Normal and variant anatomy of the nasal tip

A thorough understanding of nasal tip anatomy is a prerequisite to understanding the nuances of restructuring the nasal tip. The three-dimensional structural anatomy of the nasal tip is complex. Additionally, the interrelationship between these structures determines the ultimate form and function of the nasal tip. As a result, alteration of one structure in the tip will often lead to change in other portions of the nasal tip. This dynamic concept of anatomy in the nasal tip makes proper alteration of the nasal tip one of the most challenging tasks faced by a rhinoplasty surgeon. This article provides a fundamental knowledge of the normal anatomy of the tip structures and how their interaction with each other determines the shape and support of the lower portion of the nose. It also provides a description of some common variants of tip anatomy that cause patients to seek consultation for rhinoplasty. A proper understanding of the concepts presented provides a foundation to build on as the reader continues to explore the "nuances of the nasal tip."

Complications and management of septoplasty

Septoplasty is a common procedure in otolaryngology used to address nasal obstruction caused by a deviated nasal septum. It is often accompanied by inferior turbinate reduction. Complications that may arise from this procedure include excessive bleeding; cerebrospinal fluid rhinorrhea; extraocular muscle damage; wound infection; septal abscess; toxic shock syndrome; septal perforation; saddle nose deformity; nasal tip depression; and sensory changes, such as anosmia or dental anesthesia. Local and general anesthetics have been used to successfully perform septoplasty and the operation may be done either endoscopically or open. Overall, good intraoperative visualization is a key factor in preventing complications and achieving a functional nasal airway.

Clinical course following endoscopic repair of type 1 laryngeal clefts

OBJECTIVES

Treatment of type I laryngeal clefts (T1LCs) remains controversial. We present our experience with 16 endoscopic T1LC repairs to evaluate the effect of patient characteristics and surgical technique on outcomes.

METHODS

A retrospective study was performed. Diagnosis of T1LC was made by interarytenoid palpation during operative microlaryngoscopy. Two surgeons performed endoscopic repair using either microflap reconstruction or laser demucosalization and reapproximation. All patients received preoperative and postoperative modified barium swallow (MBS) studies. Improved MBS at 3-5 months determined success of repair. Factors contributing to success of repair were analyzed statistically.

RESULTS

No intraoperative complications occurred. One T1LC repair dehisced after 3 months. Overall, 11 of 16 repairs (68.8%) were successful. Mean age at repair was 23.3 months. Length of stay for microflap repair was significantly shorter than for laser reapproximation (0.89 days vs. 4.6 days, p<0.001, two-tail t-test). The difference in patient age between failures and successes (21.3 months vs. 24.2 months) was non-significant (p=0.661, two-tail t-test). Success for the nine patients receiving microflap reconstruction (77.8%) vs. the seven receiving laser reapproximation (57.1%) is comparable (p=0.596, Fisher's exact test). No correlation between comorbidities and failure was found (p>0.05, Fisher's exact test).

CONCLUSIONS

This series matches the largest reported series of endoscopic T1LC repairs. Success rates were lower than in previously reported studies, and comorbidities were higher. However, comorbidities did not contribute to surgical failure. No difference in outcome was seen between the two endoscopic techniques. Microflap repair may require a shorter hospital stay.

Pelvic exenteration for advanced pelvic malignancy

Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior surgery and radiotherapy. After exenteration, 5-year survival is 40% to 60% in patients with gynecologic cancer as compared to 25% to 40% for patients with colorectal cancer. Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age. Careful pre-operative staging, including either computed tomography (CT) scan or magnetic resonance imaging (MRI), usually will identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall (which generally precludes surgery). The recent application of intra-operative radiotherapy or postoperative high-dose brachytherapy for patients with more advanced pelvic disease, which may include sidewall involvement, may expand the standard indications for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operative details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Filling the pelvis with large tissue flaps, usually a rectus abdominus flap, has decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity occurs in over 50% of patients. Restorative techniques for both urinary and gastrointestinal tracts can diminish the need for stomas and, along with vaginal reconstruction, can significantly improve quality of life for many patients after exenteration. These advances in surgery and radiotherapy help make the procedure a viable option for patients with otherwise incurable pelvic malignancy.

