A comprehensive review of current knowledge on penile squamous cell carcinoma.

Neoplasm of the penis is relatively rare in most regions representing 0-2% of cancers worldwide. While the penis can be affected by sarcomas, basal cell carcinomas or even melanoma, Penile Squamous Cell Carcinoma (PSCC) represents approximately 95% of all penile neoplasms. Despite its rarity and most common presentation at later decades of life most individuals diagnosed with PSCC are faced with significant decrease in quality of life. The prevalence and incidence vary among different regions and populations, but a common trend is for diagnosis to occur late (stage 4). Underdeveloped countries are traditionally reported to have higher incidence rates; however, rates may vary significantly between urban and rural areas even in developed countries. Age adjusted rates are on the rise in some countries that used to have incidence rates of 1:100 000 or less. The list of associated risk factors is long and includes among others, lack of neonatal circumcision, poor genital hygiene, socioeconomic status, history of human papillomavirus (HPV) infection and penile intraepithelial neoplasia (PeIN). Many risk factors are widely debated among experts however HPV and PeIN are indisputable risk factors, and both also form part of the classification system for PSCC. Both conditions may have occurred in the past or be present at the time of diagnosis and identifying them plays a major role in management strategies. For such a rare condition PSCC can present in many different forms clinically making diagnosis no easy feat. Diagnosis of PSCC is done through clinical examination, including lymph node palpation, followed by a biopsy, which is essential for the classification. Lymph node involvement is a common finding at first presentation and investigation of spread to deep nodes is important and can be done with the aid of PET-CT. Treatment options for PSCC include surgery, chemotherapy, and radiation therapy. Surgical removal of the tumor is considered the most effective however can lead to severe decrease of quality of life. Chemotherapy is used in the case of fixed or bulky lymph nodes, where surgery is not indicated, and for distant metastasis. Radiation therapy is particularly effective in the case of HPV-positive PSCC.

A comprehensive study of the abdominal ganglia part 3: An overview of the most commonly observed ganglion patterns.

Chronic pain from untreatable abdominal cancers or pancreatitis can severely decrease an individual's quality of life due to accompanying neuropathic pain, the most difficult pain mechanism to treat. Current treatment modalities focus on peripheral block or neurolysis procedures of the sympathetic ganglia in an attempt to curb the pain and improve quality of life. Reports indicated that these treatments are ineffective with patients either experiencing no relief or return the pain in a few weeks. The aim of this study was to investigate the location, macro- and microscopic morphology, and interconnections of the abdominal ganglia. The abdominal sympathetic ganglia of nine adult cadavers were investigated. The locations, morphology, interconnections, and microscopic structure were studied in 108 potential abdominal ganglia. Particular emphasis was placed on direct interconnectivity between the ganglia and histological morphology. A total of 100 ganglia were confirmed histologically to contain ganglion cells. The number and locations of most of the ganglia identified in our study does not correspond to that described by previous reports. Numerous interconnections between the different ganglia, as well as direct communications with the lumbar sympathetic chain ganglia were observed. The interconnections and presence of ganglion cells the nerves connecting the ganglia lead to the belief that the system should be considered as a unit and that pain fibers may be transmitted via alternative previously undiscovered pathways. If the pain treatments are to be reassessed with this information in mind, we believe that greater success could be achieved.

A comprehensive study of the abdominal ganglia part 2: Aorticorenal ganglia.

Investigation into reports of pain treatment for abdominal cancer and abdominal pain syndromes revealed the lack of human studies on some of the abdominal sympathetic ganglia. Recent studies on renal artery denervation therapy as treatment for resistant hypertension has made the aorticorenal ganglia of particular importance. The aim of this study was to investigate the location, morphology, interconnections, and histological nature of aorticorenal ganglia. We dissected nine abdominal cavities and harvested 37 aorticorenal ganglia. Hematoxylin and Eosin, and Masson's staining techniques were used to study the histological structure. Additionally, ganglia harvested from five individuals were stained with immunohistochemical techniques to test for tyrosine hydroxylase activity. All aorticorenal ganglia were located in proximity to the renal artery, and the majority were close to the vessel origin. Identification of multiple aorticorenal ganglia was the norm, and ranged from 2 to 4 on the left and 1 to 3 on the right. While the pattern of aorticorenal ganglia seemed to be unique in each individual case, the interconnections between these and other ganglia were vast. The aorticorenal ganglia shared direct connections with the celiac, gonadal, inferior mesenteric, and first lumbar sympathetic trunk ganglion. Contributions from the greater, lesser, and least thoracic splanchnic nerves were also observed. While the results of our study may not have direct clinical implications in isolation, the vast number of interconnections with the other abdominal ganglia may cause complications in procedures such as celiac ganglion block. In addition, aorticorenal innervation interruption may lead to hypotension.

