Milk of calcium (MOC) cysts masquerading as renal calculi - a trap for the unwary

Milk of calcium (MOC) is a colloidal suspension of calcium salts occurring in calyceal cysts and diverticula. Although reported to be rare, in fact it seems to be more common than previously thought. It has characteristic appearances on plain x-rays, ultrasound, and CT imaging particularly in the prone and supine positions. Often entirely asymptomatic, its appearance may be mistaken for renal stones on radiography or angiomyolipomas on ultrasonography. In this paper, a series of cases is presented outlining its characteristic features and reviewing the relevant literature.

The role of transarterial embolization in the treatment of renal cell carcinoma

OBJECTIVE

To review the role of transarterial renal embolization in our unit, assessing the indications, tolerability and efficacy of this technique for treating renal cell carcinoma (RCC).

PATIENTS AND METHODS

Thirty patients undergoing transarterial embolization between 1991 and 1999 were identified and 25 case notes analysed retrospectively.

RESULTS

Most patients (14 of 25) presented with less advanced (stage I-III) RCC who were unable or unwilling to undergo radical surgery; the remainder (11) presented with advanced (stage IV) disease. The embolizing agent was ethanol, usually combined with stainless steel coils (85% of cases). Procedural pain and fever was controlled successfully. The median hospital stay associated with the procedure was 4 days. At the time of analysis six of 11 stage IV and 11 of 14 stage I-III patients were alive (median follow-up 27 and 39 months, respectively). Symptoms from the primary tumour were well controlled. Overall, 17 of 25 (68%) of patients reported no problems while three (12%) required brief hospital admission for treatment of persistent haematuria. Fourteen patients were subsequently re-staged; the primary tumour in two had increased, in seven remained unchanged and in five it decreased. No patients without metastases developed them and metastases in two patients regressed.

CONCLUSION

Transarterial embolization is associated with minimal morbidity and complications, and subsequent symptom control is good. The effect of palliative embolization on RCC progression is unknown and requires prospective investigation. Presently, there is no role for cytoreductive embolization; it should be included as a treatment option in clinical trials evaluating such options in patients with metastatic RCC.

The 2-year symptomatic and urodynamic results of a prospective randomized trial of interstitial radiofrequency therapy vs transurethral resection of the prostate

OBJECTIVE

To assess the 2-year symptomatic and urodynamic results of a prospective randomized trial of interstitial radiofrequency therapy of the prostate (IRFT) vs transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

Patients with lower urinary tract symptoms (LUTS) and urodynamic evidence of bladder outlet obstruction (BOO) were randomized to undergo IRFT or TURP and were followed up using the International Prostate Symptom Score (IPSS) and urodynamic assessment for 2 years.

RESULTS

At 2 years there was a clinically relevant reduction in the IPSS in the IRFT (20 to 9) and TURP groups (22 to 4). There was also a statistically significant reduction in the detrusor pressure at maximum urinary flow in both groups, but the reduction in the IRFT group was probably not sufficient to explain the observed symptomatic improvements solely from a reduction in BOO.

CONCLUSION

IRFT can produce a sustained improvement in LUTS for at least 2 years. However, such improvements are unlikely to be entirely the result of a reduction in BOO. The effects of radiofrequency energy may, at least partly, be independent of any thermal effect and depend instead on neuromodulation of lower urinary tract nerves.

Spindle Cell Lipoma of the Parotid

A 47-year-old man presented to the otolaryngologist with a 7-year history of a mass of the cheek. Fine-needle aspiration revealed foci of spindled cells admixed with abundant fat and myxoid material. A diagnosis of spindle cell lipoma was rendered on the resected specimen. The cytologic findings of spindle cell lipoma of the parotid gland as seen by fine-needle aspiration are presented along with the histologic correlates.

