Sentinel lymph node biopsy: is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in-situ with microinvasion?

BACKGROUND

Axillary lymph node status is the strongest prognostic indicator of survival for women with breast cancer. The purpose of this study was to determine the incidence of sentinel node metastases in patients with high-risk ductal carcinoma-in-situ (DCIS) and DCIS with microinvasion (DCISM).

METHODS

From November 1997 to November 1999, all patients who underwent sentinel node biopsy for high-risk DCIS (n = 76) or DCISM (n = 31) were enrolled prospectively in our database. Patients with DCIS were considered high risk and were selected for sentinel lymph node biopsy if there was concern that an invasive component would be identified in the specimen obtained during the definitive surgery. Patients underwent intraoperative mapping that used both blue dye and radionuclide. Excised sentinel nodes were serially sectioned and were examined by hematoxylin and eosin and by immunohistochemistry.

RESULTS

Of 76 patients with high-risk DCIS, 9 (12%) had positive sentinel nodes; 7 of 9 patients were positive for micrometastases only. Of 31 patients with DCISM, 3 (10%) had positive sentinel nodes. 2 of 3 were positive for micrometastases only. Six of nine patients with DCIS and three of three with DCISM and positive sentinel nodes had completion axillary dissection; one patient with DCIS had an additional positive node detected by conventional histological analysis.

CONCLUSIONS

This study documents a high incidence of lymph node micrometastases as detected by sentinel node biopsy in patients with high-risk DCIS and DCISM. Although the biological significance of breast cancer micrometastases remains unclear at this time, these findings suggest that sentinel node biopsy should be considered in patients with high-risk DCIS and DCISM.

Immunoglobulin D multiple myeloma in our hospital--a rare occurrence

Immunoglobulin (Ig) D multiple myeloma is a rare presentation, usually with an aggressive course and a poorer prognosis. It accounts for about 1-2% of newly diagnosed mulitple myeloma patients. Due to its rarity, reports on Ig D multiple myeloma are limited in the literature. We therefore present 4 cases of Ig D multiple myeloma in our hospital over a period of 8 years between 1990 to 1998. The average age of presentation of our patients was 44 years old with a female preponderance. Common presenting symptoms were appetite and weight loss and bone pain. Two patients presented with neurological symptoms and 2 with renal impairment. Three patients had an associated lambda paraproteinaemia and the fourth had a kappa paraproteinaemia. A common finding in Ig D myeloma is a small or no spike seen on serum electrophoresis together with heavy Bence Jones proteinuria. A review of the literature on Ig D myeloma is also presented.

Is routine intraoperative frozen-section examination of sentinel lymph nodes in breast cancer worthwhile?

BACKGROUND

Routine intraoperative frozen section (FS) of sentinel lymph nodes (SLN) can detect metastatic disease, allowing immediate axillary dissection and avoiding the need for reoperation. Routine FS is also costly, increases operative time, and is subject to false-negative results. We examined the benefit of routine intraoperative FS among the first 1000 patients at Memorial Sloan Kettering Cancer Center who had SLN biopsy for breast cancer.

METHODS

We performed SLN biopsy with intraoperative FS in 890 consecutive breast cancer patients, none of whom had a back-up axillary dissection planned in advance. Serial sections and immunohistochemical staining for cytokeratins were performed on all SLN that proved negative on FS. The sensitivity of FS was determined as a function of (1) tumor size and (2) volume of metastatic disease in the SLN, and the benefit of FS was defined as the avoidance of a reoperative axillary dissection.

RESULTS

The sensitivity of FS ranged from 40% for patients with Tla to 76% for patients with T2 cancers. The volume of SLN metastasis was highly correlated with tumor size, and FS was far more effective in detecting macrometastatic disease (sensitivity 92%) than micrometastases (sensitivity 17%). The benefit of FS in avoiding reoperative axillary dissection ranged from 4% for Tla (6 of 143) to 38% for T2 (45 of 119) cancers.

CONCLUSIONS

In breast cancer patients having SLN biopsy, the failure of routine intraoperative FS is largely the failure to detect micrometastatic disease. The benefit of routine intraoperative FS increases with tumor size. Routine FS may not be indicated in patients with the smallest invasive cancers.

Cloning and expression of immunoreactive antigens from Mycobacterium tuberculosis

Four immunoreactive proteins, B.4, B.6, B.10, and B.M, with molecular weights ranging from 16,000 to 58,000, were observed from immunoblots of Mycobacterium tuberculosis total lysates screened with sera from individuals with active tuberculosis. These proteins were identified from microsequence analyses, and genes of proteins with the highest homology were PCR amplified and cloned into the pQE30 vector for expression studies. In addition, a 37.5-kDa protein, designated C17, was identified from a phage expression library of M. tuberculosis genomic DNA. Preliminary immunoblot assays indicated that these five resultant recombinant proteins could detect antibodies in individuals with active pulmonary and extrapulmonary tuberculosis. The overall ranges of sensitivities, specificities, positive predictive values, and negative predictive values for the recombinant antigens were 20 to 58, 88 to 100, 69 to 100, and 56 to 71%, respectively. The B.6 antigen showed preferential reactivity to antibodies in pulmonary compared to nonpulmonary tuberculosis serum specimens. All of these recombinant antigens demonstrated potential for serodiagnosis of tuberculosis.

Spontaneous uterine perforation from uterine infarction: a rare case of acute abdomen

A case of spontaneous uterine perforation from uterine infarction is presented. The authors believe that this is the first reported case.

Evaluation of pectoralis major muscle in patients with posterior breast tumors on breast MR images: early experience

PURPOSE

To evaluate the ability to use breast magnetic resonance (MR) imaging to assess disease extent in patients with posterior breast masses who are suspected to have tumor invasion into underlying muscle.

MATERIALS AND METHODS

Nineteen patients with posterior breast masses underwent three-dimensional, gradient-echo, 1.5-T MR imaging before and after the administration of gadopentetate dimeglumine. Thirteen had deep palpable masses that were clinically determined to be fixed to the underlying chest wall. Twelve had mammographic findings that caused muscle involvement to be suspected, and seven had normal mammograms. All patients underwent surgery. MR images were reviewed and were correlated with histologic findings.

