Congenital mesoblastic nephroma, hemorrhagic shock, and disseminated intravascular coagulation in a newborn infant.

Congenital mesoblastic nephroma is a rare tumor of infancy that usually presents as an asymptomatic abdominal mass. A full-term newborn infant with an atypical variant of this neoplasm developed hemorrhagic shock and disseminated intravascular coagulation. The stormy course was complicated by persistent fetal circulation and then the inability to withdraw ventilatory support due to the mass effect of the tumor. After the removal of the tumor at 10 days of age, transient conjugated hyperbilirubinemia developed. At 15 months of age, the infant was thriving without evidence of recurrence of the tumor.

Experience with the biofragmentable anastomotic ring (BAR) in bowel preoperatively irradiated with 6000 rad.

Previous studies from the authors' laboratory using the biodegradable anastomotic ring (BAR) have demonstrated the safety of this device in animals irradiated preoperatively with the equivalent of 5000 rad; sutured, stapled, and BAR anastomoses all had leak rates of 10 percent or less in this setting. This study was undertaken to assess the safety of the BAR after irradiation with the equivalent of 6000 rad. Thirteen mongrel dogs underwent preoperative irradiation to the rectum and rectosigmoid, receiving 6000 rad according to the nominal standard dose equation. After a three-week rest period, each dog underwent anterior resection of the rectosigmoid and anastomosis with the BAR. The anastomoses were evaluated for early and late healing and anastomotic leaks. The results were compared with previous data from the authors' laboratory using an identical model. Radiographic leaks were found in 7 of 10 sutured anastomoses, 8 of 10 stapled anastomoses, and 3 of 13 BAR anastomoses (P less than 0.01). Comparative clinical leaks were 5 of 10 for sutured, 5 of 10 for stapled, and 3 of 13 for BAR anastomoses. These data suggest that the BAR may offer added safety to an anastomosis after preoperative irradiation. Whether this effect is due to the atraumatic technique of placing the device, improved blood flow to the anastomotic margins, or other factors, is still underdetermined.

Evaluation of the biofragmentable anastomotic ring following preoperative irradiation to the rectosigmoid in dogs.

An animal study was done to evaluate the safety of a sutureless colorectal anastomosis in irradiated bowel. Forty mongrel dogs received preoperative radiation with 5000 rads and then underwent a low anterior resection and anastomosis using either the EEA-31TM stapling device, a two-layer handsewn technique, or the biofragmentable anastomotic ring (BAR) 31-1.5 mm and BAR 31-2.0 mm devices. The anastomoses were then evaluated for early and late anastomotic healing and leaks. The results show four radiographic (three clinical) leaks (P less than .05) in the BAR 31-1.5 mm group and one radiographic leak in the handsewn group. No leaks were detected in the EEA or BAR 31-2.0 mm groups. Results indicate that all three techniques can be done safely with this dose of radiation, and gap size (1.5 mm vs. 2.0 mm) is of critical importance when performing a BAR anastomosis in irradiated bowel.

Triple therapy for adult Wilms tumor.

Adult Wilms tumor is still considered a rarity. Approximately 170 adult Wilms tumors have been reported. The final diagnosis is usually established with surgery. There is no specific radiologic diagnosis of adult Wilms tumor. We report on a case of Wilms tumor in a twenty-two-year-old black man. The tumor was removed with radical nephrectomy and classified as Stage II. Radiation of the renal fossa (4,000 rad) and chemotherapy with actinomycin D and vincristine were administered after surgery. Six years after surgery the patient is disease free. A review of published cases of adult Wilms tumor is presented, and a plea is made for triple therapy.

Safety of low anterior resection in the presence of chronic radiation changes in dogs.

Thirty mongrel dogs underwent 4000- or 5000-rad single treatment orthovoltage irradiation to the pelvis according to the nominal standard dose equation. Following a resting period of six months, 21 dogs were randomized to low anterior resection with either stapled or handsewn anastomoses. Anastomotic leaks were evaluated on clinical and radiographic grounds. The radiographic leak rate was 81 percent for sutured and 0 percent for stapled anastomoses. The clinical leak rate was 18 percent for sutured and 0 percent for stapled anastomoses. The difference between the 4000- and 5000-rad groups was not significant. The data suggest that late effects of irradiation do not preclude the safe construction of low anterior anastomoses, and that the circular stapling device is superior to hand-sewn techniques.

Congenital polycystic tumor of the atrioventricular node. Autopsy study with immunohistochemical findings suggesting endodermal derivation.

Atrioventricular node congenital polycystic tumor, a lesion that causes heart block and sudden unexpected death, has been postulated to arise from the lymphatics, foregut endoderm, cardiac mesoderm, and mesothelium since its initial description in 1911. No theory concerning the histogenesis of this tumor has been completely satisfactory, either from an embryologic or a clinical standpoint. Biologic studies including cell culture systems from the lesions as well as optimal ultrastructural examination have been compromised due to postmortem autolysis. We studied four examples of this entity by standard histochemical stains for mucopolysaccharides, and by modified immunohistochemical labeling for carcinoembryonic antigen, factor VIII, and keratin. Results suggest an origin from foregut endoderm. The lesion has not been reported to be outside the region of the atrioventricular junction, but was demonstrated in the thymus gland in one of our cases.

