Ulcerative colitis-associated colorectal carcinoma. DNA ploidy as indicator of impending malignant transformation?

The onset of a malignant transformation in long-standing ulcerative colitis is difficult to predict. The value of the clinical and histomorphological parameters in current use is limited. It was thus aim of the present study to investigate the value of DNA-ploidy for the early detection of a malignant transformation in long-standing ulcerative colitis. This retrospective study comprised 20 patients with long-standing ulcerative colitis. The average observation time was 7.3 years (range: four to twelve years). All patients took part in a surveillance program and had between four and seven colonoscopies within a minimum period of time of five years. At these instances mucosal biopsies were taken in a standardized manner at eight different locations throughout the colon. These paraffin-embedded specimens (n = 542) were analyzed histomorphologically and DNA-cytometrically. During the observation time five patients developed an ulcerative colitis-associated colorectal carcinoma (UCA). In these patients epithelial dysplasias were not more common than in the remaining 15 cases. The vast majority of the specimen of the patients with UCA showed distinct DNA-cytometrical alterations, i.e. they were aneuploid. Such aneuploid mucosal cell populations were distributed over the whole colon, irrespectively of the later site of the carcinoma. These aneuploid lesions were found in one case eleven years, in an average seven years prior to the final diagnosis of a UCA. In contrast, the colon epithelium of the patients without UCA showed only proliferative-diploid DNA-distribution patterns during the observation time. In summary, affected patients had multiple highly aneuploid lesions of the colon mucosa at an average of seven years prior to the final diagnosis of UCA. These lesions came from macroscopically chronic inflamed tissue, and where histomorphologically without signs of dysplastic transformation. DNA-cytometrical investigations could thus be of additional predictive value for the individual risk assessment as regards an impending malignant transformation.     

Is sarcoma a complication of arterial femoro-popliteal bypass?

Angiosarcoma is a rare neoplasm comprising 1 to 2% of soft tissue sarcoma. This tumor has been associated with previous irradiation, exposure to toxins and the presence of foreign bodies. A case report of an epithelioid angiosarcoma that developed at the site of an arterial femoro-popliteal bypass using autologous vein is described. The initial presentation looked like a painful popliteal cyst. Chronic fibrosis secondary to the thrombosis could play a role in the tumorogenesis of this uncommon tumor. This case illustrates that sarcoma may be a late complication of vascular bypass and may have a rheumatologic presentation.     

Recurrent Symptoms after Fundoplication with a Negative pH Study—Recurrent Reflux or Functional Heartburn?

Introduction  A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Over two thirds of these patients will have a negative 24-h pH study. The aim of our study is to determine whether these patients have an associated functional disorder or abnormal cytokine activity and to examine the reproducibility of pH testing. Methods  A prospective analysis was carried out on a cohort of patients who had undergone a fundoplication and postoperative pH testing for recurrent heartburn: group A—patients with recurrent heartburn and a negative 24-h pH study and group B (control group)—patients with recurrent heartburn and a positive pH study. Questionnaires, a blood sample, and repeat pH testing were completed. Results  Sixty-nine patients were identified. Group A’s depression score (8.6 ± 4.1) was significantly higher than group B’s (5.9 ± 4.2; P = 0.03). Cytokine levels were similar in both groups. Forty-seven of 49 (96%) patients who underwent repeat pH testing had a negative study. Symptom-reflux correlation was highly significant (P < 0.001). Conclusion  Some patients with recurrent heartburn and a negative pH study have associated functional or psychiatric comorbidities such as depression. Reproducibility of 24-h pH testing in these patients is excellent.     

Regional anesthesia in cardiac surgery: a friend or a foe?

