A randomized, double-blind, placebo-controlled trial of tegaserod in female patients suffering from irritable bowel syndrome with constipation.

BACKGROUND: Irritable bowel syndrome is a common functional gastrointestinal disorder which affects up to 20% of the population, with a predominance in females. AIM: To evaluate the efficacy and safety of tegaserod in female patients with irritable bowel syndrome characterized by symptoms of abdominal pain/discomfort and constipation. METHODS: In a randomized, double-blind, multicentre study, 1519 women received either tegaserod, 6 mg b.d. (n = 767), or placebo (n = 752) for 12 weeks, preceded by a 4-week baseline period without treatment and followed by a 4-week open withdrawal period. The primary efficacy evaluation was the patient's symptomatic response as measured by the Subject's Global Assessment of Relief. Other efficacy variables included abdominal pain/discomfort, bowel habits and bloating. RESULTS: Tegaserod produced significant (P < 0.05) improvements in the Subject's Global Assessment of Relief and other efficacy variables. These improvements were seen within the first week, and were maintained throughout the treatment period. After withdrawal of treatment, the symptoms rapidly returned. Overall, tegaserod was well tolerated. Diarrhoea was the most frequent adverse event; however, this led to discontinuation in only 1.6% of tegaserod-treated patients. CONCLUSIONS: Tegaserod, 6 mg b.d., produced rapid and sustained improvement of symptoms in female irritable bowel syndrome patients and was well tolerated.

Endovascular repair of traumatic pseudoaneurysm by uncovered self-expandable stenting with or without transstent coiling of the aneurysm cavity.

Various surgical options for internal carotid or subclavian artery pseudoaneurysm repair have been reported; however, in general they have resulted in poor outcomes with high morbidity and mortality rates. Recently, these open surgical procedures have been partly replaced by percutaneous transluminal placement of endovascular devices. We evaluated the potential for using flexible self-expanding uncovered stents with or without coiling to treat extracranial internal carotid, subclavian and other peripheral artery posttraumatic pseudoaneurysm. Three patients with posttraumatic pseudoaneurysm were treated by stent deployment and coiling (two cases) of the aneurysm cavity. In one case, a 5.0 x 47 mm Wallstent (Boston Scientific) was positioned to span the neck of the 9 x 5 mm size pseudoaneurysm (left internal carotid artery) and deployed. Angiography demonstrated complete occlusion of the pseudoaneurysm without coiling. In the second patient, a 5.0 x 31 mm Wallstent (Boston Scientific) was positioned to span the neck of the 9 x 7 mm size pseudoaneurysm (right internal carotid artery) and deployed. A total of six coils (Guglielmi Detachable Coils, Boston Scientific) were deployed into the pseudoaneurysm cavity until it was completely obliterated. In the third case, an 8.0 x 80 mm SMART (Cordis) stent was advanced over the wire, positioned to span the neck of the 10 x 7 mm size pseudoaneurysm of the left subclavian artery, and deployed. Fourteen 40 x 0.5 mm Trufill (Cordis) pushable coils were deployed into the pseudoaneurysm cavity until it was completely obliterated. At long-term follow-up (6-9 months), all patients were asymptomatic without flow into the aneurysm cavity by Duplex ultrasound. We conclude that uncovered endovascular flexible self-expanding stent placement with transstent coil embolization of the pseudoaneurysm cavity is a promising new technique to treat posttraumatic pseudoaneurysm vascular disease by minimally invasive methods, while preserving the patency of the vessel and side branches.

Transdermal fentanyl for chronic pain in AIDS: a pilot study.

