Association of FokI and PvuII polymorphisms with breast cancer staging and survival among Caucasian women: a prospective study.

PURPOSE: Both vitamin D and estrogens play an important role in breast cell growth and differentiation. Therefore, we hypothesized that FokI polymorphism in the Vitamin D Receptor (VDR) gene, as well as PvuII polymorphism in the Estrogen Receptor (ESR) gene might be associated with progression of breast cancer. The aim of this study was to prospectively examine the association of these polymorphisms with histopathological features and prognosis among women with histologically proven breast cancer. METHODS: Patient characteristics, tumor histopathology, and genotyping of one VDR polymorphism variant (FokI) and one ER polymorphism variant (PvuII) were recorded. Patients were also routinely followed up. RESULTS: There was a significant difference regarding nodal stage (p<0.001) between the different genotypes of FokI polymorphisms (FF, Ff, ff), even though a trend was also detected in the frequency between ductal and lobular type, as well as tumor size (p=0.077). When further analysis was performed regarding patients whose polymorphism included the f allele, we found statistically significant differences in tumor size (p<0.001), nodal stage (p=0.03), tumor grade (p=0.04) and lymphovascular invasion (p<0.001), while no differences in nodal status, distant metastases and tumor stage were noticed. No significant associations were found between any of the PvuII polymorphism variants and tumor histopathology and stage. No statistical significance was proven between FokI polymorphism's variants or f allele and overall or progression-free survival. Statistically significant associations between overall and progression- free survival and PvuII polymorphism's variants was demonstrated (p<0.001). CONCLUSION: The f allele was associated with the presence of lymphovascular invasion and poorly differentiated tumors, whereas the PP genotype was associated with increased overall and progression-free survival, suggesting that this variant is related to a more favorable prognosis.

Effects of endoscopic sphincterotomy on biliary epithelium: a case-control study.

AIM: To study the long-term effects of endoscopic sphincterotomy on biliary epithelium. METHODS: This is a prospective case-control study. A total of 25 patients with a median age of 71 years (range 49-89 years) and prior endoscopic sphincterotomy (ES) for benign disease formed the first group. The median time from ES was 42 mo (range 8-144 mo). Another 25 patients with a median age of 76 years (range 44-94 mo) and similar characteristics who underwent current endoscopic retrograde cholangiopancreatography (ERCP) and ES for benign disease formed the second group (control group). Brush cytology of the biliary tree with p53 immunocytology was performed in all patients of both groups. ERCPs and recruitment were conducted at the Endoscopic Unit of Aretaieion University Hospital and Tzaneio Hospital, Athens, from October 2006 to June 2010. RESULTS: No cases were positive or suspicious for malignancy. Epithelial atypia was higher in the first group (32% vs. 8% in the second group, P = 0.034). Acute cholangitis and previous biliary operation rates were also higher in the first group (acute cholangitis, 60% vs. 24% in the second group, P = 0.01; previous biliary operation, 76% vs. 24% in the second group, P = 0.001). Subgroup analysis showed that previous ES was the main causal factor for atypia, which was not related to the time interval from the ES (P = 0.407). Two patients (8%) with atypia in the first group were p53-positive. CONCLUSION: ES causes biliary epithelial atypia that represents mostly reactive/proliferative rather than premalignant changes. The role of p53 immunoreactivity in biliary atypia needs to be further studied.

Manual high-dose regional intraoperative thrombolysis of lower extremity emboli after open repair of a ruptured abdominal aortic aneurysm.

We describe a case of high-dose regional intraoperative thrombolysis subsequent to mechanical thrombectomy for the treatment of postoperative distal extremity embolization of the right lower limb owing to open repair of a ruptured abdominal aortic aneurysm. Mechanical thrombectomy was performed from the popliteal artery but residual embolic occlusion of all three tibial arteries remained. The limb was elevated, exsanguinated, and a blood cuff was placed below the knee and inflated to suprasystolic pressure to isolate the limb from systemic circulation. An 18-gauge infusion catheter was introduced to the exposed dorsalis pedis artery. Subsequently, the exposed great saphenous vein was cannulated and drained. A total of 100 mg of recombinant tissue-type plasminogen activator diluted in 500 mL of saline was infused into the anterior tibial artery with a slow hand infusion for 30 minutes. The infusion was continuously collected through the great saphenous cannulation and a closed loop was confirmed by angiogram. The limb was flushed with heparin and saline solution. Infusion catheter was extracted and the great saphenous vein was ligated. Blood cuff was removed, arterial flow was re-established, and a postprocedural arteriogram confirmed successful revascularization. This method may be an alternative to microtibial embolectomy at the foot ankle level after severe lower limb embolization after acute open repair of a ruptured abdominal aortic aneurysm.

