Incidental Colonic Masses and Cytomegalovirus (CMV) Infection in a Treatment- Naïve Chronic Lymphocytic Leukemia Patient without GI symptoms

Introduction/Objective

Gastrointestinal (GI) involvement by leukemia ranges from 5.7 to 13 % with very few published reports describing infiltration of the GI tract by chronic lymphocytic leukemia (CLL). GI bleeding, abdominal pain, and obstruction have been described as presenting symptoms of GI involvement. Yet, discrete lesions are rare. Infection is a common complication in patients with CLL. In untreated patients, these infections are typically by encapsulated bacteria involving the respiratory tract and associated with hypogammaglobulinemia. Viral infections often happen after therapy. This report presents a patient with a history of treatment- naïve CLL and HSV who presented for colostomy reversal and was incidentally found to have two partially obstructing colonic masses, as well as cytomegalovirus (CMV) infection.

Methods/Case Report

This is a 78-years-old female with treatment-naïve CLL and past medical history of hypertension, atrial fibrillation, diverting colostomy secondary to chronic perineal HSV-2 ulcer and recent perirectal abscess. She presented for colostomy reversal in the absence of any reported GI symptoms at that time. Labs showed leukocytosis; WBCs count of 25 K/MM3, anemia and neutropenia. Endoscopic studies incidentally discovered two partially obstructing masses in the ascending and transverse colon that were biopsied. A right hemicolectomy and colostomy closure were followed, and the patient was discharged on valganciclovir.

Results (if a Case Study enter NA)

Histopathological examination demonstrated mucosal ulceration with viral cytopathic changes and positive CMV IHC stain. In addition, a dense atypical, small sized lymphoid cell infiltrate with no sheets of large cells or confluent necrosis were identified. Flowcytometry and IHC stains showed aberrant CD5+ B cells with CD23 co-expression consistent with the patient’s history of CLL.

Conclusion

The case describes the unique presentation of a patient with treatment- naïve CLL without any GI symptoms, yet was incidentally found to have colonic involvement by CLL forming discrete colonic masses as well as CMV and HSV infections. Since she is untreated, her infections (HSV and CMV) are likely secondary to being immunocompromised by CLL and neutropenia. In conclusion, although rare, GI involvement by CLL should be considered in treatment naïve CLL patient’s and concomitant infections should be evaluated.

Unusual Case of Multiple Synchronous Gastrointestinal Stromal Tumors of the Jejunum Presenting as an Arteriovenous Malformation

Introduction/Objective

Gastrointestinal stromal tumor (GIST) arises from the interstitial cell of Cajal. 30% of GISTs arise in the jejunum. GISTS are generally solitary although multiple GISTs may be synchronous or metachronous. There are a few reports of a GIST of the jejunum mimicking a vascular malformation/arteriovenous malformation (AVM) prior to surgical excision.

Methods

Herein, we report a case of four synchronous GISTs of jejunum. One GIST, highly vascularized, presented with lower gastrointestinal bleeding. The patient was a 40-year-old female presenting with epigastric pain and melena.

Results

She was found to have an ulcerated lesion in the distal jejunum by capsule enteroscopy and double balloon enteroscopy, interpreted as an arteriovenous malformation and tattooed. Several other non-ulcerated “polyps” were described. Gross examination of the ensuing segmental resection of jejunum demonstrated four bosselated tumors ranging from 3.1 cm to 6.5 cm. Microscopically, three tumors did not extend to the surface of the jejunum and were predominantly composed of spindle cells. One tumor (identified by tattoo) extended to the surface with ulceration. This tumor was dominated by wide vascular channels with a spindle cell component between the channels. The four tumors were each positive for CD117, DOG1, and Succinate dehydrogenase B (SDH), identifying the four tumors as non-SDH-deficient GISTs. Ki-67 proliferation index was less than 5% in all four masses.

Conclusion

Multiple GISTs are rare, classified as either sporadic or familial. Familial GEISTs are described in neurofibromatosis type 1, Carney’s triad and Carney-Stratakis syndrome. Pediatric GISTs, with clinical and genetic features often differing from typical adult tumors may also be multiple. Our patient’s four GISTs are considered multiple synchronous sporadic neoplasms. This case serves as an important reminder for pathologists consider GIST in the evaluation of a highly vascular gastrointestinal proliferation and keep in mind the possibility of multiplicity.

