Outcome of glansectomy and skin grafting in the management of penile cancer.

Purpose. To report outcome data for patients with penile cancer treated surgically with glansectomy and skin grafting. Materials and Methods. We retrospectively reviewed data on all patients undergoing surgical management of penile cancer by a single surgeon between 1998 and 2008. Outcomes in patients who underwent glansectomy and skin grafting were analysed. Results. Between 1998 and 2008 a total of 25 patients with a mean age 60 (39-83) underwent glansectomy and skin grafting. Six patients had carcinoma in situ (CIS); the stage in the remaining patients ranged from T1G1 to T3G3. Mean followup for patients was 28 months (range 6-66). Disease specific survival was 92% with 2 patients who had positive nodes at lymph node dissection developing groin recurrence. One patient developed a local recurrence requiring a partial penectomy. Conclusions. Penile preserving surgery with glansectomy and skin grafting is a successful technique with minimal complications for local control of penile carcinoma arising on the glans. Careful followup to exclude local recurrence is required.

Psoas haematoma and femoral neuropathy associated with enoxaparin therapy.

Haemorrhage into the iliopsoas muscle causing femoral neuropathy is an infrequent complication of haemophilia or anticoagulant therapy. The association of an iliopsoas haematoma with enoxaparin therapy is very rare. We describe a case of femoral neuropathy secondary to psoas haematoma in a patient who was on enoxaparin therapy for suspected non-Q wave myocardial infarction. There is no clear consensus for the treatment of these haematomas, with both surgical and conservative options advocated. In this case, our patient recovered fully following conservative management.

PSA testing in general practice.

A questionnaire was sent to 400 general practitioners (GPs), concerning prostate-specific antigen (PSA) screening. Regarding the indications for PSA testing, 80% of GPs test men with urinary tract symptoms, 65% test men with a positive family history, 62% test on patient request, and 21% test men with unrelated symptoms. When PSA is measured, 91% of GPs inform their patient, and 71% discuss the significance of an abnormal result. The mean age range for PSA testing was from 50 years, without an upper age limit. The mode PSA threshold for referral was 6.6 ng/ml. De facto PSA screening appears to be widely practised.

Cellular mechanism of thymic involution.

Involution of the thymus and alterations in the development of thymocytes are the most prominent features of age-related immune senescence. We have carried out a comparative analysis of thymocyte and stroma in rapid thymic involution DBA/2 (D2) strain of mice compared with slow involution C57BL/6 (B6) strain of mice. Analysis of mice at 15 months of age suggested an age-related decrease in the thymocyte cell count, a block in the development of T cells and cortical involution in D2 mice compared with 3-month-old mice. TUNEL (terminal-deoxynucleotidyl-transferase-mediated dUTP-digoxigenin nick end labelling) staining and fluorescence-activated cell sorter (FACS) analysis showed that there was a significant increase in apoptotic cells in the cortex region of thymus in 15-month-old D2 mice compared with the same aged B6 mice. The thymocyte proliferation rate, as assessed by bromodeoxyuridine (BrdU) staining and [3H]-thymidine incorporation assay, was lower in 3-month-old D2 mice compared with the same age B6 mice. Immunohistochemical staining showed that the arrangement of MTS (mouse thymus stromal)-10+ epithelial cells and MTS-16+ connective tissue staining pattern had become disorganized in 15-month-old D2 mice but remained intact in B6 mice of the same age. These results suggest that, in D2 mice, both the thymocytes and stromal cells exhibit age-related defects, and that the genetic background of mice plays an important role in determining age-related alterations in thymic involution.

Use of nephrostomy tubes in ureteric obstruction from incurable malignancy.

