Breast Cancer and Sarcoidosis: Case Series and Review of the Literature.

BACKGROUND: Sarcoidosis is a chronic inflammatory disease of unknown etiology, which can involve different organs and systems. Accordingly, sarcoidosis can mimic breast cancer, making the differential diagnosis very difficult. CASE REPORT: 5 patients with a diagnosis of both sarcoidosis and breast cancer followed by the Rabin Medical Center between January 1993 and June 2012 were enrolled in this study. Additionally, a comprehensive literature review which identified 104 patients diagnosed with breast cancer and sarcoidosis was carried out. In both populations reviewed, the average age at diagnosis of sarcoidosis and breast cancer was 57 years. Among the 66 patients with both sarcoidosis and breast cancer, sarcoidosis preceded breast cancer in 31 cases, followed it in 23 cases, and appeared concurrently in 10 cases. CONCLUSION: Based on our clinical cases and literature review, a histological study is recommended over imaging if sarcoidosis or breast cancer may be present. Furthermore, breast cancer is rarely associated with sarcoidosis or sarcoidosis-like reaction.

Operative treatment of hepatic hydatid cysts: a single center experience in Israel, a nonendemic country.

Background. Hydatid cyst disease is a zoonosis caused by Echinococcus genera. The disease is endemic to certain rural areas in the world. Operative treatment is the main component in curing hydatid cysts of the liver. Objective. Describing the unique characteristics of the hydatid cyst patients in Israel, a nonendemic country. Methods. Data was collected form 29 patients treated operatively in Rabin Medical Center from 1994 to 2007. Results. The study included 18 females and 11 males with an average age of 54.9 years. Fifty-two% of the patients immigrated as children from Arab countries to Israel, 21% were Arab-Israelis leaving in the north and center of Israel, and 24% immigrated from the former Communist Bloc. Pericystectomy was performed in 20/29, and cyst unroofing was performed in 9/29. Hydatid cysts average size was 10.7 cm, and the cysts were located in the right or left or involved both lobes in 62%, 28%, and 10% of the lesions, respectively. Postoperative mortality occurred in one case, and severe morbidity occurred in 4 patients. Conclusions. Hydatid cyst disease in Israel is uncommon and is mostly seen in distinct 3 demographic groups. Despite the relatively low patient volume, good results in terms of morbidity, mortality, and recurrence were achieved.

Erythropoietin increases survival and attenuates fulminant hepatic failure injury induced by D-galactosamine/lipopolysaccharide in mice.

BACKGROUND: Liver transplantation is the only therapy of proven benefit in fulminant hepatic failure (FHF). Lipopolysaccharide (LPS), d-galactosamine (GalN)-induced FHF is a well-established model of liver injury in mice. Erythropoietin has a powerful tissue-protective effect in animal models. The aim of this study was to investigate the effect and mechanism of recombinant human erythropoietin (rhEPO) administration in FHF mice. METHODS: C57BL/6 (n=42) mice were studied in vivo in a fulminant model induced by GalN/LPS. rhEPO was administered 30 min after the induction of FHF. Serum liver enzymes and hepatic tumor necrosis factor (TNF)-α and interleukin (IL)-1ß levels were determined. Histologic analysis was performed, and apoptotic cells were identified by immunohistochemistry for caspase-3. Nuclear factor (NF)-κB and c-Jun-N-terminal kinase (JNK) activation were studied using Western blot analysis. RESULTS: After the induction of FHF, all control mice died within 12 hr of GalN/LPS administration. However, 83% of mice that were administered rhEPO were alive 2 weeks later, and overall survival improved (Kaplan-Meier, P<0.001). The serum liver enzymes, hepatic TNF-α and IL-1ß levels, liver histologic injury, and apoptotic hepatocytes were significantly reduced in FHF mice that were administered rhEPO compared with untreated mice. A significant decrease in hepatic NF-κB and JNK activation was noted in FHF rhEPO-treated mice compared with FHF untreated mice. CONCLUSIONS: The administration of rhEPO brought about increased survival and attenuation of the hepatic injury. This was associated with decreased hepatic NF-κB and JNK activation and thus TNF-α and IL-1ß levels. These findings have important implications for the potential use of rhEPO in FHF.

Intraoperative hydrocolonic ultrasonography for localization of small colorectal tumors in laparoscopic surgery.

