Prostate cancer: 4. Screening

OBJECTIVES: To evaluate the association between tamoxifen (TAM) treatment and rate of bone fractures in older, nursing home residents. PARTICIPANTS: A total of 93,031 women, aged 65 years and older, whose data were part of the 1993 New York State MDS and for whom there was documentation of treatment with at least one medication. SETTING: New York State long-term care facilities. DESIGN: Cross-sectional study via secondary analysis of 1385 matched sets of residents. Each set included one resident who was receiving TAM treatment and up to four residents who were not. MEASUREMENTS: Measurements included age, ethnicity, TAM treatment, hormone replacement therapy, vision impairment, any bone fractures, and, specifically, hip fractures. RESULTS: During the 1.5-year period for which bone fractures are documented in the 1993 MDS, the fracture rates were: 7.62% in women not treated with TAM, 3.20% in women receiving 10 mg TAM daily, and 6.73% in women receiving 20 mg TAM daily. The odds ratio (OR) for bone fractures among women receiving 20 mg TAM daily compared with nontreated women was 0.916 (95% confidence interval (CI): 0.720-1.164; P = .472), and was 0.312 (95% CI: 0.112-0.865; P = .025) for those receiving 10 mg daily. The rates of hip fracture were 4.98%, 2.40%, and 4.57% for controls and women receiving 10 mg and 20 mg TAM daily, respectively. Whereas the hip fracture rate for women receiving 20 mg daily was statistically similar to that of the controls (OR = .963; 95% CI: 0.718-1.291; P = .800), the difference between the controls and those receiving 10 mg daily approached significance (OR: 0.313; 95% CI: 0.096-1.018; P = .054). CONCLUSION: Although standard treatment of 20 mg TAM daily offers no apparent protection against bone fracture in older nursing home residents, a daily 10 mg dose seems to be protective.     

Surgical treatment of Basedow''s disease: total thyroidectomy

The Authors report their experience in the treatment of Graves disease. After a short review of the literature, the Authors stress the medical trait of such disease with possible spontaneous resolution. Therefore the number of cases surgically treated is necessarily low. Thirty patients, all with specific antibodies, were treated with total thyroidectomy. The therapy chosen and the results obtained are herein shown. No definitive hypoparathyroidism and inferior laryngeal nerve injuries were registered.     

Surgical treatment of Crohn's disease

Of 93 children with Crohn's disease treated at the H?pital Sainte-Justine between 1967 and 1979, 39 were operated on. Ten had abscesses and anal fistulas drained and in 29 the bowel was resected. The mean age of the children was 13 years. The average time between onset and diagnosis for both the medical and surgical groups was 13 months. Medical treatment failed in 25 patients after an average time of 22 +/- 17 months. Fourteen patients had an initial laparotomy, with a false diagnosis of appendicitis in 8, abdominal tumour in 2 and Meckel's diverticulum in 1. Indications for operation were: intestinal obstruction, bowel fistula, intra-abdominal abscess, gastrointestinal hemorrhage, growth failure and toxic megacolon. There were no deaths and only two postoperative infections. Crohn's disease seems to be becoming more frequent, more severe and starting earlier in life. Three to 6 weeks of preoperative preparation with enteral and parenteral nutrition allows operation to be performed under safer conditions. Although the recurrence rate after operation is still high, there is no doubt that the children enjoy a better quality of life, growth and a 50% chance of being disease-free 10 years later.     

Surgical treatment of Peyronie's disease: a new approach

We treated 12 patients with intractable Peyronie's disease with a new approach based on simple incision of the fibrotic plaque(s) and stenting of the corpora with penile implants. Infection in 1 case necessitated removal of the prostheses, while the remaining 11 patients had satisfactory functional and anatomical results. The procedure is indicated for patients with 1) Peyronie's disease and impotency, 2) normal potency and extensive disease and 3) normal potency and localized disease in selective cases. In this series insertion of the penile prostheses did not change sexual prowess in previously potent patients.     

Surgical treatment of penile cancer: a follow-up report

One hundred and fifteen patients with penile cancer were treated at Roswell Park Memorial Institute from 1952 to 1975. A full follow-up is reported and factors involving the prognosis are analyzed. Although the clinical error of staging was near 30%, the lymphography results suggest that this study may result in added improvement in preoperative staging. Early diagnosis, adequate surgical resection, and lymph node dissection will improve the survival significantly. When dealing with an individual patient the prognosis is poor when any one or more of the follow factors are present: the lesion involves the shaft; there is a positive margin at the surgical resection; total penectomy is necessary to obtain tumor-free margin; lymphography is positive for tumor involvement of lymph nodes; lymph node dissection has not been performed; positive lymph nodes are found on surgical exploration. The good prognostic factors include: a lesion confined to the glans and partial penectomy is sufficient to obtain a tumor-free margin of resection; no clinical evidence (including lymphography) of lymph node invovlement; performance of lymph node dissection. The histological grading of the tumor should not influence the clinical decision for treatment in our opinion at this time, based on our current results. Further prospective studies of different factors involved in etiology, diagnosis, and treatment of penile cancer are suggested.     

