Weight-bearing effects on skeletal muscle during and after simulated bed rest

The authors present two case studies of giant cell tumor of tendon sheath. This uncommon lesion of the lower extremity is presented in these two cases in correlation with clinical, radiographic, and intraoperative findings. After the pathologic diagnosis was made, the patient in the first case decided not to have the tumor resected. This patient's postoperative course continues uneventfully without expansion of the tumor. In the second case, a local recurrence was noted 13 months after en bloc resection. A review of the literature shows that treatment modalities for such lesions range from marginal excision to radiation therapy. The authors wish to emphasize the high risk of local recurrence of these tumors. Early marginal resection is the treatment of choice.     

Endoscopic treatment of gastric carcinoids

Carcinoids are the most common endocrine tumours, and arise from a multipotential primitive stem cell; the gastric location represents 2% of all carcinoids. From 1979 to 1992 at the Endoscopy Division of Istituto Nazionale Tumori, Milan, 2 patients suffering from single gastric carcinoid were endoscopically treated by electro-resection. No complication occurred during the treatment; 2 year- and 5-year-follow-up was performed in these patients, and no recurrence are observed. Surgical treatment represents the therapy of choice for gastric carcinoids, but endoscopic resection can represent an alternative in selected cases (lesions less than 1 cm or carcinoids with multicentric growth). Endoscopy can be used also in patients at high surgical risk.     

Response of rainbow trout (Oncorhynchus mykiss) growing from 50 to 170 g to supplements of either L-arginine or L-threonine in a semipurified diet

Focal nodular hyperplasia (FNH) is usually a stable lesion that does not enlarge when studied for long periods of time; recurrence after resection has not been reported. We present a patient with a solitary FNH lesion that enlarged, was resected, and then recurred. A second resection was performed because of abdominal pain and disclosed multiple lesions, two of which were acutely infarcted. Thirty-two months later there was ultrasound evidence of further recurrence. Histology of the lesions showed the usual appearance of FNH with ducts and ductules in the central stalk regions but also some areas with minimal ductular differentiation and scanty connective tissue. Because of the clinical and histological appearance, the lesions in this patient were distinct from the usual type of FNH and merit the name "focal nodular hyperplasia, progressive type."     

Local excision of rectal cancer

The prospect of treating a rectal cancer often leads to significant fear among patients because of the possibility of a permanent colostomy. Although radical resection, in particular abdominoperineal resection, has been used effectively for rectal cancer treatment, other techniques such as local excision with or without adjuvant therapy have been used with significantly less morbidity than that of the abdominoperineal resection, with excellent cure rates. There are essentially three local excision techniques that can be used to remove a small rectal cancer completely. Selection criteria are critical for choosing the appropriate patient for these techniques. Tumors must be less than 4 cm in diameter and take up less than 40% of the rectal wall circumference. They also need to be relatively close to the dentate line and have no evidence of any invasion into the mesorectum or perirectal nodes. Preoperative staging with endorectal ultrasonography, computed tomography, and digital examination helps select appropriate patients. Retrospective series have shown significant success using local excision techniques, with local recurrence rates ranging from 0% to 11% for early-stage lesions. Prospective series have shown similar recurrence rates. Postoperative function with or without adjuvant therapy has not been adequately documented along with quality of life and must be part of any future reports on local excision techniques as well as all rectal cancer treatment studies. Local excision does, however, seem to provide adequate treatment in well selected patients and provides a less morbid alternative to the treatment of rectal cancer than radical resection, particularly abdominoperineal resection, which obligates the patient to a permanent colostomy.     