Pelvic exenteration for advanced pelvic malignancy

Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior surgery and radiotherapy. After exenteration, 5-year survival is 40% to 60% in patients with gynecologic cancer as compared to 25% to 40% for patients with colorectal cancer. Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age. Careful pre-operative staging, including either computed tomography (CT) scan or magnetic resonance imaging (MRI), usually will identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall (which generally precludes surgery). The recent application of intra-operative radiotherapy or postoperative high-dose brachytherapy for patients with more advanced pelvic disease, which may include sidewall involvement, may expand the standard indications for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operative details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Filling the pelvis with large tissue flaps, usually a rectus abdominus flap, has decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity occurs in over 50% of patients. Restorative techniques for both urinary and gastrointestinal tracts can diminish the need for stomas and, along with vaginal reconstruction, can significantly improve quality of life for many patients after exenteration. These advances in surgery and radiotherapy help make the procedure a viable option for patients with otherwise incurable pelvic malignancy.

Optimism versus pessimism predicts the quality of women's adjustment to early stage breast cancer

BACKGROUND

Recent studies indicate that breast cancer patients do not usually experience the devastating psychological consequences once viewed as inevitable. However, some adjust to the disease more poorly than others. This study examined the personality trait of optimism versus pessimism as a predictor of adjustment over the first year, postsurgery.

METHODS

Seventy women with early stage breast cancer reported on their general optimism-pessimism at diagnosis. One day before surgery, and at 3-month, 6-month, and 12-month follow-ups, they reported their subjective well-being (mood scales and a measure of satisfaction with life). At follow-ups, they also rated their sex lives, indicated how much physical discomfort was interfering with their daily activities, and reported on thought intrusion.

RESULTS

Pessimism displayed poorer adjustment at each time point by all measures except interference from pain. Even controlling for previous well-being, pessimism predicted poorer subsequent well-being, suggesting that pessimism represents a vulnerability to a negative change in adjustment. In contrast, effects of pessimism on quality of sex life and thought intrusion were not incremental over time. Additional analyses indicated that effects of the optimism-pessimism measure were captured relatively well by a single item from the scale.

CONCLUSIONS

A sense of pessimism about one's life enhances a woman's risk for adverse psychological reactions to the diagnosis of, and treatment for, breast cancer. This finding suggests the potential desirability of assessing this quality informally in patients, to serve as a warning sign regarding the patient's well-being during the period surrounding and following surgery.

How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer

At diagnosis, 59 breast cancer patients reported on their overall optimism about life; 1 day presurgery, 10 days postsurgery, and at 3-, 6-, and 12-month follow-ups, they reported their recent coping responses and distress levels. Optimism related inversely to distress at each point, even controlling for prior distress. Acceptance, positive reframing, and use of religion were the most common coping reactions; denial and behavioral disengagement were the least common reactions. Acceptance and the use of humor prospectively predicted lower distress; denial and disengagement predicted more distress. Path analyses suggested that several coping reactions played mediating roles in the effect of optimism on distress. Discussion centers on the role of various coping reactions in the process of adjustment, the mechanisms by which dispositional optimism versus pessimism appears to operate, third variable issues, and applied implications.

Metastatic proclivities and patterns among APUD cell neoplasms

Neoplasms of APUD cell origin are quite variable in their metastatic behavior. Whereas pituitary and parathyroid tumors almost never metastasize, all oat cell lung cancers, malignant melanomas, trabecular carcinomas of the skin and medullary thyroid cancers are capable of dissemination. The metastatic proclivity of individual carcinoids, pancreatic and extrapancreatic islet cell tumors, and paragangliomas is much less predictable. In particular, there are no reliable histological markers of risk for lymphatic or hematogenous dissemination. The behavior of many carcinoids, islet cell carcinomas and paragangliomas is relatively indolent, even when metastatic disease is already present. However, unresectable distant metastases, especially liver involvement, connote a poor prognosis. Mortality is more often related to uncontrolled tumor growth and metastasis than to associated endocrinopathies. Curative or debulking surgical resection should be aggressively pursued as recent data show that worthwhile clinical disease-free survival can be realized in at least some patients.

