Oesophageal adenoid cystic carcinoma and its management options

Adenoid cystic carcinoma (ACC) commonly originates in the major salivary glands and respiratory tract, but extremely rarely in the oesophagus. We report the surgical and pathologic findings of a primary ACC of the oesophagus in a 59-year-old woman, and review the management options of this tumour.

Surgical approach of pulmonary hydatidosis in childhood

To review the results of different surgical treatment in hydatid disease of the lung in paediatric patients. A total of 102 children with pulmonary hydatid cysts were treated at the our clinic in the period from 1990 to 2001. There were 59 boys and 43 girls and their age ranged from 4 to 16 years (mean 10.2). Chest radiography, computed tomography and abdominal ultrasonography were the most commonly used diagnostic techniques. The cysts were located in the right lung in 68 patients (66.6%), in the left lung in 30 patients (29.4%), in both lungs in four patients (3.9%). Concomitant liver cyst hydatid was also detected in 12 patients that were located at right lung, and two patients with bilateral lung involvement. All cases were managed surgically. Of 14 cases with concomitant liver and intrathoracic hydatid cysts, right thoracophrenotomy was performed in 12, median sternotomy in one, and phrenotomy in other. Partial cystectomy and capitonnage were the most commonly used surgical methods. Post-operative complication was seen in 10 (9.8%) patients. Infection at the incision site occurred in four patients and air leakage in three. Complications of capitonnage were seen in three patients. One patient (1%) died at fourth post-operative day due to sepsis. Parenchyma protective operations should be performed especially in children living in endemic areas because of the possibility of recurrence of the disease in the future. Single stage operations in suitable cases decrease the cost of treatment and make surgical therapy suitable in both children and young adults, by reducing the hospital in-patient time and morbidity.

Comparison of CT and MRI for the diagnosis recurrent esophageal carcinoma after operation

Despite an increase in radical surgery for esophageal carcinoma, many patients continue to develop recurrent disease. Some reports have suggested that recurrent tumors should be treated aggressively with a combination of chemotherapy and radiotherapy. The aim of this study was to assess the comparative utility of computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of recurrence after curative resection of cancer of the esophagus and gastroesophageal junction. To maximize survival benefit, detection of tumor recurrence as early and accurately as possible is important. Twenty-three patients who developed recurrent tumors after curative transthoracic esophagogastrectomy for esophageal carcinoma were analyzed retrospectively. The CT and MRI findings were correlated with pathology or with endoscopic and clinical follow-up. Primary tumor recurrence was detected at the anastomosis side in 19 patients (intraluminal mass in 13 and as diffuse or focal wall thickening in six). Distant recurrence was seen in the liver (n = 5), lung (n = 4), bone (n = 3), abdominal lymph node (n = 4), pleural effusion (n = 2) and pericardial effusion (n = 1). CT and MRI were found equal in showing the intraluminal mass, liver metastasis, pleural and pericardial effusion. Thickening of esophageal wall was demonstrated in nine patients using CT, but only seven of these tumor recurrences were confirmed by MRI, the remaining two were related to secondary fibrosis. Both CT and MRI showed diffuse gastric wall thickening determined as false tumor recurrence due to severe gastritis in one case. There were two (50%) false negatives for lung metastasis in MRI and one bone metastasis (33%) false negative in CT. CT was found superior in the demonstration of lung metastasis and MRI was superior in the evaluation of wall thickening and bone metastasis.

Comparison of Subdermal and Peritumoral Injection Techniques of Lymphoscintigraphy to Determine the Sentinel Lymph Node in Breast Cancer

PURPOSE

The purpose of this study was to evaluate 2 different injection techniques for lymphoscintigraphy to determine the axillary sentinel lymph node (SLN) in patients with breast cancer.

METHODS

Thirty-six patients with early breast cancer were studied prospectively. Both peritumoral (PT) and subdermal (SD) injections were performed on each patient with Tc-99m rhenium sulfide colloid. PT injections were done 1 to 8 days before surgery and SD injections were done on the day of operation. An intraoperative gamma probe was used to explore the axillary SLNs prior to tumor excision and axillary dissection. All surgical specimens were evaluated histopathologically.

