Three-step technique for implantation of rotating hinge knee prostheses : Demonstration using the Enduro prosthesis.

OBJECTIVE: Implantation of an axis-guided knee prosthesis with consideration of the joint line and balanced flexion and extension gap to reduce the mechanical load on the prosthesis axis and to improve the movement of the prosthesis. INDICATIONS: Distinct unilateral instability due to ligament insufficiency in association with knee prostheses. Primary implantation of axis-guided knee prostheses with pronounced axial malalignment (>20-25° valgus or varus malalignment) or/and severe flexion contracture > 40°. Replacement of prosthesis with nonsignificant imbalance between flexion and extension gap. CONTRAINDICATIONS: Clearly unstable flexion gap such that the extension gap cannot be adjusted appropriately. Significant femoral bone defects requiring distal femoral replacement prostheses. SURGICAL TECHNIQUE: Reconstruction of the tibial platform with the trial prosthesis with regard to height in relation to the tip of the fibula. Determination of the femoral prosthesis size. Adjustment of the anteroposterior (AP) cutting block of the selected size, referenced anteriorly and in correct rotation. Determination of the flexion gap with spacers using the stable side of the collateral ligaments. Positioning the distal cutting block and determination of the height of the extension gap. Moving the distal cutting block until the same height of spacer as used in the flexion gap fits into the extension gap, taking into account the stable side of the collateral ligaments. The extent of the displacement D1 is noted. Reverse displacement of the distal cutting block by the distance D2 until a satisfactory bony contact surface for the femoral component in the distal femur can be created. The thickness of the required distal augments on the following chamfer-cutting guide (4-in­1 cutting block) and thus on the femoral prosthetic component is the sum of D1 + D2. The chamfer-cutting guide (4-in­1 block) with distal augments of the calculated height (D = D1 + D2) is placed in position. Definition and preparation of the posterior contact surface with positioning of any necessary posterior augments. Completion of the femoral preparation taking into account the distal and posterior augments. Assembly of the trial prostheses with a trial inlay having the height of the spacers used. Implantation of the selected prosthesis components. POSTOPERATIVE MANAGEMENT: Thrombosis prophylaxis, physiotherapy under full weight-bearing and mobility exercises. RESULTS: After implantation of 104 axis-guided Enduro™ knee prostheses (Aesculap AG, Tuttlingen, Germany) (73 knee prosthesis revisions and 31 primary implantations), the Knee Society Score increased from 42.8 ± 18.8 preoperatively to 84.8 ± 13.9 after 24 months. Complications comprised one deep vein thrombosis and one periprosthetic infection.

Expression of E-cadherin, beta-catenin and topoisomerase IIalpha in leiomyosarcomas

INTRODUCTION: The expression of E-cadherin, beta-catenin and topoisomerase II has been associated with clinical outcome of several cancers including sarcomas. We aimed to evaluate the expression of these markers in leiomyosarcomas (LMS). MATERIALS AND METHODS: Paraffin blocks of 19 primary, nonmetastatic LMS were analysed immunohistochemically for the expression of the above-mentioned markers with a cutoff level for positivity of 20% of cell staining. RESULTS: Expression of E-cadherin was negative in all LMS. Nuclear expression of beta-catenin was also negative in all cases, while positive cytoplasmic beta-catenin expression was observed in approximately half of the patients. The majority of LMS had expression of topoisomerase IIalpha, although only in 10 patients was this expression in more than 20% of tumour cells. From the analysed factors, tumour size was statistically significantly correlated with relapse-free survival. CONCLUSIONS: Further evidence with larger series is required in order to determine the implication of these markers in LMS (AU)

Aortic valve replacement with patent bilateral internal thoracic artery grafts using cross-clamp fibrillation.

Aortic valve replacement in patients with patent coronary grafts poses many challenges. Intraoperative myocardial protection remains one of the key technical issues in these redo cases. We present a case of aortic valve replacement with patent bilateral internal thoracic artery grafts, using cross-clamp fibrillation.

Local staging of endometrial carcinoma: role of multidetector CT.

