Mixed medullary-papillary carcinoma of the thyroid: report of a case and review of the literature.

BACKGROUND: Mixed medullary-follicular thyroid carcinoma denotes a rare and heterogeneous group of tumors displaying morphological and immunophenotypical features of both origins within the same lesion. METHOD: We report a case of a 41-year-old woman with a lump in the right side of the neck, increasing in pain and size over several weeks. Serum levels of calcitonine (1140 ng/L) and carcinoembryonic antigen (288 microg/L) were very high. Fine-needle aspiration cytology suggested a diagnosis of medullary thyroid carcinoma. Total thyroidectomy, along with bilateral functional neck and mediastinal lymph-node dissection, were performed. RESULTS: The histopathological examination yielded a diagnosis of medullary carcinoma in the right thyroid lobe, closely intermingled with a nonencapsulated classical papillary carcinoma. One ipsilateral lymph node showed micrometastasis of the medullary counterpart. CONCLUSION: When compared with other cases reported in literature, this particular presentation should be recognized, if required, morphologic and functional criteria are used. The treatment is mostly surgical, driven by the medullary component. The presence of micrometastasis in 1 ipsilateral cervical lymph-node underlines the importance of cervicomediastinal lymph-node dissection and careful searching for metastatic disease.

Haemorrhage into the pancreatic duct (Hemosuccus pancreaticus): recognition and management.

OBJECTIVE: To highlight the clinical presentation, investigation and treatment of haemorrhage into the pancreatic duct. DESIGN: Retrospective study and review of publications. SETTING: University hospital, Switzerland. SUBJECTS: All 4 cases from 1972 to 1993. INTERVENTIONS: 2 Whipple procedures, 1 resection of the pancreatic head, 1 exploratory laparotomy. Radiological embolisation in one case. MAIN OUTCOME MEASURES: Cessation of haemorrhage and survival. RESULTS: The diagnosis was made preoperatively in three cases by gastroduodenoscopy and arteriography. Operation was the primary treatment in all patients and was effective with low morbidity and no mortality in three of them. Embolisation stopped the haemorrhage in the fourth patient, who was alcoholic and died of progressive liver insufficiency and variceal haemorrhage. CONCLUSIONS: There is no specific indication for haemorrhage into the pancreatic duct. The diagnosis is suggested by endoscopy (absence of a more common cause, or blood in the second part of the duodenum). Arteriography is essential to confirm the site of the bleeding and to attempt embolization. Operation is usually the definitive treatment.

Video-assisted right supradiaphragmatic thoracic duct ligation for non-traumatic recurrent chylothorax

BACKGROUND: Chylothorax is an uncommon disorder with respiratory, nutritional and immunological manifestations. Surgical management is indicated in case of recurrence or failure after conservative treatment. We report our experience with video-assisted right-sided supradiaphragmatic thoracic duct ligation for non-traumatic, non-postoperative persistent or recurrent chylothorax. PATIENTS AND METHODS: The medical records of six patients operated at our institution between 1999 and 2004 were retrospectively reviewed. A right-sided chylothorax was found in four patients, a left-sided in one, and a bilateral in one. Three patients developed chylothorax after chemotherapy and chest irradiation for malignant diseases (lymphoma in two patients and breast cancer in one), one in the context of lymphangioleiomyomatosis, one due to a non-diagnosed lymphoma, and one after heart transplantation. RESULTS: The mean operative time was 102 min, with an average length of hospital stay of 14 days. Persistent cessation of chylous effusion within 7 days after surgery was observed in 5/6 patients without recurrence during a mean follow-up time of 41 months. One patient with undiagnosed mediastinal lymphoma required re-operation and thoracic duct ligation on day 8 by right-sided thoracotomy due to persistent chylothorax. No 30-day mortality was recorded. Two patients presented postoperative complications including respiratory insufficiency requiring mechanical ventilation in one, and chylous ascites development requiring peritoneo-venous LeVeen shunting in one patient. CONCLUSIONS: Recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation.

