Daisy Franzini

Neuroendocrine (Merkel cell) carcinoma of the skin. Its natural history, diagnosis, and treatment.

Over 400 cases of neuroendocrine (Merkel cell) carcinoma of the skin (NCS) have been reported. This tumor continues to pose problems in diagnosis and effective treatment for physicians unfamiliar with its biological characteristics. Reported here are five additional cases of NCS and the literature for this rare neoplasm is comprehensively reviewed. An early and accurate diagnosis is made possible by combining clinical presentation with results of histologic study, immunoperoxidase staining for neuron-specific enolase (NSE), epithelial membrane antigen (EMA), cytokeratins, and electron microscopy. NCS is an aggressive tumor. Depending on the length of follow-up, up to 40% of tumors locally recur, 55% develop regional nodal metastases, and 36% undergo distant metastasis. Survival is sex, but not age, dependent, with an overall 2-year survival rate of 72% (males 58% vs. females 79%). No standard procedure for initial and/or follow-up treatment for NCS exists. The authors recommend that NCS be treated, whenever possible, using the same rationale as applied for the treatment of squamous cell carcinoma of the skin.

Laser angioplasty with angioscopic guidance in humans

An experimental study was conducted in 11 patients to evaluate the immediate effects of laser recanalization during peripheral arterial bypass surgery. Angioscopy allowed precise localization and identification of the occlusion. A 1 or 2 mm optical fiber probe was used. Laser energy was regulated using the least amount of energy necessary for recanalization. New vascular channels were made in 10 of the 11 patients. After recanalization the arterial segment was excised for histologic evaluation. Smaller channel diameters were made with the 1 mm probe (1.5 +/- 0.6 mm) than with the 2 mm probe (3 +/- 0.3 mm) (p less than 0.05). Flow through channels (mean pressure 80 mm Hg) made with the 2 mm probe was greater than that through channels made with the 1 mm probe (150 +/- 102 versus 19.7 +/- 10 cc/min) (p less than 0.05). The amount of debris formed was small with both probes. Vascular perforations were less frequent with the 2 mm probe (two of nine arteries) compared with the 1 mm probe (four of four arteries). Successful recanalization with flow rates expected to maintain vascular patency was achieved only with the 2 mm probe. Histologic studies at nonperforated sites demonstrated that the elastica of the artery appeared to be preserved whereas the overlying plaque and underlying media were thermally disrupted. This suggests that the elastic tissue acts as an optical window allowing the argon beam to go through it without causing morphologic damage. Except for fresh thrombus, atheromas including calcific plaque and old organized thrombus were readily vaporized. These results are encouraging for the use of the laser for vascular recanalization in humans.

Long-Term Consequences After Jejunoileal Bypass for Morbid Obesity

This study assesses the long-term results ofjejunoileal bypass (JIB) in 43 prospectively followedpatients whose surgical bypass remained intact.Follow-up was 12.6 ± 0.25 years from JIB. Weightloss and improved lipid levels, glucose tolerance,cardiac function, and pulmonary function weremaintained. Adverse effects such as hypokalemia,cholelithiasis, and B12 or folate deficiency decreasedover time. The incidence of diarrhea remained constant(63% vs 64% at five years), while the occurrence ofhypomagnesemia increased (67% vs 43% at five years, P< 0.05). Nephrolithiasis occurred in 33% of patients. Hepatic fibrosis developed in 38% of patientsand was progressive. Overall, after more than 10 years,35% of patients appeared to benefit from JIB as definedby alleviation of preoperative symptoms and the development of only mild complications (vs47% at five years). On the other hand, irreversiblecomplications appeared to outweigh any benefit derivedfrom the JIB in 19% (vs no patients at five years; P < 0.01). In summary, patients with JIBremain at risk for complications, particularly hepaticfibrosis, even into the late postoperativeperiod.

