Treatment of metastatic bone lesions in the upper extremity: indications for surgery

Pathological fractures caused by metastatic malignant disease have been the subject of increasing interest in recent years. This article describes our experience with the treatment of metastatic bone disease of the upper extremity and our attempt to clarify the indications for different surgical procedures. Of 53 patients with metastatic lesions to the upper extremity, 20 who had been surgically treated were analyzed retrospectively. These comprised 13 men and 7 women with a mean patient age of 62 years. The most common primary tumors to metastasize were lung and liver, with the humerus involved in 12 cases and the scapula and forearm in 4 cases each. Four patients with scapula and forearm involvement underwent tumor resection due to uncontrollable tumor size, while 3 were successfully treated by selective arterial embolization. Three metastases to the humeral head were reconstructed with endoprosthesis, but functional restriction was noted. Five cases with metastases to the humeral shaft were treated with tumor curettage, internal fixation using intramedullary nailing, adjuvant cryosurgery, and cementing. This achieved good results for pain relief and functional restoration with minimal complications. Two metastases to the humeral condyle were unable to be stabilized with plate and locking screws. Metastatic lesions to the scapula and forearm are commonly treated nonsurgically, but some patients with uncontrollable tumor mass require surgical resection. Endoprosthetic replacement is recommended if the lesion involves the humeral head or condyle. Most patients with the humeral shaft lesion are likely to benefit from tumor curettage, intramedullary nailing with locking screw, and cementing.     

Long-term survival and functional recovery after isolated coronary artery bypass grafting in patients with severe left ventricular dysfunction

Objective  Coronary artery bypass grafting (CABG) in patients with left ventricular dysfunction has been considered to be a challenging operation. We assessed the early angiographic and long-term clinical and functional outcomes of patients with poor left ventricular function who underwent isolated CABG. Methods  We retrospectively reviewed the records of 78 patients with a poor left ventricular ejection fraction (35% or less) who underwent isolated CABG between January 1991 and November 2006. The mean age of the patients was 66.1 ± 9.4 years, and their mean New York Heart Association functional class was 3.1 ± 0.8. Their mean end-diastolic left ventricular diameter was 57.4 ± 8.1 mm, and their mean grade of mitral regurgitation was 0.7 ± 1.0. Early postoperative angiograms were performed at 32.5 ± 33.5 days after the operation. Interval echocardiographic data were analyzed, and the long-term survival rate was evaluated. Results  The average number of distal anastomoses per patient was 3.2 ± 1.1. The operative mortality rate was 7.7%. Stroke occurred in 1.3% of patients. The overall patency rates for arterial and venous grafts were 100% and 97.2%, respectively. The left ventricular ejection fraction significantly improved from 28.2% ± 5.1% to 34.4% ± 8.4%. Both the end-diastolic and end-systolic left ventricular dimensions significantly decreased from 57.4 ± 8.1 to 55.1 ± 8.8 mm and from 47.4 ± 8.4 to 45.1 ± 9.7 mm, respectively. The actuarial patient survival rate at 10 years was 73.1%. Conclusion  CABG in patients with left ventricular dysfunction was effective, with favorable early graft patency rates. The long-term outcome was also acceptable, with echocardiographic functional recovery.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.     

Efficacy of motor cortex stimulation for intractable central neuropathic pain: comparison of stimulation parameters between post-stroke pain and other central pain

Motor cortex stimulation (MCS) has now become the preferred option for neurosurgical management of intractable central neuropathic pain such as post-stroke pain and trigeminal neuropathic pain. However, the efficacy of MCS for other central neuropathic pain such as pain resulting from spinal cord or brainstem lesions is unclear. We retrospectively reviewed 11 consecutive patients with intractable central neuropathic pain who underwent MCS in our institution. Eight patients had poststroke pain caused by thalamic hemorrhage (n = 5) or infarction (n = 3) (thalamic group). Two patients had postoperative neuropathic pain caused by spinal cord lesions, and one patient had facial pain caused by a brainstem lesion associated with multiple sclerosis (brainstem-spinal group). Visual analog scale and stimulation parameters were evaluated at 1 and 6 months postoperatively. MCS was effective for six of eight patients in the thalamic group, and all three patients in the brainstem-spinal group. These efficacies continued for 6 months after surgery without significant change in the stimulation parameters compared with the parameters at 1 month in both groups. The mean amplitude at 1 month and frequency at 6 months after surgery were significantly higher in the brainstem-spinal group than the thalamic group, although the patient number was small. MCS is effective for other central neuropathic pain, but higher intensity stimulation parameters may be necessary to gain adequate pain reduction.     

