Lesions simulating retinoblastoma

Of 500 consecutive patients referred to the Ocular Oncology Service at Wills Eye Hospital with the diagnosis of possible retinoblastoma, 288 (58%) were found on clinical evaluation to have retinoblastoma and 212 (42%) had lesions that simulated retinoblastoma. A total of 23 different conditions accounted for the 212 pseudoretinoblastomas. Three most common pseudoretinoblastomas were: persistent hyperplastic primary vitreous (28%), Coats' disease (16%), and presumed ocular toxocariasis (16%). Congenital cataract and retinopathy of prematurity accounted for a much lower percent of pseudoretinoblastomas in this series as compared to a previously reported series. The pertinent clinical features that serve to differentiate these simulating lesions from retinoblastoma are reviewed.

Role of vasculitis in the natural history of abdominal tuberculosis--evaluation by mesenteric angiography

To investigate the possible role of vascular changes in the pathogenesis of tubercular lesions of the abdomen, findings on barium studies of the bowel and superior mesenteric angiography in 20 patients with abdominal tuberculosis were correlated. Barium studies showed peritoneal lesions in seven patients, isolated intestinal lesions in seven and combined lesions in six. Angiograms were abnormal in all the patients and showed encasement of arteries (13 patients), stretching and crowding of vessels (13), occlusion of vasa recta (5) and hypervascularity (6). All the 13 patients with peritoneal lesions showed arterial stretching, crowding and encasement. Five of six patients with strictures had occlusion of vasa recta. Of seven patients with ulcerations, six had hypervascularity. Our observations suggest that vascular changes occur frequently in abdominal tuberculosis and may explain some pathological and clinical manifestations of this disease. Ulcerated and hypervascular lesions occur in the active and early stages of the disease, and occlusive lesions are associated with healing and 'ischemic' bowel strictures.

Prospective comparison of the value of brushings before and after biopsy in the endoscopic diagnosis of gastroesophageal malignancy

The hypothesis that the cytodiagnostic results on endoscopic brushings obtained before biopsy may be superior to those brushings obtained after biopsy, but with the accuracy of the subsequent biopsy reduced, was examined for 300 consecutive patients, including 256 with esophageal or gastric carcinomas. Following stratification by site and endoscopic appearance of their lesions, the patients were randomized to undergo brushing either before or after forceps biopsy. The accuracy of brushing cytology in patients with carcinoma was significantly higher when the brushing was performed before biopsy than after biopsy (93.5% versus 82.6%; P less than .01). The diagnostic yield of the biopsy was not significantly different whether the lesions were brushed before or after the biopsy (92.7% versus 93.2%; P less than .5). The diagnostic superiority of brushings obtained before biopsy did not relate to the site or endoscopic appearance of the tumor. There were no false-positive cytologic or histologic reports. For all 256 carcinomas, the cumulative accuracy (brushing cytology plus biopsy) reached 98.8% and was significantly better (P less than .001) than that of biopsy alone (93.9%) or cytology alone (87.9%). Apart from reinforcing the belief that the combined application of brushing and biopsy is mandatory for achieving optimal results, this study indicated that the brushing should be performed before the biopsy.

4-Hydroxyandrostenedione in the prophylaxis of N-methyl-N-nitrosourea induced mammary tumourigenesis

We have examined the role of the aromatase inhibitor 4-hydroxyandrostenedione (4-OHA) in the prevention of mammary tumourigenesis in experiments involving 170 rats. We first demonstrated a prophylactic effect of 4-OHA (50 mg/week) in reducing tumour incidence over a 30 week period compared to controls (P = 0.04). We repeated the experiment to determine optimum dose and duration of therapy. Although 4-OHA again prevented tumour development (P less than 0.0005), there was no difference between the standard (50 mg/week) dose and the higher dose (100 mg/week). Rats were randomised at 30 weeks to either stop or to continue prophylactic therapy; marginal benefit in tumour free survival in continuing therapy was observed (P = 0.03). We conclude that 4-OHA is an effective agent in preventing carcinogen-induced mammary tumours in rats and further studies of the role of oestrogen synthesis inhibitors in the prevention of human mammary tumours may be indicated.

