bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnosis of aortic dissection: The value and limitations of transesophageal echocardiography
Authors: Paczek Anna , Rydlewska-Sadowska Wanda
Published: August 2005

Aortic dissection requires prompt and reliable diagnosis. The purpose of this study was to assess the accuracy and limitations of transesophageal echocardiography (TEE) for the diagnosis of aortic dissection. Twenty seven patients with clinically suspected aortic dissection were investigated by means of TEE. TEE results were compared to intraoperative findings (n = 18), necropsy (n = 4), and magnetic resonance imaging (n = 5). The DeBakey classification was used for differentiation of dissection type. Twenty-three patients (85%) were correctly identified as having aortic dissection. Four false-positive TEE findings (15%) were confined to the nondissecting aneurysm of the ascending aorta in elderly patients. Retrospectively we found that protruding atherosclerotic plaques were recognized as small intimal flaps. Type of dissection was correctly diagnosed in all 23 patients, the primary entry site was identified in 15 patients (65%), aortic regurgitation was found in 55.5% of patients, and pericardial effusion was detected in 33.3%. We conclude that TEE allows accurate diagnosis and classification of aortic dissection. However, some cases could be overdiagnosed in lesions of the ascending aorta, especially in nondissecting aneurysms. Another limitation of TEE is the inability to define the primary entry site in some cases. Still, overall results may favor TEE as the primary bedside diagnostic procedure to identify patients requiring urgent surgical intervention.
Bleeding varices of the small bowel as a complication of pancreatitis: Case report and review of the literature
Authors: Lein Brian C. , McCombs Peter R.
Published: August 2005

A case of a 48 year old male with a history of alcohol abuse, chronic relapsing pancreatitis, and massive hemorrhage into the small intestine is reported. The patient had previously undergone a cholecystojejunostomy. Imaging studies demonstrated occlusion of the splenic, superior mesenteric, and distal portal veins with large varices in the jejunum. He recovered following jejunal resection and Roux‐en‐Y cholecystojejunostomy. The mechanism for formation of varices in the small bowel in this clinical setting is discussed.
Injury to the popliteal vessels: The Lebanese war experience
Authors: Sfeir Roger E. , Khoury Ghattas S. , Haddad Fadi F. , Fakih Riyad R. , Khalifeh Mohammad J.
Published: August 2005

Our experience with 118 patients who underwent surgery for a total of 178 popliteal vessels injuries is reported. Forty‐nine per cent had injury to both artery and vein and 44% had associated bony fractures. Fourteen patients subsequently needed amputation for a rate of 11.9%. There were no deaths. Delay in repair (>6 hours from injury), associated fractures, and a shocked condition resulted in increased limb loss. Arterial as well as venous repair, external skeletal fixation, and fasciotomy when necessary lead to improved limb salvage.
One liver for two: Partition of the portal elements
Authors: Rat P. , Paris P. , Favre J. P.
Published: August 2005

A cadaver liver is divisible into two transplants by section between right and left lobes, or section between left medial segment and left lateral segment medial to the umbilical cleft. To establish the ideal basis of partition of the portal elements, an anatomic study of 33 livers was performed. It is preferable to section the left portal vein, longer and more constant than the right, the right branch of the hepatic artery, larger and more constant than the left, and the left hepatic duct because of the vascularization of the common hepatic duct. To use the length of the left portal vein, it is necessary to section all its branches to segment I and then to resect this segment. After a section between the left medial segment and the left lateral segment medial to the umbilical cleft, the left medial segment always loses its total portal venous vascularization and should be resected. Before a split‐liver, cholangiography and arteriography should be performed to detect anatomical variations without performing an extensive dissection which may endanger the vascularity of the bile ducts.
Liver resection for hepatocellular carcinoma (HCC) with direct removal of tumor thrombi in the main portal vein
Authors: Yamaoka Yoshio , Kumada Kaoru , Ino Keiichi , Takayasu Takashi , Shimahara Yasuyuki , Mori Keiichiro , Tanaka Akira , Morimoto Taisuke , Taki Yoshiro , Washida Masanobu , Manaka Dai , Hayashi Michihiro , Fujita Takusi , Ozawa Kazue
Published: August 2005

Since the tumor thrombus in the main portal vein appears in the terminal stage of hepatocellular carcinoma (HCC), any attempt to remove it surgically is thought to be impractical as the malignancy itself cannot be entirely removed. During the past 5 years, we have performed tumor thrombectomy combined with hepatectomy in 29 of 298 patients with HCC. This combined therapy was initially decided upon as an emergency measure to prevent impending rupture of esophageal varices, rather than to improve patient survival. Since portal flow was obtained after removal of thrombi, this condition enabled transcatheter arterial embolization (TAE) and/or percutaneous ethanol injection therapy (PEIT). Although improved patient survival was not the primary goal of the emergency operation and there was an operative mortality of 11%, half of the other patients in the present series had unexpectedly high survival rates of 1 year (52.2%), 2 years (23.2%), and 3 years (11.6%), which were significantly higher than in patients not undergoing operation (n=22).
Roux‐en‐Y hepaticojejunostomy with subcutaneous access and the use of gianturco stents for the management of biliary tract strictures
Authors: Quintero Gustavo A. , Espinosa Hector , Pineres Germán , Ariza Alvaro , Zundel Natan , Botero Rafael , Cuervo Hermann , Ucros Gonzalo , Patiño José Félix
Published: August 2005

