Dedifferentiated endometrioid adenocarcinoma of the uterus: A case series and review of literature.

Introduction Dedifferentiated endometrioid adenocarcinoma (DEAC) was first described in 2007. However, it has only been recognised as a distinct subtype of endometrioid adenocarcinoma in the last 1-2 years. DEAC is a more aggressive histological subtype and carries a poorer prognosis. Patients with DEAC tend to present with advanced disease compared the other endometrioid adenocarcinomas. Methodology The study is a retrospective review of patients with DEAC diagnosed in two institutions in Singapore between January 2012 and October 2017. Results 7 patients were diagnosed with DEAC. The mean age was 56.4 years. All patients presented with either abnormal uterine bleeding or post menopausal bleeding. Out of the 7 patients, one was diagnosed with Stage 2 disease, 5 were diagnosed with Stage 3 disease and 1 was diagnosed with Stage 4 disease. One patient had neoadjuvant chemotherapy, followed by surgery, and completion chemotherapy post surgery. The other 6 patients (87.5%) underwent primary debulking surgery. Out of these 6 patients, 5 patients had adjuvant chemotherapy post surgery and one patient had both adjuvant chemotherapy and radiotherapy. Lymphovascular invasion was found in 71.4% of the cases. Conclusion DEAC is a more aggressive histological subtype of endometrioid adenocarcinomas. Better awareness of this condition can lead to proper diagnosis and treatment.

Prognostic factors associated with clear cell sarcoma in 14 Chinese patients.

PURPOSE. To identify prognostic factors associated with clear cell sarcomas in 14 Chinese patients. METHODS. Medical records of 7 men and 7 women (mean age, 36 years) with histologically confirmed clear cell sarcoma of tendons and aponeuroses were reviewed. Patient demographics, tumour characteristics, and treatment modalities were retrieved. Prognostic factors associated with favourable 5-year survival were determined. RESULTS. The most affected sites were the thigh (n=5) and the foot (n=4); the mean time from symptom onset to diagnosis was 9.5 months. The tumour stage at diagnosis was IIA in 8 patients, IIB in 2, and III in 4. The mean tumour size was 4.5 cm in diameter. One patient was lost to follow-up. For the remaining 13 patients, the mean time to disease-related mortality was 2.5 years. Nine patients had distant metastases; the most common sites were lungs and pleura (n=7), followed by distant lymph nodes (n=4), bone (n=2), pericardium (n=2), and brain (n=1). All patients underwent surgical excision. Three women and one man (mean age, 27 years) attained 5-year disease-free survival. All had stage IIA tumours at diagnosis. Their mean tumour size was 1.75 cm in diameter, which was significantly smaller than that of all patients (4.5 cm). Tumour size of ≤ 2.5 cm in diameter (p=0.004) and stage IIA tumour at diagnosis (p=0.04) were significant prognostic factors for 5-year survival. CONCLUSION. Tumour size of ≤ 2.5 cm and early stage tumour are associated with 5-year disease-free survival. Early detection is crucial for the prognosis of clear cell sarcomas.

Involvement of two distinct signalling pathways in IGF-1-mediated central control of hypotensive effects in normotensive and hypertensive rats.

