John T. Preskitt

Cryosurgical ablation of hepatic tumors

BACKGROUND Cryosurgical ablation of hepatic tumors relies on nonspecific tissue necrosis due to freezing as well as microvascular thrombosis. Patients with selected primary and metastatic hepatic malignancies who are not candidates for surgical resection are afforded potentially curative benefit using this technique. METHODS Forty patients underwent cryosurgery for hepatic malignancy related to colorectal metastasis (n = 27), hepatocellular carcinoma (n = 8), metastatic breast (n = 2), metastatic neuroendocrine (n = 2), and metastatic ovarian carcinoma (n = 1). Intraoperative ultrasound (IOUS) was used in all patients to help locate the tumor and guide the cryosurgical trocar to the lesions. RESULTS Indications for cryosurgical ablation included bilobar and centrally located disease, poor medical risk, insufficient hepatic reserve, and involved margin after wedge resection. Major complications included hepatic parenchyma cracking requiring transfusion in 5 patients, 1 postoperative biliary stenosis, and 1 inferior vena cava injury. There were 3 postoperative deaths from non-hepatic-related events. Based on Kaplan-Meier analysis the estimated overall survival for patients with hepatocellular carcinoma (60% at 18 months) was compared with patients with colorectal metastases (30% at 18 months). Nine patients (23%) are currently free of disease with an average follow-up of 17.7 months. The pattern of failure was identified at the site of cryosurgical ablation in 2 of 88 lesions. CONCLUSIONS Cryosurgical ablation of selected hepatic malignancies is a safe and viable treatment for patients not amenable to surgical resection.

Sentinel lymph node biopsy for melanoma

BACKGROUND The most powerful predictor of survival for patients with melanoma is the status of the regional lymph nodes. Sentinel lymph node biopsy may provide improved staging accuracy without the morbidity of elective lymph node dissection (ELND). METHODS Sixty-eight patients with intermediate thickness melanoma underwent gamma probe guided sentinel node biopsy without ELND and were followed up over a mean of 22 months. RESULTS A sentinel node was found in all patients. Six patients (9%) had positive sentinel nodes; all underwent complete lymphadenectomy. Two patients (3%) with negative sentinel nodes developed nodal recurrence; 1 of these patients was found to have microscopic disease on reexamination of the sentinel node. Two patients (3%) developed systemic disease. CONCLUSION Gamma probe guided sentinel node biopsy can be performed with a high rate of technical success. It provides accurate pathological staging with a low incidence of nodal basin failure.

Surgical management of thyroid cancer invading the airway.

AbstractBackground: Locally advanced thyroid cancer invading the tracheal cartilage represents a difficult treatment dilemma during thyroidectomy. Methods: A retrospective chart review was performed to determine the results of laryngotracheal resection or tracheal cartilage shave with adjuvant radiotherapy in patients with locally advanced thyroid cancer invading the upper airway. Results: Of 597 patients undergoing thyroidectomy for thyroid cancer, 40 were found to have laryngotracheal invasion. Thirty-five patients with superficial invasion underwent cartilage shave procedures with adjuvant radiotherapy; five with full-thickness invasion underwent radical resection, including tracheal sleeve resection (n=3) or total laryngectomy (n=2). Histologic subtypes included papillary (n=32), follicular (n=2), Hurthle cell (n=1), medullary (n=3), and anaplastic (n=2). Of the cartilage shave group, 25 are currently alive with no evidence of disease at a mean follow-up of 81 months (range 1–290). Six developed isolated local/regional recurrence and were managed with total laryngectomy (n=1), tracheal resection (n=1), cervical lymphadenectomy (n=1), or repeat radiotherapy (n=3). All six patients remain free of disease at a mean follow-up of 5 years. Of those who underwent initial laryngotracheal resection, four remain free of disease at a mean follow-up of 5 years. The rates of 10-year disease-free survival and overall survival for all patients were 47.9% (95% confidence interval [CI] 24.8, 71.0) and 83.9% (95% CI 70.3, 97.5), respectively. Conclusions: These data suggest that adequate management of thyroid cancer with laryngotracheal invasion can be achieved with a more conservative surgical approach and adjuvant radiotherapy, reserving more radical resections for extensive primary lesions or locally recurrent disease.

