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Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss quadricep spasms cheap cilostazol 50 mg with visa, blood transfusion muscle relaxant metabolism buy discount cilostazol 50mg line, and the risk of postoperative renal dysfunction spasms early pregnancy discount cilostazol 100 mg mastercard. Prolonged normothermic ischaemia of human cirrhotic liver during hepatectomy: a preliminary report muscle relaxant chlorzoxazone side effects discount 100mg cilostazol visa. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study. Anatomic segmental hepatic resection is superior to wedge resection as an oncologic operation for colorectal liver metastases. Improved survival for hepatocellular cancer with combination surgery and multimodality treatment. Do the tumor cells of hepatocellular carcinomas dislodge into the portal venous system during hepatic resection Is preoperative hepatic arterial chemoembolisation safe and effective for hepatocellular carcinoma Cytoreduction and sequential resection for surgically verified unresectable hepatocellular carcinoma: evaluation with analysis of 72 patients. Selective internal radiation therapy for nonresectable hepatocellular carcinoma with intraarterial infusion of 90 yttrium microspheres. T reatment of unresectable hepatocellular carcinoma: results of a randomised controlled trial. Postoperative adjuvant chemotherapy after curative resection of hepatocellular carcinoma: a randomized controlled trial. Postoperative adjuvant arterial infusion of lipiodol containing anticancer drugs in patients with hepatocellular carcinoma. Preoperative transcatheter arterial chemoembolisation for resectable large hepatocellular carcinoma. Prevention of second primary tumors by an acyclic retinoid, polyprenoic acid, in patients with hepatocellular carcinoma. Adjuvant intra-arterial iodine-131-labeled lipiodol for resectable hepatocellular carcinoma: a prospective randomised trial. A multidisciplinary approach to hepatocellular carcinoma in patients with cirrhosis. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. Experience of orthotopic liver transplantation and hepatic resection for hepatocellular carcinoma of less than 8 cm in patients with cirrhosis. No treatment, resection and ethanol injection in hepatocellular carcinoma: a retrospective analysis of survival in 391 patients with cirrhosis. Multimodal adjuvant treatment and liver transplantation for advanced hepatocellular carcinoma. Neoadjuvant chemotherapy and liver transplantation for hepatocellular carcinoma: a pilot study in 20 patients. Dihydropyrimidine dehydrogenase activity in hepatocellular carcinoma: implication in 5-fluorouracil-based chemotherapy. Expression of P-glycoprotein in hepatocellular carcinoma: a potential marker of prognosis. Clinical trials in primary hepatocellular carcinoma: current status and future directions. Treatment of hepatocellular carcinoma: a systemic review of randomised controlled trials. Review article: overview of medical treatments in unresectable hepatocellular carcinomaan impossible meta-analysis. Experimental studies on the circulatory dynamics of intrahepatics tumor blood flow supply. Methods to enhance the efficacy of regional chemotherapeutic treatment of liver malignancies. Hepatic arterial infusion of fluorouridine, leucovorin, doxorubicin and cisplatin for hepatocellular carcinoma: effects of hepatitis B and C viral infection on drug toxicity and patient survival. Treatment of unresectable primary liver cancer with intrahepatic fluorodeoxyuridine and mitomycin C through an implantable pump. Intra-arterial versus systemic chemotherapy for non-operable hepatocellular carcinoma. Androgen and oestrogen receptors in hepatocellular carcinoma and surrounding liver parenchyma: impact on intrahepatic recurrence after hepatic resection. Prospective controlled trial with anti-estrogen drug tamoxifen in patients with unresectable hepatocellular carcinoma. Treatment of hepatocellular carcinoma with combined suppression and inhibition of sex hormones: a randomised controlled trial. Treatment of hepatocellular carcinoma with tamoxifen: a double-blind placebo-controlled trial in 120 patients. Chronic oral etoposide and tamoxifen in the treatment of far-advanced hepatocellular carcinoma. Controlled clinical trial of doxorubicin and tamoxifen versus doxorubicin alone in hepatocellular carcinoma. Response to cyproterone acetate treatment in primary hepatocellular carcinoma is related to fall in free 5a-dihydrotestosterone. Treatment of small hepatocellular carcinoma by percutaneous injection of ethanol into tumor with real-time ultrasound monitoring. Percutaneous ethanol injection for the treatment of small hepatocellular carcinoma. Tumor size determines the efficacy of percutaneous ethanol injection for the treatment of small hepatocellular