Image-guided biopsy in women with breast cancer presenting with peritoneal carcinomatosis

When women with a history of breast cancer present with peritoneal carcinomatosis, the differential diagnosis lies between recurrent breast cancer or a new primary tumor. This scenario is of particular relevance to women with a BRCA gene mutation, who have a genetic predisposition to develop second primary tumors of the ovary, fallopian tube, and peritoneum. We describe the use of image-guided core biopsy as an alternative to laparoscopy or exploratory laparotomy in providing minimally invasive diagnosis in this increasingly common clinical dilemma.

Efficacy of fibrinolysis in the emergency department for acute myocardial infarction

BACKGROUND

Patients with an acute myocardial infarction require a rapid response to their symptoms and the earlier fibrinolysis is given (where indicated), the better the outcome.

AIMS

The aim of this study is to compare 'door to needle times' for fibrinolysis in Acute Myocardial Infarction (AMI) in three phases of one year each, at Letterkenny General Hospital.

METHODS

In the PREINTERVENTION year all fibrinolysis was performed in the Coronary Care Unit (CCU). In the INTERVENTION year Emergency Department (ED) fast track fibrinolysis was introduced and in the POST INTERVENTION year most fibrinolysis was performed on fast track in the ED.

RESULTS

The time saved by the introduction of ED fibrinolysis was significant, 41 minutes on average per patient. Elderly, female patients were more likely to bypass ED fast track fibrinolysis and to be brought to CCU for fibrinolysis, with attendant delays. This has educational implications in relation to the variation in clinical presentation of AMI with age and sex.

CONCLUSION

The ED fast track fibrinolysis system is recommended as an effective, safe, achievable and worthwhile intervention towards improving 'door to needle times' for fibrinolysis in AMI.

Pathology of ovarian cancers in BRCA1 and BRCA2 carriers

PURPOSE

Germline mutations in the BRCA1 and BRCA2 genes confer increased susceptibility to ovarian cancer. There is evidence that tumors in carriers may exhibit a distinct distribution of pathological features, but previous studies on the pathology of such tumors have been small. Our aim was to evaluate the morphologies and immunophenotypes in a large cohort of patients with familial ovarian cancer.

EXPERIMENTAL DESIGN

We performed a systematic review of ovarian tumors from 178 BRCA1 mutation carriers, 29 BRCA2 mutation carriers, and 235 controls with a similar age distribution. Tumors were evaluated by four pathologists blinded to mutation status. Both morphological features and immunochemical staining for p53 and HER2 were evaluated.

RESULTS

Tumors in BRCA1 mutation carriers were more likely than tumors in age-matched controls to be invasive serous adenocarcinomas (odds ratio, 1.84; 95% confidence interval, 1.21-2.79) and unlikely to be borderline or mucinous tumors. Tumors in BRCA1 carriers were of higher grade (P < 0.0001), had a higher percentage solid component (P = 0.001), and were more likely to stain strongly for p53 (P = 0.018). The distribution of pathological features in BRCA2 carriers was similar to that in BRCA1 carriers.

CONCLUSIONS

Use of pathological features can substantially improve the targeting of predictive genetic testing. Results also suggest that BRCA1 and BRCA2 tumors are relatively aggressive and may be expected to have poor prognosis, although this may be treatment dependent.

Octupole vibration in superdeformed 152(66)Dy86

Nine transitions of dipole character have been identified linking an excited superdeformed (SD) band in 152Dy to the yrast SD band. As a result, the excitation energy of the lowest level in the excited SD band has been measured to be 14 238 keV. This corresponds to a 1.3 MeV excitation above the SD ground state. The levels in this band have tentatively been determined to be of negative parity and odd spin. The measured properties are consistent with an interpretation in terms of a rotational band built on a collective octupole vibration.

Computed tomography findings of gaseous necrosis in epithelial ovarian cancer: a report of three cases

Necrosis in pathologic specimens of ovarian cancer is well documented; however, computed tomography (CT) evidence of gaseous necrosis in the absence of fistulation with bowel has not yet been described. We report three cases of ovarian adenocarcinoma that on CT showed evidence of gross gaseous necrosis, mimicking a pelvic abscess.

Direct decay from the superdeformed band to the yrast line in 15266Dy86

The excitation energy, spin, and parity of the yrast superdeformed band in 152Dy have been firmly established. The evidence comes mainly from the measured properties of a 4011 keV single-step transition connecting the yrast superdeformed level fed by the 693 keV transition to the 27- yrast state. Four additional, weaker, linking gamma rays have been placed as well. The excitation energy of the lowest superdeformed band member is 10 644 keV and its spin and parity are determined to be 24+.

