Value of internerve tissue dissection during axillary lymphadenectomy for early breast cancer.

BACKGROUND: Breast cancer is one of the most commonly occurring malignancies in females in the Eastern Mediterranean Region. Axillary clearance is an integral part of the surgical treatment of breast cancer. Precise analysis of lymph node involvement for proper staging and adjuvant therapy is therefore necessary. During axillary dissection, lymph nodes at levels I, II and III are removed, while the important axillary structures ( axillary vein, long thoracic and thoracodorsal nerves ) are preserved. The latter two structures are particularly vulnerable to injury when dissecting the tissue between them ( the internerve tissue). PATIENTS AND METHODS: This study evaluates the necessity of dissecting the internerve tissue during axillary dissection in breast cancer surgery by reviewing the lymph node yield and metastasis rate in this tissue. This is a prospective non-randomized study, conducted on 50 female patients, who underwent axillary lymphadenectomy for breast cancer. The internerve tissue was excised separately after a routine axillary dissection. RESULTS: Twenty eight ( 56% ) of the 50 internerve specimens contained lymph nodes; the internerve nodes were positive for carcinoma in 5 patients ( 10%). In those 5 patients, metastasis was also found in some other axillary lymph nodes. There was no incidence of isolated metastasis in the internerve tissue nodes in absence of metastatic disease to other lymph nodes in the axilla. CONCLUSIONS: There is a significant incidence of lymph nodes ( 56% ) and axillary node metastases ( 10% ) in the tissue lying between the long thoracic and thoracodorsal nerves. Therefore, meticulous dissection and excision of this internerve tissue is strongly recommended in order to optimize decision making regarding adjuvant treatment and outcome in women with operable breast cancer. Key Words:Breast cancer - Axillary lymphadenectomy - Internerve tissue.

Contribution of hepatitis C virus and Helicobacter Pylori co-infection as possible predisposing factors in the occurrence of gastric mucosal dysplasia.

BACKGROUND AND PURPOSE: Current views on B-cell lymphoma genesis suggest that several exogenous factors, acting in a multistep fashion upon a predisposing condition, may be involved in B-cell clonal expansion, a potentially prelymphomatous stage. This study was done to investigate the extrahepatic localization of Hepatitis C virus (HCV)in the gastric mucosa and the possibility of its involvement besides Helicobacter pylori (H. pylori) as possible predisposing factors that might play a role in the occurrence of gastric dysplasia or lymphoproliferation following gastritis and may end in carcinogenesis. PATIENTS AND METHODS: A well characterized series of 45 patients with chronic liver disease complaining of gastric dyspepsia were subjected to Upper Gastrointestinal Endoscopy and histological examination of gastric biopsy with studying the prevalence of serologic and molecular markers of HCV and H. pylori in the patients' serum and their gastric tissue. HCV-RNA detection in gastric tissue was done only for those who showed gastric dysplasia. RESULTS: Histopathological examination of the gastric biopsies revealed that 20 patients (44.4%) had chronic active gastritis, 15 patients (33.4%) had chronic gastritis and 10 patients (22.2%) had gastric dysplasia with chronic gastritis. As for hepatitis C virus, 38 patients (84.4%) were reactive for serum antibodies (HCV-Abs) and 18 patients (40%) showed Polymerase Chain Reaction (PCR) positivity. Helicobacter pylori antibody reactivity was detected in 37 patients (82.2%) while PCR positivity was detected in 24 patients (53.3%) both in their serum as well as in gastric tissues. Seventeen out of twenty cases showing chronic active gastritis were serologically positive for both H. pylori and HCV. Patients who showed dysplasia on pathological examination (n=10) were all HCV-Abs positive (p-value = 0.32), seven patients were serum HCV-RNA positive (p-value = 0.083) and 3 of them showed HCV-RNA positivity in their gastric tissue. Nine out of the patients with gastric dysplastic changes proved positive for H. pylori DNA both in serum (p-value= 0.027) and tissue (p-value= 0.029). CONCLUSIONS: We suggest that Hepatitis C virus may be considered, in addition to Helicobacter pylori, as another potential infectious co-factor in the occurrence of gastric mucosal dysplasia and thus might be associated in the multistep hypothesis of carcinogenesis.

Intercellular adhesion molecule-1(ICAM-1), CD44s expression and serum level of sICAM-1 in disseminated non-Hodgkin's lymphoma: correlation with overall survival.

BACKGROUND AND PURPOSE: Uncontrolled growth, invasion and distant spread are the characteristics of neoplastic cells. Changes in adhesion molecule expression, such as loss of expression, de novo expression or functional alterations, can be observed in each of these steps. The aim of the present work was to study the expression of two adhesion molecules [standard CD44 (CD44s) and intercellular adhesion molecule-1 (ICAM-1)] and the soluble form of ICAM-1(sICAM-1) in adult disseminated non-Hodgkin's lymphoma (D-NHL) and to correlate the findings with overall survival. PATIENTS AND METHODS: The expression of CD44s and ICAM-1 adhesion molecules and the level of sICAM-1 were studied in 34 cases of (D-NHL). They included: 13 cases of lymphoblastic lymphoma (LBL), 5 cases of Burkitt's lymphoma (BL), one case of diffuse large cell lymphoma (DLCL), 14 cases of small lymphocytic lymphoma (SLL), one case of mantle cell lymphoma (MCL). Ten apparently healthy individuals were taken as a control group. CD44s expression was evaluated by direct immunofluoresence, ICAM-1 by immunoperoxidase on cyto-preps and serum level of sICAM-1 by ELISA. RESULTS: ICAM-1 was positive in 6/34 cases (17.6%) of D-NHL. ICAM-1 was expressed in 2/15 (13.3%) of low-grade NHL and 4/19 (21%) of high-grade lymphoma with no significant difference between the two groups (p=0.6). CD44s was expressed in 13/34 cases (38.2%) of D-NHL; in 4/15 (26.6%) of low grade NHL and 9/19 (47.3%) of high grade lymphoma with no significant difference between the two groups (p=0.2). The serum levels of sICAM-1 were elevated in all patients with D-NHL compared to healthy controls with a statistically significant difference (p <0.001), (median 1160 ng/ml, range from 150 to 2500 ng/ml, and 375 ng/ml, range from 270 to 620 ng/ml, respectively). The median of sICAM-1 in patients with high-grade D-NHL was significantly (p=0.006) lower than that of those with low-grade D-NHL (median 890 ng/ml, range from 150 to 1540 ng/ml and 1440 ng/ml, range from 380 to 2500 ng/ml respectively). The median follow-up duration for all patients was 18 months. No statistical significant difference was achieved (p=0.8) on comparing overall survival pattern between D-NHL lymphoma patients with positive or negative expression of ICAM-1 or sCD44 expression. Also, no statistically significant difference (p=0.9) was found between patients with sICAM (above and below 600 ng/ml) at 18 months from diagnosis. CONCLUSION: There is a marked heterogeneity in cell adhesion molecule (CAM) expression in NHL and this may correlate with degree of differentiation of malignant lymphocytes. However the exact significance of these findings will require functional studies to determine the role of these CAMs in each subtype of NHL.