Spontaneous late carotid-cutaneous fistula following radical neck dissection: a case report.

The authors present an unusual case of a spontaneous carotid-cutaneous fistula occurring as a late complication 4 years after radical neck dissection and postoperative radiation therapy for tonsillar squamous cell carcinoma in a 50-year-old patient. The etiologic factors predisposing patients to carotid artery rupture following radical neck dissection and a surgical option for carotid artery reconstruction instead of ligation are discussed.

Emergency laparotomy in patients on continuous ambulatory peritoneal dialysis.

Peritonitis is the most common complication of chronic ambulatory peritoneal dialysis (CAPD). It is often a diagnostic challenge to differentiate those patients with CAPD-associated infections from those who have unrelated gastrointestinal pathology as the cause of peritonitis and would benefit from surgical exploration. A retrospective chart review was performed on all patients at a single institution who were on CAPD between the years 1990 and 1998 and who underwent laparotomy for peritonitis. Six patients underwent laparotomy. Four were male and two were female; ages ranged from 34 to 80 years. Perforated appendicitis was the cause of peritonitis in three patients, perforated diverticulitis was present in two, and one was without any suppurative intra-abdominal process. In each case CT scan of the abdomen was nondiagnostic. There was a delay in diagnosis of 10 days (range 3-21 days) and an operative mortality of 16 per cent.

Parathyroid crisis in a 20 year old--an unusual cause of hypercalcaemic crisis.

Since the advent of automated serum analysis, patients with primary hyperparathyroidism (PHPT) are often asymptomatic at presentation or have mild symptoms attributable to the disease. Parathyroid crisis is a rare and potentially fatal complication of PHPT in which patients develop severe hypercalcaemia with signs and symptoms of multiple organ dysfunction. A case of parathyroid crisis in a 20 year old man who presented with brown tumours and renal stones is described.

Visceral artery aneurysms as seen in a community hospital.

BACKGROUND: Visceral artery aneurysm (VAA) is a rare but important form of vascular pathology. METHODS: A retrospective chart review was performed for all patients treated for VAAs from 1980 to 1998 at the Northern California Kaiser Hospitals. RESULTS: Thirty-one patients with VAAs were treated, 11 men and 20 women with an average age of 60 years. The arteries involved were 15 splenic, 8 hepatic, 5 superior mesenteric branch, 1 left gastric, 1 gastroduodenal, and 1 left colic. Seventy-four percent of patients presented with acute abdominal pain and/or shock secondary to aneurysm rupture. Angioembolization was performed in 9, and 25 were treated surgically. There was no morbidity, and 1 death (3.2%). CONCLUSIONS: Patients with VAAs often present to the community hospital general surgeon as acute abdominal emergencies. Symptomatic VAAs can be managed successfully by simple ligation in the primary care setting.

Outcome of Nissen fundoplication using intraoperative manometry in children.

BACKGROUND: Intraoperative manometry is useful in performing Nissen fundoplication (NF) in children. Long-term clinical outcome information after use of this method is lacking. METHODS: A retrospective review of the outcomes of 62 consecutive NFs using intraoperative manometry was performed. The follow-up period was 3.4 years. Approximately half of the patients were neurologically normal (NN) and half were neurologically impaired (NI). All patients with gastroesophageal reflux disease (GERD) did not respond to an adequate trial of medical treatment. RESULTS: The NF was tailored to result in a twofold increase in the lower esophageal sphincter pressure (LESP) and a 75% increase in the LES length (LESL). An accelerated growth rate in 40% of "failure to thrive" (FTT) patients was demonstrated. Eighty-four percent of caregivers reported improved quality of life after NF. There was a twofold reduction in the number of hospital admissions and a sixfold reduction in total inpatient days for both NI and NN children. The early and late mortality rate was 13%, and the complication rate was similar to other series reported in the literature, with more complications occurring in NI patients. There was a 2% incidence of wrap herniation. An improvement in long-term outcomes after NF was seen in 89% of NN children and over half of NI patients. CONCLUSIONS: Intraoperative manometry is useful in standardizing the tightness of the wrap in NF. There was a low incidence of complications, dysphagia, recurrent emesis, and GERD in this series. Long-term outcomes using this technique were deemed very good based on caregivers' responses.

