Male breast cancer: management and follow-up recommendations

National Comprehensive Cancer Network (NCCN) guidelines for female breast cancer treatment and surveillance are well established, but similar guidelines on male breast cancers are less recognized. As an NCCN institution, our objective was to examine practice patterns and follow-up for male breast cancer compared to established guidelines for female patients. After Institutional Review Board approval, a prospective breast database from 1990 to 2009 was queried for male patients. Medical records were examined for clinico-pathological factors and follow-up. The 5-year survival rates with 95% confidence intervals were estimated using Kaplan-Meier method and Greenwood formula. Of the 19,084 patients in the database, 73 (0.4%) were male patients; 62 had complete data. One patient had bilateral synchronous breast cancer. The median age was 68.8 years (range 29-85 years). The mean/median invasive tumor size was 2.2/1.6 cm (range 0.0-10.0 cm). All cases had mastectomy (29 with axillary node dissection, 23 with sentinel lymph node biopsy only, 11 with sentinel node biopsy followed by completion axillary dissection). Lymph node involvement occurred in 25/63 (39.7%). Based on NCCN guidelines, chemotherapy, hormonal therapy, and radiation are indicated in 34 cases, 62 cases, and 14 cases, respectively. Only 20/34 (59%) received chemotherapy, 51/62 (82%) received hormonal therapy, and 10/14 (71%) received post-mastectomy radiation. Median follow-up was 26.2 months (range: 1.6-230.9 months). The 5-year survival estimates for node positive and negative diseases were 68.5% and 87.5%, respectively (p = 0.3). Despite the rarity of male breast cancer, treatment options based on current female breast tumors produce comparable results to female breast cancer. Increased awareness and a national registry for patients could help improve outcomes and tailor treatment recommendations to the male variant.     

Sphingosine kinase 1 protects against renal ischemia-reperfusion injury in mice by sphingosine-1-phosphate1 receptor activation

The roles of sphingosine kinases SK1 and SK2 in ischemia-reperfusion injury have not been fully elucidated since studies have found beneficial effects of SK1 while others showed no role in this injury. To help resolve this, we used SK1 or SK2 knockout mice and confirmed that renal ischemia-reperfusion injury induced SK1, but not SK2, in the kidneys. Furthermore, knockout or pharmacological inhibition of SK1 increased injury after renal ischemia-reperfusion injury. In contrast, lack of SK2 conferred renal protection following injury. In addition, we used lentiviral gene delivery to selectively express enhanced green fluorescent protein (EGFP) or human SK1 coexpressed with EGFP (EGFP-huSK1) in the kidney. Mice with kidney-specific overexpression of EGFP-huSK1 had significantly improved renal function with lower plasma creatinine, renal necrosis, apoptosis, and inflammation. Moreover, EGFP-huSK1 overexpression in cultured human proximal tubule (HK-2) cells protected against peroxide-induced necrosis. Selective overexpression of EGFP-huSK1 led to increased HSP27 mRNA and protein expression in vivo and in vitro. Functional protection as well as induction of HSP27 with EGFP-huSK1 overexpression in vivo was blocked with sphingosine-1-phosphate-1 receptor(1) (S1P(1)) antagonism. Thus, our findings suggest that SK1 is renoprotective by S1P(1) activation and perhaps HSP27 induction. Kidney-specific expression of SK1 through lentiviral delivery may be a viable therapeutic option to attenuate renal ischemia-reperfusion injury.     

