Retroperitoneal sarcomas: from diagnosis to treatment. Case series and review of the literature

BACKGROUND

Retroperitoneal sarcoma is a rare malignancy arising from mesenchymal cells, most commonly presented as an abdominal mass and is associated with poor prognosis. The most effective treatment modality for retroperitoneal sarcomas is complete surgical resection, including sometimes adjacent organs infiltrated by the tumor. Radiotherapy is frequently applied and has shown some benefit, while the role of chemotherapy and molecular-targeted agents is still not clear. Local recurrence is common for retroperitoneal sarcomas and still remains the main cause of death. The major factors associated with the overall survival are tumor grade, histological subtype, complete macroscopic excision and multifocality.

AIM

To report our experience via the presentation of patients with retroperitoneal sarcomas managed in our department during the period 2014-18; and to review the current literature.

PATIENTS AND METHODS

Eight patients appeared with chronic non-specific complaints including abdominal distension and changes in bowel or bladder habit, while one patient presented with acute abdominal pain due to mass rupture. All of the patients underwent surgical resection of the tumor.

RESULTS

Among the patients, seven were operated for primary disease and one only for recurrent. The most common histologic type was liposarcoma (well-differentiated, dedifferentiated), found in five patients; followed by leiomyosarcoma found in two cases. Fibrous histiocytoma was found in only one case. The masses were removed with macroscopically clear margins (R0 and R1 resections) in four cases. In five patient cases adjuvant therapy was required. Three patients are still alive and free of disease.

CONCLUSIONS

Retroperitoneal sarcomas present to be a therapeutic challenge based on their location, their extent at the time of diagnosis and the high risk of local recurrence or distant metastasis. Their management requires a multidisciplinary approach, with the surgical resection remaining the mainstay of curative treatment, combined with surveillance for early detection of recurrence or metastases.

Discarding IVF embryos: reporting on global practices

PURPOSE

To provide a global scale report on a representative sample of the clinical embryology community depicting the practice of discarding supernumerary IVF embryos.

METHODS

A web-based questionnaire titled "Anonymous questionnaire on embryo disposal practices" was designed in order to ensure anonymous participation of practicing clinical embryologists around the world.

RESULTS

During a data collection period of 8 months, 703 filled-in questionnaires from 65 countries were acquired. According to the data acquired, the majority of practitioners, dispose of embryos by placing them directly in a trash can strictly dedicated for embryo disposal for both fresh and frozen cycles (39% and 36.7% respectively). Moreover, 66.4% of practitioners discard the embryos separately-case by case-at different time points during the day. Over half of embryologists (54%) wait until day 6 to discard the surplus embryos, while 65.5% do not implement a specially allocated incubator space as a designated waiting area prior to disposal. The majority of 63.1% reported that this is a witnessed procedure. The vast majority of embryologists (93%) do not employ different protocols for different groups of patients. Nonetheless, 17.8% reported the request to perform a ceremony for these embryos. Assessing the embryologists' perspective, 59.5% of participants stated that the embryology practice would benefit from a universally accepted and practiced protocol.

CONCLUSION(S)

This study uniquely provides insight into global embryo disposal practices and trends. Results highlight the divergence between reported practices, while indicating the significance on standardization of practice, with embryologists acknowledging the need for a universally accepted protocol implementation.

Targeting histone deacetylases in endometrial cancer: a paradigm-shifting therapeutic strategy?

OBJECTIVE

Endometrial cancer is increasingly prevalent in western societies and affects mainly postmenopausal women; notably incidence rates have been rising by 1.9% per year on average since 2005. Although the early-stage endometrial cancer can be effectively managed with surgery, more advanced stages of the disease require multimodality treatment with varying results. In recent years, endometrial cancer has been extensively studied at the molecular level in an attempt to develop effective therapies. Recently, a family of compounds that alter epigenetic expression, namely histone deacetylase inhibitors, have shown promise as possible therapeutic agents in endometrial cancer. The present review aims to discuss the therapeutic potential of these agents.