Malignancy may produce ureteric obstruction. This obstruction may be relieved by inserting a nephrostomy tube. All 31 cases of malignant ureteric obstruction from a single institution were retrospectively analysed. The commonest indications for nephrostomy tube insertion were renal failure (87%) and flank pain with hydronephrosis (13%). The mean serum creatinine levels pre and post insertion were 481 and 170 micromol/l, representing significant improvement (p<0.01). The complication rate was 13%, relating to tube blockage or dislodgement. Survival of patients was significantly worse if their malignancy was not resectable or suitable for chemotherapy (p=0.01). However, incurable patients still survived for a mean of 232 days, and although 46% of this time was spent as an inpatient, it did not differ significantly from the inpatient rate of curable patients (31%, p=0.1). Nephrostomy tube insertion should be considered for all palliative cases of malignant ureteric obstruction.

Current clinical practice of induction and maintenance immunotherapy for metastatic renal cell carcinoma.

Current systemic treatment of metastatic renal cell carcinoma revolves around the use of interleukin-2 and interferon-alpha, often in combination with 5-fluorouracil. This article looks at the currently reported response rates for these modalities. It also looks at current practice as regards maintenance treatment, i.e. the continued therapeutic regimen following the initial response to the induction immunotherapy cycles.

Neuroendoscopic third ventriculostomy for hydrocephalus in adults: report of a single unit's experience with 63 cases.

BACKGROUND: Neuroendoscopic third ventriculostomy (NTV) is becoming a first line treatment for hydrocephalus in this center. Its use in a consecutive series of adults is reported. METHOD: Initially a retrospective data collection after 7 months becoming prospective studying all patients who underwent NTV in this center. The adults (17 years or older) have been studied. RESULTS: Sixty-three patients met the criteria for inclusion: 38 male, 25 female. Mean age at first NTV 37.5 years. There was an 80% success rate (i.e., no further therapy for the hydrocephalus required). Follow-up was for a mean of 3.1 years. The largest subgroup were patients with third ventricular tumours (35%), of whom 86% were successfully treated. Mean time to failure for the whole series was 8.5 months (range immediate--30 months). Complications occurred in 17.5%; those deemed serious in 11%. There were three deaths (4.7%) within 30 days of the procedure. There were six other deaths during follow-up, five because of tumour progression and one because of pneumonia. CONCLUSIONS: This procedure lends itself to the treatment of hydrocephalus in adults and appears to be more successful than in young children. It is efficacious in both previously shunted and non shunted patients. It is now the first-line treatment for noncommunicating hydrocephalus in this center and also for patients with shunt failure who are anatomically suitable, having cerebrospinal fluid spaces large enough to admit the endoscope. The complication and mortality rates compare favorably with those for shunts.

Electrocardiogram and rhythm strip interpretation by final year medical students.

The pre-registration house officers (PRHO) is often called upon to interpret electrocardiograms ECG. We invited final-year medical students who had successfully completed their written final examinations, to interpret three rhythm-strip tracings, and three 12-lead ECG tracings. The rhythm-strips were of ventricular fibrillation (VF), ventricular tachycardia (VT), and complete heart block. Of the three 12-lead ECG tracings, one was an inferior myocardial infarction (MI), one was atrial fibrillation (AF), and one showed no abnormality. Forty-six medical students attended. Of these, 50% had received no formal training in ECG interpretation, although 89% had tried to learn ECG interpretation from books. Only 9% felt confident in their interpretation of ECG tracings. Of the rhythm-strips, 100% correctly identified VF, 96% recognised VT, and 67% identified complete heart block. Of the 12-lead ECG tracings, 61 % recognised the MI, 54% recognised AF, and only 46% successfully identified the normal ECG as such. The group were significantly worse at 12-lead ECG interpretation compared to rhythm-strips (p<0.01). The members of the group who had received formal training in ECG interpretation were significantly better at interpreting both rhythm-strips and 12-lead ECG tracings (p<0.05). It would appear that formal ECG training as an undergraduate improves PRHO interpretation of ECG tracings, and the PRHO should not interpret 12-lead ECG tracings without consulting more senior medical staff.

The oxidative metabolism of circulating phagocytes in ankylosing spondylitis: determination by whole blood chemiluminescence.

