Benign juvenile Spitz melanoma in a dermal nevus cell nevus in an adult. Molluscum contagiosum on a dermal nevus cell nevus

A patient with a cancer of the colon or rectum is at increased risk for developing subsequent cancer of his remaining large bowel, particularly when associated polyps and papillomas are present, and when the initial resection is for two or more growths. Patients who develop signs and symptoms of large-bowel tumors following colonic resections for carcinoma should be completely evaluated for another primary tumor. If it is assumed that these patients simply have recurrences of their initial cancers and therefore they are not treated, many patients would be denied a potentially curative operation. All investigators agree that this group warrants long-term follow up, ideally with regular and double-contrast enema studies and sigmoidoscopy. Earlier diagnosis of a second colorectal cancer should improve the resectability rate and prognosis. Those patients with intact cell-mediated immunologic responses seem to do better after surgical treatment.     

Subtotal colectomy with primary ileocolonic anastomosis for obstructing carcinoma of the left colon: valid option for elderly high risk patients

During a period of 4 years, 20 patients with obstructing carcinoma of the left colon were treated by subtotal colectomy with primary ileocolonic anastomosis. Thirteen patients (65%) were 65 years of age or older. All patients presented to the emergency room with large bowel obstruction. Twelve patients (age > 65) suffered other systemic diseases (chronic obstructive pulmonary disease, ischemic heart disease, morbid obesity), placing them in a high risk category. The mortality rate was 5% (1/20), 7.6% if only high risk patients are considered. The one-stage procedure in the treatment of obstructing carcinoma of the left colon offers the patient a number of advantages over stage intervention elimination of colostomy, namely removal of occult lesions in the resected colon, shorter hospitalization and low morbidity and mortality. We found this procedure to be a valid option also in the elderly (> 65) high risk patient. Metastatic disease in our view is not a contraindication, since the elimination of colostomy will improve the quality of life of these patients.     

Laparoscopic ovarian transposition for pelvic malignancies: indications and functional outcomes

OBJECTIVE: To assess the indications and effectiveness of laparoscopic ovarian transposition before pelvic irradiation for a gynecologic cancer. DESIGN: Prospective study. SETTING: A gynecologic oncology department in a French anti-cancer center. PATIENT(S): Twenty-four patients treated for pelvic cancer. INTERVENTION(S): Laparoscopic ovarian transposition to paracolic gutters. Uterine conservation in 18 patients. MAIN OUTCOME MEASURE(S): Clinical and laboratory follow-up tests of ovarian function. RESULT(S): Bilateral laparoscopic ovarian transposition was achieved in 22 patients (94%). Twelve patients were treated for clear cell adenocarcinoma of the cervix and/or upper vagina, 6 patients for invasive squamous cervical carcinoma, 3 patients for pelvic sarcoma, 1 patient for recurrent cervical cancer to the upper vagina, 1 patient for ependymoma of the cauda equina, and 1 patient for ovarian dysgerminoma. Ovarian preservation was achieved in 79%. Three pregnancies were obtained. CONCLUSION(S): Laparoscopic ovarian transposition is a safe and effective procedure for preserving ovarian function. Bilateral ovarian transposition should be performed. The main indications for laparoscopic ovarian transposition are a patient with a small invasive cervical carcinoma (<2 cm) in a patient <40 years of age who is treated by initial laparoscopically assisted vaginal radical hysterectomy and a patient with a clear cell adenocarcinoma of the cervix and upper vagina.     

