Upper Extremity Lymphedema After Axillary Lymph Node Dissection: Prospective Lymphoscintigraphic Evaluation.

This prospective study was designed to evaluate changes in upper extremity lymphatic drainage after ALND in comparison to the preoperative status using lymphoscintigraphy. The study enrolled 44 women (mean age: 57.95; range: 35-80) with a new diagnosis of unilateral invasive breast carcinoma who had been scheduled to undergo ALND. This was a substudy of the physiotherapeutic project, in which subjects after ALND were randomized into 4 groups treated with: 1) rehabilitation exercises; 2) manual lymphatic drainage; 3) pneumatic compression pump; and 4) education only. Clinical evaluation which included arm measurements and lymphoscintigraphy was performed in every subject before surgery and 3 times after surgery (1-6 weeks, 1 and 2 years after ALND). Follow-up was completed in 44 subjects at 1 year and in 32 subjects at 2 years. Lymphedema diagnosis was made in 4 subjects 1 year after ALND (9%) and in 8 subjects 2 years after ALND (25%). Among them, respectively, only 50% and 62% noticed and reported lymphedema. Quantitative analysis of lymphoscintigrams and photoplethysmography results did not reveal upper extremities lymphatic transport and/or venous function impairment after the ALND procedure. Qualitative analysis of lymphoscintigrams revealed most commonly disappearance of previously functional lymph nodes and appearance of dermal backflow in subjects who developed lymphedema. Conversely, appearance of functional lymph nodes in different locations after ALND may indicate protection from development of upper extremity lymphedema.

The role of surgery in the treatment of colorectal metastases from primary skin melanoma.

AIM: The study assessed the role of colorectal surgery in the treatment of metastatic melanoma and identified patients who can most benefit from surgical resection. METHOD: A retrospective analysis was made of 34 consecutive patients with skin melanoma who underwent surgical resection of large bowel metastasis. RESULTS: The median disease-free interval between diagnosis of the primary and metastatic melanoma was 24 (7-98) months. Nine (27%) patients underwent emergency surgery for obstruction and 25 (73%) had an elective procedure. Resection with curative intent was performed in 14 (41%) and palliative resection in 20 (59%) patients. There was no postoperative mortality and morbidity occurred in 9%. The median survival following surgery was 11.5 (4-68) months. The 1-, 2- and 5-year survival rates were 50%, 32% and 17% respectively. Median survival was significantly increased in patients without extra-abdominal metastases, with no evidence of non-large-bowel metastases, if the disease-free interval was longer than 24 months and when curative resection was performed. In multivariate analysis, an apparently complete or palliative resection and the absence or presence of extra-abdominal metastases were the most important prognostic factors. CONCLUSION: An aggressive surgical approach to large bowel metastatic melanoma results in good palliation and effective relief of symptoms with acceptable morbidity and mortality.

Axillary lymph nodes and arm lymphatic drainage pathways are spared during routine complete axillary clearance in majority of women undergoing breast cancer surgery.

Alterations in axillary lymph nodes (ALNs) after complete axillary lymph node dissection (ALND) in comparison to the preoperative status were evaluated using lymphoscintigraphy performed preoperatively and 1-6 weeks after surgery in 30 women with a new diagnosis of unilateral, invasive breast carcinoma. Analysis of lymphoscintigrams revealed that ALNs after surgery were present in 26 of 30 examined women. In comparison to preoperative status, they were visualized in the same location (12 women), in the same and additionally in different locations (9 women), or only in different locations (4 women). No lymph nodes were visualized in one woman and lymphocoele were in 4 women. Thus, after ALND, a variable number of axillary lymph nodes remain and were visualized on lymphoscintigraphy in the majority of women. The classical ALND, therefore, does not allow complete dissection and removal of axillary nodes with total disruption of axillary lymphatic pathways, accounting in part for the variable incidence and severity of lymphedema after the procedure.

Pain experienced by patients during minimal-invasive ultrasound-guided breast biopsy: vacuum-assisted vs core-needle procedure.

