Results Of Routine Examination Research Articles

Histopathological assessment of residual retroperitoneal mass removed in patients after chemotherapy for non-seminomatous germ cell tumours of the testis.

Between 1990 and 1999, 182 men were treated for non-seminomatous germ cell testicular tumours. In 24 of them after chemotherapy a residual retroperitoneal mass was removed. In 14 of them additional immunohistochemical (IHC) examinations using antibodies against cytokeratins, vimentin, PLAP, CD30, AFP, βhCG, p53, and MIB-1 were performed. We compared the results of those additional studies with the results of routine histopathological examination. Histological assessment revealed most frequently (ca. 54% of cases) non-neoplastic lesions, i.e. fibro-cystic, necrotic or inflammatory tumours and lymphatic tissue. In about 33% of cases, surviving live neoplastic cells were found.

Clinical observations in mesh suture treatment for infants of Kasabach-Merritt phenomenon.

This study aims to evaluate the efficacy and adverse effects of the mesh suture treatment for infants of Kasabach-Merritt phenomenon and to report our treatment experience. Of the three patients, two of the cases occurred in the scalp and one occurred in the back of the chest, with platelet counts < 40 × 109 /L before the treatment, reduced fibrinogen levels and increased D-dimer levels. All the three patients underwent the mesh suture treatment of the tumour area. Post-treatment observations were made regarding the surface colour and texture of the tumours, periodic routine blood examination results, fibrinogen and D-dimer levels. After treatment, the degree of swelling on the tumour surface was reduced, surface tension was decreased, the tumour colour turned pale red from dark red and the skin gradually returned to normal. Two days after treatment, the platelet counts increased to 70 × 109 /L or higher; the platelet count reached a normal level after 1 week in two cases. The fibrinogen level increased in varying degrees after treatment, whereas the D-dimer level was reduced. One case showed a small amount of exudate at the suture area, 1 month after the treatment; improvements were observed 3 days after changing the local dressing. All the patients were followed up for 6 months to 1 year, during which the patients showed complete regression of the lesion and relapse, normal platelet counts and normal fibrinogen and D-dimer levels. We recommend the mesh suture treatment as the first treatment of choice for paediatric Kasabach-Merritt phenomenon.

Forearm extravasation injury during robot-assisted low anterior resection.

A 47-year-old female with an American Society of Anesthesiologists physical status of I was scheduled for robot-assisted low anterior resection and right hepatectomy. Her routine preoperative examination results were unremarkable. Standard monitoring devices were applied in the operating room, including a noninvasive blood pressure monitoring system, electrocardiogram, and pulse oximeter. A warm blanket was placed under the patient to maintain her body temperature. General anesthesia was induced with propofol 120 mg, continuous remifentanil infusion 0.25 μg/kg/min, and rocuronium 0.6 mg/kg via a pre-existing 20-gauge intravenous catheter in the right ventral forearm without apparent resistance. Anesthesia was maintained with desflurane (5–7 vol%) and remifentanil (0.05–0.20 μg/kg/min). The right radial artery and right subclavian vein were catheterized. The patient was placed into the lithotomy and Trendelenburg position with both arms tucked using a fabric arm-straining device placed immediately proximal to the peripheral cannulation. All cannulations were confirmed to be functional. All fluids and medication were administered through the central cannulation with the exception of the anesthetic induction agents, 1.5 L of crystalloid solution (Plasmalyte A Ⓡ ; Baxter, Deerfield, IL, USA), and 250 ml of 5% albumin, the latter two of which are isotonic and iso-oncotic, respectively, with human plasma. Four hours later, both the arterial pressure waveform and the ipsilateral pulse oximeter reading were dampened. The monitor ing devices and peripheral line flow were checked, and the peripheral line was not flowing smoothly. Because the intravenous line worked well initially and only malfunctioned later, we assumed that frequent changes in positioning might have affected the alignment or tightness of the catheter and arm-restraining device, potentially kinking or dislodging the catheter. Considering that the operation was almost completed, we immediately stopped using the peripheral intravenous line to prevent extravasation injury. A new pulse oximeter probe was applied to the patient’s right ear. Because the dampening of the arterial cannulation appeared to worsen, noninvasive blood pressure was measured on the opposite arm. At the end of the procedure, the right forearm was undraped. The ventral surface of the arm was mildly swollen with bullae, redness, and skin abrasions, especially under the site of the arm-restraining device (Fig. 1). In contrast, the dorsal surface showed no abnormalities. Physical examination revealed palpable radial arterial capillary filling pressure with no sensory or motor defects. Following consulta

Associations between results of routine occupational health examinations and mortality during the following 40 years

ObjectivesMales in Norway born in 1905–1914 were recruited to a randomised clinical trial by occupational health physicians in 1964. A follow-up through 2005 offered the opportunity to estimate to which...

