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									         Annals of Fundeni Hospital
                               EDITOR: Irinel Popescu
     Fundeni Clinical Institute, Department of General Surgery and Liver Transplantation, 3rd floor,
258 Fundeni Rd., Bucharest, Romania. Tel./Fax: +4021-318.04.17. E-mail: irinel.popescu@icfundeni.ro



                                          TE
                                   ASSOCIA EDITOR
                                     Mircea Diculescu
                      Fundeni Clinical Institute, Department of Gastroenterology



                                   ASSISTANT EDITOR
                                         Vlad Herlea
                         Fundeni Clinical Institute, Department of Pathology



                                   EDITORIAL BOARD
        E. Apetrei, Bucharest                                P. Hytiroglou, Thessaloniki
        C. Arion, Bucharest                                  Virginia Ion, Bucharest
        H.G. Beger, Ulm                                      M. Martin, Chatanooga
        D. Capsa, Bucharest                                  Naoto Matsuno, Tokyo
        V. Candea, Bucharest                                 Virginia Mirea, Bucharest
        D. Colita, Bucharest                                 I. Pop D. Popa, Bucharest
        D. Constantinescu, Chattanooga                       L.M. Popescu, Bucharest
        Ileana Constantinescu, Bucharest                     D. Popovici, Bucharest
        D. Fagarasanu, Bucharest                             I. Sinescu, Bucharest
        B. Fotiade, Bucharest                                A. Stieber, Atlanta
        S. Georgescu, Bucharest                              D. Tulbure, Bucharest
        C. Gheorghe, Bucharest                               M. Voiculescu, Bucharest
        Liana Gheorghe, Bucharest




                                   EDITORIAL OFFICE
     Fundeni Clinical Institute, Department of General Surgery and Liver Transplantation, 3rd floor,
258 Fundeni Rd., Bucharest, Romania. Tel./Fax: +4021-318.04.17. E-mail: irinel.popescu@icfundeni.ro



                       AFH is atested and indexed in the datebase EMBASE (Excerpta Medica), Amsterdam

                                                              Printed in Romania, Celsius Publishing House
           Annals of Fundeni Hospital
                        Vol. 10, No. 1 - 2, January - June 2005




CONTENTS

LEADING ARTICLE
Fundeni Pediatric Department - a short presentation                                            3
   C. Arion, V. Mihailescu, B. Dima



ORIGINAL ARTICLE
The left ventricular diastolic function as prognostic predictor in patients with idiopathic
dilated cardiomyopathy                                                                         7
   Luminita Iliuta, H. Moldovan, D.P. Gherghiceanu, R.Vasile, Daniela Filipescu,
   B. Radulescu, C. Macarie, V. Candea

Microbiologic Analysis of a Cefepime; Producing Isolates 1 -Year Period                       14
  Jeni Laura Vlad

Needle core biopsy versus needle aspiration cytology in preoperative diagnosis
of solid breast lesions                                                                       20
   Mihaela Mihai, M. Lesaru, M. Ceausu, Carmen Ardeleanu



CASE REPORTS
The immunofluorescence in the assessment of the renal biopsy specimens                        30
   C. Ionescu, M. Hortopan, G. Ismail, E. Buzatu, E. Busuioc, V. Herlea, M. Voiculescu

More treatment choices for patients with chronic lymphocytic leukemia: a case report
and review of the literature                                                                  34
  C.A. Dasanu, Elena Stoica-Mustafa, V. Herlea, D.T. Alexandrescu

Primitive rhabdomyosarcoma of the diaphragm, embryonal type                                   38
   Raluca Cristea, V. Herlea, Monica Hortopan, Mihaela Mihai, C. Pechianu,
   Doina Hrehoret, Carmen Ardeleanu, Camelia Dobrea, I. Popescu


Instructions for Authors                                                                      45
Leading Article                                   Annals of Fundeni Hospital, volume 10, number 1-2, January-June




                    FUNDENI PEDIATRIC DEPARTMENT
                       - A SHORT PRESENTATION -



                                    C. Arion, V. Mihailescu, B. Dima

                        Pediatric Clinic, Clinical Institute Fundeni, Bucharest, Romania




  There are three main steps on the way to                          From the very beginning the staff was involved
modern medicine in the Fundeni Pediatric                        in the education and formation of students and of
Department, founded in 1959:                                    young specialists in Pediatrics, under the auspices
  - 1959-1961: the Chief of the Clinic being                    of "Carol Davila" University of Medicine and
    Prof. Ion Nicolau MD, PhD, associated                       Pharmacy - the first (founded in 1857) and the most
    member of the Romanian Academy for                          important School of Medicine in Romania. The
    Medical Sciences, who oriented the activity                 educational duties interferred with the medical care
    towards the field of pediatric Hematology                   offered to the sick children and teenagers,
    and Oncology;                                               primarily to those suffering from cancer, non-malig-
  - 1961-1993, when the new Head of the Clinic                  nant hematological diseases, kidney and urinary
    - Prof. Gheorghe Goldis MD, PhD, member of                  tract diseases, connective tissue diseases, congeni-
    the Romanian Academy for Medical Sciences                   tal heart defects, chronic inflammatory disorders,
    - developed not only the Pediatric                          chronic hepatitis and cirrhosis, haemofilias,
    Hematology and Oncology, but also the                       thalassemias etc.). fig. 7
    Pediatric Nephrology, Rheumatology and                          The research activities were conducted to the
    Gastroenterology;                                           same fields of modern medicine, Fundeni Clinic
  - since 1994 until the present days; during this              of Pediatrics having many priorities in Romania
    period of time - under the leadership of Prof.                  Last but not least, the doctors and nurses repre-
    Constantin Arion MD, PhD, member of the                     sented Romania at many national and international
    Romanian Academy for Medical Sciences -                     scientific meetings and participated in representa-
    the activity was focused on the modern fields               tive medical and scientific organisations.
    of contemporary interdisciplinary medicine
    (multi-modal treatment of cancer in children,                         Past and present medical
    hematological stem cell transplantation,                              and research priorities:
    hemodialysis and peritoneal dialisys, multi-
    modal treatment of connective tissue dis-
                                                                1. The 1959-1993 period:
    eases, assistance for solid organ transplanta-
    tion - kidney and liver, invasive procedures                1.1. Diagnose and treatment of pediatric
    for liver exploration, treatment of portal                       hematological diseases, including
    hypertension in children …)                                      hematological malignancies



Address for correspondence: Prof. Dr. C. Arion, Pediatric Department, Fundeni Clinical Institute, Bucharest, Fundeni street
258, 022328, Bucharest, Romania