MATERIALS AND METHODS

This literature review was performed using the MEDLINE database; the search terms histone, deacetylase, inhibitors, endometrial, targeted therapies for endometrial cancer were employed to identify relevant studies. We only reviewed English language publications and also considered studies that were not entirely focused on endometrial cancer. Ultimately, sixty-four articles published until January 2018 were incorporated into our review.

RESULTS

Studies in cell cultures have demonstrated that histone deacetylase inhibitors exert their antineoplastic activity by promoting expression of p21WAF1 and p27KIP1, cyclin-dependent kinase inhibitors, that have important roles in cell cycle regulation; importantly, the transcription of specific genes (e.g., E-cadherin, PTEN) that are commonly silenced in endometrial cancer is also enhanced. In addition to these abstracts effects, novel compounds with histone deacetylase inhibitor activity (e.g., scriptaid, trichostatin, entinostat) have also demonstrated significant antineoplastic activity both in vitro and in vivo, by liming tumor growth, inducing apoptosis, inhibiting angiogenesis and potentiating the effects of chemotherapy.

CONCLUSIONS

The applications of histone deacetylase inhibitors in endometrial cancer appear promising; nonetheless, additional trials are necessary to establish the therapeutic role, clinical utility, and safety of these promising compounds.

Intensive care unit outcomes following orthotopic liver transplantation: single-center experience and review of the literature

BACKGROUND/AIM

Orthotopic Liver Transplantation (OLT) is the treatment of choice for patients with end stage liver disease, acute liver failure, hepatocellular carcinoma and metabolic disorders. As a result of improvement in surgical and anesthesiological skills, advanced understanding of transplant immunology and better critical care management of complications, patients survive longer after liver transplantation. It has been gradually achieved one-year survival rates of 80-90%. During the early post-operative period, all patients undergoing OLT are admitted to the intensive care unit, as they need a management of both preexisting patient's conditions and post-operative complications, usually due to either adverse intra-operative or post-operative events. The purpose of this review is the detailed recording, understanding and interpretation of immediate post-operative complications occurred in patients undergoing OLT, in intensive care unit. This could help to improve patient's treatment and reduce the incidence of complications, with further reduction of morbidity-mortality and cost. We also present our experience from the first 32 OLT patients from Liver Transplantation Unit of Laiko General Hospital, the only Liver Transplantation Unit in Athens.

MATERIALS AND METHODS

This literature review was performed using the MEDLINE database. The key words were; Orthotopic liver transplantation; intensive care unit; post-operative complications; outcomes. One hundred-sixteen articles published in English until 2018 were used. We also use all the results from our 32 patients from our Liver Transplantation Unit during the period 07/2006 to 07/2009.

RESULTS

All patients undergoing OLT admitted to the intensive care unit for a period of time, depending on the occurrence of post-operative complications. The incidence of primary failure ranges between 2-14%, whereas post-operative bleeding ranges between 7-15%. The treatment is usually conservative, although surgical repair may need in 10-15%. Acute renal failure post-operative is not an infrequent problem too, and has been reported to occur in 9% to 78% of cases. Acute rejection normally occurs 7-14 days after OLT. Additionally, the delay of the weaning from mechanical ventilation in the immediate post-operative period could increase the complications. Infectious complications are quite common almost from the first post-operative day in intensive care unit.

CONCLUSIONS

Prolonged intensive care stay could increase the complications post-operative Infectious complications, renal and respiratory impairment are among the most common causes of early post-transplant morbidity and mortality.

Incidence of inactive allele CYP2D6*4 among Greek women suffering from hormone-sensitive breast cancer

BACKGROUND

The incidence of CYP2D6*4 among Caucasians is estimated up to 27%, while it is present in up to 90% of all poor metabolizers within the Caucasian population. The hypothesis under question is whether the presence of one or two non-functioning (null) alleles predicts an inferior outcome in postmenopausal women with breast cancer receiving adjuvant treatment with tamoxifen. The aim of the present study is to estimate the incidence of CYP2D6*4, in the Greek population and more precisely among females suffering from breast cancer.

