Faculty Bibliography

Recurrent pleomorphic adenomas (RPAs) of the parotid gland are an uncommon but challenging problem. The records of 31 patients with RPAs were reviewed to assess the clinical presentation and treatment results. More than half of these patients underwent total parotidectomy. Local control was achieved in 94% of patients at 7 years (median follow-up 7.3 years). Patients who had surgery for recurrence after a formal parotidectomy were more likely to have another recurrence (63% local control at 7 years) than patients whose initial procedure was a limited excision (100% local control at 7 years; P < 0.01). Better local control was seen in 11 patients who received postoperative irradiation (100% at 10 years) than in 20 patients who did not (71% at 10 years; P < 0.28). Adequate surgical resection yields an acceptable local control rate in patients with RPAs. Postoperative radiation therapy may improve control in patients at high risk for another recurrence

OBJECTIVE/HYPOTHESIS: Hemangiopericytomas are uncommon neoplasms of vascular origin that may arise in the head and neck. Their rare occurrence and variable malignant potential have limited attempts to characterize their clinical behavior. This study reviews the experience in treating hemangiopericytomas of the head and neck at a single institution. STUDY DESIGN: Retrospective. METHODS: The records of 12 patients with hemangiopericytomas of the head and neck presenting between 1979 and 1995 were reviewed. Site of origin included the neck (4), oral cavity (3), parotid (2), orbit (1), maxillary sinus (1) and mandible (1). Five patients had lesions characterized as high or intermediate grade histologically, and six had lesions characterized as low grade. RESULTS: Nine patients were treated with curative intent; three presented either with pulmonary metastasis (2) or unresectable primaries (1) and were treated with radiation therapy and/or palliative Adriamycin-based chemotherapy. Patients treated with curative intent underwent a variety of surgical resections dictated by tumor location and size. Four patients received postoperative radiation therapy to a median dose of 60 Gy, for positive surgical margins (2), high-grade histology (1) or a recurrent lesion (1). Five-year overall survival in patients treated surgically was 87.5%. A single mortality occurred in a patient with a recurrent high-grade lesion who failed at local, regional, and distant sites. Median follow-up of survivors was 73 months. CONCLUSION: The clinical behavior of hemangiopericytomas appears to be related to their histological grade. Aggressive local therapy including surgery and radiation therapy appears to be effective in providing tumor control

Unilateral vocal cord paralysis following pneumonectomy has profound effects on deglutition, phonation, protection of the airway, and generation of an adequate cough. If untreated in patients with limited pulmonary reserve, these detrimental effects can have devastating consequences. Several techniques are currently available which allow adequate medialization and rehabilitation of the paralyzed vocal cord. Adequate diagnosis and treatment can minimize the negative consequences associated with vocal cord paralysis following pneumonectomy

G207 is a multi-mutated, replication-competent type-1 herpes simplex virus designed to target, infect, and lyse neurological tumors. This study examines the feasibility of using G207 in the treatment of human colorectal cancer and defines the biological determinants of its antitumor efficacy. This virus was tested on five human colorectal cancer cell lines in vitro to determine efficacy of infection and tumor cell kill. These results were correlated to measures of tumor cell proliferation. In vivo testing was performed through direct injections of G207 into xenografts of human colorectal cancer tumors grown in flanks of athymic rats. To evaluate an alternate method of administration, hepatic portal vein infusion of G207 was performed in a syngeneic model of liver metastases in Buffalo rats. Among the five cell lines tested, infection rates ranged between 10% and 90%, which correlated directly with S-phase fraction (8.6%-36.6%) and was proportional to response to G207 therapy in vitro (1%-93%). Direct injection of G207 into nude rat flank tumors suppressed tumor growth significantly vs. control (0.58 +/- 0.60 cm(3) vs. 9.16 +/- 3.70 cm(3), P<0. 0001). In vivo tumor suppression correlated with in vitro effect. In the syngeneic liver tumor model, portal infusion resulted in significant reduction in number of liver nodules (13 +/- 10 nodules in G207-treated livers vs. 80 +/- 30 nodules in control livers, P<0.05). G207 infects and kills human colorectal cancer cells efficiently. In vitro cytotoxicity assay and tumor S-phase fraction can be used to predict response to treatment in vivo. This antineoplastic agent can be delivered effectively by both direct tumor injection and regional vascular infusion. G207 should be investigated further as therapy for colorectal cancer and liver metastases

BACKGROUND AND OBJECTIVE: This case demonstrates, for the first time, the use of in vivo confocal imaging to assess the efficacy of laser treatment of a skin lesion with a vascular component. STUDY DESIGN/PATIENT AND METHOD: A patient with lesions of sebaceous gland hyperplasia was histologically imaged in vivo before and after treatment with a 585 nm pulse dye laser (PDL) by using a near-infrared, confocal reflectance microscope. Hyperplastic sebaceous ducts and sebaceous glands were seen with high resolution in vivo. Prominent dermal vasculature was viewed as well as its selective targeting by PDL. CONCLUSION: Our results confirm the previously reported successful treatment of sebaceous gland hyperplasia with the 585 nm PDL

