Subclavian steal syndrome presenting as recurrent pulmonary oedema associated with acute left ventricular diastolic dysfunction.

Subclavian steal syndrome typically presents as angina in patients with internal mammary artery grafts. Atypical clinical presentations have been rarely described. We report an unusual case of subclavian steal syndrome presenting as pulmonary oedema with acute left ventricular diastolic dysfunction and preserved ejection fraction in a patient with internal mammary artery graft and severe stenosis of the proximal left subclavian artery. After successful angioplasty and stenting of subclavian artery, the patient remained asymptomatic for six months, but then experienced acute diastolic dysfunction and recurrent pulmonary oedema associated with critical subclavian in-stent restenosis with stent deformation. This report points out that, in patients with internal mammary-to-LAD grafts, subclavian steal syndrome may present as acute left ventricular diastolic dysfunction and pulmonary oedema even in the presence of normal ejection fraction.

Peripartum cardiomyopathy presenting with predominant left ventricular diastolic dysfunction: efficacy of bromocriptine.

Management of patients with peripartum cardiomyopathy (PPCM) is still a major clinical problem, as only half of them or slightly more show complete recovery of left ventricular (LV) function despite conventional evidence-based treatment for heart failure. Recent observations suggested that bromocriptine might favor recovery of LV systolic function in patients with PPCM. However, no evidence exists regarding its effect on LV diastolic dysfunction, which is commonly observed in these patients. Tissue Doppler (TD) is an echocardiographic technique that provides unique information on LV diastolic performance. We report the case of a 37-year-old white woman with heart failure (NYHA class II), moderate LV systolic dysfunction (ejection fraction 35%), and severe LV diastolic dysfunction secondary to PPCM, who showed no improvement after 2 weeks of treatment with ramipril, bisoprolol, and furosemide. At 6-week followup after addition of bromocriptine, despite persistence of LV systolic dysfunction, normalization of LV diastolic function was shown by TD, together with improvement in functional status (NYHA I). At 18-month followup, the improvement in LV diastolic function was maintained, and normalization of systolic function was observed. This paper might support the clinical utility of bromocriptine in patients with PPCM by suggesting a potential benefit on LV diastolic dysfunction.

Acute inflammatory bowel disease complicating chronic alcoholism and mimicking carcinoid syndrome.

We report the case of a woman with a history of chronic alcohol abuse who was hospitalized with diarrhea, severe hypokalemia refractory to potassium infusion, nausea, vomiting, abdominal pain, alternations of high blood pressure with phases of hypotension, irritability and increased urinary 5-hydroxyindoleacetic acid and cortisol. Although carcinoid syndrome was hypothesized, abdominal computed tomography and colonoscopy showed non-specific inflammatory bowel disease with severe colic wall thickening, and multiple colic biopsies confirmed non-specific inflammation with no evidence of carcinoid cells. During the following days diarrhea slowly decreased and the patient's condition progressively improved. One year after stopping alcohol consumption, the patient was asymptomatic and serum potassium was normal. Chronic alcohol exposure is known to have several deleterious effects on the intestinal mucosa and can favor and sustain local inflammation. Chronic alcohol intake may also be associated with high blood pressure, behavior disorders, abnormalities in blood pressure regulation with episodes of hypotension during hospitalization due to impaired baroreflex sensitivity in the context of an alcohol withdrawal syndrome, increased urinary 5-hydroxyindoleacetic acid as a result of malabsorption syndrome, and increased urinary cortisol as a result of hypothalamic-pituitary-adrenal axis dysregulation. These considerations, together with the regression of symptoms and normalization of potassium levels after stopping alcohol consumption, suggest the intriguing possibility of a alcohol-related acute inflammatory bowel disease mimicking carcinoid syndrome.

Isolated papillary muscle rupture complicating acute pancreatitis.

Papillary muscle rupture in the absence of coronary stenoses is a rare event. An isolated infarction of the papillary muscle is involved in most cases, but the pathogenesis is still debated. We describe an anterolateral papillary muscle rupture complicating acute pancreatitis in a patient without significant coronary stenoses and with evidence of coronary spasm. This suggests that an increased susceptibility to coronary spasm and thrombosis, triggered by an acute systemic inflammatory response, may represent a mechanism of selective papillary muscle infarction.

Axillary ultrasound scanning in the follow-up of breast cancer patients undergoing sentinel node biopsy.