Intraductal papillary mucinous neoplasm (IPMN) and chronic pancreatitis: overlapping pathological entities? Two case reports.

CONTEXT: Intraductal papillary mucinous neoplasms (IPMNs) are a recently classified pancreatic neoplasm with an increasing incidence. IPMN is often misdiagnosed as chronic pancreatitis because of symptoms of relapsing abdominal pain, pancreatitis, and steatorrhea and imaging findings of a dilated pancreatic duct of cystic lesions that are frequently confused with pseudocysts. Early recognition of IPMN allows for prompt surgical resection before malignant transformation. CASE REPORTS: We report two cases of patients with long histories of chronic pancreatitis (more than 15 years) that went on to develop IPMN. Both patients presented with symptoms of abdominal pain, nausea, steatorrhoea and eventually weight loss. Biochemical and radiological findings were suggestive of chronic pancreatitis although no clear causes for this were identified. Both patients were followed up with multiple repeat scans with no reported sinister findings. Many years after the initial diagnosis of chronic pancreatitis, radiological investigations identified pathological changes suggestive of neoplastic development and histology confirmed IPMN. CONCLUSIONS: The cases demonstrate the ongoing challenges in diagnosing and managing IPMN effectively; highlights the important aspects of epidemiology in differentiating chronic pancreatitis and IPMN; continues the discussion surrounding the relationship between IPMN and chronic pancreatitis.

GIST suture-line recurrence at a gastrojejunal anastomosis 8 years after gastrectomy: can GIST ever be described as truly benign? A case report.

We present the case of a 71 year old man with recurrence of a Gastro Intestinal Stromal Tumour (GIST) at the gastrojejunal anastomosis eight years following partial gastrectomy for a very small primary gastric GIST. He presented acutely on both occasions with haemodynamic shock secondary to massive haematemesis. During his initial presentation in 2001, an emergency laparotomy was performed, demonstrating a pre-pyloric ulcerative lesion. The histopathology was in keeping with a diagnosis of a gastric GIST with a <2 cm tumour, with <5 mitosis per 50/HPF, no signs of necrosis and invasion limited to the mucosa. Eight years later the same patient presented with a similar clinical picture of haemodynamic instability secondary to haematemesis. Emergency endoscopy showed an irregularly shaped elevated lesion on the gastrojejunostomy line suggestive of recurrence. He subsequently underwent completion gastrectomy and the histology revealed a 0.8 cm GIST tumour composed of spindle cells with <5 mitosis per 50/HPF, tumor invasion into the submucosa and positive expression of c-kit and SMA. The patient remains recurrence free 18 months post surgery. The literature suggests that tumour size, mitotic rate and tumour site are the most important predictive factors of recurrence. Additional features such as the presence of necrosis, local tumour invasion and positive resection margins, can also influence recurrence rates. In this case the lesion was a gastric GIST, very small (<2 cm), had low proliferation rate (<5 mitosis/HPF), lacked necrosis and was limited to the mucosa. Recurrence of such a primary GIST at the anastomotic line, eight years after initial resection has never been demonstrated among review of several thousand primary GISTs. This case highlights how even the most innocent GISTs can never be described as truly benign.

Cell-assisted lipotransfer.

Adipose tissue is believed to constitute an ideal source of uncultured stromal stem cells. By optimizing the harvesting, storage, and transplantation of adipose tissue, long-lasting results can be obtained. Cell-assisted lipotransfer (CAL) is a novel approach to autologous fat transplantation in which adipose-derived stem cells are attached to the aspirated fat. The authors describe the cell processing methods, delivery systems, and clinical applications of CAL.

Fenestrated and branched endografts for the treatment of thoracoabdominal aortic aneurysms: a systematic review.

