Degenerative lumbar scoliosis in elderly patients: dynamic stabilization without fusion versus posterior instrumented fusion

Background contextPosterolateral fusion with pedicle screw instrumentation is currently the most widely accepted technique for degenerative lumbar scoliosis in elderly patients. However, a high incidence of complications has been reported in most series. Dynamic stabilization without fusion in patients older than 60 years has not previously been compared with the use of posterior fusion in degenerative lumbar scoliosis.PurposeTo compare dynamic stabilization without fusion and posterior instrumented fusion in the treatment of degenerative lumbar scoliosis in elderly patients, in terms of perioperative findings, clinical outcomes, and adverse events.Study designA retrospective study.Patient sampleFifty-seven elderly patients were included. There were 45 women (78%) and 12 men (22%) with a mean age of 68.1 years (range, 61–78 years). All patients had degenerative de novo lumbar scoliosis, associated with vertebral canal stenosis in 51 cases (89.4%) and degenerative spondylolisthesis in 24 patients (42.1%).Outcome measuresClinical (Oswestry Disability Index, visual analog scale, Roland-Morris Disability Questionnaire) and radiological (scoliosis and lordosis corrections) outcomes as well as incidence of complications.MethodsPatients were divided into two groups: 32 patients (dynamic group) had dynamic stabilization without fusion and 25 patients (fusion group) underwent posterior instrumented fusion. All the patients' medical records and X-rays were reviewed. Preoperative, postoperative, and follow-up questionnaires were obtained to evaluate clinical outcomes.ResultsAt an average follow-up of 64 months (range, 42–90 months), clinical results improved similarly in both groups of patients. Statistically superior scoliosis and final lordosis corrections were achieved with posterior fusion (56.9% vs. 37.3% and ?46.8° vs. ?35.8°, respectively). However, in the dynamic group, incidence of overall complications was lower (25% vs. 44%), and fewer patients required revision surgery (6.2% vs. 16%). Furthermore, lower average values of operative duration (190 vs. 240 minutes) and blood loss (950 vs. 1,400 cc) were observed in the dynamic group than in the fusion group.ConclusionsIn elderly patients with degenerative lumbar scoliosis, pedicle screw–based dynamic stabilization was less invasive with shorter operative duration, less blood loss, and lower adverse event rates than instrumented posterior fusion. Scoliosis curve reduction and lumbar lordosis were superior after fusion; however, dynamic stabilization achieved satisfying values of both these parameters, and these results were stable after an average follow-up of more than 5 years. Furthermore, there was no difference between the two techniques in terms of functional clinical outcomes at the last follow-up.     

Scalp Metastasis as the First Sign of Small-Cell Lung Cancer: Management and Literature Review

Cutaneous metastasis from primary visceral malignancy is a relatively uncommon clinical entity, with a reported incidence ranging from 0.22% to 10% among various series. However, the presence of cutaneous metastasis as the first sign of a clinically silent visceral cancer is exceedingly rare. We describe here a case of an asymptomatic male patient who presented with a solitary scalp metastasis as the initial manifestation of an underlying small-cell lung cancer. Diagnostic evaluation revealed advanced disease. We conclude that the possibility of metastatic skin disease should always be considered in the differential diagnosis in patients with a history of smoking or lung cancer presenting with cutaneous nodules. Physicians should be aware of this rare clinical entity, and appropriate investigation should be arranged for early diagnosis and initiation of the appropriate treatment. The prognosis for most patients remains poor.Key words: Small cell lung carcinoma, Scalp, MetastasisCutaneous metastasis from a primary visceral malignancy is a relatively uncommon clinical entity, with a reported incidence ranging from 0.22% to 10% among various series.^1–10 In a meta-analysis of 7 studies comprising a total of 20,380 patients, Krathen et al⁵ found that the overall incidence of cutaneous metastasis was 5.3% and that the most common tumor to metastasize to the skin was breast cancer.⁵ Cutaneous involvement may occur due to direct extension of the tumor as a local metastasis or as a distant metastasis,⁹ and it has been associated with advanced disease and poor prognosis.^3,4,11–13 Half of the patients with cutaneous metastases die within the first 6 months after the diagnosis, whereas lung cancer has been associated with the poorest prognosis.¹⁴ Cutaneous metastasis as the first sign of an internal malignancy is an exceedingly rare occurrence. It has been reported to occur in only 0.8% of the cases and has been associated with advanced disease.¹⁵ Skin metastasis from lung cancer is a rare clinical entity that has been reported to occur in 0.22% to 12% of patients with lung cancer.^{1–4,6,10,15–17} In most cases, metastases occur after the initial diagnosis and treatment of the primary lung tumor.¹⁷ Skin metastasis as the initial manifestation of an underlying lung cancer is a very rare occurrence.^4,6,16,17 We describe herein an exceedingly rare case of an asymptomatic male patient who presented with a solitary scalp metastasis as the initial manifestation of an underlying small-cell lung cancer. Diagnostic evaluation and management are discussed along with a review of the literature.