How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer

At diagnosis, 59 breast cancer patients reported on their overall optimism about life; 1 day presurgery, 10 days postsurgery, and at 3-, 6-, and 12-month follow-ups, they reported their recent coping responses and distress levels. Optimism related inversely to distress at each point, even controlling for prior distress. Acceptance, positive reframing, and use of religion were the most common coping reactions; denial and behavioral disengagement were the least common reactions. Acceptance and the use of humor prospectively predicted lower distress; denial and disengagement predicted more distress. Path analyses suggested that several coping reactions played mediating roles in the effect of optimism on distress. Discussion centers on the role of various coping reactions in the process of adjustment, the mechanisms by which dispositional optimism versus pessimism appears to operate, third variable issues, and applied implications.

Axillary node dissection for early breast cancer: some is good, but all is better

Optimal management of the axillary lymphatics in breast cancer patients remains a contentious subject. Axillary recurrence, while infrequent, may have very significant clinical consequences in the affected patient. Axillary sampling, partial and total axillary lymphadenectomy, radiotherapy, and surgery plus radiotherapy are discussed with attention to efficacy in prevention of axillary recurrence, accuracy of nodal staging, and morbidity. The incidence of axillary recurrence decreases and accuracy of staging increases with the number of lymph nodes resected. There is little difference in incidence of morbidity between partial and total axillary lymphadenectomy. Radiotherapy is not as effective as lymphadenectomy for regional disease control and, when administered following a surgical staging procedure, increases the risk of lymphedema of the ipsilateral upper extremity and, in patients undergoing breast-conserving surgery, the ipsilateral breast. We believe that total axillary lymphadenectomy provides optimal regional disease control and axillary staging with morbidity comparable to that of partial lymphadenectomy.

Effects of mastectomy versus lumpectomy on emotional adjustment to breast cancer: a prospective study of the first year postsurgery

PURPOSE

Procedure (mastectomy v lumpectomy) and choice of procedure were examined as predictors of adjustment to breast cancer in a prospective study of the experiences of the first year after surgery.

PATIENTS AND METHODS

Breast cancer patients were interviewed the day before surgery, 10 days after surgery, and at the 3-month, 6-month, and 12-month follow-ups. Patients included 24 women who received mastectomy on strong recommendation, 24 who chose mastectomy for other reasons, and 15 who chose lumpectomy. Subjective well-being was assessed in terms of mood disturbance, perceived quality of life, life satisfaction, marital satisfaction, perceptions of social support, and self-rated adjustment.

RESULTS

Surgical groups differed in well-being in only one respect: lumpectomy patients reported a higher-quality sex life at 6 and 12 months postsurgery than mastectomy patients. Choice of surgical procedure predicted higher levels of life satisfaction at 3 months.

CONCLUSION

The lack of difference between surgical groups in areas other than sexual adjustment replicates previous findings, but extends them by (1) using a fully prospective design, (2) providing data on the period surrounding the surgery (as well as later periods), and (3) examining a broader range of indices of well-being than usual.

Sacral resection for control of pelvic tumors

A surgical approach for treating patients with resected, recurrent, posterior pelvic visceral tumors involving the sacrum is detailed. Of 11 patients, 9 had rectal cancers, 1 had chordoma, and 1 had cancer of the cervix. Five total pelvic exenterations and five posterior exenterations were performed en bloc with involved sacrum. One patient had a sacral resection only. Surgical mortality was 9%, and the average hospital stay was 1 month. Mean disease-free survival was 1 year, and mean survival was 3 years. Absolute cure rate was 18% with a complete 5-year follow-up. This experience confirms the value of this procedure in selected patients.

Breast-conserving surgery and selective adjuvant radiation therapy for stage I and II breast cancer

In this report we update our experience with selective adjuvant radiotherapy (XRT) following breast-conserving surgery (BCS) for early breast cancer. Of 150 evaluable private breast cancer patients treated by BCS since 1975, 83 were offered the option of foregoing adjuvant XRT because their primary disease met four pathological criteria: primary tumor less than or equal to 2.5 cm; adequate resection margins; no intramammary vascular, lymphatic, or perineural invasion by tumor; and minimal or no associated in situ cancer. Of the 67 patients who chose not to have XRT, four have developed local (breast) tumour recurrence at 80 months' median follow-up (5-year local recurrence rate 6.4% by Kaplan-Meier analysis). These findings are discussed in light of other series in which patients were carefully selected for BCS without XRT, and the observations of large randomized trials and unselected series of patients. We conclude that adjuvant XRT is not always necessary following BCS. The most valuable contribution of XRT to breast-conserving therapy is that a much larger proportion of breast cancer patients can be considered for conservative locoregional surgery than would otherwise be reasonable.

