Cancer-associated venous thrombosis in the surgical setting.

OBJECTIVE: Cancer patients are at a relatively high risk of venous thromboembolism (VTE), and this has implications for surgical outcome. DATA SOURCE: English literature search including the keywords cancer, surgery and VTE was undertaken to review the risk, etiology, prevention and treatment of VTE in surgical oncology patients. DATA SYNTHESIS: Malignant disease is highlighted as an important risk factor for VTE with an odds ratio of 6.5. The risk factors include higher age, previous VTE, advanced cancer, length of operation and immobility. CONCLUSIONS: Use of in-hospital thromboprophylaxis with low-molecular-weight heparin (LMWH) or low dose unfractionated heparin with graded stockings has been validated both in terms of safety and efficacy and should be considered for all patients. Subcutaneous LMWH has replaced unfractionated heparin for the initial treatment of VTE. The use of long-term LMWH instead of oral anticoagulants can substantially reduce the risk of recurrent VTE without increased bleeding. Recently, results of few trials have shown that LMWH may improve patient survival.

Laparoscopic resection of mucinous cystadenoma of appendix: a careful decision.

Appendiceal mucoceles are mainly due to cystadenoma or cystadenocarcinoma. Definite diagnosis is difficult preoperatively and is usually peroperatively. Surgical excision, either by laparoscopy or by laparotomy, is the mainstay of treatment. Rupture of the lesion causes pseudomyxoma peritonei. We present a case to highlight this point and especially deplore the use of laparoscopy if the tumor clearly extends beyond the appendix.

Breast carcinoma and malignant melanoma metastasis within a single axillary lymph node.

A 58 year old lady presented with a right breast cancer and a prior history of malignant melanoma excised from the right chest wall eight years previously. An abnormal axillary lymph node resected contained features of both metastatic breast carcinoma and malignant melanoma. Following oncologic breast cancer management, the patient is well with no evidence of recurrence at three years.

Inflammatory myofibroblastic tumour of the gallbladder.

BACKGROUND: Inflammatory myofibroblastic tumour (IMT) is a benign, nonmetastasizing proliferation of myofibroblasts with a potential for local infiltration, recurrence and persistent local growth. CASE REPORT: We report a case of a 51 year-old female, who had excision of a gallbladder tumour. Histopathology showed it to be IMT of the gallbladder. CONCLUSION: The approach to these tumours should be primarily surgical resection to obtain a definitive diagnosis and relieve symptoms. IMT has a potential for local infiltration, recurrence and persistent local growth.

Retroperitoneal myolipoma.

BACKGROUND: Myolipoma is a benign tumour in which smooth muscle cells are mixed with adipocytes. CASE PRESENTATION: A 34-year old lady presented with a mass in the right iliac fossa detected on computerised tomographic (CT) scan. Wide excision of the retroperitoneal mass was done. Histopathology showed features of myolipoma. There was no recurrence or metastasis at three years. CONCLUSION: Myolipoma is a rare benign entity; hence a benign course and good prognosis are expected.

Small bowel gastrointestinal stromal tumours and ampullary cancer in Type 1 neurofibromatosis.

BACKGROUND: Type 1 neurofibromatosis (NF-1) is an autosomal dominant disorder with variable penetrance; approximately 50% of cases present as new mutations CASE REPORT: We report a case of a 56 year-old man with Von Recklinghausen's disease, carcinoma of the ampulla of Vater and incidental benign gastrointestinal stromal tumours of the jejunum. CONCLUSIONS: Coexistence between ampullary carcinoid, ectopic pancreatic tissue in the jejunum and neurofibroma of the jejunum in NF-1 has been previously described however; the association of synchronous carcinoma of the ampulla of Vater and gastrointestinal stromal tumour of the jejunum in NF-1 has not been previously reported.

Should Internal Mammary Lymph Node Biopsy be A Routine Step in Recurrent Breast Cancer? Report of Three Cases With Negative Axilla and Positive Internal Mammary Node.

