Unilateral lobectomy for Hurthle cell adenoma

Considerable controversy exists regarding the ability to predict the biologic behavior of Hurthle cell tumors. Some have found the clinicopathologic criteria used to differentiate benign from malignant lesions to be unreliable and have advocated total thyroidectomy for all Hurthle cell neoplasms. From January 1980 to December 1995, 39 patients had surgery for Hurthle cell tumors of the thyroid. The surgical pathologic findings were reviewed by an experienced pathologist (JP). Eight patients had histologic findings of capsular or vascular invasion consistent with carcinoma and had total thyroidectomy. Four of these patients had postoperative evidence of residual disease and were treated by radiation ablation. No evidence of invasion was found in 31 patients diagnosed with Hurthle cell adenoma. Twenty-three of these patients had unilateral lobectomy; total thyroidectomy was done in the remaining 8 patients, 5 of whom were found to have an associated papillary carcinoma at the time of operation. There were no operative deaths or significant morbidity. Twenty-two adenomas (71%) were found in females, whereas males had malignant tumors in 6 of 8 cases (P = 0.025). The mean age of adenoma patients is 54.1 years, and that of the carcinoma patients is 55.8 years. Mean size of benign tumors was 2.8 cm and of malignant tumors 4.1 cm (P = 0.04). Four of seven (57%) carcinomas were larger than 4 cm as compared with 6 of 30 (20%) adenomas (P = 0.069). Follow-up has ranged from 1 month to 15 years, with a mean of 3.2 years. There have been no deaths, and no patients with Hurthle cell adenoma have had evidence of recurrence or metastases during follow-up. Our data suggest that carcinoma patients tend to be male and tumor size is larger. An association was found when trying to predict malignancy by using 4 cm as a threshold size. We conclude that pathologic evidence of capsular or angioinvasion can accurately differentiate benign from malignant tumors. Unilateral thyroid lobectomy is adequate therapy for the treatment of Hurthle cell adenoma, with total thyroidectomy reserved for those patients with histologically proven carcinoma.     

Follicular and Hurthle cell carcinomas of the thyroid: a comparative study

University of Texas M. D. Anderson Cancer Center cases filed as Hurthle cell and follicular carcinoma were reviewed. Requirements for including a case in the study were that the diagnosis of Hurthle cell or follicular carcinoma be confirmed, that histologic material and clinical information be adequate, and that there be at least 9 years of follow-up. The study group included 18 cases of Hurthle cell carcinoma and 33 cases of follicular carcinoma. Ten of the Hurthle cell carcinomas had extrathyroid invasion, three had intrathyroid invasion, and five were encapsulated (i.e., they had intracapsular invasion only). In the follicular carcinoma group, 5 tumors had extrathyroid invasion, 14 had intrathyroid invasion, and 14 were encapsulated. When the cases were stratified according to extent of invasion in this manner, there was no statistically significant difference in rate of local recurrence, rate of metastasis (either regional lymph node or distant), or patient survival between Hurthle cell carcinoma and follicular carcinoma. Other variables including patient age and sex, treatment differences, tumor size, vascular invasion, predominant growth pattern (follicular versus solid-trabecular), nuclear size and pleomorphism, mitotic rate, and tumor necrosis did not provide significant additional prognostic information. Metastases of both Hurthle cell and follicular carcinoma were mostly distant and predominantly involved bone and lung. Behavioral differences between Hurthle cell and follicular carcinoma that were not statistically significant included a higher rate of local recurrence in Hurthle cell carcinoma with intrathyroid invasion, more frequent occurrence of regional lymph node metastasis in Hurthle cell carcinoma with extrathyroid invasion, and absence of distant metastasis and death caused by tumor in encapsulated Hurthle cell carcinoma. Five follicular carcinomas and one Hurthle cell carcinoma appeared to have arisen within an adenoma.     

