Primary lymphoma of the breast: unusual presentation of breast cancer.

OBJECTIVE: To investigate 4 cases of primary lymphoma of the breast and review previous studies in a search for any preoperative characteristics that could assist the diagnosis of lymphoma of the breast. DESIGN: Retrospective study. SETTING: University hospital, Israel. SUBJECTS: 4 women. MAIN OUTCOME MEASURES: Accurate diagnosis before operation. RESULTS: No special characteristics for early diagnosis of primary malignant lymphoma of the breast were found. The predominant involvement of right breast in primary lymphoma of the breast should be noted. CONCLUSIONS: Even though primary lymphoma of the breast is rare, there are no laboratory or imaging signs of early diagnosis. Excisional biopsy or Tru-cut biopsy are the only correct methods of diagnosis.

Indirubin, the active constituent of a Chinese antileukaemia medicine, inhibits cyclin-dependent kinases.

Indirubin is the active ingredient of Danggui Longhui Wan, a mixture of plants that is used in traditional Chinese medicine to treat chronic diseases. Here we identify indirubin and its analogues as potent inhibitors of cyclin-dependent kinases (CDKs). The crystal structure of CDK2 in complex with indirubin derivatives shows that indirubin interacts with the kinase's ATP-binding site through van der Waals interactions and three hydrogen bonds. Indirubin-3'-monoxime inhibits the proliferation of a large range of cells, mainly through arresting the cells in the G2/M phase of the cell cycle. These results have implications for therapeutic optimization of indigoids.

No serological evidence of association between chlamydia pneumonia infection and acute coronary heart disease.

Today's medical literature shows more and more evidence that Chlamydia pneumoniae plays a role in coronary atherosclerotic disease. This cross-sectional study examines the serostatus for C. pneumoniae of patients with an acute cardiovascular event. A total of 58 patients with acute myocardial infarction or with proven unstable angina (occlusion > or = 70% of at least 1 vessel at coronary angiography) ('patients') were compared with 58 age- and sex-matched patients without a cardiovascular event ('controls'). Serological testing for C. pneumoniae was performed by a microimmunofluorescence test during the first week of the event and 4-6 weeks later. Although more patients from the cardiovascular event group showed a positive history of a respiratory tract infection during 6 weeks preceding hospitalization (18/58 patients, 8/58 controls, p = 0.03), there was no significant difference between the two groups for an acute, chronic or past infection by C. pneumoniae (19/58 patients, 24/58 controls, p = 0.93). In conclusion, contrary to previous published papers, this study could not confirm an association of C. pneumoniae infection with an acute coronary event. Serological testing alone may not be the best way to demonstrate this association. An acute infection by C. pneumoniae, which should have been detected by serological testing, is probably not the origin of the rupture of an atheromatous plaque.

Expression of p21WAF1/CIP1 in soft tissue sarcomas: a comparative immunohistochemical study with p53 and Ki-67.

The p53 gene controls the cell cycle by transactivating p21WAF1/CIP1, a cyclin dependent kinase (cdk) inhibitor. By inhibiting cdks, p21WAF1/CIP1 regulates the cell cycle by blocking the G1 to S phase transition. In this study, we analyzed the immunohistochemical expression of p21WAF1/CIP1 in 66 soft tissue sarcomas and its relationship to p53 and the cell cycle proliferation antigen Ki-67. Expression of p21WAF1/CIP1, was detected in 76% of the tumors and p53 in 26%. All malignant schwannomas, synovial sarcomas, leiomyosarcomas and gastrointestinal stromal tumors expressed p21WAF1/CIP1. The majority of angiosarcomas, dermatofibrosarcomas, and fibrosarcomas showed low expression or were negative for p21WAF1/CIP1. Ewing's sarcomas, liposarcomas, and malignant fibrous histiocytomas were heterogeneous in their expression of p21WAF1/CIP1. Combining p53 and p21WAF1/CIP1 staining, the following four patterns were observed: 23% of the tumors showed the p53+/p21+ pattern; 53% showed the p53-/p21+ pattern; 3% showed the p53+/p21- pattern and 21% were negative for both p53 and p21WAF1/CIP1. There was no correlation between Ki-67 and p21WAF1/CIP1 or p53 staining. Our results show that soft tissue sarcomas, independent of their histologic subtype, frequently express p21WAF1/CIP1 which is probably important in their tumorigenesis. Additionally, p21WAF1/CIP1 may play a role in determining the efficacy of various cell cycle-directed therapies in soft tissue sarcomas.

