New look at epiphrenic diverticula.

Twenty-five patients with epiphrenica diverticula were studied to clarify the mechanism for esophageal regurgitation and to evaluate methods of treatment. Esophagogastroduodenoscopy, esophageal motility, and cineradiographic studies were performed. With probes in the tubular esophagus and diverticula of two patients, motility and cineradiographic studies were performed simultaneously to correlate symptoms and pressure changes with movement of diverticular and esophageal contents. Nineteen patients were operated, and six relatively asymptomatic patients were not. There was no operative mortality, and the one esophageal fistula that occurred healed spontaneously. Results were excellent or good in 10 operated patients followed long term after resection or imbrication of the diverticula. Eight patients did not undergo myotomy. Results in four of these patients followed long term were excellent. Retrograde movement of diverticular contents into the esophagus depends on pouch volume and a pressure gradient between the pouch and the tubular esophagus after an esophageal contraction wave in the tubular esophagus has dissipated. The height of esophageal reflux and resulting symptoms depend on these factors and the lower esophageal sphincter pressure (LESP). Asymptomatic patients with an epiphrenic diverticulum do not require operation. Resection or imbrication of a diverticulum are the operative methods of treatment. We prefer the abdominal approach when this is possible. Myotomy in contraindicated when gastroesophageal reflux exists or the LESP is below normal.

Adult-type colloid milium of hands and face successfully treated with dermabrasion.

Colloid milium is an unusual cutaneous disorder characterized by multiple cystic papules. The adult form develops in sun-exposed parts of the body in patients who have actinic-damaged skin. We describe the case of a patient with the classic clinical and histologic features of this disorder. The patient was successfully treated by dermabrasion to the hands and affected facial regions and, 10 months later, has not shown any signs of recurrence.

Prostate specific antigen and gleason grade: an immunohistochemical study of prostate cancer.

Prostate cancer is histologically heterogeneous as reflected in the 5 patterns of the Gleason grading system. Gleason grade correlates with volume, extent and prognosis. Serum prostate specific antigen (PSA) levels also correlate with tumor volume but the degree to which grade correlates with PSA has not been precisely defined. To quantify this relationship further, we prepared maps of each grade of cancer in 86 radical prostatectomy specimens from patients with clinical stage T2 cancer. The median per cent of the volume of cancer per prostate composed of grade 1 was 0%, while it was 1% for grade 2, 84% for grade 3, 5% for grade 4 and 0% for grade 5. We stained 95 cancer foci (grades 1 to 5) in 40 of these specimens for PSA. The presence and intensity (0 to 3+) of staining in more than 33,000 acini (or cells) correlated inversely with grade (p < 0.0001). Nearly all acini in grade 1 and most in grade 2 stained positive (2 to 3+) for PSA; 87% were positive but with less intensity in grade 3. While many grade 4 (79%) and grade 5 (49%) cells were positive, the intensity of staining was weak. Serum PSA levels correlated with total tumor volume (r = 0.67) but serum PSA levels per cm.3 of cancer decreased with increasing grade (r = -0.24 and p < 0.02). These studies confirm the strong inverse correlation between Gleason grade and the PSA content of prostate cancer. Since more than 85% of grade 3 acini stained for PSA and grade 3 made up the largest portion (84%) of cancer, the predominant contributor to serum PSA levels from prostate cancer was Gleason grade 3. The other grades contribute relatively little to the serum PSA levels either because of the small volume (grades 1 and 2) or the diminished PSA content (grades 4 and 5).

Endoscopic needle biopsy: a comparative study of forceps biopsy, two different types of needles, and salvage cytology in gastrointestinal cancer.

One of the goals of gastrointestinal endoscopy is to diagnose whether a lesion is malignant. The desire to improve the sensitivity of biopsy-sampling techniques prompted us to compare prospectively the reliability and accuracy of obtaining tissue by forceps biopsy, needle biopsy (21 gauge 13-mm long metal needles versus 18 gauge 20-mm long plastic needles), and salvage cytology in patients with endoscopically suspected malignancy. Samples were obtained in the order of needle biopsy (the order of metal and plastic needle biopsy was randomized), forceps biopsy, followed by salvage cytology. Needle biopsies were obtained by puncturing the lesion under direct vision while aspirating with a syringe. Twenty-three patients with gastrointestinal malignancy were studied (7 esophageal, 4 gastric, and 12 colonic). Forceps biopsies were positive in 18 of 23 (78%), missing 1 gastric and 4 colon malignancies. Metal needle biopsy was positive in 16 of 19 (84%), plastic needle biopsy in 17 of 22 (77%), and salvage cytology in 20 of 22 (91%). Accuracy was increased by a combination of techniques. Endoscopic needle biopsy is a simple and rapid method to evaluate lesions seen at endoscopy and is especially useful in evaluation of submucosal lesions.

Tumor cell type versus staging in the prognosis of carcinoma of the lung.

From this and other studies, it is clear that the determination of tumor cell type is dependent on cellular and architectural patterns which are fraught with considerable interobserver and even intraobserver variations. Even though determination of cell type is semiobjective at best, previous reports have sought to determine prognosis solely on the basis of cell type or subtype while other studies have made attempts to define the prognosis of the disease based on even less precise terms. In seeking an answer to the question of which is more important for prognosis of lung cancer, cell type or TNM stage, the findings reported herein support the hypothesis that the TNM stage is the single most important factor for survival. This conclusion is substantiated by the following observations: 1. When cell type is stratified by stage, no significant differences can be determined in survival according to tumor cell type. 2. There is a minor difference (not statistically significant) in survival for tumor cell type when considering resected stage I tumors (67 of 99) in terms of adenocarcinomas which had a survival of 38 percent at 5 years versus squamous cell carcinomas which had a survival of 23 percent at 5 years. The numbers of cases in this study were not sufficiently large to comment on the possible difference between surgically resected large cell and small cell carcinomas. 3. TNM staging is a highly significant predictor in the survival of patients with lung cancer. The significance for survival by stage remains even if the data are stratified by the cell type diagnosis. These conclusions apply to the total group of 124 patients, and also to the subgroup of 99 surgically resected patients. Many reports have attempted to determine survival of carcinoma of the lung in terms of cell type without regard to its stage. Consequently, comparison of data from various institutions is difficult. We believe TNM staging of the disease not only allows reasonable comparison of data obtained from different institutions, but also, affords a useful and accurate means of assessing the extent of the disease and its prognosis.

Brunner's gland hamartomas can mimic carcinoma of the head of the pancreas.

Three patients with Brunner's gland hamartomas had symptoms preoperatively and findings intraoperatively that were consistent with carcinoma of the head of the pancreas. It is important to differentiate between these two pathologic conditions because the operation required for the treatment of the two diseases is of a different order of magnitude. A diagnosis of a Brunner's gland hamartoma can be considered on the basis of the clinical history, physical findings, laboratory findings and the appearance of the duodenal mucosa surrounding the ampulla of Vater. Confirmation of the diagnosis can be made upon biopsy of the duodenum at operation.