Giant mediastinal parathyroid cyst: an unusual cause of hypercalcemic crisis--case report and review of the literature.

BACKGROUND: Cysts of the parathyroid gland located in the mediastinum are rare but well-defined clinical and pathologic entities. Since the first case report in 1925 a total of 28 mediastinal parathyroid cysts have been reported. METHODS AND RESULTS: An 83-year-old woman with acute hypercalcemic crisis is reported. The patient had a giant mediastinal parathyroid cyst. Her symptoms resolved completely after the cystic tumor was resected. The case is discussed, and the world literature is reviewed. CONCLUSIONS: Hypercalcemic crisis is a rare but potentially fatal complication of hyperparathyroidism. Resection of the parathyroid tumor results in prompt recovery. A thorough bilateral neck exploration should be performed after the patient's condition is stabilized. Mediastinal exploration is indicated at the initial operation, if a parathyroid tumor is not present in the neck or is not accessible through a cervical incision. Localization studies can be done before the operation in patients with hyperparathyroid crisis, but the results of localization studies should not preclude a thorough surgical exploration.

Endocrine ablation for metastatic breast cancer: a reappraisal of hormone receptors.

PIP: Other indicators of hormone sensitivity, besides estrogen receptor (ER) content, such as response to oophorectomy, antiestrogens, prolactin suppression, and correlation with progesterone receptors (PR), were evaluated in the hope of further improving selectivity and response of patients undergoing endocrine ablation for metastatic breast cancers. 225 patients have undergone full endocrine ablation in the last 30 years at this hospital, 208 by adrenalectomy and 17 by hypophysectomy. 206 of these patients could be retrospectively reviewed, and of these there were objective responses to therapy in 50% of patients. ER analyses were performed in 1 or more breast cancer specimens in 113 of these patients. ER study showed that a patient who was ER+ and responded to a functional test of endocrine sensitivity had a 70-80% chance of also benefiting from adrenalectomy or hypophysectomy. Conversely, patients with absent or unknown hormone receptors who failed therapeutic trials of endocrine sensitivity had little or no chance of responding to major ablation; these cases are best treated with multiagent chemotherapy. The value of sequentially treating selected patients with endocrine manipulation in addition to chemotherapy was also studied. Patients who failed to respond to endocrine manupulation survived slightly over 2 years on chemotherapy, whereas patients who responded to major ablation lived with metastases an average of 4 years, whereas complete responders lived with metastatic disease an average of 6 years. By life table analysis, total survival of ER+ vs. ER- patients as well as responders vs. nonresponders was highly significant^ieng

Liposarcoma of the leg.

Forty-eight patients with liposarcomas of the leg were reviewed. Patients were treated by three approaches: wide local excision, amputation, and regional hyperthermic perfusion. Deaths from distant metastases occurred at a similar rate in all groups. The local recurrence rate was 43 percent in the wide excision group and 29 percent in the amputation group. No perfused patient had a local recurrence. This study demonstrates that hyperthermic regional perfusion and excision are superior to wide excision or amputation in preventing local recurrence for a liposarcoma of the leg and allow salvage of a functional limb.

Results of oophorectomy by menstrual and estrogen receptor states in patients with metastatic breast cancer.

The records of 204 women with metastatic breast carcinoma treated by oophorectomy were analyzed. Premenopausal women had a response rate of 50 percent. Forty-one percent of postmenopausal women responded. Those who responded had an average duration of response of 22 months and a length of survival twice that of the nonresponders. There was a better than 60 percent correlation between response to oophorectomy and response to further endocrine ablation. Response to endocrine manipulation is more a function of the hormonal sensitivity of the carcinoma than of menopausal status.

Multiple simultaneous and sequential estrogen receptor values in patients with breast cancer.

Fifty-nine women had multiple estrogen receptor assays done, either simultaneously or sequentially. Eighty-six percent of the patients who had multiple synchronous estrogen receptor assays from various metastatic sites showed no significant discrepancy in estrogen receptor values. When estrogen receptor assays were done sequentially without intervening therapy, 83.5 percent of the patients maintained their initial positivity or negativity. However, when the second estrogen receptor determination was preceded by either chemotherapy or hormonal therapy, 33 percent of the patients had a significant discrepancy in estrogen receptor values. The most common discrepancy was estrogen receptor-positive tumors becoming estrogen receptor-negative, although a small number of patients were found whose receptor values became more positive after hormonal ablation.