                                                                                                                       3
C. Arion et al.



    - The foundation of the Hematological Labora-              tension in children (dr. Sanda Boiu, Dr.
       tory of the Pediatric Department (dr. Lucia             Tatiana Badea-Iuga). The surgical therapy
       Lazar, dr. Stela Donovan, biologist Paraschiva          was performed in many cases by Prof.
       Radamescu); the activity is now continued by            Andrei Popovici and his collaborators from
       dr. Mirela Asan and dr. Anca Gheorghe along             the Fundeni Department of Surgery);
       with another two technicians;                      1.7. The first kidney biopsies in children in
    - 1964: Prof. Gheorghe Goldis published the                Romania and and the first hemodialysis for
       monography "Hemolytic Anemias" (Ed.                     chronic and acute renal failure in Romania
       Academiei, Bucuresti), the very first book              On December 23rd, 1992, the first Pediatric
       dedicated to Pediatric Hematology in the                Hemodialysis Unit in Romania was founded
       romanian medical literature;                            by dr. Gheorghe Chiriac-Babei;
    - In the 70's: the introduction of the tech-          1.8. The introduction of the multi-modal therapies
       niques for thrombocyte funcions evaluation              for the solid tumors in children, in co-opera-
       and for the study of calitative platelet defects        tion with the Fundeni Department of Surgery
       and von Willebrand's Disease in children (Dr.           (Prof. Dan Setlacec, Prof. Andrei Popovici,
       Caliopi Cutcudache, Prof. Gh. Goldis);                  Prof. Irinel Popescu, Assoc. Prof. Mihnea
    - Also in the 60's and 70's: the first specialized         Ionescu and Assoc. Prof. Catalin Vasilescu),
       approach to acute leukemias and lympho-                 Fundeni Department of Urology (Prof. Eugen
       mas in children and teenagers, followed by              Proca, Prof. Ionel Sinescu), Fundeni Depart-
       many scientific papers and presentations at             ment of Radiology and Imaging (Prof. Cornel
       national and international congresses and               Butnaru, Prof. Serban Georgescu, Assoc. Prof.
       symposia (Prof. Gh. Goldis, dr. Miriam                  Constantin Zaharia, Assoc. Prof. Ioana
       Bercovici, dr. Ion Popescu et al)                       Lupescu, dr. Gheorghe Goldis Jr., dr. Mihai
1.2. Clinical activities and studies of the rheumatic          Lesaru) and Fundeni Department of Radio-
       and connective tissue diseases (dr. Ghita an            bioloy (Dr. Ioan Muntiu and colleagues).
       colleagues); they published the monography
                                                          2.      The 1993 - 2005 period:
       "Rheumatic Fever";
1.3. The introduction of modern diagnostic and            2.1. The extension of the Pediatric Dialysis Unit
       treatment modalities for congenital heart               (which now has 5 full day operating
       defects, including the surgical approach in             machines, 6 days/week) and the introduc-
       the Clinic of Cardiovascular Surgery, founded           tion of new techiniques for renal replace-
       by Prof. Voinea Marinescu. His pioneer work             ment therapy: Peritoneal Dialysis (a unit with
       was continued by prominent surgeons like                2 beds and 5 cyclers) and Hemofiltration.
       Prof. Dan Setlacec, Prof. Marian Ionescu,               The Pediatric Dialysis Unit assists now 35
       Prof. Ioan Pop D. Popa, Prof. Dan Fagarasanu,           children with Chronic Renal Failure and
       by brilliant invasive investigationists like Dr.        performs 2800 hemodialysis procedures
       Bradu Fotiade and by the founder of the                 and over 18.000 peritoneal changes every
       Romanian School of Anesthesiology and                   year (Dr. Gheorghe Chiriac-Babei, Dr. Cristina
       Intensive Care - Prof. G. Litarczeck;                   Stoica, Dr. Mariana Vasilescu, Dr. Carmen
1.4. The diagnose and treatment of urinary tract               Dinca, Dr. Bogdan Dima) - fig. 1 and 2
       disorders in children, including urinary           2.2. Co-operation for the first kidney transplan-
       tract congenital anomalies, in co-operation             tations in children in Romania performed
       with Fundeni Clinic of Urology (Prof. Gh.               by Prof. Ionel Sinescu in the Fundeni
       Olanescu, Prof. E. Proca, Prof. I. Sinescu              Institute of Urology and Kidney Transplan-
       and their collaborators)                                tation (1998 - from a living donor and
1.5. Modern approaches to Staphylococcal                       1999 with a cadaveric kidney)
       respiratory tract infections and severe acute      2.3. Co-operation for the first liver transplantation
       diarrheal disorders with important dehydra-             in children in Romania, performed in 2000
       tion and to the parenteral nutrition in infants         by Prof. Irinel Popescu and his collegues at
       (dr. Valeriu Rosculet, dr. Ion Popescu);                the Fundeni Institute of General Surgery and
1.6. The diagnose and treatment of portal hyper-               Liver Transplantation;



  4                                                       Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                                                       Fundeni Pediatric Clinic - a short presentation




Fig. 1                                                    Fig. 2



2.4. The foundation in 1996 (dr. Ion Ivan) of the
     National Pilot Center for -Thalassemia and
     Haemophyliac children and adolescents.
     The patients benefit from the modern diag-
     nostic procedures (including hemoglobin
     electrophorese and molecular biology),
     from the substitution therapy and specific
     treatments (iron binding, the administra-
     tion of coagulation factors concentrates
     etc); the unit co-operates in this field with
     Fundeni Department of Hematology (dr.
     Valentina Uscatescu, dr. Dan Coriu) - fig. 3
2.5. The foundation of the Ambulatory Unit for
     Chemotherapy in children with malignan-
                                                          Fig. 3 - Dr. Alexandrina Constantinescu has been started
     cies (1997)                                          to evaluate all the children included in liver transplant
2.6. The foundation of the Bone Marrow                    program. Also she has been started in collaboration with
     Transplantation Department (2000) and the            Gastroenterology Department of Fundeni Clinical
     performing of the first pediatric autologous         Institute (Assoc. Prof. Cristian Gheorghe) therapeutic
     (March 2002) and allogenic (October 2003)            endoscopic procedures for children (as banding of
     hematopoietic stem cell transplantation for          esophageal varices) and the diagnostic and treatment
     malignant disease in children in Romania.            for complex gastroenterological.
     The team of doctors and nurses involved in
     HSCT in children is co-ordinated by Prof.
     Constantin Arion, Dr. Anca Colita, Dr.
     Luminta Dumitrache and the Chief-Nurse                    cardiac malformations and rythm distur-
     Rodica Ghelase. The program of pediatric                  bances, evaluation of children for transplant
     stem cell transplantation is extended now to              programs (renal, liver and bone marrow
     the solid tumors and the non-malignant                    transplant).
     hematological diseases (first allogenic BMT          2.8. Prof. Constantin Arion and Dr. Dorin Bleahu
     for severe aplastic anemia was performed in               participated with chapters dedicated to
     2004); fig. 4, 5, 6.                                      Anemias and the Pathology of Leukocytes
2.7. Cardiac pathology for children is repre-                  and Leukemias at the publishing of the
     sented by Dr. Alin Nicolescu, cardiologist,               most recent edition of the Romanian
     that including diagnostic and treatment of                "Textbook of Pediatrics" (editors: Eugen


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                          5
C. Arion et al.




Fig. 4                                                 Fig. 5




Fig. 6                                                 Fig. 7




       Ciofu and Carmen Ciofu, Ed. Medicala,           most prominent Romanian and International
       Bucuresti 2000)                                 Institutions; for the last category we mention
2.9. Fundeni Clinic of Pediatrics got the confir-      prestigious Medical Centers like Medizinische
       mation as Center of Excellence in               Hochshulle Hannover - Germany, L'Hopital
       Hematology by CNCSIS - the National             "Armand Trousseau" (Paris, France), L'Institut de
       Authority for Research in Universities          Cancerologie Villejuif (France), Emory University
       (2002)                                          (Atlanta, USA), Baylor College of Medicine
   We would like to underline the leading feature      (Houston, USA), Istituto Geanina Gaslini
of activity in the Fundeni Clinic of Pediatrics: the   (Genova, Italia), The Jose Carreras Foundation,
constant preoccupation for co-operation with the       Regensburg University of Medicine (Germany).




  6                                                    Annals of Fundeni Hospital, volume 10, number 1-2, 2005
Original Article                                    Annals of Fundeni Hospital, volume 10, number 1-2, January-June




     THE LEFT VENTRICULAR DIASTOLIC FUNCTION
     AS PROGNOSTIC PREDICTOR IN PATIENTS WITH
        IDIOPATHIC DILATED CARDIOMYOPATHY



               Luminita Iliuåa, H. Moldovan, D.P. Gherghiceanu, R.Vasile,
                 Daniela Filipescu, B. Rãdulescu, C. Macarie, V. Cândea

                    Institute of Cardiovascular Diseases "C.C.Iliescu", Bucharest, Romania




  Abstract Background: Previous studies have demonstrated that the presence of restrictive left ventricular (LV)
               diastolic filling pattern in patients with dilated cardiomyopathy have an unfavorable prognostic. Aim: 1. To
               establish the value of LV diastolic filling pattern as prognostic predictor in patients with idiopathic dilated
               cardiomyopathy. 2. Assessment of the betablocker treatment on these patients. Material and method:
               Prospective study on 143 patients (63%male, mean age 52 15) with dilated cardiomyopathy divided in 2
               groups: 1. Group A - 87 patients with restrictive LV diastolic filling pattern, 2. Group B - 56 patients with
               nonrestrictive LV diastolic filling pattern. 49 patients (56%) from group A and 31 patients (55%) from group
               B underwent betablocker treatment (carvedilol). Patients were evaluated every 3 months during a 2 year
               follow-up. Statistical analysis used SYSTAT and SPSS programs for the simple and multiple liniar regression
               analysis, correlation coeficient and relative risk calculations. Results: 1. Mortality rate after 2 year follow-up
               was significantly higher in group A (68.96%) compared to group B (51.78%). The restrictive LV diastolic
               filling pattern (E wave deceleration time DT<130msec, E/A>2) has increased twice the risk of death
               (RR=2.6, p=0.007). 2. Clinical amelioration after 2 years was more frequent in patients with nonrestrictive
               diastolic filling pattern (DT>130msec, E/A<2). 3.Survival rate in patient undergoing betablocker treatment
               was similar in both groups (46.93% versus 51.61%) but significantly higher in these patients versus patients
               without betablocker treatment (46.93% versus 10.53% in group A, p=0.002, respectively 51.61% versus
               44% in group B, p=001). 4. The LV diastolic pattern has remained restrictive at 2 year follow-up in 84.21%
               patients without betablocker treatment and only in 30.6% patients with betablocker treatment.
               Conclusions: 1.The persistence of the restrictive LV diastolic filling pattern at 2 years is associated with an
               increasing in the risk of death in patients with cardiac failure due to nonischemic dilated cardiomyopathy.
               2.The association of restrictive LV diastolic filling pattern leads to a more unfavourable prognostic, with
               increasing the risk of death and worsening the clinical status of these patients in a 2 year follow-up. 3. The
               restrictive LV diastolic filling pattern is reversible on betablocker treatment.


