Surgical challenges of giant parathyroid adenomas weighing 10 g or more.

PURPOSE: An average parathyroid adenoma (PA) weighs < 1 g. This study aimed to characterise giant PAs ≥ 10 g (GPAs) to facilitate surgical management of primary hyperparathyroidism (PHPT). METHODS: All patients with a GPA confirmed on histology were recruited from the Monash University Endocrine Surgery Unit database. Clinical and demographic data were collected and compared to a group of non-GPA patients. RESULTS: A total of 14 GPAs were identified between 2007 and 2018 out of 863 patients (1.6%) with a single PA excised for PHPT. The GPA patients were compared to a control group of 849 non-GPA patients in the same period with similar mean age (62 ± 16 vs 63 ± 14, P = 0.66) and gender distribution (64% vs 75% female, P = 0.35). Pre-operative calcium (Ca) and parathyroid hormone (PTH) levels were significantly higher in GPA patients (P < 0.001). A higher percentage of GPA patients (79%) had concordant localisation studies (ultrasound and sestamibi) than control patients (59%), (P = 0.13), but they were significantly less likely to undergo MIP (55% vs 82%, P = 0.02). The median GPA weighed 12.5 g (IQR 10.5-24.3). Median serum Ca normalised by day 1 post-operatively, while PTH remained elevated. Both serum Ca and PTH levels were in the normal range at 3 months. All GPA lesions were benign on histopathology. CONCLUSION: GPAs are rare and display severe clinical and biochemical abnormalities. Despite their large size, concordant pre-operative imaging was not always achieved, and a few patients were suitable for MIP.

Severe hyperkalaemia complicating parathyroidectomy in patients with end-stage renal disease.

We evaluated the incidence of perioperative hyperkalaemia in end-stage renal disease (ESRD) patients undergoing parathyroidectomy and investigated possible contributors to this phenomenon. This was a retrospective cohort study looking at patients who had undergone parathyroidectomy for chronic kidney disease-associated mineral bone disease (CKD-MBD) at The Alfred Hospital, Melbourne, since 2001. Baseline demographics including age, gender, aetiology of renal failure and mode of renal replacement therapy as well as anaesthetic technique and duration of surgery were studied as possible contributors. Perioperative potassium values were compared to preoperative baseline. Following stratification into normokalaemic and hyperkalaemic groups, demographic and operative data were compared. Twenty-two patients met the inclusion criteria with a median (interquartile range, IQR) age of 48.5 (42-59) years. There was a male predominance of 68%. The median (IQR) surgical time was 131 (115-164) minutes. Potassium levels rose perioperatively, with a 27.3% incidence of perioperative hyperkalaemia. Median duration of surgery was longer in the hyperkalaemic patients (167 minutes versus 125 minutes). Following the withdrawal of cinacalcet, parathyroidectomy is increasingly required in ESRD patients with CKD-MBD. Potentially life-threatening hyperkalaemia poses a significant risk in the perioperative period. Serial electrolyte monitoring is crucial to safety in this patient group. A multidisciplinary approach to perioperative management is required to ensure optimal timing of renal replacement therapy and appropriate means of serial blood sampling.

Factors predicting local recurrence of desmoid tumours including proliferating cell nuclear antigen.

BACKGROUND: A series of 24 patients with desmoid tumours were studied to determine factors predicting local recurrence, and to establish whether these desmoid tumours were oestrogen receptor-positive or -negative. METHODS: Histology was reviewed and immunohistochemical studies were undertaken. Risk factors for local recurrence were analysed. RESULTS: The findings indicate that the 24 desmoid tumours were oestrogen receptor- and progesterone receptor-negative. Most tumours were proliferating cell nuclear antigen (PCNA)-positive, and positivity was graded by percentage of cells staining and the intensity of the staining. The presence of incomplete macroscopic or histological surgical resection margins did not correlate with local recurrence. Although all tumours that recurred were strongly PCNA-positive with a high percentage of positive cell staining, this trend was not significant. Local recurrence was more common in desmoid tumours arising in extra-abdominal sites (P = 0.03). Extra-abdominal desmoid tumours were significantly more likely to have incomplete histological margins following resection (P < 0.05). CONCLUSION: Desmoid tumours are oestrogen receptor- and progesterone receptor-negative. Of factors analysed for local recurrence, only the extra-abdominal site was significant.

Pre-operative core biopsy of soft-tissue tumours facilitates their surgical management.

