[Extra-nodal NK/T-cell lymphoma, nasal-type, revealed by cutaneous and ocular involvement]

BACKGROUND

Extra-nodal NK/T-cell lymphoma (ENKTL) is a form of highly malignant non-Hodgkin's lymphoma. There are two types: nasal forms primarily affecting the oropharyngeal sphere and so-called nasal-type extra-nasal forms in which primary skin involvement is the most common feature enabling diagnosis. Herein, we report a case of systemic nasal-type ENKTL (ENKTL-NT) that was diagnosed based on skin involvement associated with ocular involvement.

PATIENTS AND METHODS

A 67-year-old female patient, without immunodepression, was admitted to the dermatology department for a worsening inflammatory scaly patch of skin on her right calf. Secondarily, further lesions appeared on her body as well as a generalized macropapular rash and sores. These were associated with fever spikes, as well as ophthalmoplegia and edema, preventing her from opening her right eyelid. Tests for infectious, autoimmune and inflammatory disorders were negative. A cerebro-orbital scan revealed infiltration and contrast enhancement of the right periocular fat without any mass effect or cerebral extension. A positron emission tomography (PET) scan revealed multiple hypermetabolic skin lesions. Histological analyses indicated dermal-hypodermal lymphomatous tumor proliferation, and immunohistochemical analyses revealed lymphocytes expressing NK-cell markers (strong CD56+ expression), cytotoxic markers (granzyme B and TIA-1), and the presence of Epstein Barr virus (EBV) in the tumor cells. The patient was diagnosed with systemic ENKTL-NT. Her condition deteriorated rapidly, with the onset of refractory macrophage activation syndrome leading to death due to multiple organ failure.

DISCUSSION

Skin involvement in ENKTL is non-specific and uncommon, which can delay diagnosis. Treatment is based on polychemotherapy comprising L-asparaginase and possibly consolidation therapy with autologous or allogeneic hematopoietic stem cell transplantation. The prognosis of ENKTL-NT is poor due the more aggressive nature of the disease compared with the nasal forms, with frequent visceral involvement and macrophage activation syndrome. Skin involvement seems to be a poor prognostic factor. Although ocular involvement is documented, its association with skin involvement is rare and mainly secondary to nasal forms of ENKTL. This case of an extra-nasal form of ENKTL-NT with systemic involvement illustrates the difficulty of diagnosis and the poor prognosis of this type of lymphoma.

[History of surgery of the parathyroid glands]

In 1850 Sir Richard Owen discovered the parathyroid glands in rhinoceros. After they have been discovered in man in 1880 their history spread all along the 20th century. The history started from the descriptive anatomy and the clinical pictures of their illness to the trouble of their functioning. The hormone was studied while the surgeons began to cure adenoma, hyperplasia and cancers.

Ganglions et cancer du rectum

Nodal invasion is a major prognostic factor of rectal cancer. Lymphatic extension of rectal cancer usually involves the mesorectal nodes then the inferior mesenteric chain but in 14% of patients, particularly with cancer of the lower rectum, metastasic nodes can be observed in the internal or lumboaortic chains situated beyond the usual territory of nodal dissection. On average, 30 nodes are examined on a proctectomy specimen, but with wide interindividual variation. The tumor can be adequately staged if at least 15 nodes are examined with little risk of not recognizing nodal metastasis. Metastatic nodes of rectal cancer are almost always small, more than 90% measuring less than 10 mm and 70% less than 5 mm. The number of invaded nodes and the total number of examined nodes are prognostic factors for survival. Hypofrationated preoperative radiotherapy does not alter the nodal status but a long radiotherapy protocol (45 Gy over 5 weeks) reduces significantly the total number of nodes examined without changing the number of metastasic nodes. Micrometastases (measuring less than 2 mm), identified by immunohistochemistry or gene amplification, can be detected in 25 to 70% of nodes considered metastasis-free at the usual microscopic examination. The prognostic value of these micrometastases remains to be established. The first node draining the tumor (sentinel node), which can be detected rapidly with dye infusion, appears to provide a good picture of the nodal status, the risk of finding an invaded node if the sentinel node is metastasis-free is less than 5%.

