Complications of isolated bilateral iliac artery aneurysms.

Isolated iliac artery aneurysms occur infrequently. They comprise about 2 per cent of all abdominal aneurysms. Most patients are symptomatic at the time of presentation. The average diameter is 5.7 cm at diagnosis. We report the acutely symptomatic presentation of a 76-year-old African-American man with 7- and 9-cm bilateral common iliac and a right hypogastic artery aneurysms. Aneurysmorrhaphy was complicated by pelvic ischemia. Colonoscopy and arteriography were used postoperatively to evaluate the extent of his worsening gluteal ischemia. Restoration of pelvic blood flow corrected his gluteal ischemia.

Mycotic aortic aneurysm in a patient with Tolosa-Hunt syndrome.

Mycotic aneurysms have been associated with many clinical conditions. A tender pulsatile abdominal mass in association with fever, chills, and unrelenting back pain is suggestive of a leaking mycotic aneurysm. However, the extracranial manifestations of Tolosa-Hunt syndrome (THS) may mimic several of these symptoms. We report the case of a woman who was successfully treated with high-dose steroids for THS. Two months later, she was admitted to another hospital with rigors and unremitting back and abdominal pain. CT-guided aspiration of an L5-S1 paravertebral mass was done. The aspirate and blood cultures grew Staphylococcus aureus. Intravenous antibiotics and analgesics were administered with good relief. A month after discharge from that hospital, she was admitted to our hospital with classic signs and symptoms of a leaking mycotic aneurysm. She was treated surgically and has remained asymptomatic for 21 months. Tolosa-Hunt syndrome associated with mycotic aortic aneurysms has not been previously reported.

The antiphospholipid symdrome in a teenage with miscarriages, thromboses, and diabetes mellitus.

The antiphospholipid syndrome has been associated with many clinical conditions since its description by GRV Hughes in 1983. The linkage to Type 1 diabetes mellitus has not been established. There have been no reports of deep venous thrombosis in association with antiphospholipid syndrome and diabetes mellitus. We present the case of an African-American teenager with multiple miscarriages, diabetic ketoacidosis, deep venous thromboses, and elevated immunoglobulin M and G anticardiolipin antibodies. We urge that clinicians consider testing for antiphospholipid antibodies when diabetic patients present with multiple miscarriages or deep venous thrombosis.

Primary adenocarcinoma, signet-ring, and transitional cell carcinoma of the bladder with penile metastasis.

This article reports a rare case of primary signet-ring cell carcinoma of the bladder with transitional cell and adenocarcinoma variants and metachronous metastases to the penis and lungs. This combination of lesions has not previously been reported. Together, they portend widespread dissemination and an early demise as is frequently the case with signet-ring cell carcinomas arising in other organs such as the breast and gastrointestinal tract. The optimal therapeutic intervention for this myriad of neoplasms with metastasis to the penis has yet to be ascertained because of the rarity of the lesions. Early diagnosis and an aggressive surgical approach appear to offer the best chance for quality survival and possible cure.

Growth and metastasis of surgical specimens of human breast carcinomas in SCID mice.

PURPOSE: We have studied the growth and metastatic potential of surgical specimens of breast carcinomas engrafted into the large abdominal (gonadal) fat pad of severe combined immunodeficient (SCID) mice. We present results of this study, details of the implantation protocol and histologic characterization of several of the tumor xenografts. MATERIALS AND METHODS: We evaluated the growth within SCID mice of 48 breast carcinoma specimens derived from 46 patients (45 primary breast cancers or local recurrences and 3 regional metastatic lymph nodes) obtained from resected tissues at this Institute over a 3-year period. The growth of each transplant was assessed by histologic examination of the xenografts at various times after implantation or upon passage into additional mice. RESULTS: We observed that placement of human breast tumors within the gonadal fat pad could result in tumors that grew either rapidly, slowly, or not at all. Of 48 tumors studied, 12 (25%), including one of the three lymph node-derived tumors, grew rapidly enough within some or all of the implanted mice (i.e., the tumors reached a diameter of 2-3 cm within 2-6 months) to allow repeated passage. Metastatic spread to the SCID mouse lung, liver, and/or diaphragm and other sites was observed with the xenografts derived from 8 of these 12 rapidly growing tumors. Tumors in a second category often took from 6 months to over 1 year to only double or triple in size. This slow-growth group consisted of 25 patients' tumors (53%), including the remaining two metastatic lymph node-derived tumors. These xenografts would usually maintain a slow growth rate even upon later passage into new animals. A third category consisted ofpatients' tumors (23%) that failed to grow at all (i.e., no evidence of tumor growth in any of the mice implanted), as discerned by histologic evaluation at various times after implantation. Histologic examination of tumor xenografts and metastatic tumors revealed considerable variation in histopathology among the different patients' tumors. DISCUSSION: Further examination of the heterogeneous properties of primary human breast carcinomas within SCID mice may provide a simple yet valuable new approach for the long-term study of human breast cancer biology. Importantly, use of the protocol described here can often permit the isolation of substantial quantities of human breast cancer cells for biochemical and molecular analyses. The ability to passage patients' breast tumors into large numbers of mice will permit the preclinical testing of new therapies for the treatment and prevention of this disease.

