Immunopathologic study of fixed drug eruption

Objectives: Fixed drug eruption is a common distinct variant of druginduced dermatoses. Although effector and regulatory T cells play roles in the progression and resolution of FDE, respectively, little in- vivo data exist regarding the T cell dynamics in the pathogenesis of FDE. The aim of this study was to through some light on the pathogenesis of FDE through in-situ study of the immunostaining with CD4, CD8 and HLA-DR. Design: Thirty patients with FDE, [16 females and 14 males], their ages ranged between 6 and 54 years with mean 19.6 years old, were included in this study, in addition to 10 normal, age and sex matched, control subjects Settings: Dermatology and Pathology Departments, Menoufiya Faculty of Medicine

Intervention: skin biopsies were taken from 16 active and 14 healed lesions of FDE besides 20 control biopsies [10 biopsies from lesionalnearby, skill and 10 normal skin]. H and E stained sections were subjected to ordinary pathological examination. Three unstained sections from each biopsy were prepared on poly-L lysine coated slides and subjected to immunostaining withCD4, CD8 and HLA-DR. Serum Ca, total and ionized, was measured

Results: In acute FDE lesions, H and E sections revealed prominent dermal inflammatory cells infiltrating the epidermis in 100% of cases, hydropic degeneration, spongiosis and dyskeratosis besides melanin in- continence; In healed lesions, H and E stained sections revealed epidermal atrophy and there was perivascular inflammatory infiltrate. The immunostaining of HL4-DR was evident with strong expression in the inflammatory cells in dermis [mmmcl epidermis. The immunostaining of active lesions showed CD8+ T cells and CD4 + T cells in both the epidermis and dermis. In healed lesions, CD8+ T cells were detected in 93% in the epidermis and CD4 + T cells were detected in 21.4% of lesions. Serum Ca was statistically decreased in patient than in control group

Conclusions: Activation of T cells residing in the resting FDE lesions, by ingestion of a causative drug can rapidly produce large amounts of IFN gamma followed by localized epidermal injury. Such early IFN gamma production in-situ was only observed in the intraepidermal resident T cells in the lesions but not those in the peri-lesional skin and consequently progressed to localized epidermal injury. The in-situ studies indicated that CD8 + ve T cells persist in a state of activation in the resting FDE lesions and are capable of acquiring potent cytotoxic activity with rapid kinetics on clinical challenge

Sphincter saving resection after preoperative chemoradiation for T3 carcinoma of the lower rectum

Surgical treatment has evolved over the past ten years particularly for cancer involving the mid and lower third of the rectum. carcinomas of the lower third of the rectum are usually treated by abdominoperineal resection especially for T3 lesions. Few data are available evaluating Concomitant chemotherapy with preoperative radiotherapy for increasing sphincter saving resection [SSR] in low rectal cancer The purpose of this study was to evaluate the possibility of SSR for T3 cancers of the lower third of the rectum and subsequently the complication oncologic and functional results of preoperative chemoradiation followed sphincter saving procedure is assessed and determined. Twelve patients with T3 rectal carcinoma were treated by preoperative radiation with concomitant chemotherapy were included in the study. All patients had invasive adenocarcinoma of the rectum and underwent staging before treatment by endorectal ultrasonography All patients underwent conservative surgey after chemoradiation for low rectal cancer tumors located at a mean of 5 cm from the anal verge. Transanal intersphincteric resection was done in 7 patients. A colonic J-pouch was done in 2 patients. All patients had a defunctioning loop ileastomy. There were no deaths related to preoperative chemoradiation or surgery. Morbidity occurred in 33.3% of patients was complicated by a pelvic abscess that responded to conservative treatment. The other complications local recurrence at the anastomosis site at 13 months and was treated by salvage APR After preoperative chemoradiation all the tumors appeared as an ulcerative scar without any vegetative component. The mean tumor size in fresh specimens was 3.6 cm range [l-9]. The mean distal margin, assessed in fresh specimens without traction, was 23 +/- 8 mm [range 10-40]. The mean radial margin assessed microscopically was 8 +/- 4 mm [range 1-20]. Both distal and radial margins were negative [> 2 mm] in 11 [91.6%] patients; they were positive [

