Clinics in diagnostic imaging (124). Multiple enchondromatosis in Ollier disease.

A three-year-old girl presented with slow-growing swellings at the left foot and upper right humerus. Radiographs show multiple enchondromas in both feet, proximal humeri and scapulae, as well as at multiple sites in the hands, distal forearm bones and pelvis, in keeping with multiple enchondromatosis in Ollier disease. The clinical presentation and imaging features of enchondromas and the different types of enchondromatosis are discussed.

European snapshot homeless survey: results of questions asked of passers-by in 11 European cities.

Passers-by were interviewed outside McDonalds restaurants in 11 European cities during November and December 1998. Eight questions were asked, mainly exploring the stigma levels of a particularly socially and economically excluded group (homeless people) and also the preferred remedies for homelessness. Answers varied, especially between the countries in Western Europe and those in the former Warsaw Pact countries. Stigma levels were very high in Bucharest, Kiev and Zagreb, presumably making resettlement work difficult. People in these cities saw homeless people as 'dangerous': repositories of infectious disease and likely to make unprovoked attacks. Most passers-by also believed homeless people were under threat, especially from the police, sometimes from other passers-by, from exposure to the winters and, in Cambridge, Vienna and Zagreb, from malnutrition. Suggested remedies were increased employment, improved training and increased affordable housing, rather than the imprisonment of beggars.

"Sandwich" preoperative and postoperative combined chemotherapy and radiation in tethered and fixed rectal cancer: impact of treatment intensity on local control and survival.

PURPOSE: The present "sandwich" preoperative and postoperative chemotherapy and radiation study was undertaken to evaluate the impact of treatment intensity on the local control and survival in tethered or fixed rectal adenocarcinoma (T3, 4 NX M0). METHODS AND MATERIALS: Between 1990 and 1992, 27 patients were treated with this sandwich protocol. Preoperative therapy consisted of 4 weeks of concurrent radiation (40 Gy) and chemotherapy (mitomycin C on day 1, 5-fluorouracil infusion and leucovorin on days 1-4 and days 15-18, respectively), and one cycle of bolus 5-fluorouracil and leucovorin chemotherapy. After surgery, they received 2 additional weeks of radiation (18 Gy) and 4 days of similar chemotherapy. The outcome was compared to another 54 patients who were treated with our previous preoperative chemoradiation protocol (mitomycin C, 5-fluorouracil infusion and 40 Gy of pelvic RT). RESULTS: The complete resectability rate was improved from 91% in the preoperative protocol to 100% in the sandwich protocol, and the pathologic complete response rate (T0 N0 M0) was increased from 4 to 15%. There was no local recurrence in the sandwich protocol. The 4-year local failure rate was 23 vs. 0% (p = 0.005). The 4-year distant failure rate was 47 vs. 28% (p = 0.079). The 2-year and 4-year survival were 63 and 41% for the preoperative protocol, vs. 92 and 72% for the sandwich protocol, respectively (p = 0.014). There were more treatment-related Grade 2 diarrhea, but not Grade 3/4 diarrhea in the sandwich protocol. Two patients (7%) in the sandwich protocol developed late gastrointestinal complications. CONCLUSIONS: More intensive radiation and chemotherapy appeared to improve the resectability, local control, and survival in tethered and fixed rectal cancers. There was a moderate but acceptable increase in the bowel morbidity.

Mental illness: diagnosis or value judgment?

This article is concerned with the definition of mental illness. Although it seems that it cannot be defined clearly in a legal or scientific way, this does not necessarily mean that health treatment is arbitrary and ill-founded.

Loop ileostomy for temporary fecal diversion.

The aim of this study was to prospectively assess the morbidity of creating and closing loop ileostomies in a consecutive series of patients having an ileoanal pouch procedure. Between 1983 and 1991, 203 patients had loop ileostomies created for temporary fecal diversion after an ileoanal pouch procedure. There was one death as a result of liver failure. One patient developed a persistent pouch-vaginal fistula that resulted in pouch excision. The remaining 201 patients had their ileostomies closed at a mean time of 10 weeks after the primary procedure. Only 7% needed surgery to correct ileostomy-related problems. After ileostomy closure, complications were noted in only 2% of patients. Loop ileostomy is easy to create and provides highly effective fecal diversion, which decreases the incidence of and mitigates the serious sequelae of pouch sepsis. Closure is simple, does not require a laparotomy, and is associated with few complications. Our experience with loop ileostomy for temporary fecal diversion after an ileoanal pouch procedure has been favorable. The loop ileostomy may be the stoma of choice for most clinical situations in which temporary fecal diversion is indicated.

Laparoscopic loop ileostomy for temporary fecal diversion.

Loop ileostomy is an effective means of temporary fecal diversion. This type of stoma is easy to manage and closure does not require formal laparotomy. We describe a laparoscopic technique of loop ileostomy formation. The procedure can be done with ease and with less discomfort and morbidity when compared with open laparotomy.