BACKGROUND: Accurate localization of small colorectal cancers and polyps during laparoscopic resection may be difficult and requires precise and reliable localization techniques. This study aimed to assess the usefulness of intraoperative ultrasonography (IOUS) combined with retrograde saline instillation in locating small colorectal cancers and polyps during laparoscopically assisted colectomy. METHODS: The study investigated 14 patients with left-sided lesions of the colon and rectum necessitating preoperative marking. During laparoscopically assisted colorectal surgery, the large bowel was filled with saline solution by gravity, then scanned with a 5- to 10-MHz laparoscopic ultrasound probe. RESULTS: In all patients, both polyps and small cancers were clearly detected by IOUS. Furthermore, the technique was found to be easily mastered and performed. The mean detection time was 11 min. Polyps were seen as hypodense masses protruding from the bowel mucosa, whereas invasive cancers had both hypo- and hyperdense regions with sonographically appreciable penetration through bowel layers. CONCLUSION: Intraoperative laparoscopic ultrasonography in conjunction with saline instillation can serve as a useful tool that allows the surgeon to locate small nonpalpable tumors during laparoscopically assisted resection of colorectal cancer.

Dual effect of erythropoietin on liver protection and regeneration after subtotal hepatectomy in rats.

The only currently offered curative option for many patients with primary or secondary liver tumors is the resection of hepatic tumors. The aim of this study was to evaluate the role of recombinant human erythropoietin (rhEPO) in liver protection and regeneration after subtotal hepatectomy in rats. Rats undergoing 70% hepatectomy received an intraperitoneal injection of saline (control) or rhEPO (4 U/g) 30 minutes prior to resection. Liver function was assessed by the measurement of the international normalized ratio (INR) levels, and hepatic injury was assessed by serum alanine aminotransferase and aspartate aminotransferase levels. Hepatic apoptosis was assessed by intrahepatic caspase-3 activity and morphological criteria. The regeneration capacity of remnant livers was assessed over 7 days with the regenerated liver/body weight ratio, immunohistochemistry markers of cell proliferation (Ki-67) and angiogenesis (von Willebrand factor), and phosphorylated extracellular signal-regulated kinase signaling. Two and 4 days after subtotal hepatectomy, the regenerated liver/body weight ratio was significantly higher in animals treated with rhEPO versus the control group (P < 0.005). Serum liver enzymes and INR levels on days 2 and 4 post-hepatectomy were significantly lower in animals pretreated with rhEPO in comparison with the control group (P < 0.005). No statistically significant difference was noted in intrahepatic hepatic caspase-3 activity, immunohistochemistry for caspase-3, or a terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling assay between the hepatectomized groups. In the rhEPO-pretreated group, the mitotic index, Ki-67 and von Willebrand factor expression, and extracellular signal-regulated kinase activity were significantly higher on day 2 post-hepatectomy (P < 0.05) in comparison with the control group. In conclusion, rhEPO treatment may offer a unique beneficial dual-function strategy for hepatic protection and regeneration immediately after subtotal hepatectomy in rats.

Intraoperative ultrasound in colorectal surgery.

PURPOSE: To assess the accuracy of intraoperative ultrasound (IOUS) as a localizing technique for colorectal resections, and its impact on surgical management. METHODS: Twenty-five patients (15 men and 10 women; mean age, 74.4 years) with early cancers (p T1), or polyps, not amenable to endoscopic removal were selected. IOUS was used as a sole method of intraoperative localization. Its performance was evaluated through review of preoperative colonoscopy reports, intraoperative findings, histopathology reports, and clinical follow-up. RESULTS: The lesions were situated in the cecum (n = 5), ascending colon (n = 3), transverse colon (n = 4), descending colon (n = 7), and rectum (n = 6). IOUS technique allowed correct localization in 24 of 25 patients, visualization of the bowel wall, and its penetration by malignant tumors. In rectal lesions, IOUS showed clearly the tumor and its margin, which facilitated performance sphincter-sparing procedure. CONCLUSION: In patients with small polyps and early cancers of colon and rectum, IOUS may be effectively used as a sole method of intraoperative localization and provide additional information that may alter decision making with regard to surgical technique.