OBJECTIVE: Superoxide anion radicals within the human body are regarded as a major cause of inflammation. However, their role in the pathogenesis of ankylosing spondylitis (AS) has not been well identified. This study aimed at investigating the relation between AS and the oxidative metabolism of phagocytes in whole blood. METHODS: 24 patients with classic AS were examined to determine their clinical status; complete blood count, erythrocyte sedimentation rate (ESR), and C reactive protein (CRP) were determined, and levels of the superoxide anion radicals in the patients with AS and 21 healthy subjects were assessed by the ultraweak chemiluminescence method. Subsequently, the relation between this disease and phagocytes was examined by using N-formyl-methionyl-leucyl-phenylalanine (fMLP) and phorbol-12-myristate-13-acetate (PMA) stimulants. RESULTS: In clinical assessments, patients with AS had abnormally raised serum CRP (>10 mg/l) and ESR (>15 mm/1st h) levels. In contrast with healthy subjects, patients with AS had significantly increased rates of superoxide anion radical production in their whole blood either in the resting state or with either fMLP or PMA stimulation. In addition, chemiluminescence maximum light intensity was significantly higher in patients with AS than in healthy subjects after fMLP or PMA stimulation. CONCLUSIONS: Our results suggest that the phagocytes of patients with AS are partly activated in the resting state, and are sensitive to fMLP or PMA stimulation. The priming of phagocytes in the bloodstream is likely to be a causative factor in the onset of AS.

Pulmonary malacoplakia associated with Rhodococcus equi infection in a patient with AIDS.

An AIDS patient with a cavitary lung lesion was found to have pulmonary malacoplakia associated with Rhodococcus equi infection. The diagnosis was based on the typical histologic features of transbronchial biopsy and a positive bacterial culture. All 13 reported cases of AIDS patients with pulmonary malacoplakia were associated with R equi. The recognition of this unique entity is important because of its responsiveness to therapy.

Clinical significance of azygos vein enlargement: radiographic recognition and etiologic analysis.

Azygos vein enlargement can be detected in congestive heart failure, portal hypertension, inferior vena cava thrombosis, right atrial mural thrombosis, a pulmonary embolism, congenital azygos continuation to the inferior vena cava, and the arteriovenous fistula. Radiography, particularly computed tomography (CT), is very useful, not only in recognition of azygos vein enlargement, but also in evaluation of its etiology for the institution of the appropriate treatment of the diseases.

Wegener's granulomatosis upper respiratory tract and pulmonary radiographic manifestations in 30 cases with pathogenetic consideration.

Although the radiographic manifestations and pathologic features of Wegener's granulomatosis have been well described, their relationship to two variants of anti-neutrophil cytoplasmic antibodies (c- and p-ANCA) remains unclear. The purposes of this study are to analyze the radiographic and pathologic findings in 30 patients with Wegener's granulomatosis and to correlate c- and p-ANCA with such findings. Major histologic findings included parenchymal necrosis, necrotizing vasculitis, and granulomatous inflammations. Nodular lesions were more often associated with arteritis whereas patchy fluffy lesions associated with hemorrhagic capillaritis. ANCAs, particularly c-ANCA, instead of p-ANCA, were present in a high percentage of patients tested. These findings suggest that c-ANCA could play an important pathogenetic role in Wegener's granulomatosis which showed dual pathologic processes: vasculitis and granulomatous inflammation manifested radiographically as either nodular or pneumonia-like lesions, whereas p-ANCA was more often associated with patchy fluffy lung lesions as the consequence of hemorrhagic capillaritis.

A rare common hepatic duct diverticulum causing fatal biliary obstruction and sepsis.

The case of a 59-year-old woman who presented with signs and symptoms of biliary obstruction and cholangitis is reported. The patient's clinical course was punctuated by recurring sepsis and acute hemorrhagic pancreatitis. Computed tomography revealed extrinsic compression of the common hepatic duct, which was nonfilling on cholangiography, thus raising the suspicion of a solid tumor; the common hepatic duct diverticulum was not revealed until autopsy. Diverticula in this region of the biliary tract are extremely rare and may, as in this case, present a diagnostic challenge and result in a fatal outcome.

