Primary intra-abdominal malignant fibrous histiocytoma presenting as pyrexia of unknown origin--report of a case with review of literature.

Primary intra-abdominal malignant mesenchymal tumours are very rare and there are not many cases of visceral malignant fibrous histiocytoma in the English literature. We report a new case of abdominal malignant fibrous histiocytoma presenting as abdominal pain and pyrexia of unknown origin in a 54 year old female followed by a brief review of literature. Presentation with pyrexia of unknown origin is extremely rare in this condition.

Demonstration of carcinoembryonic antigen (CEA) expression in normal, chronically inflamed, and malignant pancreatic tissue by immunohistochemistry.

The expression of carcinoembryonic antigen (CEA) was evaluated by immunoperoxidase staining with two anti-CEA monoclonal antibodies in normal, chronically inflamed, and malignant pancreatic tissue. Positive staining was not observed in normal specimens. In pancreatic cancer the expression of CEA was related to the degree of differentiation of the tumour. Positive staining was also observed in chronic pancreatitis.

Expression of proliferating cell nuclear antigen (PCNA) in gastric carcinoma: no evidence for prognostic value.

It has been proposed that immunostaining with PC10, a monoclonal antibody against proliferating cell nuclear antigen (PCNA), is of prognostic value in gastric carcinoma. Gastric carcinomas from a series of 90 patients in whom survival data were known have been studied. There was no relation between the degree of PC10 immunostaining assessed semiquantitatively and survival.

Second-look laparotomy in the management of epithelial ovarian carcinoma: an evaluation of fifty cases.

Fifty patients with ovarian cancer had a second-look laparotomy performed after chemotherapy. Complete histologic response was confirmed in 12 patients, microscopic disease was found in 12 patients, and macroscopic disease was found in 26 patients. Fifteen patients with macroscopic disease had total tumor clearance at second look. Surgical response to chemotherapy was found to correlate well with disease volume at the onset of chemotherapy. The operation is a safe, accurate technique for assessing the ovarian cancer patient. The findings and outcome probably depend upon the timing of the procedure. Any survival benefit from the operation remains to be proved.

Radical surgery for early gastric cancer.

The role of radical surgery for early gastric cancer has become a topic of considerable debate. Despite excellent results from Japan and several retrospective and uncontrolled trials, results from two large prospective randomized trials appear to demonstrate no benefit from D2 compared to the D1 resections. These trials have prompted a move away from radical lymph-node dissection. We argue that this reasoning is flawed and based not on the lack of efficacy of the D2 resection but in an attempt to reduce post-operative mortality and morbidity. Post-operative complications are largely a result of distal pancreatectomy and splenectomy and the relative inexperience of surgeons performing the operations. By preserving these organs and concentrating surgery to specialized centres the complication rate of radical surgery can be significantly reduced to approximate that of non-radical surgery. Lymph-node metastasis to the N2 nodes in early gastric cancer has been shown to be as high as 23%. Non-radical surgery poses significant risks of leaving residual disease. Radical surgery must remain the operation of choice if non-curative surgery for a curable condition is to be avoided.

A phase II study to evaluate tamoxifen in pancreatic adenocarcinoma.

Oestrogen receptors have been demonstrated in pancreatic adenocarcinoma and it has been suggested that tamoxifen increases patient survival. This study of 14 patients with unresectable carcinoma of the pancreas fails to demonstrate any objective response from endocrine manipulation using tamoxifen.

Venous access using the Hickman catheter.

Fifty silastic (Hickman) right atrial catheters were implanted in 43 patients receiving cytotoxic chemotherapy or parenteral nutrition. The mean catheter survival was 72 days (range 2-316 days), but 17 catheters were removed before treatment was complete. Thirteen catheters were removed for septic complications. It is concluded that the Hickman catheter will provide venous access for prolonged periods, but its benefits must be weighed against the risks of septic complications which may occur frequently in the absence of uniform care and maintenance of the catheter.

Defunctioning colostomy for perianal sepsis in acute leukaemia.

Perianal sepsis in patients with acute leukaemia is a life threatening complication which carries an extremely poor prognosis. The usual approach to this problem is simple incision and parenteral antibiotics but we have recently treated two patients with wide excision combined with a defunctioning colostomy which resulted in rapid and complete eradication of sepsis.

