Parathyroid carcinoma: a case series.

INTRODUCTION: We present 3 patients with parathyroid carcinoma and describe their presentations, clinical profiles, and management. MATERIALS AND METHODS: A case series review of medical records. RESULTS: Two women and 1 man (age range, 32 to 57 years) had parathyroid cancer and primary hyperparathyroidism (PHPT). One patient presented with osteitis fibrosa, 1 with renal stone and a neck mass, and 1 with recurrence of PHPT after excision of supposedly benign parathyroid adenoma 4 years ago. All had severe hypercalcaemia and elevated parathyroid hormone levels that ranged from 4 to 43 times above the normal range. Exploration of the neck clearly identified 1 parathyroid tumour with local invasion; 2 other specimens showed capsular and vascular invasion on frozen section and final histology. All 3 patients underwent parathyroidectomy and ipsilateral hemithyroidectomy. Parathyroid size ranged from 1.3 to 4 cm and no lymph node metastasis was identified. No patient had tumour recurrence after a follow-up period of 1 year. CONCLUSION: Parathyroid carcinoma is a rare endocrine malignancy. Suspicious features include marked hypercalcaemia, neck mass, and local recurrence. Parathyroidectomy with ipsilateral hemithyroidectomy and nodal clearance gives the best chance of reducing local tumour recurrence.

Primary resection and anastomosis in obstructed descending colon due to cancer.

Intraoperative colonic irrigation followed by one-stage resection is gaining popularity as the optimal surgical treatment for left-sided colonic obstruction. However, its efficacy and potential hazards have not been adequately tested in obstruction due to colonic cancer. We analyzed the early results of 23 consecutive patients with obstructive left-sided colonic carcinoma treated by primary resection and anastomosis following intraoperative antegrade colonic lavage. Two patients (8.6%) died, one from complication of anastomotic leakage. The significant postoperative complications were chest infection in three (13%) and wound infection in seven (30.4%). The average hospital stay was 16.5 days. The results of this study suggest that intraoperative bowel irrigation permits one-stage resection and anastomosis to be conducted with reasonable safety provided care is taken in operative techniques.

Treatment of primary liver cancer in Singapore. A review of 3200 cases seen between January 1, 1977, and July 31, 1987.

Between January 1977 and July 1987, 3200 patients with hepatocellular carcinoma (HCC) were studied in Singapore. HCC formed 90% of primary liver cancers seen in Singapore and is the second most common fatal malignancy seen in men in the country. Extensive clinical and basic research has defined certain treatment strategies. Of importance is the prompt detection of early nodular tumours, which can be resected. Resection, 'targetting' with anticancer drugs and, in selected cases, synchronised direct hepatic irradiation with adriamycin, used as a radiosensitiser, have been promising treatment methods. Biological modifiers, such as interferons and interleukins, offer potential for the future. Preliminary pilot studies suggest that interferons may prevent the development of HCC, but more studies are required. Similarly, selective localisation of anticancer agents with radio-isotopical agents opens opportunities for treatment.

A study of 245 infected surgical wounds in Singapore.

The aims of the study were to correlate the laboratory detection rate of wound infections with the actual wound infection rate, and to analyse the bacteriology of these wounds to provide a rationale for antibiotic usage in prophylaxis and treatment of surgical wound infections. The wound infection rate in a general surgical unit was determined using the most comprehensive surveillance available to us and was correlated with the laboratory detection rate. A correlation coefficient of 0.8 was obtained, allowing a reasonable estimation of the actual wound infection rate from laboratory data. Review of the bacteriology of consecutive infected surgical wounds over a 4 year period in a university hospital, revealed that the commonest organisms cultured were Staphylococcus aureus, Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, enterococci and beta-haemolytic streptococci. Methicillin-resistant S. aureus (MRSA) caused 50% of all staphylococcal wound infections. All MRSA isolates were sensitive to fusidic acid and vancomycin. All the non-MRSA isolates of S. aureus were sensitive to cephalexin. Some 89% of E. coli were sensitive to gentamicin, with 93% and 100% sensitive to cefuroxime and ceftriaxone respectively. Klebsiella isolates have shown an increased resistance to aminoglycosides, with a new strain from one patient, isolated in 1990, resistant to penicillins, aminoglycosides and third generation cephalosporins. Pseudomonas spp., enterococci and beta-haemolytic streptococci did not show a change in resistance patterns over the same time period.

Perforation of the large bowel during colonoscopy in Singapore.

The management of seven patients with colonoscopy-related perforations is described. This study demonstrates the need for an early laparotomy. A high index of suspicion is required to reach an early diagnosis. Patients with no preexisting medical problems who underwent early surgery recovered with little morbidity. In elderly patients (greater than 75 years), colonoscopic perforation can be fatal. Endoscopy should be performed with special care in such patients.

Adenomyoepithelioma of the breast. Report of a case with fine needle aspiration cytology and histologic, immunohistochemical and ultrastructural correlation.

