Stephen Bell

A recent trend in the classification of uterine smooth muscle neoplasms (USMNs) into clinically benign and clinically malignant groups has been to move from exclusive reliance upon mitotic index (MI) to an approach that incorporates additional histopathologic characteristics. In furtherance of this goal, we assessed a variety of histopathologic features of 213 problematic smooth muscle neoplasms for which we had > or = 2 years of clinical follow-up data or for which there was an unfavorable outcome. One hundred and thirteen of these patients have had a minimum follow-up of 5 years, and 48 have been followed for > or = 10 years. Cases eliminated from the study group included USMNs with a significant myxoid or epithelioid component and cases of intravenous leiomyomatosis. USMNs, whether cellular or not, with no cytologic atypia and with a mitotic index (MI = number of mitotic figures [mf]/10 high-power fields [hpf]) of < 5 mf/10 hpf (usual leiomyomas) were also excluded unless they had unusual features or were associated with an adverse clinical outcome. Fifty-six patients were initially treated by myomectomy or another form of local tumor removal; the remainder had a hysterectomy. From a wide variety of light microscopic features assessed, the important predictors that emerged, using a variety of data exploratory techniques, were MI, the degree of cytologic atypia, and the presence or absence of coagulative tumor cell necrosis (CTCN). Stratification of the USMNs with respect to these three features resulted in a five-group classification of USMNs with the following major characteristics. Group 1: Of the 89 USMNs with an MI in the range 5 < or = MI < 20 without CTCN and with no more than mild atypia, 88 were clinically benign. One patient with a tumor in this group died of metastatic disease 96 months after her uterine cervical primary neoplasm was removed. Combining our data with that in the literature, the failure rate in this group is approximately 1/200 (0.5%). This low failure rate warrants the use of the label "leiomyoma with increased mitotic index" for USMNs with these histologic features. Two patients whose USMNs were characterized by mild atypia, no necrosis, and MI < 5 developed identical-appearing pulmonary metastases and were judged in retrospect to have the syndrome "benign metastasizing leiomyoma." Group 2: USMNs with no CTCN and diffuse moderate to severe atypia fell into two groups based on the MI. For those patients whose neoplasms had an MI > or = 10 mf/10 hpf, four of 10 failed.(ABSTRACT TRUNCATED AT 400 WORDS)

In Brief Objective: The aim of this study was to determine whether anastomotic leakage has an independent association with overall survival and cancer-specific survival. Summary Background Data: There are many known prognostic indicators following surgery for colorectal cancer (CRC). However, the impact of anastomotic leakage has not been adequately assessed. Methods: Consecutive patients undergoing resection between 1971 and 1999 were recorded prospectively in the Concord Hospital CRC database. Total anastomotic leakage was defined as any leak, whether local, general, or radiologically diagnosed. Patients were followed until death or to December 31, 2002. The association between anastomotic leakage and both overall survival and cancer-specific survival was examined by proportional hazards regression with adjustment for other patient and tumor characteristics influencing survival. Confidence intervals (CI) were set at the 95% level. Results: From an initial 2980 patients, 1722 remained after exclusions. The total leak rate was 5.1% (CI 4.1–6.2%). In patients with a leak, the 5-year overall survival rate was 44.3% (CI 33.5–54.6%) compared to 64.0% (CI 61.5–66.3%) in those without leak. In proportional hazards regression–after adjustment for age, gender, urgent resection, site, size, stage, grade, venous invasion, apical node metastasis and serosal surface involvement–anastomotic leakage had an independent negative association with overall survival (hazard ratio [HR] 1.6, CI 1.2–2.0) and cancer-specific survival (HR 1.8, CI 1.2–2.6). Conclusion: Apart from its immediate clinical consequences, anastomotic leakage also has an independent negative association with survival. In 1722 consecutive patients having a curative resection for colorectal cancer between 1971 and 1999, the overall 5-year survival rates were 44.3% (confidence interval 33.5–54.6%) in those with anastomotic leak and 64.0% (confidence interval 61.5–66.3%) in those without leak. This association persisted after adjustment for 10 other factors associated with survival.

BACKGROUND: The aim of this study was to determine whether leakage from a colorectal anastomosis following potentially curative anterior resection for rectal cancer is an independent risk factor for local recurrence. METHODS: The study included all patients who had a potentially curative anterior resection with anastomosis for adenocarcinoma of the rectum between 1971 and 1991 at Concord Hospital. The data were collected prospectively, with complete follow-up for at least 5 years. The Kaplan-Meier method was used to compare time to recurrence between strata of categorical variables. Proportional hazards regression was used in multivariate modelling. RESULTS: There were 403 patients in the study. After adjustment for lymph node metastases, the distal resection margin of resection, non-total anatomical dissection of the rectum and the level of anastomosis, multivariate analysis identified a significant association between anastomotic leakage and local recurrence (hazard ratio 3.8, 95 per cent confidence interval 1.8 to 7.9). CONCLUSION: Leakage following a colorectal anastomosis after potentially curative resection for adenocarcinoma of the rectum is an independent predictor of local recurrence.

Pulmonary and mediastinal glomus tumors are rare lesions, with four previously reported primary pulmonary cases and three mediastinal cases. The authors report one mediastinal glomus tumor, a locally infiltrative type, and four pulmonary glomus tumors, including the first case of primary pulmonary glomangiosarcoma. These tumors show a variety of clinical and pathologic differences from the more common cutaneous variety, including later age at presentation, larger size, and more frequent atypical/malignant features. Mediastinal and pulmonary glomus tumors both have an average patient age at presentation of 45 years. However, compared with their pulmonary counterparts, mediastinal glomus tumors are less common, more often symptomatic, and are larger (average size, 5.4 cm). Additionally, mediastinal glomus tumors more often demonstrate malignant or atypical features. Pulmonary glomus tumors average 3.3 cm in greatest dimension, with the majority measuring less than 2.5 cm. The pulmonary glomangiosarcoma presented was large, measuring 9.5 cm, and showed increased mitotic count (9 mitoses/10 high-power fields), necrosis, cytologic atypia, and was associated with disseminated disease. Regardless of clinical symptoms, histologic features, and even metastases, the vast majority of all benign and malignant glomus tumors are indolent and cured surgically, with adjuvant therapy needed only for occasional patients with more advanced disease. The four patients with glomus tumors reported are currently alive and free of disease as of last follow up. The patient with the glomangiosarcoma developed widespread metastases and died of disease 68 weeks after initial therapy.

BACKGROUND: Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS: Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS: Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION: The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.