A complication of T-fasteners in percutaneous endoscopic gastrostomy (PEG) placement.

Two patients with sinus tracts from retained T-fasteners following PEG tube placement are reported. Both patients had the PEG tubes subsequently removed and presented with purulent discharge and granulations near well-healed gastrostomy sites. The management of this complication and a possible method of prevention are discussed.

Etiology of diverticular disease with classic illustrations.

Diverticulosis is a common colonic disorder and often is found incidentally on colonic endoscopy and contrast enema radiographs. Theories relating to the etiology of the pathologic processes are commonly quoted, although the actual anatomic features are rarely seen during colonoscopic examinations. Here we show classic illustrations that support the widely held theories regarding the etiologies of diverticular diseases.

Consistent hepatic metastasis of human colorectal cancer in severe combined immunodeficient mice.

A major stumbling block in the study of human colorectal cancer metastasis has been the lack of an effective in vivo model producing liver metastasis on a consistent basis. In this study surgical specimens of colorectal carcinoma were implanted in scid mice and studied for engraftment, growth, and the capacity to produce hepatic metastases. Human colorectal cancers would engraft and propagate in the subcutis and intraperitoneally. Sporadic metastasis to the liver occurred in 3 of 54 (6%) animals with cancer implanted subcutaneously. Liver metastasis occurred in 24 of 25 (96%) mice with cancer implanted in the gonad fat pad. Tumor growth to extremely large volumes subcutaneously did not enhance metastatic potential, and neither did longer term growth in the subcutaneous space. Tumor placed in the gonad fat required no special manipulation and in most cases a single piece of solid tumor was implanted. In situ hybridization confirmed the persistence of the human tissue in these metastasizing tumors. Our model will allow for the study of the processes involved in metastasis of solid tumors, characterization of differences between the primary tumor and the metastatic one, and evaluation of possible therapeutic modalities.

Laparoscopic cholecystectomy in patients with ventriculoperitoneal (VP) shunts.

Increased intracranial pressure is often relieved by a ventriculoperitoneal shunt. The shunt has a one-way valve which can withstand pressures of 300 mmHg and prevent reflux of intraabdominal fluid. We have utilized laparoscopy for cholecystectomy in four patients with VP shunts. In all patients the peritoneal cavity was free of adhesions. When CO2 insufflation pressure was as high as 10-15 mmHg cerebrospinal fluid was still noted to flow from the end of the shunts. In three patients the entire procedure was performed laparoscopically. In the fourth patient the procedure was converted to an open cholecystectomy because of extensive inflammation surrounding a gangrenous gallbladder. Postoperatively the shunts remained intact and functional. There were no central nervous system sequelae. None of the shunts became infected. Elective laparoscopic cholecystectomy in patients with VP shunts can be done safely without a need for clamping or other manipulation of the shunt.

Human villous adenomas engrafted into scid mice survive for prolonged period without malignant transformation.

Human villous adenomas are thought to represent premalignancies that subsequently give rise to colorectal adenocarcinomas. Currently there is no in vivo model in which to study the dedifferentiation and malignant transformation of these tumors. We establish here that human villous adenomas can be successfully engrafted into severe combined immunodeficient (scid) mice. Furthermore, these xenografts remain viable for up to 18 mo after either a subcutaneous or intraperitoneal inoculation of the human tissue. Tumors grew slowly and secreted a clear mucinous fluid. Examination of the tumors histologically at 1, 4, and 12 mo after implantation revealed that the villous polypoid structure was maintained and islands of atypical cells were observed within pockets of mucin surrounding the adenomatous tissue. No gross or histologic evidence of malignancy was detected throughout the 20-mo observation period. The human identity of the cells in the graft was confirmed by DNA in situ hybridization with a human-specific probe. We conclude that the human-scid xenograft described here represents a viable animal model with which to study the potential malignant dedifferentiation of villous adenomas over a prolonged period of time and to evaluate the possible contribution of selected oncogenic vectors on the malignant transformation of these adenomas.

Multiple and distinct primary cancers: a case report.