Surgical morbidity, mortality, and long-term survival in patients with peripancreatic cancer following pancreaticoduodenectomy

BACKGROUND Surgical resection of the primary tumor in peripancreatic cancer has been associated with an improved survival and decreased morbidity in the recent literature. The purpose of this review was to analyze the results at a single institution. METHODS Between 1985 and 1995, 88 patients underwent a pancreaticoduodenectomy for adenocarcinoma of the pancreatic head region and had complete long-term follow-up. Patient records were reviewed to determine morbidity, mortality, and survival. RESULTS Tumor histology included pancreatic head adenocarcinoma (n = 46), ampullary adenocarcinoma (n = 28), duodenal adenocarcinoma (n = 8), and cholangiocarcinoma (n = 6). Morbidity occurred in 26 patients (29%). Perioperative mortality was seen in 6 patients (7%). No perioperative mortality was seen over the last 3 years, which included 33 patients. The mean follow-up was 29 months, with a median survival of 19 months. At last follow-up, 24 patients were alive without disease with an average survival of 43 months (1 to 141). There were 54 patients who died with cancer with an average survival of 21 months (1 to 117). Based on Kaplan and Meier statistical analysis the estimated survival was 47% at 2 years and 25% at 5 years. The location of the primary tumor (P = 0.0006) and the presence of positive lymph nodes (P = 0.05) was shown to have a negative impact on survival. CONCLUSION Pancreaticoduodenectomy can be done with acceptable morbidity and mortality. The outlook with this disease remains poor, but long-term survival can be achieved in some patients.

Comparison of quick parathyroid assay for uniglandular and multiglandular parathyroid disease

BACKGROUND The quick intraoperative parathyroid assay (qPTH) has been proposed as an effective tool in the surgical management of hyperparathyroidism. This assay may facilitate directed, unilateral exploration for uniglandular disease; however, its role in the management of multiglandular disease remains unclear. The purpose of this study is to evaluate the use of qPTH in parathyroid surgery, and to compare the results for uniglandular and multiglandular disease. METHODS A prospective analysis of 63 consecutive patients explored for hyperparathyroidism using the qPTH assay was performed. Preoperative localization studies including ultrasonography and sestamibi scan were routinely obtained. Blood samples for qPTH were routinely drawn prior to the surgical incision, prior to gland excision, as well as 5 and 10 minutes after gland excision. Patients with primary or secondary hyperplasia had blood samples drawn relative to a 3-1/2 gland resection. Additional samples were drawn as needed for patients with a double adenoma. A qPTH decline of greater than or equal to 50% of the highest preincision or gland preexcision level was considered successful. Unilateral neck exploration was routinely performed unless multiglandular disease was identified. Patients were followed up postoperatively with serum calcium levels and an 8-month median follow-up was recorded. RESULTS Forty-nine of 63 (78%) patients were found to have a solitary parathyroid adenoma. The qPTH assay was successful in 48 (97%) patients with uniglandular disease. Forty-four of these 48 patients showed an appropriate assay decline 5 minutes after adenoma excision. One patient with a single adenoma showed a delayed 50% decline in qPTH at 20 minutes. Fourteen (22%) patients were found to have multiglandular disease: 6 patients with primary hyperplasia, 4 patients with hyperplasia secondary to renal failure, and 4 patients with double adenomas. All patients with multiglandular disease demonstrated a successful decrease in qPTH levels. All patients with hyperplasia secondary to renal failure showed a successful assay decline 5 minutes after 3-1/2 gland resection. Eight of 14 (57%) patients with multiglandular disease (4 double adenomas, and 4 hyperplasia) were suspected to have solitary adenomas preoperatively. Overall, 62 of 63 (98%) patients showed an appropriate assay decline within 10 minutes after gland excision. Postoperatively, all patients were normocalcemic with a median follow-up of 8 months. CONCLUSIONS These data suggest that qPTH can accurately facilitate unilateral, directed neck exploration for uniglandular parathyroid disease, as well as guide the extent of gland resection for multiglandular disease. This assay reliably eliminates the most common cause of parathyroidectomy failure, which is unrecognized multiglandular disease. The qPTH assay can reliably be used with similar accuracy for patients with multiglandular disease as has been shown for uniglandular parathyroid disease.

Surgical management of esophageal carcinoma

Adenocarcinoma, typically in the distal third of the esopha- gus, and squamous cell carcinoma, typically in the proximal two thirds of the esophagus, each make up 49% of cases of esophageal cancer. The remaining cancers in this area include sarcoma (1%), lymphoma (0.5%), cylindroma (0.25%), and primary melanoma (0.25%) (1). The incidence of adenocarcinoma is clearly increas- ing; it will soon become the most prevalent type of cancer of the esophagus. No malignant tumor in the past 25 years has increased in incidence as much as adenocarcinoma of the esophagus. The primary risk of adenocarcinoma is related to the duration and se- verity of gastric-esophageal reflux and the progression of mucosal changes from Barretts esophagus to dysplasia to adenocarcinoma. Early detection is the most important factor in determining sur- vival. Most patients present with stage IIB to stage IV disease, and most disease occurs at the gastroesophageal junction. Among patients with Barretts esophagus, the risk of devel- oping adenocarcinoma is 0.2% to 2.1% each year; 77% of patients with adenocarcinoma have had Barretts esophagus. Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma, since it could miss adenocarcinoma lo- cated somewhere else in that region. Forty percent of patients with Barretts esophagus and dysplasia have invasive carcinoma in the resected specimen. The incidence of squamous cell carcinoma, which used to be the major cause of esophageal cancer, has significantly decreased. The decrease may be related to reductions in risk factors, which include smoking, excessive alcohol use, caustic lye injury or ther- mal injury, diet, obesity, achalasia, and tylosis. Typical symptoms of esophageal cancer include difficulty swallowing, with a feeling of fullness, pressure, burning, or cough- ing; a feeling of both liquids and solids becoming stuck behind the sternum; indigestion; emesis; and weight loss. Many patients attribute their symptoms to heartburn and do not seek the medi- cal care they need.

