Preoperative Corticosteroid Therapy Research Articles

Histopathological Diagnosis of Primary Central Nervous System Lymphoma after Therapy with Corticosteroids or Anticoagulants.

In patients with primary central nervous system lymphoma (PCNSL), the choice of surgical strategy for histopathologic assessments is still controversial, particularly in terms of preoperative corticosteroid (CS) therapy. To provide further evidence for clinical decision-making, we retrospectively analyzed data from 148 consecutive patients who underwent surgery at our institution. Although patients treated with corticosteroids preoperatively were significantly more likely to require a second or third biopsy (p = 0.049), it was only necessary in less than 10% of the cases with preoperative (but discontinued) corticosteroid treatment. Surprisingly, diagnostic accuracy was significantly lower when patients were treated with anticoagulation or dual antiplatelet therapy (p = 0.015). Preoperative CSF sampling did not provide additional information but was associated with delayed surgery (p = 0.02). In conclusion, preoperative CS therapy can challenge the histological diagnosis of PCNSL. At the same time, our data suggest that preoperative CS treatment only presents a relative contraindication for early surgical intervention. If a definitive diagnosis cannot be made after the first surgical intervention, the timing of a repeat biopsy after the discontinuation of CS remains a case-by-case decision. The effect of anticoagulation and dual antiplatelet therapy on diagnostic accuracy might have been underestimated and should be examined closely in future investigations.

P1153 Hospital surgical volumes and outcomes in ileocaecal resection for Crohn’s disease in Sweden 2000-2019: A national cohort study

Abstract Background Intestinal resection for Crohn’s disease (CD) is often complex and remains associated with significant postoperative morbidity. In several other types of complex surgery, increased case volumes have been associated with better outcomes. In surgery for CD, such an association has not yet been demonstrated. Methods In this nationwide cohort study, we used the National Patient Register to identify all CD patients who underwent their first (primary) ileocaecal resection in Sweden 2000-2019 at age 15 years or above. Hospitals were grouped into low, middle, and high-volume centres based on the number of intestinal resections for CD the previous calendar year (1-24, 25-36 and ≥37 resections, respectively). Length of hospital stay, severe postoperative complications and deaths during the first 100 days after the date of index surgical admission were compared between groups, and adjusted for sex, age, duration of disease, preoperative corticosteroid therapy, and year of surgery. Rates of surgical reintervention were used as a measure of severe postoperative morbidity. Results In the 20-year study period, 3396 patients underwent primary ileocaecal resection for CD in Sweden; 2371 (69.8%), 527 (15.5%) and 498 (14.7%) in low, middle, and high-volume hospitals, respectively. Median age at surgery was 41, 39 and 34 years, respectively, and the proportion of patients with a diagnostic record of perianal disease was 9, 10 and 16%. Sex, extraintestinal manifestations and preoperative medical therapies and hospital admissions did not differ between hospital types. Laparoscopic surgery was performed in 351 (15%), 126 (24%) and 122 (24%) patients, respectively. Surgical reintervention within 100 days was performed in 117 (4.9%), 19 (3.6%) and 13 (2.6%) patients in the three groups (adjusted odds ratios 0.72 (95% confidence interval 0.43-1.15) for middle-volume and 0.52 (0.28-0.89) for high-volume hospitals, compared to low-volume hospitals, Figure). There were no differences in the length of index admission hospital stay or mortality. Conclusion In primary ileocaecal resection for CD, high-volume hospitals had lower odds of early surgical reintervention, compared to low-volume hospitals. This finding may inform considerations of subspecialisation and centralisation in surgery for Crohn’s disease.

