Clinicopathologic Characterization of Kaposi Sarcoma on the Foot and Ankle: Analysis of 11 Patients Seen in Our Clinics

BACKGROUND

Kaposi sarcoma (KS) has multiple clinical variants, and most frequently presents on the lower extremities. Anti-human immunodeficiency virus (HIV) therapy has significantly reduced the incidence of KS. However, KS is still prevalent in both HIV-infected and HIV-uninfected patients. This case series analysis aims to reveal the clinical presentations, differential diagnosis, and treatment options of KS on the foot and ankle.

METHODS

Eleven cases of KS involving the foot and ankle were retrieved from our patient database, and their clinicopathologic features were analyzed.

RESULTS

All patients were men, aged 29 to 85 years. Two types of KS were found: classic and acquired immunodeficiency syndrome-associated epidemic. The average ages of classic and epidemic KS were 65.7 and 41.8 years, respectively. Clinically, three patients manifested multiple erythematous or deep violaceous, or blue-violaceous macules on either the dorsal or plantar surfaces of both feet. Eight patients showed exophytic, pyogenic granuloma-like nodules on the plantar surface, heels, and toes. Histologically, all KSs had uniform intervening fascicles of elongated spindle cells with slit-like vascular spaces filled with red blood cells and immunoreactivity with human herpesvirus-8. The patients were treated according to HIV infection status. Human immunodeficiency virus-infected patients were treated with anti-HIV therapy after primary surgical excision or biopsy. Human immunodeficiency virus-negative patients were treated with either surgical excision, Mohs surgery, or a combination of surgical excision and local radiotherapy according to individual patient clinical presentation.

CONCLUSIONS

Kaposi sarcoma is still prevalent in both HIV-infected and HIV-uninfected patients with a variety of clinical presentations. Biopsy, with histologic evaluation, in combination with immunohistochemistry is essential for the differential diagnosis. The patient should be treated according their clinical manifestation, staging, comorbidity, and immune function.

Using a bone allograft to fixate proximal interphalangeal joint arthrodesis

Digital contractures are a very common deformity of the foot and ankle that require surgical correction. It has been shown that arthrodesis provides a better long-term result than arthroplasty of the interphalangeal joints. Arthroplasties usually require K-wire fixation that presents potential complications, such as pin tract infection. This study presents a new cadaveric bone matrix allograft to be used as rigid internal fixation for proximal interphalangeal joint arthrodesis. The purpose of using the allograft as a fixation device is to achieve solid bone fusion and avoid the potential complications of external pin fixation. Arthrodesis of the proximal interphalangeal joint was performed on 63 toes in 32 patients using TenFUSE (Solana Surgical, Memphis, TN), a sterile bone matrix allograft. The authors found 97% fusion rate with no complications reported to this date. It was concluded that this bone matrix allograft provides excellent results and is a suitable alternative fixation device for correction of hammer toe deformity.

LEVEL OF EVIDENCE

Level V.

Pericardiectomy for constrictive pericarditis: is prolonged inotropic support a bad omen?

Sixty-seven patients who underwent pericardiectomy for constrictive pericarditis at JIPMER, Pondicherry between 1987 and 1998 were the subjects of the study. Pre-operatively 70% of cases were in the New York Heart Association classes III and IV categories with clinical signs suggestive of constriction ie, raised jugular venous pressure in 99%, pleural effusion in 77%, pedal oedema in 61% and ascites in 55% of the cases. Seventy-five per cent of the cases underwent pericardiectomy through a median sternotomy and the rest via left anterolateral thoracotomy. Low cardiac output was evidenced in 70% of cases postoperatively which was managed by early institution and prolonged use of inotropes. There was 9% mortality especially in the early part of the experience. Tuberculous pathology was confirmed histologically in 57% cases. Sixty-three per cent of cases are presenting in follow-up in New York Heart Association class I. Prolonged use of inotropes instituted early in postoperative period is recommended to prevent postoperative ventricular dysfunction with adrenaline being the preferred inotrope. It is concluded that postoperative New York Heart Association class and long term survival were not significantly influenced by pre-operative New York Heart Association class, operative approach or peri-operative low cardiac output syndrome requiring prolonged inotropic support.

Alpha-adrenergic preservation of myocardial pH during ischemia is PKC isoform dependent

