Identification of unsuspected thyroid carcinoma using immunoperoxidase for thyroglobulin.

Two patients with poorly differentiated metastatic cancer were shown to have metastatic thyroid carcinoma. Each patient had poorly differentiated cancer and remaining thyroid tissue in the neck. The diagnosis was secured using the immunoperoxidase technique with an antibody against thyroglobulin. The proper evaluation of patients with carcinoma of unknown primary involves specific tissue identification using special techniques in pathology.

Serum-blocking factors versus specific cellular tolerance in long-term survival of rat heart allografts.

Long-term survival of Ag-B compatible rat heart allografts was obtained by short-term treatment of the recipients with antilymphocytic serum (ALS). Graft survival apparently was based on a specific change in the hosts rather than on persistent nonspecific effects of ALS. The hosts were not fully tolerant in that they were able to reject secondary skin allografts from the heart donor strain, although in a delayed fashion. The long-surviving heart allografts retained their immunogenicity as they were rejected when retransplanted to new hosts. The passive transfer of serum from long-term heart graft acceptors to new hosts receiving fresh allografts delayed rejection by several days. This effect was seen only with the serum from long-term acceptors suggesting that serum-blocking factors were involved in long-term survival of the heart allografts. However, the ability of adoptively transferred lymphoid cells to break tolerance to a heart allograft residing in a classically tolerant host was tested. In contrast to normal lymphoid cells, cells from the long-term acceptors were unable to break tolerance, suggesting that a specific cellular tolerance had been induced in this cell population. Moreover, a serum from the long-term acceptors failed to block the breakage of tolerance by normal lymphoid cells.

Composite tissue transfer in limb-salvage surgery.

After extensive resection due to extremity sarcoma, the inability to cover the defect for satisfactory healing and limb function has been an indication for amputation rather than limb salvage. We report herein our experience with seven limb-salvage cases in which we closed difficult and complex defects with composite tissue transfers utilizing microvascular techniques. Free-flap transfers were used to cover soft-tissue defects after extensive resection of primary and locally recurrent tumor and to manage radiation-induced complications. The grafts healed well when infected irradiated tissue was covered, and the grafts tolerated postoperative irradiation. Composite tissue transfer also provided soft-tissue coverage around distal joints that would not have been adequately protected with a skin graft. Complications were minimal, and all patients maintained good extremity function. No patient who underwent composite tissue transfer has had a local recurrence. A free-flap composite tissue transfer can extend the indications for limb-salvage surgery and offers an alternative to amputation in selected patients.

Bedside noninvasive detection of acute pulmonary embolism in critically ill surgical patients.

HYPOTHESIS: We hypothesized that late pulmonary dead space fraction (Fd(late)) would be a useful tool to screen for pulmonary embolism (PE) in a group of surgical patients, including patients who required mechanical ventilation and patients with adult respiratory distress syndrome. DESIGN: We prospectively calculated Fd(late) in patients with suspected PE who underwent pulmonary angiography. SETTING: University-based, level I trauma center. MAIN OUTCOME MEASURE: Ability of Fd(late) to identify patients with PE. RESULTS: Twelve patients had 14 angiograms for suspected PE. The Fd(late) was 0.12 or above in all 5 patients who had PE; 4 required mechanical ventilation. The Fd(late) values were below 0.12 in 8 of 9 patients without PE. Four patients had adult respiratory distress syndrome. The Fd(late) had 100% sensitivity and 89% specificity for the detection of PE. CONCLUSIONS: The Fd(late) is a valuable tool for bedside screening of PE in surgical patients. We were able to accurately detect all PEs.

Childbearing and child care in surgery.

