Retroperitoneal metastatic squamous cell carcinoma of the tonsil (with elevated beta human chorionic gonadotrophin): a misdiagnosis as extra-gonadal germ cell tumour.

Head and neck cancers usually spread first to the regional lymph nodes but rarely may metastasize to distant sites. Metastasis to distant lymph node groups is a rare event. Furthermore, delayed multiple metastases without local recurrence is relatively uncommon. A case of retroperitoneal metastasis from a squamous cell carcinoma of the tonsil, secreting beta human chorionic gonadotrophin (beta-hCG), is reported. A 58-year-old man had undergone a tonsillectomy and chemo-radiotherapy for squamous cell carcinoma of the left tonsil and 13 months later presented with non-specific abdominal pain. The serum beta-hCG levels were high and an abdominal ultrasound scan revealed hydronephrosis on the left side. A computed tomography scan demonstrated para-aortic retroperitoneal lymphadenopathy. The patient underwent an open lymph node biopsy. The initial pathological analysis was interpreted as extra-gonadal germ cell tumour and the patient received chemotherapy. A subsequent review was consistent with a metastatic squamous cell carcinoma of the tonsil, as immunohistochemical studies showed positive staining for epithelial membrane antigen and cytokeratins 5/6 but a negative reaction to placental alkaline phosphatase. Following this, the chemotherapy regimen was changed; however, a restaging scan demonstrated progression, and the patient died from aspiration pneumonia secondary to alcohol intoxication. To our knowledge, this is the first reported case of retroperitoneal metastasis from a squamous cell carcinoma of the tonsil, secreting beta-hCG and causing hydronephrosis. This case highlights the necessity of using clinical, histological, immunohistological and ultrastructural examination to establish precise diagnosis and to avoid inappropriate treatment.

A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire.

OBJECTIVES: To study the morbidity of radical cystectomy and radical radiotherapy in the treatment of patients with invasive carcinoma of the bladder and to report the long-term survival following these treatments. PATIENT AND METHODS: 398 patients with invasive carcinoma of the bladder treated between 1993 and 1996 in the Yorkshire region were studied. Of 398 patients studied, 302 patients received radical radiotherapy and 96 underwent radical cystectomy. A retrospective review of patients' case notes was performed to construct a highly detailed database. Crude estimates of survival differences were derived using Kaplan-Meier methods. Log-rank tests (or, where appropriate, Wilcoxon tests) were used to test for the equality of these survivor functions. These functions were produced as all-cause survival. The proportional hazards regression modelling was used to assess the impact of definitive treatment on survival. A backwards-stepwise approach was used to derive a final predictive model of survival, with likelihood ratio tests to assess the statistical significance of variables to be included in the model. RESULTS: The patients undergoing radiotherapy were significantly older (mean age: 71 years versus 66 years), but no difference was identified in the distribution of American Society of Anaesthesiologists (ASA) grades in the two treatment groups. The stage distribution of cases in the treatment groups was not significantly different. Significant treatment delays were observed in both treatment groups. The median time from being seen in the clinic to transurethral resection of bladder tumour (TURBT) and subsequent radical treatment (cystectomy or radiotherapy) was 4.3 and 9 weeks, respectively. Age was the most significant independent factor accounting for treatment delays (p < 0.001). The 30-day and 3-month treatment-associated mortality for radical cystectomy and radiotherapy was 3.1% and 8.3% and 0.3% and 1.65%. Of the patients who received radiotherapy, 57 (18.8%) were subsequently subjected to a salvage cystectomy. For these 57 patients, 30-day and 3-month mortality after the salvage cystectomy were 8.8% and 15.7%. Gastrointestinal complications were the major source of early morbidity after primary and salvage cystectomy. Bowel leakage occurred in 3% following radical and 8.7% after salvage cystectomy. Bowel complications (leakage and obstruction) were the major cause of death following salvage cystectomy. No specific cause was predominant in those undergoing radical cystectomy with intestinal anastomotic leakage and urinary leakage accounting for one death each. Exacerbation of co-morbid conditions accounted for the remaining causes of mortality. Urinary leakage occurred in 4% following both forms of cystectomy. Recurrent pyelonephritis and intestinal obstruction were responsible for the majority of complications in the follow-up period. Bladder and gastrointestinal complications accounted for the majority of complications following radical radiotherapy. Some degree of irritative bladder and rectal were noted commonly. Severe bladder problems, which rendered the bladder non-functional or required surgical correction, occurred in 6.3% of patients. 2.3% of patients underwent surgery for bowel obstruction related to radiotherapy induced bowel strictures. Following radiotherapy, 43.6% of patients had a recurrence in the bladder at varying intervals post-treatment. Of these, 40% had > or =T2 disease. The 5-year survival following radiotherapy (with or without salvage cystectomy) was 37.4% while 36.5% of patients were alive 5 years after radical cystectomy. There was no statistically significant difference in the overall 5-year survival figures between the two primary treatments. Tumour stage, ASA grade and sex were the only independent predictors of 5-year survival on multivariate analysis. CONCLUSIONS: This retrospective regional study shows that there is no significant difference in the 5-year survival of patients with invasive bladder cancer treated with either radical radiotherapy or radical cystectomy. All forms of radical treatment for bladder cancer are associated with a significant treatment-associated morbidity and mortality. Gastrointestinal complications were responsible for the majority of complications. The treatment-associated mortality at 3 months was two- or three-fold higher than the 30-day mortality; emphasising its importance as an indicator of the true risks of cystectomy. The clinical T stage, the sex and the ASA grade of the patient were the only independent predictors of survival. The data in this series suggests that radical radiotherapy and radical cystectomy should be both considered as valid primary treatment options for the management of invasive bladder cancer.

