Surgical techniques in the management of rectal cancer: a modified Delphi method by colorectal surgeons in Australia and New Zealand.

BACKGROUND: Technological developments have allowed advances in minimally invasive techniques for total mesorectal excision such as laparoscopy, robotics, and transanal surgery. There remains an ongoing debate about the safety, benefits, and appropriate clinical scenarios for which each technique is employed. The aim of this study was to provide a panel of expert opinion on the role of each surgical technique currently available in the management of rectal cancer using a modified Delphi method. METHODS: Surveys were designed to explore the key patient- and tumor-related factors including clinical scenarios for determining a surgeon's choice of surgical technique. RESULTS: Open surgery was favoured in obese patients with an extra-peritoneal tumor and a positive circumferential resection margin (CRM) or T4 tumor when a restorative resection was planned. Laparoscopy was favoured in non-obese males and females, in both intra- and extra-peritoneal tumors with a clear CRM. Robotic surgery was most commonly offered to obese patients when the CRM was clear and if an abdominoperineal resection was planned. Transanal total mesorectal excision (taTME) was preferred in male patients with a mid or low rectal cancer, particularly when obese. Transanal endoscopic microsurgery/transanal minimally invasive surgery local excision was only offered to frail patients with small, early stage tumors. CONCLUSIONS: All surgical techniques for rectal cancer dissection have a role and may be considered appropriate. Some techniques have advantages over others in certain clinical situations, and the best outcomes may be achieved by considering all options before applying an individualised approach to each clinical situation.

An assessment of an Australasian pathway for the introduction of transanal total mesorectal excision (taTME).

AIM: To evaluate the use of a pathway for the introduction of transanal total mesorectal excision (taTME) into Australia and New Zealand. METHOD: A pathway for surgeons with an appropriate level of specialist training and baseline skill set was initiated amongst colorectal surgeons; it includes an intensive course, a series of proctored cases and ongoing contribution to audit. Data were collected for patients who had taTME, for benign and malignant conditions, undertaken by the initial adopters of the technique. RESULTS: A total of 133 taTME procedures were performed following the introduction of a training pathway in March 2015. The indication was rectal cancer in 84% of cases. There was one technique-specific visceral injury, which occurred prior to that surgeon completing the pathway. There were no cases of postoperative mortality; morbidity occurred in 27.1%. The distal resection margin was clear in all cases of rectal cancer, and the circumferential resection margin was positive in two cases. An intact or nearly intact total mesorectal excision was obtained in more than 98% of cases. CONCLUSION: This study demonstrates the safe and controlled introduction of a new surgical technique in a defined surgeon population with the use of a pathway for training. The authors recommend a similar pathway to facilitate the introduction of taTME to colorectal surgical practice.

Refinement of myotome values in the upper limb: Evidence from brachial plexus injuries.

PURPOSE: We reviewed patients with partial supraclavicular brachial plexus injuries in order to refine the myotome values of the upper limb. METHODS: Forty-two patients with defined partial injuries to the supraclavicular brachial plexus were reviewed from a prospective database. The injuries patterns covered C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. Upper plexus injuries were classified on the basis of surgical exploration and intraoperative stimulation and lower plexus injuries from MRI. RESULTS: Flexor Carpi Radialis (FCR) was paralyzed in C5-7 injuries, in addition to paralysis of deltoid, supraspinatus, infraspinatus and biceps, when compared to C5-6 injuries. Complete paralysis of Flexor Digitorum Profundus (FDP) and Flexor Digitorum Superficialis (FDS) to all digits was identified in C7-T1 injuries. In C5-8 injuries weakness was noted in FDP of ulnar digits and intrinsics innervated by the ulnar nerve, while in C8-T1 injuries paralysis was noted in the FDP to the radial digits. All patients with C8-T1 injuries had paralysis of FDS and the thenar muscles. CONCLUSIONS: In upper plexus injuries paralysis of FCR indicated involvement of C7 root in addition to C5 and C6 roots. The results provide new detail of innervation of muscles acting on the hand. Flexor muscles and intrinsic muscles of the thumb and radial fingers (median nerve) have an important contribution from T1, while for those acting on the ulnar digits (ulnar nerve) the main contribution is from C8 with some input from C7. T1 also gives consistent innervation to extensor pollicis longus. A revised myotome chart for the upper limb is proposed.

