Molecular staging for melanoma and breast cancer.

Despite increased sensitivity of PCR techniques, routine H&E histology and, in some cases, immunohistochemistry remain the gold standards for the detection of micrometastatic disease. Highly sensitive and specific molecular assays such as RT-PCR provide an ideal way to detect micrometastatic disease in tissues or blood at risk for metastases. RT-PCR has been shown to increase detection of micrometastases, especially in patients with breast cancer and melanoma. These assays have the potential to provide valuable tumor staging and progression information and thus determine the need for further surgery, adjuvant chemotherapy, and antigen-specific immunotherapy. As investigators gain more experience using molecular assays, the results of these assays will be more likely to guide clinical staging and decision making.

Historical perspectives and future applications.

Lymphatic Mapping and sentinel lymph node biopsy are developing into a new field of minimally invasive surgery. These procedures were brought about by the necessity to better stage patients while minimalizing morbidity. Their application is reaching several aspects of surgery and becoming a major foundation in the armamentarium of the general surgeon.

Radioguided surgery for melanoma.

The advent of lymphatic mapping and sentinel lymph node biopsy provides an effective and less morbid procedure for staging patients with malignant melanoma. There is considerable variation on this technique. This article describes the technique that was developed and is currently in application at the H. Lee Moffitt Cancer Center and Research Institute. Understanding all the steps and paying close attention to all details are important to ensure successful mapping.

Cost analysis of sentinel lymph node biopsy as an alternative to elective lymph node dissection in patients with malignant melanoma.

In the current era of managed care and cost containment, physicians and administrators are placed in the predicament of increasing quality of care while decreasing costs. The purpose of this article is to offer a cost analysis, while also demonstrating what patients, providers, payers, employers, and industry may stand to gain from establishing sentinel lymph node biopsy as a standard care in certain groups of patients.

The progression of melanoma nodal metastasis is dependent on tumor thickness of the primary lesion.

BACKGROUND: Recent results of several clinical trials using the technique of intraoperative lymphatic mapping and sentinel lymph node (SLN) biopsy confirm the validity of the concept of there being an order to the progression of melanoma nodal metastases. This report reviews the H. Lee Moffitt Cancer Center experience with this procedure, one of the largest series described to date. These data demonstrate that the involvement of the SLNs, as well as higher-echelon nodes, is directly proportional to the melanoma tumor thickness, as measured by the method of Breslow. METHODS: The investigators at the H. Lee Moffitt Cancer Center retrospectively reviewed their experience using lymphatic mapping and SLN biopsies in the treatment of malignant melanoma. All eligible patients with primary malignant melanomas underwent preoperative and intraoperative mapping of the lymphatic drainage of their primary sites, along with SLN biopsies. All patients with positive SLNs underwent complete regional basin nodal dissection. For 20 consecutive patients with one positive SLN, all of the nodes from the complete lymphadenectomy were serially sectioned and examined by S-100 immunohistochemical analysis, to detect additional metastatic disease. RESULTS: Six hundred ninety-three patients consented to undergo lymphatic mapping and SLN biopsy. The SLNs were successfully identified and collected for 688 patients, yielding a 99% success rate. One hundred patients (14.52%) showed evidence of nodal metastasis. The rates of SLN involvement for primary tumors with thicknesses of <0.76 mm, 0.76-1.0 mm, 1.0-1.5 mm, 1.5-4.0 mm, and >4.0 mm were 0%, 5.3%, 8%, 19%, and 29%, respectively. Eighty-one patients underwent complete lymph node dissection after observation of a positive SLN, and only six patients with positive SLNs demonstrated metastatic disease beyond the SLN (7.4%). The tumor thicknesses for these six patients ranged from 2.8 to 6.0 mm. No patient with a tumor thickness of <2.8 mm was found to have evidence of metastatic disease beyond the SLN in complete lymph node dissection. All 20 patients with a positive SLN for whom all of the regional nodes were serially sectioned and examined by S-100 immunohistochemical analysis failed to show additional positive nodes. CONCLUSIONS: These results suggest that regional lymph node involvement may be dependent on the thickness of the primary tumor. As the primary tumor thickness increases, so does the likelihood of involvement of SLNs and higher regional nodes in the basin beyond the positive SLNs.

