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ANDROGEN-INDUCED HEPATOMA

Three cases of hepatocellular carcinoma are reported in young men who had been taking androgenic-anabolic steroids. The tumours were histologically similar to those described in previous reports. The tumour progressed slowly in two patients during four and seven years of observation, but in the latter bony metastases occurred. In two patients the tumours regressed after administration of the drug was discontinued. These cases strengthen the evidence that exogenous androgenic-anabolic steroids may produce liver tumours. The use of these drugs should be confined to serious conditions in which they are known to be effective. Biochemical tests of liver function and serum alphs-fetoprotein estimation are not useful as screening-tests for hepatoma in patients taking androgens, and regular isotopic liver-scanning is recommended.

Role of ischemia and infarction in late right ventricular dysfunction after atrial repair of transposition of the great arteries

OBJECTIVES This study was conducted to assess whether myocardial ischemia and/or infarction are involved in the pathogenesis of late right ventricular dysfunction in adult survivors of atrial baffle repair for transposition of the great arteries in infancy. BACKGROUND The medium-term success of intraatrial baffle repair for transposition of the great arteries is good, with many patients surviving into adult life, but prognosis can be limited by progressive right ventricular dysfunction. We hypothesized that ongoing myocardial ischemia and/or infarction are important factors in the pathogenesis of this complication. Radionuclide techniques offer an opportunity to study both myocardial perfusion and concomitant ventricular wall motion. METHODS Dipyridamole sestamibi single-photon emission computed tomography followed by rest sestamibi single-photon emission computed tomography was used to assess right ventricular myocardial perfusion, wall motion, wall thickening and ejection fraction in 22 adolescents/young adults who had undergone atrial baffle repair for simple transposition of the great arteries at median 6.7 (range 0.5 to 54) months of age. The patients were aged 10 to 25 (median 15.5) years; 19 in New York Heart Association class I, 2 in class II and 1 in class III. All were in a regular cardiac rhythm during the studies. The right ventricular tomographic images were examined in three parallel and two orthogonal planes, analyzed in 12 segments. RESULTS Perfusion defects were evident in all patients in at least one segment, in either the rest or stress images. Twelve patients (55%) demonstrated fixed defects only, nine (41%) had fixed and reversible defects and one (4.5%) had reversible defects only. Concomitant wall-thickening abnormalities occurred in 83% of segments with fixed perfusion defects, mirrored by a reduction in wall motion in 91% of segments analyzed. Right ventricular ejection fraction was correlated with age (R = 0.62; p = 0.002), and with wall-thickening abnormalities (R = 0.60; p < 0.005). CONCLUSIONS Reversible and fixed perfusion defects with concordant regional wall motion abnormalities occur in the right (systemic) ventricle 10 to 20 years after Mustard repair for transposition of the great arteries; this may be important in the pathogenesis of late right ventricular dysfunction in this group.

Lymphoscintigraphy to identify sentinel lymph nodes in patients with melanoma.

Lymphoscintigraphy (LS) has been performed for 8 years in patients of the Sydney Melanoma Unit, to define lymphatic drainage patterns. Over the past 2 years, LS has also been used to locate the sentinel lymph node prior to surgery. Our technique for LS and subsequent sentinel node biopsy has an accuracy of 97%. All sentinel nodes must be marked to ensure the successful application of the sentinel biopsy technique. We have found that the axilla and groin average just over one sentinel node per draining node group for lesions on the trunk and upper limb, but have noted that drainage to the groin differed when lower limb lesions were studied. Because of the anastomosis of lymph vessels in the upper thigh, multiple sentinel nodes are identified in the groin in some patients. We have found an average of three sentinel nodes in the groin when lymph drainage from lower limb lesions was studied with LS. This difference demands a modification of the LS technique, with early imaging of the groin nodes to identify all sentinel nodes in each patient. The depth of the sentinel nodes can also be measured and the location of all interval nodes marked on the skin. This ensures that all sentinel nodes and interval nodes can be removed at the time of surgery.

Localization of coronary artery disease with exercise electrocardiography: correlation with thallium-201 myocardial perfusion scanning☆

In 61 patients with single vessel coronary artery disease (70 percent or greater obstruction of luminal diameter in only one vessel) and no previous myocardial infarction, the sites of ischemic changes on 12 lead exercise electrocardiography and on thallium-201 myocardial perfusion scanning were related to the obstructed coronary artery. The site of exercise-induced S-T segment depression did not identify which coronary artery was obstructed. In the 37 patients with left anterior descending coronary artery disease S-T depression was most often seen in the inferior leads and leads V4 to V6, and in the 18 patients with right coronary artery disease and in the 6 patients with left circumflex artery disease S-T depression was most often seen in leads V5 and V6. Although S-T segment elevation was uncommon in most leads, it occurred in lead V1 or a VL, or both, in 51 percent of the patients with left anterior descending coronary artery disease. A reversible anterior defect on exercise thallium scanning correlated with left anterior descending coronary artery disease (probability [p] less than 0.0001) and a reversible inferior thallium defect correlated with right coronary or left circumflex artery disease (p less than 0.0001). In patients with single vessel disease, the site of S-T segment depression does not identify the obstructed coronary artery; S-T segment elevation in lead V1 or aVL, or both, identifies left anterior descending coronary artery disease; and the site of reversible perfusion defect on thallium scanning identifies the site of myocardial ischemia and the obstructed coronary artery.