BACKGROUND: Allergic contact dermatitis (ACD) is a common and often challenging clinical problem. In vivo near-infrared confocal reflectance microscopy (CM) is a new vital microscopy technique. OBJECTIVE: CM was used to evaluate acute ACD. METHODS: Patch testing by means of Finn Chambers technique was performed in 5 subjects to induce an acute allergic skin reaction. Noninvasive CM images from normal and eczematous skin were sequentially recorded before and after removal of the Finn Chambers. RESULTS: The epidermis and papillary dermis were clearly seen in high resolution. Retention of nuclei in stratum corneum, epidermal edema with microvesicle formation, and transepidermal migration of inflammatory cells were observed in vivo. Isolated dendritic cells were present in the ACD sites of 2 subjects, with morphology, size, and location consistent with Langerhans cells. Dermal vasodilation was observed as well. CONCLUSION: CM is a useful tool to study ACD and may be able to track Langerhans cell activation

OBJECTIVES: To assess the potential of a near-infrared confocal laser scanning microscope (CLSM) for imaging bladder tissue in vivo. METHODS: Confocal images of the exposed bladder of male Sprague-Dawley rats were obtained with a CLSM. To minimize tissue motion, the bladder was placed in light contact under an objective lens housing, and the top surface was lightly flattened with a coverslip. Images were obtained from the outer and inner layers of the bladder wall with a lateral resolution of 0.5 to 1 microm and an axial resolution (section thickness) of 3 to 5 microm. The confocal images were later correlated with routine histologic studies. RESULTS: The CLSM allows imaging of the urothelium, the superficial and deep portions of the lamina propria, the muscularis propria, and the serosa of the bladder wall in vivo. Urothelial cells, collagen bundles and fibers, muscle, and circulating blood cells in capillaries and larger blood vessels are easily visualized. The confocal images correlated well with the histologic studies. CONCLUSIONS: Confocal microscopy allows real-time, high-resolution, high-contrast imaging of cellular and structural morphologic features to a maximal depth of 300 microm within the bladder wall in vivo. Artifacts caused by tissue motion can be minimized with a bladder-objective lens contact housing

OBJECTIVE: To review the effectiveness of a perioperative management protocol and our experience with a large population of patients with von Willebrand disease (vWD) who require adenotonsillar surgery (T&A). DESIGN: A retrospective review of the medical records of all patients having the diagnosis of vWD who underwent T&A between January 1, 1992, and July 31, 1996. SETTING: A tertiary care, university-based children's hospital. INTERVENTIONS: Patients having a preoperative diagnosis of vWD received a single intravenous dose of desmopressin acetate, 0.3 pg/kg, approximately 20 minutes before the induction of anesthesia. Beginning January 15, 1994, a standard management protocol involving the postoperative administration of fluids and electrolytes was followed. MAIN OUTCOME MEASURES: Operative blood loss and the incidence of postoperative bleeding and of hyponatremia. RESULTS: Of approximately 4800 patients who underwent T&A during the study period, 69 patients had a diagnosis of vWD. All 67 patients identified preoperatively received desmopressin; 2 were identified by postoperative workup as a result of excessive surgical bleeding. Minimal immediate postoperative bleeding was noted in 7 patients (10%), but none required intervention. Delayed bleeding occurred in 9 patients (13%); all were readmitted to the hospital for observation, 4 (6%) requiring operative cauterization. Substantial postoperative hyponatremia occurred in 3 patients, and 1 patient had seizure activity. Symptomatic hyponatremia has been avoided since a protocol of fluid and electrolyte administration was instituted. CONCLUSIONS: Although T&A can be performed safely in patients with vWD, it is not without an increased risk of postoperative hemorrhage. The administration of desmopressin has been reported to reduce the risk of bleeding, but it is not without risk. A protocol for fluid and electrolyte management is recommended

OBJECTIVE: To reconcile conflicting reports concerning the incidence of otorrhea in children with tympanostomy tubes who swim without ear protection. STUDY SELECTION: Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Controlled trials of water precautions following tympanostomy tube placement were selected by independent observers and scored on 10 measures of study validity. Five English-language articles met all inclusion criteria. DATA EXTRACTION: Data were abstracted for an endpoint of otorrhea following swimming without ear protection with a minimum follow-up of 6 weeks. DATA SYNTHESIS: Pooled analysis of 619 children revealed a rate difference of -5.04 (95% confidence interval [CI], -11.62 to 1.54). No significant difference in the incidence of otorrhea was noted between patients who swam without ear protection and nonswimmers. CONCLUSION: There is no increase in incidence of otorrhea in children who swim without ear protection compared with children who do not swim following tympanostomy tube placement