Escalating costs and change in the profile of patients presenting for cardiac surgery requires modification of perioperative management strategies. Regional anesthesia has played an integral part of many fast-track anesthesia protocols across North America and Europe. This review suggests that for patients undergoing coronary artery bypass graft surgery, the risk-to-benefit ratio is in favor of epidural and spinal anesthesia, provided there are no specific contraindications and the guidelines for the use of regional techniques in cardiac surgery are followed. Patients managed with regional techniques seem to benefit from superior postoperative analgesia, shorter postoperative ventilation, reduced incidence of supraventricular arrhythmia, and lower rates of perioperative myocardial infarction. The results of this analysis suggest that for each episode of neurologic complication, 20 myocardial infarctions and 76 episodes of atrial fibrillation would be prevented, thus, we would consider the regional anesthesia and analgesia to be an effective strategy that improves perioperative morbidity. However, other treatment modalities such as the addition of calcium channel blockers, aspirin, and beating heart surgery, are also suggested to be beneficial in cardiac surgical patients and may impose less risk than the use of regional techniques. We believe that the results presented in this review are encouraging enough to permit continued investigation. A prospective, randomized, controlled multicenter trial needs to be adequately powered to answer important clinical questions and allow for a long-term follow-up.     

Gastrointestinal bleeding as presentation of small bowel metastases of malignant melanoma: Is surgery a good choice?

INTRODUCTIONMelanoma shows a particular predilection in involving small intestine both in a single site and in multiple localization and acute or chronic gastrointestinal bleedings are often the first sign of tumour.PRESENTATION OF CASEWe report two cases of GI metastases of malignant melanoma, one presented with only a big mass that cause intestinal obstruction and the other with a tumour spread throughout the small intestine that produce enterorrhagia.DISCUSSIONDiagnosis and follow-up are very difficult: CT scan, PET-CT scan and capsule endoscopy should be complementary for the assessment of patients with GI symptoms and melanoma history.CONCLUSIONWhat is the role of surgery? Several studies suggest metastasectomy to achieve both R0 results and palliative resolutions of acute symptoms, such as obstruction, pain, and bleeding.     

Modeling population pharmacokinetics of lidocaine: should cardiac output be included as a patient factor?

BACKGROUND: Inclusion of cardiac output and other physiologic parameters, in addition to or instead of, demographic variables might improve the population pharmacokinetic modeling of lidocaine. METHODS: Thirty-one patients were included in a population pharmacokinetic study of lidocaine. After bolus injection of lidocaine (1 mg/kg), 22 or 10 blood samples per patient were taken from a radial artery. During the experiment, cardiac output was measured using a thoracic electrical bioimpedance method. The following four population pharmacokinetic models were constructed and their performances investigated: a model with no covariates, a model with cardiac output as covariate, a model with demographic covariates, and a model with both cardiac output and demographic characteristics as covariates. Model discrimination was performed with the likelihood ratio test. RESULTS: Inclusion of cardiac output resulted in a significant improvement of the pharmacokinetic model, but inclusion of demographic covariates was even better. However, the best model was obtained by inclusion of both demographic covariates and cardiac output in the pharmacokinetic model. CONCLUSIONS: When population pharmacokinetic models are used for individualization of dosing schedules, physiologic covariates, e.g., cardiac output, can improve their ability to predict the individual kinetics.     

Aortic reconstruction and resection of malignant tumors--one- or two-stage procedure?

Surgical tactics in case of aortic aneurysms and simultaneously performed cancer resections are not uniform and still remain a matter of debate. From Jan. 1, 1995 - Oct. 31, 2001 we operated on 37 patients suffering from aortic aneurysms (34 infrarenal, 2 combined thoraco- abdominal, 1 thoracic aneurysm) and cancer (11 esophageal, 6 gastric carcinomas, 3 small-bowel tumors, 5 large-bowel, and 12 renal carcino-mas). None of the above mentioned patients presented with any graft infection, or other severe p. op. complications. According to these results, the one-stage operation of aortic aneurysms and cancer resection is feasible if appropriate care is given to patients selection, technical details and the rules of antisepsis, without affecting surgical morbidity and mortality.     

