Pseudomyxoma pleurii and peritonei secondary to sigmoid colon adenocarcinoma: a rare clinico-pathologico-radiological presentation

Pseudomyxoma peritonei (PMP) is a rare condition resulting from mucin-producing tumors that have disseminated into intraperitoneal implants and mucinous ascites. The extra-abdominal spread of PMP is exceptionally rare, with few reported cases in the medical literature. Pseudomyxoma pleurii is an infrequently encountered clinical syndrome characterized by transdiaphragmatic pleural extension and spread of PMP. The disease is highly fatal. We hereby report a case of 58 years old woman who presented with an abdominal distension and shortness of breath of 2 months duration. Histopathology confirmed the diagnosis of large mucin-producing rectosigmoid adenomatous polypoid lesion with malignant transformation and PMP that had spread to the right pleural space. PMP from colon tumor is uncommon and its transdiaphragmatic pleural extension is very unusual complicated by management challenge and high mortality rate.

Breast Camps for Awareness and Early Diagnosis of Breast Cancer in Countries With Limited Resources: A Multidisciplinary Model From Kenya

BACKGROUND

Breast cancer is the most common cancer of women in Kenya. There are no national breast cancer early diagnosis programs in Kenya.

OBJECTIVE

The objective was to conduct a pilot breast cancer awareness and diagnosis program at three different types of facilities in Kenya.

METHODS

This program was conducted at a not-for-profit private hospital, a faith-based public hospital, and a government public referral hospital. Women aged 15 years and older were invited. Demographic, risk factor, knowledge, attitudes, and screening practice data were collected. Breast health information was delivered, and clinical breast examinations (CBEs) were performed. When appropriate, ultrasound imaging, fine-needle aspirate (FNA) diagnoses, core biopsies, and onward referrals were provided.

RESULTS

A total of 1,094 women were enrolled in the three breast camps. Of those, 56% knew the symptoms and signs of breast cancer, 44% knew how breast cancer was diagnosed, 37% performed regular breast self-exams, and 7% had a mammogram or breast ultrasound in the past year. Of the 1,094 women enrolled, 246 (23%) had previously noticed a lump in their breast. A total of 157 participants (14%) had abnormal CBEs, of whom 111 had ultrasound exams, 65 had FNAs, and 18 had core biopsies. A total of 14 invasive breast cancers and 1 malignant phyllodes tumor were diagnosed

CONCLUSION

Conducting a multidisciplinary breast camp awareness and early diagnosis program is feasible in different types of health facilities within a low- and middle-income country setting. This can be a model for breast cancer awareness and point-of-care diagnosis in countries with limited resources like Kenya.

IMPLICATIONS FOR PRACTICE

This work describes a novel breast cancer awareness and early diagnosis demonstration program in a low- and middle-income country within a limited resource setting. The program includes breast self-awareness and breast cancer education, clinical exams, and point-of-care diagnostics for women in three different types of health facilities in Kenya. This pilot program has the potential of being replicated on a national scale to create awareness about breast cancer and downstage its presentation.

Breast cancer diagnosis in a resource poor environment through a collaborative multidisciplinary approach: the Kenyan experience

INTRODUCTION

The majority of women with breast cancer in Kenya present with node-positive (stage II) or locally advanced Q7 disease (stage IIIB). Diagnosis is made on fine needle aspirate cytology and treatment is with surgery if resectable. Diagnostic core biopsy is available only at subspecialty hospitals. Processing and reporting of biopsy tissue are not standardised. Hormone receptor and HER2 analyses are rarely done preoperatively.

METHODS

As part of a larger study investigating the prevalence of triple negative breast cancer in Kenya, a multidisciplinary workshop of collaborators from 10 healthcare facilities was held. Process gaps were identified, preanalytic variables impacting on ER/PR/HER2 discussed and training in core biopsy provided. Local remedial strategies were deliberated.

CONCLUSION

We describe our experience and outcome from the workshop, which can be modelled for other resource poor settings.