European survey on neurosurgical management of primary central nervous system lymphomas and preoperative corticosteroid therapy

IntroductionPreoperative corticosteroid therapy (CST) is common in primary central nervous system lymphoma (PCNSL) and may complicate histopathological diagnosis. There is an ongoing debate on the best management after preoperative CST. Research questionWe aimed to survey how different European neurosurgical units treat PCNSL patients after preoperative CST. MethodsAn English-language survey consisting of 21 questions addressing the management of patients with suspected PCNSL and preoperative CST was sent to European hospitals. The survey also included three clinical cases to assess the decision-making process in a clinical setting. ResultsThe survey was completed by 74 European hospitals. There was no clear consensus on how to treat a patient with PCNSL after CST. Accordingly, 24.3% responded that they would generally defer surgery regardless of a possible radiological response, 47.3% would defer surgery only if there is regression in preoperative MRI and the remaining 28.4% would defer surgery only if the tumor had completely vanished. Furthermore, there were distinct discrepancies in responses of neurosurgical units regarding their general management approach and their case-based decision in the three example cases. The results of our survey also showed regional differences and differences in treatment decisions between high-, intermediate- and low-volume centers. Discussion and conclusionThere was no clear consensus on how to treat patients with suspected PCNSL and preoperative CST. Furthermore, most centers also showed inconsistencies in their responses regarding their general approach as well as individual patient treatment. More high-quality evidence-based recommendations are needed to improve consensus and thus patient care.

An Update on Neurosurgical Management of Primary CNS Lymphoma in Immunocompetent Patients.

Primary central nervous system lymphomas (PCNSL) are rare CNS tumors that harbor a conspicuously longer diagnostic delay compared to other malignant brain tumors. The gold standard for diagnosis is stereotactic biopsy to acquire tissue for histopathological analysis and therefore neurosurgery plays a central role when reducing the diagnostic period is mandated. However, histopathological diagnosis could be complicated if the patient was preoperatively exposed to corticosteroids. Besides the histopathological result, diagnosis of a PCNSL also requires full diagnostic workup to exclude cerebral metastatic disease of a systemic lymphoma. Most reviews of PCNSL discuss recent advancements in systemic treatment options from an (neuro-)oncologic viewpoint, whereas our intention was to discuss the optimization of the diagnostic period and therefore describe current standards of imaging, summarizing the diagnostic workup, discussing the surgical workup and future diagnostic prospects as well as the influence of preoperative corticosteroid therapy to reduce the diagnostic delay of PCNSL patients.

Effect of preoperative long-term use of corticosteroids on the development of post-transplant lymphoproliferative disorders after lung transplantation: a single-center experience in Japan.

Post-transplant lymphoproliferative disorder (PTLD) is a major complication of lung transplantation (LTx). However, few studies on PTLD in Asian populations have been reported. We explored the characteristics of Japanese PTLD cases after LTx. We retrospectively reviewed 195 cases of LTx at our institute. We summarized the clinical experiences of 7 PTLD cases and analyzed the patient characteristics and survival outcomes of patients with (n = 7) and without (n = 188) PTLD. All PTLD patients were taking corticosteroids preoperatively (p = 0.0030), and the duration of preoperative corticosteroid therapy was significantly longer in the PTLD group (p = 0.0064) than in the non-PTLD group. The overall survival after LTx was significantly worse in the PTLD group (p = 0.027) than in the non-PLTD group. Among the three patients who died within 1year after the PTLD onset, two died of opportunistic infections without residual PTLD lesions. Chronic lung allograft dysfunction (CLAD) or bronchiolitis obliterans at an autopsy were diagnosed after PTLD treatment in four cases. Long-term preoperative corticosteroid therapy may be a risk factor for PTLD after LTx. Opportunistic infections are lethal complications of PTLD, regardless of the effectiveness of PTLD treatment. CLAD occurs at a high rate after PTLD treatment, and close monitoring is required.

Post-Transplant Lymphoproliferative Disorder in Lung Transplantation: A Single-Center Experience in Japan