HYPOTHESIS: The responsibility for childbearing and child care has a major effect on general surgical residency and subsequent surgical practice. METHODS: A survey of all graduates from a university general surgical training program between 1989 and 2000. RESULTS: Twenty-seven women and 44 men completed general surgical training at our university during the period, and 42 (59%) responded to our survey. The age at completion of the residency was 34.0 +/- 2.2 years for men and 33.9 +/- 2.8 years for women. During residency, 64% (14/22) of the men and 15% (3/20) of the women had children. At the time of the survey, 21 (95%) of the men and 8 (40%) of the women had children. Most residents (24 [57%] of 42) relied on their spouse for child care. During surgical practice, 18 (43%) indicated that they rely on their spouse; 19 (45%) use day care, home care, or both; and (8%) of 26 are unsatisfied with their current child care arrangement. During training, 38% (5/13) of men and 67% (2/3) of women took time off for maternity leave, paternity leave, or child care. Two of 3 surgeons would like to have had more time off during residency; most men (70%, or 7 of 10) recommended a leave of 1 to 3 months, and all women preferred a 3-month maternity or child care leave of absence. During surgical practice, only 12% (2/17) of men but 64% (7/11) of women have taken time off for either childbearing or child care. Half of the respondents (21/42) have a formal leave of absence policy at work, 52% (11/21) of which are paid leave programs. Although the workweek of our practicing graduates is 69 +/- 16 hours for men and 64 +/- 12 hours for women, 62% (26/42) spend more than 20 hours per week parenting. More than 80% (27/32) would consider a part-time surgical practice for more parenting involvement; one third of the responders suggested that 30 hours a week constitutes a reasonable part-time practice, one third preferred fewer than 30 hours, and one third favored more than 30 hours per week. Data are presented as mean +/- SD. CONCLUSIONS: Childbearing and child care may have an enormous impact on one's decision to pursue a career in surgery. To attract and retain the best candidates for future surgeons, formal policies on the availability of child care services in the residency program and the workplace should be studied and implemented. Furthermore, national studies are needed to define appropriate, acceptable workweeks for part-time or flexible practices and the duration of leaves of absence for childbearing or child care.

Resident experience and opinions about physician-assisted death for cancer patients.

HYPOTHESIS: Surgical residents and staff oncologists (surgical, medical, and radiation therapy) have similar opinions on participation in physician-assisted death for patients with terminal cancer. DESIGN: Prospective survey. SETTING: Tertiary care referral center. PARTICIPANTS: Residents undergoing surgical training (n = 56) and faculty oncologists (n = 24) of all specialties (surgical, medical, and radiation therapy). MAIN OUTCOME MEASURES: Subjects were queried regarding previous experience and willingness to participate (either directly or indirectly) in assisted death for terminal cancer patients. RESULTS: Response rates were 39% (22 of 56) for the residents and 87% (21 of 24) for the oncologists. Of those who responded, 86% (19 of 22) of the residents would aid any of the hypothetical patients with assisted death, whereas only 19% (4 of 21) of the staff oncologists expressed willingness to perform the same service. Furthermore, 32% (7 of 22) of the residents reported previous involvement in a case of assisted death from any disease, whereas only 19% (4 of 21) of the staff oncologists reported previous direct experience with assisted death in the terminal cancer patient. CONCLUSIONS: Surgical residents tend to have more experience with assisted death and are much more willing than staff oncologists to aid terminal cancer patients with this procedure. These opinions and practices are probably not the result of medical education but are developed from personal values.

Cost-benefit analysis of biopsy methods for suspicious mammographic lesions; discussion 994-5.