carcinoma. Gene therapy for metastatic brain tumors by vaccination with granulocyte-macrophage colony-stimulating factor-transduced tumor cells. Intratumor ethanol injection therapy for solitary minute hepatocellular carcinoma. Improved survival with percutaneous ethanol injection in patients with large hepatocellular carcinoma. Ultrasound guided internal radiotherapy using yttrium-90 glass microspheres for liver malignancies. Cytoreduction and sequential resection: a hope for unresectable primary liver cancer. Percutaneous radiofrequency tissue ablation: does perfusion-mediated tissue cooling limit coagulation necrosis Saline-enhanced radio-frequency tissue ablation in the treatment of liver metastases. Evaluation of the ligation of the hepatic artery and regional arterial chemotherapy in the treatment of primary and secondary cancer of the liver. A 5-year experience of lipiodolisation: selective regional chemotherapy for 200 patients with hepatocellular carcinoma. Hepatic arterial infusion chemotherapy with continuous low dose administration of cisplatin and 5-fluorouracil for multiple recurrence of hepatocellular carcinoma after surgical treatment. In: Proceedings of the Annual Meeting of the American Society of Clinical Oncology, vol 13. Transcatheter arterial chemoembolisation in inoperable hepatocellular carcinoma: four-year follow-up. The role of hepatic arterial embolisation in the management of ruptured hepatocellular carcinoma. Hepatic arterial embolisation in patients with unresectable hepatocellular carcinoma. A comparison of lipiodol chemoembolization and conservative treatment for unresectable hepatocellular carcinoma. Transarterial embolisation versus symptomatic treatment in patients with advanced hepatocellular carcinoma: results of a randomised controlled trial in a single institution. Prospective and randomised clinical trial for the treatment of hepatocellular carcinomaa comparison lipiodol transcatheter embolisation with and without adriamycin (first cooperative study). Transcatheter arterial embolization with or without cisplatin treatment of hepatocellular carcinoma. Selective and persistent deposition and gradual drainage of iodized oil, Lipiodol in the hepatocellular carcinoma after injection into the feeding hepatic artery.
These include rectal bleeding spasms right upper quadrant purchase cilostazol 100mg visa, discovery of occult blood in the stool muscle relaxant 503 order cilostazol 50 mg line, abdominal pain muscle relaxant potency cilostazol 50 mg line, change in bowel habits muscle relaxant lodine order cilostazol 100mg online, nausea, vomiting, distention, weight loss, fatigue, and anemia. Because it can be such an obvious symptom, patients who develop rectal bleeding come to medical attention sooner than those who do not have obvious rectal bleeding. Patients who present with rectal bleeding must not be managed for hemorrhoids without workup, even though many more patients will have benign causes for rectal bleeding as compared to the number who will have rectal carcinoma. Abdominal pain in colorectal cancer may be caused by partial obstruction, which is commonly a cramping type of pain. A more diffuse type of abdominal pain may occur with the development of perforations, leading to signs of generalized peritonitis. Locally advanced rectal cancer may be associated with involvement of the sciatic nerve or obturator nerve, producing a neuropathic pain syndrome. Partial or complete obstruction may occur in 2% to 16% of newly diagnosed cases of rectal cancer. The presence of obstruction has been found to reduce the 5-year survival rate to 31%, as compared with 72% for patients without obstruction. Approximately half of perforations caused by colorectal cancer are into the free abdominal cavity. Contained perforation with involvement of adjacent organs is most commonly seen in cecal or sigmoid carcinomas. Either type of carcinoma may involve loops of small bowel, bladder, abdominal wall, or the retroperitoneum. When there is such involvement in the setting of a sigmoid colon carcinoma, the condition may mimic diverticulitis. It is justifiable to pursue surgery in such patients to clarify the diagnosis as well as to treat. Radiologic signs indicating diverticulitis include the presence or absence of intramural fistulas and the degree of mucosal abnormality. Tumor perforation can occur either at the site of a primary tumor or in the cecum when it is dilated because of obstruction. Perforation is a bad prognostic factor, not only because it heralds an increased risk of cancer spread but also because of the mortality associated with peritonitis. In the 10% to 15% of patients who present with metastatic disease, signs and symptoms are usually present. Pain in the right upper quadrant, especially when accompanied by palpable hepatomegaly or a mass, often will indicate the presence of