The need to control recurrent biliary strictures implies the practice of repeated major surgical procedures. The hepaticojejunostomy with subcutaneous jejunal access (Chen's procedure) allows the permanent option of a non‐operative management of recurrent biliary tract anastomosis complications. Through the subcutaneous jejunal access, the application of a Gianturco metallic prosthesis is permitted and the correction of biliary‐intestinal anastomosis strictures with non‐operative methods is possible. This report is a review of a series of 20 patients treated with the Chen procedure, of whom 3 patients also had implantation of Gianturco stents via hepaticojejunostomy with subcutaneous access.
Living unrelated donor kidney transplantation between spouses
Authors: Haberal Mehmet , Gulay Huseyin , Tokyay Rifat , Oner Zafer , Enunlu Tayfun , Bilgin Nevzat
Published: August 2005

From November 3, 1975 to November 3, 1990, 874 kidney transplants were performed at our centers. Of these, 675 (77.2%) were from living donors and 199 (22.8%) were from cadaver donors. Five hundred eighty (66.4%) of the living donors were first degree related while 99 (11.3%) were unrelated or second degree related donors, 29 of which were spouses. All donor recipient pairs were ABO‐compatible, with the exception of one pair. Donor recipient relations were wife to husband in 25 cases and husband to wife in 4 cases. All were first grafts and started functioning during surgery. In this series, the follow‐up for the recipients was 4 to 64 months (mean 33.5 ± 4.5 months). One‐year patient survival and graft survival rates were 92.4% and 81.9%, respectively. Two‐year patient survival and graft survival rates were 92.4% and 78.2%, respectively. The single ABO‐incompatible case is also doing well, 21 months postoperatively. This study demonstrates that the interspouse kidney transplantation may be used when cadaver organ shortage is a problem. While providing the couple with a better quality of life, interspouse kidney transplantation also enables the couple to share the joy of giving and receiving the “gift of life” from one another.
Present status of sclerotherapy and surgical treatment for esophageal varices in Japan
Authors: Idezuki Yasuo ,   the Japanese Research Society for Portal Hypertension and Japanese Research Society for Sclerotherapy of Esophageal Varices
Published: August 2005

A nationwide survey on the treatment for esophageal varices was performed in 1990 jointly by the Japanese Research Society for Portal Hypertension and the Japanese Research Society for Sclerotherapy of Esophageal Varices to clarify the present status and strategy of this treatment in Japan. A total of 12,675 cases, including 4,159 cases of nonshunting procedures and 7,612 cases of sclerotherapy, were collected from 101 institutions. The number of patients had greatly increased in the first half of the 1980s. With regard to the therapeutic strategy, surgical procedures were not recommended in either emergency or prophylactic cases in terms of the timing of the operation, or in Child C cases in terms of the degree of hepatic insufficiency. Endoscopic injection sclerotherapy became the leading method of treatment and in 1988 only 16% of 1,528 cases were treated by surgical procedures. The strategy for the same group of patients differed between medical and surgical institutions. With regard to sclerotherapy, repeated intravariceal injection and combined intra‐ and paravariceal injection were the two main techniques and 10‐year cumulative survival rates were 62.8% in Child A cases, 47.7% in Child B cases, and 13.2% in Child C cases. With regard to surgical procedures, 10‐year survival rates were 50.6% in esophageal transection, 42.5% in gastric transection, 53.1% in cardiectomy, and 43.0% in selective shunt procedures. We are quite convinced that this report will prove useful in determining the future strategy for treating esophageal varices.
Differentiated thyroid carcinoma in children and adolescents
Authors: Harness Jay K. , Thompson Norman W. , McLeod Michael K. , Pasieka Janice L. , Fukuuchi Atsushi
Published: August 2005

From 1936 to 1990, 89 children and adolescents (72 girls and 17 boys) were treated for differentiated thyroid carcinoma at the University of Michigan Medical Center; 58 of these patients were first reported in 1971. Thirty (34%) patients had previously received external irradiation to the head and neck, although only 1 (3%) patient of the last 33 patients seen had this history. Patients first presenting from 1971 to 1990 had less advanced disease than those seen earlier. Also, during this time period, the rate of initial palpable cervical adenopathy fell from 63% to 36%, local infiltration of primary cancer from 31% to 6%, and initial pulmonary metastases from 19% to 6%. The incidence of cervical nodal metastases has remained 88% for 54 years. Papillary or the follicular variant of papillary carcinoma was found in 93% of all patients. Seventy‐nine (89%) patients had total or completion total thyroidectomy. Surgical management of lymphatic metastases varied from regional excision of nodes to radical neck dissection. The overall rate of permanent accidental recurrent laryngeal nerve palsy and hypoparathyroidism was 4.5%, although neither has occurred in a child or adolescent undergoing surgery at the center in the past 25 years. The most recent 33 patients had a low rate of local/regional persistence or recurrence. Cervical nodal persistence occurred in 21%; there were no thyroid recurrences. Eighty‐two percent of patients received131I. The long‐term mortality rate was 2.2%. We continue to advocate total thyroidectomy, cervical lymph node dissection, and postoperative131I therapy as the most conservative treatment regimen for children with differentiated thyroid carcinoma.
Follicular tumors of the thyroid gland: Diagnosis, clinical aspects and nuclear DNA analysis
Authors: Zedenius Jan , Auer Gert , Bäckdahl Martin , Falkmer Ursula , Grimelius Lars , Lundell Göran , Wallin Göran
Published: August 2005