AIMS: Insulin-like growth factor-1 (IGF-1) is abundantly expressed in the nucleus tractus solitarii (NTS). In a previous study, we revealed that the induction of nitric oxide (NO) production in the NTS reduces blood pressure (BP). It is well known that both acute administration and chronic administration of IGF-I reduce BP. The aim of this study was to evaluate the short-term hypotensive effect of IGF-1 in the NTS and to delineate the underlying molecular mechanisms of IGF-1 in the NTS of normotensive WKY rats and spontaneously hypertensive rats (SHRs). METHOD: Microinjections of the phosphatidylinositol 3-kinase (PI3K) inhibitor LY294002 and the MAP kinase-ERK kinase (MEK) inhibitor PD98059 into the NTS in WKY rats and SHRs were used to study the involvement of IGF-1-induced depressor effects. RESULT: An IGF-1 (7.7 pmol) injection into the NTS resulted in a significant decrease in BP and HR in WKY rats and SHRs. Immunoblotting and immunohistochemical analysis showed that the microinjection of LY294002 (0.6 pmol) or PD98059 (3.0 pmol) into the NTS attenuated the IGF-1-induced depressor effects and Akt or ERK phosphorylation in WKY rats. An attenuation effect of LY294002, but not PD98059, was found in the SHRs. However, the mRNA and protein expression levels of the IGF-1R showed no significant differences in the NTS of the WKY rats and the SHRs. CONCLUSION: These results suggest that distinct Akt and ERK signalling pathways mediated the IGF-1 control of the central depressor effects in WKY rats and SHRs. ERK signalling defects may be associated with the development of hypertension.

Asymptomatic grade-2 central chondrosarcoma of the distal femur with non-aggressive radiological features.

This paper discusses the case of a 57-year-old man with an incidental finding of a radiologically non-aggressive chondroid lesion and concomitant osteonecrosis in the left distal femur. The final resected specimen showed a grade-2 chondrosarcoma. This case illustrates that long-term follow-up is necessary for non-aggressive chondroid lesions. If surgical management is considered, resection with an adequate margin is superior to intralesional curettage.

A sarcoma of 23 years' duration: symptom duration is not a reliable parameter to exclude malignancy.

This report describes a 31-year-old woman with a 23-year history of a right buttock mass that was otherwise asymptomatic, but was proven to be a low-grade fibromyxoid sarcoma (a fully malignant soft tissue tumour with a potential for distant metastasis). This case illustrates that a long-standing tumour does not necessarily imply a benign pathology. A vigilant approach should be taken for any tumours that are of significant size (larger than 5 cm).

Neuroimaging techniques in epilepsy.

OBJECTIVE: To review state-of-the-art neuroimaging modalities in epilepsy and their clinical applications. DATA SOURCES AND STUDY SELECTION: PubMed literature searches to March 2010, using the following key words: 'epilepsy', 'positron emission tomography (PET)', 'single photon emission computed tomography (SPECT)', 'MR volumetry', 'diffusion tensor imaging', and 'functional MR imaging'. DATA EXTRACTION: All articles including neuroimaging techniques in epilepsy were included in the review. DATA SYNTHESIS: High-field magnetic resonance imaging is fundamental for high-resolution structural imaging. Functional radionuclide imaging (positron emission tomography/single-photon emission computed tomography) can provide additional information to improve overall accuracy, and show good results with high concordance rates in temporal lobe epilepsy. Magnetic resonance spectroscopy is a useful adjunct consistently demonstrating changing metabolites in the epileptogenic region. Magnetic resonance volumetric imaging shows excellent sensitivity and specificity for temporal lobe epilepsy but thus far it has been inconsistent for extratemporal epilepsy. Diffusion tensor imaging with tractography allows visualisation of specific tracts such as connections with the language and visual cortex to enhance preoperative evaluation. Functional magnetic resonance imaging using blood oxygen level-dependent activation techniques is mainly used in presurgical planning for the high-sensitivity mapping of the eloquent cortex. Both contrast-bolus and arterial spin labelling magnetic resonance perfusion imaging show good correlation with clinical lateralisation of seizure disorder. CONCLUSION: Structural imaging is essential in localisation and lateralisation of the seizure focus. Functional radionuclide imaging or advanced magnetic resonance imaging techniques can provide complementary information when an epileptogenic substrate is not identified or in the presence of non-concordant clinical and structural findings.

Characteristics and photocatalytic activity of TiO2 thin film sensitized with a porphyrin dye.