PURPOSE: To offer a critical review of the current literature on the use of fenestrated and branched stent-grafts in patients with thoracoabdominal aortic aneurysms (TAAA). METHODS: A thorough search of the English-language literature published between January 2000 and September 2009 identified reports of endovascular procedures using fenestrated and/or branched endografts as the intended repair strategy in patients with TAAA. Studies were selected based on specific inclusion criteria: (1) >3 high-risk patients with preoperative diagnosis of TAAA, (2) the intended treatment strategy was an endovascular repair using a fenestrated or branched endograft or both, and (3) patient demographics and outcome data (technical success rate, 30-day mortality, and follow-up length) were clearly stated. From 47 articles initially identified, 7 studies were included in the statistical analysis encompassing 155 patients (mean age 74.4 years, range 41-86) with TAAA averaging 69.2 mm in diameter. The mean follow-up was 11.8 months, and the majority of patients had Crawford type IV aneurysms. Outcome measures of eligible studies were tabulated and then analyzed cumulatively. RESULTS: Technical success was achieved in 94.2% (n = 146) of the 155 patients. Twenty-three (18.4%) primary endoleaks were reported. The 30-day mortality was 7.1% (n = 11), while the 1-year survival rate was 82.6% (n = 128). Three (1.9%) patients developed permanent paraplegia and 2 (1.3%) developed permanent paraparesis; renal failure was reported in 9 (5.8%). Overall follow-up mortality was 16.1% (n = 25). CONCLUSION: Endovascular treatment with fenestrated or/and branched stent-grafts is a new therapeutic option with encouraging results for patients considered unfit for conventional open repair. However, prolonged follow-up studies are needed in order to draw robust conclusions.

Diffuse malignant peritoneal mesothelioma presenting as intestinal obstruction.

Diffuse malignant peritoneal mesothelioma (DMPM) represents 90% of all peritoneal forms of mesothelioma. It affects mainly patients 50-69 years old. In 50% of cases there is a history of asbestos exposure. The clinical presentation of the disease is not characteristic: nonspecific abdominal pain, weight loss, and abdominal distension are common. Ascites occurs in 90% of the patients. Bowel obstruction is a late manifestation. We present three patients with DMPM, without a history of asbestos exposure and without ascites, who presented with complete bowel obstruction. All patients underwent emergency operations, and palliative surgical procedures were performed. Each patient died within 3 to 6 months postoperatively.

Hybrid procedures in the treatment of thoracoabdominal aortic aneurysms: a systematic review.

PURPOSE: To summarize the existing evidence on the use of hybrid open/endovascular repair in patients with thoracoabdominal aortic aneurysms (TAAA). METHODS: A thorough search was performed of the English-language literature published between January 1999 and October 2008. Studies that reported the results of hybrid procedures as the intended repair strategy in patients with TAAAs were selected using specific inclusion criteria [TAAA diagnosis based on the modified Crawford classification, a minimum 1-month follow-up, and data available on patient demographics, technical success, 30-day mortality, follow-up length, and outcome (neurological deficit, renal impairment, and/or graft vessel patency)]. From 35 articles initially identified, 15 studies were included in the statistical analysis encompassing 108 patients (75 men; mean age 67.6 years) with TAAAs averaging 72.7 mm in diameter. The majority of patients had aneurysms classified as Crawford types I (n = 20), II (n = 39), or III (n = 29); there were 14 type IV and 6 type V. RESULTS: Technical success was achieved in 91.6% (n = 99) of the 108 patients. Nineteen (16.6%) primary endoleaks and 3 (2.7%) secondary endoleaks were reported. Elective 30-day mortality was 10.4% (n = 10), while total 30-day mortality, including emergency cases, was 14.8% (n = 16). Three (2.7%) patients developed some permanent neurological deficit; renal failure was reported in 12 (11.1%). The mean follow-up period was 10.6 months, during which 97% of the grafts remained patent. Overall follow-up mortality was 24.1% (n = 26). CONCLUSION: Hybrid open endovascular repair is a new therapeutic option with encouraging results for patients considered unfit for conventional open repair. However, further research is required to draw robust conclusions.

Gastric carcinoid tumor in association with hepatocellular carcinoma: a case report.