Pulmonary metastasectomy for testicular germ cell tumors: a 28-year experience

BACKGROUND: The role of surgery in patients with pulmonary metastatic germ cell tumors has been evolving since the 1970s. To evaluate the results of pulmonary resection, we reviewed our 28-year experience. METHODS: Between July 1967 and May 1995, 157 patients with testicular germ cell tumors underwent pulmonary resections for suspected metastases. Their clinical and pathological data were reviewed. Kaplan-Meier and Cox regression models were used to analyze prognostic factors for survival after resection of metastatic disease. RESULTS: All patients were male with median age of 27 years (range 15-65). Complete resection was accomplished in 155 (99%) patients. Viable carcinoma was present in 44% (70) of the patients. Forty-one (26%) patients had metastases to other sites after pulmonary metastasectomy. The overall actuarial survival 5 years after pulmonary resection was 68% for the entire group and 82% for patients diagnosed after 1985. On multivariate analysis, the adverse prognostic factors were metastases to nonpulmonary visceral sites (p = 0.0069) and the presence of viable carcinoma in the resected specimen (p < 0.0001). CONCLUSIONS: With current chemotherapy regimens, almost 85% of the patients with testicular germ cell tumors undergoing complete resection of their pulmonary metastases can be expected to achieve long-term survival.     

Retroperitoneal tumors: personal experience

The Authors experience in five retroperitoneal tumors with symptoms and histopathological characteristics not different from those described in the Literature, is here reported. Topographic findings, classification, and incidence of retroperitoneal tumors as referred by various Authors are discussed. Two aspects are particularly pointed out: the histological type and the surgical strategy for their removal. Concerning the first aspect, the Authors underline that benign lesion may have an optimal outcome and a long survival, unlike the malignant ones, which have always unfavourable prognosis, despite adjuvant and complementary therapy (radiotherapy, chemotherapy). As for the second aspect, surgery is the treatment of choice even when other organs different from those exclusively retroperitoneal, may be involved in the demolition.     

Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience

PURPOSE: The operative management and followup of vena caval resection for bulky metastatic germ cell tumors have been previously described in 3 series. In 1989 Ahlering and Skinner described their experience with 12 patients. We now update this experience with the most recent followup on 19 patients. MATERIALS AND METHODS: From April 1978 to May 1995, 19 men underwent retroperitoneal lymph node dissection for stage B3 (N3) or C (N3, M+) germ cell tumor after induction chemotherapy. In all cases the inferior vena cava was resected because of extensive thrombosis or direct involvement of the vessel wall by a tumor. The inferior vena cava was resected from just below the renal veins to beyond the level of disease involvement. Complete resection of retroperitoneal disease was accomplished in all patients. Morbidity and mortality were examined. RESULTS: The mean hospital stay was 10 days (range 7 to 13) for uncomplicated recoveries (9 patients) versus 19 days (range 6 to 32) for complicated recoveries (10 patients). Followup ranged from 1 month to 16 years. Complications included prolonged ileus, small bowel obstruction, fascial dehiscence and pneumonia with pleural effusion. Chronic edema persisted in 3 of 11 patients with followup of greater than 6 months. Of the 6 patients who died of disease recurrence 4 did not have normalization of tumor markers before surgery, and all 4 had persistence of cancer in the resected specimen. Seven patients are without disease at followup of 24 months to 16 years. All survivors had normalized tumor markers before surgery. Only 1 patient (5%) had retroperitoneal recurrence. CONCLUSIONS: En bloc vena caval resection for tumor involvement or extensive thrombosis can be associated with short and long-term morbidity, is feasible, and may contribute to a prolonged tumor-free interval and a chance for cure.     

Ganglion cell tumors

INTRODUCTION: Tumours of ganglion cells are very rare. They include: gangliocytoma, ganglioneuroma, Lhermitte-Duclos disease and dysembryoplastic neuroepithelial tumour. All require microscope identification of well differentiated neurons for diagnosis. Their pathogenesis is not fully understood. Some workers consider them to be dysplasias rather than true neoplasias; others refer to them as malformations. OBJECTIVE: We aim to analyze the most characteristic findings of these tumours with regard to the elements of which they are composed, their epidemiology, behavior on imaging investigations (CT and MR) and treatment. CLINICAL CASES: We present two cases: one patient with a gangliocytoma and one with a ganglioglioma. Both were treated surgically, confirmed on histological study and had good clinical results.     