<h3>Purpose</h3> Post-transplant lymphoproliferative disorder (PTLD) affects 3-9% of lung transplant (LTx) recipients, with a mortality range of 20-50%. Despite this high morbidity and mortality, few large studies on Asian population are reported, therefore, we lack fixed consensus regarding specific predictive risk factors in LTx recipients. This study was aimed at uncovering the risk factors of PTLD and evaluating the treatment strategy and outcome of Japanese PTLD cases. <h3>Methods</h3> We retrospectively reviewed 195 patients (re-transplantation cases were excluded) who underwent LTx at our hospital between October 1998 and February 2020. <h3>Results</h3> Seven PTLD patients (3.6%) were identified. The indication for LTx in PTLD group was 2 (28.6%), 3 (42.8%), 2 (28.6%) patients for idiopathic pulmonary fibrosis, other interstitial pneumonia including connective tissue disease, lung disease after hematopoietic stem cell transplantation, respectively. The proportion of indication was significantly different from those in non-PTLD patients (p=0.046). All PTLD patients had taken corticosteroid at the time of LTx (p<0.01), and the duration of corticosteroid therapy was significantly longer in the PTLD group (p<0.01). Overall survival after LTx was also significantly worse in the PTLD group (p=0.027). Among 7 PTLD patients, 3 patients died within 1 year after the onset of PLTD, resulting from viral and fungal infection with or without PTLD progression. Remaining 4 patients lived longer than 30 months; however, 3 out of 4 patients developed chronic lung allograft dysfunction (CLAD) after the treatment of PTLD. <h3>Conclusion</h3> Long-term preoperative corticosteroid therapy can be a risk factor of PTLD after LTx. Regardless of the state of PTLD, opportunistic infection was a lethal complication and should be desperately prevented. CLAD may occur at a higher rate after treatment of PTLD, therefore, close monitoring and adjustment of immunosuppressants are needed.

INNV-01. NEUROLOGIC IMPROVEMENT WITH CORTICOSTEROIDS PRIOR TO SURGERY IS PREDICTIVE OF DURABLE POST-OPERATIVE IMPROVEMENT IN MOTOR DEFICITS DUE TO BRAIN METASTASES

Abstract Corticosteroids reduce vasogenic cerebral edema and are thought to improve related neurologic deficits or symptoms of increased intracranial pressure. Brain metastases are typically associated with a large amount of edema and, consequently, come with a disproportionate degree of mass effect that may cause such deficits. There remains no standard approach to pre-operative corticosteroid therapy, nor is it understood what clinical characteristics are associated with a neurologic response to pre-operative steroids. We examined characteristics of steroid responders versus non-responders and, further, evaluated whether a response to preoperative steroids is predictive of durable improvement in neurologic function. Patients with pathology-proven brain metastases who underwent open surgical resection between 2009 and 2019 were identified from departmental records. Charts were reviewed to identify patients with motor dysfunction who received corticosteroids prior to surgery. Multiple patient and clinical characteristics were extracted and compared using student t-, chi-square, and Fisher’s exact tests. 90 patients exhibited pre-operative motor deficits, 69 of whom received corticosteroids prior to surgery (dose 2 – 112 mg; median 25 mg). 34 patients neurologic function improved prior to surgery, whereas 35 patients had no demonstrable improvement. All 34 patients (100%) whose motor function improved pre-operatively with steroids had sustained improvement at follow-up, whereas 27 of 35 (77%) patients who did not improve pre-operatively were better at follow-up (p = 0.005). All other clinical characteristics were similar between responders and non-responders. All motor deficits related to brain metastases that responded to steroids prior to surgery demonstrated durable improvement at follow-up, suggesting such an improvement portends a favorable long-term functional outcome. Conversely, a failure to improve with steroid therapy confers a more guarded prognosis.

The clinical relevance of performing a day seven post-operative absolute CD4 count in elective brain tumor surgery – A prospective cohort study from a single South African neurosurgical center

IntroductionThe co-morbid presence of a neoplastic brain tumor, in a patient who is HIV positive, is not uncommon in South Africa. The day-7 post-operative absolute CD4 count offers a unique window into the immunological status of an individual post elective brain tumor surgery. Materials and methodsWe performed a prospective cohort study consecutively enrolling all elective adult patients admitted tom our wards from the 01 July 2018–30 March 2020, with neoplastic brain tumors. In total 19 subjects that underwent elective operative intervention had a day seven post-operative absolute CD4 count performed. Data collected and analyzed in this study included age, HIV status, pre-operative corticosteroid therapy, pre-operative day CD4 count, timing of prophylactic antibiotic administration, craniotomy type, blood loss, duration of surgery, extent of resection, day seven post-operative CD4 count, post-operative corticosteroid therapy, histology, day-7 nosocomial infection incidence, Gram-stain result, and Glasgow Outcome Score. ResultsSignificance was demonstrated between the pre-operative day CD4 count and the day 7 post-operative CD4 count (p = 0.03). This allowed us to conclude the immunological impact of the surgery to have been insignificant. Significance was demonstrated between craniotomy type and day-7 post-operative CD4 count (p = 0.04). Significance was also demonstrated between extent of resection and the day-7 post-operative absolute CD4 count (p = 0.0018). A clinical trend was demonstrated for subjects with a lower day-7 post-operative CD4 count to have an increased risk of acquiring a day-7 nosocomial infection and a trend that this would be a Gram- negative infection. ConclusionAs per a PubMed review of the literature we are the first to report the relationship of the skull base surgical approaches, and a subtotal resection, and the statistically significantly delirious effect that these have on a day-7 absolute CD4 count. We further exclude increased intra-operative blood loss as an underlying cause behind the significance of these relationships.