Partial lamellar sclerouvectomy for ciliary body and choroidal tumors

The authors reviewed the postoperative course, visual results, histopathologic findings, and mortality data on 95 consecutive patients with tumors of the ciliary body and/or choroid who were managed by a partial lamellar sclerouvectomy. This surgical procedure is designed to remove the uveal tumor and leave intact the outer sclera and sensory retina. In this group of 95 patients, vitreous hemorrhage occurred in 79 (83%) cases, intraretinal or subretinal hemorrhage in 33 (35%), retinal detachment in 26 (28%), and cataract in 32 (34%). Most of the vitreous and retinal hemorrhages resolved spontaneously, sometimes leaving subretinal or preretinal fibrosis. A number of the postoperative retinal detachments resolved spontaneously, but retinal detachment surgery was necessary in 16 patients (17%), mostly in the earlier years of the survey. Most of the cataracts were mild and did not require surgery. The eventual postoperative visual acuity was equal to or better than the preoperative visual acuity in 23 cases (24%) over a mean follow-up period of 5 years. Enucleation was eventually necessary in 15 cases (16%), usually because of residual or recurrent tumor. Histopathologic diagnosis was uveal melanoma in 81 cases (85%) and other tumors in 14 cases (15%). There were no orbital recurrences, but distant metastases developed in five patients (5%), all of whom had undergone enucleation for recurrence of the intraocular melanoma. Although the surgical technique is difficult, partial lamellar sclerouvectomy appears to be a reasonable therapeutic option in selected cases of posterior uveal tumors.

Orbital exenteration with eyelid sparing: indications, technique, and results

Of 22 orbital exenterations performed from January 1980 to December 1989, 16 were performed by an eyelid-sparing technique, and six were allowed to heal by spontaneous granulation. Reviewing these procedures, we conclude that the eyelid-sparing method is indicated mainly for advanced primary orbital malignancies and for certain secondary orbital malignancies such as orbital extension of uveal melanoma, conjunctival melanoma, and conjunctival squamous cell carcinoma. It is not usually applicable to orbital invasion of malignant eyelid tumors such as basal cell carcinoma and sebaceous gland carcinoma. Advantages of the eyelid-sparing method are more rapid healing and earlier fitting of a prosthesis.

Obstructive jaundice--an unusual complication of duodenal tuberculosis: treatment with transhepatic balloon dilatation

This is a report of a patient on treatment for duodenal tuberculosis, who developed obstructive jaundice due to a benign stricture of the terminal common bile duct. This complication of duodenal tuberculosis, to our knowledge, has not been reported before. Percutaneous, transhepatic balloon dilatation of the stricture alleviated the jaundice.

US-guided fine-needle aspiration biopsy of gallbladder masses

Ultrasonically (US) guided fine-needle aspiration biopsy was performed in 88 patients who had gallbladder masses. All masses were less than 4.8 cm in diameter. A 22- or 23-gauge, Teflon-coated needle was placed into the mass with the transhepatic or transperitoneal route. By means of this technique, gallbladder malignancy was confirmed in 69 of the 78 cases of malignancy (88.5%). Ten of 10 benign lesions were properly categorized. One patient developed bile peritonitis following a single needle pass with the transperitoneal approach. Pain, a minor complication of the procedure, was noted in four cases. No instances of hemorrhage or vasovagal reactions occurred. From their experience in this large series, the authors conclude that US-guided fine-needle aspiration biopsy of gallbladder masses is a safe, reliable, and accurate technique for the diagnosis of malignancy.

