Postirradiation angiosarcoma of the chest wall and breast: issues of radiogenic origin, diagnosis and treatment in two cases.

The authors report two cases of postradiation angiosarcoma (AS) among 5,100 breast cancer patients treated in the period 1980-1994 at the National Institute of Oncology, Budapest. Relevant data in the literature is also reviewed to analyze the questions of radiogenic origin, diagnosis and treatment. Secondary AS occurred in these cases in a previously irradiated field after a 6- and 8-year latency period, respectively. Detailed histopathological and immunohistochemical examinations from the biopsy specimens confirmed the diagnosis as AS. The first patient was treated successfully with radical surgery. The second patient, with unresectable AS, died of rapid local progression within 4 months. The incidence of chest wall and breast AS after radiotherapy was found to be 0.46 per 1,000 in our patient population, which means an estimated odds ratio of 2.9 for secondary AS. Patients treated with radiotherapy for primary breast cancer are at higher risk for developing secondary AS compared to the healthy population. An etiological relationship between radiotherapy and subsequent AS of the chest wall and breast is likely, but still controversial. Initial radical surgery is the only effective treatment for achieving long-term survival. These very rare cases deserve special attention due to the atypical clinical appearance, difficulties of differential diagnosis and poor prognosis.

[Aspiration cytology in the diagnosis of gastrointestinal tumors]. / A tápcsatorna daganatainak aspirációs citológiai vizsgálatáról.

Early experiences with the new endoscopic aspiration cytology method in the diagnosis of gastrointestinal malignancies are discussed. It was performed in five patients in case of gastric and cardiac cancers and in fifteen ones of colon tumours. Results are compared with those of biopsies and brush cytologies. The new method is quick, reliable and suggested to be widely used in the gastrointestinal endoscopy.

Re-resection of the short cicatricial stenosis of colorectal anastomoses with EEA stapler.

Following 245 stapled anastomoses reoperation was necessary in 4 cases because of non-tumourous stenoses. In each of the 4 cases re-resection was performed according to authors' method, with EEA stapler, without the mobilisation of the rectum. The method is considered suitable for non-tumourous anastomotic stenoses involving short rectal segments.

Dixon's anastomosis with "double-stapling" technique: experience with 235 cases.

The perioperative results of 235 Dixon's anastomoses performed between 1985 and 1994 are compared to those of 125 Dixon's anastomoses performed between 1956 and 1979, on the basis of recurrences and survival data. It is concluded that the operations carried out with double stapling are considerably superior interventions with respect to speed, sterility and anastomotic safety and involve less complications. There is no difference between the stapling and handsewn techniques concerning the development of local recurrences. A further advantage of stapling is that it makes possible the saving of the sphincter more often, namely in almost 50% of the cases.

Intraoperative colonoscopy.

The authors performed intraoperative colonoscopy in 31 patients. This examination is done if preoperative colonoscopy was not performed or incomplete, and intraoperative difficulty occurs. In addition, it is indicated to localize non-palpable lesions, to perform polypectomy (if unsuccessful preoperatively but manageable intraoperatively), to define the site of endoscopic polypectomy, in certain instances to determine the resection plane, and after resection of constrictive tumours to look over the proximal intestinal section, to detect the synchronous lesions. It is emphasized that by their method the opening of the lumen becomes avoidable thus resulting in a decreased postoperative morbidity and mortality.

Correlation between colon adenoma and cancer.