Corporal plication for penile curvature caused by Peyronie's disease: the patients' perspective.

OBJECTIVE: To determine the acceptability by patients of corporal plication for Peyronie's disease. PATIENTS AND METHODS: A postal questionnaire was sent to 69 patients who had undergone corporal plication for Peyronie's disease between 1992 and 1999, to ascertain the subjective outcome and acceptance by the patients and their sexual partners of the results of the procedure. Of the 65 patients who were still alive, 44 (68%) returned the questionnaire. RESULTS: The mean (range) follow-up was 4.1 (0.5-7.25) years and the mean age of the patients 54.6 (32-80) years. Of the 44 patients responding, 24 (55%) were sexually active; after surgery, 16 (36%) had significant impairment of erections, seven (16%) continued to have significant penile discomfort and 15 (34%) could feel nodules at the suture site. Twenty-five (57%) patients reported a mild and six (14%) a severe persistent penile deformity; 40 (90%) reported having a shorter penis, of whom 22 (55%) thought it significant. Overall, 14 (32%) reported 'numbness' of the glans penis. Only 23 (52%) of the patients would recommend the surgery, with 25 (57%) reporting a deterioration in their overall quality of life. Of the partners of the evaluable patients, 38 (86%) responded, and a significant deterioration in sexual performance was reported by 19 (35%). CONCLUSIONS: Overall, the long-term results of corporal plication appear to be disappointing. These poor results could be related to a current lack of understanding of the natural history and progression of the disease, to case selection, or to the surgery. We intend to use these results to counsel our patients before such surgery and inform them of the possible outcome in the long term.

Correlation between albuminuria and positively charged amino acids in gastrointestinal cancer.

This study was designed to examine a possible relationship between plasma free positively charged amino acid concentrations and the degree of microalbuminuria in patients with gastrointestinal cancer. In 42 consecutive patients (22 men and 20 women), comprised of 25 with histologically proven colorectal or gastric cancer, 9 controls and 8 weight-losing patients with benign gastrointestinal disease urinary albumin and plasma amino acid analysis was performed. Microalbuminuria was more prevalent in weight-losing cancer patients (65%) compared with their weight-stable counterparts, benign gastrointestinal patients and controls. This difference reached statistical significance at the 5% level. Additionally, a significant positive correlation (rs = 0.8, p < 0.05) was observed between ornithine and urinary albumin loss in this group of patients. This study suggests that plasma free amino acid alterations in weight-losing gastrointestinal cancer patients may have an effect on renal tubular protein reabsorption.