Molecular determinants of ovarian cancer plasticity

During development, the formation and remodeling of primary vascular networks occurs by vasculogenesis and angiogenesis. Recently, the term "vasculogenic mimicry" has been used by our laboratory and collaborators to reflect the embryonic-like ability of aggressive, but not nonaggressive, melanoma tumor cells to form a pattern of matrix-rich networks (containing channels) surrounding spheroids of tumor cells in three-dimensional culture, concomitant with their expression of vascular cell markers. Ovarian cancer is usually diagnosed as advanced stage disease in most patients when widespread metastases have already been established within the peritoneal cavity. In this study, we explored whether invasive ovarian carcinoma cells could engage in molecular vasculogenic mimicry reflected by their plasticity, compared with their normal cell counterparts. The data revealed that the invasive ovarian cancer cells, but not normal ovarian surface epithelial cells, formed patterned networks containing solid and hollow matrix channels when grown in three-dimensional cultures containing Matrigel or type I collagen, in the absence of endothelial cells or fibroblasts. Immunohistochemical analysis showed that matrix metalloproteinases (MMP)-1, -2, and -9, and MT1-MMP were discretely localized to these networks, and the formation of the networks was inhibited by treatment with MMP inhibitors. Furthermore, the RNase protection assay revealed the expression of multiple vascular cell-associated markers by the invasive ovarian cancer cells. In patient tumor sections from high-stage, high-grade ovarian cancers, 7 to 10% of channels containing red blood cells were lined by tumor cells. By comparison, all vascular areas in benign tumors and low-stage cancers were endothelial lined. These results may offer new insights and molecular markers for consideration in ovarian cancer diagnosis and treatment strategies based on molecular vascular mimicry by aggressive tumor cells.

Is transurethral resection of the prostate safe and effective in the over 80-year-old?

OBJECTIVE

To assess the safety and effectiveness of transurethral resection of the prostate (TURP) in patients over 80 years old.

PATIENTS AND METHODS

The records of all patients over 80 years old undergoing TURP at one institution over a 3.5-year period were studied retrospectively.

RESULTS

31% of patients underwent TURP for symptoms and 68% for urinary retention. The early complication rate was 41%. The late complication rate was 22%. There were no deaths within 30 days of surgery. Of all patients, 80% were satisfied with the outcome of their operation. Of all patients with retention, 80% were able to void with small residual volumes by 6 weeks after operation.

CONCLUSIONS

Although TURP in the over 80-year-old male is associated with significant morbidity, it is an effective treatment for urinary symptoms or retention. The majority of patients are able to void afterwards and are satisfied with the outcome of their surgery.

Evaluation of fine-needle aspiration cytology for renal masses

OBJECTIVE

To evaluate the accuracy and use of fine-needle aspiration (FNA) cytology for the diagnosis of renal masses because with the improved quality and increasing use of ultrasonography and computed tomography (CT), asymptomatic renal masses, particularly small (< 5 cm) tumours, are being discovered more frequently.

PATIENTS AND METHODS

Between 1995 and 1997, 49 patients (mean age 67.5 years, range 42-88, 34 men and 14 women) underwent FNA of a solid or complex cystic mass under radiological guidance. All masses were further evaluated and staged by CT. Solid masses were divided according to size (< 5 cm and >/= 5 cm). Patients were followed up to the determination of a final diagnosis on tissue histology, after nephrectomy where possible.

RESULTS

Thirty-six patients had histologically confirmed carcinoma at nephrectomy, and nine had presumed carcinoma (four unfit for surgery, five with advanced malignancy). The remaining four patients had benign diagnoses. FNA produced insufficient sample in eight cases (16%). The sensitivity was 89% for large (>/= 5 cm) solid masses, 64% for small (< 5 cm) solid masses and 50% for complex cysts.

CONCLUSION

FNA does not contribute to the diagnosis of malignancy in large (> 5 cm) masses, as good radiological imaging is nearly always diagnostic. For smaller (< 5 cm) masses and complex cysts, FNA can occasionally confirm malignancy, but lack of diagnostic yield and low sensitivity means that FNA is unreliable as a diagnostic tool and will rarely help in the routine management of these patients.

Radio-contrast enhancement of a urinary tract calculus

We report the case of a woman who presented with obstruction and urosepsis of her left kidney secondary to small cystine calculi. The calculi could not be seen on initial plain abdominal X-ray. However, following percutaneous nephrostogram the calculi became more radio-dense and visible on later X-rays. Experimental enhancement of calculi has been described before but not in man. We presume that the contrast medium was adsorbed by the calculus to increase the radio-density. Further investigation of this phenomenon could prove useful in the management of complex radiolucent calculi.

Transballoon cystometry: a new technique to assess detrusor function after urinary retention

OBJECTIVE

To validate a new urodynamic technique to assess detrusor function in patients presenting with acute urinary retention, using the balloon channel of their Foley catheter (transballoon cystometry), and to use the technique to assess patients presenting in acute retention.