The influence of age on the surgical management of carcinoma of the stomach.

The medical records of 31,808 patients with gastric cancer registered with the West-Midlands Cancer Registry between 1957-1981 were reviewed to determine the influence of age on presentation, stage assessment, management, survival and mortality rates. When analysed by stage, and excluding post-operative deaths, survival was similar in all age groups. This study confirms stage of disease to be the single most important prognostic factor. The inverse relationship between laparotomy and age implies inadequate assessment of stage in the elderly. The poor prognosis in unresected cases suggests that increased precise staging by laparotomy or laparoscopy will have minimal adverse effects. On the other hand this may result in increased resections and survival.

Rectal carcinoma: a new technique to allow safer postoperative irradiation of the pelvis.

Local recurrence after abdomino-perineal excision of the rectum for Dukes C carcinoma is common. The influence of postoperative radiotherapy in reducing this is currently under investigation, and one of the potential complications is radiation damage to the small bowel. This paper describes a simple and quick method of excluding the small bowel from the pelvis which, combined with more sophisticated radiation field planning, could dramatically reduce the incidence of enteric effects.

Laparoscopic peritoneal lavage in staging gastric and oesophageal cancer.

AIMS: Accurate staging of gastric, oesophageal and oesophagogastric cancer is essential to avoid unnecessary laparotomies in patients where only palliation is appropriate. This requires a multimodal approach utilizing endoscopy, computed tomography and laparoscopy. Previous authors have found that the presence of free peritoneal tumour cells (FPTCs) detected at laparoscopy or laparotomy confers a poorer prognosis. However, various methods of peritoneal lavage are described. The aim of this study was to evaluate the prognostic value of our technique of peritoneal lavage. MATERIALS AND METHODS: 88 staging laparoscopies with peritoneal lavage were carried out between March 1997 and February 1999 on patients eligible for attempted curative resection of a gastric, oesophageal or oesophagogastric cancer. During laparoscopy the pelvis was irrigated with 200 ml of normal saline, with 100 ml aspirated and examined cytologically. Patients were followed-up until September, 1999. RESULTS: 11 patients had FPTC-positive cytology with a median survival following laparoscopy of 122 days (95% CI 82-161) with only a single patient surviving more than one year. In the FPTC-negative group, median survival was 378 days (95% CI 256,-). Log-rank Chi(2)=16.7, P<0.001. CONCLUSIONS: The presence of FPTCs detected by our technique is a contraindication to attempted curative resection - palliation only (medical or surgical) is appropriate.

Survival following intestinal obstruction in ovarian cancer.

A retrospective survey of 38 ovarian cancer patients who developed radiologically confirmed intestinal obstruction was performed. Twenty-six patients underwent surgery. In the surgical treatment group, obstruction was not due to recurrent disease in six cases. The median survival for the group as a whole was 56 days. Patients in the operative group survived significantly longer than those in the non-operative group. There was an operative mortality of 15% and major postoperative morbidity was seen in 42%. Neither the site of the obstruction nor the type of operation influenced survival. No postoperative chemotherapy responses were seen in previously treated patients.

Redefining surgery for gastric cancer.

BACKGROUND: Despite encouraging retrospective and non-randomized trials, two large prospective, randomized trials of D1 vs D2 resections show double the mortality in the D2 group, with no increase in long-term survival. However, the D2 resection still offers the only hope of cure when N2 nodes are involved. We propose a reclassification of the International Union Against Cancer TNM "N" staging to a system with an anatomical basis that is useful in defining the surgery performed. Junctional nodes lying between the N1 and N2 tiers will act as a guide to surgery. Where these nodes are uninvolved, the probability of gastric bed (N2) involvement is low and the radical D2 dissection with its higher mortality and morbidity can be avoided.CONCLUSION: Such "stage-appropriate" surgery will reduce the number of D2 resections while ensuring that patients with N2 disease are not denied curative surgery. A prospective, randomized, controlled trial of targeted surgery is required.

Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint).