Localised amyloidosis of the urinary bladder: a case report and review of treatment.

Since the first case of primary amyloidosis of the bladder was reported by Solomin in 1871, only about 50 other case reports have appeared in the English literature to our knowledge. Due to rarity of this condition, no unit has treated enough patients to formulate a standard protocol of management which in most cases is empiric. The clinical importance of this condition is to differentiate it from a neoplasm of the bladders.

Micronutrients in gastrointestinal cancer.

The monitoring of micronutrients and the relationship between dietary intake and micronutrient status prior to and after surgery in patients with histologically proven gastrointestinal adenocarcinoma, both weight-stable and weight-losing (> 7.5% of their pre-illness weight) has been studied and the results compared to controls. Plasma vitamin C and red blood cell thiamine levels were significantly lower in weight-losing cancer patients when compared to their weight-stable counterparts (P < 0.05 and P < 0.02 respectively). Weight-losing patients had a lower vitamin C (P < 0.05) and thiamine (P < 0.002) intake, and a higher elevation in plasma C-reactive protein and a lower prealbumin level (P < 0.02), when compared to both weight-stable cancer patients and controls. Plasma vitamin C, prealbumin and C-reactive protein levels remained unchanged after curative resections of the tumours compared to a preoperative value, and there was a highly significant correlation between plasma vitamin C and dietary intake of vitamin C. This study suggests that the lower vitamin C and thiamine status in weight-losing gastrointestinal cancer patients prior to surgery is due to a lower micronutrient intake and an acute phase response to their illness. Dietary intake of vitamin C appears to be the major factor in determining plasma vitamin C concentration following curative surgical resection.

Familial transitional cell carcinoma and the Lynch syndrome II.

A family is presented in which 4 male siblings developed transitional cell carcinoma (TCC). Four upper tract tumours occurred in 3 and in the fourth the tumour was intravesical. Two of these patients also had colorectal adenocarcinoma. There were 2 other relatives in the pedigree with large bowel cancer. It is suggested that this is an example of Lynch Syndrome II, a hereditary non-polyposis colorectal cancer with extracolonic cancer sites. The implications regarding the screening, surveillance and detection of possible carrier status in healthy relatives is discussed.

Artificial urinary sphincters around intestinal segments--are they safe?

Artificial urinary sphincters (AUS) were implanted around intestinal segments to achieve urinary continence in 8 patients and faecal continence in 1. In 6 patients the cuff was placed around the lower end of the cystoplasty following bladder neck (5) or urethral (1) erosion. Four are completely dry, 1 on self-intermittent catheterisation (SIC). One has mild stress incontinence. In 1 patient the cuff eroded at 8 months. Two patients had cuffs implanted parastomally to create continent diversion. One is satisfactory on SIC and the other had her AUS explanted because of life-threatening metabolic acidosis. The rectal cuff was explanted because of faecal impaction above the cuff. As an absolute last resort, placing an AUS round a cystoplasty appears little more hazardous than round bladder neck. The use of the AUS for continent diversion has not been pursued because of reliable techniques of non-prosthetic continent diversion. The current model of the AUS is unsuitable for the treatment of faecal incontinence.

Giant cystic leiomyoma of the sigmoid colon.

Smooth muscle neoplasms may occur anywhere in the gastrointestinal tract, but are rare in hindgut derivatives. We report a case of colonic leiomyoma which had undergone cystic degeneration and presented as a huge abdominal mass. The diagnosis was aided preoperatively by C.T. scanning and the cyst shown subsequently to contain 13 litres of fluid. We believe this could be the largest reported cyst of this type.

