Les tumeurs papillaires non malignes du sein : quelle prise en charge après diagnostic percutané ?

PURPOSE

To assess the reliability of percutaneous breast biopsies in diagnosing and managing non malignant papillary lesions and determine if subsequent excision must be systematic. MATERIALS AND METHODS. Retrospective review of 2233 breast biopsies over a 43 months period (September 2001 to March 2005): sonographically guided core biopsies (n = 836), ultrasound (n = 346) or stereotactic (n:1051) guided vacuum biopsies. 86 non malignant papillary tumors were diagnosed (core biopsy:28, US:38 and stereotactic guided vacuum biopsy:20). A larger sample was systematic after core biopsy: lumpectomy (n = 19) or vacuum biopsy (n = 9). Surgical excision followed vacuum biopsy (n = 18) in case of atypia or sampling excision. Alternatively, yearly follow-up was advised (n = 40). Correlation with surgical findings (n = 37) or mammographic follow-up (n = 49) is presented. The influence of various factors on the risk of underestimation was analysed.

RESULTS

Surgical resection revealed an underestimation of 5/37 (13.5%): 4/19 with core- and 1/18 with vacuum-assisted biopsy corresponding to 4 low grade ductal carcinoma in situ and a microinvasive ductal carcinoma in situ. It was higher for core biopsies and related to age and size: higher when women<50 years and when radiological image>1 cm. The influence of the other factors was not significant. Of the 9 non operated papillomas after core biopsy, vacuum biopsy revealed an additional underestimation (low-grade ductal carcinoma in situ). Of the 49 papillary lesions that were not surgically biopsied, 40 were monitored at 2-42 months (average: 19 months). No carcinoma was detected during this follow-up.

CONCLUSION

Percutaneous biopsy is an accurate technique in managing papillary tumors. A larger histologic specimen is necessary after core biopsy. Vacuum biopsy is an attractive alternative to surgery for smaller papillomas (<1 cm), but in spite of nonsignificant results we advise subsequent excision in case of multiple papillomas, atypia or residual tumor.

[Ultrasound-guided vacuum-assisted biopsy: review of 382 cases]

PURPOSE

To evaluate the use of US-guided vacuum biopsy for diagnosis and treatment of probably benign breast masses.

MATERIALS AND METHOD

Retrospective review of 382 US guided vacuum biopsies over a 44 months period (september 2001 to may 2005) with the 11-g handheld mammotome. A total of 308 benign tumors, 59 borderline lesions and 15 carcinomas were diagnosed. The average number of specimens is 13.1 (3-37). Surgical resection has been systematic for carcinomas and selective for papillomas. Surgical correlation (n:35) or mammographic follow-up (n:347) are presented.

RESULTS

Complete removal occurred in 371/382 (97.1%) immediately after biopsy and 337/382 (88.2%) after one month: 138/142 (93.7%) for fibroadenomas and 52/53 (98.1%) papillomas less than 15 mm. Open surgical biopsy was carried out for 35 patients on the basis of incomplete removal (3 cases) or histologic findings (8 invasive carcinomas, 7 ductal carcinoma in situ, 3 atypical ductal hyperplasia, 1 fibrocystic changes with atypia and 11 papillomas). No lesion was under-diagnosed and the rate of avoided surgery was 94.5%. Of the 347 lesions that were not surgically biopsied (42 borderline lesions and 305 benign lesions), 337 were monitored at 1-43 months (average: 20 months, > or =24 months: 57 patients). Ten underwent additional biopsy but no missed cancer was detected. Patients tolerance was good or very good in 83%, and the complication rate was 1.3%.

CONCLUSION

US-guided vacuum biopsy is an accurate and well tolerated technique. It is an alternative to surgery for masses less than 15 mm including fibroadenomas and papillomas or in patients with imaging-histologic discordance at core biopsy.