MATERIALS AND METHODS

Eighty unrelated mainland Greek female volunteers suffering from hormone-sensitive breast cancer were recruited during their primary handling or follow-up examination in order to provide samples for purification and polymerase chain reaction/restriction fragment length polymorphism (PCR-RFLP) of genomic DNA derived from buccal swabs.

RESULTS

The incidence of individuals with at least one present allele*4 within the Hellenic population was estimated to be as high as 30% (n = 24/80), with a 95% confidence interval of 20% to 40%. From the statistical point of view, it can be securely stated that incidence of *4 among Greek women is over 20%. The incidence of homozygous carriers of *4 in the present sample occurred in 8.75%, while the incidence of allele*4 haplo-type occurred in 19.4% (n=160).

CONCLUSION

Although the outcoming results for Greek women are actually in line with existing data for other European nations, it should be noted, that a routine CYP2D6 testing of women suffering from breast cancer is formally not recommended, as the clinical significance of CYP2D6 phenotype in treatment and outcome of breast cancer remains unclear.

Colonic casts: unexpected complications of colonic ischaemia

Introduction Extensive colonic ischaemia can result in passage of a colonic 'cast' (CC) through the rectum. Case Study We report a 69-year-old male who initially underwent surgery to remove a sessile polyp. On postoperative day (POD)15, he was febrile, suffering from diarrhoea, and was treated conservatively. On POD18, the patient returned to our hospital with a CC that presented after defaecation. Computed tomography of the abdomen revealed a CC extending from the descending colon to the anal orifice with presentation of air between the affected colonic wall and the CC. The patient was treated conservatively and discharged on POD20 without complications having passed the CC (≈80cm) completely and becoming afebrile. Conclusions In most cases, the cause of CC passage is surgery for colorectal cancer or repair of an abdominal aortic aneurysm. A mild-to-severe presentation is dependent upon the bowel-wall layers affected by ischaemia and which therefore are included in the CC.

Nonfunctioning symptomatic paraganglioma: Is there an optimal follow-up for patients with extra-adrenal benign paragangliomas

Paragangliomas are rare neuroendocrine neoplasms originating from the embryological neural crest. In most cases, they exhibit a benign behavior. Here we report a case of a small symptomatic para-aortic paraganglioma, which was completely removed surgically and a review of the available literature regarding the optimal follow-up of a benign paraganglioma, since no guidelines are currently available for this rare entity.

How can we treat a patient with liver cirrhosis (hepatitis C virus), hepatocellular carcinoma, and synchronous colon cancer?

INTRODUCTION

The coexistence of liver cirrhosis with hepatocellular carcinoma (HCC) and colon cancer (Ca), which is a rare clinical condition, was treated in a liver transplant recipient.

PATIENTS AND METHODS

A 46-year-old man, diagnosed incidentally during an ultrasound (US) examination with a 3.5-cm HCC in segment VII related to chronic hepatitis C virus (HCV), was referred for liver resection. He underwent a laparoscopic protocol evaluation for liver cirrhosis. Liver appearance and biopsy of the left lobe showed Child B/C liver cirrhosis. Because he fulfilled the Milan criteria, we suggested an orthotopic liver transplantation (OLT). During protocol colonoscopy, we discovered an ulcerative sigmoid colon Ca. Three weeks after completing the pre-OLT assessment he underwent an OLT and was discharged home on day 9 on an immunosuppressive regimen of Everolimus, Myfortic, and Prezolone. Two months after transplantation, the patient underwent a sigmoidectomy and for nearly 1 month thereafter received chemotherapy for colon Ca (6 cycles of FOLFOX:Folinic Acid+Fluorouracil+Oxaliplatin). One and a half years after OLT, patient was in good condition but presented with an increased alpha fetoprotein (a-FP) without other findings. A couple of months later we discovered a colon Ca recurrence and 3 small liver metastases. Patient underwent a bowel resection with Hartmann's procedure. Almost immediately after the last operation, he was found to suffer multiple myeloma. He underwent chemotherapy for both malignancies with good responses, but a few months later died of severe sepsis.