In seventeen cases of irreducible atlanto-axial rotatory subluxation (here called fixation), the striking features were the delay in diagnosis and the persistent clinical and roentgenographic deformities. All patients had torticollis and restricted, often painful neck motion, and seven young patients with long-standing deformity had flattening on one side of the face. The diagnosis was suggested by the plain roentgenograms and tomograms and confirmed by persistence of the deformity as demonstrated by cineroentgenography. Treatment included skull traction, followed by atlanto-axial arthrodesis if necessary. Of the thirteen patients treated by atlanto-axial arthrodesis, eleven had good results, one had a fair result, and one had not been followed for long enough to determine the result. Of the remaining four patients, one treated conservatively had not been followed for long enough to evaluate the result, two declined surgery, and one died while in traction as the result of cord transection produced by further rotation of the atlas on the axis despite the traction.

Os Odontoideum.

A review of the cases of thirty-five patients with os odontoideum, the largest series reported to date, supports the concept that trauma is the etiology of the abnormality. Most of the patients had roentgenographic instability of the affected spinal segment, and were treated with spine fusion. Eleven patients had lesions attributable to injuries received before they were four years old, although surgical treatment usually was delayed for one to eight years. Nine patients had documented roentgenographic evidence of a normal odontoid process prior to the development of the os odontoideum. Only one-third of the patients had any signs or symptoms indicative of neural deficits, although most patients had cervical pain. Surgical treatment alleviated the pain and instability.

Spine fusion for atlanto-axial instability.

A follow-up study was done on fifty-seven spine fusions for atlanto-axial instability, classified as Type I - deficient odontoid (twenty-eight patients), Type II - deficient ligaments (twenty-three patients), and Type III - rotatory fixation (six patients). The average age of the patients at the time of the fusion was thirty years, and half had had significant trauma. Symptoms had been present for an average of 12.3 months before fusion. Preoperatively pain was the predominant complaint in twenty-nine; neurological complaints, in twenty-four; and instability in the rest. Of the forty-six Gallie fusions, there was one non-union and of the eleven occipitocervical fusions, two non-unions. Follow-up averaging 4.2 years revealed resolution of symptoms in almost all patients.

Machine learning techniques in early screening for gastric and oesophageal cancer.

A database on 2692 dyspeptic patients over the age of 40 was established, consisting of 73 epidemiological and clinical variables. A tree-based machine learning algorithm (PREDICTOR) was applied to this database, in order to attempt to find rules which would classify patients into 2 groups, i.e., those suffering from gastric or oesophageal cancer, and the remainder. The results were encouraging. The cross-validated classification performance figure showed that by classifying 61.3% of the patients as high risk, a sensitivity of 94.9% and a specificity of 39.8% could be achieved. It is planned to construct an expert system based on the rules produced by the machine learning algorithm, in order to provide preliminary screening for cancer in dyspeptic patients.

Traumatic spondylolisthesis of the axis.

A series of 123 patients suffering traumatic spondylolisthesis of the axis is reported. This lesion is associated with extension and axial loading injury, and there is a high incidence of injuries of the face or scalp and of associated fractures of the upper cervical spine. There is a low incidence of neurological injury, which seems paradoxical in the presence of what appears to be gross instability, but protection from extremes of flexion and extension may be adequate treatment. Union is usual regardless of displacement. Traction is a safe means of treatment, but early waking in a halo support reduces time in hospital without jeopardizing the result. Operation is needed only for chronic instability with or without pain, and anterior interbody fusion of C2--3 is than preferred in order to preserve rotation at the atlanto-axial joints.

Traumatic spondylolisthesis of the axis.

The lesions of C2 seen in hyperextension injuries of the cervical spine following motor vehicle accidents, diving accidents, and headlong falls resemble the cervical lesion found in judicial hangings. Although the mechanism of injury in these cervical fractures is different, the distinction is significant. The fracture seen in motor vehicular accidents today usually seems to be one of hyperextension and axial compression rather than hyperextension and distraction. This distinction is responsible for the low incidence of neurologic involvement seen in the fracture caused by motor vehicle accidents. The incidence of face and scalp injuries associated with axis pedicle fractures appears significant. Union of this fracture can generally be expected, and it rarely produces late sequelae. Management of this fracture is generally preferable on an ambulatory basis utilizing a cervicothoracic brace or a halo and caudal support in more unstable fractures. A period of 12 weeks of immobilization is recommended for satisfactory union of this fracture. Occasionally the treatment of this fracture may require traction or operative intervention. If operative intervention is required, an anterior route employing interbody fusion is suggested.