Endoscopic correction of vesicoureteral reflux by subureteric Teflon (polytetrafluoroethylene) injection: review of 6-year experience

In literature data, an uncertainty exists whether occurrence of bilateral breast cancer decreases the survival probability of affected patients. Therefore, we analyzed the medical records of 498 postoperatively irradiated (1977-1982) female breast cancer patients (T1-4,N0-3,M0). In the follow-up time, in 36 patients a bilateral breast carcinoma treated by surgery with or without radiotherapy was found. The 10-year overall survival rates were 54% in patients who had unilateral disease, compared with 56% in bilateral carcinoma patients, respectively. The incidence of metastasis did not differ between both groups: 24.2% versus 38.8%. Eleven percent of unilateral cancers recurred; in the other group, local failure of the first and second tumor was observed in 19.4% and 11.1%, respectively. We conclude that the occurrence of bilateral breast cancer has no significant impact on survival, although the development of local failures and metastases seems to be more frequent. The therapeutic strategy in bilateral carcinoma should resemble the treatment procedure in unilaterally affected patients.     

Metastasizing auricular basal cell carcinoma

Basal cell carcinoma represents the most common skin cancer and involves the head and neck area in 80% to 85% of all patients treated. Despite their frequent occurrence, metastatic spread from these tumors is rare. This paper presents a case of a patient who had a metastasizing basal cell carcinoma. Despite control of primary disease by radical surgery and adjunctive irradiation, bony metastasis was found within nine months of therapy. Palliative therapy was given, but the patient died five months later. The pathophysiology of the metastasizing basal cell carcinomas is described, and a rationale for therapy presented.     

Evaluation of dissection of the axilla in modified radical mastectomy

Fifty consecutive unselected patients with infiltrating carcinoma of the breast underwent radical mastectomy in two consecutive stages. The initial operation was a modified radical mastectomy, with preservation of the pectoral muscles, and the second stage, a procedure to transform the initial operation into a standard radical mastectomy. An analysis of the location and the number of the lymph nodes recovered in the two stage operation shows that a so-called modified radical mastectomy is inadequate to ensure the clearing of the axilla. Lymph nodes were recovered at the second stage of the operation in 36 patients, and seven of these patients had metastasis. Modified radical mastectomy was effective in erradicating the lymph nodes of the lower part of the axilla but inadequate for lymph nodes at levels II and III and, especially, the interpectoral lymph nodes.     

Surgical treatment for advanced carcinoma of the gastric remnant

BACKGROUND/AIMS: Carcinoma of the gastric remnant has increased in recent years, but a therapeutic strategy for this disease has not been established. This retrospective study was performed to determine the most appropriate surgical procedure for carcinoma of the gastric remnant. METHODOLOGY: A total of 25 patients who underwent operation for advanced carcinoma of the gastric remnant that had developed after distal gastrectomy (13 for benign gastric diseases, B group; 12 for gastric carcinoma, M group) were studied. Clinicopathological features, as well as the status of lymph node metastasis, were investigated in the B and M groups. RESULTS: There were more patients with carcinoma invading other organs, stage IV disease, and with N2 or more lymph node metastasis (especially, with a high metastatic rate to lymph nodes along the splenic artery) in the M group than in the B group. Forty percent of patients in the M group were treated by left upper abdominal evisceration (LUAE), but only 8% in the B group. The survival rate (5-year, 46.0%) of the B group was significantly higher than that (5-year, 11.9%) of the M group. When we compared the survival rate of carcinoma of the gastric remnant with that of primary carcinoma of the upper third of the stomach, there was no difference between the two groups in the curative resection cases. CONCLUSIONS: Almost the same surgical strategy can be adopted for the B group as for primary gastric carcinoma. On the other hand, for the M group, a radical surgical procedure, LUAE, should be recommended.     