Vanderbilt experience with cryosurgery for 25 advanced hepatic tumors.

There are reports that suggest cryosurgical techniques may be a useful adjunct or even a viable alternative to surgical resection for hepatobiliary malignancies. Our objective was to evaluate the clinical results following cryoablation in conjunction with surgical resection for advanced hepatic tumors. Cryosurgical techniques were used in 25 consecutive patients with advanced liver tumors (1) to achieve a > 1-cm tumor-free margin when standard surgical margins were close, (2) to manage multiple tumor nodules with or without standard surgical resection, or (3) to increase chemotherapy response rates in conjunction with hepatic arterial portocath placement. In these 25 patients cryoablation was applied to 44 of 91 lesions--independently in four patients and in combination with hepatic resection in 21 patients. Cryoablation was used in seven patients because of close surgical margins. In 18 patients cryosurgery was used for complete lesion ablation. In 14 of the 18 patients cryosurgery and resection were used for different lesions; in four cryosurgery alone was used. Transient changes in hepatic enzymes, PT, PTT, and platelets were at maximum on postoperative days 1 to 3. Surgical mortality and morbidity rates were 4% and 68% respectively. Coagulation abnormalities were common; at least 30% reduction in platelets occurred in all patients and a > 50% reduction occurred in 15 of 25 (60%). Sixteen patients had a PT > 15 sec and five of these 16 also had platelet count < 50,000. Associated complications included one wound hematoma, one GI hemorrhage, one intracranial hemorrhage, and one hepatic hemorrhage from the cryosurgical site. 96%, 66%, 49%, 35%, and 20% of patients were surviving respectively at 6, 12, 18, 24, and 36 months. This report helps define the risks and results of cryosurgical ablation in conjunction with surgical resection for very advanced hepatobiliary tumors. Management of lesions contiguous to major blood vessels can include the Pringle maneuver or total hepatic vascular isolation. Cryoablation can be applied carefully as a complement to resection to achieve total tumor ablation in selected otherwise unresectable patients.

Bupivacaine local injection in anorectal surgery.

A retrospective study of 46 patients who received bupivacaine local injections after hemorrhoidectomy were compared to a matching group of 46 patients of similar age and sex distribution who underwent the same operation. Pain medications requirement on the same day of operation and on subsequent days were measured and found to be the same in both groups. The incidence of urinary retention was equal in both groups. However, the group receiving bupivacaine had a shorter hospital stay. In this respect, local injection of bupivacaine after hemorrhoidectomy may have a role in making patients more comfortable and shortening hospital stay.

Clinical experience with cryosurgery for advanced hepatobiliary tumors.

INTRODUCTION: There have been reports that suggest cryosurgical techniques may be a useful adjunct to surgical resection or even a viable alternative treatment for hepatobiliary malignancies. Our objective was to evaluate the clinical results following cryoablation in conjunction with surgical resection for advanced hepatic tumors. MATERIALS AND METHODS: Thirty-two consecutive procedures in 31 patients with advanced liver tumors treated with cryosurgical ablation were evaluated. Cryosurgery was applied: (1) to achieve a > 1-cm tumor-free margin when standard surgical margins were close (2) with or without standard surgical resection to manage multiple tumors (3) with hepatic arterial portocath placement to increase tumor response. Cryoablation was applied to 47 of 105 lesions--independently in 4 patients and in combination with hepatic resection in 28 procedures. RESULTS: Cryoablation was used in 11 procedures because of close surgical margins. In 21 operations cryosurgery was used for primary ablation. In 17 of these 21 patients both cryosurgery and resection were used for different lesions; in 4 cryosurgery alone was used. Transient changes in hepatic enzymes, PT, PTT, and platelets were at maximum on Postoperative Days 1-3. Surgical mortality and morbidity rates were 6 and 60%, respectively. Coagulation abnormalities were common: at least 30% reduction in platelets occurred in all patients and greater than a 50% reduction occurred in 19 of 32 (59%). Twenty patients had a PT > 15 s and 6 of these 20 also had a platelet count < 50,000. Associated complications included one wound hematoma, two GI hemorrhages, one intracranial hemorrhage, and one hepatic hemorrhage from the cryosurgical site. The actuarial patient survivals were 90, 59, 33, and 22% at 6, 12, 24, and 36 months, respectively. CONCLUSIONS: This report helps define the risks and results of cryosurgical ablation as a complement to surgical resection for advanced hepatobiliary tumors. Management of lesions contiguous to major blood vessels may include either the Pringle maneuver or total vascular isolation. Since these procedures can have significant morbidity, we urge cautious application of cryosurgery for advanced hepatobiliary tumors in selected otherwise unresectable patients.