Intramuscular hemangioma of the upper extremity in infants and children

PURPOSE: Intramuscular hemangiomas (IMHs) are benign tumors comprising just 0.8% of all hemangiomas and are extremely rare in the upper limbs. These tumors can pose diagnostic as well as therapeutic challenges for orthopaedic surgeons, especially in younger children. We reviewed cases of IMH of the upper extremity in infants and children from our institute. METHODS: Six consecutive patients underwent surgical treatment for IMH in our hospital. There were 4 girls and 2 boys. Long-standing pain and swelling were common symptoms except in a 1-year-old boy. Tumors were evaluated by radiography, computed tomography, magnetic resonance imaging, and angiography. RESULTS: After a mean follow-up of 42 months, all patients except one were free of pain and without tumor recurrence or functional impairment. Minimal symptoms remained in a 6-year-old boy who underwent biopsy only. CONCLUSION: Magnetic resonance imaging is the most useful evaluation for IMH because it not only delineates the extent of tumor but also reveals characteristic structures. For young children with IMH, wide excision is the treatment of choice to prevent local recurrence, but every patient should be treated individually after evaluating the patient's age, tumor location and invasion, and cosmetic considerations. LEVEL OF EVIDENCE: Therapeutic study-level III.     

Radiofrequency ablation with hand-assisted laparoscopic surgery for the treatment of hepatocellular carcinoma in the caudate lobe

OBJECTIVE: To assess the feasibility and safety of radiofrequency ablation (RFA) with hand-assisted laparoscopic surgery (HALS) for hepatocellular carcinoma (HCC) in the caudate lobe with severe liver dysfunction. SUMMARY BACKGROUND DATA: HCC in the caudate lobe remains one of the most difficult locations where various treatments tend to pose problems regarding the optimal surgical approach. The technique of HALS has thus been proposed as a useful method for performing a safe RFA therapy. For this study, we assessed the feasibility and safety of RFA with HALS for the treatment of HCC in the caudate lobe with liver dysfunction. PATIENTS AND METHODS: Between July 1999 and February 2005, 5 patients who suffered from HCC in the caudate lobe were indicated for RFA. The percutaneous puncture was difficult and all patients have severe liver dysfunction with viral chronic hepatitis. Therefore, RFA was assisted by an inserted hand through a minimal skin incision under laparoscopic inspection. An intraoperative endoscopic ultrasound examination was performed before RFA to determine the tumor region. The hand-assisted minimal dissection around the caudate lobe was required to detect tumor and avoid injuries of other tissues. RFA for HCC was performed using a cooled-tip (Radionics Inc, Burligton, MA) connected to a RF generator under the programmed cyclic impedance. RESULTS: The surgical procedures consisted of 5 RFA to tumors in the caudate lobe with HALS, which was performed safely, and a postoperative computed tomography scan revealed a sufficient ablation in all patients. There was no operative mortality but 1 patient had minor bile leakage, which was treated conservatively, and all patients recovered and thus were eventually discharged. One patient had local recurrence after 3 months, 3 patients had tumor recurrences in another segment after 6 months. At a mean follow-up 32.2 months, all patients were still alive. CONCLUSIONS: RFA with HALS is considered to be a safe and feasible technique for HCC in the caudate lobe with liver dysfunction.     

A neutralizing anti-fibroblast growth factor (FGF) 8 monoclonal antibody shows anti-tumor activity against FGF8b-expressing LNCaP xenografts in androgen-dependent and -independent conditions