The purpose was to evaluate the accuracy of multidetector CT (MDCT) on a 16-row CT scanner in local staging of endometrial carcinoma and more specifically in the assessment of the depth of myometrial invasion and presence of cervical infiltration. This prospective study includes 21 women with newly diagnosed endometrial carcinoma. All CT examinations were performed on a 16-row CT scanner, and the protocol included scanning of the abdomen after intravenous administration of iodinated contrast material, during the portal phase, using a detector collimation of 16 x 0.75 mm and a pitch of 1.2. Sagittal, parasagittal and oblique reformatted images were evaluated for the depth of myometrial invasion, whether superficial or deep, and the presence of cervical infiltration. Imaging findings were correlated with the histopathologic results. The sensitivity, specificity and accuracy of MDCT in evaluating myometrial invasion were 100%, 80% and 95%, respectively, and for assessing cervical infiltration were 78%, 83% and 81%, respectively. In conclusion, MDCT on a 16-row CT scanner proved accurate in local staging of endometrial carcinoma.

Total miniaturized cardiopulmonary bypass: the next step in minimally invasive aortic valve replacement.

Minimally invasive aortic valve replacement has been established in many centres over the last decade. Although numerous modifications have been described to date, these solely involve variations of the utilized operative incision. Total miniaturized cardiopulmonary bypass (tMCPB) offers the theoretical potential of reducing even further the overall procedural "invasiveness". We describe our initial experience of an application of MCPB for aortic valve replacement through a minimal incision.

Expression of Bax protein in gastric carcinomas. A clinicopathological and immunohistochemical study.

BACKGROUND AND STUDY AIMS: Reduced Bax protein expression has been shown to be a negative prognostic factor in patients with breast, ovarian, colorectal, esophageal and pancreatic cancer. Our aim was to immunohistochemically study Bax protein expression in gastric carcinomas and correlate its expression with clinicopathological parameters and prognosis. PATIENTS AND METHODS: Immunohistochemistry was performed, using a monoclonal antibody against bax, in paraffin-embedded tumor specimens from 47 cases of gastric cancer. RESULTS: Positive staining for the Bax protein was found in 20/47 (42.4%) adenocarcinomas examined. Negative Bax protein expression in tumour cells was correlated with lymph node metastasis (P < 0.05), and degree of differentiation (p < 0.05). Univariate analysis showed that the variables with a significant negative impact on survival were: high TNM tumour stage, depth of penetration in the gastric wall, lymph node involvement, and Bax protein expression. Multivariate analysis showed that the only variable with an impact on survival was Bax protein expression (p < 0.05, Relative Risk: 3.34). Kaplan-Meier curves showed that the 5-year survival was 36.8% in cases with positive compared with 16% in cases with negative Bax protein expression (p = 0.0427). CONCLUSION: Negative Bax expression in gastric cancer is associated with de-differentiation, lymph node metastases, and poor clinical prognosis. Bax protein expression might play an important role in the development and phenotypic differentiation of gastric carcinomas and tumor progression.

DCIS histopathology from a historical perspective.

Ductal carcinoma in situ (DCIS) represents a biologically and morphologically heterogeneous disease. It is characterized by a proliferation of presumably epithelial malignant cells confined within the lumens of the mammary ducts, without evidence of invasion beyond the basement membrane into the adjacent breast stroma. With the widespread use of screening mammography, a dramatic change has occurred in the frequency, management and types of DCIS detected. Historically, there has been some confusion regarding the definition of DCIS and the terminology associated with the histological types of DCIS. In this review, DCIS histopathology from a historical point of view is presented.

Expression of matrix metalloproteinase-9 (gelatinase B) in benign, premalignant and malignant laryngeal lesions.

The matrix metalloproteinases (MMPs) are a family of proteolytic zinc-containing enzymes, which are responsible for the breakdown of the extracellular matrix components in pathological and physiological conditions. They are involved in basement membrane disruption, stroma and blood vessel penetration, metastasis and more recently there is evidence that they participate in tumor growth and angiogenic events. Matrix metalloproteinase 2 and 9 (MMP 2 and 9) belong to the gelatinases, a subgroup of MMPs, and have the capacity to degrade the triple helix type IV collagen of basal lamina of the basement membrane. With the present study, we tried to demonstrate the expression of MMP-9 immunohistochemically, comparatively in benign, premalignant and malignant lesions of the larynx. We studied 154 laryngeal lesions including 55 squamous cell carcinomas, 8 in situ carcinomas, 54 cases of dysplasia (of low and intermediate grade), 13 papillomas and 24 cases of keratosis. Overexpression of MMP 9 was observed in 74.4% and 50% in invasive and in situ squamous cell carcinomas respectively. In dysplastic cases, in papillomas and in keratoses the percentage of overexpression was 62.9%, 61.53% and 54.16% respectively and the expression of MMP-9 was significantly higher in invasive squamous cell carcinomas compared to dysplasias (p=0.000004). Also significantly higher was the expression of MMP-9 in dysplastic cases compared to papillomas (p=0.023). The MMP-9 expression was related neither to survival nor to the other available clinicopathological parameters (tumor size, grade, clinical stage, lymph node status and patient age). In conclusion, our study indicates that the expression of MMP-9 is up-regulated in a stepwise fashion, with two main steps, the first one, when a dysplastic lesion evolves and the next one, when the dysplasia progresses to invasive carcinoma.