From 1985 to 1990, 169 patients underwent surgery for follicular thyroid tumors at the Department of Surgery, Karolinska Hospital, Stockholm, Sweden. Nine of the patients had tumors which were diagnosed as follicular carcinoma, 4 of whom had recurrences in the neck region. In 6 of the patients the carcinomas were diagnosed as widely invasive and in 3 patients as minimally invasive. Of the 160 patients with follicular adenomas, 21 adenomas were of oxyphil type (“Hürthle” adenomas), 17 adenomas were diagnosed as “atypical”, and 6 adenomas were classified as being both “atypical” and having oxyphil cell differentiation. The nuclear DNA content was measured with image cytometry and/or flow cytometry. Six of the 9 carcinomas were euploid and 3 were aneuploid. In the adenoma group, 32 (20%) were aneuploid. Thus 38% of all adenomas showed atypical cellular features, oxyphil cell differentiation, and/or aneuploid nuclear DNA pattern. None of the patients with adenomas have shown any sign of recurrence. In the present prospective study, the nuclear DNA content could not discriminate between a benign and a malignant follicular tumor, and was of limited value in predicting prognosis in the patients with follicular carcinoma. Still, the best way to establish a diagnosis and to predict prognosis is to surgically remove the follicular tumor for a proper histopathological examination.
Recurrent renal hyperparathyroidism and DNA analysis of autografted parathyroid tissue
Authors: Tominaga Yoshihiro , Tanaka Yuji , Sato Keisuke , Numano Masahiro , Uchida Kazuharu , Falkmer Ursula , Grimelius Lars , Johansson Henry , Takagi Hiroshi
Published: August 2005

In spite of recent therapeutic advances, severe overt secondary hyperparathyroidism due to chronic renal failure necessitates parathyroidectomy and recurrent hyperparathyroidism is one of the most significant problems in this patient population. In the present study, the incidence of recurrent hyperparathyroidism was evaluated in relation to the histopathological features. Image cytometric DNA analysis was performed to estimate the proliferative potential of parathyroid tissue. The study comprised 248 patients who underwent parathyroidectomy from 1973 to 1991. The frequency of recurrent hyperparathyroidism after subtotal parathyroidectomy was 4 (21.1%) of 19 patients, the rate of graft‐dependent recurrence after removal of residual parathyroid tissue with forearm autograft was 2 (50%) of 4 patients. The frequency of graft‐dependent recurrence after total parathyroidectomy with forearm autograft was 16 (7.5%) of 212 patients. The frequency of recurrence was significantly higher (p<0.01) when nodular hyperplastic parathyroid tissue was autografted (17 of 68 patients, 25%) than when diffuse‐hyperplastic tissue was grafted (1 of 105 patients, <1%). All 58 specimens subjected to image cytometric DNA analysis showed a diploid nuclear pattern cytometrically. However, the relative number of scattered cells that displayed cytometric nuclear DNA values outside the main diploid histogram peak was significantly greater (p<0.01) in nodular hyperplastic tissue before being autografted and in parathyroid tissue removed at re‐operation performed for recurrence than in diffuse hyperplastic tissue. These clinical findings and results of DNA analysis clearly indicated that nodular hyperplastic parathyroid tissue has a higher growth potential, and it is concluded that to prevent graft‐dependent recurrence, the nodular type of hyperplastic tissue should not be autografted.
Non‐Hodgkin's lymphoma of the thyroid: Is more than biopsy necessary?
Authors: Pyke Christopher M. , Grant Clive S. , Habermann Thomas M. , Kurtin Paul J. , van Heerden Jon A. , Bergstralh Erik J. , Kunselman Allen , Hay Ian D.
Published: August 2005

Whereas excisional surgery and radiotherapy have resulted in a favorable outcome when non‐Hodgkin's lymphoma of the thyroid (NHLT) is confined to the thyroid gland, controversy persists over the potential advantage of aggressive debulking in favor of diagnostic biopsy alone when disease cannot be completely resected. Our aims in this study were to delineate the present role of surgery in NHLT in pre‐operative staging, the impact of the extent of resection on achieving complete remission and cause‐specific survival, and patterns of failure. All 62 patients who underwent primary surgery for NHLT at the Mayo Clinic between 1965 and 1989 were analyzed. By postoperative staging, 50 patients were stage IE or IIE. Overall survival was 53% and 46% at 5 and 10 years; 80% for stage IE confined to the thyroid, 58% for stage IE‐extrathyroid, 50% for stage IIE, and 36% for stages IIIE and IVE. Complete remission was achieved in 88% of patients who underwent diagnostic biopsy plus adjuvant therapy alone compared to 85% for patients in whom debulking plus adjuvant therapy was used. There was no difference in cause‐specific survival in these two groups or in cause‐specific survival in two subgroups who achieved complete remission. Relapse after complete remission occurred in 12 (26%) of 46 patients, only 2 of whom survived long‐term after salvage therapy. The role of surgery in NHLT is diminishing and advances that will increase complete remission and relapse‐free survival will not likely involve more aggressive surgical resections.
Clinical characteristics, treatment and survival in patients with pancreatic tumors causing hormonal syndromes
Authors: Grama D. , Eriksson B. , Mårtensson H. , Cedermark B. , Ahrén B. , Kristoffersson A. , Rastad J. , Öberg K. , Åkerström G.
Published: August 2005

