18F-2-Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography Scanning Affects Surgical Management in Selected Patients With High-Risk, Operable Breast Carcinoma

Background The role of positron emission tomography (PET) scanning in determining the extent of disease in patients with breast cancer has not been defined. We investigated the utility of ¹⁸F-2-fluoro-2-deoxy-D-glucose (FDG)-PET scanning compared with conventional imaging with computed tomographic scanning and bone scanning in determining the extent of disease in patients with high-risk, operable breast cancer. Methods This was a prospective study of patients who presented to Memorial Sloan-Kettering Cancer Center for operative treatment of breast cancer. Eighty eligible patients were enrolled and underwent computed tomographic chest, abdomen, pelvis, and bone scans, followed by FDG-PET. Changes in treatment based on scan findings were recorded by the operating surgeons. Imaging findings were verified by biopsy or long-term follow-up. Results Eight (10%) of 80 patients were found to have metastatic disease that was seen on both conventional imaging and PET. Four additional patients (5%) had additional foci of disease on PET that affected treatment decisions. No patient had findings on conventional imaging alone. Conventional imaging studies resulted in a higher number of findings that generated additional tests and biopsies that ultimately had negative results (17% vs. 5% for PET). There was a statistically significant difference in specificity for PET compared with conventional imaging (P = .01). Conclusions Conventional imaging and PET were equally sensitive in detecting metastatic disease in patients with high-risk, operable breast cancer, but PET generated fewer false-positive results. FDG-PET scanning should be further studied in this setting and considered in the preoperative evaluation of selected patients with breast cancer.     

Breast Cancer and Transplantation

Breast cancer is an important cancer among solid organ transplant recipients. While the incidence of breast cancer in solid organ transplant recipients is comparable to the age‐matched general population, the outcomes are generally poor. Interventions such as cancer screening that preclude the development of late‐stage disease through early detection are not well studied, and clinical practice guidelines for cancer screening rely solely on recommendations from the general population. Among patients with a prior breast cancer history, disease recurrence after transplantation is a rare but fearful event. Once disease recurs, the risk of death is high. The focus of this review is to present the epidemiology of breast cancer in solid organ transplant recipients, screening and preventive strategies for those who may be at risk, novel genomic profiling for determining tumor progression, and the newer targeted interventions for recipients who have developed breast cancers after solid organ transplantation.     

Instability of clonality in gastric lymphoid infiltrates: a study with emphasis on serial biopsies

The evolution of low-grade B-cell mucosa-associated lymphoid-tissue (MALT) lymphoma of the stomach is a multistage process, reflected in the histologic continuum from Helicobacter pylori-chronic gastritis, to low-grade and high-grade lymphoma. Interestingly, in daily gastric biopsy sign-out, the authors observed that some biopsies showed monoclonality on polymerase chain reaction (PCR) even though there were no definite histologic features of malignancy and vice versa. To address the question, the authors studied the endoscopic gastric biopsies at first presentation of 46 patients to examine any clonality differences among various histologic patterns within the spectrum of MALT lymphoma evolution. The gastric biopsies were reviewed histologically and graded according to the Wotherspoon-Isaacson histologic scoring system from grade 0 (normal) to grade 5 (MALT lymphoma). The clonality of cases in each grade was determined by performing nested PCR for immunoglobulin heavy chain (IgH) gene rearrangement using FR2/JH and FR3/JH primer sets. The monoclonality rates among different grades were as follows: grade 2, 6.3% (1 of 16); grade 3, 27.3% (3 of 11); grade 4, 83.3% (5 of 6); grade 5, 69.2% (9 of 13). Statistically significant difference of monoclonality rate is demonstrated in histologic grade 4 versus grades 2 and 3, and grade 5 versus grade 2 (P < 0.05, Fisher exact test). The authors went on to examine the progress of disease by following up the clinical status, histologic changes, and clonality fluctuation of these cases. Four of the 8 patients with monoclonality on PCR, but no definite lymphoma at first presentation later progressed to frank MALT lymphoma. Our study shows that, during the progression to MALT lymphoma, there is an instability of clonality. Clonality can fluctuate between polyclonality, oligoclonality, and monoclonality, none of which defines an irreversible stage for progression to MALT lymphoma. Monoclonality is a risk factor for development of MALT lymphoma. Those cases with dense gastric mucosal lymphoid infiltrate (without definite MALT lymphoma) and monoclonality on PCR need to be closely monitored and Helicobacter infection promptly treated if present. In combination with clinicohistologic examination, PCR can serve as a complementary tool in arriving at a definite diagnosis of MALT lymphoma in cases with borderline histologic features.     

