Long-term cardiac sequelae in operable breast cancer patients given adjuvant chemotherapy with or without doxorubicin and breast irradiation.

PURPOSE: To investigate long-term cardiac sequelae associated with anthracycline use in adjuvant chemotherapy of patients with early breast cancer. PATIENTS AND METHODS: All 1,000 patients from three prospective trials of adjuvant chemotherapy containing doxorubicin (n = 637, median total dose of 294 mg/m(2)) or not containing the anthracycline (cyclophosphamide, methotrexate, and fluorouracil [CMF] regimen alone, n = 363) were analyzed for the relative incidence of congestive heart failure (CHF) and myocardial infarction (MI) during 14 years of follow-up. The 462 women continuously free of disease as of February 1996 were recalled, and 355 consented to undergo evaluation including 12-lead ECG and cardiac ultrasound with determination of left ventricular ejection fraction (LVEF) to assess the relative incidence of abnormalities in long-term survivors. RESULTS: Among the 1,000 patients, there were six cases of CHF and three cases of MI. Cumulative cardiac mortality accounted for 0.4% (doxorubicin-treated = 0.6%; CMF-treated = 0). Eighteen (5%) of the 355 patients undergoing cardiac evaluation after median 11 years of follow-up presented systolic dysfunction as defined by pathologic (< 50%, n = 8) or borderline (50% to 55%, n = 10) LVEF. Systolic dysfunction was higher in doxorubicin-treated (15 of 192; 8%) than in CMF-treated patients (three of 150; 2%). Breast irradiation had a significant impact on the occurrence of early CHF (four of 116; 3%), but not on systolic dysfunctions. CONCLUSION: At longer than 10 years of follow-up, the use of doxorubicin at a total dose commonly applied in regimens of adjuvant chemotherapy does not lead to cardiac clinical sequelae that counter-balance the benefit of treatment in patients with operable breast cancer who may be cured of their disease.     

An injection technique to create a bloodless field in arthroscopically assisted anterior cruciate ligament reconstruction.

We did a retrospective study of 67 patients who had arthroscopically assisted anterior cruciate ligament reconstruction using the middle one-third of the patellar tendon to evaluate a technique for creating a bloodless field using a local anesthetic with epinephrine injection (the injection technique). For 37 patients, the bloodless field was created using the injection technique. In 30 others, hemostasis was achieved in the usual fashion with the pneumatic tourniquet. All patients underwent general anesthesia. Mean operative time and length of hospital stay was similar for each group. Mean postoperative pain medication consumption was significantly decreased for patients treated with the injection technique. No clinically recognizable complications could be attributed to either technique. We conclude that subcutaneous and intraarticular injection of local anesthesia with epinephrine is a satisfactory method of establishing a bloodless field in arthroscopically assisted anterior cruciate ligament reconstruction operations.     

Paternal coeliac disease and neonatal outcome

Abstract

Objective. To assess whether endoscopic flushes of the bubble-bursting agent Gascon and the mucolytic agent Pronase are as effective in terms of improving endoscopic mucosal visibility as a pre-endoscopic drink of the same agents. Material and methods. A total of 112 patients attending a Japanese tertiary referral centre for upper gastrointestinal endoscopy were randomized to receive either the standard Japanese procedure of a pre-endoscopic drink of water containing Gascon and Pronase with endoscopic flushes of 20-ml aliquots of water, or no pre-endoscopic therapy but endoscopic flushes of 20-ml aliquots of water containing Gascon, with or without Pronase as necessary. Results. Visibility scores were significantly better in the pre-endoscopic drink group than in either of the endoscopic flush groups. The group receiving a pre-endoscopic drink required fewer flushes during the procedure and there was no difference in the endoscopic time between the three groups. Conclusions. Our results suggest that endoscopic spraying of these bubble-bursting and mucolytic agents is not able to offer equivalent improvements in endoscopic mucosal visibility when compared with the standard Japanese therapy of a pre-endoscopic drink of these agents. The addition of Pronase to the spray solution had no measurable benefit over Gascon alone. We therefore cannot recommend endoscopic spraying of mucous clearing agents over their use as a pre-endoscopic drink.     

