Successful Tumor Removal Research Articles

Surgery of the adrenal gland.

The features of modern medicine consist of minimal invasiveness and promoting the quality of life. The Niigata University Urological group in Japan performed the first successful laparoscopic removal of the adrenal tumor in 1992 [1]. That success was quickly followed by the Tokyo [2], Hamamatsu [3], Kyoto [4], and Kitazato [5] groups, all of which were located in Japan. Immediately after the successful laparoscopic adrenalectomy, we realized that, compared wi th open adrena lec tomy, l aparoscopic adrenalectomy was much less invasive, induced much less postoperative pain, and involved a much shorter convalescence, resulting in quicker recuperation to preoperative daily activity [6]. Therefore, laparoscopic adrenalectomy has become widely accepted around the world and is popular today. The incidence of adrenal incidentaloma has increased with the advent of many innovative diagnostic tools. Do we have to remove all adrenal incidentalomas? Obviously the answer is “no.” In that case what are the indications and limitations of laparoscopic adrenalectomy? According to Michel et al. [7], the indications of laparoscopic adrenalectomy for incidentalomas include the following: 1) functioning tumors; 2) tumors measuring larger than 4 cm in diameter or growing in size during the follow-up course; 3) tumors showing necrosis, bleeding, or irregular contour on computed tomography; and 4) cases with the higher concentration of serum dehydroepiandrosterone sulfate. I presume that most of the laparoscopists performing adrenalectomy will agree with the authors’ criteria, although exact size of the tumor as an indication is varied. In our observation of 210 cases with incidentalomas [8], 14 cases (6.7%) were malignant. All of the tumors were larger than 6.5 cm in diameter. The fourth category suggests that pre-Cushing’s syndrome can exist among the patients with incidentaloma, even if they do not show clinical symptoms of Cushing's syndrome despite serum or urinary abnormal endocrinologic data. Up until the present time, nobody knows whether these cases will develop Cushing's syndrome in due course. Besides the previous indications, there are some technical limitations in laparoscopic adrenalectomy. These include marked adhesion and infiltration surrounding the tumor probably due to previous surgery or malignancy, and extreme obesity (more than 35 in the body mass index). The indication for pheochromocytoma [9] was controversial because pneumoretroperitoneum or pneumoperitoneum caused great or unstable increase of the blood pressure and because of possible multiple tumors. With the advance of the cardiocirculatory control technique and the image diagnostic procedures, at present most laparoscopists include pheochromocytoma as an indication. However, laparoscopic removal of adrenal malignancy is still controversial, because these malignancies are usually large and intraoperative dissemination or port site recurrence is always possible. Although Heniford [10] reported 10 successful cases, with only one failure in malignancy accompanied by caval invasion, I personally do not perform laparoscopic removal of a malignancy that is mostly large and might be associated with lymph node metastases. The retroperitoneal approach to the adrenal gland showed less postoperative complications in one report [11]. However, I believe that both approaches are excellent and that the outcomes are just a matter of the learning curve. Laparoscopic adrenalectomy is one of the most prominent areas in which urologists have pioneered and significantly contributed to the progress of medicine for the past decade. I recommend that all the urologic laparoscopists acquire full command of laparoscopic adrenalectomy.

Sir Charles Ballance: pioneer British neurological surgeon.

