Simple Local Excision Research Articles

Long-term impact of postoperative radiotherapy in carcinoma of the vulva FIGO I/II

Purpose: Between 1953 and 1978, postoperative radiotherapy was used as an adjuvant therapy for carcinoma of the vulva that had not been treated with radical vulvectomy. We evaluated long-term results and possible prognostic factors. Methods and Materials: Ninety-two patients were treated. Surgical procedures were simple vulvectomy, electrocoagulation, or local excision. Radiotherapy doses to the vulva ranged from 0 to 90 Gy. All patients received radiotherapy to the inguinal lymph nodes, ranging from 30 to 60 Gy. Thirty-year retrospective follow-up was done evaluating the records and statistical survival rates. Results: Five-year actuarial survival rates in T1 patients were 71% (77% cause-specific survival rate), for T2 patients 43% (48% cause-specific survival rate). The difference between T1 and T2 patients was significant ( p < 0.05). Patients with tumors of the labia minora had a significantly higher survival rate than those with different sites affected. Doses of 45 Gy or more to the vulva were sufficient to increase the 5-year cause-specific survival rate from 55% to 88%. The results in three subgroups were analyzed, group 1 having received electrocoagulation, but no radiotherapy of the vulva; group 2, local excision and doses of 40 Gy to the vulva; group 3, local excision and doses of 60 Gy to the vulva. There was a significant effect on 10-year cause-specific survival rates: 48% in group 1, 11% in group 2, and 88% in group 3. In multivariate analysis, the significant independent factors were T classification, tumor sites and—with only marginal significance—radiation doses to the vulva. Conclusions: The prognosis in early vulva carcinoma after nonradical surgery primarily depends on T classification and the site of the primary tumor. With univariate analyses, the dose has a significant effect on survival. In multivariate analyses the dose is a marginal independent factor in the whole group of patients. After nonradical surgery of early vulva carcinoma, the vulva should be irradiated resulting in better long-term survival.

Collagenous fibroma (desmoplastic fibroblastoma): a distinctive fibroblastic soft tissue tumor.

Collagenous fibroma is a distinct, benign, fibroblastic/myofibroblastic proliferation, probably neoplasm. It is a slow-growing tumor arising in predominantly subcutaneous tissue. This tumor is composed of stellate-shaped fibroblasts and abundant interstitial collagen. Since none of reported collagenous fibromas recurred, simple excision is an appropriate treatment. Collagenous fibroma should be differentiated from fibromatosis, which has a high risk of local recurrence if simple local excision is done. Fibromatosis is more cellular and shows short fascicular arrangements of tumor cells and greater infiltration at the periphery than collagenous fibroma.

Dendritic fibromyxolipoma: clinicopathologic study of a distinctive benign soft tissue lesion that may be mistaken for a sarcoma.

Twelve cases are described of a distinctive benign soft tissue lesion that may be mistaken for a sarcoma. The tumors occurred in 11 men and a woman aged 33 to 81 years (mean, 64 years), and measured from 2 to 11 cm in greatest diameter (mean, 6 cm). They were grossly described as soft, well-circumscribed, yellow-gray, with a mucoid cut surface. All cases were superficially located in the subcutis or muscular fascia of the head and neck region or the chest and back. Histologically, the tumors were characterized by a proliferation of spindle or stellate fibroblastic cells variably admixed with mature adipose tissue embedded in an abundant myxoid and collagenized stroma. The spindle and stellate fibroblastic cells were characterized by slender dendritic prolongations of their cytoplasm, which appeared to extend for short distances along connective tissue planes. Electron microscopy in two cases confirmed the dendritic nature of the fibroblastic cells, which showed elongated cytoplasmic processes lacking external lamina and displaying foci of pinocytotic activity. Immunohistochemical studies in 11 cases showed strong positivity of the spindle cells with vimentin, CD34 and bcl-2, and negative staining for smooth muscle actin, muscle-specific actin (HHF35), desmin, S-100 protein, keratin, and EMA. Because of their prominent myxoid stroma and relatively large size, some of these tumors were initially misinterpreted as low-grade sarcomas. Clinical follow-up in five cases, however, showed that the patients were alive and well without evidence of recurrence between 5 and 13 years (mean follow-up, 8 years) after simple local excision. The present cases appear to represent a distinctive form of benign soft tissue neoplasm that should be distinguished from myxoid liposarcoma and other benign and malignant myxoid tumors of superficial soft tissues.