Postoperative biomarkers predict acute kidney injury and poor outcomes after pediatric cardiac surgery

Acute kidney injury (AKI) occurs commonly after pediatric cardiac surgery and associates with poor outcomes. Biomarkers may help the prediction or early identification of AKI, potentially increasing opportunities for therapeutic interventions. Here, we conducted a prospective, multicenter cohort study involving 311 children undergoing surgery for congenital cardiac lesions to evaluate whether early postoperative measures of urine IL-18, urine neutrophil gelatinase-associated lipocalin (NGAL), or plasma NGAL could identify which patients would develop AKI and other adverse outcomes. Urine IL-18 and urine and plasma NGAL levels peaked within 6 hours after surgery. Severe AKI, defined by dialysis or doubling in serum creatinine during hospital stay, occurred in 53 participants at a median of 2 days after surgery. The first postoperative urine IL-18 and urine NGAL levels strongly associated with severe AKI. After multivariable adjustment, the highest quintiles of urine IL-18 and urine NGAL associated with 6.9- and 4.1-fold higher odds of AKI, respectively, compared with the lowest quintiles. Elevated urine IL-18 and urine NGAL levels associated with longer hospital stay, longer intensive care unit stay, and duration of mechanical ventilation. The accuracy of urine IL-18 and urine NGAL for diagnosis of severe AKI was moderate, with areas under the curve of 0.72 and 0.71, respectively. The addition of these urine biomarkers improved risk prediction over clinical models alone as measured by net reclassification improvement and integrated discrimination improvement. In conclusion, urine IL-18 and urine NGAL, but not plasma NGAL, associate with subsequent AKI and poor outcomes among children undergoing cardiac surgery.     

Comparison of the effect-site concentrations of remifentanil for Streamlined Liner of the Pharynx Airway (SLIPA) versus laryngeal mask airway SoftSealTM insertion during target-controlled infusion of propofol

This study was designed to determine the optimal dose of remifentanil required for the successful insertion of Streamlined Liner of the Pharynx Airway (SLIPA) and to compare it to that required for laryngeal mask airway (LMA) insertion in patients receiving a propofol infusion at a standard effect-site concentration. Fifty-eight patients scheduled to undergo general anaesthesia were randomly assigned to either the SLIPA (n = 29) or LMA (n = 29) group. All patients were premedicated with midazolam 0.05 mg x kg(-1) and glycopyrrolate 0.004 mg x kg(-1) intramuscularly. After the administration of lignocaine 1 mg x kg(-1) intravenously, a propofol infusion was started at an effect-site concentration of 3.5 microg x ml(-1) with a remifentanil infusion without a neuromuscular blocking agent. The remifentanil dose was determined by the modified up-and-down method starting in each group at 4 ng x ml(-1). Six minutes after induction, the airway device was inserted. Airway device insertion was classified as 'success' or 'failure' based on patient response. From the isotonic regression analysis and bootstrap distribution, the EC50 of remifentanil for SLIPA and LMA were 0.93 ng x ml(-1) (95% confidence interval [CI] 0.81 to 1.50 ng x ml(-1) and 1.36 ng x ml(-1) (95% CI 1.19 to 2.06 ng x ml(-1)) respectively, and the EC95 for SLIPA and LMA insertions were 1.90 ng x ml(-1) (95% CI 1.39 to 1.95) and 2.43 ng x ml(-1) (95% CI 1.80 to 2.46 ng x ml(-1)) respectively. Using the 83% CIs from the bootstrap distribution, EC50 for SLIPA was significantly less than that of LMA (0.83 to 1.23 vs 1.26 to 2.00, respectively) (P < 0.05). These findings suggest that the insertion of SLIPA needs about a 32% lower depth of anaesthesia than LMA insertion.     

Spontaneous rupture of a sigmoid colon gastrointestinal stromal tumor manifesting as pneumoretroperitoneum with localized peritonitis: Report of a case

Colonic gastrointestinal stromal tumors (GISTs) account for only 5%-10% of tumors arising in the digestive tract. Spontaneous rupture is a very rare manifestation of a GIST; however, we report what to our knowledge is the first documented case of pneumoretroperitoneum caused by the rupture of a GIST. A 77-year-old woman was admitted to our hospital with acute abdominal pain and hematochezia. Colonoscopy showed luminal narrowing in the sigmoid colon, but no definite mucosal defect. Computed tomography (CT) showed an air-containing heterogeneous mass, 9.7 × 9.3 cm, in the pelvic cavity and a small amount of air in the retroperitoneum. Emergency laparotomy revealed a ruptured sigmoid colonic GIST with localized peritonitis. Pathologic examination confirmed that the tumor was composed mainly of round epithelioid cells. It was immunohistochemically positive for CD34 and negative for C-kit protein. This report describes how we successfully managed pneumoretroperitoneum with localized peritonitis caused by the spontaneous rupture of an epithelioid GIST originating from the sigmoid colon.     

