Evidence-based risk factors for seroma formation in breast surgery

BACKGROUND: Seroma is a common problem in breast surgery. The aim of this systematic review was to identify risk factors for seroma formation. METHODS: Articles published in English were obtained from searches of Medline and additional references were found in the bibliographies of these articles. Risk factors were graded according to the quality and strength of evidence and to the direction of association. RESULTS: One meta-analysis, 51 randomized controlled trials, 7 prospective studies and 7 retrospective studies were identified. There was no risk factor supported by strong evidence, but there was moderate evidence to support a risk for seroma formation in individuals with heavier body weight, extended radical mastectomy as compared with simple mastectomy, and greater drainage volume in the initial 3 days. On the other hand, the following factors did not have a significant influence on seroma formation: duration of drainage; hormone receptor status; immobilization of the shoulder; intensity of negative suction pressure; lymph node status or lymph node positivity; number of drains; number of removed lymph nodes; previous biopsy; removal of drains on the fifth postoperative day versus when daily drainage volume fell to minimal; stage; type of drainage (closed suction versus static drainage); and use of fibrinolysis inhibitor. In contrast, sentinel lymph node biopsy reduced seroma formation. Evidence was weak, or unproven, for other factors that were commonly cited in the literature. CONCLUSIONS: Although a number of factors have been correlated with seroma formation, strong evidence is still scarce. However, there is evidence showing that sentinel lymph node biopsy reduces seroma formation.     

Pathologic processes leading to cerebral hemorrhage in amyloid angiopathy

This report concerns a study undertaken to eluidate the pathogenesis of arterial rupture related to amyloid deposition. For this purpose, histochemical and immunohistochemical analyses were carried out on brain tissue specimens of a case of cerebral amyloid angiopathy (CAA) with multiple cortical hemorrhages. A small amount of amyloid β-protein was found in the tunica media vasorum in which the smooth muscle cells were well preserved. with increases in amyloiod deposition, the entire arteriolar wall became concenmtrically thick, with amyloid largely occupying the tunica media; the number of smooth muscle cells was decreased and these cells were located in the intimal side of the vessel wall. Under these conditions, the elastic fibers and endothhelial cells were relatively well preserved. In the advanced stage of amyloid deposition, the arterioles became devoid of smooth muscle cells and underwent wither fibrous luminal occlusionor aneurysmal dilatation with fibrinoid necrosis and loss of elastic fibers; the latterwould eventually rupture causing the hemorrhage. These findings suggest that amyloid β-protein-related loss of arteriolar smooth muscle cells could be the initial event, with the subsequent damage of the vascular wall leading to cerebral hemorrhages in CAA patients.     

Promotion of tumorigenesis by heterozygous disruption of the beclin 1 autophagy gene

Malignant cells often display defects in autophagy, an evolutionarily conserved pathway for degrading long-lived proteins and cytoplasmic organelles. However, as yet, there is no genetic evidence for a role of autophagy genes in tumor suppression. The beclin 1 autophagy gene is monoallelically deleted in 40-75% of cases of human sporadic breast, ovarian, and prostate cancer. Therefore, we used a targeted mutant mouse model to test the hypothesis that monoallelic deletion of beclin 1 promotes tumorigenesis. Here we show that heterozygous disruption of beclin 1 increases the frequency of spontaneous malignancies and accelerates the development of hepatitis B virus-induced premalignant lesions. Molecular analyses of tumors in beclin 1 heterozygous mice show that the remaining wild-type allele is neither mutated nor silenced. Furthermore, beclin 1 heterozygous disruption results in increased cellular proliferation and reduced autophagy in vivo. These findings demonstrate that beclin 1 is a haplo-insufficient tumor-suppressor gene and provide genetic evidence that autophagy is a novel mechanism of cell-growth control and tumor suppression. Thus, mutation of beclin 1 or other autophagy genes may contribute to the pathogenesis of human cancers.     

Occult breast carcinoma presenting with axillary lymph node metastases: follow-up of eleven patients

BACKGROUND: Breast carcinoma presenting with axillary metastases and no clinically apparent primary tumor in the breast is an uncommon form of stage IIdisease. The methods of diagnosis and treatment of these patients are not established. We present our eleven treated cases of occult carcinoma and discuss the issues of evaluation and management. METHODS: Eleven patients with occult breast carcinoma (OBC) presenting between January, 1985 and April, 1998 at the National Shikoku Cancer Center were evaluated clinically and with immunohistochemical staining. Immunohistochemical staining was performed using the Envision method. The primary antibodies for gross cystic disease fluid protein-15 (GCDFP-15), estrogen receptor (ER) and progesterone receptor (PR) were used. RESULTS: Nine patients underwent mastectomy. Breast-conserving surgery was performed in one patient. One patient did not receive any operation for the breast. No primary tumor was found among three of nine cases receiving mastectomy. Some adjuvant therapies after the operation were performed in eight cases. Follow-up ranged from 5 to 310 months (median, 54 months), and the five-year disease free survival rate was 62.5%. There were eight GCDFP-15 positive cases (72.7%) and four ER and/or PR positive cases (36.4%). CONCLUSIONS: GCDFP-15 is useful for confirming the primary site of breast carcinoma. Ultrasonography, computed tomography, and magnetic resonance imaging are thought to be good for detecting occult primary tumors. The incidence of OBC is still unclear, but it is possible that these patients need to be treated as typical stage II patients.     

