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Breast carcinomas are graded according to the "Nottingham modification of the Bloom-Richardson system" (SBR). The system is hindered, however, by lack of precision in assessing all three parameters including nuclear grade, mitosis, and tubular formation, leading to an element of subjectivity. Our objective was to evaluate a new grading system [the nuclear grade plus proliferation (N+P) system] for subjectivity, ease, and better representation of tumor biology. Its components are nuclear grade and automated proliferation index. Invasive ductal carcinomas, consisting of 137 SBR grade I, 247 grade II, and 266 grade III, were re-evaluated by the N+P system. The two systems were compared with each other and correlated with patients' overall survival, tumor size, angiolymphatic invasion, lymph node status, and biomarker status including estrogen receptor, progesterone receptor, p53, epidermal growth factor receptor, BCL-2, and Her-2. Although there was an agreement between the two systems with histologic and prognostic parameters studied, there was 37% disagreement when grading individual tumors. Fifty-three percent of SBR grade II tumors were "down-graded" to N+P grade I, and 7% were "up-graded" to N+P grade III. Distinction among the different histologic grades for overall survival curves was better indicated by the N+P than the SBR system.

Rearrangements of the mixed-lineage leukemia (MLL) gene have been associated with a poor prognosis in infant acute lymphoblastic leukemia (ALL). Previously, MLL translocations involving the CREP-binding protein (CREBBP) gene at chromosome band 16p13.3 have primarily been reported in treatment-related acute myeloid leukemia, after chemotherapy for other primary malignancies using topoisomerase II inhibitors. We report a case of de novo infant ALL with t(11;16)(q23;p13.3). After chemotherapy, this patient developed an acute monoblastic leukemia (M5b) with retention of the t(11;16)(q23;p13.3), indicating that this is a lineage switch of the original leukemic clone. To our knowledge, these findings have not been previously reported.

Appendiceal CT was first reported in the radiological literature, and has only recently begun to appear in the surgical literature. Much of the enthusiasm surrounding appendiceal CT has come from several publications by relatively few authors. We report the feasibility of implementing an appendiceal CT scanning technique and our initial results. The charts (940) of all patients evaluated for possible appendicitis during a 3-month period were reviewed. A new appendiceal CT scanning technique was performed when the indication was solely to exclude appendicitis. The accuracy of this new technique was determined. Eighty-seven patients were evaluated. Twenty-nine underwent appendiceal CT scanning. The accuracy of interpretation was 85 per cent. In 58 patients who did not receive an appendiceal CT scan the accuracy of surgical decision-making was 82 per cent. These values were not statistically different. We found appendiceal CT scanning to be relatively easy to implement; and its accuracy was better than expected. Our accuracy does not match that reported in the literature by the pioneers of appendiceal CT scanning. More experience with this technique will be required to achieve consistently successful accuracy; the technique can then be utilized in surgical practice and potentially change the diagnostic approach to acute appendicitis.

Flavodoxins are electron-transfer proteins that contain the prosthetic group flavin mononucleotide. In Escherichia coli, flavodoxin is reduced by the FAD-containing protein NADPH:ferredoxin (flavodoxin) oxidoreductase; flavodoxins serve as electron donors in the reductive activation of anaerobic ribonucleotide reductase, biotin synthase, pyruvate formate lyase, and cobalamin-dependent methionine synthase. In addition, domains homologous to flavodoxin are components of the multidomain flavoproteins cytochrome P450 reductase, nitric oxide synthase, and methionine synthase reductase. Although three-dimensional structures are known for many of these proteins and domains, very little is known about the structural aspects of their interactions. We address this issue by using NMR chemical shift mapping to identify the surfaces on flavodoxin that bind flavodoxin reductase and methionine synthase. We find that these physiological partners bind to unique overlapping sites on flavodoxin, precluding the formation of ternary complexes. We infer that the flavodoxin-like domains of the cytochrome P450 reductase family form mutually exclusive complexes with their electron-donating and -accepting partners, complexes that require conformational changes for interconversion.

Portal vein resection during pancreaticoduodenectomy has recently experienced renewed interest. We describe our results with this procedure over a 20-year period. Among 88 consecutive pancreatectomies for cancer of head of the pancreas, 14 included en bloc removal of the portal vein. There was no hospital mortality. Only 21% were found to have histologically confirmed cancer invasion, and the remainder had inflammatory adherence. Two-year survival was 15% compared to 34% for patients who did not have portal vein resection. There were no 5-year survivors. We discuss our results in light of other recent reports.

Objective: To assess the results of a refined approach to repair of postcholecystectomy bile duct strictures., Design: An 11-year retrospective review of patients who had surgical repair of bile duct strictures developing late after cholecystectomy., Setting: A major university teaching hospital in France., Patients and Interventions: During an 11-year period from 1987 to 1997, 22 patients (mean [+/-SD] age, 55+/-15 years) were operated on for bile duct strictures after cholecystectomy (11 after laparoscopic surgery and 11 after open surgery). Thirteen (59%) of the 22 patients had previous repair. Most patients had episodic cholangitis (14 patients [64%]) and biochemical evidence of cholestasis (20 patients [91%]). There were 5 Bismuth type 1 strictures; 4, type 2; 7, type 3; 5, type 4; and 1, type 5. The average (+/-SD) time from initial surgery to repair was 6.3+/-9.6 years. Intraoperative cholangiography was used to plan the repair in 18 patients (82%). Fifteen patients (68%) were repaired with high Hepp-Couinaud hepaticojejunostomies. The last 4 patients had the hilum exteriorized by the posterior approach to improve access., Results: There was 1 intraoperative complication (bleeding) and 4 postoperative complications (biloma, fistula, and 2 cholangitis). There were no deaths; mean (+/-SD) length of stay was 12.8+/-5.8 days; and mean (+/-SD) follow-up was 4.8+/-3.3 years (range, 1-10.7 years). Three patients were reoperated on, 1 with an obstructed Roux-en-Y limb and the 2 others for incisional hernias. Eighteen patients remain well, 3 had sporadic recurrent cholangitis after surgery that resolved spontaneously, and 1 patient remains unwell requiring antibiotics to control cholangitis., Conclusions: Hepp-Couinaud hepaticojejunostomy without stenting remains a reliable repair of postcholecystectomy strictures. Intraoperative cholangiography and exteriorizing the hilum by the posterior approach are useful adjuncts to this technique.