liver metastases. Patients with diffuse liver involvement or carcinomatosis may manifest ascites with signs of abdominal distention or symptoms of early satiety or bowel obstruction. In patients with advanced colorectal cancer, supraclavicular adenopathy may be present. Inguinal adenopathy may develop in patients with an advanced low rectal carcinoma. A 1-cm, clinically detectable colorectal neoplasm may contain 30 or more successive generations of malignant cells prior to detection. Annular tumors produce obstructive symptoms and have the classic appearance of an apple-core lesion on barium enema. Tumors of the right colon often are fungating masses that grow into the lumen and for which the symptom is occult bleeding as opposed to obstruction; they often present with a palpable mass. The number and type of neoplastic lesions, polyps, or invasive carcinomas in a colorectal specimen are important in identifying associated inherited colorectal cancer syndromes. World Health Organization Classification of Malignant Primary Tumors of the Large Intestine: Histopathologic Variants of Colorectal Carcinoma the vast majority of colorectal cancers are moderately differentiated, gland-forming adenocarcinomas. Less common variants are classified on the basis of the predominance of an unusual pattern as compared with the usual adenocarcinoma of the colon. Mucinous or colloid carcinomas exhibit the majority of tumor in mucin pools, which are often of low cellularity. These often are associated with diffuse intramural spread beyond the obvious mucosal lesion. In poorly differentiated cancers, features of neuroendocrine differentiation may appear. Approximately 4% to 17% of carcinoid tumors appear in the rectum, and 2% to 7% are found in the colon. Broders (1925) designated four grades of differentiation based on the percentage of differentiated tumor cells found in the overall tumor specimen. The degree of differentiation for colonic adenocarcinoma commonly refers to the degree to which there are well-formed glands. There is a spectrum of histopathologic findings used to assess differentiation in typical cancers of the colon and rectum. Gland formation is usually associated with tumors that are well or moderately differentiated. At the other extreme of differentiation, glandular architecture may form sheets of infiltrating individual cells, which characterize a poorly differentiated tumor. Other aspects of the histopathologic evaluation of a colorectal tumor include assessments for vascular or lymphatic invasion. The pattern of infiltration at the edge of tumors can be pushing, expansile, or infiltrative. The host inflammatory response at the periphery of tumors can be composed of lymphocytes, neutrophils, mast cells, and macrophages. Invasion into the submucosa is the hallmark of the development of the potential for metastatic spread and is the key histopathologic characteristic of colorectal cancer. In colon carcinoma, the mesentery and serosal surfaces are at greatest risk for violation by tumor penetration. In rectal cancer, perirectal fat and adjacent organs are most commonly involved by direct invasion through the bowel wall. Gross assessment of local extent can be misleading in some cases due to desmoplastic response, the effect of neoadjuvant therapies, or infection surrounding tumor perforation. Locally recurrent tumors are characterized by the predominance of the tumor mass in or around the bowel wall or an anastomotic site rather than in the mucosa itself. Lymph Node Pathology Gross pathologic evaluation of lymph nodes in colorectal cancer specimens is unreliable. Large nodes may show only lymphoid hyperplasia, whereas smaller nodes may harbor micrometastases detectable only by histologic examination, immunohistochemistry, or molecular techniques. This factor is important in understanding the inaccuracy of imaging techniques that typically rely on the size of lymph nodes as criteria for determining nodal involvement with tumor. Molecular Detection of Micrometastases Owing to the effective use of adjuvant therapies for node-positive colorectal cancer, there is a theoretic advantage to the use of a more intensive method of detecting cancer cells in the lymph nodes of resected specimens. Colorectal cancers can spread locally or distantly via the lymphatic and venous systems. In addition to unregulated tumor growth, imbalances in regulation of motility and proteolysis are required for those events to occur. Dukes believed that lymph node invasion and distant metastasis could occur only after the tumor had extended through the bowel wall. Although years earlier, Miles had described metastasis with earlier-stage primaries, Dukes considered these rare events. Dukes hypothesis could not explain why a large number of patients with complete surgical resection eventually die of tumor recurrence. After reviewing 20 rectal