Irreducible dorsal dislocation of the interphalangeal joint of the thumb due to the palmar plate. A case report

Dorsal dislocation of the thumb interphalangeal joint is rare. Only very few cases of irreducible dislocation has been reported at this joint. The authors report a case of compound irreducible dislocation due to the palmar plate interposition. The sesamoid, the flexor pollicis longus have been reported to block reduction of the dorsal dislocation of the thumb interphalangeal joint doctors on casualities should not insist if reduction is not easily obtained, the patient should then be guide towards a surgical team for surgical treatment.

Trapezo-metacarpal and metacarpo-phalangeal dislocation of the thumb associated with a carpo-metacarpal dislocation of the four fingers

The authors report a case of combined dorsal fracture-dislocations of all 4 fingers, palmar trapezo-metacarpal dislocation and metacarpophalangeal dislocation of the thumb following a motorbike accident. These exceptional lesions were treated as an emergency by reduction and pinning. With a follow-up of 13 years, the patient still worked as an electrician.

[Distal traumatic avulsion of the triceps brachii. Apropos of a treated cases]

Traumatic distal avulsion of triceps brachii is a rare injury, usually due to a fall on the outstre ched elbow, with sudden contraction of the triceps muscle. Examination reveals pain, swelling, and a palpable depression just proximal to the olecranon. Lateral X rays show avulsed osseous material. Surgical therapy was advisable for complete avulsion. In this case, the authors used absorbable sutures for this reinsertion. Immediate surgical repair always achieves good results.

Hepatic fibrosis in rheumatoid arthritis patients treated with methotrexate: application of a new semi-quantitative scoring system

OBJECTIVE

Evaluation of hepatic lesions in patients treated with methotrexate (MTX) generally used the Roenigk histological score. However, the sensitivity of the method for hepatic fibrosis assessment has been discussed. The semi-quantitative histological scoring system (SSS) offers a sensitive and specific evaluation of liver fibrosis. Both scores have been evaluated in liver biopsies of patients with rheumatoid arthritis.

METHODS

Seventy-four liver biopsies were obtained in 57 rheumatoid arthritis patients before initiation of MTX (group 1, 38 cases), in cases of a persistently high level of transaminases during 1 yr of treatment (group 2, 10 cases) and after a MTX total dose of 2 g (group 3, 26 cases). Eleven biopsies of groups 1 and 3 originated from the same patient in 11 cases. Specimens were examined blindly by two anatomopathologists. The three groups were compared with an ANOVA. Sequential biopsies performed in 11 patients were compared with the Wilcoxon paired test.

RESULTS

The Roenigk score and the SSS were significantly correlated (P<0.0001). Only a mild fibrosis was found in 33.8% (25/74) of the biopsies with the Roenigk score. Liver fibrosis, graded as mild (48.6%), moderate (41.8%) or severe (4%), was demonstrated in 94.6% (70/74) of the biopsies with the SSS. The Roenigk score and the SSS of the three patient groups were not statistically significantly different. The scores did not progress in the 11 patients who had serial biopsies.

CONCLUSION

SSS is much more sensitive than the Roenigk score for the evaluation of hepatic fibrosis. However, SSS did not show progression of hepatic fibrosis in patients with rheumatoid arthritis treated with MTX.

[Functional treatment of isolated fractures of the ulnar diaphysis in adults. A prospective study apropos of 10 cases and review of the literature]

In this prospective study, ten consecutive isolated fractures of the ulna were treated by short-arm plaster cast (an average of 16.8 days) with immediate mobilization in our institution since January 1995. The minimum follow-up was eight months and the longest was two years. All fractures were closed. The median age of the patients was 36.7 years (17 to 61), the male to female ratio was 7 to 3. The patients were seen and radiographed every two weeks until bridging external callus was detected by same surgeon. Monteggia fractures-dislocation, open fractures, fractures with elbow or wrist dislocation and gunshot fractures were also excluded. The fracture involved the distal third in 5 cases, the distal quarter in 4 cases and the middle third in one case. Seven fractures were displaced between 2.5 and 6 mm, but no fracture needed reduction. All patients returned to work a mean of 4 months after the accident. Some angulation was found in most cases, but it rarely exceeded 10 degrees. In this study, the average healing time was 8 weeks and there were no non-unions. We did not encounter any synostosis between the radius and ulna in our patients. Motion at the wrist and elbow was always restored. All patients were satisfied by the functional method. The method that we have described can be safely recommended as treatment of choice for these fractures. Completely displaced, Monteggia fractures, comminuted or gunshot fractures of the ulna should be treated by other methods.