RESULTS

In 19 of 36 patients, the same lymphatic drainage sites were observed with both techniques. Of these, 17 patients showed only axillary, 1 showed axillary and internal mammary (IM), and 1 showed axillary and subclavicular drainage sites. With PT injections 26 of 36 patients (72%), and with SD injections 33 of 36 patients (92%), showed axillary drainage and axillary SLNs. With PT injections 9 patients, and with SD injections only 2 patients, did not show any drainage site. During the operation with a gamma probe, axillary SLNs were excised in 35 patients (success rate, 97%). IM drainage was seen in 8 of 36 patients who underwent PT injections and in 3 of 36 with SD injections.

CONCLUSION

The success rate was found to be higher with the SD injection technique than with PT injections to visualize the axillary SLN. To increase the visualization of both axillary and IM SLNs, it may be useful to perform lymphoscintigraphy with SD and PT injections together.

Mediastinal bronchogenic cyst treated by mediastinoscopic drainage

Bronchogenic cysts are rare congenital anomalies located in the mediastinum and lung parenchyma. We present the clinical findings and describe the mediastinoscopic treatment of a bronchogenic cyst at the subcarinal space in a 50-year-old man. CT revealed a lesion at the subcarinal space with soft tissue density. Initially, mediastinoscopy was performed for diagnostic purposes. Histopathological evaluation of biopsy material taken from the cyst wall confirmed that the lesion was a bronchogenic cyst. The cyst contents were drained and a sclerosant agent was applied to the cyst lumen via the drainage tube. Mediastinoscopy not only provides diagnostic information but can also be used safely in the treatment of anterior bronchogenic cysts in patients not amenable to a second operation.

Localized Castleman's disease and nephrotic syndrome not responsive to resection plus colchicine therapy

We describe one patient with localized Castleman's disease (CD) of the mixed hyaline vascular and plasma cell type located at the mesentery of the small bowel, associated with systemic amyloidosis and nephrotic syndrome. A true nephrotic syndrome has rarely been reported in patients with CD. In the literature, it has been suggested that clinical and laboratory manifestations generally improved after surgical resection of the tumor. However, in our case, clinical and laboratory findings did not regress after operation followed by colchicine therapy.

Self-expandable metallic stent therapy of esophagojejunal stricture in a stapled anastomosis: a case report and review of the literature

The introduction of the stapler apparatus has provided safe and effective gastrointestinal anastomotic surgical operations for most surgeons. However, the major disadvantage of stapler surgery is an increased risk of anastomotic stricture formation. Treatment of this kind of stricture is performed mainly by using endoscopic balloon dilators. However, this therapy may fail or the patient may become reactive or uncooperative during dilatation sessions. Herein, we present a case to show the successful and uncomplicated insertion of a self-expanding metallic stent into an esophagojejunal anastomotic stricture which developed 1 month after total gastrectomy and stapled esophagojejunal anastomosis in a patient with gastric carcinoma. This is the 3rd report in the literature.

Beneficial effect of intracellular trehalose on the membrane integrity of dried mammalian cells

Recently, there has been much interest in using trehalose and other small carbohydrates to preserve mammalian cells in the dried state as an alternative to cryopreservation. Here, we report on the successful preservation of plasma membrane integrity after drying, as a first step toward full preservation of mammalian cells. Trehalose was introduced into cells using a genetically engineered version of alpha-hemolysin, a pore-forming protein; the cells were then dried and stored for weeks at different temperatures with approximately 90% recovery of the intact plasma membrane. We show that protection of the plasma membrane by internal trehalose is dose dependent and estimate the amount of internal trehalose required for adequate protection to be approximately 10(10) molecules/cell. In addition, a minimal amount of water (approximately 15 wt%) appears to be necessary. These results show that a key component of mammalian cells can be preserved in a dried state for weeks under mild conditions (-20 degrees C and 5% relative humidity) and thereby suggest new approaches to preserving mammalian cells.

