[Angiosarcoma following breast-conserving therapy]. / Angiosarcoom na borstsparende behandeling.

Two women with breast cancer, 59 and 72 years of age, were treated by means of breast-conserving surgery and radiotherapy. At the age of 66 and 77, respectively, discolouration of the skin was seen in the treated breast. Punch biopsy did not show secondary malignancy. Diagnostic (deeper) excisional biopsy revealed angiosarcoma. Ablation of the breast was performed in both patients. The younger woman, however, had a recurrence four months later that was treated with wide local excision and omentum-plasty. The older woman died two years after the ablation as a result of haematogenous metastases. Knowledge of the symptoms and diagnostic pitfalls of radiotherapy-induced angiosarcoma after breast-conserving treatment is important in the follow-up of breast-cancer patients. Histological diagnosis of a biopsy taken at sufficient depth is indicated when a secondary angiosarcoma is suspected.

Bannayan-Riley-Ruvalcaba syndrome: further delineation of the phenotype and management of PTEN mutation-positive cases.

Bannayan-Riley-Ruvalcaba syndrome (BRRS) is characterised by macrocephaly, intestinal hamartomatous polyps, lipomas, pigmented maculae of the glans penis, developmental delay and mental retardation. The syndrome follows an autosomal dominant pattern of inheritance. In 1997 reports on two BRRS patients with a deletion at 10q23.2-q24.1 were published. In the same year, the first two families with BRRS and a mutation of the PTEN gene were reported. Mutations in the PTEN gene have also been demonstrated in patients with Cowden syndrome (CS), which shows partial clinical overlap with BRRS, and in families with cases both of BRRS and CS. PTEN mutation positive BRRS and CS are likely to be different phenotypic presentations of the same syndrome. If BRRS and CS are one single condition, the question arises whether patients with BRRS should be screened for malignant tumours, since patients with Cowden syndrome have an increased risk of breast, endometrial, thyroid and renal cancer. We present two isolated cases and one family and confirm that BRRS and CS are allelic. Furthermore, we review the PTEN mutation positive BRRS cases, to further delineate the phenotype and to compare the cases with a genomic deletion with the cases with a point mutation. We recommend offering BRRS cases with a mutation in PTEN the same surveillance protocol for (malignant) tumours as is currently recommended for CS. In addition, we propose a yearly haemoglobin test from early infancy for the early detection of intestinal hamartomas, which are likely to give severe complications, especially in BRRS cases.

Effect of isosorbide dinitrate ointment on anal fissure.

BACKGROUND/AIMS: Until recently, the treatment of choice for anal fissure was surgery, consisting of a partial lateral internal sphincterotomy. This treatment has a high complication rate: impaired continence is reported in 8-30% of the patients in the literature. Therefore, recently nonsurgical treatment modalities have been developed, such as local application of isosorbide dinitrate (ISDN) ointment. This treatment has comparable effectiveness with lower complication rates. To study the effect of ISDN on the healing of anal fissures in a general surgical practice, a prospective study was performed in our hospital. METHODS: In the period between June 1997 and January 2000, 100 consecutive patients with anal fissure were treated with ISDN. RESULTS: Of these 100 patients, 93 were healed within 8 weeks and 7 patients had no response and were operated. Of the 93 patients with primary healing fissures, 13 patients had recurrence during the 1-year follow-up. Seven of them were cured with ISDN, and the remaining 6 patients needed surgery. The only complication observed in this study was temporary headache which was observed in 7 patients. CONCLUSIONS: The primary healing rate of anal fissures was 93% with ISDN. In case of recurrence, 54% (7/13) could again be treated successfully with ISDN. Therefore, we recommend ISDN as first choice treatment for primary and recurrent anal fissures.

Prevention of urinary retention after general surgery: a controlled trial of carbachol/diazepam versus alfusozine.