The healing process in normal canine arteries and in atherosclerotic monkey arteries after transluminal laser irradiation

To evaluate the healing response of both normal and atherosclerotic arteries to laser radiation, 7 mongrel dogs and 4 hypercholesterolemic atherosclerotic monkeys underwent catheterization with a right Judkins catheter-optical fiber system designed to maximize arterial wall injury. Argon laser radiation was then delivered to the abdominal aorta and iliofemoral arteries. In the 11 animals, a total of 917 sites were irradiated in 33 arteries. Angiography did not reveal dissection or aneurysm formation; occlusive thrombosis was found in 2 arteries. Perforation of the arterial wall was a frequent complication. In animals killed between 1 hour and 4 days, light and electron microscopy of lased sites showed craters filled with a coagulum of blood and cellular debris with only a few adherent platelets. Healing occurred with a minimal inflammatory response and involved both fibroblasts and smooth muscle cells. Reendothelialization was seen in all animals killed between 7 and 14 days after lasing and was complete by 30 to 60 days. Within this period, no accelerated atherosclerosis was seen at lased sites in the hypercholesterolemic monkeys. It is concluded that transluminal lasing of normal arteries in dogs and in atherosclerotic arteries of monkeys is followed by healing and reendothelialization within a few weeks.

Reduction in myocardial neutrophil accumulation and infarct size following administration of thromboxane inhibitor U-63,557A

We examined the effects of a new selective thromboxane A2 (TXA2) synthetase inhibitor, U-63,557A, on myocardial infarct size 48 hours following left coronary ligation in rats. With a single 8 mg/kg dose of U-63,557A (furegrelate) administered prior to coronary ligation, platelet aggregation and serum TXA2 formation declined significantly (p less than 0.02) for up to 48 hours. Myocardial infarct size, as measured by planimetry of serial left ventricular sections, was decreased from 44 +/- 3% (saline-treated control rats) to 34 +/- 4% (p less than 0.05). Left ventricular creatine kinase (CK) following coronary ligation was also preserved in U-63,557A vs saline-treated control animals (p less than 0.05). These beneficial effects of U-63,557A were not accompanied by reduction in the indices of myocardial oxygen demand (heart rate and arterial pressure). Furthermore, neutrophil accumulation in the infarcted myocardium was significantly decreased by U-63,557A (26 +/- 6 vs 96 +/- 3/high-power field [p less than 0.01]). These data suggest that administration of a single dose of selective TXA2 synthetase inhibitor prior to coronary ligation modulates platelet function for up to 48 hours and reduces the extent of myocardial injury, which may, in part, relate to decrease in neutrophil accumulation.

Transfer of hepatitis B virus by contaminated reusable needle electrodes after electrodesiccation in simulated use

Reusable needle electrodes have been standard for electrodesiccation procedures commonly done by dermatologists. This study investigates the risk of transmission of hepatitis B virus by such electrodes during simulated use with electrodesiccation. Sterile needle electrodes were inoculated with either purified hepatitis B surface antigen (HBsAg+) concentrate or serum positive for both HBsAg and deoxyribonucleic acid (DNA) polymerase activity (a measure of infectious and replicating hepatitis B virus), followed by simulated use for electrodesiccation at various settings and rinsing of the tip with negative serum. The rinse serum was then assayed for HBsAg, DNA polymerase activity, and the presence of viral particles by electron microscopy. HBsAg could be transferred through the electrodesiccation procedure at all settings used. Although DNA polymerase activity was negative in the rinse serum, electron microscopy demonstrated transfer of HBsAg forms and complete virus. These results suggest a potential risk of spread of hepatitis B virus by reusable needle electrodes for electrodesiccation.