A comprehensive study of the abdominal ganglia part 1: Celiac, phrenic and superior mesenteric ganglia.

INTRODUCTION: Patients with pancreatic cancer, chronic pancreatitis and other abdominal pain syndromes may develop debilitating pain throughout the course of their illness with little to no relief by most conventional methods. While some form of relief is experienced by patients, not all benefit from these procedures and side effects, while transitory in most cases are severe and often not expected. Our aim was therefore to investigate the anatomy surrounding the abdominal sympathetic ganglia, the target for the invasive procedures in an attempt to understand the variations in results. MATERIALS AND METHODS: The abdominal cavities of nine individuals were dissected and the ganglia investigated, harvested and histologically and immunochemical stained. RESULTS: The phrenic ganglion was found inconsistently and more often in the left than the right. If present it was located in association with the inferior phrenic artery and often connected to the celiac ganglion. The celiac ganglion was located anterior to the diaphragmatic crus on both sides and specifically posteromedial to the suprarenal gland and superior to the renal artery on the left. On the right it was located posterior to the suprarenal gland and inferior vena cava also superior to the renal vessels. The superior mesenteric ganglion was only positively identified in one individual and was located on the left lateral aspect of the superior mesenteric artery. CONCLUSION: The blockade procedures for treatment of pain are developed to target the area around the celiac artery where the ganglion is commonly described to be located. However, based on our results of its location and interconnections the ganglion is not located in the targeted area.

Heterogeneity in head and neck cancer incidence among black populations from Africa, the Caribbean and the USA: Analysis of cancer registry data by the AC3.

BACKGROUND: Africa and the Caribbean are projected to have greater increases in Head and neck cancer (HNC) burden in comparison to North America and Europe. The knowledge needed to reinforce prevention in these populations is limited. We compared for the first time, incidence rates of HNC in black populations from African, the Caribbean and USA. METHODS: Annual age-standardized incidence rates (IR) and 95% confidence intervals (95%CI) per 100,000 were calculated for 2013-2015 using population-based cancer registry data for 14,911 HNC cases from the Caribbean (Barbados, Guadeloupe, Trinidad & Tobago, N = 443), Africa (Kenya, Nigeria, N = 772) and the United States (SEER, Florida, N = 13,696). We compared rates by sub-sites and sex among countries using data from registries with high quality and completeness. RESULTS: In 2013-2015, compared to other countries, HNC incidence was highest among SEER states (IR: 18.2, 95%CI = 17.6-18.8) among men, and highest in Kenya (IR: 7.5, 95%CI = 6.3-8.7) among women. Nasopharyngeal cancer IR was higher in Kenya for men (IR: 3.1, 95%CI = 2.5-3.7) and women (IR: 1.5, 95%CI = 1.0-1.9). Female oral cavity cancer was also notably higher in Kenya (IR = 3.9, 95%CI = 3.0-4.9). Blacks from SEER states had higher incidence of laryngeal cancer (IR: 5.5, 95%CI = 5.2-5.8) compared to other countries and even Florida blacks (IR: 4.4, 95%CI = 3.9-5.0). CONCLUSION: We found heterogeneity in IRs for HNC among these diverse black populations; notably, Kenya which had distinctively higher incidence of nasopharyngeal and female oral cavity cancer. Targeted etiological investigations are warranted considering the low consumption of tobacco and alcohol among Kenyan women. Overall, our findings suggest that behavioral and environmental factors are more important determinants of HNC than race.

The Evolution of Corpus Callosotomy for Epilepsy Management.

