Surgical management of rectal GIST. A case report and a review of literature

AIM

Rectal GIST is a rare tumor of the gastrointestinal tract. The few literature cases didn't show significant evidence about diagnostic and therapeutic management. We present a rare case of rectal GIST treated with laparoscopic anterior rectal resection (RARLs) preceded by neoadjuvant therapy with Imatinib Mesylate (IM).

CASE REPORT

A 68-year-old woman with abdominal pain, rectal bleeding and palpable mass on rectal exam has been subjected to computerized tomography (CT) of the abdomen and pelvis and magnetic resonance imaging (MRI) that revealed a rectal GIST of 5x4x2 cm at 3 cm from anal verge. The diagnosis was confirmed with colonoscopy. After 3- mounts neoadjuvant therapy with IM, which allowed to down-stage the neoformation, the patient underwent RARLs without intraoperative or postoperative complications. Immunohistochemistry revealed cluster of differentiation CD 117 positive, HPF 5/50, Ki 67overexpressed. PDGF mutation was detected. The patient was therefore taken in charge by the oncologist.

DISCUSSION AND CONCLUSION

Resection appear curative for rectal GIST. Extensive resections aren't necessary because of downstaging after IM therapy. However, the appropriate surgical technique is still debated. Further studies are necessary for a correct surgical standardization.

KEY WORDS

Rectal GIST, Cajal cell, Laparoscopic rectal resection, Imatinib.

Primary malignant melanoma of the bowel diagnosed following a bowel intussusception in an adult patient. A case report and review of the literatureport

AIM

Primary small bowel melanoma is a very rare clinical entity with a paucity of publications in literature. Most cases of gastrointestinal melanomas are metastatic lesions arising generally from primary lesion of the skin, eyes, or anus. We present a case of a small bowel intussusception with primary malignant melanoma as lead point and a gluteal melanoma metastasis after four years free from disease.

CASE REPORT

A 77-year-old female has come to our attention with signs and symptoms of intestinal occlusion. She was subjected to a computerized tomography (CT) of the abdomen and pelvis that revealed small bowel intussusception caused by intestinal polypoid lesion. She was treated with a bowel resection. The histological exam has shown the presence of an amelanocytic malignant melanoma. The examination of skin, eyes, esophagus, colon and anus, a tot al body contrast- enhanced CT and a bone scintigraphy were negative for primary melanoma. So, the final diagnosis was primary melanoma of the ileum. After four-years disease-free survival, the patient came back to our attention for a gluteal melanoma metastasis, that was surgically removed. Afterwards she started immunotherapy, that is still ongoing.

DISCUSSION AND CONCLUSION

The diagnosis and the treatment of primary intestinal melanoma is a challenging due to the lack of scientific indications. Our case shows how an early diagnosis, although accidental, can offer a good survival free from disease. Moreover, a careful follow-up of our patients allows us to promptly identify neoplasm recurrence or distant metastasis that can be treated with surgery and systematic therapy.

KEY WORDS

Intussusception, Primary bowel melanoma.

Endoscopic Ultrasound-Guided Fine Needle Aspiration of a PET/CT-Positive Small Hilar Lymph Node for the Diagnosis of Metastatic Merkel Cell Carcinoma

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Weekly alternate intensive regimen FIrB/FOx in metastatic colorectal cancer patients: an update from clinical practice

Background

Several trials evaluated the role of intensive regimens, made of triplet chemotherapies plus bevacizumab, as first-line treatment for patients with metastatic colorectal cancer (mCRC). We previously reported, in a Phase II prospective study, the efficacy and the tolerability of FIrB/FOx regimen, reporting interesting results in terms of received dose intensities (rDIs) and safety.

Methods

We reported a retrospective update of 85 patients treated with FIrB/FOx, an intensive regimen of 5-fluorouracil, bevacizumab, and weekly alternate irinotecan and oxaliplatin, to confirm its feasibility in “real life”. Subgroup analyses were performed, particularly among patients treated with standard and modified FIrB/FOx (based on age, performance status, and/or comorbidities).