Role and extent of lymphadenectomy for early breast cancer

A better understanding of the locoregional and systemic approaches to breast cancer over the past decade and one-half has altered the perspective on surgical management of the axilla. An increased awareness of the importance of early diagnosis and appropriate staging has focused further attention on the extent of resection of axillary lymph nodes. Examined here are the anatomy and physiology of the axillary lymph nodes, their clinical evaluation, the significance of histologic evaluation, a discussion of the procedure's role in staging and therapy, and a presentation of the complications of axillary lymph node dissection. It is in this light that we discuss the extent of axillary lymphadenectomy in early diagnosis of breast cancer.

Total axillary lymphadenectomy in the management of breast cancer

The optimal extent of axillary dissection in patients with breast cancer remains unclear. We report 278 total axillary lymphadenectomies (levels I, II, and III and Rotter's [interpectoral] nodes) that were performed in 264 closely followed up private patients. There have been no axillary recurrences to date (mean follow-up, 50 months). If only level I and II nodes had been removed, the false-negative staging error would have been only 2.6%. However, 29 (31.5%) of 92 pathological node-positive axillae contained apical and/or Rotter's metastases. The incidence of complications was comparable with that reported for partial lymphadenectomy. Arm lymphedema developed in 6% of nonirradiated patients; postoperative radiotherapy and gross nodal disease were significant risk factors for lymphedema. Total axillary lymphadenectomy largely prevents axillary, recurrence, eliminates the small staging error inherent in partial lymphadenectomy, and has acceptable morbidity, provided radiotherapy to the regional nodal areas is avoided.

Nonoperative techniques for tissue diagnosis in the management of thyroid nodules and goiters

As only 10% of thyroid nodules are malignant, the surgical oncologist is faced with the challenge of selecting for thyroidectomy only those patients likely to benefit therapeutically from surgery. Demonstration of nonfunction on scintigraphic thyroid scan increases the yield of cancer only by 15% to 20%. Aspiration cytology and needle biopsy are potent aids in selecting patients for thyroidectomy. In 1,504 patients for whom a benign or malignant cytological diagnosis was made prior to thyroidectomy, the sensitivity of this technique was 92.0%, specificity was 97.3%, and overall diagnostic accuracy 95.7%. Morbidity is minimal. The reliability of these techniques is dependent on proficient specimen procurement and the cytopathologist's expertise and experience. Differentiation of benign from malignant follicular and lymphocytic lesions is not possible with conventional cytology preparations; 28% of such "indeterminant" lesions prove to be cancer at thyroidectomy. Aspiration cytology is a simple, reliable technique for selection of patients with thyroid nodules for surgery.

Surgical palliation for recurrent rectal cancers ulcerating in the perineum

This report describes a unique palliative approach of radical surgical debridement for uncontrollable, recurrent pelvic tumors ulcerating through the perineum. All conservative treatment attempts with radiotherapy and chemotherapy had failed. Seven patients have been treated with resection of the tumor including a portion of the sacrum to obtain all but the deep margins clear of tumor. Coverage was obtained with myocutaneous flaps. All patients were significantly relieved of pain, requiring little or no subsequent analgesics. Three patients returned to work and the remainder led a relatively comfortable existence at home until their demise. At the time of death, four patients had no visible perineal disease. When conservative attempts at chemotherapy and radiotherapy have failed in this situation, the authors believe that palliative surgery prolongs both quantity and, more importantly, quality of life.

Segmental mastectomy without radiotherapy for T1 and small T2 breast carcinomas

We describe 111 patients with invasive breast cancer treated by segmental mastectomy at the University of Miami (Fla) since 1975. Postoperative adjuvant radiotherapy was recommended as optional rather than mandatory to 64 of these patients based on small (2.5 cm or less) primary tumor size, adequate resection margins, no lymphatic or vascular invasion within the segmental mastectomy specimen, and minimal associated in situ cancer. Fifty-one of these patients elected to forego postoperative adjuvant radiotherapy. At 72 months median follow-up, relapse occurred in the ipsilateral breast in three patients who elected to forego postoperative adjuvant radiotherapy (6% by Kaplan-Meier analysis). Retrospective pathologic review revealed that tumor grade may also be important in determining whether postoperative adjuvant radiotherapy is necessary following segmental mastectomy. These data suggest that postoperative adjuvant radiotherapy may not be required in every patient treated by segmental mastectomy. Further studies to define which patients can be spared the inconvenience, expense, and potential morbidity of postoperative adjuvant radiotherapy are warranted.