AIMS: To evaluate comparatively the pain associated with ultrasound-guided core-needle (CN) and vacuum-assisted (VA) biopsy for non-palpable breast lesions. METHODS: 723 women undergoing ultrasound-guided breast biopsy for BIRADS IV and V lesions according to the same standardised protocol were prospectively studied. 14-gauge CN biopsy with an automated gun was performed in 321 patients. In 402 women biopsy was made using 11-gauge VA hand-held probe. Immediately after the procedure patients were interviewed about the pain experienced during the biopsy and were asked to indicate at the pain intensity on a eleven-point scale: from 0 (none) to 10 (extreme, worst possible pain). RESULTS: The median rate of pain experienced by women during biopsy was 4 (range 2-7). There were no significant differences between CN and VA groups with regard to age, body mass index, menopausal status, history of parity, hormone replacement therapy, menopausal status, breast parenchymal pattern (according to Wolfe's classification), family history of breast cancer, lesion size and number of samples. CN biopsy with an automated gun was significantly more painful (P < 0.01) than procedure with VA hand-held device as evaluated by patients: median 6 (4-7) vs 3 (2-5), respectively. CONCLUSIONS: Despite using the larger needle VA procedure results in less pain experienced by women in comparison to CN biopsy with automated gun. Reduced patient discomfort should be one of the reasons for the preferential use of VA biopsy in the assessment of non-palpable breast masses.

The impact of pre- or postoperative radiochemotherapy on complication following anterior resection with en bloc excision of female genitalia for T4 rectal cancer.

OBJECTIVE: The aim of the study was to assess the mortality and morbidity following extended anterior resection with excision of internal female genitalia combined with pre- or postoperative chemoradiotherapy in women with extensive rectal cancer. METHOD: The study included a consecutive series of 21 women with T4 adenocarcinoma of the rectum infiltrating the reproductive organs treated with curative intent between 1997 and 2003. All patients had an extended anterior sphincter preserving resection of the rectum (total mesorectal excision) and hysterectomy with or without posterior vaginal wall excision. In all patients, surgery was combined with adjuvant radiochemotherapy. Ten patients received preoperative radiotherapy (50.4 Gy) concurrently with two courses of chemotherapy [fluorouracil with folinic acid (FA)] followed by surgery within 6-8 weeks and subsequently four courses of postoperative chemotherapy. Eleven received postoperative chemoradiotherapy (50.4 Gy plus fluorouracil with FA). RESULTS: There was no postoperative mortality. Postoperative complications were observed in 57% patients (early in 14% and late in 52%). These included: anterior resection syndrome with anorectal dysfunction in 52% (requiring proximal diversion in 5%), urinary complications in 24% (complete incontinence requiring a permanent catheter in 5%). In addition, postoperative acute bleeding requiring relaparotomy, delayed wound healing caused by superficial infection, anastomotic leakage, prolonged bowel paralysis, benign rectovaginal fistula and anastomotic stricture occurred (5% each). The risk of postoperative morbidity (52%) was similar for patients with or without preoperative radiochemotherapy. CONCLUSION: Despite this aggressive therapeutic approach, most postoperative complications were transient or could be treated. Preoperative radiochemotherapy did not increase the risk of morbidity.

Predictive value of lymphocytic infiltration and character of invasive margin following total mesorectal excision with sphincter preservation for the high-risk carcinoma of the rectum.

PURPOSE: To assess the prognostic significance of clinicopathological factors, especially histological parameters of new Jass classification, following sphincter-sparing total mesorectal excision (TME) for high-risk rectal cancer. MATERIAL AND METHODS: Forty-five consecutive patients treated with curative intent in 1998-1999 due to rectal cancer in Dukes stage B and C were studied prospectively. All of them underwent anterior resection with TME technique. Prognostic value was evaluated by the impact on five-year recurrence-free survival (RFS) in uni- and multivariate analysis. Only factors significant in univariate analysis entered the multivariate regression model. P value <0.05 was stated as a significance limit. RESULTS: Regarding traditional clinico-pathological factors patient age, tumor site, differentiation grade, mucinous histology and the extent of direct tumor penetration did not significantly affect survival rates. Only the lymph nodes status was associated with prognosis with statistical importance (negative vs positive, RFS: 53.8 +/- 10.0% vs 26.3 +/- 10.4%, respectively). Considering the additional parameters of Jass classification the character of invasive margin of the tumor did not reveal the important predictive value although the lymphocytic tumor infiltration was significantly related to patient outcome (presence vs absence, RFS: 63.6 +/- 15.2% vs 37.5 +/- 8.7%, respectively). In multivariate analysis the only one statistically important and independent predictive parameter was the lymph nodes status. CONCLUSIONS: Lymph nodes metastases remain the most important prognostic factor after anterior resection with TME for Dukes B and C rectal cancer. From variables included into Jass classification the absence of lymphocytic infiltration of the tumor can be helpful to identify patients with enhanced risk of oncological relapse.