Eighty‐five patients with endocrine pancreatic tumors associated with clinical syndromes of hormone excess were retrospectively analyzed regarding symptomatology, means of diagnosis, and results of surgical and medical treatment during follow‐up of 3–18 years (median 8 years). The combination of angiography and computed tomography was most successful in pre‐operative localization of both primary tumors and metastases. Surgery provided long term cure in 39 of 44 patients with benign islet cell lesions, the majority having insulinomas. Forty‐one patients had malignant tumors, which at the time of diagnosis or operation were associated with liver and/or regional lymph gland metastases in 56% and 24%, respectively. Sixteen patients with metastatic disease and/or very large tumors were considered inoperable, 5 patients underwent palliative resection of their malignant tumors, while grossly radical tumor removal was accomplished in 20 patients. Long‐term cure was achieved in 5 patients by excision of primary tumors and localized liver or lymph gland metastases. Half of the patients, particularly those with insulinoma, gastrinoma, or vipoma, showed response to streptozotocin, in combination with other cytostatics, for a median of 24 months or a response to interferon for a median of 10 months. The overall 5‐year and 10‐year survival among the patients with malignant islet cells tumors was 54% and 28%, respectively. Absence of liver metastases at time of operation/diagnosis, smaller size of the primary tumor, grossly radical tumor resection as well as response to medical therapy predicted the more favorable survival.
Adrenal cortical carcinoma in Norway, 1970–1984
Authors: Søreide Jon Arne , Brabrand Knut , Thoresen Steinar Ø.
Published: August 2005

Adrenal cortical carcinoma is a rare and highly malignant tumor. This retrospective study includes 99 patients (57 males and 42 females) reported to The Cancer Registry of Norway during the 15 year period from 1970 to 1984. The age adjusted incidence was 1.5 per million per year. Eighty‐one patients were diagnosed with adrenal cortical carcinoma when still alive. In 18 cases the diagnosis was first made at autopsy. Median age at diagnosis was 54 years (range 2–88 years) with a slight male predominance. Information about initial symptoms was available in 67 patients, of whom 26 patients (18 females and 8 males) presented with clinically functioning tumors, the Cushing syndrome and virilization being most frequently encountered. Only 28 (35%) of 81 patients diagnosed when still alive had tumors confined to the adrenals. Half of the patients had distant metastases, with lungs and liver being the most frequent sites. Sixty‐one patients underwent surgery; 51 patients had a radical or debulking operation and 10 patients had laparotomy with tumor biopsy. After a complete follow‐up for at least 6 years (range 6–21 years), only 9 patients were still alive. Early stage (Stage I and II) and curative resection had a significant impact on the outcome of this disease. To improve prognosis, early diagnosis and radical surgery, if feasible, are needed.
Solid cell nests of the thyroid gland: Precursor of mucoepidermoid carcinoma?
Authors: Ozaki Osamu , Ito Kunihiko , Sugino Kiminori , Yasuda Kentaro , Yamashita Tomoyuki , Toshima Koji
Published: August 2005

Solid cell nests (SCN) are found within the thyroid parenchyma on routine clinical pathological examinations, but their histogenesis and clinical significance are still obscure. From November 1987 to May 1991, a total of 3,260 patients underwent thyroid surgery at Ito Hospital and SCN were noted in 42 (1.3%) patients. Serial sections of the specimens from these patients were studied morphologically and immunohistochemically. The location and growth pattern of SCN within the thyroid parenchyma were distinct from those of hyperplastic C‐cells. SCN were located in the isthmus lobe in 1 patient and even in the pyramidal lobe in 3 patients. In another patient neoplastic proliferation of SCN was observed. Immunohistochemically, SCN were negative for neuron‐specific enolase, chromogranin A, and S‐100 protein. These findings strongly suggest that SCN are of endodermal origin and that they may be closely related to mucoepidermoid carcinoma of the thyroid gland.
Serum chromogranin A in the diagnosis and follow‐up of neuroendocrine tumors of the gastroenteropancreatic tract
Authors: Schürmann Guido , Raeth Ulrich , Wiedenmann Bertram , Buhr Heinz , Herfarth Christian
Published: August 2005

Hormonally active neuroendocrine tumors may easily be diagnosed by elevated serum levels of their specific peptides and hormonal products, but there are no reliable markers for neuroendocrine tumors without hormonal activity. Chromogranin A (CgA), a secretory protein of neuroendocrine cells, has recently been characterized as a valuable tissue marker in hormonally activeand non‐functioning neuroendocrine tumors. This study analyzes the role of CgA as a serum marker for different neuroendocrine tumors. Thirty‐three patients with neuroendocrine tumors of the stomach (n=7), the ileum (n=18), and the pancreas (n=8) were investigated. Serum CgA levels were analyzed by radioimmunoassay at the time of diagnosis and during follow‐up under different therapeutic regimens. Serum CgA was elevated in 30 (91%) patients. Mean CgA serum levels varied with tumor location (pancreas: 7068±3008 ng/ml, ileum: 5381±1740 ng/ml, stomach: 529±179 ng/ml, x±SEM ng/ml) but did not differ between functioning and non‐functioning tumors. Eight of 10 patients treated with either somatostatin or interfer‐on‐alpha showed changes of CgA concentrations corresponding to tumor growth. We conclude that CgA is a useful broad‐spectrum tumor marker in gastroenteropancreatic neuroendocrine tumors. Its determination is especially recommended in tumors without hormonal activity.
Prognostic factors in parathyroid cancer: A review of 95 cases
Authors: Sandelin Kerstin , Auer Gert , Bondeson Lennart , Grimelius Lars , Farnebo Lars‐Ove
Published: August 2005