Retinoblastoma in older children

A review of 400 consecutive patients with retinoblastoma who presented to the Ocular Oncology Service at Wills Eye Hospital showed that 34 (8.5%) patients were older than 5 years of age at the time of initial diagnosis. The tumor was active in 26 (76%) cases and inactive (retinoma) in 8 (24%). An evaluation of the 26 patients with active retinoblastoma showed several unique features. At the time of diagnosis, their median age was 6 years and the oldest was 18 years. In 20 (77%) cases, the patient volunteered symptoms that prompted the eye examination; the presenting symptoms included leukocoria (9 cases), decreased vision (9 cases), strabismus (4 cases), pain (1 case), floaters (1 case), and no symptoms (2 cases). All of the 26 patients (100%) had unilateral sporadic retinoblastoma. Misdiagnosis before referral was common in these older children with active retinoblastoma. Five patients (19%) had prior vitrectomy for presumed vitreous hemorrhage or endophthalmitis while the retinoblastoma was unsuspected clinically, one patient (4%) had cryotherapy for presumed Coats disease, and one (4%) was observed for 7 months for presumed vitreous hemorrhage. The clinician should seriously consider the possibility of retinoblastoma in children who present with signs of unexplained vitreous hemorrhage or endophthalmitis, even if they are older than 5 years of age.

Tuberculous fistulas of the pharynx and esophagus

Four patients with tuberculous fistulas communicating with the pharynx or the esophagus are reported. In 1 patient, there was strong evidence to suggest primary involvement of the esophageal mucosa. The other 3 cases were related to involvement of the pharynx or the esophagus from adjacent tuberculous process, as confirmed by histopathological proof. The patients had varying degrees of symptoms, which in two dramatically responded to antituberculous therapy; the third patient needed surgery for complete cure and the last patient was lost to follow-up.

Choledochoduodenal fistula complicating duodenal ulcer disease (a report of 3 cases)

Choledochoduodenal fistula complicating duodenal ulcer disease is a rare occurrence. The present paper describes 3 such cases which were incidentally picked up on upper gastro-intestinal (GI) radiographic study and endoscopy done for ulcer like symptoms. The relevant literature is reviewed.

Control of life-threatening hemorrhage in cecal tuberculosis by transcatheter embolisation

Torrential hemorrhage is rare in tuberculous affection of the bowel. The traditional method of treatment has been immediate surgical intervention aimed at bowel resection. To our knowledge, this is the first report of successful control of such life-threatening hemorrhage by transcatheter embolisation.

Tortuous aorta--a new cause for esophageal chest pain?

Three patients (average age 61 years) presenting with retrosternal pain were evaluated with barium studies of the upper gastrointestinal tract. In each case, the esophagus was significantly displaced by a tortuous aorta. All patients had sliding hiatal hernias; these hiatal hernias, and the esophagitis and disordered motility seen in our patients, could be a consequence of esophageal displacement by the tortuous aorta. Two patients were relieved symptomatically with antacids and metoclopramide. Thus, tortuosity of the thoracic aorta can cause esophageal chest pain.

Ileal endometriosis (a case report)

A case of endometriosis involving small bowel is reported here. It is the first case reported at our institution in the last 10 years period.

Intramural pseudodiverticulosis of the esophagus in corrosive strictures: report of three cases

First described in 1960, esophageal intramural pseudodiverticulosis (EIPD) is a rare disease characterized by narrow-necked diverticuli confined to the esophageal wall. The cause is debatable, but esophageal strictures commonly accompany this entity. The association with EIPD of strictures caused by corrosives has been reported only once to date. We describe three additional examples.

Pneumoperitoneum and pneumomediastinum: unusual complications of laparoscopy

Pneumoretroperitoneum and pneumomediastinum are rare complications of laparoscopy. We report one such case. The mechanism of development of these complications is explained. No specific treatment needs to be instituted in most of these patients.