[Role of surgery in closed abdominal trauma]

Over the past twenty years, nonoperative management has increasingly been recommended for the care of patients with blunt abdominal trauma. Emergency laparotomy remains the rule in patients with hemodynamic instability or in those with peritonitis due to intestinal perforation. Surgical treatment of liver and splenic lesions tends to be more conservative. After assessment of the lesions by computed tomography, nonoperative management in intensive care unit is allowed in the majority of patients.

Extracorporeal lithotripsy of ureteric calculi using the Dornier HM-3 lithotriptor

Over a 5-year period (November 1984-November 1989), we treated 356 patients with ureteric calculi; 170 were treated by extracorporeal shock wave lithotripsy (ESWL) on a Dornier HM-3 lithotriptor. The calculi (n = 176) were uniformly distributed along the length of the ureter: 44 were just below the pelviureteric junction, 59 were lumbo-iliac, 42 were in the upper bony pelvis and 32 in the lower bony pelvis. The mean diameter of the upper ureteric calculi was 10 mm and for the others it was 8 mm. Thirty-four patients with acute obstructive pyelonephritis required pre-ESWL drainage of the urine. X-ray localisation required intravenous urography during lithotripsy in 52 cases (30%). On plain X-ray the following day 170 stones (96%) were judged to have disintegrated. The 6 patients whose stones were not fragmented received further treatment (ureterotomy (4) and ureteroscopy (2)). Five patients required additional treatment because of pain or fever (catheterisation (3) and ureterotomy (2)) and 2 patients had a second lithotripsy owing to insufficient fragmentation. Four patients were lost to follow-up. In 153 patients (90%) the fragments were eliminated completely, 146 in the first month and the remainder before the sixth month. No serious sequelae were observed. In addition to the 5 patients who required supplementary treatment. 11 patients with pain or fever needed medical treatment. We recommend first intention in situ ESWL for all ureteric calculi.

Tumors of the upper urinary tract: 10 years of experience

We reviewed 108 patients with upper urinary tract tumors who underwent surgical treatment during a 10-year period (87 men and 21 women with a mean age of 63.5 years). Of the tumors 97% were unilateral and only 3 patients had bilateral tumors. Two-thirds of the patients had a single tumor focus and a third had 2 or more tumor foci. Additionally, there were 31 patients (28.7%) with previous and/or simultaneous bladder tumors. Nephroureterectomy was performed in 92 cases, nephrectomy in 6 and a conservative operation in 13. In 65 cases lymphadenectomy was added. The survival rates at 5 and 10 years were 67 and 65%, respectively. Of the patients 90% with cancer-related deaths had high grade tumors. Of the 15 patients with positive lymph nodes 87% died of metastasis compared to 8% of the 50 patients with negative lymph nodes. Nine patients (8.7%) had relapse in the upper urinary tract, 6 (5.8%) in the ipsilateral ureter and 3 (2.9%) in the contralateral ureter. Of these 3 patients 2 had recurrent multifocal bladder tumors. For patients who present with an upper urinary tract tumor the risk of a bladder cancer was approximately 9% and that of a contralateral urothelial tumor was 1%.

[Do posterior urethral valves alter the results of renal transplantation in children?]

