99Tc(m)-tetrofosmin scintimammography for detecting breast cancer: a comparative study with 99Tc(m)-MIBI.

Scintimammography using 99Tc(m)-MIBI (99Tc(m)-sestamibi) has demonstrated promising results in the detection of breast cancer. Recently scintimammography using 99Tc(m)-tetrofosmin has been suggested as a better diagnostic tool and a more convenient agent to use in this condition. In this study we compared both agents in 35 consecutive women with abnormal mammographic or physical findings. Thirty-four of them underwent MIBI scan, followed by tetrofosmin scan 2 days later (performed on all 35 women). Within 2 weeks, a pathological diagnosis was obtained either by needle or open biopsy. In both scans the uptake ratio between the lesion and the background uptake was calculated. Twenty patients who underwent tetrofosmin scan and 19 patients with MIBI scan had malignant breast tumours, while 15 women had benign lesions. The sensitivity, specificity, positive and negative predictive values and total accuracy of the MIBI scan were 89.4%, 80%, 85%, 85.7% and 85.3%, respectively; almost identical values were obtained with tetrofosmin (90%, 80%, 85.6%, 85.7% and 85.7%, respectively). The uptake ratios in the MIBI and tetrofosmin scans were 1.68 +/- 0.52 and 1.7 +/- 0.47, respectively. No differences were found between the two scintimammographies in all the parameters examined. In conclusion, MIBI and tetrofosmin breast scans are accurate and equally efficient for the detection of breast malignancies.

Bolus high dose interleukin-2 for the treatment of malignant melanoma.

BACKGROUND: High dose interleukin-2 therapy, administered in bolus, is considered to be a reasonable treatment option in a selected group of patients with metastatic malignant melanoma. OBJECTIVES: To present our experience using this mode of therapy in 21 patients with metastatic melanoma. MATERIALS AND METHODS: The 21 patients in our study group comprised 13 men and 8 women with a mean age of 46 years (range 29-63). Their metastatic disease was present in all extracranial sites, dermal and sub-dermal metastases being the most common (15 patients had at least one site, in addition to other locations of metastases). Patients with intracranial disease were excluded due to the poor effectivity of IL-2 at this site. Treatment comprised a course of 2 weeks of therapy with a 1 week rest interval between. Radiological and physical evaluation was performed 6-8 weeks after the first course. If a response was achieved a second course of therapy was given. Patients received up to 14 planned doses of IL-2 in each week, 720,000 IU/kg of IL-2 per dose i.v. in 15 minutes. All treatments were given in the surgical ward, and only one patient was hospitalized in the intensive care unit. RESULTS: Of the 21 patients, one had a complete response that has lasted for 17 months and 5 patients had a partial response (range 3 months to 3 years). One patient died during treatment, and one patient who refused further treatment because of no response died a few days after completion of treatment. Prior to therapy three of the responders had received autologous vaccines with good immunological response (P = 0.115). Toxic side effects were significant, but they were treated successfully with no residual damage. CONCLUSIONS: High dose IL-2 can be administered safely in a surgical department. The response rates achieved in this series justify the use of high dose IL-2 in a selected group of patients. To improve response rates, a combination of autologous vaccines prior to high dose IL-2 may be recommended.

Cecal diverticulitis: a diagnostic challenge.

BACKGROUND: Cecal diverticulitis is frequently indistinguishable from acute appendicitis preoperatively and is sometimes mistaken for carcinoma at laparotomy. The surgeon must be aware of the possibility of diverticulitis of the cecum in the operating room and choose the appropriate treatment. PURPOSE: Because there is no universal therapeutic approach to these patients, we decided to assess the presenting symptoms, clinical findings, preoperative diagnosis, operative findings determining the proper management of these patients. METHODS: A retrospective chart review of 13 patients with pathologically confirmed cecal diverticulitis, who underwent surgery in our department from 1984 to 1998, was undertaken. RESULTS: The mean age of patients was 43.5 years. Right lower quadrant pain and local tenderness were the only clinical findings in 92.3%, with preoperative diagnosis of acute appendicitis in 84.6% of patients. The operative finding in most cases was inflammatory mass of the cecum; in 6 cases it was indistinguishable from perforated cecal carcinoma. Six patients underwent right hemicolectomy, 5 had ileocecectomy, 1 patient was treated by tube cecostomy, and 1 had diverticulectomy. There were three minor postoperative complications: pneumonia, wound infection and lower limb superficial thrombophlebitis. CONCLUSIONS: Cecal diverticulitis needs a high index of suspicion for achieving a preoperative diagnosis. We suggest that the operative therapy should be ileocecectomy. The surgical specimen should be examined during surgery and only if carcinoma is found should the patient have a formal colectomy.

