Ewing’s Sarcoma of the Breast in a Young Woman: A Case Report and Review of the Literature

Ewing’s Sarcoma Family Tumors (ESFT) include classic Ewing’s sarcoma of bone, extra-skeletal Ewing’s sarcoma (EES), malignant small cell tumor of the chest wall (Askin tumor), and soft tissue-based Peripheral Primitive Neuroectodermal tumors (pPNET). The t(11;22)(q24;q12) translocation is associated with 85% of tumors and leads to EWS-FLI-1 (Ewing’s Sarcoma–Friend Leukemia Integration-1) formation. This is a potent transforming gene that encodes a chimeric protein that plays a role in the genesis of Ewing’s Sarcoma and Primitive Neuroectodermal Tumors. The breast location of ESFT remains exceptional. The prognosis is among the poorest of all subtypes of breast cancer and even poorer than other extraosseous Ewing’s sarcomas. We describe the case report of a 23-year-old patient with a growing breast lump, who required an accurate and challenging diagnostic estimation and who ultimately resulted in a peripheral primary neuroectodermal tumor (pPNET). Through this case description and a brief narrative review of the literature, we aim to highlight the rarity of ESFT located in the breast. Histopathological confirmation is mandatory for all growing masses of the breast to reach a conclusive diagnosis and plan the correct treatment. Patients with rare diagnoses should always be centralized in breast units, conducting multidisciplinary meetings and, when necessary, the diagnosis should be shared through wider national or international registries.

Hand Rehabilitation Treatment for Charcot-Marie-Tooth Disease: An Open Label Pilot Study

Objective

Charcot-Marie-Tooth neuropathy affects mainly and early the lower limbs, but hands deformities are a relevant problem, which involves the quality of life of the patients. Unfortunately, there are few studies about the evaluation of the upper limbs and very rare works about the rehabilitation. A treatment study at the moment is missing and it is important to search rehabilitation exercises to improve the dexterity and the quality of life of the patients.

Methods

We recruited 9 patients with clinical and genetic diagnosis of CMT and we proposed a rehabilitation protocol which includes muscle recruitment, stretching and proprioceptive exercises for the hand with the duration of 4 weeks (two sessions for week). We evaluated the patients before and one week after the treatment with Thumb Opposition Test, Sollerman Hand Function Scale, dynamometry (tripod pinch and hand grip).

Results

The rehabilitation protocol has been well tolerated and there were not dropouts. We did not observe any worsening in every scale we used. Every parameter tested showed an improvement especially in the right/dominant hand.

Conclusion

This study demonstrates that this three phases treatment is well tolerated by patients, it is not detrimental for the hands status and perfectly reproducible by professionals. Moreover, this could be the basis for future randomized single blind projects.

Preoperative assessment of respiratory function in severely obese patients undergoing biliopancreatic diversion

Since severe obesity is often associated with a pulmonary function defect and abdominal surgery increases the risks of respiratory postoperative complications (RPC), an increased incidence of RPC might occur after bariatric operations. A cohort of 146 severely obese patients undergoing biliopancreatic diversion (BPD) was retrospectively evaluated for the occurrence of RPC. Respiratory function was evaluated prior to BPD from the quotient between measured and predicted values of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)) and the Tiffeneau index (TI: FEV(1)/FVC). In this cohort of obese individuals the BMI degree prior to the operation was totally unrelated to the standardized values of TI and to the presence of restrictive or obstructive pulmonary disease. Globally, a very low rate of RPC (7.5%) was found; in patients with suspected restrictive pulmonary impairment, a high occurrence of RPC was observed (p < 0.05). When data are controlled for preoperative BMI values, smoking status and presence of sleep apnoea, a logistic regression model indicates that respiratory function data cannot predict the occurrence of RPC after bariatric surgery.

Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer

Lymphedema is a common complication of axillary dissection and thus emphasis should be placed on prevention. Fifty-five women who had breast-conserving surgery or modified radical mastectomy for breast cancer with axillary dissection were randomly assigned to either the preventive protocol (PG) or control group (CG) and assessments were made preoperatively and at 1, 3, 6, 12 and 24 months postoperatively. Arm volume (VOL) was used as measurement of arm lymphedema. Clinically significant lymphedema was confirmed by an increase of at least 200 ml from the preoperative difference between the two arms. The preventive protocol for the PG women included preoperative upper limb lymphscintigraphy (LS), principles for lymphedema risk minimization, and early management of this condition when it was identified. Assessments at 2 years postoperatively were completed for 89% of the 55 women who were randomly assigned to either PG or CG. Of the 49 women with unilateral breast cancer surgery who were measured at 24 months, 10 (21%) were identified with secondary lymphedema using VOL with an incidence of 8% in PG women and 33% in CG women. These prophylactic strategies appear to reduce the development of secondary lymphedema and alter its progression in comparison to the CG women.

