Level III dissection in locally advanced breast cancer following neoadjuvant chemotherapy: a retrospective study

INTRODUCTION

Breast cancer is the most common female cancer in India, and 30-60% of patients present with locally advanced breast cancer. Level III clearance is routinely performed in India in locally advanced breast cancer following neoadjuvant chemotherapy, even in clinical complete response. We analysed our data of patients with locally advanced breast cancer post-neoadjuvant chemotherapy who have undergone level III clearance to identify any subgroup in which level III dissection can be avoided.

MATERIAL AND METHODS

This is a retrospective study of female patients with locally advanced breast cancer who received neoadjuvant chemotherapy and underwent breast surgery including level III nodal clearance between June 2016 and May 2018. Data collected included age, menopausal status, TNM stage at presentation, grade, estrogen, progesterone, human epidermal growth factor receptor 2 status, response to treatment, post-chemotherapy stage and final histopathology. Uni- and multivariate analysis was undertaken.

RESULTS

Data from 200 patients was analysed. The level III positivity rate was 15.5%. The clinical complete response rate was 43%, of which 41% had pathological complete response. A significant association was present between level III node positivity and pathological T stage (p=0.03). No association was seen between level III positivity and any other studied variables. In the subset of patients with cT3N1 and cT2N2, level III positivity was seen in only 3/49 (6.1%) and 1/31 (3%), respectively.

CONCLUSION

Level III positivity rate is high and so cannot be avoided in locally advanced breast cancer following neoadjuvant chemotherapy. None of the preoperative factors predict for level III positivity. Level III positivity in cT3N1 and cT2N2 is low and these subgroups require further studies.

Anorectal melanoma: experience from a tertiary cancer care centre in South India

Introduction Mucosal malignant melanoma of the anorectum is a rare and aggressive disease, in which early diagnosis is difficult. The prognosis remains extremely poor, irrespective of the treatment. We share our experience in treating this malignancy at our centre in South India. Methods This study describes a retrospective analysis of 31 cases of anorectal melanoma presented to our centre between January 2001 and December 2013. Results Twenty-two patients (71%) presented with metastasis and had a median overall survival of nine months. None of the 22 patients survived for two years. Nine patients (29%) had curative surgery, in the form of abdominoperineal resection (six patients), abdominoperineal resection with bilateral inguinal node dissection (one patient), abdominoperineal resection with liver resection (one patient) and posterior exenteration (one patient). In patients who underwent curative surgery, the median overall survival was 15 months and disease-free survival was nine months, with a two-year overall survival of 22%. Conclusions Anorectal melanoma is an aggressive disease with a poor prognosis. The majority of patients present with distant metastases. Prognosis depends on stage at presentation. Early diagnosis and surgical resection may improve the overall outcome. Newer modalities such as immunotherapy and targeted therapies such as anti-CTLA4 monoclonal antibody and anti-programmed cell death protein 1 monoclonal antibodies have radically changed the management of mucosal melanoma and may, in the future, improve the overall prognosis of anorectal melanoma.

Prevalence of oral lesions of autoimmune etiology in patients with primary Sjogren's syndrome

OBJECTIVE

The primary objective of this study was to determine the prevalence of oral lesions of autoimmune etiology (OLAIE) in a cohort of patients with primary Sjögren's syndrome (pSS).

MATERIALS AND METHODS

A multi-center retrospective cohort study was conducted at the oral medicine practices of Carolinas Medical Center (CMC), Baylor College of Dentistry (BCD), and the University of Florida (UF). Each site performed a chart review of patients with well-characterized pSS. Clinical variables such as OLAIE, traumatic lesions, and medical conditions were compiled at each site. The association between clinical variables and the presence of OLAIE was then assessed for significance.

RESULTS

We evaluated 155 patients diagnosed with pSS. Nineteen patients with pSS (12.3%) had an OLAIE. CMC reported 11 (21.2%) patients with OLAIE, while BCD and UF reported 4 (7.3%) and 4 (8.3%), respectively. Eleven of the 19 (58%) patients with OLAIE had lichen planus, 6 (32%) had aphthous stomatitis, 1 (5%) had chronic ulcerative stomatitis, and 1 (5%) had lesions of systemic connective tissue disease by immunofluorescence.

CONCLUSION

The results of our analysis suggest that patients with pSS have a 12% prevalence of OLAIE with a wide range (7.3-21.2%) found between practices. This difference is likely related to the different screening protocols for oral dryness between sites.

Factor V Leiden mutation: An added risk in single ventricle palliation

We present the case report of a child with Factor V Leiden mutation who underwent Fontan procedure. Thromboembolism is a widely recognized complication of the Fontan procedure and its modifications. Factor V Leiden mutation, being a hypercoagulable state, posed a higher risk for thromboembolism in this child. Appropriate measures taken before and after surgery prevented postoperative coagulopathy.

Myocardial ischemia following arterial switch operation: An uncommon etiology

Myocardial ischemia following arterial switch operation (ASO) usually occurs due to coronary ostial narrowing that might result from technical failure in translocation of the coronary arteries to the neoaorta. We present an unusual case report of neonatal myocardial ischemia caused by coronary steal secondary to aortopulmonary collaterals, following ASO in transposition of great arteries.