Sir Charles A. Ballance (1856-1936) began his medical career at St. Thomas's Hospital the University College, London, England, in 1875, receiving honors in every subject and a gold medal in surgery. Victor Horsley (1857-1916) and Ballance were classmates at the University and in the later 1880s began work together at the Brown Institute and the National Hospital, Queen Square. In addition to important studies on vascular surgery, Ballance was involved in primate work on cerebral localization with lifelong friends Charles Beevor, Charles Sherrington, David Ferrier, and others. In June of 1887, Ballance assisted Horsley at Queen Square in the successful removal of an extramedullary spinal cord tumor. Horsley was about to abandon the operation, but his friend urged the removal of one lamina higher and the tumor was discovered. Ballance, a demonstrator in anatomy, realized the spinal cord segments lay higher in relation to the vertebral bodies than was generally appreciated. Ballance popularized the operation of radical mastoidectomy for advanced middle ear infection (1890), standardized an approach to drain or excise temporal brain abscesses, and was the first to clearly understand the neurological signs of cerebellar abscess (1894). Ballance also devised cranial base approaches to attack infectious thrombophlebitis of the lateral, petrosal, and cavernous sinuses. He was the first to completely remove an acoustic tumor (1894); 18 years later, the patient remained well. Ballance also drained a posterior fossa subdural hematoma (1906) and successfully sectioned the auditory nerve for Meniere's syndrome (1908). Ballance's operative experience with both supra- and infratentorial brain lesions included approximately 400 cases, which are detailed in his 1907 book, Some Points in the Surgery of the Brain and Its Membranes. His two-volume set, Essays on the Surgery of the Temporal Bone (1919), remains a brilliantly written and illustrated classic. Ballance was an expert on nerve regeneration and nerve grafting, and after many years of devoted research, he devised successful operations for facial nerve paralysis. For this and early vascular work, he is often credited as the first English surgeon to reintroduce classical Hunterian methods of experiment into surgery. He was honored as the founder and President of The Society of British Neurological Surgeons in 1926. Perhaps best known as a general and aural surgeon, Ballance was second only to Horsley in reputation as a pioneer British neurological surgeon. Described as a painstakingly slow but delicate and meticulous operator, Ballance made a contribution to neurosurgery and temporal bone surgery that was immense.

Relationship between serum concentrations of the growth factor pleiotrophin and pleiotrophin-positive tumors.

Growth factors produced by tumor cells are essential for tumor expansion and may be useful in monitoring tumor progression or therapeutic efficacy if the factors are released into the circulation. In this study, we measured serum levels of pleiotrophin, a secreted heparin-binding growth and angiogenesis factor, in mice bearing human tumor xenografts to determine whether these levels reflected overall tumor burden, and we examined the relationship between tumor expression of pleiotrophin and serum levels of this factor in patients with cancer. Pleiotrophin in serum from mice and humans was measured by use of a highly sensitive enzyme-linked immunosorbent assay. For the clinical studies, serum specimens were obtained from 193 patients with various cancers of the gastrointestinal tract and from 28 healthy control subjects. In a subset of 64 cancer patients, serum levels of pleiotrophin were measured at the time of surgery, and tumor expression of this factor was detected immunohistochemically. All P values are two-sided. In mice, serum pleiotrophin levels were found to increase as a function of tumor size. In humans, elevated serum pleiotrophin levels were found in patients with pancreatic cancer (n = 41; P<.0001) and colon cancer (n = 65; P = .0079) but not in patients with stomach cancer (n = 87; P =.42). A statistically significant positive association was found between elevated levels of pleiotrophin in serum drawn at the time of surgery and expression of this factor by tumors (P<.0001). In both mice and humans, serum pleiotrophin levels dropped after successful tumor removal. Elevated serum pleiotrophin levels can indicate the presence of tumors expressing this factor. Monitoring serum levels of pleiotrophin may prove useful in determining the pharmacologic efficacy of cytotoxic or anti-pleiotrophin therapy.

Experience with the Biostator for diagnosis and assisted surgery of 21 insulinomas