The clinical value of a day one post-operative absolute CD4 count in elective neoplastic brain tumor surgery – A prospective cohort study from a single South African neurosurgical center

IntroductionMultiple simultaneously occurring intra-operative immune modulating interventions make it impossible to compare, the pre-operative day and day one post-operative absolute CD4 counts, and assume one has a measure of the pure surgical impact on this variable. Materials and methodsWe conducted a prospective cohort study by consecutively enrolling 41 elective subjects, with neoplastic brain tumours, in which we obtained a pre-operative day CD4 count and a day one post-operative CD4 count. Data collected included age, HIV status, pre-operative corticosteroid therapy, pre-operative day CD4 count, type of craniotomy, blood loss, duration of surgery, extent of resection, day one post-operative CD4 count, histological diagnosis, day-7 nosocomial infection incidence and Gram-stain result, and Glasgow Outcome Score. ResultsRegarding HIV status 29/41 (71%) subjects were HIV negative and 12/41 (29%) subjects were HIV positive. High significance was demonstrated between the pre-operative day CD4 count and the post-operative day CD4 count (p = 0.0001). While no significance was demonstrated (p = 0.51), a clinical trend was suggested where more than 1000 ml of blood loss had a detrimental effect on the day one post-operative CD4 count, which was often below 500 cells/mm. Again, while no significance was demonstrated (p = 0.13), a clinical trend was suggested where the longer the duration of surgery, the lower the day one post-operative CD4 count would be. No significance was demonstrated between day one post-operative CD4 count and day 7 nosocomial infection incidence (p = 0.35). A clinical trend was however demonstrated where a lower day one post-operative CD4 count suggested an increased risk of incurring this complication. Finally, significance was demonstrated between the day one post-operative CD4 count and the nosocomial infection gram stain result (p = 0.0058). ConclusionThe highly significantly similar pre-operative day CD4 count, to the day one post-operative CD4 count indicated that overall, the elective surgical procedures considered, had an insignificant effect.

Establishing the significance of a pre-operative day absolute CD4 count in patients booked for elective brain tumor surgery – A prospective cohort study from a single neurosurgical center in South Africa

IntroductionUnlike the situation in many 1st World-countries, new HIV infections in South Africa continue to rise. While mandatory HIV testing is unethical, a pre-operative absolute CD4 count can be performed in patient’s pre-elective brain tumour surgery. Materials and methodsThis was a prospective cohort study performed by consecutively enrolling 78 patients admitted to the adult neurosurgical wards at our hospital, from the 01 July 2018–30 March 2020, with neoplastic brain tumours that were taken for elective resection. Data collected and analysed in this study included subject age, gender, HIV status, admission absolute CD4 count, admission Glasgow Coma Score, pre-operative corticosteroid therapy, length in in-hospital stay prior to surgery, pre-operative day absolute CD4 count, operative day Glasgow Coma Score, intra-operative blood loss, duration of surgery, extent of resection, histological diagnosis, day-7 nosocomial infection incidence, and Glasgow Outcome Score. ResultsHigh significance was demonstrated between admission absolute CD4 count and the pre-operative day absolute CD4 count (p < 0.0001). With regards elective brain tumour surgery the relationship between the use of pre-operative steroids and the pre-operative absolute CD4 count is insignificant (p = 0.73). While no significance was demonstrated (p = 0.93), a clinical trend was suggested that the lower the pre-operative day absolute CD4 count, the longer the duration of surgery. No significance was demonstrated between pre-operative CD4 count and histology result (p = 0.45), although our results suggested a trend for cancers, of known and suspecting links to infective aetiology, to cluster in subjects with a pre-operative CD4 count < 500 cells/mm. No significance was demonstrated between pre-operative CD4 count and day 7 nosocomial infection incidence (p = 0.59). ConclusionHIV infection, and its complications, remain very real to HIV positive patients presenting with brain tumours in South Africa. Through the trends demonstrated we recommend the use of a pre-operative absolute CD4 count in the work-up of these patients.