The usefulness of p57 KIP2 immunohistochemical staining and genotyping test in the diagnosis of the hydatidiform mole

Classification of molar gestations into complete hydatidiform mole (CHM) and partial hydatidiform mole (PHM) and their differentiation from nonmolar hydropic abortions (HA) are traditionally accomplished by morphology alone. Sometimes, the process may be inaccurate or inconclusive especially in early diagnosed cases. With the availability of p57 KIP2 immunostaining (the product of a strongly paternally imprinted and maternally expressed gene), it may be possible to classify these lesions objectively. P57 KIP2 immunostaining is absent in CHM because it lacks a maternal genome, whereas PHM and HA show positive staining. The aims of this study were to evaluate the results of routine histopathological examination and p57 KIP2 immunoreactivity in a large series of molar and nonmolar HA in Tunisia, and to compare the accuracy of p57 KIP2 immunohistochemistry with that of nuclear DNA microsatellite polymorphism in identifying CHM. The immunohistochemical expression of p57 KIP2 protein was investigated in 220 specimens of first trimester hydropic abortuses, and it was compared with the original diagnosis based on morphology, including 132 CHM, 49 PHM, and 39 HA. Concordant results were obtained in 210 cases. In 9 of 10 cases with a discordant diagnosis (negative immunostaining in 8 cases morphologically diagnosed as PHM and one case diagnosed as HA), microsatellite DNA genotyping analysis agreed with the results of p57 KIP2 staining, confirming the diagnosis of CHM in these cases. Twenty cases of CHM with negative p57 KIP2 immunostaining were also analyzed by genotyping and indicated the absence of maternal contribution and the homozygosity for a single paternal allele in concordance with the androgenetic and monospermic origin of CHM in these cases. We confirm that for distinguishing CHM from its mimics, p57 KIP2 immunohistochemistry can be used as successfully as DNA microsatellite genotyping. However, molecular techniques are still required for the evaluation of some difficult cases with discordant positive p57 KIP2 staining.

Hearing loss, uveomeningitis, and stroke in a 55‐year‐old man

Hearing loss, uveomeningitis, and stroke in a 55‐year‐old man

Pattern electroretinogram (PERG) and pattern visual evoked potential (PVEP) in the early stages of Alzheimer’s disease

Alzheimer’s disease (AD) is one of the most common causes of dementia in the world. Patients with AD frequently complain of vision disturbances that do not manifest as changes in routine ophthalmological examination findings. The main causes of these disturbances are neuropathological changes in the visual cortex, although abnormalities in the retina and optic nerve cannot be excluded. Pattern electroretinogram (PERG) and pattern visual evoked potential (PVEP) tests are commonly used in ophthalmology to estimate bioelectrical function of the retina and optic nerve. The aim of this study was to determine whether retinal and optic nerve function, measured by PERG and PVEP tests, is changed in individuals in the early stages of AD with normal routine ophthalmological examination results. Standard PERG and PVEP tests were performed in 30 eyes of 30 patients with the early stages of AD. The results were compared to 30 eyes of 30 normal healthy controls. PERG and PVEP tests were recorded in accordance with the International Society for Clinical Electrophysiology of Vision (ISCEV) standards. Additionally, neural conduction was measured using retinocortical time (RCT)—the difference between P100-wave latency in PVEP and P50-wave implicit time in PERG. In PERG test, PVEP test, and RCT, statistically significant changes were detected. In PERG examination, increased implicit time of P50-wave (P < 0.03) and amplitudes reductions in P50- and N95-waves (P < 0.0001) were observed. In PVEP examination, increased latency of P100-wave (P < 0.0001) was found. A significant increase in RCT (P < 0.0001) was observed. The most prevalent features were amplitude reduction in N95-wave and increased latency of P100-wave which were seen in 56.7% (17/30) of the AD eyes. In patients with the early stages of AD and normal routine ophthalmological examination results, dysfunction of the retinal ganglion cells as well as of the optic nerve is present, as detected by PERG and PVEP tests. These dysfunctions, at least partially, explain the cause of visual disturbances observed in patients with the early stages of AD.