Moesin expression is associated with the estrogen receptor-negative breast cancer phenotype.

BACKGROUND: Estrogen receptor (ER)-positive breast carcinomas possess a less aggressive phenotype than ER-negative breast carcinomas. We hypothesize that a set of genes exists that is expressed only in ER-negative breast carcinomas, which account for the more malignant phenotypic characteristics of these tumors. METHODS: We have used a new technique of polymerase chain reaction select suppression subtractive hybridization to identify genes that are expressed only in ER-negative carcinomas. RESULTS: Seventy-one cDNA clones generated by suppression subtractive hybridization were screened by Northern blot analysis with RNA from ER-positive MCF7 and ER-negative MDA-MB-231 breast carcinoma cell lines. Fifteen clones were differentially expressed in MDA-MB-231 cells. Five of these 15 clones were consistently found to be associated with the ER-negative phenotype in a panel of eight breast carcinoma cell lines. Sequence analysis demonstrated that three of these clones were derived from vimentin and two clones from moesin. Western blot analysis with antihuman moesin antibody confirmed that moesin protein was overexpressed in ER-negative breast carcinoma cell lines but absent from ER-positive breast carcinomas. Moesin mRNA was examined in a panel of 29 primary breast carcinomas with semi-quantitative reverse transcriptase-polymerase chain reaction. Moesin expression was found to be decreased significantly in ER-positive compared with ER-negative tumors (P < .01). CONCLUSIONS: Vimentin and moesin are differentially expressed in association with the ER-negative breast cancer phenotype. Moesin is a membrane/actin filament protein involved in dynamic restructuring of the cell surface and filopodia, a cell structure needed for cell adhesion and motility. Moesin may play a role in the invasiveness and pattern of metastasis characteristic of ER-negative breast cancers.

Ultrasound-guided fine-needle aspiration biopsy of thyroid masses.

The purpose of this study was to determine the impact of ultrasound-guided fine-needle aspiration biopsy (USFNA) in the cytological diagnosis of nodular thyroid disease. It remains unclear exactly what role USFNA should play in the cytological diagnosis of nodular thyroid disease. All patients who underwent fine-needle aspiration (FNA) for nodular thyroid disease at Stanford University Medical Center from 1991 to 1996 were included in the study. Histopathologic diagnoses were compared to cytological diagnoses for those patients who underwent surgery. FNA was performed on a total of 497 thyroid nodules. Palpation-guided FNA (pFNA) was performed on 370 nodules, and USFNA was done on 127. The USFNAs were performed for the following reasons: 95 (75%) for nonpalpable or difficult-to-palpate nodules; 14 (11%) for previously failed FNA; and 18 (14%) for incidentally detected nodules. FNA had an unsuccessful biopsy rate of 16% and a sensitivity and specificity of 89% and 69%, respectively. USFNA had an unsuccessful biopsy rate of 7% and a sensitivity and specificity of 100% and 100%, respectively. The cancer yield at surgery for pFNA was 40%, and the cancer yield at surgery for USFNA was 59%. The complementary use of USFNA with pFNA improves the diagnostic approach to nodular thyroid disease. The use of USFNA has increased the cancer yield at surgery and the sensitivity of thyroid biopsy at our institution.

Abdominal apoplexy.

We describe the case of a patient with abdominal apoplexy, the spontaneous rupture of a visceral vessel. Laparotomy revealed a hematoma arising from a ruptured gastroepiploic artery. We report the usefulness of preoperative abdominal computed tomography and transgastric ultrasonography and discuss the condition of abdominal apoplexy. An increased awareness of the condition is perhaps the most valuable aspect of the early preoperative diagnosis of this potentially fatal condition.