Evaluating Outcome in HIV positive and HIV negative patients post elective brain tumor surgery at a single South African neurosurgical center – A prospective cohort study

IntroductionMultiple simultaneously occurring variables are recognized to have an impact on eventual outcome in patient presenting with neoplastic brain tumors that undergo elective resection. Materials and methodsWe conducted a prospective cohort study by consecutively enrolling 78 patients, from the 01 July 2018–30 March 2020, with neoplastic brain tumors that were taken for elective resection. Data collected and analyzed included age, gender, medical co-morbidities, HIV status, admission CD4 count, admission Glasgow Coma Score, length of stay prior to surgery, pre-operative corticosteroid therapy, pre-operative day CD4 count, timing of prophylactic antibiotic administration before skin incision, type of craniotomy, blood loss, duration of surgery, extent of resection, duration of post-operative steroid therapy, histological diagnosis, early nosocomial infection incidence, total length of in-hospital stay, and Glasgow Outcome Score. ResultsRegarding subject age, significance was demonstrated with Glasgow Outcome Score (p = 0.04). A clinical trend was suggested where subjects with medical co-morbidities had an unfavourable outcome. A further clinical trend was suggested whereby subjects who were HIV negative, as well as subjects with an absolute CD4 count > 500 cells/mm, tended to have a more favourable outcome than HIV positive subjects, or subjects with an absolute CD4 count < 500 cells/mm. Significance was demonstrated between histological tumor type and Glasgow Outcome Score (p = 0.04). Further trends were suggested where acquiring a day-7 nosocomial infection, and a prolonged length of in-patient stay, both suggested an increased chance of having an unfavourable outcome, although neither demonstrated significance. ConclusionIn our study the primary determinant of patient outcome was histological tumor type, and due to age clustering of specific histological tumor types, subject age was similarly demonstrated to be significantly associated with outcome. Our study furthermore demonstrated that HIV status, and absolute CD4 count, both demonstrated insignificance in relation to outcome.

Favorable survival in lung transplant recipients on preoperative low-dose, as compared to high-dose corticosteroids, after hematopoietic stem cell transplantation.

Although the number of patients developing pulmonary complications after hematopoietic stem cell transplantation (HSCT) necessitating lung transplantation (LT) is increasing, a little information is available about factors influencing the prognosis after LT in these patients. Corticosteroids represent the first-line therapy for pulmonary complications after HSCT; however, prolonged corticosteroid treatment prior to LT increases the potential risks of LT. In this study, we assessed the effect of preoperative corticosteroid therapy on long-term survival in patients undergoing LT after HSCT. We retrospectively investigated data from 13 patients who had received high-dose corticosteroid therapy and nine who had received low-dose corticosteroid therapy prior to LT for pulmonary complications after HSCT. Other than the preoperative corticosteroid dose, patient clinical characteristics did not differ. The incidence of postoperative complications within the first year after LT was significantly lower in the low-dose corticosteroid group (p=0.026). Survival after LT was also significantly better in the low-dose corticosteroid group than in the high-dose corticosteroid group (p=0.034). In recipients of LT after HSCT, preoperative low-dose corticosteroid use, as compared to preoperative high-dose corticosteroid use, could limit the risks of postoperative complications developing within the first year after the LT, leading to improved long-term survival after LT.

National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis.