A case of adenomyoepithelioma of the breast was studied by cytology, histology, immunohistochemistry and electron microscopy. Aspiration cytology of the tumor showed sheets and tubular-type clusters of cohesive, regular polygonal cells with abundant, fairly well preserved, pale, granular to finely vacuolated, clear cytoplasma and a low nuclear/cytoplasmic ratio. The nuclei were small, round and monotonous, with dispersed chromatin and small or inconspicuous nucleoli. Acinus formation was striking: an occasional gland showed a suggestion of an inner layer of cells with denser cytoplasm surrounded by an outer mantle of paler cells. The histologic, immunohistochemical and ultrastructural findings confirmed the two cell populations, constituting an inner epithelial and outer myoepithelial component, both participating in the neoplastic process. The differential diagnoses of various breast lesions with somewhat similar cytologic features are discussed.

Biliary cystadenocarcinoma arising in a cystadenoma. Report of a case diagnosed by fine needle aspiration cytology.

Hepatic cyst fluid cytology tends to yield disappointing results. We report a case of a 56-year-old woman with a biliary cystadenocarcinoma diagnosed by fine needle aspiration cytology. Computed tomography scans had shown a solitary, unilocular hepatic cyst over a five-year period. There was a recent increase in the size and development of a mural echogenic focus. Cytologic examination revealed clusters of malignant glandular cells in a background of cellular debris and mucinophages. The resected specimen confirmed the presence of an adenocarcinoma arising from malignant transformation of a preexisting cystadenoma.

Informed patient consent--historical perspective and a clinician's view.

Informed patient consent, in this day and age, is usually taken for granted, poorly understood, and inadequately practised. Historically, informed patient consent is relatively new to medical practice, as there was no such consent during the times of the ancient Egyptians, the ancient Greeks or Romans. The culture of individual rights as part of a social trend and evolution of human civilisation with landmarks such as the American Revolution two centuries ago also brought along greater patient awareness of their health and persons as well as their rights in the investigations, treatment and research of their illnesses. The rationale and elements in the practice of informed patient consent is part of this trend. However, there are moral and legal dilemmas involved. Discussion is needed, and though the practice of such consent may sometimes be difficult, the spirit of its application should never be compromised.

Primary gastric lymphoma.

Primary gastric lymphoma is a rare gastrointestinal lymphoma. The treatment of this condition remains controversial, especially the extent of surgical resection. Ten cases were operated on over a five-year period at our institution and the outcome was reviewed. Early results suggest no difference in survival whether the margin of resection was clear or not so long as postoperative chemotherapy was given. The outcome appear to depend more on the extent of the disease at the time of surgery. Full thickness involvement of the stomach wall with lymph node involvement were bad prognostic indicators.

Renal transplantation in Singapore--a brief historical perspective.

Renal transplantation in Singapore has been practised for the last 20 years. It was prompted by the extreme shortage of haemodialysis facilities in 1970. Because of the scarcity of cadaver kidneys, a living related programme was commenced in 1976. Since then, both programmes have run parallel. The renal transplantation programme has been influenced by such factors as importation of cadaver kidneys from abroad and living non-related transplantation programme in neighbouring countries. The great beneficial effects of Cyclosporin A (CyA), was evident in the results from 1986 onwards. It has been necessary to modify and expand the legislative rules to encourage and broaden kidney transplantation in Singapore.

Totally implantable central venous access for cancer patients in Singapore.

Sustained venous access is assuming increasing importance in clinical medical practice for the infusion of antibiotics, cytotoxic drugs, blood products and parenteral nutrition. The limitation of peripheral venous access in patients receiving cancer chemotherapy can be a major problem. Many antineoplastic drugs are vesicant and may cause chemical ulcers when infiltrated or phlebitis and thrombosis. Recent technological advances in development of non-thrombogenic silastic catheters have facilitated in-dwelling catheters to be implanted for long periods. Port-A-Cath is a totally implantable vascular access system which allows for blood to be sampled and also infusion of drugs and blood products. Between March 1985 to October 1987, 20 devices were implanted on 19 patients (14 males and 5 females). Criteria were drawn up to select these patients. The quality of life was significantly improved for these patients who receive long term chemotherapy or blood products through this device. There were 6 episodes of transitory occlusion of catheter and 1 episode of infection. Continuous infusion of drugs given through this device does not produce chemical phlebitis. It has also facilitated new methods of delivering cytotoxic drugs and analgesia.

The solitary thyroid nodule.

213 clinically solitary nodules were analysed. Their clinical pattern, diagnostic problems, pathological varieties and surgical management have been assessed. 9.9% of the nodules were malignant in this series.

Traumatic duodenal injuries.

Eleven cases of duodenal injury are reviewed. A correct preoperative diagnosis was made in only one patient. In 10 patients, the duodenum was disrupted in the second part. When duodenal injury was associated with devitalisation of tissue or there was delay in operative intervention, repair was aided by a serosal patch graft. In these high risk cases, an attempt to defunction the injured area was done by suction gastrostomy or gastrojejunostomy with vagotomy, Three patients died and in two of these, there was delay in surgical intervention.

