Columbus® computer navigated total knee arthroplasty: Gap balancing versus measured resection.

BACKGROUND: The aim of this study was to compare the medium term functional outcome and patient satisfaction of gap balanced (GB) with measured resection (MR) total knee arthroplasty (TKA) using computer navigation. METHODS: A cohort of 144 consecutive computer navigated TKA were retrospectively identified from an arthroplasty database. Functional assessment using the Oxford Knee Score (OKS) and patient satisfaction were obtained from 113 patients at a mean follow-up of 5.4 (range four to seven) years. There were 44 patients in the GB group and 69 patients in the MR group. RESULTS: The mean OKS for the GB group was 36.9 (SD 9.2) and for the MR was 33.6 (SD 9.8), with a difference of 3.3 (95% CI 0.3 to 6.3) points, which was statistically significant (p=0.01). Linear regression analysis confirmed the independent effect of surgical technique when adjusting for confounding factors and surgeon, with the GB group achieving a greater post-operative OKS (R2=0.39, 3.0 points, 95% CI 1.2 to 4.8, p=0.001). There was a greater rate of patient satisfaction in the GB group (88.6%, n=39/44) compared to the MR group (81.1%, n=56/69), but this was not statistically significant (odds ratio 1.8, 95% CI 0.6 to 5.5, p=0.31). CONCLUSION: Computer navigated Columbus® TKA using a GB technique results in a statistically significantly greater functional outcome but no significant difference in patient satisfaction in the medium term compared to patients undergoing a MR technique.

Paget sarcoma of the spine: Scottish Bone Tumor Registry experience.

STUDY DESIGN: Retrospective case study of 13 cases of Paget sarcoma of the spine accrued from a prospectively collected Tumor Registry database. OBJECTIVES: To analyze the clinical, radiologic, and histologic features of Paget sarcoma of the spine and to determine the factors influencing the prognosis. SUMMARY OF BACKGROUND DATA: Paget disease of bone is a common disorder with the spine being involved in over 50% of patients. However, sarcomatous degeneration in the vertebral column is an extremely rare complication. There is very little in the literature with regard to clinical presentation and prognosis of patients with Paget sarcoma affecting the vertebral column. METHODS: Between January 1944 and December 2003, 89 patients were registered with a diagnosis of Paget sarcoma in the Scottish Bone Tumor Registry. Thirteen patients with Paget sarcoma of the spine were analyzed with regard to their clinical, radiologic, and histopathologic features along with the prognostic predictors. RESULTS: The mean age was 66.9 years (range: 56-79 years). There were 10 males and three females. There were seven cases involving the sacral spine (63.6%), three cases involving lumbar vertebrae, two affecting the dorsal spine, and one with diffuse dorsolumbar involvement (D11-L3). The mode of presentation was progressively increasing low back pain (in all 13), unilateral sciatica (six; left-sided, five; right-sided, one), bilateral sciatica (two), lower limb weakness (eight), and autonomic dysfunction (four). Ten of 13 cases (76.9%) were osteosarcoma. The rest were chondrosarcoma (n = 1), fibrosarcoma (n = 1), and malignant fibrous histiocytoma (n = 1). Decompression laminectomy was performed in three patients with progressive neurologic deficit. Eight patients had received radiotherapy. The mean survival was 4.22 months. CONCLUSIONS: This series confirmed that Paget sarcoma of the spine has a very poor prognosis. We found a constellation of symptomatology in patients with sarcomatous Paget spine resulting from radiculomedullary compression, primarily lumbosacral involvement and predominantly osteosarcomatous histology. There was no significant difference observed on the overall prognosis of the patients with Paget sarcoma of the spine in the last 6 decades.

BTB ACL reconstruction: femoral nerve block has no advantage over intraarticular local anaesthetic infiltration.

Fifty patients were randomly recruited to receive either femoral nerve block (0.375% Bupivacaine) or an intraarticular local anaesthetic injection for pain control for arthroscopically-assisted ACL reconstruction. Both groups were evenly matched for age ( t-test p >0.05). Tourniquet time did not differ significantly between the groups ( t-test p=0.24). The VAS pain levels were not significantly different at 4 h and the first morning postoperatively in both groups. Femoral block (Median VAS: 20 & 18.5) did not confer a significant advantage (Mann Whitney U test p =0.36, 0.67) over intraarticular injection of bupivacaine (Median VAS: 18 & 20). There was no correlation between tourniquet time and postoperative pain ( r=0.19, 0.08). All patients but one were discharged home on the first postoperative morning. Our study demonstrates that pain levels can be sufficiently controlled by intraarticular infiltration of bupivacaine coupled with oral analgesia. The level of pain relief achieved could allow this procedure to be performed in a day surgery setting.

