Detection and Significance of Occult Axillary Metastatic Disease in Breast Cancer Patients

▪ Abstract: After clinical staging, the single most important prognostic factor for patients with newly diagnosed primary breast cancer is the presence or absence of detectable metastases to axillary lymph nodes when examined by conventional light microscopy. More sensitive methods of determination of lymph node status, such as evaluation of serial sections, immunohistochemical staining, and use of molecular biological assays increase the rate of detection of micrometastases. Although the feasibility of enhanced detection of occult axillary metastatic disease is well established, the prognostic significance of such detection is only recently starting to emerge. Furthermore, the enormous recent interest in the application of sentinel lymph node biopsy as an alternative to the evaluation of the entire axilla in patients with breast cancer makes the first-time detailed evaluation for micrometastases practically feasible. In this review the different methods of detecting micrometastatic disease in the axilla and the significance of such findings are discussed. ▪     

Cytogenetics of pediatric acute myeloid leukemia

Acute myeloid leukemia (AML) is a clinically and genetically heterogeneous disease accounting for 15–20% of all childhood acute leukemias, while it is responsible for more than half of the leukemic deaths in these patients. This article focuses on the significance of cytogenetic analysis in pediatric AML supporting the importance of cytogenetic analysis in the pathogenesis, diagnosis, prognosis, follow‐up and treatment selection in childhood AML. It reviews in detail the types and frequencies of most common chromosomal aberrations, their molecular background, their correlation with French American British (FAB) subtypes and age distribution and their prognostic relevance. It also summarizes some less frequent or rare chromosome aberrations in which the prognostic classification has not been determined yet owning to the small number of patients and the variable treatment modalities used in different study groups. Furthermore, it discusses the association of specific chromosome rearrangements with prenatal exposure to carcinogenic agents or therapeutic agents and highlights the ongoing and future research on pediatric AML in the evolving field of Cytogenetics.     

Clinical study of the factors affecting radioulnar deviation of the wrist joint

Background  

The radioulnar carpal joint is critical for hand and wrist function. Radioulnar deviation indicates distal radioulnar joint flexibility and reflects the structure and function of the carpal bones, ulna, radius and ligaments. The present study examined whether radioulnar deviation is affected by gender, manual labor, playing a musical instrument, playing sport, handedness, previous fracture or prior inflammation. The study used clinical findings based on anatomical landmarks     

Modified technique of percutaneous dilational tracheostomy in 600 cases

Tracheostomy is frequently required for the treatment of critically ill patients to prevent the complications with prolonged translaryngeal intubation. It may facilitate airway suctioning and improve patient comfort during the process of weaning. The purpose of the study was to introduce a new modified technique for percutaneous dilational tracheostomy (MPDT) and assess its advantages. From November 1997 through December 2000, a series of 600 patients (350 men, 250 women; mean age 44.5 years) underwent MPDT in our department. The technique we used is a combination of the Seldinger and Schachner techniques with an incision of 2 to 3 cm between the cricoid cartilage and the notch. Using a small automatic retractor, the thyroid muscles were dissected with the help of a curved mosquito clamp. This gave us the opportunity to control the isthmus and offered the possibility of ligation when the thyroid was large, providing a good operative field directly on the trachea. Hence we avoided traumatizing the isthmus, which is the main source of hemorrhage during this procedure. The mean operating time was 4.5 minutes. The morbidity rate was 0.04%. One patient developed a subcutaneous emphysema and in three cases we had to ligate the external jugular vein. The surgical incision was completely healed within 3 to 4 days after removing the tracheostoma. No tracheal stenoses were observed during the follow-up. MPDT is a safe, applicable technique that can be performed quickly even by a nonsurgeon in the intensive care unit and emergency department, with a low risk of complications because there is a direct view of the trachea and minimal trauma.     

MIB-1 Proliferation Index in Ductal Carcinoma In Situ of the Breast: Relationship to the Expression of the Apoptosis-Regulating Proteins bcl-2 and p53

Tumor growth is the net result of cell proliferation and cell death. To investigate the relationship between these phenomena in ductal carcinoma in situ (DCIS), we studied proliferation index (PI) in DCIS in relation to the expression of two proteins involved in the regulation of cell death, bcl-2 and p53. Thirty-nine consecutive cases of DCIS were studied. PI was determined using immunolabeling with the monoclonal antibody MIB-1. The proportion of MIB-1-positive nuclei among 500 tumor cell nuclei was determined for each case and constituted the PI. All cases were also assessed immunohistochemically for bcl-2 and p53 protein expression. DCIS cases were graded using the criteria of Holland et al. PI ranged from 0 to 57% (mean 11.2%, median 4.6%). PI was significantly lower in well-differentiated and intermediately differentiated DCIS cases (mean 7.3% and 4.8%, respectively) than in poorly differentiated lesions (mean 24%, p = 0.01). PI was significantly lower in bcl-2-positive cases than in bcl-2-negative cases (mean PI for bcl-2-positive cases 6% and for bcl-2-negative cases 26%, p = 0.01). PI was higher in lesions expressing the p53 protein than in p53 negative cases (19% versus 8.3%), but this difference did not reach statistical significance. PI was also examined in relation to combinations of bcl-2 and p53 expression. Twenty-five of the DCIS lesions (64%) showed the bcl-2-positive/p53-negative phenotype which is similar to that seen in normal breast tissue and benign lesions and can be considered the "physiologic" combination. Among these cases the mean PI was 6.4%. In contrast, 14 cases showed "aberrant" combinations of bcl-2 and p53 expression suggesting dysregulated control of apoptosis. Among these cases the mean PI was 19.6% (p = 0.03). The highest mean PI was in cases with the bcl-2-negative/p53-positive phenotype (PI = 29.7%). DCIS lesions with the physiologic bcl-2-positive/p53-negative phenotype have low PI. In contrast, DCIS lesions with "aberrant" bcl-2/p53 phenotypes have high PI. This combination may favor tumor growth and progression in DCIS.     

