Aspecific binding of anti-NK1.1 antibodies on myeloid cells in an experimental model for malaria-associated acute respiratory distress syndrome

BACKGROUND

Conventional natural killer (cNK) cells play an important role in the innate immune response by directly killing infected and malignant cells and by producing pro- and anti-inflammatory cytokines. Studies on their role in malaria and its complications have resulted in conflicting results.

METHODS

Using the commonly used anti-NK1.1 depletion antibodies (PK136) in an in-house optimized experimental model for malaria-associated acute respiratory distress syndrome (MA-ARDS), the role of cNK cells was investigated. Moreover, flow cytometry was performed to characterize different NK cell populations.

RESULTS

While cNK cells were found to be dispensable in the development of MA-ARDS, the appearance of a NK1.1+ cell population was observed in the lungs upon infection despite depletion with anti-NK1.1. Detailed characterization of the unknown population revealed that this population consisted of a mixture of monocytes and macrophages that bind the anti-NK1.1 antibody in an aspecific way. This aspecific binding may occur via Fcγ receptors, such as FcγR4. In contrast, in vivo depletion using anti-NK1.1 antibodies was proved to be specific for cNK cells.

CONCLUSION

cNK cells are dispensable in the development of experimental MA-ARDS. Moreover, careful flow cytometric analysis, with a critical mindset in relation to potential aspecific binding despite the use of commercially available Fc blocking reagents, is critical to avoid misinterpretation of the results.

Tumor endothelial cell autophagy is a key vascular-immune checkpoint in melanoma

Tumor endothelial cells (TECs) actively repress inflammatory responses and maintain an immune-excluded tumor phenotype. However, the molecular mechanisms that sustain TEC-mediated immunosuppression remain largely elusive. Here, we show that autophagy ablation in TECs boosts antitumor immunity by supporting infiltration and effector function of T-cells, thereby restricting melanoma growth. In melanoma-bearing mice, loss of TEC autophagy leads to the transcriptional expression of an immunostimulatory/inflammatory TEC phenotype driven by heightened NF-kB and STING signaling. In line, single-cell transcriptomic datasets from melanoma patients disclose an enriched InflammatoryHigh /AutophagyLow TEC phenotype in correlation with clinical responses to immunotherapy, and responders exhibit an increased presence of inflamed vessels interfacing with infiltrating CD8+ T-cells. Mechanistically, STING-dependent immunity in TECs is not critical for the immunomodulatory effects of autophagy ablation, since NF-kB-driven inflammation remains functional in STING/ATG5 double knockout TECs. Hence, our study identifies autophagy as a principal tumor vascular anti-inflammatory mechanism dampening melanoma antitumor immunity.

A cellular hierarchy in melanoma uncouples growth and metastasis

Although melanoma is notorious for its high degree of heterogeneity and plasticity1,2, the origin and magnitude of cell-state diversity remains poorly understood. Equally, it is unclear whether growth and metastatic dissemination are supported by overlapping or distinct melanoma subpopulations. Here, by combining mouse genetics, single-cell and spatial transcriptomics, lineage tracing and quantitative modelling, we provide evidence of a hierarchical model of tumour growth that mirrors the cellular and molecular logic underlying the cell-fate specification and differentiation of the embryonic neural crest. We show that tumorigenic competence is associated with a spatially localized perivascular niche, a phenotype acquired through an intercellular communication pathway established by endothelial cells. Consistent with a model in which only a fraction of cells are fated to fuel growth, temporal single-cell tracing of a population of melanoma cells with a mesenchymal-like state revealed that these cells do not contribute to primary tumour growth but, instead, constitute a pool of metastatic initiating cells that switch cell identity while disseminating to secondary organs. Our data provide a spatially and temporally resolved map of the diversity and trajectories of melanoma cell states and suggest that the ability to support growth and metastasis are limited to distinct pools of cells. The observation that these phenotypic competencies can be dynamically acquired after exposure to specific niche signals warrant the development of therapeutic strategies that interfere with the cancer cell reprogramming activity of such microenvironmental cues.

Short time effects of radiotherapy on lymphatic vessels and restorative lymphatic pathways: experimental approaches ina mouse model

Radiotherapy (RT) is an important component in the therapeutic approach to oncologic conditions. This study presents the investigative results on the impact of RT on lymphatic vessels and on the regenerative response of the lymphatic system in a mouse model. We first irradiated 3 groups of ten mice using brachytherapy in a single treatment of 20 Gy. We then performed morphological examination of the irradiated lymphatic vessels using an in vivo microscopic transillumination technique at 2, 4, and 6 weeks. Next we evaluated lymphatic flow using lymphoscintigraphy and in vivo microscopy at 6 to 11 weeks in: 10 additional mice following irradiation as above (IR), in 10 mice following incision of a lymphatic vessel (I), and in a non-treated control group of 10 mice (N). Intact lymphatic vessels were observed in all mice at 2, 4, and 8 weeks following the single dose of radiotherapy in the first group of mice and normal lymphatic flow was fully restored in the irradiated (IR) and incised (I) mice indicating that the reparative substitution lymphatic pathways are functioning normally. We found that following irradiation with one dose of 20 Gy, lymphatic vessels were not visibly damaged and also that lymphatic flow was consistently restored and substitutive lymphatic pathways formed.

Abstract P1-13-06: Correlation between aromatase-induced arthralgia and inflammatory cytokines in postmenopausal patients with early breast cancer treated with surgery followed by adjuvant hormone therapy: A prospective open-label single center study

Introduction: Nine randomized trials in early breast cancer(EBC) have demonstrated an advantage of aromatase inhibitors(AI’s) over tamoxifen in disease-free survival. Joint symptoms are common toxicities and lead to treatment interruption in up to 20% in case of severe aromatase-induced arthralgia(AIA). During menopause levels of markers of inflammation such as IL-1b, TNF-alpha and IL-6 increase. We hypothesized that estrogen deprivation by aromatase inhibition could be associated with similar changes in these markers and that this could play a role in AIA. In an earlier study, similar toxicities were observed in patients(pts) treated with a recombinant form of IL-6. In several cell types it has been shown that ligand activated estrogen receptor blocks nuclear factor kappa beta controlled gene transcription of IL-6.

