The impact of the number of lymph node metastases on the overall recurrence of colon cancer in the era of sentinel lymph node mapping

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Background: Sentinel Lymph Node Mapping (SLNM) in colon Cancerc (Cca) has been shown to be successful, sensitive and accurate. We aimed to evaluate the recurrence rates in patients(pts) with Cca after SLNM and correlate it to the number of positive(+ve) LNs. Methods: Between 1996 and 2006, pts diagnosed with Cca were enrolled in a prospective trial and underwent SLNM and oncologic resection including regional LNs. The primary outcome was development of recurrence with minimum follow-up (f/u) of 24 months. For recurrence analysis, exclusion criteria included: stage IV disease, benign pathology, lost to follow-up, refusal of indicated chemotherapy, non cancer related death or second cancer. A retrospective matched control (diagnosed with Cca undergoing standard colon resection without SLNM, gp B) from our own institution were analyzed and compared to the SLNM group for the same period. Results: A total of 486 pts with Cca were included. Of these, 272 consecutive pts underwent SLNM between 1996–2006. SLNM was successful in 99.8% of pts, with a sensitivity, negative (-ve) predictive value, and overall accuracy of 85.3%, 91.7% and 94.4% respectively. The nodal positivity was 46.0%; of these, 15.1% had micrometastasis. The average number of LNs resected / pt was 15.0 and the average number of SLNs / pt was 2.4. For recurrence analysis, 153/272 pts with minimum f/u 2 years were included. Of these, 49 had stage I, 46 had stage II and 58 had stage III disease. The recurrence rates were 4.1%, 8.6% and 15.5% in stage I, II, and III disease respectively. The recurrence rates were significantly lower when our 153 pts were compared to 214 matched controls ( table 1 ). The recurrence rates increased from 6.3% in pts with no +ve LNs to 11.5% when one LN was +ve, 16.7% when 2 LNs were +ve and 20% when 3 or more LNs were +ve. Conclusions: SLNM in Cca is associated with decreased rates of recurrence as compared to conventional therapy. The number of positive LNs is an independent risk factor for recurrence.

[Table: see text]

No significant financial relationships to disclose.

Unusual case of ruptured sinus of Valsalva: rupture into left ventricle cavity along with distortion of mitral valve requiring double valve replacement

We report a rare case of sinus of Valsalva aneurysm of left aortic sinus, which was bulging into left atrium (LA) distorting mitral valve and rupture into the left ventricle with severe aortic regurgitation in a 25 years old male patient. Due to the rupture, both aortic and mitral valves were irreparable and required a double valve replacement along with the closure of the neck of the aneurysmal cavity occupying the left atrial roof.

"Tuck In" Lamellar Keratoplasty (TILK) for corneal ectasias involving corneal periphery

AIMS

Evaluation of a new surgical technique for the management of corneal ectasia with peripheral corneal involvement.

METHODS

Twelve eyes of 12 patients with corneal ectasias and peripheral corneal thinning requiring surgical intervention, including eight patients with combined keratoconus and PMD and four patients of keratoglobus, were enrolled for the study in a tertiary care hospital. All patients were contact lens intolerant and had a best corrected visual acuity (BCVA) </=20/120 with nine patients (75%) having BCVA </=20/200. "Tuck In" Lamellar Keratoplasty (TILK) that included a central lamellar keratoplasty with intrastromal tucking of the peripheral flange was performed in these patients. The main outcome measures analysed were uncorrected visual acuity (UCVA), BCVA, keratometry, refractive status and time for epithelial healing.

RESULTS

At the last follow-up (mean: 1.7 years (range 13-48 months)), six patients (50.0%) had BCVA >/=20/60, and all patients had BCVA >/=20/80. The mean keratometry decreased from 57.54 (SD 6.89) D preoperatively to 46.36 (2.39) D (p = 0.003), and the mean spherical equivalent (SEQ) refractive error decreased from -7.8 (4.6) D preoperatively to 1.23 (1.88) D (p = 0.007). A significant decrease was also seen in mean refractive astigmatism which decreased from 5.93 (3.06) D preoperatively to 3.23 (1.14) D (p = 0.037).

CONCLUSION

Our technique of TILK is an effective surgical modality for the management of ectatic corneal dystrophies with peripheral corneal thinning.