A second primary malignancy (SPM) can occur in patients with gastrointestinal carcinoids. A patient underwent endoscopic resection of a gastric carcinoid. Repeat gastroscopy revealed recurrence of the lesion and multiple nodular gastric lesions, while an abdominal computed tomography scan revealed a small solid lesion in the left hepatic lobe. The patient underwent total gastrectomy and wedge resection of what proved to be a hepatocellular carcinoma. This case illustrates the significance of considering SPM in every patient with gastrointestinal carcinoids. SPMs are more aggressive than carcinoids, and awareness and early resection of these tumors may improve prognosis.

Prognostic factors in patients with locally advanced (unresectable) or metastatic pancreatic adenocarcinoma: a retrospective analysis.

BACKGROUND: Most patients with pancreatic adenocarcinoma are diagnosed with locally advanced (unresectable) or metastatic disease. The aim of this study was to investigate possible prognostic factors of survival in such patients. PATIENTS AND METHODS: Two hundred and fifteen patients were studied retrospectively. Twenty-four potential prognostic variables (demographics, clinical parameters, biochemical markers, treatment modality) were examined. RESULTS: Mean survival was 29.0 weeks. 21.9% survived more than 36 weeks. On multivariate analysis, 10 factors had an independent effect on survival: tumour localisation, metastasis, performance status, jaundice, weight loss, C reactive protein, CEA, CA 19-9, palliative surgery and chemotherapy. Patients managed only with palliative care had a hazard ratio of 8.94 versus those offered a combination of palliative surgery and chemotherapy. CONCLUSION: Many factors could be used as predictors of survival in patients with advanced or metastatic pancreatic cancer. Chemotherapy and palliative surgery are associated with increased survival, and should be offered to all eligible patients.

Inflammatory pseudotumor associated with Mycobacterium tuberculosis infection.

BACKGROUND: Inflammatory pseudotumor is a relatively rare entity; originally identified in the lung, it has been described in multiple extrapulmonary anatomic locations. CASE REPORT: We report on the unusual case of an inflammatory pseudotumor associated with Mycobacterium tuberculosis infection, which was initially mistaken for a renal malignancy both in clinical and radiological settings. We additionally present three brief reviews concerning: (1) infectious agents postulated to induce morphological changes of an inflammatory pseudotumor; (2) mycobacterial pseudotumors; and (3) distinction from inflammatory myofibroblastic tumors of the renal pelvis. CONCLUSIONS: The present case highlights the diagnostic importance of PCR-based detection of mycobacterial DNA in granulomatous tissue responses. It is of crucial importance that clinicians are aware of this unusual manifestation of mycobacterial infection to ensure that pertinent laboratory evaluation is employed and appropriate treatment is administered in order to avoid potential clinical implications.

Malondialdehyde as an indicator of oxidative stress during abdominal aortic aneurysm repair.

Ischemia-reperfusion injury significantly contributes to abdominal aortic aneurysm (AAA)- related mortality and morbidity; therefore, we measured oxidative stress during open AAA repair and investigated any potential associations with intraoperative or perioperative events (aortic clamping time, blood loss, and the need to transfer to the intensive care unit). Blood samples were collected at specific time points from 53 patients undergoing open AAA repair: (1) before induction of anesthesia; (2) 15, 30, 60, and 120 minutes after aortic clamping; (3) 15 and 60 minutes after clamp removal; and (4) 24 hours postoperatively. Malondialdehyde (MDA) levels were measured by a spectrophotometric method. Baseline MDA values in patients with AAA were significantly higher than in controls (P < .0001). A positive correlation was found between preoperative MDA levels and the size of AAAs (Pearson correlation = 0.578, P < .001). No difference was observed in MDA levels between ruptured and nonruptured AAAs; however, when all symptomatic patients (ruptured and elective symptomatic AAAs, n = 18) were considered, there was a significant elevation in MDA levels (P < .001). There was also a significant increase in MDA values in patients transferred postoperatively to the intensive care unit (P < .001). Finally, a positive association was found between the duration of aortic clamping with MDA values at 15 and 60 minutes after declamping, but not after 24 hours (Pearson correlation = 0.467, P < .001). MDA levels may predict the postoperative course of elective and ruptured AAAs.

Sequential administration of 5-fluorouracil (5FU)/leucovorin (LV) followed by irinotecan (CPT-11) at relapse versus CPT-11 followed by 5-FU/LV in advanced colorectal carcinoma. A phase III randomized study.

