Biomedical subjects
Publications and source records attributed to M R Pittam.
A case of pyomyositis mimicking a soft-tissue sarcoma of the adductor muscle group is described. The aetiology and several presentations of pyomyositis and their differential diagnosis from sarcoma are discussed.
Eight patients with axillary-subclavian vein thrombosis were studied. Three presented acutely and five with chronic symptoms of pain and swelling exacerbated by and limiting normal use. Initial venography showed complete occlusion of the axillary vein in 7 cases and marked narrowing in the remaining patient. Venographic evidence of narrowing or occlusion was also seen in 6/8 clinically normal contralateral arms. One of these arms became symptomatic 2 years later, and required surgery. The patients presenting acutely were anticoagulated. Symptoms resolved slowly in 2 cases, but persisted in one. This patient and the five presenting chronic symptoms underwent decompression of the thoracic outlet by transaxillary resection of the first rib. Satisfactory decompression was confirmed at operation by eliciting and then abolishing "nipping" of the surgeon's finger between the first rib and the clavicle on abducting and then relaxing the arm. Symptomatic relief was achieved in 5/7 limbs thus treated (one patient had bilateral first rib resection). Although postoperative venographic improvement was seen in some cases, clinical success did not depend on recanalisation of the main axillary-subclavian vein. The two patients with persistent symptoms after first rib resection subsequently had venous bypass procedures. Despite initial patency, both had occluded with return of symptoms within 4 months.
Transurethral resection (TUR) is regarded as the treatment of choice for relief of outflow tract obstruction in the male, but bladder neck incision (BNI) is an acceptable alternative when the gland is small. Seven hundred cases of TUR/BNI have been reviewed (TUR = 388; BNI = 312). BNI was performed when the gland was less than 35 g and where there was no clinical suspicion of malignancy. The operative details of our single incision technique are given. While the patients in the BNI group were younger, catheter stay was shorter, there was less infection, a significantly reduced need for blood transfusion and a satisfactory outcome in terms of control and need for further surgery. BNI is a technically simpler procedure than TUR and is easy to teach and learn. Results show it is safe and effective for patients in acute retention as well as those treated electively and it is the operation of choice for small benign prostates.
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Two hundred and fifty five patients were treated surgically for adenocarcinoma of the colon or rectum on the Surgical Unit at Westminster Hospital in the years 1962-78. After 13 patients had been excluded on the grounds of inadequate data, 57 of the remaining 242 had tumours which, at laparotomy, were firmly adherent to neighbouring organs or the abdominal wall. These 'locally advanced' tumours were treated by an extended en-bloc resection of the tumour and neighbouring organs. The operative mortality after extended resections was higher than after standard resections, but subsequent survival did not differ significantly from survival after standard excisions for tumours of the same Dukes' stage. Histological examination of the neighbouring organs included in the extended resections confirmed direct tumour spread in only 33%.
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Patterns and mechanisms of local bone invasion by squamous carcinomas of the head and neck have been investigated. Detailed surgical pathology has shown that these tumors invade contiguous skeletal or metaplastic bone principally through an indirect process; the normal bone resorbing cells of the host (osteoclasts) are activated and erode bone in front of the advancing tumor edge. Tumor cells take over the destructive process when the osteoclast response has waned. These morphologic patterns have been reproduced in an in vitro model where calcium-45-labelled mouse calvaria, cocultured with a tumor for 3 days, are resorbed by osteoclasts. Freshly excised tumors, established tumor cell lines, and tumor xenografts release osteolysins in vitro which act as osteoclastic stimulants. They include both prostaglandins E2 and F2 alpha, and nonprostaglandin factors, and are derived from tumor cells and from the associated host stroma. Virtually all the tumors examined released osteolysins and resorbed bone in vitro independent of their site, size, degree of differentiation, and the presence or absence of clinical bone invasion.
Mechanisms of bone invasion by squamous carcinomas of the head and neck have been investigated using fresh tumours and established tumour cell lines in an in vitro bone resorption assay with 45Ca-labelled mouse calvaria. Fresh tumours regularly resorb bone in vitro. Activity is consistently reduced by indomethacin. The tumours release E2 prostaglandins (PGE2) in amounts sufficient to account for approximately 50% of the bone resorption observed. Small amounts of non-prostaglandin (indomethacin-resistant) osteolytic factors are also produced. Control non-neoplastic tissues show a variable capacity to resorb bone in vitro; PGE2 levels in these tissues may be related to their content of inflammatory cells. Tumour cell lines also resorb bone in vitro but, for most lines, activity is not significantly blocked by indomethacin and PGE2 levels are generally insufficient to account for the osteolysis observed. Non-prostaglandin bone resorbing factors thus predominate. It is concluded that most squamous cancers of the head and neck are osteolytic in vitro and release a mixture of prostaglandin and non-prostaglandin factors which stimulate osteoclastic bone resorption. These factors are derived from both neoplastic and stromal elements, and are "tumour-associated" rather than "tumour-specific". In vitro bone resorption and prostaglandin release does not correlate with pathological features of the tumour or with post-operative survival.