Clinical and molecular prognostic factors in sphincter-preserving surgery for rectal cancer

As many as a third of patients with rectal cancers may be candidates for sphincter preservation surgery. The goal of the conservative management of adenocarcinoma of the distal rectum is to preserve rectal sphincter function without sacrificing local tumor control. To achieve this goal, a combined modality approach is necessary because multimodality therapy for more advanced disease has improved both local control and survival. Candidates for local excision are those with adenocarcinomas with a maximal diameter of less than 4 cm, mobile, and not poorly differentiated or mucinous and within 10 cm of the anal verge--usually within 6 cm. These criteria should be defined objectively by biopsy combined with state-of-the-art endorectal imaging. Newer molecular markers that are associated with prognosis and response to therapy may also be important for assessing prognosis, probability of local recurrence, and whether conservative treatment is appropriate. Patients with T0-3 N0 lesions meeting these standard clinicopathologic criteria have been treated successfully with wide local excision combined with chemotherapy and radiotherapy. Patients with larger or more advanced lesions may undergo low anterior resection with coloanal anastomosis. After resection, radiotherapy to at least 45 to 50 Gy is delivered to the pelvis and tumor bed often with concomitant chemotherapy. The overall rate of local failure in prospective single-institution trials in which local excision is performed with postoperative chemoradiotherapy has been 5% for T1 lesions, 7% for T2 lesions and 24% for T3 lesions. Although single-institution studies have supported the concept of conservative therapy, the safety and efficacy of this approach must still be confirmed in a multicenter, prospective trial, such as that underway in several of the cooperative oncology groups, before it may be considered a standard of practice.     

Giant cell tumor and aneurysmal bone cyst of the talus: clinicopathological review and two case reports

Two cases of giant cell tumor and aneurysmal bone cyst of the talus were analyzed with a review of eight cases from the literature. This anatomic setting represents a distinct clinical and roentgenographic entity with a less aggressive natural history than the more common sites. All lesions presented a characteristic radiographic involvement of the head and neck of the talus. Eight of ten lesions were treated by curettage, with or without bone grafting, and healed. Two underwent partial en bloc resection. None developed late fracture, recurrence, avascular necrosis, or metastases. We concluded that a giant cell tumor or aneurysmal bone cyst when located in the talus may be difficult to differentiate but tends to exhibit a less aggressive biological behavior and a more favorable prognosis than the more classical proximal lesion. Talectomy is not indicated in the primary treatment. Curettage with or without bone graft has a high success rate. Cryosurgery should be reserved for a recurrent lesion.     

Surgical aspects in the multidisciplinary treatment of soft tissue sarcomas

Sarcomas are rare malignant tumors with a large variety of histologic subtypes. The surgical approach depends more on the histologic grade, the size and the site of the tumor. Radiologic diagnosis relies predominantly on MR-imaging. Discernible improvements have taken place in soft tissue sarcoma patient survivorship and quality of life over the past 20 years, with overall 5-year survival currently at approximately 50-80%. The place of surgery in the treatment of soft-tissue sarcoma is defined in the light of a review of the recent literature. Radical surgical resection is the mainstay of therapy. Local recurrence is the most common type of failure. Local recurrence is resectable and limb preservations possible in the majority of patients. Survival after treatment of local recurrence is determined mainly by the grade and secondarily by the size of the tumor. The essential risk factor for local recurrence is the quality of surgical resection, defined by the definitive resection margins. A lateral safety margin of 5 cm and of 2 cm to the depth should be respected. In sarcoma of the extremity the compartment is defined based on clinical, radiographic, histopathologic and operative findings. The use of muscle flaps to fill the surgical defects can improve the functional result and reduce the complication rate. Only about 5% of the patients need amputation. Evaluation of functional results must be based on objective criteria. In retroperitoneal sarcoma the significant factors for determining prognosis are grade and completeness of exzision. Multidisciplinary treatment according to common protocols is essential. Shifts in treatment have taken place over the past decade, from single-modality treatment involving radical surgery with compartment resection to sophisticated limb-salvage strategies combined with radiation therapy. In case of inadequate surgery e.g. in a large tumor with positive margins in high-grade soft tissue sarcomas the addition of radiotherapy can improve local control, but cannot ensure that obtained by adequate surgery. Patients with large (greater than 5 cm), high grade soft tissue sarcoma are at high risk for distant recurrence and disease-related mortality. Investigations of combined modality therapy with newer chemotherapy agents and dose intensification treatment strategies are warranted.     

