Sonographic correlations with the new molecular classification of invasive breast cancer.

Ultrasound is a useful adjunct to mammography for the characterisation and biopsy of solid breast lesions. Protein expression profiling of breast cancer has identified specific subgroups with potential clinical, biological and therapeutic implications. The aim of this study was to determine the ultrasound correlates of these novel molecular classes of invasive breast cancer. The ultrasound findings in 358 patients with operable breast cancer were correlated with the previously described protein expression classes identified by our group using immunohistochemical (IHC) assessment of a large series of breast cancer cases in which 25 proteins of known relevance in breast cancer were assessed, including hormone receptors, HER2 status, basal and luminal markers, p53 and e-cadherin. The proportion of occult lesions was not significantly different in the two groups. Significant differences were noted between the two groups expressing luminal epithelial markers and hormone receptors (1 and 2), including a greater proportion of ill-defined, irregular and distally attenuating tumours in group 2. Tumours characterised by c-erbB2/MUC1 expression, with weak hormone receptor positivity (group 3) were also more likely to be ill defined. Tumours expressing basal markers (group 5) were less likely to have an echogenic halo. The ultrasound features of breast cancer show areas of significant correlation with molecular classes of invasive breast cancer identified by IHC analysis. The biological reasons for these findings and their implications regarding imaging protocols require further study and may enable improved detection of these lesions.

Neural connections of hypothalamic neuroendocrine nuclei in the rat.

The secretion of many hormones, including oxytocin, vasopressin and growth hormone, is not constant but shows a day-night rhythm. The suprachiasmatic nucleus (SCN) is thought to generate most mammalian biological rhythms and previous studies have reported suprachiasmatic efferents to the paraventricular nucleus (PVN) and the supraoptic nucleus (SON). We used in vivo extracellular electrophysiological techniques to show that the SCN also sends direct and indirect neural projections to the arcuate nucleus (ARC). This projection consisted of both excitatory and inhibitory components and may contribute to the entrainment of the rhythm in growth hormone secretion to the day-night cycle. Some SCN neurones appear to project to both the SON and the ARC. The SCN in turn receives excitatory and inhibitory inputs from the ARC and the peri-nuclear zone of the SON (peri-SON), which may provide feedback information, as well as allowing nonphotic entrainment of the SCN, for example, in response to feeding. Our data thus suggest extensive two-way connections between the SCN and its target nuclei which may contribute to the generation of day-night neuroendocrine rhythms. They also suggest the existence of indirect retinal projections to the ARC and PVN. We further investigated the retinal projection to the SCN. We were unable to demonstrate a significant difference in retinal input to those suprachiasmatic cells which had efferent projections to particular hypothalamic targets (SON and/or ARC), and those which did not.

Review of surgical management of aldosterone secreting tumours of the adrenal cortex.

AIMS: To evaluate the investigation and surgical management of primary hyperaldosteronism. Retrospective case note analysis of thirty-three patients who underwent adrenalectomy for primary hyperaldosteronism between 1982 and 2001 and a current relevant literature review. METHODS: The records of twelve male and twenty-one female patients, age range 18 to 81 (mean 48 years) were reviewed. Eleven operations were performed by an open approach and twenty-two laparoscopically. Preoperative investigations included computed tomography (CT), magnetic resonance imaging (MRI), selective venous sampling and seleno-cholesterol isotope scanning, along with biochemical and hormonal assays. Twenty-six benign adenomas, three nodular hyperplastic lesions, one primary adrenal hyperplasia and three functional carcinomas were excised. Mean follow up was 12 months. RESULTS: Patients had a mean blood pressure of 185/107 mmHg for 6.2 years mean duration. The mean severity of hypokalaemia was 2.7 mmol/l. Sensitivity of CT scanning was 85%, and of MRI 86%. Fifty percent of seleno-cholesterol scans were accurate. Mean operating time was 158 min for laparoscopic adrenalectomy whilst open surgery took 129 min (p=0.2, NS). Two cases commenced laparoscopically required open access for control of primary haemorrhage whilst one other bleed was managed via the operating ports. Mean postoperative stay was significantly shorter for the laparoscopic group (3 days compared with 7.9 days, p<0.0001). Thirty day mortality was zero. There were three infective complications in the open group (two chest, one wound) with no postoperative complications in the laparoscopic group. All patients were cured of hypokalaemia, whilst 62% cure of hypertension was achieved. Of those patients whose blood pressure was improved preoperatively by spironolactone 78% were cured by adrenalectomy. Adrenalectomy led to an overall reduction in the mean number of anti-hypertensive medications (2.3 drugs preoperative to 0.6 postoperative, p<0.0001). Of those not cured, 58% had improved blood pressure control requiring less medication on average (1.6 drugs compared with 2.6 drugs, p=0.08). Mean age of patients not cured by surgery was 55 years, whilst those cured was 44 years (p=0.03). CONCLUSIONS: Primary hyperaldosteronism is a rare but important cause of hypertension. Selective venous sampling is a useful tool where investigations are inconclusive and fail to lateralise secretion. Patients with primary hyperaldosteronism enjoy lower complication rates and earlier discharge with the advent of laparoscopic surgery. Most patients will be cured of their hypertension and all of hypokalaemia. Laparoscopic adrenalectomy is now the accepted method of surgery for benign hyperaldosteronism. Those with bilateral disease due to idiopathic hyperaldosteronism (IHA) are not candidates for surgery and should be treated medically.

Isolated cerebral cortical tears in children: aetiology, characterisation and differentiation from non-accidental head injury.

A wide spectrum of intracranial injuries has been described as complicating difficult birth, particularly following instrumental delivery. We describe five children in whom isolated cortical tears were observed on MRI. Four cases were characterised by a difficult instrumental delivery. None of the children developed long-term neurological sequelae. As far as we are aware, isolated cerebral cortical tears have not been reported previously although recognition of this injury pattern is important because of its possible misinterpretation as a marker of a non-accidental head injury. Other differential diagnoses that should be considered include cerebral infarcts, schizencephaly and accidental head injury. The importance of high-quality cross-sectional brain imaging in newborn infants with seizures is emphasised.

Randomised controlled clinical trial of stapled haemorrhoidectomy vs conventional haemorrhoidectomy; a three and a half year follow up.

OBJECTIVE: This article presents the results of a three and a half year follow up of patients recruited to a randomised controlled clinical trial comparing circumferential mucosectomy (stapled haemorrhoidectomy) vs conventional haemorrhoidectomy. METHODS: Patients were assessed in an outpatient setting to examine a number of outcome measures. RESULTS: Our data suggest that at the three and a half year follow up, there are no significant differences in outcome between the two groups. CONCLUSIONS: It will be important to review the long-term results of larger trials.