Phase II study of UFT with leucovorin plus hepatic arterial infusion with irinotecan, 5-fluorouracil and leucovorin for non-resectable liver metastases of colorectal cancer.

BACKGROUND: Compared with systemic therapy, hepatic arterial infusion (HAI) increases the response to fluoropyrimidines. METHODS: Thirty-one patients with non-resectable, colorectal cancer (CRC) liver metastases received irinotecan 120 mg/m(2), followed by leucovorin (LV) 20 mg/m(2) and 5-fluorouracil (5-FU) 500 mg/m(2) administered by HAI every 2 weeks, plus UFT (tegafur-uracil) 200 mg/m(2)/day with LV 30 mg/day on days 1-22, followed by a 6-day rest. RESULTS: The objective response rate was 65% (all 20 patients achieving a partial response). Ten patients (32%) had stable disease. The median time to progression (TTP) and overall survival (OS) were 12 and 36 months. OS was similar in patients with low versus high expression of thymidylate synthase (TS) and/or dihydropyrimidine dehydrogenase (DPD). The regimen was well tolerated. CONCLUSIONS: UFT with LV plus HAI irinotecan and 5-FU/LV was a feasible and effective treatment for non-resectable CRC liver metastases, increasing response, TTP and OS. TS and DPD levels in liver metastases did not predict outcome.

Should Echogenic Material in the Urinary Bladder Noticed on FAST Preclude Urinary Catheter Insertion in a Trauma Patient Until Further Evaluation?

BACKGROUND: Serious urethral and bladder injuries are most often associated with severe blunt trauma. The most common diagnostic tool used to assess lower urinary tract injuries is a retrograde urethrogram. However, the decision to place a Foley catheter is often made on clinical grounds during initial stabilization phase of a trauma victim. If there is a clinical suspicion of a urethral injury, a Foley catheter should not be introduced until further evaluation is made. Focused abdominal sonography for trauma (FAST) is a major tool for primary evaluation of trauma victims. Treating trauma patients, we encountered an unusual "pick up", namely, blood clots in the urinary bladder in two patients. CASE REPORT: We report on two cases of severely traumatized patients on which FAST examination detected an echogenic material in the bladder. This correlated with severe injuries to the urethra and urinary bladder. Moreover, ignorance of this finding in a patient without obvious clinical signs of urethral injury (Patient 1) led to a Foley catheter insertion, and as a consequence, a complex jatrogenic injury to the urethra. On the basis of this study, we hypothesize that the presence of an echogenic material on FAST examination should be considered blood until proven otherwise, and a urinary bladder catheter should not be passed, even in the absence of clinical signs of urethral injury. Since urogenital trauma is rare, this concept should be validated in the prospective study in a high-volume trauma center.

Does a second-look operation improve survival in patients with peritonitis due to acute mesenteric ischemia? A five-year retrospective experience.

Second-look laparotomy is one of the mainstays of surgical treatment of acute mesenteric ischemia (AMI). The aim of this study was to analyze its role in the survival of patients with infarcted gangrenous bowel resulting from AMI. A retrospective chart review of all patients admitted over the study period was undertaken. The study population consisted of 41 patients with clinical evidence of peritonitis and gangrenous, perforated bowel on surgical exploration. Outcome was compared among patients who underwent second-look laparotomy and those who did not. Fifteen patients with an American Society of Anesthesiologists (ASA) score of less than 4 underwent second-look laparotomy. Six patients had residual necrotic bowel that required additional resection. Only one (17%) of them survived. Of the nine remaining patients, who had no evidence of necrosis, only two survived (22%). Overall survival in this group was 20%. Twenty-six patients were managed without second-look laparotomy. Nine of them, with an ASA score of 4-5, died soon after the operation. The decision not to operate on the remaining 17 patients with an ASA score < 4 was made by an experienced surgeon. Eleven of those patients (65%) survived. Overall survival in the non-second-look group was 42%. Excluding the early deaths, the survival in the non re-explored group was significantly higher than in the second-look group (65% vs. 20%, p = 0.011). A selective approach to the surgical treatment of acute mesenteric ischemia based on the sound clinical judgment of an experienced surgeon may be as appropriate as its universal application.

Intraoperative ultrasonography: a tool for localizing small colonic polyps.

