Intralesional excision compared with en bloc resection for giant-cell tumors of bone

We reviewed the results for forty consecutively seen patients, each of whom had been managed by one surgeon for a giant-cell tumor of bone in an extremity between 1976 and 1990. Twenty patients had been managed with an en bloc resection and twenty, with an intralesional excision of the tumor with adjunctive local insertion of methylmethacrylate or phenol. All patients had been followed for a minimum of two years. Both en bloc resection and intralesional excision were found to be excellent oncological procedures. There were fewer complications and better functional results after the intralesional procedure than following the en bloc resection.     

Sphincter preservation therapy for distal rectal carcinoma: a review

BACKGROUND: There has been increasing interest in the use of sphincter-preserving therapy for patients with distal rectal carcinomas. The outcomes of conservative treatments for early stage rectal carcinoma appear to be comparable to that achieved with abdominoperineal resection. METHODS: Retrospective and prospective clinical series of patients with distal rectal carcinoma treated by local excision alone, local excision with postoperative adjuvant therapy, preoperative radiation followed by local excision, or radical circumferential sphincter-sparing surgeries were reviewed. The local control rates, salvage rates, and treatment complications in patients treated by these various methods were examined. RESULTS: Patients with T1 distal rectal carcinoma with favorable clinical and histopathologic characteristics treated with local excision alone had a local control rate of greater than 90% in most series. Postoperative chemoradiation improved local control for those with T1 disease with unfavorable characteristics, or those with T2 disease. Most T3 patients had failure rates of greater than 30% despite adjuvant local and systemic therapy. With high dose preoperative radiation, approximately 80% of patients with locally advanced or unresectable tumors were able to undergo sphincter-preservation treatment. CONCLUSIONS: Patients with favorable T1 rectal carcinoma are likely to be adequately treated with local excision alone. Patients with T1 disease with unfavorable characteristics as well as T2 patients will benefit from postoperative chemoradiation. The use of local therapy in T3 patients needs to be carefully considered because these patients are at relatively high risk for local recurrence despite adjuvant therapy. Preoperative radiation followed by either local excision or radical circumferential sphincter-sparing resections appears promising in allowing sphincter preservation in patients with locally advanced tumors.     

Sutureless repair of major intracranial vessels with the Sundt clip-graft: technical note

Laryngeal granulomas are uncommon lesions of an inflammatory origin. They are conventionally managed by simple excision with the occasional use of adjuvant treatment depending on the aetiological factors. Unfortunately, recurrences can occur, requiring repeated excision. Some lesions are refractory to this approach and alternative management approaches include excision and immediate adjuvant radiotherapy. The use of radiotherapy in the management of benign disease can be limited by the risk of induction of late malignancy and informed consent of a patient must include an assessment of this risk. We describe a case of refractory laryngeal granuloma successfully treated by excision and immediate radiotherapy in a patient occupationally dependent upon his voice.     

Treatment of chondrosarcoma. A retrospective study at the Norwegian Radium Hospital

The authors present a retrospective analysis of 59 chondrosarcoma patients treated at the Norwegian Radium Hospital during the period 1981 to 1993. 31 patients were admitted with untouched tumour, seven after fine needle cytology and 20 after open biopsy or partial excision. One patient had recurrent local disease. Only 20% of the tumours were of high grade malignancy. 51 patients were treated by surgery. Reconstructions were performed in 16 patients, using allografts or endoprostheses. Amputations were performed in six cases and wide excision in 12 cases. In these 18 patients local recurrence appeared in one case, and two developed lung metastases. Only one of the 18 patients operated by amputation or wide excision has since died from chondrosarcoma. Marginal excisions were performed in 26 cases. Nine of these patients developed a local recurrence, five developed metastases and three have died. Six patients had partial excisions. Postoperative radiotherapy was given to one patient only. Five of the six are alive. In one case, the quality of the margins could not be evaluated. A total of 45 of the 51 patients treated for the primary tumour by surgery are alive. The median observation time is four years. Treatment of nonmetastatic chondrosarcoma should be surgical. Chondrosarcoma patients show wider variations in age, localization of tumour and tumour growth rate than patients with other bone sarcomas. Although wide excisions provide the best local control of any grade of malignancy, the mutilation or risk involved may be so great that some patients may benefit from marginal or even partial excision.     