BACKGROUND: Soft-tissue sarcomas are rare, and clinical differentiation of benign tumours from sarcomas is sometimes impossible. Further, the diagnosis of soft-tissue sarcomas may be unsuspected pre-operatively, and the presenting mass enucleated. While enucleation (excisional biopsy) is acceptable for benign lesions, it is inappropriate for sarcomas, because the opportunity for the most effective management resulting in both adequate local control and functional limb salvage surgery is compromised. A high rate of wound complications following open incisional biopsy may also compromise local treatment. Inappropriate siting of the incision for both incisional and excisional biopsies may adversely affect subsequent surgery and radiotherapy. METHODS: We therefore assessed the accuracy of core biopsy in the diagnosis of soft-tissue tumours, and planning of definitive surgery. All patients with primary soft-tissue tumours managed by two surgeons with a special interest in soft-tissue sarcomas since 1991 were reviewed. More than half (53%) were referred from other specialists. RESULTS: Of 45 cases, 37 (82%) were referred with the tumour intact, and of these 31 (84%) underwent core biopsy. The overall accuracy of core biopsy was 84%. The sensitivity was 94%, with 100% specificity. In most patients this allowed planning of definitive one-stage surgery (P < 0.005). Of the remaining five non-diagnostic cores, four were benign and one was a non-specific malignancy. CONCLUSIONS: Core biopsy has a high degree of accuracy in the diagnosis of soft-tissue tumours, particularly malignant lesions, and is not misleading. Core biopsy avoids the complications of open biopsy, and enables planning of one-stage surgery when used in combination with appropriate imaging.

Cosmesis following complete local excision of breast cancer.

BACKGROUND: With the establishment of the safety of breast conservation in early breast cancer, cosmesis has become an increasingly important end-point of treatment. The aim of the present study was to establish a model to assess breast cosmesis after complete local excision and to assess cosmesis achieved in patients who had surgery using the seroma technique. METHODS: A total of 42 patients were retrospectively reviewed and assessed by independent clinical assessment by a surgeon, structured questionnaire and clinical photography. RESULTS: A total of 86% of patients were rated by surgeon and patient as having a good or excellent cosmetic outcome. There was a high degree of concordance between independent clinical assessment and clinical photographic analysis. CONCLUSIONS: A model has been established for the assessment of breast cosmesis; the technique of seroma formation without reconstruction of the defect results in good or excellent cosmesis in the majority of patients.

Pre-operative histological diagnosis of breast cancer.

BACKGROUND: A concordant triple assessment (clinical, mammographic and cytological) diagnosis of breast malignancy allows for pre-operative planning of surgery and may also allow for one-stage surgery. However, while the accuracy of cytology is high, it is unable to distinguish invasive cancer from ductal carcinoma in situ (DCIS). A malignant mass may be due to pure in situ cancer and hence axillary dissection may be avoided if pre-operative histology is available. METHODS: A consecutive series of 300 cases of breast cancer treated over the last 5 years by the two authors was analysed to determine: the method of achieving pre-definitive operation histology; the number of stages of surgery required; and the number of cases of mass-forming DCIS which could be susceptible to over-treatment. RESULTS: Of 289 patients undergoing local definitive surgery for breast cancer, 12 (42%) had clinical masses predominantly due to DCIS and in most of these patients axillary dissection was avoided. Histology was obtained prior to definitive surgery in 272 (94.1%) patients, by intra-operative frozen section in 159 (55.0%), incisional biopsy in 37 (12.8%), needle localization biopsy in 62 (21.5%) and core biopsy in 14 (4.8%). A total of 189 patients (65.4%) underwent one-stage surgery only. Breast conservation was achieved in 210 (72.7%) patients. Those requiring mastectomy were significantly more likely to have required two stages of surgery as were those with lesions detected by screening. CONCLUSIONS: Mass-forming DCIS cannot be predicted pre-operatively by triple assessment alone; and therefore pre-operative histology is required to avoid axillary dissection. Pre-operative histology may be obtained by core biopsy or intra-operative frozen section to identify DCIS and distinguish it from invasive disease, but both allow a one-stage surgical procedure in the majority of cases.

Phlegmonous enteritis: an unusual cause of abdominal pain.