Technetium-99m-HIDA scintigraphy versus endoscopic retrograde cholangiopancreatography in demonstrating bile leaks after laparoscopic cholecystectomy.

In two patients who had laparoscopic cholecystectomy, the postoperative course was complicated by continuous bilious drainage from the surgical drain in one and by jaundice in the other. In both patients, the findings of 99mTc-N-substituted-2,6-dimethylphenyl carbamoylethyl iminodiacetic acid (HIDA) scanning were interpreted as clearly demonstrating a significant bile leak in one and the complete absence of bile passage from the liver to the intestines in the other. These findings could result from either spontaneous closure of the bile leak or false-positive HIDA scans. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed the common bile duct and the cystic duct to be normal, without any evidence of bile leakage or any problem with drainage to the intestines. In all patients who have a positive 99mTc-HIDA scan, ERCP should be performed before deciding on further surgical intervention.

Optimal pH for simple cold storage or machine perfusion of dog kidneys with UW solution.

Metabolic suppression by temperature is a key to successful organ preservation. Additional methods for inducing metabolic suppression may further improve organ preservation. Extracellular acidosis has been shown to suppress warm anoxic injury to various isolated cells. Acidosis may suppress enzymes with a pH optimum at the pH of the cytosol (pH 7.3). In this study, the combination of hypothermia and acidosis was used to determine if it would improve renal preservation. Dog kidneys were cold-stored (CS) for 48 h in University of Wisconsin (UW) solution with the pH adjusted to 6.4, 6.8, 7.4, or 7.8. Kidneys were also machine-perfused (MP) for 3 days with the gluconate perfusion solution (Belzer's machine perfusion solution, MPS) at pHs similar to those tested for CS. Renal function (serum creatinine, SCr) and survival were recorded in immediate contralateral nephrectomized recipients. On the basis of maximum SCr values, kidneys preserved by CS or MP were best preserved at pHs of 7.4 or 7.8. At a pH of 6.8, SCr values were elevated and returned to normal at a slower rate than in those preserved at higher pHs. This study shows that acidosis is not cytoprotective to cold-stored dog kidneys and causes preservation/reperfusion injury.

[Splenic artery aneurysm].

Splenic artery aneurysm is an uncommon form of vascular disease of unknown etiology. Its clinical importance is due to its high mortality, especially in pregnancy, when maternal mortality is 70% and fetal mortality 95%. Most cases of splenic artery aneurysm are asymptomatic and are diagnosed incidentally. We present a woman with incidentally diagnosed splenic artery aneurysm in whom the splenic artery and its aneurysm were resected.

Protocol for immunocytochemical detection of SIL in cervical smears using MIB-1 antibody to Ki-67 [corrected].

Ki-67 nuclear antigen is expressed in upper epithelial levels of intraepithelial neoplasia of the cervix and vulva, variably in condyloma, and in basal and parabasal cells of normal squamous mucosa in histologic preparations. The application of antibodies to Ki-67 as a marker of squamous intraepithelial lesions in cervical smears was explored using either air-dried, acetone-fixed cervical smears obtained from 106 consenting patients or a single slide from archival two-slide cases of squamous intraepithelial lesions MIB-1 monoclonal antibody to Ki-67 was tested using two immunocytochemical techniques. In one set of smears, avidin-biotin peroxidase was used for detection and diaminobenzidine with H2O2 as the chromogen. Some specimens were incubated with 0.3% H2O2 and phosphate buffered saline for blockade of endogenous peroxidase. Alternatively, other air-dried smears were stained using alkaline phosphatase antialkaline phosphatase for detection and new fuchsin as the chromogen. Nuclear staining in squamous intraepithelial lesions was identified in air-dried smears using all of the above methods. Slides stained with avidin-biotin peroxidase and blocked with 0.3% H2O2 and phosphate buffered saline showed less background staining from neutrophils and erythrocytes compared with those without blocking. Slides stained using alkaline phosphatase antialkaline phosphatase showed excessive cytoplasmic staining of endocervical cells, making intraepithelial difficult. No nuclear staining of squamous intraepithelial lesions was observed in destained archival smears. Air-dried smears blocked with 0.3% H2O2 and phosphate buffered saline, incubated with MIB-1, and stained using avidin-biotin peroxidase gave the best results for identification of Ki-67 expression in squamous intraepithelial lesions.