Stereotactic radiosurgery for patients with nonsmall cell lung carcinoma metastatic to the brain

BACKGROUND: A retrospective study of patients undergoing stereotactic radiosurgery for one to four brain metastases from nonsmall lung cell carcinoma (NSCLC) was performed to document outcomes and risks. METHODS: Seventy-seven patients underwent radiosurgery during a 7-year interval; 71 also underwent whole brain radiation therapy. Univariate and multivariate analyses were used to determine significant prognostic factors affecting survival. RESULTS: The overall median survival was 10 months after radiosurgery, and 15 months from the diagnosis of brain metastases. Five factors significantly affected survival: extent of systemic disease, presence of a neurologic deficit, size of the intracranial tumor, initial imaging appearance of intratumoral necrosis, and initial resection of the primary tumor of the chest. Median survival time was 26 months in a subgroup of patients with no extracranial metastases, no neurologic deficits, and a small tumor without necrosis. The authors evaluated 91 tumors with imaging. Local tumor control was achieved in 77 lesions (85%) and tumoral radiation necrosis developed in 4 lesions (4.4%). Nineteen new metastatic tumors developed during the observation interval. CONCLUSIONS: Stereotactic radiosurgery for NSCLC brain metastases is effective and is associated with few complications. The early detection of brain metastases and treatment with radiosurgery combined with radiation therapy provide the opportunity for extended high quality survival.     

Imaging of huge lingual thyroid gland with goitre

One year after a nonspecific trauma and with a history of pain of four weeks only, an osteoid osteoma of the first phalanx of the left thumb was diagnosed in a 31-year-old man. The radiologic appearance as well as a bone scan were suggestive for an osteoid osteoma. The diagnosis was confirmed histologically after resection of the tumor. As indicated in the literature, osteoid osteoma of the hand is relatively rare. The symptoms and radiologic features (osteolytic nidus and sclerosis) of osteoid osteomas are independent of the tumor location. Surgery with resection of the nidus is the only known curative therapy. The etiological role of trauma is discussed and a review of the literature is done with 15 other cases of posttraumatic osteoid osteoma having been reported.     

Artemisinin derivatives in the treatment of falciparum malaria in pregnancy

A defect resulting from resection of advanced breast tumor can be quite large, posing a difficult reconstructive challenge. A significant number of such patients are found to have local recurrences after receiving beam radiation therapy and chemotherapy. The external oblique musculocutaneous flap is now considered a reliable option, with segmental blood supply from the posterior intercostal arteries. We report a 57-year-old man with local recurrence of breast tumor after external beam therapy. We faced a difficult challenge in performing reconstruction because of (1) several previous operations that used most of the usual options and (2) the absence of recipient vessels for microsurgery. We performed an external-internal oblique musculocutaneous flap with a reverse blood supply from the lateral branches of the inferior epigastric artery. Our use of a reverse-flow external-internal oblique flap supports the concept of rotating the muscles as a unit to encourage viability of the denervated and relatively devascularized component.     

Adult onset nemaline myopathy: a distinct nosologic entity?

Endoscopic evaluation and transurethral resection are the most important steps in the management of patients with bladder cancer. While multifocality is primarily a prognostic factor with respect to tumor recurrence, tumor grade and depth of invasion are prognostic regarding progression in stage. Transurethral resection biopsies of the prostate should always been obtained in patients with high grade tumors. Follow-up of patients should be individualized: patients with risk for progression, but not necessarily for recurrence, should be followed more closely than patients with low-grade tumors and low risk for progression. In this setting cytology is especially helpful because most high-grade tumors will be detected by cytology. Intravesical therapy is indicated in patients with high-grade tumors, carcinoma in-situ and multiple low grade tumors. While there is a growing body of evidence that BCG is superior to intravesical chemotherapy, one also has to take into account the more frequent and more serious side effects of BCG when compared with mitomycin C or thiotepa.     