DISCUSSION

The relevant literature regarding treatment of liver cirrhosis complicated with HCC and synchronous colon Ca reveals poor and controversial outcomes. Our patient underwent chemotherapy immediately after colon resection in the presence of with a good functioning liver. Although his condition was satisfactory after OLT, the optimal treatment of such complicated patients is as yet uncertain.

Primary malignant fibrous histiocytoma of the spleen--an extremely rare entity

Malignant fibrous histiocytoma (MFH) is a frequently occurring soft tissue tumour with aggressive biological behaviour. Primary MFH of the spleen, however, is an exceedingly rare occurrence. Herein, we report a case of such a neoplasm in a 66-year-old female. The tumour was well localised within the spleen and the patient remains alive and well 34 months after splenectomy without any adjuvant therapy. A brief discussion and review of the few cases of primary splenic MFH previously reported in the English language literature is included.

Evaluation of Sperm Chromatin Quality and Screening of Y Chromosome Microdeletions in Greek Males with Severe Oligozoospermia

Normal (n = 20) and abnormal (n = 21) semen samples were explored for possible relationships between conventional semen parameters, chromatin status, and microdeletions in the Y chromosome. DNA fragmentation was detected by the terminal deoxynucleotidyl trasferase-mediated dUTP-nick end labelling (TUNEL) assay, chromatin condensation, and DNA packaging quality were assessed by chromomycin A3 (CMA(3)) staining. All men were investigated for Y chromosome microdeletions using polymerase chain reaction (PCR). No deletions were detected in 21 severely oligozoospermic men for the three screened regions (AZFa, AZFb, and AZFc). Men with normal semen parameters showed better chromatin condensation. Spermatozoa with low motility were more likely to contain loosely packaged chromatin. In the abnormal semen group, DNA fragmentation (TUNEL) correlated significantly with sperm motility, concentration, and chromatin packaging assessed by chromomycin A3. However sperm morphology did not correlate significantly with TUNEL and CMA(3) staining.

Impact of Breast Cancer Surgery on the Self-Esteem and Sexual Life of Female Patients

Patient satisfaction with cosmetic outcome and the psychological impact of breast cancer surgery were evaluated. A total of 207 patients with primary breast cancer, treated with either breast-conserving surgery ( n = 83), modified radical mastectomy without reconstruction ( n = 108), or mastectomy with delayed breast reconstruction ( n = 16) rated their cosmetic outcome and satisfaction following surgery, and the impact of surgery on their self-esteem and sexual life, by questionnaire. Patients undergoing breast-conserving surgery were most satisfied with their surgery and body image, followed by those treated with mastectomy with delayed reconstruction. Although diagnosis of breast cancer had a negative impact on the psychology of all patients, those undergoing breast-conserving surgery or mastectomy with delayed reconstruction were more satisfied and reported a lower impact on their self-esteem and sexual life versus those who only had mastectomy. Diagnosis of breast cancer has a negative psychological impact on the patient, but the type of surgery has a significant role in post-operative self-esteem and sexual life.

Adrenal rupture after blunt abdominal trauma

The case of a patient, victim of a car accident, with rupture of the left adrenal gland associated with splenic rupture and liver laceration is reported. Injury of the adrenal glands is most frequently caused by blunt abdominal trauma and is usually associated with injuries of other abdominal organs. Careful exploration of the upper retroperitoneal space where adrenals are located is considered necessary during laparotomy for severe blunt abdominal trauma. If adrenal lesion has been overlooked continuous hemorrhage may occur, which could be lethal if not promptly treated.

