Effectiveness of multiple-level sectioning in detecting axillary nodal micrometastasis in breast cancer: a retrospective study with immunohistochemical analysis.

OBJECTIVE: To evaluate the effectiveness of original multiple-level sectioning in detecting axillary nodal micrometastasis in breast carcinoma. DESIGN: Retrospective analysis of 707 axillary nodes from 34 consecutive node-negative invasive breast cancers from the years 1989 and 1990. All but 2 cases were originally examined by multiple-level sectioning. The original histologic sections were reviewed. Additional sections were cut for hematoxylin-eosin staining and cytokeratin immunohistochemistry. RESULTS: A micrometastasis was found in only 1 case (1 node) on the original histologic section, which was 1 of the 2 cases not originally processed by multiple-level sectioning. Additional sections and cytokeratin immunostains were negative on all cases, including the false-negative case identified on original section. CONCLUSIONS: The finding of a micrometastasis in 1 case on the original, but not on any additional recuts or cytokeratin immunostains, indicates that the original multiple-level sectioning was very effective (0% false negatives). Immunohistochemistry provided no additional benefit in detecting micrometastases in cases already examined by multiple-level sectioning. Thorough histologic examination on properly prepared sections is probably the most efficient and cost-effective way to detect the vast majority of axillary nodal micrometastases.

Large Brunner's gland hamartoma simulating a pancreatic mass with obstruction and bleeding.

Brunner's gland hamartomas can present as a mass lesion causing obstruction but are also an uncommon cause of upper gastrointestinal bleeding. These tumors may not be accurately identified on radiographic study. Endoscopic examination may be used for diagnostic purposes and may also have therapeutic benefits. Endoscopy can complement surgical intervention, when necessary, for the proper treatment of these lesions.

Gallstone ileus: a review of 1001 reported cases.

Although rare in the general population, gallstone ileus accounts for 25 per cent of nonstrangulated small bowel obstructions in those over the age of 65. While mortality has declined over the years, it remains high at 15-18 per cent. This is largely due to the patient population, with comorbid medical conditions contributing to mortality. The proper extent of surgery continues to be actively debated. Proponents of minimal surgery feel that relief of the obstruction is all that is required. Others argue that the gallbladder and biliary-enteric fistula must be removed to prevent future recurrence (a one-stage procedure). The one-stage procedure carries an associated mortality of 16.9 per cent, compared to 11.7 per cent for simple enterolithotomy. Morbidity after enterolithotomy is low. The recurrence rate of gallstone ileus was less than 5 per cent, and only 10 per cent of patients required reoperation for continued symptoms related to the biliary tract. Simple enterolithotomy is both safe and effective in dealing with a patient with gallstone ileus.

Effect of TCDD on the density of Langerhans cells in murine skin.

Tetrachlorodibenzo-p-dioxin (TCDD) is a prototype for a group of toxic polyhalogenated aromatic hydrocarbons. We have studied the effect of TCDD on skin, specifically the difference in cutaneous response of congenic haired (hr/+) and hairless (hr/hr) mice. Topical application of 0.6 microgram of TCDD induces epidermal hyperplasia/hyperkeratinization in the skin of hr/hr mice, but does not affect the epidermis of congenic hr/+ littermates. Suppression of various parameters of the immune response has been found to be another effect of TCDD exposure in experimental animals. In the present study, we investigated the effect of topical treatment with TCDD on the density of epidermal immune cells, the Langerhans cells (LC), in the skin of hr/hr and hr/+ mice. Results showed that TCDD-induced epidermal hyperplasia/hyperkeratinization in skin of hr/hr mice is accompanied by an increase in the density of LC. In the skin of hr/+ mice, in which TCDD exposure does not induce hyperplastic changes, LC densities are not affected. The increase in LC densities in TCDD-treated hr/hr mouse skin did not result in increased sensitivity of the skin to contact hypersensitization with dinitrofluorobenzene, as measured by changes in ear thickness. When hr/hr murine skin was grafted into skin of hr/+ mice and the entire dorsal skin (including the graft) treated with TCDD, LC were increased in the grafted skin, but not in the surrounding hr/+ skin. Conversly, when hr/+ murine skin was grafted into hr/hr mice and both treated with TCDD, there was no increase in the density of LC in the grafted hr/+ skin. Concomitant treatment of hairless mice with TCDD and with indomethacin did not affect the increase in the density of LC induced by TCDD treatment alone. These findings suggest that TCDD-induced epidermal changes in hr/hr murine skin involve production of factors which mediate the increase in epidermal LC.

Evaluation of topical erythromycin and oral tetracycline in acne vulgaris.