RESULTS

Enhancing masses were identified on MR images in all 19 patients. Five (26%) of the 19 patients had masses that abutted the muscles, with obliteration of the fat plane and muscle enhancement. All five had muscle involvement at surgery. In the remaining 14 (74%) patients, no enhancement of muscle was seen; none of these had invasion of the muscle at surgery.

CONCLUSION

Extension of adjacent tumor into underlying musculature was indicated by abnormal enhancement within these structures. Violation of the fat plane between tumor and muscle, without other findings, did not indicate tumor involvement of these deep structures.

Successful living related liver transplantation from a donor with von Willebrand's disease

We report a successful living related liver transplantation from a donor with von Willebrand's disease. With proper preparation, a substantial liver resection can be performed safely in such patients, and the transplanted liver will function normally.

Two dosing regimens for preinduction cervical priming with intravaginal dinoprostone pessary: a randomised clinical trial

OBJECTIVE

To compare the efficacy within 24 hours of a three-times-a-day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming.

DESIGN

Randomised controlled trial.

SETTING

Department of Obstetrics and Gynaecology, Singapore General Hospital.

PARTICIPANTS

One hundred singleton term primigravidae with cephalic presentation with unfavourable cervical scores (Bishop score < or = 5) requiring induction of labour.

METHODS

Eligible women were randomly assigned the standard regimen (3000 microg dinoprostone [Prostin, Upjohn, Crawley, UK] once daily) or an intensive regimen (3000 microg dinoprostone given sequentially three times daily four hours apart) for cervical priming until successful priming (Bishop score of > or = 6) or the onset of active labour occurred.

MAIN OUTCOME MEASURES

Number of women whose cervices were ripened successfully or who entered active labour within 24 hours of starting cervical priming, priming to induction interval, and priming to delivery interval.

RESULTS

Forty-nine women were assigned to the standard regimen and 51 to the intensive regimen. The median number (range) of dinoprostone pessaries used was two (one to seven) in the standard regimen and three (one to nine) in the intensive regimen. Forty-two women (82.4%) who underwent the intensive regimen achieved successful cervical ripening or active labour within 24 hours, compared with 21 assigned to standard regimen (OR 6.2, 95% CI 2.3-17.4). This difference was statistically significant. The median intervals from priming to induction, and from priming to delivery, were also statistically significantly shorter in women treated with the intensive regimen. Thirty-five women (68.63%) assigned the intensive regimen experienced pain, compared with 21 (42.86%) in the standard regimen (OR 2.92, 95% CI 1.19-7.21), with two and one women in the respective regimens requiring opiate analgesics. Five women with oligohydramnios had transient cardiotocographic abnormalities during priming with the intensive regimen, none of which required immediate intervention, and the babies were born in good condition. There were no cases of uterine hypertonus and the outcomes of labour were similar for women from both regimens.

CONCLUSIONS

Preinduction cervical priming with the intensive dosing regimen improves the chances of successful ripening within 24 hours for primigravidae with unfavourable cervical scores at full term singleton pregnancies, and shortens the interval from priming to induction, and priming to delivery. This regimen may be more cost effective by shortening the period of hospital stay. The overall incidence of adverse reactions to the mother and fetus during priming was low. However, close fetal surveillance must be maintained, particularly in pregnancies complicated with oligohydramnios.

Six-year follow-up of patients with microinvasive, T1a, and T1b breast carcinoma

BACKGROUND

Management of patients with breast cancers < or = 1 cm remains controversial. Reports of infrequent nodal metastases in tumors < or = 5 mm has led to suggestions that axillary dissection should be selective, and that tumor characteristics should guide adjuvant therapy.

METHODS

A retrospective review of 290 patients with breast cancer 1 cm in size or smaller from 1989 to 1991 was done. Distant disease-free survival (DDFS) was the primary outcome measure.

RESULTS

There were 95 T1a (< or = 5 mm) and 196 T1b (6-10 mm) cancers. Nodal metastases were found in 8 T1a and 26 T1b tumors. Larger size, poorer differentiation, and lymphovascular invasion (LVI) were associated with more nodal metastases, but none of these trends reached statistical significance. The 6-year DDFS was 93% for node-negative and 87% for node-positive patients (P = .02). Overall, breast cancers with poorer differentiation and LVI trended toward a poorer outcome. For patients with node-negative tumors, LVI was associated with a poorer outcome (P = .03). The size of the primary tumor was not predictive of outcome. There were no nodal metastases or recurrences in the 18 patients with microinvasive breast cancer.

CONCLUSIONS

Lymph node status is the major determinant of outcome in breast cancers 1 cm in size or smaller. Accurate axillary assessment remains crucial in management of small breast cancer.

Cytotoxicity and DNA interaction of the enantiomers of 6-amino-3-(chloromethyl)-1-[(5,6,7-trimethoxyindol-2-yl)carbonyl]indo- line (amino-seco-CI-TMI)

The enantiomers of the previously reported racemic 6-amino-3-(chloromethyl)-1-[(5,6,7-trimethoxyindol-2-yl)carbonyl] indoline (amino-seco-CI-TMI) were prepared via resolution of a precursor by chiral HPLC. The only detectable product isolated from reaction of the racemic compound with calf thymus DNA, followed by thermal cleavage, was shown by mass spectrometry and two-dimensional NMR spectroscopy to be the adenine N3 adduct. Polyacrylamide gel electrophoresis assays with the racemate and with each enantiomer also showed adenine to be the only site of alkylation. While the racemic amino compound exhibited sequence selectivity identical to that of the previously characterized phenol analogue, the enantiomers exhibited distinctly different sequence selectivities, allowing the (+) enantiomer to be assigned the "natural" S configuration. The (+)-(S) enantiomer is 3-fold more cytotoxic than the (-)-(R) enantiomer (IC(50) values of 240 and 700 nM, respectively, in AA8 cells, after exposure for 4 h).