Management of 150 flail chest injuries: analysis of risk factors affecting outcome.

OBJECTIVE: Flail chest continues to be an important injury with significant complications. The records of 150 patients presenting with flail chest injury were reviewed to determine risk factors affecting morbidity and mortality. MATERIAL AND METHOD: During a 7-year period 150 patients with a flail chest injury were admitted to our trauma center. There were 111 men (74%) and 39 women (26%) ranging in age from 18 to 88 years with a mean age of 56.9. Only 66 (44%) had an isolated flail chest injury on admission. The majority of patients were older than 55 years (n = 89, 59.3%), 80 (53.3%) presented with an hemo-, or/and pneumothorax, 36 (24%) sustained a head injury and 25 (16.7%) needed ICU monitoring. The mean ISS score was 38. Age, concomitant diseases, presence of pneumothorax and/or hemothorax, Severity Score (ISS), the need for mechanical support, length of stay and deaths were evaluated by using the t-test and chi2 test where appropriate. RESULTS: Sixty-seven patients (44.6%) were conservatively treated, while 80 (53.3%) needed thoracic drainage. Only in 6 cases (4%) thoracotomy was required, while in 9 (6%) laparotomy was performed. Mortality rate reached 5.3%. The main factors correlated with an adverse outcome were: ISS and the presence of associated injuries, while age, hemopneumothorax and mechanical support affected the length of hospitalization but not the mortality. CONCLUSIONS: (1) Age and hemopneumothorax did not affect mortality. (2) ISS was found to a strong predictor on outcome concerning morbidity and prolonged hospitalization but did not influence mortality rate. (3) Mechanical support was not considered a necessity for the treatment of flail chest.     

Recurrent torticollis secondary to Langerhans cell histiocytosis: a case report

Torticollis is a common clinical sign encountered by pediatricians and orthopaedic surgeons in a wide spectrum of childhood conditions ranging from benign to life-threatening. We report the case of a child with recurrent torticollis caused by Langerhans Cell Histiocytosis (LCH). The patient was a 1-year-old boy with recurrent torticollis, followed by a painless swelling over the right temporal bone. The diagnosis was confirmed by an open biopsy of the calvarial lesion. As LCH is a very rare cause of torticollis it was not considered in the initial differential by the primary care physicians and the diagnosis was delayed about 4 months. The patient received chemotherapy with steroids and etoposide for 52 weeks. He showed complete regression of the sign and imaging tests at the end of treatment were normal. No relapse of symptoms occurred during a follow-up period of 2 years. The rarity of this disease as well as the site and form of presentation are emphasised to alert physicians for an early diagnostic evaluation, which is important to prevent neurological lesions and other late complications.     

Correlation of her-2/neu gene amplification with other prognostic and predictive factors in female breast carcinoma

The purpose of this study was to determine if any relationship exists between Her-2/neu gene amplification and estrogen receptor (ER), progesterone receptor (PR), MIB-1, grade, size and age in female breast cancer. Five hundred and eighteen female patients with invasive breast carcinoma, 390 ductal and 128 lobular, in which assessment of Her-2/neu amplification by fluorescence in-situ hybridization (FISH) has been performed, were reviewed retrospectively. Each patient was further assessed for ER, PR, MIB-1, grade, size and age at diagnosis. Chi-square analysis was then used to correlate the above observations. Overall gene amplification was seen in 76 (15%) of the cases, 68 (17%) were ductal and 8 (6%) were lobular. Her-2/neu gene was amplified in 37 (10%) out of 379 ER positive cases and in 39 (28%) out of 139 ER negative cases. Her-2/neu was amplified in 22 (7%) out of 301 PR positive cases and in 54 (25%) out of 217 PR negative cases. Amplification occurred in 18 (8%) out of 222 negative MIB-1 cases and amplified in 58 (20%) out of 296 positive cases. Amplification was seen in 5 (10%) out of 49 grade I tumors, 17 (12%) out of 143 grade II tumors and 54 (27%) out of 198 grade III tumors. Lobular carcinomas were not graded. Amplification was present in 52 (15%) out of 346 T1 lesions, in 17 (13%) out of 130 T2 lesions, in 5 (17%) out of 30 T3 lesions and in 2 (17%) out of 12 T4 lesions. Her-2/neu was amplified in 67 (14%) out of 467 woman 41 years and older, and in 9 (18%) out of 51 women 40 years and younger. Comparison of these frequencies using chi-square test revealed statistically significant correlation between Her-2/neu amplification and ductal versus lobular carcinoma (p<0.0003), ER (p=0.0001) and PR (p<0.0001) negative tumors, over-expression of MIB-1 (p<0.0005) and high tumor grade (p=0.0009), while size of the tumor (p=0.08) and age of the patients (p=0.67) were not statistically significant. Correlation was found between Her-2/neu amplification and tumor type, high histological grade, ER and PR negative tumors, and high proliferative MIB-1 index. No correlation was found between size of the tumor and age of the patient with Her-2/neu amplification.