D. Kavanagh

Oestrogen and the colon: potential mechanisms for cancer prevention

The role of oestrogen in oncogenesis has been examined extensively, especially in the context of breast cancer, and receptor modulators are an integral part of targeted treatment in this disease. The role of oestrogen signalling in colonic carcinoma is poorly understood. Men are more susceptible than women to colon cancer. Furthermore, hormone-replacement therapy affords an additive protective effect for postmenopausal women, and when these women do develop cancer, they typically have less aggressive disease. The discovery of a second oestrogen receptor (ERbeta) and its over expression in healthy human colon coupled with reduced expression in colon cancer suggests that this receptor might be involved. The underlying mechanism, however, remains largely unknown. In this Review, we discuss the various hypotheses presented in the published literature. We examine the cellular and molecular mechanisms through which oestrogen is purported to exert its protective influence, and we review the evidence available to support these claims.

Factors affecting metastases to non-sentinel lymph nodes in breast cancer.

Aims: Because sentinel lymph node (SLN) biopsy for breast cancer has become well established, one of the challenges now is to determine which patients require a completion axillary dissection following a positive SLN biopsy. Methods: A prospective database of patients who underwent SLN biopsy for invasive breast cancer from July 1999 to November 2002 (n  =  180) was analysed. Fifty four patients (30%) had one or more positive SLN, and all underwent a completion axillary dissection. This subgroup was further analysed to delineate which factors predicted non-SLN metastasis. Results: Twenty six of the 54 patients with a positive SLN had additional metastases in non-SLNs. Significant variables that predicted non-SLN metastasis included extranodal extension (odds ratio (OR), 17.399; 95% confidence interval (CI), 1.69 to 178.96) and macrometastasis within the SLN (OR, 6.985; 95% CI, 1.291 to 37.785). Conclusions: In patients with invasive breast cancer and a positive SLN, extranodal extension or macrometastasis within the SLN were both independent predictors of non-SLN involvement.

Unusual presentation of a giant parathyroid adenoma: report of a case.

Parathyroid adenomas account for most cases of primary hyperparathyroidism (1° HPT). Certain symptoms and biochemical abnormalities alert the surgeon to their presence, since these benign tumors are rarely evident on physical examination. Moreover, because they are usually very small, preoperative localization using sestamibi scanning or ultrasonography is required to avoid bilateral neck exploration. Parathyroid adenomas rarely attain huge proportions. We report a case of a parathyroid adenoma measuring 8 × 5 × 3.5 cm and weighing 110 g; to our knowledge the greatest mass reported in the literature. Interestingly, despite its huge size it did not cause many of the hypercalcemic symptoms usually associated with larger adenomas, but rather it manifested with symptoms of local pressure, another unusual property of this atypical tumor.

Adjuvant therapies in the treatment of stage II and III malignant melanoma

BACKGROUND The incidence of cutaneous melanoma has increased during the past three decades. The development of sentinel lymph node biopsy has facilitated better staging. Despite these improvements, 5-year survival rates for American Joint Committee on Cancer stage II and III disease range from 50%-90%. METHODS A review of the current literature concerning adjuvant therapies in patients with stage II and III malignant melanomas was undertaken. RESULTS The focus of adjuvant therapies has shifted from radiotherapy, BCG and levamisole to newer biological agents. Interferon, interleukin and vaccines have been evaluated but none of these agents have demonstrated an increase in overall survival in patients with stage II and III melanoma. Interferon can prolong disease-free interval. CONCLUSION At present, no adjuvant therapy improves overall survival in patients with stage II and III melanoma. New staging allows more accurate stratification of patients for clinical trials.

The impact of evolving management strategies on negative appendicectomy rate

Aim  The management of appendicitis has evolved from the era of open surgery with a negative appendicectomy rate ranging from 20 to 30%. Diagnostic adjuncts such as computed tomography (CT), ultrasound (US) and diagnostic laparoscopy (DL) facilitate refinement of the clinical impression in equivocal cases. The aim of this study was to determine the impact of the increased availability and selective utilization of diagnostic adjuncts on the negative appendicectomy rate.

Incarcerated transmesosigmoid hernia presenting in a 60-year-old man: a case report

IntroductionInternal hernias are a rare cause of small bowel obstruction and are estimated to account for 1% to 5% of cases. Herniation through a defect in the sigmoid mesocolon constitutes 6% of all internal hernias.Case presentationIn this case report we describe a rare case of a fit and healthy 60-year-old man, with no previous history of abdominal surgery, who presented with signs and symptoms of small bowel obstruction as a result of an incarcerated transmesosigmoid hernia. The hernia was reduced and the incarcerated loop of small bowel was found to be viable. The patient made a good recovery and was discharged home on the fourth post-operative day.ConclusionInternal hernias can cause considerable morbidity and mortality, so prompt diagnosis is paramount. Transmesosigmoid hernias are most common in the paediatric population; however, our patient was 60 years old. This report highlights the importance of considering an internal hernia as a cause of small bowel obstruction in individuals of all age groups and especially in those without a previous history of abdominal surgery.