Inequality in infant morbidity: causes and consequences in England in the 1990s. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood

Leiomyosarcomas (LMS) of the heart are exceptional primary malignant tumours with a catastrophic prognosis and a mean survival measured in months. Extensive radical surgical resection clearly remains the most appropriate treatment. We report three cases observed over a 3-year period, consisting of an LMS of the inferior vena cava, an LMS of the pulmonary artery trunk and an LMS of the left atrium. The first case was treated by radical resection and reconstruction by autologous vein graft of the cavorenal junction, the second case was treated by extensive resection and prosthetic reconstruction of the pulmonary artery bifurcation and the third case was treated by a first radical resection of the left atrium, requiring total cardiectomy and orthotopic heart transplantation for local recurrence at the sixth month. The survical was significantly improved compared to other treatment options (chemotherapy, radiotherapy). The first patient is still alive without recurrence at two years; the second died 12.5 months after the surgical procedure and the medium-term follow-up of the transplanted patient revealed cerebral and hepatic metastases nine months after transplantation. The authors review the literature concerning these extremely rare malignant tumours. Recent progress of diagnostic investigations, such as spiral CT with reconstruction, MRI, positron emission tomography (PET), are now able to establish the diagnosis more rapidly and therefore allow more radical surgical resection. This resection, possibly combined with venous reconstruction, must be associated with adjuvant therapies. Heart transplantation should be considered among the treatment options for leiomyosarcomas of the heart, in order to improve the poor prognosis of these lesions affections a young population.     

Significance of full-thickness chest wall resection as a local treatment for sternum metastasis of breast cancer

Bone metastasis of breast cancer generally tends to be multiple. However, breast cancer frequently metastasizes to the sternum as solitary metastasis. Resection of the sternum was reported to be an effective surgical technique for sternum metastasis which could not be remarkably improved by chemo-endocrine therapy and locoregional recurrent breast cancer invading the skin. A first patient was diagnosed with sternum metastasis invading the skin 44 months after radical mastectomy for breast cancer of stage II. A second patient had breast cancer of stage IV simultaneously with metastases to the sternum and the lung. Only the lung metastasis was successfully controlled by chemo-endocrine therapy, but the sternum metastasis was progressive, following radical mastectomy. Both patients manifested solitary bone metastases and underwent full-thickness chest wall resection. The defect of the chest wall was reconstructed with the mucocutaneous flap using the dorsal latissimus muscle in case 1 and with the abdominal rectus muscle in case 2. Twenty months after the resection of the sternum, the first patient suffered from supraclavicular lymph node metastasis, and the multidisciplinary treatment including radiation therapy was indicated. This therapeutic procedure was effective, and the patient survived for 63 months after resection of the sternum. The second patient has made good progress for six months in maintaining complete remission with chemo-endocrine therapy. These findings suggested that surgical resection was a useful local treatment for solitary sternum metastasis.     

Failure of colonoscopic surveillance in ulcerative colitis

A prospective surveillance programme for patients with longstanding (> = 8 years), extensive (> = splenic flexure) ulcerative colitis was undertaken between 1978 and 1990. It comprised annual colonoscopy with pancolonic biopsy. One hundred and sixty patients were entered into the programme and had 739 colonoscopies (4.6 colonoscopies per patient; 709 patient years follow up). Eight eight per cent of examinations reached the right colon. There was no procedure related death. One Dukes's A cancer was detected. Forty one patients (25%) defaulted. Of these 25 remain well; 13 are unaccounted for, and one died from colonic cancer. One patient had colectomy for medical reasons, and another died of carcinoma of the pancreas. Retrospectively an additional 16 eligible patients were identified who had not been recruited. Of these, 14 remain well, two are unaccounted for. None developed colonic cancer. Four patients refused colonoscopy. All remain well. Over the same period seven other cases of colonic cancer were found in association with ulcerative colitis, two in patients who had erroneously been diagnosed as having only proctitis and were therefore not entered into the programme, but were found at operation to have total colitis, one in a patient with colitis of seven years duration, and four patients who had previously attended the clinic but had been lost to follow up before 1978 and then had represented with new symptoms during the surveillance period. Thus, of the nine colitis related cancers diagnosed in this centre during the study period only one was detected by the surveillance programme. The results of this large study, a a review of published works, cast doubts on the effectiveness of colonoscopic surveillance programmes in detecting colorectal cancer in patients with ulcerative colitis.     