Optimizing breast cancer diagnosis in Kenya: Importance of standardization of technical methodologies for comparative breast cancer data

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Background: An analysis of 322 cases referred to Aga Khan University, Nairobi, revealed 56% estrogen receptor (ER) positive tumors and 35% prevalence of triple-negative breast cancer (TNBC). Findings were retrospective and limited by inability to control pre-analytical variables that could potentially impact results. Methods: As part of an ongoing prospective study assessing prevalence of TNBC in the three major ethnic groups in Kenya, we gathered a multidisciplinary team from 10 collaborating health facilities around Kenya for an educational workshop. The objectives were to assess baseline capabilities and pre-analytic variables at each center, identify gaps and provide hands-on training in order to ensure accuracy and validity of ER/PR/HER2 prevalence data gathered as part of the study. Results: See table. Breast cancer biopsies ranged from one to 20 per month per center. Diagnosis was predominantly by FNA and ER/PR/HER2 was not routinely performed. Buffered formalin fixative and standardized CAP reporting format was employed only at one center. A survey 3 months following the workshop demonstrated increase in diagnostic core biopsiesby 90%, and uniform use of buffered formalin fixative, and adoption of synoptic reporting. 66 prospective cases of breast cancer from the 10 institutions with patients from different ethnic backgrounds have been subsequently collected and IHC data will be presented. Conclusions: Much has been made of the difference in prevalence of TNBC in Africa as compared to North America, yet little attention has been paid to differences in diagnostic methodologies and basic tissue handling techniques that can potentially alter results. Despite limitations of resources, educational workshops make it possible to improve the practice of breast cancer diagnosis, and thereby enable accurate comparative analysis between breast cancers in the developing and the developed world. [Table: see text]

Lymphomas in sub-Saharan Africa--what can we learn and how can we help in improving diagnosis, managing patients and fostering translational research?

Approximately 30 000 cases of non-Hodgkin lymphoma (NHL) occur in the equatorial belt of Africa each year. Apart from the fact that Burkitt lymphoma (BL) is very common among children and adolescents in Africa and that an epidemic of human immunodeficiency virus (HIV) infection is currently ongoing in this part of the world, very little is known about lymphomas in Africa. This review provides information regarding the current infrastructure for diagnostics in sub-Saharan Africa. The results on the diagnostic accuracy and on the distribution of different lymphoma subsets in sub-Saharan Africa were based on a review undertaken by a team of lymphoma experts on 159 fine needle aspirate samples and 467 histological samples during their visit to selected sub-Saharan African centres is presented. Among children (<18 years of age), BL accounted for 82% of all NHL, and among adults, diffuse large B-cell lymphoma accounted for 55% of all NHLs. Among adults, various lymphomas other than BL, including T-cell lymphomas, were encountered. The review also discusses the current strategies of the International Network of Cancer Treatment and Research on improving the diagnostic standards and management of lymphoma patients and in acquiring reliable clinical and pathology data in sub-Saharan Africa for fostering high-quality translational research.

Alteration of microRNAs regulated by c-Myc in Burkitt lymphoma

Background

Burkitt lymphoma (BL) is an aggressive B-cell lymphoma, with a characteristic clinical presentation, morphology and immunophenotype. Over the past years, the typical translocation t(8;14) and its variants have been considered the molecular hallmark of this tumor. However, BL cases with no detectable MYC rearrangement have been identified. Intriguingly, these cases express MYC at levels comparable with cases carrying the translocation. In normal cells c-Myc expression is tightly regulated through a complex feedback loop mechanism. In cancer, MYC is often dysregulated, commonly due to genomic abnormalities. It has recently emerged that this phenomenon may rely on an alteration of post-transcriptional regulation mediated by microRNAs (miRNAs), whose functional alterations are associated with neoplastic transformation. It is also emerging that c-Myc modulates miRNA expression, revealing an intriguing crosstalk between c-Myc and miRNAs.

Principal Findings

Here, we investigated the expression of miRNAs possibly regulated by c-Myc in BL cases positive or negative for the translocation. A common trend of miRNA expression, with the exception of hsa-miR-9*, was observed in all of the cases. Intriguingly, down-regulation of this miRNA seems to specifically identify a particular subset of BL cases, lacking MYC translocation. Here, we provided evidence that hsa-miR-9-1 gene is heavily methylated in those cases. Finally, we showed that hsa-miR-9* is able to modulate E2F1 and c-Myc expression.