Debulking or biopsy of malignant glioma in elderly people – a randomised study

Summary. Background: Patients with radiologically (MRI and/or CT images) suspected malignant glioma is referred to radiotherapy after craniotomy and resection of the tumour or after diagnostic biopsy. Patients with poor preoperative status and elderly patients are diagnosed more often by biopsy and treated by radiotherapy rather than by craniotomy and tumour resection. However, based on previous retrospective studies it is not possible to conclude which procedure is better for elderly patients. Thus a prospective study comparing these two procedures with elderly patients was planned.  Methods: 30 patients older than 65 years with radiologically (CT and/or MRI) obvious malignant glioma were randomised into two groups: I) stereotactic biopsy and II) open craniotomy and resection of the tumour. Nineteen patients were diagnosed to have grade IV glioma and four patients grade III glioma. Seven out of 30 (23%) were followed in the “intention-to-treat” group with diagnosis of stroke (n=3), metastasis (n=2), malignant lymphoma (n=1) and one with out histological diagnosis. Patients with histologically verified malignant glioma (grade III–IV) were diagnosed by stereotactic biopsy (n=13) or by open craniotomy and resection (n=10) and all the patients were referred to radiotherapy. Survival and time of deterioration were followed.  Findings: The overall median survival time was 146 (95% CI 89–175) days after the procedure. The estimated median survival time was 171 (95% CI 146–278) days after the craniotomy versus 85 (95% CI 55–157) days after the biopsy (p=0.035). The estimated survival time was 2.757 times longer (95% CI 1.004–7.568, p=0.049) after craniotomy. However, there was no significant difference in the time of deterioration between these two treatments (p=0.057). Amount of radiotherapy given had a significant effect on survival (p=0.001).  Interpretation: Longer survival time is achieved after open craniotomy and resection of tumour. However, overall benefit of open surgery to patient seems to be modest, while time of deterioration did not differ between two treatment groups. Our results support previous studies on the benefit of radiotherapy in the treatment of malignant glioma. Published online January 14, 2003 Acknowledgments  The authors thank Dr M?ntyl? at the department of Oncology in Helsinki University hospital for his help in organising postoperative radiotherapy. The authors are grateful to Dr Anders Petau at the department of pathology and neuropathology in Helsinki University hospital, for histological studies. This study was supported by the grant of Maire Taponen foundation.  Correspondence: Ville Vuorinen, Department of Surgery/Neurosurgery, Turku University Hospital, Kiinanmyllynkatu 4, 20520 Turku, Finland.     

Extrapleural pneumonectomy or supportive care: treatment of malignant pleural mesothelioma?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether extrapleural pneumonectomy (EPP) is superior to supportive care in the treatment of patients with malignant pleural mesothelioma (MPM). Overall, 110 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that EPP confers no advantage to chemotherapy and palliative treatment in terms of survival and symptom improvement. Ten studies evaluated the role of EPP in the management of MPM. The median survival was 13 months and perioperative and 30-day mortality rates were 5.7% and 9.1%, respectively. There was a high morbidity rate of 37% including atrial fibrillation, empyema and supraventricular arrhythmias. Disease recurred in 73% of patients at a median time of 10 months. Median hospital stay was 13 days and intensive care unit stay was 1.5 days. At three months postsurgery, improvement in symptoms was achieved in 68% of patients. Significant advantages were observed in patients with epithelial MPM (19 vs. 8 months, P<0.01) compared to non-epithelial MPM and with N2 disease (19 vs. 10 months) compared to N1 or N0 disease, respectively. Two studies reported outcomes after chemotherapy in patients with MPM. The median survival was 13 months and symptoms improved in 50% of patients. Response rate of 21% was achieved and the median time to disease progression was 7.2 months. Postoperative haematological toxicity was common and included neutropenia (25%), anaemia (5%) and thrombocytopenia (7.4%). Two studies analysed palliative treatment in mesothelioma and reported a median survival of seven months and improvement in symptoms in 25% of patients at one-year post-treatment. The 30-day mortality rate was 7.8% and complications included prolonged air leak (9.8%) and empyema (4%). Median hospital stay was seven days. Overall, EPP shows no benefit in terms of survival or symptom improvement which is compounded by its high operative mortality and recurrence rate.