BACKGROUND: Postoperative urinary retention is a common complication after surgical procedures. It can cause bladder dilatation, infection, and even sepsis. Carbachol/diazepam and alfusozine have been reported to lower the incidence of postoperative urinary retention, but no study showed the benefits of these drugs in a randomized, placebo-controlled trial. STUDY DESIGN: We used a double blind, placebo-controlled trial in which 249 patients with postoperative urinary retention were randomly assigned to receive carbachol/diazepam (n = 72), alfusozine (n = 82), or placebo (n = 95). The primary endpoint was miction within 2 hours after taking the medication. RESULTS: There was no significant difference in miction frequency after taking the medication among the three groups (p = 0.31). The miction rate was 60% for patients in the alfusozine group, 61% in the carbachol/diazepam group, and 51% in the placebo group. CONCLUSIONS: Alfusozine and carbachol/diazepam had no apparent benefit on the incidence of postoperative urinary retention.

[Myiasis caused by Dermatobia hominis]. / Myiasis door Dermatobia hominis.

In two patients, a woman of 35 and a man of 62 years old, myiasis caused by the larvae of the fly Dermatobia hominis was diagnosed. Both patients had recently returned from a visit to Central America. This ectoparasitosis is found in Central and South America. Patients present themselves with an insect bite which fails to heal. If the clinical presentation is unknown, the disease may well be mistaken for furunculosis. The condition may be easily treated by applying vaseline to the insect bite, which causes extrusion of the larva.

Enhanced tumour growth in the rat liver after selective elimination of Kupffer cells.

The evidence that Kupffer cells are capable of controlling metastatic growth in the liver in vivo is largely circumstantial. The best approach when studying natural cytotoxicity activities of Kupffer cells is to investigate the effect of Kupffer cell elimination on tumour growth. Until now it has not been possible to eliminate Kupffer cells without affecting other cell populations. We have recently developed a new method to eliminate Kupffer cells selectively: intravenous injection of liposome-encapsulated (dichloromethylene)bisphosphonate (Cl2MDP-liposomes) leads to effective elimination of all Kupffer cells, without affecting non-phagocytic cells. Wag/Rij rats were injected with Cl2MDP-liposomes. After 48 h, rats were inoculated with syngeneic CC531 colon carcinoma cells by injection in the portal system. The results show a strongly enhanced tumour growth in the liver of the Cl2MDP-liposome-treated rats. In these animals, livers were almost completely replaced by tumour and had increased in weight, whereas in the control groups only a few (four to eight) small (1-mm) tumour nodules were found. These data show that selective elimination of Kupffer cells results in enhanced tumour growth in the liver, implying that Kupffer cells play a crucial role in controlling tumour growth in the liver.

Macrophage populations in different stages of induced hepatic metastases in rats: an immunohistochemical analysis.

Macrophages play a role in the host defence against cancer. Little is known about changes in macrophage populations during early metastatic growth. To evaluate the distribution, number and phenotype of macrophages in the development of hepatic metastases in a rat model (Wag/Rij rats and syngeneic CC531 colon carcinoma cell line), an immunohistochemical study was performed with the monoclonal antibodies ED1 (monocytes, and all macrophages), ED2 (resident tissue macrophages, like Kupffer cells) and ED3 (a subpopulation of macrophages which may play a role in the recruitment of lymphocytes). OX19 and His14 were used to identify lymphocytes. In this study a new monoclonal antibody CC52 is described, which recognizes the CC531 tumour cell line. Liver metastases were induced by injection of CC531 colon carcinoma cells into a mesenteric vein. Rats were killed at various intervals. Results show three major macrophage populations during hepatic tumour growth: (1) on day 3, infiltrates are observed around the micrometastases, which contain mainly newly recruited macrophages (ED1+ and ED2-); (2) after 7 days, ED3-positive (ED3+) macrophages together with T lymphocytes are found in the infiltrates; (3) an increase in the number of ED2-positive (ED2+) Kupffer cells is observed in the liver parenchyma after 14 days. In conclusion, the present results suggest that various populations of macrophages, newly recruited (ED1+) as well as resident Kupffer cells (ED2+), are involved in the immune response against tumour cell deposits in the liver.

The impact of intraoperative ultrasonography of the liver on the surgical strategy of patients with gastrointestinal malignancies and hepatic metastases.

