Incidentally detected leiomyosarcoma of lingular lobe of left lung—a case report

Successfully surgical resection of an incidentally detected primary bronchopulmonary leiomyosarcoma is reported. Histopathology and immuno histochemistry are the valuable roles for diagnosis and total excises is the treatment of choice. Relevant literature is reviewed briefly.     

Is T2 non-small cell lung cancer located in left lower lobe appropriate to upstage?

In the TNM classification, patients with T2 non-small cell lung cancer (NSCLC) have heterogeneous factors. The efficacy of surgery for T2 disease remains unsatisfactory. We retrospectively reviewed 268 T2 patients with non-small cell lung cancer for whom a curative approach had been attempted between January 1994 through December 2003. All patients were subjected to lobectomy, including dissection of hilar and mediastinal lymph nodes contained in pathologically proven adenocarcinoma or squamous cell carcinoma. The overall survival rates at 5 and 7 years were 58.4% and 48.5%, respectively. Five-year survival of patients with a tumor in the left lower lobe (LLL) was 38.8%; other lobe, 61.6%. Primary tumor distribution in the LLL was significantly associated with a poor survival in T2 NSCLC. In univariate analysis, tumors size less than 4 cm, tumor in the left lower lobe, histological differentiation, lymph node involvement were significantly associated with prognosis. Multivariate analysis showed that tumor in the left lower lobe (P=0.0159), histological differentiation (P=0.0071), and lymph node involvement (P=0.0266) were found to be independent prognostic factors in cases of T2 disease. In cases where the primary tumor without well differentiation is in the LLL, surgery for T2 NSCLC should be considered carefully.     

Is thrombolysis of lower extremity acute arterial occlusion cost-effective?

BACKGROUND: The TOPAS (thrombolysis or peripheral artery surgery) trial randomized 544 patients with acute lower extremity ischemia to either surgery or thrombolysis. Although statistically equivalent 1-year morbidities and mortalities were demonstrated, the comparative cost-effectiveness of these two interventions has not been explored. MATERIALS AND METHODS: We constructed a Markov decision-analytic model to determine the cost-effectiveness of thrombolysis relative to surgery for a hypothetical cohort of patients with acute lower extremity arterial occlusion. Our measure of outcome was the cost-effectiveness ratio (CER), defined as the incremental lifetime cost per quality-adjusted life year gained. Estimates of 1-year outcomes were based on the TOPAS trial: mortality (lysis, 20%; surgery, 17%), amputation (lysis, 15%; surgery, 13%), the number of additional interventions required following the initial procedure (lysis, 544; surgery, 439). Procedural costs were estimated from the cost accounting system at the New York Presbyterian Hospital as well as from the literature. RESULTS: Operative intervention for acute lower extremity arterial occlusion extended life and was less costly compared to thrombolysis. The projected life expectancy for patients who underwent initial surgery was 5.04 years versus 4.75 years for initial thrombolysis. The lifetime costs were $57,429 for surgery versus $dollar;76,326 for thrombolysis. In performing sensitivity analyses, a threshold CER of $60,000 was considered what society would pay for accepted medical interventions. Thrombolysis became cost-effective if the 1-year mortality rate for lysis was lowered from 20 to 10.7%, if the amputation rate for lysis diminished from 15 to 3.9%, or if the 1-year cost of lysis could be reduced to a level below $13,000. CONCLUSIONS: Initial surgery provides the most efficient and economical utilization of resources for acute lower extremity arterial occlusion. The high cost of thrombolysis is related to the expense of the lytic agents, the need for subsequent interventions in patients treated with initial lysis, and the long-term costs of amputation in patients who fail lytic therapy.     

Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah’s Witness undergoing left hepatectomy

IntroductionMajor liver resection in a Jehovah’s Witness presents unique clinical challenges requiring multimodal blood minimization strategies to reduce perioperative complications. We report a case where complete left hepatic lobe devascularisation was undertaken to minimize bleeding in a Jehovah’s Witness undergoing left hepatectomy.Presentation of caseA 65-year-old male Jehovah’s Witness presented for open left hepatectomy for a large left-sided hepatocellular carcinoma involving segment IV of the liver. Three weeks prior to surgery, the patient underwent left portal vein embolization. To isolate and devascularise the left lobe, the gastroduodenal artery and left hepatic artery were then occluded with coils. The bed of the left hepatic artery was then embolised to stasis with particles. Finally, the anastomosis back to the right hepatic artery was also occluded by coils. The patient underwent uneventful surgery with an estimated blood loss of 450 mls.DiscussionLeft hepatectomy in a Jehovah’s Witness patient is feasible but requires careful planning and a multidisciplinary approach. Major liver resection represents a well defined but complex haemostatic challenge from tissue and vascular injury, further complicated by hepatic dysfunction, and activation of inflammatory, haemostatic and fibrinolytic pathways. In addition to the haemoglobin optimization strategies utilized preoperatively, the use of interventional radiology techniques to further reduce perioperative bleeding should be considered in all complex cases.ConclusionCombination of portal vein embolization and hepatic lobe devascularisation to produce total vascular occlusion of inflow to the left lobe radiologically allowed a near bloodless surgical field during major liver resection in a Jehovah’s Witness patient.     