Clinical relevance of the i(12p) marker chromosome in germ cell tumors

BACKGROUND: Germ cell tumors in men are curable at all stages and are among the most sensitive of all cancers to chemotherapy. An isochromosome of the short arm of chromosome 12, i(12p), has been reported to be a frequent marker of these tumors and to have diagnostic and prognostic significance. PURPOSE: We evaluated the possible association between this cytogenetic marker and clinical outcome for men with germ cell tumors. METHODS: One hundred seventy-eight germ cell tumor samples from 150 men were studied using conventional and molecular cytogenetic techniques. Of these samples, 171 were evaluable. Patient characteristics, disease stage, treatment outcome, and disease status were correlated with the observed cytogenetic changes. In addition, 28 biopsy specimens obtained from 28 patients with tumors of uncertain histogenesis were evaluated to determine whether the presence of i(12p) could serve as a diagnostic marker of a germ cell origin for these tumors. RESULTS: Of the 171 evaluable tumor accessions, 101 (59%) yielded abnormal karyotypes. i(12p) was determined to be present in 79 of the 101 (79%) abnormal karyotypes, which were derived from all cell types and primary sites. An abnormal karyotype was more frequently obtained from nonseminomatous tumors (91/137 [81%]) than from seminomas (10/34 [30%] [P < .001]). Tumors resulting in a cytogenetic failure were more likely to respond completely to chemotherapy than tumors with an abnormal karyotype (P = .004). i(12)p copy number was not associated with response or survival. Fluorescence in situ hybridization using a chromosome 12 centromere-specific probe detected i(12p) in 47 of 47 tumors (100%) already shown to have i(12p) by cytogenetic analysis and in 13 of 49 tumors (27%) exhibiting either an abnormal karyotype or a cytogenetic failure. One or more copies of i(12p), excess 12p copy number, or a deletion on the long arm of chromosome 12 was found in seven of 28 (25%) midline tumors of uncertain histogenesis, thus establishing a diagnosis of a germ cell tumor in these patients. One partial and five complete responses were observed in these seven patients. Only two partial responses were seen in the 17 patients who had no detectable germ cell tumor-related cytogenetic marker (P = .009). CONCLUSIONS: i(12p) is a highly nonrandom chromosomal marker seen in about 80% of male germ cell tumors with evaluable cytogenetic abnormalities. The presence of this isochromosome has diagnostic and possibly prognostic importance for patients with these tumors. IMPLICATIONS: Cytogenetic studies of germ cell tumors in prospective clinical treatment trials are warranted to define more precisely the relationship between histologic subtype, serum tumor marker production, and prognosis.     

Pediatric germ cell tumors

Germ cell tumors are relatively rare tumors in childhood which often present with very large tumors in both gonadal and extragonadal locations. Extragonadal tumors are more common in neonates and infants, whereas gonadal sites predominate in childhood and adolescence. Management consists of surgical resection for localized disease, chemotherapy for residual or metastatic disease, and neoadjuvant chemotherapy and delayed surgical excision for unresectable lesions. The survival for children with germ cell tumors has improved significantly over the past 2 decades with the development of platinum-based chemotherapy. Mature and immature teratomas at any site, and completely resected (Stage I) malignant gonadal and extragonadal tumors, are treated with surgical excision and observation. Malignant lesions with microscopic residual, lymph node disease, or metastatic disease receive platinum-based chemotherapy. Current survival for low-stage (Stages I and II) gonadal sites approaches 100% and survival for higher stage (Stages III and IV) gonadal sites is approximately 95%. Survival for extragonadal lesions is approximately 90% for Stages I and II and 75% for Stages III and IV.     

Clinical experience in temporomandibular joint arthroscopy

Clinical experience of arthroscopy in 12 temporomandibular joints with a clinical diagnosis of closed lock was described. There were 10 patients and all were females with a mean age of 31.2 years (range 20 to 59 years). The antero-lateral approach was used for entry into 11 joints. The clinical findings were adhesions (64%), fibrillation (64%), anterior displacement of disc (36%) and scuffing of the articular surface of the glenoid fossa (9%). Two of the joints that had arthrocentesis prior to arthroscopy did not show any different findings from the rest. Of the 8 patients who had pre-arthroscopy pain, 7 patients (88%) had reduction of the symptom. Three patients (38%) had complete resolution of pain. The range of mouth opening (measured as maximal incisor opening) increased in all patients two weeks following arthroscopy. The average change in maximal incisor opening was 40.3% with a range of 22% to 85%. The mean follow-up was 34 months (range 4 to 68 months).     

