Understanding and treating depression among cancer patients.

Cancer is a devastating disease. Awareness of this disorder tremendously impacts an individual's life, creating a host of changes to occur. Depression is one concern that many cancer patients experience. It is important to make an accurate and complete assessment of depressive symptoms. Furthermore, a heightened awareness of patients' culture and their perceptions is vital to their assessment, diagnosis, and treatment of depression. In cases of clinical depression, appropriate antidepressants prescribed along with the treatment for cancer are significant for the patient. Palliative counseling for patients and supportive counseling for their family are recommended as part of a treatment plan.

Prognostic indicators in cystosarcoma phylloides.

Cystosarcoma phylloides is a breast neoplasm that has a frequently unpredictable clinical course. We made a retrospective study of 25 patients with this disease in an attempt to evaluate the indicators of aggressive behavior. In our series, older patient age, nulliparity, rapid tumor growth, pain, and large size of tumors increased the suspicion of malignancy but were not always reliable indicators of malignancy. Skin ulceration, tumor necrosis, and infiltrating tumor margins were the most ominous characteristics. High-grade tumors, that is, those with increased cellularity, vascularity, mitotic figure, and pleomorphism, often indicated aggressive behavior. Mixed mesenchymal components were sometimes related to a malignant course. We found a 24 percent incidence of associated breast cancer. Carcinoma of the ipsilateral breast was found in four patients and later in the contralateral breast in two patients. Of our 25 patients, 10 (40 percent) had recurrence and 4 (16 percent) died from disease. Recurrences after treatment usually occurred within 3 years. Patients must be followed carefully for local recurrence or metastases, since the clinical course is not predictable. Forty percent of the lesions were diagnosed as being malignant. Local excision was associated with recurrence in six of eight patients and was clearly inadequate treatment. Quadrantectomy was effective for benign peripheral lesions when a generous margin could be obtained. From these data, we believe that mastectomy is indicated in all patients with malignant lesions and in those with large benign lesions.

Acute cholecystitis and common-duct calculi.

The detection of common-duct stones is important in the treatment of patients with acute cholecystitis. The records of 256 patients with histopathologically confirmed acute cholecystitis were reviewed retrospectively. Associated choledocholithiasis was found in 32 (12.5%). Preoperative serum bilirubin and alkaline phosphatase levels were inconsistent predictors of common-duct calculi. Gray-scale ultrasonography is useful in the diagnosis of acute cholecystitis, but its role in the detection of common-duct calculi is uncertain. Dilated bile ducts were found in only three of eight icteric patients examined with ultrasonography. Intraoperative cholangiograms were obtained in 24 of 32 patients with choledocholithiasis, and common-duct stones were successfully demonstrated in 23 of these. Intraoperative cholangiography is a reliable method of detecting common-duct calculi and should be routinely used in the surgical treatment of acute cholecystitis.

Diagnosis of choledocholithiasis.

A review of the records of 75 consecutive patients with a discharge diagnosis of choledocholithiasis has been conducted. Clinical assessment as well as laboratory assessment of patients who are suspected of having common duct calculi continues to present significant problems in diagnostic accuracy. More than 90 per cent of the patients who presented with Charcot's triad of pain, fever and jaundice had common duct calculi; however, only one-fourth of the patients in our study with choledocholithiasis had this combination of symptoms. Imaging techniques before operation are associated with a significant incidence of false-negative and false-positive findings. Palpation of the common duct and cholangiography at the time of operation remain the most reliable means of detecting choledocholithiasis.

Hyperparathyroidism: problems in surgical management.

A retrospective study of 210 patients who had 225 operations for hyperparathyroidism over a 20 year period has been reported. These patients were operated on by 20 staff surgeons, 12 of whom performed such an operation less than five times for this disease during the study period. There was a significant operative and postoperative morbidity of about 8 percent. There was one postoperative death, and two patients died later of related problems. The recurrence rate was 1 percent. The total rate of untoward results was about 18 percent. The success rate of primary operations was 95 percent (71 percent for reoperations). These findings were similar to those in many published reports, but were less than satisfactory. It is possible that results could be improved by putting such patients in the care of experienced surgeons. Careful identification of all of the parathyroid glands is essential to obtain satisfactory results. There was an unusually large incidence of this disease in patients with thyroid disease, immobilization, and thiazide intake. There was a correlation between the preoperative serum calcium levels and the size of the parathyroid tumors that were removed. An interesting "rebound" postoperative hypercalcemia has been described.

Coated Vicryl synthetic absorbable sutures.

An absorbable lublicating coating applied to Vicryl sutures has improved the ease with which the sutures pass through tissue and has made handling and tying better. The coated sutures were found to be safe, strong and secure. No disadvantages were seen as a result of coating the synthetic absorbable Vicryl sutures in the 49 patients studied. Over-all, the coated Vicryl sutures eliminated some of the disadvantages of the braided synthetic absorbable suture without producing new problems.

Choledocholithiasis associated with acute cholecystitis.

A retrospective review of the records of 1,507 patients with a diagnosis of cholecystitis was conducted for the five-year period, 1972 to 1977. Of this group of patients, a histopathologic diagnosis of acute cholecystitis was established in 154 patients (10.2%). Common duct calculi were detected in 17 of these 154 patients, an incidence of 11%. Preoperative evaluation by means of serum bilirubin and alkaline phosphatase levels and intravenous cholangiography was unsatisfactory for consistent demonstration of choledocholithiasis in the presence of acute cholecystitis. Intraoperative cholangiography was found to be the most reliable method for detection of common duct calculi and was successfully employed in 14 of 17 patients with choledocholithiasis. The remaining three patients had palpable stones.

Lipoma of the colon.

Lipoma, an uncommon tumor in the gastrointestinal tract, occurs most often in the colon. The majority are asymptomatic but may cause abdominal pain, obstruction, or bleeding. The diagnosis can be made roentgenographically but is usually not made until operation is performed. Small lipomas may be removed by colonoscopy or followed conservatively after biopsy via colonoscopy. The treatment for symptomatic or large lipomas is surgical excision.