Modified-Mathieu''s technique: a variation of the classic procedure for hypospadias surgical repair

For years, a wide and deep excision of primary cutaneous melanomas has been recommended to achieve a better care and to decrease the risk of local recurrence of the disease. However, recent studies indicate that removal of peritumoral tissue beyond complete excision of the primary neoplasm does not decrease significantly the risk of local metastases. In addition, it confers no benefit to the patient survival.     

Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence?

PURPOSE: This study examines the prognostic significance of circumferential margin involvement by tumor in resected specimens after potentially curative rectal cancer surgery. METHODS: During an eight-year period, all patients with rectal cancer were prospectively audited. For tumors of the middle and lower thirds of the rectum, a total mesorectal excision was performed; for tumor of the upper third, mesorectal excision proceeded at least 5 cm distal to the primary tumor. Resected specimens were subjected to careful histologic assessment, and patients undergoing curative procedures were entered into a surveillance program to detect both local and distant recurrence. RESULTS: Of 218 patients in the cohort, 9 had no resection, 14 underwent local excision, 1 had pre-operative radiotherapy, and 42 patients (20 percent) had palliative resections and were excluded from further analysis. This left 152 patients having a curative resection, of whom 20 (13 percent) had tumor within 1 mm of the circumferential margin. After follow-up until death or a median period of 41 months, recurrent disease was seen in 24 percent of patients with a negative margin and 50 percent with a positive margin. Both disease-free survival and mortality were significantly related to margin involvement (log-rank, P = 0.01 and P = 0.005, respectively). Local recurrence, however, was not significantly different in the two groups (11 and 15 percent, respectively; log-rank, P = 0.38). CONCLUSIONS: When mesorectal excision is performed, circumferential margin involvement is more an indicator of advance disease than inadequate local surgery. Patients with an involved margin may die from distant disease before local recurrence becomes apparent.     

Malignant fibrous histiocytoma of the hand: multimodal therapy and extensor tendon reconstruction

A patient with malignant fibrous histiocytoma of the dorsum of the hand, managed with irradiation and wide local excision, is presented. Biopsy technique, the rationale for preoperative irradiation, and the details of extensor tendon reconstruction are discussed. Tendon grafts, rather than transfers, were used to reconstruct the extensor tendon defects. Although this approach is simple, little is known regarding the healing of irradiated tendons or the use of dynamic splinting protocols in this setting. Our patient experienced no difficulty with either tendon healing or early dynamic splinting and achieved an acceptable range of motion.     

Primary amyloidoma of the chest wall

Primary amyloidoma of the chest wall presents as an aggressive tumor that causes local destruction. It is best treated with wide local excision and reconstruction as required, which usually is curative. A search for occult systemic disease also is recommended.     

Kimura's disease

An Asian man aged 42 had a pre-auricular swelling on the left with local skin itching. Owing to the highly probably benign nature at examination, surgical treatment was refrained from. One year later, the swelling had increased while the itching was unchanged, so that surgical excision was performed. Morbid-anatomical examination revealed angiolymphoid hyperplasia with eosinophilia, compatible with Kimura's disease. Kimura's disease is a chronic inflammatory disorder which is very rare in Europe, but which is frequently diagnosed in Asian countries and in immigrants from these countries. Tumours in the head and neck region, enlarged lymph nodes and increased eosinophil counts are typical signs. The IgE level is increased. The cause of this disease is so far not clear, although there are indications that an inflammatory reaction to an unknown allergen plays a part. It is essential that this disease should be distinguished in the diagnostic work-up from presence of a malignancy. Fine-needle aspiration cytology is often inconclusive; as a rule the diagnosis can only be made after surgical excision of the tumour. There is no consensus on the treatment of this disease, but symptomatic therapy usually suffices.     

Conservative treatment of favorable rectal carcinomas

Conservative treatment of rectal cancer with either full thickness en bloc local excision or endocavitary irradiation provides excellent local control for highly selected early rectal carcinomas. For either approach the selection criteria are similar. An ideal lesion should be: 1) freely mobile; 2) less than 3 cm in diameter; 3) no evidence of extension into the perirectal fat either on digital examination or on transrectal US; 4) no clinical evidence of involved nodes on physical examination of diagnostic studies; 5) the surgical alternative would be an abdominal perineal resection; 6) well or moderately differentiated. External beam radiation therapy can contribute to the results of conservative treatment by improving the chances of controlling subclinical nodal disease in the pelvis as well as by improving the control of disease in the rectum at the margins of the local procedure. For highly selected patients, the local control and disease-free interval is on the order of 90% with either endocavitary radiation or local excision.     