Basal Cell Carcinoma of the Penis: Case Report and Review of the Literature

Basal cell carcinoma of the skin is the most common tumor in humans but occurrence in the penis is extremely rare. We report the sixteenth case of basal cell carcinoma of the penis. This lesion was successfully treated with simple local excision. A review of the literature revealed that most such tumors present in the fifth through seventh decades of life on the shaft of the penis. Natural history is that of a slowly growing tumor with little propensity to metastasize. Universal success has been achieved with simple local excision.

Intraosseous leiomyoma of the mandible: report of a case

A rare case of intraosseous leiomyoma of the mandible is reported. This is the fourth recorded case involving the mandible. The literature is reviewed and the amenability of the lesion to simple local excision is highlighted.

Calcifying Fibrous Pseudotumor

We report 10 cases of a distinctive benign fibrous lesion characterized by the presence of abundant hyalinized collagen with psammomatous or dystrophic calcifications and a lymphoplasmacytic infiltrate. The lesions were present from 2 months to 10 years before resection and ranged in size from 2.5 to 15 cm. They involved subcutaneous and deep soft tissues and, although relatively well-circumscribed, occasionally infiltrative borders or entrapped structures were seen on microscopic examination. The lesions were located in the extremities (three cases), trunk (two cases), scrotum (two cases), groin (one case), neck (one case), and axilla (one case). Both sexes were equally affected. The mean and median ages of the patients were 16.2 and 18.5 years, respectively (range, 1 to 33 years). All cases were initially managed by simple local excision. Follow-up ranging from 2 months to more than 10 years (median, 41.5 months) was available in six cases and revealed a local recurrence in one instance; this became clinically apparent about 7.5 years after the initial resection. Morphologic features and follow-up data suggest this may be a unique form of fibrous pseudotumor.

Breast cancer

Breast cancer will affect 1 out of 10 women in the United States and cause 27 deaths per 100,000 women per year. The etiology remains unknown, but the incidence correlates with genetic as well as environmental factors. Screening programs have been shown to prolong the survival by early detection compared with control populations but remain underutilized by physicians and patients. Breast disease can be evaluated by physical examination and mammography and a definitive diagnosis made by needle aspiration, needle biopsy, or excisional biopsy. This allows the patient to participate in the decision regarding mastectomy vs. conservative surgery plus radiation therapy. These two approaches have equivalent survival in selected patients. Patients with locally advanced, nonmetastatic disease benefit from a multidisciplinary approach using preoperative chemotherapy and postoperative radiation therapy. This approach has allowed less disfiguring surgery and improved survival. Preinvasive carcinoma is diagnosed more frequently with the increased use of screening mammography. Local therapy options include simple mastectomy, local excision plus radiation, or local excision alone. The natural history and results of therapy in preinvasive disease are evolving as more data are accumulated. Systemic adjuvant therapy is recommended for all node-positive patients and most node-negative patients with invasive cancer. The specific modality (hormonal or cytotoxic) varies with the subgroup involved. Treatment of metastatic disease to palliate symptoms and prolong survival includes the use of local therapies (surgery and radiation) and hormonal and cytotoxic agents. Most patients benefit, but cure has been unobtainable. Newer approaches utilizing high-dose chemotherapy and bone marrow support with growth factors or autologous transplantation are currently being explored.

摘出術後追加切除を行った軟部悪性腫ようの検討

Most patients with soft tissue sarcomas of relatively small size are firstly treated by primary doctor with simple local excision or enucleation because of the relative rarity of malignant soft tissue tumors and the unfamiliarity of this breed. Seventeen patients with soft tissue sarcomas initially treated by simple local excision were managed by additional surgical procedure of wide curative resection. Although three patients of trunk sarcomas had local recurrence again, the rest 14 were free from the tumor locally.Many quetions remain unanswered regarding how much surgery is enough, what is the best adjunct and what is the better method of curative surgical management. Additional management is capable of either suppressing or eradicating micro- or macro-residual tumors. Local conservative procedures augumented by adjunctive management have less recurrences than simple local excision alone has had in the past. More patients live longer and have good prognosis because of additional management.

Myxomas of the Conjunctiva

Fourteen cases of rare conjunctival myxoma were studied clinicopathologically. The median age of the eight men and six women was 50 years (range, 18 to 76 years). The tumors appeared as slowly growing, freely movable solitary lesions located primarily in the temporal bulbar conjunctiva. The clinical diagnosis was cyst in many cases. The lesions were removed by simple local excision and did not recur. Histologically, they were hypocellular and were composed of stellate and spindle-shaped cells; some had small intracytoplasmic and intranuclear vacuoles. The stroma contained abundant mucoid material and sparse reticulin and delicate collagen fibers. Scattered mast cells were found in many lesions. Ultrastructurally, the intracytoplasmic vacuoles appeared to be extremely dilated cisternae of rough-surfaced endoplasmic reticulum. Invaginations of the nuclear membrane by the cytoplasm correlated with intranuclear vacuoles seen by light microscopy. Conjunctival myxomas are benign tumors and should be differentiated from other benign and malignant soft-tissue tumors with myxomatous features.