SMARCA4 Deficient Thoracic Sarcoma Presenting with a Pathologic Fracture of Proximal Tibia and L5 Vertebral Body: a Case Report and Review of Literature

Introduction/Objective

SMARCA4 (BRG1) is a central component of the Switch/Sucrose-Non-Fermentable (SWI/SNF) chromatin remodeling complex which plays a critical role in the initiation, progression and dedifferentiation of a variety of cancers arising in different anatomical sites. The recently discovered SMARCA4-deficient thoracic sarcoma (DTS) can present as a mediastinal, pleural or pulmonary mass and constitutes a unique and highly lethal entity.

Methods

Here we present an interesting case of a 66-year-old, smoker male with past medical history of COPD, polysubstance abuse, hepatitis C virus, and alcoholic cirrhosis who presented with left proximal tibia pathological fracture, L5 vertebral body lytic lesion, left leg cellulitis and hypercalcemia. Imaging studies, tibia biopsy, thoracocentesis, histopathological examination, and immunohistochemical stains were performed.

Results

Imaging studies revealed a 3.1 cm, right upper lobe speculated lung mass along with multiple other lung nodules. Numerous arterially enhancing hepatic masses up to 2.8 cm were also identified. The patient underwent intramedullary nail, cementation and tibia biopsy followed by thoracentesis a month later.The histological sections revealed sheets of poorly differentiated malignant epithelioid cells showing high nuclear pleomorphism, prominent nucleoli, eosinophilc cytoplasm with extensive necrosis, and high mitosis (Ki-67 around 100%). The tumor cells lacked the expression of SMARCA4 (BRG1), cytokeratin, SALL4, CD34, TTF-1, P40, S100, HMB45, pan melanoma, desmin, CD31, ERG, CD30, CD56, chromogranin, CD38, CD45, CD3, ALK-1, myeloperoxidase, glypican-3, hepatocyte, and inhibin with mixed kappa and lambda. Tumor cells expressed SATB2 and focal synaptophysin, consistent with SMARCA4 deficient thoracic sarcoma metastasizing to the bone. The patient’s condition rapidly deteriorated and he died within two months.

Conclusion

An accurate diagnosis of these tumors is paramount and can be challenging. However, recognizing SMARCA4-DTS from other types of epithelioid tumors that involve the thoracic region is clinically relevant, as targeted therapies for SMARC-deficient tumors are currently being investigated and new clinical trial data show therapeutic benefit.

Sensing of Damage and Repair of Cement Mortar Using Electromechanical Impedance

Lead zirconium titanate (PZT) has recently emerged as a low-cost material for non-destructive monitoring for civil structures. Despite the numerous studies employing PZT transducers for structural health monitoring, no studies have assessed the effects of both damage and repair on the electromechanical impedance response in cementitious materials. To this end, this study was conducted to assess the effects of the damage and repair of mortar samples on the electromechanical response of a surface-mounted PZT transducer. When damage was introduced to the specimen in stages, the resonance frequencies of the admittance signature were shifted to lower frequencies as the damage increased, and an increase in the peak amplitude was detected, indicating an increase in the damping and a reduction in the material stiffness properties. Also, increasing the damage in the material has been shown to decrease the sensitivity of the PZT to further damage. During the repair process, a noticeable difference between the after-damage and the after-repair admittance signatures was noted. The root-mean-square deviation (RMSD) showed a decreasing trend during the repair process, when compared to the before repair RMSD response which indicated a partial recovery for the material properties by decreasing the damping property in the material.

A sirs-based automated alarm system for the diagnosis of sepsis after burn injury