Traumatic abdominal wall herniation

Most reported cases of traumatic abdominal wall herniation result from seatbelt or handlebar injuries. The diagnosis is often made on physical examination or abdominal computed tomography (CT). We report a 59-year-old man with traumatic herniation through the rectus muscle following low-velocity blunt abdominal trauma. This patient was initially thought to have a rectus sheath haematoma and initial CT showed a soft tissue haematoma over the left lower anterior abdominal wall but no herniation. The traumatic herniation was diagnosed four days later, and confirmed on CT. Intraoperatively, a segment of the sigmoid colon was found to have herniated through the rectus defect and was gangrenous with impending perforation. A left hemicolectomy followed by primary repair of the defect was done. This case highlights the need for a high index of suspicion for traumatic herniation in patients who sustain low-velocity blunt abdominal wall trauma even when initial CT scans are negative.

Cortical visual function in the rd12 mouse model of Leber Congenital Amarousis (LCA) after gene replacement therapy to restore retinal function

One eye of rd12 mice received a sub-retinal injection of a vector carrying normal human RPE65 cDNA at post-natal day 18, and at 6- and 13-months of age. Electroretinograms (ERGs) and visual-evoked potentials (VEPs) were recorded to luminance, and to spatially and temporally modulated stimuli to assess the consequences of delayed treatment on visual pathway function. Early treatment resulted in better overall retinal rescue and better rescue of cone-mediated function. VEPs to low temporal frequency luminance modulation were well preserved at all but the oldest treatment age and corresponded to predictions based on the amount of retinal rescue. In contrast, VEPs to high frequency spatially and temporally modulated stimuli were impaired even at the earliest age. These results provide further support that early treatment in human LCA will have the most hope for optimal visual performance.

Epidemiologic classification of seizures associated with neurocysticercosis: observations from a sample of seizure disorders in neurologic care in India

AIMS

To determine the etiologic role of neurocysticercosis (NC) in a hospital-based sample of epilepsies divided according to International League Against Epilepsy (ILAE) epidemiological criteria and number of seizures prior to presentation.

METHODS

A sample comprising 1026 consecutive patients with either definite seizures or epilepsy attending a Neurology Outpatient Service was divided into four subgroups: single seizure (n = 314), incident epilepsy (n = 127), prevalent epilepsy (n = 398) and recurrent acute symptomatic seizures (RASS) (n = 175). The etiologic contribution of NC to each of the subgroups was examined with imaging studies.

RESULTS

Neurocysticercosis was diagnosed on imaging studies in 34.6% of patients with seizure disorder of any type, 59.2% of those with a single seizure, 23.7% of those with recurrent seizure disorder, 92.0% of those with RASS, none of cases of incident epilepsy and 2.0% with prevalent epilepsy. A diagnosis of NC was significantly associated with single seizures (P < 0.001).

CONCLUSIONS

Imaging abnormalities consistent with NC are frequently noted in persons presenting with a single seizure in neurologic care in NC-endemic countries like India. The probability of diagnosing NC diminishes with increasing numbers of seizures. Among samples of individuals with recurrent-unprovoked seizures, it is rare for imaging to demonstrate lesions of NC.

Cutaneous reactions in patients with solitary cysticercus granuloma on phenytoin sodium

Several medical conditions are believed to be associated with an increased risk of cutaneous adverse reactions to anti-epileptic drugs. The aim of this study was to study the frequency and nature of cutaneous reactions in a cohort of patients being treated with phenytoin sodium for seizures, who were divided into those with a solitary cysticercus granuloma (SCG) and those with a condition other than SCG, to determine if the presence of SCG increases the risk of cutaneous adverse reaction to phenytoin. A cohort of 117, consecutively begun on treatment with phenytoin for seizure control, were followed up prospectively for the development of cutaneous reactions. There were 63 patients with SCG upon imaging and 54 patients to whom phenytoin was administered for seizures due to causes other than SCG or multiple neurocysticercosis. Cutaneous reactions were significantly more common (p = 0.02) in patients with SCG (9/63 patients; 14.3%) than in controls (2/54 patients; 3.7%). The spectrum of skin reactions in patients with SCG included benign skin rash (n = 3), anticonvulsant hypersensitivity syndrome (n = 4), Stevens-Johnson syndrome (n = 1), and urticaria (n = 1). Individuals with seizures due to SCG have a high incidence of cutaneous adverse reactions to phenytoin. This fact should be kept in mind when initiating them on treatment with this anti-epileptic drug.

Role of phospholipid transfer protein in rabbit lung development

A 36-kDa phospholipid transfer protein (PLT-P(R)), which preferentially transfers phosphatidyl choline (PC) compared to phosphatidyl inositol (PI), was purified 827-fold from rabbit lung homogenate. Incorporation of cholesterol in unilamellar vesicles reduced the PC transfer activity of PLTP(R). Dipalmitoyl phosphatidyl choline uptake by alveolar type II cells was increased in the presence of the protein, and further enhanced in the presence of surfactant liposomes. However, a decrease in uptake was noted with cholesterol in host membranes. Incorporation of PI into host membranes had a low stimulatory effect on the process. All these effects were more pronounced in adult type II cells compared to premature, term and 3-day-old pups.