Aim of the study: We initiated a prospective open-label study to examine the role of inflammatory cytokines and other serum markers(CRP and hormones) in the pathogenesis of AIA.

Methods: 29 evaluable postmenopausal pts with hormone sensitive, Her 2 negative EBC stage I-III, with baseline G0-1 arthralgia were included. Before chemotherapy, at baseline, at month 3, 6, 9, 12 and 18 after AI initiation, serum samples were taken for CRP and hormones (estradiol, androstenedion) and cytokines were analyzed with a human cytokine 25-plex panel. A detailed rheumatologic questionnaire and Visual Analog Scale(VAS) was performed at each visit. Arthralgia grading was assessed using the CTCAE criteria 4.0. The T-test and the Wilcoxon Signed Rank test were used to look for the difference in terms of IL-6, Il-1b, IL-8, TNF, CRP, estradiol and androstenedion between G0 versus G1-2-3 arthralgia.

Results: The mean age was 56 yrs. (34-72yrs). All patients were treated with surgery followed by concomitant chemoradiation and letrozole (31) or anastrazole (1). In 16 pts G1 arthralgia was present before the start of the chemotherapy. Grade 2 and 3 arthralgia appeared at mth 3. The proportion of pts with grade 2 remained more or less the same, while grade 3 pts declined from month 6 onwards and disappeared at month 18.

Grade of arthralgia at different time pointsArthralgiamth omth 3mth 6mth 9mth 12mth 18G045231911618G1553954615955G202319222927G30158560

There was a significant correlation between the grade of arthralgia and the VAS score at all-time points (p<0.05). CRP levels were significantly higher in the patients with arthralgia at month 3 (p<0.001) and 6 (p<0.005). Patients with G2-3 arthralgia had higher estradiol levels at mth 3 (p<0.001) and 6 (p<0.001).Cytokine results are currently available for the first 12 patients only. In these preliminary data, IL-6 levels were significant higher in the pts with arthralgia before initiation of AI ‘s. The examination of correlations during AI treatment needs the analysis of the full cohort.

Conclusion: This study indicates that both menopause and AIA have inflammatory mediators (IL6 and CRP) that correlate with the degree of lowering of estradiol levels. This is consistent with the regulation of IL-6 by the ligand activated ER through NFkB in vitro.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-13-06.

Abstract P1-13-05: A prospective study to evaluate joint changes by ultrasound and magnetic resonance imaging induced by adjuvant chemotherapy followed by aromatase inhibitors in postmenopausal early breast cancer patients developing G3 arthralgia

Introduction: Aromatase inhibitors (AI) are a well-established component of the adjuvant hormonal therapy in postmenopausal (PM) EBC patients (pts). AI have been associated with joint symptoms in 20 to 40% of pts adversely affecting quality of life and compliance. The subjective nature of these toxicities warrants objective correlates. In this study we have compared synovial changes on MRI with ultrasound (US).

Aim of the study: The primary aim was to assess joint changes in PM EBC pts by MRI and US at baseline and at occurrence of arthralgia G3 during AI therapy. The secondary aim was to investigate the relationship between clinical severity of articular symptoms and markers of bone metabolism.

Methods: PM EBC pts, stages I-III, with a grade 0, 1 arthralgia (CTCAE version 4.0) at baseline were recruited for the study. At baseline and at 3, 6, 9, 12 and 18 months (mths) a rheumatologic questionnaire was performed. At the same time points serum samples for bone markers (Ca, ostase, intact PTH, alkaline phosphatase and vit. D), rheumatoid factor (RF) and urine samples for urinary N-telopeptide (uNTX) were taken. Pain was assessed by the Visual Analog Scale (VAS). Before start of AI, osteoarthritis was quantified by plain radiography (hands, wrists and knees), joint changes were assessed baseline and at occurrence of arthralgia G3 by MRI and US (hands and wrists), and bone density by DEXA.

Results: 29 evaluable PM EBC pts were included in the study. At baseline, 60% of the pts had a mean VAS score of 2 (0/10-5/10), which increased to 2.5 after the adjuvant chemotherapy and to 4.5 (0-8) at mth 12 (p = 0.013) of AI therapy, and subsequently dropped to 2.5 at mth 18 (p = 0.2). The most commonly affected joints at baseline were knees (47%), shoulders (41%), and ankles/feet (29%); whereas during AI therapy it involved mainly knees (53%), shoulders (46%) and hands/wrists (32%). Fifty percent of the pts had signs of osteoarthritis of the hands (25%), knees (16%) and both (8%) on plain radiographs obtained at baseline. Grade 0-1 arthralgia was not significantly correlated with the imaging of osteoarthritis or grade of osteoporosis. At baseline intra-articular fluid was detected on MRI of the hands/wrists in 6 pts, 14 pts had synovial changes and 4 had both. Six out of 29 pts had also signs of synovitis with hyperaemia on US before the start of an AI. G3 arthralgia occurred in five pts of which only three agreed to the repeat radiological imaging. In two of these pts a worsening of imaging both by MRI and US was observed, whereas in the third pt imaging was unchanged.

Markers of bone metabolism and uNTX did not differ significantly between groups with arthralgia and without (p>0.05). RF was positive in only two pts, one with arthralgia G1 at baseline and one pt at the moment of G3 arthralgia.