                       Key words: dilatative cardiomyopathy, left ventricular diastolic filling pattern
          Abbreviations: DCM - dilated cardiomyopathy, LV - left ventricle, LVEF- left ventricular ejection fraction,
                               DT- deceleration time, NYHA - New York Heart Association




Address for correspondence: Dr. Luminiþa Iliuþã, Institute of Cardiovascular Diseases "C.C.Iliescu", Bucharest, Fundeni street
258, 022328, Bucharest, Romania



Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                                       7
L Iliuþã et al.



Introduction                                               prognostic in patients with idiopathic dilated
                                                           cardiomyopathy. We have also tried to assess the
                                                           impact of betablocker treatment on the left
     Dilated cardiomyopathy is a significant cause         ventricular diastolic filling pattern in these patients.
of morbidity and mortality among patient with
congestive heart failure and aging population. In
United States, the reported incidence of
cardiomyopaties is 400,000-500,000 cases per               Material and Methods
year, with a prevalence of 2-3 million people [1].
     In spite of modern therapy which associates               We carried out a prospective study on 143
vasodilators, angiotensin-converting enzyme                patients with idiopathic dilated cardiomyopathy
inhibitors to digitalis treatment, and of progresses       addmitted to the Institute of the Cardiovascular
on surgical treatment, the overall prognostic              Diseases "CC Iliescu" between 1 january 2000 and
remains poor. Facing this heart condition, clinician       1 January 2003. Most of the patients were male
is in the position to decide which of various              (62.72%), with a mean age of 52±15 years and
parameters should be used in order to evaluate the         the mean left ventricular ejection fraction was
severity and the prognostic of disease.                    25±5.2%.
     The long and medium term prognosis in                     The patients were evaluated clinically and by
patients with idiopathic dilated cardiomyopathy            echocardiography at the enrollment into study and
is influenced by many parameters among which               during the treatment at every 3 months for two
left ventricular diastolic function is one of the          years. For each patient taken into study we
most important. It is also appears to be the one           assessed echocardiographically the left ventricular
of the earliest detectable abnormalities in many           systolic and diastolic performance and the left
of the heart disorders.                                    atrium function.
     Diastolic dysfunction is a condition in which             All patients received the standard treatment for
filling of the left ventricle is impeded, leading to       heart failure with digitalis, diuretics, converting
symptoms of low cardiac output or/and elevated             enzime inhibitors and spironolactone. At the
pulmonary venous pressure. There are two distinct          enrollment into study all the patients were in sinus
abnormal filling patterns which can be detected by         rhythm.
Doppler echocardiography [2]: "impaired relaxation"            The left ventricular diastolic filling was evaluated
characterized by a prolonged isovolumetric                 by Doppler examination and the restrictive
relaxation time, an increased deceleration time of         diastolic filling pattern was defined as an E wave
early transmitral filling velocity (E wave) and a          deceleration time less than 130msec and the E
decrease in E/A ratio and "restrictive pattern" charac-    wave /A wave velocity ratio more than 2.
terized by a shortened isovolumetric relaxation time,          Depending on the LV diastolic filling pattern
a decreased deceleration time, and an elevated E/A         the patients were divided in two groups (fig.1):
ratio.                                                         a) Group A - 87 patients with a left ventricular
     It is known that the presence of a restrictive left          restrictive diastolic filling pattern, and
ventricular diastolic filling pattern is associated with       b) Group B - 56 patients with a left ventricular
a more unfavourable prognosis in most of cardiac                  non restrictive filling pattern.
diseases (valvular, coronary or congenital). The               Depending on both diastolic performance of
impact of restrictive left ventricular diastolic filling   the left ventricle and the type of the treatment,
pattern presence on the evolution and prognosis in         each group was divided in two subgroups as
patients with idiopathic dilated cardiomyopathy            follows:
has been evaluated in some previous studies and                a) Subgroup A1 with 49 patients with a
we tried to evaluate it also taking into considera-               restrictive LV diastolic filling pattern under-
tion the beta-blocker treatment in these patients as              going betablocker treatment;
well.                                                          b) Subgroup A2 - 38 patients with a restrictive
     That is why the purpose of this study is to                  diastolic filling pattern without betablocker
establish the implication of the left ventricular                 treatment
diastolic filling pattern on the evolution and                 c) Subgroup B1 comprising 31 patients with



   8                                                       Annals of Fundeni Hospital, volume 10, number 1-2, 2005
          The Left Ventricular Diastolic Fuunction as Prognostic Predictor in Patients with diopathic Dilated Cardiomyopathy



                                    Subgroup A1 - 49 pts
              Group A - 87 pts      Betablocker treatment
                     Restrictive
            LV diastolic pattern    Subgroup A2 - 38 pts
                                           Without
                                    betablocker treatment
143 Eco
pts PW
                                    Subgroup B1 - 31 pts
              Group B - 56 pts      Betablocker treatment
                 Nonrestrictive     Subgroup B2 - 25 pts
            LV diastolic pattern          Without
                                    betablocker treatment

Fig. 1 - Patients structure depending on the LV                 Fig. 2 - Risk of death at 1 year in patients with
diastolic filling pattern and treatment undergone               idiopathic dilated cardiomyopathy




      an non restrictive LV filling pattern who                 the presence of other parameters known to
      underwent betablocker treatment, and                      increase mortality in patients with dilated
   d) Subgroup B2 - 35 patients with an non                     cardiomyopathy. The restrictive left ventricular
      restrictive LV filling pattern but without                diastolic filling pattern turned out to be an inde-
      betablocker treatment.                                    pendent predictor for increasing the risk of death
   The two groups were comparable concerning:                   or hospitalization for heart failure decompensa-
mean age, gender, mean LVEF, secondary mitral                   tions (p=0.001), regardless the left ventricle
regurgitation degree, the mean pulmonary artery                 dimensions or performance, the presence of a
pressure.                                                       secondary mitral regurgitation haemodinamically
   Statistical analysis used SYSTAT and SPSS pro-               significant or pulmonary hypertension.
grams for the simple and multiple linear regression                  These data are presented in figure 2 which
analysis, correlation coefficient calculation and               shows the relative risks of death at one year
relative risk calculation. The most important                   follow-up for the patients with dilatative cardiomy-
endpoints used for the estimation of the medium                 opathy associated with different parameters
term prognosis were: type of LV diastolic filling               known for increasing the mortality rate. Thus, the
pattern, NYHA class for heart failure, quality of life          risk of death at one year was increased by 4.2 fold
(appreciated on a scale from 1 to 10 using a ques-              by the presence of rhythm disorders, by 2.8 fold by
tionnaire filled in by the patient at each visit),              an associated restrictive left ventricular diastolic
death.                                                          filling pattern, by 3.2 fold by a severe left ventricu-
                                                                lar sistolic dysfunction with an ejection fraction less
                                                                than 20% and by 1.9 fold by the presence of an
                                                                associated haemodinamically significant mitral or
Results                                                         tricuspid regurgitation.
                                                                     In figure 3 there are represented the relative
     1. Mortality rate at 2 year follow-up was signifi-         risks of death at two years follow-up for the patients
cantly higher in patients with restrictive LV diastolic         taken into study associated with different known
filling pattern (68.96% in Group A) compared to                 parameters that increase the mortality level in
patients with nonrestrictive LV diastolic filling               idiopathic dilated cardiomyopathy (such as the
pattern (51.78% in Group B), regardless the LV                  presence of atrial or ventricular rhythm disorders,
systolic performance.                                           an associated haemodinamically significant mitral or
     2. The presence of the restrictive LV diastolic            tricuspid regurgitation, systolic performance of left
filling pattern (E wave DT<130msec, E/A>2) has                  ventricle). The relative risks are also represented
increased the risk of death by 2.8 times at 1 year              distinctly depending on the type of left ventricular
and by 2.6 times at 2 year follow up, regardless                diastolic filling pattern. The predictive value for


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                                9
L Iliuþã et al.