Corpus callosotomy, first used in the management of epilepsy by William P. van Wagenen in 1940, was for years a contentious procedure. Two decades later, Nobel Laureate Roger W. Sperry's split-brain studies inspired surgeons to reexamine the role of corpus callosotomy in the control of epileptic seizures. In 1962, Joseph Bogen and Philip Vogel performed complete corpus callosotomies in patients with a history of generalized seizures. The identification of a set of postsurgical disconnection symptoms and other neurologic deficits begged the improvement of the surgical technique. Modifications to the operation, including anterior callosotomy, posterior callosotomy, partial callosotomy, staged callosotomy, microsurgical techniques, and radiosurgical techniques, continue to refine the procedure.

The rotational position of the aortic root related to its underlying ventricular support.

We aimed to assess the relationship of the rotational position of the aortic root to its underlying ventricular support, and to the position of the inferior margin of the membranous septum, which serves as a surrogate of the atrioventricular conduction axis. We analyzed 40 normal heart specimens (19 children, 21 adults). The inferior margin of the membranous septum was measured relative to the virtual basal ring. The rotational position of the aortic root was determined by assessing the relationship of the aortic leaflet of the mitral valve to the interleaflet triangle between the non- and left coronary leaflets. The extent of supporting fibrous versus myocardial tissues was measured. We also performed a similar investigation of 30 adult computed tomographic data sets. The median age was 0.25 years (44% male) for children, and 64 years (33% male) for adults. The aortic root was positioned centrally in 22 specimens (55%), rotated counterclockwise in 6 (15%), and clockwise in 12 (30%). In the setting of counterclockwise rotation, 53.4% (median) of the supporting circumference was myocardial, as opposed to 41.4% (median) in those with centrally positioned roots, and 31.9% (median) in those with clockwise rotation (P < 0.0001). The position of the inferior margin of the membranous septum was not associated with the rotational position. Analysis of the 30 adult computed tomographic data sets (median age 66.5 years, 57% male) confirmed the positive relationship between clockwise rotation of the aortic root and an increase in the extent of fibrous as opposed to myocardial support. The rotational position of the aortic root correlates with variation in the extent of its fibrous as opposed to myocardial ventricular support, but not with the position of the inferior margin of the membranous septum relative to the virtual basal ring. Clin. Anat. 32:1107-1117, 2019. © 2019 Wiley Periodicals, Inc.

Incidence and 5-year survival rate for head and neck cancers in Grenada compared to the African American population over the period 1991-2010.

Very little data exist on the incidence and burden of cancer in the individual Caribbean countries. Some data are available for larger areas, reported under a bigger geographical region; Latin America and the Caribbean, but many of the individual countries are not included. One of the main reasons is a lack of official cancer registries. Data are usually collected from hospital records or private physician records, and since it is not in an official registry, these data are not always accessible for inclusion in databases such as SEER and GLOBOCAN. Grenada is one of the countries that currently does not have a registry. Our aim is to report on the incidence for head and neck cancer with subcategories; hypopharynx, oropharynx, oral cavity, salivary glands, and larynx from data collected by the sole ear nose and throat specialist over a 20-year period. The age adjusted incidence per 100,000 for these cancers, whether combined or individually, is lower than that of similar populations. The incidence in males is only slightly higher than those reported in some parts of Africa. In females, only Eastern Africa is reported to have a lower incidence than that found in our study. While the incidence of oral cancers is lower than that of African Americans, the survival rate is comparable. Socioeconomic status, lack of infrastructure, and advanced stage at diagnosis appear to be closely related to the survival rate. Incidence reports suggest that incidence of head and neck cancers in individuals of African descent is lower than other populations. It is therefore not surprising that the incidence in Grenada is relatively low, although the incidence may be underestimated.

The blood supply to the sacrotuberous ligament.