The evolving role of computer-assisted navigation in musculoskeletal oncology.

We report our experience of using a computer navigation system to aid resection of malignant musculoskeletal tumours of the pelvis and limbs and, where appropriate, their subsequent reconstruction. We also highlight circumstances in which navigation should be used with caution. We resected a musculoskeletal tumour from 18 patients (15 male, three female, mean age of 30 years (13 to 75) using commercially available computer navigation software (Orthomap 3D) and assessed its impact on the accuracy of our surgery. Of nine pelvic tumours, three had a biological reconstruction with extracorporeal irradiation, four underwent endoprosthetic replacement (EPR) and two required no bony reconstruction. There were eight tumours of the bones of the limbs. Four diaphyseal tumours underwent biological reconstruction. Two patients with a sarcoma of the proximal femur and two with a sarcoma of the proximal humerus underwent extra-articular resection and, where appropriate, EPR. One soft-tissue sarcoma of the adductor compartment which involved the femur was resected and reconstructed using an EPR. Computer navigation was used to aid reconstruction in eight patients. Histological examination of the resected specimens revealed tumour-free margins in all patients. Post-operative radiographs and CT showed that the resection and reconstruction had been carried out as planned in all patients where navigation was used. In two patients, computer navigation had to be abandoned and the operation was completed under CT and radiological control. The use of computer navigation in musculoskeletal oncology allows accurate identification of the local anatomy and can define the extent of the tumour and proposed resection margins. Furthermore, it helps in reconstruction of limb length, rotation and overall alignment after resection of an appendicular tumour.

Primary bone tumours of the talus: the Scottish Bone Tumour Registry experience.

BACKGROUND: Primary bone tumours of the talus are rare and the existing literature is limited. The aim of this study was to investigate the epidemiology of primary bone tumours affecting this uncommon site and suggest a management protocol for these tumours. METHODS: We retrospectively reviewed the Scottish Bone Tumour Register from January 1954 to May 2010 and included all primary bone tumours of the talus. RESULTS: We identified only twenty three bone tumours over fifty six years highlighting the rarity of these tumours. There were twenty benign and three malignant tumours with a mean age of twenty eight years. A delay in presentation was common with a mean time from onset of symptoms to diagnosis of ten months. CONCLUSIONS: Tumour types identified were consistent with previous literature. We identified cases of desmoplastic fibroma and intraosseous lipodystrophy described for the first time. We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the talus.

Paediatric forearm fractures in the west of Scotland.

Forearm fractures are common paediatric injuries. This study aimed to describe the epidemiology and treatment of paediatric forearm fractures in the urban population of Glasgow. We reviewed all forearm fractures treated by the orthopaedic service in Yorkhill Children's Hospital in 2008 up to the age of 13 years. Data were gathered from case-notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 439 fractures. Census data were used to derive absolute age-specific incidences. Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year and 294 fractures per 100,000 population per year for non-torus fractures. An increased number of fractures occurred between May and August. A fall from less than 1 m was the most common mechanism of injury. Sporting injuries were the second most common. This study identifies some features which are in agreement with studies from elsewhere in Britain. However, there are also interesting differences, such as the Glasgow peak incidence for forearm fractures being at age eight, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention and likelihood of successful treatment.

The rate of abdominoperineal resections for rectal cancer in the state of Victoria, Australia: a population-based study.

PURPOSE: The aim of this study was to document a population-based rate of abdominoperineal resections for adenocarcinoma of the rectum in the state of Victoria, Australia. It also determined whether surgeon caseload or specialist colorectal training affects this rate. METHODS: All resections for adenocarcinoma of the rectum (International Classification of Diseases for Oncology, 3rd edition C20) that were performed in Victoria in the year 2005 were included. Procedures for rectosigmoid or colon cancer were excluded. The sample was taken from the Victorian Cancer Registry. The rate of abdominoperineal resections was calculated by dividing the total number of abdominoperineal resections by the total number of procedures for rectal cancer. Mixed-effects logistic regression was used to estimate the odds ratio for surgeon caseload and specialist colorectal training. RESULTS: There were 582 resections available for analysis. Patients were mostly males (66%) and over 60 years of age (67.7%). The overall rate of abdominoperineal resection was 23.4%. The rate of abdominoperineal resections for low rectal cancers was lower (42.8%) among surgeons who had specialist colorectal training compared with those who did not (60.6%) (OR = 2.06; 95% CI, 1.24-3.42). CONCLUSION: The rate of abdominoperineal resection in Victoria for 2005 was 23.4%. Patients with low rectal cancer operated on by surgeons who had had specialist colorectal training were significantly less likely to undergo an abdominoperineal resection compared with patients undergoing an operation by surgeons who did not have specialist colorectal training.