cancer specimens, he made the important observation that the long axis of the ulcerating tumor was always transverse, with the lesion tending to involve the bowel circularly rather than longitudinally. Contrary to the previously held belief, Cole theorized that recurrences were due to extramural deposits of tumor cells that were not removed by local excision and not to persistence of tumor along the bowel wall. One notable exception to this common pattern of circumferential growth is seen in tumors showing perineural invasion. Tumor cells may reach as far as 10 cm from the primary tumor when spreading through the perineural spaces, and local recurrences are 2. This preferential mural growth, the importance of which was recognized early, may result in local failure and peritoneal seeding. Although Dukes initially incorrectly considered these events to be rare, he and Bussey (1958) demonstrated the direct relationship of the extent of local spread to the incidence of lymphatic metastasis. Grinnell (1964) was able to demonstrate that tumor limited to the submucosa and muscularis propria metastasized to lymph nodes in 13% of patients. More recent studies have corroborated these findings, with a 10% to 20% incidence of lymph node metastasis for tumors limited to the bowel wall.
The Patterns of Care study examined 400 patients treated at 61 academic and nonacademic radiation oncology practices to determine practice patterns in the United States from 1992 to 1994 muscle relaxant neck pain buy cilostazol 100 mg line. Various oncology groups have published treatment guidelines; however spasms knee generic 50mg cilostazol otc, there is still no consensus at present spasms prostate purchase cilostazol 50mg. Primary Therapy Primary therapy of esophageal cancer is either surgical or nonsurgical muscle relaxant before exercise cilostazol 50mg for sale. Although the overall results of these approaches are similar, the patient populations selected for treatment with each modality are usually different, resulting in a potential selection bias against nonsurgical therapy. Patients with poor prognostic features, including those with comorbid conditions, or unresectable or metastatic disease, are more commonly selected for treatment with nonsurgical therapy. Furthermore, surgical series report results based on pathologically staged patients, whereas nonsurgical series express results pertaining to clinically staged individuals. Pathologic staging has the advantage of excluding some patients with metastatic disease. In addition, because some nonsurgical patients are treated with palliative rather than curative intent, the intensity of chemotherapy and the doses and techniques of radiation therapy may be suboptimal. Many series have reported results of external-beam radiation therapy alone; most include patients with unfavorable features such as clinical T4 disease and positive lymph nodes (Table 33. Overall, the 5-year survival rate for patients treated with conventional doses of radiation therapy alone is 0% to 10%. Furthermore, given the large size of many unresectable esophageal cancers, doses of 60 Gy or greater are probably required. Shi and colleagues 355 reported a 33% 5-year survival rate with the use of late-course accelerated fractionation to a total dose of 68. Selected Series of Radiation Therapy Alone for Esophageal Cancer There is one report of radiation therapy alone for patients with clinically early-stage disease. Collectively, these data indicate that radiation therapy alone should be reserved for palliation or for patients who are medically unfit to receive chemotherapy. As discussed in the following section, combined modality therapy should be the standard of care. A number of single-arm, nonrandomized trials have been conducted to evaluate the efficacy of combined modality therapy alone in esophageal cancer patients. The local failure rate was 25%, the 5-year actuarial local relapse-free survival was 70%, and the 5-year actuarial survival was 30% in early-stage patients. Since the choice of further management (observation, radiation, chemotherapy, and surgery) was based on the tumor response, this study cannot be considered a pure combined modality therapy trial. Although the median survival was 20 months, the authors concluded that the complexity and toxicity of this treatment regimen precluded its further use. Six randomized trials have been performed comparing radiation therapy alone with combined modality therapy (Table 33. Randomized Trials of Radiation Therapy versus Combined Modality Therapy for Esophageal Cancer In the Eastern Cooperative Oncology Group Esophagal Cancer Trial-1282 trial, patients who received combined modality treatment had a significantly increased median survival compared with those receiving radiation alone (15 vs. However, this was not a pure nonsurgical trial since approximately 