Isolated local recurrence is rare after radical prostatectomy in men with Gleason 7 prostate cancer and positive surgical margins: therapeutic implications

PURPOSE: We determined whether the high biochemical failure rate in men with Gleason score 7 disease and positive surgical margins after radical retropubic prostatectomy is secondary to distant metastasis or to local tumor recurrence that could be eliminated by immediate adjuvant radiation therapy. MATERIALS AND METHODS: Between 1982 and 1997, 112 men with Gleason score 7 disease and positive surgical margins but no seminal vesicle or lymph node involvement underwent radical retropubic prostatectomy without immediate adjuvant radiation or hormonal therapy. Median followup was 8 years (range 1 to 16) and 45 men (40%) were followed 10 years or more. Kaplan-Meier actuarial survival estimates were used to determine the actuarial 5 and 10-year post-prostatectomy, and 5-year post-radiation recurrence rates. RESULTS: The actuarial 5 and 10-year post-prostatectomy biochemical, local and distant recurrence rates were 40% and 52%, 6% and 6%, and 7% and 16%, respectively. For 20 men who received radiation therapy for isolated prostate specific antigen elevation actuarial 5-year post-radiation biochemical recurrence-free rate was 34%. For 5 men who received radiation therapy for local recurrence actuarial 5-year post-radiation biochemical recurrence-free rate was 20%. CONCLUSIONS: Isolated clinical local recurrence is rare during long-term followup of men with Gleason score 7 disease and positive surgical margins at radical prostatectomy. Radiation therapy given at prostate specific antigen elevation poorly controlled the disease. Because patients with biochemical failure rarely had local recurrence at long-term followup, they most likely harbored subclinical distant metastasis. These data suggest that immediate adjuvant radiation therapy will not have a major impact on outcome because most men with Gleason score 7 disease and positive surgical margins in whom treatment fails most likely had distant metastasis at surgery. To improve the outcome in cases of Gleason score 7 disease and positive surgical margins a systemic approach to adjuvant therapy is necessary.     

Choice of induction with, or standby of, extracorporeal lung assist (ECLA) in anesthetic management of bronchoscopic yttrium-aluminium-garnet (YAG) laser treatment of airway tumor

Bronchoscopy with an yttrium-aluminium-garnet (YAG) laser is often used to resect benign and malignant airway tumors and for relief of associated airway stenosis. Complications of this procedure include airway obstruction and hemorrhage. Partial extracorporeal circulation for YAG laser resection in the airway may be helpful in minimizing these complications. Extracorporeal lung assist (ECLA) should be available for such bronchoscopic surgery, although it is not always required. We managed the general anesthesia for bronchoscopic YAG laser resection of airway tumors in two patients. The first case was a 60-year-old man with a right bronchial tumor that had invaded into the trachea across the carina. The narrowest inner diameter of the part of the trachea affected by the lesion was 3 mm. ECLA was initiated for a bronchoscopic YAG laser resection. The second case was a 74-year-old woman with a metastastic lung tumor from osteosarcoma. The narrowest inner diameter of the lesion in the right truncus intermedius was 4 mm. ECLA was kept on standby for possible complications in the bronchoscopic YAG laser resection. These treatments were completed successfully in both patients without any adverse events. ECLA is a useful supporting technique for performing bronchoscopic YAG laser treatment safely ECLA is recommended where a bronchial lesion invades the trachea and crosses the carina, and where a tracheal lesion will not allow passage of a tracheal tube under the bronchoscope. However, ECLA may be kept on standby for a airway tumor limited to one main bronchus, and for a peripheral bronchial lesion, and even for an invasive tracheal lesion through which the tracheal tube under the bronchoscope can pass. Whether it is used or kept on standby depends on the location and severity of airway compromise caused by the airway lesions.     

Computerised axial tomography of the trachea

Case histories are reported of three patients who had large retrosternal goitres which were responsible for significant abnormalities of the airway. Computerised axial tomography demonstrated the exact anatomy. The site of tracheal compression was shown and accurate measurements of the diameter of the trachea at its narrowest point were made. This information was useful when the management of the patient was planned.     

Anesthesia for a patient with severe tracheal stenosis due to thoracic aortic aneurysm

Tracheobronchial compression is a well-recognized complication of thoracic aortic aneurysm. We describe the anesthetic management of a patient with severe tracheal stenosis due to thoracic aortic aneurysm. An 81-year-old woman was scheduled for endovascular aortic stent graft placement. Computed tomographic (CT) scans showed that the narrowest diameter of the trachea was 3 x 18 mm. Awake fiberoptic intubation was selected for anesthesia induction, and percutaneous cardiopulmonary support (PCPS) was ready to be established prior to induction of anesthesia. We successfully inserted ID 6.0 mm spiral tube beyond the tracheal compression using bronchoscope and induced hypotension. The operation was completed successfully without any adverse events. We conclude that, in patients with thoracic aortic aneurysm, careful attention should be paid not only to circulation but to respiration.     