Pasteurella multocida endocarditis: report of a case and review of the literature.

We report on a cirrhotic patient who presented with an aortic valve endocarditis due to Pasteurella multocida. This disease entity is rare and we take this opportunity to review the 6 cases published to date.

Malignant fibrous histiocytoma of the breast.

Primary malignant fibrous histiocytoma of the female breast (MFH) occurs very rarely, and only 22 cases have been reported so far. We describe a 42-year-old female in whom MFH of the breast was diagnosed, and review the available literature. In accordance with knowledge concerning the biological and clinical behaviour of breast MFH, either wide local excision or mastectomy combined with axillary lymph nodes dissection is recommended, due to the high rate of recurrence and metastatic potential of this tumour.

Alteration of pulmonary function by filtration of intravenous nutrient mixture.

In view of contradicting results concerning alteration in lung function during hyperalimentation and the administration of intravenous lipid emulsion, a study was planned to determine possible changes in pulmonary blood perfusion during administration of total nutrient admixture (TNA) and the effect of filtration. Sixteen patients (8 men, 8 women; mean age 65.6 yr) with no previous lung disease received TNA at the rate of 4-5 g lipid/h as preoperative treatment for 5-9 days (mean 6.7 days). The 5-microns filter was randomly used in eight patients. The lung blood perfusion parameters measured repeatedly during this period included blood gases, percentage of the predicted value of vital capacity (VC), and pulmonary diffusing capacity for carbon monoxide (DLCO), as well as the value of the dead space volume and the tidal volume ratio (VD/VT) and the calculated shunt (QS/QT). TNA infusion appears to cause only a slight decrease in PaO2 and DLCO and a similar increase in VC and QS/QT, whereas VD/VT decreased significantly. The latter effect was abolished by filtration of TNA. There were no significant differences between the two groups. We therefore conclude that short-term preoperative administration of TNA at the rate of 4-5 g lipid/h in patients without preexisting lung disease does not jeopardize lung functions. Filtration of the TNA is, however, recommended to avoid the potential hazardous effects of long-term treatment of TNA on lung function.

Upper thoracic sympathectomy.

In the extremities, the vascular response to sympathetic stimulation is vasoconstriction with blanching and cooling of skin and increased sweating, whereas, blocking of the sympathetic system results in increased blood flow through cutaneous arteriovenous fistulae and cessation of sweating, thereby, resulting in increased dryness, warmth and accentuation of pink color. In the past, sympathetic denervation of the upper extremity was suggested as a treatment of many disorders; bronchial asthma, essential hypertension, peptic ulcer disease, hyperthyroidism, hyperhidrosis, vasospastic syndromes (Raynaud's disease), thoracic outlet syndrome, causalgia, post-traumatic sympathetic dystrophy (Sudeckatrophy), and angina pectoris. The indications for upper thoracic sympathectomy are limited today to hyperhidrosis, causalgia, severe vasospastic disorders, and ischemic changes of the extremities (Buerger's disease).

[Subcutaneous emphysema complicating laparoscopic cholecystectomy].

Laparoscopy using carbon dioxide has been a standard gynecological procedure for many years. During the past 3 years, it has become commonly used in general surgery as well. Laparoscopic cholecystectomy is rapidly spreading world-wide. Although minor and major complications have been attributed to this procedure, their frequency is low. We report a case of subcutaneous emphysema following laparoscopic cholecystectomy.

Auditory brainstem evoked response in patients undergoing carotid endarterectomy.