Avian Influenza Prevalence in Pigs, Egypt

To the Editor: Since 1996, avian influenza virus (H5N1) has spread to >65 countries (1). The disease represents a serious threat for the poultry industry and public health. Egypt has the highest human infection and fatality rates outside Asia (2). Some isolates of influenza virus (H5N1) in Egypt are resistant to oseltamivir (3), and in others, virulent mutations have developed, leading to case-fatality rates of 100% (4). Pigs have the largest epidemiologic role in the evolution of new influenza viruses (5). Recombination between the newly emerged influenza virus subtypes H1N1 and H5N1 in pigs would have catastrophic results. We therefore investigated the seroprevalence of influenza virus (H5N1) in pigs in Egypt. In May 2008, we collected 1 serum sample and 1 nasal swab from each of 240 pigs (11 herds) in Cairo slums. May was selected because it directly follows the season of bird migration and the seasonal storms usually accompanied by airborne diseases. Cairo slums were selected because 1) pigs there feed on organic remains, including dead birds, and thus have a higher chance of becoming infected; 2) Cairo is at the base of the Nile Delta, where most subtype H5N1 foci occurred; and 3) Cairo is near Fayum, the main stopover site for migrating birds. To detect anti–avian influenza antibodies in the serum, we used hemagglutination inhibition (HI) assays with 2 inactivated antigens: subtype H5N2 from the Veterinary Laboratories Agency, UK; and a local subtype H5N1 prepared according to the protocol used in the central national laboratories. To detect viral RNA in the nasal swabs, we used real-time PCR, as was recommended for detection of influenza (H5N1) infection during outbreaks in Southeast Asia (6). Although all nasal samples reacted negatively to influenza A/H5 by real-time PCR, only 4 serum samples showed positive results by HI when using subtype H5N2 antigen; titers were 32 for 3 samples and 64 for 1. Seven additional positive serum samples were detected when antigen prepared from local subtype H5N1 virus was used; titers ranged from 16 (6 samples) to 512 (1 sample). Also during this 2-week sampling period, titers of 32 for 3 samples and 128 for 1 were obtained. Seroprevalence rate of avian influenza for the 240 pigs was 1.67% and 4.6% when the nonlocal or local viral antigens, respectively, were used. Of the 11 positive pigs, 8 were from 1 herd and 3 were from 3 other herds. Failure to detect viral RNA in the upper respiratory tract indicates the absence of acute infections in the investigated pigs. Inability of the virus to persist in the pigs was reported (7). Contrary to the HI results, results of routine examination of the 240 pigs found no abnormalities. Absence of clinical signs in infected pigs was reported (8) and was attributed to their low susceptibility to influenza (H5N1) (7). The results indicate that infection rate for pigs in Egypt is clearly higher than that for pigs in China and Vietnam (8,9). This increase may be attributed to different spatial and temporal factors leading to increased infection risk among sampled pigs, higher antigenicity of native isolates, or most probably to the disease situation in Egypt. The detection of 8 positive reactors from 1 herd indicates a subtype H5N1 focus there as was reported in Indonesia (8). The difference in the number of reactors when using different antigens indicates the difference in antigenicity. These data are supported by field observations regarding low protection level (≈35% in some reports) of imported vaccines (A. El-Sayed, unpub. data). The relatively low seroprevalence of avian influenza in pigs may be misleading because of the poor immunogenicity of some avian influenza lines and lack of sensitivity for detecting low titers of induced antibodies (10). It may be also explained by the use of a virus antigen other than that existing in the population, as was done in the present study. Human risk for influenza (H5N1) infection in Egypt seems to be associated mainly with infected birds. It has not yet been associated with infected pigs.

