Pathological determinants of survival in node-negative oesophageal cancer.

BACKGROUND: Many studies have analysed prognostic factors following oesophagectomy, but few have examined survival determinants in node-negative (N0) oesophageal cancer. The prognostic significance of a number of histological variables following surgical resection of N0 oesophageal cancer was studied. METHODS: The case notes of 219 patients undergoing potentially curative oesophagectomy for N0 squamous cell carcinoma or adenocarcinoma of the oesophagus were reviewed. Details of the patient's sex, age at operation, histological type, longitudinal tumour length, tumour (T) stage, circumferential resection margin involvement, tumour grade, presence of vascular invasion, perineural invasion, Barrett's metaplasia, and survival were noted. Univariate and multivariate analyses were performed to identify prognostic factors. RESULTS: Univariate analysis revealed three factors that correlated with poor prognosis: T stage (P = 0.024), adenocarcinoma (P = 0.033) and degree of differentiation (P = 0.001). Multivariate analysis revealed that all three were significant independent adverse prognostic indicators. CONCLUSION: Surgical resection of node-negative oesophageal cancer is associated with diverse long-term outcomes. This diversity of outcome is not reflected in the tumour node metastasis (TNM)-based staging system. The utility of the TNM system in predicting prognosis after surgical resection is open to question.

Prognostic significance of circumferential resection margin involvement following oesophagectomy for cancer.

The factors affecting long-term survival following oesophagectomy for oesophageal cancer are poorly understood. We examined the significance of microscopic tumour involvement at the circumferential resection margin (CRM) on postoperative survival following oesophagectomy. The case notes of 329 patients who underwent a potentially curative oesophagectomy for squamous or adenocarcinoma were reviewed retrospectively. As part of the procedure, all patients underwent an en-bloc resection of their periesophageal tissue. The presence of tumour either at, or within, 1 mm of the CRM was recorded and correlated with their TNM and survival data. A total of 67 patients (20%) were noted to have a positive CRM, of which 40 cases (12%) had tumour at the resection margin and the remainder had tumour within 1 mm of the margin. Univariate analysis showed no statistically significant association between survival and either category of CRM involvement. Multivariate analysis showed that only T-stage, nodal status and tumour grade were prognostic markers. In conclusion, the presence of microscopic tumour at the CRM following an en-bloc oesophagectomy is not a significant prognostic marker.

Surgical treatment of para-oesophageal hiatal hernia.

The development of laparoscopic antireflux surgery has stimulated interest in laparoscopic para-oesophageal hiatal hernia repair. This review of our practice over 10 years using a standard transthoracic technique was undertaken to establish the safety and effectiveness of the open technique to allow comparison. Sixty patients with para-oesophageal hiatal hernia were operated on between 1989 and 1999. There were 38 women and 22 men with a median age of 69.5 years. There were 47 elective and 13 emergency presentations. Operation consisted of a left thoracotomy, hernia reduction and crural repair. An antireflux procedure was added in selected patients. There were no deaths among the elective cases and one among the emergency cases. Median follow-up time was 19 months. There was one recurrence (1.5%). Seven patients (12%) required a single oesophagoscopy and dilatation up to 2 years postoperatively but have been asymptomatic since. Two patients (3%) developed symptomatic reflux which has been well controlled on proton-pump inhibitors. Transthoracic para-oesophageal hernia repair can be safely performed with minimal recurrence.

Chylothorax following oesophagogastrectomy for malignant disease.