Results

Overall, 3-month objective response rate (ORR) and 6-month ORR were 75.9% and 55.3%, respectively. Median progression-free survival (PFS) and median overall survival (OS) were 14.4 and 34.9 months, respectively. Among the patients treated with standard and modified regimens, 3-month ORR, PFS, and OS were 75.8% and 76% (P=1.0000), 14.4 and 14.4 months (P=0.8589), and 37.8 and 26.6 months (P=0.7746), respectively. Among the K/NRAS wild-type and K/NRAS mutant patients, 3-month ORR, PFS, and OS were 95.2% and 74.5% (P=0.0526), 15.3 and 14.4 months (P=0.8753), and 37.8 and 51.4 months (P=0.8527), respectively. The rDIs were ≥80% of full doses both in the standard and in the modified regimens subgroups. Cumulative G3/4 toxicities were neutropenia (14.1%), diarrhea (17.6%), asthenia (9.4%), vomiting (5.6%), and hypertension (16.5%).

Conclusion

This update shows that intensive regimens such as FIrB/FOx are also feasible options for first-line treatment of mCRC patients in the “real-life” setting.

Timed‑flat infusion of 5‑fluorouracil with docetaxel and oxaliplatin as first‑line treatment of gastroesophageal adenocarcinoma: A single institution experience with the FD/FOx regimen

To date, there is no consensus regarding first‑line chemotherapy for patients with HER2‑negative, locally advanced/metastatic gastric cancer (a/m GC). In the present study we reported a retrospective case‑series of patients treated with a weekly regimen containing timed‑flat infusion of 5‑fluorouracil (TFI/5‑FU), docetaxel and oxaliplatin. From June 2007 to July 2017, 32 consecutive a/m GC patients were treated with first‑line standard (st) or modulated (mod) 'FD/FOx' regimen: Weekly 12 h (from 10.00 p.m. to 10.00 a.m.) TFI/5‑FU for two consecutive nights at 900 mg/m2/day, associated to weekly alternating docetaxel, 50 mg/m2 and oxaliplatin, 80 mg/m2. The median age of the patients was 60 years and their Eastern Cooperative Oncology Group‑performance status (ECOG‑PS) was as follows: i) ECOG‑PS 0/1, (n=28, 87.5%); and ii) ECOG‑PS 2 (n=4, 12.5%). Patient activity, efficacy and safety data were collected and subgroup analyses were conducted among patients treated with st and mod FD/FOx. In the intention‑to‑treat (ITT) analysis, the objective response rate (ORR) was 75% (95% CI, 53‑90) and the disease control rate (DCR) was 87.5% (95% CI, 67.6‑97.3). After a median follow‑up of 16 months, median progression‑free survival (PFS) and median overall survival (OS) were 14.0 and 19.0 months, respectively. The received dose‑intensities were ~80% of the standard doses for each agent. The most relevant treatment‑related grade 3 adverse events were: Neutropenia (40.6%), asthenia (18.7%) and diarrhea (18.7%). The only treatment‑related grade 4 adverse event was neutropenia (9.3%). No febrile neutropenia was observed and none of the patients died as a result of adverse events. FD/FOx regimen appeared to be a feasible option as a first‑line treatment of a/m GC patients, especially in case of high‑tumor burden, with the need of rapid tumor shrinkage and disease‑related symptoms palliation.

Dose-finding study of oxaliplatin associated to capecitabine-based preoperative chemoradiotherapy in locally advanced rectal cancer

Introduction

Proper administration timing, dose-intensity, efficacy/toxicity ratio of oxaliplatin added to fluoropyrimidin should be improved to safely perform two-drugs intensive preoperative chemoradiotherapy in locally advanced rectal cancer (LARC). This dose-finding study investigated recommended oxaliplatin dose, safety of oxaliplatin/capecitabine regimen and preliminary activity.