Persistent hypomagnesaemia following parathyroid surgery, hypermagnesuria as a possible cause.

A patient who had prolonged hyperparathyroidism with extensive bone involvement developed delayed post-surgical complications of pseudogout and the hungry bone syndrome with persistent hypocalcaemia and hypomagnesaemia. Although urinary calcium excretion was appropriate for the hypocalcaemia, there was severe excessive renal loss of magnesium despite the hypomagnesaemia. Renal magnesium excretion returned to normal only after correction of the hypocalcaemia. Hypermagnesuria may be an important cause of resistant hypomagnesaemia after parathyroid surgery.

Major salivary gland tumours.

Forty-one major salivary gland tumours and tumour-like glandular enlargements are reviewed. In nine patients the swellings could not be differentiated from a true neoplasm. The diagnostic and therapeutic approaches to these patients are discussed. The clinical features, diagnostic and surgical management of 31 salivary neoplasms involving the parotid and submandibular glands are correlated with their histological features.

Neurilemmoma of the vagus nerve.

A case of neurilemmoma of the cervical portion of the vagus nerve is reported to illustrate its common presentation as a lateral neck swelling often mistaken for more common neck lesions. Recognition of its vagal origin, followed by careful meticulous surgery is imperative for preservation of ipsilateral vocal cord mobility.

Techniques of ureteric reimplantation in kidney transplantation and its related urological complications.

Two common techniques of ureteric reimplantation for kidney transplantation, the Politano-Leadbetter and the extravesical ureteroneocystostomy are described in detail. Correct techniques of donor ureter harvesting, appropriate method of reimplantation and judicious use of double J stent are also emphasised so as to reduce the urological complications which occurred in about 7% to 15% in most series. More than 90% of urological complications are due to urinary fistulae and ureteric obstruction which carry a significant morbidity and mortality. The causation, diagnosis and management of these complications are reviewed. Early diagnosis and early aggressive surgical treatment is the key to a successful outcome.

A descriptive study of emergencies admitted to a surgical department.

A study was undertaken to evaluate the pattern of emergency admissions and their management by the surgical firm in a medium size (700 beds) general hospital. Over a three month period, 258 patients were admitted to one surgical team that was on take every third day. All patients were entered into a protocol that was updated daily by a registrar. In four (13.3%) of the 30 days on take, patients had to be referred to a nearby hospital due to shortage of emergency beds. The accuracy of diagnosis by the Accident and Emergency (A&E) resident, surgical resident and surgical team were 75.7, 77.2 and 88.4% respectively. The mean delay before attendance by an intern after admission was 47 (SD +/- 29) mins. Forty-four (17%) of these admissions were probably unnecessary. A further 22 (8.5%) patients had to be referred to other disciplines, indicating an initial wrong diagnosis. A substantial number of investigations were unnecessarily done on an emergency basis. Ninety-three (36.0%) patients required surgery. The median duration of hospital stay was three days. The overall morbidity was 4.2% and mortality 1.2%. The study was valuable in revealing the deficiencies in the existing emergency service; leading to new proposals to achieve our ultimate aim of providing high quality patient care.

Surgical treatment of primary tumours of the innominate bone.

9 cases of primary malignant tumours of the pelvis were treated in our department from 1981 to 1987. There was three chondro-sarcomas, one giant cell tumour and five had soft tissue tumours. One has a classical hemipelvectomy while eight had limb preservation surgery performed. In this later group., three had type I (Enneking) resection, three combined type II/III and one a type III resection. Four patients have died since and three deaths were related to surgery and its complications. As to date, no local recurrences has occurred in those living (up to 7 years' follow up). We feel that local resection with limb preservation provides adequate local control of tumour. Various reconstructive procedures to cover skin defects, and reconstruct stability of the pelvis or create hip stability were also performed. Patients with no previous irradiation has less mobidity and tend to do well.

Clinico-pathological prognostic factors of large bowel cancer in Singapore: a multivariate analysis.

Clinical and pathological data from 219 cases of large bowel cancer were analysed using the Cox regression model to evaluate their effects on survival. Clinical variables such as sex, change in bowel habit, bleeding per rectum, tumour site, size and duration of symptoms had no significant influence on survival. Individually, age, abdominal distension, Dukes' stage and tumour grade had significant influence on survival. When considered together, Dukes' stage was the only variable selected. Therefore Dukes' stage is the most important prognostic factor in colorectal cancer. The distribution of patients was 25, 18, 26 and 31 percent for Dukes' A, B, C and D respectively. The probabilities of survival at five years were 71, 55, 36 and 16 percent for the respective Duke's stages. These data show that the clinical and pathological variables of patients with colorectal cancer in Singapore and the factors significantly associated with survival are similar to those in western countries.