Relationship between CA 15-3 serum levels and disease extent in predicting overall survival of breast cancer patients with newly diagnosed metastatic disease

Soft tissue sarcomas (STS) of the hand are rare in children and adolescents. From 1965 through 1995, 18 children with STS of the hand were treated at our institution. Rhabdomyosarcoma (RMS) was diagnosed in 11 patients; alveolar histological results predominated (7 of 11 cases). Seven patients presented with metastatic disease and died 4 to 23 months (median, 9 months) from diagnosis; their surgical treatment comprised above-elbow amputation (n = 1), local excision (n = 1), and biopsy (n = 5). For the four patients who presented with localized RMS, surgery consisted of wide local excision (n = 1), local excision (n = 2), or ray amputation (n = 1). With an average follow-up of 5.5 years (range, 4 months to 18 years), 3 of the 11 patients diagnosed with RMS still survive (27%). The remaining seven patients presented with nonrhabdomyosarcomatous soft tissue sarcoma (NRSTS); the most common histological variants were epithelioid and malignant fibrous histiocytoma (two cases each). Surgical treatment for these patients comprised ray amputation (n = 3), wide local excision (n = 3), excisional biopsy (n = 1), and regional lymph node dissection (n = 3). One patient received adjuvant multiagent chemotherapy; three patients received supplemental radiotherapy. Six of the seven (85%) patients are alive with no evidence of disease at an average follow-up of 4.7 years (range, 6 months to 12 years).     

Oncological outcomes of operative treatment of subcutaneous soft-tissue sarcomas of the extremities

We reviewed the cases of sixty-two patients who had had a subcutaneous sarcoma to determine the effect of tumor and treatment-related variables on the rates of survival and local recurrence. Fifty-nine (95 per cent) of the patients had had an operation at another hospital before being referred to us. Twenty-nine (47 per cent) of the sixty-two tumors were high-grade, forty-two (68 per cent) were small (five centimeters or less), and thirty (48 per cent) were malignant fibrous histiocytomas. We followed a treatment strategy that consisted of repeat excision with the goal of obtaining wide margins. Excluding thirteen patients who had had a palpable local recurrence at the time of presentation, twenty (49 per cent) of forty-one patients who had had a marginal excision at another hospital had microscopic residual tumor on repeat excision. At a median of fifty-six months after the repeat excision, fifty (81 per cent) of the sixty-two patients had been continuously disease-free, one had no evidence of disease, eight had died of the disease, and three had died of other causes. The five-year rate of disease-free survival was 85 per cent (fifty-three of sixty-two patients). There were three local recurrences, all in patients who had had a marginal resection. No recurrences were noted in patients who had had a wide local excision of the tumor or of the previous operative field. Multivariate analysis revealed that a large tumor (greater than five centimeters), a marginal excision, and adjuvant radiation therapy were associated with a worse prognosis. Excellent rates of survival for patients who have a subcutaneous sarcoma, including those who have a large or high-grade tumor and those who have residual tumor following a previous operation, can be obtained with carefully planned operative treatment alone. We recommend operative excision or repeat excision with wide margins because of the high prevalence of residual tumor. Size is the most important tumor-related factor, and the operative margin is the most important treatment-related factor. The additional value of adjuvant radiation therapy remains unproved.     

Frequent expression of Bcl-2 in renal-cell carcinomas carrying wild-type p53

Lunate excision alone is seldom utilized in the management of Kienbock's disease due to concerns about progressive carpal collapse following removal of this central carpal bone. We report a 32-year follow-up of a patient who underwent lunate excision only for treatment of Kienbock's disease with a successful outcome. Although lunate excision is thought to be associated with a high failure rate, a review of the literature suggests that success rates following lunate excision are comparable to those reported for other more conventional techniques such as radial shortening, ulnar lengthening, limited carpal fusions, and proximal row carpectomy. The current perception that lunate excision is associated with a high failure rate is not supported in the literature. As such, it may not be appropriate to assign this operation to the category of "historical interest only."     