Survival after curative resection for stage IE and IIE primary gastric lymphoma

BACKGROUND/AIMS

There is considerable controversy regarding the optimal treatment of patients with primary gastric lymphomas. However, surgery still plays an important role in the management of stage IE and IIE gastric lymphomas. We aimed at assessing survival of primary gastric lymphoma cases with stage IE or IIE that were surgically treated at the Surgical Oncology Department.

METHODOLOGY

Thirty-seven patients with stage IE and IIE primary gastric lymphoma who were surgically treated and had complete follow-up from January 1990 to September 1998 were reviewed retrospectively. Patients' age, gender, tumor location, tumor grade, histologic type, depth of tumor invasion, regional lymph node status, tumor stage, type of gastrectomy (total/subtotal), combined resection, extensive lymphadenectomy, adjuvant chemotherapy were used as the clinicopathologic variables.

RESULTS

Five-year survival rates for stage IE and stage IIE disease were 75% and 37%, respectively. The overall 5-year survival rate of the patients was 57%. Univariate analysis demonstrated that age, tumor stage, and type of gastrectomy were associated with prognosis, but only type of gastrectomy (subtotal gastrectomy) and tumor stage were found to be independent prognostic factors (P < 0.05).

CONCLUSIONS

To obtain prolonged survival we recommend radical resection with extensive lymphadenectomy for malignant lymphoma stages IE and IIE. Patients with small distal lymphomas of the stomach can be treated with subtotal gastric resection.

Giant hydatid lung cysts

OBJECTIVE

In this clinical retrospective study, we aimed to evaluate giant hydatid lung cyst cases as a different clinical entity that recorded in last 10 years in our clinic.

METHODS

Between February 1990 and May 2000, a total of 305 hydatid lung cyst cases from patients that had been operated were reviewed, and 67 (21.9%) cysts with more than 10 cm in diameters of them were regarded as a giant hydatid lung cyst. Further investigations were made with respect to different factors.

RESULTS

Thirty-six (54%) cases were male and 31 (46%) were female. The ages ranged between 5 and 54 (mean 21.6) years. The most common symptoms recorded were; cough (68%), thoracic pain (55%) and dyspnea (52%). Cyst sizes were ranged between 10 and 22 cm (mean 13.4) in diameters. Forty-two (62%) of them were in the right, 22 (33%) were in the left hemithorax, and three (5%) were located bilaterally. Cystotomy or cystectomy and capitonnage was the most frequent applied operation procedure (71%). Resection was performed in nine (13%) cases. Thirteen (19%) cases had air leakage more than 10 days in which five (7%) of them empyema occurred postoperatively. One case died due to respiratory failure in fourth postoperative day. The postoperative hospital stay ranged between 6 and 43 (mean 10.5) days. No recurrence was recorded in 1-5 years of a follow-up period.

CONCLUSIONS

Giant hydatid lung cysts must be regarded as a different clinical entity because of their early occurrence, having more serious symptoms, with frequent operative complications, and they need prolonged care with higher cost effects.

Prevention of intra-abdominal adhesions by using Seprafilm in rats undergoing bowel resection and radiation therapy

OBJECTIVE

Intra-abdominal adhesions are an important surgical problem. Colorectal operations are a major cause of adhesive obstruction. Radiation therapy (RT) is frequently used as an adjuvant therapy to surgery for rectal cancer, though its value for colon carcinoma remains unclear. Peritoneal injuries including the surgical trauma, tissue ischaemia as well as RT are associated with peritoneal fibrinolytic activity. A sodium hyaluronate and carboxymethylcellulose bioresorbable membrane (Seprafilm) has been used to reduce intra-abdominal adhesion formation. We have investigated the effect of Seprafilm on intra-abdominal adhesion in rats receiving RT after the resection of the left colon.

MATERIALS AND METHODS

Thirty-two male Wistar rats were divided into two groups: group 1 (n=16), control (colon resection, no Seprafilm); group 2 (n=16), study group (colon resection and Seprafilm). All the rats received 50 Gy RT after left colon resection. Intra-abdominal adhesions were evaluated by grading and measurement of tissue-type plasminogen activator (tPA) as a tissue adhesion marker in peritoneal samples from the rats. tPA was determined using a commercially available ELISA kit.