Epidermal growth factor, estrogen, and progesterone receptor expression in primary sweat gland carcinomas and primary and metastatic mammary carcinomas

The distinction between primary sweat gland carcinomas and metastatic breast carcinoma to the skin is sometimes difficult. In an effort to improve this discrimination, we compared the immunohistochemical staining pattern of 42 primary sweat gland carcinomas (SGCs) with 30 metastases from breast carcinoma (BC) to the skin, 125 primary BCs, and 30 noncutaneous metastases from BCs. The antibodies used were against the receptors for epidermal growth factor (EGF-R), estrogen receptor (ER), and progesterone receptor (PR). The frequencies of positive staining were as follows for EGF-R: 34 (81%) of 42 SGCs, 5 (17%) of 30 BCs metastatic to skin, 28 (22%) of 125 primary BCs, and 6 (20%) of 30 noncutaneous BC metastases. For ER, the frequencies were 9 (21%) of 42 SGCs and 10 (33%) of 30 BCs metastatic to skin. The frequencies for PR were 8 (19%) of 42 SGCs and 8 (27%) of 30 BCs metastatic to skin. These results suggest that expression of EGF-R may be diagnostically helpful, because it is strongly associated with SGCs when compared with metastatic BCs (P < .0001). This association is also present when ductal eccrine and apocrine types of SGC, which are the histologic subtypes of SGC most difficult to distinguish from metastatic BC, are separately analyzed (P < .001). The frequencies of expression of ER and PR in SGCs and BCs metastatic to skin were not significantly different.

Lymphangiomyomatosis: radiological and measured lung function deterioration after contrast-enhanced computed tomography

Pulmonary lymphangiomyomatosis (LAM) is a rare disease of unknown aetiology which occurs exclusively in women, usually of reproductive age. The findings on CT and high-resolution CT (HRCT) are well described and characteristic, and in a young woman they are virtually pathognomonic. A case of symptomatic, radiological and measured lung function deterioration following contrast-enhanced CT in a patient with LAM are reported here. These observations, to the authors' knowledge, have never been reported before. The authors attempt to explain these observations based on the known pathology of LAM.

Epistaxis

Epistaxis is a common clinical problem. The widespread availability of endoscopic equipment is shifting management philosophy toward targeting the bleeding point. This shift may have a significant impact on decreasing length of stay and blood transfusion rates. Advances in interventional radiology have also reduced the risk of embolization. Patient education, especially teaching first-aid measures to patients at high risk for nosebleeds, also encourages more effective use of health care resources.

Outcome of early cervical carcinoma treated by Wertheim hysterectomy with selective postoperative radiotherapy

Seventy-five consecutive patients with histologically confirmed FIGO stage IB-IIA cervical carcinoma who underwent Wertheim hysterectomy were studied retrospectively. Poor prognostic factors were found in 42 (56%) patients in whom postoperative adjuvant pelvic irradiation was given. The overall disease-free survival rate was 78% at 5 years and 75% at 9 years. The tumour recurrence rate was 12.1% in the low-risk patients and 35.7% in the high-risk patients. Tumour recurrences occurred significantly more frequently in patients with tumours with high grade squamous cell carcinomas and adenosquamous carcinoma. No recurrences occurred in patients with adenocarcinomas. After adjuvant radiotherapy, there was no statistically significant difference in the recurrence rates between lymph node positive and negative patients (26.7% and 19.6% respectively), however extrapelvic recurrences were more common in those with diseased lymph nodes. The recurrence rate was 40% in patients with involved resection margins compared to 16.7% of patients with clear margins. The recurrence rates were similar for patients with and without tumour embolisation of vascular/lymphatic channels. Wertheim hysterectomy with postoperative pelvic irradiation for selected high-risk patients was an effective treatment for FIGO stage IB-IIA cervical carcinoma. Despite radiotherapy, the high-risk patients still experienced a high tumour recurrence rate.

Expression of TERT in early premalignant lesions and a subset of cells in normal tissues

Activation of telomerase, the enzyme that synthesizes the telomere ends of linear chromosomes, has been implicated in human cell immortalization and cancer cell pathogenesis. Enzyme activity is undetectable in most normal cells and tissues, but present in immortal cells and cancer tissues. While expression of TERC, the RNA component of telomerase, is widespread, the restricted expression pattern of TERT, the telomerase catalytic subunit gene, is correlated with telomerase activity, and its ectopic expression in telomerase-negative cells is sufficient to reconstitute telomerase activity and extend cellular lifespan. We have used in situ hybridization to study TERT expression at the single-cell level in normal tissues and in various stages of tumour progression. In normal tissues, including some that are known to be telomerase-negative, TERT mRNA was present in specific subsets of cells thought to have long-term proliferative capacity. This included mitotically inactive breast lobular epithelium in addition to some actively regenerating cells such as the stratum basale of the skin. TERT expression appeared early during tumorigenesis in vivo, beginning with early pre-invasive changes in human breast and colon tissues and increasing gradually during progression, both in the amount of TERT mRNA present within individual cells and in the number of expressing cells within a neoplastic lesion. The physiological expression of TERT within normal epithelial cells that retain proliferative potential and its presence at the earliest stages of tumorigenesis have implications for the regulation of telomerase expression and for the identification of cells that may be targets for malignant transformation.

Incidence of axillary lymph node metastases in T1a and T1b breast carcinoma

BACKGROUND

We investigated the incidence of axillary lymph node metastases in patients with T1a (< or = 0.5 cm) and T1b (> 0.5 cm and < or = 1.0 cm) breast cancers.

METHODS

The charts of 2000 patients who underwent axillary lymph node dissection for breast cancer at our institution from 1989 to 1991 were reviewed. Of these, 81 patients had T1a and 166 had T1b primary breast cancers.

RESULTS

Among the 247 patients with T1a and T1b breast cancers, nodal metastases were present in 30 (12.1%), with a 7.4% positivity rate for patients with T1a and 14.5% positivity rate for T1b tumors. Of the 212 patients who had > or = 10 nodes dissected, 29 (13.7%) had positive nodes. Of those, 6 of 60 (10.0%) patients with T1a and 23 of 152 (15.1%) with T1b tumors had positive nodes. The presence of lymphovascular invasion (LVI) predicted a significantly higher nodal positivity rate (27.8% vs. 10.9%, p = 0.05).

CONCLUSIONS

Of patients with adequately evaluated axillae, 10% with T1a and 15% with T1b cancers were found to have nodal metastases. Although LVI was significantly associated with a higher risk of lymph node metastases, we could not characterize any subgroup at acceptably low risk of nodal positivity. Until a more useful prognostic indicator is discovered, axillary dissection should continue to be part of the mainstay of management for small breast cancers.