A new method of endoscopic mucosal resection of neoplastic lesions in the stomach: its technical features and results

BACKGROUND/AIMS: In gastric cancer, endoscopic treatment can be expected to provide an absolute cure only if the lesion is mucosal and not accompanied by metastatic lymph nodes. To further evaluate such possibly curable lesions, we retrospectively reviewed 208 cases of early gastric cancer surgically resected over the past 20 years. METHODOLOGY: Our new method of endoscopic mucosal resection using a cap-fitted panendoscope, which is called EMRC, has been employed in the treatment of 73 gastric neoplastic lesions. RESULTS: It was found that curable lesions would, as the primary condition, be histologically well-differentiated carcinomas and measure 2 cm or less of the elevated type and less than 1 cm of the depressed type. The lesions were consequently identified as 49 early cancers (46 mucosal, 3 submucosal), 23 adenomas and 1 carcinoid. Although resection was completed in a single session of EMRC treatment in all cases, approximately 40% of them required fractionated resection, leaving an ulcer measuring 3 cm or more in approximately 30%. Bleeding or muscle resection occurred in 7 patients, in whom conservative treatment was effective. No recurrence has been found in any of the 73 lesions, demonstrating a favorable outcome. CONCLUSIONS: This method is advantageous in that it is simple and relatively easily applied at almost any location within the stomach. In addition, the size of the specimen obtained by en bloc resection is approximately 2 cm. The method is thus fairly likely to come into widespread use.     

Improving the treatment of colorectal cancer: the role of EUS

The two most important factors for determining the risk of local failure and overall prognosis in colorectal carcinoma are nodal status and the depth of tumor penetration into or through the bowel wall. These features have traditionally been determined pathologically because the clinical-staging accuracy of other imaging modalities such as computed tomography (CT) has not proven sufficiently predictive of surgical staging. However, endorectal or endoscopic ultrasonography (EUS) can be used to preoperatively evaluate nodal involvement with an accuracy of up to 86% (median: 80%) and depth of tumor penetration through the bowel wall with an accuracy of up to 97% (median: 85%) for effective clinical staging. This high staging accuracy is useful in managing colorectal cancer. Through clinical evaluation of the initial stage of colorectal cancer with EUS, a patient's risk of disease recurrence can best be determined and patients stratified for the most appropriate treatment. EUS can be used to select patients with lesions that can be treated with local excision or sphincter-sparing surgery, often combined with radiation therapy, in situations otherwise requiring an abdominoperineal resection. EUS can also be used to preoperatively identify patients with locally advanced or unresectable disease. Chemoradiation can then be given preoperatively, when it appears to be better tolerated and more effective than postoperative treatment. Unresectable tumors can often be downstaged sufficiently to allow their excision. In resectable disease, EUS can also identify patients at high risk for recurrence who would benefit from adjuvant chemoirradiation. EUS for precise staging or for earlier diagnosis of recurrence will further improve the clinical outcome of patients with colorectal tumors as significant advances both in surgical techniques and in combined chemotherapy/radiotherapy continue to be made and applied selectively in a stage-dependent manner.     

Intralesional and topical chemotherapy and immunotherapy

This article covers the principles and applications of radiation therapy in horses. The goal in treating tumors by irradiation is tumor control with minimum treatment complications. Various treatment techniques are available to achieve this goal. The prognosis depends on many factors such as the extent and location of the tumor, tumor type and tumor cell proliferation. Radiation therapy is a very effective treatment modality for equine tumors but logistical reasons limit its impact in equine oncology.     

Superficial bladder cancer: decreasing the risk of recurrence

Bladder cancer appears to develop through two alternative pathways. Papillary bladder cancer, the most common pathway, has a less aggressive course and is frequently heralded by hematuria, whereas carcinoma in situ appears to be more aggressive and is more difficult to detect. Superficial bladder cancer has a high propensity for recurrence but a low rate of progression. Transurethral resection is frequently employed for both diagnosis and treatment. The risk of tumor recurrence is related to the number of tumors at presentation and the findings on the first follow-up cystoscopy. Even patients with a low risk of recurrence need periodic cystoscopic examinations. Patients with a higher risk of recurrence may benefit from adjuvant intravesical chemotherapy or immunotherapy. Bacillus Calmette-Guérin (BCG) appears to be the most effective drug for intravesical therapy but has the highest rate of side effects. It is the treatment of choice for carcinoma in situ. Newer treatment strategies include perioperative intravesical chemotherapy and chemoprevention.     