Video-assisted right supradiaphragmatic thoracic duct ligation for non traumatic recurrent chylothorax

Introduction : Un chylothorax est une pathologie comprenant des manifestations respiratoires, nutritionnelles et immunologiques. La récidive du chylothorax ou l'échec du traitement conservateur imposent un traitement chirurgical. Ce travail rapporte notre expérience de ligature supra-diaphragmatique, vidéo-assistée du canal thoracique, pour chylothorax récurrent non traumatique. Patients et méthodes : Entre 1999 et 2004, nous avons recensé six observations (quatre du côté droit, un du côté gauche et un bilateral) Le chylothorax s'est développé chez trois patients traités par radio et chimiothérapie pour tumeur (deux lymphomes et une tumeur du sein) un dans le contexte d'une lymphangioléiomatose et un après greffe cardiaque. Résultats : Les patients ont bénéficié sous anesthésie générale, d'une ligature du canal thoracique supra-diaphragmatique, vidéo-assistée. Le temps opératoire moyen a été de 102 minutes. Le chylothorax a régressé chez cinq des six patients en sept jours. Un patient a été repris par thoracotomie droite au huitième jour pour chylothorax persistant. Dans la phase post-opératoire, un patient a développé une détresse respiratoire nécessitant une ventilation mécanique. Un autre patient a présenté un chylopéritoine important traité par un stent de Le Veen®. Le séjour moyen a été de quatorze jours sans mortalité péri-opératoire. Conclusion : Le traitement du chylothorax non traumatique récurrent est, en première intention, un traitement médical. En cas de récidive ou d'échec du traitement conservateur, le traitement chirurgical par ligature du canal thoracique supra- diaphragmatique, vidéo-assistée, permet de traiter avec succès le chylothorax récurrent non traumatique. -- Background: Chylothorax is an uncommon disorder with respiratory, nutritional and immunological manifestations. Surgical management is indicated in case of recurrence or failure after conservative treatment. We report our experience with video-assisted right-sided supradiaphrag¬matic thoracic duct ligation for non-traumatic, non-postoperative persistent or recurrent chylothorax. Patients and methods: The medical records of six patients operated at our institution between 1999 and 2004 were retrospectively reviewed. A right-sided chylothorax was found in four patients, a left-sided in one, and a bilateral in one. Three patients developed chylothorax after chemotherapy and chest irradiation for malignant diseases (lymphoma in two patients and breast cancer in one), one in the context of lymphangioleiomyomatosis, one due to a non-diagnosed lymphoma, and one after heart transplantation. Results: The mean operative time was 102 min, with an average length of hospital stay of 14 days. Persistent cessation of chylous effusion within 7 days after surgery was observed in 5/6 patients without recurrence during a mean follow-up time of 41 months. One patient with undiagnosed mediastinal lymphoma required re-operation and thoracic duct ligation on day 8 by right-sided thoracotomy due to persistent chylothorax. No 30-day mortality was recorded. Two patients presented postoperative complications including respiratory insufficiency requiring mechanical ventilation in one, and chylous ascites development requiring peritoneo-venous LeVeen shunting in one patient. Conclusions: Recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation.

Changing responsiveness to chemokines allows medullary plasmablasts to leave lymph nodes.