Stage IA uterine serous carcinoma: a study of 13 cases

Although in endometrioid type endometrial carcinoma depth of invasion is a powerful predictor of extrauterine disease and survival, in serous carcinoma its importance is unclear. Recurrences and death in patients with serous tumors confined to the endometrium or an endometrial polyp have been reported. In other studies, however, the absence of myometrial invasion was correlated with a more favorable course. In an attempt to clarify this issue, we reviewed 13 completely staged, stage IA serous carcinomas with follow-up from 10 to 93 months (median 38), in which extensive histologic examination had been performed. Serous carcinoma was identified in an endometrial polyp in six cases, in an endometrial polyp and associated endometrium in four, and solely in the endometrium in three cases. No other histologic types of endometrial carcinoma were present, and there was no myometrial invasion. Multifocal serous intraepithelial carcinoma was also seen in 12 cases. Two of the patients died of disease with intraabdominal carcinomatosis at 10 and 14 months after presentation. The overall estimated survival was 83%, showing a relatively favorable prognosis. In conclusion, although the absence of histologically detected myometrial invasion may be associated with recurrences and death in serous carcinoma, an accurately assessed stage based on a careful histologic examination appears to be, at present, the most reliable predictor of survival.

Absence of p16 gene (CDKN2) deletions in microdissected primary breast carcinoma specimens

BACKGROUND

The p16 gene (CDKN2), a tumor suppressor gene located on chromosome 9p21, has been demonstrated to be mutated or deleted with high frequency in a variety of tumor cell lines, including breast. While previous studies have not demonstrated CDKN2 mutations in primary breast carcinomas, it is possible that gene deletion in neoplastic DNA was marked by the presence of contaminating normal stromal DNA in breast carcinoma specimens.

METHODS

We investigated the incidence of homozygous deletion of CDKN2 by analyzing 20 microdissected pure populations of primary breast carcinoma cells. Using polymerase chain reaction (PCR) techniques, the entire coding region and intervening introns of CDKN2 were amplified. The PCR products were resolved by agarose gel electrophoresis and single-strand conformation polymorphism (SSCP) analysis.

RESULTS

We detected no deletions or mutations of the p16 gene.

CONCLUSIONS

CDKN2 is not deleted with high frequency in primary breast carcinomas, and the p16 gene does not play a role in breast carcinogenesis via this mechanism.

p53 over-expression in laryngeal carcinoma is not predictive of response to radiotherapy

It has been suggested that alteration involving the p53 gene may influence tumour response to radiotherapy. If this were so, then p53 overexpression (which is usually associated with p53 mutation and readily detectable in routine diagnostic pathology) may help determine the most appropriate form of cancer therapy. p53 expression was assessed in 90 formalin-fixed paraffin-embedded laryngeal carcinomas that were subsequently treated with radiotherapy. The polyclonal antibody DO1 (1 in 50 dilution) was used, together with an avidin-biotin immunoperoxidase technique, but in the absence of any additional antigen retrieval techniques. p53 expression was assessed and correlated with various clinicopathological parameters. Using Chi square analysis, no significant difference between p53 positive and p53 negative lesions was found for response to radiotherapy, as measured by survival and recurrence rates. Furthermore, no correlation with p53 expression was found for tumour size, nodal metastasis, sex, age, alcohol intake, tobacco habit and histological grade. This absence of correlation may in part be explained by discrepancies between immunohistochemical detection of p53 and p53 mutation, although the lack of predictive response to radiotherapy mimics that recently found for irradiated head and neck cancer cell lines.

Comparison of direct monocular endoscopic, two- and three-dimensional display systems on surgical task performance in functional endoscopic sinus surgery

Surgeons performing functional endoscopic sinus surgery (FESS) traditionally rely on direct endoscopic viewing through a single monocular Hopkins rod lens telescope. While the majority of surgeons have found this satisfactory, most other endoscopic surgical specialties have moved to 2-D video endoscopy, where a monoscopic image is presented on a television monitor. This study set out to determine whether 2-D or 3-D display systems had any advantage over direct endoscopy in FESS. Ten otolaryngology trainees performed a series of standardized procedures on a FESS model using direct endoscopic vision, 2-D and 3-D. A performance score was obtained by dividing the execution time by the number of tasks achieved. There was a significant difference in both surgical and diagnostic task performance with 2-D (mean scores 56.8 and 41.1) performing better than direct endoscopy (mean scores 94.1 and 74.1) (P < 0.05). Tasks were also performed significantly better with 3-D compared with 2-D (P < 0.05).

Nasal mucociliary clearance and salmeterol

In vitro studies have suggested that beta 2-adrenergic agents increase the ciliary beat frequency in human respiratory epithelium. We carried out a randomized, double-blind placebo-controlled trial to investigate the effects of a topical spray, salmeterol, on nasal mucociliary clearance using the saccharin test. Thirty-three healthy adults were recruited. There was a 21% reduction of nasal mucociliary transport time of saccharin with salmeterol compared to placebo (P = 0.0001). There was no effect of age, sex, order of treatment, interval between spray and saccharin test, or history of seasonal allergic rhinitis on the improvement in clearance times.

Spiculated axillary adenopathy

PURPOSE

To describe the mammographic and sonographic appearance of a pattern of spiculation of the contour of axillary lymph nodes.

MATERIALS AND METHODS

Eleven cases of axillary nodes with spiculated contour were prospectively identified on routine mammograms. All cases were in women with breast cancer. Sonograms of axillary nodes were available in three cases. Medical records were reviewed, and histologic and nodal histopathologic findings and patient outcome were correlated.

RESULTS

All women had primary, invasive breast carcinoma. Although disease was evident mammographically, four of nine women for whom the results of the physical examination were known did not have palpable adenopathy. Nodes were iso-to hyperdense (compared with breast parenchyma) on mammograms and were hypoechoic with irregular margins on sonograms. The spiculated pattern of the nodes correlated with extension of metastatic tumor in axillary nodes into perinodal fat. At a mean follow-up of 17 months, one patient was dead of disease, eight were alive with disease, and two were alive without disease.

CONCLUSION

A pattern of spiculated axillary adenopathy in a patient with breast cancer appears to be consistent with extranodal extension of tumor into perinodal fat. This finding suggests a biologically aggressive tumor with a poor prognosis.