Changing from analog to digital images: Does it affect the accuracy of alignment measurements of the lower extremity?

Background and purpose

Medical imaging has changed from analog films to digital media. We examined and compared the accuracy of orthopedic measurements using different media.

Methods

Before knee arthroplasty, full-length standing radiographs of 52 legs were obtained. The mechanical axis (MA), tibio-femoral angle (TFA), and femur angle (FA) were measured and analyzed twice, by 2 radiologists, using (1) true-size films, (2) short films, (3) a digital high-resolution workstation, and (4) a web-based personal computer. The agreement between the 4 media was evaluated using the Bland-Altman method (limits of agreement) using the true-size films as a reference standard.

Results

The mean differences in measurements between the traditional true-size films and the 3 other methods were small: for MA –0.20 to 0.07 degrees, and for TFA –0.02 to 0.18 degrees. Also, the limits of agreement between the traditional true-size films and the three other methods were small.

Interpretation

The agreement of the alignment measurements across the 4 different media was good. Orthopedic angles can be measured as accurately from analog films as from digital screens, regardless of film or monitor size.During the last 15 years a gradual change from traditional, analog film radiographs to digital imaging has occurred. This has implemented a change not only in the way images are obtained, but also in the way images are archived and, above all, evaluated. The image transition time in daily clinical practice has decreased (May et al. 2000). Traditional film evaluation has changed to image reading on monitor screens; this change affects not only radiologists, but also orthopedic surgeons. In addition to the change in the visual analysis of images, there has also been a change in how measurements are performed. Light boxes, rulers, and grease pencils have been exchanged for computers using graphics software.In knee surgery, it is common to assess the alignment of the whole lower extremity with a hip-to-ankle radiograph from which the mechanical axis (MA), the tibio-femoral angle (TFA), and femur angle (FA) are measured. Excellent intra- and interobserver reproducibility of analog MA measurements has been reported in several studies (Henderson and Kemp 1991, Sharma et al. 2001, Rauh et al. 2007, Gordon et al. 2009). In osteoarthritis, the tibio-femoral joint space narrowing is often unsymmetrical, leading to angular deformity of the lower extremity, more commonly of varus type. In order to be able to restore the alignment, knowledge of the preoperative malalignment is crucial. A malalignment of the knee prosthesis not only increases the likelihood of postoperative malfunction, but also affects the lifespan of the prosthesis (Sorrells et al. 2007).We investigated the accuracy of alignment measurements performed using 4 techniques: analog true-size films, films of reduced size, high-resolution workstations, and web-based personal computers (PCs). Before that, we assessed the intra- and interobserver reliability of these 4 techniques, separately for each technique.     

Geometrical dimensions of the lower lumbar vertebrae – analysis of data from digitised CT images

The precise dimensions of the lumbar vertebrae and discs are critical for the production of appropriate spinal implants. Unfortunately, existing databases of vertebral and intervertebral dimensions are limited either in accuracy, study population or parameters recorded. The objective of this study is to provide a large and accurate database of lumbar spinal characteristics from 126 digitised computed tomographic (CT) images, reviewed using the Picture Archiving Communication System (PACS) coupled with its internal measuring instrumentation. These CT images were obtained from patients with low back pain attending the spinal clinic at the Hammersmith Hospitals NHS Trust. Measurements of various aspects of vertebral dimensions and geometry were recorded, including vertebral and intervertebral disc height. The results from this study indicated that the depth and width of the vertebral endplate increased from the third to the fifth lumbar vertebra. Anterior vertebral height remained the same from the third to the fifth vertebra, but the posterior vertebral height decreased. Mean disc height in the lower lumbar segments was 11.6 ± 1.8 mm for the L3/4 disc, 11.3 ± 2.1 mm for the L4/5, and 10.7 ± 2.1 mm for the L5/S1 level. The average circumference of the lower endplate of the fourth lumbar vertebra was 141 mm and the average surface area was 1492 mm². An increasing pedicle width from a mean of 9.6 ± 2.2 mm at L3 through to 16.2 ± 2.8 mm at L5 was noted. A comprehensive database of vertebral and intervertebral dimensions was generated from 378 lumbar vertebrae from 126 patients measured with a precise digital technique. These results are invaluable in establishing an anthropometric model of the human lumbar spine, and provide useful data for anatomical research. In addition this is important information for the scientific planning of spinal surgery and for the design of spinal implants. Received: 9 November 1998 Revised: 14 January 2000 Accepted: 26 January 2000     