This prospective, open-label, before-after trial was designed to compare the efficacy of oral opioids with that of transdermal fentanyl in severe AIDS-related chronic pain, as well as assess barriers, patient satisfaction, and side effects. Thirty-five sequentially selected male and female outpatients with AIDS who were at least 18 years old were enrolled. All had chronic pain requiring continuous treatment with > or = 45 mg/day oral morphine or an equivalent. Eighteen of the patients had a history of chemical dependency. Baseline data were collected while patients received their previously prescribed opioid; assessments were made again after a stable transdermal fentanyl dose (25--300 microg/h) had been maintained for 15 days. Patients completed the International Association for the Study of Pain Classification of Chronic Pain Syndromes questionnaire, the Brief Pain Inventory, and a Satisfaction With Pain Medication questionnaire for assessing pain intensity, relief, and interference with normal functioning. With transdermal fentanyl, pain severity scores decreased significantly, mean pain relief scores increased, and daily functioning measures improved significantly. Most adverse events were mild and unrelated to fentanyl use. Transdermal fentanyl was effective for chronic pain in both chemically dependent and non-chemically dependent patients with AIDS.

An alternative algorithm for dosing transdermal fentanyl for cancer-related pain.

Many cancer patients are undermedicated and inappropriately managed for pain, leading to a diminished quality of life. Patients with moderate to severe pain often require opioid analgesics. Recently published guidelines emphasize individualization of opioid treatment to provide the drug and route of administration that meet the needs of the particular patient. Intolerable side effects, ineffective pain relief, or a change in the patient's clinical status can dictate the need for a new pain management regimen. Physicians must be able to readily quantify relative analgesic potency when converting from one opioid to another or from one route of administration to another. Transdermal fentanyl (Duragesic) is an opioid agonist that has been shown to be safe and effective for the treatment of cancer pain. However, clinicians should realize that the manufacturer's recommendations for equianalgesic dosing of transdermal fentanyl may result in initial doses that are too low in some patients, and in a titration period that is too long. Under these circumstances, the patient is likely to experience unrelieved pain. An alternative dosing algorithm that considers both a review of the literature and our combined clinical experience with transdermal fentanyl should help clinicians individualize the treatment of pain.

Modulation of chemokine expression during ischemia/reperfusion in transgenic mice overproducing human glutathione peroxidases.

Renal ischemia/reperfusion (I/R) injury is a major cause of kidney damage. There is accumulating evidence that inflammatory reactions are involved in the pathogenesis of this process. Our studies demonstrate that transgenic mice overexpressing human extracellular and intracellular glutathione peroxidases (GP) are protected against kidney I/R injury. Importantly, significant reduction in neutrophil migration was observed in GP mice compared with nontransgenic mice. Analysis of signaling molecules mediating neutrophil activation and recruitment indicates reduction in the level of KC and macrophage inflammatory protein-2 chemokine expression in transgenic animals. The molecular mechanism mediating this effect appears to involve repression of NF-kappaB activation at the level of IkappaBalpha and IkappaBbeta degradation. In the case of IkappaBalpha, no apparent phosphorylation was detected. These results suggest that IkappaBalpha proteolysis is triggered during the renal I/R pro-oxidant state by a still unknown mechanism, which might be different from other stimuli. A central role of NF-kappaB in CXC chemokine activation was demonstrated in cell culture anoxia/ATP repletion experiments as a model of I/R. The data presented indicate the important role of GP-sensitive signal transduction pathways in the development of inflammatory response and tissue injury during I/R.

Balloon-assisted Guglielmi detachable coiling of wide-necked aneurysms: Part I--experimental evaluation.

OBJECTIVE: Balloon-assisted technique is a promising technical adjunct to use of Guglielmi detachable coils for embolization of wide-necked aneurysms. In this study using experimental aneurysms in swine, the safety and long-term efficacy of this technique were evaluated. METHODS: Sixteen wide-necked aneurysms (sidewall model) were surgically created in common carotid arteries of swine. In the acute study of eight aneurysms, intra-aneurysmal pressure changes were recorded during balloon inflation in different positions of the balloon relative to the neck of the aneurysm. In the chronic study, eight aneurysms were treated with this technique, and follow-up angiography was performed 14 days postembolization. The animals were then killed for macroscopic evaluation. RESULTS: In the acute study, the systolic intra-aneurysmal blood pressure increased with balloon inflation at the distal portion of the neck and with balloon inflation/occlusion across the entire neck of the aneurysm. In the chronic study, seven of eight cases were embolized with satisfactory occlusion, and six showed no coil displacement on the follow-up angiogram. In five cases, macroscopic evaluation of the aneurysm showed that the coils were compacted at the neck of the aneurysm with a concave shape consistent with the shape of the inflated balloon across its neck. CONCLUSION: This preliminary study indicates that balloon-assisted Guglielmi detachable coiling technology may produce a temporary increase of pressure within the aneurysm while occluding the aneurysmal neck during coil delivery. This sudden change of intra-aneurysmal pressure may potentially be the cause-of aneurysm rupture in the clinical setting. The balloon must be inflated and deflated very slowly to minimize these potentially risky hemodynamic changes. Although angiographic follow-up showed successful obliteration of aneurysms, further long-term angiographic studies are necessary to establish the durability of this technique.