The effect of a synthetic analogue of prostaglandin E2 on wound healing in rats

This was a prospective, randomized, double-blind experimental study to assess the effect of a long-acting prostaglandin (PG) analogue on wound healing in rats. Eight-cm long, dorsal midline skin incisions were made on rats (n = 44) and immediately resutured. The treatment group (n = 22) received daily intraperitoneal injections of 16,16-dimethyl prostaglandin E2-methyl ester (di-MPGE2) for 7 days, whereas the controls (n = 22) received normal saline. The rats were sacrificed in groups of 11 at 7 and 14 days, respectively. The wounds were excised and analyzed. Histology showed that there was increased fibrosis (p < 0.03) and a decreased number of macrophages (p < 0.02) in the PG group at 7 days. Tensile strength and hydroxyproline content also increased but did not attain significant levels. The differences between the PG and control groups at 14 days similarly did not attain statistical significance. The results suggest that in wound healing, the administration of di-MPGE2 may be beneficial during the early stages of inflammation, rather than during the later stages of remodelling.

Age-related prognostic factor analysis in non-Hodgkin's lymphoma

BACKGROUND

Age is known to have an important influence on survival in non-Hodgkin's lymphoma (NHL). This observation and the relationship of age to other prognostic factors are of interest in designing treatment programs for these patients. This study was conducted to investigate the relationship of age to other known prognostic variables and survival in NHL.

PATIENTS AND METHODS

Data on clinical features, treatment, response, survival and cause of death from 547 patients with NHL diagnosed between 1980 and 1989 were collected and analyzed by age group. Multivariate analysis of prognostic factors and a survival comparison to an age and sex matched control population were performed.

RESULTS

Survival curves for 5-year age groups up to and including age 60-64 years were similar, after which a major effect of age upon survival was apparent. When groups aged < 65 years and > and = 65 years were compared, there were similar proportions of most known prognostic factors, except for a higher proportion with increased lactate dehydrogenase (LDH) levels and extranodal disease in older patients. When analyzed by age group, older patients had a lower response rate to initial therapy and salvage treatments. In younger patients, several recognized prognostic variables were found to lack significance.

CONCLUSIONS

Prognostic variables differ between younger and older patients with NHL. Age, histology, LDH elevation and gender are less important in younger patients; only bulky disease is more important than in older patients. A lower response rate, poor response to salvage therapy and excess mortality, often due to concurrent diseases, were apparent in older patients. Age is a significant prognostic factor only in patients age > and = 65 years.

Antigen retrieval: p53 staining in benign, pre-malignant and malignant tissues of the larynx

Antigen retrieval techniques have been reported to increase p53 detection. Using an antigen retrieval technique applied to immunohistochemistry, a study was performed on 67 laryngeal lesions (21 benign, 16 carcinoma in situ, 30 squamous cell carcinoma). p53 staining was observed in 30% of carcinoma in situ specimens and 53% of squamous cell carcinomas but was not detected prior to antigen retrieval in any benign lesion. However, over-expression of p53 was identified in 92.5% of benign lesions after antigen retrieval using the microwave oven heating. There was also increased p53 staining in both the carcinoma in situ (43.7%) and squamous cell carcinomas (30.0%) after antigen retrieval. We conclude that antigen retrieval using microwave oven heating increases immunohistochemical detection of p53 such that positive staining is observed in benign conditions. We postulate that this apparent over-expression is a manifestation of the wild-type protein, which may be found in more evidence in basal cells than suprabasal cells. Our results thus offer a cautionary note to such studies involving squamous cell cancers that attempt to correlate p53 over-expression with clinical parameters.

Surgical bone wax causing epistaxis

A case of recurrent epistaxis caused by bone wax in the nasal cavity is reported. This is the first reported case of a nasal complication due to surgical bone wax.

Imaging patterns in melioidosis

Melioidosis is an infectious disease caused by Pseudomonas pseudomallei. It is seldom diagnosed promptly and, if untreated, can lead to an 80-100% mortality rate. Twenty-eight patients with melioidosis were identified over a 6 year period, and their imaging patterns were analysed. Respiratory infections were the commonest form of presentation, frequently shown as diffuse airspace consolidation, and accounted for the highest mortality. Visceral and musculoskeletal infections were associated with chronicity and a high relapse rate. Multifocal splenic abscesses were a common occurrence. Septic arthritis of the knee was frequently seen. The majority of patients had diabetes mellitus and chronic ill-health. An increased awareness of the disease can contribute to its early detection and appropriate treatment.

Glycerol versus radiofrequency rhizotomy--a comparison of their efficacy in the treatment of trigeminal neuralgia

Ever since the anatomical basis of trigeminal neuralgia has been postulated to be vascular compression, microvascular decompression has been gaining acceptance as the definitive treatment of the condition. However, the majority of patients are over 50 years of age, and posterior fossa procedures carry significant risk in terms of morbidity and mortality. Radiofrequency and glycerol rhizotomy are the two procedures commonly performed in patients considered unsuitable for posterior fossa craniectomy. This study attempts to assess the relative merits and demerits of these two procedures and seeks to establish indications for each. It is felt that glycerol rhizotomy is better as the first line treatment.

Epidermoid cyst of the liver complicated by microscopic squamous cell carcinoma: CT, ultrasound, and pathology

Though cystic hepatic lesions may have features that help characterize them by noninvasive imaging modalities, these findings are often nonspecific and may be unable to establish the presence of malignancy. This is illustrated here by describing an epidermoid cyst of the liver containing microscopic foci of squamous cell carcinoma. The importance of totally resecting an epidermoid cyst of the liver is emphasized.

Nasal complications of the direct transnasal approach to the pituitary fossa

The transnasal trans-sphenoidal approach to the pituitary fossa is direct and fast. This study is aimed at establishing the nasal morbidity arising from this approach. One of the 25 patients developed secondary haemorrhage and another suffered recurrent minor epistaxis. The peak nasal inspiratory flow rates showed no significant difference between the left and right anterior nasal passages. Adhesions were noted in seven patients and no septal perforations were found. Three patients, who had no previous nasal symptoms, developed postoperative unilateral nasal obstruction, two secondary to left septal deviation and the other caused by right-sided anterior nasal space adhesions. The study suggests that the operation has a low nasal morbidity.