[Treatment of complex fractures of the ankle and their sequellae using trans-plantar intramedullary nailing]

Nine patients were treated for complex tibial pilon and talus fractures or non unions from 1990 to 1997 using intramedullary nails introduced through the calcaneus. All patients were followed until healing. The average follow-up was 14 months. Failure of the procedure was defined by the occurrence of complications or reintervention. We used a modified Seidel nail in 5 cases, a tibial shaft nail in 3 cases, and a special nail in one case. All nails but two were locked.

CASES

These arthrodeses were performed for treatment of sequels from open talus fractures. Transplantar nailing was performed between 9 months and 3 years after arthrodesis, because of non union. In two cases fusion was obtained at 3 and 8 months postoperatively. In the third case non union occurred due to instability of fixation (the nail was unlocked). Replacement by an interlocked nail was performed through a proximal tibial approach, and healing was obtained in 6 months. PSEUDARTHROSES: 2

CASES

These two cases presented comminuted tibial pilon and open talus fractures in association with vascular and tendon lesions. They had previously undergone debridement and external fixation. Transplantar nailing was performed 8 and 10 months after trauma using a locked modified Seidel nail. Radiographic fusion was obtained in 5 months. PRIMARY SURGERY: 4

CASES

The first two cases were foot reimplantations after traumatic amputation. Skeletal stabilization was obtained using a transplantar locked tibial nail. Revascularization attempts failed and an amputation was performed on the fourth day in one case. The reimplantation succeeded in the second case. Radiographic fusion was obtained in 2 months. The third case was a distal tibial shaft fracture. The patient was an obese mentally deficient and invalid woman. Bone union was achieved in four months. The last case was a primary arthrodesis for post-trauma necrosis of the talus. Radiographic fusion was observed 45 days after operation. Transplantar locked nailing offers an optimal stabilization for complex ankle fractures. We had two failures not related with the principle of the technique. We think that transplantar nailing is best indicated to obtain tibiotalar or tibiocalcaneal arthrodesis and to treat compound ankle fractures. Another indication could be distal tibial shaft fractures in invalid or mentally deficient patients.

Quantitative studies on liver fibrosis and alpha-smooth muscle actin expression in heroin abusers

Lobular hepatic fibrosis and the presence of myofibroblasts were studied in heroin abusers, by quantitative automatic image analysis. Nineteen addicts (DA) and thirteen patients having stopped consumption (exDA) were compared to a non-addict group (CONTROL). Addicts, all anti-HIV and HBsAg negative, showed increased transaminase levels. Hepatitis C markers were ot available, at the time of biopsy. The surface of the centrolobular fibrosis, measured on picrosirius stained slides, was respectively 1.9 and 3.5 times larger in DA and exDA than in CONTROL (p < 0.0001). Immunolabelling with an alpha-smooth muscle actin antibody (alpha-SMA) revealed stellate cells in a perisinusoidal location, mainly in areas of matrix thickening in the space of Disse. Morphometric analysis of alpha-SMA expression showed significant differences between the three groups of patients, p < 0.0001 (CONTROL: 198.06 +/- 5.59 microns2; DA: 2227.91 +/- 88.02 microns2; exDA: 3469.10 +/- 154.98 microns2). The surface density of collagen and of alpha-SMA reactivity was also significantly different between these groups (p < 0.0001). These data strongly suggest that heroin is responsible for an early and progressive centrolobular liver fibrosis, occurring simultaneously with a myofibroblastic response. It might represent a reparative phenomenon arising from a direct vascular injury, leading to an impairment of blood-hepatocyte exchange.