RESULTS

The levels of tPA were significantly increased in group 2 rats compared with those in the control group (P=0.0276). It was also seen that adhesions in the rats receiving Seprafilm were significantly less severe than those in the control group.

CONCLUSION

Our findings suggest that the intraperitoneal administration of Seprafilm reduced the frequency and strength of adhesions.

Hydatid disease of rib

Osseous hydatidosis, especially when located in the rib, is a very rare disease. In 1978, only 39 costal echinococcosis cases were published. The course of the disease is generally slow and laboratory tests are frequently negative. Diagnosis is generally made through the combined assessment of clinical, radiologic, and laboratory data. Living in a rural area is an important risk factor for the disease. The gold standard for therapy is radical removal of the involved ribs or chest wall. We present the case of a 63-year-old herdsman with costal echinococcosis and a review of the literature.

Activities of adenosine deaminase and 5'-nucleotidase in cancerous and noncancerous human colorectal tissues

In order to characterize human colorectal cancer, much attention has been paid to enzyme studies. However, little is known about the correlation between the levels of key enzymes of purine nucleotide pathway and some clinical and biological indicators of tumor invasiveness and aggressiveness. Adenosine deaminase (ADA) and 5'-nucleotidase (5'-NT) were measured in cancerous and cancer-free adjacent large bowel tissues from 38 patients with colorectal carcinoma. We have analyzed the relationship between the enzyme levels and some clinical and pathological parameters. The enzymes' activities were markedly higher in primary tumors than in corresponding normal mucosae. The ADA level in tumor tissue was significantly correlated with lymph node metastasis, histologic type, tumor location, and patient's age, whereas the 5'-NT level showed a significant correlation with tumor grade and tumor location. ADA activity in tumor tissues was significantly higher in patients whose clinical course remained stable than in those with recurrent diseases. The purine metabolism and salvage pathway activity of purine nucleotides are accelerated in the cancerous human colorectal tissue. Although our findings suggest that these enzymes' activities are most likely related to the same histomorphological architecture of the tumor, the authors believe that long-term follow-up studies are needed to evaluate the prognostic value of purine enzymes for colorectal cancer.

Correlation between tissue levels of carboxy-terminal propeptide of type I procollagen and clinicopathological characteristics in human colorectal cancer

BACKGROUND/AIMS

Type 1 collagen is the most abundant protein in the human body and a major constituent of the interstitial connective tissue. However, little is known about carboxy-terminal propeptide of type I procollagen (PICP) expression in human colorectal tumor tissues. We therefore evaluated the concentrations of PICP in colorectal tumor tissue as well as surrounding normal tissues and examined the relationship between its level and clinicopathological variables.

METHODOLOGY

Tumor and normal tissues from 40 patients with colorectal carcinoma who had been operated on were stored at -80 degrees C until assays. PICP was assayed by sandwich immunoassay.

RESULTS

It was found that the PICP level was significantly higher in the tumor extracts than in the normal tissue extracts (P < 0.0001). The ANOVA test showed that the level of PICP in tumor tissue was higher in the patients with advanced colorectal tumor than those with early stage disease (P < 0.0001). There were statistically significant differences with regard to the depth of tumor invasion, presence of lymph node metastasis, and hepatic metastasis (P < 0.05). There were also quantitative differences with respect to the PICP levels between obstructing tumors and non-obstructing carcinoma (P < 0.05), but the elevated PICP levels in tumor tissues were not associated with the type of histologic differentiation (P > 0.05).

CONCLUSIONS

Although these findings suggest that PICP value in tumor tissue is most likely related to the some histomorphological architecture of the tumor, the authors believe that the prognostic significance of PICP expression in primary colorectal tumor and normal tissues requires further evaluation.

