Obturator Canal Lymph Node Metastasis from Rectal Carcinoid Tumors: Total Mesorectal Excision May Be Insufficient

Background

Optimal surgical treatment for small early rectal carcinoids is controversial. Large tumors (greater than 2 cm) and those with imaging evidence of lymph node metastasis are generally treated by low anterior resection (LAR) with total mesorectal excision (TME). We first observed and reported that midgut carcinoid with extensive mesenteric lymphadenopathy often develops alternated lymphatic drainage pathways. We hypothesize that rectal carcinoids have the same potential to develop alternated lymphatic pathways outside the mesorectal envelope, which allows tumor deposits to be missed by traditional TME.

Methods

Twenty-two consecutive rectal carcinoid surgical patient charts were reviewed to determine if alternated lymphatic drainage occurred and resulted in extra-mesorectal metastasis. We attempted to identify any risk factor(s) that may lead to developing such alternated lymphatic drainage pathways.

Results

Thirteen patients underwent initial LAR with TME (13/22, 59 %) and nine underwent a staged debulking for locoregional residual disease or regional/distant metastasis after previous resection (9/22, 41 %). Fourteen (14/22, 64 %) underwent radio-guided surgery in attempt to achieve a higher level of pelvic/distant metastatic disease detection and debulking. Six patients (6/22, 27 %) had obturator canal lymph node metastases confirmed histologically.

Conclusions

Based on our study, at least 27 % of rectal carcinoid patients may have extra-mesorectal metastasis that would be missed by the traditional TME. Radio-guided surgery can identify and remove such metastasis. The effect of having such extra-mesorectal metastasis and its surgical removal on long-term survival has yet to be determined.

     

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What is the Safest Sprint Starting Position for American Football Players?

The main objective of this study was to perform a biomechanical analysis of three different sprint start patterns to determine the safest position in term of neck injury and Sport-Related Concussion (SRC). The second objective was to collect data on the learning process effect between football players and non-players. Three different sprint initial positions adopted by football players were studied (i.e., 4-, 3- and 2-point positions). Twenty five young healthy males, including 12 football players, participated to this study. A stereophotogrammetric system (i.e., Vicon) was used to record motion patterns and body segments positions. Various measurements related to head and trunk orientation, and player field-of-view were obtained (e.g., head height, trunk bending, time to reach upright position, head speed (vertical direction) and body speed (horizontal direction)). Learning process was found to have no influence on studied parameters. Head redress is also delayed when adopting a 4-point position leading to a reduce field-of-view during the start and increasing therefore the probability of collision. Concerning the three different positions, the 4-point position seems to be the more dangerous because leading to higher kinetic energy than the 2- and 3-point start positions. This study proposes a first biomechanical approach to understand risk/benefit balance for athletes for those three different start positions. Results suggested that the 4-point position is the most risky for football players.

Key points

• Motion analysis and biomechanical analysis of the initial start position of the sprint could be used to increase the safety of the football players.
• Analysis of kinematic and trajectory of the head and the time to reach the upright position could be used to determine whether or not a player can return to play after concussion.
• A balance needs to be found between player’s safety (2-point start) and speed (4-point start).

Key words: Sports, sports medicine, brain concussion, biomechanics     

Primary small-cell carcinoma of the esophagus. Report of 11 cases and review of the literature.

Primary small-cell carcinoma of the esophagus is an uncommon esophageal malignancy. This report details the clinical and pathologic aspects of 11 cases seen at our institution over 20 years, as well as 123 other cases reported in the literature. Small-cell carcinomas of the esophagus show considerable histologic heterogeneity. Neurosecretory granules can be found in the majority of cases and some show evidence of multidifferentiation. Like primary small-cell cancers of the lung, those in the esophagus are highly aggressive, are usually associated with spread at the time of diagnosis, and have a dismal prognosis regardless of treatment. The possible origin of this interesting variety of esophageal neoplasm is also discussed.     

Autografting with blood progenitor cells: predictive value of preapheresis blood cell counts on progenitor cell harvest and correlation of the reinfused cell dose with hematopoietic reconstitution

One hundred and nine patients suffering from various malignancies underwent 285 apheresis procedures for PBPC collection. A median of two leukaphereses (range: 2–5) resulted in median numbers of 4.6×10 ⁸ MNC/kg, 14.1×10 ⁴ CFU-GM/kg, and 6.0×10 ⁶ CD34+ cells/kg. Preleukapheresis peripheral blood CD34+ cells correlated significantly with collected CD34+ cells/kg ( r=0.94; p<0.0001) and with CFU-GM/kg ( r=0.52; p<0.0001). A value >4×10 ⁴ CD34+ cells/ml was highly predictive for a collection yield >2.5×10 ⁶ CD34+ cells/kg harvested by a single leukapheresis. Sixty patients were evaluated for hematologic reconstitution and engrafted in a median time of 10 days for WBC >1.0×10 ⁹/l (range: 7–21 days), 10 days for ANC >0.5×10 ⁹/l (7–20) and 11 days for PLT >20×10 ⁹/l (7–62). Reinfused CD34+ cells/kg correlated significantly with hematologic engraftment ( r=0.44–0.52 and p<0.006–0.001) as well as CFU-GM/kg ( r=0.36–0.44 and p<0.007–0.001). A progenitor cell dose >2.5×10 ⁶ CD34+ cells/kg or >8.0×10 ⁴ CFUGM/kg led to a significantly faster recovery for WBC, ANC, and PLT when compared with patients receiving <2.5×10 ⁶ CD34+ cells/kg or <8.0×10 ⁴ CFU-GM/kg. We conclude that rapid hematopoietic engraftment after high-dose therapy and PBPC reinfusion correlates well with a progenitor cell dose >2.5×10 ⁶ CD34+ cells/kg or >8.0×10 ⁴ CFU-GM/kg, and that above a preleukapheresis threshold of 4×10 ⁴ CD34+ cells/ml a PBPC autograft containing >2.5×10 ⁶ CD34+ cells/kg can be collected by a single leukapheresis. We suggest that patients recovering from myelosuppression should be monitored for CD34+ cells in serial blood samples to determine the course of circulating hematopoietic progenitor cells. This issue will help to define the optimal time point to start apheresis and to predict a PBPC autograft harvested by a single leukapheresis, which will lead to rapid and stable hematopoietic reconstitution following transplantation.