One-day or two-day procedure for sentinel node biopsy in melanoma?

PURPOSE: We compared the outcome of a 1-day and a 2-day sentinel node (SN) biopsy procedure, evaluated in terms of lymphoscintigraphic, surgical and pathological findings. METHODS: We studied 476 patients with melanoma from two melanoma centres using static scintigraphy and blue dye. A proportional odds model was used for statistical analysis. RESULTS: The number of SNs visualized at scintigraphy increased significantly with time from injection to scintigraphy and activity left in the patient at scintigraphy, and depended on the melanoma location. The number of SNs removed at surgery increased with the number of SNs visualized at scintigraphy and time from injection to surgery. The frequency of nodal metastasis increased with increasing thickness and Clark level of the melanoma, and was highest for two SNs visualized at scintigraphy. CONCLUSION: This study showed that early vs. late imaging and surgery do make a difference on the outcome of the SN procedure and confirmed the importance of the scintigraphic visualization of all true SNs.

The incidence of respiratory symptoms and sensitisation in baker apprentices.

The aim of the current study was to describe the incidence of respiratory symptoms and allergic sensitisation and the sequence of events leading to respiratory symptoms among Danish baker apprentices (BA). A total of 114 BA were surveyed over a 20-month period. Questionnaires were completed along with spirometric analysis and skin-prick tests to common and work-related allergens. Bronchial hyperresponsiveness (BHR) was determined at baseline and at the end of the follow-up period. The incidences of work-related rhinitis and asthma-like symptoms were 22.1 and 10.0 cases.100 person-yrs(-1), respectively. At 20 months the cumulative incidence proportion was 40.2 and 20.5% for rhinitis and asthma-like symptoms, respectively. The cumulative incidence of occupational sensitisation was 6.1%. An increased risk of asthma-like symptoms was found in both atopic subjects and in females. In the BA with new onset respiratory symptoms, an increase in BHR from baseline was observed. Forced expiratory volume in one second and forced vital capacity did not change during the follow-up period. No relationship was observed between new sensitisation and new symptoms. In conclusion rhinitis- and asthma-like symptoms were found to develop commonly in Danish baker apprentices. The mechanism by which symptoms arose was perceived to reflect the development of an inflammation rather than the production of a specific immunoglobulin E pathway, as sensitisation to occupational allergens was rarely observed. Hence, respiratory symptoms and allergy may develop through separate pathways.

Primary lymphoma of the lacrimal sac: an EORTC ophthalmic oncology task force study.

AIM: To define the clinical and histopathological characteristics of primary lacrimal sac lymphoma in a predominantly white population. METHODS: Specimens of lacrimal sac lymphoma and follow up data were solicited from members of the Ophthalmic Oncology Task Force of the European Organization for Research and Treatment of Cancer (EORTC) and the European Ophthalmic Pathology Society (EOPS). Specimens were stained with haematoxylin and eosin and an immunohistochemical panel against leucocyte antigens was applied. Diagnosis was reached by consensus of five experienced pathologists according to the World Health Organization classification system. The histopathological findings were correlated with the clinical data. RESULTS: Of 15 primary lacrimal sac lymphomas, five (33%) were diffuse large B cell lymphoma (DLBCL), five (33%) were extranodal marginal zone B cell lymphoma of mucosa associated lymphoid tissue (MALT lymphoma), three were classified as "transitional MALT lymphoma," being in transition from MALT lymphoma to DLBCL, and two were unclassified B cell lymphomas. Nine of the patients were female, and the median age at the time of diagnosis was 71 years (range 45-95 years). The most frequent presenting symptoms were epiphora (85%), swelling in the region of the lacrimal sac (79%), and dacryocystitis (21%). All but one patient presented in stage I. Systemic spread occurred in three of nine patients (33%). The 5 year overall survival was 65%. CONCLUSIONS: DLBCL and MALT lymphoma are equally common in the lacrimal sac in contrast with the remaining periorbital and/or orbital region where MALT lymphoma predominates.

Epstein-Barr positive T-cell lymphoma in the ocular region.

PURPOSE: To present two cases of rapidly growing tumors in the ocular adnexa. Both tumors were Epstein-Barr virus (EBV) positive peripheral T-cell lymphoma. METHODS: Case 1 was a 60-year-old man with a non-tender ulcerating tumor involving the lateral third of both upper and lower right eyelid. Case 2 was a 55-year-old man with a swelling of the left eyelid expanding cranially and dislocating the left eye, resulting in proptosis and diplopia. Both patients underwent incisional biopsy that did not disclose the malignant nature of the tumors. Clinical evaluation resulted in suspicion of malignancy and surgical excision was performed. RESULTS: The tumors were found to be consistent with EBV-positive peripheral T-cell lymphoma. CONCLUSIONS: Peripheral T-cell lymphoma is uncommon but a diagnosis to be considered in a patient with a tumorous lesion in the eye region. Furthermore, peripheral T-cell lymphoma may be EBV-positive.