HYPOTHESIS: Stereotactic core biopsy (SCB) is more cost-effective than needle-localized biopsy (NLB) for evaluation and treatment of mammographic lesions. DESIGN: A computer-generated mathematical model was developed based on clinical outcome modeling to estimate costs accrued during evaluation and treatment of suspicious mammographic lesions. Total costs were determined for evaluation and subsequent treatment of cancer when either SCB or NLB was used as the initial biopsy method. Cost was estimated by the cumulative work relative value units accrued. The risk of malignancy based on the Breast Imaging Reporting Data System (BIRADS) score and mammographic suspicion of ductal carcinoma in situ were varied to simulate common clinical scenarios. MAIN OUTCOME MEASURES: Total cost accumulated during evaluation and subsequent surgical therapy (if required). RESULTS: Evaluation of BIRADS 5 lesions (highly suggestive, risk of malignancy = 90%) resulted in equivalent relative value units for both techniques (SCB, 15.54; NLB, 15.47). Evaluation of lesions highly suspicious for ductal carcinoma in situ yielded similar total treatment relative value units (SCB, 11.49; NLB, 10.17). Only for evaluation of BIRADS 4 lesions (suspicious abnormality, risk of malignancy = 34%) was SCB more cost-effective than NLB (SCB, 7.65 vs. NLB, 15.66). CONCLUSIONS: No difference in cost-benefit was found when lesions highly suggestive of malignancy (BIRADS 5) or those suspicious for ductal carcinoma in situ were evaluated initially with SCB vs. NLB, thereby disproving the hypothesis. Only for intermediate-risk lesions (BIRADS 4) did initial evaluation with SCB yield a greater cost savings than with NLB.

Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy.

HYPOTHESIS: Minimally invasive esophagectomy can be performed as safely as conventional esophagectomy and has distinct perioperative outcome advantages. DESIGN: A retrospective comparison of 3 methods of esophagectomy: minimally invasive, transthoracic, and blunt transhiatal. SETTING: University medical center. PATIENTS: Eighteen consecutive patients underwent combined thoracoscopic and laparoscopic esophagectomy from October 9, 1998, through January 19, 2000. These patients were compared with 16 patients who underwent transthoracic esophagectomy and 20 patients who underwent blunt transhiatal esophagectomy from June 1, 1993, through August 5, 1998. MAIN OUTCOME MEASURES: Operative time, amount of blood loss, number of operative transfusions, length of intensive care and hospital stays, complications, and mortality. RESULTS: Patients who had minimally invasive esophagectomy had shorter operative times, less blood loss, fewer transfusions, and shortened intensive care unit and hospital courses than patients who underwent transthoracic or blunt transhiatal esophagectomy. There was no significant difference in the incidence of anastomotic leak or respiratory complications among the 3 groups. CONCLUSION: Minimally invasive esophagectomy is safe and provides clinical advantages compared with transthoracic and blunt transhiatal esophagectomy.

Clinical immunoscintigraphy of recurrent ovarian cancer with indium 111-labeled B72.3 monoclonal antibody.

OBJECTIVE: To prospectively evaluate the ability for immunoscintigraphy with monoclonal antibody CYT-103 labeled with indium 111 to detect tumor presence in 15 patients with ovarian cancer undergoing second-look surgery. DESIGN: Prospective, open-label, nonrandomized trial. SETTING: Hospital-based nuclear medicine facility and operating room. STUDY PARTICIPANTS: Patients with previous ovarian cancer scheduled for second-look surgery. MAIN OUTCOME MEASURE: Correctness of prediction of immunoscintigraphy for presence or absence of ovarian cancer compared with serum CA 125 titer and computed tomography. RESULTS: Immunoscintigraphy, computed tomography, and serum CA 125 titer had respective sensitivities of 92%, 42%, and 42%; specificities of 67%, 100%, and 100%; accuracies of 87%, 53%, and 53%; and diagnostic values of 59%, 42%, and 42%. The full regional extent of recurrent tumor was correctly detected in 45% of patients by immunoscintigraphy and in none of the patients by computed tomography. Immunoscintigraphy detected miliary tumor in two of four patients and computed tomography, as expected, was unable to detect miliary disease. CONCLUSIONS: Recurrent ovarian cancer often presents as multiple small lesions throughout the abdominal cavity. In this subset of patients, immunoscintigraphy may be particularly well suited for detection of the presence of recurrent tumor.

Intraoperative autotransfusion in hepatic resection for malignancy. Is it safe?