Upper limb reflex sympathetic dystrophy associated with occult malignancy

Reflex sympathetic dystrophy, characterized by pain, swelling, vasomotor instability, and trophic changes in an extremity, has been infrequently described in patients with occult malignancy. Two cases of reflex sympathetic dystrophy associated with local tumor involvement are reported. Both patients had a history of cancer in clinical remission. Despite aggressive physical therapy measures, the patients' symptoms persisted. Workup of the first patient found an apical paravertebral mass in the lung; biopsy revealed recurrent breast carcinoma. In the second case, workup found an axillary mass contiguous with the lower brachial plexus. Biopsy revealed lymphoma, a second primary malignancy. In both cases, medical treatment of the tumor was instituted, with consequent improvement of hand and shoulder function. Both patients required prolonged hospitalization and multiple procedures that might have been avoided if malignancy had been suspected. Spontaneous development of reflex sympathetic dystrophy in patients with a history of cancer should alert the physician to the possibility of occult malignancy.     

Compare and contrast

We report a patient with squamous cell carcinoma that developed at the ureteroileal anastomosis and extended into the ileal conduit 11 years after a radical cystectomy for transitional cell carcinoma of the bladder. To our knowledge, this is the first report to document the development of a squamous cell carcinoma in an ileal conduit after a radical procedure for bladder cancer.     

Synchronous hepatocellular carcinoma or metastatic hepatic tumor with primary gastric cancer

BACKGROUND/AIMS: When a solitary hepatic tumor occurs synchronously with gastric cancer, it is usually presumed to be metastatic. However, this may not be true in a place like Taiwan, where hepatocellular carcinoma (HCC) is prevalent. This study was conducted to examine the clinicopathological factors of both conditions. METHODOLOGY: A retrospective analysis of 14 patients who underwent a synchronous hepatectomy in combination with radical gastrectomy over the past 15 years was performed. RESULTS: Seven patients had metastatic gastric cancer, and seven had concomitant gastric and hepatic cancer. Serosal invasion and lymph node metastasis were the major features in the patients with metastatic gastric cancer. Early gastric cancer was found in three of the patients with the coexisting primary cancers. No patient with solitary metastatic cancer survived more than one year, but long-term survival of more than two years was achieved in two patients with the two forms of cancer. CONCLUSIONS: Double cancer of the stomach and liver should be kept in mind in patients with gastric cancer concomitant with a solitary hepatic tumor, in order to provide optimal treatment.     

Lymphedema after breast carcinoma. A study of 5868 cases

BASIC PROBLEM AND OBJECTIVE: According to published reports, the incidence of lymphoedema of the arm in patients with cancer of the breast, treated by either surgery or radiotherapy, varies widely. We obtained basic data on the treatment of breast cancer in a large number of patients in order to determine the relationship between the incidence of lymphoedema and the radical nature of the primary treatment. PATIENTS AND METHODS: Data were collected on all women with lymphoedema of the arm after treatment for breast cancer between 1972 and 1995. The increase in arm circumference was measured by a standardised method. Only those patients were included in the final analysis whose arm circumference had increased by at least 2 cm. The type of operation and(or) radiotherapy, tumor histology and TNM classification were recorded. RESULTS: There were 1405 cases of arm lymphoedema after treatment of 5868 cases of breast cancer (24%). 2515 breast cancers had been treated surgically. 3353 surgically and by radiotherapy. Lymphoedema occurred in 22.3% after radical mastectomy without radiotherapy and in 44.4% with it; after modified radical mastectomy without radiotherapy in 19.1%, in 28.9% with radiotherapy; after breast-preserving operation without radiotherapy in 6.7%, with radiotherapy in 10.1%. Until the 1970s radical mastectomy with conventional postoperative radiotherapy has been the treatment of choice, with 38% cases of lymphoedema. This incidence gradually decreased to 16% in subsequent years. CONCLUSION: The incidence of lymphoedema of the arm depends on the radical nature of the primary treatment. The quality of life could be easily improved through minimising the incidence of lymphoedema if current standards of breast-preserving surgery were generally practised.     