The enigmatic nature of apocrine breast lesions.

Epithelial cells of fetal breast glandular structures, at the third trimester of pregnancy (28 weeks), produce GCDFP-15, in the absence of specific apocrine morphology. Apocrine epithelium of the breast may be a normal process of differentiation rather than a result of metaplasia, and it has been demonstrated that it is estrogen-receptor, progesterone-receptor and bcl-2 negative, but androgen-receptor (AR) positive. The significance of AR expression in apocrine epithelium is uncertain. Apocrine epithelium is seen in a wide spectrum of breast entities, ranging from benign lesions to invasive carcinoma. Breast cancer accounts 32% of all cancer cases among women and is the most common type of cancer in women. Little is known about breast carcinogenesis. Widely, it is accepted that breast cancer, like most other type of cancer, is being developed through the accumulation of genetic aberrations. Apocrine epithelium may reflect instability of the breast epithelium, creating an environment favouring further oncogenic alterations. In the last decade, several lines of evidence support the idea that some breast benign epithelial apocrine lesions are clonal lesions and may be considered as truly pre-malignant or precursors of breast carcinoma. Apocrine changes in many cases do not present any diagnostic difficulty; on the other hand, apocrine proliferations with cytologic atypia can be particularly difficult and challenging. The purpose of this study is to collect and highlight the areas of consensus in the literature as well as the controversial areas concerning the apocrine epithelium of the breast.

Clinicopathological study of metallothionein immunohistochemical expression, in benign, borderline and malignant ovarian epithelial tumors.

Metallothioneins (MTs) are a family of cystein-rich metal-binding proteins, which are expressed in normal cells during fetal and postnatal life but also in a variety of human neoplasms. MT expression in human tumors has been linked to resistance to anticancer drugs and differentiation and progression in some types of tumors. This study examined the immunohistochemical expression of MTs in benign, borderline and malignant tumors of ovarian surface epithelium and the possible correlations with clinicopathological parameters and survival. A total of 87 cases with diagnosis of ovarian surface epithelial tumors were included. Specifically, 21 cases of benign cystadenomas (11 serous and 10 mucinous), 14 borderline (low malignant potential tumors, 8 mucinous and 6 serous) and 52 cases of ovarian cancer were analysed. Immunohistochemical expression of MT (cut-off level > 10% of tumor cells) was clearly associated with malignancy. A statistically significant correlation was found between the expression of MT in cancer cases and benign tumors (p < 0.0001) and cancer cases and borderline tumors p = 0.003. In cancer cases a difference was observed between grade I and III (p = 0.002). There was no correlation of MT overexpression with survival in the small number of ovarian carcinoma patients where it was analysed. MT constitutes a marker that characterizes aggressiveness and a high malignant potential in ovarian epithelial tumors. In diagnostic problems MT may help distinguish between benign, borderline and malignant tumors.

Cell cycle proteins in laryngeal cancer: role in proliferation and prognosis.

A study of laryngeal carcinomas was performed in order to analyze (a) the expression of p53/p21, cyclin D1/cyclin E, p21/p27 (b) the relation of normal and abnormal protein expression, with the proliferation status, as determined by the expression of Ki67 and PCNA and (c) the correlation of our findings with prognosis. We performed a retrospective analysis of 57 cases of squamous cell carcinomas of the larynx. We applied monoclonal antibodies against p53, p21, p27, cyclin D1, cyclin E, Ki67 and PCNA, using streptavidin-biotin method. Analysis of the p53/p21 proteins, revealed abnormalities in 25/37 cases (67.57%), while 12/37 (32.43%) cases displayed normal phenotype (p53-/p21-). Analysis of cyclins revealed overexpression in 17/48 cases (35.42), while the majority 31/48(64.58%) displayed normal phenotype (cyclin D1-/cyclin E-). Concerning CDKIs expression, the majority 30/50(60%) presented high levels of both inhibitors (p21+/p27+). Cases with simultaneous overexpression of CDKIs demonstrated significantly higher levels of Ki67 protein (p = 0.05). Analysis of p53/p21, cyclin D/cyclin E, p21/p27 patterns showed no association between the presence of one or two alterations and prognosis. In conclusion, we demonstrated that p53 tumor suppressor pathway is frequently disrupted in laryngeal cancer. Furthermore, levels of CDKIs, although they act as cell cycle activity blockers, are not reliable markers for the estimation of laryngeal neoplastic cells growth fraction.