The present study examined the effectiveness of an automated systemic inflammatory response syndrome (SIRS)-based alarm system for the early detection of sepsis in adult burn patients. In addition, the relevance of the sepsis criteria from the American Burn Association (ABA) and the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) for this patient group was determined. In this prospective observational study, we included 41 consecutive patients who were admitted to our burn ICU within a one-year period. SIRS alarms were calculated for these patients according to predefined criteria using the PREDEC ALARM automated alarm system and alarms generated according to ABA criteria and daily Sequential Organ Failure Assessment (SOFA) results. The alarms were not visible to the treating doctors and nurses. The alarms identified were related to episodes of sepsis with positive blood cultures. Twenty-one sepsis events were recorded in 41 patients. The receiver operating characteristic (ROC) curve revealed an area under the curve (AUC) of 0.72 for alarms using 2 SIRS criteria, 0.77 for 3 SIRS criteria, and 0.61 for 4 SIRS criteria. AUC values of 0.53 and 0.59 were calculated for the ABA criteria and Sepsis-3 definition, respectively. An alarm system using 3 SIRS criteria proved to be suitable for the early detection of sepsis in burn patients. The frequent number of false alarms requires further refinement of the alarm system. Based on the results of our study, the ABA criteria and the Sepsis-3 definition provide no advantages over the SIRS criteria in the early diagnosis of sepsis after burn injury.

Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain: a randomised controlled trial

OBJECTIVES

To compare the efficacy, safety and satisfaction from two modes of oral analgesia administration for the treatment of post-caesarean pain in the first 48 h following surgery: on-demand versus fixed time interval administration.

DESIGN

Open label parallel-group, randomised-controlled trial from February to December 2013.

SETTING

University-affiliated hospital in Israel.

POPULATION

Two-hundred women who underwent caesarean delivery with regional anaesthesia.

METHODS

Patients were randomly assigned to receive predetermined combinations of tramadol, paracetamol and diclofenac either following patient demand or at predetermined 6-h intervals for the first 48 h. If the patient requested additional analgesia, Percocet (oxycodone and paracetamol) was given as a rescue treatment.

MAIN OUTCOME MEASURES

Pain intensity and satisfaction were self-evaluated with visual analogue scale of 0 (no pain/least satisfaction) to 10 (worst pain/highest satisfaction). Breastfeeding, need for supplemental formula, and maternal and neonatal adverse effects were also evaluated.

RESULTS

The 'fixed time interval' group, compared with the 'on-demand' group, had lower mean pain score (2.8 ± 0.84 versus 4.1 ± 0.48, respectively; P < 0.0001), higher satisfaction rate (9.1 ± 1.2 versus 8.3 ± 1.5, respectively; P < 0.0001), more breastfeeds (23.7 ± 6.5 versus 19.2 ± 6.2, respectively; P < 0.0001) and less use of supplemental formulas (8.2 ± 5.2 versus 11.9 ± 6.5, respectively; P < 0.0001). The number of times that drugs were given was slightly higher in the 'fixed time interval' group without an increase in maternal adverse effects, which were mild. No adverse effects were reported for the neonates.

CONCLUSION

Administration of oral analgesia in fixed time intervals is superior to drug administration following patient demand without increasing maternal or neonatal adverse outcomes.

TWEETABLE ABSTRACT

Oral analgesia in fixed time intervals is superior to analgesia following demand.

Ligamentum flavum cyst in the lumbar spine: a case report and review of the literature

Degenerative changes in the lumbar spine can be followed by cystic changes. Most reported intraspinal cysts are ganglion or synovial cysts. Ligamentum flavum pseudocyst, as a cystic lesion in the lumbar spine, is a rare and unusual cause of neurologic signs and symptoms and is usually seen in elderly persons (due to degenerative changes). They are preferentially located in the lower lumbar region, while cervical localization is rare. Complete removal of the cyst leads to excellent results and seems to preclude recurrence. We report the case of a right-sided ligamentum flavum cyst occurring at L3–L4 level in a 70-year-old woman, which was surgically removed with excellent postoperative results and complete resolution of symptoms. In addition, we discuss and review reports in the literature.

A new herbal combination, Etana, for enhancing erectile function: an efficacy and safety study in animals

We present herein a new herbal combination called Etana that is composed of five herbal extracts including Panax quinquelotius (Ginseng), Eurycoma longifolia (Tongkat Ali), Epimedium grandiflorum (Horny goat weed), Centella asiatica (Gotu Kola) and flower pollen extracts. Most of the above-mentioned extracts have a long historical and traditional use for erectile dysfunction (ED). On the basis of the mechanism of action of each of the above, a combination is introduced to overcome several physiological or induced factors of ED. This study was conducted to show an enhancement of erectile function in male rats. The animals were observed for 3 h after each administration for penile erection, genital grooming and copulation mounting, and the penile erection index (PEI) was calculated. The maximum response was observed at the concentration of 7.5 mg kg(-1) of Etana. At a 7.5 mg kg(-1) single dose, the percentage of responding rats was 53+/-7 with a PEI of 337+/-72 compared with 17+/-6 with a PEI of 30+/-10 for control animals. This PEI was significantly (P<0.001) higher than each single component and than the sum of any two herbal components of Etana. When compared with sildenafil citrate, Etana induced more pronounced PEI than 0.36 mg kg(-1), but similar to 0.71 mg kg(-1) of sildenafil. Furthermore, full acute and sub-acute toxicity studies showed no toxic effects of Etana. In conclusion, this study describes a new and safe combination of herbal components that enhance erectile function in male rats. Clinical studies are warranted for evaluating Etana's significance in ED.