Loop diathermy or laser excisional conization for cervical intraepithelial neoplasia.

BACKGROUND: Cervical intraepithelial neoplasia (CIN) can be managed by ablative or excisional procedures. We have compared the excision time, effectiveness, and safety of loop diathermy (loop) against laser conization. METHODS: In a prospective study in two hospital departments 222 women were randomized to loop or laser conization. Data were collected by questionnaires after operation and at two follow-up examinations. RESULTS: At department A (122 women), two physicians performed 27% of the loop and 35% of the laser excisions; at department B (100 women), the corresponding figures were 69% and 59%. Loop was quicker than laser conization in both departments (median 3-4 min versus 10-20 min), while laser conization was more time consuming in department A (median A/B = 20/10 min). Peroperative bleeding dominated during the laser procedure in both departments and complicated the loop procedure more frequently in department A. Postoperative bleeding occurred with equal frequency in the four groups (41.8%, 52.7%, 59.2%, 64.7%). At both departments, bleeding for more than two weeks was reported twice as often after laser conization (A:13.8%, B:24.2%), when compared to loop excision (A:7.1%, B:13.7%). Residual CIN was found in all of three re-conizations and in one of eight hysterectomy specimens. CONCLUSIONS: Loop was quicker than laser excision, per- and postoperative bleeding diminished, and the success rates were comparable. Physicians mastered Loop excision after a few attempts. However, the results improved, when performed by a restricted number of physicians. Histological incomplete excision indicates close colposcopic and cytologic follow-up to identify residual CIN.

Fatal virus-associated hemophagocytic syndrome associated with coexistent chronic active hepatitis B and acute hepatitis C virus infection.

A 28-year-old man was admitted to our department with intermittent fever, hepatosplenomegaly and pancytopenia. Liver parameters and serum ferritin were markedly elevated. Bone marrow biopsy showed hypocellularity, histiocytic hyperplasia, and hemophagocytosis consistent with a virus-associated hemophagocytic syndrome (VAHS). There was serological evidence of chronic active hepatitis B and acute hepatitis C virus infection. The patient died despite aggressive immunosuppressive and supportive treatment. Autopsy revealed signs of acute viral hepatitis with cholestasis. Histiocytes engaged in hemophagocytosis were observed in bone marrow and spleen. The condition was interpreted as VAHS associated with chronic active hepatitis B and acute hepatitis C virus infection. To our knowledge this is the first report of a hemophagocytic syndrome in that setting.

[Sentinel node diagnostics in malignant melanoma]. / "Sentinel node"-diagnostik ved malignt melanom.

New trial have shown that immediate regional lymph node dissection offers increased survival in patients with regional lymph node metastases only. Introduction of isotope technique to identify the first node, the sentinel node (SN), receiving lymph from a tumour area has made it possible to avoid node dissection in SN metastasis negative patients. The feasibility of the technique is illustrated by to examples.

Expression of polypeptide GalNAc-transferases in stratified epithelia and squamous cell carcinomas: immunohistological evaluation using monoclonal antibodies to three members of the GalNAc-transferase family.

Mucin-type O-glycosylation is initiated by a large family of UDP-GalNAc: polypeptide N -acetyl-galactosaminyltransferases (GalNAc-transferases). Individual GalNAc-transferases appear to have different functions and Northern analysis indicates that they are differently expressed in different organs. This suggests that O-glycosylation may vary with the repertoire of GalNAc-transferases expressed in a given cell. In order to study the repertoire of GalNAc-transferases in situ in tissues and changes in tumors, we have generated a panel of monoclonal antibodies (MAbs) with well defined specificity for human GalNAc-T1, -T2, and -T3. Application of this panel of novel antibodies revealed that GalNAc- transferases are differentially expressed in different cell lines, in spermatozoa, and in oral mucosa and carcinomas. For example, GalNAc-T1 and -T2 but not -T3 were highly expressed in WI38 cells, and GalNAc-T3 but not GalNAc-T1 or -T2 was expressed in spermatozoa. The expression patterns in normal oral mucosa were found to vary with cell differentiation, and for GalNAc-T2 and -T3 this was reflected in oral squamous cell carcinomas. The expression pattern of GalNAc-T1 was on the other hand changed in tumors to either total loss or expression in cytological poorly differentiated tumor cells, where the normal undifferentiated cells lacked expression. These results demonstrate that the repertoire of GalNAc-transferases is different in different cell types and vary with cellular differentiation, and malignant transformation. The implication of this is not yet fully understood, but it suggests that specific changes in sites of O-glycosylation of proteins may occur as a result of changes in the repertoire of GalNAc-transferases.