Lysyl oxidase gene expression in the stromal reaction to in situ and invasive ductal breast carcinoma

Lysyl oxidase is involved in the main pathway of collagen and elastin cross-linking: it has a role in the maturation of fibrillar matrix proteins in fibrosing processes and dictates their stability against metalloproteases. The stromal reaction patterns in ductal breast carcinoma are known to be morphologically varied. This has raised the hypothesis that there might be a differential expression of the lysyl oxidase gene as a function of stromal reaction pattern. The present study investigates this potential correlation and the role of matrix protein cross-linking in stromal differentiation. Lysyl oxidase was detected by immunohistochemistry and lysyl oxidase gene expression by in situ hybridization. Maximal expression was observed in myofibroblasts and myoepithelial cells around in situ tumors and in the reactive fibrosis facing the invasion front of infiltrating tumors. The lysyl oxidase substrates were observed in parallel, resulting in the stabilization of a scar-like peritumor barrier. In contrast, a lack of lysyl oxidase was associated with the loose or scirrhous stroma accompanying invading tumors; here, in situ hybridization revealed type I collagen synthesis, resulting in the deposition of non-cross-linked matrix proteins susceptible to degradation. The early development of a cross-linked matrix around ductal breast carcinoma suggests a possible bost defense mechanism, whereas the synchronous or late stromal reaction lacking lysyl oxidase favors tumor dispersion.

Connective tissue disease due to intentional inhalation of scouring powder

There have been reports in the literature of acute and chronic silicosis and connective tissue disease induced by occupational exposure to silica in factories producing scouring powder. Reports of connective tissue diseases induced by intentional inhalation of such a powder are rare and perhaps underestimated. We report the case of a young woman who developed Sharp's syndrome 5 yrs after diagnosis of acute silicosis due to scouring powder inhalation. The frequency of diseases from scouring powder as well as physiopathological and therapeutical issues of the association of pneumoconiosis and connective tissue disease are discussed.

Serial transmission of spongiocytic hepatitis to woodchucks (possible association with a specific delta strain)

BACKGROUND/AIMS

Outbreaks of severe hepatitis have been reported from Africa and South America. Description of the cases has shown the histological hallmark to be the presence of ballooning hepatocytes with fat drops surrounding the nucleus (spongiocytes or morula cells).

METHODS

Experimental reproduction of this syndrome for the verification of a possible role of a specific HDV strain was performed by the inoculation of serum and liver extracts from African patients (Bangui-Central African Republic), who died with this syndrome, into American woodchuck carriers of WHV (WC 231,144), the results of which were then compared with animals inoculated with a reference wild HDV strain (WC 300,173,154), and those which received material from a European fulminant HDV case (WC 88,93).

RESULTS

Following the initial inoculation, the animals receiving African inocula had a delayed anti-HDV seroconversion, high mortality and showed the presence of spongiocytes, while the other animals had a classical evolution of HDV superinfection in woodchucks. Furthermore, the African inocula caused less inhibition of WHV replication, as well as a predominant cytoplasmic expression of HDAg, in contrast to the animals which received the other inocula. The second passage experiments gave similar results.

CONCLUSIONS

We conclude that this peculiar form of HDV fulminant hepatitis can be experimentally reproduced and might be specifically related to a more pathogenic strain.