Methods

Schedule: oxaliplatin dose-levels, 35-40 mg/m²/week; capecitabine 825 mg/m²/ twice daily, radiotherapy on rectum/nodes, 50/45 Gy, 45 and 9 boost/45 Gy, in first 5 and subsequent patients, 5 days/week, respectively; for 5 weeks. Pathologic complete response (pCR) 10% was projected in order to positively affect clinical outcome.

Results

Seventeen fit <75 years patients enrolled: median age 60; young-elderly 4 (23%); T3/T4, 15/2, N0/N1/N2, 7/9/1. At first dose-level, no dose-limiting toxicity (DLT). At second, 2 DLT, G3 mucositis, G3 thrombocytopenia, in 2/6 patients (33%). Oxaliplatin recommended dose, 40 mg/m²/week. Cumulative G3-4 toxicities: mucositis 6%, thrombocytopenia 6%. Limiting toxicity syndromes 18%, 25% in young-elderly, all single site. Objective response rate intent-to-treat 94%. Sphinter preservation 87%, pCR 6%. After 17 months follow-up, progression-free survival and overall survival were not reached.

Conclusions

Oxaliplatin can be safely added to preoperative capecitabine-based chemoradiotherapy at the recommended dose 40 mg/m²/week, in LARC, with promising pCR and high activity.

Identification and characterization of microRNAs in the screwworm flies Cochliomyia hominivorax and Cochliomyia macellaria (Diptera: Calliphoridae)

MicroRNAs (miRNAs) are small noncoding RNAs that modulate gene expression through post-transcriptional regulation. Here, we report the identification and characterization of miRNAs in two closely related screwworm flies with different feeding habits: Cochliomyia hominivorax and Cochliomyia macellaria. The New World screwworm, C. hominivorax, is an obligatory parasite of warm-blooded vertebrates, whereas the secondary screwworm, C. macellaria, is a free-living organism that feeds on decaying organic matter. Here, the small RNA transcriptomes of adults and third-instar larvae of both species were sequenced. A total of 110 evolutionarily conserved miRNAs were identified, and 10 putative precursor miRNAs (pre-miRNAs) were predicted. The relative expression of six selected miRNAs was further investigated, including miRNAs that are related to reproduction and neural processes in other insects. Mature miRNAs were also characterized across an evolutionary time scale, suggesting that the majority of them have been conserved since the emergence of the Arthropoda [540 million years ago (Ma)], Hexapoda (488 Ma) and Brachycera (195 Ma) lineages. This study is the first report of miRNAs for screwworm flies. We also performed a comparative analysis with the hereby predicted miRNAs from the sheep blowfly, Lucilia cuprina. The results presented may advance our understanding of parasitic habits within Calliphoridae and assist further functional studies in blowflies.

Prognostic relevance of KRAS genotype in metastatic colorectal cancer patients unfit for FIr-B/FOx intensive regimen