PATIENTS AND METHODS

The technique of transballoon cystometry is described and validated in vitro using a specially constructed water manometer, and in vivo on five patients who had a suprapubic catheter in addition to the urethral Foley catheter. Fifty-two patients presenting in acute retention underwent transballoon cystometry one week after catheterization; they were divided according to their clinical presentation into uncomplicated acute retention (41 patients) and acute-on-chronic retention (11 patients). The results from transballoon cystometry were compared between these groups.

RESULTS

The pressure recorded through the balloon channel was equal to that recorded through the lumen of the catheter, both in vitro and in vivo. Patients with acute-on-chronic retention had a larger volume at first sensation, a larger maximum cystometric capacity, higher end-filling pressure and lower maximum detrusor pressure during isometric contraction than patients in uncomplicated retention.

CONCLUSION

Transballoon cystometry is accurate and easy to perform. The clinical distinction between uncomplicated acute retention and acute-on-chronic retention was supported by the urodynamic data. This test could be used before surgery to identify patients with detrusor failure.

Interstitial radiofrequency therapy of the prostate in the management of acute urinary retention

OBJECTIVE

To evaluate in a prospective study the efficacy of interstitial radiofrequency therapy (IRFT) of the prostate in relieving acute urinary retention in patients with benign prostatic hyperplasia.

PATIENTS AND METHODS

Twenty-seven patients presenting in acute urinary retention who failed at least one trial of voiding one week after presentation were treated with IRFT of the prostate. During the 6-month follow-up, the International Prostate Symptom Score (IPSS), urinary flow rate, post-void residual volume (PVR) and serum creatinine were determined and changes in erectile and ejaculatory functions recorded. The treatment was considered successful if the patient resumed normal voiding, without compromising renal function and without troublesome lower urinary tract symptoms necessitating further treatment.

RESULTS

Of the 26 evaluable patients, 77% resumed normal voiding. At 6 months after treatment, the mean (SD) IPSS had decreased from 15.0 (8.3) to 8 (5.4), the PVR from 950 (203) to 88 (60) mL and the maximum flow rate was 10.5 (4.36) mL/s.

CONCLUSION

IRFT of the prostate is a safe and effective treatment, at least in the short-term, for relieving acute urinary retention in patients with benign prostatic hyperplasia. The longer term follow-up is continuing.

A prospective randomized trial of interstitial radiofrequency therapy versus transurethral resection for the treatment of benign prostatic hyperplasia

OBJECTIVE

To carry out a prospective randomized trial comparing interstitial radiofrequency therapy (IRFT) with transurethral resection of the prostate (TURP) in the treatment of bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia.

PATIENTS AND METHODS

The change in detrusor pressure at maximum flow (PdetQmax) was chosen as the primary measure of outcome but the symptom score, Qmax and residual volume were also measured. Patients with urodynamic evidence of BOO were randomized to receive IRFT (n = 25) or TURP (n = 25); the urodynamics were repeated 6 months after treatment.

RESULTS

There was a statistically significant reduction in PdetQmax at 6 months for TURP (P < 0.001) and IRFT (P < 0.01) although the change seen in the latter group was probably not clinically relevant. Nevertheless, a clinically relevant reduction in symptom score occurred in both groups. Both techniques were associated with a low morbidity.

CONCLUSION

IRFT is a cheap and safe technique which may be useful in the treatment of lower urinary tract symptoms in certain groups of patients in whom symptomatic improvement is a priority rather than objective outcome. The underlying mechanism for this symptomatic improvement is at present unclear.

Estrogen reduction by aromatase inhibition for benign prostatic hyperplasia: results of a double-blind, placebo-controlled, randomized clinical trial using two doses of the aromatase-inhibitor atamestane. Atamestane Study Group

BACKGROUND

The concept of estrogen withdrawal by an aromatase inhibitor in the treatment of benign prostatic hyperplasia (BPH) was assessed in a prospective, randomized, double-blind, placebo-controlled multicenter trial.

METHODS

Two hundred and ninety-two patients with clinical symptoms of BPH were randomly allocated to one of the following treatments for 48 weeks: placebo or the selective aromatase inhibitor, atamestane, at a daily dose of 100 mg or 300 mg. Both doses of atamestane significantly reduced serum concentrations of estradiol and estrone, and produced a slight, dose-dependent, counter-regulatory increase in peripheral androgen concentration.