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection.

BACKGROUND: Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS: Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS: Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION: The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.

Cystic fibrohistiocytic tumours presenting in the lung: primary or metastatic disease?

AIMS: Cystic fibrohistiocytic tumour of the lung is a rare proliferative process. Its histogenesis is uncertain, but evidence suggests that some cases represent metastatic disease from apparently indolent skin lesions, namely cellular fibrous histiocytomas. This study presents four cases and reviews the literature concerning this pattern of disease and its aetiology. METHODS AND RESULTS: All patients were male (age range 35-54 years). Two presented with recurrent haemoptysis. Two cases had histories of cutaneous fibrohistiocytic lesions in the chest wall, excised 10 and 23 years prior to presentation with lung disease. Imaging data showed multiple bilateral cystic lung lesions in all four patients with nodular cavitating opacities seen on high-resolution computed tomography scans. Microscopy showed variably dilated thin-walled cystic airspaces lined by cuboidal epithelium and an underlying layer of mildly pleomorphic spindle cells with slightly wavy morphology and storiform architecture, admixed with inflammatory cells. Tumour cells stained for CD68 in three of four cases. All cases were negative for CD34. All patients were alive with disease, although one required pneumonectomy for intractable haemoptysis. CONCLUSION: This study and a review of published cases show that the majority of cystic fibrohistiocytic tumours of the lung probably represent metastases from cellular fibrous histiocytomas. However, rare cases may be either primary in origin or the primary site remains occult; the term cystic fibrohistiocytic tumour remains appropriate for such cases.

Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence.

BACKGROUND: The aim of this study was to determine whether leakage from a colorectal anastomosis following potentially curative anterior resection for rectal cancer is an independent risk factor for local recurrence. METHODS: The study included all patients who had a potentially curative anterior resection with anastomosis for adenocarcinoma of the rectum between 1971 and 1991 at Concord Hospital. The data were collected prospectively, with complete follow-up for at least 5 years. The Kaplan-Meier method was used to compare time to recurrence between strata of categorical variables. Proportional hazards regression was used in multivariate modelling. RESULTS: There were 403 patients in the study. After adjustment for lymph node metastases, the distal resection margin of resection, non-total anatomical dissection of the rectum and the level of anastomosis, multivariate analysis identified a significant association between anastomotic leakage and local recurrence (hazard ratio 3.8, 95 per cent confidence interval 1.8 to 7.9). CONCLUSION: Leakage following a colorectal anastomosis after potentially curative resection for adenocarcinoma of the rectum is an independent predictor of local recurrence.

Tracheobronchial glomus tumor.

Glomus tumors are uncommon. A review of the literature for tracheobronchial glomus tumors revealed 13 tracheal glomus tumors. The diagnosis may be elusive and so the true incidence of tracheobronchial glomus tumors may be greater than that reported. Three of the 14 glomus tumors were initially believed to be carcinoid. Glomus tumors should be included in the differential diagnosis of tracheobronchial tumors.

Pulmonary and mediastinal glomus tumors--report of five cases including a pulmonary glomangiosarcoma: a clinicopathologic study with literature review.