Peritoneal carcinomatosis: image-guided peritoneal core biopsy for tumor type and patient care

PURPOSE

To assess image-guided peritoneal core biopsy for the diagnosis of tumor type and treatment of patients with peritoneal carcinomatosis.

MATERIALS AND METHODS

Thirty-five women (age range, 47-85 years; mean age, 69 years) prospectively identified in a gynecologic oncology center underwent 18-gauge core biopsy in omental cake (n = 25), peritoneal (n = 7), or adnexal (n = 3) sites. No complications of biopsy occurred. Standard hematoxylin-eosin analysis of the biopsy cores was supplemented by immunohistochemical markers to CA-125, carcinoembryonic antigen, cytokeratin 7, and cytokeratin 20. Diagnoses were validated with further multidisciplinary review, subsequent surgery, and response to specific chemotherapy.

RESULTS

In 27 (77%) of the 35 women, a confident primary site diagnosis was obtained with standard hematoxylin-eosin analysis of core biopsy material from the following sites: ovary (n = 22), breast (n = 2), colon (n = 2), and lymphoma (n = 1). The finding at hematoxylin-eosin analysis in another seven (20%) women was poorly differentiated adenocarcinoma with no definite primary site but with an immunohistochemical profile suggesting ovarian cancer (CA-125 positive, carcinoembryonic antigen negative, cytokeratin 7 positive, cytokeratin 20 negative). There was one false-negative biopsy result.

CONCLUSION

Image-guided peritoneal core biopsy with hematoxylin-eosin analysis supplemented with immunohistochemical analysis is a simple, safe, and accurate technique for providing site-specific diagnoses in women with undiagnosed peritoneal carcinomatosis.

Bladder transplantation in rats using FK-506

PURPOSE

We created viable bladder tissue by transplantation with immunosuppression.

MATERIALS AND METHODS

For bladder transplantation the bladder of newborn Brown-Norway rats was excised and each was transplanted into a pouch created in the distal omentum of a 5-week-old Lewis rat. In 15 group 1 rats no immunosuppressive agent was used. In 20 group 2 rats 0.6 mg./kg. FK-506 daily were given intramuscularly until a predetermined day of harvest. Recipient rats were sacrificed on day 3, 5, 7 or 14 after bladder transplantation, and the bladder grafts were harvested and formalin fixed. Hematoxylin and eosin staining was done to examine bladder graft survival and the degree of rejection, and immunohistochemical testing was performed for assessing the vesical nervous system. In 5 rats in the control group bladder augmentation was performed by anastomosing the bladder graft to the native bladder. Each augmented bladder was harvested 21 days later for histopathological assessment.

RESULTS

Overall bladder graft survival was 96.4%. Each successfully transplanted bladder graft appeared macroscopically as a thin walled cyst. In group 1 all bladder grafts showed rejection with cellular infiltration. In group 2 there was mild rejection in 5 rats and no evidence of rejection in the remaining 15. All group 2 bladder grafts had intact nerve distribution. Bladder augmentation was successful in all 5 cases and the mucosa was normal throughout each augmented bladder.

CONCLUSION

Because FK-506 successfully prevents rejection, our technique would appear to have the potential for creating viable bladder tissue that may be used for bladder augmentation in cases of vesical exstrophy or neurogenic bladder.

Use of Abdominoplasty Technique and Marlex for Closure of a Major Abdominal Wall Defect

Surgical resection of extensive primary or secondary abdominal wall tumours leads to major defects requiring reconstruction. The present case report describes the use of Marlex (polypropylene) mesh (CR Bard Inc, USA) with Mitek GII suture anchors (Mitek Products, USA) and an abdominoplasty technique to close a defect involving the entire lower half of the abdominal wall.

Benefits of pravastatin on cardiovascular events and mortality in older patients with coronary heart disease are equal to or exceed those seen in younger patients: Results from the LIPID trial

BACKGROUND

The effect of cholesterol-lowering therapy on death from coronary heart disease in older patients with previous coronary heart disease and average cholesterol levels is uncertain.

OBJECTIVE

To compare the relative and absolute effects of pravastatin on cardiovascular disease outcomes in patients with coronary heart disease who are 65 years of age or older with those in patients 31 to 64 years of age.

DESIGN

Subgroup analysis of a randomized, placebo-controlled trial.