The authors conducted a retrospective study based on a series of 715 renal transplantations in children performed between January 1973 and December 1989 at the Hôpital Necker-Enfants Malades in order to determine whether the long-term result of renal transplantation was as good in children with posterior urethral valves (PUV) as in children with a normal lower urinary tract. Group 1 consisted of 50 renal transplantations performed in 41 children in whom the primary urological disease was PUV. The bladder was able to be used without modification in 36 cases and had to be enlarged in 5 cases. A permanent cutaneous urinary diversion was not required in any of these transplanted patients. Group 2 consisted of 665 renal transplantations performed in children without PUV. There was no significant difference between the two groups in terms of the distribution of cadaver kidney and living related donor transplantations. Immunosuppressive treatment consisted of various combinations of prednisone, azathioprine, ALS for the earlier patients in the series, OKT 3 and cyclosporin for the more recent patients. In group 1, we observed a urological complication rate of 20% and a vascular complication rate of 14%, while, in group 2, the urological complication rate was 16.9% and the vascular complication rate was 9.5%. The actuarial 5-year and 10-year graft survival rates were 63% and 49% in group 1 and 63% and 49% in group 2, respectively. The actuarial graft survival rates were therefore identical in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of the human nephron differentiation molecules in renal cell carcinomas

The authors tested frozen sections from 28 renal cell carcinomas (RCC)--21 clear, 1 eosinophilic, 4 basophilic, and 2 spindle-shaped cell type--with monoclonal antibodies (MAb) reacting against cytokeratin, vimentin, CD24, CALLA/CD10, villin, CD26, and HLA class I and class II molecules. These molecules are markers of specific segments of the mature kidney, and their loss or acquisition reflects the different steps of human nephrogenesis. KI67 MAb was used to evaluate cell-proliferating activity. All RCC cases expressed cytokeratin. Coexpression of vimentin was observed in 21 of 28 cases. Whether of clear or chromophilic type, all tumoral cells strongly expressed CD24 molecule, present on primitive blastema cells. All clear-type RCCs expressed CALLA/CD10 and 60% were also villin positive; some were faintly positive for CD26. CALLA, villin, and CD26 were not detected in basophilic cell type. HLA class I molecules were variably expressed in almost all cases, but HLA class II were never detected on tumoral cells. Except for the spindle-shaped population, cell-proliferating activity was low. These results favor the hypothesis that RCCs derive from cells that have 'recovered' the different options of metanephric differentiation. Clear cells show evidence of maturation toward proximal type, while basophilic cells do not. It would be of interest to evaluate the usefulness of serum measurements of villin and/or CALLA as markers in clear cell-type RCC.

[Mortality and morbidity after total cystectomy for cancer]

The authors review mortality and morbidity in 100 consecutive patients who during a six year period underwent total cystectomy for carcinoma of the bladder. The postoperative mortality was 15 (15%), essentially as a result of septic and respiratory complications. In relation to the type of diversion: 6 deaths in 46 cases of cutaneous ureterostomy, 4 deaths amongst 19 cases of trans-intestinal cutaneous ureterostomy, 3 deaths amongst 24 cases of uretero-colic implantation and 2 deaths amongst 11 cases of replacement enterocystoplasty . Amongst factors involved in the cause of postoperative mortality, three appeared to be of essential importance: a very high anaesthetic class (class IV), defective drainage of dissected areas, sources of deep abscesses , and use of the intestine in the method of completing total cystectomy. In the last 40 cases, the use of cutaneous ureterostomy in 82.5% of cases and careful attention to drainage of the operative site led to a reduction in mortality to 5% (2/40) whilst in the first 60 cystectomies of the series, 68.3% of which were completed by ureterocolic implantation, mortality was 21.7% (13/60). Early and late complications were also much more frequent in diversion procedures using the intestine than after direct cutaneous ureterostomy. But after replacement enterocystoplasty , late complications were virtually nonexistent. The authors indicate the following guidelines as conclusions: - in patients who accept a cutaneous implant, direct cutaneous ureterostomy is the best bypass procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[The reversed stomach technique of oesophagoplasty (author's transl)]

A technique of oesophagoplasty using the whole stomach is described and discussed. In this technique, the duodenum is divided and the stomach is turned-up, passed through a retrosternal tunnel and anastomosed with the cervical oesophagus. Continuity of the intra-abdominal digestive tract is restored by anastomosing the gastric fundus with the duodenum. The new technique, successfully used by the authors in 10 patients, is applicable to oesophageal carcinomas as a palliative measure or as the first stage of secondary oesophagectomy; and to oesophageal stenosis consecutive to caustic burns.