RESULTS

Clinical symptoms improved during treatment in all three groups. Even after 48 weeks, the effect of active treatment did not exceed the effect seen with placebo. Overall tolerance of 100 mg atamestane was excellent, but 300 mg showed a slightly increased incidence of side effects compared with placebo.

CONCLUSIONS

The conclusion from this study is that the reduction in estrogen concentration using the selective aromatase inhibitor atamestane has no effect on clinically established BPH.

Interstitial radiofrequency therapy of the prostate: results of a pilot study

PURPOSE

We assessed the feasibility of using interstitial radiofrequency therapy for benign prostatic hyperplasia (BPH) in 50 patients.

MATERIALS AND METHODS

Therapy was given using a standard diathermy unit as the radiofrequency generator and a disposable needle electrode. The main outcome measure was improvement in symptoms assessed by symptom scores.

RESULTS

Patients with bothersome symptoms or acute retention showed clinically significant improvements in symptom score, while those with chronic retention did not. There were no serious complications.

CONCLUSIONS

Interstitial radiofrequency therapy may be effective for symptomatic BPH. Further studies with long-term objective data are under way to assess its role in the management of BPH.

A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic

OBJECTIVE

To compare the analgesic efficacy of a single 30 mg intramuscular dose of ketorolac with that of intramuscular pethidine 100 mg, in a double-blind, parallel-group investigation of patients presenting with pain suggestive of renal colic.

PATIENTS AND METHODS

Seventy-six patients (17 women, 15 men; mean age 45.2 years, range 20-80) were allocated by means of a pre-determined randomization schedule to receive ketorolac and 78 patients (20 women, 58 men; mean age 42.1, years range 18-70) to receive pethidine. Data from eight patients in the ketorolac group and six in the pethidine group were excluded from the efficacy analyses because of protocol violations. The severity of each patient's pain was assessed on a four-point verbal rating scale (VRS) and a 10 cm visual analogue scale at pre-dose and at 15 min intervals for the first hour post dosing. The time to first administration of rescue analgesic, up to 24 h following dosing with the study medication, was recorded. Adverse events were elicited by general questioning.

RESULTS

Eighty-eight per cent of patients in each treatment group had improved according to the VRS of pain severity 1 h after dosing; the summed pain intensity differences up to 1 h were statistically significantly different in favour of ketorolac (P < 0.05). Fifty-six per cent of patients who were receiving ketorolac required rescue analgesia during the study period compared with 74% receiving pethidine. The incidences of adverse events were lower in the ketorolac group (28%) than the pethidine group (51%).

CONCLUSION

Ketorolac can be considered a viable alternative to pethidine for the treatment of renal colic.

Irrigation or no irrigation after transurethral prostatectomy?

Urologists remain divided as to the need for routine irrigation following transurethral prostatectomy (TURP). This randomised prospective study compared a policy of irrigation with that of no irrigation in a consecutive group of 200 patients undergoing TURP. In the irrigation group, a mean of 15 litres of irrigating fluid was used in each patient and one-third of patients required at least one bladder washout. In the no irrigation group, although two-thirds of the patients required at least one bladder washout, only one-third required more than one washout. No significant difference in blood loss, electrolyte balance, infection rate or recovery was seen in the 2 groups. This study led to a local change in practice, converting from a policy of routine irrigation to one of no irrigation.

1500 cases of renal and ureteric calculi treated in an integrated stone centre

Fifteen hundred consecutive cases of renal and ureteric calculi were treated in an integrated stone centre; 1464 of these were treated by extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy, ureterorenoscopy and ureteroscopic lasertripsy. Only 36 (2.4%) required open surgery.

Diurnal and Nocturnal Habitat Utilisation by the Whiptail Wallaby, Macropus Parryi

Diurnal and nocturnal habitat use was determined from walk transect counts in a 40 000 ha study area in SE Queensland containing 3 land systems: (a) alluvial flats mainly clear of natural vegetation; (b) hills extending from the alluvial flats with open forest; and (c) plateaux with grassy and shrubby open forest. Habitat utilization was examined in relation to 3 vegetation variables (shrub density, live tree density and dead tree density) and 3 topographic variables (altitude, aspect and slope). Utilization was most consistent between day and night for live tree density and slope, being biased toward areas of moderate live tree density and against flat areas at both times. A preference for areas with moderate shrub density was more pronounced during the day than at night. Areas with moderate dead tree density were strongly preferred over areas with low dead tree density during the day, but at night there was no strong bias for or against areas with dead trees. M. parryi avoided very low altitudes at all times. Utilization of higher areas varied day and night, a diurnal preference for higher altitudes being ameliorated by some apparent downhill movement to lower slopes at night. A preference during the day for north and west aspects was not evident at night.