Conjunctivochalasis

Conjunctivochalasis is an isolated bilateral condition in which redundant conjunctival tissue overlies the lower eyelid margin or covers the lower punctum. It causes tearing by mechanically disrupting the normal flow of tears. Unlike the boggy conjunctiva seen in an allergic reaction, the extent of this redundant tissue is small, well-localized, and unresponsive to antihistamine drops. During the 40-month period from May 1981 through September 1984, 15 patients complaining of epiphora were found to have this problem. Simple local surgical excision relieved their symptoms. Follow-up period ranged from 10 to 40 months, with an average of 27 months. Conjunctivochalasis can be recognized by a thorough ocular examination and managed by simple excision of the redundant tissue. Consequently, before extensive surgery such as dacryocystorhinostomy, eyelid surgery, or silicone intubation of the lacrimal system is contemplated, conjunctivochalasis should be ruled out and corrected.

Malakoplakia of the Larynx

The first case of malakoplakia of the larynx in the world literature is reported. The soft raised plaques were removed from a 61-year-old white male, who was a heavy smoker and complained of hoarseness, but was otherwise in good general condition. From the follow-up of our patient, it is concluded that malakoplakia is not of particularly bad prognosis when affecting the larynx, and that simple local excision seems to be enough to produce cure. On these grounds, the laryngologists should be aware of the entity and consider it when dealing with raised nodules or plaques in the larynx, while the pathologists should be alert to look for the Michaelis-Gutman bodies, when encountered with peculiar histiocytic reactions anywhere in the body, even in the larynx.

Synovial Sarcoma

Thirty-three patients with synovial sarcoma were studied with respect to age, sex, site, clinical presentation, pathologic findings, and primary surgical treatment. Seventy percent of the patients were in the first three decades of life, and there was a 2:1 male predominance; the overall survival rate was 36%. There was a high local recurrence rate (64%) after simple local excision, and poor survival (27%). While wide local resection gave the best results (50% survival), it also carried a risk of high recurrence. Patients treated by amputation had a 42% survival rate. Thus, it can be concluded that adequate surgical treatment improved survival and reduced the recurrence rates. The lungs were the most common metastatic site, but lymph node metastasis occurred in 27% of the patients, often after tumor recurrence. Favorable prognostic factors included youth (patients younger than 20) and biphasic or epitheloid histologic types.

Follow-up study of 14 oral granular cell tumors

The granular cell tumor is an uncommon benign lesion with a predilection for the oral cavity. Fourteen tumors from 13 patients have been reviewed with a follow-up period ranging from 7 months to 21 years with an average of 7.1 years. Women were affected twice as often as men, and the age of the patients varied from 14 to 75 years. Eleven of the lesions were located on the tongue, the remaining on the lower lip, sublingual papilla, and the buccal mucosa. Multiple lesions were found in one patient. The tumors varied in size from 3 to 25 mm in diameter and were all firm to hard in consistency. All the lesions were treated by local excision. Pseudoepitheliomatous hyperplasia of the overlying epithelium was seen in four patients. In spite of a possible inadequate removal of 10 of the lesions where granular cells extended to the margin of excision, no recurrence was seen. A simple but deep local excision is the recommended treatment.

I.Perineal Endometriosis

Endometriosis involving the perineum is rare. We have collected total 110 cases of perineal endometriosis from the literature which included only 5 cases in Japan. The cases reported have steadily increased in recent years. Based on the fact that four new cases have been found in our Hospital in a relatively shorter period, we postulate much higher incidence of this disease in Japan than that would appear from the literature. Almost all of cases were managed by episiotomy associated with parturition, and the resultant endometriosis developed in previous episiotomy scar or at its adjacent site. The patients commonly complained of painful paeineal swelling during menstruation. The period of latency between episiotomy and manifestation of symptoms varied 45 days to 14 years, showing a peak between 1 to 3 years. The average age of patients was reported to be between 28 and 38 years from different institutions, being somewhat lower than the usual age group for patients with endometriosis. The perineal lumps were recognized as a single dark reddish or bluish nodule which varied 1 to 2 cm in diameter. On palpation, the mass was less movable, often tender due to periodic bleeding into cystic space. It increased in size and became painful during menstrual period ; after menses, the nodule became almost painless and decreased in size. When the patients fulfilled these clinical features, the preoperative diagnosis of perineal endometriosis is possible. The treatment of choice is simple local excision. Complementary hormonal therapy has been suggested in several cases with large or recurrent mass. Definite histologic diagnosis can be made by demonstrating endometrial glands and stroma, accom-panying hemorrhage, and granulation tissues characteristically containing large amounts of hemosiderin and lipid debris. The specimens obtained from Gase 3 and 4 of our series were subjected to ultrastructural analysis.Electron microscopic examination showed that the epithelial cells in specimen of Case 3 retained the fine structure of endometrial cells during proliferative phase, and those in specimen of Case 4did that of the cells during early secretory phase. As to histogenesis of perineal endometriosis, the most cases reported including our cases can reasonably be explained by direct wound implantation of shed endometrial tissues during delivery. On the basis of this implantation theory, we proposed some measures to eliminate the occurrence of this disease.