In breast cancer patients with negative sentinel node biopsy (SNB), surveillance of the unremoved nodes is recommended. Clinical examination has poor sensitivity. The aim of this study was to evaluate the role of axillary ultrasound scan (AUS) in the follow-up of these patients. AUS was performed every 12 months in a series of 165 patients with negative SNB. During the follow-up (median 45.6 months), in 154 patients, the AUS was carried out as a routine examination and in three cases (1.9%) it showed suspicious nodes, which underwent core biopsy. No evidence of axillary recurrence was found. Conversely, in 11 patients, AUS was performed to clarify a palpable lymphadenopathy; none of them was suspicious at US. We conclude that routine AUS to follow-up patients who have had a negative SNB is unnecessary. However, AUS may be useful in the presence of palpable nodes, to select those patients who do not require biopsy.

Radiofrequency ablation for minimally invasive treatment of breast carcinoma. A pilot study in elderly inoperable patients.

OBJECTIVES: Radiofrequency ablation (RFA) has been used to treat hepatic, renal and prostate tumors. Preliminary experiences in breast cancer, followed by surgical excision, were encouraging. We performed a pilot trial of ultrasound-guided percutaneous RFA, not followed by surgery, in three elderly inoperable patients with breast carcinoma. The study was undertaken to determine the feasibility of treating small breast malignancies with RFA only and to evaluate the safety and complications related to this treatment. METHODS: Three patients with core-needle biopsy-proven invasive carcinoma (<2 cm in greatest dimension) underwent ultrasound-guided RFA under local anesthesia, as outpatient procedure. Treatment was planned to ablate the tumor and a margin of surrounding breast tissue. All the patients were evaluated after a 1, 6, 12 and 18 months of follow-up. RESULTS: All the patients completed the treatment with minimal or no discomfort and returned home after 1 h. The mean age was 81.3 years (range, 76-86 years) and the mean tumor size was 11.6 mm (range, 10-13 mm). The tumors laid more than 10 mm from chest wall and from the skin. The mean time required for ablation was 10.3 min (range, 8-12 min). There were no treatment-related complications. Post-ablation ultrasound scan, mammography, Magnetic Resonance Imaging scan and core biopsy, confirmed the tumor necrosis. After 18 months of follow-up no recurrence occurred. CONCLUSIONS: RFA was feasible and safe for minimally invasive treatment of elderly inoperable patients with early-stage, primary breast carcinoma.

Role of axillary lymph node ultrasound and large core biopsy in the preoperative assessment of patients selected for sentinel node biopsy.

PURPOSE: The aim of this study was to evaluate the diagnostic accuracy of axillary lymph node sonography, if necessary in combination with US-guided large core biopsy, in the preoperative evaluation of breast cancer patients scheduled for quadrantectomy and sentinel lymph node excision. MATERIALS AND METHODS: From July 2001 to December 2002, we evaluated 117 breast cancer patients with ultrasound and, where indicated, FNAB. Breast lesions had diameters between 4 and 26 mm (mean diameter 11 mm). Fifteen (13%) of the 117 patients were excluded from the series as they did not fulfil the criteria for preliminary sonography of the axilla: in 9 patients fewer than 4 nodes were detected and in 6 patients the breast lesions were intraoperatively found to be benign. Eleven patients (10.7 %) with sonographically suspicious axillary nodes were sampled by US-guided core biopsy using a 14 or 16 Gauge Tru-Cut needle. RESULTS: The ultrasound study aims to evaluate the dimensions and morphology of the breast lesion as well as detect and assess at least 4 axillary nodes. These were evaluated for hilar and cortical thickening and ratio between the sinus diameter and the total longitudinal diameter. Lymph nodes with hilar diameters equal to or greater than 50% of the longitudinal diameter were considered normal. Of the 102 patients evaluated, 77 (75.7%) had normal axillary nodes according to the US criteria adopted. Negativity was confirmed by histology in 56 cases (72.7%, true negative); 21 (27.3%, false negative) were found to be positive, in contrast with the sonographic appearance. The false negative cases were due to lymph node micrometastasis which probably did not cause morphologic alterations perceptible at ultrasound. The remaining 25 patients (24.5%) had axillary lymph nodes classified as suspicious. In 13 cases of (52%, true positive) there was agreement with histology, whereas in 12 cases (48%, false positive) the US suspicion was not confirmed at surgery. The most important sonographic alteration was the gradual reduction in hilar echogenicity (seen in 100% metastatic nodes); conversely, hilar denting or irregularities, as well as dimensional criteria, proved to be poorly specific. CONCLUSIONS: The sonographic assessment of axillary and internal mammary chain nodes, possibly in addition to core biopsy, improves the preoperative evaluation of breast cancer patients scheduled for conservative surgery of the breast (quadrantectomy) and the axilla (sentinel node biopsy). US findings suspicious for metastatic involvement of axillary lymph nodes should be considered as an exclusion criterion for sentinel node biopsy. A more widespread use of axillary node biopsy and an accurate sonographic evaluation of the excised lymph node increase the specificity of the procedure, allowing a better correlation between sonographic findings and definitive histology.