Crossover analysis using immunofluorescent detection of MLH1 foci in frozen–thawed testicular tissue

To date, the effects of freezing on spermatogenesis have not yet been fully investigated at a molecular level. Antibody localization studies have identified the MutL homolog 1 (MLH1) protein, a mis-match repair protein, at the prophase I stage of meiosis, which allows the detection of recombination foci during pachytene. This study investigated the effect of long-term testicular tissue cryopreservation on meiotic prophase I, identified by recombination foci frequency and synaptonemal complex (SC) integrity. Frozen-thawed testicular tissues from 12 males who had each fathered a child were used. Because vasectomy or reverse vasectomy procedures are rare in the locale of the investigation, it was not possible to obtain fresh testicular tissue and use the males as their own controls. Immunocytogenetic analysis of 612 spermatocytes at the pachytene stage was performed. The results indicated a mean number of MLH1 foci of 49.2 (SD +/- 5.9), and no correlation was found between the freezing period, the MLH1 frequency and the SC integrity. The results suggest that freezing of testicular tissue taken post-puberty does not appear to be detrimental to the crossover process as identified by occurrence of MLH1 loci.

Bilateral renal angiomyolipoma

Angiomyolipomas are frequent tumours of the kidneys. They are very important in the differential diagnosis of other kidney tumours; sometimes they can present a large size and manifest as an acute massive retroperitoneal haemorrhage. They generally should not be treated unless there are life-threatening problems. In this case report, we present an acute surgical condition due to rupture and haemorrhage of a giant angiomyolipoma. In addition, we review the literature on angiomyolipomas and their severe complications in order to help young surgeons who may be involved in such difficult and life-threatening cases as ours.

Paraffinomas of the breast or oleogranulomatous mastitis-a rare entity

Breast augmentation with the injection of a high-viscosity fluid has been practiced in the past, especially in Asia, resulting in most cases in different varieties of paraffinoma, alternatively known as oleogranulomatous mastitis, a complication of a 'foreign body' reaction type. We report our series of four consecutive cases of destructive paraffinomas that occurred in female patients who had had paraffin injection for cosmetic reasons. Complications due to paraffinoma reactions of breast tissue and skin, as well as progression of the disease and treatment of our patients, are presented here, together with a review of the relevant literature.

Evaluation of gram stain as an alternative in the assessment of human spermatozoa quality

INTRODUCTION

During spermiogenesis, protaminosis and sperm chromatin condensation are important prerequisites for the preservation of DNA integrity in spermatozoa. The aim of this study is to assess Gram stain as an alternative technique for the evaluation of human sperm chromatin condensation status.

PATIENTS AND METHODS

Aniline blue and Gram staining were applied to semen samples from 34 donors in order to determine the relationship between sperm chromatin condensation and infertility. In addition, the possible correlation between morphology and vitality (eosin-Y staining) of spermatozoa compared with their nuclear status (aniline blue and Gram staining) was studied.

RESULTS

Chromatin condensation and sperm vitality were significantly higher in fertile men compared to the subfertile. A significant correlation was found between chromatin condensation and (a) sperm vitality (p < 0.01), and (b) nuclear protein status (p < 0.01).

CONCLUSIONS

Gram staining may be used as a routine method in assisted reproduction laboratories and could assist in the evaluation of sperm quality as well as in the selection of the appropriate fertilization technique.

Wire localisation biopsy of non-palpable breast lesions: reasons for unsuccessful excision

Surgical excision following needle-wire localization of nonpalpable, mammographically detected breast lesions is a very valuable diagnostic and therapeutic procedure. No further treatment is usually required after establishing an accurate histological benign diagnosis of indeterminate lesions on preoperative assessment. On the other hand, ductal carcinoma in-situ (DCIS) and early invasive cancer, properly excised, may sometimes require further management depending on specific histologic findings. An uncommon problem of this procedure is the failure to identify, localize or excise the breast lesion. In this review article, factors that contribute to the failed needle localization procedure are presented.

Surgical management of nipple discharge

PURPOSE

Nipple discharge is reported in 2.5-3% of women with breast carcinoma. Breast carcinoma is found in approximately 8% of surgically treated patients presenting with bloody nipple discharge (ND).

METHODS

In the present study 110 women with ND as a presenting symptom were examined. The discharge was spontaneous in 76 and elicited in 11 patients.