Ballonn-assisted Guglielmi detachable coiling of wide-necked aneurysma: Part II--clinical results.

OBJECTIVE: To demonstrate the indications and efficacy of balloon-assisted Guglielmi detachable coiling (BAGDC). METHODS: BAGDC was used for 23 patients (19 women and 4 men; mean age, 55 yr) (17%) of a series of 136 consecutive patients who underwent Guglielmi detachable coiling of aneurysms. Every aneurysm had a wide neck, and 57% were large (11-25 mm in diameter). In each case, a nondetachable silicone balloon was advanced in the parent artery and inflated to occlude the neck of the aneurysm and stabilize the Guglielmi detachable coil delivery microcatheter at the aneurysm neck. Guglielmi detachable coils were then deposited. The balloon was then deflated to verify appropriate coil placement and stability, and finally, the Guglielmi detachable coils were detached. This process was repeated until the aneurysm was suitably embolized. RESULTS: One hundred percent aneurysm embolization was achieved in 19 patients (83%), and 95 to 100% embolization was achieved in 4 patients (17%). Twenty-two patients (96%) were at their preprocedure neurological baseline after the procedure. There were three complications in the study. One patient died after sustaining subarachnoid hemorrhage-induced vasospasm followed by a hemorrhagic infarction. She had undergone an unsuccessful clip ligation of her aneurysm. A second patient developed an intra-arterial thrombus at the site of balloon deployment. She sustained ischemic events that were treated with thrombolysis and anticoagulation. She made a complete recovery. A third patient developed an intra-arterial thrombus that was noted during the procedure. She was treated with intra-arterial thrombolysis and experienced no clinical sequelae. No permanent complications could be attributed to the BAGDC technique. The median clinical follow-up time was 10 months. No patient required additional treatment or developed a recurrent aneurysm neck or lumen. CONCLUSION: BAGDC is a promising adjunct to the treatment of wide-necked aneurysms. The balloon serves two purposes: it stabilizes the microcatheter in the aneurysm during coil delivery, and it forces the coil to assume the three-dimensional shape of the aneurysm without impinging on the parent artery.

Acetaminophen toxicity. Opposite effects of two forms of glutathione peroxidase.

Acetaminophen is one of the most extensively used analgesics/antipyretics worldwide, and overdose or idiopathic reaction causes major morbidity and mortality in its victims. Research into the mechanisms of toxicity and possible therapeutic intervention is therefore essential. In this study, the response of transgenic mice overexpressing human antioxidant enzymes to acute acetaminophen overdose was investigated. Animals overexpressing superoxide dismutase or plasma glutathione peroxidase demonstrated dramatic resistance to acetaminophen toxicity. Intravenous injection of glutathione peroxidase provided normal mice with nearly complete protection against a lethal dose of acetaminophen. Surprisingly, animals overexpressing intracellular glutathione peroxidase in the liver were significantly more sensitive to acetaminophen toxicity compared with nontransgenic littermates. This sensitivity appears to be due to the inability of these animals to efficiently recover glutathione depleted as a result of acetaminophen metabolism. Finally, the results suggest that glutathione peroxidase overexpression modulates the synthesis of several acetaminophen metabolites. Our results demonstrate the ability of glutathione peroxidase levels to influence the outcome of acetaminophen toxicity.

Embolization of neurosurgical lesions involving the ophthalmic artery.