Low anterior anastomotic dehiscence following preoperative irradiation with 6000 rads.

Twenty mongrel dogs received 6000 rads of irradiation to the rectum and colon using the Nominal Standard Dosage Equation. Three weeks after irradiation each dog underwent anterior resection of the rectosigmoid with reconstruction randomized to either an EEA stapled or a two layer handsewn anastomosis. Each dog was studied digitally and by barium enema at the time of surgery, on the seventh postoperative day, and at autopsy. Five clinically significant leaks and three radiographic leaks occurred in the EEA stapled anastomoses. The handsewn anastomoses had five clinically significant leaks and two radiographic leaks. The data indicate that low anterior resection with either an EEA stapled or handsewn anastomosis cannot be done safely after 6000 rad preoperative irradiation.

Unusual therapeutic response of massive squamous cell carcinoma of the bladder to aggressive radiation and surgery.

We report a case of stage D, poorly differentiated invasive squamous cancer of the bladder. Following transurethral resection of the tumor (170 gm.) and urinary diversion, the patient received 6,500 rad external radiation. After completion of radiation the bladder was converted from an inoperable (fixed to the pelvis) to an operable (mobile) condition. A cystectomy was performed and the patient was without evidence of disease 4 years later. The controversies of the therapeutic approach to squamous cancer of the bladder are discussed.

Effects of high-dose and low-dose preoperative irradiation on low anterior anastomoses in dogs.

Twenty mongrel dogs underwent preoperative irradiation to the colon and rectum, receiving 4000 rads according to the Nominal Standard Dose Equation. Each dog then underwent anterior resection of the rectosigmoid, and reconstructive technique was randomized into two groups consisting of either handsewn or EEA-stapled anastomoses. Anastomoses were examined digitally and radiographically at the time of surgery and on the seventh postoperative day. There were four radiographic leaks among the handsewn anastomoses, but only one was clinically significant and associated with peritonitis. There were no leaks among the ten EEA-stapled anastomoses. The data suggest that low anterior resection and anastomosis can be done safely after 4000 rad irradiation and that the EEA-stapled anastomosis may be preferable.

Effects of low-dose preoperative irradiation on low anterior anastomosis in dogs.

Twenty mongrel dogs underwent preoperative radiation therapy to the colon and rectum using the Nominal Standard Dose Equation to simulate treatment with 2000 rads. Each dog then underwent anterior resection of the rectosigmoid, and reconstruction was randomized into two groups consisting of either handsewn or EEA-stapled anastomoses. Anastomoses were examined digitally and radiographically on the day of surgery and on the seventh postoperative day. There were three radiographic leaks among the ten dogs having the handsewn anastomoses and one radiographic leak among the ten dogs having the EEA-stapled anastomoses. There was one clinically significant leak which occurred in a dog having an EEA-stapled anastomosis and was associated with peritonitis and death. The overall leak rate was 30 per cent among dogs having handsewn anastomoses and 20 per cent among dogs with stapled anastomoses. The data suggest that an anterior resection in low colorectal anastomosis can be done safely after low-dose radiation using either handsewn or stapling techniques.

Primary embryonal-choriocarcinoma of the mediastinum in a woman. A case report with immunohistochemical study.

Primary malignant germ cell tumors of the mediastinum are extremely rare among females. This report describes such a tumor arising in the mediastinum of a 26-year-old woman and correlates immunohistochemical studies of the neoplasm with serum tumor markers. Microscopic examination of the tumor revealed an embryonal carcinoma with choriocarcinoma, the latter consisting of sheets of polygonal cells intimately related to multinucleate giant cells that contained beta-human chorionic gonadotropin (beta-HCG) when stained immunohistochemically. The serum beta-HCG level at the time of diagnosis was 8,300 mU/ml and remained elevated throughout the patient's course. Alpha-fetoprotein was not detected in serum or tissue. Postoperative chemotherapy failed to control the growth of the tumor, and the patient died as a result of massive intrathoracic tumor involvement. At autopsy, metastases were found in two periaortic lymph nodes and in the liver. There was no gross or microscopic evidence of ovarian disease. This case illustrates the typical behavior of malignant germ cell tumors of the mediastinum, rare among females and infrequently described in the literature. To our knowledge, this is the first detailed immunohistochemical study of a mediastinal germ cell tumor in a female.

Anorectal verrucose squamous carcinoma: report of two cases.

Two cases of anorectal verrucose squamous-cell carcinoma are presented. The clinical course and pathology of these tumors are reviewed. Surgical treatment based on the depth of histologic invasion is recommended.