Basaloid squamous cell carcinoma of the vagina metastasizing to the lung. A case report.

BACKGROUND: While observed on the vulva, basaloid squamous cell carcinoma (BC) of the vagina is extremely rare, with no reported cases. CASE: A 54-year-old, African American woman presented with carcinoma metastatic to both lungs, morphologically similar to her BC of the vagina four years previously. She was treated initially in 1995 with local excision. Reexcision and radiation therapy were given for a recurrence in 1996. CONCLUSION: BC of the vagina is an extremely rare and aggressive tumor, which can recur and metastasize.

Use of 3.5-mm acetabular reconstruction plates for internal fixation of flail chest injuries.

The technique of using 3.5-mm acetabular reconstruction plates for multiple rib fractures with cerclage wires has been successful. We modified it by securing the reconstruction plates to the fractured ribs with cortical screws using the standard AO-ASIF (Arbeitsgemeindschaft fur Osteosynthesefragen [Association for the Study of Internal Fixation]) group technique. Our method for the internal fixation of the unstable chest wall is described. It is relatively simple and provides uniform results.

Inhibition of capillary transport reserve by sodium pentobarbital anesthesia in isometrically contracting dog heart.

We tested the hypothesis that different anesthetic may produce different effects on the ability of the myocardium to recruit capillaries. The experiments were performed on the isolated hearts of five dogs anesthetized with sodium pentobarbital (Nembutal), and six dogs anesthetized with chloralose. The isolated hearts were perfused with heparinized blood at controlled flows from a support dog anesthetized with the same agent. The adaptive capacity of the heart to recruit capillaries in response to rising left ventricular pressure (LVP) was determined by measuring the permeability-surface area product. (PS) of 22Na and 51Cr-ethylenediamine tetraacetic acid (EDTA). The myocardial ability to recruit functional capillary perfusion and transport was estimated by the ratio of the PS-Na (and EDTA) obtained at a given LVP to the PS-Na (and EDTA) at LVP = 0. In chloralose-anesthetized dogs there was a gradual increase in PS as a function of LVP. At systolic LVP ranges of 60-120 mm Hg and 130-200 mm Hg, mean PS-Na ratios were 1.15 and 1.60, while mean PS-EDTA ratios were 1.10 and 1.50, respectively. In Nembutal-anesthetized dogs there was no increase in PS associated with the increases in LVP. For the same range of LVP, the mean PS ratios for both Na and EDTA varied between 1.05 and 1.18. The results show the inhibition of capillary recruitment in Nembutal anesthetized dogs for LVP of 130-200 mm Hg. They also support the concept that Nembutal inhibits the ability of the myocardium to increase blood tissue transport of nutrients in response to increased metabolic demands.

Management of nonpenetrating stab and gunshot wounds of the chest.

Records of 102 patients with gunshot and stab wounds to the chest but with normal roentgenogram of the chest upon admission were reviewed. There were no delayed hemothoraces or pneumothoraces. The three complications probably resulted from admission to the hospital and would not have occurred if the patients had maintained their normal daily activities. The cost of these admissions was $104,319, and no benefit resulted from them. A significant number of routine studies were done with an extremely low yield. These patients need not be admitted to the hospital unless there is some other compelling clinical factor.

Surgical treatment of pulmonary aspergilloma.

Fourteen patients with aspergilloma (fungus ball) were reviewed. Hemoptysis was the major symptom (93%). Chest roentgenograms disclosed a "fungus ball" in every patient, and the mycelia of Aspergillus fumigatus were recovered from all resected specimens. One of three patients treated by pneumonectomy died post-operatively. A lobectomy was performed in ten patients, and segmental resection in one without mortality or significant morbidity. There has been no evidence of recurrence in a follow up of six months to ten years. On the basis of this experience and a review of the literature, excision of a solitary "fungus ball" is recommended when the diagnosis is made. Non-surgical therapy should be reserved for patients whose general medical status or pulmonary reserved prohibit resection.

Prostaglandin influence on pulmonary intravascular leukocytic aggregation during cardiopulmonary bypass.

A variety of pharmacologic agents have been infused during cardiopulmonary bypass in an attempt to prevent intravascular leukocytic aggregation in the lung. To date corticosteroids have been advocated because of their ability to stabilize lysosomes. We have studied two additional agents, prostaglandin E1 (PGE1) and dipyramidole (DIPYR) and compared their effects with those of methylprednisolone sodium succinate (MPSS) and a control group. The drugs were infused into the dog during perfusion and lung biopsies obtained before, during, and at the end of 2 hours of cardiopulmonary bypass using whole blood prime of the Bentley bubble oxygenator. The biopsies were interpreted by a pathologist who was unaware of the modality of treatment. Our results indicate that PGE1 provides more protection from intravascular pulmonary leukocytic aggregation than DIPYR and MPSS.

Prosthetic reconstruction of the trachea and carina.

Twenty-six patients with tracheal stenosis owing to benign stricture and malignancy have had airway reconstruction with a molded silicone rubber prosthesis. In 8 patients the distal trachea and carina were replaced with a bifurcated graft. One individual with respiratory insufficiency could not be weaned from the respirator and died in 3 weeks. Two other patients with malignancy died 15 and 18 months following operation from disseminated cancer. The remainder are living from 1 to 5 years postoperatively. Eighteen individuals have had the trachea reconstructed with a straight graft of silicone rubber. In 5 patients with long strictures the prosthesis was invaginated into the upper and lower ends of the trachea. Thirteen individuals had circumferential resection of the airway with end-to-end anastomosis of the graft to the trachea. There was one early death from erosion of the innominate artery and 5 late deaths unrelated to the prosthesis.

Homograft replacement of the trachea using immunosuppression.

The experiments were divided into three-ring and five-ring autografts and allografts. In the animals receiving allografts, the trachea was exchanged between paired animals which were preoperatively immunosuppressed with Imuran (azathioprine) and postoperatively given Decadron (dexamethasone). Seven of the 14 dogs receiving a three-ring allograft survived until put to death months after the operation. Postmortem examination demonstrated a patent airway, but the cartilaginous rings were absent and the proximal and distal suture lines were approximated. By contrast, none of the dogs receiving the five-ring allografts survived beyond 29 days. In all, the cartilage had disappeared and the intervening fibrous tissue had collapsed and constricted the airway. On the other hand, in animals in which the trachea was simply transected and resutured over an area of seven to ten rings, leaving membranous portion intact, the trachea was entirely normal when the animals were put to death. It is concluded that tracheal replacement with an allograft is not feasible, even with immunosuppression. It is the blood supply to the grafted segment which precludes success.

Diabetes insipidus secondary to penetrating thoracic trauma.

Three cases of diabetes insipidus following non-cranial trauma are presented. They are believed to be the first of their kind reported. The etiology, pathogenesis and differential diagnosis of diabetes insipidus are discussed. The literature if briefly reviewed and similarities between patients with DI due to long bone trauma with fat embolism, post open heart surgery hypotension, Sheehan's syndrome following postpartum hemorrhage, DI and our own patients are discussed. It is concluded that the diabetes insipidus is caused by selective disruption of posterior pituitary circulation due to fat globules, thrombi and hypovolemia resulting in hypoxia and tissue necrosis.