Modulation of inflammatory response by pentoxifylline is independent of heme oxygenase-1 pathway

OBJECTIVE

It was reported that some effects of pentoxifylline (PTX) are mediated by heme oxygenase-1 (HO-1) induction. We investigated the role of HO-1 in anti-inflammatory activity of PTX.

METHODS

Experiments were performed in human and murine monocytes and endothelial cells and in HO-1 deficient mice.

RESULTS

PTX dose-dependently decreased expression of HO-1 in cell lines studied. As expected, PTX reduced also production of TNF. This effect was independent of HO-1 activity, as demonstrated in cells treated with HO-1 activators and inhibitors or in cells overexpressing HO-1. Moreover, inhibition of TNF was the same in human endothelial cells of different HO-1 genotypes, showing that PTX is similarly efficient in carriers of more and less active HO-1 promoter variants. In mice, PTX did not influence HO-1 expression, as measured in liver, kidney, spleen, heart, and skin. Accordingly, the response of PTX treated animals to LPS was the same in wild type and HO-1 deficient mice. PTX to a similar extent increased influx of leukocyte into peritoneal cavity, decreased production of TNF and reduced expression of VCAM-1 in vascular intima.

CONCLUSION

PTX inhibits production of TNF and may decrease inflammatory reaction both in vitro and in vivo, but these effects are independent of HO-1.

Behavior of the organophosphorus insecticide fenitrothion in stored faba beans and its biological effects towards experimental animals

Sound whole-seed faba beans were treated with (methyl-(14)C) fenitrothion [O, O-dimethyl-O-(3-methyl-4-nitrophenyl) phosphorothioate] at 5 and 10 mg insecticide/kg seeds, a dose normally used in practice. During the 30 weeks of storage period, the penetration and distribution of insecticide residues were studied. The amount of surface residues, internal residues and bound insecticide residues was estimated. Surface residues were found to decrease with the increase in time of storage, whereas internal residues showed a gradual increase with time apparently not dose dependent. Grain-bound residues increased with time and reached to its maximum (14-18%) after 24 weeks of storage. Chromatographic analysis of the internal extracts revealed the presence of the parent compound together with three main metabolites which were found in both free and conjugated form. Feeding mice for 90 days with a diet mixed with total internal fenitrothion residues in stored faba beans led to a reduction in body weight gain, and an appreciable decrease in cholinesterase activity of 32% for plasma and 15% for red blood cells (RBC(S)) after two months of experiment. Also, a significant decrease was showed in both total protein and albumin concentration at the end of feeding period (90 days). Liver and kidney function, as well as lipid profile of treated mice significantly increased at the end of feeding period. After a one-month recovery period, all the examined blood parameters returned to about the control values except blood urea and serum triglyceride.

NMR conformational analysis of proadrenomedullin N-terminal 20 peptide, a proangiogenic factor involved in tumor growth