During T cell-dependent antibody responses lymph node B cells differentiate either to plasmablasts that grow in the medullary cords, or to blasts that proliferate in follicles forming germinal centers. Many plasmablasts differentiate to plasma cells locally, but some leave the medullary cords and migrate to downstream lymph nodes. To assess the basis for this migration, changes in the responsiveness of B cells to a range of chemokines have been studied as they differentiate. Naive B cells express high levels of CCR6, CCR7, CXCR4 and CXCR5. When activated B cells grow in follicles the expression of these chemokine receptors and the responsiveness to the respective chemokines is retained. During the extrafollicular response, plasmablast expression of CXCR5 and responsiveness to B-lymphocyte chemoattractant (CXCR5) as well as to secondary lymphoid tissue chemokine (CCR7) and stromal cell-derived factor (SDF)-1 (CXCR4) are lost while a weak response towards the CCR6 chemokine LARC is maintained. Despite losing responsiveness to SDF-1, extrafollicular plasmablasts still express high levels of CXCR4 on the cell surface. These results suggest that the combined loss of chemokine receptor expression and of chemokine responsiveness may be a necessary prerequisite for cells to migrate to the medullary cords and subsequently enter the efferent lymph.

FOXC2 and NFATc1 control formation and maturation of collecting lymphatic vessels

The mechanisms of blood vessel maturation into distinct parts of the blood vasculature such as arteries, veins, and capillaries have been the subject of intense investigation over recent years. In contrast, our knowledge of lymphatic vessel maturation is still fragmentary. In this study, we provide a molecular and morphological characterization of the major steps in the maturation of the primary lymphatic capillary plexus into collecting lymphatic vessels during development and show that forkhead transcription factor Foxc2 controls this process. We further identify transcription factor NFATc1 as a novel regulator of lymphatic development and describe a previously unsuspected link between NFATc1 and Foxc2 in the regulation of lymphatic maturation. We also provide a genome-wide map of FOXC2-binding sites in lymphatic endothelial cells, identify a novel consensus FOXC2 sequence, and show that NFATc1 physically interacts with FOXC2-binding enhancers. These data provide novel insights into the molecular program of lymphatic vascular specification and suggest that FOXC2 and NFATc1 are potential targets for therapeutic intervention.

A transvesical approach to mullerian duct remnants

Surgical extirpation is the treatment of choice for symptomatic mullerian duct remnants (prostatic utricle, PU), and several surgical approaches have been described for the treatment of this pathology. A group of 11 patients with symptomatic PU were observed and treated. Associated anomalies included proximal or penoscrotal hypospadias in all patients and cryptorchidism in 9 (81.8%). In all cases the PU needed surgical correction, as the patients had recurring symptomatology. Surgery was carried out transvesically in 10 (91%) cases and in 1 a perineal approach was used. There were no surgical complications, and at follow-up all patients showed complete resolution of the symptoms. We believe the transvesical approach, compared to other techniques, is more advantageous in the treatment of this pathology, as it permits excellent exposure, ease of surgery, good reconstruction, and good functional results with no sequelae.

Tomoscintigraphy for detecting gastrointestinal and medullary thyroid cancers: first clinical results using radiolabelled monoclonal antibodies against carcinoembryonic antigen.

Transaxial tomoscintigraphy (or single-photon emission computerised tomography) was used to detect secondary deposits of carcinoma in 17 patients who had been injected with iodine-131-labelled monoclonal antibodies against carcinoembryonic antigen. Of 17 tumor sites studied by tomoscintigraphy 16 were detected (sensitivity 94%); five sites had a volume smaller than 10 cm3. Tomoscintigraphy also detected three unknown tumour deposits later confirmed by surgery or radiology. In contrast, when 21 tumour sites in the same patients were studied by rectilinear scintigraphy, only nine tumour sites were detected (sensitivity 43%), of which eight had a volume larger than 50 cm3.

A nasopalatine duct cyst in a 7-year-old child.

The nasopalatine duct cyst (NPDC) is a developmental cyst of the anterior palate's midline, usually presenting as an asymptomatic swelling located just behind the maxillary central incisors. It is the most common non-odontogenic cyst of the jaws but is seen rarely in children. The purpose of this paper was to report an unusual case of nasopalatine duct cyst in a 7-year-old boy who presented with a slow-growing, slight swelling of the anterior palate together with malpositioned permanent maxillary central incisors. Although rare in children, NPCD should be included in the differential diagnosis of anterior palate swelling, particularly if associated with malpositioned maxillary central incisors.