Ovarian serous borderline tumors with lymph node involvement. Clinicopathologic and DNA content study of seven cases and review of the literature

Although several studies have established the excellent prognosis of ovarian serous borderline tumors (OSBTs) in general, the significance of lymph node involvement has not been thoroughly addressed. In this article, we describe seven OSBTs with lymph node involvement and their DNA content and S-phase fraction. Lymph node involvement was identified at presentation in four cases (pelvic, paraaortic, and omental) and after 4, 5, and 7 years in the other three (omental, scalene, and cervical, respectively). In the first group, clusters of cells cytologically similar to those of the OSBT were identified in the nodal sinusoids in all four cases and focally in the lymph node parenchyma in three of them. In contrast, the involved lymph nodes of the three cases with delayed nodal disease showed an almost complete replacement by tumor. In one of them, the tumor in the lymph node was histologically similar to the OSBT, while in the other two cases the tumor was more solid and poorly differentiated, suggesting true metastatic disease. Flow cytometric analysis of nuclear DNA content and S-phase fraction were performed on paraffin-embedded tissue of all of the primary OSBTs and of the involved lymph nodes in six cases; diploid DNA content and low S-phase fraction were seen in all cases. All patients were alive and free of disease 2-9 years after initial diagnosis. While the clinical significance of LN involvement in OSBT is still uncertain, DNA ploidy analysis seems to be unable to identify those cases at risk for tumor progression.

Fine needle aspiration biopsy of hepatocellular carcinoma. Diagnostic dilemma at the ends of the spectrum

A diagnostic dilemma exists at the extreme ends of the spectrum in the cytodiagnosis of hepatocellular carcinoma (HCC). The cytologic features of fine needle aspiration biopsies from 30 well- and 16 poorly differentiated HCC were reviewed and the adjunctive role of serum alpha-fetoprotein (AFP), hepatitis B virus (HBV) markers and radiologic findings evaluated. Some subtle features noted in very well differentiated HCC include small tumor cell size with increased nuclear/cytoplasmic ratio, monotony of atypia, hepatocytic tumor giant cells and narrow trabeculae with tendency for cell dissociation. Useful features in poorly differentiated HCC include cell dehiscence, large cells with ovoid nuclei and thickened nuclear membranes, and one or more increasingly prominent nucleoli, with some assuming a reniform configuration. The serum AFP levels are not always elevated. Positive HBV markers, cirrhosis and compatible imaging findings are suggestive but not diagnostic. The general inclination, however, is still toward a diagnosis of HCC if the aspirate is from a focal lesion or lesions in a hepatitis B surface antigen-positive, cirrhotic liver. Cell block sections provide histologic confirmation.

Non-Hodgkin's lymphoma in Saskatchewan. A review of 10 years' experience

BACKGROUND

The incidence and treatment of non-Hodgkin's lymphoma (NHL) have changed in recent years. This study was intended to compare current features with a previous study (1966-1975) and assess the impact of these changes in our jurisdiction.

METHODS

Clinical features and treatment of 547 patients with NHL registered at our center from January 1980 through December 1989 were reviewed, including reassessment of histologic type in each patient. Multivariate analysis of potential pretreatment prognostic factors was performed using the Cox proportional hazards model, and survival was analyzed in relation to treatment outcome.

RESULTS

This review includes virtually all incident cases of NHL in a defined geographic area, representing an average annual incidence of 11.3/100,000 population. The male-to-female ratio was 1.1:1, median age was 65 years (range, 4-92 years). Median survival time (MST) of 482 patients with disease diagnosed antemortem was 4.8 years (95% confidence interval [CI], 3.7-6.1 years), 52% of whom have died. Thirty-nine percent of patients with disease classified by the International Working Formulation (IWF) had low-grade disease (MST, 103 months); 27% had intermediate disease (MST, 62 months), and 30% had high-grade disease (MST, 35 months). Sixteen percent of patients had associated neoplasms: 4 acute leukemias, 35 skin cancers, and 37 miscellaneous solid tumors. Results of radiation therapy (RT), chemotherapy (CT), and combined CT/RT were analyzed. Survival correlated strongly with responsiveness to treatment. Considering all patients treated with CT, anthracycline-containing CT was associated with the highest response rate, and survival time (more than 48 months) may have been affected by the addition of this agent. A survival advantage for patients with bulky Stage I and II disease treated with consolidative RT after CT is suggested, but not for more advanced stage disease. The proportional hazards model identified histologic type, disease stage, patient age, hemoglobin level, lactate dehydrogenase (LDH) level, bulky abdominal disease, and systemic "B" symptoms as significant independent prognostic factors influencing survival.

CONCLUSIONS

The incidence of NHL has increased, and the survival of patients with high-grade disease has improved significantly since the previous study. A high incidence of other associated malignancies was demonstrated in this group of patients with NHL. Recognition of prognostic factors should permit a rational application of innovative treatments for patients in unfavorable prognostic categories.

Late recurrence of clear cell adenocarcinoma of the vagina and cervix: a report of three cases

Three patients with clear cell adenocarcinomas who developed recurrent disease after a prolonged disease-free interval are presented. The first patient developed a recurrence in the lung 7 years and 3 months after wide local excision and pelvic radiotherapy for clear cell adenocarcinoma of the vagina. She then underwent thoracotomy and chemotherapy and has remained free of disease for more than 13 years after treatment of the recurrence. The second patient with clear cell adenocarcinoma of the vagina developed recurrent disease at the apex of the vagina 5 years after radical hysterectomy, bilateral pelvic lymphadenectomy, and partial vaginectomy. She then underwent exploratory laparotomy, partial vaginectomy, and vaginal irradiation and has been free of disease in follow-up for 6 months. The third patient underwent radical hysterectomy, bilateral pelvic lymphadenectomy, and total vaginectomy for clear cell adenocarcinoma of the cervix that also involved two-thirds of the vagina. Four years and 6 months after this operation, she underwent an exploratory laparotomy, with complete resection of recurrent disease in the abdomen in continuity with a left nephrectomy. Following surgery, she was treated with abdominal and pelvic radiotherapy and chemotherapy and remained clinically free of disease for 1 year, but subsequently developed an unresectable pelvic mass. Despite further chemotherapy, she died 5 years and 10 months after the initial diagnosis.

Biliary cystadenocarcinoma arising in a cystadenoma. Report of a case diagnosed by fine needle aspiration cytology

Hepatic cyst fluid cytology tends to yield disappointing results. We report a case of a 56-year-old woman with a biliary cystadenocarcinoma diagnosed by fine needle aspiration cytology. Computed tomography scans had shown a solitary, unilocular hepatic cyst over a five-year period. There was a recent increase in the size and development of a mural echogenic focus. Cytologic examination revealed clusters of malignant glandular cells in a background of cellular debris and mucinophages. The resected specimen confirmed the presence of an adenocarcinoma arising from malignant transformation of a preexisting cystadenoma.