Reduced Myocardial Neutrophil Accumulation and Infarct Size Following Thromboxane Synthetase Inhibitor or Receptor Antagonist

Since thromboxane A2 (TXA2) re lease may relate to the extension of myocardial injury following coro nary ligation, the authors examined the effects of pretreatment with a se lective TXA 2 synthetase inhibitor U- 63,557A, or a TXA2 receptor anta gonist SQ-29,548, on myocardial in farct size forty-eight hours following left coronary ligation in rats. Myocardial infarct size (as percent of left ventricle, LV) was decreased from 44±3% in saline-treated con trol animals to 34±4% (P < 0.05) in U-63,557A-treated animals and to 32±4% (P < 0.05) in SQ-29,548 treated animals (U-63,557A-treated vs SQ-29,548-treated, P=NS). LV creatine kinase (CK) was 5.08 ± 0.42 IU/mg protein in noninfarcted un treated rats and 1.79 ± 0.21 IU/mg protein in saline-treated infarcted rats. LV CK was 2.86 ± 0.40 IU/mg protein in U-63,557A-treated rats and 3.11 ± 0.51 IU/mg protein in SQ-29,548-treated infarcted rats (both P < 0.05 compared with saline- treated rats). The beneficial effects of U-63,557A and of SQ-29,548 were not accompanied by reduction in in dices of myocardial oxygen demand (heart rate and arterial pressure). However, neutrophil accumulation in the infarcted myocardium was mark edly decreased by U-63,557A and SQ-29,548 pretreatment. Myocardial myeloperoxidase activity, a specific marker of neutrophil infiltration, was also decreased (P < 0.02) in U- 63,557A- and SQ-29,548-treated ani mals (0.09 ± 0.03 and 0.07 ± 0.02 units/100 mg, respectively) compared with saline-treated infarcted rats (0.19 ± 0.04 units/100 mg). In vitro incubation of U-63,557A and SQ- 29,548 caused a significant and simi lar reduction in f-MLP-induced neu trophil chemotaxis, and U-63,557A increased prostacyclin formation in whole blood. These data suggest that reduction in the extent of myocardial injury by TXA2 synthetase or recep tor inhibitors may, in part, relate to a decrease in neutrophil accumulation in the infarcted tissue. In spite of dif ferences in mechanisms of action of U-63,557A and SQ-29,548, both agents exert a similar protective ef fect on the extent of myocardial in jury following coronary ligation. Reduction in neutrophil accumula tion in the infarcted zone, as well as in f-MLP-directed chemotaxis in vi tro, suggests that TXA2 inhibition may modulate neutrophil migration.

The presence of benign prostatic glands in perineural spaces.

The close neural-epithelial interaction seen in cases of prostatic carcinoma often is a criterion for malignancy. In a retrospective histological study of 26 nonneoplastic prostate glands obtained at autopsy benign glands were found in the perineural spaces in 6. In 5 of these cases the glands were cytologically benign, with a double layer of epithelial cells without nuclear pleomorphism, hyperchromatism and eosinophilic nucleoli. The remaining case involved an atrophic gland. Owing to the small size, nuclear hyperchromatism and, sometimes, crowded architectural arrangement atrophic glands may mimic malignant glands. This could be a potential cause of concern for the surgical pathologist when these glands appear around nerves. Perineural invasion should be interpreted cautiously when used as a criterion for malignancy.

Anaplastic neoplasm in a patient with hairy cell leukemia

A 63‐year‐old white man had a history of recurrent pneumonia, pancytopenia, and splenomegaly when the diagnosis of hairy cell leukemia was made on bone marrow biopsy examination. Splenectomy confirmed that diagnosis and his pancytopenia moderately improved. Three years following the diagnosis, the patient developed an upper abdominal mass involving the stomach wall that was found to be an anaplastic “large cell” neoplasm. Palliative radiotherapy was started, but the patient died 2 months later. Cytochemical studies of the anaplastic gastric neoplasm revealed cytoplasmic tartrate resistant acid phosphatase activity. Electron microscopy showed no epithelial differentiation. These observations suggest that the gastric neoplasm represented an evolution of hairy cell leukemia into a more aggressive tumor analogous to the transformation that occurs in other B‐cell neoplasms.