In this study, a novel porphyrin dye, 5, 10, 15, 20-tetraphenyl-21H, 23H-porphine nickel (TPPN) doped TiO2 (TiO2/TPPN) thin film with visible light respondency was prepared using a sol-gel method and characterized with XRD, SEM, UV-Vis instruments. The observation showed that the absorption edge of TPPN dye-doped thin film shifted into the visible light region. The photocatalytic indigo carmine degradation results showed that under visible light irradiation (lambda > 400 nm) for 6 hrs, the photocatalytic activity of TiO2 thin film sensitized with 200 microM of TPPN dye showed the best performance, with an indigo degradation ratio up to 96%. Moreover, the TiO2/TPPN thin film showed a relevant photocatalytic bactericidal effect on Erwinia carotovora subsp. carotovora 7 induced vegetable soft rot disease in the visible spectral region. Evidence for the photocatalytic disinfection technique against a plant pathogen under visible light irradiation will have potential for direct application in future control of plant diseases in irrigation water systems.

Glove punctures in orthopaedic surgery.

From February 2001 to May 2001, 792 latex gloves used in 100 operations from three orthopaedic sub-specialties (paediatrics, hand and spine) were tested for puncture by a water infusion test. Sixty-nine gloves from 45 operations were punctured, giving an overall glove perforation rate of 8.7% (69/792) and an operative perforation rate of 45% (45/100). The hand operations had the lowest operative perforation rate (19.4%) while the spine operations had the highest (63.6%). The glove perforation rate increased in bony procedures (60% versus 22.5%), in procedures with major instrumentation (66% versus 18%) and in more lengthy procedures. The thumbs and the left index finger had more punctures than other parts. In addition, the glove perforation rate for single gloving was 9.6% (53/552) while that for the inner glove of double gloving was 0.8% (1/120). Based on these findings, we would like to recommend double gloving and regular glove changing in these high-risk surgeries.

Patient effective dose from sentinel lymph node lymphoscintigraphy in breast cancer: a study using a female humanoid phantom and thermoluminescent dosemeters.

The aim of this study was to measure the dose delivered to patients undergoing sentinel lymph node lymphoscintigraphy by taking into account both the transmission scan dose using a (57)Co flood source and the (99)Tc(m) internal emission dose. An adult female humanoid phantom and a set of thermoluminescent dosimeters were used in the measurements. The choice of measurement organs in the humanoid was guided by the recommendations described in the International Commission on Radiological Protection report number 60. A (57)Co flood source was used in external transmission to irradiate the humanoid at posterior, left lateral, left posterior oblique, right lateral and right posterior oblique positions. Four (99)Tc(m) deposits as internal emission sources were used to simulate patient peritumoural injection. The individual effective doses for external transmission and internal emission, normalized to the cumulated activity and expressed in micro Sv(MBq x h)(-1) were then calculated. The effective dose for a transmission scan was on average 0.061 micro Sv(MBq x h)(-1) for each (57)Co flood source position and for internal emission 0.312 micro Sv(MBq x h)(-1) and 0.291 micro Sv(MBq x h)(-1) for left and right breast injection, respectively. Using these results, the effective dose from both transmission and emission sources can be calculated according to the nuclear medicine scanning protocol and surgical procedure of the individual institution. For our protocols, the patient receives a maximum effective dose of 52 micro Sv for the 1 day protocol (18 MBq injection) and 204 micro Sv for the 2 day protocol (74 MBq injection) if only the sentinel lymph node is excised. If other tissues containing radioactivity are removed, the patient effective dose will be reduced by about 50% and 6%, respectively, for the 1 day protocol and 2 day protocol. Although the doses are low compared with other radiological examinations, the results are informative for patients concerned about radiation exposure for this new imaging technique.

Lateral temporal hyperperfusion in postictal psychosis assessed by 99mTc-HMPAO SPECT.

