Treatment of cutaneous angiosarcoma of the scalp and face in Chinese patients: local experience at a regional hospital in Hong Kong.

INTRODUCTION: Angiosarcoma is a rare aggressive sarcoma that occurs mostly in the skin of the head and neck in the elderly population. The optimal management is dubious and most studies are from Caucasian populations. We aimed to examine the treatment and outcome of this disease in Chinese patients. METHODS: Data of patients with histopathologically verified cutaneous angiosarcoma of the head and neck during December 1997 to September 2016 were retrieved from our hospital cancer registry. The demographic data, clinicopathological information, modality of treatment, and outcomes were reviewed. RESULTS: During the study period, 17 Chinese patients were treated. Their median age was 81 years. The tumours were present in the scalp only (n=11), face only (n=4), or both scalp and face (n=2). Only two patients had distant metastases. The modalities of treatment were surgery (n=6), surgery and adjuvant radiotherapy (n=1), palliative radiotherapy (n=5), or palliative chemotherapy (n=3). The remaining two patients refused any treatment initially. Of the seven patients treated surgically, there were four local and two regional recurrences. The median time to relapse was 7.5 months. Overall, 16 patients had died; causes of death were disease-related in 12 whereas four other patients died of inter-current illnesses. One patient was still living with the disease. The median overall survival was 11.1 months and the longest overall survival was 42 months. CONCLUSION: The outcome of angiosarcoma in our series is poor. A high index of suspicion is mandatory for prompt diagnosis. Adjuvant radiotherapy is recommended following surgery. The benefit and role of systemic treatment in various combinations with surgery or radiotherapy require further study.

Malignant presternal goitre.

Goitres usually enlarge and descend caudad into the substernal space and are not palpable. We report on a patient whose goitre spread downward but anterior to the sternum. The thyroid mass was subsequently removed and was proven to be a papillary thyroid carcinoma. The mechanism by which a presternal goitre develops is probably due to invasion and erosion of the strap muscles and the cervical linea alba. The clinical implication of this presentation is complete extirpation of the presternal goitre with a cuff of the strap muscles.

Right-sided pyriform sinus fistula in an adult.

Pyriform sinus fistula is important despite its rarity, as it can induce a recurrent neck abscess. Most of the reported cases occur in children and the majority affect only the left side. We report a patient with a pyriform sinus fistula of the right neck in an adult, which was successfully treated by surgery. The aetiology of this entity is also discussed herein.

Kuttner's tumour (chronic sclerosing sialadenitis) of the submandibular gland: a clinical perspective.

OBJECTIVE: To study clinical perspectives pertaining to chronic sclerosing sialadenitis, which is also known as Kuttner's tumour. DESIGN: Retrospective medical chart review. SETTING: Regional hospital, Hong Kong. PATIENTS: From February 2005 to February 2007, nine cases with Kuttner's tumour were identified from our hospital electronic database. INTERVENTIONS: They underwent submandibular sialadenectomy under either local (n=6) or general (n=3) anaesthesia. MAIN OUTCOME MEASURES: The results of preoperative ultrasonography, fine-needle aspiration cytology, and intra-operative frozen section examination were correlated with the final diagnosis. Operative morbidity was also evaluated. RESULTS: The mean age of the patients at diagnosis was 61 years; three were females. Three had bilateral submandibular swellings. Following preoperative ultrasonography in six of the patients, tumours were suspected in two, an enlarged lymph node in one, and diffuse enlargement was visualised in the other three. Six patients had preoperative fine-needle aspiration cytology; five yielded scanty acini with normal-looking ductal cells, variable degrees of infiltration by chronic inflammatory cells without granuloma admixing fibrosis. In the sixth patient, only bland-looking epithelial cells, indicative of ductal differentiation suspicious of neoplasm were noted. Intra-operative frozen section examination was conducted in three patients: chronic inflammation without evidence of carcinoma was visualised in each. Operations performed under local anaesthesia were well tolerated; only one patient endured a transient, marginal facial nerve palsy. CONCLUSIONS: Kuttner's tumour is by no means rare. When supported by ultrasonography and fine-needle aspiration cytology, an accurate diagnosis can be made preoperatively and surgery can be reserved for symptomatic cases. Submandibular sialadenectomy is a safe and effective means of treating Kuttner's tumour, and can be accomplished under local anaesthesia.