Surgical removal is the treatment of choice for insulinomas. Definitive biochemical diagnosis of organic hyperinsulinism has to be established before surgery. These tumors are sometimes undetected by preoperative imaging investigations and, in addition, surgical management may also be complicated by the absence of palpable tumors or the presence of multiple tumors. We report the value of the euglycemic clamp technique for diagnosis and surgical treatment in 21 patients with confirmed insulinomas. Data were compared with 12 controls, and nine patients were retested after surgery. During the euglycemic hyperinsulinic clamp, the mean C-peptide value was 3.6+/-2.2 ng/ml and it remained high (3.8+/-2.5 ng/ml), despite exogenous hyperinsulinemia (1762.7+/-233.2 microU/ml for the highest plateau). In contrast, the C-peptide concentration declined in 12 control patients (0.3+/-0.1 ng/ml, P < 0.001) and after successful surgery in nine retested patients (0.3+/-0.2 ng/ml, P < 0.01). During continuous glucose monitoring, successful removal of the insulin-secreting tumor was accompanied by an increase in plasma glucose concentrations and a loss of requirement for endogenous glucose within 36 min (range 28-43 min). The continuing requirement for glucose after the ablation of the tumor revealed the existence of additional and initially undetected tumors in four patients, among whom two had the multiple endocrine neoplasia type I (MEN I) syndrome. We conclude that the euglycemic hyperinsulinic clamp is a reliable and convenient diagnostic test for insulinoma, as it is both safe (no hypoglycemia) and relatively brief (3 x 90 min). Glucose monitoring and glucose clamping provide a reliable indicator of complete removal of insulin-hypersecreting tissue, especially in patients with occult or multiple tumors.

Intraoperative gastrin measurements during surgical management of patients with gastrinomas: experience with 20 cases.

Despite recent advances in imaging techniques for endocrine tumors of the duodenum and the pancreas, preoperative localization of gastrinomas is inconsistent. Successful surgical management of patients with Zollinger-Ellison syndrome (ZES) and removal of all gastrin-secreting tumors remains a difficult task. The aim of the study was to evaluate the predictive value of intraoperative gastrin measurements for successful surgical treatment in patients with gastrinomas. Intraoperative gastrin measurements were performed in 20 patients with ZES who underwent resection of gastrin-secreting tumors. Gastrin was measured with a radioimmunologic assay in blood samples obtained from a peripheral vein and from the portal vein at the beginning of the operation (T0) and 20 minutes after removal of the lesion(s) (T1). In 16 patients gastrin was also measured 4 minutes after injection of secretin 3 U/kg (T2). Thirteen patients (65%) were cured by surgery. In two of them, peripheral and portal gastrin levels were normal at T0, precluding any further interpretation of the test. Completeness of surgery was confirmed by normalization of gastrin levels at T1 or the absence of stimulation at T2 (or both) in 10 patients. In only one case did the gastrin levels remain elevated at T1 despite a favorable outcome after surgery. In each of the seven patients (35%) who had persisting disease at 1 year, failure of the surgical procedure was predicted by persistence of high levels of gastrin at T1. In patients with hypergastrinemia, the positive predictive value of intraoperative gastrin measurement for completeness of surgery and the specificity were 100%. The negative predictive value was 88% and the sensitivity 91%. The overall accuracy of the test was 94%. In patients with ZES the normalization of systemic hypergastrinemia during surgery affirms the successful removal of all gastrin-secreting tumors. We conclude that intraoperative gastrin measurement is a valuable addendum for optimizing the surgical management of gastrinoma.

Pheochromocytoma Associated With Clinical and Echocardiographic Features Simulating Hypertrophic Obstructive Cardiomyopathy

Left ventricular hypertrophy simulating hypertrophic obstructive cardiomyopathy is a rare complication of pheochromocytoma. In this report, two cases of pheochromocytoma with this complication are described. Successful tumor removal in both cases led to relief of symptoms, normalization of BP, regression of abnormal clinical features, normalization of the ECGs, but only partial regression of the echocardiographic features despite prolonged follow-up of 24 and 32 months, respectively.

Hot flushes in men with pituitary adenoma

Hot flushes are common in menopausal women and also in men made acutely hypogonadal after orchiectomy or testicular injury. It is, however, an unusual symptom in patients with hypogonadism secondary to pituitary tumors. In evaluating the histories of men with hypogonadal state associated with nonfunctioning pituitary macroadenoma we were struck by the presence of hot flushes in four of them. All four of the patients were hypogonadal with sexual dysfunction preoperatively. All had low gonadotropins and low testosterone levels with varying degrees of panhypopituitarism. All had successful transsphenoidal removal of tumors. None had endocrine improvement following surgery. All patients had improvement in sexual function and the hot flushes with administration of testosterone postoperatively. Hot flushes are an uncommon presentation in men with pituitary adenoma. Perhaps the symptom will become more prominent if it is specifically questioned. We postulate that the cause of the flushing is related to nonsuppressed pulsatile secretion of gonadotropin-releasing hormone (GnRH) from the hypothalamus.