[The management of syncope in the hospital: the OESIL Study (Osservatorio Epidemiologico della Sincope nel Lazio)]

BACKGROUND

While syncope is generally considered a frequent finding in clinical practice, no clear epidemiological evidence is available about the relevance of such an event in the general population of Italy.

METHODS

The OESIL Study was designed and undertaken in 15 hospitals of the Italian region of Latium in order to assess the percentage of emergency-room visits and admissions due to syncope, as well as to analyze the in-hospital diagnostic work-up performed for this condition.

RESULTS

During a two-month observation period, 781 (372 males and 409 females, mean age 55.2 (22.8 years) consecutive patients came to the emergency rooms of the 15 hospitals included in the investigation due to a syncope spell (0.9% of emergency room visits); 450/781 patients (57.6%) were subsequently hospitalized (1.3% of all admissions): 48.0% of the admissions were admitted to a general medical ward, 29.3% to an observation ward, 13.3% to a cardiology section, 1.6% to a neurology section and 7.8% to other clinical sections (neurosurgery, general surgery). The mean duration of in-hospital stay was 6.9 (5.8 days; range 1-40 days). During the hospitalization period, 93.1% of patients underwent an ECG, 51.0% an EEG, 44.3% a CT scan of the central nervous system, 40.2% an echocardiogram and 19.5% a tilt-test. The syncope spell was considered to have a cardiovascular origin in 33.8% of the cases and a non-cardiovascular in 11.6% of the cases, while the origin was unknown in 54.4% of the cases.

CONCLUSIONS

Collected data support the idea that syncope represents a frequent event in the general population and is responsible for a significant percentage of emergency-room visits and hospital admissions. However, the performance of conventional diagnostic work-ups is far from being satisfactory.

[The role of an electropharmacological transesophageal test in the prevention of paroxysmal atrial fibrillation. Experience with flecainide]

BACKGROUND

The management of patients with paroxysmal atrial fibrillation (AF) is unsuccessful, because AF recurs in about 50% of patients despite an antiarrhythmic treatment. Usefulness of non-pharmacological strategies is available in a limited subset of patients and it does not present a global solution to the problem. At present, treatment with antiarrhythmic agents is the only available tool in patients with AF recurrence. The aim of this study was to assess the predictive value of the electropharmacological transesophageal (TE) test in the management of patients with paroxysmal AF treated by flecainide.

METHODS

In 32 patients, ranging in age from 38 to 70 years (mean: 59 +/- 12 years), with documented episodes of paroxysmal AF (mean: 5.6 +/- 3.7 episodes/last year), we performed an electrophysiological transesophageal (TE) test following pharmacological wash-out. An aggressive protocol was used: step A: 10 sec atrial burst at Wenckebach point + 10 bpm, 200 and 250 bpm; step B: 10 sec atrial bursts at 300, 400, 500 and 600 bpm; step C: 8 sec increasing rate burst from 200 to 800 bpm. Induction of sustained AF (> 1 min) was considered the end-point. Patients were treated with flecainide 100 mg bid and a second TE test was performed at the steady-state, with an identical induction protocol and end-point. Based on the response of the second test, patients were divided into responders (R Group: non-inducible AF) and non-responders (NR Group: inducible, sustained AF). Patients were followed-up by periodical controls and contacted by telephone to confirm their clinical status.

RESULTS

Sustained AF was induced in 30 patients (94%) at the first TE study. Eight of them dropped-out at the time of the second TE test (6 patients for lack of consent, 1 patient for side-effects and another one for proarrhythmic effects). In the mean follow-up of 15 +/- 6 months, among patients who underwent a second TE test, AF recurrence was documented in 2 out of 14 patients from the R Group and in 7 out of 10 patients from the NR Group (p < 0.01). There were 4 AF episodes in the R Group and 19 in the NR Group (p < 0.001). We did not find significant statistical differences between the two groups in terms of age, sex, body weight, AF episodes/past year, P-wave duration, left atrial dimension, structural heart disease, AF duration at the first TE test and follow-up duration. In five patients from the NR Group with induced AF lasting > 5 min, the percentage of recurrence was 100% and there were 16 AF episodes. Global percentage of patients with recurrence was 37%.

CONCLUSIONS

Flecainide is effective in reducing the incidence of AF and results are similar to other antiarrhythmic agents generally used. The electropharmacological TE test might be a useful tool to predict the response to an antiarrhythmic treatment.