BACKGROUND AND AIMS: Small colonic polyps are difficult to palpate and thus difficult to localize during surgery. Preoperative injection of dyes and "on-the-table colonoscopy" are some of the methods used to allow the surgeon to find the polyps. The aim of the present study was to evaluate the value of intraoperative ultrasound as a tool that may allow detection of small colonic polyps during surgery. RESULTS: The study population consisted of nine consecutive patients referred to surgery for polyps of the large bowel that were not amenable to endoscopic removal. At surgery, the colon was filled with saline and than scanned by linear ultrasound probe. In 8 out of 9 patients, intraoperative ultrasound successfully detected all polyps, even those smaller than 0.5 cm. In one patient with two polyps, one in the right colon was easily localized, but a second flat, 0.4-cm tubular adenoma at the splenic flexure was missed. In three patients, intraoperative ultrasound showed penetration into the muscular coat. These polyps were found on pathology to be invasive cancer. CONCLUSION: Intraoperative ultrasound makes it possible for surgeons to easily localize small nonpalpable polyps of the large bowel. Furthermore, it can determine the aggressive potential of these lesions with great accuracy.

Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome.

BACKGROUND: Ovarian vein embolization was recently suggested as the preferred treatment for chronic pelvic pain syndrome. OBJECTIVE: To evaluate the technical feasibility, complications and early clinical and radiographic results of ovarian vein embolization in women with pelvic pain syndrome. METHODS: Percutaneous transcatheter ovarian vein embolization with coils was performed in six patients aged 27-53 years who presented with pelvic pain syndrome. All had lower abdominal pain, and pelvic varicosities were found on Doppler ultrasound and retrograde ovarian vein venography. Embolization was done unilaterally in three patients (on the left side) and bilaterally in three. Mean follow-up by telephone questionnaire was 7.3 months. RESULTS: The procedure was technically successful in all patients. Two patients reported partial relief of symptoms (33.3%) and three had complete relief (50%), for a total of 5 patients (83.3%) with some measure of improvement. There were no complications following the procedure. CONCLUSIONS: Percutaneous transcatheter ovarian vein embolization seems to be safe and feasible for the treatment of pelvic pain syndrome. The procedure is performed on an outpatient basis and is well tolerated by patients.

Radiofrequency ablation for the management of liver tumors.

BACKGROUND: Radiofrequency ablation has recently become a viable treatment option for unresectable primary or secondary lesions confined to the liver. OBJECTIVE: To study the local therapeutic efficacy, side effects and complications of radiofrequency ablation for the treatment of hepatocellular carcinoma and liver metastases. This is the first reported experience of radiofrequency ablation for treating malignant hepatic tumors in Israel. METHODS: Fifteen consecutive patients, aged 53-73 years, with 23 lesions (8 patients with HCC and 7 with secondary liver tumors) underwent radiofrequency ablation under general anesthesia. RITA nine-array 5 cm thermal ablation catheter and the model 1500 generator were used. The mean diameter of all tumors was 4.28 cm (range 1-10 cm). Three lesions were 1-3 cm in diameter (small), 17 lesions measured 3.1-5 cm (medium), and 3 measured 5.1-10 cm (large). RESULTS: Complete necrosis was found in 8 (66%) of 12 HCCs by computed tomography scan. Of the remainder, diffuse tumor recurrence was demonstrated in three lesions (25%) after lipiodol injection and there was one local tumor recurrence. In the metastases group complete necrosis was found in 5 of 11 lesions (45%). One major complication (peritonitis) was treated with antibiotics and four (26%) minor complications (right pleural effusion, small subcapsular hematoma) were monitored. CONCLUSIONS: Radiofrequency ablation appears to be an effective, safe and relatively simple procedure for the treatment of liver tumors.

Colonic anastomosis with the nickel-titanium temperature-dependent memory-shape device.

BACKGROUND: This study was prompted by our successful experience with a compression anastomosis clip (CAC) in an animal model. METHODS: The study sample included 20 patients scheduled for colonic resections, of whom 10 underwent anastomosis with the CAC and 10 with staplers. RESULTS: Neither group had anastomotic or other complications, except for 1 patient in the CAC group in whom a subphrenic infected hematoma developed after left hemicolectomy with splenectomy. CONCLUSIONS: Our study demonstrates that this CAC is safe and simple to use, coming close to the "no touch surgery concept" and is of low cost compared with the staples used today.