                              Restrictive LV diastolic pattern                           Nonrestrictive LV diastolic pattern



                                                   4,2




                                                  5,8                                                                          4,1




        Relative Risk                                                        Relative Risk

Fig. 3 - Risk of death at 2 years in patients with idiopathic dilated cardiomyopathy depending on the type of
LV diastolic filling pattern




death at two years follow-up of the left ventricle               undergone. In addition, the quality of life score
systolic dysfunction, of the atrioventricular valve              >5 was found at about three fold more patients
regugitation or of the arrhythmias was higher in                 with a nonrestrictive LV diastolic filling compared
patients with a non-restrictive LV diastolic filling             with a restrictive one in both years of follow-up
pattern. In these patients, values of left ventricular           (fig. 4)
ejection fraction less than 20%, the presence of a                   4. Follow-up at 2 years showed that survival
mitral or tricuspid regurgitation three or four                  rate in patients undergone betablocker treatment
degreee or ventricular arrhythmias increased about               was similar in both types of the left ventricle
four times the risk for death at two years follow-up.            diastolic filling pattern but significantly higher com-
     The presence of a restrictive left ventricular              pared with patients without betablocker treatment:
filling pattern homogenized the relative risk values.                - in Group A 46.93% patients with betablocker
In patients from group A, the risk for two years                        treatment respectively 10.53% in patients
mortality was increased by the type of the diastolic                    without betablocker treatment, p=0.0022;
filling regardless the left ventricular systolic                     - in Group B 51.61% patients with betablocker
performance or the presence of mitral or tricuspid                      treatment respectively 44% in patients with-
regurgitation or atrial arrhythmias. In these                           out betablocker treatment, p=0.001.
patients, the only independent predictor for                         In figure 5 the percents of survivors at one
increasing the risk of death at two years follow-up              year and two years follow-up are presented for
was the presence of ventricular rhythm disorders.                all four subgroups taken into study depending on
     3. Taking into consideration the patient                    both the type of left ventricle diastolic filling and
evolution, the percent of those with a favourable                on the type of treatment (patients who received
evolution quantified as NYHA class of heart                      or not beta blockers):
failure less than 3 and the quality of life score >5                 - In group A (patients with a restrictive left
was higher in the group of patients with a non-                         ventricular filling pattern) the survival rate at
restrictive left ventricular diastolic filling pattern,                 one year was aproximatively 2.5 times
regardless whether they received betablocker                            higher in patients who received betablocker
treatment or not.                                                       treatment compared with those without
     Thus, at one year follow-up, the percent of                        betabloker treatment (about 66% versus
patients in a low NYHA class was nearly double                          28%). In addition, at two years follow-up the
in group B and at two years follow-up three                             survival rate in subgroup A1 was 3 times
times higher compared with patients with a                              higher in patients with betablocker treatment
restrictive left ventricular diastolic filling pattern                  (about 44% versus 14%);
(group A), regardless the betablocker treatment                      - in group B (patients with a non restrictive



  10                                                             Annals of Fundeni Hospital, volume 10, number 1-2, 2005
               The Left Ventricular Diastolic Fuunction as Prognostic Predictor in Patients with diopathic Dilated Cardiomyopathy

  % patients




                                                                        % patients
Fig. 4 - NYHA class and quality of life in patients depending the LV diastolic filling pattern and year of follow-up




Fig. 5 - Survival rate at 1 and at 2 years depending on the treatment undergone and the LV diastolic filling
pattern in patients with idiopathic dilated cardiomyopathy




     left ventricular filling pattern) the percent of                diastolic filling pattern has remained restrictive at
     survivors at one year and at two years was                      two years follow-up in 84.21% patients without
     aproximatively 1.5 times higher in patients                     betablocker treatment and only in 30.6% patients
     with betablocker treatment compared with                        undergoing betablocker treatment.The evolution
     patients who did not receive this treatment.                    of the left ventricular diastolic filling was
   5.Betablocker treatment has influenced the LV                     influenced by the betablockers. Thus, at two year
diastolic filling pattern evolution, too. Thus, LV                   follow-up, left ventricular diastolic filling pattern


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                                    11
L Iliuþã et al.



has remained restrictive in about 84% patients            literature maybe because of the transplantation
who did not received betablockers and only in             surgery which is not very well developed yet.
aproximatively one third - thirty percent of the              Previous studies have demonstrated that
patients undergoing betablocker treatment.                beta-adrenergic blocking therapy has a consistent
                                                          beneficial effect on LV ejection fraction in
                                                          cardiomyopathy patients [24] with a more variable
                                                          and controversial effect on diastolic relaxation
Discussions                                               properties [20, 22, 23, 24, 25]. There was initially
                                                          reported [23] an improvement in LV end-diastolic
    Data from present study support the hypothesis        pressure with metoprolol. Subsequently, the MDC
tested in other previous studies which highlighted        Study Group evaluated LV diastolic filling using
the importance of LV diastolic filling as predictor of    transmitral Doppler echocardiography [20]. They
severity and prognosis in dilated cardiomyopathy.         reported that metoprolol resulted in a significant
    Dilated cardiomyopathy is characterized by an         improvement in early LV diastolic deceleration
abnormal LV diastolic filling and severe cases            times in cardiomyopathy patients. The maximum
showed the restrictive type of diastolic pattern          improvement in deceleration times occurred with-
[19] with a E/A>2 cases with a poor prognosis             in 3 months of initiation of betablocker therapy.
and cases with a E wave DT<150ms usually indi-            These observations in a large group of cardiomy-
cating bad outcome.                                       opathy patients are consistent with an improve-
    The literature showed also that the restrictive LV    ment in diastolic relaxation properties [21].
diastolic filling pattern is frequent in dilated              These was shown by our study in which the
cardiomyopathy and is associated with more                betablocker treatment associated to the standard
severe disease being the best predictor for cardiac       therapy has influenced the diastolic filling pattern
death in these patients [6, 8, 10, 13, 15].               which remained restrictive at 2 year follow-up in
    The mortality rates showed in our study are in        84.21% patients without betablocker treatment
line with those from literature. Thus, the mortality      and only in 30.6% patients with betablocker
rate at 2 year follow-up found was of 68.96% in           treatment.
patients with dilated cardiomyopathy with a
restrictive filling pattern and of 51.78% for those
with a nonrestrictive filling pattern.
    The clinical evaluation by NYHA class of heart
                                                          Conclusions
failure and quality of life has shown an amelioration
at 2 years which was more frequent in patients                 In patients with dilated cardiomyopathy, the
with nonrestrictive diastolic filling pattern, which is   presence of a restrictive left ventricular diastolic
in line with the literature studied [5, 7, 8, 10, 11]     filling pattern is associated to a more unfavorable
    The survival rates presented by literature in         prognosis. This type of filling increased the risk of
patients with dilated cardiomyopathy have                 death and worsened the clinical status of the
shown different figures. The survival rates at 2          patients (quantified as NYHA class and the quality
year follow-up was 52% for patients with restric-         of life).
tive LV diastolic filling as compared with 94% in              On medium term, the use of betablockers
patients with a nonrestrictive filling pattern            associated with conventional therapy of heart
(defined as prolonged DT) [4]. Another study has          failure was shown to improve the left ventricle
shown a survival rate with standard therapy of            diastolic filling and, in the same time to decrease
84%, 73% and 61% at 1, 2 and 4 years respec-              the mortality rate and to improve the quality of
tively that is significantly poorer than that of age-     life.
and gender-matched population.[9].
    In our study the survival rates were calculated
separately for the patients who underwent
betablocker treatment or not. The figures at the 2
                                                          References
year follow-up for those who received standard
treatment seams to be slightly lower than in the           1.   Kannel WB, Belanger AJ, Epidemiology of heart failure.




  12                                                      Annals of Fundeni Hospital, volume 10, number 1-2, 2005
           The Left Ventricular Diastolic Fuunction as Prognostic Predictor in Patients with diopathic Dilated Cardiomyopathy