Dysphagia due to mediastinal fibrosis in advanced pulmonary tuberculosis

Dysphagia in patients with pulmonary tuberculosis may be due to tuberculous esophagitis or compression of the esophagus by enlarged mediastinal lymph nodes or mediastinal fibrosis. We studied the clinical and radiologic findings in nine patients with advanced pulmonary tuberculosis who presented with dysphagia. In each patient, dysphagia first occurred while the patient was on antituberculous therapy. Chest radiographs in each case showed extensive tuberculous disease of the lung, affecting especially the left upper lobe. In addition, dense mediastinal pleural fibrosis was seen along the medial aspects of the upper thorax. Tomograms did not show mediastinal lymph node enlargement. Barium esophagograms showed extrinsic compression and various degrees of narrowing of the supracarinal part of the esophagus. No mucosal abnormality was seen on esophagoscopy. On the basis of these findings, the compression of the esophagus in these patients was attributed solely to tuberculous mediastinal fibrosis. The dysphagia remained constant in all patients except one, in whom worsening dysphagia improved after balloon dilatation. We conclude that mediastinal fibrosis is a significant cause of dysphagia in patients with advanced pulmonary tuberculosis.

Probe directed at a segment of Rickettsia rickettsii rRNA amplified with polymerase chain reaction

In an effort to explore a sensitive taxon-specific detection system for bacteria, we sequenced the 16S rRNA from two strains of Rickettsia rickettsii, five other rickettsiae, and Coxiella burnetti to find a probe site unique to R. rickettsii. We then synthesized a 16-mer that hybridized only to the rRNA of R. rickettsii. Using a primer complementary to a sequence found only in rickettsial rRNA, we then generated a cDNA. We amplified the probe site in a 180-base segment of the cDNA by using the cDNA primer and a second primer also unique to rickettsiae in a polymerase chain reaction. The segments of rRNA from each of the rickettsiae were amplified 10(6)- to 10(7)-fold, and the R. rickettsii probe hybridized only to the amplified segment from R. rickettsii. The rRNAs from Staphylococcus aureus, C. burnetii, and Neisseria meningitidis were not amplified and did not hybridize with the probe. The approach detailed below may prove clinically useful in the direct detection of pathogens that are difficult to cultivate.

Isolated, segmental lipomatosis of the jejunum. Case report

A case of segmental lipomatosis of the jejunum producing intermittent intussusception is reported. Preoperative barium studies suggested the diagnosis. Segmental resection of the affected bowel gave complete relief from symptoms. Of the 19 previously reported cases of small-bowel lipomatosis, only one had isolated involvement of the jejunum.

Anterior neck lipoma masquerading as an external laryngocoele

Lipomas of the anterior neck are rare lesions with about 40 cases reported so far in the world literature. Though lipomas are known to change shape depending upon adjacent compressive forces, our case is unique in that the change in shape clinically mimicked an external laryngocoele. A possible explanation for the unusual behaviour of this lipoma is offered.

Inactivation of aldehyde dehydrogenase in intact rat liver mitochondria by dopamine

Aldehyde dehydrogenase (EC 1.2.1.3) within isolated rat liver mitochondria was inactivated by incubation with dopamine. Concurrent with this inactivation, incorporation of radioactivity from 14C-labelled dopamine into three mitochondrial matrix proteins (subunit mol.wt. = 120,000; 54,000; 20,000 daltons) occurred. The 54,000 mol.wt. protein also interacted with antihuman mitochondrial aldehyde dehydrogenase antibody. Inactivation of aldehyde dehydrogenase by dopamine occurred more readily in females than in males. Use of monoamine oxidase (EC 1.4.3.4) inhibitors (deprenyl and clorgyline) partially protected against inactivation. Monoamine oxidase catalyzed conversion of to 3,4-dihydroxyphenylacetaldehyde only partially accounted for aldehyde dehydrogenase activity loss.