Fabry disease: clinical and genotypic aspects of three cases in first degree relatives

Fabry disease is an X-linked, lysosomal storage disease caused by the inherited deficiency of the enzyme α-galactosidase A. The diagnosis is usually late, with renal, cardiovascular and/or cerebral complications that reduce life expectancy. Angiokeratomas are asymptomatic lesions present as the initial manifestation and usually less appreciated. Their detection is important for early diagnosis and institution of treatment with enzyme replacement therapy, which prevents late complications reducing morbidity and mortality. We report a case of a male teenager with acroparestesias and angiokeratomas. Family medical research discovered that his mother and brother had similar signs and symptoms and that the three patients had the same mutation in the gene encoding the enzyme, confirming the diagnosis.     

Mammary and extramammary Paget's disease

Paget''s disease, described by Sir James Paget in 1874, is classified as mammary and extramammary. The mammary type is rare and often associated with intraductal cancer (93-100% of cases). It is more prevalent in postmenopausal women and it appears as an eczematoid, erythematous, moist or crusted lesion, with or without fine scaling, infiltration and inversion of the nipple. It must be distinguished from erosive adenomatosis of the nipple, cutaneous extension of breast carcinoma, psoriasis, atopic dermatitis, contact dermatitis, chronic eczema, lactiferous ducts ectasia, Bowen''s disease, basal cell carcinoma, melanoma and intraductal papilloma. Diagnosis is histological and prognosis and treatment depend on the type of underlying breast cancer. Extramammary Paget''s disease is considered an adenocarcinoma originating from the skin or skin appendages in areas with apocrine glands. The primary location is the vulvar area, followed by the perianal region, scrotum, penis and axillae. It starts as an erythematous plaque of indolent growth, with well-defined edges, fine scaling, excoriations, exulcerations and lichenification. In most cases it is not associated with cancer, although there are publications linking it to tumors of the vulva, vagina, cervix and corpus uteri, bladder, ovary, gallbladder, liver, breast, colon and rectum. Differential diagnoses are candidiasis, psoriasis and chronic lichen simplex. Histopathology confirms the diagnosis. Before treatment begins, associated malignancies should be investigated. Surgical excision and micrographic surgery are the best treatment options, although recurrences are frequent.     

High frequency of loss of heterozygosity at 11p15 and IGF2 overexpression are not related to clinical outcome in childhood adrenocortical tumors positive for the R337H TP53 mutation

The homeobox gene BP1 is expressed in over 80% of breast cancers and is associated with tumor progression and invasion. However, the mechanism of BP1 activation in these tumors remains unknown. Therefore our aim in this study is to assess the amplification status of the BP1 gene in breast cancer and to determine whether BP1 protein expression is caused by gene amplification in these tumors. BP1 amplification and expression were assessed in 36 samples. Twenty primary breast tumors (PBT) and 14 sentinel lymph node (SLN) metastases were analyzed using fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC), respectively. Because of the close proximity of BP1 and HER2/NEU genes on 17q, correlation between their amplification/expression was also investigated. Increased BP1 copy number was observed in 33% of the cases, with a frequency of 36% and 29% in the PBT and SLN metastasis, respectively. BP1 protein was expressed in 91% of the samples: in all of the PBT with increased BP1 copy number and 65% of PBT with normal copy number. HER2/NEU amplification was detected in 22% of the cases. Concordance between BP1 and HER2/NEU copy numbers was found in 68% of the PBT and 90% of the SLN metastasis. In conclusion, we demonstrated that the BP1 homeobox gene is amplified in breast cancer, both in PBT and SLN metastasis, with a significant correlation with HER2/NEU amplification. Considering that BP1 expression was observed in cases with both increased and normal BP1 copy number, we conclude that other mechanisms in addition to gene amplification play a role in BP1 protein expression.