Conclusions: This study is the first to prospectively report on synovial changes by combined MRI and US before initiation of adjuvant AI in PM women and at occurrence of arthralgia G3. Only 17% of pts developed G3 arthralgia which corresponded to worsening imaging signs. From the small sample size it seems that baseline MRI changes predicts the development of G3 arthralgia with higher sensitivity than baseline US. Sensitivity of US improved during AI therapy.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-13-05.

Comparative study between mobile infrared optoelectronic volumetry with a Perometer and two commonly used methods for the evaluation of arm volume in patients with breast cancer related lymphedema of the arm

There is no consensus on the definition of Breast Cancer Related Lymphedema of the arm (BCRL) because there are no agreed standards in measurement methods and diagnostic criteria. The main objective of this study is to compare mobile infrared optoelectronic volumetry with a Perometer with two commonly used methods for the evaluation of arm volume in patients with different degrees of BCRL. Bilateral arm volumes of eighty participants, with and without clinical BCRL, were calculated with a mobile Perometer, by water displacement, and with circumferential measurements, integrated in the frustrum, single frustrum, and disc model method. The ICC of the Perometer was between 0.997 and 0.999. The frustrum and disc model method produced the largest volume measurements and water displacement the smallest, while Perometer measures were in between. On average, volume of the dominant arm was found to be 2.2% higher than the non-dominant arm in the healthy control group, cautioning for intra- patient differences between both arms when comparing ipsilateral to contralateral arm for the diagnosis of BCRL with a threshold value. Future research would likely benefit from the use of the Perometer compared to the other arm volume evaluation tools for BCRL, and further, the single frustrum method should not be used for volume estimations of edematous arms.

Abdominal wall desmoid tumours

We present two cases of desmoid tumour of the anterior abdominal wall in young women in whom the defect after radical excision could not be closed without using prosthesis. The first case warranted the use of a composite mesh, the second a polypropylene prosthesis. In both cases primary closure of the skin was possible. Both women are doing fine with no sign of relapse or incisional hernia.

Lymphedema of the operated and irradiated breast in breast cancer patients following breast conserving surgery and radiotherapy

The National Institutes of Health Consensus Development Conference on Treatment of Early Stage Breast Cancer in 1990 indicated that breast conserving surgery with radiotherapy is the primary therapy for the majority of women with early stage breast cancer. Despite good aesthetic results, a remarkable number of patients suffer from lymphedema of the operated and irradiated breast. 131 study participants scored 8 subjective symptoms of breast edema on a scale from 0 to 10 and completed the EORTC QLQ-BR23 questionnaire to assess the health related quality of life among breast cancer patients. Incidence of breast edema, up to 5 years following surgery, was 75.5%. There was a significant positive correlation between breast edema and body mass index. Breast edema also correlated significantly with chemotherapy treatment, anti-hormone therapy, age, and all aspects of quality of life, except sexual functioning, sexual enjoyment, and upset by hair loss. There were no significant differences in breast edema related to the post- operative period, the level of nodal dissection, preoperative bra cup size, tumor location and whether the surgery was performed on the dominant side. Despite the benefits of breast conserving surgery and radiotherapy, breast edema is a common complication that lowers quality of life significantly.

P2-17-08: rospective Study of Aromatase Inhibitor Induced Bone Loss and Lipid Levels in Early Postmenopausal (PM) Hormone Receptor Positive (HR+) Breast Cancer (BC) Patients Treated with Adjuvant Letrozole Extended beyond 5 Years (yrs)

Introduction/Aim: Adjuvant treatment with aromatase inhibitors (AI) is associated with accelerated bone loss and increase in lipid levels. The effectiveness and tolerance of extended treatment with AI beyond 5 years is currently under investigation. In the SOLE study, five years of continuous (C) extended letrozole is compared to interrupted therapy (9 months on, 3 months off letrozole) after 5 yrs of tamoxifen, AI or sequential hormonal therapy. We have evaluated the bone mineral density and lipid levels during the extended use of letrozole beyond 5 yrs in a cohort of patients included in the SOLE study.

Patients and methods: Postmenopauzal women with HR+ BC, receiving extended continuous (C) or intermittent (I) letrozole for 5 yrs after 5 yrs of tamoxifen, 5 yrs of an AI, or switch therapy within the first 5 years, were included. Bone mineral density was measured at the lumbar spine (L2-4) and total hip BMD (g/cm2), by dual energy X-ray absorptiometry (DXA). The mean percentage change in BMD at 12, 36 and 60 months (mths) was compared between the C and I treatment with letrozole and with baseline values. Differences between the treatment groups were assessed by the independent samples T test. We also compared the evolution ofthe serum lipid levels in both arms. Results: Thirty two patients (pts) were included with a mean age of 62 yrs (+/− 8.7 yrs). Thirty pts were valuable because of missing baseline DXA values in 2. In their first 5 years of adjuvant letrozole, prior to inclusion in the current study, twenty three pts had a mean percentage decrease of −0,76 (13,25 SD) and 7 pts who had received preventive zoledronate in the ZOFAST study, had a mean percentage increase in BMD of 4,4 (6,08 SD).

Currently 12 pts receiving the continuous letrozole are evaluable after a first one year extension of adjuvant letrozole. They had a mean percentage increase in BMD for the lumbar spine of 1.8 (3.3 SD), and a mean percentage increase in BMD for the hip of 0.85 (SD 1.93). Eight pts included in the intermittent arm are evaluable. They experience a mean percentage decrease in BMD for the lumbar spine of −0.32(2.7 SD) and a mean decrease in BMD for the hip of −2.9(SD 3.6) The difference between the two treatment groups was not significant for the lumbar spine measurements (p=0.14), but it was significant for the hip (p=0.02). The mean fasting cholesterol levels at 12 months in the C arm (12pts) was 228mg/dl (24.4 SD) and in the I arm (11pts) was 225,5mg/dl(32,3 SD) (p=0.37).