False aneurysm secondary to aortic cannulation--rupture into lung with fatal hemoptysis during aortography

We report a case of fatal rupture of a false aneurysm of the ascending aorta during aortographic injection. The aneurysm had formed at the site of aortic cannulation done for a cardiac bypass at an earlier date. The rupture manifested as hemoptysis as the false aneurysm had burrowed and ruptured into the anterior segment of the right upper lobe of the lung.

Pneumococcal Waterhouse-Friderichsen syndrome despite a normal spleen

A previously fit 56 year old female presented with a rapidly progressive and fatal pneumococcal septicaemia with disseminated intravascular coagulation. Post-mortem studies confirmed a Waterhouse-Friderichsen syndrome and revealed an anatomically normal spleen; intracellular diplococci were seen within splenic macrophages providing evidence of normal splenic function. This appears to be only the second case of Waterhouse-Friderichsen syndrome due to pneumococcal septicaemia in a patient with a normal spleen.

Increased beta-receptor density and improved hemodynamic response to catecholamine stimulation during long-term metoprolol therapy in heart failure from dilated cardiomyopathy

Severe heart failure is associated with a reduction in myocardial beta-adrenergic receptor density and an impaired contractile response to catecholamine stimulation. Metoprolol was administered during a 6-month period to 14 patients with dilated cardiomyopathy to examine its effects on these abnormalities. The mean daily dose of metoprolol for the group was 105 mg (range, 75-150 mg). Myocardial beta-receptor density, resting hemodynamic output, and peak left ventricular dP/dt response to dobutamine infusions were compared in 9, 14, and 7 patients, respectively, before and after 6 months of metoprolol therapy while the patients were on therapy. The second hemodynamic study was performed 1-2 hours after the morning dose of metoprolol had been given. Myocardial beta-receptor density increased from 39 +/- 7 to 80 +/- 12 fmol/mg (p less than 0.05). Resting hemodynamic output showed a rise in stroke work index from 27 +/- 4 to 43 +/- 3 g/m/m2, p less than 0.05, and ejection fraction rose from 0.26 +/- 0.03 to 0.39 +/- 0.03 after 6 months of metoprolol therapy, p less than 0.05. Before metoprolol therapy, dobutamine caused a 21 +/- 4% increase in peak positive left ventricular dP/dt; during metoprolol therapy, the same dobutamine infusion rate increased peak positive dP/dt by 74 +/- 18% (p less than 0.05). Thus, long-term metoprolol therapy is associated with an increase in myocardial beta-receptor density, significant improvement in resting hemodynamic output, and improved contractile response to catecholamine stimulation. These changes indicate a restoration of beta-adrenergic sensitivity associated with metoprolol therapy, possibly related to the observed up-regulation of beta-adrenergic receptors.

Effect of human recombinant tumour necrosis factor and rat gamma interferon on nitrosomethylurea-induced mammary tumours

We have used the nitrosomethylurea-induced rat mammary tumour model to study the effects of parenteral administration of human recombinant tumour necrosis factor (rHu-TNF) and rat gamma interferon (IFN-gamma). An inbred strain of tumour bearing female Ludwig/Wistar/Olac rats were randomised to either treatment or control groups. Two independent studies showed that combined treatment with rHu-TNF and rat IFN-gamma induced significant tumour regression over 4 weeks (P = 0.004, P = 0.005 respectively). Treatment with either rHu-TNF or rat IFN-gamma given individually did not affect the overall rate of tumour growth (P = 0.157 and 0.40 respectively) although an initial reduction in tumour size was observed during the first few days after injection. Measurement of circulating oestradiol levels in groups in which maximum tumour regression was observed showed no statistically significant difference when compared to the control group. Similarly, measurement of oestrogen receptor content showed no statistically significant difference between rHu-TNF-gamma or rat-IFN-gamma treatment or combined treatment of rHu-TNF and IFN-gamma with the control group. We conclude from these observations that combined therapy with rHu-TNF and rat IFN-gamma may prove to be useful new forms of treatment for human breast cancer.