Radiotherapeutic management of cervical carcinoma that complicates pregnancy

BACKGROUND: Data regarding radiation therapy for pregnant patients with cervical carcinoma are limited. The goal of this study was to assess the effects of pregnancy on tumor control, survival, and morbidity associated with radiation therapy administered to pregnant patients. METHODS: The authors performed a retrospective case-control analysis of 26 women with cervical carcinoma who were diagnosed during pregnancy and treated primarily with radiation therapy. These cases were matched with 26 controls based on age, histology, stage, treatment, and year of treatment. RESULTS: Patients were treated with external beam radiation (mean dose, 46.7 gray [Gy]) and intracavitary radiation (mean dose, 56.5 Gy to Point A). Two patients with Stage IA2 squamous cell carcinoma treated in the third trimester had a planned delay in treatment of 3 weeks, and both infants had an uncomplicated neonatal course. Seven pregnant patients (2 Stage IB1, 5 Stage IB2) underwent radiation after radical hysterectomy was aborted due to positive regional lymph nodes. Three patients diagnosed during the first trimester were treated with radiation with the fetus in situ, and all had spontaneous abortions 20-24 days after the start of radiation (mean dose, 34 Gy). In all these cases, radiation was interrupted for only 3 days or less. There were no statistically significant differences in recurrence rates or survival between the pregnant group and the controls. Short term toxicity was comparable in pregnant and nonpregnant patients and easily controlled. Long term complications were more common in controls (12% in pregnant patients, 27% in controls), but this difference was not statistically significant. Most complications were likely related to radiation techniques (particularly the predominance of cobalt-60). CONCLUSIONS: Planned delay in treatment should be offered to pregnant patients with early stage squamous cell carcinoma in the late second and early third trimester. Patients diagnosed in the first or second trimester who are not good candidates for planned delay in treatment should be given radiation therapy immediately. It may be necessary to reconsider planned radical hysterectomy for pregnant women with Stage IB2 disease due to the high rate of lymph node positivity found on exploration. For patients with advanced disease, radiation therapy appears to be a safe and effective modality.     

Regional chemotherapy with hemofiltration: a rationale for a different treatment approach to advanced pancreatic cancer

BACKGROUND/AIMS: Since 1989, thirty-two patients with advanced, intra-abdominal pancreatic cancer were treated with regional chemotherapy in combination with extracorporeal hemofiltration. PATIENTS and METHODS: Eleven patients had locally advanced, unresectable cancer, and ten had advanced disease with liver metastases. Three patients had developed liver metastases following a radical resection. One patient had an incomplete resection with local residual disease, and a second had developed a local recurrence after a radical resection. One patient had an unresectable cystadenocarcinoma. Five patients had failed prior systemic therapies for unresectable pancreatic cancer. The patients underwent 85 treatments with regional chemotherapy plus hemofiltration, an average of 2.7 treatments per patient. RESULTS: Of 21 patients treated primarily with regional chemotherapy plus hemofiltration, there were two complete responses (9%) and eight partial responses (38%), an overall total response rate of 47%. The average survival for patients with Stage II/III localized, unresectable disease is 13 months and that for Stage IV unresectable disease with liver metastases is 9 months. CONCLUSIONS: Patients with recurrent disease following a radical resection or having failed prior systemic therapies generally had no benefit from regional chemotherapy plus hemofiltration.     