The French experience of treatment of chronic type D hepatitis with a 12-month course of interferon alpha-2B. Results of a randomized controlled trial

Hepatitis due to hepatitis delta virus (HDV) infection is generally associated with severe histological abnormalities and rapid progression of the disease. To assess the efficacy of recombinant interferon-a2b in treatment of chronic delta hepatitis, 22 patients were entered into a randomized controlled trial: 11 received interferon-a2b subcutaneously three times weekly for 12 months (5 MU/m2 for 4 months and then 3 MU/m2 for a further 8 months) and 11 were untreated. All patients were followed up for 6 months after the completion of therapy. Nine treated patients completed the trial: one was withdrawn with hyperthyroidism and one committed suicide. Serum ALT levels were normalized or significantly reduced, always within 3 months of initiating treatment, and remained so in 73% of treated patients at the 4th month and in 54.5% at the 12th month, compared with 18% and 18%, respectively, in the untreated group. Moreover, in seven of nine treated patients, interferon was associated with the clearance of serum HDV-RNA, associated with amelioration of the histological picture, whereas this occurred in only four of 11 untreated patients. On cessation of therapy, all patients but one experienced a biological and/or virological relapse over the 6-month follow up. In conclusion, our data confirm that HDV is sensitive to inhibition by interferon-a2b, although the schedule used did not achieve permanent control of the disease. The adverse effects of interferon require consideration; in particular, care will be needed to avoid serious psychiatric side effects.

A histological semiquantitative scoring system for evaluation of hepatic fibrosis in needle liver biopsy specimens: comparison with morphometric studies

The evaluation of hepatic fibrosis on histological sections is of great interest for the staging and follow-up of chronic liver disease. Because no reliable scoring system is yet available, we have designed a semiquantitative scoring system in which the four main sites of fibrotic deposit--centrilobular vein, portal tract and perisinusoidal space, together with width and number of septa when present--are analyzed. These different items have been previously settled from comparison with morphometric measurements to evaluate surface density of total collagen performed on the same liver needle biopsy specimens stained with picro-sirius. The score has been tested on samples from 200 consecutive patients with various liver diseases and compared with the surface density of total collagen and Knodell scoring system. For observer variation study, the features by three independent pathologists were coded on 20 cases. There was a good interobserver (Kendall's tau-b = 0.75) and intraobserver (tau-B = 0.73) reproducibility. Each component of the fibrosis scoring system and total collagen surface density were significantly linearly related (one-way polynomial analysis, p < 10(-4); the correlation between semiquantitative scoring system and surface density of total collagen was 0.73 (p < 10(-5). Our semiquantitative scoring system, simple and reproducible, describes both liver architecture and fibrotic deposit. It is better related to morphometric measurement of fibrosis than each of its constituents or than the fibrosis item of the Knodell scoring system. It represents a reliable and convenient method for fibrosis evaluation, which is mandatory for clinical use.

Action of methotrexate on cytochrome P-450 monooxygenases in rats. Study performed with [13C]-aminopyrine micro breath test

The aim of this work was to study the action of methotrexate on the cytochrome P-450 hepatic monooxygenases and to follow the evolution of the metabolic processes with time, after oral and intra-peritoneal administration of these drugs to rats. In order to perform this study, we used a new technique the [13C]-aminopyrine breath test (ABT). At the end of the in vivo study, the rats were sacrificed and the cytochrome P-450 concentration as well as microsomal enzymatic activities of aminopyrine N-demethylase, 7-ethoxyresorufin desalkylase, 7-ethoxycoumarin desalkylase, 7-pentoxyresorufin desalkylase were determined. A histological study of the liver was also carried out. Finally, haematological and biochemical parameters were also determined. In this study, 3 series of 6 rats were used: a control group, a group receiving 70 mg/kg of methotrexate by intra-peritoneal route, and a group of rats treated orally with 1 mg/kg of methotrexate every 2 days. For each observation, the variation of the ABT scores and of the cytochrome P-450 amounts as well as the microsomal aminopyrine N-demethylase activity were in good agreement.