alpha-adrenergic stimulation of patients with ischemic heart disease should intuitively impose a destructive stress. However, therapeutic alpha1-adrenergic receptor mediated cardioadaptation prior to myocardial ischemia protects ventricular mechanical function, promotes electrophysiologic stability, and preserves myocyte viability. Prior to an anticipated cardiac ischemic insult, alpha1-adrenergic preconditioning attenuates ischemic myocardial acidosis by a protein kinase C-(PKC) dependent mechanism. The alpha1-adrenoceptor can directly stimulate calcium-independent nPKC isoforms via diacylglycerol (DAG) or indirectly stimulate calcium-dependent cPKC isoforms through the release of intracellular calcium via inositol triphosphate, (IP3). We hypothesized that alpha1-adrenergic limitation of ischemic acidosis is mediated by the family of calcium-dependent PKC isoforms. [31P]NMR spectra were obtained in isolated, buffer perfused rat hearts treated with alpha1-adrenergic stimulation [phenylephrine (PE) 50 microM, 2 min]; PKC blockade [chelerythrine chloride, (Chel) 20 microM]; or stearoyl-arachidonoyl glycerol (SAG, a DAG analogue, 100 microM, 2 min) administered 10 min prior to ischemia. Control hearts were perfused under normoxic conditions for 20 min. All hearts were then subjected to global ischemia (20 min, 37.5 degrees C). Developed pressure (DP) and heart rate were recorded continuously. pHi was obtained from chemical shift of inorganic phosphate. Immunohistochemical staining was utilized to delineate the translocation and activation profiles of specific PKC profiles established with each stimulus. Pre-ischemic alpha1-adrenergic stimulation did attenuate the myocellular hydrogen ion accumulation during sustained normothermic ischemia (6.90 +/- 0.13 vs control 6.54 +/- 0.10; P < 0.05). General PKC inhibition abrogated this effect (end-ischemic pH 6.17 +/- 0.10; P < 0.05 vs control and PE). Ischemic acidosis was not attenuated following selective nPKC stimulation (SAG, 6.48 +/- 0.08; NS vs control). Myocellular immunohistochemical staining revealed translocation of the calcium-independent PKC-epsilon isoform in the calcium-dependent PKC (SAG) group, but not in response to alpha1-adrenergic stimulation. The results suggest that (1) alpha1-adrenoceptor stimulation limits ischemic acidosis, (2) alpha1-adrenergic stimulated attenuation of ischemic acidosis is PKC dependent, (3) direct nPKC stimulation with SAG does not limit ischemic acidosis, and (4) SAG stimulates nPKC-epsilon isoform activation where alpha1-adrenergic stimulation does not. We conclude that alpha1-adrenergic stimulation limits ischemic acidosis by a cPKC-dependent mechanism and that the mobilization of the IP3 arm by receptor stimuli suppresses PKC-epsilon thus permitting the limitation of ischemic acidosis.

Identification of a ubiquitin-like protein in the mammalian vitreous humor

An 8 kDa ubiquitin-like peptide (ULP) was isolated by high performance liquid chromatography from the rabbit vitreous humor, and the N-terminal amino acid sequence of this peptide showed complete homology with ubiquitin. Western blot revealed the presence of free ULP in both the iris-ciliary (IC) complex and the aqueous humor extracts. In the IC complex, fluorescence and immunoelectron microscopy detected high concentrations of ULP in the posterior epithelial cells, suggesting this tissue as a possible source of ULP in the ocular fluids. Significantly, this is the first time that the presence of free ULP has been reported in mammalian extracellular fluids. Furthermore, we recently demonstrated that the 8 kDa fraction of vitreous humor containing ULP is a potent inhibitor of protein synthesis [Banerjee et al. (1992): J Cell Biochem 49:66-73]. These findings taken together suggest a novel biological role for ULP in the control of lens cell growth.

Polychemotherapy in squamous cell carcinoma of the buccal mucosa

Thirty-nine patients with previously untreated squamous cell carcinoma of the buccal mucosa were treated by two polychemotherapeutic regimens. The first regimen consisted of bleomycin and methotrexate (BLM-MTX): bleomycin 30 mg was given intravenously twice weekly, and methotrexate 25 mg intravenously twice weekly for 2 1/2 and two weeks, respectively. The second program consisted of Cytoxan (cyclophosphamide), methotrexate and 5-FU (CMF): methotrexate 25 mg twice weekly for two weeks, Cytoxan 100 mg/day for two weeks, and 5-FU 500 mg twice weekly for 1 1/2 weeks. All of the patients were evaluated one week after completion of their chemotherapy regimen. Although the patients were not randomly allocated to either treatment, they matched in age and extent of disease. High response rates (88.9%) were noted with the BLM-MTX combination, which is comparable to the best responses reported previously using cis-platinum, Oncovin (vincristine), and methotrexate. This may suggest that buccal cancers are highly sensitive to an initial treatment by BLM-MTX, and therefore the authors highly recommend its use as preoperative adjuvant therapy in patients who present with Stage III and IV (Mo) disease.

A double-blind comparison of flupenthixol decanoate and fluphenazine decanoate in the treatment of chronic schizophrenia

Sixty-four chronic stabilised schizophrenics were studied for 18 months in order to assess the possible difference in therapeutic effects and side effects between flupenthixol decanoate and fluphenazine decanoate. Although certain differences in the BPRS sub-scores in favour of flupenthixol were present at various stages in the study, there was no significant difference between the two drugs in the overall antipsychotic scores at the end of the assessment period; however, more patients on fluphenating required additional therpay for depression or anxiety during the trial period.