Postictal psychosis is a rare complication of epileptic seizure characterized by reversible psychotic symptoms after flurries of seizure attack. It has been attributed to a phenomenon similar to Todd's paralysis without definitive proof. We studied regional cerebral blood flow (rCBF) of six patients with postictal psychosis by (99m)Tc-HMPAO SPECT scan. Baseline rCBF was compared with the rCBF during postictal psychosis. An asymmetry index (ASI) was calculated as 200 x [(ipsilateral ROI count density - contralateral ROI count density)/(ipsilateral ROI count density + contralateral ROI count density)] %. Significant differences could be found between ASIs during postictal psychosis and interictal state SPECT scan over the lateral temporal neocortex region (P = 0.017). Although hyperperfusion abnormality in SPECT can be found in Todd's paralysis, such findings are more commonly found in cerebral hyperactivity conditions. Taking into account the clinical characteristics of postictal psychosis, namely a preceding lucid interval and crescendo-decrescendo clinical course, these may be an alternative psychopathogenic mechanism for the development of postictal psychosis.

Cementless total hip arthroplasty in young Chinese patients: a comparison of 2 different prostheses.

Sixty-one primary cementless total hip arthroplasties were performed in 45 Chinese patients <40 years old. There were 27 Anatomic Medullary Locking (AML, Depuy, Warsaw, IN) prostheses and 34 Porous Coated Anatomic (PCA, Howmedica, Rutherford, NJ) prostheses. The average follow-up was 7.6 years (range, 3-11 years). Ten hips (16%) were reoperated; the reason was polyethylene wear with or without osteolysis in 7 hips. Osteolytic lesion was present in 34 hips (56%). The cumulative successful rate at 10 years was 67% using reoperation for any reason as the endpoint. The cumulative successful rate was 98%, however, if revision for aseptic loosening was used as the endpoint. The 2 prostheses did not show significant differences in most parameters except that the PCA hips had significantly more acetabular loosening (P =.02) and periprosthetic osteolysis (P =.01).

Charnley total hip arthroplasty in Chinese patients less than 40 years old.

Forty-seven total hip arthroplasties were reviewed in 33 Chinese patients who were <40 years old at the time of operation. The preoperative diagnosis was avascular necrosis in 40% of the hips. A Charnley prosthesis was inserted using early cementing techniques in every hip. The average follow-up was 14.9 years (range, 6.9-21.1 years). The mean preoperative Harris hip score was 43.8 (range, 26-74), and the mean score at latest follow-up was 87.7 (range, 74-99) for the surviving hips. Thirty hips (63%) were revised, and 1 hip was removed because of late deep infection. The main cause of failure was aseptic loosening of the acetabular component. Using revision and radiologic loosening as endpoints, the cumulative survival rate for the acetabular component was 86.3% at 10 years and 27.0% at 15 years. The survival of the femoral components was 81.3% at 15 years. Patients with avascular necrosis had a higher failure rate than patients with other diagnoses (P =.001). An area of cement mantle that was <2 mm thick affected adversely the survival rate of the acetabular components (P =.04).

The performance of three vacuum-mixing cement guns--a comparison of the fatigue properties of simplex P cement.

We tested three commercially available cement-mixing systems (Howmedica, Summit and Stryker). After mixing the cement was allowed to cure in metal moulds under standard conditions. Sixty-nine cement blocks were produced. The fatigue behavior of the blocks was tested until failure. A wide scattering of results was observed in all the three systems. Uneven mixing of the polymer and monomer was observed in the Howmedica system. A significantly stronger cement (P=0.018) was produced with the Stryker system.

A five-year longitudinal study of the regional cerebral metabolic changes of a schizophrenic patient from the first episode using Tc-99m HMPAO SPECT.