The clinical course, histopathology, and tumor DNA distribution patterns were analyzed in 95 patients with parathyroid cancer. The median follow‐up was 6 years (range 1–25 years). Eighteen patients received a benign diagnosis at their first operation. The initial procedure was tumor resection in 42 patients and tumor resection plus partial or total thyroidectomy in 40 patients. Forty patients developed recurrent disease and 36 patients underwent 1 to 9 re‐operations. Cervical recurrence and lung metastases were most commonly encountered. The median time from the first operation to recurrence was 33 months (range 1–228 month). Twenty‐one patients died of parathyroid cancer a median of 28 months following discovery of their first recurrence. The histopathological reevaluation confirmed unequivocal parathyroid cancer, i.e., infiltration and/or metastases, in 41 cases. Fifty‐four cases lacked these criteria but showed various forms of atypia. Image cytometry demonstrated tumor aneuploidy in 26 of 39 cases with definite cancer by histological criteria, compared to the 13 of the 52 with equivocal histological diagnosis. Twelve patients with aneuploid tumors and 7 patients with euploid tumors died of parathyroid cancer. In a multivariate analysis, patients treated with extensive surgery, i.e., tumor resection and unilateral or bilateral thyroidectomy, had a longer survival and a longer relapse‐free period. Other factors of importance for survival were age and histopathology. Histopathology and an aberrant nuclear DNA content were important factors for the time to recurrence. We conclude that histopathology alone is unable to confirm a cancer diagnosis in the absence of infiltration and/or metastases. Because recurrence may occur late, patients should be followed closely. Even repeated surgical interventions have proven beneficial.
The value of measurement of RAS oncogenes and nuclear DNA analysis in the diagnosis of Hürthle cell tumors of the thyroid
Authors: Schark Claudia , Fulton Noreen , Yashiro Tohru , Stanislav Greg , Jacoby Russell , Straus Francis H. , Dytch Harvey , Bibbo Marluce , Kaplan Edwin L.
Published: August 2005

Hürthle cell tumors (HCT) remain difficult to treat because some which appear non‐malignant on light microscopy later metastasize. In order to improve diagnostic accuracy, the value of ras mutations and nuclear DNA analysis was determined in 65 patients with HCT. Rapid nuclear DNA cytometry (MicroTICAS system) was performed. Mutations of H‐ras, K‐ras, and N‐ras genes were analyzed by oligonucleotide probe hybridizations to polymerase chain reaction (PCR) amplified DNA. HCT were classified by light microscopy as benign (n=22), intermediate (n=30), and malignant (n=13). After a mean follow‐up of 7 years, 1 (4.5%) of 22 benign tumors and 4 (13%) of 30 intermediate tumors had metastasized, leading to tumor death in 3 of these 5 patients. Six of the 13 cancers diagnosed by light microscopy also resulted in tumor‐related deaths.

Aneuploidy was found in 83% of all Hürthle cell cancers, including 3 (60%) of the 5 cancers not diagnosed microscopically. However, 49% of non‐malignant HCT also demonstrated aneuploidy. A nuclear area of less than 55 square microns was found in 83% of all Hürthle cell cancers and in 100% of those cancers not diagnosed by light microscopy. However, 47% of non‐malignant HCT also demonstrated a “small” nuclear area. Aneuploidy correctly identified 8 of 9 cancers that resulted in tumor death and each of 3 other tumors that developed metastases. However, 1 patient with a diploid tumor died of metastatic cancer. A nuclear area of less than 55 square microns identified each cancer that resulted in a tumor death.

Ras mutations were found in 9 (14%) of 65 Hürthle cell tumors. Only N‐ras mutations were found, and 8 of 9 were N‐ras, codon 61. Twenty‐two percent of Hürthle cell cancers and 11% of non‐malignant HCT exhibited ras mutations (p=N.S.) Ras mutations were found in 2 (40%) of 5 cancers which were not recognized microscopically. Of 4 cancers which exhibited ras mutations, 2 (50%) resulted in tumor death. Of 14 cancers that were ras negative, 7 (50%) resulted in death from tumor.

We conclude that nuclear DNA cytometric studies are not useful in separating benign from malignant Hürthle cell neoplasms. However, aneuploidy and a nuclear area less than 55 square microns clearly demonstrate those cancers that are likely to act in an aggressive manner and result in tumor death. It should be noted, however, that one patient with a diploid cancer died of metastatic Hürthle cell cancer. Finally, the presence of ras mutations has limited usefulness as a prognostic factor.
Percutaneous ethanol injection treatment of autonomously functioning single thyroid nodules: Optimization of treatment and short term outcome
Authors: Goletti O. , Monzani F. , Caraccio N. , Del Guerra P. , Lippolis P. V. , Pucciarelli M. , Seccia M. , Carmassi F. , Cavina E. , Baschieri L.
Published: August 2005