Vexed surgeons, perplexed patients, and breast cancers which may not be cancer

In situ cancer of the breast is being diagnosed with increasing frequency due to the widespread use of mammography and heightened awareness of these lesions among pathologists. Treatment of these preinvasive cancers is controversial in light of recent data supporting breast-conserving therapy for small invasive cancers. Therapy for in situ breast cancer is discussed with attention to known risk factors for recurrence and breast cancer-related mortality. The controversies surrounding treatment of ductal and lobular carcinoma in situ compel the conscientious oncologist to seek fully informed consent and to respect the individual patient's feelings about cosmesis and breast cancer risk. Hopefully, prospective randomized studies such as the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-17 trial will relieve the oncology community of much of its confusion about the natural history and optimal therapy for these diseases.

Breast cancer: management of the opposite breast

Women who have or had cancer in one breast are at especially high risk for developing cancer in the contralateral breast. Other risk factors for second primary breast tumors include age, the use of radiation in treating the index cancer, and pathological characteristics of the original cancer. Management approaches range from close clinical and mammographic surveillance only to immediate prophylactic contralateral mastectomy. Routine and selective biopsy of the opposite breast at the time of treatment of the initial cancer have their proponents. The authors discuss these methods and the effect of a second cancer on overall prognosis.

Breast carcinoma post-augmentation mammaplasty: therapy with limited surgery and radiation

Due to the recent surgical and technical developments in aesthetic surgery and occasional dissatisfaction of women with their external contour, augmentation mammaplasty has become a common occurrence in the surgical practice of the aesthetic surgeon. Breast carcinomas, incidentally associated with augmentation mammaplasty, have been sporadically reported in the literature and have all been treated with a mastectomy when resection was possible. We present a case of breast carcinoma occurring 5 years after augmentation mammaplasty performed with silicone-gel-filled implants. Therapy of this carcinoma was achieved through a segmental mastectomy followed by postoperative radiation. The patient remains well 15 months postoperatively. A large number of breast implants are performed each year and the likelihood of a higher incidence of incidental breast carcinomas seen with implants is certainly possible as these patients become older; thought should be given to the notion that possibly not all of these cases need to be managed with radical surgery.

Early discharge after mastectomy. A safe way of diminishing hospital costs

In order to assess the risks and benefits of early discharge after major breast surgery, the authors analyzed 73 consecutive private patients who underwent operations by four surgeons over a 1-year period. Patient's ages ranged from 34 to 84 years, with a mean of 56.2 years. One patient was excluded from analysis because thoracotomy with a pulmonary resection was performed during the same hospitalization. Thirty-seven patients underwent total mastectomy with complete axillary dissection, 30 underwent segmental mastectomy with complete axillary dissection, and five underwent total mastectomy alone. For each patient the chest wall and axilla were drained by means of one or two Jackson-Pratt (American Heyer Schulte Corp., Goleta, CA) closed suction drains. Prior to discharge, all patients were instructed in the proper technique of drain care and were directed to record the daily drainage. Patients were discharged when they were fully mobile, did not require injectable narcotics, and felt capable of taking care of the drains as outpatients. The length of postoperative stay ranged from 1 to 9 days (mean 2.9), with all but three patients being discharged by the fifth postoperative day. Patient acceptance of early discharge with drains was excellent. Drains were pulled on an outpatient basis, usually within 7 to 10 days after surgery. Complications were observed in twelve patients (18%), consisting of seromas (8 patients), cellulitis (2 patients), and minimal superficial skin necrosis (2 patients). All complications were managed easily on an outpatient basis. We conclude that early discharge with Jackson-Pratt drains remaining in place is safe, well tolerated by patients, and has tremendous potential for substantial cost savings.