Identification of two estrogen receptor transcripts with novel 5' exons isolated from a MCF7 cDNA library.

Two novel transcripts of human estrogen receptor (ER) have been identified that differ in the 5' untranslated sequence. It has previously been determined that an alternate ER transcript is generated from transcription initiated upstream of the main ER cap site (P1), and utilizes a splice acceptor site at +163. Here we report the isolation of 21 ER clones from a MCF7 cDNA library. Eleven of these clones correspond to transcripts that initiate at the P1 cap site, whereas the remaining 10 clones are derived from two previously unidentified ER transcripts (designated E and H) that both utilize the +163 splice acceptor site. A panel of breast and endometrial carcinoma cell lines were screened by reverse transcriptase-polymerase chain reaction (RT-PCR) for expression of the E and H transcripts. It was found that all ER-positive cell lines expressed both of the novel transcripts. In addition, 10 primary human breast cancers were analyzed, of which six expressed the E transcript and five abundantly expressed the H transcript. These data indicate that expression of ER in human breast cancers can be dependent upon an alternate promoter at least 20 kb upstream of the primary cap site for ER.

Analysis of estrogen receptor messenger RNA in breast carcinomas from archival specimens is predictive of tumor biology.

As the size of breast tumors continues to decrease, it has become more difficult to obtain adequate tumor tissue for molecular studies. We have used the estrogen receptor (ER) gene as a model to study the ability to perform a quantitative analysis of ER mRNA extracted from archival breast carcinoma specimens using reverse transcriptase polymerase chain reaction. Based upon ER mRNA abundance, tumors were characterized as having low, medium, or high ER mRNA expression. These data were compared with ER and progesterone receptor (PR) status determined by enzyme immunoassay, tumor histology, and Bloom-Richardson grade. Comparing the low and high ER mRNA groups, there were statistically significant differences in ER-positive status (10% versus 95%; P = 0.0001), PR-positive status (10% versus 90%; P = 0.0001), and tumor grade (2.67 +/- 0.12 versus 2.09 +/- 0.14; P = 0.0025). Of the 28 tumors in the high ER mRNA group, 5 (18%) were invasive lobular carcinomas whereas all 24 tumors with low ER mRNA were invasive ductal carcinomas. These data demonstrate that archival breast tumor specimens can be characterized for ER mRNA abundance. In addition, we conclude that the mechanisms regulating ER gene transcription influence the phenotype of breast carcinomas. These results also suggest that this technique can be designed to provide a quantitative analysis of gene expression for any gene of interest utilizing archival tumor specimens.

Identification of a gene (GPR30) with homology to the G-protein-coupled receptor superfamily associated with estrogen receptor expression in breast cancer.

Using the technique of differential cDNA library screening, a cDNA clone was isolated from an estrogen receptor (ER)-positive breast carcinoma cell line (MCF7) cDNA library based upon the overexpression of this gene compared to an ER-negative cell line (MDA-MB-231). Sequence analysis of this clone determined that it shared significant homology to G-protein-coupled receptors. This receptor, GPCR-Br, was abundantly expressed in the ER-positive breast carcinoma cell lines MCF7, T-47D, and MDA-MB-361. Expression was absent or minimal in the ER-negative breast carcinoma cell lines BT-20, MDA-MB-231, and HBL-100. GPCR-Br was ubiquitously expressed in human tissues examined but was most abundant in placenta. GPCR-Br expression was examined in 11 primary breast carcinomas. GPCR-Br was detected in all 4 ER-positive tumors and only 1 of 7 ER-negative tumors. Based upon PCR analysis in hybrid cell lines, the gene for GPCR-Br (HGMW-approved symbol GPR30) was mapped to chromosome 7p22. The pattern of expression of GPCR-Br indicates that this receptor may be involved in physiologic responses specific to hormonally responsive tissues.