The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases

BACKGROUND: The study addresses the controversial prognostic and therapeutic aspects of phyllodes tumor of the breast. METHODS: Records of 170 women with phyllodes tumor of the breast were reviewed. On the basis of the criteria proposed by Azzopardi and Salvadori et al., including estimation of tumor margin, growth of the connective tissue component, mitoses, and cellular atypia, the entire series was divided into three histotypes of phyllodes tumor, i.e., benign (92 cases, 54.1%), borderline (19 cases, 11.2%), and malignant (59 cases, 34.7%). Ninety-eight patients (57.6%) were treated by wide local excision (79 benign, 15 borderline, and 4 malignant), 43 (25.3%) by simple mastectomy (13 benign, 4 borderline, and 26 malignant), and 29 (17.1%) by radical mastectomy (all malignant). RESULTS: Of the 170 treated patients, 141 (82.9%) survived 5 years without evidence of disease. In the Cox multivariate analysis the histotype of the tumor was the only independent prognostic factor: 5-year NED survival was observed in 95.7% of the patients with benign phyllodes tumor, 73.7% with borderline phyllodes tumor, and 66.1% with malignant phyllodes tumor. After a wide local excision 98.7% of the patients with benign tumor, and 80% with borderline tumor, were cured. Local recurrence was found in 14 patients (8.2%) (4 benign, 3 borderline, and 7 malignant); 10 of these underwent reoperation (7 wide local excision, 3 radical mastectomy) and survived 5 years NED. CONCLUSIONS: The histotype of phyllodes tumor (benign, borderline, and malignant), assessed on the basis of the criteria proposed by Azzopardi and Salvadori et al., was the only prognostic factor in our group of patients. Based on the data from literature and our own observations, we observed that a wide local excision, with an adequate margin of normal breast tissue, is the preferred initial therapy for phyllodes tumor of the breast.     

Variable management of soft tissue sarcoma: regional audit with implications for specialist care

BACKGROUND: The aim of this study was to determine how and by which specialties patients with soft tissue sarcoma are investigated and treated within a single large health region and with what outcomes and implications for resource uptake. METHODS: By retrieving the records of 377 patients with primary soft tissue sarcoma treated in the South-East Thames Region between 1986 and 1992, the presentation, investigation, treatment and outcome were compared with defined criteria for optimal management. Patient management was assessed and compared between specialties and districts on the basis of outpatient time, appropriate use of radiological investigations and preoperative biopsy, type of surgery, content of the pathology report and the incidence of local recurrence, metastasis and death over a mean follow-up period of 2.5 years. RESULTS: Most patients (53.6 per cent) were treated by general surgeons, irrespective of tumour location. Overall only 21.3 per cent of patients were investigated optimally with wide variation among specialties. Only 60.0 per cent were treated adequately (wide excision or surgery with radiotherapy). Uptake of adjunctive therapy and follow-up were variable. Outcome was poorer in patients having a marginal excision and recurrence. CONCLUSION: Investigation and management of many patients with soft tissue sarcoma was both variable and suboptimal. This has implications for patient care, resource uptake and costs. As has been amply demonstrated elsewhere, patients with sarcoma are more appropriately managed in specialist centres.     

Salvage of the diabetic foot with exposed os calcis

Fifty consecutive heel ulcers were managed in three groups by debridement, split-thickness skin graft (STSG), bypass procedures, and orthotics. Group I consisted of 24 ulcers in patients with diabetes (DM) and peripheral vascular disease (PVD), 14 patients in Group II with DM only, and 12 patients with PVD only (Group III). Healing occurred in 56.5%, 64.3%, and 83.3%, respectively. An average of 2.2 procedures were performed per patient. Follow-up periods were for a minimum of two years or until amputation. Time for complete healing and the number of amputations performed were similar in all groups. Of the diabetics (combined from Groups I and II), a subgroup of 27% required partial excision of the os calcis to facilitate closure. After saline dressing changes, STSG was accomplished over thin granulation tissue. Forty percent of this subgroup healed, 30% remained open, and 30% were amputated. Aggressive management, soft-tissue coverage, and orthotic use can lead to a functional weight-bearing extremity.     

External-bean megavoltage radiation therapy in the treatment of post-radical prostatectomy residual or recurrent tumor preliminary results

High dose, external-beam megavoltage radiation therapy was administered to 21 patients because of incomplete excision (11 patients) or palpable local recurrence (10 patients) following radical prostatectomy. Of the 21 patients 8 were alive without clinical evidence of cancer for 29 to 97 months after radiation therapy. The best survival was in the 11 patients referred because of incomplete excision. Of these 11 patients 9 were alive, 6 without cancer, and 2 were dead of intercurrent disease without evidence of cancer. Of the 10 patients with palpable local recurrence 2 were alive without evidence neoplasm, while 2 died of intercurrent disease without cancer. Acute treatment-associated symptoms occurred in 11 of the 21 patients. Generally, these symptoms were mild and responded to conservative, symptomatic management. Two serious complications were recorded.     