Mesh erosion to urinary bladder causing fistulation to abdominal wall resulting in necrotizing fasciitis: A case report of late complication of incisional hernia.

INTRODUCTION: Incisional hernia is not an uncommon complication after abdominal operation, and laparoscopic ventral hernia repair with mesh is commonly performed nowadays. It is thought to have less complication compare to the traditional open repair, yet late complication is still observed occasionally and can be disastrous. CASE REPORT: We hereby report a case of abdominal wall necrotizing fasciitis 21 months after laparoscopic incisional hernia repair in lower midline with dual mesh, due to mesh migration and erosion into urinary bladder, resulting in fistulation between bladder and abdominal wall. Repeated debridement and removal of mesh was required for sepsis control and the patient required intensive care support due to multi-organ failure. Subsequent repair of urinary bladder and abdominoplasty was performed after condition stabilized. CONCLUSION: This case was the first reported incident with bladder erosion by dual mesh causing vesico-cutaneous fistula complicated with necrotizing fasciitis. Although dual mesh theoretically reduces the risk of mesh erosion, mesh erosion to viscera can still happen and cause severe complication. Its risk should be balanced and discussed with patient with full consent.

Oesophageal tuberculosis mimicking oesophageal carcinoma.

Tuberculous involvement of the oesophagus is rare, and is usually caused by direct spread from adjacent afflicted structures. We report an 83-year-old male patient with oesophageal tuberculosis secondary to tuberculous mediastinal lymphadenitis who presented with non-specific symptoms of anorexia and lethargy. Upper gastro-intestinal endoscopy revealed an ulcerative tumour-like lesion in the mid-oesophagus suggesting oesophageal carcinoma. Repeated endoscopic biopsies revealed a non-specific acute-on-chronic inflammation consisting of non-caseating granulomas, with no evidence of malignancy. Endoscopic ultrasonography demonstrated that the oesophageal lesion was secondary to direct extension of mediastinal lymphadenopathy. The diagnosis of tuberculosis was eventually confirmed by histological and microbiological analysis of a surgically excised cervical lymph node. The patient responded promptly to treatment with antituberculous drugs. We suggest that oesophageal tuberculosis has to be kept in mind in the differential diagnosis of oesophageal ulcerohypertrophic lesions.

Surgical management of substernal goitre: local experience.

OBJECTIVES: To examine the presentation, workup, and surgical complications of substernal goitre. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: Twenty-four mostly elderly patients (mean age, 60.1 years) who underwent thyroidectomy for substernal goitres between 2000 and 2003 (substernal goitres were defined as those having either a caudal mass transgressing the fourth thoracic vertebra or having more than 50% of their overall mass residing within the thorax). MAIN OUTCOME MEASURES: Symptoms, histopathological diagnoses, morbidities, and complications. RESULTS: Dyspnoea was the most common symptom (n=8, 33%). Three (12.5%) patients presented with acute airway obstruction; however, 13 (54.2%) were asymptomatic apart from the presence of cervical masses. Computed tomographic scans were performed on all but two patients. Malignancy was present in 12.6% of patients, or 16.8% if occult papillary carcinoma is included. Partial or full sternotomies were performed in two (8.3%) patients. Complications included recurrent laryngeal nerve injury (n=1, 2.7% of nerves at risk), transient hypoparathyroidism (n=2, 13.3% of patients at risk), haematoma (n=1, 2.7%), pneumonia (n=1, 2.7%), and wound infection (n=1, 2.7%). There was no operative mortality or permanent hypoparathyroidism. The complication rate was significantly lower in the asymptomatic patients (P=0.033 by Fisher's exact test); clinicopathological parameters were otherwise statistically comparable between the two groups. CONCLUSIONS: There is rarely any mortality in thyroidectomy for substernal goitre, and the morbidity is also very low, especially in asymptomatic patients. In the absence of contra-indications, substernal goitre should be treated with early surgery rather than having it run the risk of acute airway distress or cancer.

Focused parathyroidectomy without intra-operative parathyroid hormone monitoring for primary hyperparathyroidism: results in a low-volume hospital.