Laparoscopic Pancreatic Enucleation With End-to-End Pancreatic Duct Reconstruction.

BACKGROUND: Laparoscopic enucleation for neuroendocrine pancreatic tumors has become a feasible technique, with a reported incidence of pancreatic fistula ranging from 13 to 29 %.1 (-) 3 This report describes the first successful case of laparoscopic pancreatic enucleation with resection of the main pancreatic duct followed by end-to-end anastomosis. METHODS: A 41-year-old woman was admitted to the authors' hospital for repeated syncope. Hypoglycemia also was noted. A contrast-enhanced computed tomography examination showed a highly enhanced tumor measuring 22 mm in diameter on the ventral side of the pancreatic body adjacent to the main pancreatic duct. The patient's blood insulin level was elevated, and her diagnosis was determined to be pancreatic insulinoma. Laparoscopic pancreatic enucleation was performed. Approximately 2 cm of the main pancreatic duct was segmentally resected, and a short stent (Silicone tube: Silastic, Dow Corning Corporation, Midland, MI) was inserted. The direct anastomosis of the main pancreatic duct was performed using four separate sutures with an absorbable monofilament (6-0 PDS). RESULTS: The operation time was 166 min, and the estimated blood loss was 100 mL. The postoperative course was uneventful, and the patient was discharged from hospital on postoperative day 7. The pathologic findings showed a well-differentiated insulinoma and a negative surgical margin. A computed tomography examination performed 1 month after the operation showed a successful anastomosis with a patent main pancreatic duct. CONCLUSIONS: Laparoscopic segmental resection of the main pancreatic duct and end-to-end anastomosis can be performed safely with the insertion of a short stent. This technique also can be used for a central pancreatectomy.

Ecological niche overlap in sister species: how do oil-collecting bees Macropis europaea and M. fulvipes (Hymenoptera: Melittidae) avoid competition and hybridization?

Oil-collecting bees are found worldwide and always in association with particular oil-producing flowers. In the Western Palearctic, three oil-collecting bee species within the genus Macropis (Hymenoptera, Melittidae) interact in a tight pollination mutualism with species of the only European oil-producing plant genus Lysimachia L. (Myrsinaceae). Two of these oil-collecting bees (Macropis europaea and Macropis fulvipes) show overlapping geographic distributions, comparable morphologies, and similar ecological characteristics (e.g., habitat type, floral preferences). In view of these similarities, we presume that hybridization should occur between the two species unless potential variation among the species' ecological niches prevents it, simultaneously decreasing competition for resources. Using modern genetic analyses and ecological niche modeling on a large bee sampling throughout Europe, we discuss new perspectives on the ecology and evolutionary history of this mutualism.

Hémorragie par le canal de Wirsung: forme rare d'hémorragie digestive haute. A propos d'une observation [Hemorrhage through Wirsung's duct: rare form of upper gastrointestinal hemorrhage. A case report].

The case of a 41-year-old alcoholic patient who presented with massive upper gastrointestinal bleeding is reported. The diagnosis was established rapidly by endoscopy which revealed bleeding through the papilla of Vater. Selective angiography of the superior mesenteric artery opacified the pancreatic duct as well as the duodenum. CT scan showed signs of chronic pancreatitis. Because of the recurrence of bleeding and shock, an urgent operation was necessary and a Whipple procedure was performed. Recovery was complete. The clinical presentation, the etiology, the diagnostic modalities and the treatment of this particular condition are discussed. Usually, hemorrhage through the pancreatic duct presents as repeated episodes of upper gastrointestinal bleeding with no source found at endoscopy. The presence of chronic pancreatitis or of epigastric pain during bleeding should suggest the diagnosis. Upper gastrointestinal endoscopy and angiography are the principal diagnostic tools. Definitive treatment requires surgery, and resection in most of the cases.