2-stage surgery of neoplastic left colonic obstruction remains the safest procedure

From January 1989 to December 1996, 56 consecutive patients underwent emergency surgery for occlusive cancer of the left colon. Excepting 12 patients whose symptomatology and radiographic presentation required medial laparotomy, the elective procedure was initial colostomy. There were 11 men and 33 women, mean age 76 years (range 50-97). Two patients in poor general status (ASA III) died during the postoperative period. Among the 42 survivors, the second procedure was not performed because of poor general status or disease progression in 6. Mean delay to the second procedure for resection was 11.5 days; during the same hospitalization for 32 out of 36 patients. The second procedure was segmentary colectomy in 34 cases and limited to exploratory laparatomy because of inextricable lesions in 2. Among the 34 re-operations with segmentary colectomy, the ostomy was removed in 28 at the second procedure and a third procedure was required in 6 cases. All the anastomoses in this series were sutured manually. Mortality for re-operation was nil. Pathology results (Duke's classification) in the 36 reoperated patients was: stage B = 3, stage C = 19, stage D = 14. In this series, operative mortality only concerned those patients whose condition was incompatible with selective surgery for colostomy. This risk cannot be lowered by any, other surgical approach. For the 34 resection-anastomosis elective operations, no major complications or deaths were observed. These results led us to recommend two stage surgery as routine strategy since survival of all those patients capable of sustaining an elective colostomy in an emergency setting can be assured.     

Gynaecological state of health of 2 654 women in Nurmes 1970-71. A clinical outpatient study

Eighty-one patients who had had colectomy and ileorectal anastomosis for ulcerative colitis or Crohn's disease of the colon from 1 to 13 years previously were interviewed and examined by a surgeon with whom they had had no previous contact. Sixty-four patients (79 per cent) had a satisfactory result. In 12 patients the operation had failed and an ileostomy had been established, and in a further 5 patients the result was considered unsatisfactory. Despite a high incidence of frequent loose stools and minor anorectal complications, most of the patients were satisfied with the result and would not contemplate the alternative of an ileostomy. No patient had developed rectal cancer. Provided that the rectum is examined regularly for pre-malignant or malignant change, colectomy and ileorectal anastomosis offer a satisfactory alternative to proctocolectomy and ileostomy for many patients with ulcerative colitis or Crohn's disease.     

White-coat resistant hypertension

OBJECTIVE: To identify women treated for endometrial carcinoma with increased risk for recurrent disease, to examine how and when recurrences are discovered, and to assess the clinical benefit of routine follow up investigations. DESIGN: Retrospective case analysis. SETTING: Hordaland county, Norway. POPULATION: All women treated for endometrial carcinoma in a demographically well defined area, in a 10-year period (1981-1990). METHODS: Data concerning patient characteristics and course of the disease were collected through review of the medical records, correspondence with the primary physician and from the Norwegian Cancer Registry. Univariate and multivariate survival analysis. RESULTS: After curative surgical treatment 249 women diagnosed with endometrial carcinoma were followed for a median period of 9 years (range 4-16) or until death. Among these 249 radically treated patients, 47 had recurrent disease, 32 within the first two years. Ten of the recurrences were diagnosed at routine follow up, but only four were asymptomatic. In our follow up programme, one asymptomatic recurrence was detected for every 653 routine consultations. A low risk group, with FIGO Stage IA/IB or patient age below 60 years at primary operation was identified in multivariate recurrence-free survival analysis. No asymptomatic recurrences were found in this group. CONCLUSIONS: Low risk women should be considered for an alternative, less frequent follow up. The sensitivity for current practice of routine follow up in detecting asymptomatic recurrences is so low that other beneficial effects should be documented to defend the large resources spent on this programme.     

Preliminary results of preoperative radiotherapy in carcinoma of the rectum (author's transl)

Preliminary results were evaluated in patients with carcinoma of the rectum of whom 33 had preoperative radiotherapy and 23 were treated by operation only. The tumour stage was T2-4 NX MO in all patients. There was no significant difference between the groups as to postoperative mortality, would healing, and postoperative admission time. However, the recurrence rate was significantly lower in pre-irradiated patients than in those treated by operation only. The combination of radiotherapy and radical operation appears to be a possible means of significantly improving the survival rate of patients with carcinoma of the rectum.