Phlegmonous enteritis is a rare infective inflammatory condition of the gut which is difficult to diagnose and which is often fatal. Although first described more than 150 years ago, very few cases have subsequently appeared in the literature. In this case the diagnosis of atypical small intestinal pathology was suggested by unusual CT findings. Coupled with the clinical picture, this prompted laparotomy which in turn confirmed the diagnosis of phlegmonous enteritis. A literature review discusses the epidemiology, predisposing conditions, postulated aetiologies and treatment.

Modification of growth of desmoid tumours in tissue culture by anti-oestrogenic substances: a preliminary report.

BACKGROUND: Tamoxifen and toremifene have been used in patients with advanced desmoid tumours with response rates of 51%. METHODS: We developed an experimental model of desmoid tumour cells in tissue culture to study their effect. Four cell lines were established in tissue culture. All native and corresponding cultured tumours were oestrogen receptor negative. Tumour 1 was from a 22 year old with familial adenomatous polyposis (FAP) and recurrent abdominal wall desmoid tumours. She remains disease free on tamoxifen 4 years following surgery. Both her mother and sister also have shown regression of their FAP-associated desmoid tumours at the menopause and on tamoxifen, respectively. We assessed the effect of tamoxifen on desmoid tumours in tissue culture at 780 ng/mL. The results were assessed by cell density counting. RESULTS: Tumours 1 and 2 have responded with an approximately. 50% reduction in growth to tamoxifen at 780 ng/mL. CONCLUSIONS: This apparent growth inhibitory effect of tamoxifen on two desmoid tumour cell lines appears to be independent of oestrogen and correlates with the in vivo effect of tamoxifen on three desmoid tumours in an FAP family.

Obturation of the small bowel.

Obturation of the small bowel is an uncommon but important cause of small bowel obstruction. There are a great number of substances that may impact at the narrow portions of the small bowel. More than one object may be present in the alimentary tract and should be actively sought. Certain groups of patients are more likely to suffer from the condition. We present two cases of small bowel obstruction due to obturation and review the relevant literature.

Small bowel fistula: a complication of percutaneous endoscopic gastrostomy insertion.

A 22 year old man who sustained a severe closed head injury after a high speed motor car accident underwent routine placement of percutaneous endoscopic gastrostomy (PEG) for feeding purposes. Nine days after its insertion an enterocutaneous fistula was diagnosed around the PEG tube. A loop of mid-jejunum had been transfixed during the insertion of the PEG.

Traumatic diaphragmatic hernia presenting as an intercostal hernia: case report.

Intercostal hernias are rarely reported in the literature. We report a case of intercostal hernia secondary to a ruptured right hemidiaphragm and fractured costal margin caused by blunt trauma. The patient was ventilated at initial hospitalization because of rib fractures and advanced age, and the intercostal hernia was not evident. After physical rehabilitation treatment elsewhere, a painful chest wall bulge developed. A chest film and computed tomographic scan revealed the hernia. Surgery with a thoraco-abdominal incision in the line of the hernia allowed reduction of the hernial contents.

Benign mimics of soft tissue sarcomas.

We reviewed all new patients referred for treatment to the Sarcoma Unit at the Royal Marsden Hospital with a clinical diagnosis of soft tissue sarcoma (STS) during the course of 1 year (1989-1990). Of 118 patients, 65 (55.1%) had primary STS, 26 (22.0%) had recurrent STS, 19 (16.1%) had benign soft tissue tumours and eight (6.8%) had malignant tumours other than STS involving soft tissues and presenting clinically as soft tissue tumours. All patients underwent CT scanning which was used to assist diagnosis, assess operability or for radiotherapy planning. The CT findings of the benign lesions, all clinically suspicious of sarcoma, are discussed. The role of CT in the identification and management of these cases is emphasized.

The diagnosis of soft tissue tumours.

We prospectively analysed methods of diagnosis in 118 patients referred for definitive treatment with documented or presumed soft tissue sarcoma (STS). Of 65 patients with primary STS, 54 were biopsied before referral. Of these, 5 (9%) were biopsied by Tru-cut biopsy, 17 (32%) by incisional biopsy and 32 (59%) by excisional biopsy. The remaining 11 patients with primary STS, referred without biopsy, were all diagnosed by Tru-cut biopsy. An additional eight patients suspected of having STS were referred without biopsy and were found to have malignant tumours other than STS involving soft tissue by Tru-cut biopsy. Nineteen patients were proved to have benign soft tissue tumours; in 13 presumed to have STS, the diagnosis was unknown at referral. In four of these, biopsy was inappropriate. Of nine submitted to Tru-cut biopsy, an unequivocal diagnosis was made in 5 (56%) and incisional biopsy was required in the other four. Therefore, paradoxically, benign soft tissue tumours may be more difficult to diagnose with Tru-cut biopsy than malignant tumours. This study confirms the high degree of accuracy of Tru-cut biopsy in diagnosing malignant soft tissue tumours and highlights the disadvantages of open biopsy techniques.