Lymphatic drainage of the female breast: a surgical perspective

Although the origin of breast lymphatic 'napping dates back to the 17th and 18th century, until recently the lymphatic drainage of the breast has been poorly understood. These old classic studies of the lymnphatic drainage of the breast were based on cadaveric or postoperative specimens. A different view currently prevails; more recent studies were done, reviewed during surgical procedures when the lymphatics of the breast are in active physiologic process allowing the lymph to flow. Lymphatic napping with sentinel nod biopsy is an essential component of staging patients with breast cancer and is rapidly becoming recognized and accepted means of assessing regional lymph node status for multiple tumors including the breast. This study evaluated 23 patients with breast cancer. These 23 patients were divided as follows al 23 patients were injected with 99 Tc -albumin nanocolloid 1-3 days preoperatively. Intraoperatively during the surgical procedure: 8 patients with unicentric breast cancer were injected with the methylene blue dye subareolarly, 3 patients with multicentric breast cancer were injected with the mnethylene blue dye in the dominant tumor, 4 patients with unicentric breast cancer were injected with the blue [dye in a Separate quadrant [discordant quadrant] away from the tumor in patients with clinical diagnosis of T1 N0 or T2 N0 breast cancer. The remaining 8 patients were T1N1M0 or T2-3 N0-1 M0 invasive breast cancel and were included in the study after receiving neoadjuvant chemotherapy then were injected with the blue dye subareolarly. The visualization rate of routine preoperative lymphoscintigraphy was 22/23 [96.5%], i e at least one sentinel node was visualized in 22 out of 23 patients. A total of 31 nodes were depicted in 24 basins. Lymphatic drainage exclusively to the axilla was observed in 20 patients. Two patients had drainage to both the axilla and other non-axillary basins: to the internal mamary chain in one patient and to the infraclavicular.fossa in one patient. During axillary dissection a lymphatic trunk was typically found in most cases heading towards a totally or partially blue or a non blue lymph node. A total of 21 sentinel lymph nodes were identified using the blue dye techniques [21/23] leading to a Success rate of 91.3%.In the lesions with successful SLN localization, an average of 1.6 +/- 0.4 SLNs were removed. The SLNs were metastatic in 10 patients of 21 [47.6%]. In 3 patients, the SLN was the only positive lymph node among the patients with metastasis, the number of involved nodes ranged from 1 to 9. The false-negative rate was 0 or the 21 patients with positive sentinel nodes. Through experience with sentinel node biopsy we can conclude that, axillary drainage is the principle lymphatic path of the breast, rarely any [Drainage pattern from any], quadrant of the breast can occur. Second, most lymph from the breast flows to the nodal basins with a direct course, not passing through the subareolar plexus. Our results support the hypoihes is that the lymphatic drainage of the breast parenchymna and the subareolar plexus leads to the value sentinel lymph node

Systematic pelvic and aortic lymphadenectomy in cervical, endometrial and ovarian malignant tumours: patterns of spread and surgical implications

Pelvic and aortic nodes are common sites of metastasis from gynaecologic malignancies, and there is no question that evaluation of lymph node status provides an important prognostic infomation. The aim of the study was to assess the patterns of lymphatic spread of gynaecologic malignancies, the number of nodes which can be excised from each pelvic and aortic group, and the impact of this surgical procedure on the perioperative complications and survival. Between January 1998 and December 2002, 50 patients with previously untreated and biopsy-proven gynaecologic malignancies: cervix [n=15], ovary [n=17], and endometrium [n=18] Were operated upon in the Departments of General Surgery, and Gynaecology and Obstetrics, Minoufnya University Hospital. The surgical procedure consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy and/or omentectomy, in addition to systematic pelvic and Para-aortic Iymphadenectomy. The median number of nodes removed was 21 pelvic [range 11-38] and 8 aortic [range 5-18]. Positive nodes were found in 22 patients [44%], 12 having pelvic, 4 aortic, and 6 both pelvic and aortic metastasis. The median number of positive nodes was 5 pelvic [range 1-12] and one aortic [range 1-6] nodes. The most frequently involved node groups were the obturator group with both cervical and ovarian carcinomas, and the external iliac group with endometrial carcinoma. The higher prevalence of aortic metastasis was observed in ovarian carcinoma. Lymphocele was the most frequent postoperative complication in 20% of patients. No postoperative mortality occurred in this series. The 5-year survival rate of patients with lymph node metastasis was significantly worse than that of patients without node metastasis [31% versus 84% P=<0.001]. These data may be useful for tailoring lymphadenectomy in relation to the preferred sites of retroperitoneal lymph node metastasis and the median number of nodes resected from each group, and confirms that systematic pelvic and aortic lymphadenectomy is a feasible procedure and can be performed with acceptable morbidity and no mortality. However, to provide solid evidence that this procedure has a therapeutic benefit, randomized controlled studies are needed