Squamous cell carcinoma of the rectum: a multimodality approach

A 60-year-old homosexual male with a diagnosis of squamous cell carcinoma of the rectum, arising 7 cm from the dentate line, was treated with a rectal preserving multimodality approach consisting of excisional biopsy and chemotherapy with 5-fluorouracil (5-FU) and mitomycin-C with concomitant administration of radiation therapy to the tumor and pelvic nodal bearing areas. The patient has remained disease-free with full preservation of anorectal function on follow-up at 2 years. This approach to a difficult and unusual problem is recommended as a first line of therapy rather than surgical resection if it is deemed that the patient can tolerate a combination of chemo and radiation therapy and the patient will be able to participate in a long-term follow-up.

Infrared light scanning of the breast

Transillumination and Infrared Light Scanning (I.L.S.) of the breast were evaluated in a high referral breast clinic over a 15-month period. Seven hundred (700) patients were examined and blindly transilluminated; 101 were biopsied, all had mammography. The study was conducted in two phases: Phase I evaluated transillumination without I.L.S. This included 22 biopsied patients out of 101, with eight carcinomas identified histologically, demonstrating 87 per cent sensitivity and 64 per cent specificity for transillumination, versus 87 per cent and 71 per cent for mammography, and 87 per cent and 57 per cent for examination. Phase II evaluated simple transillumination combined with I.L.S. This included 79 biopsied patients out of 101 with 26 carcinomas identified histologically, demonstrating 96 per cent sensitivity and 74 per cent specificity for transillumination combined with I.L.S. compared to 85 per cent and 72 per cent for mammography and 81 per cent and 73 per cent for examination. Of the 26 Phase II carcinomas identified, two were not felt by examination, and two were neither felt nor read correctly by mammography. I.L.S. of the breast has proven effective in the hands of trained personnel and should be used with routine breast examination or mammography to increase yield of breast pathology.

Pure squamous cell carcinoma of the breast

Pathological curiosities have always fascinated the surgical community, and management of breast cancer by the physician has, at times, revealed such rarities. A recent case of squamous cell carcinoma in a clear fluid breast cyst has prompted a review of our experience with this rare pathology, and allowed us to make the following statements: We propose that squamous cell carcinoma of the breast arises from ductal metaplasia. When the T.N.M. system is applied to the squamous cell lesion, the apparent poor prognosis that it is believed to carry may not be so apparent. If no other primaries are identified after extensive metastatic work-up, surgical therapy consisting of total mastectomy with complete axillary dissection, is very effective in local control of tumor progress. Nodal status will indicate the need for additional modalities of therapy.

The use of the skin stapler for drape fixation during operations

Skin staplers used in drape fixation have been found to be effective and safe in a study of 75 patients seen over a period of one year. They are an alternative to the tedious suturing of surgical drapes.

Primary squamous carcinoma of the rectum. Report of a case and review of the literature

Squamous cell carcinoma of the colorectum is a rare pathologic curiosity. Since the first report by Schmidtman in 1919, only 69 cases have been reported in the English medical literature. The mean age at presentation is 52 years, and the disease presents itself equally in men and women. The rectum accounts for slightly less than one half of all cases. Survival appears to correlate with nodal status and findings of visceral metastases at presentation. Most tumors can be identified easily by physical examination and/or barium enema. Therapy is limited largely to surgical resection, although attempts at irradiation and chemotherapy have been made. At this time, the etiology of this disease process is unknown, but a likely explanation revolves around replacement of damaged epithelium by cells which undergo anaplasia due to repeated trauma. In addition to this review of the literature, the authors wish to add one additional report of a patient treated successfully by a multimodality approach.

Preservation of the intercostobrachial nerve during axillary dissection for breast cancer

Preservation of the intercostobrachial nerve during axillary dissection in 50 patients with stage I breast cancer resulted in a significant improvement in sensory function compared with the standard dissection in which the nerve is routinely sacrificed. No local recurrence was found during the 3 to 5 year follow-up period. This modification is worthwhile in patients with axillas that are clinically negative for cancer.

Tumors of the paranasal sinuses: a therapeutic challenge

Cancer involving the ethmoid and sphenoid frontal sinus complex can be successfully eradicated by a combined transcranial and transfacial surgical dissection. Survival rates of 44 to 58 percent with a 3 percent hospital mortality rate in patients whose previous surgery or radiotherapy was largely unsuccessful suggest that this cosmetically acceptable surgical endeavor should be used more often by the head and neck surgeon in treating paranasal sinus cancer. Utilizing the principles of antibiotic prophylaxis, strict attention to principles of tumor removal and surgical technique, and the talents of the combined surgical and neurosurgical team, this aggressive surgical approach to the paranasal sinuses can be safely and successfully carried out. The approach described herein has the following advantages: it allows accurate evaluation of intracranial tumor extension while protecting the intracranial contents, it essentially avoids cerebrospinal fistulization, it provides adequate exposure for hemostasis, facilitates en bloc tumor resection, selectively conserves the orbital contents, and provides patient survival rates up to 58 percent for paranasal cancer that involves the ethmoid and sphenoid frontal sinus complex.