Surgical treatment of leiomyosarcoma of the distal duodenum.

Malignant tumors of the small intestine are rare. An uncommon finding of leiomyosarcoma located in the fourth part of the duodenum was diagnosed by gastrointestinal contrast studies, CT and angiography. Although malignant lesions of the small bowel are usually diagnosed late and thus are far advanced, curative resection was possible in our case. The location and histology of the tumor permitted a 'pancreas-preserving segmental duodenectomy'. The operative approach and exposure using the Cattell maneuver is described. It is emphasized that the more extensive pancreatoduodenectomy should be reserved for adenocarcinomas or lesions situated in the proximal part of the duodenum. Thirteen years following the operation, the patient is asymptomatic while CT and gastrointestinal contrast studies reveal no evidence of disease.

[Primary breast tumor and malignant phyllodes tumor of the breast-- two rare cases demonstrated by technetium 99m scintimammography].

Breast cancer can be detected by scintimammography using Tc-99m sestamibi (MIBI). The method is highly accurate, sensitive and specific. Histologically, most of the tumors have been adenocarcinomas. We present 2 women with rare breast tumors, primary squamous cell carcinoma and malignant phyllodes tumor. In both, mammography and cytological biopsy were not diagnostic, but MIBI scintimammography demonstrated focal uptake in the diseased breast.

Tumor immunity in perforin-deficient mice: a role for CD95 (Fas/APO-1).

CTL and NK cells use two distinct cytocidal pathways: 1) perforin and granzyme based and 2) CD95L/CD95 mediated. The former requires perforin expression by the effectors (CTL or NK), whereas the latter requires CD95 (Fas/APO-1) expression by the target. We have investigated how these two factors contribute to tumor immune surveillance by studying the immunity of perforin-deficient mice against the progressor C57BL/6 Lewis lung carcinoma 3LL, which expresses no CD95 when cultured in vitro. Unexpectedly, the results indicated that the perforin-independent CD95L/CD95 pathway of CTL/NK plays a role in acting against D122 and Kb39.5 (39.5) high and low metastatic sublines, respectively, derived from the 3LL tumor. Although no membrane-bound CD95 was detected on cultured D122 and 39. 5 cells, surface CD95 expression on both D122 and 39.5 was considerably up-regulated when the tumors were grown in vivo. A similarly enhanced expression of CD95 was observed with three additional tumors; LF-, BW, and P815, injected into syngeneic and allogeneic mice. The finding of up-regulated CD95 expression on tumor cells placed in vivo suggests that a CD95-based mechanism plays a role in tumor immunity at early stages of tumor growth. Consequently, the progressive down-regulation of CD95 expression during tumor progression may indeed be an escape mechanism as previously reported. Together, these results suggest a role for CD95-dependent, perforin-independent immunity against certain tumors.

Inflammatory fibroid polyp and Helicobacter pylori. Aetiology or coincidence?

OBJECTIVE: To evaluate our incidence of inflammatory fibroid polyps, compare our experience with that of others, and to analyze the possible pathophysiological and aetiological factors. DESIGN: Retrospective review. SETTING: Teaching hospital. MATERIAL: All histopathological slides of the gastrointestinal tract. MAIN OUTCOME MEASURES: Incidence and treatment in our Medical Center and elsewhere. RESULTS: We could find only one case of inflammatory fibroid polyp, an estimated incidence of 1/4000. Between 1987-1996 only 331 were reported elsewhere, most of which (293, 88.5%), were located in the stomach. CONCLUSION: Primary mucosal damage can expose the stroma to several irritants (chemical, mechanical and biological), that may subsequently cause inflammatory fibroid polyps in certain people.

99Tcm-MIBI scintimammography for the detection of breast malignancies: the contribution of the count ratio to specificity.

We evaluated the efficacy of 99Tcm-sestamibi (MIBI) scintimammography for the detection of breast cancer in 332 patients. Two hundred and seven scans were confirmed by histological or cytological results; the other patients were examined because they belonged to high-risk groups or had dense fibroglandular breasts. Of 207 patients with histological confirmation, 112 positive studies were obtained: 86 true-positive and 26 false-positive. Scintimammography was negative in 95 patients: 88 true-negative and seven false-negative. Six of seven false-negative results were obtained in patients with impalpable tumours. The sensitivity, specificity, positive and negative predictive values were 92.5%, 77.2%, 76.8% and 92.6% respectively. The overall accuracy was 84.1%. To identify false-positive results, the count ratio of the target lesion to the contralateral normal area on 38 true-positive scans and in 26 false-positive examinations was calculated from the region of interest drawn on the 99Tcm-MIBI scan (L/N ratio). A significantly higher ratio was found for the true-positive scans (1.583 +/- 0.501 vs 1.246 +/- 0.213; P = 0.0002). In conclusion, 99Tcm-MIBI scintimammography is a sensitive and accurate method for the detection of breast malignancies.