A double-blind, prospective, randomised, controlled clinical trial of minimally invasive dynamic hip screw fixation of intertrochanteric fractures

Objective

To compare minimally invasive dynamic hip screw (MIDHS) fixation with conventional dynamic hip screw (CDHS) fixation for treatment of intertrochanteric femoral fracture.

Methods

Of the 66 participants in this double-blind study, 35 were randomised to MIDHS and 31 to CDHS fixation. Main outcome measurements were wound size, haemoglobin decrease, blood transfusion rate, pain score, analgesic consumption, Elderly Mobility Scale score, hip screw position, tip-apex distance, union rate, time to healing and complication rate.

Results

The groups had similar preoperative clinical data. Postoperatively the MIDHS group had significantly smaller wound size, less blood loss, lower blood transfusion rates, pain scores and rates of analgesic consumption, and higher early Elderly Mobility Scale scores. There were no significant differences in fracture alignment, hip screw position, tip-apex distance, union rate, time to healing or complication rate.

Conclusion

MIDHS fixation of intertrochanteric fractures is effective and safe and significantly reduces blood loss, pain and rehabilitation period, without sacrificing reduction alignment, screw position, fixation stability or bone healing.     

特发性脊柱侧凸患者脊柱畸形段凸侧及凹侧关节突松质骨三维微结构比较

目的比较青少年特发性脊柱侧凸(AIS)患者脊柱畸形顶椎区和端椎区两侧关节突松质骨的三维微结构。方法AIS患者9例,均为女性,年龄12～17岁,平均14.9岁;Cobb角48°～84°,平均56°。患者均接受后路矫形融合内固定手术,术前与患者家长签署同意书,在去皮质手术时取下顶椎区和上下端椎区两侧关节突。标本取材后用中性福尔马林固定,然后用解像度为20μm的微焦点CT扫描,三维图像重组进行骨形态计量学测量对比。结果顶椎区凸侧与凹侧相比有显著差异,分别为:骨量容积比BV/TV为0.268/0.354(P<0.05),骨小梁厚度TbTh为0.20/0.24(P<0.05),骨小梁分离度TbSP为0.66/0.56(P<0.05),骨小梁面积体积比BS/BV为12.7/10.4,P<0.05)。端椎区左右两侧关节突松质骨骨小梁无明显差异,上胸椎和胸腰椎关节突骨小梁微结构比较未见差异。结论由于脊柱侧凸凹侧承受不同应力,凹侧关节突出现更多的骨小梁,骨小梁间的连接更紧密,而且骨小梁更粗,从而可使脊椎楔形变的速度变缓,提示脊柱的骨骼本身并不是AIS脊柱侧凸畸形进展的促进因素。     

青少年特发性和先天性脊柱侧凸患者的骨微结构及骨密度比较

目的探讨青少年特发性脊柱侧凸(adolescentidiopathicscoliosis,AIS)、先天性脊柱侧凸(congenitalscoliosis,CS)患者与同年龄正常人骨密度(BMD)的差异,并用高分辨率微焦点CT(microCT)扫描成像,定量研究AIS、CS患者的骨小梁形态计量学特征。方法AIS患者15例,均为女性,年龄12～19岁,Cobb角48°～104°。CS患者16例,男4例,女12例,年龄13～18岁,Cobb角40°～125°。正常对照组35例,均为女性,年龄13～16岁。正常组和术前AIS、CS患者均接受双能X线吸收骨密度仪(DEXA)扫描,评估腰椎和股骨颈BMD状况。对AIS与CS患者的髂骨进行骨形态计量学分析。结果AIS患者腰椎和股骨颈BMD低于正常人,CS患者BMD和骨量(BMC)均低于正常人。CS与AIS患者比较股骨颈BMD和BMC显著降低。microCT中的骨容积比与DEXA下的BMD显著相关。AIS骨组织体积比值(19.9%±3.4%)明显高于CS患者(13.3%±3.0%)。AIS患者骨小梁厚度和骨面积比值与CS患者比较,差异均有统计学意义,骨小梁厚度分别为(155.5±54.9)μm和(108.1±17.4)μm,骨面积比值分别为16.4%±3.3%和22.0%±3.4%。CS患者骨连接度和骨小梁数目低于AIS患者。结论AIS患者骨量低,髂骨骨小梁微结构异常,骨容积比低,骨小梁细小。CS患者BMD与骨小梁微结构均低于正常人和AIS患者。     