Extracorporeal shockwave lithotripsy: first 1000 cases at the London Stone Clinic

One thousand patients underwent extracorporeal shockwave lithotripsy for renal and ureteric calculi at this clinic. An overall success rate of 91.8% was achieved (stone free or less than 2 mm fragments at three months) and for stones measuring 1 cm 96.3%. Lithotripsy produced extremely low morbidity, and no deaths have occurred at the clinic. Patients who had lithotripsy alone had a mean hospital stay of three days and in most instances were able to perform their full range of activities on discharge. Planned combination of lithotripsy with minimally invasive endourological procedures such as percutaneous nephrolithotomy and ureterorenoscopy has allowed us to extend the range of treatable cases to include large stones. Prophylactic use of Double-J ureteric stents in selected cases has reduced the incidence of obstruction by stone fragments after lithotripsy, thereby decreasing morbidity and hospital stay.

Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in children

The possibilities for treating children with renal stone disease by extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) have not been widely explored. We report ten children, aged between 5 and 16 years, treated by PCNL, and six children, aged between 6 and 15 years, treated by ESWL alone. A 16-year-old spina bifida child with a staghorn calculus was treated electively by a combination of the two methods. Hospital stay was 3 to 8 days for treatment by PCNL or ESWL, and was only 11 days for the combination treatment. Complete stone clearance was achieved in 12 children followed for 3 months. No significant complications occurred. ESWL and PCNL are suitable methods for the management of renal calculi in children.

Plasma cell balinitis of Zoon

Superficial lesions of the glans penis can pose diagnostic difficulties. Plasma cell balanitis is such a condition and it may be confused clinically with erythroplasia of Queyrat. It is unresponsive to topical medication and curable only by circumcision.

Combination of percutaneous surgery and extracorporeal shockwave lithotripsy for the treatment of large renal calculi

Open surgery for large or complex renal calculi may be difficult, particularly in patients with recurrent stones, and may require special operative techniques to preserve renal function. With the advent of percutaneous nephrolithotripsy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) new approaches are now available for the treatment of these difficult cases. A review of 67 patients who presented between November 1984 and May 1986 has shown that it was possible to clear large stones in 71% of patients using a combination of PCNL and ESWL. There was no mortality; the morbidity for both procedures was low and was less than when either procedure was used alone for the treatment of complex stones.

The complications of extracorporeal shockwave lithotripsy: management and prevention

Extracorporeal shockwave lithotripsy has been shown to be a safe and effective method of treating most upper urinary tract stones. Major complications, although few, include haemorrhage, septicaemia, "Steinstrasse" formation and cardiac arrhythmias. The experience from 600 consecutive cases is reviewed and methods of prevention are discussed.

Treatment of urethral hemangioma by selective arterial embolization

Control of significant hematuria by embolization of angiographically demonstrated vascular malformations of the prostatic and membranous urethra is reported in a patient with multiple diffuse superficial hemangiomas.

Treatment of hilar carcinoma by bile drainage combined with internal radiotherapy using 192iridium wire

Eighteen patients with a cholangiocarcinoma involving the hilum of the liver, and one patient with a carcinoma of the gall bladder causing obstruction of the common hepatic duct, have been treated with bile drainage using a U-tube (8 patients) or a percutaneous transhepatic catheter (11 patients) followed by internal radiotherapy with 192iridium wire. The median survival is 11 months, and 9 patients (47 per cent) have survived for 12 months or longer. The addition of internal radiotherapy may be beneficial to patients with hilar cholangiocarcinoma causing biliary obstruction in whom bile drainage can be established.