Giant transit thrombus—From right to left

Pulmonary embolism can be associated with paradox embolism requiring immediate surgical therapy regardless of hemodynamic status. Here we present images illustrating a giant transit thrombus as a concomitant finding in a patient with pulmonary artery embolism.     

Leiomyosarcoma of left atrium extending into left pulmonary vein—a case report

Left atrial leiomyosarcoma is an uncommon entity and accounts for 0.25 % of all cardiac tumors. Though long term survival is a rarity, surgical excision of the tumor helps in prolonging life. Its diagnosis is almost always confirmed on histopathology. We report a 72 years old male who presented with severe dyspnoea. A diagnosis of left atrial myxoma was made before surgery. The tumor was found to occupy the whole of the left atrial cavity and extended into left pulmonary vein. The left atrial tumor mass was excised along with the left atrial wall but due to his advanced age and severe pulmonary hypertension no attempt was made to do a left pneumonectomy.     

Management of massive lower limb plexiform neurofibromatosis--when to intervene?

Massive plexiform neurofibromatosis is an uncommon manifestation of Type 1 neurofibromatosis. These tumours result in functional disability and severe disfigurement. Due to the variable natural history od these lesions, the optimal management is not well defined and surgery is often delayed until significant disfigurement has occurred. The aim of this report is to discuss the optimum timing of surgical intervention and to highlight the difficulties in dealing with an advanced lesion.     

Does a standardization tool to direct invasive therapy for symptomatic lower extremity peripheral arterial disease improve outcomes?

OBJECTIVES: While decision analysis and treatment algorithms have repeatedly been shown to improve quality of care in many areas of medicine, no such algorithm has emerged for the invasive management of lower extremity peripheral arterial disease. Using the best available evidence-based outcomes data, our group designed a standardization tool, the Lower Extremity Grading System (LEGS) score, which consistently directs limbs to a specific treatment on the basis of presentation. The purpose of this study was to examine whether use of such a tool improves outcomes by directing treatment of lower extremity peripheral arterial disease. METHODS: Over 18 months (July 2001-December 2002) our group intervened in 673 limbs (angioplasty, open surgery, primary limb amputation) with lower extremity peripheral arterial disease. During this time we developed the LEGS score, and implemented its prospective use for the final 362 limbs. For the purpose of this study, all 673 limbs were retrospectively scored with the LEGS score to determine the LEGS recommended best treatment. Of the 673 limbs, 551 (81.9%) received the same treatment as recommended with LEGS and 122 (18.1%) received treatment contrary to LEGS. Limbs treated contrary to LEGS (cases) were then compared with matched control limbs (treated according to LEGS), with similar angiographic findings, clinical presentation, preoperative functional status, comorbid conditions and operative technical factors. Outcomes measured at 6 months included arterial reconstruction patency, limb salvage, survival, and maintenance of ambulatory status and independent living status. Kaplan-Meier curves were used to assess patency, limb salvage, and survival; associated survival curves were compared with the log-rank test. Functional outcomes were compared with the Fisher exact test. RESULTS: After matching case limbs with control limbs, 9 limbs had no control match. Thus 113 limbs in 100 patients treated contrary to LEGS were compared with 113 limbs in 100 patients treated according to LEGS. Limbs treated contrary to LEGS resulted in significantly inferior outcomes at 6 months for measures of primary patency (57.5% vs 84.3%; P < .001), secondary patency (73.2% vs 96.2%; P < .001), limb salvage (89.7% vs 97.2%; P = .04), and maintenance of ambulatory status (78% vs 92%; P = .02). As an additional finding, 29.6% (92 of 311) of interventions performed before implementation of the algorithm were treated contrary to LEGS, and thus contrary to objectively determined best therapy, compared with 8.3% (30 of 362) after LEGS implementation (P < .001). CONCLUSIONS: Limbs treated according to our standardization tool resulted in better outcomes compared with limbs treated contrary to the algorithm. These data suggest that routine use of an appropriately validated treatment standardization algorithm is capable of improving overall results for invasive treatment of lower extremity peripheral arterial disease.