Faculty Bibliography

Malignant melanoma metastases to regional lymph nodes may be mimicked by several non-neoplastic processes, including sinus histiocytosis induced by fragments shed from joint prostheses. A patient who had an elective lymph node dissection for malignant melanoma and was found to have 'post-prosthesis lymph node histiocytosis' resembling metastatic disease is described. Knowledge of the patient's past history of a total shoulder joint replacement along with the use of polarized light microscopy to identify birefringent particles of prosthetic debris allows for an accurate histologic diagnosis

BACKGROUND: Patients with stenosis of one carotid artery and occlusion of the contralateral carotid artery (stenosis-occlusion) who are treated medically are at high risk for stroke. We have recently reported that carotid endarterectomy on the stenotic artery has a low perioperative risk in these patients. We now present follow-up data to define the long-term effectiveness of this operation. PATIENTS AND METHODS: From 1985 to 1991, 135 patients with stenosis-occlusion underwent endarterectomy of the stenotic carotid artery. Selective intra-arterial shunting was performed based on mental status changes under regional anesthesia, preoperative neurologic deficit, or evidence of preoperative cerebral infarction on computed tomography scan. Shunting was used in 70 patients (52%). Saphenous vein was used for patch closure in 132 patients (98%), and polytetrafluoroethylene in 3 (2%). RESULTS: By life-table analysis, 92% of patients have remained stroke-free at 5 years. Fourteen deaths, none related to cerebrovascular disease, have occurred during follow-up. The life-table cumulative stroke-free survival rate at 5 years is 74%, and the overall survival rate is 82%. CONCLUSION: Carotid endarterectomy in the presence of a contralateral occlusion provides long-term benefit to the patient with respect to prevention of stroke. With lower perioperative stroke rates and proven long-term benefit, carotid endarterectomy of the stenotic artery should be the treatment of choice in the patient with stenosis-occlusion

Recent data from the North American Symptomatic Carotid Endarterectomy Trial revealed a 14.3% perioperative risk of stroke or death with carotid endarterectomy contralateral to a carotid artery occlusion. Since last reporting on this topic in the mid-1980s, the authors have reviewed 180 patients with occlusion of one internal carotid artery (ICA) and who underwent endarterectomy of the stenotic contralateral ICA operated from 1965 to 1984 (group A) compared with 135 operated on from 1985 to 1991. The two groups were similar with respect to age, sex, incidence of coronary artery disease, hypertension, diabetes and history of smoking, but group B had a significantly increased incidence of patients who were neurologically symptom-free before surgery (21.5% versus 7.8%, P < 0.001). The combined perioperative stroke or death rate for patients in group B was significantly lower than for those in group A (0.7% versus 6.7%, P < 0.01). Comparison of the operative techniques showed more frequent placement of intra-arterial shunt (52.6% versus 29.4%, P < 0.001) and increased use of general anesthesia (20.0% versus 9.4%, P < 0.01) in patients of group B. Analysis of the etiology of the complications, however, showed that shunting alone could not account for the improved results. Lower incidences of postoperative thrombosis, embolization and intracerebral hemorrhage were equally important.(ABSTRACT TRUNCATED AT 250 WORDS)

PURPOSE: The purpose of this study was to examine the cause of perioperative stroke after carotid endarterectomy. METHODS: The records of 2365 patients undergoing 3062 carotid endarterectomies from 1965 through 1991 were reviewed. Sixty-six (2.2%) operations were associated with a perioperative stroke. The mechanism of stroke was determined in 63 of 66 cases. Patient risk factors and surgeon-dependent factors were analyzed. RESULTS: More than 20 different mechanisms of perioperative stroke were identified, but most could be grouped into broad categories of ischemia during carotid artery clamping (n = 10), postoperative thrombosis and embolism (n = 25), intracerebral hemorrhage (n = 12), strokes from other mechanisms associated with the surgery (n = 8), and stroke unrelated to the reconstructed artery (n = 8). Dividing the operative experience approximately into thirds, during the years 1965 to 1979, 1980 to 1985, and 1986 to 1991 the perioperative stroke rates were 2.7%, 2.2%, and 1.5%, respectively. This, in part, is associated with a better selection of patients (more symptom free, fewer with neurologic deficits). There has been a notable decrease in perioperative stroke caused by ischemia during clamping and intracerebral hemorrhage, but postoperative thrombosis and embolism remain the major cause of neurologic complications. CONCLUSIONS: Although patient selection seems to play a role, most perioperative strokes were due to technical errors made during carotid endarterectomy or reconstruction and were preventable

PURPOSE: We examined the perioperative course and long-term fate of individuals who required reoperation for recurrent carotid artery disease. METHODS: The records of 2289 patients undergoing 2961 consecutive operations during a 22-year period were reviewed. Forty-two patients (1.8%) who underwent reoperations were studied. Forty-seven redo carotid artery reconstructions were performed on these 42 patients for neurologic symptoms or asymptomatic high-grade stenosis. Long-term follow-up was obtained on 41 of 42 patients (mean 54 months; range 9 to 202 months). RESULTS: The forty-seven reoperations consisted of endarterectomy with patch angioplasty (n = 36), saphenous vein or polytetrafluoroethylene interposition graft (n = 7), or simply vein or polytetrafluoroethylene patch angioplasty (n = 4). There were no perioperative strokes or deaths. Three patients had perioperative transient ischemic attacks and two had cranial nerve injuries. The incidence of late failure after secondary surgery was 19.5% (8/41 patients). These failures consisted of one stroke, three transient ischemic attacks, and four asymptomatic occlusions. One tertiary carotid artery reconstruction was performed for a restenosis at the site of the secondary reconstruction. CONCLUSION: The factors responsible for the high incidence of late failures after secondary carotid artery reconstruction are unclear. Reoperation for recurrent carotid artery disease appears less durable than primary carotid endarterectomy. Close postoperative surveillance is recommended after carotid artery reoperation

The concentration of 16 alpha-hydroxydehydroepiandrosterone-3-sulfate (16 alpha-OHDHAS) was determined in 29 samples of human breast cyst fluid (BCF) and in 15 of these, androst-5-ene-3 beta,16 alpha,17 beta-triol-3-sulfate (A-TriolS) was also assayed. The median value of both was about 100 ng/mL and the ranges were from 1.4 to about 1800 ng/mL. There was a significant association in the values for the two sulfates (p less than 0.05). These concentrations are consistent with a role for 16 alpha-hydroxy androgens as possible precursors for estriol-3-sulfate. The latter is highly elevated relative to other body fluids in BCF. The androgens also correlated directly with the concentrations of K+, an indicator of apocrine proliferation of breast cysts