Traumatic injuries of the alimentary tract in children.

Traumatic alimentary tract (AT) perforations in children secondary to instrumentation, though rare, can occur at any age, especially in neonates and young infants. Awareness of such a possibility is essential for prompt management to be initiated. Over a 10-year period (1986-1995), eight pediatric patients with AT perforations secondary to instrumentation were managed at the American University of Beirut Medical Center. Five had upper AT injuries that included three hypopharyngeal, one esophageal, and one gastric lesion. The remaining three patients had lower AT injuries involving the transverse colon in one and the rectum in two. All the patients but two (one with a hypopharyngeal and one with an esophageal injury) were managed surgically and all survived. These rare injuries are discussed in addition to the preventive measures to be taken.

Lingual thyroid: tongue-splitting incision for transoral excision.

Two patients presenting to the Central Military Hospital of Beirut with symptomatic lingual thyroid are reported. I131 thyroid scanning revealed the lingual thyroid to be the only functional thyroid tissue present in each patient. Subsequent CT scanning demonstrated the large size of these ectopic thyroids causing significant mechanical obstruction. These were excised transorally using a posterior midline tongue-splitting incision and reimplanted in the rectus abdominis muscles. Details of this modified tongue-splitting surgical approach are described. A brief review of the literature concerning lingual thyroid and its surgical treatment is also presented as well as three patients operated on for lingual thyroid at the American University of Beirut Medical Centre between 1975 and 1994 using an external neck incision.

Injury to the popliteal vessels: the Lebanese war experience.

Our experience with 118 patients who underwent surgery for a total of 178 popliteal vessels injuries is reported. Forty-nine per cent had injury to both artery and vein and 44% had associated bony fractures. Fourteen patients subsequently needed amputation for a rate of 11.9%. There were no deaths. Delay in repair (> 6 hours from injury), associated fractures, and a shocked condition resulted in increased limb loss. Arterial as well as venous repair, external skeletal fixation, and fasciotomy when necessary lead to improved limb salvage.

Reduction of lateral trochanteric fractures in external rotation.

Displaced lateral trochanteric fractures require satisfactory reduction by external rotation and internal fixation with a Richard's nail plate for acceptable clinical results. In cases where the proximal fragment lies in external rotation, classic reduction procedures may accentuate displacement. External rotation of the distal fragment by temporary fixation of the proximal fragment allows all fracture fragments to move together during subsequent internal rotation and internal fixation. This paper discusses the anatomic and roentgenographic aspects of these injuries.

Injury to the femoral vessels--the Lebanese War experience.

Over a 10-year-period extending from January 1976 to September 1986, 800 peripheral vascular injuries were surgically treated at the American University of Beirut Medical Centre. Of these, 150 were operated on because of injury to the femoral vessels. Bullets were the commonest wounding agents (60% of cases). Thirty-seven patients had a femoral artery injury, 27 a femoral vein injury and 86 combined femoral artery and vein damage. Twenty-three per cent of the patients had an associated fracture of the femur. Patients with fractures had an 11% amputation rate compared with 1% for those without fractures. Our data reveals the importance of venous reconstruction in the presence of an arterial injury instead of its ligation (P less than 0.05), particularly when there is an associated fracture of the femur. Thirty-seven per cent of patients were in shock on admission (systolic BP 90 mmHg). The amputation rate in these patients was 6.8% in contrast to 1% in the haemodynamically stable group (P less than 0.05). The overall amputation rate was 3.3%. Complications occurred in 36.6% of patients and the mortality was 4.0%.