Twenty‐five patients with solitary autonomous thyroid nodules (15 nontoxic, 10 toxic) received percutaneous ethanol injection treatment (PEIT) under sonographic guidance in 4–7 sessions (1–2 weekly). To test different doses, smaller nodules (volume <15 mL) were given 0.75–2.8 mL ethanol/mL nodular tissue while larger nodules received 0.5–1 mL/mL. Except for 1 patient who developed hyperpyrexia, no relevant adverse effects were observed. A slight, asymptomatic increase in serum thyroid hormone levels was observed in both groups during the treatment. Three months after treatment, a biochemical and clinical remission of hyperthyroidism was observed in 8 of 10 patients with toxic nodules. A significant increase of TSH level was seen in both groups (p<0.01). Significant shrinkage of volume (p<0.001) as well as structural alternations of nodules were consistently recorded at sonography. A linear relationship (r=0.98;p<0.0001) between pretreatment volume and volume reduction was found both for large and small nodules, thus suggesting that even limited ethanol doses may be therapeutically effective. A recovery of extranodular parenchyma activity at scintiscan occurred in 16 (64%) of 25 patients. These data confirm that PEIT is effective in obtaining functional ablation and in inducing remission of hyperthyroidism. Adverse effects are infrequent. In spite of the small patient sample, a 0.5–1 mL ethanol dose per each mL of tissue appears as effective as larger doses and seems appropriate for treatment.
Melanoma and sun exposure: Contrasts between intermittent and chronic exposure
Authors: Elwood J. Mark
Published: August 2005

The evidence relating cutaneous malignant melanoma to previous sun exposure is now very strong. Major northern hemisphere studies consistently show increases in melanoma in association with recreational and vacation activities related to intermittent sun exposure. These studies have also recorded amounts of sun exposure from such activities. Several studies suggest an increased risk related to short periods of intensive exposure in early adult life. In contrast, regular outdoor occupation confers a decreased risk in these same studies. Australian studies, in populations with much higher levels of total sun exposure, do not show such a clear distinction between intermittent and chronic exposure. The evidence is consistent with a complex relationship of melanoma risk to sun exposure, the risk being increased by intermittent exposure to levels of sun which are higher than normal for that individual, but no increased risk or even a decreased risk related to long term chronic exposure. Possible biological mechanisms for this complex relationship are discussed. In the Western Canada Melanoma Study the effects of occupational and recreational exposure are different in form and are independent. The increased risks seen with various measures of sun exposure do not appear to be systematically different for individuals who have a good tanning response as compared to individuals who do not.
Desmoplastic melanoma: Patterns of recurrence
Authors: Smithers B. Mark , McLeod G. Roderick , Little John H.
Published: August 2005

Desmoplastic melanoma is a rare type of malignant melanoma, recognized since 1971. Other variants of desmoplastic melanoma include neural transforming melanoma and neurotropic melanoma.

The pathology and clinical features of 58 patients whose tumor had the features of desmoplastic melanoma, neural transforming melanoma, and neurotropic melanoma, either separately or in combination, were examined to assess patterns of recurrent disease. The tumor was situated on the head and neck in 41% of patients and was amelanotic in 71% of patients. There was an associated superficial melanoma in 48% of patients. There was a combination of the 3 histologic patterns, commonly found in the 1 melanoma. Local recurrence occurred in 29% of patients and malignant cranial neuropathies were documented in 4 patients. Nineteen percent of patients have died from disseminated disease. Neurotropic melanomas had a lower incidence of visceral recurrence. Desmoplastic and neural transforming melanomas had similar rates of local and visceral recurrence.

When this specific variant of melanoma is compared with larger series of malignant melanoma in general, they appear to be more advanced locally, with a higher incidence of local recurrence. When considered in relation to the thicker nondesmoplastic melanomas, the survival is no worse and may be more favorable.

Surgeons should excise the primary tumor and local recurrences with wide margins and adopt close follow‐up. On the head and neck, symptoms and signs relating to trigeminal or facial nerve innervation may herald a developing malignant cranial neuropathy.
Cutaneous melanomas exhibiting unusual biologic behavior
Authors: Shaw H. M. , Rivers J. K. , McCarthy S. W. , McCarthy W. H.
Published: August 2005

In rare instances, primary malignant melanoma thickness fails to predict the biologic course of the disease: lesions <0.8 mm thick may recur locally or metastasize, lesions >5.5 mm thick may not prove to be fatal within the expected interval of time, and melanoma recurrences may develop >10 years after first definitive melanoma treatment. The large Sydney Melanoma Unit data base of over 9,500 patients treated over a 41‐year period provided a unique opportunity to study the characteristics and prognosis of these patients with unusual melanomas. In stage I patients with thin lesions, and no sign of disease elsewhere, presence of ulceration, high mitotic activity, and/or penetration into the reticular dermis predisposed these melanomas to recur and regression did not emerge as a risk factor for recurrence. This was in sharp contrast to the histology of the thin lesions in patients with concurrent regional lymph node metastases (stage II). Moderate to severe regression was present in all the latter lesions, ulceration and mitoses were absent, and none penetrated beyond the papillary dermis. No specific criteria were found that could identify those stage I or II patients with thick melanomas but at low risk for recurrence or those patients with localized disease (stage I) who required long‐term follow‐up beyond 10 years.