Auditory brainstem evoked response-(ABR) may be affected by changes in cerebral blood flow. Apart from its primary indications for prevention of stroke and transient ischemic attacks-(TIA's), internal carotid endarterectomy-(ICE) has been shown to improve cognitive function and cause diminution of tinnitus and vertigo. A one-week postoperative ABR previous study of patients undergoing ICE demonstrated no change in ABR recordings. In order to evaluate possible late changes, we have conducted a prospective study of the delayed effects of ICE on ABR in 13 patients. No initial pathology was noted and no significant change found in any of the absolute and interpeak latencies of ABR waves.

The effect of impairment of blood supply to the rat uterus.

Over the last decades much attention has been directed to establishing the cause of altered fetal growth and habitual abortion. Great emphasis has been placed on placental blood flow, but relatively few studies have been published on the effect of impaired uterine blood supply. This study examined the effect of impaired uterine blood flow using the white rat, with its bilateral uterine horns. Three groups of rats with bilateral, left unilateral, or right unilateral artery ligation were compared with a control group for number and weight of fetuses at term. The results showed that the impaired rats produced significantly fewer fetuses than controls (means: 8.59 vs. 11.21, respectively; P less than .001) and those fetuses had lower mean birth weights than controls (5.295 g vs. 5.800 g, respectively; P less than .05). While conception was possible even in rats with impaired uterine blood flow, the differences at term suggest that impairment of the maternal blood flow may contribute toward intrauterine growth retardation and habitual abortion. The clinical significance of these findings and suggestions for future research are discussed.

[Laparoscopic cholecystectomy].

The standard treatment for cholelithiasis is cholecystectomy at open operation, which requires relatively long hospitalization and long absence from work. These socio-economic factors and a desire to avoid operative trauma and its complications led to the development of noninvasive therapy. The methods used so far, stone dissolution and extracorporeal shock wave lithotripsy, have proven unsatisfactory. The first takes a long time and has a high recurrence rate, the second has relatively frequent complications. Furthermore, both methods leave the diseased gallbladder in place. During the past year laparoscopic cholecystectomy has been developed in various centers and has been adopted in our department. We describe our initial experience with the technique in 70 cases aged 18-79 years.

Squamous and basal cell cancers directly invading major salivary glands.

Epidermoid carcinoma of the skin of the head and neck may uncommonly involve the parotid gland by either direct extension or metastases to the parotid lymph nodes. The parotid gland contains a rich network of superficial and deep nodes, draining a large area of the facial region, with the preauricular, cheek, ear, and eyelid dominating. Few patients with direct parenchymal invasion of the parotid gland by a simultaneously existing squamous or basal cell carcinoma were reported. We could find no report discussing direct tumoral invasion into the submandibular salivary gland. Three patients with squamous cell carcinomas and 2 with basal cell carcinomas of the skin directly involving the underlying salivary glands are presented. The few authors discussing this subject concur that treatment should include resection of the primary tumor along with parotidectomy. Elective neck dissection and irradiation are proposed. The course of disease, treatment, and survival of our patients are discussed.

Syndrome of inappropriate antidiuretic hormone secretion in cancer of the head and neck.

The syndrome of inappropriate secretion of arginine vasopressin (AVP) known as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by hyponatremia that results from water retention attributable to persistent AVP release. It may occur in a variety of malignant and nonmalignant lesions, with small cell or oat cell carcinoma of the lung by far responsible for the largest number of these cases. Cancer of the head and neck may be a rare cause of SIADH, and only a few such cases have been reported. We describe four patients with advanced cancer of the head and neck region with coexisting SIADH. Diagnosis and treatment are reported and the literature is reviewed. The possible occurrence of SIADH in the head and neck surgical practice should be kept in mind. Since SIADH is usually transient, water restriction and parenteral sodium chloride may be sufficient in overcoming the acute phase.

[Duodenal duplication cyst].

Duodenal duplication cysts are rare and are usually found in neonates or young children who present with obstructive symptoms. It accounts for 4-12% of all duplications in the gastrointestinal tract. The rate of other developmental abnormalities has been reported as high as 38%. In few instances have duodenal duplication cysts been described in adults. A case of duodenal duplication cyst in a 46-year-old woman is presented. The diagnosis was established preoperatively by computerized tomography and ultrasound examination.