Industry and radiology in Singapore

Singapore is an ideal educational and commercial hub because of its its central location within Asia, its excellent communication and transportation network, and its ability to remain in the forefront of technology where medical equipment and radiology are concerned. Technologists well trained and fluent in more than one language with an excellent command of English ensures that they benefit from their training stints overseas. From the manufacturer's vantage point, the training center at NUH remains a highly developed center of excellence in Asia, functioning as a shop window for potential clients. Catering to both technologists and radiologists, the center represents the manufacturer's contribution to growth and continued up-grading of the standards in Southeast Asia. We hope that this experiment, the only concrete attempt by any manufacturer in contributing to the radiologic community in Singapore and Southeast Asia, will continue to grow and to develop and become a channel for industry to continue such contributions. One important question that must be addressed is whether all equipment must be purchased from this one manufacturer. There is no such arrangement, and whatever equipment is needed is purchased from any source, depending on budgetary constraints and other restrictions. We believe that training and contributing to the growth, understanding, and application of all modalities in radiology should be worldwide, but organized regionally. In planning training programs, companies must look beyond their countries of origin and rely more heavily on input from their local, regional, and national offices. We hope that the program we have established will serve as a model that can be used elsewhere.

Magnetic resonance imaging of leptomeningeal metastases to the spine

Neurologic complications of malignancy can result from paraneoplastic manifestations, cerebral metastases or leptomeningeal involvement. Radiologic evaluation by computerised tomography (CT) has proven to be an invaluable tool in cancer patients with neurologic symptoms. Myelography and CT myelography have been the main modalities for evaluating leptomeningeal metastases. The advent of magnetic resonance imaging (MRI) with contrast has provided an alternative modality for evaluation of leptomeningeal disease. MRI as compared to CT myelography is non-invasive and at least as sensitive. The findings in two patients with leptomeningeal involvement are reported to illustrate the value of MRI.

Colorectal smooth-muscle tumors. A pathobiologic study with immunohistochemistry and histomorphometry

Smooth-muscle tumors are an interesting group of tumors that show considerable site specificity in their pathobiology. Recent work has also shown that some previously so-called smooth-muscle tumors were not, in fact, truly leiomyogenic, hence the origin of the more embracing term stromal tumors. The purpose of this retrospective study was to delineate the tumor subsets constituting colorectal stromal tumors, and to determine the histopathologic correlates for biologic aggressiveness for these tumors. The cohort was constituted of 12 patients; the mean follow-up was 6.6 years with a median of 5.0 years. Immunohistochemical evaluations showed tumoral positivity for muscle-specific actin (12 of 12), vimentin (11 of 12), desmin (two of 12), and S100 protein (zero of 12). Electron microscopic examinations corroborated this leiomyogenicity profile (five of five). Semiquantitative histomorphometric analysis showed that tumor size, cellularity, mitoses, and necrosis, in that order, correlated with biologic aggressiveness. The immunohistochemistry results for this cohort of colorectal stromal tumors vindicated the traditional histochemical evaluations in that all tumors showed features of leiomyogenicity. For colorectal smooth-muscle tumors, tumor size appears to be the best predictor for biologic aggressiveness. This study reinforces the concept of site-specificity for smooth-muscle tumors.

Signal transduction by the T cell antigen receptor

The T cell antigen receptor (TCR) must recognize antigen, and translate this recognition event into intracellular signal transduction events. Two signal transduction events are regulated by the TCR: the activation of a protein tyrosine kinase (PTK) and phospholipase C (PLC). Recent studies suggest that the TCR-activated PTK regulates PLC activation by the phosphorylation of tyrosine residues of PLC gamma 1. The complex structure of the TCR is now being related to its signal transduction function. Studies with chimeric receptors reveal that the antigen binding Ti heterodimer communicates with the subunits involved with signal transduction, the CD3 chains and zeta dimers, through the carboxy-terminal regions of the Ti chains that surround and include the transmembrane domains. Other chimeras have helped demonstrate that the zeta chain family of dimers function to couple the TCR to intracellular signal transduction mechanisms. The signal transduction function of the TCR can be regulated in a number of ways and by other T cell surface molecules. The plasma membrane tyrosine phosphatase CD45, plays a critical role to specifically regulate TCR-mediated activation of PTK's and PLC. Thus, an understanding of the complex structure of the TCR and the intricacies of its signal transduction function is rapidly emerging.

The Saskatchewan Heart Foundation Blood Pressure Survey: The efficacy of community-based detection and referral programs

Between 1975 and 1988, demographic data, weight and height measurements, and blood pressure readings were obtained for 77 890 residents of Saskatchewan (about 7.6% of the population). High readings were present in 7.8% of those surveyed, but prevalence fell over the lifetime of the survey. Subjects whose drug therapy was modified had a larger fall in blood pressure than those whose medical regimen was unchanged.

Herpes labialis in parturients receiving epidural morphine following cesarean section

A significant association exists between the use of epidural morphine (EM), reactivation of herpes labialis (HL) commonly known as coldsores, and pruritus in the obstetric population. A randomized prospective study was designed to eliminate previously identified confounding variables. Immediately following delivery, parturients having undergone cesarean section with epidural anesthesia with carbonated lidocaine (Xylocaine CO2, Astra, Mississauga, Ontario, Canada) with 1:200,000 epinephrine were sequentially randomized to receive either EM or im opioids for postoperative analgesia. One blood sample was collected for viral serology and two mouthwashes (day 0 and 2) were collected to determine oral viral shedding. The patients were observed daily for 5 days. Coldsores were cultured for herpes simplex virus (HSV). Of 187 patients, 96 received EM and 91 im opioids; herpes labialis occurred in 14 of 96 (14.6%) of the former but in 0 of 91 of the latter (P = 0.0004). All 14 experienced facial pruritus. The two groups were at equal risk for reactivation (seropositivity 64.6% and 62.6%, respectively). Analysis of data for those with positive HSV serology reveals 14 of 62 (22.5%) had EM and herpes labialis compared with 0 of 57 in the im group (P less than 0.0001). The incidence of oral viral shedding was low. Surgical stress, the local anesthetic solution, and epinephrine addition to the local anesthetic were eliminated as confounders. Stepwise logistic regression analysis revealed that EM and a history of herpes labialis in these patients were predictive for reactivating oral HSV.

