Neutropenic acute acalculous cholecystitis (AAC) in a 12-year-old boy with T-acute lymphoblastic leukemia successfully managed with conservative treatment.

Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder without the presence of gallstones. In children with malignancies or chemotherapy-induced neutropenia, AAC is very rare. Clinical diagnosis of AAC remains difficult in this patient population but an early recognition followed by an appropriate intervention may confer a benefit. Only three pediatric patients with underlying hematological malignancies whose clinical treatment course was complicated by the development of AAC have been described. We describe a neutropenic pediatric patient who developed AAC following chemotherapy for acute T-cell acute lymphoblastic leukemia (T-ALL), which was successfully managed with conservative treatment. ABBREVIATIONS: AAC: Acute acalculous cholecystitis; T-ALL: T-cell acute lymphoblastic leukemia; TPN: Total parenteral nutrition.

Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial.

BACKGROUND: Initial results of the UK/ANZ DCIS (UK, Australia, and New Zealand ductal carcinoma in situ) trial suggested that radiotherapy reduced new breast events of ipsilateral invasive and ductal carcinoma in situ (DCIS) compared with no radiotherapy, but no significant effects were noted with tamoxifen. Here, we report long-term results of this trial. METHODS: Women with completely locally excised DCIS were recruited into a randomised 2×2 factorial trial of radiotherapy, tamoxifen, or both. Randomisation was independently done for each of the two treatments (radiotherapy and tamoxifen), stratified by screening assessment centre, and blocked in groups of four. The recommended dose for radiation was 50 Gy in 25 fractions over 5 weeks (2 Gy per day on weekdays), and tamoxifen was prescribed at a dose of 20 mg daily for 5 years. Elective decision to withhold or provide one of the treatments was permitted. The endpoints of primary interest were invasive ipsilateral new breast events for the radiotherapy comparison and any new breast event, including contralateral disease and DCIS, for tamoxifen. Analysis of each of the two treatment comparisons was restricted to patients who were randomly assigned to that treatment. Analyses were by intention to treat. All trial drugs have been completed and this study is in long-term follow-up. This study is registered, number ISRCTN99513870. FINDINGS: Between May, 1990, and August, 1998, 1701 women were randomly assigned to radiotherapy and tamoxifen, radiotherapy alone, tamoxifen alone, or to no adjuvant treatment. Seven patients had protocol violations and thus 1694 patients were available for analysis. After a median follow-up of 12·7 years (IQR 10·9-14·7), 376 (163 invasive [122 ipsilateral vs 39 contralateral], 197 DCIS [174 ipsilateral vs 17 contralateral], and 16 of unknown invasiveness or laterality) breast cancers were diagnosed. Radiotherapy reduced the incidence of all new breast events (hazard ratio [HR] 0·41, 95% CI 0·30-0·56; p<0·0001), reducing the incidence of ipsilateral invasive disease (0·32, 0·19-0·56; p<0·0001) as well as ipsilateral DCIS (0·38, 0·22-0·63; p<0·0001), but having no effect on contralateral breast cancer (0·84, 0·45-1·58; p=0·6). Tamoxifen reduced the incidence of all new breast events (HR 0·71, 95% CI 0·58-0·88; p=0·002), reducing recurrent ipsilateral DCIS (0·70, 0·51-0·86; p=0·03) and contralateral tumours (0·44, 0·25-0·77; p=0·005), but having no effect on ipsilateral invasive disease (0·95, 0·66-1·38; p=0·8). No data on adverse events except cause of death were collected for this trial. INTERPRETATION: This updated analysis confirms the long-term beneficial effect of radiotherapy and reports a benefit for tamoxifen in reducing local and contralateral new breast events for women with DCIS treated by complete local excision. FUNDING: Cancer Research UK and the Australian National Health and Medical Research Council.

Implications of inconsistent measurement of ER status in non-invasive breast cancer: a study of 1,684 cases from the Sloane Project.