Expression of HLA antigens and T cell infiltrates in chronic viral hepatitis. A comparison of biopsy and fine-needle aspiration findings

To evaluate the expression of hepatocyte HLA Class I and II antigens and the infiltration of CD8-positive lymphocytes in patients with chronic hepatitis, cells obtained by the technique of fine-needle aspiration were compared with those obtained by percutaneous liver biopsy. In general, correlation between cytological and histological specimens of HLA Class I and Class II antigen expression and CD8 lymphocyte infiltration was excellent when comparing results of the core biopsy expressed semiquantitatively, and results from fine-needle aspiration quantitatively as percentage of cells stained. Although the major potential of multiple fine-needle aspiration sampling probably will be in the surveillance of patients who have received orthotopic liver transplants, the results of this study indicate that fine-needle aspiration can provide a useful technique for following antigen expression and inflammatory changes in studies in which frequent periodic samples may be necessary to monitor efficacy or toxicity of treatment regimens.

[The diagnosis of genital papillomavirus infections using molecular hybridization]

Human papillomaviruses (HPV) are non-cultivable, small ADN viruses, of which about sixty different types are known at present. They infect specifically the stratified epithelium and are responsible for skin lesions (warts) and mucous lesions (condylomata). Their presence can probably be associated with the possible development of genital neoplasia. They cannot be detected by culture and it is at present impossible to reveal their presence by specific antigens. However, the presence of their genome in the infected cells can be detected by hybridization with the use of marked nucleic probes, Southern-blot (method of reference), dot-blot, quicker but less specific, or hybridization in situ which enables the assessment of the histopathological environment. Finally, the very sensitive technique of enzymatic amplification of the genes (Polymerase Chain Reaction-PCR) could become a method of choice for the detection of HPV. These techniques of molecular biology have shown that genital HPV infections are widely spread, but the markers necessary to determine the risk of neoplastic degeneration are yet to be discovered.

Vascular hepatotoxicity related to heroin addiction

The hepatotoxic effect of heroin has been demonstrated in liver biopsies by morphometric analysis of four groups of patients: twenty-one drug abusers (DA) at the time of the biopsy, eighteen patients who had stopped drug consumption for at least six months (ex-DA), twelve patients with post-transfusional chronic active hepatitis (PTCAH), and eleven controls (CONTROL). Semiquantitative assessment showed the extent of sinusoidal dilatation and the inflammatory and fibrotic reaction in the terminal hepatic vein (THV). Thickening and cellularity of the venular wall and the volume density of sinusoidal lumen (Vsl) in the Zone I and III of the hepatic acinus, were also evaluated. The morphometric analysis used computerized measurements. In DA, the sinusoidal dilatation (100% of cases), the sinusoidal and THV inflammation (81% and 67.7%, respectively), localized mainly in the centrilobular zone, were more pronounced than in ex-DA, in patients with PTCAH and in CONTROL (significantly different P less than 0.0001). Conversely, the fibrotic reaction (perisinusoidal fibrosis--44.4% and perivenular fibrosis--61.1%) was more frequent in ex-DA. The THV inflammation in DA was replaced by a fibrotic matrix deposit in the THV wall (wall surface/internal surface = 2.72 +/- 0.37 in ex-DA; 1.38 +/- 0.32 in DA; 0.87 +/- 0.14 in PTCAH and 0.45 +/- 0.03 in CONTROL--significantly different P less than 0.001), associated with a perisinusoidal fibrosis, after drug withdrawal. Moreover, there was significantly decreased venular wall cellularity in ex-DA (wall surface/mesenchymal cells = 949 +/- 158 in ex-DA; 622 +/- 40 in DA; 619 +/- 61 in PTCAH; 547 +/- 23 in CONTROL--P less than 0.001). Semiquantitative and morphometric data suggest that these vascular lesions and their reversibility may be due to the direct hepatotoxic effects of heroin.

Total hip replacement in patients with rheumatoid arthritis

In this prospective study, 50 patients with a confirmed diagnosis of rheumatoid arthritis had total hip replacement. Preoperatively and at regular intervals postoperatively, all patients had evaluation of pain, ambulation, and range of motion according to the scale of d'Aubigne and Postel. Follow-up ranged from three to seven years, with the average being longer than four years. All patients demonstrated significant improvement in these parameters. Specific problems of the rheumatoid patient are discussed in detail.