Endovascular management of mycotic aortic aneurysms- A 20-year experience from a single UK centre.

AIM: To present the authors' experience of endovascular treatment of confirmed and presumed (microbiology negative) mycotic aortic aneurysms (MAA). MATERIALS AND METHODS: Patients undergoing endovascular aortic repair were identified retrospectively from 1998 using the radiology information system and an internally kept database until 2018. The primary aim was to assess the technical success and peri-operative morbidity and mortality. The secondary aim was to assess progression of infection, re-interventions, late mortality, and correlation to antibiotic duration pre- and post-procedure. RESULTS: Thirty-four endovascular aortic procedures were performed for MAA, excluding aorto-enteric fistulas, inflammatory aneurysms, and infected grafts without a new aneurysm. Seventy-six percent of these were thoracic and 24% abdominal. The technical success was 100%. Additional procedures were undertaken in four patients with two requiring a further endovascular procedure. There were two inpatient aneurysm-related mortalities and no inpatient conversions to open repair. The 30-day re-admission and re-intervention rate was 0%. Blood cultures were positive in 45%. There were no secondary graft infections. CONCLUSION: This is the largest European single-centre study. It supports endovascular management of MAA as a lower-risk alternative to open surgery with the majority of patients presenting acutely, later in life and requiring emergency management.

Transmesenteric Internal Herniation Leading to Small Bowel Obstruction Postlaparoscopic Radical Nephrectomy.

Internal herniation following laparoscopic surgery is rare. We present a case of small bowel obstruction secondary to internal herniation in a 76-year-old male patient. Presentation was on postoperative day 28 following transperitoneal laparoscopic radical left nephrectomy for suspected renal carcinoma. The herniation was through a defect in the large bowel mesentery identified at exploratory laparotomy. To date, 10 cases of internal herniation following laparoscopic nephrectomy have been described in the literature. Two cases were managed laparoscopically and the remainder by laparotomy. One case required resection of an ischaemic portion small bowel and the remainder were managed by reduction of the hernia and closure of the defect. Internal herniation is rare but carries significant morbidity. It must be considered in cases presenting with obstructive symptoms after laparoscopic nephrectomy. Early CT scanning and prompt surgical management are hallmarks of best management.

c-MYC is a radiosensitive locus in human breast cells.

Ionising radiation is a potent human carcinogen. Epidemiological studies have shown that adolescent and young women are at increased risk of developing breast cancer following exposure to ionising radiation compared with older women, and that risk is dose-dependent. Although it is well understood which individuals are at risk of radiation-induced breast carcinogenesis, the molecular genetic mechanisms that underlie cell transformation are less clear. To identify genetic alterations potentially responsible for driving radiogenic breast transformation, we exposed the human breast epithelial cell line MCF-10A to fractionated doses of X-rays and examined the copy number and cytogenetic alterations. We identified numerous alterations of c-MYC that included high-level focal amplification associated with increased protein expression. c-MYC amplification was also observed in primary human mammary epithelial cells following exposure to radiation. We also demonstrate that the frequency and magnitude of c-MYC amplification and c-MYC protein expression is significantly higher in breast cancer with antecedent radiation exposure compared with breast cancer without a radiation aetiology. Our data also demonstrate extensive intratumor heterogeneity with respect to c-MYC copy number in radiogenic breast cancer, suggesting continuous evolution at this locus during disease development and progression. Taken together, these data identify c-MYC as a radiosensitive locus, implicating this oncogenic transcription factor in the aetiology of radiogenic breast cancer.

MLL amplification in acute leukaemia: a United Kingdom Cancer Cytogenetics Group (UKCCG) study.

The MLL gene, located at 11q23, is frequently rearranged in acute leukaemia as either chimaeric fusion genes or partial tandem duplications. We report a series of 12 acute leukaemia cases with apparent amplification of the MLL gene ascertained using fluorescence in situ hybridisation (FISH). Seven cases showed intrachromosomal amplification of MLL, four cases showed extrachromosomal amplification as double minute chromosomes (dmin) and one case had separate subclones with dmin and homogenously staining region (hsr). Southern blot analysis of the MLL gene showed MLL gene rearrangement in three of the 10 successful cases. These cases do not naturally fall into either of the two recognised categories of MLL rearrangement and may represent a third variety of MLL gene abnormalities.

Sensitivity of FISH in detection of MLL translocations.