Pneumatocyst, mimicking a sclerotic bony lesion on magnetic resonance imaging

Background Context Intravertebral pneumatocyst is an uncommon benign lesion, not related to conditions, such as osteomyelitis and postsurgical state, with only a few cases reported in the literature. Purpose The purpose of the study was to report a case of cervical pneumatocyst resembling a sclerotic lesion on magnetic resonance imaging (MRI) and review of literature. Study Design/Setting The study was designed to be a case report. Patient Sample The patient chosen was a 48-year-old woman with the chief complaint of neck pain and bilateral upper extremity paresthesia of 6 months duration. Neurologic examination and results of routine hematologic and biochemical examination were normal. Results Cervical spine MRI revealed a low signal bony lesion on T1 and T2 images. Considering the signal characteristics, initial diagnosis of sclerosis was made. Reviewing the cervical X-ray, a round faint lytic lesion was detected. Correlation with cervical computed tomography scan showed the lesion being of air density, compatible with the diagnosis of pneumatocyst. Conclusion Intraosseous pneumatocyst of cervical spine is a benign finding, which needs no specific treatment; however, it must be included in the differential diagnosis of lucent vertebral lesions seen on conventional radiography and should be differentiated from bony neoplasm and osteomyelitis by its characteristic imaging findings.

Erythema multiforme‐like lesions associated with lesional infiltration of tumor cells occurring with adult T‐cell lymphoma/leukemia

A 66‐year‐old Japanese woman visited our hospital with a complaint of multiple papules on her trunk and extremities. She had a past medical history of appendicitis and blood transfusion 40 years earlier. For the last 10 years, she had noticed multiple, gradually enlarging papulonodular lesions with surrounding erythema on her trunk and extremities. Physical examination revealed multiple, violaceous papules or nodules, less than 10 mm in diameter, with surrounding erythema on her trunk and extremities (Fig. 1). The results of routine laboratory examinations, including blood count, liver function, renal function, serum calcium, and lactate dehydrogenase, were within the normal range. The peripheral blood picture showed a small population of atypical lymphocytes below 1% of the total white blood cells. Human T‐cell lymphotropic virus type I (HTLV‐I) serology was positive. A microscopic examination of a biopsy specimen from a nodule on the abdomen demonstrated diffuse infiltration of large pleomorphic T cells in the upper and middle dermis, although highly atypical lymphocytes, so‐called flower cells, could not be recognized. Infiltrating lymphocytes were positive for CD2, CD3, CD4, CD5, CD7, and CD45, but negative for CD8 and CD20, immunohistologically. Bone marrow biopsy also demonstrated the infiltration of lymphocytes expressing CD2, CD3, CD4, CD5, and CD7, but not CD25. Southern blot analysis of the infiltrating cells in the skin revealed an integration of HTLV‐I proviral DNA in T cells. Clonal T‐cell receptor γ gene rearrangement was detected in skin and bone marrow biopsies. No abnormal mass or bone defect was detected by chest or abdominal computed tomographic scanning, systemic gallium‐67 citrate scintigraphy, or chest radiography. On the basis of these data, the patient was diagnosed with smouldering‐type adult T‐cell lymphoma/leukemia.Clinical features of adult T‐cell lymphoma/leukemia (ATL) skin lesions. Crusted, target‐like, dark‐red plaques on the lower legsimage The patient was started on topical steroid and electron beam radiation therapy (27 Gy/14 days). Five days after the start of irradiation, she noticed multiple patches of edematous erythema appearing on the trunk and extremities (Fig. 2). As it was initially suspected that these newly emerging erythema multiforme or toxic eruptions were caused by irradiation, therapy was interrupted. Anti‐herpes simplex virus antibody was not checked because no typical herpes simplex lesions were noticed. The patient was not taking any systemic drugs. A skin biopsy was taken from a representative lesion on the chest. The pathologic specimen showed epidermotropism, liquefaction degeneration in the basal layer, marked edema, and dense infiltration of mononuclear cells in the upper dermis. Infiltrating cells possessed abundant cytoplasm and large pleomorphic nuclei with distinct nucleoli (Fig. 3). These findings were consistent with the histopathologic findings of erythema multiforme, except for the atypical lymphoid cell infiltration. Immunohistochemical staining demonstrated that the phenotype of the skin‐infiltrating cells was identical to that of the atypical cells in the initial lesions. As the eruptions did not disappear in spite of the interruption of radiation, total skin irradiation was restarted. After completion of therapy, both the erythema multiforme‐like lesions and the initial adult T‐cell lymphoma/leukemia nodules on the trunk and extremities had resolved, leaving brown pigmentation. The patient has been free of any recurrence of skin lesions or systemic symptoms for 6 years after the completion of total skin irradiation.Appearance of erythema multiforme (EM)‐like lesions. Edematous red plaques involving the breastimageMicroscopic examination of a biopsy specimen from (EM)‐like lesions on the chest (hematoxylin and eosin staining). (a) Epidermotropism, liquefaction degeneration in the basal layer, and dense infiltration of mononuclear cells and severe edema in the upper dermis (×100). (b) High‐power magnification revealed that the dermal infiltration included atypical lymphoid cells with abundant cytoplasm, convoluted large nuclei, and distinct nucleoli (×400)image