RESULTS

After surgical intervention benign breast disease was found in 85% of patients. Thirteen women (15%) were found to have malignancy and underwent additional surgery. Cytology of the discharge was positive or suspicious for malignancy in only seven out of 13 patients found to have in situ or invasive carcinoma.

CONCLUSION

Women with spontaneous, single duct ND, especially when it is darkish or bloody, should have cytological examination of the fluid and mammography according to their age or additional clinical findings. Most of them will require a microdochectomy, as the possibility of finding a carcinoma among those women is between 10-15%. However, single duct papilloma is the most common cause of bloody discharge.

Open surgical biopsy for nonpalpable breast lesions detected on screening mammography

The aim of this retrospective clinical study was the analysis of histologic findings of nonpalpable breast lesions managed by open surgical biopsy. A series of 630 women underwent 664 preoperative localizations of nonpalpable, mammographically detected breast lesions during the last 10-year period. Indications for biopsy were (1) clustered microcalcifications, (2) solid mass, and (3) radiologic parenchymal distortion. The lesions were localized preoperatively using hook-wire methods, and all biopsies were performed under general anesthesia. Histopathology revealed carcinoma in 172 (25.9%) cases; noninvasive in 114 (66.3%) cases and infiltrating in 58 (33.7%) cases. The highest malignancy rate was found in cases with microcalcifications (112 carcinomas out of 323 cases, 34.7%). Lymph node invasion was present in 25% of patients with invasive cancers. The hook-wire localization of nonpalpable breast lesions is a simple, accurate and safe method for detection of early breast cancers. Frozen section is feasible and accurate in the majority of these lesions, and therefore, diagnostic and therapeutic one-step surgical procedures could be performed.

Mondor's disease of the breast: is there any relation to breast cancer?

Ten cases of Mondor's disease of the breast (9 females, 1 male) are described. The diagnosis was based mainly on clinical examination, while breast imaging, used in five cases, was complementary. Most of our cases (9) had complete restoration of the thrombosed subcutaneous breast vein, either spontaneously (4), or after anti-inflammatory medication (5). Only one of our patients had surgical management (vein excision) due to delayed remission. None of our cases was related to breast cancer.

Breast arterial calcifications as an indicator of systemic vascular disease

PURPOSE

To evaluate the association between mammographically detected arterial calcifications and systemic vascular disease.

MATERIAL AND METHODS

The medical records of 77 women who had either breast arterial calcifications or underwent surgery for carotid stenosis, abdominal aortic aneurysm, or femoropopliteal bypass (study groups A and B) were evaluated and compared with 33 women without breast arterial calcifications (group C). Patients in both arms of the study underwent additional vascular tests or mammography.

RESULTS

Currently available data indicate that there is a statistically significant correlation between the presence of arterial calcifications on the mammogram and atheromatosis of the carotid or femoral arteries.

CONCLUSION

Screening mammograms might be useful in the detection of women at risk for systemic vascular disease.

Unusual presentation of renal cell carcinoma metastasis

The aim of this study is to present an unusual site of renal cell carcinoma metastasis. A 60-year old man presented to our clinic with massive rectal bleeding. A large small intestine metastasis from renal cell carcinoma was evidenced by an elective angiography of the superior mesenteric artery. This metastasis was surgically excised.

Gastrointestinal carcinoid tumors: 10-year experience of a general surgical department

Gastrointestinal (GI) carcinoids are rare neuroendocrine tumors of great interest because of the multitude of the peptide hormones they produce, their clinical manifestations, the carcinoid syndrome they cause, their biologic behavior, and the methods of their surgical and adjuvant treatment. In this retrospective study, 25 patients with carcinoid tumors admitted and surgically treated in our department during the last 10 years are presented. Most of the cases were located in the ileum (n = 8) and appendix (n = 12). The remaining cases were located in the rectum (n = 2), stomach (n = 1), duodenum (n = 1), and ileocecal valve (n = 1). After tumor resection and postoperative treatment, mainly with somatostatin analogs, our patients had a good recovery, and only five deaths were reported during follow-up. Carcinoids, despite the fact that they are usually silent and diagnosed with advanced stage, have good prognosis and offer, after effective treatment, long survival.