Perineural spread has been demonstrated histologically in 65/180 (36%) major surgical resections for squamous carcinomas of the head and neck; the incidence in a smaller necropsy series was 18/20 (90%). Perineural infiltration was observed most commonly in the vicinity of carcinomas arising in the buccal cavity (31/63, 50%) and, at all sites, it was most commonly encountered near tumours less than or equal to 2.5 cm in diameter. Perineural spread near cervical node metastases was, by contrast, uncommon in the surgical series. Tumour within perineural spaces tends to be concentrated at the margin of the nerve and shows only limited extension inwards, but cells may track upwards and downwards within the spaces. Distant spread for greater than 2 cm is unusual, and interval sampling of involved nerves in necropsy material indicates that most perineural tumour cells are confined to the distal 1 cm of the affected nerve. Infiltrated nerves regularly show varying degrees of myelin and axonal degeneration, probably anoxic in origin, and segmental infarction of nerve trunks was observed in three patients. Fine changes in axons and myelin have been regularly demonstrated with two monoclonal antibodies, and the use of these new reagents is described.
Surgical urinary diversion for incurable pelvic malignancy has a high morbidity and mortality, and external drainage provides less than ideal palliation. Six patients with ureteric obstruction caused by cancer have been managed by operative or endoscopic insertion of self-retaining polyethylene tubes. These techniques also have applications in non-malignant disease, and the treatment of two patients with benign ureteric stricture is described.
Fifty-six patients who had undergone salvage surgery for residual or recurrent squamous carcinomas of the tongue between 1967 and 1977 were reviewed. Failure to obtain operative clearance led to certain local recurrence. The tongue or cervical lymph nodes were involved in 27 of the 28 patients who died with recurrent tumour. The overall age-corrected actuarial postoperative survival was 45.1 per cent at 2 years and 35.3 per cent at 5 years. Survival was reduced in women and patients aged over 60 years at operation, and in patients whose tumors were at first biopsy moderately or poorly differentiated, classified as stage III or IV at initial presentation or preoperatively, or recurred within 6 months of completing primary treatment.
Forty-nine patients who were free of tumour 5 months to 14 years (mean 30 months) after total laryngectomy or a commando procedure were given questionnaires designed to obtain the patient's assessment of their resulting disability. Sixteen areas of disability were studied grouped under five main headings: speech, eating, cosmetic, employment and social. Following laryngectomy more than half of the patients achieved successful communication by oesophageal speech. Success in this was usually associated with minimal problems in other areas. The disabilities after commando procedures were more varied and complex. More patients reported severe disability in more than one area. Difficulties with chewing and swallowing were prominent. The results are illustrated with patients' comments. Ways in which rehabilitation might be improved are considered.
Clinical and pathological features of perineural spread have been investigated in patients with squamous carcinomas at several sites in the head and neck. In 100 surgical cases, the clinical and pathological findings were congruent in 76%. Combined clinical and histological evidence of perineural invasion was recorded in 33% and the overall incidence of nerve involvement detected morphologically was 44%. Perineural infiltration was demonstrated histologically in 51% of major excisions from the buccal cavity and in 34% of resections from the oropharynx, hypopharynx and cervical oesophagus. The neurological findings were dominated by hypoaesthesia, dysaesthesia and referred pain - mainly in the territories of cranial nerves V and IX. Multiple and/or sequential nerve involvement was occasionally seen. No correlation was established between nerve invasion and metastasis to regional lymph nodes. Long-distance infiltration of nerve trunks, and multiple involvement, are grave prognostic features.In 17 terminal patients submitted to autopsy, 65% had combined clinical and pathological evidence of perineural spread and the overall incidence of nerve involvement detected morphologically was 88%. Sensory changes again predominated. Multiple nerve involvement was observed in 35%. An apparently new `dysphagia syndrome' is described in 4 patients with oropharyngeal carcinomas in whom gross mechanical obstruction was simulated by a combination of perineural spread of tumour into the ipsilateral vagal trunk, sometimes accompanied by segmental infarction, variable invasion of the sympathetic chain, and `splinting' of the pharynx by local fibrosis and tumour in the soft tissues of the neck. Short-term palliation was achieved in these patients with high-dose steroids.
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Five tumour cell lines have been derived from a primary squamous carcinoma of the tongue, from 2 subsequent local recurrences, and from 2 lymph-node metastases--all from the same patient. While the cell lines shared many morphological and biochemical characteristics, those derived from recurrences and metastases appeared to be less differentiated, were less well organized in culture, and displayed fewer desmosomes and tonofilaments than cells in the primary tumour line. A recurrent line showing greatest morphological divergence from the primary tumour line also demonstrated the greatest differences at the ultrastructural level, in increased production of plasminogen activator and in the composition of cell-surface glycoproteins.
Patterns of tumour spread are examined in 160 patients with squamous carcinomas of the head and neck with reference to perineural infiltration, direct invasion of bone and ossified cartilage, and lymph node metastases in the previously irradiated neck. Perineural spread is comparatively common in large (T3, T4) tumours; it may be apparent early in the disease; it is often detectable clinically; and it is an adverse prognostic feature which may modify clinical management. Direct bone invasion is described with particular reference to tumours of the oral cavity. Most bone destruction is mediated by osteoclasts which appear to be stimulated by materials such as prostaglandins released in the vicinity of the tumour. The numbers of involved lymph nodes in surgical dissections from the irradiated neck are usually few and restricted to the submandibular and jugular groups; nodes in the posterior triangle are infrequently involved by metastatic carcinoma. Transcapsular spread and keratin granulomas are common. The scope of modified neck dissections in this group of patients is discussed.