals need to be enrolled in strong surveillance programs and are clear candidates for prophylactic surgery. The risk of prophylactic surgery (morbidity, mortality, quality of life following surgery) must be clearly weighted against the increasing risk of cancer. These patients should be treated in experienced centers for colorectal surgery in close connection with a genetic testing and counseling team, a molecular laboratory and a psychological support group.

Combined copy status of 18q21 genes in colorectal cancer shows frequent retention of SMAD7

Deletions of chromosome band 18q21 appear with very high frequency in a variety of carcinomas, especially in colorectal cancer. Potent tumor suppressor genes located in this region encode transforming growth factor beta (TGF-beta) signal transducers SMAD2 and SMAD4, and inactivation of either one leads to impaired TGF-beta-mediated cell growth/apoptosis. Following the assignment of SMAD7 to 18q21, we first refined the SMAD7 gene position within this region by genetically mapping SMAD7 between SMAD2 and SMAD4. Further, to compare the respective frequencies of genetic alterations of these three SMAD genes in colorectal cancer, we undertook a large-scale evaluation of the copy status of each of these genes on DNA samples from colorectal tumor biopsy material. Among a subset of 233 DNA samples for which data were available for all four genes, SMAD4, SMAD2, and the nearby gene DCC showed high deletion rates (66%, 64%, and 59%, respectively), whereas SMAD7 was deleted in only 48% of the tumors. Unexpectedly, we found some gene duplications; SMAD7 appears to be more frequently amplified (10%) than the three other genes (4-7%). Compiled data for SMAD genes in each tumor show that the most common combination (26% of all the tumors) consists of the simultaneous deletions of SMAD2 and SMAD4 associated with normal diploidy or even duplication of SMAD7. Since SMAD7 normally counteracts SMAD2 and SMAD4 in TGF-beta signaling, we hypothesize that the tumor might not benefit from simultaneous SMAD7 inactivation, thereby exerting selective pressure to retain or even to duplicate the SMAD7 gene.

[Transfusion use in curatively operated patients with colorectal carcinomas. Swiss Study Group for Clinical Cancer Research]

OBJECTIVE

Is there an improvement of the behaviour for restrective blood transfusions after the data in the literature and especially the preliminary data of the SAKK 40/81 study have been published? They have shown a worsening of the prognosis in patients with colorectal cancer after pre-/postoperative blood transfusions have been given.

MATERIAL AND METHODS

Analysis of the retrospective transfusion data of the SAKK 40/81 study in comparison with the prospective transfusion data of the study SAKK 40/87.

RESULTS

The analysis of the data showed that in the SAKK 40/81 study more patients received blood transfusions than in the SAKK 40/87 study (77% versus 49%). Especially there was a diminution from 90% in the SAKK 40/81 to 59% in the SAKK 40/87 study for the rectal cancer patients respectively from 70% to 44% in the colon cancer patients having received blood transfusions. The mean value of hemoglobin of the patients not having received transfusions has decreased from 11.2 (7.8-15) g/100 ml in the SAKK 40/81 to 10.6 (5.4-15) g/100 ml in the SAKK 40/87 study (p = 0.0001).

CONCLUSION

The data of the two SAKK studies showed that in Switzerland the donation of blood transfusions in patients with colorectal cancer has continuously been handled more and more restrictive. An even more restrective use may be possible in future due to new operation techniques and the possibility of preoperative administration of erythropoetin to increase the hemoglobin level.

[Role of lymph nodes in rectal carcinoma]

The significance of the lymph nodes for the therapy and the prognostics of the rectal cancer are reviewed. Not only the depth of penetrations, but the probability of lymph node involvement (in our series tumors staged T1 had in 12% positive lymph nodes, T2 in 20% respectively, T3 in 37% and T4 in 80%) determine the possible surgical treatment. The available data of different techniques in lymphadenectomy and lymph node staging are compared and discussed. The aim of this paper is to give the oncologically interested the opportunity to pursue the actual questions and to inform themselves about the current standards in regard to the lymphatics in rectal cancer.