Sentinel node biopsy for melanoma: Where have we been and where are we going?

The sentinel node (SN) concept is not new, but its potential surgical application was not fully appreciated until the landmark report by Morton and Cochran et al. in 1992. It has since been confirmed that SN status in melanoma patients accurately reflects the status of the entire regional node field, and is a critically important prognostic indicator. However, randomized trials have yet to determine whether the SN biopsy technique is of any therapeutic value. With extended follow-up times, false-negative SN rates of up to 15% are being reported and presumably represent failures of nuclear medicine and/or surgery and/or histopathology. Innovative methods of increasing the accuracy of SN identification and of checking this retrospectively are being assessed. The next great challenge is to develop methods of SN assessment that are noninvasive yet are even more accurate than present methods. Techniques such as in vivo proton magnetic resonance spectroscopy hold great promise and suggest that this goal might be achievable.

Outcome following sentinel node biopsy plus wide local excision versus wide local excision only for primary cutaneous melanoma: analysis of 5840 patients treated at a single institution.

Objective:Worldwide, sentinel node biopsy (SNB) is now a standard staging procedure for most patients with melanomas 1 mm or more in thickness, but its therapeutic benefit is not clear, pending randomized trial results. This study sought to assess the therapeutic benefit of SNB in a large, nonrandomized patient cohort. Methods:Patients with primary melanomas 1.00 mm or more thick or with adverse prognostic features treated with wide local excision (WLE) at a single institution between 1992 and 2008 were identified. The outcomes for those who underwent WLE plus SNB (n = 2909) were compared with the outcomes for patients in an observation (OBS) group who had WLE only (n = 2931). Median follow-up was 42 months. Results:Melanoma-specific survival (MSS) was not significantly different for patients in the SNB and OBS groups. However, a stratified univariate analysis of MSS for different thickness subgroups indicated a significantly better MSS for SNB patients with T2 and T3 melanomas (>1.0 to 4.0 mm thick) (P = 0.011), but this was not independently significant in multivariate analysis. Compared with OBS patients, SNB patients demonstrated improved disease-free survival (DFS) (P < 0.001) and regional recurrence-free survival (P < 0.001). There was also an improvement in distant metastasis-free survival (DMFS) for SNB patients with T2 and T3 melanomas (P = 0.041). Conclusions:In this study, the outcome for the overall cohort after WLE alone did not differ significantly from the outcome after additional SNB. However, the outcome for the subgroup of patients with melanomas more than 1.0 to 4.0 mm in thickness was improved if they had a SNB, with significantly improved disease-free and DMFS.

Variability of cutaneous lymphatic flow rates in melanoma patients.

Preoperative lymphoscintigraphy was performed in 198 consecutive patients with cutaneous melanoma prior to their definitive surgical treatment. After intradermal injection of antimony sulphide colloid labelled with technetium- 99m, lymphatic flow rates were measured in each patient and found to vary according to the location of the primary tumour. The fastest flow rates occurred from melanoma sites on the distal limbs, particularly the lower limbs. The slowest flow rates were from the head and neck region and the proximal limbs, especially the upper arms and shoulders. Lack of flow in the early dynamic images occurred most commonly for tumours on the upper arms and shoulders. These results can be used to optimize the timing of blue dye injection prior to surgery and may influence the sentinel node biopsy method to be used in individuals who show no early drainage.

Demonstration of second-tier lymph nodes during preoperative lymphoscintigraphy for melanoma: incidence varies with primary tumor site.

AbstractBackground: Preoperative cutaneous lymphoscintigraphy (LS) to identify sentinel (first-tier) lymph nodes was performed in 250 consecutive melanoma patients before wide local excision only or wide local excision with sentinel node biopsy. Methods: The location of the sentinel nodes was marked on the overlying skin in all patients. Whether or not tracer was present in second-tier lymph nodes on the delayed scans was recorded for each patient and related to the lesion site at which the tracer had initially been injected. For 100 consecutive patients the rate of tracer movement through the lymphatic channels was compared to the incidence of second-tier drainage. Results: Second-tier nodes were visualized in all patients with melanomas on the leg and thigh, and in almost all patients with melanomas on the forearm and hand, but were seen less often in patients with more centrally located melanomas. There was a significant correlation between the rate of lymph flow and the incidence of demonstrable second-tier drainage. Conclusion: The results suggest that the physiology of the lymphatic system varies depending on the origin of the lymphatic vessel. These findings have important implications for application of the sentinel node biopsy technique in individual patients.

Antimony by ICP-MS as a marker for sentinel lymph nodes in melanoma patients

A sensitive, accurate and specific method for the analysis of antimony by ICP-MS is presented as a marker of the sentinel lymph node in melanoma patients.

Sentinel lymph node biopsy in patients with melanoma and breast cancer

Abstract