Patients undergoing surgical treatment of chronic ulcerative colitis usually undergo a staged approach to IPAA. The purpose of this work was to identify the national trends in approach to IPAA for chronic ulcerative colitis and to evaluate 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program. This was a retrospective review study : This study was conducted at a tertiary care cancer center. Patients with chronic ulcerative colitis who underwent IPAA from 2005 to 2011 were identified. Those who underwent colectomy with pouch procedure were placed in a 2-stage cohort, and those without simultaneous colectomy were part of a 3-stage cohort. Emergent operations were excluded. Trends in procedure mix, preoperative characteristics, and postoperative 30-day outcomes were compared. Multivariate analysis was used to identify independent risk factors for postoperative infection. Of 2002 patients who underwent IPAA, 1452 (72.5%) underwent 2-stage and 550 (27.5%) underwent 3-stage surgery. Since 2007, the distribution of 2- versus 3-stage procedures has not changed (p = 0.66). At the time of pouch surgery, patients who had undergone 3-stage surgery were less likely to have preoperative corticosteroid therapy, albumin <3 mg/dL, preoperative sepsis, and weight loss (all p < 0.05). Superficial surgical site infection was more common after 3-stage surgery (11.5% vs 7.3%; p < 0.01). After controlling for preoperative factors, wound classification was the only independent predictor of deep incisional or organ space infection (p < 0.01; OR, 1.76; 95% CI, 1.23-2.53). This was a retrospective study. National trends of 2- versus 3-stage IPAA have remained stable over the last 5 years. Patients who underwent a 3-stage approach were healthier at the time of pouch surgery, with decreased corticosteroid use, hypoalbuminemia, and weight loss. Mixed results were seen for infectious complications with either approach. Prospective research is needed to determine the best approach to IPAA for chronic ulcerative colitis.

A Case of Axillary Kaposiform Hemangioendothelioma Resembles a Soft Tissue Sarcoma

Kaposiform hemangioendothelioma is a rare, aggressive vascular proliferation in children that is clinically and histologically distinct from hemangioma of infancy. It is often complicated with Kasabach-Merritt syndrome. The authors describe a 2-month-old girl who developed a rapidly enlarging deep subcutaneous solid tumor in the left axilla. The tumor size was about 10x7 cm and there was no skin change over the mass. The results of laboratory tests were significant for a moderate anemia (7.0 g/dL) and a profound thrombocytopenia (3x10/L). The preoperative radiologic findings were suspicious for a soft tissue sarcoma with scapular erosion. Anemia and thrombocytopenia were corrected by preoperative corticosteroid therapy and blood component transfusion. The tumor was excised totally and the pathologic findings were consistent with Kaposiform hemangioendothelioma. Serial blood examinations showed that the hemoglobin and platelet count returned to the normal range after surgery.

114 Benefit of preoperative corticosteroid therapy on the hepatic ischemia-reperfusion injury and cytokine response in patients unfdergoing hepatic resection: A prospective randomized trial

114 Benefit of preoperative corticosteroid therapy on the hepatic ischemia-reperfusion injury and cytokine response in patients unfdergoing hepatic resection: A prospective randomized trial

Cytomorphologic features characteristic of tumor stages of thymomas

The cytologic findings of the tumor cells characteristic of the stages of thymomas were investigated to assess the invasiveness of the tumors. Forty-six patients with thymoma who underwent extensive thymectomy without pre-operative corticosteroid therapy were included in this study. The histologic subtypes included 18 round/oval, 20 mixed, and 8 spindle type. The stages of thymoma classified according to Masaoka's clinicopathological classification included 16 stage I, 20 stage II, 6 stage III, 2 stage IVa, and 2 stage IVb, and myasthenia gravis was recognized in 5 patients. Cytologic findings were retrospectively analyzed in the Papanicolaou-stained stamp smears obtained from the cut surfaces of thymoma specimens. Morphometry of the epithelial tumor cells using Cosmozone-1A was performed to evaluate the validity of our cytologic categories. Compared with the cytologic findings of stage I or II thymomas, those of epithelial tumor cells in stage III or IV more frequently showed necrotic background (50.0%-stage III or IV vs 11.1%-stage I or II, p=0.006), large clusters of epithelial tumor cells (70.0% vs 36.1%, p=0.055), marked nuclear enlargement (90.0% vs 52.7%, p=0.033), marked anisokaryosis (100% vs 52.7%, p=0.006), marked nuclear polymorphism (40.0% vs 5.5%, p=0.004), hyperchromasia (50.0% vs 11.4%, p=0.007) and prominent nucleoli (50.0% vs 16.6%, p=0.028) whereas no significant correlation was observed between cytologic findings and tumor volume. Morphometric studies of thymoma tumor cells revealed that the nuclear size (mean values, 78.8 microm(3)-stage III or IV vs 58.2 microm(3)-stage I or II), the coefficient of variation of the nuclear size (0.326 vs 0.282), and the nuclear rotundity (0.849 vs 0.858) differed significantly between the two categories (p<0.05). Our findings demonstrated that there were significant differences between the cytologic findings of epithelial tumor cells of stage I or II thymomas and those of stage III or IV thymomas, and that the cytologic findings of thymoma tumor cells appear to be useful for distinguishing between non-invasive and invasive thymomas.