Missed cancers on mammograms: causes and measures of prevention

Mammographically missed breast cancers remain a major medical and legal issue. In order to clarify causes and methods of the limitations, we present the experience of our Unit on this field. During the years 1999 and 2000, 319 breast cancer patients were admitted for surgical treatment to our Unit. Their files were reviewed in order to identify cases with mammography-related delayed diagnosis. Thirty-three cases of mammographically missed cancers were found (10.3%). The usual reasons for the delayed diagnoses were: retrospectively visible cancers, in benign looking lesions no further action was taken, and lesions with a rather malignant appearance were reported as benign. Missed cancers could be reduced by simple measures such as the full assessment of breast patients with clinical, radiologic, and cytologic-histologic evaluation, the double screening of mammograms, and improvement of the mammographic equipment and technique.

Fibroadenomas of the breast: is there any association with breast cancer?

PURPOSE

The experience of our Breast Unit in the diagnosis and treatment of fibroadenomas is presented in this retrospective study, focusing specifically in cancer development within these common benign tumors of young age.

MATERIAL-METHODS

310 women with histologically verified breast fibroadenomas who had surgical management in our Unit over the last 14 years were included in the study.

RESULTS

Most of them (n: 255) presented with palpable lesions and had triple assessment preoperatively, while the remaining 55 had nonpalpable lesions and underwent needle-wire localization biopsies. Nine cases had cancer development, usually in situ, within the fibroadenomas (2.9%).

CONCLUSION

Coexistence of fibroadenomas and breast cancer is relatively rare, but it should not be ignored by breast surgeons, and patients should be properly informed.

Pre-operative Tc-99m-sestamibi scanning and intra-operative nuclear mapping: are they accurate in localizing parathyroid adenomas?

PURPOSE

Presentation of the results of Tc-99m-sestamibi imaging in the pre-operative localization of parathyroid adenomas and the intra-operative localization of those lesions using a gamma detector (prospective study).

PATIENTS & METHODS

Eighteen consecutive patients aged 27-75 years with primary hyperparathyroidism (PHPT) underwent Tc-99m-sestamibi scanning 1-2 hours before the operation and the presence of a single adenoma was recognized. All our patients underwent bilateral neck exploration based on pre-operative scanning and intra-operative gamma detector guidance and the adenoma was detected in the positions shown by both methods.

RESULTS

In 16 patients we found a single adenoma localized in the same position shown by pre-operative scanning, while the intra-operative method accurately revealed all abnormal glands. In one of the two patients where an inaccurate pre-operative localization technique had been carried out, we performed thyroid lobectomy (the adenoma proved to be intrathyroidal), while the other one had an adenoma which was not close to the site indicated by the pre-operative scintigraphy. Serum calcium reverted to normal within a few days postoperatively.

CONCLUSION

Patients with true-positive scans for single parathyroid adenoma could be eligible for minimally invasive operations since the abnormal gland is easily identified by the above-mentioned methods.

Carcinosarcoma of the breast: report of two cases

Carcinosarcoma is a rare, malignant tumor of the breast, consisting of intraductal or infiltrating carcinoma contiguous or subtly merged with a highly cellular, mitotically active pleomorphic spindle cell stroma (sarcoma). It is a form of the metaplastic mammary carcinomas and it is probably derived of myoepithelial cells. We report two cases of breast carcinosarcoma in two white women. The patients, following a frozen section positive for malignancy, had had a modified radical mastectomy. Paraffin sections and positive immunohistochemical cell staining (in our first case) confirmed the diagnosis of carcinosarcoma. This tumor should be distinguished from other forms of metaplastic carcinomas because it is very aggressive and has an ominous prognosis.

Palliative treatment for bile duct carcinoma

BACKGROUND/AIMS

Extrahepatic bile duct carcinoma remains a very difficult problem for the surgeon. The aim of this study was to evaluate the differences between surgical treatment and endoscopic or transhepatic dilatation and intubation.