Conclusion: This is the first prospective BMD and lipid follow-up study during adjuvant letrozole extended beyond 5 yrs in PM early breast cancer pts. After the first year of extended intake of continuous or intermittent letrozole a possible difference in bone mineral density between the two arms is emerging, but the two groups are too small to make final conclusions. An updated longer follow-up on more patients will be presented. After one year no differential effect on cholesterol levels has been observed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-17-08.

Role of intra-operative touch imprint cytology in the treatment of breast cancer

OBJECTIVES

A prospective study was carried out to evaluate the role of intra-operative touch imprint cytology (TIC) in the assessment of sentinel lymph node (SLN) involvement for staging and treatment of early-stage, clinically node-negative breast carcinoma.

METHODS

Forty-five patients with early-stage, clinically node-negative breast cancer underwent a SLN biopsy with intra-operative TIC. The SLN was bisected if its width was less than 4 mm or sliced every 2 mm if it was more than 4 mm. The imprint specimens were stained with haematoxylin and eosin (H&E). Rapid immunochemistry (IH) was performed in case of equivocal cytological result. Permanent sections were evaluated with H&E and IH staining. The results of TIC were compared to histopathological results.

RESULTS

The sensitivity, specificity and overall accuracy of TIC on a node basis were 65.5%, 96.3%, 85.5%, respectively. When calculated according to the size of SLN metastasis, the sensitivity of TIC for overt metastasis was 84.6%, while it was 62.5% for micrometastasis and 37.5% for sub-micrometastasis. The mean size of nodal metastasis was 5.08 mm and 1.25 mm for true positive and false negative results, respectively (P = 0.0236). Because of intra-operative TIC, 76.5% of the patients who needed further axillary lymph node dissection (ALND) could undergo this during the same operating time.

CONCLUSIONS

TIC is a rapid and reliable method for the intra-operative assessment of metastatic sentinel node involvement in patients with early-stage, clinically node-negative breast carcinoma. Despite a low sensitivity comparable to frozen section (FS) in detecting micro- and sub-micrometastases, the technique offers the advantage of full tissue preservation for subsequent histological analysis.

Isolated traumatic gallbladder rupture

Blunt traumatic injury to the extrahepatic biliary system is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon, but poses a potential life-threatening surgical emergency. Delay in the diagnosis of the injury for several days due to no or vague symptoms and an insidious course are common. Early diagnosis is essential, as protracted treatment may result in significant morbidity and mortality. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma from a fall. The subject of isolated traumatic gallbladder rupture is reviewed because of the rarity of this condition and the diagnostic challenges it poses.

Primary primitive neuro-ectodermal tumour of the lung

A case of intrapulmonary primitive neuro-ectodermal tumour (PNET) without thoracic wall involvement is presented in a 33-year-old man. PNET of the thoracopulmonary region, also called Askin tumour, is a rare undifferentiated sarcoma usually involving the thoracic wall. Primary intrapulmonary PNET without parietal pleura or thoracic wall involvement is very rare. The correlation between anatomo-pathological aspects and clinical imaging is emphasized, which is discussed in the light of the most recent literature.

Tumor location does not influence the survival effects of radiotherapy in node-negative breast cancer

Abstract #4134

Background
 Medial (inner quadrants) tumor location has been shown to adversely influence survival in breast cancer. We investigated whether tumor location should alter the choice of local-regional treatments (surgery, with or without radiation therapy - RT), in women with node-negative breast cancer.
 Materials and methods
 Data were abstracted from the Surveillance, Epidemiology, and End Results (SEER) 2006's database for 58,709 women aged 25-95 years, diagnosed between 1988-1997 with non-metastatic T1-2 node-negative breast cancer, who underwent breast conserving surgery (BCS) and axillary dissection. We used Cox proportional hazards to examine the effect of tumor location (medial versus other) on overall mortality after accounting for other prognostic factors (covariates listed in footnote table 1) and interactions identified by the Akaike Information Criteria.
 Results
 There were no notable differences in patients' characteristics according to tumor location. Among them, 25,232 had BCS, 33,477 had mastectomy. However the distribution according to the use of adjuvant RT showed marked heterogeneity. RT was used in 88% of BCS and in 3% of mastectomy patients. In the multivariate analysis that adjusted against the imbalances, medial location was associated with an increased mortality, hazard ratio (HR) 1.08 (95% confidence interval 1.04-1.13). Mastectomy had no significant impact on survival, HR=0.99 (0.92-1.07). RT was associated with a significant mortality reduction, HR=0.81 (0.75-0.88). There was no interaction between tumor location and surgery, or between tumor location and RT, while the interaction between surgery and RT was significant, HR=1.31 (1.14-1.51). The corresponding factorial summary showed no subgroup effect of tumor location: RT after BCS was associated with the same mortality reduction of 19% regardless of tumor location, and RT after mastectomy was associated with the same relative increase of 7% regardless of tumor location (Table 1).
 Conclusion
 We confirm the poorer prognosis associated with tumor medial location. However there was no subgroup effect. The survival outcomes of local-regional treatments were not affected by tumor location, arguing that tumor location is not a sufficient indication to modify local-regional treatments in node-negative patients. Local-regional treatment should be based on tumor characteristics and not tumor location.
 


Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4134.