ASSESSMENT OF THE ROLE OF THROMBIN ACTIVATABLE FIBRINOLYSIS INHIBITOR IN RETINAL VEIN OCCLUSION

To determine whether elevated levels of thrombin activatable fibrinolysis inhibitor (TAFI) may contribute to thrombotic risk for patients with retinal vein occlusion (RVO) and to investigate the possible correlations between TAFI activity level and other conventional risk factors. Ninety patients with RVO (cases), except those receiving medication affecting the study parameters, those undergoing a surgical procedure within the last week, and those with kidney and/or liver failure, were enrolled in the study. The control group included similar patients matched for age and sex. After written informed consent was obtained, parameters including TAFI activity levels, conventional risk factors, results of routine hematological examination, and factor V Leiden and prothrombin G20210A mutations were evaluated by analysis of blood samples obtained after an 8-hour fast. Although TAFI activity levels were slightly elevated in cases (190.5 +/- 43.8) compared with controls (183.9 +/- 41.8), the difference was not statistically significant (P = 0.36). According to evaluation of TAFI activity in subgroups (>200%, 150-200%, and 0-150%), 36.7% with central RVO, 40.0% with branch RVO, and 30% of controls were found to have TAFI activity of >200% (P = 0.83). TAFI activity levels did not correlate with age, sex, demographics, clinical status, and hematological variables. Finally, in stepwise regression analysis, TAFIa (carboxypeptidase U) activity was not found to be an important risk factor for RVO. On the basis of these data, TAFI activity was not found to be a new risk factor for either type of RVO. However, further larger studies may better identify the exact role of TAFI in the pathogenesis of RVO.

A large solitary fibrous tumor of the mediastinum

The patient was a 27一year—old woman with chest distress and short— ness of breath that suddenly started one month before her examina— tion.The symptoms were relieved with resting,SO she failed to go to the hospital for an examination.She had no complaints of fever, cough or hempotysis.One day,the symptoms became SO severe that she was sent to the emergency room and adiography disclosed an opaciW in her right hemithorax.A subsequent CT scan showed a 1arge.sharply delineated and nonhomogeneous mass in the iriferior fight middle mediastinum,which protruded to the right hemithorax. The mediastinal structure was apparently displaced to the left and the mass seemed to be adherent to the pleura,pericardium and adjacent large vessels(Fig.1A).There were enhancing areas peripheral to the mass after injecting the contrast material(Fig.1B).The 1eft side was shown to be normal.She was admitted to OUr hospital for further ex— amination on the same day. Her medical history was unremarkable except for being allergic to penicillin.She never smoked or drank alcohol,but she had been a worker spraying lacquer in a factory for about two years. Physical examination revealed regular BP(120/80 mmHg)and pulse (80 bpm).The expansion of thorax was symmetric.The breathing sounds were absent in the inferior site of the right lung.The 1eft was normal.and routine 1aboratory examination results were negative.Her blood glucose was 4.9 mmol/L and her B—HCG 1evel was 1ess than

Nuclear factor-kappaB expression in peripheral blood polymorphonuclear leukocytes of patients with acute pancreatitis and the preventive effectiveness of pyrrolidine dithiocarbamate on NF-kappaB in vitro