Multiple primary cancers in a single individual are rare when more than three distinct lesions are considered. This article reports a patient who developed four separate primary cancers: squamous cell carcinoma of the larynx, squamous carcinoma of the lung, adenocarcinoma of the breast, and adenocarcinoma of the colon. No specific hereditary syndrome could be identified from this patient's pedigree. Individuals with a history of multiple cancers should have a complete family history evaluation and follow-up for development of subsequent primaries.

Colon cancer in blacks: age-related presentation and survival within a similar socioeconomic group.

Young blacks with colon cancer continue to have a poor survival rate for reasons that remain undetermined. Medical records of blacks with colon cancer diagnosed at an inner-city hospital during a 10-year period were reviewed. The cohort consisted of 118 indigent, nonmigratory patients grouped by age. Group 1 consisted of 11 patients under age 50, and group 2 consisted of 107 patients age 50 and over. Admission symptoms were significantly different between groups. Patients in group 1 presented with abdominal pain more often than patients in group 2, and none of the patients in group 1 had anemia or obstruction, which comprised 14% and 11%, respectively, of the presenting symptoms in group 2 patients. Overall, survival difference was significant; the survival rate was 22.8 months for group 1 and 64.2 months for group 2 (P < .02). There was no difference in stage at presentation to account for the decreased survival in group 1. It is possible that the overwhelming majority (45%) of patients in group 1 with abdominal pain actually had more virulent disease, which accounts for the short survival. These individuals must be targeted for more aggressive patient education, surveillance, early detection and treatment, and follow-up.

A simple technique for insertion of PEJ via PEG.

Percutaneous endoscopic jejunostomy provides good access for enteral nutrition in those patients at high risk for aspiration and poor tolerance of gastric feeding. Positioning the jejunostomy tube through the PEG tube and into the duodenum can be difficult and time consuming. We describe a simple method for gaining rapid control of the jejunal tube and its duodenal insertion.

Endocrine organ metastases in subjects with lobular carcinoma of the breast.

OBJECTIVE: To define the frequency and pattern of endocrine organ metastases in patients dying of invasive lobular carcinoma. DESIGN: Postmortem microscopic evaluation of the ovaries and adrenal, pituitary, thyroid, and parathyroid glands for breast cancer metastases. SETTING: Roswell Park Cancer Institute, Buffalo, NY, between 1971 and 1990. SUBJECTS: One hundred eighteen subjects who died of their cancer: 86 had infiltrating ductal carcinoma; 32, invasive lobular carcinoma. MEAN OUTCOME MEASURE: Quantitative measurements to allow frequency determinations and statistical comparisons. RESULTS: Endocrine organ metastases were found in 91% of the subjects with invasive lobular carcinoma vs 58% of subjects with infiltrating ductal carcinoma. The adrenal gland was most frequently involved. Multiple endocrine metastases were most common in the group with invasive lobular carcinoma. CONCLUSIONS: A relationship exists between invasive lobular carcinoma and endocrine metastases. This indicates that antemortem endocrine evaluation may subsequently improve quality-of-life treatment.

Fiberoptic examination of the inferior vena cava during circulatory arrest for complete removal of renal cell carcinoma thrombus.

Renal cell carcinoma is known to invade the inferior vena cava and may extend its entire length. Profound hypothermic circulatory arrest has been demonstrated to be a very effective technique to facilitate removal of tumor thrombus from the cava while limiting the amount of blood loss. We describe an innovative method of ensuring complete removal of tumor thrombus from the retrohepatic cava with a fiberoptic bronchoscope introduced through the right atrium during profound hypothermic circulatory arrest. Fiberoptic examination of the cava and hepatic vein orifices under these circumstances will prevent incomplete removal of tumor.

The effect of a novel C5 inhibitor (K-76 COONa) on tumor cell chemotaxis.

Walker carcinosarcoma cells were cultured as an ascitic tumor in the rat. These cells were studied for their response to human chemotactic factors derived from complement. Complement activation for tumor chemotaxis was performed by reaction of serum with a tumor extract. An anticomplementary agent, K-76 sodium monocarboxylic acid (K-76 COONa), was tested in these systems. It was found to be effective in blocking the formation of a chemotactic factor for tumor cells from human complement at a concentration of 300 micrograms/ml. Addition of K-76 COONa after complement activation had no effect. No effect on random migration of tumor cells was found at concentrations of 500 micrograms/ml. No effect on tumor cell viability was found up to 500 micrograms/ml. At 1000 micrograms/ml there was a 15% decrease in viability (p less than 0.05). Since chemotactic mechanisms (probably from activated complement) may play a role in the movement of tumor cells, this apparently low toxic anticomplementary agent (K-76 COONa) may be of value in the prevention of tumor metastases.