Tumor of the liver (hepatocellular and high grade neuroendocrine carcinoma): a case report and review of the literature

We describe a rare hepatic collision tumor composed of a hepatocellular carcinoma and a high-grade neuroendocrine carcinoma. The patient, a 50-year-old man, underwent a partial hepatectomy because of a 5.0-cm mass. The tumor had two distinctive patterns. The majority of the tumor was a high-grade neuroendocrine carcinoma with features of a small cell carcinoma that was positive for chromogranin, synaptophysin, and cytokeratin 19 and negative for hepatocellular antigen and alpha-fetoprotein (AFP). The second component was a moderately differentiated hepatocellular carcinoma that was positive for hepatocellular antigen and AFP and negative for neuroendocrine markers. The two tumors were separated by fibrous bands. In areas where they collided, there was no transition or intermingling of cells between the two components, thus, it is different from the combined type of tumors. After removal of the tumor, the patient had intrahepatic and mesenteric recurrences within a follow-up period of 16 months.     

Head-to-head comparison of the activities of currently available antifungal agents against 3,378 Spanish clinical isolates of yeasts and filamentous fungi

We have compared the activities of posaconazole and other currently available antifungal agents against a collection of 3,378 clinical isolates of yeasts and filamentous fungi. A total of 1,997 clinical isolates of Candida spp., 359 of other yeast species, 697 strains of Aspergillus spp., and 325 nondermatophyte non-Aspergillus spp. were included. The average geometric means of the MICs of agents that were tested against Candida spp. were 0.23 microg/ml for amphotericin B, 0.29 microg/ml for flucytosine, 0.97 microg/ml for fluconazole, 0.07 microg/ml for itraconazole, 0.04 microg/ml for voriconazole, 0.15 microg/ml for caspofungin, and 0.03 microg/ml for posaconazole. Voriconazole and posaconazole were active in vitro against the majority of isolates, with resistance to fluconazole and itraconazole, and against Cryptococcus neoformans and other Basidiomycota yeasts. Posaconazole was the most active of antifungal agents tested against Aspergillus spp., with an average geometric mean of 0.10 microg/ml. It was active against Paecilomyces spp., Penicillium spp., Scedosporium apiospermum, and some black fungi, such as Alternaria spp. Multiresistant filamentous fungi, such as Scedosporium prolificans, Scopulariopsis brevicaulis, and Fusarium solani, were also resistant to voriconazole, caspofungin, and posaconazole. Amphotericin B and posaconazole were found to be active against most of the Mucorales strains tested. Posaconazole and currently available antifungal agents exhibit a potent activity in vitro against the majority of pathogenic fungal species.     

Multicenter Collaborative Study for Standardization of Candida albicans Genotyping Using a Polymorphic Microsatellite Marker

Microsatellite-based genotyping for Candida albicans can give discrepant results between laboratories when expressed in fragment sizes, because their determination depends on electrophoretic conditions. The interlaboratory reproducibility was assessed in six laboratories provided with an allelic ladder. Despite variations in size determinations, alleles were correctly assigned, making data transportable between laboratories.Candida albicans is a diploid yeast responsible for a wide range of fungal infections in both immunocompetent and immunocompromised individuals. It is the most frequent fungal species involved in recurrent infections, outbreaks, and nosocomial infections (18). Genotyping of C. albicans can be performed using fluorescence-based microsatellite length polymorphism (MLP) analysis of PCR-amplified DNA fragments (2, 4, 5, 9, 11, 20, 21). Microsatellite sequences are defined as tandemly repeated stretches of 1 to 6 nucleotides and are excellent candidates for genetic analysis as they are polymorphic. Microsatellite alleles are often expressed as DNA fragments of different sizes obtained after PCR amplification with primers flanking the microsatellite region (22). Based on the variations in repeat numbers, genetic relatedness between different isolates can be assessed.MLP analysis is a method with a high discriminatory power and reproducibility, and it allows high throughput. It has proved its efficacy in genotyping large collections of samples in epidemiological studies of not only C. albicans but also other yeasts, such as Candida glabrata (10, 13), Candida tropicalis (6), and filamentous fungi, such as Aspergillus fumigatus or Penicillium marneffei (1, 7, 17). However, interlaboratory exchange of microsatellite data can be difficult, because the use of different equipment and diverse capillary electrophoresis conditions can lead to altered assessment of PCR fragment lengths. In the past, calibration by means of allelic ladders was applied for the analysis of population data (12, 14, 19, 23). More recently, de Valk et al. (8) produced locus-specific allelic ladders for the microsatellite-based analysis of Aspergillus fumigatus and tested its utility for assigning allele sizes in an interlaboratory study. In order to normalize C. albicans microsatellite results, we developed an allelic ladder that includes the most frequently occurring alleles of the CDC3 polymorphic microsatellite marker (2). Our objective was to test interlaboratory genotyping results by using the allelic ladder as an internal reference for a given marker.First, the allelic ladder for the tetranucleotide repeat (AGTA) CDC3 marker was constructed. Seven alleles in C. albicans were identified in our previous studies (2, 11). Genomic DNA of isolates known to contain the different alleles was extracted using the High Pure PCR template preparation kit as described by the manufacturer (Roche Applied Biosciences, Germany). Alleles were amplified in single-plex PCRs in a 20-μl reaction volume, consisting of 2 μl DNA, 1× PCR buffer (Roche Diagnostics GmbH, Mannheim, Germany), 0.2 mM each deoxynucleoside triphosphate, 5 mM MgCl₂, and 5 pmol of each CDC3 primer, with the sense primer labeled with hexachlorocarboxyfluorescein (HEX) (2) and 1.25 U of Taq Gold polymerase (Applied Biosystems, les Ulis, France). PCR was performed in an iCycler thermocycler (Bio-Rad, Hercules, CA) and consisted of an initial denaturation step at 95°C for 10 min, followed by 30 cycles of 30 s at 95°C, 30 s at 55°C, and 1 min at 72°C, with a final extension step of 30 min at 72°C. PCR products were then pooled in equivalent volumes, and 2 μl of this allelic pool was added to 13.5 μl of Hi-Di formamide (Applied Biosystems) and 0.5 μl 6-carboxy-X-rhodamine (ROX)-labeled Geneflo 625 size standard (Eurx, Gdansk, Poland). Capillary electrophoresis of the allelic ladder was performed using the ABI Prism 3730XL sequencer (Fig. ​(Fig.1).1). Sizes of the seven alleles were calculated with GeneMapper (version 4; Applied Biosystems). Reproducibility was tested in 10 separate experiments that resulted in allele size variation of ≤0.08 nucleotides for the seven alleles.Open in a separate windowFIG. 1.Example of allele assignment using the CDC3 allelic ladder for two isolates, numbers 22 and 15. Allele peaks in the ladder (black lines) are marked as p1 to p7. GeneFlo 625 internal size standards (black filled peaks) with sizes in bp are shown beneath each peak. Isolate 15 is p2-p5 heterozygous, and isolate 15 is p4 homozygous.The CDC3 ladder (10 μl) was sent to six participating laboratories with previous experience in MLP analysis. The National Reference Center for Mycoses and Antifungals (NRCMA) also provided five C. albicans DNA samples of known CDC3 genotypes (DNA samples 1 to 5) and the CDC3 primers (2). To test the influence of the DNA extraction method, each participant laboratory selected five isolates from their own strain collection, extracted the genomic DNA, and performed MLP genotyping on these samples (samples 6 to 35). The 35 DNA samples were sent to the NRCMA for blind MLP analysis.Participants were made aware of the number of allele peaks identified in the ladder (one to seven) and were asked to perform MLP using the NRCMA''s PCR amplification/cycling conditions and their own equipment and reagents (Table ​(Table1).1). For each DNA sample, genotyping results were expressed as peak numbers (1 to 7), and fragment sizes were expressed in bp. As shown in Table ​Table2,2, reported fragment sizes varied between the laboratories, with size differences of up to 4.3 bp. However, upon comparing the results to the allelic ladder, all laboratories correctly assigned peak numbers to the five DNA samples.