In the course of 1301 colonoscopies performed by the authors, in cases of 127 patients (9.76%), 177 polyps were removed; 159 (89.83%) out of them proved to be adenomas by histology. In 23 adenomas (14.46%) malignant transformation was observed. The highest percentage of polyps was detected in the group of patients with tumours, and a somewhat lower proportion was found in the case of patients who underwent resection surgery because of tumours. A similar tendency could be seen concerning the malignant transformation of the removed adenomas. Our data seem to support the theory by Morson and Hermanek regarding the transformation from adenoma to cancer in the large bowel. Surgery is proposed in the following types of colon polyps: (1) polyps unremovable by endoscopic polypectomy, even by piecemal snare excision; (2) invasion (adenoma with invasive adenocarcinoma)--if the tumour is situated within a 3 mm distance from the resection line; (3) following endoscopic removal of polypoid adenocarcinoma (in this case the site of polypectomy can be marked by preoperative injection of ink or in the course of intraoperative colonoscopy); (4) in the case of complications of endoscopic polypectomy (perforation, bleeding uncontrollable by conservative or endoscopic means); (5) colotomy and polypectomy should be performed when the adenoma cannot be reached with the endoscope--for technical reasons--and the intraoperative method cannot be used under the conditions of an open abdomen but without the necessity of opening the bowel.

Comparative evaluation of manual and instrumental rectum resections.

The authors compared the perioperative results of 125 + 125 Dixon operations performed at two time intervals (1956-1979 and 1985-1990), the postoperative recurrences and the survival data. It is established that, from the anastomosis point of view, the instrumental resections--beside their rapidity and favourable sterility--are safer interventions associated with less complications. With respect to local recurrences the two methods do not differ significantly. A further advantage of the double stapling is that a larger number of patients can undergo a sphincter-saving resection, and a lower lying anastomosis can be performed than with hand-sewn sutures.

Ovarian metastases of colorectal tumours.

The authors, based on their own experience and review of the literature, discuss the incidence of ovarian metastases of patients with colorectal tumours. They take a stand for the prophylactic oophorectomy in the management of female patients over 40 years operated on for rectal cancer localized on the left colon side.

Endoscopic diagnostics of colorectal cancers.

According to the data of cancer registries, the morbidity and mortality of colorectal cancers have considerably increased in the past 15 years. The Hungarian data follow this international trend: yearly 2000-3000 new cases must be reckoned with. Early diagnosis could substantially improve the mortality rates which in Hungary are rather unfavourable as compared to the international data. The results of the surgical treatment of colorectal cancers have not improved essentially in the past decades, although early diagnosis, followed by timely treatment, may increase the chances for cure and improve the postoperational quality of life. Screenings performed in Hungary also report on the favourable results of early diagnosis.

When should endoscopic polypectomy be followed by surgery?

The authors give an account of their observations concerning the examination of 148 polyps endoscopically removed from 116 patients. Malignant transformations were found in 16 adenomas out of 139 neoplastic polyps. The author's view regarding the therapeutic strategy after endoscopic polypectomy is presented. The systematic control and follow-up of polypectomized patients is considered to be important.

[Diagnosis and therapy of metastatic and recurrent colorectal tumors]. / Metastatikus és recidiv colo-rectalis daganatok diagnosztikája és terápiája.

77 patients were treated by the authors because of recurrent or metastatic colorectal cancers. Follow-up protocol of elective surgery is discussed with respect to the two different types of surgery that is those performed because of colon and rectal cancer, respectively. The diagnostic and therapeutic principles as well as the results gained by the authors are discussed in details in case of the different types of recurrent and metastatic tumours (anastomotic recurrence, metachron tumour, local recurrence, hepatic, pulmonary, lymph node and osseal metastasis). In contrast to the previous principles a more active surgical therapy is advised by the authors in case of recurrence and metastases of colorectal cancers.

[Esophago-bronchial fistula originating in an esophageal diverticulum]. / Nyelöcsö diverticulumból kiinduló oesophago-bronchialis sipoly.

In connection with an esophageal diverticulum the case of an infrequent acquired esophago-bronchial fistula appearing in symptom-poor form is described. The fistula persisted over a long period however owing to the poor symptoms and absence of pulmonary complications operation was left out of consideration. In the course of the regular control the complaints of the patient ceased and the endoscopy showed shrinking of the fistula. No similar observation was found in the Hungarian literature.

Endoscopic polypectomy in the segment of colon used for oesophageal replacement.

A polyp was found in the replaced colon segment one year after the operation. It was removed endoscopically.