The preferred conformation of Proadrenomedullin N-Terminal 20 Peptide (PAMP; ARLDVASEFRKKWNKWALSR-amide) has been determined using 1H and 13C two-dimensional nuclear magnetic resonance (NMR) spectroscopy and molecular modeling. PAMP is a peptide that has various physiological functions, including its role as a proangiogenic factor in facilitating tumor growth and its inhibitory effect on catecholamine secretion at nicotinic receptors. The preferred conformation of PAMP was determined in a helix-inducing trifluoroethanol and water (TFE/H2O) solution, and in a membrane-mimetic sodium dodecylsulfate-d25 (SDS) micellar solution. The secondary structure consists of an alpha-helix for residues Arg2 to Arg20 in TFE/H2O solution and an alpha-helix for residues Arg2 to Ala17 in SDS solution. We postulate that the polar charged residues Arg2, Lys12, and Arg20 are responsible for the initial interaction of the peptide with the micelle, and that this is followed by the binding of the hydrophobic residues Leu3, Val5, Phe9, Trp13, and Trp16 to the micellar core. The three C-terminal amino acid residues adopt an extended structure in SDS, suggesting that they are important in receptor recognition and binding. This is supported by truncation studies done by Mahata et al. (Hypertension, 1998, Vol. 32, pp. 907-916), which show the importance of the C-terminal in physiological activity. Furthermore, Belloni et al. (Hypertension, 1999, Vol. 33, pp. 1185-1189), and Martinez et al. (Cancer Research, 2004, Vol. 64, pp. 6489-6494) suggested that the N-terminal was also important in PAMP activity. However, no differences in conformational preference of the N-terminal were observed between the two solvent systems.

Mineralization of 14C-ring labelled 2,4-D in Egyptian soils under aerobic and anaerobic conditions

OBJECTIVES

To study the mineralization of 2,4-D in clay and clay loam Egyptian soils under subtropical conditions over a period of 90 d.

METHODS

Using 14C-ring labelled pesticide, laboratory studies under aerobic and anaerobic conditions were conducted. 14C-activity in solutions was directly determined by liquid scintillation counting. Unextractable soil residues were determined by combustion. The nature of methanolic 14C-residues was determined by thin layer and high performance liquid chromatographic analysis.

RESULTS

Under aerobic conditions 10%-14% of applied dose was mineralized during 90 d irrespective of soil type. The soil extractable pesticide residues decreased with time and the bound residues gradually increased. The highest binding capacity of about 26%-29% was observed in clay soil under aerobic conditions after 90 d. A good balance sheet was obtained and the percentage recovery was generally between 91% and 100%.

CONCLUSION

The mineralization of 2,4-D in clay soil was higher than that in clay loam soil under anaerobic conditions. Under aerobic conditions, the soil type had no influence on mineralization capacity of 2,4-D during 90 d. The soil binding increased with time whereby the extractable 14C-residues simultaneously decreased. Chromatographic analysis of the methanol extractable 14C-residues of soils revealed the presence of 2,4-D as a main product together with 2,4-dichlorophenol.

Recurrent cholangiocarcinoma: negative autopsy results after aggressive management

Cholangiocarcinoma is one of the most common malignancies of the biliary tree. Most cases are perihilar. Cholangiocarcinoma usually has an indolent, slowly progressive course and is associated with a high mortality rate. In this article, we discuss the management of perihilar cholangiocarcinoma by radiation therapy and chemotherapy in a case in which no recurrence was found on autopsy.

Is regional tonometry a reliable index of tissue oxygenation? A comparative study with conventional global monitoring

This study was carried out on 30 critically ill patients admitted to the ICU of Farwania Hospital (Kuwait). All patients had clinical evidence of organ dysfunction or impending multiple organ failure. The severity of their pathology on admission was assessed according to the APACHE II score. The study of each patient began after inserting the pulmonary artery catheter. The prospectively defined end-point of the study was the removal of the pulmonary artery catheter (72 hours) or death of the patient with the catheter in situ. The aim of the study was to determine the sensitivity and specificity of the intra-gastric mucosal pH (pHi) and other derived data in assessing the adequacy of tissue oxygenation, guiding therapy and prediction outcome. The results showed that pHi, pHa-Hi and PaCO2-PO2regional (reg) gradients were the most sensitive indices of tissue oxygenation and predictors of outcome. The mortality rate increased when pHi, PaCO2-PCO2reg and pHa-pHi gradients were < 7.3, > 10 mm Hg and < 0.2 respectively. The derived variables obtained by invasive monitoring like base deficit (BD), lactate concentration in mixed venous blood (Lmv) and oxygn uptake index (O2 UI) were valuable adjunct indices of tissue oxygenation. The risk ofmortality increased whten the BD was > -5.5 +/- 1.2 meq.L-1, Lmv was > 4.5 +/- 1.2 mmol.L-1, and O2UI was < 100 +/- 6 ml.min-1.m-2. We recommend the use of gastric tonometry in routine ICU clinical practice.

