What to expect from immediate salvage hysterectomy following concomitant chemoradiation and image-guided adaptive brachytherapy in locally advanced cervical cancer.

PURPOSE: Concomitant chemoradiation followed by brachytherapy is the standard treatment for locally advanced cervical cancers. The place of adjuvant hysterectomy remains unclear but tends to be limited to incomplete responses to radiotherapy or local relapse. The aim was to analyse the benefit from immediate salvage surgery following radiation therapy in incomplete responders. METHODS: Among the patients with locally advanced cervical cancer treated with concomitant chemoradiation followed by 3D image-guided adaptive brachytherapy and hysterectomy, cases with genuine macroscopic remnant, defined as at least 1cm in width, were identified. Their clinical data and outcomes were retrospectively reviewed and compared to the patients treated with the same modalities. RESULTS: Fifty-eight patients were included, with a median follow-up of 4.2 years. After hysterectomy, 9 patients had macroscopic residual disease, 10 microscopic and the remaining 39 patients were considered in complete histological response. The 4-year overall survival and disease-free survival rates were significantly decreased in patients with macroscopic residual disease: 50 and 51% versus 92% and 93%, respectively. Intestinal grades 3-4 toxicities were reported in 10.4% and urinary grades 3-4 in 8.6% in the whole population without distinctive histological features. Planning aims were reached in only one patient with macroscopic residuum (11.1%). In univariate analysis, overall treatment time (>55 days) and histological subtype (adenocarcinomas or adenosquamous carcinomas) appeared to be significant predictive factors for macroscopic remnant after treatment completion (P=0.021 and P=0.017, respectively). In multivariate analysis, treatment time was the only independent factor (P=0.046, odds ratio=7.0). CONCLUSIONS: Although immediate salvage hysterectomy in incomplete responders provided a 4-year disease-free survival of 51%, its impact on late morbidity is significant. Efforts should focus on respect of treatment time and dose escalation. Adenocarcinoma might require higher high-risk clinical target volume planning aims.

Comparison between the ICRU rectal point and modern volumetric parameters in brachytherapy for locally advanced cervical cancer.

PURPOSE: The implementation of image-guided brachytherapy in cervical cancer raises the problem of adapting the experience acquired with 2D brachytherapy to this technique. The GEC-ESTRO (Groupe européen de curiethérapie - European Society for Radiotherapy and Oncology) has recommended reporting the dose delivered to the rectum in the maximally exposed 2 cm(3) volume, but so far, the recommended dose constraints still rely on 2D data. The aim of this study was to evaluate the relationship between the doses evaluated at the ICRU rectal point and modern dosimetric parameters. MATERIAL AND METHODS: For each patient, dosimetric parameters were generated prospectively at the time of dosimetry and were reported. For analysis, they were converted in 2 Gy equivalent doses using an α/ß ratio of 3 with a half-time of repair of 1.5 hours. RESULTS: The dosimetric data from 229 consecutive patients treated for locally advanced cervical cancer was analyzed. The mean dose calculated at ICRU point (DICRU) was 55.75 Gy ± 4.15, while it was 59.27 Gy ± 6.16 in the maximally exposed 2 cm(3) of the rectum (P=0.0003). The D2 cm(3) was higher than the DICRU in 78% of the cases. The mean difference between D2 cm(3) and DICRU was 3.53 Gy ± 4.91. This difference represented 5.41% ± 7.40 of the total dose delivered to the rectum (EBRT and BT), and 15.49% ± 24.30 of the dose delivered when considering brachytherapy alone. The two parameters were significantly correlated (P=0.000001), and related by the equation: D2 cm(3)=0.902 × DICRU + 0.984. The r(2) coefficient was 0.369. CONCLUSION: In this large cohort of patients, the DICRU significantly underestimates the D2 cm(3). This difference probably results from the optimization process itself, which consists in increasing dwell times above the ICRU point in the cervix. Considering these findings, caution must be taken while implementing image-guided brachytherapy and dose escalation.