False-positive magnetic resonance imaging of small internal auditory canal tumors: a clinical, radiologic, and pathologic correlation study.

Magnetic resonance imaging with gadolinium facilitates the early diagnosis of internal auditory canal tumors at a small enough stage to permit increasing application of hearing preservation surgical techniques. Surgeons report successful removal of tumors as small as 3 mm, which are diagnosed with enhanced magnetic resonance imaging. A retrospective study was performed to determine the risk of false-positive "tumor" diagnosis with enhanced magnetic resonance imaging. We reviewed the imaging records, office notes, and surgical records of 112 consecutive "tumors" involving the internal auditory canal treated by the Wilford Hall USAF Medical Center Neurotology Service between July 1991 and July 1994. Two categories of false-positive magnetic resonance imaging were identified: (1) surgically confirmed absence of internal auditory canal neoplasm and (2) spontaneous resolution of the internal auditory canal lesions on subsequent, enhanced magnetic resonance images. Overall, eight false-positive scans were identified. Three were surgically confirmed as false-positive, and five resolved on subsequent imaging studies. All cases were smaller than 6 mm and involved the distal internal auditory canal (fundus). The surgically confirmed cases were approached through a middle fossa technique with successful hearing preservation. The overall rate of surgical false-positive results was 3.5% (3 cases in 86 surgeries). However, the overall false-positive rate for intracanalicular "tumors" was 32% (8 cases in 25 intracanalicular lesions). Although hearing preservation is more likely in small lesions, the surgeon must consider the possibility that an internal auditory canal lesion smaller than 6 mm may actually represent a nonneoplastic process. Enhancing lesions limited to the internal auditory canal fundus may be treated by reimaging the patient in 6 months after the first image rather than by prompt surgical exploration.

False-positive magnetic resonance imaging of small internal auditory canal tumors: A clinical, radiologic, and pathologic correlation study

Magnetic resonance imaging with gadolinium facilitates the early diagnosis of internal auditory canal tumors at a small enough stage to permit increasing application of hearing preservation surgical techniques. Surgeons report successful removal of tumors as small as 3 mm, which are diagnosed with enhanced magnetic resonance imaging. A retrospective study was performed to determine the risk of false-positive "tumor" diagnosis with enhanced magnetic resonance imaging. We reviewed the imaging records, office notes, and surgical records of 112 consecutive "tumors" involving the internal auditory canal treated by the Wilford Hall USAF Medical Center Neurotology Service between July 1991 and July 1994. Two categories of false-positive magnetic resonance imaging were identified: (1) surgically confirmed absence of internal auditory canal neoplasm and (2) spontaneous resolution of the internal auditory canal lesions on subsequent, enhanced magnetic resonance images. Overall, eight false-positive scans were identified. Three were surgically confirmed as false-positive, and five resolved on subsequent imaging studies. All cases were smaller than 6 mm and involved the distal internal auditory canal (fundus). The surgically confirmed cases were approached through a middle fossa technique with successful hearing preservation. The overall rate of surgical false-positive results was 3.5% (3 cases in 86 surgeries). However, the overall false-positive rate for intracanalicular "tumors" was 32% (8 cases in 25 intracanalicular lesions). Although hearing preservation is more likely in small lesions, the surgeon must consider the possibility that an internal auditory canal lesion smaller than 6 mm may actually represent a nonneoplastic process. Enhancing lesions limited to the internal auditory canal fundus may be treated by reimaging the patient in 6 months after the first image rather than by prompt surgical exploration. (OTOLARYNGOL HEAD NECK SURG 1995;113:61-70.)