PURPOSE: The purpose of the present study was to evaluate the differences in the sequence of administration of 5-fluorouracil (5-FU)/leucovorin (LV) followed by irinotecan (CPT-11), or CPT-11 followed by 5-FU/LV in advanced colorectal cancer (ACC). PATIENTS AND METHODS: Chemotherapy-naïve patients with ACC were allocated to the following treatment groups: group A, a bolus of 20 mg/m(2) LV and 425 mg/m(2) 5-FU for 5 days until progression/relapse, and upon progression treatment with weekly CPT-11 (100 mg/m(2)), and group B, CPT-11 followed at progression/relapse by 5-FU/LV at the same doses and schedules as in group A. RESULTS: 120 patients were randomized to receive one of the two treatment sequences and their pretreatment characteristics were equally balanced between treatment arms. No statistically significant difference was found in the objective response rate to CPT-11 (p = 0.45); partial response (PR) was 23.3% for group A patients and 33.3% for group B. Following documented progression and second line treatment there was a significant difference between the response rate in group A (23.3%) and group B where no patients were found to respond to second-line treatment with 5-FU/LV (p = 0.024). The median overall survival was 42.0 weeks (range, 36.6-47.4 weeks) for group A and 32.0 weeks (range, 28.2-35.8 weeks) for group B. The median time to progression for patients in group A following first-line 5-FU/LV was 18 weeks (range, 10-36 weeks) and 12 weeks (range, 10-16 weeks) for group B following first-line CPT-11 (p = 0.0005). Toxicity, according to WHO, was similar between groups. CONCLUSIONS: Treating patients with CPT-11 upon progression to 5-FU/LV treatment seems to be superior to the opposite sequence. We used these treatments as sequential monotherapies (at progression/relapse), and the best results are gained when 5-FU/LV is followed by CPT-11 at disease progression or relapse.

Fungal infection of aortoiliac endograft: a case report and review of the literature.

Infection of aortoiliac endografts is, to date, a rare complication of endovascular surgery. Staphylococcus species are the most common responsible pathogens, just as in cases with infected grafts after open aortic surgery. We report a case of a 65-year-old man with a history of diabetes mellitus and bladder cancer who developed stent-graft infection 3 years after endovascular treatment for a 5.6 cm abdominal aortic aneurysm. The diagnosis of endograft infection was established radiologically by computed tomographic scans. After intravenous administration of antibiotics and fluids to improve his clinical condition, the patient underwent surgical excision of the infected prosthesis and a bifurcated rifampicin-impregnated Dacron graft was placed in situ. Cultures from the purulent fluid around the aorta and from the endograft revealed development of Candida albicans. To our knowledge, this is the first case of an infected endograft due to a fungus. The patient died from septic shock 3 days postoperatively in the intensive care unit.

Liver tissue dissection: ultrasonic or RFA energy?

BACKGROUND: Hepatic resection is the only potential curative treatment for a wide variety of conditions. However, liver surgery is technically demanding and closely associated with a number of serious complications. New devices and techniques are currently being applied in practice, which will improve the surgical outcome. METHODS: This retrospective study compares two methods of liver parenchymal division: ultrasound energy, a modern but already widely used technique, and radio-frequency ablation (RFA), a completely novel method. The parameters investigated include the amount of blood transfused, the necessity of the Pringle maneuver, the length of time required for parenchymal division, and postoperative morbidity and mortality. The patients were divided into two groups. In one group (Group A), 15 patients underwent 17 ultrasound-assisted liver resections, in which ten metastatic tumors, six hepatomas, and one cholangiocarcinoma were resected. In Group B, 21 patients underwent 22 RFA-assisted hepatectomies in which 11 metastatic tumors, ten hepatomas, and two cholangiocarcinomas were removed. RESULTS: Thirteen patients (87%) in Group A and 11 (52%) in Group B received a transfusion, with an average of 3.5 and 1.6 units of red blood cells, respectively. The Pringle maneuver was necessary in two cases in Group A but was unnecessary in Group B. The mean length of time required for parenchymal dissection was 124 min in Group A and 93.18 min in Group B. One (6.7%) and four (19%) complications were observed in Group A and B, respectively (statistically not significant). Mortality remained zero in both groups. CONCLUSIONS: RFA energy provides a novel reliable and safe alternative that can be used exclusively or as a supplement to the older techniques. Both resection time and amount of blood transfusion were reduced in the RFA group.