Anesthesia for a cervical myelopathy patient with tracheal stenosis

A 71-year-old male with cervical myelopathy was scheduled for C 3-7 laminectomy. Once he had been rejected of general anesthesia in other hospital because of his tracheal stenosis. The diameter of the narrowest part of his trachea was 5 mm probably resulting from tracheostomy at 2 years of age. His cervical myelopathy seemed to be no problem for anesthesia induction because he had no problems in his neck movement and opening mouth. We evaluated his tracheal stenosis carefully using bronchofiberscopy, chest X-ray, computed tomography and pulmonary function tests. After intravenous fentanyl 100 micrograms and midazolam 2.5 mg, it was impossible to ventilate the patient. Therefore, tracheal intubation was performed immediately after lidocaine administration into the trachea. During surgery, tracheal tube dilated the narrowed portion. After surgery, the tracheal tube was removed under bronchofiberscopic observation without any problems. Tracheal stenosis was observed by chest X-ray after surgery, but he had no complaints.     

Management of radiation dermatitis in a patient after mastectomy.

Women who are diagnosed with breast cancer and undergoing chemotherapy and radiation are at high risk of developing acute radiation dermatitis. The purpose of this case study is to explore an alternative topical therapy for skin toxicity in the post-radiation care of a patient with a history of breast cancer. The patient, a 54-year-old white female, was treated by modified radical mastectomy, chemotherapy, and radiation. During post-radiation therapy the patient developed wet desquamation reaction over the midincision line into the right axilla. Balsam Peru, hydrogenated castor oil, trypsin (Xenaderm Healthpoint, San Antonio, Tex) was trialed to evaluate efficacy in providing wound healing to the denuded skin. Within 14 days of treatment, the area was completely healed and topical therapy stopped. This case study provides the basis for further research into the area of topical therapy for women with moist desquamation after radiation for breast cancer.     

A rare image of post-CTRT iatrogenic tracheoesophageal fistula

A tracheoesophageal fistula may occur due to direct extension of tumour tissue in the trachea and oesophagus, pressure necrosis by a tracheostomy tube in apposition to a nasogastric tube, or tracheoesophageal injury due to other sorts of instrumentation. Bevacizumab is known to cause post-chemotherapy tracheoesophageal fistulae. We present barium swallow x-rays of a female with squamous cell carcinoma of the middle third of the oesophagus; she was being treated weekly with a 6-week regimen of concurrent chemoradiotherapy (CTRT). The x-rays show the formation of a tracheoesophageal fistula at the mid-oesophagus with dye traversing in both directions. It is likely that the tracheoesophageal fistula was formed by trauma due to food matter on a friable sloughed off post-CTRT oesophageal mass. In the majority of cases, these fistulae do not form during chemoradiotherapy, but manifest about six months later. However, in the case presented herein, the fistula was formed in the immediate post-radiation phase.     

Post-radiation Atypical Vascular Lesion/Angiosarcoma Arising in the Larynx

Atypical vascular lesions (AVL) and angiosarcomas (AS) are lesions known to arise after radiation therapy. These lesions can show overlap in both their gross and histologic pictures, and distinction between the two can be extremely challenging at times. They are known most commonly to arise in the breast region after radiation therapy. We present the first unique case of post-radiation AVL/AS arising in the larynx of a 51 year old woman, occurring 8 years after she received radiation for tonsillar squamous cell carcinoma.     

Acute infective airway obstruction associated with subglottic stenosis

Pre-existing subglottic stenosis in a 22-month-old child with laryngotracheobronchitis resulted in failure to intubate the trachea on the intensive therapy unit. Tracheostomy was necessary in the operating theatre to secure the airway. The implications for safe management are discussed.     

Anesthetic management using extracorporeal circulation of a patient with severe tracheal stenosis by thyroid cancer]

A 64-year-old male with tracheal stenosis by thyroid cancer was scheduled for the emergency management of airway maintenance and total thyroidectomy. Dyspnea and orthopnea appeared suddenly on the admission for operation. Cervical CT and bronchial fiberscope examination revealed the trachea oppressed at the frontal neck by thyroid tumor. The trachea diameter was nearly 5 mm at the narrowest part. Therefore it seemed to be of high risk of perform tracheal intubation and tracheostomy. Extracorporeal circulation was adopted for the respiratory management at anesthesia induction. At first, the femoral artery and vein were cannulated with local anesthesia for cardiopulmonary bypass (CPB). After confirming CPB pump working, intravenous anesthetic agents were infused. Thyroid tumor was partially resected and tracheostomy was done under CPB. After the tracheostomy, a spiral tracheal tube was inserted. Anesthesia was maintained with sevoflurane and managed with controlled ventilation. Thereafter operation and anesthesia were uneventful. After the operation, pleural bloody effusion was noticed. Blood in effusion seemed to be due to the heparinization in extracorporeal circulation. We conclude that anesthetic management with extracorporeal circulation is one of useful methods for managing severe tracheal stenosis.     