Laparoscopic cholecystectomy in a freestanding outpatient surgery center.

Laparoscopic cholecystectomy in a freestanding outpatient surgery center was evaluated. Fifty-five patients undergoing laparoscopic cholecystectomy during a 10-month period from December 1992 to October 1993 were included in this study. There were 10 males and 45 females, with a mean age of 42 years. All patients had a history consistent with biliary colic. Forty-nine patients had documentation of cholelithiasis by ultrasonography, 3 had documentation of cholelithiasis by other diagnostic procedures, and 3 had a diagnosis of biliary dyskinesia. The mean surgery time was 75 min, with a range of 43-145 min. Fifty-four intraoperative cholangiography attempts were made, and 81% were successful. In 19%, intraoperative cholangiography was unsuccessful secondary to a small cystic duct. Fifty of the patients (90%) in this study were discharged from the surgery center without significant sequelae. Four patients were admitted to the hospital postoperatively, 1 for bradycardia, 1 for nausea, 1 for i.v. antibiotics secondary to purulent cholecystitis, and 1 for inability to maintain an adequate oxygen saturation. Another patient was admitted 1 week postoperatively for right upper quadrant pain. After a negative hepatobiliary scan, this patient was discharged without sequelae. The average facility charge of laparoscopic cholecystectomy in this series was $2300, compared with the average charge of $6500 in our community hospital. We conclude that laparoscopic cholecystectomy can be performed safely and cost effectively in a freestanding outpatient surgery center with proper patient selection.

Laparoscopic cholecystectomy in a private community setting.

In order to evaluate early results and safety of laparoscopic cholecystectomy in community hospitals, the charts of 380 consecutive patients, scheduled between February 8 and November 28, 1990, were reviewed. There were 294 women and 86 men, with a mean age of 48 years. Forty-one patients required conversion to open cholecystectomy, for reasons including adhesions in 18 patients, intraductal filling defects in 11, marked inflammation in 6, excessive bleeding in 3, poor visualization of the operative field in 2, and gangrenous gallbladder in 1. Hospital stay (excluding patients converted to laparotomy) ranged from 0.29-18 days, with a mean of 1.4 days. Operative time ranged from 29-280 min, with a mean of 114 min. Cystic duct operative cholangiography was performed in 71% of patients. In 29%, operative cholangiography was either not performed at all or was attempted and unsuccessful, due to inability to cannulate the cystic duct. Procedure-related morbidity was 2.6%, which includes three common bile duct injuries, three intraabdominal abscesses requiring drainage, and one pneumonia. There was one death resulting from respiratory failure. Our results compare favorably with those reported in the literature. We conclude that laparoscopic cholecystectomy in community hospitals is a safe procedure in properly selected patients.

Cystic duct remnant fistulization to the gastrointestinal tract.

Cystic duct remnant (CDR)-enteric fistulization is a rare entity, with only four recorded cases in the literature. CDRs can be found in at least 30% of patients after cholecystectomy and have been reported in as many as 83% of these patients. Calculous obstruction of the CDR or the common bile duct in a patient with a CDR must be present for fistulization to occur. Patients with a CDR-enteric fistula will have biliary tract symptoms after cholecystectomy and may have biliary sepsis. The septic episode or cholangitis may and can resolve when the CDR decompresses through the fistula. In a patient with persistent biliary tract symptoms, CDR should be considered as a possible cause, and common bile duct stones are often associated with CDRs. Signs of systemic infection in patients with biliary symptoms after cholecystectomy may indicate CDR fistulization. If a CDR is suspected, endoscopic retrograde cholangiopancreatography is the diagnostic and potentially therapeutic test of choice. If the patient cannot be successfully treated with endoscopic retrograde cholangiopancreatography or has recurrent symptoms, operative therapy is indicated, including division of the fistula, excision of the CDR, and common bile duct exploration. There may be an increase in the number of complications associated with CDRs, considering the increasing frequency of laparoscopic cholecystectomy resulting in more lengthy CDRs.

