Dina Lev-Chelouche

Morgagni Hernia: Unique Presentations in Elderly Patients

We present case reports of 2 patients who were admitted to our ward for complications of Morgagni hernias. Both patients were elderly. Morgagni hernia is a rare condition. Its unique and late presentation are presented and discussed.

Is forequarter amputation justified for palliation of intractable cancer symptoms

Background: Limb-sparing surgery has replaced the radical surgical approach for treating limb sarcomas in most cases. Amputation has been advocated as a palliative procedure for symptomatic locally advanced disease that has already failed to respond to radiation therapy, chemotherapy and limited surgery. Methods: Twelve patients with advanced malignant tumors involving the shoulder girdle or the proximal humerus underwent forequarter amputation (FQA) for palliative purposes. The tumor-related local problems were severe pain, limb dysfunction, tumor fungation, bleeding (requiring emergency FQA in one case) and infection. The preoperative Karnofsky performance status (KPS) in our series ranged from 30 to 70%. Results: No perioperative mortality was observed. The morbidity was well tolerated by the patients. The KPS improved in most of the patients, and was assessed as 90–100% in 9 of the 12 patients. Overall, quality of life was reported to be at least moderately improved by 2 out of 3 patients. Survival was measured in months (3–24 months), but ultimately had no meaning since the procedure was palliative. Lung metastases were the dominant cause of death in our patients. Conclusions: The results of FQA in our series point to its feasibility and the gain in quality of life and performance status in severely ill patients with advanced malignancies. Local symptoms and signs were controlled, and quality of life was restored.

Limb desmoid tumors: A possible role for isolated limb perfusion with tumor necrosis factor-alpha and melphalan

BACKGROUND The management of extensive, recurrent limb desmoid tumors is extremely difficult. The failure of multimodality treatments, such as repeated resections, radiotherapy, systemic chemotherapy, or endocrine manipulations, can end up with multilating surgery or even amputation, similar problems sometimes encountered in soft tissue sarcoma of the limbs. The high rate of limb salvage achieved by isolated limb perfusion (ILP) with tumor necrosis factor (TNF) and melphalan for extensive, high-grade soft tissue sarcoma led us to implement this modality in difficult cases of limb desmoids. METHODS During a 4-year period, 6 patients aged 14 to 52 years were treated. All were significantly symptomatic and candidates for amputation or mutilating surgery. Five had lower and one had upper limb lesions. Two had multifocal disease. At ILP, 3 to 4 mg TNF and 1 to 1.5 mg/kg melphalan were delivered during a 90-minute period. One patient had a double perfusion. All patients underwent definitive resective operation 6 to 8 weeks after perfusion. RESULTS No systemic complications were observed, and local complications included reversible skin redness and blisters. Response rate was 83% with 33% (2 of 6) complete response and 50% (3 of 6) partial response. In 1 patient less than 50% regression was observed. Limb salvage rate was 100%; even the patient with stabilization of disease could be locally resected. Local recurrence during a follow-up period of 7 to 55 months (median 45 months) occurred in 2 patients at 8 and 24 months, respectively; the first underwent amputation, whereas for the second a wide excision was possible. CONCLUSIONS ILP with TNF and melphalan can be used as a limb preservation modality in patients with recurrent desmoids and significant symptoms who would otherwise require multilating surgery to control their neoplasm.

Hyperthermic isolated limb perfusion with tumor necrosis factor-α and melphalan in advanced soft-tissue sarcomas: Histopathological considerations

Background: Hyperthermic isolated limb perfusion with tumor necrosis factor-α and melphalan was used as induction treatment in locally advanced extremity soft-tissue sarcomas for limb sparing surgery. The typical histopathological changes that occur in these tumoral masses are described in a series of 30 patients.Methods: Fresh tumor specimens of 27 high grade extensive soft-tissue sarcomas and 3 recurrent desmoid tumors of the extremities were collected 6 to 8 weeks after hyperthermic isolated limb perfusion with tumor necrosis factor-α plus melphalan. The specimens were studied for surgical margins, extent and type of tumor necrosis, lymph node involvement, perineural and vascular invasion, and the effects on adjacent normal tissues such as nerves, muscles, and blood vessels.Results: The typical histological changes were central cystic hemorrhagic necrosis with pericystic extensive fibrosis. Some nonspecific changes were noted in the soft tissues around the mass. In eight cases, more than 90% necrosis was found. In 17 cases, the extent of necrosis ranged between 60% and 90% (80%–90% in 4 of 17 cases). In five cases, less than 60% necrosis was noted. The best responses (.90% necrosis) were observed in distally located tumors. The responsive types were malignant fibrous histiocytoma, followed by myxoid liposarcoma and synovial sarcoma. Desmoid tumors showed less necrosis than high grade sarcomas. Vascular invasion was observed in two cases and intralesional venous thrombosis in one case. No perineural invasion or lymph nodes involvement were observed. The soft tissues adjacent to the tumor bed did not show major morphological changes. No correlation was found between the histological changes and each of the following: the anatomical (upper vs. lower limb) or compartmental location of the tumor; whether the tumor was primary or recurrent; and the types of previous treatment (systemic chemotherapy or radiotherapy) and tumor size.Conclusions: This is the first serial histological description of the effects of tumor necrosis factor-α and melphalan administered via hyperthermic isolated limb perfusion on the tumoral masses of limb soft-tissue sarcomas. The small number of specimens and, especially, the variability of tumors preclude definite conclusions. Larger numbers and more homogeneity are needed in future studies.

Isolated Limb Perfusion in the Treatment of Advanced Soft-tissue Sarcomas

The idea was to apply the newly invented technique of cardiopulmonarybypass to regional chemotherapy. ILP entailed exposing the major blood vessels to an extremity, isolating ittemporarily and perfusing the extremity via a heart–lung machine with very high doses of chemotherapeutic drugs(Figure 4.1) . The authors believed it would be possible to obtain high tissue concentrations of the drug with minimalsystemic exposure and hence few complications. Following the observation that heat has its own antineoplasticproperties, Stehlin

Isolated Limb Perfusion for Malignant Melanoma and Soft Tissue Sarcoma

In 1958, Creech et al. (1) introduced a novel method of drug delivery in advanced cancer, and named it isolated limb perfusion (ILP). The idea was to use the newly invented technique of cardiopulmonary bypass, which at that time had paved the way for open-heart surgery, in regional chemotherapy. They described a surgical method of exposing the major blood vessels of an extremity, providing its temporary isolation, and permitting perfusion of that extremity via the heart-lung machine, utilizing high doses of chemotherapeutic drugs. It would be possible to obtain high tissue concentrations of the drug with minimal systemic exposure and complications. Following the observation that heat on its own has antineoplastic properties (2), in 1969, Stehlin (3) modified the technique to include hyperthermia. Since then, ILP with melphalan, more than any other drug, has been widely recognized as the standard treatment strategy for advanced extremity melanoma.