Isolated limb perfusion with cisplatin and doxorubicin for locally advanced soft tissue sarcoma of an extremity

AIMS

To identify independent adverse clinico-pathological factors for disease-free and overall survival in patients undergoing isolated limb perfusion (ILP) with cisplatin and doxorubicin for locally advanced soft tissue sarcoma (STS) of an extremity.

METHODS

A retrospective analysis was carried out, using a univariate method and a multivariate analysis, to look at the patient, tumour and treatment associated with prognostic factors in 37 patients with locally advanced STSs of the limbs who underwent ILP with cisplatin and doxorubicin. Patient's age, gender, presenting status, tumour location, tumour grade, tumour stage according to TNM classification, tumour size and radiotherapy (RT) were analysed. Survival curves were calculated according to the Kaplan-Meier method. A Cox proportional hazard model was used to indicate which factors related to overall survival and the recurrence-free interval after ILP.

RESULTS

No major systemic toxicity was seen. Regional toxicity was limited. Limb salvage was achieved in 94.6% of the patients. The estimated 5-year overall and disease-free survival rates were 62% and 54%, respectively. It was found that tumour stage, tumour grade, presenting status, RT and tumour size were associated with cumulative overall survival when the Kaplan-Meier method was applied (P<0.05). By Cox proportional hazards model, only tumour grade (P=0. 0254) was found to have significant influence on overall survival; however, tumour stage (P=0.0157) and RT (P=0.0014) were related to disease-free survival.

CONCLUSIONS

ILP and delayed excision followed by RT achieves good limb salvage rates and may improve survival.

Intracellular trehalose improves the survival of cryopreserved mammalian cells

We report that the introduction of low concentrations of intracellular trehalose can greatly improve the survival of mammalian cells during cryopreservation. Using a genetically engineered mutant of Staphylococcus aureus alpha-hemolysin to create pores in the cellular membrane, we were able to load trehalose into cells. Low concentrations (0.2 M) of trehalose permitted long-term post-thaw survival of more than 80% of 3T3 fibroblasts and 70% of human keratinocytes. These results indicate that simplified and widely applicable freezing protocols may be possible using sugars as intracellular cryoprotective additives.

Cytoskeleton and polyploidy after maturation and fertilization of cryopreserved germinal vesicle-stage mouse oocytes

PURPOSE

Our purpose was to assess the effect of cryopreservation on cytoskeleton of germinal vesicle (GV) mouse oocytes and determine whether irreversible spindle damage and related digyny associated with cryopreservation of metaphase II (MII) oocytes can be avoided.

METHODS

The GV oocytes were cryopreserved using a slow-cooling (0.5 degree C/min) and slow-thawing (8 degrees C/min) protocol in 1.5 M dimethylsulfoxide supplemented with 0.2 M sucrose and analyzed before and during fertilization by multiple-label fluorescence and differential interference contrast microscopy techniques.

RESULTS

When examined after in vitro maturation, the vast majority (> 95%) of cryopreserved and control oocytes displayed normal microfilament and microtubule organization. With respect to barrel-shaped spindle and normal chromosome alignment, no significant differences were observed between cryopreservation (78 and 86%, respectively) and control (85 and 95%, respectively) groups. In fertilization experiments, spindle rotation, formation of the second polar body, and pronuclear migration were displayed by similar percentages of cryopreserved (96, 94, and 37%, respectively) and control (98, 97, and 45%, respectively) oocytes, indicating normal functionality of the cytoskeleton during this period. However, pronuclear formation was significantly inhibited by cryopreservation (81%) compared with controls (100%). Regarding digyny and polyspermy, no significant increase was observed after cryopreservation (3 and 10%, respectively) compared with controls (3 and 6%, respectively).

CONCLUSIONS

Cryopreservation of mouse oocytes at the GV stage is particularly advantageous to circumvent the spindle damage and increased digyny noted after cryopreservation of MII oocytes.

Alterations of the cytoskeleton and polyploidy induced by cryopreservation of metaphase II mouse oocytes

OBJECTIVE

To determine cryopreservation-induced alterations in the cytoskeleton of metaphase II mouse oocytes and the implications of these alterations in functionality of the cytoskeleton and polyploidy after fertilization.