Identification of HER-2/neu overexpression and the clinical course of lung carcinoma in non-smokers with chronic lymphocytic leukemia.

Patients with CLL have an excess risk of developing second primary malignancies. The etiology of this excess risk is unclear, and has been thought to be related to smoking. HER-2/neu overexpression has evolved as a prognostic/predictive factor in some solid tumors. We reviewed our experience with non-smokers who had CLL and subsequently developed lung carcinoma, in an effort to better understand the clinical course of these patients, and to evaluate the role of HER-2/neu overexpression. We reviewed the records of all patients who had a diagnosis of both CLL and lung carcinoma between 1986 and 2000. HER-2/neu overexpression was estimated by immunohistochemistry (IHC) using the Hercep test (DAKO). An IHC score of 2+ or greater was considered positive. Overall survival was calculated from the date of diagnosis of lung carcinoma by the Kaplan-Meier product limit method. Fourteen non-smokers in whom a diagnosis of CLL was made at least 6 months prior to the diagnosis of lung carcinoma were identified. The median age for diagnosis of CLL in this group was 67 years while that for lung carcinoma was 70 years. The lung carcinomas included 10 non-small cell (NSCLC) and four small cell (SCLC) carcinomas. Nine specimens (six NSCLC and three SCLC) showed HER-2/neu overexpression. Interestingly, 90% of patients with advanced stage cancer (stage IIIB/IV NSCLC or extensive SCLC) overexpressed HER-2/neu. The presence of CLL did not alter outcome in patients with early stage lung cancer. However, after adjustment for age and performance status, patients with advanced stage NSCLC and CLL had a worse than expected outcome. HER-2/neu overexpression (independent of smoking) may be involved in the development/progression of lung cancer in patients with CLL, and has an associated worse outcome. It is appropriate to consider heightened surveillance of CLL patients for lung carcinoma.

Phase I study of gemcitabine and carboplatin in advanced non-small cell lung carcinoma.

BACKGROUND: This phase I study was designed to determine the maximum tolerated dose of carboplatin with a fixed dose of gemcitabine without growth factor or hematopoietic precursor support. METHODS: Nineteen patients with previously untreated non-small cell lung cancer (NSCLC) were treated at three dose levels. Initially, the gemcitabine dose was 1000 mg/m(2) given on days 1 and 8. Of the first five patients treated with carboplatin AUC 4, three experienced dose limiting toxicity (DLT). The study was, therefore, amended to decrease the dose of gemcitabine to 800 mg/m(2) given on days 1 and 8 in a 21-day cycle. RESULTS: Dose limiting toxicity (neutropenia and thrombocytopenia) were seen at dose level 2A (carboplatin AUC=5). Thus, no further dose escalation was performed. Grade 3 and 4 toxicities were seen as follows: leukopenia in five of 18 (28%); neutropenia, four of 18 (22%); and thrombocytopenia, four of 18 (22%) evaluable patients. Grade 3 or 4 anemia occurred in one of 18 (6%) patients and no neutropenic fever or treatment related mortality was observed. Partial responses were seen in six patients and one patient with evaluable disease had an objective response. The overall response rate was 37% (seven of 19). Six other patients had stable disease. A total of 89 courses were administered with a median of five courses per patient (range: two to six courses). The median time to progression for all patients was 3.7 months. The median overall survival was 7.4 months with four patients still alive (median follow up 13.5 months). The survival at 6 months and 1 year is 64 and 23%, respectively. CONCLUSION: The maximum tolerated dose (MTD) in this group of patients was defined as carboplatin AUC 4 when administered with gemcitabine 800 mg/m(2) on days 1 and 8 of a 21-day schedule.

Intramedullary spinal cord metastases (ISCM) and non-small cell lung carcinoma (NSCLC): clinical patterns, diagnosis and therapeutic considerations.