Intracardiac extension of an intracaval sarcoma of endometrial origin

A 52-year-old woman was diagnosed with a cardiac tumor by transesophageal echocardiography and magnetic resonance imaging. An intraoperative biopsy indicated the mass was low-grade endometrial stromal sarcoma. Successful tumor removal from the heart and inferior vena cava was accomplished with the use of hypothermic circulatory arrest. The chronically occluded infrarenal portion of the inferior vena cava was transected. The patient has no evidence of recurrent disease after a follow-up of 18 months and has no significant restriction in her daily activities.

Intraoperative measurement of adrenocorticotropin (ACTH) during removal of ACTH-secreting bronchial carcinoid tumors.

The optimal treatment for ectopic ACTH syndrome is the complete removal of the tumor secreting ACTH. These tumors are often occult, with their location suggested but not proven with imaging techniques. The intraoperative measurement of ACTH by immunoradiometric assay in five patients with the occult ectopic ACTH syndrome during removal of suspicious intrapulmonary lesions is reported. A significant ACTH gradient was detected in the pulmonary veins of the affected lobes in two patients. ACTH had decreased significantly in all five patients by 10 and 15 min after tumor removal. All five patients had histologically proven ACTH-secreting bronchial carcinoid tumors, suppressed plasma ACTH by 24 h after tumor removal, and subsequent secondary adrenal insufficiency indicating successful surgical therapy (five of five true-positive). In one patient, previous surgery was not curative and did not result in a decrease in intraoperative measurement of ACTH (one of one true-negative). It was demonstrated that a rapid ACTH immunochemiluminescence assay with a 15-min incubation time has sufficient sensitivity and precision to detect decreases in ACTH described above. These results demonstrate that complete removal of ACTH-secreting bronchial carcinoid tumors can be detected intraoperatively by a decrease in arterial ACTH by 15 min. The modification of the ACTH immunochemiluminescence assay to 15 min incubation allows the documentation of a successful tumor removal in the operating room. It may also be used to locate the tumor intraoperatively by selective pulmonary vein sampling. This protocol may be applicable to the intraoperative measurement of ACTH during pituitary microadenomectomy for Cushing's disease.

Persistence of rapid growth hormone (GH) pulsatility after successful removal of GH-producing pituitary tumors

Persistence of rapid growth hormone (GH) pulsatility after successful removal of GH-producing pituitary tumors

Persistence of rapid growth hormone (GH) pulsatility after successful removal of GH-producing pituitary tumors.

GH concentration profiles in patients with acromegaly are characterized by rapid GH pulsatility and high interpulse GH concentrations. Animal and human studies have shown that GH pulses are consequent upon periodic discharges of hypothalamic GHRH, whereas interpulse GH levels might reflect tonic secretion of hypothalamic SRIH. Thus, the pattern of GH secretion in acromegaly may conceivably be attributed to high GHRH pulse frequency and/or SRIH deficiency. If this assumption is correct, removal of a GH-producing tumor should be followed by a persistently high GH pulse frequency and a high recurrence rate. We have studied pulsatile GH secretion in 12 patients with acromegaly before and after apparently complete removal of their pituitary tumors. Despite normalization of GH secretion after surgery, the disease recurred in 3 patients within 3 yr. The other 9 patients had normal insulin-like growth factor-I and basal and dynamic GH concentrations for 24 +/- 4 months postsurgery. Parameters of GH secretion in this group (pre- and postsurgery) were compared to sex-, age-, and body mass index-matched controls. Plasma GH concentrations in the postoperative and control series were analyzed by a chemiluminescent assay with a sensitivity of 0.01 micrograms/L. Removal of the somatotroph tumor led to normalization of mean and interpulse (but not the nadir) GH levels, pulse amplitude, and responses to GHRH. However, GH pulse frequency (14.2 +/- 1.2 vs. 11.8 +/- 0.9 pulses/24 h) did not change and was significantly (P < 0.001) higher than the control value (8.7 +/- 0.9 pulses/24 h). Thus, SRIH secretion in acromegaly is not inherently deficient, and high interpulse GH levels reflect the mass of tumorous somatotrophs. The persistence of rapid GH pulsatility in apparently "cured" patients with acromegaly suggests that abnormally rapid GHRH pulsatility may be an inherent component of the disease process.

