L. E. Hughes

Clinical classification of perianal Crohn's disease

Assessment of the efficacy of therapeutic approaches to anal lesions of Crohns disease is frustrated by the lack of precise definition of its various manifestations. A classification that is clinical and based on anatomic and pathologic aspects is presented; it has been derived from a 20-year prospective study of anal Crohns disease in Cardiff. Conceptually, the classification is analogous to the TNM system for cancer. The main classification (U.F.S.) defines the presence of Ulceration, Fistula/abscess, and Stricture, qualified by numeric values reflecting severity (0=not present, 1=limited clinical impact, and 2 =severe). A subsidiary classification (A.P.D.) defines Associated conditions, Proximal intestinal involvement, and Disease activity. In addition, the classification may be used in a detailed form for research or comparative purposes or in a simple form defining only the dominant lesions for routine clinical use. General use of the classification would make it possible to compare in detail incidence, management, and results of treatment in different centers.

Neovascularization in human cutaneous melanoma: A quantitative morphological and Doppler ultrasound study

A study of tumour blood flow in 36 patients with 38 malignant melanomas using Doppler Ultrasound flowmetry has shown that tumour blood flow can be detected in most melanomas more than 0.9 mm thick, and is absent in most melanomas less than this thickness. Histological quantitation of blood vessels using lectin staining to delineate vascular endothelium and automated image analysis has shown a high degree of correlation between vascularity at the tumour base and tumour thickness. Since it is likely that the development of a vascular plexus at the tumour base is a prerequisite for dissemination, the development of these blood vessels may prove to be an independent prognostic factor for thin melanomas. This work also provides a new model for dynamic, in vivo investigation of the vascularity of human tumours.

Complications of latissimus dorsi myocutaneous flap breast reconstruction

AIMSnTo review the experience of a single unit in post-mastectomy reconstruction using the latissimus dorsi flap.nnnMETHODSnA retrospective review of 111 cases treated between 1984 and 1993. The notes were evaluated for type of procedure, associated treatment and complications.nnnRESULTSnA significant morbidity of this procedure was demonstrated with 41 (37%) patients requiring a second operation during the period of the study. The majority of these second operations were related to the prosthesis used to achieve symmetry. Second operations were more common in those who had saline-filled prostheses. Other complications seen included wound infection, small areas of flap necrosis, hypertrophic scars and problems with the donor scar. No differences in complication rates were demonstrated for delayed vs immediate procedures or for patients receiving or not receiving radiotherapy. No life-threatening complication were seen during the study.nnnCONCLUSIONSnThe latissimus dorsi reconstruction is reliable but the overall programme is beset with considerable morbidity. This factor needs to be taken into consideration when discussing reconstructive options with the post-mastectomy patient.

Parastomal pyoderma gangrenosum in inflammatory bowel disease

PURPOSE: Parastomal pyoderma gangrenosum is uncommon and its association with inflammatory bowel disease is unclear. This is a review of five patients with parastomal pyoderma gangrenosum. METHODS: A retrospective review of five patients with ulcerative colitis (two patients) or Crohns disease (three patients) who have been seen in one surgical unit was conducted. RESULTS: All patients were females and each presented within nine months of abdominal surgery and stoma construction. All had active proctitis (n=3) or perianal Crohns disease (n=2). Both patients with perianal Crohns disease had a mild clinical course with healing of parastomal pyoderma gangrenosum when treated with steroids with and without low-dose cyclosporin A. They both had curettage of the perineal wound as well. In the remaining three patients with active proctitis, the parastomal lesions failed to resolve despite high-dose systemic steroids. By contrast, the parastomal pyoderma gangrenosum healed promptly in two of these patients following proctectomy for active proctitis. CONCLUSION: The variable clinical outcome of parastomal pyoderma gangrenosum may be related to the activity of the underlying inflammatory bowel disease or possibly to low-grade perineal sepsis.

Abdominoperineal resection for severe perianal Crohn's disease

Despite the high incidence of involvement of the perianal region in Crohns disease, excisional surgery seldom is required for perianal disease alone. Nine patients are presented who had severe perianal Crohns disease, which eventually required abdominoperineal excision of the anorectum. In all nine patients, it was secondary manifestations of anal Crohns disease that precipitated proctectomy, such as high fistulas, strictures, and rectovaginal fistulas. These secondary phenomena, especially fistulas caused by cavitating ulceration, become self-perpetuating by the mechanical effect of feces being forced into the tract. During the same period, 17 patients required rectal excision by abdominoperineal resection, where perianal disease was incidental to severe colorectal disease. There is a tendency for excessive delay before advising surgery for severe perianal disease. An attempt should be made to identify patients with a poor prognosis to avoid unnecessarily prolonged morbidity. Assessment of the exact nature of the anal lesion and assessment of Crohns disease activity are important in making this decision.