        Am Heart J 1991; 11; 951-957                                         implications. SPIC (Italian Multicenter Cardiomyopathy
  2.    Vitarelli A, Gheorghiade M., Diastolic heart failiure:               Study) Group. Am Heart J. 1993 Feb; 125(2 Pt 1):410-
        standard Doppler approach and beyond. Am J Cardiol                   22.
        1998; 81 (12A): 115G-121G                                      15.   Florea VG, Henein MY, Cicoira M, Anker SD, Doehner
  3.    Mikami T, Kudo T, Hashimoto M, Sugawara T,                           W, Ponikowski P, Francis DP, Gibson DG, Coats AJ.
        Sakamoto S, Yasuda H., Left ventricular diastolic flow               Echocardiographic determinants of mortality in patients
        dynamics in dilated cardiomyopathy: a color flow                     >67 years of age with chronic heart failure. Am J
        imaging and pulsed Doppler echocardiographic                         Cardiol. 2000 Jul 15; 86(2):158-61.
        study. J Cardiol. 1989 Dec; 19(4):1073-80                      16.   Pinamonti B, Zecchin M, Di Lenarda A, Gregori D,
  4.    Werner GS, Schaefer C, Dirks R, Figulla HR, Kreuzer                  Sinagra G, Camerini F. Persistence of restrictive left
        H., Prognostic value of Doppler echocardiographic                    ventricular filling pattern in dilated cardiomyopathy: an
        assessment of left ventricular filling in idiopathic dilated         ominous prognostic sign. J Am Coll Cardiol. 1997 Mar
        cardiomyopathy. Am J Cardiol. 1994 Apr 15;                           1; 29(3):604-12.
        73(11):792-8                                                   17.   Forleo C, Resta N, Sorrentino S, Guida P, Manghisi A, De
  5.    Werner GS, Fuchs JB, Schulz R, Figulla HR, Kreuzer H.,               Luca V, Romito R, Iacoviello M, De Tommasi E, Troisi F,
        Changes in left ventricular filling during follow-up study           Rizzon B, Guanti G, Rizzon P, Pitzalis MV. Association of
        in survivors and nonsurvivors of idiopathic dilated                  beta-adrenergic receptor polymorphisms and progres-
        cardiomyopathy. J Card Fail. 1996 Mar; 2(1):5-14                     sion to heart failure in patients with idiopathic dilated
  6.    Pinamonti B, Di Lenarda A, Sinagra G, Camerini F.,                   cardiomyopathy. Am J Med. 2004 Oct 1; 117(7):451-8.
        Restrictive left ventricular filling pattern in dilated car-   18.   Temporelli PL, Corra U, Imparato A, Bosimini E,
        diomyopathy assessed by Doppler echocardiogra-                       Scapellato F, Giannuzzi P. Reversible restrictive left
        phy: clinical, echocardiographic and hemodynamic                     ventricular diastolic filling with optimized oral therapy
        correlations and prognostic implications. Heart                      predicts a more favorable prognosis in patients with
        Muscle Disease Study Group. J Am Coll Cardiol. 1993                  chronic heart failure. J Am Coll Cardiol. 1998 Jun;
        Sep; 22(3):808-15.                                                   31(7):1591-7.
  7.    Weihs W, Anelli-Monti B, Schuchlenz H, Harb S.,                19.   Dubourg O, Bourdarias JP. Doppler echocardiographic
        Practical assessment using transmitral Doppler                       investigation of cardiomyopathies Arch Mal Coeur
        echocardiography for the evaluation of left ventricular              Vaiss. 1996 Jul; 89 Spec No 2:39-45.
        filling pressure in patients with systolic ventricular         20.   Andersson B, Caidahl K, di Lenarda A, Warren SE, Goss
        dysfunction. Acta Med Austriaca. 1999; 26(1):8-11.                   F, Waldenstrom A, Persson S, Wallentin I, Hjalmarson
  8.    Piszczek I, Cieslinski A., Prognostic significance of                A, Waagstein F. Changes in Early and Late Diastolic
        doppler-derived and left ventricular diastolic filling               Filling Patterns Induced by Long-term Adrenergic
        variables in patients with dilated cardiomyopathy. Pol               ß-Blockade in Patients With Idiopathic Dilated
        Arch Med Wewn. 1996 Dec; 96(6):552-60.                               Cardiomyopathy. Circulation. 1996; 94:673-682.
  9.    Rihal CS, Nishimura RA, Hatle LK, Bailey KR, Tajik AJ.,        21.   Kim MH, Devlin WH, Das SK, Petrusha J, Montgomery
        Systolic and diastolic dysfunction in patients with                  D, Starling MR. Effects on beta-Adrenergic Blocking
        clinical diagnosis of dilated cardiomyopathy. Relation               Therapy on Left Ventricular Diastolic Relaxation
        to symptoms and prognosis. Circulation. 1994 Dec;                    Proprieties in Patients with Dilated Cardiomyopathy.
        90(6):2772-9.                                                        Circulation. 1999; 100:729-735.
  10.   Boni A, Cortigiani L, Nannini E., Echocardiographic            22.   Eichhorn EJ, Bedotto JB, Malloy CR, Hatfield BA,
        evaluation of left ventricular diastolic function in                 Deitchman D, Brown M, Willard JE, Grayburn PA. Effect
        patients with dilated cardiomyopathy: correlation                    of b-adrenergic blockade on myocardial function and
        among doppler, hemodynamic and clinical findings.                    energetics in congestive heart failure: improvements in
        G Ital Cardiol. 1998 Oct; 28(10):1120-7.                             hemodynamic, contractile, and diastolic performance
  11.   Fuchs JB, Werner GS, Schulz R, Kreuzer H. Prognostic                 with bucindolol. Circulation. 1990; 82:473- 483.
        significance of changes in left ventricular diastolic          23.   Eichhorn EJ. The paradox of b-adrenergic blockade for
        function in follow-up of dilatative cardiomyopathy. Z                the management of congestive heart failure. Am J
        Kardiol. 1995 Sep; 84(9):712-23.                                     Med. 1992; 92:527-538.
  12.   Suwa M, Ito T. Doppler evaluation of systolic and              24.   Waagstein F, Bristow MR, Swedberg K, Camerini F,
        diastolic heart failure in patients with cardiomyopathy. J           Fowler MB, Silver MA, Gilbert EM, Johnson MR, Goss
        Cardiol. 2001; 37 Suppl 1:103-7.                                     FG, Hjalmarson A. Beneficial effects of metoprolol in
  13.   Dujardin KS, Tei C, Yeo TC, Hodge DO, Rossi A, Seward                idiopathic dilated cardiomyopathy. Lancet. 1993;
        JB. Prognostic value of a Doppler index combining                    342:1441-1446.
        systolic and diastolic performance in idiopathic-dilated       25.   Eichhorn EJ, Heesch CM, Barnett JH, Alvarez LG, Fass
        cardiomyopathy. Am J Cardiol. 1998 Nov 1;                            SM, Grayburn PA, Hatfield BA, Marcoux LG, Malloy CR.
        82(9):1071-6.                                                        Effect of metoprolol on myocardial function and
  14.   Gavazzi A, De Maria R, Renosto G, Moro A, Borgia M,                  energetics in patients with non-ischemic dilated
        Caroli A, Castelli G, Ciaccheri M, Pavan D, De Vita C, et            cardiomyopathy: a randomized, double-blind, placebo-
        al. The spectrum of left ventricular size in dilated                 controlled study. J Am Coll Cardiol. 1994; 24:1310 -
        cardiomyopathy: clinical correlates and prognostic                   1320.




Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                                         13
Original Article                                        Annals of Fundeni Hospital, volume 10, number 1-2, January-June




          MICROBIOLOGIC ANALYSIS OF A CEFEPIME;
           PRODUCING ISOLATES 1 - YEAR PERIOD


                                                   Jeni Laura Vlad

                             Department of Microbiology, Clinical Institute Fundeni




  Abstract     Study obiective. We have studied the Cefepim's evolution, during a period of 1 year. Design. Review study.
               Setting. 106 patients have confirmed in culture with: Pseudomonas aeruginosa, Enterobacter spp., Proteus
               spp., Escherichia coli, Acinetobacter spp. and other non-fermentative Gram negative germs.
               Measurements and Main Results. Cefepime is a 4-rd generation cephalosporine. It has a unique structure at
               physiological pH. It has the advantage of an unique action in the empirical therapy. Since February 2004 to
               February 2005 in one study performed with 106 selected patients in Department of Microbiology of our
               Clinical Institute, have estimated in vitro action of this substance. The neutropenic patients have monitored
               particularly: 87% from isolates (75) was microbiologic reactive (sensible) and 13%(31) resistant.
               Conclusion. Cefepime rests a choice in severe infections (intra-abdominal infections, peritonitis, post-surgical
               infections, etc) with fermentative and non-fermentative aerobe and anaerobe Gram negative rods and also
               Gram positive germs. Only cefepime or in conjunction with other substances, increases the rate of clinical
               recovery. The patient's compliance for selected antibacterial agents have a reduced frequency of a daily
               administration and when the cure is reduced (1-2g/12h, 7-10 days). Cefepime is comparable with
               carbapenemes. Cefepime is useful in the tratment of mixed infections and in the empirical treatment before
               involved germ identification.