Development of a nerve scaffold using a tendon chitosan tube

Bridge grafting (15 mm) into the sciatic nerve of SD rats was carried out using tendon chitosan tubes having either a circular or triangular cross-section, as well as triangular tubes combined with laminin, CDPGYIGSR, or CSRARKQAASIKVAVSAD (n = 15 in each group). As a control, isografting (15 mm) was carried out in the SD rats (n = 7). Specimens were taken after 1, 2, 4, 6, and 8 weeks for histology, and nerve regeneration was evaluated electro-physiologically and histologically after 12 weeks. The mechanical strength of triangular tubes was found to be higher than circular tubes, and the inner volume of a triangular tube tends to be larger than in circular tubes. Nerve tissue regeneration along the tube wall was found in both the laminin and laminin peptide groups. According to the result of percentage neural tissue in relation to evoked action potentials, the consecutive treatments of YIGSR and IKVAV was found to match the effectiveness of intact laminin.     

Cytotoxicity and radical modulating activity of Moxa smoke

The biological activities of Moxa, used as moxibustion, have not been well documented. We investigated here Moxa smoke for its tumor-specific cytotoxicity, anti-HIV activity, radical intensity and radical scavenging activity, in comparison with previously published data of Moxa extract. Moxa smoke showed slightly higher cytotoxicity against human tumor cell lines (oral squamous cell carcinoma HSC-2, HSC-3, promyelocytic leukemia HL-60) than against normal oral cells (gingival fibroblast HGF, pulp cell HPC, periodontal ligament fibroblast HPLF), yielding a tumor specificity index of 1.29. Moxa smoke dose-dependently induced internucleosomal DNA fragmentation, activation of caspases 3, 8 and 9, and slightly modified the expression of apoptosis-related proteins (Bcl-2, Bad, Bax) in HL-60 cells, but to much lesser extents than attained by positive controls (UV irradiation, actinomycin D treatment). ESR spectroscopy showed that Moxa smoke generated semiquinone-type radicals under alkaline conditions, and scavenged O2(-), hydroxyl radical, singlet oxygen and NO. All Moxa smoke preparations showed no apparent anti-HIV activity. These data demonstrate the antitumor potential of Moxa smoke.     

Role of technetium-99m pertechnetate scintigraphy in the management of extra-abdominal fibromatosis

The purpose of this study was to investigate technetium-99m pertechnetate (Tc-99m) as a tumor-scanning agent in patients with extra-abdominal fibromatosis, and to establish the sensitivity of this type of scintigraphy. Eleven patients with extra-abdominal fibromatosis were studied: all but one having postsurgical recurrences. Of the 11 patients, diagnosed histologically, 5 underwent repeated Tc-99m scintigraphic follow-up examinations. The injected 370 MBq Tc-99m gave us an early scintigram within 10 min and a delayed one 2 h later. For adequate comparison, the region of interest (ROI) of the scintigram was placed over the tumor. The tumor-to-background (T/BG) count ratio was computed. Extra-abdominal fibromatoses, even recurrences, were demonstrated scintigraphically in both the early and the delayed phase, in all 11 patients. The average T/BG ratio was 2.11 in the early scintigram and 2.15 in the delayed one. The sensitivity and the specificity were both 100%. Tc-99m scintigraphy has proved useful in detecting extra-abdominal fibromatoses and in the follow-up of patients.     

Resection of a Recurrent Parasagittal Meningioma with Cortical Vein Anastomosis: Technical Note

Background

Simpson Grade I resection of parasagittal meningiomas is not always feasible because of the involvement of the sagittal sinus and cortical veins. Complete resection requires reconstruction of the sagittal sinus and cortical veins. This report describes a surgical technique to preserve patency of the cortical veins.

Case Report

A recurrent parasagittal meningioma completely occupied the superior sagittal sinus and encased several large cortical veins. The tumor in the sagittal sinus was totally resected and the roof of the sinus was sutured. To avoid thrombotic cortical vein occlusion, two cortical veins encased by the meningioma were anastomosed end-to-end, regardless of their flow directions. The postsurgical course was uneventful and patency of the anastomosed veins was confirmed by postoperative angiography.

Conclusions

End-to-end anastomosis of cortical veins was a useful surgical technique for radical resection of a parasagittal meningioma.     

A case of cerebellar hamartoma suggesting abnormal cell migration

Summary A rare case of hamartoma of the left cerebellar hemisphere was recognized in an 11-monthold male infant whose mother had a history of unspecified medication in the early gestational period and had a difficult delivery. A notably large head and marked developmental disorders, like hypotonic cerebral palsy, were observed soon after birth. A computed tomogram revealed an iso-minimally enhanced large mass in the left cerebellar hemisphere, which deformed the fourth ventricle and compressed the right cerebellum, as well as moderate cerebral atrophy. Histologically, the border between the cerebellar cortex and this tumor was not apparent. The main tumor, located in the cerebellar white matter, was composed of numerous scattered Purkinje cell-like neurons and glial cells surrounded by abundant GFAP-positive matrix. The small part of the tumor, located near the choroid plexus, was composed of intensely proliferated capillaries such as in capillary hemangioma, and numerous fibrocytes, which were intermingled with several large Purkinje cell-like neurons and some GFAP-positive glial cells. The cerebellar cortex showed a thin molecular layer with some residual external granular cells, a marked decrease of Purkinje cells and a moderate decrease in the internal granular layer, in which large Purkinje cell-like neurons were scattered. Purkinje cells and large Purkinje cell-like neurons scattered in the internal granular layer, cerebellar white matter and choroid plexus showed positive immunoreactivity for anti-Leu-4 monoclonal antibody, which is known to be a marker for Purkinje cells. These findings suggest that this case had the background of abnormal cell migration caused by some kind of disorder during pregnancy.