TABLE 1.

Conditions and equipment used by NRCMA and the six participant teams

Insertion of Right Ventricular Assist Device and Its Removal Under Local Anesthesia

Abstract   A patient with acute right ventricular infarction was treated with coronary artery bypass grafting. A few days later developed right ventricular failure and required insertion of a right ventricular assist device through a sternotomy approach (TandemHeart^®, CardiacAssist, Inc., Pittsburgh, PA, USA). We herein report a technique in which the removal of the right ventricular assist device is performed under local anesthesia without a sternotomy incision. (J Card Surg 2010;25:113-115)     

Tuberculosis and HIV infection

We review important new recommendations on the treatment and prophylaxis of tuberculosis in HIV-infected individuals. Large-scale studies and expert consensus panels have both concluded that shorter courses and intermittent antituberculous regimens are adequate for the treatment of dually infected individuals. Also, the substitution of rifabutin for rifampin for the treatment and prophylaxis of tuberculosis has been shown to be advantageous, providing equivalent efficacy to regimens containing rifampin, and fewer drug interactions with antiretroviral medications.     

Targeted radiotherapy for small cell lung cancer using 90Yttrium-DOTATOC, an Yttrium-labelled somatostatin analogue: a pilot trial

BACKGROUND: Some small cell lung carcinomas (SCLC) express neuro-endocrine markers, such as somatostatin receptors. Therefore, somatostatin analogues can be radio-labelled with 111Indium (Octreoscan) for diagnostic scintigraphy, or with 90Y-DOTATOC for therapeutic use. This is the first trial to assess the toxicity and efficacy of treatment with 90Y-DOTATOC in patients with Octreoscan positive SCLC. METHODS: Patients with SCLC after > or =first line chemotherapy received an Octreoscan scintigraphy and results were compared to CT scans. Patients with strong somatostatin-receptor expression were treated with 60 mCi/m2 90Y-DOTATOC i.v. every 3 weeks, for a total of three cycles. Major inclusion criteria were measurable tumour lesions, disease progression, normal creatinine clearance, PS < or = 2. RESULTS: Octreoscan scintigraphy identified 70% of all primary tumours, 87% of all mediastinal lesions, but only 26% of all extrathoracic tumour manifestations. Six patients were treated. Median number of 90Y-DOTATOC cycles was 2 (1-3). The only grade 3 toxicity was fatigue (n = 2) and dyspnea (n = 1). There were no severe renal or haematological toxicities. All six patients had tumour progression, median progression free survival (PFS) was 37.5 days (28-52) and median overall (OS) was 103.5 days (28-269). CONCLUSION: This is the first report of somatostatin-receptor targeted radiotherapy for SCLC in the literature. In contrast to well differentiated neuro-endocrine tumours, 90Y-DOTATOC seems to be inactive in SCLC.