First-line triplet chemotherapy plus bevacizumab (FIr-B/FOx) can improve efficacy of metastatic colorectal cancer (MCRC), KRAS wild-type and mutant. Prognostic relevance of KRAS genotype was evaluated in patients unfit for FIr-B/FOx, treated with conventional medical treatments. Consecutive MCRC patients not eligible for FIr-B/FOx regimen due to age (≥75 years) and/or comorbidities were treated with tailored conventional first-line treatments. KRAS codon 12/13 mutations were screened by direct sequencing. Activity and efficacy were evaluated and compared according to medical treatments, age (non-elderly and elderly≥65 years), comorbidity stage (Cumulative Illness Rating Scale), metastatic extension (liver-limited and other/multiple metastatic), and KRAS genotype, using log-rank. Selected first line treatments were medical in 37 patients (92.5%), and surgical in 3 patients (7.5%). Medical treatment regimens: triplet, 18 (45%); doublet, 15 (37.5%); mono-therapy, 4 (10%). At median follow-up of 8 months, objective response rate (ORR) was 37%, median progression-free survival (PFS) 7 months, liver metastasectomies 8% (liver-limited disease 37.5%), median overall survival (OS) 13 months. Triplet regimens failed to significantly affect clinical outcome, compared to doublet. According to KRAS genotype, ORR, PFS and OS were, respectively: wild-type 50%, 8 months, 13 months; mutant 25%, 6 months, 9 months. KRAS genotype wild-type compared to mutant significantly affected PFS, while not OS. KRAS c.35 G>A mutation (G12D) significantly affected worse PFS and OS compared to wild-type and/or other mutations. KRAS genotype, specifically the c.35 G>A KRAS mutation, may indicate poor prognosis in MCRC patients unfit for intensive medical treatments.

Differential prognosis of metastatic colorectal cancer patients post-progression to first-line triplet chemotherapy plus bevacizumab, FIr-B/FOx, according to second-line treatment and KRAS genotype

Clinical outcome post-progression to first-line triplet chemotherapy (CT) plus bevacizumab (FIr-B/FOx) was evaluated in metastatic colorectal cancer (MCRC) patients (pts). Second-line treatment was selected according to fitness, KRAS genotype, previous efficacy and safety. Efficacy was evaluated and compared according to treatment or KRAS genotype, using log-rank analysis. Among 54 pts, median overall survival (OS) post-progression was 12 months, significantly better in 40 (74.1%) treated compared to 14 (25.9%) who died without further treatment. Second-line surgical treatment, 4 pts (7.4%), medical treatment, 36 pts (66.7%): triplet CT plus targeted agent, 10 (18.5%); triplet regimens, 19 (35.2%); doublet/monotherapy, 7 (13%). At follow-up of 14 months, objective response rate (ORR) was 38%, metastasectomies 12.5%, progression-free survival (PFS) 10 months, OS 14 months. According to treatment, ORR, metastasectomies, PFS and OS were significantly favourable in triplet CT plus targeted agent compared to triplet, respectively: 80%, 40%, 13 months, not reached; 28%, 6%, 8 months, 11 months. PFS and OS were significantly worse in c.35 G>A mutant compared to wild-type and/or other mutant patients. Prognosis after progression to first-line FIr-B/FOx may be significantly favourable in MCRC pts re-challenged with intensive regimens, and unfavourable in c.35 G>A KRAS mutant patients.

Worse prognosis of KRAS C.35 G > A mutant metastatic colorectal cancer (MCRC) patients treated with first-line triplet chemotherapy plus bevacizumab (FIr-B/FOx) and post-progression

e14596

Background: Prognosis of MCRC patients (pts) treated with bevacizumab (BEV) and chemotherapy (CT) is not significantly different according to KRAS genotype. Specificmutations confer different aggressiveness. Prognostic relevance of the prevalent c.35 G > A KRAS mutation was retrospectively evaluated in pts treated with first line FIr-B/FOx, and post-progression. Methods: KRAS codon 12/13 and BRAF mutations were screened by SNaPshot and/or sequencing. FIr-B/FOx: weekly 2 days/12h-timed-flat-infusion/5-fluorouracil 900 mg/m2, weekly alternating irinotecan 160 mg/m2/BEV 5 mg/kg, or oxaliplatin 80 mg/m2. Second-line treatment was selected according to fitness, KRAS genotype, previous efficacy and safety. Efficacy was evaluated and compared according to treatment or KRAS genotype, using log-rank. Results: At 21.5 months, 59 pts were evaluated. KRAS mutant pts: c.35 G > A, 15 (25.4%); c.35 G > T, 7 (11.8%); c.38 G > A, 3 (5%); other, 3 (5%). KRAS wild-type, 31 pts (52.7%). ORR, PFS, OS were, respectively: c.35 G > A, 71%, 9 months, 14 months; other mutants, 61%, 12 months, 39 months. OS was significantly worse in c.35 G > A pts compared to KRAS wild-type (p = 0.002), KRAS/BRAFwild-type (p = 0.03), other pts (p = 0.002), other mutants (p = 0.05), other codon 12 (p = 0.03) mutant pts; PFS was not significantly different. Post-progression, at 14 months follow-up, PFS and OS were significantly worse in c.35 G > A compared to wild-type and/or other mutant pts. ORR of second line treatments was 38%, metastasectomies 12.5%, PFS 10 months, OS 14 months. PFS and OS were significantly favourable in pts treated with triplet CT plus targeted agent compared to triplet, respectively: PFS 13 months versus 8 months; OS not reached versus 11 months. Conclusions: KRAS c.35 G > A mutation may significantly affect worse OS of MCRC pts. It does not significantly affect worse PFS of intensive first line FIr-B/FOx, while after progression significantly affect worse efficacy of second line treatments. Re-challenge of intensive regimens may affect significantly favourable PFS and OS.