The role of the air traffic controller in future air traffic management: an empirical study of active control versus passive monitoring

Proposals for air traffic management such as Free Flight call for a transfer of responsibility for separation between aircraft from air traffic controllers (ATCos) to pilots. Under many proposals, the role of the ATCo will change from one of active control to passive monitoring. The present study directly compared these types of control with respect to ATCo mental workload, conflict detection, and memory. Eighteen ATCos participated in an air traffic control simulation of Free Flight procedures under moderate and high traffic load. Dependent variables included accuracy and timeliness in detecting potential conflicts, accepting and handing off aircraft, mental workload (as assessed by a secondary task, heart rate variability, and subjective ratings), and memory for aircraft location. High traffic density and passive control both degraded conflict detection performance. Actual or potential applications of this research include the recommendation that designs for future air traffic management keep authority for separation of aircraft with the controller.

[Perforation of Meckel's diverticulum by a toothpick]

We report the case of a 31-year-old man with lower abdominal pain, leucocytosis and normal sonographic findings. When performing laparoscopy we found a Meckel's diverticulum perforated by a toothpick. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Symptoms normally occur only when there are complications, when bleeding, obstruction and inflammation are most frequent. Despite modern imaging techniques the diagnosis is difficult and often made intraoperatively. Resection should be performed in any case, because the risk of future complications of the diverticulum outweigh the morbidity after simple diverticulectomy.

[Results of therapy after primary conservative management of distal radius fractures in patients over 65 years of age]

BACKGROUND

In the clinical routine of our City Hospital Triemli, Zürich, Switzerland, we prefer to treat old patients with fractures of the distal radius conservatively. It was our aim to examine the long-term effects of this treatment on anatomical position, mobility, strength, and patient satisfaction.

PATIENTS AND METHODS

We reviewed the data of 102 consecutive patients over 65 years of age. 95 were treated with a plaster cast and controlled weekly in our outpatient department, finally discharged after 50 days. After an average time of eight months, 79 patients could be controlled clinically and radiologically.

RESULTS

Although a significant (p < 0.001) reduction of joint mobility and grip strength was found in all cases, we documented no loss of independence in every-day life. Radiological malalignment of the distal radius with a dorsal or palmar angle of more than 20 degrees in the lateral view or a radio-ulnar angle of less than 15 degrees in the dorsopalmar view was associated with increased complaints and patients dissatisfaction.

CONCLUSION

In old-aged patients with distal radius fractures, the indication for surgical treatment should be made very carefully, since certain degrees of radiological malalignment are tolerated well.

Prognostic value of beta1,6-branched oligosaccharides in human colorectal carcinoma

Increase of beta1,6-branched oligosaccharides is possibly associated with tumor progression and lymph node metastasis. The aim of this study was to determine the prognostic value of beta1,6 branches in human colorectal carcinoma. Expression of beta1,6 branches was histochemically evaluated using the leukoagglutinating Phaseolus vulgaris lectin, PHA-L, in 92 clinically documented colorectal carcinomas, of which 31 had formed lymph node metastases. The follow-up time ranged between 4 and 14 years (median, 10.3 years). A PHA-L staining index (SI), taking into account staining intensity and its percentage of tumor cut surface area, was established. The carcinoma SI was highly associated with the disease-free survival (P = 0.004) and overall survival (P = 0.005). Patients with a carcinoma SI of >1, as compared to those with a SI of < or =1, were at significantly higher risk for tumor recurrence, with a shorter disease-free survival (hazard ratio = 2.59, P = 0.005) and significant higher risk of death with shorter overall survival (hazard ratio = 2.51, P = 0.007). The carcinoma SI was also associated with the presence of lymph node metastases. We conclude that PHA-L staining in human colorectal carcinoma sections provides an independent prognostic indicator for tumor recurrence and patient survival and is associated with the presence of lymph node metastases.