Biliary electrolytes and enzymes in patients with and without gallstones.

pH, osmolarity, various electrolytes, nine enzymes, and bile acid were determined in hepatic and gallbladder biles from 108 and 100 patients, respectively, relating to various types of gallstones. The pH, osmolarity, and electrolytes were essentially identical in all groups of patients except for slightly higher Ca and Mg in the hepatic bile in patients with muddy pigment stones. The gallbladder bile contained much higher inorganic cations yet remained isosmotic as a result of their sequestration into bile acid micelles. Excluding extremely high values, the activities of nine enzymes in the bile showed only minor differences among four groups of patients except for a high beta-glucuronidase activity in the hepatic bile in patients with muddy pigment stones. The biliary baseline activities of various enzymes and the relation to their serum levels were determined by their sources and subcellular localization in the hepatocytes. We concluded that biliary electrolytes and enzymes were basically similar in patients with and without gallstones except for higher levels of Ca, Mg, and beta-glucuronidase in hepatic bile in patients with muddy pigment stones.

Papillary parathyroid adenoma. A rare occurrence and its importance in differentiation from papillary carcinoma of the thyroid.

The case of a 67-year-old woman with primary hyperparathyroidism manifested by hypercalcemia with anorexia, nausea, and weakness; low serum phosphorus; high circulating parathyroid hormone; and mildly elevated calcitriol and parathyroid hormone-related protein is reported. A cystic lesion was removed from the inferior pole of the right lobe of the thyroid, and serum calcium levels rapidly returned to normal. The lesion was proven histologically to be a parathyroid adenoma with predominate papillary features. The differentiation of such a rare lesion from papillary carcinoma of the thyroid, both histologically and cytologically, is stressed.

Extensive pulmonary metastasis of an intracranial meningioma with repeated recurrence: radiographic and pathologic features.

Recurrent intracranial meningioma with multiple pulmonary metastases is rare. In this case, the initial tumor had been diagnosed and removed 10 years earlier, and subsequent locally recurrent tumors were removed three times. Nine pulmonary metastases were discovered and resected recently. The metastatic lesion was confirmed as meningioma or arachnoidocytoma by light and electron microscopy and immunohistochemical studies. The patient survived all the operations.

Unusual computed tomographic manifestations of benign metastasizing leiomyomas as cavitary nodular lesions or interstitial lung disease.

The unusual computed tomographic manifestations of benign metastasizing leiomyomas diagnosed in two patients 3 1/2 and 6 years after hysterectomy for uterine fibroids are described. One showed multiple pulmonary nodules with a round or irregular air-filled cavity representing obstructive emphysema. The other showed interstitial lung disease with tumor cells spreading along alveolar septa, the vascular wall, and the bronchial tree. We consider such metastasizing tumors as low-grade leiomyosarcomas.

Squamous cell carcinoma of the uterine cervix. Patterns of thoracic metastases.

RATIONALE AND OBJECTIVES: Distant metastasis of cervical cancer, once considered rather uncommon, has become more common in recent years because of longer survival of the patients. The purpose of this study is to evaluate the radiographic patterns of its thoracic metastases correlating with the pathways of metastatic tumor spread. METHODS: The conventional radiographs (62 cases), thoracic computed tomography images (20 cases), and medical records of 62 patients with advanced squamous cell carcinoma of the uterine cervix with thoracic metastases who died of extensive disease and its complications during a recent 5-year period were reviewed retrospectively. RESULTS AND CONCLUSIONS: In addition to the most typical pattern of multiple pulmonary nodules (71%), mediastinal and hilar lymphadenopathy (32%) and pleural metastases (27%) were frequently observed. Rare findings included bone metastases (6%), endobronchial obstruction (5%), and lymphangitic carcinomatosis (3%). The mechanisms of metastasis in relation to the above manifestations are proposed.