The management of recurrent rectal carcinoma

Rectal carcinoma remains an enigma to surgical and medical oncologists. The chemo- and radiotherapeutic approaches have been fraught with failure, and when this happens the patient is left to the challenge of the surgical oncologist who sometimes must perform extensive re-resection to include adjacent structures. Experienced surgical judgement is assisted by preoperative and intraoperative criteria, which are contraindications to resection: preoperatively, they include metastases, fixation of tumour to pelvic wall, sciatica, obstruction of both ureters and leg edema. Intraoperatively, metastases within aortic nodes or beyond the pelvis and extension of disease laterally or deep to pelvic wall or to multiple loops of bowel are all contraindications. These tumours are often slow to metastasize so that aggressive local surgical resection is warranted to minimize the morbidity prone complications associated with low-lying perineal or pelvic recurrence of rectal cancer.

A single layer open anastomosis for all intestinal structures

Dissatisfaction with time-consuming double layer anastomoses in intestinal surgery and with occasionally questionable stapled anastomoses prompted a review of available techniques for hand sewn suture lines. Single layer anastomoses have been used extensively and their integrity and safety have often been questioned. In 1951, Gambee described a method of single layer anastomosis which, in practice, is a double layer technique. His results at 10 years were comparable to those obtained with other techniques. We have sought a modification to decrease anastomotic complications and improve ease of suture insertion. Along with a description of technique, a review of 170 anastomoses performed from July 1982 to June 1984 is presented without a single clinically apparent leak.

Hartmann's pouch carcinoma

Since 1921, when Henry Hartmann first described his procedure for rectal carcinoma, multiple modifications of the original technique have been proposed. However, the basic principle of a rectal pouch has always been retained. Two cases of carcinoma developing in such a pouch are described; both occurred years after creation of the pouch. One was managed by local resection through a transsacral approach; the other required an abdominoperineal resection. Consideration must be given to careful examination and sigmoidoscopy of these pouches as they tend to be forgotten by the physicians due to their hidden location.

The Penrose drain: a safe, atraumatic colostomy bridge

Because of the problems associated with the large, bulky bridges presently used for construction of loop ostomies, particularly complications of leaks and skin excoriation, we have studied the use of the Penrose drain as an alternative. This method has been time-tested on 45 patients and has been found to be safe, reliable, and inexpensive and has gained popularity among patients and ostomy nurses. The bulky colostomy bridge should no longer be accepted as a standard of care.

Hyperthermia for cancer: a practical perspective

A causal relationship between hyperpyrexia and tumor regression was first suggested in 1866, when Busch reported the cure of a histologically diagnosed sarcoma in a middle-aged woman, following a bout of erysipelas. Over the years, interest in the effect of heat on cancer has remained alive, but this interest has increased dramatically in recent years. The literature on this subject is broadly reviewed and the clinical results discussed. It is apparent from clinical studies thus far that it is a relatively simple undertaking to treat superficial neoplasms with hyperthermia. However, the major challenges in clinical thermotherapy pertain to patients with deeply situated tumors. The lack of safe and reliable methods of monitoring temperature in deep tissues is a major impediment to a thorough understanding of thermal dosimetry in clinical hyperthermia, and routine thermal dosimetry in clinical hyperthermia will have to await the development of reliable noninvasive thermometry. As responses have been reported with modest levels of hyperthermia, the need for thermometry is somewhat lessened, given that invasive monitoring is imperfect and somewhat risky when used in deeply seated tumours. The eventual place of thermotherapy in the treatment of malignant tumours in man is as yet unclear and must be rigourously and thoroughly assessed in well-designed, prospective, randomized patient trials.