To investigate the expression of NF-kappaB in peripheral blood polymorphonuclear leukocyte (PMN) of acute pancreatitis (AP) and to assess the preventive effectiveness of pyrrolidine dithiocarbamate (PDTC) on NF-kappaB in vitro. Nineteen patients and 16 healthy individuals as control were enrolled in this study. The expression of NF-kappaB in PMNs was determined by gel electrophoretic mobility shift assay (EMSA). Routine clinical examination results and computed tomography findings of AP were recorded in all patients. The PMNs from the patients with AP showed higher levels of NF-kappaB activities than those from control subjects (P < 0.01), severe acute pancreatitis (SAP) group showed much higher than mild acute pancreatitis (MAP) group (P < 0.05). In vitro, PDTC could reduce the NF-kappaB activity in PMNs of patients with AP, and its effectiveness at 2 mmol/L was stronger than at 1 mmol/L (P < 0.05). The PMNs from control subjects pretreated with 2 mmol/L PDTC before stimulation with the plasma from patients with SAP showed lower levels of NF-kappaB activities than did those untreated (P < 0.05). The NF-kappaB activation in peripheral blood PMNs participate in the course of acute pancreatitis and can be inhibited by PDTC in vitro.

Invasive Pulmonary and Central Nervous System Aspergillosis After Near-Drowning of a Child: Case Report and Review of the Literature

Invasive aspergillosis is extremely rare in immunocompetent children. Here we describe the clinical, radiologic, and laboratory course of fatal invasive pulmonary and central nervous system aspergillosis in a previously healthy child after a near-drowning incident with submersion in a pond. Findings were compared with data from the literature, which is reviewed. Serum Aspergillus galactomannan levels were determined retrospectively and were compared with the results of routine microbiological and radiologic examinations, showing a significant diagnostic and therapeutic delay of the routine diagnostic approach in comparison with the use of the Aspergillus galactomannan assay. This delay may have contributed to the fatal course. Serial determination of serum Aspergillus galactomannan may be helpful in diagnosing invasive aspergillosis early in case of pulmonary disease after near-drowning and may contribute to an early appropriate treatment. Currently voriconazole, eventually in combination with caspofungin, should be considered as the drug of choice in the management of invasive aspergillosis after near-drowning.

Persistent Auditory Hallucinations That Are Unresponsive to Antipsychotic Drugs

Persistent Auditory Hallucinations That Are Unresponsive to Antipsychotic Drugs

Sonographic Screening for Thyroid Cancer in Females Undergoing Breast Sonography

The purpose of our prospective study was to evaluate incidental thyroid cancer diagnosed by screening sonography in a population who underwent breast sonography and the differences in the incidences of thyroid cancer between those with and those without breast cancer. Between January 2003 and March 2004, we examined thyroid glands during routine diagnostic or follow-up breast sonography. A total of 5,549 females underwent breast and thyroid screening sonography (n = 4,864) or sonography for diagnosis or follow-up of breast cancer (n = 685). When a thyroid lesion was suspicious for malignancy, sonographically guided fine-needle aspiration was performed. We compared the cases of pathologically proven thyroid cancer in two groups: a cancer group, including patients with breast cancer, and a noncancer group, including patients with negative or benign breast disease. Among the 5,549 cases, 42 (0.76%) were diagnosed as thyroid cancer; all were papillary carcinomas. Pathologically proven thyroid cancers were identified in 13 (1.9%) of the 685 breast cancer patients and in 29 (0.6%) of the 4,864 non-breast-cancer patients. The diameters of the 13 thyroid masses were 0.1-3.0 cm; the mean diameters in the cancer and noncancer groups were 9.9 and 8.6 mm, respectively. The incidence of thyroid cancer was significantly higher in the group with breast cancer than in the group who did not have breast cancer. The results of routine concurrent sonographic breast and thyroid examinations were helpful in detecting small thyroid tumors in both patient groups.

Primary local orbital amyloidosis: biochemical identification of the immunoglobulin light chain κIII subtype in a small formalin fixed, paraffin wax embedded tissue sample

Background: Amyloidosis refers to a heterogeneous group of disorders associated with the deposition of chemically distinct amyloid fibril proteins. Precise determination of chemical amyloid type has diagnostic, therapeutic, and prognostic...