Case Presentation

A 74-year-old man presented with a 2-month history of a slowly growing, painless nodule in his right temporal region. His past medical history was significant for arterial hypertension. He was a heavy smoker but had no history of lung disease. He denied any respiratory symptoms, fever, or weight loss, and his general condition was good.Clinical examination revealed a painless, movable, nonulcerated nodule in the right temporal region measuring approximately 2 cm in diameter. There were no signs of infection and the overlying skin was normal. A chest X-ray showed a large mass occupying the upper lobe of the left lung. Subsequent computed tomography (CT) showed a large mass involving the left upper lobe associated with extensive mediastinal lymphadenopathy. In addition, a head CT revealed 3 metastatic brain lesions.The scalp lesion was easily resected down to the epicranial aponeurosis. Histopathologic examination and detailed immunohistochemical analysis revealed extensive infiltration from small-cell lung carcinoma (Fig. 1). Immunohistochemically, the tumor cells were strongly positive for TTF-1 and cytokeratin 8.18 and focally positive for CD56 and synaptophysin (Fig. 2). A CT-guided biopsy of the lung tumor confirmed the presence of a small-cell lung carcinoma, and the patient was advised to start chemotherapy and radiotherapy. Unfortunately, although he completed the first cycle of chemotherapy, he refused to continue and was subsequently lost to follow-up.Open in a separate windowFig. 1Histopathologic findings. (1A) Typical appearance of small-cell carcinoma. Small hyperchromatic nuclei and squeezing artifact [hematoxylin and eosin (H&E) ×100]. (1B) Whole-mount section showing large metastatic infiltration of dermis leaving surprisingly unaffected the epidermis (H&E ×25). (1C) Note the border between neoplastic cells (left) and the basal layer of epidermis (right; H&E ×200).Open in a separate windowFig. 2Immunohistochemical analysis. (2A) Strong nuclear positivity for TTF-1 (original magnification ×400). (2B) Diffuse cytoplasmic reactivity for cytokeratin 8/18 (original magnification ×400). (2C) Many of the neoplastic cells show membranous-pattern positivity for CD56 (original magnification ×200). (2D) Focal cytoplasmic positivity for synaptophysin (original magnification ×400).     

Current and Future Challenges in the Surgical Treatment of Hepatocellular Carcinoma: A Review