OBJECTIVE: A number of anteriorly located cranial base and extracranial lesions receive their vascular supply wholly or in part from the ophthalmic artery, and embolization of the ophthalmic artery can be helpful in the management of these lesions, either as the primary treatment or as an adjunct to surgery. We present situations in which the embolization of lesions involving the ophthalmic artery was performed to effect a partial or total cure of the lesion. METHODS: Twelve patients underwent a total of 15 embolization attempts on lesions involving the ophthalmic artery. Four patients had arteriovenous malformations of the orbit, four had dural arteriovenous fistulae, two had orbital meningiomas, one had a planum sphenoidale meningioma, and one had a juvenile nasal angiofibroma. In each case, a Tracker No. 18 microcatheter (Target Therapeutics, Inc., Fremont, CA) was navigated into the ophthalmic artery using a steerable guidewire and digital road mapping. Embolic agents included polyvinyl alcohol particles ranging from 350 to 1500 microm in diameter, 2-mm platinum microcoils, and n-butyl-cyanoacrylate. In 12 of 15 cases, lidocaine and amytal provocation tests were conducted before any attempt at embolization to assess the role of the ophthalmic artery in vision. RESULTS: Embolization was successfully performed in the 14 situations in which it was attempted. Positive results of two lidocaine/amytal tests were noted. In one case, embolization was not attempted. In the other case, a larger caliber embolic agent (2-mm platinum coils) was used. A single transient decrease in visual acuity lasting 4 days was the only embolization-related complication. CONCLUSION: Proper case selection, judicious use of embolic agents, and use of provocative testing can result in safe embolization of lesions supplied by the ophthalmic artery.

Carotid angioplasty and stenting in high-risk patients.

BACKGROUND: To examine our initial experience in carotid stenting (CS) for the prevention of stroke in patients with high-grade carotid stenoses. METHODS: The authors performed 26 CS procedures in 25 carotid vessels in 22 patients over a 15-month period. All carotid stenoses treated, except one, were 70% or greater. Of all CS procedures, 84% were performed for obstructing atherosclerotic plaques. CS was performed in one patient each for carotid dissection and pseudoaneurysms caused by a gunshot wound, post-radiation stenosis, post-carotid endarterectomy (CEA) restenosis, and a flow-obstructing post-CEA intimal flap. Of all patients, 68.2% were symptomatic, with a history of stroke or transient ischemic attacks ipsilateral to the treated carotid artery. In addition, 36.4% of our patients were either hospitalized or required skilled nursing care before CS because of severe neurologic deficits. Using the Sundt CEA-risk classification system, 59.1% of our patients were classified as Grade III and 40.9% were Grade IV pre-CS. All but one patient had either a compelling medical or anatomic reason for endovascular treatment of their carotid disease. We used both Wallstents and Palmaz stents, and all procedures were performed via the transfemoral route. Three procedures were performed in conjunction with detachable platinum coil embolization for multiple carotid pseudoaneurysms, a residual carotid "stump" after previous ICA thrombosis, and an ipsilateral MCA saccular aneurysm. RESULTS: We had a 96.2% procedural technical success rate. There was one death in our series 3 weeks post-CS attributable to myocardial infarction. Despite a high 30-day combined death, stroke, and ipsilateral blindness rate of 27.3% (6/22 patients), only two ipsilateral strokes directly related to CS occurred (7.7% per procedures performed) from which one patient recovered fully within 5 days. The average follow-up post-CS was 5.9 months (range, 3 weeks-15 months). Of successfully treated vessels, 58.3% have undergone 6-month follow-up vascular imaging, which has revealed a 14.3% rate of occlusion or restenosis greater than 50%. At or beyond 1 month post-CS, 19 of 21 surviving patients (90.5%) were ambulatory, fluent of speech, and independent, and none has thus far suffered a delayed stroke or TIA. CONCLUSION: CS seems to be a reasonable alternative to medical management for the treatment of carotid disease in patients deemed to be poor candidates for standard carotid surgery. Longer term follow-up is necessary to assess the durability of carotid revascularization using CS.

Overexpression of human glutathione peroxidase protects transgenic mice against focal cerebral ischemia/reperfusion damage.