Pulmonary and mediastinal glomus tumors are rare lesions, with four previously reported primary pulmonary cases and three mediastinal cases. The authors report one mediastinal glomus tumor, a locally infiltrative type, and four pulmonary glomus tumors, including the first case of primary pulmonary glomangiosarcoma. These tumors show a variety of clinical and pathologic differences from the more common cutaneous variety, including later age at presentation, larger size, and more frequent atypical/malignant features. Mediastinal and pulmonary glomus tumors both have an average patient age at presentation of 45 years. However, compared with their pulmonary counterparts, mediastinal glomus tumors are less common, more often symptomatic, and are larger (average size, 5.4 cm). Additionally, mediastinal glomus tumors more often demonstrate malignant or atypical features. Pulmonary glomus tumors average 3.3 cm in greatest dimension, with the majority measuring less than 2.5 cm. The pulmonary glomangiosarcoma presented was large, measuring 9.5 cm, and showed increased mitotic count (9 mitoses/10 high-power fields), necrosis, cytologic atypia, and was associated with disseminated disease. Regardless of clinical symptoms, histologic features, and even metastases, the vast majority of all benign and malignant glomus tumors are indolent and cured surgically, with adjuvant therapy needed only for occasional patients with more advanced disease. The four patients with glomus tumors reported are currently alive and free of disease as of last follow up. The patient with the glomangiosarcoma developed widespread metastases and died of disease 68 weeks after initial therapy.

Problematic uterine smooth muscle neoplasms. A clinicopathologic study of 213 cases.

A recent trend in the classification of uterine smooth muscle neoplasms (USMNs) into clinically benign and clinically malignant groups has been to move from exclusive reliance upon mitotic index (MI) to an approach that incorporates additional histopathologic characteristics. In furtherance of this goal, we assessed a variety of histopathologic features of 213 problematic smooth muscle neoplasms for which we had > or = 2 years of clinical follow-up data or for which there was an unfavorable outcome. One hundred and thirteen of these patients have had a minimum follow-up of 5 years, and 48 have been followed for > or = 10 years. Cases eliminated from the study group included USMNs with a significant myxoid or epithelioid component and cases of intravenous leiomyomatosis. USMNs, whether cellular or not, with no cytologic atypia and with a mitotic index (MI = number of mitotic figures [mf]/10 high-power fields [hpf]) of < 5 mf/10 hpf (usual leiomyomas) were also excluded unless they had unusual features or were associated with an adverse clinical outcome. Fifty-six patients were initially treated by myomectomy or another form of local tumor removal; the remainder had a hysterectomy. From a wide variety of light microscopic features assessed, the important predictors that emerged, using a variety of data exploratory techniques, were MI, the degree of cytologic atypia, and the presence or absence of coagulative tumor cell necrosis (CTCN). Stratification of the USMNs with respect to these three features resulted in a five-group classification of USMNs with the following major characteristics. Group 1: Of the 89 USMNs with an MI in the range 5 < or = MI < 20 without CTCN and with no more than mild atypia, 88 were clinically benign. One patient with a tumor in this group died of metastatic disease 96 months after her uterine cervical primary neoplasm was removed. Combining our data with that in the literature, the failure rate in this group is approximately 1/200 (0.5%). This low failure rate warrants the use of the label "leiomyoma with increased mitotic index" for USMNs with these histologic features. Two patients whose USMNs were characterized by mild atypia, no necrosis, and MI < 5 developed identical-appearing pulmonary metastases and were judged in retrospect to have the syndrome "benign metastasizing leiomyoma." Group 2: USMNs with no CTCN and diffuse moderate to severe atypia fell into two groups based on the MI. For those patients whose neoplasms had an MI > or = 10 mf/10 hpf, four of 10 failed.(ABSTRACT TRUNCATED AT 400 WORDS)

Microvillous inclusion disease. The importance of electron microscopy for diagnosis.

We report two cases of microvillous inclusion disease (MID) occurring in a set of siblings. Although it is a rare disorder, MID appears to be a common cause of familial intractable secretory diarrhea. Diagnosis rests on the ultrastructural finding of intracytoplasmic inclusions that are lined by intact microvilli. These inclusions are present in the absorptive surface epithelial cells of the small and large intestine and are associated with poorly developed surface brush border microvilli. The prognosis of MID is poor and curative therapy is not currently available. Because MID appears to be a hereditary disorder, genetic counseling of affected families is essential.

Preparative techniques for freezing and freeze-sectioning macrophages for energy dispersive x-ray microanalysis.