This is a naturalistic study of the relationship between cerebral metabolic activity, clinical symptoms and treatment response in a schizophrenic patient for 5 years from the onset of her illness. Serial technetium-99m-HMPAO brain SPECT was used to measure regional cerebral metabolism. The Cambridge Neurological Inventory and neuropsychological tests (WAIS-R verbal subscales, Wisconsin Card Sorting Test, semantic verbal fluency, logical memory in Weschler Memory Scale) were used for neurocognitive assessment. Under-activity of the left temporal area was observed in the course of patient illness despite remission of the psychotic symptoms. Bilateral prefrontal metabolic under-activity was noted at the emergence of negative symptoms, executive neurocognitive dysfunction and the treatment-resistant state. After response to clozapine, the right prefrontal activity returned to a normal level. Our findings suggested that persistent left temporal underactivity detected by SPECT despite clinical remission may indicate a vulnerability for further relapses and development of a treatment-resistant state. Treatment-resistant state, negative symptoms and executive neurocognitive deficit may involve abnormal prefrontal metabolic activity and can be alleviated in clozapine-responsive patients.

Construction and preliminary characterization of a library of "lethal" preterminal protein mutant adenoviruses.

Adenoviruses containing lethal in-frame insertion mutant alleles of the preterminal protein (pTP) gene were constructed with cell lines that express pTP. Thirty in-frame insertion mutant alleles, including 26 alleles previously characterized as lethal and 4 newly constructed mutant alleles, were introduced into the viral chromosome in place of the wild-type pTP gene. The viruses were tested for ability to form plaques at 37 degrees C in HeLa-pTP cells and at 32 degrees C and 39.5 degrees C in HeLa cells. Two of the newly constructed viruses exhibited temperature sensitivity for plaque formation, one virus did not form plaques in the absence of complementation, seven additional mutants exhibited a greater than 10-fold reduction in plaque formation in the absence of complementation, and another eight mutants exhibited stronger phenotypes than did previously characterized in-frame insertion mutants in the plaque assay. These mutant viruses offer promise for analysis of pTP functions.

Transient bone marrow oedema: a variant pattern of sacral insufficiency fractures.

A 71-year-old woman presenting with severe low back pain was found to have a large oval area of increased sacral uptake on Tc-99m MDP scan, with corresponding T1-hypointense and T2-hyperintense areas on magnetic resonance (MR) images, highly suggestive of malignancy. Open biopsies showed only callus formation. The patient responded clinically to conservative measures, with twice-repeated follow-up Tc-99m MDP and MR scans documenting resolution of transient bone marrow oedema. We suggest that this form of marrow oedema represents a variant pattern of sacral insufficiency fractures.

A range of CD4 T cell tolerance: partial inactivation to organ-specific antigen allows nondestructive thyroiditis or insulitis.

T cell receptor (TCR) transgenic mice specific for hen egg lysozyme (HEL) were crossed with mice expressing HEL on the thyroid epithelium, on pancreatic islet beta cells, or systemically. Depending on the pattern of HEL expression, deletion of double-positive thymocytes ranged from minimal to complete, and peripheral CD4 cells exhibited graded reduction in TCR expression, in vitro responsiveness, and in vivo helper ability. CD4 cells were least tolerant in TCR/thyroid-HEL and TCR/islet-HEL mice, which developed an extensive lymphocytic thyroiditis or insulitis that nevertheless did not eliminate HEL-expressing endocrine cells. Autoreactive CD4 clones thus escape the thymus under a range of circumstances, retain sufficient function to initiate subclinical autoimmune inflammation when self-antigens are concentrated in the thyroid or pancreas, and may regulate progression of subclinical inflammation to destructive autoimmune disease.

Applications of bone scintigraphy in ankylosing spondylitis.

Eighteen bone scintisans performed in 14 patients with ankylosing spondylitis were reviewed. In young patients with low back pain, positive serology, and indeterminate radiographs, quantitative sacroiliac joint assessment and the presence of typical uptake patterns, particularly costovertebral, were useful in suggesting the diagnosis. Scintigraphy was helpful in the early detection of pseudoarthrosis complicating long-standing disease, especially in patients presenting with recurrent back pain. Selective application of bone scintigraphy aids the diagnosis of ankylosing spondylitis and its potential complications.