BACKGROUND: The role of routine intra-operative parathyroid hormone monitoring for sporadic primary hyperparathyroidism is contentious. Satisfactory results can be achieved in high-volume centres. The results of low-volume hospitals are rarely studied. METHODS: A retrospective, non-comparative study was conducted. From November 2002 to October 2012, 105 patients with clinically sporadic primary hyperparathyroidism underwent focused parathyroidectomy without intra-operative parathyroid hormone monitoring. Single adenoma was localised on pre-operative ultrasonography or sestamibi scan. The cure rate, surgical complication rate and pathology findings were evaluated. RESULTS: Most of the operations (63.8 per cent) were performed under local anaesthesia. All but two patients (98.1 per cent) were cured after surgery. There was only one case of double adenomas. No recurrent hyperparathyroidism was observed after a mean follow up of 56.9 months. Surgical complications comprised two cases (1.9 per cent) of transient vocal fold palsy and one case (1.0 per cent) of permanent vocal fold palsy. Seven patients (6.7 per cent) suffered temporary hypocalcaemia. CONCLUSION: Satisfactory results of focused parathyroidectomy without routine intra-operative parathyroid hormone monitoring for appropriately selected primary hyperparathyroidism cases can be attained in a low-volume hospital.

A comparison of the prognostic significance of tumor diameter, length, width, thickness, area, volume, and clinicopathological features of oral tongue carcinoma.

BACKGROUND: The present study aims at evaluation of the prognostic value of tumor size including diameter, length, thickness, width, area, and volume in the prediction of nodal metastasis, local recurrence, and survival of oral tongue carcinoma. The results will have important implications for the management of patients. METHODS: Eighty-five glossectomy specimens of oral tongue carcinoma were serially sectioned in 3 mm thickness for the tumor size evaluation with computer image analyzer. RESULTS: Among all the tumor size parameters being evaluated, tumor thickness was the only significant factor for the prediction of local recurrence, nodal metastasis, and survival. With the use of 3 mm and 9 mm division, tumor of up to 3 mm thickness has 10% nodal metastasis, 0% local recurrence, and 100% 5-year actuarial disease-free survival; tumor thickness of more than 3 mm and up to 9 mm has 50% nodal metastasis, 11% local recurrence, and 77% 5-year actuarial disease free survival; tumor of more than 9 mm has 65% nodal metastasis, 26% local recurrence, and 60% 5-year actuarial disease-free survival. CONCLUSIONS: Tumor thickness should be considered in the management of patients with oral tongue carcinoma.

Endoscopic management of submandibular sialolithiasis.

BACKGROUND: Transoral removal and sialoadenectomy are the two main modalities of treatment for submandibular stones. However, missed ductal stones are not uncommon, and there is a risk of lingual or hypoglossal nerve injury. We attempted to avoid these complications by using an endoscopic technique. METHODS: The case notes of the patients who had undergone endoscopic removal of submandibular stones were studied retrospectively. The procedure was performed under general anesthesia. The submandibular orifice was incised by carbon dioxide laser, and a 3.1-mm rigid scope was inserted under direct vision with normal saline irrigation after dilatation. The stones were either broken down by laser or removed with a Dormia basket or forceps. RESULTS: A total of 13 patients underwent the procedure. The duration of median follow-up was 15 months. In 11 patients, the stones were identified and removed. No stone was found in two patients (15.4%). There were no false negatives, since no stones were discovered subsequently in these two patients. One, two, three, and four stones were present inside the ducts in seven patients (54.6%), one patient (7.7%), two patients (15.4%), and one patient (7.7%), respectively. The symptoms subsided completely in 11 patients within 4 weeks after the procedure. Persistent swelling occurred in two patients. In one of them, no residual stone was revealed by CT scan. The other patient had a large calculus that was only partially fragmented by laser lithotripsy at the initial operation. No lingual nerve or hypoglossal nerve injury was detected in any patient. CONCLUSION: Sialoendoscopy is a safe and efficacious treatment for submandibular ductal stones. It reduces the incidence of missed stones, and nerve injury, as well as the need for sialoadenectomy.

Conservative approach is feasible in the management of acute diverticulitis of the right colon.