To evaluate whether intraoperative autologous transfusion increases the risk of hematogenous dissemination of tumor we reviewed the risk of lung metastasis as well as disease-free and long-term survival of patients who underwent resection of malignant hepatic neoplasms with this technique. A retrospective review of patients undergoing liver resection for malignant disease revealed 39 patients in whom intraoperative autologous transfusion was used. The 2-year actuarial survival in the patients in this series, as calculated with the Kaplan-Meier method, was predicted to be 75%. Two-year actuarial disease-free survival was predicted to be 28%, and the risk of developing lung metastasis at 3 years was estimated to be 40%. The predicted overall survival and risk of recurrence in this series compare favorably with published data for patients in whom intraoperative autologous transfusion was not used.

Minimally invasive Ivor Lewis esophagectomy.

Ivor Lewis esophagectomy consists of a laparotomy and right thoracotomy for resection of the intrathoracic esophagus. Recent advances in minimally invasive surgical technology have allowed surgeons to apply laparoscopy and thoracoscopy to perform esophagectomy. However, there have been few reports that describe a totally minimally invasive Ivor Lewis esophagectomy. We present a case of combined laparoscopic and thoracoscopic resection of the distal third esophagus with an intrathoracic esophagogastric reconstruction for esophageal carcinoma.

A simplified technique to resect abnormal bony radiolocalizations using a gamma counter.

A simplified technique for localizing and verifying the correct biopsy site of lesions identified on a bone scan has been utilized. A hand-held gamma counter was used for localization of incision placement, determination of extent of bone to be resected, and verification that appropriate tissue was resected. This technique was used to guide biopsy of bony lesions in five patients and to guide resection of a pubic ramus chondrosarcoma. We conclude that intraoperative use of a gamma counter to guide biopsy of bony lesions minimizes surgery time, increases the confidence of obtaining correct tissue, and makes a frequently frustrating procedure very simple. In addition, the probe may assist with determining adequate margins at definitive resection of tumours which accumulate technetium-99m MDP.

Limb-sparing surgery for extremity sarcomas after preoperative intraarterial doxorubicin and radiation therapy.

Complete local control of 25 extremity bone and soft tissue sarcomas was obtained by combined preoperative intraarterial doxorubicin and radiation therapy, followed by limb-sparing resection with reconstruction and adjuvant chemotherapy. At a 32 month median follow-up, there are no local tumor recurrences. Functional limbs were salvaged in 21 patients (84 percent). Fifteen patients (60 percent) were continuously disease-free and overall survival was 80 percent. After the extensive combined modality therapy, extremity complications, including delays in wound healing, occurred in 10 patients. Nevertheless, most complications were resolved with salvage of functional limbs. These results support an aggressive multimodality limb-sparing approach to high-grade extremity sarcomas.

Evaluation of minimally invasive surgical staging for esophageal cancer.

BACKGROUND: Conventional imaging studies (computed tomography and endoscopic esophageal ultrasonography) used for preoperative evaluation of patients with esophageal cancer can be inaccurate for detection of small metastatic deposits. We evaluated the efficacy of minimally invasive surgical (MIS) staging as an additional modality for evaluation of patients with esophageal cancer. METHODS: Between December 1998 and February 2001, 33 patients with esophageal cancer were evaluated for surgical resection. Conventional imaging studies demonstrated operable disease in 31 patients and equivocal findings in 2 patients. All patients then underwent MIS staging (laparoscopy, bronchoscopy, and ultrasonography of the liver). We compared the results from surgical resection and MIS staging with those from conventional imaging. RESULTS: MIS staging altered the treatment plan in 12 (36%) of 33 patients; MIS staging upstaged 10 patients with operable disease and downstaged 2 patients with equivocal findings. MIS staging accurately determined resectability in 97% of patients compared with 61% of patients staged by conventional imaging. The specificity and negative predictive value for detection of unsuspected metastatic disease in MIS staging were 100% and 96%, respectively, compared with 91% and 65%, respectively, for conventional imaging studies. CONCLUSION: In addition to conventional imaging studies, MIS staging should be included routinely in the preoperative work-up of patients with esophageal cancer.

Radioimmunotherapy for breast cancer: treatment of a patient with I-131 L6 chimeric monoclonal antibody.

