Faculty Bibliography

PURPOSE/OBJECTIVE:To provide an estimate of long-term prognosis for patients with osteosarcoma of the extremity treated in a single institution with neoadjuvant chemotherapy and observed for at least 10 years. PATIENTS AND METHODS/METHODS:Patients with nonmetastatic osteosarcoma of the extremity were preoperatively treated with high-dose methotrexate, cisplatin, and doxorubicin (ADM). Postoperatively, good responders (90% or more tumor necrosis) received the same three drugs used before surgery, whereas poor responders (less than 90% tumor necrosis) received ifosfamide and etoposide in addition to those three drugs. RESULTS:For the 164 patients who entered the study between September 1986 and December 1989, surgery was a limb salvage in 136 cases (82%) and a good histologic response was observed in 117 patients (71%). At a follow-up ranging from 10 to 13 years (median, 11.5 years), 101 patients (61%) remained continuously free of disease, 61 relapsed, and two died of ADM-induced cardiotoxicity. There were no differences in prognosis between good and poor responding patients. ADM-induced cardiotoxicity (six patients), male infertility (10 of the 12 assessable patients), and second malignancies (seven patients) were the major complications of chemotherapy. Despite the large number of limb salvages performed, only four local recurrences (2.4%) were registered. CONCLUSION/CONCLUSIONS:With an aggressive neoadjuvant chemotherapy, it is possible to cure more than 60% of patients with nonmetastatic osteosarcoma of the extremity and amputation may be avoided in more than 80% of them. Because local or systemic relapses, myocardiopathies, and second malignancies are possible even 5 years or more after the beginning of treatment, a long-term follow-up is recommended for these patients.

PURPOSE/OBJECTIVE:Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia. METHODS:Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60-124) months. RESULTS:Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48-100) months. CONCLUSIONS:Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.

It is reported a case of "carcinoid tumorlets" of the lung, in a 63-year-old woman, who underwent surgery for a breast cancer. These lesions are histologically similar with carcinoid, but different for clinical evolution. They are benign lesions generally without metastasis. The authors point out the importance of histological, clinical and diagnostical aspects, and the follow-up of patients in order to have evidence of the eventual malignant evolution.

Between September 1986 and September 1991, 44 patients with lung metastases originating from an osteosarcoma of an extremity were treated with: primary chemotherapy, simultaneous resection of primary and metastatic lesions (when feasible), and then further chemotherapy. After primary chemotherapy, lung metastases disappeared in 5 patients, whereas in 11 patients they remained surgically unresectable. All 16 patients received local treatment of the primary tumor only. In the remaining 28 patients simultaneous surgical treatment of the primary and the metastatic tumor was performed. The removal of metastatic lesions was complete in 25 and incomplete in 3 patients. With a median follow-up of 8 years (5.5-10.8) all 14 patients who never achieved a tumor-free status died. Of the 30 patients who achieved remission 5 (17%) remained continuously free of disease and 25 developed new metastases, associated with local recurrence in 4 cases. The 5-year overall survival for all 44 patients of the study was 14%, and the 5-year disease-free survival for the 30 patients who reached remission was 17%. These results are significantly worse than those achieved with the same chemotherapy protocol in 144 contemporary patients with localized disease at presentation (73% disease-free and 79% overall survival). We conclude that, despite aggressive chemotherapy which is successful in patients with localized disease, the prognosis remains very poor for patients with osteosarcoma of the extremities with lung metastases at presentation, and justifies the use of novel therapies.

This paper reports the results of a trial, comparing the use of disposable skin staplers with conventional nylon or silk sutures in skin closure. This study began in 1986; 7274 patients undergoing elective and emergency operations were controlled during the postoperative period, 3 and 6 months after surgery. It was shown that skin clips instead of sutures decrease the operative time, produce wound healing with a good cosmetic results, and above all a significant lowering of the wound infection rate.

The authors analyze the complications of acetabuloplasty in the treatment of CHD during the growth age, evaluating the incidence and the possible causes, that emerged from a review of cases at the Rizzoli Orthopaedic Institute including 238 patients treated from 1970 to 1986 using different methods. The techniques adopted were: acetabuloplasty for lowering in 100 cases, Salter osteotomy in 30 cases, triple pelvic osteotomy in 48 cases and acetabuloplasty according to the Chiari method in 50 cases. Complications of various types were observed in 9.6% of the cases after a mean follow-up of 5 years. It is the purpose of ths study to discuss the complications that are observed during each operation, and to compare them with those reported in the literature, as well as to present a pathogenetic interpretation. A study of complications influences indications and surgical technique.

Postoperative infections are an outstanding problem in a surgical department. We have been studying them from a clinical and experimental point of view has a long time. In this study we present a method standardisation of postoperative peritoneal lavage as prevention of surgical infections. Winstar mice, infected with intra peritoneal E. coli cultures, underwent peritoneal lavage with saline solution or sterile water. The results showed the right amount of solution and the exact administration of lavage according to grade of infection. Encouraged by this result we are going to test the efficacy of anti microbial agents for the postoperative peritoneal lavage.

The authors report a comparative study between endorectal ultrasonography (EU) and computed tomography (CT) in the preoperative assessment of 94 patients with rectal cancer. In evaluating the depth of wall penetration of rectal tumors EUS and CT offered good results: EUS confirmed a clear superiority with overall accuracy of 88.4% versus 80% of CT. On the contrary, in detecting lymph node metastases both techniques had poor results obtaining a correct diagnosis in 75.6% of the cases with EUS and in 69.4% of the cases with CT. In conclusion, the authors believe that EUS and CT may by very useful in the study of tumor penetration of the rectal wall; while in the study of lymph node involvement new techniques for a more accurate diagnosis are needed.