Lymph node status is the most important clinicopathological prognostic factor for breast cancer patients and in most breast units it reflects only the axillary lymph nodes. A second often overlooked basin consists of the internal mammary lymph nodes (IMLNs) whose evaluation is not done as a routine step during the staging process. We highlight the need to consider incorporation of IMLNs into a patient's staging by presenting three cases of recurrent breast cancer with negative axilla and positive IMLN, a finding which altered their final management. We suggest that biopsy of IMLN should be a routine step in recurrent breast cancer when axillary lymphatics are disrupted by previous surgery although further research is required to define the optimal management of node positive cases.

Intestinal obstruction secondary to torsion of an appendix epiploica: a case report.

INTRODUCTION: Appendices epiploicae are affected by spontaneous torsion, calcification, primary or secondary inflammation, enlargement by lipomas or metastases and incarceration in hernias. CASE PRESENTATION: A 20-year-old Asian man was admitted with non-specific abdominal pain, which later evolved to intestinal obstruction. Operative findings showed the small bowel obstruction was due to an omental band adhered to a nodule. Histopathology of the nodule revealed an infarcted appendix epiploica. CONCLUSION: Heightened suspicion and increased awareness of this entity would have led to an earlier diagnosis. Acute torsion of an appendage usually manifests as localised abdominal pain in one of the lower quadrants. Untreated, peritonitis or intestinal obstruction may result. Use of diagnostic laparoscopy in non-resolving abdominal pain would help to resolve the issue at an earlier stage and prevent additional morbidity.

Ruptured hepatic artery aneurysm presenting as abdominal pain: a case report.

Aneurysms of the hepatic artery are rare. This patient presented to the emergency department with severe epigastric pain and subsequently became haemodynamically unstable. Plain abdominal radiograph showed a ring lesion in the right upper quadrant, ultrasound scan demonstrated a mass with arterial blood flow, and computed tomography revealed a left hepatic artery aneurysm. At surgery, the ruptured aneurysm was identified and the left hepatic artery was successfully ligated. Prompt diagnosis is of paramount importance and crucial information may be gleamed from investigations in the emergency department. If a ruptured aneurysm is diagnosed, we recommend prompt referral to a surgical team for definitive management.

Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery.

INTRODUCTION: Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals. PATIENTS AND METHODS: The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ). RESULTS: Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived. CONCLUSIONS: The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.

Primary malignant tumors of the iliopsoas compartment.

BACKGROUND AND OBJECTIVES: Primary malignant tumors of the iliopsoas compartment are rare entities that have been infrequently reported. We present our experience of iliopsoas malignancy to better characterize and define the natural history of this condition. METHODS: Primary iliopsoas tumors occurring from January 1990 were identified from the Royal Marsden Hospital's (RMH) Sarcoma Unit prospective database. RESULTS: Nineteen malignant tumors (11 limited to the psoas muscle only, 1 involving only the iliacus muscle and 7 involving both the iliacus and psoas) of the iliopsoas compartment were evaluated and treated at the RMH during this period. Leiomyosarcoma (n = 5) and liposarcoma (n = 3) were the most frequent histologic types. There were 3 G1, 5 G2, 10 G3 tumors and grade could not be assessed in 1 patient. There were 17 T2 tumors and size was not available in 2 patients. Surgery was done in 14 patients (negative microscopic margins-7, positive microscopic margins-3, and positive gross margins-3 and the margin of excision was not known in 1 patient). Five of 14 surgically treated patients had local recurrence and 6 of 19 patients developed metastases. Ten patients died of their disease at a median follow-up of 12 months. The estimated 2 and 5 year survival rates were 44 and 23%, respectively. CONCLUSIONS: Tumors in this location have a poor prognosis due to the lack of early diagnosis, large size at presentation, multiple attachments of the psoas muscle, and being relatively surgically inaccessible.

Prognosis of lymph node metastasis in soft tissue sarcoma.