Local depot methylprednisolone injection for painful anal Crohn's disease

Treatment, by local depot methylprednisolone injection, of severe anal pain in Crohns disease not associated with overt sepsis is reported. It has given dramatic relief in 5 patients, but has not been successful in 2 patients where anal disease was in continuity with severe rectal involvement. Treatment has been effective for greater than 1 yr, and no complication of the technique has been found on regular follow-up. When compared with previous attempts at treatment, the beneficial results attained with methylprednisolone injection suggest that the effect is more than a placebo response. Careful patient selection to exclude overt sepsis or severe rectal disease is recommended before proceeding to steroid injection.

A randomized controlled trial of prophylactic isolated cytotoxic perfusion for poor-prognosis primary melanoma of the lower limb

A randomized controlled trial of prophylactic isolated hyperthermic limb perfusion (IHLP) using melphalan at 2 mg/kg body weight has been performed on a total of 30 patients with primary melanoma of the lower limb > or = 1.7 mm thick. Excision (control, n = 14) was compared to excision plus IHLP (n = 16). The two groups were well matched for sex, tumour thickness and duration of follow-up (control group median: 63 months (range: 16-108), perfusion group median: 80 months (range: 37-113)). Recurrent disease developed in nine of the control group, seven of whom have died. In the perfusion group only two patients have developed recurrent disease, both of whom have died (recurrence: P < 0.004, mortality: P < 0.03, using Fishers exact probability test). Inguino-femoral nodal recurrence occurred in five of nine control patients, but in only one patient in the perfusion group. These data support the use of adjuvant IHLP in the management of poor-prognosis primary melanoma of the lower limb.

Long-term follow-up of general immune competence in breast cancer

SummaryPre-treatment and sequential post-treatment (at 3 months, 6 months, 1, 2, 3, 4 and 5 years) examination of general immune competence was performed in 185 consecutive breast cancer patients. The patients were followed for 5 to 11 years to monitor the dynamic relationship between host immunity and cancer and to examine the effect of the treatment method. The tests of immune competence used were immunoglobulins IgG, IgA, IgM, leucocyte counts, percentage and total lymphocyte counts and Mantoux and DNCB skin hypersensitivity tests.Serum IgG and IgA showed no change relating to treatment method in recurrence-free patients; but IgG levels were higher when recurrent disease was imminent or established; IgM diminished (P<0.001) after treatment and this continued at 5 years in all patient groups. Simple lymphocyte counts showed the most interesting changes. They remained depressed for as long as 60 months following radiotherapy (P<0.01). After treatment by surgery, lymphocyte counts rose in patients without recurrence, but fell when systemic recurrence was imminent or established. This effect was not seen in patients with local recurrence only. There was no change in immune competence immediately before recurrence sufficient to be of clinical usefulness, but a low pre-treatment lymphocyte count with a steady rise after surgery carried a good prognosis. Similarly a high initial lymphocyte count with a fall after surgery was indicative of recurrence. Universal and prolonged depression of lymphocyte counts following radiotherapy was confirmed, and the effect was additive to that of tumour load in recurrent disease.Because of the large number of statistical calculations carried out, some of the apparently significant findings may be due to chance. However, the general trends emerging suggest that similar long-term studies, using the more sophisticated measures of lymphocyte function now available, might be rewarding.

Implantation of a benign rectal villous adenoma in the surgical track after transsphincteric excision: Report of a case

A 56-year-old male patient underwent excision of a rectal villous adenoma by a transsphincteric approach. Six years after surgery, an extrarectal mucinous mass was noted, which, on biopsy, had histologie features of implantation of benign villous adenoma within the operative scar. For medical reasons, surgery was avoided and the lesion enlarged until symptoms necessitated rectal excision five years later. Histologic examination of the resected mucinous tumor supported an origin from implanted adenomatous epithelium. This is apparently the first description of implantation of an adenoma in the surgical track. Care should be taken during transsphincteric and transsacral excision of rectal adenomas to prevent implantation at the time of surgery.

Long-term (5–11 years) follow-up of general immune competence in breast cancer

SummaryGeneral immune competence was measured before treatment in 185 breast cancer patients. They were then followed for 5 to 11 years to determine its relationship to recurrence and its clinical value in predicting prognosis. The tests of immune competence used were immunoglobulins IgG, IgA, IgM, leucocyte counts, percentage and total lymphocyte counts and Mantoux and DNCB skin hypersensitivity tests.None of these tests was strongly predictive of recurrence on an individual basis, a finding similar to our results at 2 years. The longer period of follow-up now reported has provided no findings of unequivocal statistical significance, but suggests a biphasic host response to early tumours. The patients who developed recurrence within 5–11 years due to micrometastasis had higher lymphocyte counts in their preoperative assessment than patients who remained recurrence free. This suggests that small tumour volumes do not stimulate immunity and that large volumes depress it; tumours in between these groups are associated with higher levels. Examination of studies by a number of authors reveal parallel findings which have not been previously noted. It is not possible to confirm the significance of these findings from this study because of the heterogeneity of human breast cancer. However, if they indicate a general principle of a dynamic host-tumour interplay they have important implications for assessing immune competence at any single point of time and for the theory that cancer may arise during an anergic state. We hope that these findings will stimulate other workers to examine host-tumour interaction from this point of view.