Estrogen and progestin receptors in acoustic and spinal neurilemmomas.: Clinicopathologic correlations

Estradiol and progestin receptors were studied in 20 patients with neuraxial Schwann cell tumors, and their presence was correlated to the clinicopathologic features and the amount of preoperative corticosteroid therapy. Based on an arbitrary cutoff value of 200 fmol per gram of tumor as indicative of a positive receptor value in breast cancer, 4 and 13 of the neurilemmoma tissue samples could be considered as positive for estrogen and progesterone receptors, respectively. Whereas there was no convincing correlation between the estrogen and progestin receptor activity and the age, sex, or menopausal status of the patients, overweight patients had significantly higher estrogen and progestin binding values. The correlation between the amount of preoperative prednisone therapy and the amount of [ 3H]estradiol and [ 3H]promegestone binding revealed no dose relationship. Correlating [ 3H]estradiol and [ 3H]promegestone content with the histologic type of the schwannomas (Antoni types A and B, respectively), we were not able to draw conclusions, because of the predominance of Antoni type A over Antoni type B tissues in our material. The necessity of nuclear receptor assays, ligand specificity testing, and in vitro studies is stressed as a prerequisite for answering the questions whether neurilemmomas contain genuine sexual steroid hormone receptors and whether these receptors are regulated via an estrogen-estrogen-receptor system as is the case in classical sexual steroid hormone target tissues.

Estrogen and progestin receptors in meningiomas: clinicopathological correlations.

Estradiol and progesterone receptors were studied in 44 patients with meningiomas and correlated to the clinicopathological features and amount of preoperative corticosteroid therapy. Thirty-four (77%) of the meningiomas contained high titers of specific high-affinity cytosol [3H]promegestone (R 5020) binding sites (mean 2,902 fmol/g tumor; range 0-9,598 fmol/g tumor) whereas only miniscule amounts of a nonspecific cytoplasmic [3H]estradiol binding component (mean 48 fmol/g tumor; range 0-201 fmol/g tumor) were detectable. No nuclear binding activity for [3H]estradiol was demonstrable. There was no convincing correlation between high PR activity and the age, sex, or menopausal status of the patients. The correlation study between the amount of preoperative corticosteroid therapy with the amount of [3H]promegestone binding revealed no dose relationship. Correlating [3H]promegestone content with the histologic type, we found 96% of meningothelial, 71% of transitional, and 40% of fibroplastic meningiomas to contain progesterone receptors. The necessity of in vitro studies is stressed to assess the biosynthesis and biological activity of the progesterone receptor in meningiomas, which is apparently not estrogen regulated, as is the case in other estrogen target tissues.

Anaesthetic management of insulinoma

The anaesthetic management of two cases of insulinoma treated by distal pancreatectomy is presented. Stress is laid on pre-operative and intra-operative glucose administration in sufficiently high quantity. Pre-operative corticosteroid therapy is better avoided. Dextrose infusion should be stopped soon after removal of the tumour to prevent excessive hyperglycemic response in the postoperative period. Methyoxyflurane was used because it tends to raise the blood sugar level. Pancuronium bromide was preferred because of the stable cardiovascular conditions it produces.