Conclusions

Particularly, this study identifies hsa-miR-9* as potentially relevant for malignant transformation in BL cases with no detectable MYC translocation. Deregulation of hsa-miR-9* may therefore be useful as a diagnostic tool, suggesting it as a promising novel candidate for tumor cell marker.

Athletic stress fractures: part II. The lower body. Part III. The upper body--with a section on the female athlete

Part I of this article (published in the November issue) focused on the history, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment of stress fractures. Part II reviews the specifics of stress fractures involving the lower body, the upper body, and includes a special section on the female athlete.

Athletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment

This 3-part article is a comprehensive review of the literature on athletically induced (fatigue) stress fractures. As typical signs and symptoms of stress fracture may differ slightly depending on the bone involved, physicians examining a fracture need to be aware of these subtle differences. Stress fractures are the result of excessive loading of bone. (Excessive loading is caused by muscle pull, fatigue loading, or both and may be exacerbated by anatomic risk factors, age, and sex. Loading leads to a metabolic response by osteoclasts and osteoblasts. This response, which normally helps bone heal, instead causes the stress fracture.) Stress fractures resolve with 6 to 8 weeks of rest and rehabilitation. Part 1 of this article focuses on the history, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment of stress fractures. Part 2 reviews the specifics of stress fractures involving the lower body--the lower extremities, pelvic girdle, and feet and ankles. Part 3 reviews the specifics of stress fractures involving the upper body-shoulder girdle and thoracic region, upper extremities, hands and wrists, and pars interarticularis--and includes a special section on the female athlete. (Parts 2 and 3 will appear in the next issue.)

Simvastatin-associated memory loss

The statins are widely used to treat dyslipidemias. They are generally associated with mild adverse effects, but rarely, more serious reactions may occur. A 51-year-old man experienced delayed-onset, progressive memory loss while receiving simvastatin for hypercholesterolemia. His therapy was switched to pravastatin, and memory loss resolved gradually over the next month, with no recurrence of the adverse effect.

Acute patellar tendon rupture: A new surgical technique

The most common method used in the treatment of acute patellar tendon ruptures is primary end-to-end repair. The use of the Acufex ACL guide (Acufex Microsurgical, Mansfield, MA) provides efficient and accurate placement of transosseous drill holes in the patella and minimizes the risk, tourniquet time, and surgical time of acute patellar tendon repairs.

Delayed-onset ticlopidine-induced cholestatic jaundice

An 86-year-old man experienced a rash approximately 2 weeks after starting ticlopidine therapy, necessitating discontinuation of the drug. About 1 month later, despite discontinuation, he developed jaundice and liver test abnormalities. These resolved gradually over the next few months. Based on case reports and the drug's pharmacokinetic profile, a high index of suspicion for ticlopidine-induced jaundice is prudent in patients with recent exposure to the agent who have evidence of liver damage.

Possible ciprofloxacin-induced acute cholestatic jaundice

OBJECTIVE

To report a case of acute cholestatic jaundice in a patient who was receiving oral ciprofloxacin.

CASE SUMMARY

An 84-year-old woman residing in a long-term care facility developed acute cholestatic jaundice while being treated with ciprofloxacin for a urinary tract infection. On day 6 of ciprofloxacin therapy, she was noted to have an erythematous, pruritic rash over her chest and abdomen. At this point ciprofloxacin treatment was discontinued, as an allergy was suspected. Three days later she was noted to have jaundiced sclera and skin, and liver function test results were markedly elevated. The plasma cholesterol concentration was increased substantially; there was no decrease in plasma albumin concentration or increase in prothrombin time. The patient was treated with intravenous fluids. Within the next month, the liver function test results decreased to near normal and the patient was asymptomatic. Follow-up liver test results three months later were normal.

DISCUSSION

To our knowledge, there are only a few other case reports in the literature of a possible ciprofloxacin-induced liver injury. Enoxacin, a fluorinated quinolone antibiotic similar to ciprofloxacin, was reported to cause cholestatic liver injury in one patient. The exact mechanism by which fluoroquinolones may cause liver injury is unknown.

CONCLUSIONS

We believe that this is only the second reported case of acute cholestatic jaundice resulting from ciprofloxacin therapy. Although this reaction seems to occur rarely, it is prudent to be alert for the signs and symptoms of cholestasis when administering ciprofloxacin.