Assessment of the poorly contractile or acontractile bladder in the older male in the absence of neuropathy.

Up to 30% of patients who undergo prostatectomy are left with residual symptoms. Most have persistent detrusor instability, but some have poorly contractile or acontractile bladders. Over a 2-year period, 42 neurologically normal patients were shown to have a hypocontractile or acontractile bladder on urodynamic testing; 27 had undergone outflow tract surgery. Four patients who were totally incontinent had undergone at least 2 transurethral resections. The remainder had severe frequency, urgency and nocturia. Urodynamically, all but 7 patients with poor compliance had normal filling cystometrograms, all but 8 had residual urine volumes less than 100 ml, and 26 had less than 5 ml. Thus their symptoms are difficult to explain. Apart from the insertion of an artificial sphincter in those with total incontinence, treatment did not improve any of these patients.

Diet-induced thermogenesis in patients with gastrointestinal cancer cachexia.

1. Indirect calorimetry has been used to measure resting energy expenditure (REE) and the thermogenic response to a test meal (diet-induced thermogenesis) in groups of weight-stable and weight-losing patients with gastrointestinal adenocarcinoma. Average daily intakes of energy and protein were computed from dietary assessment for the week before hospitalization. Results were compared with a control group of patients with benign gastrointestinal disease. 2. Weight-losing cancer patients had a significantly reduced mean total energy and protein intake. 3. There was no significant difference in REE between the groups when results were normalized in terms of metabolic body size (kJ/kg 0.75) and lean body mass (kJ/kg). 4. Diet-induced thermogenesis was reduced in weight-losing cancer patients. 5. It is suggested that the reduction of diet-induced thermogenesis in weight-losing cancer patients is another element of starvation adaptation, subsequent to their weight loss, and that altered thermogenesis does not contribute to the weight loss seen in cancer cachexia.

Care of the injured in the Third World--what can we learn?

There is a need to put more emphasis on primary surgical care centred on provincial and district hospitals in the developing world using simple equipment which needs little maintenance and low running costs. The general duty doctors and paramedicals who are at the first point of contact with the patient, need practical on-site instruction in dealing with common surgical emergencies, of which injury forms a large part. To achieve this change in emphasis, provision should be made for surgical trainees and experienced surgeons from the United Kingdom or else where to work in selected provincial and district hospitals where support services can be adequately provided. The experience they would gain, would in turn benefit their patients in the National Health Service. If this activity is to have any chance of success, the training and research potential must be recognized by the Royal Colleges as valid experience in higher surgical training programmes. The National Health Service and the Health Authorities must accept these periods overseas as integral parts of a career in the National Health Service. This would include provision for superannuation, encouraging proleptic appointments to consultant posts, and secondment or early retirement of Consultants. Funding should be sought from international and national agencies for a pilot project based on a direct link between a district hospital in this country and a selected district or provincial hospital in a developing country.(ABSTRACT TRUNCATED AT 250 WORDS)

Colonoscopy or barium enema as initial investigation of colonic disease.

To determine whether double-contrast barium enema (DCBE) or fibreoptic examination should be the first-line investigation for colonic disease 76 consecutive patients presenting for the first time to the outpatient clinic with symptoms of colonic disease deemed to need a DCBE after negative rigid sigmoidoscopy were entered into a trial. All underwent flexible sigmoidoscopy, then DCBE, and finally colonoscopy. 66 patients completed the study. DCBE alone gave the final diagnosis in 42 (67%) and colonoscopy alone in 60 (91%) (p = 0.0004). A combination of flexible sigmoidoscopy and DCBE led to the diagnosis in 50 patients (76%). With DCBE alone 73% of polyps and 64% of patients with inflammatory bowel disease were missed. No complications arose from the investigations. 32 (48%) patients found DCBE distressing and 15 (23%) found colonoscopy uncomfortable (p = 0.004). Its high diagnostic accuracy and relative lack of discomfort for patients make colonoscopy the primary procedure for investigating patients with large bowel symptoms referred to the general surgeon.