Intramedullary spinal cord metastasis (ISCM) is an unusual occurrence in systemic cancer, occurring in as few as 2% of autopsy cases and also represents 8.5% of all cases of central nervous system metastases. Although ISCM from small cell lung carcinoma is well documented, ISCM from non-small cell lung carcinoma of the lung is rarely diagnosed prior to the patients' demise and very little data regarding outcomes exists in such patients. We present the results of our observational case series to better delineate the presentation and clinical course of this uncommon entity which shows that ISCM may present atypically and should be considered in any patient with a previous history of bronchogenic carcinoma and neurologic symptoms.

"Uneasy lies the hand in which rests the crown" an unusual foreign body following a punch injury.

A case of cellulitis of the hand resulting from embedding of a dental crown following a punch injury is described. This report emphasises the need for X-ray imaging in all cases of penetrating hand trauma, particularly when the history is vague, and also the difficulty in using metronidazole in alcoholic patients.

Prognostic markers in resected stage I and II non small-cell lung cancer: an analysis of 260 patients with 5 year follow-up.

We performed a retrospective analysis of potential prognostic markers in 260 patients with surgically resected stage I and II non small-cell lung cancer (NSCLC) with a minimum 5-year follow-up. Cox proportional hazard models and Wilcoxon tests were employed to analyze the effect of patient characteristics on survival and disease-free survival (DFS). In the univariate analysis, the following were significant predictors of shorter overall survival: N-stage (N1 vs N0) (p<0.001); T-stage (T2 vs T1) (p<0.001); antigen A (loss vs presence) (p<0.01); cough (present vs absent) (p=0.01); bcl-2 expression (positive vs negative) (p=0.03); age (>63.5 vs <63.5) (p=0.03); mucin (positive vs negative) (p<0.03). The following were significant predictors of shorter DFS: N-stage (p<0.001); T-stage (p=0.001); loss of antigen A (p=0.01); mucin expression (p<0.01); cough (p=0.02); Ki-67 expression (p=0.02) and negative bcl-2 expression (p=0.03). Analysis of survival difference for histologic subtype, degree of differentiation, aneuploidy, %S-phase, codon 12 K-ras mutation, and immunohistochemistry staining for Lewisy, p53, Rb, microvessel count, HER2, E-cadherin and neuroendocrine markers did not reach statistical significance. In multivariate analysis, the following predicted for shorter overall survival: N-stage (p<0.01), antigen A (p=0.01), age (p<0.01), and bcl-2 (p=0.05); and for DFS, N-stage (p<0.01), antigen A (p<0.01), Ki-67 (p=0.03), mucin (p=0.04) and T-stage (p=0.05). Of all the clinical-pathological, proliferative, and biological markers studied, only a few carried independent prognostic significance.

Prognostic significance of Lewis y antigen in resected stage I and II non-small cell lung cancer.

BACKGROUND: The role of Lewis y (Le(y)) antigen expression has been studied extensively in predicting the outcome of various malignancies. We evaluated the expression of Le(y) and its relationship to survival, disease-free survival and other clinicopathologic variables in patients with stage I and II non-small cell lung cancer (NSCLC). OBJECTIVE: To investigate the prognostic significance of Le(y) antigen expression in a large group of well characterized patients with resected stage I and II NSCLC. PATIENTS: Two hundred and sixty patients with surgically resected stage I (n = 193) and II (n = 67) NSCLC with at least 5-year follow-up were identified. RESULTS: The median survival for patients with negative expression of Le(y) (< 50% of cells that were positive) was 46 months, whereas for those with positive expression of Le(y) (> or = 50%), the median survival was 54 months (p = 0.99). The disease-free survival for patients with Le(y)(-) expression was 39 months and 34 months for patients with Le(y)(+) expression (p = 0.3). CONCLUSIONS: We found no relationship between loss of blood group antigen A and expression of Le(y). No statistically significant difference was found in survival between positive and negative expression of Le(y) antigen in patients with resected stage I and II NSCLC.

A study of filgrastim (rG-CSF) priming of etoposide/cisplatin in advanced non-small cell lung cancer.