We report the first treatment of metastatic breast cancer by systemic radioimmunotherapy. The serial therapy doses were chosen based on quantitative imaging data in a treatment planning approach. A terminally ill patient with aggressive, locally advanced breast cancer who had failed radiation treatment and chemotherapy was injected intravenously with radiolabeled I-131 chimeric L6, a human-mouse chimeric lgG1 monoclonal antibody to adenocarcinoma. Initially, an imaging 10 mCi dose of I-131 chimeric L6 (dose 1) deposited 8.8% of the injected dose in her chest wall tumor at 48 hours. Ten days later the patient was given a 150 mCi I-131 chimeric L6 dose (dose 2) followed three weeks later by a 100 mCi dose (dose 3). Tumor uptake and retention were comparable for doses 1 and 2, and decreased for dose 3. Following dose 3 the patient developed a manageable thrombocytopenia and transient Grade IV granulocytopenia. The tumor was observed to decrease in size with peak tumor regression occurring two weeks after dose 3. This partial response (PR) was achieved by radioimmunotherapy at a time when conventional therapy had been unable to impact the growth of the patient's massive and aggressive tumor.

Bile duct carcinoma.

Bile duct carcinoma most often causes death by obstructing bile flow; relief of this obstruction extends survival. Options include passage of tubes through the tumor to maintain internal bile drainage, hepatic-enteric bypass, and percutaneous tube drainage. As experience with liver surgery has grown, the number of bile duct carcinomas that have been successfully resected has increased. Complete removal of the tumor produces more long-term survivors than other procedures, but most patients still succumb to their disease. Nevertheless, aggressive treatment to excise the lesion or bypass the biliary obstruction significantly improves quality and length of life for many patients.

Hemobilia.

Hemobilia is a relatively rare manifestation of hepatobiliary disease that is usually characterized by recurrent colicky upper abdominal pain, gastrointestinal bleeding, and obstructive jaundice. In most instances, hemobilia presents as complication of liver injury, blunt abdominal trauma, or liver surgery. Other causes are percutaneous diagnostic procedures, hepatic artery aneurysms, inflammatory disease, biliary tract stones, and liver and bile duct neoplasms. The diagnosis of hemobilia is confirmed by endoscopy and selective angiography. Treatment of hemobilia is primarily surgical, with direct exploration of the liver, ligation of the bleeding point, and relief of bile duct obstruction. If liver damage is minimal, nonoperative management may be successful but requires careful observation and serial arteriography.

Apocrine adenoma of the breast.

Apocrine adenoma of the breast is a very rare entity. Criteria for diagnosis include qualification as adenoma and differentiation from apocrine carcinoma.

Fine-needle aspiration cytology in locally advanced breast adenocarcinoma: a case with complete response to preoperative chemotherapy in association with granulomatous inflammatory reaction.

Preoperative chemotherapy for locally advanced breast carcinoma (stage IIIA,B) is increasingly utilized demonstrating a 70 to 95% objective response and 15 to 35% complete response. A 70-yr-old woman presented with a 9 cm left upper outer quadrant breast mass associated with overlying skin redness and a 2.5 cm left axillary mass. Fine-needle aspiration cytology (FNA) showed a pleomorphic adenocarcinoma in both the breast and axilla. Following three courses of chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF), the patient had a dramatic clinical reduction of tumor, reduction of serum CA 15-3 from 161 to 64 U/ml, and underwent a modified radical mastectomy and axillary dissection. The specimen showed no viable tumor in association with an extensive granulomatous response in both the breast and axillary lymph nodes. This case illustrates two points concerning preoperative chemotherapy for locally advanced breast cancer: (1) The role of FNA v. tissue biopsy is examined. Positive cytology must be conclusive since, as in this case, no viable carcinoma may be present after therapy. (2) Chemotherapy induced host tissue reaction has not been extensively studied. This case showed a remarkable granulomatous reaction in association with tumor elimination. Since this reaction was not present on the original aspiration cytology slides, the chemotherapy treatment must have induced this reaction. Mechanisms for creating this effective host response need further investigation.