Preoperative concurrent 5-fluorouracil infusion, mitomycin C and pelvic radiation therapy in tethered and fixed rectal carcinoma.

PURPOSE: This is a Phase I/II study of preoperative concurrent radiation and chemotherapy in tethered and fixed rectal carcinoma. This study examined the curative resectability, the acute toxicities during chemo-radiation and the surgical complications. METHODS AND MATERIALS: Between 1986 and 1990, 46 patients were treated with preoperative pelvic radiation (4000 cGy in 20 fractions in 4 weeks), 5-Fluorouracil infusion (20 mg/m2, days 1-4 and 15-18) and Mitomycin C (8 mg/m2, day 1). This was followed by surgery 6 to 8 weeks later. 30 patients had tethered tumors and 16 patients had fixed tumors. RESULTS: After preoperative chemo-radiation, 41 patients (89%) underwent curative resection. Two patients (4%) had no residual tumor found (T0N0M0). Seven patients (15%) had nodal metastases. Two patients developed grade 3 neutropenia (WBC = 1-2 x 10(9)/L) during chemo-radiation. Five patients had delay in perineal wound healing. One patient had an anastomotic leak. Four patients developed stomal stenosis which required surgical revision. The 2-year actuarial survival was 73%. The 2-year local relapse rate was 16%. Patients with fixed carcinoma had a higher incidence of local failure (38% vs. 10%) and the difference was statistically significant (p = 0.0036). The 2-year distant failure rate was 41%, and the rates were similar for both tethered and fixed carcinomas. CONCLUSION: Preoperative pelvic radiation, chemotherapy and surgery could achieve a curative resection rate of 89% in tethered and fixed rectal carcinomas. However, distant metastases remained the major cause of failure.

Chronic fissure-in-ano: a randomized study comparing open and subcutaneous lateral internal sphincterotomy.

A prospective study comparing open and subcutaneous lateral internal sphincterotomy for chronic anal fissure was conducted. One hundred twelve patients were randomized to open (n = 54) or subcutaneous (n = 58) sphincterotomy. There was no significant difference in acute complications between the subcutaneous (8.6 percent) and open (7.4 percent) groups. Postoperative length of stay was significantly shorter for the subcutaneous group (1.7 +/- 0.2 days) than for the open group (2.3 +/- 0.1 days; P less than 0.001). Although the response rate to a pain questionnaire was less than 50 percent, the data suggest a lower level of postoperative pain in the subcutaneous group. Fissure healing was similar between the subcutaneous (96.6 percent) and open (94.4 percent) groups. We conclude that subcutaneous lateral internal sphincterotomy for chronic fissure-in-ano is effective and may result in significantly less postoperative discomfort, shorter postoperative lengths of stay, and a comparable rate of complications compared with the open technique.

Polymorphic reticulosis and conventional lymphomas of the nose and upper aerodigestive tract: a clinicopathologic study of 70 cases, and immunophenotypic studies of 16 cases.

Seventy patients with malignant lymphomas, including the entity known as polymorphic reticulosis (PR), involving the nose, nasal sinuses, nasopharynx, oropharynx (excluding tonsil), and larynx were studied. There were 26 cases of PR, 19 cases of lymphoma with features of PR (ML[PR]) and 25 cases of conventional lymphomas. Fourteen of the 25 conventional lymphomas were due to dissemination from distant sites. For all histologic types of primary lymphoma, the presenting symptoms were similar, and the nasal cavity was more commonly involved than the nasopharynx. Patients with PR were younger, had a higher male:female ratio, and had a better overall survival rate than patients with conventional lymphomas. Cryostat section immunohistochemistry performed on 17 samples from 16 patients showed only one B lymphoma out of 11 primary lesions; the other 10 cases and three recurrent tumors at distant sites showed phenotypic markers of T lymphocytes and natural killer cells. All three secondary tumors were of B-cell type. Of eight patients with sequential biopsies, progression to a more malignant histopathologic type was found in six. In the PR and ML[PR] biopsies, angiocentricity was detected in 11%, and angioinvasion in 22%. We could not confirm identity of PR with other angiocentric immunoproliferative lesions.

Tube decompression of the dilated colon.

With the technique described herein, decompression of a massively dilated colon is effectively accomplished, allowing resection to proceed safely. This method of decompression has allowed us to perform colonic resection in all patients with toxic megacolon seen in recent years. It is desirable to remove the infected and inflamed colon in such a circumstance. We have not resorted to blowhole colostomies in cases of toxic megacolon, as this leaves the colon, which is the septic source, within the abdominal cavity. This technique has also been used successfully to expedite subtotal colectomy and ileosigmoid anastomosis in patients with obstructing lesions of the left side. It allows colonic decompression and on-table bowel preparation by irrigation with antiseptics such as povidone-iodine (Betadine).

The management of blunt splenic trauma.