As stroke is a major cause of disability and death in the western world, there is great interest in the basic mechanisms by which ischemia/reperfusion (I/R) causes damage. To this end, extensive research has been carried out which identifies reactive oxygen species (ROS) as key participants in brain damage resultant from I/R. Brain tissue is protected from ROS damage by antioxidant enzymes, such as superoxide dismutase (SOD) and glutathione peroxidase (GP). Overexpression of SOD in transgenic mice has already been demonstrated to confer protection against I/R damage in murine stroke models. We are using transgenic mice overexpressing the intracellular form of glutathione peroxidase (GP1) to determine the protective capacity of overexpression of this enzyme on stroke damage. 1 h of focal cerebral ischemia followed by 24 h of reperfusion was induced using the intraliminal suture method. Volume of infarction was reduced by 48% in GP1 mice compared to nontransgenic littermates. Brain edema was reduced by 33%. Behavioral deficits agreed with histologic data. Overexpression of glutathione peroxidase confers significant protection against I/R damage in our stroke model possibly through direct scavenging of ROS or through the influencing of signalling mechanisms which lead to tissue damage.

Pediatric intracranial epidural abscess secondary to an infected scalp vein catheter.

The authors present a case of a 5-week-old infant developing a retrotorcular epidural abscess as a result of an infected scalp vein catheter. The abscess developed in the absence of sinusitis, otitis, trauma, or prior surgery. The diagnosis of epidural abscess was made on the basis of magnetic resonance imaging and ultrasound-guided aspiration of the fluid collection. An identified strain of Staphylococcus epidermidis was cultured from both the intravenous catheter and the abscess. The patient underwent a suboccipital craniectomy with drainage of the abscess and a 6-week total course of intravenous antibiotics. Magnetic resonance imaging 4 months after the procedure and 2.5-year pediatric clinic follow-up have demonstrated no evidence of neurologic deficit or recurrence. When present, a scalp vein catheter must be considered as an etiologic agent for an intracranial epidural abscess in this age-group.

Prognostic variables in surgery for skull base meningiomas.

The authors have retrospectively analyzed selected surgical and pathological observations made among a group of 20 patients harboring recurrent cranial base meningiomas in an attempt to reveal which factors may be important in predicting tumor recurrence. This cohort was compared with a group of 34 patients with cranial base meningiomas that underwent primary resection and in whom tumor recurrence has not been demonstrated over a median follow-up period of 33 months. Features analyzed included brain, cranial nerve, carotid artery, or muscle invasion as well as tumor cellularity, nucleolar prominence, cellular pleomorphism, and percentage of cells staining positive for the Ki-67 antigen. As expected, increased cellularity and tumor necrosis were relatively more prevalent in recurrent tumors. With regard to tumor type, atypical and anaplastic tumors were more common in the group of patients with recurrent tumor compared with the primary group (p < 0.02). As expected, increased cellularity was relatively more prominent in recurrent tumors. Invasion of muscle and bone (72%) was more frequently associated with recurrent tumors, suggesting that these characteristics may be important features of recurrent skull base meningiomas.

Pain management guidelines: implications for managed care--a roundtable discussion.

One of the most important concerns of patients with cancer, particularly those with metastatic disease, is "Will I be in constant pain?" This is a similar concern voiced by patients with late-stage human immunodeficiency virus infection. The management of chronic pain has enormous implications on a patient's ability to function and on his or her quality of life. In June 1996, Medical Interface convened a panel of experts in Chicago to discuss pain management therapies, guidelines, and how these issues will affect, and be affected by, the managed care environment.

Pain management for the AIDS patient.

The relief of pain in persons with HIV disease, while similar to other patient populations such as cancer patients, has some unique aspects. Pain must be a focus, and a priority, of care in persons with HIV disease along with treatment of the underlying HIV infection and the complications of immune compromise. Pain in patients with AIDS is very prevalent and often undertreated. Pain contributes to psychological and functional morbidity in AIDS. At the present time, the guidelines developed for treatment of cancer pain are used in patients with HIV disease, with the recognition that neuropathic pain should be treated differently from nociceptive pain. A multidisciplinary approach to pain management is optimal; however, consultations with pain specialists are adequate for management of pain in most patients, including those with HIV disease. Approaches to management of pain in patients with HIV disease are: Localize and characterize pain Work up possible etiologies Rule out infections and malignancies Be aware of multiple etiologies Explore the psychological/emotional contribution to pain Perform a thorough history and physical examination including medication history, history of substance use/abuse, and neurological and psychological assessments Treat the medical and psychological causes of pain Use appropriate pain medications in adequate doses Consult specialists in pain management, when necessary.

