An evidence-based treatment algorithm for colorectal polyp cancers: results from the Scottish Screen-detected Polyp Cancer Study (SSPoCS).

OBJECTIVES: Colorectal polyp cancers present clinicians with a treatment dilemma. Decisions regarding whether to offer segmental resection or endoscopic surveillance are often taken without reference to good quality evidence. The aim of this study was to develop a treatment algorithm for patients with screen-detected polyp cancers. DESIGN: This national cohort study included all patients with a polyp cancer identified through the Scottish Bowel Screening Programme between 2000 and 2012. Multivariate regression analysis was used to assess the impact of clinical, endoscopic and pathological variables on the rate of adverse events (residual tumour in patients undergoing segmental resection or cancer-related death or disease recurrence in any patient). These data were used to develop a clinically relevant treatment algorithm. RESULTS: 485 patients with polyp cancers were included. 186/485 (38%) underwent segmental resection and residual tumour was identified in 41/186 (22%). The only factor associated with an increased risk of residual tumour in the bowel wall was incomplete excision of the original polyp (OR 5.61, p=0.001), while only lymphovascular invasion was associated with an increased risk of lymph node metastases (OR 5.95, p=0.002). When patients undergoing segmental resection or endoscopic surveillance were considered together, the risk of adverse events was significantly higher in patients with incomplete excision (OR 10.23, p<0.001) or lymphovascular invasion (OR 2.65, p=0.023). CONCLUSION: A policy of surveillance is adequate for the majority of patients with screen-detected colorectal polyp cancers. Consideration of segmental resection should be reserved for those with incomplete excision or evidence of lymphovascular invasion.

Comparison of two-dimensional echocardiographic and angiographic findings in arrhythmogenic right ventricular dysplasia.

Comparison of 2-dimensional (2-D) echocardiographic and right ventricular (RV) angiographic findings was performed in 10 patients with arrhythmogenic RV dysplasia. Diagnosis was based on accepted electrocardiographic and angiographic criteria. Nine patients underwent invasive electrophysiologic study, which confirmed RV source of ventricular tachycardia (VT) in 7. Biopsy findings of RV dysplasia were available in 3 patients. Two-dimensional echocardiography and angiography corresponded closely when diffuse RV enlargement and hypokinesia were present. Such diffuse findings were not invariably present. Localized abnormalities consisting of bulging or sacculation of the RV wall were noted by both techniques, even in the absence of diffuse changes. Echocardiographic evidence of localized disease predicted the presence of similar lesions at angiography, but agreement as to specific location was poor. Subjectivity in interpreting subtle RV abnormalities by either technique and the inherent differences in information provided by the 2 methods probably account for the inconsistencies. In the patient with suspected arrhythmogenic RV dysplasia, 2-D echocardiographic evidence of diffuse RV enlargement, otherwise unexplained, strongly supports the diagnosis and angiography may be avoided. Isolated local changes seen by echocardiography should increase suspicion of RV dysplasia, but complementary angiographic study is warranted.

Negative cytology preceding cervical cancer: causes and prevention.

AIM: To assess the validity of negative cervical smear reports in women who subsequently developed cervical cancer; and to determine means of improving the screening process. METHODS: One hundred and forty cervical smears, initially reported as negative from 103 women, and taken up to 12 years before diagnosis of cervical cancer, were reviewed. RESULTS: Ninety two smears contained dyskaryotic cells. Analysis showed that these smears formed several well defined patterns. False negative reports were likely to occur if fragments of neoplastic tissue rather than dissociated dyskaryotic cells were present or if the smear contained few dyskaryotic cells. Screening fatigue appeared to be a factor in others. It was also considered important that smears contained cells from the endocervix. These were deficient in 64% of the 47 smears confirmed as negative on review and in 69% of smears containing only a few dyskaryotic cells. CONCLUSIONS: Current methods of quality assurance will not remedy these defects in the screening process. It is the responsibility of laboratories to identify sources of poor smears and liaise with smear takers to ensure an improvement in quality. Assessment of the quality of smears received by a laboratory should become an important part of audit. Staff training should place more emphasis on the interpretation of "microbiopsies". The adoption of a quick scanning technique before conventional screening would probably also substantially reduce false negative results.

Malignant lymphoma with a high content of epithelioid histiocytes.

A series of 12 patients with a rare malignant lymphoma containing numerous epithelioid histiocytes (MLEH), originally believed to be an atypical variant of Hodgkin's disease, is described. Clinicopathological studies suggest MLEH is a distinct entity among the non-Hodgkin's lymphomas which is generally resistant to therapy and has an unfavourable prognosis. Differentiation of the disease from angioimmunoblastic lymphadenopathy and Hodgkin's disease is discussed. In the necropsy case MLEH had transformed into a malignant lymphoma of histiocytic type.

Marrow hypoplasia with splenomegaly in adolescence.