Mesenteric desmoid tumor causing ureteric obstruction

Abstract:  Desmoid tumors are rare, accounting for just 0.03% of all neoplasms and less than 3% of all soft tissue tumors. Although these tumors are benign, they are locally invasive and can cause considerable morbidity and mortality. We describe the case of a 16‐year‐old female who presented with hydronephroureter secondary to an intra‐abdominal desmoid tumor. This case report draws the attention of urologists to the diagnostic dilemma and therapeutic challenges associated with an intra‐abdominal mass causing ureteral obstruction especially in young patients.

The significance of immunohistochemistry positivity in sentinel nodes which are negative on haematoxylin and eosin in breast cancer

INTRODUCTION Sentinel lymph node (SLN) biopsy allows a more detailed examination of a smaller number of lymph nodes in patients with clinically node negative breast cancer. Immunohistochemistry detects small tumour burden not routinely seen on haematoxylin and eosin (H&E). The significance of such findings remains to be fully elucidated. AIM To assess the axillary disease burden of patients in whom the sentinel lymph node biopsy was positive on immunohistochemistry and negative on H and E. METHODS An analysis of patients who underwent SLN mapping for breast cancer at St Vincents University Hospital from January 1st, 2000 to December 31st, 2006 was conducted. All SLNs were assessed by serial H&E and IHC sections. Patients with micrometastases (0.2-2mm) underwent a completion axillary lymph node dissections (CLND). Patients with ITC (<0.2mm) were individually discussed and a CLND was performed selectively based on additional clinicopathological criteria and patient preference. Analysis of the additional nodes from CLND was performed. Patients were followed for a median of 27 months (range 12-72 months). RESULTS 1076 patients who underwent SLN were included for analysis. 211 (20%) had a positive SLN biopsy using H&E. Forty-nine patients (5%) had a negative SLN on H&E which was positive on IHC. Of these, 15 had micrometastases and underwent a CLND. Two had further axillary nodal disease. ITC were found in the remaining 34 patients. Sixteen of these patients underwent a CLND. Five of this group had further nodal disease. CONCLUSION Micrometastases and isolated tumour cells, detected only by immunohistochemical analysis of sentinel lymph nodes, are associated with further positive nodes in the axilla in up to 15% of patients. This upstaging of disease may impact upon patient outcome.

Management of gestational nephrolithiasis in the presence of a bicornuate uterus and pelvic kidney.

Abstract  A 39‐year‐old para 0+1 woman with known nephrolithiasis within a left‐sided pelvic kidney presented with left‐sided renal colic at 7 weeks gestation. She had a previous miscarriage due to a bicornuate uterus. Ultrasound and magnetic resonance urography confirmed an incomplete obstruction of the left upper renal tract which was relieved by percutaneous nephrostomy. She presented again at 14 weeks with renal colic and minimal output. An ultrasound confirmed recurrent hydronephrosis and a nephrostogram showed that the catheter had retracted almost completely from the collecting system. This was considered to be due to the upward pressure of the enlarging uterus on the catheter, which had been fixed externally to the skin. This problem was obviated by not securing the replacement nephrostomy tube to the skin. She developed pre‐eclamptic toxaemia and gave birth at 35 weeks gestation by caesarean section. The calculus was later dissolved using extra‐corporeal shockwave lithotripsy.

Needle-localised biopsy of impalpable breast lesions: A novel adjunct to surgical technique and specimen mammography

Successful screening programmes have resulted in the more frequent detection of early impalpable breast tumours. Effective surgical management of impalpable lesions demands a precise approach to excision which is currently aided by radiologically guided needle-localisation of the lesion prior to operative removal. The surgical specimen procured is most commonly evaluated for tumour presence by specimen mammography intra-operatively or by histological analysis. The latter is more accurate but requires lengthy laboratory processing, which may result in re-operation if the primary excision is inadequate. Although advocated as the standard of care, specimen mammography remains an imperfect technique. In this article we describe a piece of surgical apparatus which attempts to address some of the concerns associated with specimen mammography. It is an inexpensive compression device which reduces operative time, avoids portable fluoroscopy, increased radiation and the necessity for specialised equipment