Hepatic cryosurgery for metastatic colorectal carcinoma

PURPOSE/OBJECTIVES: To review an innovative, potentially curative surgical approach for the treatment of select patients with colorectal cancer metastatic to the liver. DATA SOURCES: Published articles and reported and unreported research results. DATA SYNTHESIS: The liver is the primary site of recurrence in 60%-80% of patients who develop recurrent disease following resection of the colorectal primary cancer. Less than 25% of patients with liver metastases are candidates for hepatic resection because of the location or number of liver metastases. Hepatic cryosurgery provides a viable treatment option for some patients with unresectable metastatic colorectal carcinoma confined to the liver, including patients with bilobar and multiple lesions. CONCLUSIONS: Because colorectal cancer is the second most common cause of cancer mortality in the United States, interventions that improve survival rates are an important focus of care. With knowledge of patient selection criteria and implications of hepatic cryosurgery, informed oncology nurses are resources for patients contemplating this therapy. IMPLICATIONS FOR NURSING PRACTICE: Preoperative evaluation and postoperative nursing care focus on careful assessment, education, and interventions aimed at preventing and detecting complications unique to hepatic cryosurgery. Knowledge of hepatic cryosurgery as a treatment option for colorectal liver metastases, patient selection criteria, and related implications allows oncology nurses to serve as resources for patients and families considering this therapy.     

Giant cell tumor of bone

Giant cell tumor is a locally aggressive tumor with a high recurrence rate if not completely excised. The condition is more common among Asians than whites. During a 10-year period 44 patients, ranging in age from 12 to 51 years, were treated. The most common sites were the proximal femur and the distal radius. The aim of treatment was to excise the tumor completely. Because the tumor usually occurred at the juxtaarticular region of the bone, difficult reconstruction was expected. The authors' method of choice for filling large defects resulting from resection was to use a large vascularized bone graft from the iliac crest to enhance bone to bone corporation. The recurrence rate was low (4.5%), with only 2 recurrences: 1 at the proximal femur and the other at the proximal tibia. The functional results were highly satisfactory, with excellent stability of the joint, although in the case of the distal radius there was some degree of subluxation of the wrist joint. By applying microsurgical technique for the reconstruction, one was able to be more aggressive with excision of this locally aggressive tumor while maintaining excellent functional results. In the case of the knee, as long as 1 tibial condyle was intact, reconstruction of the other condyle using a vascularized iliac crest block maintained the joint integrity perfectly or created a pseudojoint component that was perfectly stable.     

Percutaneous management of upper-tract transitional cell carcinoma

Standard management of upper tract transitional cell carcinoma is a nephroureterectomy; however, there is a distinct subgroup of patients who would be rendered dialysis dependent, or at high risk for functionally significant renal insufficiency, and for whom a nephron-sparing approach is warranted. Historically, the options for such "conservative" management have been limited to variations of open pyelotomy or partial nephrectomy. More recently, endourologic techniques have been applied to the treatment of these difficult patients. Though a ureteroscopic approach can occasionally be therapeutic, it may be precluded by the size or location of the tumor, or by a urinary diversion that makes ureteroscopic access difficult or impossible. Many of these patients can, however, be managed with a well planned percutaneous approach that provides excellent access to virtually the entire upper tract. The subsequent addition of topical BCG as an adjunct to percutaneous upper tract tumor resection may then be beneficial in decreasing the incidence of local recurrence.     

Successful treatment of cutaneous Kaposi's sarcoma by the 585-nm pulsed dye laser

The clinical appearance of Kaposi's sarcoma (KS) can cause significant disfigurement and lead to functional impairment, particularly if the lesions ulcerate and become secondarily infected. We describe a patient with a KS plaque on the face that was successfully treated with 585-nm pulsed dye laser (PDL) therapy. No recurrence of the tumor was noted 12 months after the final laser treatment.