Challenges in the treatment of hepatocellular carcinoma Hepatocellular carcinoma (HCC) represents one of the most frequent types of cancer worldwide. Surgery, although only a part of the armamentarium against HCC, represents the cornerstone in the management of this aggressive disease. This article will review the current and future challenges in the surgical management of HCC, with a special emphasis on the following areas: (1) the evolution of staging of the disease and the importance of the biological nature and behavior of HCC, (2) the effort to increase resectability, (3) technical innovations and the role of image-guided surgery, and, finally, (4) the role of liver transplantation in the continuum of care for these patients. Although by no means an exhaustive list, the issues mentioned above represent some of the most promising prospects for significant progress in the management of HCC.Key words: Hepatocellular carcinoma, Image-guided surgery, Liver transplantation, ResectabilityThe incidence of hepatocellular carcinoma (HCC) has risen significantly in the United States in the last decade, only to be surpassed by the increased incidence in East Asia and sub-Saharan Africa because of the high prevalence of hepatitis B in that area.^1,2 In other parts of the world, such as North America, Europe, and Japan, the main culprit appears to be the high prevalence of chronic hepatitis C infection, together with confounding factors, such as alcohol abuse, nonalcoholic steatohepatitis, obesity, and tobacco use.^3–5 The common theme is the association between liver cirrhosis and HCC, with 80% of HCC cases being in cirrhotic livers.⁶ Although the exact mechanism has not been fully elucidated yet, it may have to do with changes in the normal hepatic architecture seen in cirrhosis or with damage caused by the viral DNA in the cases of hepatitis infection, both representing a cancerous transformation signal.Given the complexity of the disease, it should come as no surprise that its treatment is multimodal and requires the cooperation of multiple specialties. Even so, surgery remains the cornerstone of the management of HCC, as it has the unique ability to provide a therapeutic option. The 2 main curative surgical therapies are liver resection and orthotopic liver transplantation (OLT). Even with careful patient selection, recurrence and metastatic disease remain the 2 main problems encountered in liver resection, with OLT having to deal with the additional obstacle of the limited number of available donors. Other treatments, such as chemoembolization or radiofrequency ablation, may be able to limit the disease in certain situations or act as bridging therapies, although overall the results cannot be compared with those of resection or OLT. The limitations mentioned above serve to underscore the challenges facing hepatic surgery, as well as to identify the areas where the research efforts should be focused. In this article, the areas that will be reviewed represent promising prospects for progress in the surgical management of HCC.     

Aprotinin reduces oxidative stress induced by pneumoperitoneum in rats

Background

Ischemia–reperfusion injury induced by pneumoperitoneum is a well-studied entity, which increases oxidative stress during laparoscopic operations. The reported anti-inflammatory action of aprotinin was measured in a pneumoperitoneum model in rats for the first time in this study.

Materials and methods

A total of 60 male Albino Wistar rats were used in our protocol. Prolonged pneumoperitoneum (4 h) was applied, causing splanchnic ischemia and a period of reperfusion with a duration of 60 or 180 min followed. Several cytokines and markers of oxidative stress were measured in liver, small intestine, and lungs to compare the aprotinin group with the control group. Tissue inflammation was also evaluated and compared between groups using a five-scaled histopathologic score.

Results

In aprotinin group values of biochemical markers (tumor necrosis factor α, interleukin 6, endothelin 1, C reactive protein, pro-oxidant–antioxidant balance, and carbonyl proteins) were lower in all tissues studied. Statistical significance was greater in liver and lungs (P < 0.05). Histopathologic examination revealed significant difference between control and aprotinin groups in all tissues examined. Aprotinin groups showed mild to moderate lesions, while in control groups severe to very severe inflammation was present. Aprotinin subgroup with prolonged reperfusion period (180 min) showed milder lesions in all tissues than the rest of the groups.

Conclusions

Aprotinin reduced inflammatory response and oxidative stress induced by pneumoperitoneum in liver, small intestine, and lungs.     

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

The treatment of premenstrual dysphoric disorder (PMDD) is far from satisfactory, as there is a high proportion of patients who do not respond to conventional treatment. The antidiuretic sulfonamide, acetazolamide, inhibits carbonic anhydrase and potentiates GABAergic transmission; the latter is putatively involved in PMDD. We therefore tried acetazolamide in a series of women with intractable PMDD. Here, we describe a series of eight women diagnosed with DSM-IV-TR PMDD, five of whom had comorbidity with a mood disorder and one with an anxiety disorder, who were resistant to treatment and responded with symptom disappearance after being added-on 125 mg/day acetazolamide for 7-10 days prior to menses each month. Patients were free from premenstrual symptoms at the 12-month follow-up. We suggest that acetazolamide may be used to improve symptoms of PMDD in cases not responding to other treatments. GABAergic mechanisms may be involved in counteracting PMDD symptoms.