Background: A palliative bypass operation may be beneficial when severe dysphagia or tracheoesophageal fistula occurs after radiochemotherapy for unresectable tumor of the esophagus., Methods: Thirty-two patients with an unresectable tumor of the esophagus underwent a palliative retrosternal gastric (29) or colonic (3) bypass operation with ligature of the lower esophagus (3) or drainage (27). Tracheoesophageal fistula was present at operation in 20 (62.5%), including 8 after radiochemotherapy., Results: The overall operative mortality rate was 34.4%: 45% with tracheoesophageal fistula and 16.6% without (p < 0.01). Median intensive care and hospitalization times were 5 and 19 days, respectively. Median postoperative survival was 6 months (range, 53 to 492 days). Complications in 21 survivors were lung infections (seven), cervical fistulas (eight), and failure of the esophageal suture (two); 19 patients resumed oral nutrition, and quality of life was excellent in 6. All eight cervical fistulas regressed favorably. Postoperative radiotherapy or chemotherapy did not improve survival., Conclusions: Despite the high operative mortality rate, bypass operation can provide good palliation and allow subsequent radiochemotherapy in selected patients with an unresectable tumor of the esophagus.

Unlabelled: From 21st of april 1978 to 1st september 1994, 200 liver transplantations in 172 patients were performed in the Medical Center of University of Rennes. Three patients had a liver and kidney transplant. 26 patients received a second transplant (13%) and 2 patients a third transplant (1%). There were 110 males and 62 females with a mean age of 43.7 years (range 17 months-66 years). The indications of transplantations were the following: 22 fulminant hepatitis (12%), 104 cirrhosis (60.5%), including 41 alcoholic cirrhosis (24%), 21 post-hepatitis B cirrhosis (12.2%), 24 post-hepatitis C cirrhosis (14%), 6 autoimmune cirrhosis, 7 primary biliary cirrhosis (4%), 21 non A non B cirrhosis (12.9%), 3 undetermined cirrhosis. Thirty one patients had a liver transplantation for cancer. The other indications were 5 sclerosing cholangitis and 2 atresia of the biliary tract. 45% of the patients had an uneventful postoperative course. In hospital mortality rate is related to the indication and Child Pugh classification in cirrhotic patients. The vascular surgical complications were 8.5%, biliary complications 6.1%, intra-abdominal infection 9.2%, intra-abdominal bleeding 5.5%. The rate of reoperation was 18.5%. 23 re-transplantations were performed in emergency and 6 electively (one from outside). The overall survival of patients from 1978 to 1994, including the patients before cyclosporine era, the use of extracorporeal circulation, the preservation with Wisconsin solutions and with main indications for cancer was 69% at 1 year and 59% at 5 years. After 1988, the overall patient survival was 75% at 1 year and 70% at 5 years. The graft and patient survival is mainly related to the indications. In fulminant and subfulminant hepatitis, the quality of the graft was preferred as often as possible. The actuarial graft survival at 1 year, 3 years and 5 years was respectively 75%, 70.45% and 70.45%. The actuarial patient survival was 77.3%, 72.5% and 72.5%. In liver transplantation for cancer, the actuarial patient survival at 1 year, 3 years and 5 years is respectively 55%, 32% and 23.5%. 5 patients are alive and well at 5 years, including a patient who underwent a Cluster operation for Klatskin tumor. In post-hepatitis cirrhosis, the patient actuarial survival at 1 year, 3 years and 5 years was 79%, 76.5% and 76.5% and in alcoholic cirrhosis 75%, 72% and 72%. The actuarial survival is closely related to Child Pugh Classification (at one year Child A 87%, Child B 72.4%, Child C 58%)., Conclusion: in this series of the first 200 liver transplants at the University of Rennes Medical Center, graft and patient survival depends on the evolution of the surgical technic but it is also closely related to the indication. In fulminant hepatitis, the quality of the graft (without incompatible graft, if possible) should permit to avoid retransplantation and to obtain results closely to the elective transplantation. Liver transplantation for cancer should be restricted. In cirrhosis, results are depending upon Child Pugh classification. The conclusions of Paris consensus conference should be followed. The limited number of donor livers call for the "priorization" (T.E. Starzl) favoring those patients who will benefit most, i.e., patients with the most serious conditions and the poorest short term vital prognosis.

Multi-septate gallbladder is a very rare anomaly. In this 13-years-old girl with a complaint of nausea, vomiting and abdominal pain, sonographic examination and oral cholecystogram demonstrated a normal size gallbladder with many thin septa. The longitudinal section of the removed gallbladder revealed multiple inter-communicating lobules divided by many thin septa. She has been free of the previous complaints after surgery. Only two pediatric cases have been reported previously. Our case illustrates the main features of this entity.