Endovascular treatment of a dissecting posteroinferior cerebellar artery aneurysm: case report.

IMPORTANCE: To demonstrate the usefulness of endovascular techniques in the treatment of fusiform, dissecting aneurysms. CLINICAL PRESENTATION: A 45-year-old woman presented with the acute onset of left-sided neck pain and headaches. Computed axial tomography demonstrated subarachnoid and intraventricular hemorrhage as well as a left posterior cerebellar infarct. Conventional cerebral and magnetic resonance angiography demonstrated a dissecting fusiform aneurysm at the origin of the left posteroinferior cerebellar artery. INTERVENTION: A balloon occlusion of the left vertebral artery at the posteroinferior cerebellar artery origin was tolerated without complication, and the patient underwent successful occlusion of the left posteroinferior cerebellar artery, with platinum microembolization coils. CONCLUSION: In patients who tolerate temporary balloon occlusion, endovascular treatment of dissecting fusiform aneurysms with platinum microembolization coils is safe and effective therapy.

Antihypertensive therapy and quality of life. Influence of blood pressure reduction, adverse events, and prior antihypertensive therapy.

Quality of life is an important attribute of antihypertensive therapy. Previous studies have not addressed the importance of a patient's prior pharmacotherapy on quality of life, which may serve as the basis of reference for a new therapy. Nor have previous studies compared commonly used quality of life instruments for consistency, or investigated whether improvement or worsening of quality of life correlates with adverse events or blood pressure reduction. Two hundred eighteen hypertensive patients with diastolic blood pressure (95 to 114 mm Hg) after a 4- to 5-week placebo washout period were enrolled in a randomized double-blind, parallel group dose-escalation trial to compare the effects of amlodipine (2.5 to 10 mg), bisoprolol (2.5 to 10 mg)/hydrochlorothiazide (HCTZ) 6.25, and enalapril (5 to 20 mg) on blood pressure, adverse events, and quality of life. Three quality of life instruments (General Well-Being Index, Vital Signs Quality of Life, Zung Self-Rating Depression Scale) were administered during original therapy, after placebo washout, and after 12 weeks of optimally titrated clinical trial pharmacotherapy. Our results demonstrated that removal from prior therapy had no detectable influence on subsequent evaluation of quality of life. The three quality of life instruments were consistent with the changes observed with the three therapies: a trend toward better quality of life with amlodipine and bisoprolol/HCTZ. Adverse events, but not systolic or diastolic blood pressure reduction correlated directly with changes in quality of life.

Aggressive angiomyxoma: a clinicopathologic study of 29 female patients.