BACKGROUNDS: Fibroblast growth factor 8-isoform b (FGF8b) has been detected in human clinical sex-organ related cancers including hormone-refractory prostate cancer. There are, however, few relevant experimental models. A murine monoclonal anti-FGF8 antibody, KM1334, has been shown to neutralize FGF8b and inhibit the growth of androgen-dependent mouse mammary SC-3 cells in vitro and in vivo. In the present study, we evaluated the anti-tumor activity of KM1334 against androgen-dependent and -independent progression of FGF8b-expressing human prostate cancer xenografts. METHODS: FGF8b cDNA was transfected into androgen-dependent human prostate cancer cell line LNCaP, and its xenograft tumors were established subcutaneously in SCID mice with or without castration. KM1334 at the dose of 400 microg/head was injected twice weekly. RESULTS: FGF8b-expressing LNCaP cells secreted FGF8b, showed enhanced level of Erk1/2 phosphorylation, and showed more potent growth properties than mock-expressing cells in vitro and in vivo. KM1334 reduced these properties in vitro, inhibited tumorigenecity in vivo (T/C=0.33), and showed anti-tumor activity against established tumors (T/C=0.47) of FGF8b-expressing cells. FGF8b-expressing LNCaP tumors were androgen-dependent. However, they recurred as androgen-independent FGF8b positive tumors after castration. KM1334 also inhibited the growth of established FGF8b-expressing tumors in the androgen-independent states (T/C=0.47). CONCLUSIONS: These results indicate that humanized monoclonal antibodies, conserving the paratope of KM1334, are a promising candidate for therapy of FGF8b-expressing clinical prostate cancers. Follow-up studies using xenograft models with clinical FGF8b-expressing tumors are required to validate these early findings.     

Modification of the Bentall operation using the proximal double sewing technique without excision of leaflets

We present a report on reinforcement of the proximal anastomosis during the Bentall operation. The aortic wall was excised with a 5-mm remnant, and aortic valve leaflets were preserved. Interrupted horizontal mattress sutures (2-0 Polyestel) reinforced with pledgets were placed. The composite graft was placed at the intraannular position inside of the preserved leaflets. The aortic valve leaflets were then pasted to the sewing cuff with fibrin glue. A running suture with 4-0 monofilament was placed between the remnant of the aortic wall and the peripheral side of the sewing cuff wrapped with native aortic valve leaflets.     

Reconstruction of the middle hepatic vein tributaries draining segments V and VIII of a right liver graft by using the recipient’s own middle hepatic vein and vascular closure staples

A right liver graft lacking the middle hepatic vein can result in congestion of the anterior segment. We describe a method of reconstructing the middle hepatic vein tributaries by using the recipient’s own middle hepatic vein with vascular closure staples. During a living donor right liver transplantation, the middle hepatic vein tributaries draining segments V (V5) and VIII (V8) of the right lobe graft were reconstructed using the recipient’s own middle hepatic vein and secured with vascular closure staples. Computed tomography showed good venous outflow from the middle hepatic vein and no congestion or atrophy of the anterior segment of the right liver grafts. Thus, using the recipient’s own middle hepatic vein is a suitable option for reconstructing the middle hepatic vein tributaries (V8 and V5) in right-liver living donor transplantation and the application of vascular closure staples helps to accomplish this.     

Down-regulation of HLA class I antigens in prostate cancer tissues and up-regulation by histone deacetylase inhibition

PURPOSE: HLA class I down-regulation in cancer cells confers immunological escape from cytotoxic T lymphocytes. We assessed the frequency of down-regulation of HLA class I antigens in a large series of prostate cancer tissues and determined the mechanism of up-regulation by investigating prostate cancer cell lines. MATERIALS AND METHODS: Immunohistochemical staining for HLA class I was done in specimens of 419 prostate cancers. We also investigated clinicopathological parameters, and the relationships between HLA class I down-regulation and the parameters. Furthermore, we examined whether HLA down-regulation was caused by epigenetic changes in vitro. RESULTS: HLA class I was down-regulated in 311 prostate cancers (74.2%) and it significantly correlated with beta2-microglobulin down-regulation and a higher clinical stage. Flow cytometric analysis revealed a low level of HLA class I in LNCaP cells, which was up-regulated by the histone deacetylase inhibitor trichostatin A (Sigma). Trichostatin A up-regulated LNCaP beta2-microglobulin at the protein level. Furthermore, chromatin immunoprecipitation assay using an anti-acetylated histone H3 antibody provided direct evidence that trichostatin A up-regulated beta2-microglobulin by modulating the acetylation status of the promoter region in LNCaP cells. CONCLUSIONS: The current study shows that the prevalence of HLA class I down-regulation is high in prostate cancer but histone deacetylase inhibitors can up-regulate HLA class I in LNCaP cells by up-regulating beta2-microglobulin. We suggest that the combination of an immunotherapeutic approach and histone deacetylase inhibition would accentuate the effects of current immunotherapies for prostate cancer.