The effects of right-hemisphere brain damage on patients'' use of terms of personal reference

The majority of patients with lung cancer have disseminated disease at the time of presentation. For the minority of patients with disease localized to the chest, the concept of staging becomes particularly important because it has a major impact on the treatment plan. Guided by findings on the computed tomographic scan, mediastinoscopy remains the definitive invasive staging procedure to document unequivocally the involvement of the mediastinal lymph nodes. Equally as important is the documentation of absence of disease in contralateral lymph nodes. Patients with locally advanced non-small cell lung cancer, especially those with involvement of mediastinal lymph nodes (N2), are candidates for a multimodality approach to treatment involving either chemotherapy alone or in combination with radiation therapy. Surgical excision may be important in the management of these patients after an induction regimen. If surgical excision is performed, complete excision is the single most important factor. Postoperative adjuvant therapy may reduce the incidence of local recurrence but has not been shown to improve survival.     

Childhood soft tissue sarcoma: a 20-year experience

PURPOSE: To evaluate the disease-free and overall survival of pediatric patients with nonrhabdomyosarcoma soft-tissue sarcomas. METHODS: We retrospectively analyzed the records of 67 pediatric patients with a diagnosis of nonrhabdomyosarcoma soft tissue sarcoma treated with curative intent between 1970 and 1992. Median follow-up time for the 52 survivors was 120 months (range, 7 to 277 months). Fifty-nine patients received external beam radiotherapy, in a median dose of 5400 cGy (range, 1800 to 6660 cGy.) All patients underwent an initial surgical procedure. Eighteen patients had gross residual disease, and 15 had gross total excision with microscopic residual disease or positive margins. Adjuvant chemotherapy was administered to 44 patients (65%). RESULTS: The actuarial 10-year freedom from progression or recurrence and overall survival rates were 76% and 75%, and the 20-year rates were the same. Of 18 patients with gross residual disease, 9 (50%) had local progression and 6 died of local-only disease. By contrast, only one patient with microscopic residual disease who received postoperative radiotherapy had a local recurrence. The disease-free survival rate also correlated with histologic grade. CONCLUSIONS: As with adult soft tissue sarcomas, gross residual disease predicts local failure. Our results suggest that pediatric patients with soft tissue sarcomas treated with surgery and postoperative radiotherapy generally have a favorable overall survival rate.     

Adenoviral gene transfer in arteries of hypercholesterolemic nonhuman primates

Osteoid osteoma, a benign bone tumor, has traditionally been treated with operative excision. A recently developed method for percutaneous ablation of the tumor has been proposed as an alternative to operative treatment. The relative outcomes of the two approaches to treatment have not previously been compared, to our knowledge. The rates of recurrence and of persistent symptoms were compared in a consecutive series of eighty-seven patients who were managed with operative excision and thirty-eight patients who were managed with percutaneous ablation with radiofrequency. Patients who had a spinal lesion were excluded. The minimum duration of follow-up was two years. There was a recurrence, defined as the need for subsequent intervention, after operative treatment in six (9 per cent) of sixty-eight patients who had been managed for a primary lesion and in two of nineteen who had been managed for a recurrent lesion. The average length of the hospital stay was 4.7 days for the patients who had a primary lesion and 5.1 days for those who had a recurrent lesion. There was a recurrence after percutaneous treatment in four (12 per cent) of thirty-three patients who had been managed for a primary lesion and in none of five who had been managed for a recurrent lesion. The average length of the hospital stay was 0.2 day for these thirty-eight patients. With the numbers available, we could detect no significant difference between the two treatments with regard to the rate of recurrence. The rate of persistent symptoms (that is, symptoms that did not necessitate additional treatment) was greater than the rate of recurrence. According to responses to a questionnaire, eight (30 per cent) of twenty-seven patients had persistent symptoms after operative treatment and six (23 per cent) of twenty-six patients had persistent symptoms after percutaneous treatment with radiofrequency. Two patients had complications after operative excision, necessitating a total of five additional operations. There were no complications associated with the percutaneous method. The results of the present study suggest that percutaneous ablation with radiofrequency is essentially equivalent to operative excision for the treatment of an osteoid osteoma in an extremity. The percutaneous method is preferred for the treatment of extraspinal osteoid osteoma because it generally does not necessitate hospitalization, it has not been associated with complications, and it is associated with a rapid convalescence.