Radiotherapy for prostate cancer and sexual health

Sexual dysfunction is very common after treatment of prostate cancer. Radiation therapy together with radical prostatectomy is the most effective treatment for localized disease. Percentages of erectile dysfunction (ED) reported in prospective studies after external-beam radiotherapy (RT) vary from 60-70%, and these are similar after brachytherapy. In randomized trials more realistic percentages of 30-40% are reported. Modern techniques do not seem to decrease post-radiation ED. No final conclusions can be drawn whether or not the radiation dose to the penile structures correlates with post-radiation ED in patients treated for prostate cancer. The etiology of ED after RT of prostate cancer is most probably multi-factorial. The phosphodiesterase type 5 inhibitors (PDE5-I) sildenafil and tadalafil have been shown to be effective to treat post-radiation ED in about half of the patients in randomized trials. Patients and their partners need to be adequately counselled on the effects of cancer treatment on their sexual life and relationship, and about the different treatment possibilities. Sexual counselling has not become yet a routine part of oncology care in most hospitals, but this should be provided. Due to the lack of robust data, prevention of post-radiation ED with PDE5-I cannot be recommended so far.     

Arteriotracheal fistula as a fatal complication after tracheal resection and twice-a-day-irradiation for thyroid carcinoma

Background The arteriotracheal fistula is a severe, and mostly fatal complication in the treatment of patients with head and neck cancer. Methods We report a case of fatal haemorrhage from a fistula between the right brachiocephalic trunk and the trachea after radical thyroidectomy, resection of the frontal wall of the cervical trachea, and twice-a-day-irradiation. Results Compared to conventional irradiation therapy, twice-a-day-irradiation seems to be the major cause of this fatal complication. Conclusions Therefore we prefer conventional irradiation therapy to twice-a-day-irradiation in patients with R0 resection (curative tumor removal) and reconstructive surgery of the trachea and/or esophagus. In patients where R0 resection is impracticable, a reconstructive approach to the trachea or esophagus has to be avoided. In these cases, early postoperative twice-a-day-irradiation may prevent early tumor recurrence.      

Ureteral complications after intravesical formalin instillation

Results of formalin therapy for hemorrhage owing to post-radiation cystitis have been studied with special reference to the frequency and severity of ureteral complications. Gross bleeding stopped in 25 of 27 patients within 48 hours. However, 5 patients became anuric immediately after the instillation and in another 7 patients a transient increase in the serum creatinine level was observed. Urinary diversion was necessary in 11 of the 27 patients. The complication rate in the present study is considerably higher than reported previously. Complications may be explained by vesicoureteral reflux of a too strong formalin-alcohol solution. To avoid future complications we suggest that 1) a high diuresis should be induced peroperatively, 2) a 1 to 2 per cent formalin solution without alcohol should be used and 3) the instillation pressure should not exceed 15 cm. water.     

A case of giant thyroid tumor with tracheal stenosis

A 61-year-old female underwent resection of a giant thyroid tumor, and tracheal stenosis ensued. She had cough, dyspnea, and palpitation in the supine position. The giant thyroid tumor was of the size of 11 x 12 cm and the diameter of trachea was 8 x 6 mm at 3.5 cm below the vocal cord, at which point the trachea was the narrowest on cervical computed tomography. The peak expiratory flow rate from the flow-volume curve was 2.94 l x sec(-1) (% predicted value 55.2%) in the upright position. We were concerned about difficult airway management. Oro-tracheal intubation with an armored tube (ID 7.5 mm) was performed after intravenous midazolam 2 mg and fentanyl 50 microg, 4% lidocaine spray 2 ml with oxygen 6 l x min(-1) inhalation keeping spontaneous breathing and consciousness. Anesthesia was induced and maintained with intravenous propofol, fentany, vecuronium and nitrous oxide in oxygen to keep the bispectral index between 40 and 60. The extracted thyroid tumor was 620 g in weight. A careful preoperative evaluation of the airway using ultrasonography, CT, MRI, laryngoscopy, bronchoscopy and respiratory function test, especially peak expiratory flow rate of the flow-volume curve is important in such a case of a giant thyroid tumor. Intubation under conscious sedation with midazolam and fentanyl is useful for a patient with a giant thyroid tumor and tracheal stenosis.     