These results indicate that guidelines for follow‐up of melanoma patients after first definitive treatment may not be appropriate for a small proportion of patients. Since recurrences are mainly loco‐regional and most patients who develop a recurrence detect the recurrence themselves, education of the patient in self‐examination, and also self‐referral may be the best pragmatic approaches to facilitate early diagnosis of recurrences without imposing too heavy a burden on health services.
Neck dissection for cutaneous malignant melanoma
Authors: O'Brien Christopher J. , Gianoutsos Mark P. , Morgan Matthew J.
Published: August 2005

This retrospective study examines the experience of the Sydney Melanoma Unit in the management of cervical lymph nodes among patients with cutaneous melanoma of the head and neck. From 1960 to 1990, 397 patients had neck dissections for cutaneous malignant melanoma of the head and neck. This number represents 40% of all patients treated for head and neck melanoma at the Sydney Melanoma Unit during this period. Neck dissections were therapeutic in 152 patients, elective in 234 patients and for an unknown indication in 11 patients. Lymph nodes were histologically positive in 39% of operations overall and in 7% of elective neck dissections. The incidence of recurrence in the neck after dissection was 24% overall, 28% when nodes were histologically positive and 13% when nodes were histologically negative. Patients who developed recurrent neck disease after neck dissection had a worse prognosis than those with positive nodes who did not recur, but the difference in survival was not statistically significant. Patients with histologically positive nodes had a significantly worse survival than those with negative nodes, 34% vs 67% respectively at 10 years (p < 0.001). Elective neck dissection was associated with a significant improvement in survival for patients with melanomas 1.5–3.9 mm thick, using univariate analysis. This apparent benefit was lost when multivariate analysis was carried out. Patients having elective neck dissection currently have selective modified radical dissections depending upon the anatomic site of the primary melanoma. Postoperative radiotherapy is used for multiple positive nodes or extracapsular spread.
In transit metastases of malignant melanoma treated by high dose rTNFα in combination with interferon‐γ and melphalan in isolation perfusion
Authors: Liénard Danielle , Lejeune Ferdy J. , Ewalenko Patricia
Published: August 2005

To increase the therapeutic efficacy of recombinant tumor necrosis factor alpha (rTNFα) and reduce the systemic side effects, a protocol was designed using isolation perfusion of the limbs with hyperthermia for in transit metastases of melanoma. A triple combination of high dose rTNFα + recombinant interferon‐gamma (rIFN‐γ) + melphalan was chosen because of a synergistic anti‐tumor effect of rTNFα with rIFN‐γ and of rTNFα with alkylating agents reported in the literature. Twenty‐nine patients of mean age 60 years (range 22–82 years) entered the study after informed consent and received a total of 31 isolation perfusions with the triple combination. There were 24 women and 5 men with multiple progressivein transit melanoma metastases of the lower limb (stage IIIa or IIIab). rTNFα at the unique dose of 4 mg was injected as a bolus in the arterial line, under mild hyperthermic conditions (40 to 40.5°C) for 90 minutes. rIFN‐γ was given subcutaneously on days −2 and −1 and in the perfusate, with rTNFα, at the dose of 0.2 mg. Melphalan was administered in the perfusate at dose giving a concentration of 40 µg/ml.

In all the 31 isolation perfusions performed in the triple combination protocol, in order to prevent a septic shock‐like syndrome which had been encountered in 2 patients treated outside this protocol for sarcoma and carcinoma, the patients received dopamine continuous infusion at 3 µg/kg/min from the start of isolation perfusion and for 48 hours, and only showed mild hyptension and very transient chills and temperature. Regional toxicity attributable to rTNFα was minimal. There have been 16 patients with hematologic toxicity consisting of neutropenia (11 cases, 1 case grade 4 and 1 case grade 3) and neutropenia with thrombocytopenia (12 cases, 1 case grade 4 and 4 cases grade 2). Eighteen of 29 patients had been previously treated with melphalan in isolation perfusion (n=13) or with cisplatinum (n=2), rTNFα‐Melphalan (n=1), or rTNFα alone (n=2). Median follow‐up has been 41 weeks. The 29 patients are evaluable: there have been 26 (90%) complete remissions (CR), 3 (10%) partial remissions (PR), and no failures. Actuarial disease‐free survival and total survival have been 63% and 73%, respectively, at 12 months. In all cases, softening of the nodules was obvious within 3 days after isolation perfusion and time to definite response ranged between day 6 and 22.

This interim analysis of a phase II study suggests that high dose of rTNFα can be administered with acceptable toxicity by isolation perfusion with dopamine and hyperhydration. Tumor responses can be evidenced in all patients, with 90% CR. Furthermore, combination of rTNFα, rIFN‐γ, and melphalan seems to achieve high efficacy with minimal toxicity, even after failure of prior therapy with melphalan alone.
What has the surgeon to know about pathophysiology of reflux disease?
Authors: Sivri Bulent , McCallum Richard W.
Published: August 2005

Much has been learned about the pathophysiology of gastro‐esophageal reflux (GER) since it was initially described by Asher Winkelstein in 1935. With the development and refinement of esophageal function tests in the past decades, the diagnostic modalities have become available for a deliberate and systematic evaluation of antireflux mechanisms. Some of the newer concepts of the pathogenesis of reflux esophagitis are reviewed in this article.
The neoplastic potential of columnar‐lined (Barrett's) esophagus
Authors: Tytgat G. N. J. , Hameeteman W.
Published: August 2005