Four adolescents presented with leucopenia, thrombocytopenia, and splenomegaly; three had associated congenital abnormalities and two had a cirrhosis. They provide further evidence of an association between hepatic disease and bone marrow dysfunction. It is considered that these patients suffer from a genetic or constitutional disorder which may result in a susceptibility of their bone marrow to hypoplasia following viral hepatitis or other infections.

Cytological changes preceding cervical cancer.

Cervical smears were reviewed from 62 women who developed squamous carcinoma of the cervix up to 18 years later. The findings indicate that the prevention of cervical cancer by screening depends very largely on the detection of severe dyskaryosis. In this series there was no evidence that mild dyskaryosis was a forerunner of invasive disease. Cytology during the evolution of squamous carcinoma is not characterised by a dyskaryosis which progressively increases in severity. Instead the findings support new concepts that cervical cancer generally arises from an aggressive CIN 3 lesion widely present in the cervix, and in our series, established years before invasion occurs. It would be more useful to report cytology as showing either a low or high grade abnormality rather than distinguishing between different degrees of dyskaryosis.

Identification of cellular immunoglobulins in chronic lymphocytic leukaemia by immunoperoxidase staining.

An indirect immunoperoxidase technique has been used for visualisation of cellular immunoglobulins in chronic lymphocytic leukaemia. Baker's formol calcium was used as fixative. Monoclonal light and heavy chain patterns were demonstrated in 24 out of 27 cases. Only one case did not have any demonstrable immunoglobulins. The presence of alpha or gamma heavy chain immunoglobulin isotypes in leukaemic lymphocytes was found to be related to low mouse rosetting capacity (p less than 0.05).

An assessment of the macrophage electrophoretic mobility test (MEM) in cancer diagnosis.

The results of an assessment of the macrophage electrophoretic mobility test in cancer diagnosis are described. We found that the test did not reliably distinguish between a group of 18 patients with benign disorders and a group of 25 with malignant disease.

Comparative histological and radiographic effects of CO2 laser versus standard surgical anterior cervical discectomy in the dog.

The use of the CO2 laser in the extirpation of selected intracranial and spinal tumors has been shown to be of great benefit. The role of the CO2 laser as applied to other neurosurgical procedures has not been adequately explored or defined. The authors have compared the radiological and histological effects of performing anterior cervical discectomy with the CO2 laser to those of performing it by standard operative technique. Groups of laboratory dogs underwent anterior cervical discectomy performed in both operative fashions. The animals were killed and the operated disc spaces were examined radiographically and microscopically. Observations were made 1, 3, 5, 8, and 10 weeks postoperatively. Based upon these radiographic and microscopic evaluations, the authors were able to draw certain conclusions with respect to the use of the CO2 laser in performing anterior cervical discectomy.

High resolution computed tomographic scanning in the detection of intratemporal neuromas of the facial nerve.

Continued refinements in the technique of high resolution computed tomographic scanning now allow the study of the pathology of intratemporal tumors of the facial nerve. The normal anatomy of this area and a selected case of facial nerve neuroma diagnosed with high resolution computed tomography are presented.

Use of the carbon dioxide laser in the operative management of intracranial meningiomas: a report of twenty cases.

This study presents 20 cases of meningioma of various intracranial locations, all of which were removed with the carbon dioxide surgical laser system. The carbon dioxide laser is contrasted with other means of meningioma removal to emphasize the advantages of this new technology. These advantages include: (a) the ability to operate with smaller exposures, (b)reduced brain retraction, (c) a reduced amount of mechanical manipulation by vaporizing the tumor mass, (d) vaporization of the dural attachment after the removal of tumor, (e) improved operative precision, and (f) decreased intraoperative significant advancement in the ability to remove meningiomas that might prove difficult to extirpate by conventional means.

Malignant nerve sheath tumor of the facial nerve: case report and discussion.

The third reported case of a malignant nerve sheath tumor of the facial nerve is presented. The clinical course and pathological findings are described and serve as the basis for a discussion concerning malignant nerve sheath tumors arising in the cranial nerves.

Use of cranial surface anatomic fiducials for interactive image-guided navigation in the temporal bone: a cadaveric study.

OBJECTIVE: Because of the intricate anatomy of the temporal bone, we examined the feasibility and reliability of cranial surface anatomic fiducials to register computed tomographic images of the temporal bone by using a frameless image-guided system. METHODS: One-millimeter thick computed tomographic slices and the smallest possible field of view were used to register 10 dry and 10 fresh temporal bones from cadavers. The fiducials used for registration included the umbo of the tympanic membrane, emissary foramina, the asterion, various sutures, the tip of the mastoid process, and Henle's spine. RESULTS: Mean initial fiducial registration error ranged from 0.6 to 0.7 mm, and was reduced to 0.5 and 0.4 mm for the dry cranial and cadaveric studies, respectively, by eliminating or reregistering inexact fiducials. Mean target localization error ranged from 0.91 to 2.44 mm for superficial structures of the temporal bone in the dry cranial specimens and from 0.71 to 1.52 mm for deep structures such as the facial nerve, semicircular canals and ossicles in the cadaveric study. CONCLUSION: Interactive image-guided navigation in the temporal bone is possible with registration of cranial surface anatomic fiducials. It may be useful to the neurosurgeon and otologist in identifying critical anatomic structures of the temporal bone encountered during the translabyrinthine, retrolabyrinthine presigmoid, and suboccipital approaches.