Cisplatin induced reversible bilateral vocal cord paralysis: an undescribed complication of cisplatin

BACKGROUND

Bilateral vocal cord paralysis is uncommon. Most cases occur secondary to trauma, malignancy, surgery, or intubation. Also, it was reported as a side effect of Vinca alkaloids.

METHODS

We report a patient with small cell lung cancer who developed bilateral vocal cord paralysis and needed to be intubated after treatment with cisplatin and etoposide. All workups excluded metastases as a cause of bilateral vocal cord paralysis. The patient required tracheostomy; she did not receive any further chemotherapy. After 11 weeks, vocal cord paralysis disappeared, tracheostomy was reversed, and the patient remained symptom free; however, 6 months later, the patient developed brain and liver metastases and died from her disease with no evidence of vocal cord paralysis.

RESULTS

We report a case of reversible bilateral vocal cord paralysis that we believe to be secondary to cisplatin toxicity, which is an undescribed complication of this drug.

CONCLUSION

Cisplatin can induce reversible bilateral vocal cord paralysis. The concurrent use of cisplatin and etoposide might have contributed to this complication in our patient.

Dietary cancer risk from conditional cancerogens in produce of livestock fed on species of spurge (Euphorbiaceae). III. Milk of lactating goats fed on the skin irritant herb Euphorbia peplus is polluted by tumor promoters of the ingenane diterpene ester type

Special procedures were developed to investigate poisonous milk of lactating goats fed experimentally on aerial parts of the herb Euphorbia peplus L. In extracts of the milk, weakly irritant in the mouse-ear assay, three diterpene ester toxins were detected by techniques of high-performance liquid chromatography. They are of the ingenane structural type: Euphorbia factor Pel (ingenol 20-acetate 3-angelate), Euphorbia factor Pe2 (20-deoxyingenol 3-angelate) and Euphorbia factor Pe4 (20-deoxyingenol-6alpha,7alpha-epoxide 3-angelate). From goats milk collected 15 days after cessation of the experimental feeding period, extracts were completely free of diterpene ester toxins. The toxins polluting the milk are identical to diterpene ester entities occurring in the aerial parts of E. peplus. Of these, Euphorbia factors Pel and Pe2 are known as promoters of tumors of mouse skin. Apart from the toxic Euphorbia factors, the non-toxic parent alcohol ingenol was also detected in the milk. It is absent in the plant, and may have been generated metabolically from a certain portion of the toxic diterpene esters picked up by the goats from their fodder. The results presented here provide, for the first time, data for a novel interpretation of the locally high incidence of esophageal cancer observed in certain areas in the Caspian littoral of Iran, associated with a greater consumption of goat's (and sheep's) milk.

Dietary cancer risk conditional cancerogens in produce of livestock fed on species of spurge (Euphorbiaceae). I. Skin irritant and tumor-promoting ingenane-type diterpene esters in E. peplus, one of several herbaceous Euphorbia species contaminating fodder of livestock

The hypothesis was proposed that there is a risk of dietary cancer from conditional cancerogens in produce of livestock polluted with irritants of the diterpene ester type, picked up by feeding on species of Euphorbiaceae (spurge). To challenge this, several herbaceous plants of the genus Euphorbia, widespread as weeds and contaminants of livestock fodder, were identified botanically and extracts of their aerial parts were tested for irritancy on the mouse ear. As compared to a standard probe of croton oil, the extracts of E. peplus, E. nubica and E. helioscopia displayed irritancy. The most active extract (that from E. peplus) was investigated by a fractionation procedure monitored by the mouse ear assay, and five molecularly uniform irritant Euphorbia factors Pe1-Pe5 were identified as diterpene ester-type toxins. Together these factors comprise at least 11 ppm in the aerial parts. They were characterized individually to carry the diterpene parent alcohols ingenol, 20-deoxyingenol, and 20-deoxyingenol-6 alpha, 7alpha-epoxide. The irritancy of the aerial plant parts was shown to be caused mainly by the Euphorbia factors Pe1 and Pe2 together. Upon chronic administration of these irritants and hyperplasiogens as principal cancerogenic risk factors in the mouse skin initiation/promotion bioassay, Pe1 and Pe2 were established as tumor promoters. These findings together support the initial hypothesis and suggest the need for further investigations to determine whether there is a consequent risk of dietary cancer.