SETTING

87 centers in Australia and New Zealand.

PATIENTS

3514 patients 65 to 75 years of age, chosen from among 9014 patients with previous myocardial infarction or unstable angina and a baseline plasma cholesterol level of 4.0 to 7.0 mmol/L (155 to 271 mg/dL).

INTERVENTION

Pravastatin, 40 mg/d, or placebo.

MEASUREMENTS

Major cardiovascular disease events over 6 years.

RESULTS

Older patients were at greater risk than younger patients (31 to 64 years of age) for death (20.6% vs. 9.8%), myocardial infarction (11.4% vs. 9.5%), unstable angina (26.7% vs. 23.2%), and stroke (6.7% vs. 3.1%) (all P < 0.001). Pravastatin reduced the risk for all cardiovascular disease events, and similar relative effects were observed in older and younger patients. In patients 65 to 75 years of age, pravastatin therapy reduced mortality by 21% (CI, 7% to 32%), death from coronary heart disease by 24% (CI, 7% to 38%), coronary heart disease death or nonfatal myocardial infarction by 22% (CI, 9% to 34%), myocardial infarction by 26% (CI, 9% to 40%), and stroke by 12% (CI, -15% to 32%). For every 1000 older patients treated over 6 years, pravastatin prevented 45 deaths, 33 myocardial infarctions, 32 unstable angina events, 34 coronary revascularization procedures, 13 strokes, or 133 major cardiovascular events, compared with 22 deaths and 107 major cardiovascular events per 1000 younger patients. Among older patients, the numbers needed to treat were 22 (CI, 17 to 36) to prevent one death from any cause, 35 (CI, 24 to 67) to prevent one death from coronary heart disease, and 21 (CI, 17 to 31) to prevent one coronary heart disease death or nonfatal myocardial infarction.

CONCLUSIONS

In older patients with coronary heart disease and average or moderately elevated cholesterol levels, pravastatin therapy reduced the risk for all major cardiovascular events and all-cause mortality. Since older patients are at greater risk than younger patients for these events, the absolute benefit of treatment is significantly greater in older patients.

Venous aneurysm of the dorsal venous arch

Clinically, a venous aneurysm is seen as a nonpulsatile mass with shrinkage upon elevation and enlargement with dependency. Confirmation of the diagnosis is best made by venography. In the case presented here of a rare aneurysm of the dorsal venous arch, the diagnosis of venous aneurysm was based on the histopathologic and intraoperative findings. If a venous aneurysm is symptomatic, it should be excised, with ligation of all feeder veins. In all cases, accurate preoperative diagnosis and evaluation allows for appropriate surgical planning.

Effects of pravastatin in 3260 patients with unstable angina: results from the LIPID study

BACKGROUND

The LIPID study is a major trial of secondary prevention of coronary-heart-disease events that includes hospital admission with unstable angina (as well as myocardial infarction) as a qualifying event. In this substudy of LIPID, we compared subsequent cardiovascular risks and the effects of pravastatin in patients with previous unstable angina or previous myocardial infarction.

METHODS

3260 patients diagnosed with unstable angina and 5754 with acute myocardial infarction 3-36 months previously were randomly assigned 40 mg pravastatin daily or placebo over a mean of 6.0 years. The risk reduction of a range of cardiovascular events was estimated by means of the hazard ratio in Cox's proportional hazards model.

FINDINGS

Among patients assigned placebo, survival in the two diagnosis groups was similar. The relative risk reduction for mortality with pravastatin was 20.6% in the myocardial infarction group and 26.3% in the unstable angina group (p=0.55). Pravastatin significantly reduced the rates of all prespecified coronary endpoints in the myocardial infarction group. In patients with previous unstable angina, coronary heart disease mortality, total mortality, myocardial infarction, a need for coronary revascularisation, the number of admissions to hospital, and the number of days in hospital were significantly lower with pravastatin. Overall, hospital admission for unstable angina was the most common endpoint (24.6% of the placebo group; 22.3% of the pravastatin group).

INTERPRETATION

Patients who have survived acute myocardial infarction or unstable angina have a similar long-term prognosis, a high occurrence of subsequent unstable angina, and benefit similarly from therapy with pravastatin.

Neural networks in the diagnosis of malignant ovarian tumours

OBJECTIVE

To assess the role of neural networks in predicting the likelihood of malignancy in women presenting with ovarian tumours.

DESIGN

Retrospective case study.

SETTING

University Department of Obstetrics and Gynaecology, St James's Hospital, Leeds.