Pipeline for macro- and microarray analyses

The pipeline for macro- and microarray analyses (PMmA) is a set of scripts with a web interface developed to analyze DNA array data generated by array image quantification software. PMmA is designed for use with single- or double-color array data and to work as a pipeline in five classes (data format, normalization, data analysis, clustering, and array maps). It can also be used as a plugin in the BioArray Software Environment, an open-source database for array analysis, or used in a local version of the web service. All scripts in PMmA were developed in the PERL programming language and statistical analysis functions were implemented in the R statistical language. Consequently, our package is a platform-independent software. Our algorithms can correctly select almost 90% of the differentially expressed genes, showing a superior performance compared to other methods of analysis. The pipeline software has been applied to 1536 expressed sequence tags macroarray public data of sugarcane exposed to cold for 3 to 48 h. PMmA identified thirty cold-responsive genes previously unidentified in this public dataset. Fourteen genes were up-regulated, two had a variable expression and the other fourteen were down-regulated in the treatments. These new findings certainly were a consequence of using a superior statistical analysis approach, since the original study did not take into account the dependence of data variability on the average signal intensity of each gene. The web interface, supplementary information, and the package source code are available, free, to non-commercial users at http://ipe.cbmeg.unicamp.br/pub/PMmA.

Cortical excitability in drug-naive patients with partial epilepsy: A cross-sectional study

OBJECTIVE

To use paired-pulse transcranial magnetic stimulation (TMS) to investigate cortical excitability in drug-naive patients with partial epilepsy.

METHODS

Twenty-one drug-naive patients with partial epilepsy and 15 control subjects were studied. The relaxed threshold to TMS, the central silent period, and the intracortical inhibition/facilitation were measured. Statistics implied cluster analysis methods. Also assessed were the patient interictal EEG epileptiform abnormalities (EAs) on a semiquantitative basis. Then the TMS was contrasted to the clinical and EEG findings, using chi2 or Fisher exact tests.

RESULTS

One-third of the patients made up a "pathologic" cluster with a disrupted intracortical inhibition (p < 0.01). Two-thirds had a normal inhibition. Interictal EAs predominated in the pathologic cluster, for frequency (p < 0.04), duration (p < 0.04), and focality (p < 0.02).

CONCLUSIONS

Intracortical inhibition, which was impaired in one-third of the patients, reflects gamma-aminobutyric acid (GABA) activity within cortical area 4. Defective GABA inhibition is a typical pathogenic factor in partial epilepsy. Transcranial magnetic stimulation proved able to detect it. The weaker cortical inhibition had a direct relation to the severity of interictal epileptiform abnormalities.