Ankle reconstruction for malunion by fibular osteotomy and lengthening with direct control of the distal fragment: a report of three cases and review of the literature

Malunion of ankle fractures will lead to severe osteoarthritis when the architecture and mechanics of the talocrural joint are deranged. When fibular shortening is present, ankle reconstruction can be achieved by fibular lengthening and can provide an alternative to early arthrodesis for deformity and pain. Acceptable clinical and radiographic results can be achieved, provided that accurate reconstruction is achieved and intra-articular osteochondral injury is minimal. Restoration of fibular length, necessary for a good clinical result, can be estimated radiographically by the bimalleolar angle. We report three cases of ankle reconstruction by fibular lengthening with an average follow-up of 33 months.

Rotator cuff lesions: signal patterns at MR imaging

The signal intensity patterns of rotator cuff lesions at magnetic resonance (MR) imaging were evaluated in 80 patients who had surgical correlation and in 13 asymptomatic individuals (14 shoulders). Six cadaver shoulders were examined with MR, and histologic correlation was obtained in four. All studies were performed at 1.5 T with a flexible circular surface coil. The accuracy of MR imaging in detection of full-thickness cuff tears (31 patients) was 0.95 and of partial thickness tears (16 patients), 0.84. The most common and accurate pattern for full-thickness cuff tears (22 of 31 tears) was a region of intense signal seen on T2-weighted images. Less often the torn region consisted of an extremely degenerated and attenuated tendon with moderate signal intensity or was obscured by low-signal-intensity scar. The intense signal pattern on T2-weighted images was also accurate, although a less common finding (seven of 16 cases), in the diagnosis of partial tears. Tendinitis was recognized as focal or diffuse regions of increased signal intensity or a nonhomogeneous pattern of increased signal often associated with tendinous enlargement. In some patients, manifestations of subacromial-subdeltoid bursitis was present. Tendon degeneration was also manifested as regions of increased signal intensity. Some similarity and overlap of signal patterns of partial interstitial tears, tendinitis, and tendon degeneration are observed.

Computed tomography (CT) arthrography of shoulder instabilities in athletes

Sixty professional and recreational athletes underwent CT arthrography of the shoulder for evaluation of suspected shoulder joint derangement. These athletes, 46 males and 14 females ranging in age from 15 to 60 years (mean, 32 years), all had persistent pain that interfered with their sports activity and was resistant to conservative treatment. Seventeen patients had shoulder instability based on clinical manifestations and CT arthrographic findings. An additional five patients, also based on clinical manifestations and CT arthrographic findings, were considered to have an unobtrusive degree of anterior joint laxity. Patients with anterior instability (20 cases) all had an anteroinferior tear or detachment of the glenoid labrum, as well as some violation of the insertion of the joint capsule onto the scapula. Those with posterior instability (two cases) had a combination of labral and capsular tears. Two other major patterns of labral tears, both unaffiliated with shoulder instability, were identified. These included total or partial detachment of superior segments of the labrum, and anterior labral tears at the midglenoid level. Moreover, various degrees of labral attenuation (or, less often, enlargement), osteophyte formation, and alterations in articular cartilage were observed. Surgical correlation was obtained in 25 patients, with 95% accuracy of CT arthrographic findings. CT arthrography is a minimally invasive and highly accurate technique for investigation of glenohumeral derangement. Specifically, the extent of pathologic changes associated with instability can be determined and differentiated from other intraarticular causes of incapacity, such as labral tears caused by throwing, or degenerative changes.

Posterior fracture dislocation of the shoulder with biceps tendon interposition

Posterior dislocation of the shoulder, a rare injury, results from direct trauma, indirect trauma, or via a seizure or electrical shock. We present a case with a posterior fracture dislocation of the shoulder secondary to a seizure in which interposition of the biceps tendon precluded closed reduction. The fractured lesser tuberosity fragment included the bicipital groove, allowing the biceps tendon to sublux posteriorly preventing closed reduction, thus requiring a subsequent open reduction.

Peroneal nerve compression secondary to posterior osteophyte

A 45-year-old man was treated for peroneal nerve compression secondary to an osteophyte in the posterior compartment of the knee. Surgical excision led to complete resolution of symptoms.