BEAM+autologous stem cell transplantation in malignant lymphoma: 100 consecutive transplants in a single centre. Efficacy, toxicity and engraftment in relation to stem-cell source and previous treatment.

One hundred consecutive patients with malignant lymphoma treated with high-dose chemotherapy and autologous stem cell transplantation, followed at least 1 yr post-transplant, are reported, 68 with non-Hodgkin's lymphoma and 32 with Hodgkin's disease. At transplant, 23 patients were in first remission, 69 in later chemosensitive disease and 8 were chemotherapy resistant. Based on previous treatment and stem-cell source, the patients were subdivided into 3 cohorts: BMT1: bone-marrow harvest and transplant after > or =3 treatment regimens (38 patients); BMT2: bone marrow harvest and transplant after less than 3 treatment regimens (24 patients); PBSCT: peripheral-blood stem cell transplant (38 patients, 5 of these with CD34+ cell selected PBSC). The 4-yr survival and progression-free survival of all patients was 45 and 40%, respectively. Forty-one patients have died, 27 of lymphoma, evenly distributed in the cohorts. Fourteen treatment-related deaths occurred, 13 of these in the BMT1 cohort, significantly more than in the other cohorts (p=0.001). In univariate survival analysis cohort, age, disease status at transplant and number of previous treatment regimens were significant. In multivariate survival analysis cohort, age and sex were independently significant, women having a shorter survival. The patients transplanted with unselected PBSC had significantly shorter duration of pancytopenia and hospital stay than the otherwise comparable BMT2 patients, but their progression-free survival was identical. We confirm that high-dose therapy with autologous stem cell transplant from blood or bone marrow in not-too-heavily pretreated patients is a safe procedure but will cure only half the patients.

Combined bilateral submandibular and sublingual swelling, macroglossus, and carpal tunnel syndrome caused by light chain amyloidosis.

Three cases of light chain kappa amyloidosis in multiple myeloma patients are described with remarkable involvement of the tongue and swelling of the sublingual and submandibular regions, and without signs of nephropathy despite Bence Jones kappa proteinuria. All three patients had carpal tunnel syndrome at the beginning of their disease course and only moderate gastrointestinal involvement. Primarily for prognostic reasons, amyloidosis should be suspected in such cases, even in the presence of these highly unusual manifestations, and the diagnosis should be confirmed by unambigously-positive biopsies.

Transesophageal multiplane imaging of the human pulmonary artery: a comparison of MRI and multiplane transesophageal two-dimensional echocardiography.

OBJECTIVE: To evaluate the anatomical relationship between the esophagus and pulmonary artery including assessment of the correct transesophageal Doppler insonation angle into the mid-pulmonary artery trunk. METHODS: We evaluated the anatomical relationship between the esophagus and pulmonary artery (PA) from comparable magnetic resonance (MR) and transesophageal echocardiographic (TEE) multiple two-dimensional images (0 degree, 45 degrees, 90 degrees and 135 degrees clockwise rotation of the standard transverse scanning plane when seen bearfrom the esophagus) obtained in 10 healthy, young volunteers. RESULTS: The main PA could be visualized with both techniques in all 10 volunteers and provided highly identical images of good quality. A mean insonation angle of 35 degrees (range 26 degrees-46 degrees) for a fictive esophageal Doppler beam into the main PA was disclosed. The PA trunk was short with a mean length of 23.4 mm (range 17-30 mm). CONCLUSIONS: These anatomical data contradict the general assumption of alignment of the pulmonary artery and the transesophageal Doppler beam. Angle correction should be applied in the clinical setting using MTEE by rotation of the scanning plane to approximately 45 degrees. Ignoring the insonation angle of approximately 35 degrees may cause 20% underestimation of blood flow velocity and cardiac output in the PA.

Carcinomas occurring in papillomas of the nasal septum associated with human papilloma virus (HPV).

Carcinomas arising in pre-existing sinonasal papillomas of the nasal septum are rare. To our knowledge only one case has been reported. We report two cases of carcinomas occurring in septal papillomas. In the first case a carcinoma developed in an exophytic papilloma 16 years after the first operation for a papilloma. In the second case a carcinoma was present at the first presentation within an inverted papilloma, and a metastasis had also developed. In the first case HPV type 6/11 was demonstrated by in-situ hybridisation and PCR in the original papilloma as well as in the recurrent papilloma and in the carcinoma. In the second case HPV type 18 was found in the nasal lesion as well as in the metastasis. All samples were examined for Epstein-Barr virus (EBV) by PCR, but with negative results. We believe that case one is the first reported case of carcinomatous transformation within an exophytic septal papilloma.