Fluorescence in situ hybridisation (FISH) detection of MLL translocations is now commonplace in cytogenetics laboratories. One of the most widely used probes is the Oncor MLL probe (Oncor, Gaithersburg, MD) that theoretically demonstrates the presence of an MLL rearrangement by a splitting of the FISH signal between the two derivative chromosomes generated by a translocation. Recently, another commercial probe has been made available from Vysis (Vysis, Downers Grove, IL) that uses a dual colour system. We examined material from 29 patients and 4 cell lines, all with recognised MLL translocations by G-banding, that were confirmed using Southern blot analysis of the MLL breakpoint cluster region. Both Oncor and Vysis MLL FISH probes were applied to these cases to compare their performance in detection of the MLL translocations. Thirty of the 33 cases demonstrated a clear splitting of Oncor MLL FISH signal in concordance with the Southern blot analysis and cytogenetics. Three cases failed to demonstrate a split MLL FISH signal. Therefore, we conclude that the Oncor MLL FISH probe has a 9.1% false negative rate, i.e., 90.9% sensitivity in detection of classic MLL translocations. Vysis MLL FISH detected the rearrangement in all 33 cases.

Jumping translocation at 11q23 with MLL gene rearrangement and interstitial telomeric sequences.

myeloid leukemia of acute myeloid leukemia (AML) M5a showing a jumping translocation with a breakpoint at 11q23. Fluorescence in situ hybridization (FISH) demonstrated triplication of the MLL gene and the presence of interstitial telomeric sequences, supporting the role of repetitive sequences in the mechanism of jumping translocations. Southern blot analysis of the MLL breakpoint cluster region showed the presence of an MLL gene rearrangement. Jumping translocation with MLL gene rearrangement is a previously unreported phenomenon in leukemia cytogenetics.

Combined nuclear and digital subtraction contrast arthrography in painful knee prosthesis.

The evaluation of a painful knee prosthesis remains a difficult problem for both orthopaedic surgeons and radiologists. We have compared digital subtraction arthrography with nuclear arthrography in 7 patients with a painful knee prosthesis. Three patients showed a loose tibial component, demonstrated by both digital subtraction and nuclear arthrography. All 3 underwent revision of their prosthesis. One patient had an equivocal digital subtraction arthrogram and negative nuclear arthrogram, while both studies were negative in the 3 remaining patients. Nuclear arthrography is a simple procedure and can provide useful additional information when combined with digital subtraction arthrography.

Indium 111 leucocyte scintigraphy in abdominal sepsis. Do the results affect management?

We have studied the clinical utility of indium 111 autologous leucocyte scintigraphy retrospectively in 45 patients presenting with suspected intra-abdominal sepsis. The sensitivity was 95% (21/22) and the specificity was 91% (21/23). Some 34 of the studies (17 positive and 17 negative) were considered helpful in furthering patient management (76%) and 8, unhelpful (18%). In 3, the study results were misleading and led to inappropriate treatment. Indium 111 scintigraphy, whether positive or negative, provides information in patients with suspected intra-abdominal sepsis upon which therapeutic decisions can be based.

Relapse of Graves' disease after medical therapy: predictive value of thyroidal technetium-99m uptake and serum thyroid stimulating hormone receptor antibody levels.

In 49 patients with Graves' disease, the 20-min thyroidal uptake of 99mTc and serum levels of thyroid stimulating hormone (TSH) receptor antibody were estimated at presentation and at intervals during a 1-yr course of carbimazole and triiodothyronine. In the 12 mo after cessation of therapy, 29 patients developed recurrent thyrotoxicosis. Thyroidal 99mTc uptake had a poor predictive value for recurrence of thyrotoxicosis, both at presentation and during therapy. A very high level of TSH receptor antibody was present in seven patients at presentation, all of whom relapsed on withdrawing therapy. An abnormal value of TSH receptor antibody at the end of the course of medical therapy was present in 24/29 (83%) patients who relapsed and in 1/20 (5%) patients who remained euthyroid 1 yr after stopping antithyroid drugs.

Scintigraphic evaluation of the painful prosthetic joint: a comparison of gallium-67 citrate and indium-111 labelled leucocyte imaging.

The radiopharmaceuticals gallium-67 and indium-111 labelled leucocytes have been compared in 15 patients with a painful joint prosthesis in an attempt to identify those patients with periprosthetic infection. Gallium-67 images were abnormal in five out of six patients with periprosthetic infection and normal in seven out of nine without evidence of infection. Indium-111 leucocyte images were abnormal in three out of six patients with infection and normal in all nine patients without infection. Indium-111 labelled leucocyte imaging is technically more difficult to perform than gallium-67 imaging. This, combined with the higher sensitivity of gallium-67 imaging for infection around a prosthetic joint, leads us to conclude that gallium-67 imaging is superior to indium-111 leucocyte imaging in identifying infection as a cause of a painful prosthetic joint.

Frequency and pattern of radionuclide administration to medical patients in a general hospital.

As part of a drug surveillance programme details of nuclide administration were recorded for 5288 consecutive patients admitted to the medical wards of a large general hospital. Overall use of nuclides amongst this group was found to be low, and multiple exposure to radiation as a result of nuclide administration is not a major hazard when compared to the diagnostic information provided.