Rat renal proximal tubular gluconeogenesis: possible involvement of nonmitochondrial carbonic anhydrase isozymes

The carbonic anhydrase (CA) inhibitor ethoxzolamide decreases the rate of glucose synthesis from 10 mM pyruvate by tubules incubating in 25 mM HCO3- but not in 50 mM HCO3-: this is evidence that rat renal cortical mitochondrial CA (CA V) provides HCO3- for pyruvate carboxylation in renal tubular gluconeogenesis at physiological total CO2 (CO2 + HCO3-). In renal proximal tubules prepared from 48-h-starved rats and incubating in 10 mM pyruvate in 25 mM HCO3- buffered saline (Krebs-Henseleit buffer) the CA inhibitors acetazolamide (AZ) and benzolamide (BZ) decreased the rate of glucose synthesis. Maximal inhibition was reached with 125 microM AZ or with 450 microM BZ. The rate of glucose synthesis increased with increasing pyruvate concentration from 3.33 to 20 mM; including 600 microM BZ or 188 microM AZ results in glucose synthesis becoming independent of increasing pyruvate concentration. Doubling the physiological concentration of bicarbonate restored the dependence of glucose synthesis on pyruvate concentration and partly, but not completely, alleviated the inhibitory effect of AZ and BZ, leading to the conclusion that AZ and BZ influence gluconeogenesis by affecting enzymes in addition to CA V. Tubules were incubated with substrates which do not require pyruvate carboxylation for synthesis of oxaloacetate. When tubules were incubated in 10 mM malate the rate of glucose synthesis was unaffected by less than 100 microM AZ or 400 microM BZ and was decreased maximally by 40 and 20%, respectively, by 125 microM AZ, 450 microM BZ, and higher concentrations of these drugs. Increasing the malate concentration from 3.33 to 20 mM increased the rate of glucose synthesis; 600 microM BZ inhibited the rate of glucose synthesis only when the malate concentration was greater than 10 mM but 188 microM AZ decreased the rate of glucose synthesis at each concentration of malate. Results were similar when tubules were incubated in glutamine with CA inhibitors. The rate of glucose synthesis differed with the substrate metabolized and the substrate concentration except when 600 microM BZ was included.(ABSTRACT TRUNCATED AT 400 WORDS)

Mitochondrial carbonic anhydrase is involved in rat renal glucose synthesis

At 37 degrees C, pH 7.4, carbonic anhydrase activity (kenz) of disrupted rat renal proximal tubules and cortical mitochondria was 2.5 +/- 0.8 (n = 3) and 0.15 +/- 0.40 (n = 3) ml.mg-1.s-1, respectively. Turnover number for renal mitochondrial carbonic anhydrase (CA V) was 24,000 s-1. CA V activity of intact mitochondria was completely inhibited by 0.15 microM ethoxzolamide (EZ). Intact proximal tubules, prepared from 48-h starved male rats, were incubated at 37 degrees C in 10 mM pyruvate in Krebs-Henseleit bicarbonate saline buffer, 5% CO2-95% O2. The rate of glucose synthesis over 60 min was reduced 50% by including 0.6 microM EZ in the incubation solution. The concentration of NaHCO3 was doubled to 50 mM (with a corresponding decrease in NaCl) and the solution gassed with 10% CO2-90% O2; 2.4 microM EZ no longer decreased glucose synthesis. It was concluded that inhibition of glucose synthesis by EZ was directly a result of inhibiting the carbonic anhydrases. The rate of glucose production was subsequently determined with tubules incubating in a HCO3(-)-free N-2-hydroxyethylpiperazine-N'-2-ethane-sulfonic acid (HEPES) buffer; this rate was decreased 50% by 0.6 microM EZ. These data support the hypotheses that CA V provides HCO3- for pyruvate carboxylase and that CO2 can be provided by tubular metabolism. Intact tubules were incubated in from 5 to 20 mM pyruvate in either 25 or 50 mM HCO3-; in either buffer, the rate of glucose synthesis was similar, increasing with increasing pyruvate concentration. At no pyruvate concentration was there a change in the rate of glucose production when tubules were incubated in 50 mM HCO3- buffer with 1.6 microM EZ. These data also support the hypothesis that CA V provides the HCO3- substrate for pyruvate carboxylation when there is a high rate of intracellular CO2 production and external CO2 is low. It is further concluded that the cytosolic carbonic anhydrase (CA II) and the membrane-bound carbonic anhydrase (CA IV) are not involved in glucose synthesis from pyruvate.