METHODOLOGY

Clinical data from 62 consecutive patients with carcinoma of the extrahepatic bile ducts, who underwent palliative treatment during the past 25 years in our department, were retrospectively analyzed. Preoperative assessment defined site, stage and resectability of tumors.

RESULTS

Tumors were located in the upper third of the bile duct in 32 cases, in the middle third in 17 cases and in the distal third in 13 cases. Transtumoral dilatation was performed in 36 patients (Group A) and cholangioenteric bypass in the remaining 26 patients (Group B). The overall mortality rate was 12.9%. The average survival rate was 6.5 months in group A and 7.3 months in group B.

CONCLUSIONS

In conclusion we suggest that the cholangioenteric bypass offers a better quality of life than non-operative techniques.

Granular cell tumor of the breast: a rare lesion resembling breast cancer

Granular cell tumor (GCT) is an uncommon, usually benign tumor that occasionally involves the breast. It is possibly of neural origin (Schwann cells) and usually occurs in premenopausal black women. Physical examination, mammographic, ultrasonographic findings and pathologic examination may suggest breast malignancy. Positive immunohistochemical staining of the cells for S-100 protein, NSE, and CEA is indicative of GCT. Surgical treatment of choice is wide local excision. We report a case of granular cell tumor of a female breast. A 52-yr-old white woman had a palpable mass close to her right axilla. Computer tomography (CT) showed a 3.74 cm mass in the mammary tail of Spencer. The findings were suspicious for malignancy and the lesion was widely resected. Pathologic examination showed granular cell tumor.

Diverticular disease of the small bowel: report of 27 cases

Diverticula of the small bowel are usually asymptomatic but occasionally can present with serious complications. Because of the rarity of small bowel diverticulosis and the limited case number in most published reports, we analyzed one of the largest series with symptomatic small bowel diverticular disease. In this retrospective review, we studied 27 symptomatic patients with diverticula of the small bowel that was treated surgically. The study included 13 male and 14 female patients (age range, 30-87 years; mean age, 69.3 years). Fourteen patients underwent an elective operation for chronic refractory symptoms. Thirteen patients underwent emergency surgery because of rupture of the diverticula and associated peritonitis, diverticulitis and small bowel obstruction, or lower gastrointestinal bleeding. Surgical treatment consisted of resection of the intestinal segment containing the diverticula. All patients were symptom-free postoperatively and no "short bowel" problems developed. Abdominal pain, gastrointestinal bleeding, and bowel obstruction were the most common clinical symptoms. Small bowel diverticulosis should be treated surgically only when refractory symptoms or severe complications are present.

High efficient production of Pr55(gag) virus-like particles expressing multiple HIV-1 epitopes, including a gp120 protein derived from an Ugandan HIV-1 isolate of subtype A

The main goal of this study was to investigate a novel approach for an efficient and reproducible production of Virus-Like Particles (VLPs) expressing multiple HIV-1 epitopes. The HIV-1 Pr55(gag)-based VLPs have been produced in a Baculovirus expression system, using a transfer vector able to support the independent expression of different open reading frames (ORFs). In this regard, the gp120 derived from 94UG018 HIV-1(A) isolate, previously studied in our laboratory, has been packaged into the VLPs together with nef and pol ORFs. In particular, the gp120(UG) sequence shows a 90% homology in the V3 region compared to African HIV-1 strains of the A-clade. This novel approach is extremely effective for the production of VLPs expressing all the epitopes, as confirmed by Western Blot characterization. Furthermore, the resulting HIV-VLP(A)s show the expected density (1.14--1.18 g/ml) on a 10--60% sucrose gradient and the morphology of an immature virion at standard transmission electron microscopy. Our results demonstrate that this strategy is highly efficient for expressing a balanced amount of multiple epitopes and their packaging in VLP structures, without affecting the Pr55(gag) autoassembling capacities. Furthermore, the genetic transposition performed in a modified E. coli represents a methodological improvement, allowing a faster and more reproducible identification of recombinant Baculovirus DNA molecules.