50% of patients in each arm underwent resection after 40 Gy. Furthermore, the decision to proceed with surgery was left to the discretion of the individual investigator. Radiation therapy (50 Gy at 2 Gy/d) was given concurrently with day 1 of chemotherapy. Curiously, cycles 3 and 4 of chemotherapy were delivered every 3 weeks (weeks 8 and 11) rather than every 4 weeks (weeks 9 and 13). This intensification may explain, in part, why only 50% of the patients finished all four cycles of the chemotherapy. The control arm was radiation therapy alone, at a higher dose (64 Gy) than that delivered in the combined modality treatment arm. Patients who were randomized to receive combined modality therapy had a significant improvement in median survival (14 vs. Although African Americans had larger primary tumors (all of which were squamous cell cancers), there was no difference in their survival compared with whites. The protocol was closed early due to the positive results; however, following this early closure, an additional 69 patients were treated with the same combined modality therapy regimen. In this nonrandomized combined modality group, the 5-year survival was 14% and local failure rate was 52%. Combined modality therapy not only improves the results compared with radiation alone, but is also associated with a higher incidence of toxicity. The first site of clinical failure was local in 39% of patients and distant in 24% of individuals. For the total patient group, there were six deaths during treatment of which 9% (4 of 45) were treatment related. Therefore, this intensive neoadjuvant approach did not appear to offer a benefit compared with conventional doses and techniques of combined modality therapy. In contrast with Intergroup 0122, no chemotherapy was delivered with the radiation therapy. With a median follow-up of 78 months, the local failure rate was 62%, median survival was 11 months, and the 5-year actuarial survival was 15%. In summary, neoadjuvant chemotherapy, as delivered in the previously mentioned trials, does not appear to improve the results of combined modality therapy. Another approach to dose intensification of combined modality therapy involves increasing the radiation dose above 60 Gy. There are two methods by which to increase the radiation dose to the esophagus: brachytherapy and external-beam radiation. Brachytherapy Intraluminal brachytherapy allows the escalation of the dose to the primary tumor while protecting the surrounding dose-limiting structures such as the lung, heart, and spinal cord. Brachytherapy has been used both as primary therapy (usually as a palliative modality), 375,376,377 and 378 as well as boost following external-beam radiation therapy or combined modality therapy. As a single therapy, brachytherapy is used as a palliative modality and results in a local control rate of 25% to 35% and a median survival of approximately 5 months. The primary isotope is 192Ir, which is usually prescribed to treat to a distance of 1 cm from the source. Therefore, any portion of the tumor that is greater than 1 cm from the source receives a suboptimal radiation dose. With a median follow-up of 39 months, the 3-year and 5-year actuarial survivals were 27% and 18%, respectively. Two patients (4%) developed a fistula; however, both were due to tumor progression. Other trials of brachytherapy following external-beam radiation or combined modality therapy have reported less favorable results. Schraube and associates 381 treated 54 patients with 60-Gy external-beam radiation followed by a 14-Gy brachytherapy boost, observing a median survival of 8 months and a 2-year overall survival of 10%. Using a similar treatment regimen in 35 patients with squamous cell carcinomas, Akagi et al. A total of 125 patients received 40- to 60-Gy external-beam radiation followed by a 8- to 24-Gy high dose-rate brachytherapy boost. Due to low accrual, the low dose-rate option was discontinued and the analysis was limited to patients who received the high dose-rate treatment. High dose-rate brachytherapy was delivered in weekly fractions of 5 Gy during weeks 8, 9, and 10. Following the development of several fistulas, the fraction delivered at week 10 was discontinued. Although the complete response rate was 73%, with a median follow-up of only 11 months, local failure as the first site of failure occurred in 27% of patients. The cumulative incidence of fistula was 18% per year and the crude incidence was 14%. Given the significant toxicity, this treatment approach should be used with caution. The American Brachytherapy Society has developed guidelines for esophageal brachytherapy. Contraindications include tracheal or bronchial involvement, cervical esophagus location, or stenosis that cannot be bypassed. Lastly, brachytherapy should be delivered after the completion of external-beam radiation, and not concurrently with chemotherapy. In summary, in the palliative setting, intraluminal brachytherapy is an effective modality for decreasing symptoms such as dysphagia and bleeding. In patients treated in the curative setting, the addition of brachytherapy does not appear to improve results compared with radiation therapy or combined modality therapy alone.