Clinical research of sentinel node biopsy in oral tongue carcinoma

This study was designed to evaluate whether sentinel node (SN) biopsy can accurately assess the cervical lymph node status of oral tongue carcinoma, as well to research the best method and indications of SN biopsy. Preoperative lymphoscintigraphy with (99m)Tc-SC and intraoperative sentinel node mapping with methylene blue dye were administered on 20 cases of oral tongue carcinoma with cN(0) neck and 5 cases with cN(+) neck; routine pathological examination was used to assess the status of SNs. The results of routine pathological examination of cervical specimen were set as golden standard to assess the efficacy of SN biopsy in evaluating the cervical lymph node status. 53 SNs were detected in 24 cases out of the total 25 cases (96%), averaging 2.2 SNs per case. SNs were detected in all 20 cases with cN(0) neck, in which 4 cases with occult cervical metastasis were detected by SN diopsy, without false negative case found in the procedure. In 5 cases with cN(+) neck, SNs were detected in 4 cases. In 4 cases whose SNs were detected, there were 5 cN(+) necks, out of which SNs were detected in 4 cN(+) necks but failed to predicted the cervical lymph node status in 2 necks. However, SNs were detected in 2 out of the other 3 cN(0) necks, both of which were diagnosed as SN(+)pN(+). Nuclear lymphoscintigraphy and blue dye mapping can be used to trace the SNs in cases with oral tongue carcinoma, with satisfactory detective rate. SN biopsy can accurately evaluate the cervical lymph node status in cases of oral tongue carcinoma with cN(0) neck. Whether it can be used to evaluate the lymph node status of the cN(0) neck in case with a contralateral cN(+) neck is worthy of further research.

Breast Cancers with Ocular Metastases are Early Onset, Non-Familial and Non-BRCA1/BRCA2 Tumours

Dear Sirs, Ocular metastases of solid tumors are very rare, but in most of them (~45-70% of all detected ocular metastases) the primary site of origin is the breast [1,2]. Ocular metastases of breast cancer appear frequently without previous dissemination to organs even those in close proximity. Thus, occurrence of ocular metastases may be the characteristic feature of a special subgroup of breast cancers. Herein, we decided to analyse whether breast cancers with associated ocular metastases belong to a group of cancers constituting a specific part of a subset of breast cancer family syndromes. We investigated a series of 15 breast cancer patients with ocular metastases, detected in 1998-2002 by ophthalmologists in Szczecin (10 of 15) and Poznan (5 of 15). The distinction between breast cancer metastases and primary ocular tumours was based on results of routine ophthalmological examination supported in most cases by angiography, ultrasonography, computer tomography and magnetic resonance imaging. Tumours were verified pathologically (aspiration biopsy or surgical section) in 3 cases. In all three cases the metastatic character of the tumour was confirmed. In all 15 cases, age at diagnosis and pedigree data on the occurrence of cancers among first and second degree relatives was collected. In 11 of 15 cases peripheral blood lymphocyte DNA for mutations analyses were available. A search for the most common Polish BRCA1 gene mutations (5382insC, C61G and 4153delA) was performed as described by Gorski et al (2000). This test can detect around 90% of all BRCA1 mutation carriers in the Polish population [3]. The presence of BRCA2 mutations was also investigated by full sequencing of coding regions of this gene [4]. Familial aggregation of breast cancers (one, additional to the proband, breast cancer patient among first degree relatives) was found in only one family. No patient with BRCA1 constitutional mutation was identified. BRCA2 mutations (3562 A/G and 9079 G/A) were detected in two patients. The remaining 12 patients did not present with any other unusual characteristics apart from early disease onset. In 10 of 12 cases, breast cancers have been diagnosed under 51 years of age (27, 29, 29, 36, 40, 41, 42, 42, 44, 50). Only in the case of two patients cancers were diagnosed in other first degree relatives (pancreatic cancer diagnosed at the age of 58 and endometrial cancer diagnosed at the age of 68). Histopathology was not verified in this set of breast cancer patients, but multifocal disease was reported in 3 of 10 non-familial, non-BRCA1/2 mutation early onset cases. Furthermore, only one of them was reported to be a lobular type; all others were diagnosed as ductal cancers. Our observation has several limitations: the studied series is small, not all metastatic tumours have been verified histopathologically and more precise data about the pathologic and molecular features of breast cancers is required. Nevertheless, this small study shows that the characteristic features of breast cancers with ocular metastases include early age at diagnosis and the lack of familial aggregation of breast cancers and of BRCA1 and BRCA2 constitutional mutations. The early onset of breast cancer in these cases suggests a genetic predisposition and given the low frequency of cancers among first degree relatives, this predisposition might be a gene defect with recessive inheritance, a de novo dominant mutation, a complex genetic inheritance that does not follow obvious Mendelian inheritance (or possibly even an X-linked mutation with expression in females only).

