J. E. M. Young

Intermittent chemotherapy in patients with metastatic androgen-independent prostate cancer: results from ASCENT, a double-blinded, randomized comparison of high-dose calcitriol plus docetaxel with placebo plus docetaxel.

Survival in patients with metastatic, chemotherapy‐naive, androgen‐independent prostate cancer (AIPC) is improved with 10 to 12 cycles of docetaxel‐containing chemotherapy but further management is undefined. In the current study, the authors examined retreatment with the same regimen after a treatment holiday.

A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease

BACKGROUND Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done. METHODS Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected. RESULTS A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 +/- 27.3 mg in the thoracoscopy group and 52.5 +/- 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 +/- 30 minutes, thoracotomy 37 +/- 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 +/- 28 hours, thoracotomy 31 +/- 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 +/- 82 hours, thoracotomy 69 +/- 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients. CONCLUSIONS There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.

Surgical patterns of venous drainage of the free forearm flap in head and neck reconstruction.

A retrospective review of 40 consecutive free forearm flaps used in head and neck reconstruction in our Head and Neck Service identified five different patterns of venous drainage. In type 1, the cephalic vein and two venae comitantes join into a larger median cubital vein, which itself splits into two sizable branches (n = 8, two anastomoses). In type 2, a median cubital vein drains both the cephalic vein and the two venae comitantes (n = 17, single anastomosis). In type 3, the cephalic vein and the confluence of two venae comitantes are drained separately (n = 1, two anastomoses). In type 4, the cephalic vein and each of two venae comitantes are anastomosed separately (n = 2, three separate anastomoses). In type 5, the cephalic vein and the larger of the two venae comitantes are drained separately (n = 6, two anastomoses). Understanding these possible venous drainage patterns substantially expedites the raising of the free forearm flap. The selection of patterns 1 and 2, when possible, with the large-caliber veins ensures the safety of the flap. Long vascular pedicles permit anastomoses to contralateral neck recipient vessels, obviating vein grafts, and permit safe full head and neck mobility. (Plast. Reconstr. Surg. 93: 54, 1994.)

The superficial ulnar artery trap and the free forearm flap

A superficial ulnar artery identified during the elevation of a free forearm flap is reported. This is the second case appearing in the English literature. The free forearm flap is increasingly popular among plastic surgeons, and it is therefore imperative that this anomaly be well recognized because inadvertent injury of this anomalous artery may devascularize the hand. In cadaver dissections, the incidence of this anomaly has been reported to be 3.1%. This variation is probably encountered in clinical practice more commonly, but it is not recognized. Identification of this anomalous artery is facilitated by elevating but not exsanguinating the forearm prior to harvesting the flap.

The free vascularized anterior rib graft.

The free vascularized anterior rib graft, one of the earliest free osseous transfers to the head and neck,has not gained widespread acceptance, perhaps due to early reservations concerning the adequacy of the periosteal circulation. The authors present further laboratory evidence, with clincal cases, attesting to the adequacy of the periosteal circulation alone. Our surgical technique varies from other reports in that a substantially greater length of the internal mammary vessels is harvested and includes the dual periosteal supply by means of the supracostal and intercostal vessels, both branches of the internal mammary vessels. This modification is based on anatomic and angiographic findings. The incorporation of both branches enhances the margin of safety in raising this free bone graft.

Pleural effusion in breast cancer. Thoracoscopy for hormone receptor determination

Metastatic breast cancer frequently presents as a malignant pleural effusion. Knowledge of the estrogen and progesterone receptor status of the tumor predicts response to hormonal therapy, but breast cancer tissue in the pleural space is not readily accessible for hormone receptor determination. Thoracoscopy was used in six breast cancer patients with pleural effusions; all but one had concurrent sites of metastases. In five of six women recurrent breast cancer in the pleural cavity was diagnosed by thoracoscopy, and in four sufficient tissue was obtained for receptor assay. All patients achieved excellent control of their pleural effusions through a combination of local sclerotic measures and systemic therapy. Thoracoscopy is a safe procedure that can be performed under local anesthesia and is useful to visualize the pleural space, not only for diagnosis but also for obtaining breast cancer tissue for hormone receptor determination.

Fever of Unknown Origin in a Migrant Farm Worker from Mexico: History, Her Story and His Story

A 29-year-old migrant farm worker from Mexico presented to a hospital in Ontario with fever of unknown origin. She had arrived in Canada six weeks previously to work at an orchard. Her past medical history included two caesarean sections, postpartum hemorrhage requiring transfusion, and cholecystectomy. She was not on any medications. She began experiencing daily rigors one week after her arrival, often accompanied by drenching sweats, and she lost approximately 5 kg of weight. She had intermittent midthoracic back pain, but no other localizing symptoms. Painful vaginal sores and dysuria developed one week later. She presented to the emergency room, where she was diagnosed with genital herpes simplex and secondary bacterial infection. She was prescribed a one-week course of cephalexin and one dose of azithromycin, but she continued to have rigors. One week later, she developed intermittent epigastric pain with no nausea, vomiting or diarrhea. She returned to the emergency room with a fever of 39.5°C, and was admitted for presumed pelvic inflammatory disease. She was treated with various broad-spectrum antibiotics and acyclovir but remained persistently febrile. All cultures were negative and her pelvic ultrasound was unremarkable. She was transferred to a tertiary care hospital one week later for consultation with an infectious disease specialist. Further questioning revealed that she was from a city in Mexico where she lived in close proximity to chickens. She denied having recent insect bites, sick contacts, intravenous drug use and tattoos. She had two previous male sexual contacts, including her husband, who she said had died at 27 years of age from lung cancer. On examination, she was hemodynamically stable and slightly tachypneic, with a temperature of 38.4°C and an oxygen saturation of 96% on room air. Her head and neck examinations revealed two small umbilicated papules on the right upper eyelid and white lesions on the tongue and buccal mucosa. There was no lymphadenopathy. Her cardiovascular, respiratory, abdominal and neurological examinations were unremarkable. Blood tests on admission were significant for the following: hemoglobin of 90 g/L with a mean corpuscular volume of 75.8 fL, white blood cell count of 3.1×109/L (2.9×109/L neutrophils and 0.2×109/L lymphocytes), aspartate amino-transferase level of 132 U/L, alanine aminotransferase level of 28 U/L, alkaline phosphatase level of 386 U/L, bilirubin level of 6 μmol/L and lactate dehydrogenase level of 1283 U/L. Her chest x-ray showed a diffuse reticulonodular pattern. Diagnostic tests were performed.