Reflux of gastric contents is the most important factor contributing to the development of a columnar‐lined esophagus (CLE). CLE should be considered a “mosaic” of cells, glands, and architectural types showing variable degrees of maturation towards intestinal and gastric epithelium. Dysplasia refers to an unequivocally neoplastic alteration in the epithelium. High‐grade (severe) dysplasia consists of neoplastic cellular and/or architectural changes within the columnar epithelium, without invasion through the basement membrane. The prevalence of dysplasia is usually 5% to 10%. Dysplasia has been found in the vast majority in the specialized columnar‐type or intestinal‐type epithelium. Adenocarcinoma in CLE is most often seen in males. At the time of diagnosis transmural tumor infiltration is found in 60% to 88% of patients, and lymph node invasion in 55% to 74% of patients. The prognosis is poor with a low 5 year survival. Estimates of incidence of cancer vary from 1 case per 52 patient years of follow‐up to 1 case per 441 patient years of follow‐up.
Fundoplication: How to do it? Peri‐esophageal wrapping as a therapeutic principal in gastro‐esophageal reflux prevention
Authors: Siewert J. R. , Feussner H. , Walker S. J.
Published: August 2005

The prerequisites for a successful outcome after fundoplication are careful patient selection, good technique, and an understanding of the principles of antireflux surgery. The most important aspect of any such operation is the construction of a peri‐esophageal ring around the gastro‐esophageal junction buttressing the sphincter and, thus, neutralizing the gastric opening pressure. Accordingly, the operation has to comprise: 1) generous dissection around the gastric fundus to allow the formation of a “floppy” fundoplication; 2) construction of the cuff as short as possible (2 cm to 3 cm); and 3) proper fixation of the cuff at the correct site in the region of the lower esophageal sphincter. Adherence to these principles will avoid postoperative dysphagia or functional gastro‐intestinal disorders and produce long‐lasting reflux control in approximately 90% of patients at 10 years. Problems of hypercontinence may occasionally occur since gastro‐esophageal reflux suppression is usually complete and any physiological reflux abolished. With the advent of modern drug treatment, the excellent results achieved by fundoplication need to be maintained despite fewer operations. Careful postoperative quality control including pH monitoring is therefore mandatory. The principle of periesophageal wrapping is likely to remain the cornerstone of antireflux surgery. Current techniques are, however, likely to evolve. One direction being investigated is laparoscopic fundoplication, rendering the procedure much less invasive.
The relationship between intra‐operative manometry and clinical outcome in patients operated on for gastro‐esophageal reflux disease
Authors: Jamieson Glyn G. , Myers Jennifer C.
Published: August 2005

Lower esophageal sphincter pressure has been assessed pre‐operatively, intra‐operatively, and more than 6 months postoperatively in 34 patients having antireflux surgery for gastro‐esophageal reflux disease. The sphincter pressures associated with the outcome in relation to pH measured reflux and the symptoms of recurrent heartburn, gas bloating, and dysphagia have been determined. There was no significant difference between the intra‐operative sphincter pressure or the postoperative sphincter pressure and any of these parameters. It is concluded that intra‐operative manometry in its present form is not useful in antireflux surgery for primary gastro‐esophageal reflux disease.
Design and Automated Control of the Electron Microscopy Proteomic Organellar Preparation Robot
Authors: Waterbury Raymond G. , Punwani Karishma , Bergeron John J.M. , Kearney Robert E.
Published: August 2005

The Electron Microscopy Proteomic Organellar Preparation (EMPOP) robot is a tool for high-throughput preparation of subcellular fraction samples for electron microscopic identification. It provides a means of validating subcellular sample purity and confirming protein localization needed for organellar proteomics.

The device handles all chemical and mechanical manipulations required to prepare organelles for electron microscopic examination. It has a modular, integrated design that supports automated filtration, chemical processing, delivery, and embedding of up to 96 subcellular fraction samples in parallel. Subcellular fraction specimens are extremely fragile. Consequently, the system was designed as a single unit to minimize mechanical stress on the samples by integrating a core mechanism, composed of four modular plates, and five support subsystems: (1) a cooling platform, (2) an automated fluid handling subsystem, (3) an electromagnetic arm, (4) a plate transfer platform, and (5) a 5-axis motion control system (X, Y, Z, θ, ø).

System control is fully automated to provide standardized, reproducible subcellular fraction sample processing while maintaining flexibility for adjustment and recall of instrumentation and process operational parameters. To achieve this, the control software was built on two coordinated levels: (1) a user interface for system testing, calibration, setup, and process monitoring and (2) low-level real-time control routines.

The EMPOP robot provides, for the first time, massive, parallel electron microscopic screening and quantitative analysis of subcellular and protein targets necessary for high-throughput proteomics.
Assessing hERG Channel Inhibition Using PatchXpress
Authors: Ly Justin Q. , Shyy Gordon , Misner Dinah L.
Published: August 2005

PatchXpress, an automated 16-channel parallel patch clamp system, was used to determine inhibition of human ether-a-go-go related gene (hERG) potassium channels by known blockers. A monoclonal cell line stably expressing hERG potassium channels was generated in CHO-KI cells. Results were compared to conventional patch clamp experiments using similar voltage protocols and solutions. Success rates were evaluated for cell recordings under a variety of conditions, including Accumax versus trypsin treatment to harvest cells, single versus double compound additions, and polystyrene versus glass-coated compound plates. We found that the average success rates rose from 27% with trypsin treatment to 38% with Accumax treatment, which improved to 55–65% following long-term culturing using only Accumax to harvest cells. Two drug additions (spaced 1 min apart with suction off) were also found to produce data that more closely matched conventional experiments. Finally, polystyrene versus glass-coated compound plates were evaluated, and we found that for some compounds (but not all), preparation of compound samples in glass-coated plates resulted in inhibition that more closely matched data obtained by conventional experiments. Therefore, we have established an assay to evaluate the ability of compounds to inhibit hERG potassium channels, which closely matches data produced using conventional methods but with much greater throughput.