Endotoxin, prostaglandins and renal fibrin deposition in obstructive jaundice

The delayed clearance of endotoxins in obstructive jaundice may cause renal impairment by inducing renal vasoconstriction and glomerular fibrin deposition as a consequence of intravascular coagulation. As endotoxins activate arachidonic acid metabolism we have examined the effects of selective inhibitors on mortality, plasma TXB2 and 6-oxo-PGF1 alpha production and renal fibrin deposition in rats with obstructive jaundice following endotoxin administration. Jaundiced rats had a high mortality following endotoxin--58 per cent at 4 h and 83 per cent at 24 h. Pretreatment with indomethacin 3 mg/kg i.p., dazoxiben 3 mg i.p. or prostacyclin 300 ng/kg i.v. produced significant improvements in survival. Endotoxaemia was associated with significant elevations of plasma TXB2 and early inhibition of plasma 6-oxo-PGF1 alpha generation. Renal fibrin deposition, assessed using indirect immunofluorescence and a 125I-labelled fibrinogen uptake ratio, occurred in jaundiced kidneys following endotoxin and could be prevented using indomethacin, dazoxiben and prostacylin. These results suggest that endotoxin-induced TXA2 production can cause renal fibrin deposition in obstructive jaundice, thus contributing in the pathogenesis of the renal impairment.

Hepatic dysfunction in renal carcinoma

In a retrospective review of 81 patients with renal carcinoma 34 (42%) had abnormalities of one or more liver function tests. Fifteen patients (18.5%) had abnormalities of 3 or more liver function tests but without evidence of hepatic metastases. There was a significant association between these patients and the presence of fever, anaemia, weight loss and a raised ESR (P less than 0.001) compared with those whose liver function was normal. Following nephrectomy, liver function returned to normal in 5 patients. Median survival in these patients was 35 months, whilst in those whose liver function remained abnormal the median survival was 8 months (P less than 0.01).

The aetiology and investigation of haemospermia

The cause of haemospermia was determined in 70 (86%) of 81 patients. Inflammatory lesions accounted for the bleeding in most men under 30 years of age. Neoplasia (6), trauma (3) and amyloidosis (2) of the seminal vesicle were diagnosed in the other patients. Persistent haemospermia should always be investigated since clinically unsuspected tumours may be the source of bleeding in the older age groups. Analysis of the semen, prostatic fluid and urine should be performed initially. Cystourethroscopy should then be carried out if the initial investigations are negative and, if this too is negative, vasography is indicated.

Long term follow-up of interposition mesocaval shunting in portal hypertension

The long term results of 28 interposition mesocaval shunts performed between 1971 and 1975 are analysed over a follow-up period of 5-9 years. There were 6 emergency operations and 22 elective operations, with an overall operative mortality of 14.3 per cent and a 5-year survival for the complete series of 31.5 per cent (class A patients 55.5 per cent, class B 33 per cent and class C 0 per cent). Shunt patency at 7 months was 95 per cent but by 5 years this had fallen to 53 per cent. Further variceal bleeding occurred in 6 patients (31.5 per cent) in 4 of whom shunt occlusion was confirmed.

Gastric perforation secondary to metastatic carcinoma of the lung: a case report

This is a report of a gastric perforation secondary to a metastasis from a primary squamous cell carcinoma of the lung in a 70-year-old white man who was being treated with cimetidine for a presumed benign gastric ulcer. The literature concerning bronchogenic carcinoma metastasizing to the stomach and small bowel is reviewed, and the effect of cimetdine on malignant gastric ulcers is discussed.

Benign liver nodules presenting as apparent hepatic metastases: a report of 5 cases

Five cases are described in which hepatic nodules discovered as an incidental finding at laparotomy performed for other reasons were thought to be metastatic tumour. In each case histology and clinical course proved this assumption to be incorrect. It is emphasized that biopsy is mandatory in such circumstances to establish the diagnosis. Where the nature of the hepatic lesion might affect the choice of operative procedure frozen section examination should be performed at the time of surgery. Bacteriological culture may also be helpful.

Partial nodular transformation of the caudate lobe of the liver presenting with ascites

Partial nodular transformation is a rare condition which effects the perihilar portion of the liver and may cause chronic portal hypertension. This case report describes an elderly women in whom the condition was confined to the caudate lobe, which had become greatly enlarged and, by external compression of th portal vein at the hilum of the liver, had caused portal vein thrombosis and subsequent acute ascites.

Neoplastic autovagotomy causing gastric stasis

Neoplastic autovagotomy causing atonic gastric stasis is extremely rare. Two cases are reported in which marked gastric stasis was complicated by a bezoar and a gastric volvulus respectively. Both cases were associated with a left hilar bronchial carcinoma, and malignant invasion of the vagus nerve may have been the underlying cause.