Tolerance of adjuvant letrozole outside of clinical trials

Recently aromatase inhibitors have become a standard care as an adjuvant treatment for many postmenopausal patients with hormone receptor positive early breast cancer. Adjuvant letrozole was made available either immediately postoperative, after 2-3 years of tamoxifen, or as an extended treatment after 5 years of tamoxifen. Between October 2003 and October 2005, we analyzed the subjective tolerance in 185 postoperative early breast cancer patients receiving letrozole outside of a clinical trial. The most prominent toxicity was musculoskeletal pain. In addition hot flushes, increased fatigue, nausea, vomiting, anorexia, mood disturbances, vaginal dryness, hair loss and rash were also recorded. In contrast to the prospective randomized clinical trials, a high drop-out rate of 20% was documented, mainly due to aromatase inhibitor-associated arthralgia syndrome interfering significantly with the daily life of our patients. Although adjuvant aromatase inhibitors have proven to be generally superior to tamoxifen in the adjuvant setting, it is important to focus attention on the tolerance during the adjuvant therapy and to balance this against the potential benefit in individual patients. Alternative options including switching to tamoxifen remain available.

Demonstration of tissue alterations by ultrasonography, magnetic resonance imaging and spectroscopy, and histology in breast cancer patients without lymphedema after axillary node dissection

Estimates of the incidence of arm swelling after axillary lymph node dissection for breast cancer range from 10 to 37%. Yet the subjective sensation of edema is described in at least 54% of patients. The purpose of this research was to examine the structural changes occurring in the subcutaneous tissue that might explain these subjective complaints using multiple imaging modalities. Two female cadavers with unilateral breast amputation and axillary dissection were studied. The dermal and subcutaneous layers of both arms were visualized with high frequency ultrasonography, and magnetic resonance imaging and spectroscopy (MRS), and tissue biopsies were taken for histological evaluation. On the operated side, ultrasound imaging showed a hyperechogenic subcutis and the fat-to-water relationship in adipose cells was higher as measured by MRS. Dissection of the arms revealed structural adipose tissue changes, which were confirmed by microscopic evaluation.

Granulomatous lobular mastitis: a rare chronic inflammatory disease of the breast which can mimic breast carcinoma

Granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. The differential diagnosis with malign breast disease is often not easy. In most cases a surgical biopsy is needed for correct diagnosis. Idiopathic granulomatous mastitis is an exclusion diagnosis, based on the demonstration of a characteristic histological pattern, combined with the exclusion of other possible causes of granulomatous breast lesions. There is still no generally accepted optimal treatment. If surgery forms part of the treatment, a conservative approach seems to be adequate in most cases. Another option is a long-term steroid treatment. It is mandatory to exclude infectious causes of granulomatous mastitis before corticoid therapy is started.

Drainage pattern of the upper medial quadrant of the breast in young healthy women after subdermal injection: a lymphscintigraphic study

This study examines the lymphatic drainage after injection of a radiotracer in the upper medial quadrant of the right breast in young healthy female subjects. Most studies concerning lymphatic drainage pathways have focused on the upper lateral quadrant of the breast because of the high incidence of carcinoma in this quadrant while the drainage pattern of the medial quadrant has been less studied. We injected radiotracer (Human Serum Albumin labeled with 99 technetium) subdermally into the upper medial quadrant of the right breast tissue of 33 young healthy female volunteers and obtained static images with a scintillation camera briefly after injection and approximately one hour after injection. We identified lymphatic pathways in 82.8% of our subjects, lymph nodes in 79.3% and in 3.4%, a sentinel lymph node was found in the internal mammary chain. In early images, lymph nodes were visualized in 65.5% of subjects while in 17.2% of subjects, lymphatic vessels only appeared on later images.

Use of a Port-a-Cath system in the home setting for the treatment of symptomatic recurrent malignant pleural effusion

Symptomatic malignant pleural effusions represent a common problem in metastatic cancers and are associated with a significant morbidity. Pleurodesis still remains the primary therapy of choice. In a few cases, however, pleurodesis is unsuccessful because of a limited lung expansion and pleuroperitoneal shunts have been used. We describe two cases where an implantable PORT-A-CATH system is used for regular drainage of the pleural effusion. The main advantage of this technique is the fact that the procedure of drainage can be performed by a nurse in the home setting.

Lymphedema development following breast cancer surgery with full axillary resection

Several studies have investigated the influence of disease related, treatment related, and patient related risk factors on the development of postmastectomy edema (PME). The aim of the present study was to determine which factors present a higher risk of developing PME after breast surgery with full axillary resection (level I, II and III). To accomplish this aim, we investigated 245 women who underwent unilateral breast cancer surgery in the Academic Hospital of the Vrije Universiteit, Brussels. Information concerning treatment and disease related factors were collected from the patient's medical records and factors related to clinical condition were obtained by a personal interview. Arm circumference was taken at 15 cm proximal and 10 cm distal to the olecranon. PME was defined as 2.5 cm difference between the arms. Height and weight of the patient were also measured. Statistical analysis was performed by calculating the Odds Ratio and the 95% Confidence Interval. We found the following factors posed an increased risk of developing PME: axillary/supraclavicular radiotherapy, pathological status of the lymph nodes, overweight (BMI > 25 kg/m2), trauma to the arm, menopause and surgery on the dominant side.

Lymphatic pathways of the upper medial quadrant of the breast in healthy women: radiotracer study of the sentinel lymph node

This study examined the lymphatic drainage after injection of a radiotracer into the upper medial quadrant of the breast in healthy women. Most studies of lymphatic pathways of the breast have been performed in patients with breast cancer and concentrate on the upper lateral quadrant of the breast because of the high incidence of carcinoma at this site. The lymphatic drainage pathways of the medial half of the breast, however, has been less studied. A radiotracer (Tc-99m human serum albumin nanocolloid or HSA) was injected intradermally into the upper medial quadrant of the right breast in 12 healthy women. Dermal markers were placed at the middle of the clavicle, the axilla and at the jugular incisura. Three minutes after injection a static image of the injection site was made with a scintillation camera (Multispect 2 Gamma Camera System) over 20 seconds. After nine minutes, local soft massage was instituted at the injection site for 6 minutes. Fifteen minutes after injection, a graphic scintigraphic image was made of both breasts and axillae over 22 minutes. After this interval, three or four static images were made for a few seconds to locate the sentinel lymph node as related to the injection site. A sentinel lymph node (lymphatic pathway) in the axilla was visualized in 11 subjects (91.9%) and was undetected in one subject (8.3%). The radiotracer migrated in all patients (100% ) towards the ipsilateral axilla. In 9 subjects, the sentinel lymph node was visualized 15 minutes after injection, whereas in 2 subjects it appeared within an hour.