OBJECTIVE: To define the incidence, causes, management and impact of Chylothorax after oesophagogastrectomy for malignant disease in Nottingham Thoracic Surgery unit. PATIENTS AND METHODS: Retrospective analysis of 523 patients with cancer of the oesophagus or the gastro-oesophageal junction who underwent oesophageal resection between January 1987 and November 1997 in a single unit using similar techniques and uniform routine perioperative management. RESULTS: Chylothorax occurred in 21 patients (4.0%). There were 12 males and 9 females with a mean age of 64.7 years (SD 7.5). Age, sex, tumour site, length, histological type, depth of wall penetration, nodal status and type of operative approach were not significant predisposing factors on univariate and multivariate analysis. Seventeen patients were treated conservatively (four deaths, 23.5%) and four surgically (one death, 25.0%), effective control of the chylous leak being achieved in all four cases. Eleven patients with a chylous drainage of up to 2.2 l/day, diminishing within 1 week of conservative treatment had an uneventful recovery. However, a chylous drainage of more than 2.5 l/day in the remaining ten patients was associated with increased morbidity, hospital stay, operative mortality and the need for surgical intervention. In comparison with the remaining patients (n = 502), those who developed chylothorax (n = 21) had more respiratory complications (42.8%, P = 0.008), longer mean hospital stay (23.8 days, P = 0.004), higher operative mortality (23.1%, P = 0.004) and, unexpectedly, reduced 5 year survival rate (P < 0.0001). CONCLUSIONS: There appeared to be no clear predisposing factor in the development of a chylous leak other than the routine extensive dissection. Although definitive conclusions can not be drawn, where there is early reduction of the initial amount (in this series up to 2.2 l/day) of drainage, there may be a place for successful non-surgical management; in cases of high output chylothorax, persisting after a few days of conservative treatment, however, early re-operation and ligation of the thoracic duct, seems to be advisable.

Primary angiosarcomas of the chest wall and pleura.

Primary angiosarcomas of the chest wall and pleura are extremely rare and carry a dismal prognosis. Two cases are reported. One patient (case 1), presented with massive recurrent haemothorax, was found to have multifocal angiosarcoma of the pleura, treated with surgical de-bulking, chemical pleurodesis and chemotherapy, achieving control of the bleeding. She died 10 months later from complications related to chemotherapy. A full post-mortem examination confirmed this was a primary pleural angiosarcoma with no evidence of disease elsewhere. Another patient (case 2) with a large solitary angiosarcoma of the chest wall, discovered incidentally on a routine physical examination, was successfully treated with surgical excision and subsequent radical radiotherapy, remaining well 15 years post-operatively.

Surgery for esophageal cancer in elderly patients: the view from Nottingham.

OBJECTIVE: Our aim was to compare the outcome of esophageal resection for carcinoma in elderly patients (aged over 70 and over 80 years) with that of younger patients managed within a single specialist thoracic surgery unit. PATIENTS AND METHODS: Between January 1987 and November 1997, 523 patients underwent esophagectomy for carcinoma in the Nottingham City Hospital Thoracic Surgery Unit. The patients were divided into 3 groups by age: group I, under 70 years (n = 337); group II, 70 to 79 years (n = 150), and group III, 80 to 86 years (n = 36). These groups were compared with regard to preoperative medical status, operability and resectability, complications, operative mortality, and longterm survival. RESULTS: Patients in groups II (6.0%) and III (2.8%) had fewer preexisting respiratory problems than patients in group I (12.5%), and the patients in group III had fewer preexisting cardiovascular problems (16.7%) than patients in groups I (25.2%) and II (32.7 %). Although patients in group III were generally less likely to have operable lesions (64.3%), no significant differences in resectability rate were detected among the 3 groups (80.8%, 77.7%, and 80%). Elderly patients (groups II and III) had a higher incidence of overall (34% and 36.1%), respiratory (24.7% and 19.4%), and cardiovascular (7.3% and 11.1%) complications than those aged under 70 years (24.6%, 16.3%, and 2.1%, respectively). However, operative mortality (4.7%, 6.7%, and 5.6%) and 5-year survivals inclusive of operative mortality (25.1%, 21.2%, and 19.8%) were similar among the 3 groups. CONCLUSIONS: Accumulated experience in all aspects of perioperative management may account for a low hospital mortality in elderly patients despite a greater operative risk. The survival benefit is similar to that in the younger age groups, enforcing the view that esophagectomy within specialist thoracic units can be safely offered (in appropriately selected patients) with acceptable long-term survival in all age groups.

Inflammatory pseudotumors of the lung.

Two unusual cases of inflammatory pseudotumors in young female patients are described. One presented with massive hemoptysis and a solitary circumscribed mass treated with urgent lobectomy. The second presented initially with cough and a small right lower lobe mass. She presented again, 8 years later, with a lung mass so expanded as to necessitate a pneumonectomy with partial resection of surrounding structures. Both cases indicate the need for early and complete removal of the inflammatory pseudotumors.

Goitre: a cause of obstructive sleep apnoea in euthyroid patients.

While hypothyroidism is considered to predispose to obstructive sleep apnoea (OSA), the presence of a goitre itself is not a recognized cause of OSA. We present the cases of two euthyroid patients with large goitres and clinical evidence of OSA, whose OSA symptoms significantly improved following partial thyroidectomy. This finding suggests that the goitre contributed to their symptoms.