A double-blind study was conducted to compare topical erythromycin 1.5 percent solution (Staticin solution) with oral tetracycline (250 mg) twice a day in fifty-four patients with Grades II and III acne vulgaris. Although both therapies produced a statistically significant reduction in the number and severity of the acne lesions, the topical preparation usually showed an effect earlier and to a greater degree than the oral medication. By the end of the study, some of these differences were statistically significant. After twelve weeks of treatment, topical erythromycin therapy produced a 58 percent reduction in the overall lesion count, as opposed to the 38 percent reduction produced by oral tetracycline therapy. In addition, the Propionibacterium acnes counts were reduced with erythromycin by over 90 percent and with tetracycline treatment by over 80 percent. Two patients treated with tetracycline developed vaginal candidiasis and therapy had to be discontinued. During topical treatment with erythromycin only mild adverse experiences were reported and none resulted in withdrawal from the study.

Differences in the lipid constituents of sebum from pre-pubertal and pubertal subjects.

Significant differences have been reported in the composition of skin surface lipid in pre-pubertal subjects when compared to pubertal subjects. Analytical studies were performed to determine whether group mean changes in the fatty acid composition of the triglyceride and wax ester fractions of sebum could be detected in pre-pubertal versus pubertal subjects. Twenty males (ages 6-9), twenty females (ages 6-9) and twelve teenagers (ages 11-16) were studied. Skin surface lipid was examined by densitometry and gas chromatography. There were significant changes in the fatty acid composition of the wax fraction of sebum in the 11-16-year-old children when compared to the 6-9-year-old group. As wax is of sebaceous gland origin, this may represent a change in sebum composition probably in response to the hormonal stimulus. Changes in the fatty acid fraction of triglycerides were also noted with age, but this may be due to the change in source of triglyceride from predominantly epidermal origin to sebaceous gland origin.

Lymphocyte transformation in subjects with nodulo cystic acne.

Patients with severe nodulo-cystic acne are known to have elevated serum antibody levels and increased immediate hypersensitivity reactions to Propionibacterium acnes. This organism is the predominant bacterium in normal pilosebaceous follicles of human skin, and can be consistently isolated from pustular lesions in acne. Previously it had been observed that delayed cutaneous hypersensitivity reactions to P. acnes were negative in patients with acne. The present study investigated the proliferative response of lymphocytes from patients with nodulo-cystic acne to phytohaemagglutinin (PHA) and P. acnes antigen stimulation. The response to PHA stimulation was within normal limits. The response to P. acnes antigen showed a significant increase over control values obtained by testing lymphocytes from acne-free subjects. Thus cell mediated immunity to P. acnes may be present in subjects with severe inflammatory acne. These findings raise the possibility that reactions to P. acnes may contribute to intensifying the inflammatory response in acne lesions.

Quantification of bacteria in isolated pilosebaceous follicles in normal skin.

A technique for quantitating bacteria in isolated pilosebaceous follicles is described. This involves microdissection of the follicles from biopsies of skin, using the method of chemical pretreatment of skin to facilitate the separation of the epidermis and epidermal appendages from the dermis. The aerobic cocci and anaerobic diphtheroids in pilosebaceous follicles in 66 biopsies of scalp and 48 biopsies of skin of the upper back were quantitated using this technique. On the back, aerobic staphylococci were very sparse in normal follicles, indicating that their primary habitat on the skin must be on the skin surface rather than within follicles. Of 138 isolated follicles from skin of the upper back, 94 contained no aerobic cocci. Anaerobic organisms were present in high numbers within normal follicles. The geometric mean density of anaerobes in 138 isolated follicles from skin of the upper back was 3.8 X 10(4) diphtheroids per follicle. Eighty-eight follicles contained more than 10(4) anaerobic diphtheroids. Using data from scalp biopsies we found that there was a correlation between the weight of sebaceous glands and the density of anaerobes within the follicles attached to these glands (coefficient of correlation = 0.6).

Analysis of lipid composition of isolated human sebaceous gland homogenates after incubation with cutaneous bacteria. Thin-layer chromatography.

The effects of specific species of skin bacteria on human sebaceous gland lipids in vitro were analyzed. Isolated dissected sebaceous glands were pooled, homogenized, and sterilized, then incorporated into peptone-yeast extract medium and used as substrate for growth of Propionibacterium acnes, P. granulosum, and Staphylococcus epidermidis subgroup II. The sebaceous lipids were analyzed by thin-layer chromatography before and after bacterial growth. The most striking effect of bacteria on sebaceous gland lipid composition was the hydrolysis of sebaceous triglycerides. The degree of hydrolysis varied with bacterial strain but was most complete with P. acnes and P. granulosum. Staphylococci were not effective in hydrolyzing sebaceous triglycerides at pH 4.5 although, when the pH of the medium was raised to pH 6.4, some strains of staphylococci were as effective as the propionibacteria in hydrolyzing sebaceous triglycerides to free fatty acids. Thus minor changes in acidity may play asignificant role in controlling the lipolytic activity of staphylococci on skin. Another effect of bacterial action on sebaceous gland lipids was the esterification of sebaceous cholesterol to cholesteryl esters. Thus, bacterial action must be taken into account in evaluating studies of alterations in cutaneous cholesterol and cholesteryl esters in skin surface lipids in normal and disease states.