Diaphragmatic and external intercostal muscle control during vomiting: behavior of inspiratory bulbospinal neurons

1. The role of dorsal and ventral respiratory group (DRG and VRG) bulbospinal inspiratory (I) neurons in the control of diaphragmatic and external intercostal (inspiratory) muscle activity during vomiting was examined by recording from these neurons during fictive vomiting in decerebrate, paralyzed cats. Fictive vomiting was defined by a characteristic series of bursts of coactivation of phrenic and abdominal muscle nerves, elicited either by electrical stimulation of abdominal vagal afferents or by emetic drugs, which would be expected to produce vomiting if the animals were not paralyzed. 2. Data were recorded from 22 DRG and 29 VRG I neurons that were antidromically activated from the fourth cervical spinal segment (C4). Only 10% (5/51) of these neurons started to fire near the beginning of phrenic discharge during fictive vomiting and thus had the appropriate discharge pattern to contribute to the initial activation of the diaphragm and coactive external intercostal muscles during vomiting. The frequency of occurrence of these Active neurons was not significantly different in the DRG (3/22) and VRG (2/29) (chi 2 test). Most remaining neurons were either totally silent (n = 7) or had only sporadic, infrequent firing (n = 16) (Silent neurons, 23/51 = 45%), or else fired near the end of phrenic discharge during fictive vomiting (End neurons, 21/51 = 41%). Two neurons were categorized as having miscellaneous (Misc) behavior. 3. No differences were found among neurons having different response patterns during fictive vomiting in regard to the following: the manner in which fictive vomiting was elicited: cell location: conduction velocity; and neuronal firing onset, rate, and pattern during respiration.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of the hinge region on complement activation, C1q binding, and segmental flexibility in chimeric human immunoglobulins

We have characterized a series of genetically engineered chimeric human IgG3 and IgG4 anti-dansyl (DNS) antibodies with identical antibody-combining sites but different hinge region amino acid compositions to determine how the hinge region influences Fab fragment segmental flexibility, C1q binding, and complement activation. Our data support the correlation between "upper hinge" length and Fab segmental flexibility; moreover, we confirm that a hinge region is essential for C1q binding and complement activation. However, the hinge length by itself is not sufficient for complement activity in IgG molecules. We have demonstrated that the IgG4 hinge, which imparts restricted segmental flexibility, reduces the ability of IgG3 molecules to activate complement. We also find that the IgG3 hinge region, which imparts greater segmental motion, is not sufficient to create complement activation activity in IgG4 anti-DNS antibodies. Finally, we conclude that (i) segmental motion is correlated with "upper hinge" length, (ii) hinge length and segmental flexibility is not enough to alter complement binding and activation, and (iii) segmental flexibility does not correlate with proficiency to activate the complement cascade.

Brainstem projections to cats' upper lumbar spinal cord: implications for abdominal muscle control

Unilateral L1-L2 gray matter HRP injections labeled neurons bilaterally in nucleus retroambiguus (expiratory neuron region of caudal ventral respiratory group) and ventromedial reticular formation. Minor labeling occurred in raphe, vestibular, and medial parabrachial nuclei, lateral reticular formation, and C1-C2. Midsagittal lesions between C1 and obex prevented nucleus retroambiguus labeling (except 1 contralateral cell adjacent an incomplete lesion), indicating that these neurons decussate between C1 and obex and have collaterals that recross the spinal cord.

The role of fine needle aspiration for breast cancer in the climacteric--a preliminary report

Fine needle biopsy has been used with great accuracy in the diagnosis of breast tumours. There have been few reports on its efficacy as an adjunct to other breast screening techniques like x-ray mammography. Abnormal mammograms in the absence of a palpable breast lump are sometimes detected in the climacteric and these pose a problem of tissue sampling for pathologic diagnosis. We have tried to evaluate the technique of radiologically guided fine needle aspiration in such patients. Our report is of an initial series of 13 cases of non-palpable, mammographically abnormal breast lesions. Eight cases were fibroadenoma, 4 cases mammary dysplasia and 1 a benign breast lesion. Representative cytologic samples were obtained in 11 of our 13 cases. Cytologic diagnosis should be correlated with mammographic findings.

Treatment of primary liver cancer in Singapore. A review of 3200 cases seen between January 1, 1977, and July 31, 1987

Between January 1977 and July 1987, 3200 patients with hepatocellular carcinoma (HCC) were studied in Singapore. HCC formed 90% of primary liver cancers seen in Singapore and is the second most common fatal malignancy seen in men in the country. Extensive clinical and basic research has defined certain treatment strategies. Of importance is the prompt detection of early nodular tumours, which can be resected. Resection, 'targetting' with anticancer drugs and, in selected cases, synchronised direct hepatic irradiation with adriamycin, used as a radiosensitiser, have been promising treatment methods. Biological modifiers, such as interferons and interleukins, offer potential for the future. Preliminary pilot studies suggest that interferons may prevent the development of HCC, but more studies are required. Similarly, selective localisation of anticancer agents with radio-isotopical agents opens opportunities for treatment.

Production and characterization of genetically engineered antibody molecules

Expression of antibody heavy- and light-chain genes by transfection permits the production of monoclonal antibodies with improved biological and antigen-binding properties. The immunoglobulin genes are placed in vectors containing a gene for encoding a protein that provides a biochemically selectable function in eukaryotic cells; these vectors are transfected into myeloma and hybridoma cells. Selection of drug-resistant cells permits the efficient isolation of the rare cells that express the transfected DNA. By placing heavy and light chains on plasmids with different selectable markers, one can deliver heavy- and light-chain genes simultaneously to the same cell. The transfected immunoglobulin genes are efficiently expressed and the proteins produced are a faithful mirror of the genes that were introduced. Using the standard techniques of genetic engineering and gene transfection, we can now produce antibodies of widely varying structures, including chimeric antibodies with segments derived from different species. These antibodies provide useful reagents to study structure-function relationships within the antibody molecule. Ultimately it will be possible to produce a new generation of antibody molecules with improved antigen-binding properties and effector functions.