METHODS

Information from 217 cases with histologically proven benign, borderline or malignant tumours was extracted for study. Four variables (age, ultrasound findings with and without colour Doppler imaging and CA125) were entered in the neural network classifier. The neural network results were compared with logistic regression analysis.

RESULTS

When used in the neural network the variables of age, CA125 and ultrasound score produced the best result with a sensitivity of 95% and a corresponding specificity of 78% in predicting malignancy. Logistic regression gave a sensitivity or 82% for a specificity of 51%.

CONCLUSION

The neural network is a good method of combining diagnostic variables and may be a useful predictor of malignancy in women presenting with ovarian tumours. A comparison of the performance of the neural network with conventional diagnostic methods would be warranted prior to use in clinical practice.

Port-site metastasis following laparoscopic lymphadenectomy for adenosquamous carcinoma of the cervix

Although incisional metastases following surgery for cervical cancer are extremely rare, port-site disease following minimal-access surgery is becoming increasingly reported. We report a case of a metastasis which occurred at a port site following laparoscopic removal of lymph nodes affected by cervical adenosquamous carcinoma. This report adds to the literature suggesting that cutaneous tumor deposition may be enhanced by this method of surgery.

CT appearances and prognostic significance of splenic metastasis in ovarian cancer

DESIGN

A retrospective review of women undergoing computed tomography (CT) as part of the investigation and management of pathologically proven ovarian cancer in a single specialist gynaecological cancer centre.

OBJECTIVE

To ascertain CT appearances and prognostic significance of splenic involvement in ovarian cancer.

RESULTS

We found a 10.3% frequency of splenic metastasis in a series of 321 patients with ovarian cancer. Thirty-three women had splenic metastases demonstrated on CT. Twenty-three women had surface lesions with an irregular scalloped shape and broad contact with the splenic surface; 17 of these women had lesions at presentation. Ten women had parenchymal lesions, five at presentation and five at relapse, typically with a rounded shape surrounded by normal splenic tissue. Four out of 10 cases with parenchymal involvement showed lesion progression during chemotherapy. However, lesion progression occurred in only one of 23 cases with surface disease (P < 0.025, Fisher's exact test). In 16 cases with disease involving both spleen and liver, the response to chemotherapy was the same in both organs.

CONCLUSION

We have found a higher frequency of splenic metastasis from ovarian cancer during life than previously reported. Parenchymal lesions are significantly less likely to respond to treatment than surface lesions but are more commonly a feature of relapsed disease. We have demonstrated that splenic metastases behave similarly to liver metastases in ovarian cancer. We suggest that the presence of splenic parenchymal metastasis is indicative of FIGO stage IV disease. This finding has implications for proposed cytoreductive surgery.

Malignant melanoma metastatic to the ovary: presentation and radiological characteristics

Cutaneous melanomas rarely metastasize to the ovary; however, we have recently encountered three cases which have proved a diagnostic dilemma. All presented with a pelvic mass and a past history of cutaneous melanoma but both ultrasound examination and CT scanning proved inconclusive and neither was able to accurately characterize the lesions. Magnetic resonance imaging (MRI) was able to demonstrate the presence of melanin in one of the ovarian lesions as peripheral high signal change on T1-weighted images. The two lesions without melanin failed to show this feature. MRI may therefore be useful in the diagnosis of ovarian melanoma but only if melanin is present.

Spontaneous perforation of choledochal cyst: a study of 13 cases

Of the 187 cases of infantile choledochal cyst treated at our hospitals, we encountered 13 with spontaneous perforation. All cases were under 4 years old. Eight cases were found to have biliary peritonitis and 5 had a sealed perforation. The shape of the extrahepatic bile duct was cystic in 8 and fusiform in 5. The cyst wall around the perforation was filmy and bile was found to be oozing through the thinned wall. Nine perforations were single while 4 cases had multiple perforations. Four of 17 perforations occurred in the posterior part of the cyst wall. Only 1 case of perforation was associated with protein plugs in a common channel, while 7 of the 10 cases of choledochal cyst requiring percutaneous biliary drainage due to signs of raised intrabiliary pressure were found to have protein plugs. We consider that spontaneous perforation of a choledochal cyst is not rare in infancy. The etiology of a perforation must be epithelial irritation of the biliary tract due to refluxed pancreatic juice caused by pancreatico-biliary malunion associated with mural immaturity due to infancy, rather than an abnormal rise in ductal pressure or congenital mural weakness at a certain point.