Primary management of cutaneous melanoma: excision and sentinel node biopsy

During the last decade, the treatment of primary cutaneous melanoma has considerably changed. The aggressive behaviour of this disease stimulated surgeons to perform extensive resections and manage the regional nodes in a radical way. However, numerous studies indicate that a less aggressive treatment with lesser cosmetic and functional injury is associated with a similar outcome. There is no doubt that the quality of life will be significantly improved by using narrower excision margins and by further refinements of the sentinel node technique.

A key to understanding postoperative lymphoedema: a study on the evolution and consistency of oedema of the arm using ultrasound imaging

Post-mastectomy oedema is a very serious complication that, in the course of time, will transform into fibrotic tissue. The aim of our study is to evaluate when and in which layer liquid oedema transforms into fibrotic tissue. To do so, ultrasonographic images were taken of 22 patients and 9 control women at the shoulder and 10 cm proximal and distal from the olecranon, with the images then being scanned and imported into a computer program to determine echogenicity of the dermis, subcutis, subcutis on dermal side and subcutis on fascial side. Statistical analyses were performed by means of the Wilcoxon test and a Student's t-test. No significant differences (P< or =0.05) were found for the different parameters in the control group. In the experimental group: significant differences in perimeter, skinfold, thickness of dermis and subcutis were found. Although not significant, subcutaneous tissue was more echogenic on the oedematous side, with significant hyperechogenicity at the fascial subcutaneous layer. This indicates that fibrotic tissue develops distally in the forearm.

Bronchoscopic cryotherapy: preliminary experience

Our preliminary experience with the bronchoscopic application of cryotherapy using rapid decompression of liquid nitrous oxide as cooling agent is reported. Seventeen applications through rigid bronchoscopy in twelve patients were performed. A single cryotherapy session was successful in the debulking of obstructive malignant lesions of the central airways in five patients (four non-small cell carcinoma, one renal cell cancer metastasis), and in the treatment of a capillary haemangioma (one patient). Two sessions were successful in the treatment of a metastatic melanoma (one patient) and benign granulation tissue (one patient). Cryotherapy was also successful in the treatment of early bronchial cancer (carcinoma in situ) in four patients, requiring repetitive sessions in two. There were no complications or side-effects. These preliminary findings confirm the safety and efficacy of bronchoscopic cryotherapy in a variety of airway lesions.

Non-secreting atypical parathyroid adenoma

Parathyroid tumors can be divided in adenomas and carcinomas, usually detected by hypercalcemia. We report a case of parathyroid adenoma in a young man, who complained of a pressure in the left neck region. Physical examination revealed a firm mass in the neck, without lymphnodes. Although Ca (9.7 mg/dl), phosphorus (3.3 mg/dl) and intact-PTH (49 pg/ml) were normal, imaging techniques (computed tomography scan and sestamibi substraction scan) suggested that the mass could arise from the parathyroid gland. Histology and immune staining for chromogranin and parathyroid hormone confirmed the parathyroid nature of the mass. Histological criteria defined the lesion as an atypical parathyroid adenoma. We review the pathology, diagnosis and treatment of parathyroid adenomas in its non-secreting atypical form.

Incidence of invasive versus non-invasive carcinoma in comparing palpable and non-palpable solid breast lesions

A retrospective study was done of all patients with a suspicious mammographic breast lesion surgically biopsied in our institution within the last 5 years. Incidence of invasive versus non-invasive carcinoma and stage at presentation (according to TNM classification system) of palpable and non-palpable lesions were compared. We found a significant difference of non-invasive carcinoma in non-palpable and palpable cancers: 42.2% versus 4.3% (p < 0.001). Patients with a non-palpable invasive carcinoma presenting at stage I (i.e. pT1 with no axillary metastasis) rated significantly higher compared to those with palpable lesions 51.8% versus 9.4% (p < 0.001). The true positive biopsy rate is 30%. As low as 10% has been considered reasonable. We have a total of 56% carcinomas detected on all biopsies: 30% for non-palpable lesions and 66.8% for palpable lesions. A more aggressive approach towards screening and biopsy of breast lesions might increase early detection of carcinoma and so improve survival.

Cardiac surgery with extracorporeal circulation in 23 infants weighing 2500 g or less: short and intermediate term outcome

OBJECTIVE AND METHODS

From September 1990 to February 1997, 23 consecutive critically ill infants (12 males, 11 females) weighing 2500 g or less underwent cardiac surgery necessitating extracorporeal circulation (ECC). A retrospective study was carried out to evaluate short- and intermediate-term outcome. Mean weight at operation was 2265 g (range 1750-2500 g). Mean age at operation was 24 days. The indications for surgery were transposition of the great arteries (TGA; 7), ventricular septal defect (VSD; 4), aortic stenosis (AS; 3), univentricular heart (UVH; 2), tetralogy of Fallot (TOF; 2), interrupted aortic arch (IAA; 2), atrial septal defect (ASD; 1), atrioventicular septal defect (AVSD; 1) and total abnormal pulmonary venous return (TAPVR; 1). All patients were in NYHA class IV; 17 patients (74%) were intubated pre-operatively.