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This finding has particular significance in patients with familial adenomatous polyps muscle relaxant drugs over the counter buy cilostazol 50 mg on line, in whom polyps of the upper gastrointestinal tract are being recognized with increasing frequency muscle relaxant 24 buy 50 mg cilostazol. Because these patients often have an adenomatous component in their primarily hyperplastic and hamartomatous polyps spasms trapezius cheap 100 mg cilostazol amex, the development of malignancy more likely represents malignant evolution of that adenomatous component rather than transformation of the other hamartomatous elements muscle relaxant before massage cheap 50mg cilostazol visa. The second, or descending, portion of the duodenum is approximately 10 cm long, just anterior to the hilus of the right kidney. Typically, the ampulla of Vater, through which pancreaticobiliary secretions pass into the small bowel, is found midway down the descending second portion of the duodenum medially. The third portion of the duodenum travels transversely in close relationship to the uncinate process of the pancreas, anterior to the ureter, inferior vena cava, vertebral column, and aorta. The jejunum, comprising the proximal 250 cm of the small bowel distal to the duodenum, and the ileum, the remaining 350 cm of small bowel, are supported on a fan-shaped mesentery that measures approximately 15 cm in length. More distally, this mesentery becomes progressively longer, with arterial blood supply, venous and lymphatic drainage, and small bowel innervation traversing between its two leaves. Grossly, the duodenum tends to be the largest in diameter and the ileum the smallest. The arterial blood supply for the duodenum is derived from the gastroduodenal branch of the hepatic artery as well as the inferior pancreaticoduodenal branch of the superior mesenteric artery. The blood supply for the remaining small bowel is derived from intestinal branches of this superior mesenteric artery. The remainder of the small bowel drains into the abundant lymph nodes through channels that parallel the course of the mesenteric blood vessels. Autonomic innervation of the small bowel is by means of the celiac and superior mesenteric plexus. Microscopically, the intestine is a hollow muscular tube composed of four layers: serosa, muscularis, submucosa, and mucosa. The muscular layer consists of an outer longitudinal layer and an inner circular layer. For practical purposes, they can be subdivided as benign and malignant and further classified according to their cell of origin (Table 33. Pathology of Primary Small Bowel Tumors by Cell of Origin A number of authors have commented on the inordinately high incidence of second primary malignant tumors in patients with primary small bowel malignancy. Any patient who has had a primary small bowel malignancy should be watched closely for the development of a second malignant tumor. Malignant lesions are more often symptomatic than are benign lesions, and for a shorter duration. In patients with benign tumors, pain from obstruction is the most common symptom, occurring in 42% to 70% of cases. In patients with malignant tumors, the most common symptoms are pain (not always associated with obstruction) in 32% to 86% and weight loss in 32% to 67% of cases. A mass that may represent dilated bowel proximal to an obstructing tumor is palpable in fewer than 25% of patients with malignant small bowel tumors. In fact, the diagnosis of small bowel malignancy is frequently delayed, not necessarily because of delay in presentation to the physician. Maglinte and colleagues, 80 in a review of 77 patients with small bowel malignancy, reported the average delay between onset of symptoms and presentation to the physician as 1 month, whereas the average interval from seeing the physician to final diagnosis was 7. With the exception of an elevated 5-hydroxyindole acetic acid level in the presence of carcinoid syndrome, all the presenting signs and symptoms of small bowel tumors are nonspecific. Laboratory examination may reveal a mild anemia in the presence of chronic blood loss. Mild to moderate elevations of liver function tests may be seen in the presence of hepatic metastases, occasionally associated with an elevation in carcinoembryonic antigen. Plain abdominal films that reveal signs of partial or complete bowel obstruction in the absence of prior laparotomy are suggestive of primary small bowel neoplasm, although nonspecific