BACKGROUND: Acute diverticulitis of the caecum and ascending colon is uncommon. Controversies abound as regards the optimal surgical treatment, ranging from appendectomy, diverticulectomy to right hemicolectomy. The aim of the present paper was to review treatment strategy followed by a critical appraisal. METHODS: The case notes of 30 patients with acute diverticulitis of the right colon who were treated at the United Christian Hospital, Hong Kong from 1992 to 1998 were systematically reviewed. The data were subjected to statistical analysis. RESULTS: The median age was 34 years, with a male:female ratio of 1:1.15. All patients presented with acute right lower abdominal pain and localized rebound tenderness. All were diagnosed preoperatively as having appendicitis. The mean duration of symptoms was 2 days (range: 1-6 days). Two treatment groups were identified. Group A (n = 16; 53%) received appendicectomy alone, while group B (n = 14; 47%) underwent diverticulectomy in addition to appendicectomy, including one patient with perforated diverticulitis. Overall, there was no procedure-related morbidity or mortality. Both groups received a similar duration of broad-spectrum antibiotics. All the patients were interviewed by phone after operation to detect any recurrence of symptoms, with a median follow-up interval of 34 months (range: 11-78 months). There was no recurrence of symptoms in group A, which received appendicectomy and antibiotics. The only difference was operative time. CONCLUSION: For non-perforated diverticulitis of the right colon, appendicectomy and intravenous antibiotics without diverticulectomy is the preferred treatment strategy.

Lymphoepithelioma-like carcinoma of oral cavity: report of three cases and literature review.

Lymphoepithelioma-like carcinoma is a rare tumour in the oral cavity and is characterized histologically by non-keratinizing, undifferentiated squamous cell carcinoma with lymphocytic infiltration. Three consecutive cases of intraoral lymphoepithelioma-like carcinoma are reported. A review of the literature reveals a similar biological behaviour to that of nasopharyngeal lymphoepithelioma: a high incidence of cervical nodal spread and remarkable radiosensitivity. Chemotherapy should be considered when nodal or distant metastases are present. The association of the Epstein-Barr virus with this tumour remains unclear but our experience suggests a positive correlation in Chinese individuals.

Comparison of antigenic structure and pathogenicity of bovine intestinal Chlamydia isolate with an agent of epizootic bovine abortion.

A bovine fecal Chlamydia, isolated from a clinically normal cow, had pathogenic capabilities and antigenic structure similar to those of a chlamydial agent of epizootic bovine abortion (EBA). Intravenous inoculation of the fecal chlamydia into a pregnant heifer caused abortion and lesions in the fetus indistinguishable from those of experimentally induced EBA. In serotests with species-specific complement fixation antigens, the intestinal agent was similar to the EBA agent.

Use of botulinum toxin type A in a case of persistent parotid sialocele.

Sialocele is an uncommon complication of parotidectomy. Most cases resolve after conservative therapy consisting of repeated aspiration and pressure dressing. The condition is, however, occasionally resistant to such therapy. We report on a 52-year-old Chinese man who had a 10-year history of right parotid swelling. Following fine-needle aspiration cytology, Warthin's tumour was diagnosed, but after elective parotidectomy, a swelling developed and parotid sialocele was diagnosed. Botulinum toxin type A was given after the sialocele had persisted for almost 3 weeks after surgery, and after conservative management had been tried; the sialocele disappeared after two doses of treatment. Botulinum toxin therapy was thus an effective method of treating persistent sialocele.

Outcomes and complications of thyroid surgery: retrospective study.

OBJECTIVE: To study the outcome and complications of thyroid surgery. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: Three hundred and twelve patients (266 women and 46 men) underwent thyroid surgery between January 1994 and December 1999. MAIN OUTCOME MEASURES: Complications of thyroidectomy for various thyroid diseases according to surgical technique used. RESULTS: Capsular dissection gradually became a more popular surgical technique: 33% and 58% in the first and second halves of the study period respectively (P<0.001). The overall rate of permanent vocal cord palsy was 2%. Near-total thyroidectomy became the preferred surgical treatment for toxic goitre over the study period. The incidence of recurrent hyperthyroidism was reduced from 21% to 7% (P>0.1, not significant). The incidence of hypoparathyroidism was approximately 30% after thyroidectomy for cancer. CONCLUSION: Capsular dissection is increasingly utilised in thyroid surgery. Low complication rates can be achieved after thyroidectomy for benign diseases. Hypoparathyroidism, however, is a relatively common complication after surgery for thyroid cancer.