Brunner's gland hyperplasia.

Brunner's gland adenomas are uncommon benign duodenal tumors. They are an infrequent cause of upper gastrointestinal hemorrhage and duodenal obstruction but can occasionally mimic duodenal malignancy in their presentation. Conservative endoscopic or surgical resection followed by a regimen of antacids and H2 antagonists is the treatment of choice.

The acute abdomen in the pregnant patient. Is there a role for laparoscopy?

BACKGROUND: The acute abdomen in the pregnant patient poses a difficult diagnostic and therapeutic challenge to the surgeon. Appendicitis, cholecystitis, and bowel obstruction account for the majority of the abdominal pain syndromes which require surgical intervention. Laparoscopy is being used increasingly in the diagnosis and operative management of these disorders. METHODS: We examine our experience over the last 3 years with 47 women who developed significant abdominal pain during pregnancy. Thirty-four patients had symptomatic gallstone disease, nine had appendicitis, two had incarcerated inguinal hernias, and two had pelvic masses. Twenty-two patients with biliary colic and two patients with acute cholecystitis were managed conservatively during pregnancy. Twenty-three of these underwent laparoscopic cholecystectomy in the postpartum period. A total of 23 women required surgical intervention during pregnancy and 15 underwent a variety of laparoscopic procedures. Ten patients underwent laparoscopic cholecystectomy, and five had laparoscopic appendectomy. The remaining five patients had open appendectomy. Among the 15 laparoscopic procedures, four were performed in the first trimester, seven were performed in the second trimester, and four were performed in the third trimester. RESULTS: Laparoscopy didn't result in increased maternal morbidity. There were no congenital malformations, fetal losses, or premature deliveries in the pregnant patients who underwent laparoscopy. CONCLUSIONS: Laparoscopy can be a useful means of diagnosis and in addition a therapeutic tool in selected pregnant patients with abdominal pain. Close maternal and fetal monitoring is essential during and after the procedure. Laparoscopic cholecystectomy is safe and can be performed without additional risk to the fetus for those who require surgical intervention during pregnancy.

Resection of a gastric leiomyoma using combined laparoscopic and gastroscopic approach.

Laparoscopy has added a new perspective to the diagnosis and treatment of abdominopelvic disease. A wide variety of gastric procedures have been completed with laparoscopy in the past several years. The authors here present successful resection of a submucosal gastric leiomyoma laparoscopically with the combined use of intraoperative gastroscopy for localization. A 2.5 x 2.0 cm submucosal gastric nodule is resected with ample margins laparoscopically. Intraoperative endoscopy is used for accurate localization because the lesion was not visible to the laparoscope on the serosal surface of the organ. Laparoscopic surgery can be applied to the traditional surgical principles with equal efficacy in selected patients.

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis.

BACKGROUND: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially in cases where surgeons are not limited by technical constraints. METHODS: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July 1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy was performed using a three-trocar technique and the endoscopic stapler. RESULTS: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669; p = ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom had perforated appendicitis. CONCLUSIONS: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis.

The importance of treatment sequence in advanced and metastatic carcinoma of the breast.

From 1965 to the present, 287 patients with advanced and metastatic carcinoma of the breast have been treated according to a uniform philosophy of sequential therapy. Surgical castration was the initial procedure for premenopausal women and for postmenopausal women with clinical or laboratory evidence of endocrine responsive tumors. Tumor progression following castration was treated with major endocrine ablation, either adrenalectomy or hypophysectomy. Patients who relapsed following major ablation were treated with antiestrogen therapy as it became available. Nonresponders to major ablation and patients relapsing after antiestrogen therapy were treated with combination chemotherapy including cytoxan, methotrexate, 5-fluorouracil, and vincristine followed by adriamycin alone or in combination. Progression following chemotherapy was treated with additive hormonal therapy. Radiation therapy was used throughout for the control of localized disease, usually following complete hormonal ablation, except in cases of brain and spinal metastatic disease. The median survival for the entire group was 40.5 months from the onset of metastatic disease. Patients who responded to both oophorectomy and major ablation had a median survival of 61 months, which compares favorably to survival of 14 to 22 months reported in major combination chemotherapy trials. Survival following this method of sequential therapy is superior to other plans of management.