BACKGROUND: We defined the tumor characteristics and prognosis of patients with regional lymph node metastasis (RLNM) from soft tissue sarcoma. METHODS: All patients with RLNM from soft tissue sarcoma were identified from the Royal Marsden Hospital Sarcoma Unit prospective database from January 1990. RESULTS: A total of 73 (3.4%) of 2127 patients had RLNM. Fifty-seven patients (78.1%) had RLNM as the first site of spread, and 16 patients (21.9%) presented with RLNM and distant metastasis synchronously. The most common histologies were rhabdomyosarcoma, epithelioid sarcoma, and angiosarcoma. There were 9 T1 and 36 T2 tumors, and tumor size was not available in 28 patients. There were 6 grade 1, 16 grade 2, and 51 grade 3 tumors. Forty-two patients presented with RLNM along with the primary tumor. Of the remaining patients, the median time to development of RLNM from diagnosis of the primary tumor was 13.5 months (95% confidence interval [CI], 1-100 months). The 1-year survival for patients with isolated RLNM was 77.49% (95% CI, 62.99%-86.88%), compared with 36.27% (95% CI, 13.32%-60.04%) for patients who presented with RLNM and distant metastasis (P =.005). The 1-year survival for metachronous and synchronous RLNM was 94.44% (95% CI, 66.64%-99.20%) and 67.54% (95% CI, 47.89%-81.12%), respectively (P =.05). CONCLUSIONS: Lymph node metastasis is rare. Patients who present with isolated RLNM have an improved survival compared with patients who present with regional and distant metastasis at diagnosis. Synchronous RLNM with the primary tumor have a poorer outcome than metachronous RLNM in the absence of distant metastasis.

Laser in treatment of laryngeal amyloidosis.

Amayloidosis is the extracellular deposition of the fibrinous protein amyloid in one or more body sites. Amyloidosis may broadly be classifed as either primary or secondary. Primary amyloidosis is idiopathic (56 %), whereas the secondary form is associated with a chronic inflammatory or infectious process (5%). Amyloidosis is also related to multiple myeloma (26%), senescence (5%) and where tumor like deposits occur in isolated organ without systemic involvement (8%). Laryngeal amyloidosis is a rare disease. Surgery has been the mainstay of treatment either endoscopicalfy or by an external neck approach. One case of laryngeal amyloidosis, treated with endolaryngeal microsurgery and carbon dioxide laser is presented with a follow up of 8 years.

Intra-abdominal metastases from soft tissue sarcoma.

OBJECTIVE: To define the clinical features and prognosis of patients with abdominal metastasis from primary soft tissue sarcoma (STS) at other sites. METHODS: All patients with abdominal metastasis from STS were identified from the Royal Marsden Hospital Sarcoma Unit prospective database from January 1990 to July 2001. RESULTS: Nineteen patients developed abdominal metastasis out of a cohort of 2127 patients (0.9%) evaluated during the study interval. The median age was 49 (19-71) years. The median time to abdominal metastasis from diagnosis of the primary was 27 (8-91) months. The presenting complaints were incomplete intestinal obstruction (n = 5), abdominal pain (n = 4), mass (n = 2), gastrointestinal bleed (n = 2), urinary obstruction (n = 2), anorexia (n = 1), and abdominal distension (n = 1). Emergency laparotomy was done for perforative peritonitis (n = 2), intussusception (n = 2), and bleed in spleen (n = 1). Two patients were asymptomatic. The common histologies were myxoid liposarcoma (n = 6) and leiomyosarcoma (n = 4). The median follow-up of survivors post metastasis was 12 months. Abdominal metastatectomy was performed in 16 patients, 3 of these patients had abdominal recurrences. The 1- and 2-year overall disease specific survival for the 19 patients was 66% (SE = 11%) and 43% (SE = 13%) with a median survival of 13 months (95% CI = 11.8-14.7). Metastasectomy was associated with slight improved median post-metastasis survival (33 months vs. 8 months for unresected patients). CONCLUSIONS: Although abdominal metastasis is rare, vigilance is warranted. Symptomatic patients should be examined and investigated thoroughly for metastases. Surgery is the treatment of choice for patients with an acute presentation; however, survival is dismal.