                  Key words: Cefepim, bacteria, Cephalosporine IV, neutropenia, intraabdominal infection




Introduction                                                      substance's action during the contact with the
                                                                  bacterium, which caused the illness. Thus,
                                                                  Cefepime is a 4-rd generation cephalosporine, with
           "Everything can be invented has been                   a complex chemical structure and a bactericidal
       invented" Charles H. Duell, Commissioner,                  effect.
                     U.S. Office of Patents, 1899.                   The study has included the group of fermenta-
                                                                  tive and non-fermentative, Gram negative bacteria.
  The bacteriological image against Cefepime                         The zwitterion structure confers hydrosolubili-
hydrochloride represents the object of this                       ty and fast penetration of bacterial membrane.
microbiological study. We have estimated the                      The cefem-core the N-methyl pyrolidone group




Address for correspondence: Dr. Jeni Laura Vlad, Department of Microbiology, Fundeni Clinical Institute, Fundeni street
258, 022328, Bucharest, Romania, Tel. 021-318.04.00/ 2145; Fax: 021-318.04.54; e-mail: laurettajeni@yahoo.com



 14                                                                Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                                Microbiologic analysis of a Cefepime; Producing Isolates 1 -Year Period




Table1. International Ordinary Name (ION)




         Fig. A - The biochemical structure of cefepim




and the sin-oximinothiazole-chain, increase the            lactamases (table 2); It penetrates the pores of
activity of substance against Gram-negative                bacterial membrane fastly. It has bactericidal
fermentative and non fermentative rods and                 effect in periolasmic space by increasing of
Gram positive germs.                                       concentration. It has high afinity for PBP (peni-
   These components also determine increased               cillin binding proteins); for exemple PBP 1, PBP 2,
activity against Pseudomonas aeruginosa. The               PBP 3 in E.coli, PBP 1, PBP 3 in Pseudomonas
Cefepime has low activity with BUSH 1 group ß              aeruginosa.


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                          15
J. L. Vlad



Table 2. The Biochemical action of Cefepime




Material and method                                       bacterial species and for standard antibiogramme.
                                                             The Bactec System (BD) was used for screening
                                                          detection of bacterial strains in hemoculture.
    Bacteria: Klebsiella spp., Pseudomonas aerugi-           The result interpretation was performed
nosa, Enterobacter spp., E. coli, Proteus spp.,           according to the NCCLS Standard. (Table 3)
Acinetobacter spp.                                           Interpretation should be as stated above for
    Bacterial culture: Over 106 bacterial strains         results using dilution techniques. Interpretation
have tested with Cefepime in the Research                 involves correlation of the diameter obtained in
Laboratory of Microbiology in our clinic.                 the disk test with the MIC for Cefepim (Fig. B).
    Culture media used for isolation: Nutrient               The susceptibility to Cefepim can be determined
Agar-blood, Nutrient-Broth, Cled Agar, Mac                by standardized test methods. The MIC values
Conkey Agar and Mueller Hinton Agar.                      obtained should be interpreted according to the
    Biochemical media for identification: SIM             NCCLS standard.
(mobility-indole-hydrogen sulfide), TSI agar                 Interpretation is identical to that stated above
(Triple sugar iron agar), Ureea Agar Base,                for result dilution techniques. As with other sus-
Simmons Citrate Agar, Phenylalanine agar, Lysine          ceptibility techniques, the use of laboratory control
iron agar.                                                microorganisms is required to control the technical
    Pathological collections (samples): ascytic           aspects of the laboratory standardized procedures.
fluide, cholecystic fluide, drainage tubes,                  Cefepime is comparable to piperacillin-tazobac-
abscesses, various collections, blood, urine,             tam and carbapenems. Therefore, cefepime,
bronchoalveolar aspirates, respiratory secretions.        piperacillin-tazobactam, meropenem, imipenem
    Testing conditions:                                   should be selected for initial empiric antibiotic
    - Culture media: Mueller Hinton Broth with            therapy. Same studies evaluate cefepim in mono-
      adapted cathion (CAMHB), Mueller Hinton             therapy comparable with ticarcillin/clavulanic acid
      Agar dilutions.                                     with aztreonam in neutropenic patients.
    - Inoculum: growth method or direct method
      with suspended colonies (0,5 McFarland
      standard).
    - Incubation: 35ºC, 16-24 h, enviromenteal
                                                          Table 4. First therapy in neutropenic patient
      air;
    - Biodisks (30 mcg) and E-test strips with             Monotherapy                 Combination
      cefepime;                                            Ceftazidime                 Acylaminopenicilline + AMG
                                                           Cefepime                    Cefalosporin III/IV + AMG
   Same panels and the Phoenix 100 System                  Piperacillin-Tazobactam     Cefepime +Metronidazol*
(Becton Dickinson) were used for identification of         Carbapenems




         Table 3. Interpretation of results. NCCLS (Table Enterobacteriaceae M7-mic)




  16                                                      Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                                 Microbiologic analysis of a Cefepime; Producing Isolates 1 -Year Period



            Pseudomonas aeruginosa                                     Acinetobacter baumanii /ccpx




Fig. B - Diffusion diameter / E-test -MIC




Fig. C - Empiric initials therapy: IDSA guidelines



Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                           17
J. L. Vlad



Table 5. The sensitivity of tested microorganisms         Table 6. The rate of microbiological response

Microorganism                    Sensible    Rezistant    Frequency of infections                       Bacteriological
                                    %           %         Encountered bacteria                               response
Pseudomonas aeruginosa              76          24        Intraabdominal infections                               87%
Acinetobacter spp.                  65          35        (peritonitis, abscesses)
                                                          (E. coli, Enterobacter spp., Proteus spp.,
Klebsiella spp.                     78          22        Pseudomonas spp.)
Enterobacter spp.                   78          22        Infections of respiratory tract (pneumonia)             72%
Proteus spp.                        69          31        (Klebsiella pneumoniae,
                                                          Enterobacter spp, Acinetobacter spp.)
Escherichia coli                    80          22
                                                          Infection of urinary tract                              94%
Stenotrophomonas maltophilia        67          33
                                                          (E.coli tip 1, 2, Proteus spp.,
Totally                             87          13        Enterobacter spp., Pseudomonas spp.)
                                                          Severe sepsis, septic shock                             54%
                                                          (Stenotrophomonas maltophilia,
                                                          Comamonas testosteroni, Pseudomonas
                                                          aeruginosa, Acinetobacter baumanii
Results                                                   calcoaceticus complex, Klebsiella
                                                          pneumoniae s.a).

   87% from tested strains were sensible with
cefepime. Bacterial resistance was approximately
13%. Cefepime is a bactericidal agent with broad          be eradication (presumed eradication/ causative-
spectrum of action, useful in empirical therapy of        organism, absent or no material to culture
various infections with parenteral treatment, which       in a patient who was clinically cured), persistance/
was evaluated in our hospital practice. Its efficiency    presumed persistance (causative organism present
was demonstrated particularly in intraabdominal           or no material to culture in a patient whose clinical
mono or multibacterial infections.                        response was failure), or indeterminate.
   It could be also indicated in the primary testing          Cefepime could be only solution for empirical
for a diversity of species of Pseudomonas                 therapy. The association of cefepime with amino-
spp.(other than P. aeruginosa), Stenotrophomonas          glycosides was increased the sensitivity of
malthophilia and Acinetobacter spp., (over 81%            strains. The association with metronidazole could
action) and particularly in neutropenic patients.         be an efficient therapy in -patients with severe
Table 5, 6.                                               intraabdominal infections.
                                                              The in vivo and in vitro actions of the substance
                                                          were approximately identical.
                                                              Cefepime rests a choice in severe infection
Conclusions                                               (intra-abdominal infections, peritonitis, post-surgi-
                                                          cal infections, etc) with Gram negative fermenta-
    The clinical action was demonstrated be               tive or non-fermentative, aerobe and anaerobe
favorable in the next diagnosis: lower respiratory        rods and also Gram positive germs. Only Cefepime
tract infections, urinary tract infections, skin infec-   or in combination with other substances increases
tions, intraabdominal infections (peritonitis,            the rate of clinical recovery and is a revolution in
cholecystitis, pancreatitis), sepsis, neutropenic         the modern cephalosporins evolution.
patients, etc.
    Cefepime is useful in tratment of mixed
infections and also in empirical therapy before           Acknowledgement
identification of causative germs.
    The rate of bacterial response of the substance          Thanks to the members of Medical Department
could be seen in the table 6                              of Bristol Myers Squibb Romania for their ideas,
    Bacteriological response was determinated to          suggestions and data.