Clathrin exchange during clathrin-mediated endocytosis

During clathrin-mediated endocytosis, clathrin-coated pits invaginate to form clathrin-coated vesicles (CVs). Since clathrin-coated pits are planar structures, whereas CVs are spherical, there must be a structural rearrangement of clathrin as invagination occurs. This could occur through simple addition of clathrin triskelions to the edges of growing clathrin-coated pits with very little exchange occurring between clathrin in the pits and free clathrin in the cytosol, or it could occur through large scale exchange of free and bound clathrin. In the present study, we investigated this question by studying clathrin exchange both in vitro and in vivo. We found that in vitro clathrin in CVs and clathrin baskets do not exchange with free clathrin even in the presence of Hsc70 and ATP where partial uncoating occurs. However, surprisingly FRAP studies on clathrin-coated pits labeled with green fluorescent protein-clathrin light chains in HeLa cells show that even when endocytosis is blocked by expression of a dynamin mutant or depletion of cholesterol from the membrane, replacement of photobleached clathrin in coated pits on the membrane occurs at almost the same rate and magnitude as when endocytosis is occurring. Furthermore, very little of this replacement is due to dissolution of old pits and reformation of new ones; rather, it is caused by a rapid ATP-dependent exchange of clathrin in the pits with free clathrin in the cytosol. On the other hand, consistent with the in vitro data both potassium depletion and hypertonic sucrose, which have been reported to transform clathrin-coated pits into clathrin cages just below the surface of the plasma membrane, not only block endocytosis but also block exchange of clathrin. Taken together, these data show that ATP-dependent exchange of free and bound clathrin is a fundamental property of clathrin-coated pits, but not clathrin baskets, and may be involved in a structural rearrangement of clathrin as clathrin-coated pits invaginate.

Ultrastaging of colorectal cancer by sentinel lymph node mapping technique--a multicenter trial

Sentinel lymph node (SLN) mapping accurately diagnoses the status of nodal basin with >95% accuracy in melanoma and breast cancer. A multicenter trial for SLN mapping was performed on 203 patients with colorectal cancer to determine accuracy, upstaging, skip metastasis, and aberrant drainage. Lymphazurin 1% was injected subserosally around the tumor and 1-4 blue staining nodes were marked as SLNs for detailed histological analysis. SLN mapping was successful in 98% of patients with an average of 1.7 SLNs per patient. SLNs were negative in 63% of the patients and positive in 37% of the patients. Skip metastasis was seen in 8 of the patients. Occult micrometastasis was found in 14% of patients. In 5% of the patients, unusual lymphatic drainage lead to an alteration of the extent of lymphadenectomy. This multicenter trial proved that SLN mapping in patients with colorectal cancer is simple, cost effective, and upstages at least 14% of patients from AJCC stage I/II to stage III. These patients may then benefit from adjuvant chemotherapy.

Aortic valve endothelial cells undergo transforming growth factor-beta-mediated and non-transforming growth factor-beta-mediated transdifferentiation in vitro

Cardiac valves arise from endocardial cushions, specialized regions of the developing heart that are formed by an endothelial-to-mesenchymal cell transdifferentiation. Whether and to what extent this transdifferentiation is retained in mature heart valves is unknown. Herein we show that endothelial cells from mature valves can transdifferentiate to a mesenchymal phenotype. Using induction of alpha-smooth muscle actin (alpha-SMA), an established marker for this process, two distinct pathways of transdifferentiation were identified in clonally derived endothelial cell populations isolated from ovine aortic valve leaflets. alpha-SMA expression was induced by culturing clonal endothelial cells in medium containing either transforming growth factor-beta or low levels of serum and no basic fibroblast growth factor. Cells induced to express alpha-SMA exhibited markedly increased migration in response to platelet-derived growth factor-BB, consistent with a mesenchymal phenotype. A population of the differentiated cells co-expressed CD31, an endothelial marker, along with alpha-SMA, as seen by double-label immunofluorescence. Similarly, this co-expression of endothelial markers and alpha-SMA was detected in a subpopulation of cells in frozen sections of aortic valves, suggesting the transdifferentiation may occur in vivo. Hence, the clonal populations of valvular endothelial cells described here provide a powerful in vitro model for dissecting molecular events that regulate valvular endothelium.