A previous phase II study (CALGB 9132) of etoposide/cisplatin + rG-CSF in patients with advanced non-small cell lung cancer (NSCLC) showed a marked difference in the absolute neutrophil count (ANC) nadirs between courses 1 and 2. Median ANC nadirs for courses 1 and 2 were 200 and 2500, respectively, suggesting a priming effect for rG-CSF. The present study was designed to determine whether rG-CSF given prior to the first cycle of chemotherapy would decrease the severity and duration of neutropenia. Twelve patients with stage IIIB or IV NSCLC and performance status 0-1 received rG-CSF 5 microg/kg for 5 consecutive days starting 7 days before treatment with etoposide 200 mg/m2 on days 1-3 and cisplatin 35 mg/m2 on days 1-3, repeated every 3 weeks. Patients also received rG-CSF 5 microg/kg s.c. day 4 to postnadir ANC > 10,000. The median WBC nadir, ANC nadir, and platelet nadir after the first cycle of chemotherapy in the historical group (CALGB 9132) were 1300 cells/microl, 200 cells/microl, and 80,000 cells/microl, respectively. In the present study, the median WBC nadir, ANC nadir, and platelet nadir were 1300 cells/microl, 144 cells/microl, and 56,000 cells/microl, respectively. The median time for ANC to reach 10,000 cells/microl was 15 days in both the historical and the present study. For course 2, the WBC, ANC, platelet nadirs, and duration of grade 4 neutropenia were 2600, 1450, 70,000, and 0 days, respectively. This study failed to show a priming effect for rG-CSF when given in this dose and schedule.

Prognostic significance of Ki-67 immunostaining and symptoms in resected stage I and II non-small cell lung cancer.

The proliferative rate of a tumor has been considered predictive of its clinical course. We evaluated the expression of the proliferative marker Ki-67 and its relationship to survival, disease-free survival and other clinicopathologic variables in both stage I and stage II non-small cell lung cancer (NSCLC). A total of 260 patients with surgically resected stage I (n = 193), and II (n = 67) NSCLC with at least 5 years follow-up were identified. The median survival for patients with low expression of Ki-67 (< or = 25%) was 54 months, while for those with high expression (> 25%), it was 45 months (P = 0.1). The disease-free survival in patients with low expression of Ki-67 was 59 months while it was only 32 months for patients with high Ki-67 (P = 0.1). Out of 136 patients, 84 (62%) had both increased S-phase (> 8%) and high Ki-67 (P = 0.001). A total of 28 of 30 patients who had loss of antigen A had high expression of Ki-67 (93.3%) (P = 0.03). Ki-67 expression was also higher in squamous cell (54/63, 85.7%) compared to nonsquamous cell cancer (70/108, 64%) (P = 0.03). We also analyzed for the presence of symptoms with survival. The presence of symptoms was not found to be statistically significant, for overall survival (P = 0.33) or disease-free survival (P = 0.72). When individual symptoms were analyzed, the presence of cough was statistically significant for both overall and disease-free survival. The median survival was 39 months for patients with cough, and 57 months for patients without cough (P = 0.04). Multivariate analysis showed higher N and T stages, presence of cough and loss of antigen A, predicted for poorer overall survival. Higher N and T stages, loss of antigen A, presence of mucin and cough and increased expression of Ki-67 predicted decreased disease-free survival. Although we did not find a statistically significant difference between low and high Ki-67, there was a trend for a poorer overall and disease-free survival in patients with high Ki-67 expression. Larger studies may be needed to prove a statistically significant effect of Ki-67 on survival. Future studies should assess the potential prognostic significance of the presence of symptoms (particularly cough) in addition to clinical-pathologic variables (such as T and N stage) and biological markers in patients with early stage NSCLC.

In situ cell cycle kinetics in bone marrow biopsies following sequential infusions of IUdR/BrdU in patients with hematopoietic malignancies.

Examination of the proliferative characteristics of myeloblasts was undertaken in situ in bone marrow (BM) biopsies of patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) following sequential infusions of iodo- (IUdR) and bromodeoxyuridine (BrdU). The ability to identify S-phase cells which have incorporated both or either one of the labels in vivo by using two monoclonal antibodies in vitro permitted the measurement of labeling index (LI) and durations of S-phase (Ts) and the total cell cycle (Tc) both from the BM aspirates and biopsies. While the LI is 2-3 times higher in biopsies, Ts and Tc are fairly comparable in the two samples in 8/10 cases (p = 0.02 and 0.003 respectively). Advantages associated with the determination of cell cycle parameters in BM biopsies have been discussed at length.