Mutagenic activity of methyl- and fluoro-substituted derivatives of polycyclic aromatic hydrocarbons in a human hepatoma (HepG2) cell-mediated assay

Several series of methyl- and fluoro-substituted polycyclic aromatic hydrocarbon (PAH) derivatives were tested for mutagenic activity in cell-mediated assays with cells of the human hepatoma cell line, HepG2, as PAH activators. The mutagenic activity of dibenz[a,h]anthracene [DB(a,h)A] increased progressively with the substitution of a methyl group at one or both non-benzo bay-region sites. At a concentration of 0.25 micrograms/ml, the mutation frequencies induced by DB(a,h)A, and 7,14-diMeDB(a,H)A were 1.3, 13.1 and 59.0 6-thioguanine-resistant colonies/10(5) viable V79 cells, respectively. Methyl groups at non-benzo bay-region sites in 3-methylcholanthrene and benzo[e]pyrene had little effect on mutagenic activity at the highest concentration which could be tested (2 micrograms/ml). The presence of a fluorine atom on the bay-region A-ring of 7,12-dimethylbenz[a]anthracene (DMBA) drastically drastically reduced mutagenic activity. At a concentration of 1.0 micrograms/ml, the mutation frequencies induced by DMBA, 1-fluoro-DMBA and 4-fluoro-DMBA were 50.5, 6.8 and 1.6, respectively. On the other hand, the mutation frequency was increased 6-fold when the fluoro substituent was in the 10-position of the D-ring of DMBA. Thus, for the most part, the relative mutagenic activities of these compounds in the HepG2 cell-mediated assay paralleled their skin tumor-initiating activity in SENCAR mice reported earlier (DiGiovanni et al., 1982, 1983a, b). These studies demonstrate the value of the HepG2 cell line as an exogenous, intact human cell activation system in short-term assays designed to evaluate the genotoxic effects of PAHs.

Increased synthesis of aortic collagen and elastin in experimental atherosclerosis. Inhibition by contraceptive steroids

Rabbits were fed an atherogenic or normal control diet for 3 months; half of each group were treated with mestranol--norethynodrel (M--N) and half with cottonseed oil vehicle. At the end of the 3-month period rabbits were killed and aortic collagen and elastin synthesis determine. Collagen and elastin synthesis was increased in aortas of rabbits on an atherogenic diet, but those treated with M--N had a lower rate of collagen synthesis and less deposition of cholesterol in the aorta than those administered cottonseed oil. It is suggested that long-term administration of the contraceptive steroid combination may retard the progression of atherosclerosis through the hormone's effect on vascular connective tissue.

Increased vascular collagen and elastin synthesis in experimental atherosclerosis in the rabbit. Variation in synthesis among major vessels

Collagen and elastin synthesis was determined in 5 regions of the vascular system in rabbits on (a) normal diet and (b) atherogenic diet. Increased connective tissue synthesis was found in 3 different sections of the aorta and in the pulmonary artery of rabbits on the atherogenic diet. The inferior vena cava showed no difference between the two groups. Regional variation in connective tissue synthesis was found in both normal and atherosclerotic animals, the vessels associated with the greatest degree of pulsatile distention in vivo having the greatest synthesis and the inferior vena cava, a low pressure, low distention vessel having the lowest synthesis. It is concluded that the atherogenic process includes stimulation of collagen and elastin synthesis. It is suggested that in addition to the effect of pressure on connective tissue synthesis, pulsatile distention may be a factor in synthesis and may be related to lesion formation.

Pulsatile distention and vascular collagen synthesis in the rabbit

In rabbits, collagen synthesis was studied in five different regions of the vasuclar tree which are subjected to different degrees of pulsatile distention, i.e., cyclic stretching, and mean pressure. The vessels with greatest pulsatile distention had the highest specific activity of hydroxyproline in collagen after incubation with 14C-proline and the inferior vena cava with low pressure and negligible pulsatile distention had the lowest specific activity. The findings suggest a link between mechanical stretching and cellular metabolic function and have significance as to the relationship of pulsatile flow to normal vascular and organ physiology.

Tracheal injury following prolonged intubation

Prolonged respiratory assistance by positive pressure ventilation via cuffed tracheostomy or endotracheal tube can be complicated by mucosal erosions, tracheal stenosis, tracheomalacia, excavation of the tracheal wall with loss of tissue and tracheoesophageal fistula. Stenosis can occur at the subglottic region, at the stoma, or at the cuff site, whereas the other complications occur most often at the cuff site. This paper is concerned with complications occurring below the first tracheal ring.

The interaction of cationic liposomes containing entrapped horseradish peroxidase with cells in culture

Cationic liposomes composed of sphingomyelin, cholesterol, and stearylamine were prepared with horseradish peroxidase trapped inside. Stable particles were formed in which 10-12% of the enzymic activity appeared to be located at, or near, the outer surface of the liposome. Adsorption and uptake of liposomes by HeLa cells were followed cytochemically by electron microscopy and quantitated by enzyme assay and by the distribution and fate of particles labeled with [(14)C]cholesterol and [(125)I]horseradish peroxidase. The particles were adsorbed by HeLa cells at least 300 times as efficiently as was free horseradish peroxidase. Many of the particles remained at the cell surface, but numerous membrane-bound cytoplasmic inclusions were observed to contain peroxidase-staining material. In addition, many areas of the cell membrane gave a positive staining reaction. It was concluded that many particles (presumably the larger ones) did not gain access to the interior of the cells, many were phagocytized, and some enzyme was transferred to the cell membrane, perhaps as a result of fusion of the liposomal membrane with the cell membrane.