Congenital heterotopic gastrointestinal cyst of the oral cavity in a neonate: case report and review of literature.

Heterotopic gastrointestinal cysts of the oral cavity are rare benign lesions which may mimic both benign and malignant neoplasms. These cysts are usually discovered during infancy, but may not appear until well into adulthood. This lesion involves the tongue and floor of the mouth in 97% of cases and has a male predilection. The cyst may range in size from less than 1 cm to 9 cm, with most lesions being 1-3 cm in size. About 30% of affected individuals have symptoms related to difficulties with feeding, swallowing and respiration. The epithelial lining is quite variable, but all cysts have an enteric lining. The histogenesis is related to entrapment of undifferentiated, noncommitted endoderm within the oral cavity during the 3rd-4th week of fetal life. The purpose of this paper is to report a congenital heterotopic gastrointestinal cyst of the oral cavity presenting in a neonate. The clinical and histopathologic features of this cyst are reviewed, as well as the histogenesis of this lesion.

Surgical management of macroglossia in children.

Congenital macroglossia is associated with a variety of syndromes, most commonly Down syndrome and Beckwith-Widemann syndrome. Clinically, macroglossia may result in respiratory compromise, dysphagia, and poor cosmesis. A variety of treatments have been proposed, with surgical resection being the most common. We review management and describe a new surgical technique, consisting of a keyhole resection to decrease the width and length of the tongue. Between 1990 and 1992, five keyhole resections for congenital macroglossia were performed on four consecutive children at Texas Children's Hospital, Baylor College of Medicine, Houston. Patients had improved cosmesis and improved function of the oropharyngeal airway, with no change in speech and feeding. Keyhole resection is an effective treatment for macroglossia.

The surgery of lung cancer.

Surgery remains the best chance of cure in lung cancer, and should be offered to between 10% and 20% of patients. The success of surgery depends on accurate assessment of patient fitness and tumour stage. Surgery has an established role in stages I and II and some subtypes of stage III non-small cell carcinoma of the lung. The combination of surgery with radiotherapy and/or chemotherapy may have survival benefit. A multidisciplinary approach is essential for optimum patient care and the promotion of further research into this terrible disease.

Histopathology of temporal bone fractures: implications for cochlear implantation.

Temporal bone fractures often cause loss of audiovestibular function. Those patients with bilateral profound sensorineural hearing losses secondary to temporal bone fractures become candidates for cochlear implantation. The authors present the histopathology of five temporal bone fractures in three patients, evaluating specifically the traumatic effects on the neural elements of the inner ear. Transverse fractures of the temporal bone result in severe loss of hair cells, ganglion cells, and other supporting cells in the inner ear. Occasionally labyrinthitis ossificans may occur as a consequence of trauma or infection. While longitudinal fractures do not violate the otic capsule, these same neural elements may be damaged by concussion.

High and prolonged pulmonary tissue concentrations of azithromycin following a single oral dose.

Antibiotic concentrations in pulmonary tissue samples and plasma were studied in this open investigation. Twenty-nine patients scheduled for elective pulmonary surgery received a single oral dose of 500 mg azithromycin 24, 72, 96 or 120 h prior to the operation; two patients received 250 mg b.i.d. Blood samples were taken before and at the time of resection, and tissue was obtained during surgery. Plasma and tissue concentrations of azithromycin were measured by high performance liquid chromatography (HPLC) and a microbiological bioassay. Only one patient had a detectable plasma concentration of azithromycin (0.13 micrograms/ml), measured 24 h post-dose by HPLC. However, high and sustained levels were found in lung tissue: mean concentrations measured by HPLC were 3.10 micrograms/g (SD +/- 2.17), 2.55 micrograms/g (SD +/- 1.36), 3.94 micrograms/g (SD +/- 2.40) and 3.13 micrograms/g (SD +/- 0.50) at 24, 72, 96 and 120 h, respectively. Bioassay results were similar to those for the HPLC assay. In summary, azithromycin levels in pulmonary tissue remained close to 3 micrograms/g for up to 5 days after a single oral 500 mg dose, in contrast to plasma levels which were much lower. The lung concentrations found are inhibitory for many sensitive respiratory pathogens and short-course azithromycin therapy is therefore a possibility.