Intraoperative Use of the Moblie Gamma Camera in Localizing and Excising Osteoid Osteomas of the Spine

Three patients (ages 12, 13, and 15 years) had histologically verified osteoid osteomas of the spine (specifically in the facet processes of L3, L2, and C5) which were localized preoperatively with nuclear scintigraphy utilizing technetium 99m diphosphonate. Intraoperative nuclear scintigraphy utilizing the mobile gamma camera was essential in both localizing the tumor during surgical excision and ensuring adequacy of excision. The authors strongly recommend intraoperative scintigraphy, and en bloc resection rather than shelling out and curettage. All three patients required facet process excision for successful tumor removal, and therefore required local fusion with internal fixation.

Preoperative differentiation between meningioma of the cerebellopontine angle and acoustic neuroma using MRI.

Preoperative differentiation between acoustic neuroma (AN) and meningioma of the cerebellopontine angle (CPA) is important in selection of the surgical approach, successful tumor removal, and preservation of hearing and facial nerve. We retrospectively reviewed the magnetic resonance imaging (MRI) findings associated with 30 meningiomas involving the CPA (MCPA) encountered between 1987 to 1991 at the University of California, San Francisco. Magnetic resonance imaging was critical in differentiating meningioma from AN in the CPA. Typical findings on MRI associated with MCPA, differentiating them from ANs, include: meningiomas are sessile, possessing a broad base against the petrous face, whereas ANs are globular; they are often extrinsic and eccentric to the internal auditory canal (IAC); when involving the IAC, they usually do not erode the IAC; MCPAs demonstrate hyperostosis of the subjacent bone and possess intratumoral calcification; they involve adjacent intracranial spaces and structures; and meningiomas are characterized by a distinctive dural "tail" extending away from the tumor surface. While any one finding may not be diagnostic by itself, taken together the constellation of these findings is strongly indicative of meningioma. In our experience, MRI with gadolinium enhancement was able to distinguish MCPA from AN in nearly every case.

Renal cell carcinoma in the inferior vena cava demonstrated by transesophageal echocardiography

thrombus. Resection of renal cell carcinoma from the IVC can now be assisted by intraoperative use of the TEE. Treiger et al6 reported accurate placement of caval clamps guided by the TEE with successful tumor removal in a series of 5 patients. In their study, there was a consistent correlation between the gross specimen and the TEE image. The presence of strands projecting from the tumor thrombus in the present case has not been previously reported. Because the strands appeared to be intact until the application of caval clamps, disintegration may have occurred during the resection of the tumor from the IVC. Small fragments remaining in the IVC may then have embolized when the caval clamps were removed to restore blood flow. The patient’s subsequent clinical course of lung metastases after tumor resection indicates that pulmonary seeding with tumor probably occurred in the perioperative period. The fragile appearance of these projections on TEE makes embolization prior to surgery likely. The occurrence of this tumor morphology may therefore be a sign of poor prognosis. The use of the TEE during resection of renal cell carcinoma may become standard practice in identification of the tumor extension. As increasing numbers of IVC thrombi are imaged, a correlation between their appearance on TEE and the gross morphology should provide insight into the prognosis and management of these patients. Detection of these fragile-appearing strands may affect a patient’s suitability for operative resection or necessitate meticulous techniques for removing any fragmented tumor from the IVC before restoring flow to that vessel.

Transcatheter treatment of hepatic metastases.

After successful removal of a primary tumor, the exclusive or dominant site of metastatic spread is often the liver. Existing palliative treatments, particularly chemotherapy, have low success rates. Fortuitous physiologic circumstances allow the use of regional treatments, such as hepatic artery infusion therapy, for both primary and secondary malignant tumors in the liver. Despite encouraging results in early uncontrolled trials, subsequent randomized studies have failed to show survival benefit with regional infusion therapy via surgically implanted pumps in patients who have colorectal metastases, the most common tumor studied. Dissatisfaction with current treatments has led to a host of novel therapies, including embolization of liver tumors and the combined infusion of embolic particles and chemotherapeutic agents (i.e., chemoembolization).