  18                                                      Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                                         Microbiologic analysis of a Cefepime; Producing Isolates 1 -Year Period



                                                                            Pseudomonas aeruginosa to broad-spectrum cephalo-
References                                                                  sporins via step-wise mutations. Jurnal of Antimicrobial
                                                                            Chemotherapy, 1993; 32(suppl.B):75-80.
  1.   Axel Glasmacher, An evidence-based evaluation of               9.    Yamaguchi et al, Diagn. Microbiol. Infect. Dis 1999, jun;
       empiric antibiotic therapy in febrile neutropenic patients;          34(2): 123-34.
       A Satellite Symposium, 2004.                                   10.   Briskier A, Clin Microbiol Infect 1997; 3 (suppl. 1):
  2.   Frenei J., Renaoud F., Hansen W.et Bollet C., Precis de              S1-S6.
       Bacteriologie Clinique, 2000.                                  11.   Kieft H., Hoepelman A. I. M., et al, Cefepime Compared
  3.   Jehl F., Chomarat M., Weber M., Gerard A., De la                     with Ceftazidime as Initial Therapy for serious Bacterial
       antibiograma la prescriptie, 2003.                                   Infections and Sepsis Syndrome. Amtimicrobial Agents
  4.   NCCLS document M7 - Methods for Dilution                             AND Chemotherapy, 1993.
       Antimicrobial Susceptibility Tests for Bacteria That Grow      12.   Paul G. Ambrose, Robert C. Owens et al. Pharmaco-
       Aerobically; 2003.                                                   dynamic considerations in the treatment of moderate
  5.   Fleming D, Ziegler C, Baize T et al, Cefepime versus                 to severe pseudomonal infections with cefepime.
       ticarcillin and clavulanate potassium and aztreonam for              Journal of Antimicrobial Chemotherapy, 2002.
       febrile neutropenia therapy in high-dose chemotherapy          13.   Philip S. Barie et al. A Randomized, Double blind
       patients. Am J Clin Oncol 2003; 26(3): 285-288.                      Clinical Trial Comparing Cefepime Plus Metraonida-
  6.   Agenda Medicala 2000.                                                zole With Imipenem-Cilastatin in the Tratment of
  7.   Tan JS, Winsnow RM, Talan DA, et al, Treatment of                    Complicated Intra-abdominal Infections. Arch.
       hospitalized patients with complicated skin and skin                 Surg.132: 1294-1302.1997.
       structure injections: Double blind, randomized                 14.   Badaro R; Molinar F; Seas C; Stamboulian D; Mendoca J;
       multicenter study of piperacillin-tazobactam versus                  Massud J; Nascimento LO; A multicenter comparative
       ticarcillin-clavulanate. Antimicrob Agents Chemother,                study of cefepime versus broad-spectrum antibacterial
       1993.                                                                therapy in moderate and severe bacterial infections. Braz
  8.   Gradelskl E et al, Development of resistance in                      J Infect Dis 6(5): 206-18, oct 2002.




Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                                        19
Original Article                                  Annals of Fundeni Hospital, volume 10, number 1-2, January-June




NEEDLE CORE BIOPSY VERSUS NEEDLE ASPIRATION
CYTOLOGY IN PREOPERATIVE DIAGNOSIS OF SOLID
              BREAST LESIONS


           Mihaela Mihai1,3, M. Lesaru2,4, M. Ceausu3,4, Carmen Ardeleanu3,4
                             1
                               Department of Pathology, Fundeni Clinical Institute
                    2
                     Clinic of Radiology and Medical Imaging, Fundeni Clinical Institute
                                 3
                                  "Victor Babes" National Institute of Pathology
                             4
                              "Carol Davila" University of Medicine and Pharmacy




  Abstract    Aim: Comparative study of the histological and cytological diagnosis value of specimens and samples
              obtained by needle core biopsy followed by aspiration in solid breast lesions. Material and methods: We
              performed ultrasound-guided needle core biopsy followed by aspiration for evaluation of 41 BI-RADS
              mammographic categories 2 (typical benign), 3 (probably benign), 4 (suspect) and 5 (probably malignant)
              breast lesions. After the preparation of the biological material obtained by aspiration the findings of the
              smears was compared with those of histological sections obtained by needle core biopsy and paraffin
              embedded. The results were interpreted and reported as C1-C5 and B1-B5 categories according to
              recommendations of European Commission Working Group for Breast Screening Pathology/European
              Breast Screening Program (2000). Results and discussions: The sensitivity, accuracy and negative predictive
              value of the histological diagnosis of tissue fragments obtained by needle core biopsy were proved to be
              superior those obtained by cytological examination of needle aspiration ones, proportion of false negative
              results in case of cellular aspirates being higher (5,72%) than in microbiopsies (2,86%). Concordance between
              breast imaging findings and morphological aspects was established in 37 cases and discordance was
              established in 4 cases. Conclusions: We consider that histological report of needle core biopsy specimens is
              a more accurate method evaluating breast lesions than the cytological report of the needle aspiration
              samples. Our study confirm the present day accepted opinion that needle core biopsy is characterized by
              performance indicators and diagnostic advantages better than needle aspiration cytology and is the
              standard method of assessment of preoperative solid breast lesions with undetermined or suspect clinical
              and imaging signification.




        Key words: needle core breast biopsy, needle aspiration breast cytology, image guidance, solid breast lesions




Address for correspondence: Dr. Mihaela Mihai, Department of Pathology, Fundeni Clinical Institute, Fundeni street 258,
022328, Bucharest, Romania; E-mail: mictekro@yahoo.com



 20                                                              Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                   Needle core biopsy versus needle aspiration cytology in preoperative diagnosis of solid breast lesions



Introduction                                                 followed by aspiration in solid breast lesions,
                                                             according to the recommendations of European
                                                             Commission Working Group for Breast Screening
    Screening mammography performed regularly                Pathology / European Breast Screening Program
to female patients over 40 years with no symp-               (2000).
toms can lead to an early identification of malig-
nant lesions and also of a many breast lesions with
undetermined clinical and imaging signification
[15, 20, 49]. In the last years huge efforts have            Material and Methods
been done for development of non-invasive or
minimal invasive preoperative diagnostic methods                 Our study included 36 patients with solid breast
because many of identified and radiologic charac-            lesions mammographically characterized as being
terized lesions as suspect for malignancy were               suspects and probably malignant (BI-RADS 4 and
proved to be benign after surgical treatment [11,            5 categories) and also 3 patients with mammo-
20, 26].                                                     graphic abnormalities most probably benign (BI-
    At the time needle core biopsy (tissue micro-            RADS 3 categories); other 2 patients with benign
biopsy) and fine needle aspiration cytology repre-           abnormali-ties (BI-RADS 2 categories) were
sent usual preoperative diagnostic methods in                biopsied on demand. Ages of patients were
order to differentiate malignant form benign breast          between 30 and 73 years and lesions were
lesions [7, 20, 26, 45, 55]. Preoperative cytological        clinically palpable and non-palpable. The cyto-
and histological diagnosis of clinical suspect breast        histopathological specimens were obtained under
lesions allows the assessment of therapy and                 ultrasonographic guidance (Fig. 1) with True-Cut
discussion with the patient decreasing in this way           needles 14-18G (Cook, Bard) using a coaxial
the number of useless surgical operations [11, 20,           system (automated biopsy guns); after the tissue
26, 45, 55]. Despite of its simplicity fine needle           sampling an aspiration on the needle sheath has
aspiration cytology, which assumes to obtain bio-            been done in order to perform cytological examina-
logical material for cytology, is not an accessible          tion. The procedure required local anesthesia with
method to any institution because it requires                1% xilin and took 30-45 minutes per each case.
trained cytopathologists [11, 45], capable of inter-             Three to nine 4 to 15 mm length tissue frag-
preting the microscopic findings of the aspirate             ments were achieved per case. Samples were
establishing a cytological diagnosis which does not          fixed in 10% buffered formalin and embedded in
make distinction between in situ lesions and inva-           paraffin. Serial sections were cut at 4 m, one
sive carcinomas and only occasional allows a tissue          being stained with hematoxylin and eosin (H E)
specific diagnosis for a benign lesion [11, 55].             for routine histological and others for immuno-
    Needle core biopsy (NCB), which assumes to               histochemical assessments. The histological
obtain histological material (tissue samples), is            diagnosis followed the recommended criteria of
characterized by superior performance indicators             European Commission Working Group for Breast
than fine needle aspiration cytology and in the last         Screening Pathology/European Breast Screening
time has became the dominant method of pre-                  Program (2000) reporting every case as B1-B5
operative diagnosis of palpable and non-palpable             categories. Immunohistochemical tests have
breast lesions [7, 11, 20, 45, 46, 55]. However, the         been done in some cases of positive biopsies for
superiority of one diagnostic method over the                assessment of prognostic molecular factors. The
other has not yet been established, both of them             biological material aspirated at the end of the
being dependent on the nature of the breast lesion,          procedure was quickly displayed on slides (3-12
the skill of the individual obtaining the sample and         preparations per case), dried in the air, fixed by
the skill of the pathologist interpreting the speci-         immersion in methylic alcohol and stained with
mens [5, 46, 55].                                            Giemsa. Results were reported as C1-C5 cate-
    In this study we tried to compare the diagnos-           gories, according to recommendations of
tic value of histological and cytological examina-           European Commission Working Group for Breast
tion of tissue samples and aspirates obtained by             Screening Pathology/ European Breast Screening
ultrasound-guided needle core breast biopsy                  Program (2000). Immunohistochemical tests were



Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                            21
M. Mihai et al.