New options for treating gallstone disease.

Gallstone disease is a major health problem in the United States and in most Western countries. During the past century, cholecystectomy has been the treatment of choice. Recently, new modalities of treatment have been developed, including oral dissolution therapy, extracorporeal shock-wave lithotripsy, percutaneous transhepatic cholecystolitholysis using methyl tert-butyl ether, and laparoscopic cholecystectomy. In selected patients, these new options have been successful in the treatment of gallstones.

Role of needle localization of nonpalpable breast lesions.

This study of 89 women who underwent 100 consecutive needle localization procedures for nonpalpable breast lesions revealed a 19 percent malignancy rate. These lesions tended to be small and had a 6.2 percent incidence of nodal metastasis. Needle localization also identified 19 additional patients who were at increased risk for invasive breast cancer. The procedure was effective, well tolerated, carried a low morbidity, and resulted in the removal of a minimal amount of breast tissue. It must be emphasized that although mammography and needle localization are useful tools, they are only adjuncts to breast self-examination and clinical observation.

Is nasogastric intubation necessary in colon operations?

Fifty-six patients undergoing elective colonic resection were prospectively randomized into two groups either with or without postoperative nasogastric decompression. The results demonstrated only minimal differences between the two groups. Postoperative abdominal distention was more common in patients without nasogastric tubes, whereas pulmonary complications were more common in patients with nasogastric tubes. Other morbidity and mortality and hospital stay were the same in both groups. We conclude that in elective colon operations, the routine use of postoperative nasogastric decompression is unnecessary and can safely be omitted.

The use of interstitial radiation therapy in the treatment of persistent, localized, and unresectable cancer in children.

Two children with cancer that persisted after multiple exploratory laparotomies, external beam radiation therapy, and multidrug chemotherapy had gold 198 (198Au) seeds implanted into their localized but unresectable tumor. Both children are alive, are receiving no therapy, and are disease-free more than 2 years later. These two cases indicate the value of interstitial implant therapy in the treatment of some children with cancer.

Incidence and associated mortality of retained common bile duct stones.

A hundred consecutive patients who underwent cholecystectomy and exploration of the common bile duct were studied. The traditional indications for exploration resulted in a yield of 55 percent positive explorations. There were nine patients with retained stones, three of whom died. The high mortality rate of patients with retained stones stresses the importance of systematic and thorough exploration of the biliary tree during initial operation. Choledochoscopy, when combined with cholangiography, may decrease the incidence of retained stones.

Acute diverticulitis. Comparison of treatment in immunocompromised and nonimmunocompromised patients.

The clinical course and required treatment of diverticulitis were reviewed in 76 nonimmunocompromised patients and 10 immunocompromised patients. The immunocompromised patients presented with either minimal or no symptoms and findings. Therefore, to make the diagnosis of acute diverticulitis in this group, a high index of suspicion must be maintained. The required treatment varied considerably between the two groups. In 45 nonimmunocompromised patients (76 percent), medical therapy was successful. Medical treatment failed in the other 14 patients (24 percent). However, the compromised group had no patients in whom medical therapy was successful (100 percent failure rate). Thirty-one of the nonimmunocompromised patients (41 percent) required an operation, whereas 100 percent of the immunocompromised patients with acute diverticulitis required an operation. By relating postoperative complications, we were unable to determine the initial operative procedure of choice in the nonimmunocompromised group; however, in the immunocompromised group, colostomy and resection had fewer surgical complications than colostomy and drainage. The immunocompromised patient with acute diverticulitis requires operation. We believe the operation of choice is colostomy and resection of the involved segment.

Drainage in elective cholecystectomy.