The role of fine-needle aspiration biopsy in the management of patients with thyroid nodules.

Fine-needle aspiration biopsy (FNAB) of the thyroid gland is the most cost-effective examination in the evaluation of thyroid nodules. The aim of this study was to present our experience from all patients who underwent thyroid FNA in the University Hospital of Ioannina, Greece, in the period 1993-2003, and its value in the diagnostic management of patients with thyroid nodules. FNA was performed in 900 patients of whom 753 were females and 147 males. The cases were classified according to diagnosis into five groups: benign/negative 628, primary carcinoma 28, metastatic carcinoma 5, suspicious/indeterminate 60 and non-diagnostic 179. Cytological findings were compared with histopathological findings and the statistical analysis in our data yielded the following results: sensitivity 92.1%, specificity 93.2%. These results are in accordance with the already published data in the international literature. In cases of differential diagnosis between adenomatoid hyperplasia and follicular neoplasia, four cases were diagnosed as hot nodules. In the benign group, three cases were diagnosed as nodular hyperplasia with cystic degeneration on FNA, but, after surgical treatment, histologically were diagnosed as papillary carcinomas. In the group of suspicious/indeterminate, two cases were diagnosed as suspicious for follicular neoplasia on FNA and, after surgical treatment, were diagnosed histopathologically as medullary carcinomas. In conclusion, we suggest that routine measurement of serum calcitonin is useful and mandatory in the detection of medullary carcinoma among patients with nodular thyroid diseases. Taking into consideration the clinical data can minimize false-positive and false-negative rates. We conclude that FNA is an effective screening test in the evaluation of the necessity for surgical treatment in patients with thyroid nodules.

FNAC: its role, limitations and perspective in the preoperative diagnosis of breast cancer.

Fine-needle aspiration cytology (FNAC) was first described and performed in 1930. Thirty years later, it gained acceptance first in Europe and about a decade later in North America. The method is generally considered as a rapid, reliable, safe diagnostic tool to distinguish non-neoplastic from neoplastic breast lesions. In developed countries, in the last 20 years, mammographic screening programmes, which have been used extensively, are designed to detect the earliest possible breast cancer. The FNAC report is extremely important because it gives the necessary information for the management of patients, in order to proceed with more invasive diagnostic methods or surgical treatment, and to decide what kind of operation to perform. In the preoperative phase, FNAC has taken a fundamental role of both palpable and nonpalpable lesions, using ultrasound or stereotactic guidance. New developed techniques, breast biopsy instrumentation (ABBI) and mammotome have the advantage of complete removal of breast lesions, but this is not possible in all the examined cases. In developing countries, economical restrictions, low budget for health care and screening programmes put the patients at a disadvantage because of the high cost of sophisticated diagnostic methods, thus we recommend that FNAC be used as a routine diagnostic method because of its low cost compared with the others and this policy maximizes the availability of health care to women with breast cancer. We conclude that FNAC plays an important and essential role in the management of patients with breast lesions and also offers a great potential for prediction of patient outcome, disease response to therapy and assessment of risk of developing breast cancer. The reliability and efficiency of the method depends on the quality of the samples and the experience of the medical staff that performs the aspiration.

The role of tumor markers in non-palpable breast cancers.

Screening mammography and clinical breast examination are the best tools available for the diagnosis of breast carcinomas in asymptomatic women. Many studies have attempted to determine the pathological and biological characteristic findings in screening-detected cancers. Tumor size, histologic type, cytological grading and lymph node status have an important role in estimating the biological profile of non-palpable breast cancers. Tissue tumor markers, such as proliferation markers, hormone receptors, c-erbB-2 and p53 oncoproteins, bcl-2 gene and angiogenesis-related markers do not seem to distinguish mammographically detected tumors from clinically presented cancers. Further studies are needed to assess the prognostic role of certain biological factors in well-designed clinical studies along with long follow-up of screened patients.