Seventy cases of blunt splenic trauma were retrospectively reviewed for the period 1979-1984. There were 57 adults and 13 children. Motor vehicle accidents were implicated in 62%. Forty-five splenectomies and eight splenorrhaphies were performed. The patients fell into two groups. Group A, numbering 48 patients, were those operated upon within 24 hours of injury. The mortality rate was 16%, and no deaths were attributable to splenic injury. Indications for surgery were hemodynamic instability in 46% and positive peritoneal lavage in 40%. Group B included 22 patients, 17 of whom were managed nonoperatively with no deaths. Five patients eventually went to laparotomy. Fifty per cent of all patients had associated intra-abdominal injury but only 17% needed repair; 31% of patients were initially managed conservatively with a 77% success rate and no mortality. It is concluded that conservative management is safe in stable patients with blunt splenic trauma.

Management of stage I-II diffuse aggressive non-Hodgkin's lymphoma of the Waldeyer's ring: combined modality therapy versus radiotherapy alone.

Twenty five patients with stage I and II diffuse aggressive non-Hodgkin's lymphoma of the Waldeyer's ring were reviewed. There were 19 patients with diffuse histiocytic, 4 diffuse lymphocytic poorly differentiated and 2 diffuse mixed lymphoma. Their median age was 51 years. There were 12 males and 13 females. Eight patients had stage I, and 17 had stage II disease. There was a significantly higher incidence of involvement of the left side of the Waldeyer's ring compared to the right (p = 0.0251). Fifteen patients received radiotherapy alone, and ten had radiotherapy and chemotherapy. The median durations of follow-up were 42 (range 8-162) and 44 (range 8-97) months respectively. All patients had complete remission but 9 patients (36 per cent) subsequently had relapse of their lymphomas. Stomach was the commonest site of relapse (44 per cent). The disease free survival and overall survival at 5 years were 59 per cent and 57 per cent respectively. Higher relapse rate was observed in the radiotherapy alone group (60 per cent) as compared to the combined modality therapy group (0 per cent). Patients who received combined modality therapy had significantly superior 5 years disease free survival (100 per cent versus 32 per cent, p less than 0.01) and overall survival (81 per cent versus 40 per cent, p less than 0.05). After radiotherapy alone, patients with stage II disease appeared to have a high relapse rate than those with stage I disease (70 per cent versus 40 per cent) but the difference did not reach statistical significance due to small sample sizes. The histological subtypes did not appear to affect their prognosis. All patients with stage I and II diffuse aggressive non-Hodgkin's lymphoma of the Waldeyer's ring should have gastrointestinal barium studies at initial staging, and a prospective randomised study on these patients comparing radiotherapy alone and combined modality therapy should be performed.

Clinico-pathological features of malignant lymphomas in 294 Hong Kong Chinese patients, retrospective study covering an eight-year period.

The clinical records and histological material from 294 adult Chinese patients with malignant lymphoma were examined. These patients were first seen at the Queen Mary Hospital, Hong Kong, during the 8-year period 1975-82. There were 27 patients (9.2%) with Hodgkin's disease (HD) and 267 with non-Hodgkin's lymphoma (NHL). The median age at presentation was younger for HD (45 years) and the male: female ratio was higher (2:1) than the corresponding figures for NHL of 51 years and 1.4:1. In 76 patients (28.5% of NHL), the disease was thought to have originated in an extra-nodal site, 48 of these cases being gastrointestinal lymphomas. It was possible to reclassify 234 NHL according to the Rappaport and Kiel classifications, and the Working Formulation (WF) proposed by the US National Cancer Institute Study; for HD, the Rye classification was used in 26 cases where suitable material was available. Nodular/follicular lymphomas made up 17.1% of nodal NHL and 5.3% of extra-nodal NHL. The "histiocytic" (Rappaport) or large-cell (WF) subtype was the commonest amongst diffuse NHL. There were only four cases of Burkitt's lymphoma. For HD, the nodular sclerosing subtype was commonest in females (5 out of 8 cases) and for males, the commonest was mixed cellularity (10 out of 18 cases). Of patients with nodal NHL 64.7%, presented with Stage IV disease. For HD, there were about equal numbers of patients presenting with Stage II and Stage IV disease (10 and 9 respectively). The low incidence of Hodgkin's disease and of follicular lymphomas is comparable to figures from other "oriental" countries such as Japan.

Salvage chemotherapy for non-Hodgkin's lymphoma.

Nineteen patients with advanced non-Hodgkin's lymphoma resistant to previous chemotherapy were treated with combination chemotherapy consisting of lomustine (CCNU), cytarabine, and prednisone. Eight patients (42%) had complete remission and four (21%) had partial remission. The median survival time of the 19 patients was greater than 14 months. The eight patients who had complete remission were still alive as of May 1, 1982, with a median follow-up time of 632 days (range, 365-1247). We believe that this combination chemotherapy scheme warrants further investigation.