Endoscopic cross-trigonal ureteral reimplantation under carbon dioxide bladder insufflation: a novel technique

PURPOSE: To report on a novel technique of endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting primary vesicoureteral reflux (VUR) in infants and children. PATIENTS AND METHODS: Ten boys and six girls with dilating primary VUR (7 bilateral; 23 refluxing ureters) associated with recurrent urinary-tract infections and multiple pyelonephritic renal scars underwent endoscopic Cohen's cross-trigonal ureteral reimplantation with CO(2) pneumovesicum. Their ages ranged from 10 months to 13 years (mean 4.1 years). The endoscopic procedure was preceded by distention of the bladder with saline and insertion of a 5-mm Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and insufflated with CO(2) to 10 to 12 mm Hg pressure with a suction catheter inserted per urethra to occlude the internal urethral meatus. A 5-mm 30 degrees endoscope was used to provide intravesical vision. Two more 3- to 5-mm working ports were inserted on the lateral bladder wall on either side. Endoscopic intravesical mobilization of the ureter, dissection of a submucosal tunnel, and a Cohen's type of crosstrigonal ureteral reimplantation using interrupted 5-0 monofilament sutures was then performed under videoscopic guidance. Bladder drainage by a urethral catheter was maintained for 24 hours postoperatively. RESULTS: Endoscopic cross-trigonal ureteral reimplantation under CO(2) pneumovesicum was successfully performed in all except one patient, who had displacement of a port into the extravesical space after completion of the ureteral reimplantation necessitating a small vesicotomy for closure of the mucosal defect. The mean operating time was 136 minutes (range 80-230 minutes), being 112 minutes for unilateral cases and 178 minutes for bilateral cases. Two boys developed mild suprapubic and scrotal emphysema postoperatively that subsided spontaneously. All other patients recovered uneventfully and remained well. Follow-up cystograms showed complete resolution of VUR in all except one unit that had persistent grade I reflux, thus giving a success rate of 96%. CONCLUSIONS: This early experience illustrates that endoscopic intravesical ureteral mobilization and crosstrigonal ureteral reimplantation can be performed safely and effectively with routine laparoscopic surgical techniques and instruments under CO(2) insufflation of the bladder, achieving a high success rate in reflux resolution that is equivalent to that obtained with the open technique but with minimal invasiveness and much faster recovery. The longer-term outcome and potential physiological effects of CO(2) pneumovesicum on the bladder and upper-tract function will need to be evaluated further.     

A randomised trial comparing conventional semen parameters,sperm DNA fragmentation levels and satisfaction levels between semen collection at home and at the clinic

The aim of the randomised trial was to compare conventional semen parameters, sperm DNA fragmentation levels and satisfaction levels between semen samples collected at home and at the clinic. We recruited 110 men with a history of infertility for at least 1 year from the outpatient andrology clinic. Each man collected two semen samples, one at home and one at the clinic. Men were randomly assigned into the home first (n = 55) or clinic first (n = 55) groups. The primary outcome was sperm concentration. There was no significant difference in sperm concentration, sperm DNA fragmentation levels or other conventional semen parameters between home first and clinic first samples (p > .05), while satisfaction levels were significantly higher for home first samples (p < .01). Consistent results were obtained when comparing home-collected and clinic-collected samples within individuals. Men can be offered the option to collect semen samples at home for examination or assisted reproduction without compromising semen quality, especially for those with difficulty in producing semen samples at the clinic.     

Clinical and genetic features of variegate porphyria in a Chinese patient

Acute porphyria is rare in orientals. We describe a Chinese woman with recurrent generalised tonic-clonic seizures and abdominal pain. Genomic DNA studies identified a heterozygous base substitution from guanine to adenine at nucleotide position 503, resulting in substitution of arginine by histidine at position 168 of the protein (R168H). This genetic abnormality is similar to the mutation reported in Caucasians with variegate porphyria. To the best of our knowledge, this is the first report in the English literature a Chinese patient with variegate porphyria with an identifiable mutation. A brief review of porphyria is presented.