Osteosarcoma of the skull. Report of a post-Paget and post-radiation case in an elderly woman

Osteosarcomas rarely affect the skull, preferring the long bones. As at other sites, osteosarcomas of the skull may be classified chiefly as de novo, post-radiation and post-Paget cases.Plain films of the skull and, even more, CT and MRI are the key diagnostic procedures for this disease.The treatment is surgery plus chemotherapy, in some cases radiotherapy.We report an odd case of post-radiation and post-Paget osteosarcoma in an elderly woman whose sister had been similarly affected.     

Intubation injuries of the trachea in children. Management and prevention.

The problem of intubation injuries of the trachea in children has been summarized. Preventive measures designed to protect the trachea from injury have been outlined. In spite of these measures, acute intubation injuries have occurred in 15 children. An aggressive approach combining bronchoscopic evaluation, intratracheal injection of steroids, tracheal stenting with an endotracheal tube and systemic steroids has been employed in the treatment of these injuries. We feel that this therapy has prevented the development of cicatrical stenosis in many of the cases and has allowed permanent decannulation of the trachea.     

Acinic Cell Carcinoma of the Trachea: Report of a Case

Acinic cell carcinoma (ACC) is a very rare primary tracheal carcinoma. We report a case of primary ACC of the trachea, which represents, to the best of our knowledge, only the fifth such case ever documented. Pharyngolaryngoesophagectomy was necessary for complete resection because the tumor invaded the trachea widely, up to the cricoid cartilage and involving the cervical esophagus. Although invasion of the upper aerodigestive tract by neoplasma is rare, to achieve complete resection and an acceptable prognosis, even a tumor with low malignancy requires wide resection.     

Clinical study of 18 vesicointestinal fistulas

We studied 18 cases of vesicointestinal fistula surgically treated between January 2001 and July 2005. The underlying'cause was an inflammatory disease in 12 cases, a carcinoma in 5 and injury (post-radiation therapy) in 1 case. The fistula was visualized by cystography in 2 cases and enterography in 4. Surgical procedures were cystectomy with enterectomy in 2 cases, partial cystectomy with enterectomy in 3, bladder wall overlay-suture with enterectomy in 6 and enterectomy alone in 4. In 3 cases, colostomy without enterectomy was performed for palliative surgery. In all cases the postoperative course was good and surgical treatment was effective. Surgical procedures varied in each case depending on the etiology and the patient's condition.     

Salvage Lymphadenectomy of the Right Recurrent Nerve Node with Tracheal Involvement After Definitive Chemoradiation Therapy for Esophageal Squamous Cell Carcinoma: Report of Two Cases

Thoracic esophageal cancers frequently metastasize to the right recurrent nerve nodes (RRNNs). In fact, huge RRNNs invading the trachea sometimes remain after definitive chemoradiation therapy (CRT), despite complete remission of the primary lesion. We performed salvage lymphadenectomy of a large RRNN combined with partial resection of the trachea in two patients. Using an anterior approach, we removed part of the sternum, clavicle, and the first and second costal cartilage; then, we removed the RRNNs with combined resection of the lateral quarter circumference of the trachea, the esophageal wall, and the recurrent nerve. Reconstruction was done with a musculocutaneous patch of major pectoral muscle to cover the tracheal defect. The only minor complication was venous thrombosis in one patient. Thus, combined removal of the RRNN and trachea was performed safely as a salvage operation after definitive CRT for esophageal squamous cell carcinoma.     

Endovascular repair of radiation-induced bilateral common carotid artery stenosis and pseudoaneurysms: a case report

BACKGROUND

Radiation-induced damage to small and medium-sized vessels has been observed in both animals and humans. Changes may appear in the immediate postradiation period or many years later. In this case, we report an unusual presentation of bilateral radiation-induced carotid artery stenoses associated with pseudoaneurysms, and a previously unreported application of a recently established treatment.

CASE DESCRIPTION

A 72-year-old African-American male presented with recurrent right hemispheric transient ischemic attacks (TIA) and neck pain. Thirteen years previously, the patient had received radiation therapy for laryngeal carcinoma. Diagnostic carotid angiography demonstrated moderate radiation-induced bilateral carotid artery stenosis and associated common carotid pseudoaneurysms. The patient was treated with bilateral endovascular stents and electrolytically detachable coils in staged procedures. At his most recent follow-up, there is no evidence of re-stenosis and the patient remains asymptomatic.

CONCLUSIONS

This case illustrates a novel and successful treatment for the endovascular repair of post-radiation bilateral carotid artery stenosis and pseudoaneurysms. In our practice, we have seen three such cases of radiation-induced vasculopathy. Therefore, patients with a previous history of radiation therapy for head and neck neoplasms merit cautious monitoring and judicious use of stents and secondary coils, when necessary.