Effect of omental angiogenic lipid factor on revascularization of autotransplanted spleen in dogs.

Since the turn of the century, studies have been carried out showing that the omentum contains a factor which enhances revascularization of ischemic tissues. This study was conducted for a period of 3 months and was designed to evaluate the effect of an omental lipid fraction on neovascularization of autotransplanted spleen chips in dogs. Twelve dogs underwent splenectomy and autotransplantation of 5 splenic chips into an omental pouch. In 4 dogs, the splenic chips were immersed in omental angiogenic lipid factor (OAF), while on another 4 dogs, an intramuscular injection of 4 cm3 of OAF was given each day for 7 days postoperatively. A further 4 dogs were not given any of the above treatments (control group). Serial angiographies and histologic examinations demonstrated better neovascularization and regeneration of the transplanted spleen in the dogs from the immersion plus injection group. These data suggest that the omental lipid fraction contains a factor which induces a better regeneration of splenic transplants.

Surgery in Israel.

The evolution and development of surgery in Israel reflects the influence of its dramatic historical events. The immigration of surgeons, particularly since the fourth decade of the 20th century, highly contributed to the framework of modern surgery. Medical education occurs at 4 medical schools, in Jerusalem, Tel Aviv, Haifa, and Beer Sheva, and postgraduate surgical training takes place in all public hospitals, most of which are university hospitals or have university-affiliated departments, and is controlled by the Scientific Council of the Israel Medical Association (Tel Aviv). Health care is provided by 4 health insurance funds and has been recently influenced by the National Health Insurance Bill and the Bill of Patient's Rights. Surgical standards are high and similar to the very best of Western countries. The geographical location of Israel in the Middle East, surrounded by hostile Arab countries, has dramatically influenced the development of Israeli surgery. The practice of surgery ranges from full-time service in state and insurance-funded mostly academic hospitals, to private part-time clinics for wealthy and insured patients. Surgical training occurs only in departments accredited by the Scientific Council, which are mostly affiliated with the 4 medical schools. A surgical residency in Israel usually requires 6 years, and its guidelines and regulations are elaborated and recommended by the Israel Surgical Society and controlled by the Scientific Council. Most Israeli surgeons were trained in Israeli hospitals, but a substantial number of surgeons immigrated to the country, especially from eastern Europe.

Penetration of clindamycin and metronidazole into inflamed appendiceal tissue.

OBJECTIVE: To calculate the penetration of clindamycin and metronidazole into inflamed appendiceal tissue. DESIGN: Prospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 20 Consecutive men and women operated on for acute appendicitis. INTERVENTIONS: Appendicectomy. Each patient was given three intravenous injections of gentamicin 80 mg combined with either clindamycin 600 mg or metronidazole 500 mg immediately before operation over a period of 15 minutes. MAIN OUTCOME MEASURES: Serum and tissue concentrations of the antibiotics. RESULTS: There was no significant difference between the mean serum concentrations of the drugs (clindamycin 17.86 micrograms/ml and metronidazole 9.75 micrograms/ml) but the mean tissue concentrations of clindamycin (10.41 micrograms/g in the base and 9.86 micrograms/g in the tip of the appendix) were significantly higher than those of metronidazole (5.65 micrograms/g in the base and 5.89 micrograms/g in the tip; p = 0.02 and p = 0.05, respectively). Tissue concentrations of clindamycin and serum concentration of both drugs were more than twice their MIC90. The tissue concentrations of metronidazole were close to its MIC90. CONCLUSIONS: Clinical trials are necessary before any conclusion about therapeutic superiority of one or other agent can be drawn.

Richter's hernia--a surgical pitfall.

BACKGROUND: Although Richter's hernia was first described in 1598, little attention has been given to this topic in recent literature. The diagnosis of Richter's hernia is difficult because of the innocuous development of signs and symptoms and it is associated with a high mortality rate. Awareness of this relatively rare surgical entity is important. STUDY DESIGN: Of 350 patients with incarcerated hernias who underwent operation between 1977 and 1994 at the Department of Surgery "A," Assaf Harofeh Medical Center, 14 had strangulated Richter's hernia. A retrospective study was carried out in order to characterize the clinical manifestations of Richter's hernia and to assess preoperative delay, hospital stay, and complication and mortality rates. A comparison study was made with matched patients with strangulated hernias of non-Richter's type. Differences in morbidity and mortality rates, preoperative delay, and hospital stay of patients with Richter's hernias and the comparison group were evaluated. RESULTS: Of 14 patients with Richter's hernia, seven underwent intestinal resection. The hernia most commonly occurred at the femoral and inguinal sites. Compared with patients with other hernias, patients with Richter's hernias had greater preoperative delay, rate of bowel resection, length of hospital stay, and postoperative morbidity and mortality rates. CONCLUSIONS: Early operative intervention is the mainstay of successful management of Richter's hernia and awareness of this disease and its misleading clinical presentation is of utmost importance.