[Percutaneous dilatation tracheostomy. A preliminary study]. / Perkutan dilatationstrakeostomi. En proeliminoer undersøgelse.

Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study. The median time for insertion of the tracheostomy tube was 13.1 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period complications included one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion. Our preliminary results indicate that the technique as performed with the Ciaglia Introducer Set is effective and safe with only minor complications. Furthermore, we now use it as a bed-side procedure in the ICU, thus avoiding the transportation of critically ill patients to the operating theatre. A conclusion on the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies including more patients.

Elevated ambulatory blood pressure in microalbuminuric IDDM patients is inversely associated with renal plasma flow. A compensatory mechanism?

OBJECTIVE: To evaluate the relationship between renal function, ambulatory blood pressure (AMBP), and glycemic control in microalbuminuric IDDM patients compared with normoalbuminuric patients. RESEARCH DESIGN AND METHODS: Nineteen male patients (age 33 +/- 6 years) with slight microalbuminuria (UAE 20-70 micrograms/min) were compared with 19 normoalbuminuric (UAE < 15 micrograms/min) age-matched (33 +/- 6 years) male patients. Through constant infusion technique, 125I-iothalamate marked the glomerular filtration rate (GFR), and 131I-hippuran marked effective renal plasma flow (RPF). AMBP was measured by oscillometric technique (Spacelabs 90202). RESULTS: The microalbuminuric group had higher daytime systolic AMBP (132 +/- 11 vs. 125 +/- 7 mmHg, P < 0.05) and a poorer glycemic control (HbA1c 9.5 +/- 1.5 vs. 8.2 +/- 1.3%, P < 0.01). GFR (135 +/- 22 and 135 +/- 17 ml/min) and RPF (598 +/- 112 and 542 +/- 98 ml/min) were similar in the two groups. In the microalbuminuric group, daytime systolic AMBP was inversely correlated to both RPF (r = -0.77, P < 0.005) and GFR (r = -0.53, P = 0.02). HbA1c and GFR correlated positively in the microalbuminuric group (r = 0.47, P < 0.04). In contrast, the normoalbuminuric patients exhibited no such associations. CONCLUSIONS: IDDM patients with moderate microalbuminuria have elevated AMBP and a strong negative association between AMBP and RPF. This leaves several possibilities of interpretation. Primary blood pressure increase (of unknown origin) may induce morphological changes leading to reduction in renal function. Alternatively, blood pressure increase early in the course of incipient nephropathy may represent a compensatory mechanism, initially aiming at preservation of renal function, but later becoming maladaptive.

Effect of felodipine on renal function and vasoactive hormones in infrarenal aortic surgery.

We have examined the possible renoprotective effect of felodipine 5 mg orally, given daily for 5 days before operation, in 29 patients undergoing elective infrarenal aortic surgery in a randomized, blinded and placebo-controlled study. Effective renal plasma flow (ERPF), glomerular filtration rate (GFR), urine output, fractional sodium clearance and plasma concentrations of angiotensin II, aldosterone, arginine vasopressin and atrial natriuretic peptide did not differ between the felodipine and placebo groups. ERPF and GFR were not reduced after operation in the placebo group. In the felodipine group, GFR was higher 24 h after operation compared with before operation. We conclude that increased GFR in the felodipine group, measured 24 h after operation, may indicate a beneficial effect of felodipine but in the present context this was not clinically important. Felodipine had no significant effect on vasoactive hormones.

Percutaneous dilatational tracheostomy.

METHODS: Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study. RESULTS: The median time for insertion of the tracheostomy tube was 13.9 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period, complications were one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion. CONCLUSIONS: Our preliminary results indicate the technique as performed with the Ciaglia Introducer Set to be effective and safe with only minor complications. Furthermore, we now use it as a bedside procedure in the ICU, thus avoiding the transportation of critically ill patients to the operating theatre. The conclusion of the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies, including more patients.

[BiPAP (Biphasic Positive Airway Pressure)--an apparatus for non-invasive respiratory support]. / BiPAP--et apparat til ikkeinvasiv respiratorisk støtte.

Ventilatory support to patients suffering from respiratory insufficiency using a non-invasive technique has gained increasing popularity during the last few years. BiPAP (biphasic positive airway pressure) (Respiconics) offers inspiratory support and expiratory resistance to this group of patients both in the hospital and, in particular, in the home. The apparatus has proven to be effective as for instance a long term support device for patients suffering from neuromuscular diseases, sleep apnoeas and during the postoperative period. It works without pressurized air and is portable.