RESULTS

The mean aortic cross-clamping time was 40 min. Twelve patients required deep hypothermia (<20 degrees C) with total circulatory arrest (mean duration 19 min). All patients were successfully weaned from extracorporeal circulation (ECC). Five patients left the operating room with an open sternum (mean duration before closure: 3.5 days). Mean duration of artificial ventilation was 10.6 days; of inotropic support 6.7 days and of intensive care stay 17.8 days. Severe complications were observed in 19 patients (83%): cardiac failure requiring high inotropic support (13), sepsis (7), and acute renal insufficiency (5). One patient needed a ventricular assist device. Five patients (22%) died in the intensive care unit (ICU): 2 AS with fibroelastosis, 2 IAA with VSD. and 1 UVH with pulmonary atresia. At discharge from the ICU, 7 patients were receiving no treatment. Mean duration of follow-up was 32 months (range 2-80 months). We had 2 reoperations: 1 for right ventricular outflow tract obstruction 1 year after a switch operation and 1 for mitral valve replacement 1 year after total abnormal pulmonary venous return repair (death 30 days post mitral valve replacement). Survival at I year was 73%. At the last clinical examination 16 patients were in NYHA class I.

CONCLUSION

Despite the severity of pre-operative cardiac disease, early surgical repair with ECC in infants weighing 2500 g or less is feasible with tolerable mortality yet with significant early morbidity.

Can primary breast cancer patients sense the presence of lymph node metastasis? An unexpected research finding

We found that primary breast cancer patients with lymph node metastasis, compared to patients without apparent metastasis, had a greater expectation that their breast lump biopsy would be malignant. This difference in expectation between the two groups remained after controlling for a range of possible confounding variables.

What determines primary breast cancer patients' hope to recover

The main purpose was to offer evidence for the hypothesis that the stronger an acute real life stressor, namely, hearing from the physician that one has breast cancer and that one has to undergo mastectomy, the greater the induced noradrenaline (NA) depletion in the central nervous system (CNS) and the more the patient loses hope to recover. The data were derived from answers to interviews, questionnaires, and analyses of blood samples obtained from the patients on the day of admission to the hospital for a biopsy and 24 hours after the surgeon communicated the results of the biopsy to the patients. Analysis showed that a decline in 3-Methoxy 4-Hydroxy Methoxy 4-Hydroxy Phenylethylene Glycol (MHPG) concentration in blood plasma samples after being informed of the diagnosis is associated with less hope of recovery. MHPG is the main metabolite of CNS noradrenaline.

DNA synthesis, cell proliferation index in normal and abnormal gallbladder epithelium

The observation of mitotic figures in the epithelium of the normal gallbladder is exceptional because cell renewal is occurring at a very slow rate. It is only after using 3H-thymidine and autoradiography to observe the cells in DNA synthesis that evidence of a significant epithelial cell replication has been provided. Because numerous mitotic figures and increased 3H-thymidine uptake have been observed after intraluminal introduction of foreign bodies or after ligation of the common bile duct in animals, mechanical distension has been supposed to represent an important trigger factor of cell proliferation in this hollow organ. An increased epithelial cell renewal was also observed in human gallbladders of patients with a complete obstruction of the common bile duct causing the distension. However, the absence of correlation between the degree of gallbladder distension and the proliferative response was suggesting that factors other than distension could be involved. In studies on experimental lithiasis cell proliferation appeared to be enhanced in the gallbladder epithelium of mice fed on a cholesterol-cholic acid-rich lithogenic diet. The fact that the increase in proliferative activity was preceding the formation of gallstones was another indication that factors other than mechanical stimulation by stretching or by the stones may stimulate cell renewal in this organ. Factors in the bile of animals receiving a lithogenic diet could be involved which might cause cellular death and, hence, a regenerative reaction. Direct mitogenic effect of an unknown factor in the bile of these animals is an alternative possibility. On the other hand the stimulating effect of postprandial hormones on gallbladder cell renewal suggested by the observation of a DNA synthesis peak after feeding has been established. Synthetic cholecystokinin analogues have been shown to increase the proliferative activity and to induce epithelial hyperplasia in this organ. In one recent study using fundusectomy to increase the serum gastrin levels, a significant proliferative stimulation in the gallbladder was also observed. In human gallbladder mitotic activity in gallbladders with gallstones in much higher than in the controls. No correlation between stone number, weight or volume and the proliferative activity was put in evidence, whereas cell renewal appeared to be more influenced by the composition of the stones than by their physical presence. Epithelial DNA synthesis activity was, namely, much higher in gallbladders with cholesterol stones than in those with pigment stones. Whether increased cell turnover and, hence, cellular shedding into the lumen could represent a nucleating factor for cholesterol stones is an attractive working hypothesis. Considering the very high frequency of gallstones in man and also the frequent association of gallbladder cancer and lithiasis, further studies on mitotic activity in this organ are required. In conclusion, data from animal experiments and in vitro studies on human gallbladders indicate that gallbladder epithelial cell proliferation may be influenced by several mechanical, chemical and hormonal factors. The list of these factors is still incomplete while their possible role in gallbladder disease is a fascinating exploration field for future research.

Bilateral Wilms' tumor: in situ cooling of the kidney facilitates curative excision of tumors, with preservation of renal function

Bilateral synchronous multifocal Wilms' tumor is a rare malignancy for which no optimum treatment has been established thus far. The need to preserve renal parenchyma whenever possible is obvious. The authors describe a patient who underwent removal of six subcapsular tumors from a kidney that had been protected from ischemia by in situ cooling with UW-Belzer solution and by surface cooling. This technique was safe, easy to perform, and allowed all the time required to resect the tumors under adequate visual control and to wait for analysis of the frozen sections. It might be a useful alternative to the more complicated "bench" technique.