Knowledge of the vascular supply associated with the sacrotuberous ligament is incomplete, and at most attributed to a single coccygeal branch. Our aim was to investigate the sacrotuberous ligament vasculature with a focus on its origin and distribution. We dissected 21 hemipelvises (10 male and 11 female). The gluteus maximus was reflected medially, and a special emphasis was placed on the dissection of the vascular and neuronal structures. All specimens exhibited several (1-4) coccygeal arteries branching from the inferior gluteal artery penetrating the sacrotuberous ligament along its length. Seven specimens demonstrated the superior gluteal artery supplying sacral branches to the proximal superior border of the sacrotuberous ligament. Our study highlights several branches from a variety of origins as the supply to sacrotuberous ligament unlike previous reports stating only one vessel. Our results implicate surgical procedures in and around the area of the gluteal region such as decompressive procedures of the pudendal nerve, as it travels between the sacrotuberous and sacrospinous ligaments.

Ultrasound-guided central venous catheterization: A review of the relevant anatomy, technique, complications, and anatomical variations.

Central venous catheterization is a commonly used and important intervention. Despite its regular use it is still associated with a high incidence of complications especially infection and catheter tip embolization. Addition of ultrasound guidance to the technique has shown great improvement to the time and number of attempts for successful catheterization. The preference of vein depends greatly on the situation; subclavian vein is the preferred method overall but internal jugular vein is preferred in patients undergoing cardiac or thoracic surgery. This is especially true for pediatric patients in whom femoral vein catheterization is still preferred despite it carrying a higher risk than other locales. Addition of ultrasound guidance greatly reduces the incidence of arterial puncture and subsequent hematoma formation regardless of location. This is because it allows for visualization of anatomical variation prior to intervention and continual visualization of the needle during the placement. It is noteworthy however, that addition of ultrasound does not prevent complications such as catheter tip embolization as this may occur even with perfect placement. The value of ultrasound usage is undisputable since all studies assessing the difference between it and landmark based methods showed preferable outcome. Reduction of time and number of attempts is sufficient argument to make ultrasound guidance standard practice. Clin. Anat. 30:237-250, 2017. © 2017 Wiley Periodicals, Inc.

Ultrasound and stethoscope as tools in medical education and practice: considerations for the archives.

OBJECTIVES: In recent years, the use and portability of ultrasound has threatened the utility of the stethoscope, with many debating and even advocating its replacement. The authors set out to assess opinions in this regard among faculty within a medical school and specifically within an anatomy department where ultrasound is incorporated into the curriculum from the first term. METHODS: A debate was elicited during a biweekly Anatomy Journal Club session and was centered on three published papers presented. Several questions were raised regarding the possible replacement of stethoscope - the value of early exposure to students as well as how ultrasound and stethoscope should be considered by physicians, students, and teachers. RESULTS: The general consensus was that the stethoscope should not be replaced but should be used in conjunction with emerging portable ultrasound. Caution was given that technology could "overcomplicate" diagnosis and lead to increased tests resulting in increased cost of care. In terms of exposing students to ultrasound, just as the stethoscope requires practice to use effectively, so does the ultrasound and should be introduced as early on as possible. As is the case with the stethoscope, students may not initially appreciate all the finer details on ultrasound; however, continual use would improve skill. CONCLUSION: The stethoscope should always remain part of the physical examination and ultrasound should be used in addition to, not replacement of. As technology advances the need for apprenticeship, training increases and students of the medical profession should be exposed to these technologies as early as possible. Hence, it is not yet time to archive the stethoscope. Perhaps never.

The subdiaphragmatic part of the phrenic nerve - morphometry and connections to autonomic ganglia.

Few anatomical textbooks offer much information concerning the anatomy and distribution of the phrenic nerve inferior to the diaphragm. The aim of this study was to identify the subdiaphragmatic distribution of the phrenic nerve, the presence of phrenic ganglia, and possible connections to the celiac plexus. One hundred and thirty formalin-fixed adult cadavers were studied. The right phrenic nerve was found inferior to the diaphragm in 98% with 49.1% displaying a right phrenic ganglion. In 22.8% there was an additional smaller ganglion (right accessory phrenic ganglion). The remaining 50.9% had no grossly identifiable right phrenic ganglion. Most (65.5% of specimens) exhibited plexiform communications with the celiac ganglion, aorticorenal ganglion, and suprarenal gland. The left phrenic nerve inferior to the diaphragm was observed in 60% of specimens with 19% containing a left phrenic ganglion. No accessory left phrenic ganglia were observed. The left phrenic ganglion exhibited plexiform communications to several ganglia in 71.4% of specimens. Histologically, the right phrenic and left phrenic ganglia contained large soma concentrated in their peripheries. Both phrenic nerves and ganglia were closely related to the diaphragmatic crura. Surgically, sutures to approximate the crura for repair of hiatal hernias must be placed above the ganglia in order to avoid iatrogenic injuries to the autonomic supply to the diaphragm and abdomen. These findings could also provide a better understanding of the anatomy and distribution of the fibers of that autonomic supply.