Intraoperative ultrasonography (IOUS) of the liver is a very useful tool during surgery for gastrointestinal tumors or hepatic tumors. In a prospective study of 82 elective operations for 57 gastrointestinal tumors and 25 hepatic tumors or metastases, we compared IOUS with preoperative ultrasonography, CT-scanning and MRI. IOUS supplied additional information in 38% of the operations. In 22% of the cases, this had a major impact on the intraoperative strategy with an alteration of the procedure. IOUS has a higher detection rate of intrahepatic lesions, discriminates better between solid or cystic nature of the tumor and offers the possibility of performing a safe and radical hepatic resection by its ability to localize lesions in relation to vascular structures. IOUS is a safe and simple technique which will be more cost-effective than extensive preoperative evaluation of the liver. It provides a more complete clinical staging of patients for whom adjuvant therapy is considered after resection of a colorectal carcinoma.

Cryosurgery for locally recurrent rectal cancer.

Locally recurrent rectal cancer is, in most cases, unresectable and incurable. Palliative treatment is warranted in many cases because of the presence of severe distressing symptoms. In recurrent disease, intraluminal cryotherapy is an option for palliation. Twenty patients with local recurrence after anterior resection were treated palliatively with cryosurgery for their local symptoms. Six patients had previously had a colostomy before they were referred for palliative treatment. Thirteen patients had more than one symptom. Distant metastases were present in ten cases. The beneficial effect of cryosurgery was evident after two to three sessions. In nine patients cryotherapy achieved complete relief of local symptoms. In these patients the symptom free interval varied from 1 to 24 months (median 11 months); five patients died of disease without local symptoms. Three of these nine patients underwent a bowel diversion at a later stage because of complete stenosis. The number of treatment sessions in this group of patients varied from three to 14. The palliative index varied from 37 to 100% (mean 78%). In nine patients cryotherapy of the local recurrence gave no relief at all. Our results show that in almost half of the patients cryosurgery can palliate local complaints resulting from recurrent tumor growth after anterior resection.

Anal sphincter imaging in fecal incontinence using endosonography.

Clinical anal examination, manometry (resting and squeeze pressures), and single-fiber electromyography were compared with endosonography of the anal sphincters in 14 patients with fecal incontinence. Technical aspects of the procedure and normal imaging of the puborectal muscle and both sphincters were defined. Defects in both sphincters were seen in nine patients. The defect is visualized as a clear discontinuity in the muscular ring. Compared with the conventional studies, anal endosonography gave significant information in six patients (four male patients after perianal surgery and two women), showing sphincter defects in five patients and integrity of the sphincters in another one. This information obtained by endosonography was important in understanding the type and extension of the lesion and deciding upon the surgical repair. Anal endosonography is an imaging technique of the sphincters that can assess their integrity in fecal incontinence.

Intra-operative ultrasonography of the liver: a prerequisite for surgery of colorectal cancer?

The results and consequences of intra-operative ultrasonography of the liver were studied in 50 patients who had laparotomy for colorectal cancer. Compared with preoperative imaging techniques like US, CT and MRI, intra-operative US had a higher sensitivity for intrahepatic lesions. Especially in case that adjuvant therapy could have been considered, intra-operative US gave relevant information in 10 patients (20%) by altering the stage of the primary tumour. Four of the 50 patients showed more liver metastases at intra-operative US than detected by preoperative imaging techniques. Resectional therapy of liver metastases could be prevented in these four patients. We advise intra-operative US as routine for all patients undergoing laparotomy for colorectal cancer especially if adjuvant chemotherapy is considered. When surgery is scheduled extensive preoperative liver examination can be avoided if intra-operative US is available.

The diagnosis of gallstones--a prospective comparison of oral cholecystography and real-time ultrasound.

A prospective study was made to compare the diagnostic value of ultrasound and oral cholecystography. 256 Patients were examined, 143 of whom were operated on. Ultrasound proved to have less chance of missing gallstones, whereas oral cholecystography showed a high percentage of false-positive results at first examination. Ultrasound is recommended as the method of choice for screening gallstones.