BACKGROUND: Aggressive angiomyxoma is an uncommon mesenchymal tumor that preferentially involves the pelvic and perineal regions of females. Since its initial description in 1983, approximately 65 cases have been reported in the English literature. METHODS: The clinical and pathologic features of 29 cases of aggressive angiomyxoma were evaluated in a review of archival material from the Armed Forces Institute of Pathology (1960-1992). Histochemical stains for mucosubstances and immunohistochemistry (avidin-biotin complex method) were utilized to characterize the neoplasms further. RESULTS: All patients were females, between 16 and 70 years (median; 34 years). The soft tissues of the pelvis, perineum, vulva, buttock, retroperitoneum, and inguinal regions were involved. The majority of the tumors were > or = 10 centimeters in greatest dimension. Follow-up ranging from 8 to 198 months (mean, 93 months; median, 95 months) was available for 22 patients. Eight patients developed recurrent tumor, from 10 months to 7 years after the initial resection. No patient developed metastases and there were no tumor related deaths. Histologically, the neoplasms were sparsely to moderately cellular and predominantly composed of bland, relatively nondescript. stellate and spindled cells embedded in a loosely collagenized matrix with scattered vessels of varied caliber. A few cases contained some tumor cells with more abundant eosinophilic cytoplasm that raised the possibility of focal smooth muscle differentiation. The tumor matrix was no more than weakly reactive for mucosubstances; thus, while glycosaminoglycans are present to a limited extent, edema fluid appears to be a major component of the noncollagenous stroma. The neoplastic cells were at least focally immunoreactive for desmin (22/22), smooth muscle actin (19/20), muscle specific actin (16/19), vimentin (17/17), CD34/QBEND-10 (8/16), and estrogen (13/14) and progesterone (9/10) receptor. All of the examined tumors were negative for S100 protein (20/20). Ki67 (MIB1) immunoreactivity was present in <1% of the tumor nuclei in all 16 cases tested. CONCLUSIONS: Aggressive angiomyxoma is a distinctive, locally aggressive, mesenchymal tumor that appears to be relatively site specific and has a peak incidence in females in the fourth decade of life. There is a strong propensity for local recurrence but metastatic disease has not been reported. Since the first evidence of recurrence may be many years after the initial resection, long term follow-up is required. The neoplastic cells of aggressive angiomyxoma exhibit fibroblastic and myofibroblastic features and appear to be hormonally influenced. The possibility that the progenitor cell has a capacity for smooth muscle differentiation is raised.

Atypical apocrine adenosis of the breast: a clinicopathologic study of 37 patients with 8.7-year follow-up.

BACKGROUND: Apocrine metaplasia is occasionally superimposed on sclerosing adenosis (apocrine adenosis) in breast biopsies, and cytologic atypia is sometimes present (atypical apocrine adenosis). The long term risk of patients developing breast carcinoma subsequent to the diagnosis of this lesion is unknown. METHODS: Atypical apocrine adenosis was defined as apocrine adenosis with enlarged nucleoli and a greater than threefold variation in nuclear area. Lesions with recognizable cytoarchitectural patterns of intraductal carcinoma were excluded. Surveillance, Epidemiology and End Results (SEER) data were used as the reference population for calculations of relative risk. RESULTS: Thirty-seven women with atypical apocrine adenosis had a mean follow-up of 8.7 years. Four patients developed invasive ductal carcinoma of the breast (3 ipsilateral, 1 contralateral) after a mean of 5.6 years. The relative risk of developing carcinoma was 5.5 (95% confidence interval [CI], 1.9-16). All patients who developed carcinoma were older than age 60 at the time of breast biopsy showing atypical apocrine adenosis, and carcinoma developed at a mean age of 70 years. In the older than 60 years age group (11 patients), the relative risk of developing carcinoma was 14 (95% CI, 4.1-48). CONCLUSIONS: Atypical apocrine adenosis confers an increased risk of developing breast carcinoma in women older than age 60, and the risk in younger women is probably low. Some cases of atypical apocrine adenosis may represent in situ apocrine carcinomas that are difficult to diagnose because of the absence of the usual architectural features of intraductal carcinoma.

Primary diffuse large B-cell lymphoma of the breast. A clinicopathologic study of 31 cases.

Primary non-Hodgkin's lymphoma of the breast is a rare neoplasm for which survival data vary among the reported studies. Thirty-one cases of diffuse large B-cell lymphoma of the breast, which had been seen in consultation from 1973 to 1985 at our institution, were reviewed. This represents the largest number of lymphomas of this histologic subtype reported to date in the English literature. Histologic examination and immunophenotypic analysis were performed and the results were correlated with clinicopathologic data. The patient population consisted of 29 females and 2 males with a mean patient age of 58.2 years. At the time of diagnosis, 26 patients had unilateral involvement (16 left, 10 right), and 5 had bilateral disease. Mean tumor size was 3.8 cm. Histologically, all cases showed a diffuse large B-cell lymphoma as classified by the Revised European-American Classification of Lymphoid Neoplasms (R.E.A.L Classification). Immunophenotypic studies on paraffin sections confirmed a B-cell lineage in every case. The majority of patients received chemotherapy and/or radiation therapy. The median survival was 36 months, confirming that this neoplasm has a poor prognosis.