[Diagnosis and treatment of non-palpable breast lesions: from the biopsy to the microhistology results. Our experience]

The aim of modern senology lies in the diagnosis and treatment of non-palpable breast lesions (NPBLs). Through the diffusion of regional mammography screening the lesions being observed are continuously smaller, thus calling for more and more accurate methodology. Our experience in this area is based on the use of certain methods for retrieval and removal of NPBLs, such as Kopan's sec. philo-guide, ultrasound and advanced breast biopsy instrumentation. In our opinion methods allowing total removal of lesions in order to obtain complete histopathological characterization and enabling adequate therapeutic programs are to be preferred. In reviewing case studies a noteworthy increase of initial carcinoma (DCIS or LCIS), from 19.5% to 57.1%, has been observed in the last three years due to the extensive use of the aforementioned methods.

[Can analysis of the molecular status of the p53 gene contribute to improving the therapeutic strategy for breast carcinoma?]

The occurrence of mutations in the p53 tumor suppressor gene is a specific and recurring genetic event in solid tumors. P53 plays a pivotal role in multiple cellular processes such as cell growth control, DNA repair and programmed cell death. Genotoxic damage, also induced by chemotherapy or radiotherapy, induces p53 overexpression in order to control the rate of proliferating damaged cells, thus triggering the mismatch repair or apoptotic pathways. P53 inactivation determines a condition of genetic instability, justifying the subsequent susceptibility to acquire mutations of different other genes. P53 mutations are associated with worse prognosis and with chemo/radioresistance, due to the inability to trigger p53-dependent programmed cell death. Molecular diagnostic strategies show 32% p53 mutations in breast cancer. The analysis of the p53 gene performed by FAMA (Fluorescence Assisted Mismatch Analysis) in high-risk breast cancer patients with > or = 10 involved axillary nodes may help identify a subset of very high risk BC patients (vHR-BC) with poorer prognosis and a subset with better prognosis, potentially responsive to medical treatments. The accurate evaluation of the p53 status can predict prognosis and sensitivity to chemotherapy, thus representing the first step toward better definition of therapeutic strategies according to the molecular characterization of the individual patient.

Cortical excitability and sleep deprivation: a transcranial magnetic stimulation study

The objective was to assess the changes in cortical excitability after sleep deprivation in normal subjects. Sleep deprivation activates EEG epileptiform activity in an unknown way. Transcranial magnetic stimulation (TMS) can inform on the excitability of the primary motor cortex. Eight healthy subjects (four men and four women) were studied. Transcranial magnetic stimulation (single and paired) was performed by a focal coil over the primary motor cortex, at the "hot spot" for the right first dorsal interosseous muscle. The following motor evoked potential features were measured: (a) active and resting threshold to stimulation; (b) duration of the silent period; (c) amount of intracortical inhibition on paired TMS at the interstimulus intervals of 2 and 3 ms and amount of facilitation at interstimulus intervals of 14 and 16 ms. The whole TMS session was repeated after a sleep deprivation of at least 24 hours. After the sleep deprivation, the threshold to stimulation (in the active and resting muscle), as well as the silent period, did not change significantly. By contrast, the paired stimulus study showed a significant (p<0.05) reduction in both intracortical inhibition and facilitation. Thus, TMS showed that sleep deprivation is associated with changes in inhibition-facilitation balance in the primary motor cortex of normal subjects. These changes might have a link with the background factors of the "activating" effects of sleep deprivation.