Clinical experience in nonstressed antepartum cardiotocography

The condition of the fetus during pregnancy was assessed by 1,763 antepartum cardiotocograms made in 386 patients with the use of fetal movements and physiologic uterine contractions. There appeared to be a significant correlation between the cardiotocograms and the obstetric outcome.     

Sucralfate in odontostomatology. Clinical experience

BACKGROUND: We here describe the pharmacological and pharmacodynamic characteristics of the molecule sucralfate, the aluminum subsalt of sucrose-8-sulphate, introduced in Japan in 1968 as a mucoprotector for the treatment of peptic ulcers. For many years, attempts have been made to broaden the therapeutic indications of this molecule as has happened in oral medicine. This paper describes the results of the clinical trials reported in the international literature which were designed to investigate the use of sucralfate in the treatment of mucositis secondary to radio- and/or chemotherapy and during the course of recurrent aphtous stomatitis (RAS). METHODS: The authors carried out a pilot study with the aim of testing the efficacy and the tolerability of two formulations of sucralfate (20% suspension and 1 gram chewable tablets) in a total of 28 patients [14 with RAS: group A; and 14 with burning mouth syndrome (BMS): group B]. Each group was further divided into two subgroups [A1, A2, B1, B2] of 7 patients each. RESULTS: The results obtained in the RAS patients were encouraging, with an improvement in symptomatology in respectively 71.4% and 42.8% of the patients in subgroups A1 and A2; a number of authors have previously suggested that this is due to a primarily mucoprotective mechanism similar to that occurring in patients with peptic ulcer. The results were less favourable in the BMS patients: symptoms improved in respectively 42.8% and 28.6% of the patients in subgroups B1 and B2, but worsened in 28.6% and 28.6% in teh same subgroups. CONCLUSIONS: In conclusion we believe that sucralfate can be considered a valid therapeutic support in the context of the lenitive pharmacological protocols in which it is currently used, but our results do not allow a definitive judgement of its efficacy in patients with BMS.     

Clinical experience of Rotablator

26 patients (27 lesions) who had severe calcified and diffuse lesions underwent Rotablator treatment, lesion characteristics were type B2, Type C of AHA/ACC classification. There were no patients who had type A1, type B1 lesions. Procedural success rate is 96%, coronary perforation occurred in one patient but not necessary for surgical treatment. Non Q myocardial infarction occurred only in one patient. Follow up Angioplasty were performed 1 and 3 months later after procedures. There were no restenosis after 1 month, but after 3 months, 56% of patients had restenosis.     

Giant cell tumors of bone

Giant cell tumor is a lesion that usually presents with a radiographically characteristic appearance in a predictable location and patient population. It has a few rare presentations such as pulmonary metastases and multifocal lesions. Prognosis of ultimate tumor behavior is dependent on surgical staging (which requires careful radiographic analysis to detect cortical breakthrough and joint involvement) and type of treatment. The recurrence rate is relatively high with simple curettage but decreases with adjuvant treatment at the tumor site. Optimal therapy for the more aggressive lesions is wide resection, but compromise is frequently required when such a resection would sacrifice joint function because of the subarticular location of the giant cell tumor. Radiation therapy is reserved for surgically inaccessible or otherwise inoperable lesions because of a relatively poor radiosensitivity and concerns about induction of high grade sarcomas. Radiographic follow-up evaluation for recurrence is recommended for approximately 5 years but may be difficult to interpret in individual patients because of an overlap in the appearance of healing and recurrence.     

Clinical experience with heart transplantation in infants

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.     

Clinical experience with sodium valproate in children

Good control was achieved with sodium valproate (Epilim) in 44 (71%) of a sample of 62 children with severe recurrent epileptic seizures. The medication was most effective in the control of petit mal; good results, however, were also achieved in some patients with previously poorly controlled grand mal epilepsy and psychomotor and myoclonic seizures. Twenty children required no other anti-convulsant and 28 required only one other. Side-effects were infrequent and mild. Only the high cost of sodium valproate in South Africa precludes its more general use in childhood epilepsy.