Gluteus maximus myocutaneous flap for the treatment of recalcitrant pilonidal disease

The treatment of a patient for multiple recurrent pilonidal disease failed all forms of conventional therapy. After re-excision, a gluteus maximus myocutaneous flap, measuring 15 X 15 cm and based on the superior gluteal artery, was swung to cover the defect. Complete relief from severe pain was obtained immediately. No recurrence is noted after two and one-half years of follow-up.

The effects of syngeneic soluble tumor membrane extract on concomitant spleen cell immunity and spontaneous metastases

The effects of a soluble tumor KCl extract, containing membrane antigen on spontaneous metastases and spleen cell immunity were studied in a syngeneic C57BL/6J murine sarcoma model. The extract was shown to be antigenically distinct from normal tissue by tumor immunization rejection experiments. Tumor soluble extract (SE) was administered daily during the growth of a murine sarcoma. The afferent and efferent arc of immunity were monitored by proliferative index (PI) and in vitro cytotoxicity of spleen cells, as well as the incidence of metastases. PI was significantly activated in the group receiving sarcoma SE as compared to the two control groups receiving muscle SE or saline P less than 0.05. However, in vitro cytotoxicity was significantly depressed on Days 7 and 14 (P less than 0.05) of tumor growth in the mice receiving sarcoma SE. The incidence of metastases was significantly increased to 70% in the sarcoma SE group as compared to the incidence in the control groups of 50% P less than 0.05. This data supports the hypothesis that release of soluble antigen membrane components by growing tumor facilitates the growth of metastases in this model.

Extended myocutaneous flap to cover major pelvic and craniofacial defects

Experience with the extended myocutaneous flap, including distal randomly vascularized tissue, is seldom reported. This report details the use of five extended flaps--sternocleidomastoid, posterior trapezius, total rectus abdominis, tensor fascia lata and inferior gluteal. An average delay of 2 weeks was used to ensure viability. These flaps facilitated the resection of otherwise inoperable craniofacial and pelvic tumours by providing a safe primary closure. Such flaps are unique in their size and their particular application.

The closure of large pelvic defects by extended compound tensor fascia lata and inferior gluteal myocutaneous flaps

This report describes the use of myocutaneous flaps in two unique situations with extensive pelvic and perineal defects. In the first patient, bilateral tensor fascia lata myocutaneous flaps 10 x 40 cm were rotated posteriorly to cover a perineal defect measuring 15 x 30 cm. In the second patient, bilateral inferior gluteus maximus myocutaneous flaps 10 x 32 cm were rotated to fill a pelvic defect 10 x 15 x 8 cm that remained after a pelvic exenteration and sacral resection. Both flaps were delayed 2 weeks prior to surgery to insure 100% viability.

The total thigh and rectus abdominis myocutaneous flap for closure of extensive hemipelvectomy defects

Hemipelvectomy is a lifesaving procedure when used appropriately and yields a 35%, five-year survival in the cancer patient. However, the standard posterior flap for closure is not always available. Two flaps, the thigh flap and the rectus abdominis myocutaneous flap, are described in which any soft tissue defect resulting from hemipelvectomy can be safely closed primarily when the posterior flap is not available. The total rectus abdominis flap is previously undescribed and unique in its application. These techniques significantly contribute to the surgeon's armamentarium for decreasing morbidity and mortality and resectability of unusual pelvic and thigh tumors.

Intestinal fistula following pelvic exenterative surgery: predisposing causes and treatment

An interest fistula is a life-threatening complication when associated with the treatment of pelvic cancer. Such fistulae arise in 10% of patients treated by the combination of aggressive surgery and radiation therapy. Nineteen such occurrences developing in 245 patients who had pelvic exenterations are used to demonstrate the need for directing immediate attention toward correcting the physiologic and metabolic abnormalities created by the fistulae. Local control of the fistulae is facilitated by techniques for identifying its cause and precise location.

Osteosarcoma associated with Thorotrast administration: report of two cases and literature review

Two cases of osteosarcoma are described arising in patients who had undergone angiography with Thorotrast during childhood. In both patients, there was radiographic and pathologic evidence of radioactive thorium dioxide deposition in bone as well as throughout the reticuloendothelial system. Thorotrast deposits were demonstrated in the immediate vicinity of the primary tumors by both histology and autoradiography. Previous cases of osteosarcoma associated with Thorotrast administration from the literature are cited, and possible causal relationships are discussed between thorium retention in bone and neoplastic transformation by chronic radiation.