DESIGN

Comparative study.

SETTING

Clinical and academic research environment at a medical school teaching hospital.

INTERVENTION(S)

Oocytes were frozen using a slow-cooling (0.5 degrees C/min) and slow-thawing (8 degrees C/min) protocol in 1.5 M dimethyl sulfoxide and 0.2 M sucrose and were analyzed before and after fertilization.

MAIN OUTCOME MEASURE(S)

Cytoskeletal alterations, fertilization, and polyploidy rates.

RESULT(S)

When analyzed immediately after thawing, the oocytes displayed dramatic cytoskeletal alterations. Only slight recovery was observed upon removal of the cryoprotectants. However, incubation after thawing of 1 hour at 37 degrees C completely reestablished a normal microfilament and microtubule pattern while partially restoring normal spindle morphology and chromosome alignment. Accordingly, insemination immediately after removal of cryoprotectants resulted in a significantly decreased fertilization rate and aberrant dynamics of cytoskeleton-dependent events, whereas oocytes inseminated after the post-thaw incubation displayed fertilization rates and cytoskeletal dynamics comparable to those in controls. Cryopreservation did not increase polyspermy but significantly increased digyny when the oocytes were inseminated after the post-thaw incubation. All digynic eggs displayed an abnormal spindle remnant in comparison with diploid or polyspermic eggs.

CONCLUSION(S)

A brief period of incubation after thawing allows recovery and positively affects fertilization and cytoskeletal dynamics. Cryopreservation does not impair the functionality of microfilaments and cytoplasmic microtubules during postfertilization events. Our findings suggest that the increased rate of digyny in cryopreserved oocytes may be related to the spindle disorganization, leading to failure in segregation of the chromosomes, rather than to direct malfunction of the microfilaments in polar body formation.

Anomalous origin of circumflex coronary artery from the right pulmonary artery associated with subaortic stenosis and coarctation of the aorta

Anomalous origin of the circumflex coronary artery is extremely rare and may cause acute cardiac decompensation associated with correction of coexisting congenital malformations. We describe a 10-year-old female patient who underwent surgical repair of the aortic coarctation at 4 years of age. Six years later, she presented with chest pain during exercise. Cardiac catheterization demonstrated 25 mmHg subaortic systolic gradient and retrograde filling of the circumflex coronary artery from the left anterior descending and right coronary artery, with drainage into the right pulmonary artery. Reimplantation of the anomalous circumflex coronary artery to the aorta and resection of subaortic fibrous membrane was performed. Her postoperative course was uneventful, with complete relief of symptoms.

Fertilization and development of mouse oocytes cryopreserved using a theoretically optimized protocol

Rational design of a cryopreservation protocol was demonstrated by using theoretical models of the cryopreservation process to develop an optimal freezing protocol for mouse oocytes. A coupled mechanistic model of the processes of freeze-induced cell dehydration and intracellular ice formation was developed, and cryomicroscopical measurements of intracellular ice formation kinetics were used to determine biophysical parameters required by the model, and to test model predictions of the freezing behaviour of mouse oocytes. A simple phenomenological model for oocyte damage resulting from exposure to concentrated electrolyte and cryoprotectant solutions during cryopreservation was obtained by defining a cost function equal to the duration of the freezing protocol. A two-step freezing protocol was theoretically optimized by using a sequential simplex algorithm to minimize the cost function, subject to the constraint that the predicted probability of intracellular ice formation remain below 5%, yielding a putative optimum at the cooling rate B = 0.59 degrees C/min, and plunge temperature Tp = -67 degrees C. By systematically varying B and Tp about these values in experiments with mouse oocytes cryopreserved in 1.5 M dimethyl sulphoxide, the maximal recovery of intact oocytes with a normal morphology (82%) was obtained for B = 0.5 degrees C/min and Tp = -80 degrees C. Further evaluation of the fertilizability and developmental capacity of oocytes cryopreserved using the optimized protocol yielded cleavage to the 2-cell stage in 65% of oocytes inseminated, and blastocyst formation in 50% of these 2-cell embryos.