1. Clinicopathologic Analysis of Rectal Carcinoids Reported in Japan

The cases of rectal carcinoid reported in Japan have shown a significant increase in recent years, and total numbers of cases recorded in the literature until 1976 were 65. Average age of the patients was 48 years, and the overall percentages were 61% in males and 39% in females. The primary tumors were usually found 4 to 6 cm above the anal ring as a single submucosal nodule with yellowish color, but there was no constant laterality in their localization. The majority of the tumors were below 2 cm in diameter, and the simple local excision was performed. The cases reported had nonspecific rectal symptoms of bleeding and pain, and only two cases were accompanied by carcinoid syndrome. The metastasis into local lymph nodes or liver was observed in 11 cases including one with a primary tumor below 2 cm in diameter. The rectal carcinoids regardless of their size proliferated in lamina propria mucosae, and often invaded submucosa beyond muscularis mucosae. The muscular invasion and lymph node metastasis were more pronounced in the cases with the lesion more 2 cm, in whom the radical operation including an abdominoperineal excision of rectum was undertaken as adequate therapy.A primary carcinoid tumor of rectum can be correctly diagnosed by characteristic histologic patterns such as the formation of ribbon or rosette and sclerosing pattern compres-sed by dense connective stroma. It was found that the rectal carcinoid belongs to the family of slightly argyrophilic carcinoid by Grimelius' silver nitrate stain. In all of the cases examined by electron microscope, neoplastic cells contained abundant round secretory granules measuring 200 nm on average in diameter.

Paget's disease of the vulva

Paget's disease of the vulva and Paget's with an underlying adenocarcinoma may be two separate lesions. The clinical aspects of the two follow entirely different courses. Paget's disease without invasion has a rather indolent behavior and can reoccur locally without subsequent invasion. Paget's with invasion appears to be aggressive with potential spread to regional lymph nodes. Simple local excision may be adequate therapy for Paget's disease without invasion. Radical vulvectomy and inguinal lymphadenectomy appears to be minimal treatment for Paget's disease with an associated adenocarcinoma.

Proliferative myositis. Report of thirty-three cases.

Proliferative myositis is a pseudosarcomatous process of muscle characterized by an ill-defined proliferation of basophilic giant cells and fibroblasts chiefly involving the perimysium, the epimysium and the neighboring fascia. Because of its rapid growth, its cellularity and the presence of giant cells, the condition had been initially confused with a sarcoma in 14 of the 33 cases reviewed. Clinically, the process usually presented as a painless firm solitary mass that grew rapidly and chiefly affected, as a poorly circumscribed scarlike process, the muscles of the shoulder region, the thorax and the thigh. In 19 of the 33 cases the lesion had been noted for two weeks or less prior to surgery. Proliferative myositis differed from other pseudosarcomatous lesions such as nodular fasciitis or myositis ossificans principally by its infiltrative diffuse growth, the presence of bizarre giant cells and the high incidence in patients older than 45 years. Lesions closely resembling proliferative myositis, but affecting only the fascia or the subcutaneous fat, were observed in 12 additional patients. Follow-up data on 30 patients with proliferative myositis revealed a benign and probably self-limiting process having no tendency to recur. Treatment by simple local excision is recommended. Radical or mutilating surgery should be discouraged.

Plasma cell mastitis

1. 1. A brief review of the current opinions on the etiology and pathology is presented. 2. 2. A new case of plasma cell mastitis is reported to add to the existing series of fifty cases. 3. 3. The treatment of choice seems to be radical mastectomy instead of simple mastectomy or local excision, should the axillary glands be involved as is usually the case. 4. 4. Repeated follow-up of these cases for several years is advised in order to detect local or remote recurrences.