Mycobacterium tuberculosis meningitis: a report of twelve cases and a literature review.

Twelve recent cases of Mycobacterium tuberculosis meningitis were presented, and the literature was reviewed. There are no particularly new or unique therapies or approaches to the management of this most serious disease. The major obstacle to successful diagnosis and treatment of tuberculous meningitis continues to be a lack of clinical suspicion of its presence. As illustrated in the cases presented, it has been our experience that patients already moribund or nonresponsive do not respond, regardless of the intervention undertaken. The most sensitive and economical method of detecting M. tuberculosis in the CSF may be LPA. However, this has not yet been widely validated or accepted. Larger volumes of CSF should be sent to the laboratory for testing and centifuged to about 5x concentrations before both acid-fast bacilli staining and culture are attempted. If tuberculous meningitis is suspected, three-drug therapy can be started immediately without jeopardizing subsequent culture confirmation of the presence of the TB bacillus. In addition, these patients must be followed closely to detect hydrocephalus at the earliest possible moment. When patients fail to respond to appropriate antituberculosis and pressure-reducing therapy, hydrocephalus should be actively sought by either CT or radioisotope cisternography. Although the decision to proceed to ventricular drainage or shunting must be individually made in adult patients with infection-related hydrocephalus, we agree with others that surgical intervention should be considered early and should be performed if the level of consciousness deteriorates, intracranial pressure increases, or ventricular enlargement or enhancing basal exudates are identified on CT.

Reformatted sagittal images in the differential diagnosis of meningiomas and pituitary adenomas with suprasellar extension.

Approximately 3 to 4 times a year, a tumor with suprasellar extension escapes classification on high resolution coronal and transaxial computed tomography. When arteriography failed to determine the diagnosis, the differential choices were usually meningioma or pituitary adenoma. The authors report the use of sagittal reformatted images in this differential diagnosis and conclude that these images may aid in the distinction between pituitary tumors with suprasellar extension and meningiomas located in this area.

Use of the carbon dioxide laser for acoustic tumor surgery.

The carbon dioxide laser has been used clinically in both otorhinolaryngology and neurological surgery for approximately 10 years. Only recently, however, have technical modifications allowed its use with the operating microscope, providing the increased precision and control necessary for intracranial surgery. This paper reports the authors' experience with the carbon dioxide laser in the removal of acoustic tumors, details the surgical technique involved, and describes the advantages that may accompany the use of the laser in the removal of these difficult lesions.

Sacral plexus nerve sheath tumor: case report.

A young woman with chronic sciatica was found to have an intrapelvic sacral plexus nerve sheath tumor. Computed tomography of the pelvis was used to delineate this unusual site of tumor development. The case report and a discussion of pelvic nerve sheath tumors are presented.

Neuroradiological detection of small and intracanalicular acoustic tumors: an emphasis on CO2 contrast-enhanced computed tomographic cisternography.

Seventy patients suspected clinically of having an acoustic tumor were evaluated using the computed tomographic (CT) scan as the initial neuroradiological procedure, followed by CO2 contrast CT cisternography in cases where the intravenous contrast-enhanced scan did not reveal any lesion. Forty-eight gas CT cisternograms revealed 10 small acoustic tumors, 2 of which were totally intracanalicular. The authors present a review of the basic CT anatomy of the temporal bone as it relates to acoustic tumors. Based upon the ease of performance of the procedure, the low postexamination morbidity, and the excellent diagnostic results, CO2 CT cisternography is recommended as the procedure of choice in the diagnosis of small and intracanalicular acoustic tumors.

Nonsurgical management of small and intracanalicular acoustic tumors.

Although surgical removal is generally regarded as the management strategy of choice for acoustic tumors, there remains a small group of patients usually with small or intracanalicular tumors in whom nonoperative management may be a desirable alternative to operation. The authors present a series of six such cases and discuss criteria that may aid in the selection of patients suitable for initial nonoperative management.

Microprocessor-controlled scanning micromanipulator for carbon dioxide laser surgery. Technical note.

A microprocessor-controlled scanning device for use in carbon dioxide laser surgery is described. This device increases the speed of dissection, allows the surgeon to keep both hands in the operative field, and thereby decreases the fatigue associated with manual control of the micromanipulator used in a surgical laser system.