Comparison of perindopril and amlodipine in cyclosporine-treated renal allograft recipients

The objective of this study was to compare the antihypertensive efficacy and influence on renal function of perindopril and amlodipine in cyclosporine-treated renal allograft recipients with mild to moderate hypertension. We conducted a randomized, double-blind, double-dummy crossover trial in ambulatory patients. Four phases were conducted: 2 weeks on placebo, 8 weeks of maintenance (perindopril or amlodipine), and 2 weeks of washout between treatment periods. Ten hypertensive patients with stable renal allograft function transplanted more than 6 months previously and receiving cyclosporine as part of their immunosuppressive regimen were studied. The patients were allocated to perindopril (2 or 4 mg/d) and amlodipine (5 mg/d) in a random sequence. If office diastolic pressure was greater than or equal to 90 mm Hg after 4 weeks, the dosage was doubled and continued for another 4 weeks. The main outcome measures were office and 24-hour ambulatory blood pressure changes after 8 weeks of active treatment and treatment and time effect on glomerular filtration rate and effective renal plasma flow. Perindopril and amlodipine were equally effective in lowering office blood pressure and similarly efficacious for the 24-hour period of the day. Neither drug affected glomerular filtration rate or effective renal plasma flow. Both agents demonstrated equivalent capacity (time x treatment, P = .955) to reverse renal vascular resistance (amlodipine from 0.35 +/- 0.02 to 0.30 +/- 0.02 mm Hg/mL per minute per 1.73 m2; perindopril from 0.36 +/- 0.03 to 0.32 +/- 0.01) (time effect of all treatments together, P = .043).(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of axillary lymph node metastasis in breast cancer

The pattern of axillary lymph node involvement was analyzed in a review of 377 cases of T1-4 breast cancers. Clinical judgment of the axillary status proved to be wrong in approximately one-third of the cases. In univariate analysis, a strong correlation (P < .01) between the number of involved nodes, tumor size, and blood vessel invasion was found. Other features of the primary tumor (lymphatic invasion, degree of differentiation, presence of necrotic areas) were related to a lesser degree (P < .05). While others (age, site) were not at all significant. However, the number of nodes resected proved to be the most important determinant of all (P = .003). Also, the simple distinction between node-negative and node-positive cases is strongly dependent on the extent of axillary dissection (P = .009). In multivariate analysis, only the number of resected nodes and T stage showed a good relationship with the number of positive nodes. Skip metastases above levels 1 and 2 were seen in only 2% of the cases. A clear influence of the number of invaded nodes on survival could be demonstrated. These findings are discussed, especially as concerns the technique, prognostic significance, and therapeutic usefulness of axillary dissection.

Benign cystic teratoma: an uncommon cause of anterior mediastinal mass

Teratomas of the mediastinum are rare, accounting for 8% to 13% of the tumours in this region. They primarily occur in the anterior mediastinum of young adults. Surgery should be performed whenever complications, such as atelectasis of lung tissue, adhesion to or compression of adjacent structures, or malignant transformation, are likely to be present. Results after surgical resection are excellent.

Stimulating effect of pentagastrin on cancer cell proliferation kinetics in chemically induced colon cancer in rats

Pharmacological doses of pentagastrin or gastrin are known to stimulate cell proliferation in normal colonic epithelium but the growth-promoting effect of gastrin on colon carcinoma is still controversial. In this study morphological parameters were measured to study the effect of pentagastrin (240 micrograms/kg) on the cell proliferation kinetics in experimental tumours. Colon cancer was produced in rats by weekly injections (20 mg/kg b.wt.) of 1.2-dimethylhydrazine for 24 weeks. Tritiated thymidine was given after administration of pentagastrin or the control solution to the animals. 75% of the animals from the pentagastrin group and 66% of the controls had at least one colon cancer. Autoradiographs of the colonic tumors were performed and the percentage of labeled cells in the cancer cell population was determined after counting 4000 to 16,000 cancer cells per tumor. The labeling index for cancer cells in the pentagastrin-treated group (21.49 +/- 1.76%) was higher (P less than 0.01) than in the control group (14.76 +/- 0.66%). In a second study vincristine sulphate (1 mg/kg) was given to the animals 20 h after administering pentagastrin or the control solution. The percentage of arrested metaphases in the tumours was determined after counting 10,000 to 24,000 cancer cells per histological section. Pentagastrin increased (P less than 0.01) the mean metaphase index by 108% (4.9 +/- 0.44% vs 2.35 +/- 0.32%). These data indicate that cell cycle manipulation of colon cancer is possible with hormonal peptides.

[Breast-sparing surgery in T1 breast carcinoma]

31 female patients with a T1 No N1a Mo breast tumour (diameter smaller or equal to 2 cm) were treated by segmental resection with complete axillar dissection, followed by radiotherapy. Chemotherapy was given in any case of axillary lymph node involvement. The mean follow-up period was 44 months. Absolute survival is 100%. One patient (3%) developed distant metastasis, 2 patients (6%) had a loco-regional recurrence and 3 presented with a metachronous tumour in the contralateral breast. 97% of the patients are actually alive and free of disease.

Repair of pericardial rupture by abdominal transphrenic approach solely

The abdominal transphrenic approach enabled us to repair a left lateral pericardial rupture on a polytrauma patient who also had a rupture of the spleen and a retroperitoneal hemorrhage. A pericardial exploration was necessary because of a sudden upper venous congestion syndrome during operation, suggestive of a cardiac tamponade.

[Free perforation of the colon in Crohn's disease]

Free intestinal colonic perforation in Crohn's disease. Free intestinal colonic perforation in Crohn's disease is a serious complication. In reference to the case history of a Crohn patient with sigmoid perforation, a literature survey of free colonic perforations has been given. Only 18 cases of free colonic perforations in Crohn's disease have so far been described in world literature. Pathogenesis, treatment and evolution of this affection have been dealt with.