Surgical treatment of gastroesophageal reflux disease

Modern techniques have substantially improved the outcome of surgical therapy for reflux. Surgery, therefore, should not be considered a method of last resort but instead a reasonable alternative to treat patients with abnormal reflux. Adequate preoperative staging of the disease helps design the most appropriate operation. Minimally invasive techniques improve exposure and enhance recovery. Control of symptoms is achieved in the great majority of patients, and complications are minimal if the operation is performed following basic principles of sound operative technique.     

Surgical treatment of gastroesophageal reflux disease

Antireflux surgery is successful in 85-90% of eligible patients, with relief of symptoms, cure of oesophagitis and possibly prevention of progression of the dysplasia in a Barrett's oesophagus. The mortality in the latest publications is given as 0.05%. The morbidity, apart from recurrences, is not yet sufficiently known. Some 250 antireflux operations are performed annually in the Netherlands, fewer than 20% of the estimated requirement of 10 operations per 100,000 of the population per year, and also fewer than in Scandinavia. Nissen fundoplication (folding the fundus of the stomach around the entire circumference (360 degrees) of the oesophagus) is generally accepted as the standard primary operation. Nissen fundoplication during laparoscopy seems to be just as good. Results of randomized clinical trials will have to be awaited to prove this assumption. Belsey's operation (folding the fundus around 270 degrees of the circumference of the oesophagus via thoracotomy) is nowadays performed almost exclusively in recurrent reflux disease and in persistent dysphagia after a primary operation.     

Prognostic factors and treatment of localized Hodgkin's disease]

Cure is warranted in most cases of localized Hodgkin's disease, the more frequent ones. However, after 10 years of follow-up, early and late mortality of iatrogenic origin exceed casualties related to tumor progression. Reductions in irradiation doses and fields, as well as wiser chemotherapy choices attempt to circumvent these complications. Nevertheless, as long as the mechanism of disease propagation and the prognostic factors are not better defined, only pragmatic approaches are being tested. Large cooperative trials are therefore needed to improve the outcome.     

Prostate cancer: clinical perspectives

1. When obtaining a screening history for prostate cancer, important risk factors include age, family history, and ethnicity. The digital rectal examination remains the "gold standard" physical examination screening technique. 2. If prostate cancer is detected at an early stage, it is potentially curable. It is incumbent upon occupational health care providers to afford those constituents who fall into a high risk category, or who are > or = 40 years of age, every opportunity for prostate cancer screening. 3. Education is the "sine-qua-non" of complete health care provision for prostate cancer clients. The occupational health care provider can play a pivotal role in allaying a client's fear and misconception of this disease. 4. Providing appropriate assessment and advocacy for clients returning to the workplace following diagnosis and treatment of prostate cancer is crucial.     

Surgical treatment of locally advanced rectal cancer. Options and strategies

To evaluate the contribution of the subsets of T helper lymphocyte (Th) to the development of pulmonary lesion in mycoplasma pneumonia, we compared the pathological findings between Th1 dominant mice (C57BL/6) and Th2 dominant mice (BALB/c) in experimental Mycoplasma pulmonis (M. pulmonis) pneumonia. Mice (ICR, C57BL/6, and BALB/c) were intranasally inoculated with 0.03 ml of a solution containing M. pulmonis (1 x 10(8)) colony forming units per ml. Another M. pulmonis inoculated ICR mice were treated with interleukin-2 (IL2; 4.8 micrograms/day), days 3-9, intracutaneously). All mice were sacrificed at day 14, and the lung specimens were examined. Peribronchial lymphocyte cuffing was more prominent in C57BL/6 mice than that of ICR mice, and intra-alveolar inflammatory-cell infiltration in BALB/c mice was more prominent than in ICR mice. Pathological patterns of the lung in IL-2 treated ICR mice were mimicking those of C57BL/6 mice. These results suggested that pathological patterns of mycoplasma pneumonia in mice might be altered by the imbalance of host T helper lymphocyte subset.     

Surgical treatment of metastatic long bone disease

A retrospective study of the results of operative treatment of 60 long bones secondaries in 46 patients was carried out. The mean period of follow-up was 10 months. The most common primary in this study was carcinoma of the breast (28.2%), followed by carcinoma of the lung (21.7%) and unknown primary (10.9%). Three groups of patients were studied--pathological fracture group, prophylactic fixation group and a mixed group. In the pathological fracture group, 70% of patients achieved good to excellent pain relief and 60.9% was able to walk with or without walking aids. In the prophylactic group, all the patients achieved good to excellent pain relief and 60% were able to ambulate with or without walking aids. In the mixed group, all the patients achieved good to excellent pain relief and 66.6% of the patients were able to walk with aids. The operative mortality in both the pathological fracture group and prophylactic fixation group was 10% and 33.3% in the mixed group. Multiple internal fixation performed at one operative session was associated with high operative mortality (50%).     