In order to study the subcellular distribution of normal intracellular electrolytes and of metal pollutants, rabbit alveolar macrophages and mouse peritoneal macrophages were maintained in standard tissue culture medium with or without various concentrations of cadmium chloride or ammonium vanadate. A variety of preparative techniques were employed to study both monolayers and cell pellets by light microscopy, transmission electron microscopy, scanning electron microscopy and energy-dispersive x-ray microanalysis. Pellets of macrophages centrifuged in narrow bore centrifuge tubes were successfully snap-frozen in liquid-nitrogen-cooled liquid propane and either sectioned on a cryoultramicrotome or freeze-substituted with 1% osmium tetroxide in acetone and embedded in Epon. Spot probes of freeze-dried, frozen thin sections for normal intracellular electrolytes such as potassium, phosphorus and sulfur showed good localization to the cells and differences between organelles. Monolayers were freeze-dried and directly embedded in Epon. When Epon thin sections of these cells and of the freeze-substituted, Epon embedded pellets were obtained with a dry knife, intracellular electrolytes such as potassium, phosphorus and cadmium could still be detected by energy-dispersive x-ray microanalysis. It is concluded that in studies using snap-freezing for element localization, maximum information is obtained with the simultaneous application of a combination of preparatory techniques.

Ultrastructure and x-ray microanalysis of macrophages exposed to cadmium chloride.

Macrophages have a direct role in the inflammatory response to cadmium exposure. Cadmium is not only an important air pollutant, but is also one component of cigarette smoke. To study the effects of soluble cadmium on macrophages, two model systems were chosen:rabbit alveolar macrophages (RAMs) obtained by pulmonary lavage and peritoneal macrophages elicited by intraperitoneal injections of 10(7) viable M. bovis, bacillus Calmette Guérin (BCG MACs). Macrophages were maintained in standard tissue culture medium from 4 to 30 hours with concentrations of cadmium chloride (CdCl2) ranging from 0 to 1.0 mM. Attached macrophages and RAMs in suspension were studied by conventional transmission electron microscopy (TEM), scanning electron microscopy (SEM), and energy dispersive x-ray microanalysis (EDX). In addition to routine techniques for TEM and SEM, preparatory procedures included snap freezing in liquid propane, and either cryoultramicrotomy or freeze-substitution with 1% osmium tetroxide in acetone. By TEM many macrophages exhibited laminated nuclear inclusions at doses as low as 0.05 mM CdCl2) (at 20 hrs) and as early as 4 hrs (at 1.0 mM CdCl2). Sections of cells fixed by freezing exhibited the same nuclear inclusions as well as mitochondrial densities that were not visible with any other preparative technique. Cadmium was demonstrated in the nuclear inclusions and mitochondrial densities by EDX in snap frozen cells. Lesser amounts of cadmium were also detected diffusely in treated cell cytoplasm and nuclei. Cadmium was only detected by EDX in cells fixed by freezing. These studies document the localization of Cd in nuclear inclusions and mitochondria providing morphological support for the biochemical findings of other laboratories. In addition, the value of fixation by freezing over conventional chemical fixation is illustrated.

Hemidesmosome-like intercellular specializations in human meningiomas.

Desmosomes, gap junctions and tight junctions are intercellular specializations which have been described in human meningiomas. We report, in five of five meningiomas, including a pulmonary metastasis from a malignant intracranial meningioma, a fourth type of intercellular specialization which is similar to but not identical with the hemidesmosome of the epidermis. Idential intercellular specializations have been described between arachnoidal cells, but not between dural fibroblasts. The presence of the junction in human meningeal neoplasms of diverse histologic pattern supports the origin of the meningioma from arachnoidal epithelium. The consistent occurrence of these structures in a pulmonary metastasis as well as benign intracranial tumors suggests that they may be a useful morphologic marker in the differential diagnosis of putative extracranial metastatic meningiomas.

The ultrastructure of human limbal collagen.

In human limbal tissue from four glaucomatous and four nonglaucomatous eyes, the average collagen fibril diameter in the inner and outer layers was 100.86 and 115.33 nm., respectively. In both layers the fibrils occupied an average of two thirds of the total area The possible implications of this observation in the trabeculectomy procedure are discussed.