Biology of vascular endothelial growth factor and its receptors in head and neck cancer: beyond angiogenesis

Angiogenesis is a necessary process for tumor progression and is driven through molecular interactions between cancer cells and neighboring vascular endothelial cells. The primary mediators of angiogenesis are the vascular endothelial growth factors and their respective receptors on endothelial cells. There are several U.S. Food and Drug Administration-approved anti-angiogenic agents in clinical use. In head and neck cancer there are clinical trials assessing the efficacy of anti-angiogenic agents in combination with chemoradiation therapy. Although the aforementioned growth factors and receptors have been traditionally viewed as anti-angiogenic targets, there are concomitant efforts to understand the role these molecules play within the tumor cells. In this review, we first discuss the biology of angiogenic proteins and the targeting of angiogenic molecules for cancer treatment. We summarize the current clinical trials of anti-angiogenic therapies in head and neck squamous cell carcinoma. Finally, the additional role these molecules play in tumor progression independent of angiogenesis is discussed.     

Delayed occurrence of spinal arachnoiditis following a caudal block

Context

Spinal arachnoiditis is a rare disease caused by fibrosis and adhesion of the arachnoid membrane due to chronic inflammation. The causes of arachnoiditis are infection, spinal surgery, intraspinal injection of steroid or myelography dye, and spinal anesthesia.

Method

Case report.

Findings

A 60-year-old woman presented with progressive weakness and sensory change of both legs and urinary symptoms. She had received a single caudal block 6 months before symptom onset. Magnetic resonance imaging of the thoraco-lumbar spine showed an intradural extramedullary tumor at the T5–T7 level. She underwent laminectomy and tumor resection. The pathological finding was arachnoiditis. After surgery, a rehabilitation program of strengthening exercises of both lower extremities and gait training was started. At 2-month follow-up, she was able to walk with orthoses and performed daily activities with minimal assistance.

Conclusion

Symptoms of spinal arachnoiditis occurred 6 months after a single caudal block in this woman. Clinicians should be aware of this possible delayed complication.     

Plain Radiograph Fails to Reflect the Alignment and Advantages of Navigation in Total Knee Arthroplasty

The study purposed to determine if a navigation in total knee arthroplasty (TKA) leads to accurate limb alignment and component position than the conventional technique as measured by full length standing radiographs and to evaluate the correlation between navigation and radiographic measurements. A total of 160 knees underwent navigation (n = 80) or conventional (n = 80) TKAs. The frontal femoral alignment was more accurate in navigation TKAs, whereas mechanical axis and frontal tibial alignment were similar in both techniques. Although the intraoperative navigation alignment showed no outliers, postoperative radiographic measure resulted as much as 20% of outliers, and there was no correlation between the two measurements. This lack of correlation and inherent limitations in measuring TKA alignment may bring to question if plain radiograph are useful to determine if alignment achieved by navigation is accurate.     

Primary total hip arthroplasty with an uncemented femoral component five- to nine-year results

This study reports the outcome of total hip arthroplasty with use of an uncemented, tapered stem with a 5- to 9-year follow-up. The first 200 consecutive patients (214 hips) undergoing total hip arthroplasty with the Accolade TMZF stem (Stryker Orthopaedics, Mahwah, NJ) were enrolled prospectively. Follow-up for these patients averaged 7.6 years and encompassed review of clinical records as well as review of serial anteroposterior and lateral radiographs. There were 5 revision surgeries for aseptic loosening, 2 cases of infection, instability, and polyethylene wear. Our failure rate, defined as hips needing revision, was 2.6%, and the failure rate due to aseptic loosening of the femoral component was 0.6%. These results demonstrate the high success rate of this implant providing support for its continued use.