[Non-palpable lesions of the breast: retrospective clinical study]

A non-palpable breast lesion (NPBL) is a disease of the mammary gland that cannot be detected during clinical examination but that can be visualized by mammography and/or ultrasonography, either during screening programs or sometimes in asymptomatic women. These small lesions require an adequate diagnostic-therapeutic approach to ensure correct treatment. The aim of the present study was to analyse a series of NPBLs retrospectively in order to define them nosologically and establish an adequate diagnostic-therapeutic work-up for such cases. Ninety-three patients with a total of 99 NPBLs were observed from January 1989 to December 1999. The 99 NPBLs were submitted to ultrasonography and 31 (31.3%) were also submitted to US-guided fine needle aspiration biopsy (FNAB). Later on the diagnostic-therapeutic procedure involved surgical biopsy after radiological centering and, in the case of malignant neoplastic lesions, surgical intervention and adjuvant therapy. Ultrasonography confirmed the presence of NPBL in 45 cases of the 99 detected at mammography (45.4%). Cytological examination of the 31 FNABs yielded the following results: unreliable 19.3%, suspected malignancy 42%, negative for neoplastic cytology 6.5%, positive for carcinoma 32.3%. The histological diagnosis was one of mammary carcinoma in 41 patients (43%). Among the 41 carcinomas there were 8 (19.5%) carcinomas in situ, 24 (58.5%) invasive ductal carcinomas, 8 (19.5%) invasive lobular carcinomas, and 1 (2.5%) medullary carcinoma. In the 32 (80%) patients submitted to lymphadenectomy for 33 invasive carcinomas, 6 patients (18.7%) presented positive lymph nodes (N1). The Authors conclude that NPBLs are an important clinical entity because they may be the expression of a malignant lesion; most NPBLs are diagnosed during screening programs or sometimes in asymptomatic women by means of mammography, which is the only standardised method for their identification. The poor diagnostic capability of non-invasive methods and the potential malignancy of NPBL justify the indication for surgical excisional biopsies; in cases of histological findings of malignancy it is often possible to perform conservative surgery with similar results to radical surgery in terms of survival. When NPBLs turn out to be invasive carcinomas, a concomitant lymphadenectomy is mandatory.

Effects of a photic input on the human cortico-motoneuron connection

OBJECTIVES

Disease manifestations such as photic cortical reflex myoclonus or myoclonus due to intermittent light stimulation rely on a pathologic interaction between non-structured visual inputs and the corticospinal system. We wanted to assess the normal interaction, if any, between a prior photic input and the output of the cortico-motoneuron connection.

METHODS

In 9 consenting healthy subjects we quantified the changes exerted by a sudden, unexpected bright light flash on (i) the motor potentials (MEPs) evoked in the right first dorsal interosseous muscle (FDI) by transcranial magnetic or electrical stimulation (TMS/TES) of the primary motor cortex, (ii) the FDI F-waves and (iii) the soleus H-wave. Separately, we measured the simple reaction times to the flash itself. All determinations were repeated twice with an interval of 2-24 months.

RESULTS

When the flash preceded TMS by 55-70 ms, the MEP size was reduced, while at interstimulus intervals (ISIs) of 90-130 ms it was enlarged. Statistical significance (P<0.05) emerged at ISIs of 55, 70, 100, 105 and 120 ms. Conversely, the MEP latency was prolonged at ISIs of 55-70 ms and shortened at ISIs of 90-130 ms (P<0.05 at ISIs of 55, 110 and 130 ms). Electrical MEPs were enhanced at an ISI of 120 ms. The F-wave size showed a non-significant trend of enhancement at ISIs of 90-130 ms. The soleus H-wave showed significant enlargement at ISIs of 90-130 ms (P<0.05 at ISIs of 100 and 105 ms). The minimum reaction time was on average 120 ms.

CONCLUSIONS

An unexpected photic input, to which no reaction is planned, can cause an early inhibition of the responses to TMS. We think its origin lies within the primary motor cortex, since it is not associated with changes in spinal excitability or electrical MEPs. A later facilitation persists using TES and has a temporal relationship with an enlargement of the soleus H-wave. Thus, it likely results from activation of descending (possibly reticulospinal) fibers that excite the spinal motor nucleus.