Synergy between preactivated photofrin-II and tamoxifen in killing retrofibroma, pseudomyxoma and breast cancer cells

Exposure of photoactive compounds to light prior to their use in biological systems (preactivation) results in the generation of tumour cell specific metastable cytotoxic species that are no longer dependent on the light energy. Thus, preactivation renders the photoactive compounds suitable for systemic use. We have examined the in vitro effect of preactivated photofrin-II and tamoxifen in retroperitoneal fibroma, pseudomyxoma and male breast carcinoma cell lines. These cells were found to be non-responsive to tamoxifen and were negative for oestrogen receptors. Incubation of these cells with 0.5 microgram/ml preactivated photofrin-II and tamoxifen (less than 10(-6) mol/l) resulted in a significantly enhanced (P less than 0.001) inhibition of DNA synthesis compared with either agent alone. This synergistic effect between tamoxifen and preactivated photofrin-II was determined by multiple drug effect analysis. Treatment of cells with preactivated photofrin-II did not cause the increased expression of oestrogen receptors. These observations suggest that a combination of antihormonal drugs with preactivated compounds may be of clinical value.

Sports hernia: the experience of Baylor University Medical Center at Dallas.

Groin injuries in high-performance athletes are common, occurring in 5% to 28% of athletes. Athletic pubalgia syndrome, or so-called sports hernia, is one such injury that can be debilitating and sport ending in some athletes. It is a clinical diagnosis of chronic, painful musculotendinous injury to the medial inguinal floor occurring with athletic activity. Over the past 12 years, we have operated on >100 patients with this injury at Baylor University Medical Center at Dallas. These patients have included professional athletes, collegiate athletes, competitive recreational athletes, and the occasional “weekend warrior.” The repair used is an open technique using a lightweight polypropylene mesh. Patient selection is important, as is collaboration with other experienced and engaged sports health care professionals, including team trainers, physical therapists, team physicians, and sports medicine and orthopedic surgeons. Of the athletes who underwent surgery, 98% have returned to competition. After a minimum of 6 weeks for recovery and rehabilitation, they have usually returned to competition within 3 months.

Biochemical prognostic indicators for pancreatic neuroendocrine tumors and small bowel neuroendocrine tumors

Pancreatic neuroendocrine tumors (PNETs) and small bowel neuroendocrine tumors (SBNETs) are rare tumors that are frequently diagnosed late in the course of the disease. Several biomarkers have been proposed in the literature as prognostic factors for patients with these tumors. This article discusses a recent publication in Annals of Surgical Oncology from the University of Iowa analyzing the effect of different biomarkers on survival in patients with PNETs and SBNETs.

Surgical treatment of hyperparathyroidism using the quick parathyroid assay

The quick intraoperative parathyroid assay (qPTH) has been proposed as an effective tool in the surgical management of hyperparathyroidism. By measuring intact parathyroid hormone intraoperatively, the qPTH assay may facilitate directed exploration for solitary adenomas and may help guide the extent of resection in hyperplasia. In this study, results of the qPTH assay were analyzed prospectively in 63 consecutive patients who underwent exploration for hyperparathyroidism. Blood samples were drawn prior to surgical incision, prior to gland excision, and 5 and 10 minutes after gland excision. A decline ≥50% of the highest preincision or preexcision level within 10 minutes of resection was considered successful. Forty-nine patients (78%) had a solitary parathyroid adenoma. The qPTH assay was successful in 48 (98%) of these patients. One patient showed a delayed decline at 20 minutes. Fourteen patients (22%) had multiglandular disease: 6 with primary hyperplasia, 4 with hyperplasia secondary to renal failure, and 4 with double adenomas. The assay was successful in all of these patients. It detected multiglandular disease in 8 of 14 patients thought preoperatively to have solitary adenoma. Overall, the qPTH assay was successful in 62 of 63 patients (98%). All patients were normocalcemic after a median follow-up interval of 8 months. These data suggest that the qPTH assay can accurately facilitate directed neck exploration for solitary adenomas, guide the extent of resection for hyperplasia, and identify unknown multiglandular disease. It appears to eliminate the most common cause of parathyroidectomy failure, thereby improving surgical success rates while potentially decreasing morbidity, cost, and operative time.