as to the diagnosis. Upper gastrointestinal series with small bowel follow-through is abnormal in 53% to 83% of patients and delineates small bowel tumor in 30% to 44% of patients. This finding, however, is nonspecific and can be identical to the appearance of regional ileitis. Hyams and associates 49 suggested that a rectal biopsy revealing granulomatous disease can reliably distinguish between inflammatory and neoplastic changes in the terminal ileum. Angiograms may be distinctly abnormal in vascular smooth muscle tumors of the small bowel 84 and may help to define the source of occult but active upper gastrointestinal bleeding in patients with a small bowel hemangioma. Alfidi and colleagues 94 reported angiography as being helpful in patients with small bowel arteriovenous malformations, identifying lesions in nine patients after negative laparotomy. In addition, angiography may on occasion demonstrate occlusion of the peripheral branches of the mesenteric circulation that is responsible for a syndrome of mesenteric ischemia seen occasionally in the carcinoid syndrome. Nuclear medicine scans using technetium-labeled red blood cells may be helpful, again to delineate an occult source of chronic gastrointestinal blood loss in the presence of a normal colonic and upper gastrointestinal endoscopy. It can be difficult to localize the site of bleeding with this test, however, and Oliver and coworkers95 suggested that if technetium-labeled red blood cell scanning is used, the sensitivity of the examination improves if more frequent images are obtained. With more sophisticated instrumentation, endoscopy is being more frequently used in the investigation of small bowel disease. Clearly, upper gastrointestinal endoscopy with total duodenoscopy is the mainstay for detection, diagnosis and, occasionally, treatment of more proximal neoplasms. Enteroscopy can be helpful in diagnosing both focal lesions 97 and more diffuse lesions, such as Mediterranean lymphoma. Most common are leiomyomas, followed by adenomas, lipomas, vascular lesions, and fibrous lesions. Distribution of Benign Tumors of the Small Bowel by Site in 13 Series Leiomyomas Leiomyomas of the small bowel account for 20% to 40% of all benign small bowel tumors and are the most common small bowel tumor according to a review by Wilson and associates. It can be difficult to distinguish benign from malignant smooth muscle tumors of the gastrointestinal tract intraoperatively, even with histologic evaluation by frozen section. According to the comprehensive review by Skandalakis and Gray, 104 malignancy in lesions less than 4 cm in diameter is distinctly unusual. Histologic criteria of malignancy include necrosis, nuclear pleomorphism, and frequent mitotic activity. Surgical management of small bowel leiomyomas includes adequate segmental resection with grossly negative serosal margins. Because lymph node metastases are unusual, even for malignant leiomyosarcomas of the small bowel, extensive mesenteric lymphadenectomy is not required. Small bowel polyps can be divided into three broad categories based on principles of management: villous adenomas of the duodenum, adenomas of the distal small bowel, and Peutz-Jeghers hamartomas. Although villous adenomas of the duodenum are unusual, the duodenum is the most common small bowel location for these lesions. Their most common presenting sign is obstructive jaundice, and diagnosis is straightforward with upper gastrointestinal endoscopy. Most lesions are located in the second portion of the duodenum, usually on the medial wall, surrounding the ampulla of Vater. They are being increasingly recognized as a component of the familial adenomatous polyposis syndrome. Risk factors associated with malignancy include size greater than 5 cm, 105 age over 50 years,106 and more distally situated polyps. Although a number of experts have advocated local excision for benign lesions, 107,108 one cannot always be certain of the benign nature of a tumor before complete histologic examination. Furthermore, local recurrence rates of 17% to 75% have been reported after local excision of these tumors,109,110,111,112 and 113 occasionally with malignant degeneration. Certainly, close ongoing endoscopic surveillance is mandatory after local excision of these lesions. Lesions in the third and fourth portion of the duodenum shouldbe managed with wedge or sleeve resection. Lesions in the first or second portion of the duodenum should be managed with pancreaticoduodenectomy, particularly if any question remains about the diagnosis. Survival after complete excision is excellent in patients with both benign villous adenomas and carcinoma in situ. Patients with invasive carcinoma fare comparably to those with periampullary adenocarcinoma. These tend to be distributed more proximally, and case reports of malignant degeneration have appeared.