The internal anatomy of the inferior vena cava with specific emphasis on the entrance of the renal, gonadal and lumbar veins.

Major tributaries such as the renal and adrenal veins have been studied extensively; however, tributaries of the infra-renal segment of the inferior vena cava (IVC) have not been given much attention. Accurate knowledge of the anatomy of these veins is necessary for improved efficacy of surgical interventions in the retroperitoneum. The aim of this study therefore was to provide a comprehensive picture of the internal anatomy of the tributaries of the infra-renal segment of the IVC. Dissection of the posterior abdominal wall was performed on 30 formalin-fixed cadavers. Endoscopic study was carried out followed by a midline venotomy on the anterior wall of the isolated IVC, the location and orientation of its tributaries and their ostia were observed and measurements taken. The results showed that while there was great variation in the drainage pattern of the lumbar veins, most lumbar veins had ostia located between L2 and L3 vertebrae irrespective of the location of renal and gonadal tributaries. Valves were found in 81.81 % of gonadal veins, in 56.60 % of all lumbar veins and discrete ostial valves in 14.81 % of renal veins. The location of the tributaries of the IVC was correlated with the vertebral levels. Empirical data regarding their ostio-valvular complexes were established, which put into question widely accepted concept of valveless tributaries. Our results may implicate surgical procedures in and around the retroperitoneal region.

The clinical anatomy of the musculotendinous part of the diaphragm.

The thoracoabdominal diaphragm is a composite musculotendinous structure, separating the thoracic and abdominal cavities. Reemphasis of the already well-delineated variations of the muscular and tendinous portions, and blood and nerve supply of the diaphragm is becoming apparent. Scientific reports concerning reconstruction of the pericardium, activation of the muscle and the phrenic nerves by use of laparoscopically placed intramuscular electrodes, and repair of congenital and traumatic hernias reemphasize the importance of the muscular to tendinous relationships. The objective of this study, therefore, was to measure the ratio of the surface area of the tendinous central region to the muscular region of the diaphragm and provide a clear description across various specimens. We classified diaphragmatic measurements from 104 adult human diaphragms into six classes (I-VI) based on the ratio of surface area between its tendinous and muscular components. The majority of specimens, 56.7%, was attributed to class II and indicated a tendon-to-muscle ratio of between 10 and 15%; however, a small number of specimens indicated a very large tendon area at the expense of muscle bulk. Future research should be geared toward assessing the relationship between surface area of the musculature and its motor points with focus on interventions for herniation repair and recovery. Our results have shown that surgical interventions should be tailored to the individual, as diaphragm size may not necessarily predict tendon-to-muscle ratio.

The surgical anatomy of the inguinal lymphatics.

Knowledge of the lymphatic system plays critical importance in surgical oncology. The study of the lymphatic system and its role in tumor metastasis continues to advance with new anatomical and surgical studies, and with a new study, we can gain a better understanding on how aggressive surgeons need to be with nodal dissection while balancing the complications with overly aggressive approaches. The lymphatics of the inguinal region represent a network of lymph nodes and vessels, which act as the bridge among the lower extremities, pelvis, perineum, and rest of the body. These lymph nodes are of particular importance in the metastatic spread of genitourinary and lower gastrointestinal epithelial cancer to the inguinal nodes. The aim of this article is to reveal the literature with regard to the inguinal lymph nodes and their relation in various carcinomas.

The surgical anatomy of the lymphatic system of the pancreas.