The Sloane Project is an anonymized UK-wide audit of screen-detected atypical hyperplasia and in situ carcinoma of the breast. Full histopathology data have been provided by the local reporting pathologist on 1,684 of 2,615 cases entered to date. These include estrogen (ER), progesterone, and Her2 receptor status and the scoring/cut-off criteria for positivity used. We review the recorded data on receptor status of cases of ductal carcinoma in situ (DCIS) entered into the Sloane Project and the cut-off criteria for negative/positive status-determination for those cases. ER status was recorded on the Sloane Project pathology datasheets for 763 cases, 79% were positive and 21% negative. For hormone receptors, the distribution of use of the three scoring systems: Allred scoring, histoscore, and a simple percentage score was 62%, 21%, and 17%, respectively. Cut-off criteria were provided for 78% of the ER positive cases and 48% of ER negative cases. There was a wide range of cut-off values applied, with Allred scores of <2-5, percentages of <1-70%, and histoscores of 30-50. Reporting practice was commonly inconsistent within individual laboratories. Thirty-nine percent of ER positive patients were referred for consideration of endocrine therapy. Eight percent of patients were entered into clinical trials. There is a pressing need to standardize reporting of receptor status in DCIS and to give clear guidance on both scoring methodologies and recommended cut-off points. There are significant implications for the interpretation of clinical trials data in this area.

Facile, fast, and inexpensive synthesis of monodisperse amorphous nickel-phosphide nanoparticles of predefined size.

Monodisperse, size-controlled Ni-P nanoparticles were synthesised in a single step process using triphenyl-phosphane (TPP), oleylamine (OA), and Ni(II)acetyl-acetonate. The nanoparticles were amorphous, contained ~30 at% P and their size was controlled between 7-21 nm simply by varying the amount of TPP. They are catalytically active for tailored carbon nanotube growth.

Audit of blood transfusion in elective breast cancer surgery--do we need to group and save pre-operatively?

INTRODUCTION: Current guidelines on blood ordering in our hospital require all patients undergoing elective breast cancer surgery to have blood grouped, screened and saved as an part of a pre-operative assessment. The aim of this audit was to assess the need for, and cost effectiveness of, this approach in elective breast cancer surgery. PATIENTS AND METHODS: Retrospective data collection was undertaken for a 2-year period using the theatre booking system. As a result, 497 consecutive elective breast surgery operations including mastectomies, wide local excisions and breast reconstruction procedures were identified for analysis. Using the hospital blood bank computer system, we established the blood group and save or cross-match status as well as the pre- and postoperative haemoglobin results and blood transfusion related data for each of the patients identified. RESULTS: Of the 497 patients, 438 (88.1%) had blood sent for group-and-save. Of the total 497 patients identified, only 19 (3.82%) patients received a blood transfusion. From the 447 patients undergoing simple mastectomy or wide local excisions alone, 9 patients (1.81%) required transfusion. Fifty patients underwent an immediate reconstruction procedure of whom 10 (20%) required a transfusion. CONCLUSIONS: This study demonstrates that reconstruction is more likely to be associated with the need for a postoperative transfusion. However, in the context of all breast surgery, blood transfusion is rarely requested. Given this, the time and cost involved in processing a group-and-save pre-operatively is not justified.

Relationship between quantitative estrogen and progesterone receptor expression and human epidermal growth factor receptor 2 (HER-2) status with recurrence in the Arimidex, Tamoxifen, Alone or in Combination trial.

PURPOSE: To determine the relationship between quantitative estrogen-receptor (ER) and progesterone-receptor (PgR) expression and human epidermal growth factor 2 (HER-2) status with time to recurrence (TTR) in postmenopausal women with hormone receptor-positive primary breast cancer treated with anastrozole or tamoxifen as adjuvant therapy. PATIENTS AND METHODS: Formalin-fixed, paraffin-embedded tumor blocks were retrospectively collected from patients in the monotherapy arms of the Arimidex, Tamoxifen Alone or in Combination (ATAC) trial and centrally tested for ER, PgR and HER-2. ER and PgR were scored using continuous scales and HER-2 was scored as 0 to 3+ with 2+ cases being analyzed by fluorescence in situ hybridization. RESULTS: Blocks were collected from 2,006 of 5,880 eligible patients. Tissue was assessable and ER and/or PgR positivity confirmed centrally in 1,782 cases. In these, TTR was longer for anastrozole than for tamoxifen by a similar extent to that in the overall trial. None of the three biomarkers identified a set of patients with differential benefit from anastrozole over tamoxifen. Patients with low ER, low PgR, and high HER-2 expression had a poorer prognosis with either drug. Only 2.6% of patients in the highest quartile of PgR experienced recurrence after 5 years, compared with 13.2% in the lowest quartile. CONCLUSION: Quantitative expression of ER and PgR and HER-2 status did not identify patients with differential relative benefit from anastrozole over tamoxifen: TTR was longer for anastrozole than for tamoxifen in all molecular subgroups. Low ER or PgR or high HER-2 expression are associated with a high risk of recurrence with either anastrozole or tamoxifen.