Mucoepidermoid carcinoma of the thymus: a case presentation and a literature review.

Mucoepidermoid carcinoma of the thymus is an unusual, but well-recognized variant of thymic malignant tumors. Its biologic behavior generally depends on the degree of differentiation and the amount of cellular atypia. High grade tumors can be aggressive neoplasms with a tendency to invade and develop metastases. We report on a case of a 53-year-old man, who presented chest discomfort, dyspnea, and weakness. As heart function tests were normal, the patient underwent radiologic examination, which showed a well-demarcated mass in the anterior mediastinum. Histologic examination of the surgically resected mass showed features of a mucoepidermoid carcinoma with associated infiltration of the pleural tissue. Postoperative radiotherapy and chemotherapy were performed, and the patient died two months after initial diagnosis. In case of the absence of metastatic disease or other common primary neoplasms of the thymus, the diagnosis of a mucoepidermoid thymic carcinoma should be taken into consideration, although this tumor is rare.

Tumor markers in cancer patients. an update of their prognostic significance. Part II.

The primary determinant of outcome in patients with cancer is the development of distant metastasis. Metastasis is a multistep process involving disruption of cell-matrix adhesion, dissolution of the extracellular matrix, angiogenesis, invasion in the blood vessel wall, extravasation and establishment of a secondary growth. Nowadays, a large number of biochemical and cell biological studies have indicated the important role of extacellular matrix adhesion molecules, proteinases and angiogenic factors in the dissemination of cancer. Cell adhesion molecules, such as integrins, E-cadherin, catenins and CD44 appear to have some prognostic significance, especially in gastric, colorectal and lung cancer patients. Since matrix degrading proteinases are involved in cancer spread, they should be good candidates as prognostic factors. The proteinase which has been investigated in greatest detail is uPA in breast cancer. As a marker of cancer, its main value is to aid in selecting the subgroups of node-negative breast cancer patients that are unlikely to benefit from adjuvant chemotherapy. Cathepsin D and metalloproteinases (MMPs) look promising prognostic markers but further work is needed to establish their utility. Intratumoral angiogenesis is a putative prognostic indicator for some types of cancer. High expression of the angiogenic factor VEGF is associated with angiogenesis and an unfavourable survival.

Immunohistochemical expression of vascular endothelial growth factor correlates with positive surgical margins and recurrence in T1 and T2 squamous cell carcinoma (SCC) of the lower lip.

Tumor angiogenesis is associated with tumor progression and aggressiveness in a number of malignancies, and vascular endothelial growth factor (VEGF) is considered as a leading candidate in this process. The aim of the present study was to investigate the role of VEGF immunohistochemical expression and tumor angiogenesis in predicting local recurrence in surgically treated lip SCC. We performed a retrospective analysis of 50 patients with lip SCC in order to investigate whether VEGF immunohistochemical expression and tumor angiogenesis correlate with clinicopathologic parameters and outcome. Tumor angiogenesis was estimated by determining microvessel density (MVD) with the use of CD34 antibody. Our results showed that VEGF was strongly correlated with tumor invasion towards the surgical margin. There was also a significant association of high VEGF expression with a higher incidence of local recurrence (p < 0.001). We suggest that VEGF expression may be used as an index to distinguish patients with higher risk of relapse.

Direct endobronchial metastasis is a rare metastatic pattern in breast cancer.

Breast cancer is the most common cancer in women. Lungs represent a common site of metastases in breast cancer cases. Lung parenchyma, pleura, lymphatics, regional lymph nodes as well as trachea with bronchi are sites of metastatic involvement of the lungs in patients suffering from breast cancer. Endobronchial metastasis, especially of the direct type, is a very rare metastatic pattern in this type of cancer. We describe a case of endobronchial metastasis in a 59 years old Caucasian woman who had had a radical mastectomy 2 years before her present admission because of breast cancer. She was admitted to Joannina University hospital complaining of non-productive cough. Chest X-rays showed atelectasis of the right upper pulmonary lobe. Flexible fiberoptic bronchoscopy findings, cytologic examination of the bronchial excretions as well as the histological examination of the excised during bronchoscopy tumour specimen, strongly suggested a breast adenocarcinoma. Hereby, review data from the literature is given in brief.