Intensity of apoptosis as related to the expression of metallothionein (MT), caspase-3 (cas-3) and Ki-67 antigen and the survival time of patients with primary colorectal adenocarcinomas.

The present study aimed at analysing the intensity of apoptosis, as related to the expression of pro- and anti-apoptotic cellular markers (cas-3, MT, Ki-67 antigen), and at evaluating their expression in relation to the survival time of patients with colorectal adenocarcinoma. Material for the studies was obtained from 40 patients with primary colorectal adenocarcinomas (G2, T3N0M0), treated at the Lower Silesia Centre of Oncology in Wroclaw. Tumour samples were fixed in 4% buffered formalin and embedded in paraffin blocks. In obtained paraffin sections, TUNEL reaction (detection of apoptosis) and immunocytochemical reactions were performed (detection of cas-3, MT and Ki-67 antigen expression). The results disclosed a weak correlation between the intensity of apoptosis and the expression of MT, cas-3 and Ki-67 antigen (r = 0.18; r = 0.33; r = 0.15, respectively) in cells of colorectal adenocarcinomas. The survival time of the patients was shorter, when the apoptosis and expression of Ki-67 antigen were highly pronounced. The time periods of the patients' survival showed no correlation with the expression of cas-3 or MT. The obtained results point to the key role of apoptosis and proliferation processes in the clinical course of colorectal adenocarcinomas.

Prognostic significance of metallothionein expression in correlation with Ki-67 expression in adenocarcinomas of large intestine.

The study aimed at determining levels of metallothionein (MT) and Ki-67 antigen expression in adenocarcinomas of large intestine and examining relation of the expression levels with various clinical and pathological variables. The studies were performed on 81 cases of large intestine adenocarcinoma. Using immunocytochemistry, expressions of MT (positive reaction in 73 cases) and of Ki-67 (positive reaction in 79 cases) antigen were examined and the obtained results were compared with, i.a., grade (G) of the tumour and depth to which intestinal wall was infiltrated by individual tumours. Patient survival analysis was also performed, as correlated to expression levels of the two antigens. The obtained results permitted to disclose that the lower was grade of histological differentiation (G2, G3), the more pronounced was expression of MT and Ki-67. Also, the deeper was neoplastic infiltration of intestinal wall, the more pronounced was MT and Ki-67 expression. Despite the relatively strong correlation between MT expression and Ki-67 expression (r=0.536; p<0.05), only Ki-67 antigen expression in large intestine adenocarcinomas was inversely correlated to survival of the patients. Ki-67 proved to be a better prognostic marker, as compared to MT, in large intestine adenocarcinomas.

[Neurofibroma and meningioma of the spinal canal]. / Nerwiakowlókniak i oponiak w kanale kregowym.

The authors described a 22-year-old female patient in whom a neurofibroma had been removed at the age of 13 years (laminectomy L1, 2, 3), and 9 years later psammoma was removed by laminectomy Th7, 8, 9). Both tumours developed outside the cord and were removed radically. The patient without complaints and without neurological deficit returned to work.

[Meningomyelocele with spinal cord cyst and internal hydrocephalus in a 9-month-old boy]. / Przepuklina oponowa z torbiela rdzeniowa oraz wodoglowiem wewnetrznym u 9-miesiecznego chlopca.

The authors describe a boy aged 9 months with open myelomeningocele which changed gradually into meningocele with spinal cord cyst. During treatment internal hydrocephalus developed requiring insertion of Pudenz-Heyer ventriculoatrial. valve. The treatment was successful. The case illustrates the succession of changes which may develop in myelomeningocele and the relationship between the state of internal hydrocephalus and the volume of meningocele and spinal cyst (cerebrospinal fluid production exceeding its resorption).

[Developmental anomalies of the metencephalon in the craniofacial and vertebral malformation syndrome]. / Zaburzenia rozwojowe tylomózgowia w zespole wad twarzoczaszki i kregoslupa.

The authors describe a case of a girl aged 9 years with a syndrome of malformations--cleft of the upper lip, maxilla and palate, lack of C2 arch fusion, polycystic lesions of the vermis and cerebellar hemisphere with obliteration of the aqueduct. The syndrome of intracranial hypertension with prevailing cerebellar symptoms was the cause of diagnostic and surgical management. Suboccipital craniotomy was done with insertion of ventriculoatrial valve which restored the normal intracranial pressure. The girl recovered and resumed education.