This randomized, prospective study evaluates drainage of the subhepatic space in patients undergoing simple, uncomplicated cholecystectomy. One hundred twenty-two patients were divided into open (Penrose) drainage, closed sump drainage and no drainage groups. Open drainage resulted in increased morbidity and a longer postoperative hospital stay. The best results were in patients without drains. Subhepatic drainage is unnecessary in simple, uncomplicated cholecystectomy.

The incidence and significance of elevations of serum and urinary amylase levels following transcystic duct cholangiography.

Transcystic duct cholangiography does not increase the incidence of amylase elevations or clinical pancreatitis postoperatively. Significant rises in serum and two hour urinary amylase following routine cholecystectomy are quite common, regardless of whether or not transcystic duct cholangiography is performed. Many of these elevated amylase levels may arise from sources other than the pancreas.

Pseudolymphoma of the breast. I. In a study of 8,654 consecutive tylectomies and mastectomies.

Pseudolymphoma is a benign pathological process that morphologically resembles malignant lymphoma. Its occurrence in the mammary tissue has been described but has not been well investigated. We conducted a prospective and retrospective study of 8,654 consecutive mastectomies and tylectomies of the breast and found only 9 cases (0.1%) of primary lymphoreticular lesions. Of these 9, 5 were pseudolymphomas; 3, histiocytic lymphomas; and 1, Hodgkin's disease. Clinically, pseudolymphoma of the breast was described as an enlarging mass giving a dull, aching sensation. A history of physical trauma to the affected area could be traced in 3 patients with certainty. The mean patient age of the entire series was 36 years. Grossly, the tumor was a solid, firm nodule without any evidence of fibrocystic disease. Microscopically, it showed a lymphoid infiltrate with a nodular pattern. Three of the 5 cases revealed distinct germinal centers. Atypical lymphoid cells were not observed in any of these cases. After local excision, no patients had recurrence over a period of two to eight years. In view of a history of trauma, accompany fat necrosis in some cases, IgG gammopathy, it is postulated that pseudolymphoma of the breast, probably akin to pseudolymphoma of the lung, may represent an overwhelming local response to an injury. This lesion, reactive in nature, should be differentiated from a malignant lymphoma so that patients are not subjected to unnecessary mastectomy, radiation, or chemotherapy.

Abdominal aortic aneurysms. A comparative analysis of surgical treatment of symptomatic and asymptomatic patients.

This retrospective study of 120 patients identified three separate variables that influence operative mortality in patients with abdominal aortic aneurysms. These are age, presence or absence of symptoms, and presence of three preoperative risk factors or more. Based on this study and the fact that any aneurysm may rupture without warning, we conclude that observation of good risk asymptomatic patients until symptoms occur is unjustified. Asymptomatic patients less than seventy years old can undergo abdominal aortic aneurysmectomy with minimal mortality. Carefully selected asymptomatic patients more than seventy years old can also under surgical intervention with acceptable results.

Massive upper gastrointestinal hemorrhage in the elderly.

Sixty-six elderly patients with massive upper gastrointestinal bleeding were retrospectively analyzed. This study supports the concept of vigorous resuscitation, early diagnosis with fiberoptic endoscopy, and prompt surgical intervention in patients with continued bleeding. When this approach was utilized in a community hospital, operative mortality was reduced to 5 per cent.

Inguinal herniorrhaphy under local anesthesia. A prospective study of 100 consecutive patients with emphasis of perioperative morbidity and patient acceptance.

For various reasons, repair of inguinal hernias under local anesthesia is not well accepted. The purpose of this study is to evaluate the effectiveness of local anesthesia in inguinal hernia repairs. One hundred consecutive inguinal herniorrhaphies are reported. The selection of patients, surgical technique, and incidence of intraoperative and postoperative complications are reported. Patient acceptance and their immediate postoperative course are also described. The study demonstrates that inguinal hernias can be easily repaired under local anesthesia, complications are minimal, and patient acceptance, excellent. We strongly recommend thath this form of anesthesia be used in the "routine" repair of inguinal hernias in cooperative patients.