Colorectal cancer: treatment of advanced disease

It has been reported that corticotropin-releasing factor (CRF) may regulate its own biosynthesis in the paraventricular nucleus of the hypothalamus (PVH). Whether this CRF autoregulation is mediated by local circuitry or from extra-PVH CRF neuronal fibers terminating on CRF perikarya within the PVH is unknown. In the present study, we sought to determine the origin(s) of this CRF innervation using retrograde transport of wheat germ-conjugated-gold particles (WGA-apoHRP-Au) combined with immunohistochemistry for CRF. The rats also received colchicine (100 microg, icv) 5-7 days after tracer injection and were perfused 24 h later. Results of retrograde labeling with pressure injections of WGA-apoHRP-Au centered to PVH and subsequent immunohistochemical staining for CRF demonstrated numerous retrogradely labeled CRF neurons in the perifornical hypothalamic nucleus (PeF), the dorsolateral hypothalamic area (DA) (medial and lateral portions) and the dorsomedial nucleus of the hypothalamus (DMH). Smaller groups of CRF-ir neurons that were retrogradely labeled were found in the bed nuclei of the stria terminalis (BnST), the Barrington's nucleus (Bar) and the dorsal raphé (DR). These CRFergic pathways to the PVH may represent an anatomical substrate underlying the function of the stress-integrative PVH neurons in the autonomic, behavioral and neuroendocrine regulation during the stress response, including CRF autoregulation.     

Surgical treatment in proximal bile duct cancer. A single-center experience

OBJECTIVES: The authors evaluated the experience and results of a single center in surgical treatment of proximal bile duct carcinoma. SUMMARY BACKGROUND DATA: Whenever feasible, surgery is the appropriate treatment in proximal bile duct carcinoma. To improve survival rates and with special regard to liver transplantation, the extent of surgical radicalness remains an open issue. PATIENTS AND METHODS: Retrospective analysis of 249 patients who underwent surgery for proximal bile duct carcinoma via the following procedures: resection (n = 125), liver transplantation (n = 25), and exploratory laparotomy (n = 99). Survival rates were calculated according to the Kaplan-Meier method, uni- and multivariate analysis of prognostic factors, and log rank test (p < 0.05). RESULTS: Survival rates after resection and liver transplantation are correlated with international Union Against Cancer (UICC) tumor stage (resection: overall 5-year, 27.1%; stage I and II, 41.9%; stage IV, 20.7%; liver transplantation: overall 5-year, 17.1%; stage I and II, 37.8%; stage IV, 5.8%). Significant univariate prognostic factors for survival after liver resection were lymph node involvement (N category), tumor stage, tumor-free margins, and vascular invasion; for transplantation, they were local tumor extent, N category, tumor stage, and infiltration of liver parenchyma. For resection and transplantation, a multivariate analysis showed prognostic significance of tumor stage and tumor-free margins. CONCLUSION: Resection remains the treatment of choice in proximal bile duct carcinoma. Whenever possible, decisions about resectability should be made during laparotomy. With regard to the observation of long-term survivors, liver transplantation still can be justified in selected patients with stage II carcinoma. It is unknown whether more radical procedures, such as liver transplantation combined with multivisceral resections, will lead to better outcome in advanced stages. With regard to palliation, surgical drainage of the biliary system performed as hepatojejunostomy can be recommended.     

Surgical treatment of stomach cancer: analysis of our personal experience

The "curative" treatment of gastric carcinoma includes the complete removal of the tumour and of the nodes involved without any macroscopic residual of disease (RO). Out of 326 patients with gastric cancer observed, a series of 114 consecutive patients underwent surgical resection (total gastrectomy or subtotal distal gastrectomy) with D2 or D3 lymphadenectomy. Overall operative mortality was 5.3%. Since 1988 no postoperative death occurred. Overall morbidity was 15.8%, specific morbidity 10.5%, reduced after 1988 to 6.6%. No significant differences in operative mortality and need of blood transfusions were recorded between D2 and D3 lymphadenectomy. Overall 5-year survival was 32%. Univariate and multivariate analysis showed that only T and N stages are significant prognostic factors, whereas tumour location, total or subtotal gastrectomy in antral cancers, extent of lymphadenectomy (D2 vs D3) and histology were not significantly related to survival. Since most studies have clearly shown that T and N stages are the most important prognostic factors in gastric cancer, the present aim should be to plan the extent of surgical resection according to the T and N stages characteristics of the neoplasm.     

Surgical treatment of pulmonary metastasis of colorectal cancer. Prognostic survival factors

SURVIVAL RATES: Less than 5% of patients with pulmonary metastasis from colorectal carcinoma will survive at 5 years, but 30% will survive at 5 years after surgical treatment. MAIN PROGNOSTIC FACTORS: The number of nodules, presence of regional lymph node metastases, disease-free interval between treatment of the primary tumor and development of metastasis as well as serum CEA level are the main prognostic discriminants. INDICATIONS FOR SURGERY: An aggressive operative approach is indicated even when there are pulmonary and extra-pulmonary localizations. Repeat thoracotomy is warranted for recurrent disease.