Structural and functional integrity of ovarian tumor tissue obtained by ultrasonic aspiration

For patients with ovarian epithelial cancer, survival increases when residual disease approaches zero after surgical removal of the tumor. A previous study using the Cavitron Ultrasonic Surgical Aspirator (CUSA) (Cavitron Lasersonic Corp., Stamford, CT) showed the successful removal of ovarian tumors from areas often considered unresectable: the diaphragm, spleen, stomach, and small bowel. However, the CUSA has not yet been approved by the Food and Drug Administration for gynecologic surgery except on an experimental basis. This study was designed to test whether ultrasonic irradiation produced by the CUSA caused alterations in cell structure or physiology of gynecologic tissue in adjacent areas. Paired tumor samples, unirradiated and irradiated, were obtained from ten patients, and portions were sent for pathologic structural evaluation and physiologic tissue culture evaluation. Histologic sections, stained with hematoxylin and eosin, showed that CUSA irradiation produced only minor tissue distortion as observed under the light microscope. A correct diagnosis would have been made in all cases had only tissue fragments obtained from the CUSA specimen trap been stained. For nine of ten patients, initial tumor cell viability was similar in the two specimen types. Flow cytometric DNA analysis confirmed that surgical methods produced matched samples. Cells that survived high-frequency ultrasound appeared functionally intact. For five of eight patients, the cells from the CUSA specimen traps survived and/or divided to a greater extent than those from the knife-dissected tumors. Cells from both surgical routes attained a similar number of passages in culture. It seems reasonable to extrapolate these in vitro observations with pelvic tumor tissues to normal surrounding tissue left in situ. Thus pelvic tissue is believed to be uninjured by CUSA ultrasonic irradiation.

Extra-axial cavernous hemangiomas involving the dural sinuses

Extra-axial cavernous hemangiomas are rare lesions previously associated with unacceptable mortality and morbidity rates that precluded surgical resection. The authors analyze the clinical presentation, surgical results, and histology of eight intrasinus cavernous hemangiomas: six located in the cavernous sinus, one in the petrosal sinus, and one in the torcula. Magnetic resonance imaging is the best radiographic test for surgical planning. Successful tumor removal was achieved in six cases with no mortality and low morbidity. In the remaining two patients, only subtotal resection was achieved because of massive hemorrhage in one and the misdiagnosis of a pituitary adenoma leading to a transsphenoidal approach in the other. For hemangiomas arising within the cavernous sinus, extradural removal of the sphenoid bone facilitated preservation of the neurovascular structures. Since the clinical and histological characteristics of these lesions are distinct from intra-axial cavernous hemangiomas, a more appropriate term may be "sinus cavernoma" to indicate that these lesions are primarily intrasinus in origin.

Epithelial tumors of the lacrimal gland: Clinico-pathologic correlation and management

Between 1960 and 1987 29 patients underwent surgery at the Munich University Eye Hospital for benign and malignant tumors of the lacrimal gland. Fifteen tumors were classified as pleomorphic adenomas (three of them with malignant transformation), nine as adenoid cystic carcinomas, two as adenocarcinomas, two as oxyphilic adenomas, and one as oxyphilic adenocarcinoma. The clinico-pathologic correlation of these tumors is described. All age groups were involved in both benign and malignant epithelial gland tumors. A fast growing lesion with bone destruction of the lacrimal fossa in association with pain was found to be highly suspicious of a malignant epithelial tumor. Prior to surgery, inflammatory lesions and lymphomas should be ruled out by clinical history, examination, diagnostic imaging techniques, and, occasionally, by a short course of oral corticosteroids. A diagnostic biopsy prior to tumor excision and a transfrontal surgical approach via craniotomy has a negative impact on the prognosis. Thus it is mandatory to remove epithelial lacrimal gland tumors completely at the time of the initial surgical procedure. Craniotomies facilitate recurrences of lacrimal gland tumors by infiltration into the central nervous system. Lateral orbitotomies using the Krönlein technique are the best surgical approach for successful removal of these unusual tumors.