Factors influencing local recurrence and survival in patients with soft tissue sarcoma of the upper limb.

Fifty-one patients with soft tissue sarcoma of the upper limb were studied to identify risk factors for local recurrence and survival. More than half (53 per cent) of the patients referred had locally recurrent disease. The flexor aspect of the forearm was the most common site of origin. The majority of patients were managed by a combination of conservative surgery and radical radiotherapy. Wide or radical excision was achieved in 49 per cent of cases. One-third of patients required partial resection of bone or neurovascular structures; 75 per cent of them had presented with local recurrence after treatment elsewhere. Skin grafts and flap repairs were used more often in patients with local recurrence (P = 0.013) and 20 (74 per cent) of those referred with locally recurrent disease have had no further local relapse. The overall 5-year survival rate of 80 per cent (95 per cent confidence interval 61-90 per cent) supports a policy of conservative surgery. Factors associated with a lower survival rate were deep fixation, origin in the flexor aspect of the forearm, and previous local recurrence. Deep fixation was also associated with an increased risk of local recurrence. Referral to a specialist unit at the time of initial presentation may result in lower rates of local recurrence and may improve the survival rate.

Complicated Crohn's disease in the over 70 age group.

Crohn's disease is rare and is infrequently reported in the over 70 age group. Such patients often present urgently with acute complications of Crohn's disease. Seven patients with Crohn's disease all presented with complications. The diagnosis was initially unsuspected in these patients, and in 3 cases coexisting diverticular disease led to a delay in diagnosis. Three patients with ileocolic disease presented with peritonitis or bowel obstruction. In a further 2 patients a diagnosis of Crohn's disease was not made until after histological examination of resected tissue. It is likely that, as the population ages, more elderly patients will present with complicated Crohn's disease. Surgeons should be aware of this possibility to allow appropriate management of this condition, which generally has a favourable prognosis in this age group.

Primary soft tissue tumours of the pelvis causing referred pain in the leg.

Referred pain in the leg is occasionally due to a pelvic soft tissue tumour. Among 11 patients who presented this way, one had a lymphoma, one had a benign schwannoma, and nine had soft tissue sarcomas. Most patients had undergone a variety of procedures, including laminectomy, before the correct diagnosis was established. In five cases, an accurate diagnosis was obtained by needle biopsy. The lymphoma responded to chemotherapy, and the benign schwannoma was excised. Of the nine patients with soft tissue sarcoma, six underwent marginal/intracapsular excision, three receiving supplementary radiotherapy, and two were treated by nonsurgical means. Hindquarter amputation was technically impossible or inappropriate in these cases. All those with high-grade tumours have died or have metastases. Of four patients with low-grade tumours, three have exhibited only slow disease progression. Careful judgment and a precise histopathological diagnosis are required in planning treatment for patients with pelvic soft tissue tumours causing referred pain in the leg.

Non-recurrent laryngeal nerves. The role of digital subtraction angiography to identify subjects.

Three cases of non-recurrence of the right recurrent laryngeal nerve are reported. In one, the predicted anomaly of dorsal origin of the right subclavian artery was confirmed by intravenous digital subtraction angiography (IVDSA). The surgical anatomy and embryology of this rare condition are discussed. Non-recurrent laryngeal nerves are at increased risk of injury, especially during re-operative thyroid surgery. It is, therefore, suggested that an IVDSA be performed in that small subset of patients in whom re-operative thyroid surgery is contemplated on the right, and in whom the nerve was not found at the previous operation.

Preoperative localization of parathyroid tumours does not reduce operating time.

Accurate preoperative localization of abnormal parathyroid glands might be expected to result in a reduction in operating time. To test this hypothesis the duration of surgery was recorded in a consecutive series of 50 patients who underwent neck exploration after preoperative localization by thallium-201 and technetium-99m subtraction scanning and were found to have parathyroid tumours. A total of 34 patients had accurate localization by the scan, and these patients had a median operating time of 90 min. When the tumour had not been localized before operation, the median operating time was not significantly different (80 min). Accurate preoperative localization of parathyroid tumours does not reduce operating time.