Severe Generalized Ulcerative Lichen Planus

Sir,Ulcerative lichen planus (ULP), a rare variant of lichenplanus, is characterized by chronic painful ulcers on thefeet (1). We report a patient who presented after PUVAtherapy with generalized ulcerations on an erythema-tous base, and with natural remission within a month.CASE REPORTA 67-year-old man was referred to our hospital inMarch 2000 for evaluation of poikiloderma on theentire body surface. The lesions started as an itchingrash on the buttock in 1965 and had gradually spread,especially during summer months. Erosions and/or ulcershad formed on the trunk and limbs a few times peryear since 1968. These lesions healed within a monthwithout treatment, leaving either hypo- or hyper-pigmented macules, and developed to poikilodermawhen he was 64 years of age. Simultaneously, hegradually lost the hair on his scalp. His medical historyincluded atrial fibrillation without medication since theage of 50. He had not used any kinds of drugshabitually.Physical examination revealed diffuse erythema withfine scales, based on reticulate pigmentation and tele-angiectasia on the trunk, limbs and head. Hyperker-atosis was seen on the palms and soles. The scalp hairwas sparse (Fig. 1). The finger and toe nails showedpachyonychia with yellowish discoloration. There wereno lesions on the mucous membranes.The results of routine laboratory examinations, inclu-ding liver function tests, were within normal limits. Theresults of the following laboratory studies were withinnormal limits or negative: anti-HTLV-1 antibody, anti-hepatitis C virus antibody, hepatitis B surface antigen,LE test and uroporphyrine.A skin biopsy from the erythema on the thighshowed wedge-shaped hypergranulosis, irregularacanthosis, damage to the basal cell layer, and band-like dermal lymphocytes. Interestingly, fatty tissues,reaching to the upper dermis, were seen beneath theband-like zone of inflammation. Below the fatty tissuethere were thick collagen deposits through the deepdermis and a few hair follicles.Direct immunofluorescence showed no specific depo-sits. The findings were highly suggestive of lichen planus,but a provisional diagnosis of parapsoriasis lichenoideswasmadebecauseofthegeneralizedlesions.Topicalappli-cations of diflucortolone valerate and tacalcitol, andtopical PUVA therapy to the back, were initiated inMarch 2000 and had a moderate effect.In April, the patient had a sudden onset of high feverwith numerous small vesicles and erosions on the back.These symptoms led us to discontinuation of PUVAtherapy.Aciclovirwasgivenwithouteffectandantibodiesto herpes simplex and varicella zoster viruses were nega-tive. Direct immunofluorescence of the vesicular skinshowed no linear deposits of IgG or C3 in the basalmembrane zone, with positive immunostaining forlaminin on the floor of the cleft (Fig. 2). Furthermore,immunoblot analysis demonstrated no specific anti-bodies. Ulcerative lichen planus was diagnosed on thebasis of these data.A spiking fever continued and the erosions developedrapidly into irregular-shaped ulcers, widespread overthe whole body. The patient was treated with sympto-matic therapies and the ulcers began to re-epithelize onthe upper trunk. In mid-May, the high fever graduallysubsided and the ulcers cleared almost completely.Several erosions and vesicles were noted occasionally,but they did not spread widely during the subsequent2 months. The patient suffered from recurrent episodesof widespread vesicular lesions in mid-July. In this epi-sode, the patient became bed-ridden due to pain fromthe ulcers, and had worsening decubitus on the sacralregion. The ulcers and general condition improved withunchanged symptomatic therapies in September. How-ever, his condition progressively deteriorated due to