The Sentinel Lymph Node in T1N0 Breast Cancer

The authors report their experience gathered from December 1998 to December 1999 in the use of the sentinel lymph node (SN) method in breast cancer treatment. In 20 out of 21 cases (95%) localization of the SN was obtained by scintigraphy while in 19 cases (90.5%) the SN was found during surgery. Histological examination of the axillary lymph nodes gave a 95% accuracy with only one negative SN associated with positive axillary lymph nodes out of a total of 19. However, the authors have subjected all patients to a complete three-level axillary dissection since they believe the method applied has not yet been fully validated.

Intravenous leiomyomatosis of the uterus. A report of three cases

Three cases of intravenous leiomyomatosis (IVL) of the uterus, a rare benign smooth-muscle tumor, are described. A preoperative diagnosis of IVL was not made in any of the patients, all of which presented with a pelvic mass with the presumptive diagnosis of leiomyoma. Surgical exploration confirmed the presence of uterine mass and two of the three cases showed extra-uterine extension into the ovarian or uterine veins. Histological examination demonstrated a fascicular pattern of bland spindle-shaped smooth-muscle cells, which extended to veins inside the myometrium or to extrauterine veins. This was confirmed by immunohistochemical stain for desmin and factor VIII. Despite their histological benignity, these lesions have a tendency to metastasize and are closely related to the conditions called "benign metastasizing leiomyoma" and "intracaval mass and cardiac extension". The primary treatment of IVL is hysterectomy and excision of any extrauterine tumor, when technically feasible. Anti-estrogenic therapy has been suggested as potentially useful in controlling of unresectable tumor. According to the literature, the follow-up must be long and periodic postoperative ultrasonic or magnetic nuclear resonance imaging studies may be useful in detecting growth of residual intravascular tumor.

[Value of echography in the measurement of changes in the total and visceral adipose mass]

Various methods to assess lean and fat body masses and abdominal-visceral adipose tissue were compared in 26 obese women on extremely hypocaloric diets. The following anthropometric parameters were measured before and after 15 days of extreme calorie restriction: arm circumference (A), waist circumference (W), hip circumference (H) and thigh circumference (T); W/H, W/T, A/H and A/T ratios; subcutaneous biceps , triceps , subscapular, abdominal and thigh folds; echographic thickness of abdominal muscle-aorta; area of visceral (VAT), total (AT) and subcutaneous adipose tissue measured using computed tomography, lean and fat body masses assessed by impedance measurement. Under standard conditions it was shown that echography, like impedance measurement, was the most useful method for assessing lean and fat body masses in obese subjects, whereas plicometry was not found reliable. On extremely hypocaloric diets, echography is able to assess the variations of lean and fat body masses, whereas impedance measurement overestimated the lean body mass. Localisation indexes of visceral fat based on body circumferences were shown not to be suitable for the evaluation of changes in visceral adipose tissue, at least when these were slight. Echography was also the most useful method to assess slight changes in visceral adipose tissue.

Resting metabolic rate, body composition and thyroid hormones. Short term effects of very low calorie diet

27 obese women (relative body weight 191 +/- 27%), aged 35 +/- 11, underwent a 15 day very low calorie diet (VLCD: 1337 kJ/day). Mean body weight loss was 6 +/- 1.5 kg. Resting metabolic rate (RMR), measured by indirect calorimetry, showed a significant decrease both in absolute values (from 1793 +/- 225 to 1569 +/- 231 kcal/day; P less than 0.001), and in keal/kg body weight/day (from 17 +/- 2, to 16 +/- 2, P less than 0.001). Serum triiodothyronine (T3) significantly decreased from 1.1 +/- 0.2 to 1 +/- 0.2 microgram/1 (P less than 0.001). Before VLCD the differences between measured RMR and theoretical RMR (RMR-T) were not significant. After VLCD RMR values were significantly (P less than 0.001) lower than RMR-T. It was concluded that fat-free mass loss, combined with periferic thyroxin (T4) reduced monodeiodination in its more active form mainly due to low calorie intake T3 could be responsible for the important reduction observed in the resting metabolic rate.