The lymphatic system of the pancreas is a complex, intricate network of lymphatic vessels and nodes responsible for the drainage of the head, neck, body, and tail of the pancreas. Its anatomical divisions and embryological development have been well described in the literature with emphasis on its clinical relevance in regards to pancreatic pathologies. A thorough knowledge and understanding of the lymphatic system surrounding the pancreas is critical for physicians in providing diagnostic and treatment strategies for patients with pancreatic cancer and pancreatitis. Pancreatic cancer has an extremely poor prognosis and is a notable cause of morbidity and mortality worldwide. Although a surgeon may try to predict the routes for metastasis for pancreatic cancer, the complexity of this system presents difficulty due to variable drainage patterns. Pancreatitis also presents as another severe disease which has been shown to have an association with the lymphatics. The aim of this article is to review the literature on the lymphatics of the pancreas, pancreatic pathologies, and the available imaging methodologies used to study the pancreatic lymphatics.

Anatomical significance in aortoiliac occlusive disease.

Aortoiliac occlusive disease is a subset of peripheral arterial disease involving an atheromatous occlusion of the infrarenal aorta, common iliac arteries, or both. The disease, as it is known today, was described by the French surgeon René Leriche as a thrombotic occlusion of the end of the aorta. Leriche successfully linked the anatomic location of the occlusion with a unique triad of symptoms, including claudication, impotence, and decreased peripheral pulses. The anatomical location of the atheromatous lesions also has a direct influence on classification of the disease, as well as choice of treatment modality. Considering its impact on diagnosis and treatment, we aimed to provide a detailed understanding of the anatomical structures involved in aortoiliac occlusive disease. Familiarity with these structures will aid the physician in interpretation of radiologic images and surgical planning.

A review of the anatomy and clinical significance of adrenal veins.

The adrenal veins may present with a multitude of anatomical variants, which surgeons must be aware of when performing adrenalectomies. The adrenal veins originate during the formation of the prerenal inferior vena cava (IVC) and are remnants of the caudal portion of the subcardinal veins, cranial to the subcardinal sinus in the embryo. The many communications between the posterior cardinal, supracardinal, and subcardinal veins of the primordial venous system provide an explanation for the variable anatomy. Most commonly, one central vein drains each adrenal gland. The long left adrenal vein joins the inferior phrenic vein and drains into the left renal vein, while the short right adrenal vein drains immediately into the IVC. Multiple variations exist bilaterally and may pose the risk of surgical complications. Due to the potential for collaterals and accessory adrenal vessels, great caution must be taken during an adrenalectomy. Adrenal venous sampling, the gold standard in diagnosing primary hyperaldosteronism, also requires the clinician to have a thorough knowledge of the adrenal vein anatomy to avoid iatrogenic injury. The adrenal vein acts as an important conduit in portosystemic shunts, thus the nature of the anatomy and hypercoagulable states pose the risk of thrombosis.

The lateral thoracic artery revisited.

BACKGROUND: Although the variations in the origin of the branches of the axillary and subclavian arteries have been well documented, little information regarding the highly variable lateral thoracic artery (LTA) is available. Descriptions of the LTA variations may prove useful during procedures of the lateral aspects of the thorax such as reconstructive plastic surgery and modified radical mastectomy. PURPOSE: The aim of this study was to examine the anatomy of the LTA and offer an accurate account of its variability. METHODS: The entire course and distribution of the LTA was examined in 420 formalin-fixed adult human cadavers. RESULTS: The LTA was found in 96.7 % of the specimens, showing great morphological variability and classified into six types according to its origin. The most common type was where the LTA arose from the thoracoacromial artery (Type I 67.62 %). In decreasing order of incidence were origins from: the axillary artery (Type II 17.02 %), the thoracodorsal artery (Type III 5 %), and the subscapular artery (Type IV 3.93 %). Additionally, multiple LTAs were present (Type V 3.09 %) and complete absence of LTA (Type VI 3.33 %) was observed. CONCLUSION: Despite variations in origin of the vessels, our dissections demonstrated that the ultimate tissue distribution of the LTA remained typical in the vast majority of the specimens and descended on the lateral border of the pectoralis minor. Our results illustrate the need for re-evaluation of the branches of the thoracoacromial artery with possible consideration that the LTA arises from it, instead of directly from the axillary artery. We hope that the information supplied by this study will provide useful information to anatomists and surgeons alike.