Routine laparoscopic ultrasonography in biliary surgery. A preliminary experience.

A new technique of intraoperative imaging of the biliary tract in laparoscopic cholecystectomy is described. A specifically designed laparoscopic ultrasonographic probe is used to obtain both transverse and longitudinal views of the entire extrahepatic biliary tract. This technique was successfully used in 28 patients. The ultrasonographic imaging quality achieved equals our experience with intraoperative ultrasonography in open biliary surgery. It may be assumed, therefore, that the advantages of ultrasonography over cholangiography as documented in conventional open surgery will also apply to laparoscopic operations.

Immunological profile changes following perioperative autologous vs. homologous blood transfusion in oncologic patients.

To determine the effect of perioperative blood transfusion on immunological parameters, T cells, T-cell subsets, and concanavalin A-induced suppression were measured in 25 patients with colorectal and breast cancer. During the operation, 15 patients received autologous blood and 10 patients had homologous transfusion. The immunological status was again determined after curative surgery. Before surgery, normal percentage of T lymphocytes, decreased ratios of helper/suppressor cells, and impaired con A-induced suppression were found. Following the operation, the helper and suppressor cell percentages reversed to normal, whereas the con A-induced suppression remained impaired. This change was significantly more pronounced in patients who received autologous blood transfusion than in the other group. Autotransfusion has an impact on immune parameters that might prove less detrimental to the clinical outcome in oncologic surgery than homologous transfusion.

Intra-operative ultrasonography as a routine screening procedure in biliary surgery.

Intra-operative cholangiography and ultrasonography were compared in screening for unsuspected common bile duct stones. In 57 consecutive patients both procedures were performed, and in 60 only ultrasonography was used. Although the study was conducted during the initial self-teaching period (regarding ultrasonography) the results show an advantage of this relatively new diagnostic technique. The false positive rate was lower and consequently the predictive value of a positive test was higher for intraoperative ultrasonography. The main benefit would thus be a lower rate of negative common bile duct explorations. Our early results suggest that the general surgeon would need only a short adaptation period to this imaging modality, which would seem to be a valuable alternative to intra-operative cholangiography.

Bilateral localized Castleman disease of the retroperitoneum.

A case report of a 23-year-old patient with abdominal pain was found to have a bilateral, retroperitoneal localized form of Castleman disease. To the best of our knowledge, it is the first report of a bilateral form described in the literature. Surgical excision resulted in the disappearance of symptoms and both masses were found to be of the hyaline type. Follow-up computerized tomography revealed no pathological sequelae.

[Sutureless intestinal anastomosis with a biofragmentable anastomotic ring].

There have been efforts to develop an ideal method of intestinal anastomosis throughout medical history. In ancient China, Egypt and India living ants were used to approximate the transected edges of bowel. Many other devices and techniques have since been introduced, using organic or synthetic, nonabsorable or absorbable materials. Lately mechanical stapling devices have become exceedingly popular. The recently introduced biofragmentable anastomotic ring (BAR) is composed of an absorbable polyglycolic acid in 12.5% barium sulfate suspension to permit x-ray visualization. Prospective randomized studies have shown it to be both effective and safe as compared to conventional handsutured or stapled anastomosis. Its main advantages are simplicity and ease of handing, short operating time and the absence of foreign bodies at the anastomotic site that might interfere with imaging methods, such as CT or MRI. We present our preliminary, satisfactory experience with BAR in 14 patients with a mean age of 67 years. 8 underwent right colectomy, 2 left colectomy, 1 sigmoidectomy, 2 resection of upper rectum, 1 subtotal colectomy, 1 excision of a giant lymphoma of the cecum, and 1 had had recurrent bouts of volvulus of the sigmoid.

Penetration of ceftriaxone and cefoperazone into bile and gallbladder tissue in patients with acute cholecystitis.

The penetration of ceftriaxone and cefoperazone into bile and gallbladder tissue was prospectively studied in 21 adult patients undergoing early surgery for acute cholecystitis. Comparable tissue, bile, and serum concentrations of the drugs were demonstrable; however, significantly fewer preoperative doses of ceftriaxone were required for adequate perioperative treatment. In view of its higher serum half-life and superior antibacterial activity toward common biliary pathogens, ceftriaxone appears to be a useful drug for the perioperative management of acute cholecystitis.