   a                                                                                                      b
  Fig. 1 - a. Mammographic BI-RADS 5 breast lesion;
           b. Ultrasound-guided needle core solid breast biopsy




carried out on smears assessed as being cellular        4 categories). 7 cases were reported as B5 cate-
rich, but the results were not satisfactory com-        gory (positive biopsies), from which 6 cases with
pared with those done on histological sections of       malignant cytology (C5 categories) and 1 case
the tissue fragments. For sensitivity, specificity,     with suspect cytology (C4 category). One case
predictive value calculus a descriptive statistic       has been microscopically assessed as benign
analysis has been done (binary tests).                  lesion with unknown biological potential (B3
                                                        category) and cytological as benign lesion (C2
                                                        category); however the lesion proved to be
                                                        malignant (invasive carcinoma) after the excision
Results                                                 biopsy. Other 2 cases have been histological and
                                                        cytological diagnosed as benign lesions (B2/C2
   Two cases of mammographical abnormalities            categories), such as isolated fibrosis, and the
typical benign (BI-RADS 2 categories) were              lesions were clinical and imaging stationary at 3
confirmed by histopathology and cytology (B2 and        and 6 months interval.
C2 categories), being interpreted as fibroadenoma           The 26 cases mammographically assessed as
and fibrocystic changes.                                being most probably malignant (BI-RADS 5
   Among 3 cases mammographically characteri-           categories) were confirmed by histopathology
zed as most probably benign (BI-RADS 3 cate-            examination: B5 categories (positive biopsies) -
gories), one case with suspect cytology (C4             26 cases, from which 23 cases with malignant
category) was histological confirmed (B5 category).     cytology (C5 categories), 2 cases with suspect
The other 2 cases imaging assessed as being             cytology (C4 categories) and 1 case with atypical
BI-RADS 3 abnormalities have been proved to be          cytology, probably benign (C3 category) (Fig. 3
benign (1 case B2/C2 category and 1 case B3/C3          and 4) (Table 1).
category) (Fig. 2); histopathology examination of           Diagnostic accuracy, sensitivity and negative
the excision biopsies confirmed the benign nature       predictive value of histological examination of
of these specimens (fibroadenoma and sclerosing         tissue fragments obtained by needle core biopsy
adenosis).                                              proved to be superior those obtained by cytologi-
   In our archive 10 cases were mammographi-            cal examination of aspiration specimens, the pro-
cally assessed as suspect abnormalities (BI-RADS        portion of false negative results in case of aspiration



 22                                                      Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                   Needle core biopsy versus needle aspiration cytology in preoperative diagnosis of solid breast lesions




  a                                                              a




 b                                                               b




Fig. 2 - Benign solid breast lesion (same case: S.E.,         Fig. 3 - Invasive breast carcinoma
40 years old): a. Benign cytology (Giemsax200);               (same case: C.F., 40 years old): a. Negative cytology
b. Fibroadenoma findings on the core biopsy                   (C3 category, Giemsax400); b. Positive biopsy
(HE x 100)                                                    (B5b category, HEx40)




 a                                                               b




Fig. 4 - Invasive ductal breast carcinoma with extensive intraductal component (same case: P.C., 56 years old):
a. Positive cytology (C5 category, Giemsax400); b. Positive biopsy (B5a+b category, HEx200)


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                            23
M. Mihai et al.



Table 1: Distribution of cases on mammographic and cyto-histological categories

                  Number of            B categories                                       C categories
                      cases   B1       B2       B3       B4       B5       C1     C2       C3        C4        C5
BI-RADS 1
BI-RADS 2              2               2                                           2
BI-RADS 3              3               1        1                  1               1        1         1
BI-RADS 4              10              2        1                  7               3                  1         6
BI-RADS 5              26                                         26                        1         2        23




Tabel 2: Performance indicators obtained in our study

                                        Histological report (B category)           Citological report (C category)
Sensitivity                                                       97,14                                    94,28
Specificity                                                         100                                      100
Positive predictive value                                           100                                      100
Negative predictive value                                         85,71                                        75
Accuracy                                                          97,56                                    95,12
False negative rate                                                2,86                                      5,72
False positive rate                                                    0                                        0




samples being higher than those of microbiopsies          cancer [11, 20, 26, 45, 55]. Selection between fine
(Table 2).                                                needle aspiration cytology and needle core biopsy
    Concordant results between clinical-imaging           is realized under clinical circumstances [55] and
and cyto-histological findings have been estab-           depends mostly on the pathologist abilities. [20,
lished in 37 cases. In 4 cases of discordant results      45, 55]
was necessary imaging follow-up at short interval             Comparative with an excision biopsy needle
(2 cases) and excision biopsy (2 cases).                  aspiration cytology is characterized by simplicity,
                                                          quickness and minimum discomfort of the
                                                          patient with reduced costs [45, 55], having
                                                          variable sensitivity and specificity: values of
Discussions                                               sensibility between 53-100% and specificity
                                                          between 34-100% are quoted in the literature
    Indicated by existing therapeutic guides and the      [18, 20, 46, 55]. Positive predictive value for
international consensus [20] percutaneous breast          needle aspiration cytology tends to be near
microbiopsy with 14G devices is considered at this        100% (99,6-100%) and the negative predictive
time the main diagnostic modality prior to excision       value between 60-90% [23, 45, 56]. Needle core
for preoperative diagnosis of palpable lesions and        biopsy (NCB) requires local anesthesia and
those found by breast imaging, being a faster, less       presumes image guidance in most situations [5,
invasive and less expensive method than the               26, 55], especially in non-palpable solid breast
surgical biopsy for diagnostic purpose [26]. A            lesions. However it shows a higher diagnostic
suspicious clinical-imaging diagnosis for breast          sensitivity (92-99%, with an average of 95%) [9,
cancer, but cytological and/or histological con-          19, 41], and a specificity and a positive predic-
firmed, can obviate the need for surgery in women         tive value about 100% [20]. This procedure tends
with benign lesions and can optimize surgical             to replace needle aspiration cytology and the
procedures performed in women with breast                 excision biopsy in most institutions because it


 24                                                        Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                   Needle core biopsy versus needle aspiration cytology in preoperative diagnosis of solid breast lesions



has a diagnostic accuracy almost identical to                well differentiated tumor (lobular carcinoma, tubu-
excision [47, 9, 11, 19, 32, 39, 41] and a defini-           lar carcinoma, cribrifom carcinoma) (Fig. 3), but
tive diagnosis is possible in 90-99% of cases [29,           especially allows distinction between the prolifera-
46]. In our study both procedures have been                  tive high-risk lesions, in situ and invasive carcino-
done consecutively, the sampling of NCB                      mas [2, 5, 7, 11, 24, 46, 52, 55] (Fig. 4); in case of
specimens being followed by aspiration on the                malignant lesions the type and tumor grading may
needle sheath used for biopsy. Although the                  be done with a reasonable accuracy degree [55]
entire cellular aspirates have been hemorrhagic              (Fig. 3 and 4), being possible the diagnostic of
microscopic examination of the smears (3-12 per              malignant lymphoma or breast metastasis [7], and
case) permitted to establish a quickly cytological           immunohistochemical results about prognostic
diagnosis, its performance indicators (sensitivity,          molecular factors shows an increased level of
negative predictive value, diagnostic accuracy)              concordance with those obtained on the surgical
proving to be inferior to histological diagnosis             excised samples [22, 55] (Fig. 5).
obtained after the microscopic examination of                    In our archive we included in C2 and C3
the samples (Table 2).                                       categories five cases and 1 case, respectively. In
    Fine needle aspiration cytology is a very safe           these situations the histological reports were
technique in experienced hands [3, 25, 51], but              described B2 and B3 categories and correlated with
only occasionally allows a specific tissue diag-
nostic for a benign lesion [7, 11, 55] (Fig. 2) and
in case of malignant lesions gives insufficient
informations for a further therapeutic decisions,              a
because it not allows a distinction between
proliferative lesions with atypia, in situ lesions
and invasive ones (Fig. 4), lesions which can be
diagnosed on the base of cytological criteria
combined with the architectural one [2, 7, 11, 24,
52, 55]. At the same time cytological atypia from
the cytological specimens are not diagnostic, 45%
of them being malignant lesions [7]. The diagnos-
tic limits of fine needle aspiration cytology have
determined Klein et al. [25] to suggest that this
technique should be used supplementary and not
complementary to histological examination and
Pinder et al. [42] demonstrated that the preopera-
tive diagnostic accuracy in breast lesions detected            b
by screening may increase from 72% using only
needle aspiration cytology to 90% if the method is
used in combination with microbiopsy. Cohesive
tissue samples are obtained by tissue microbiopsy
(NCB) and allows a histological diagnosis using
standard histological criteria [11, 20, 45, 55]: for
these specimens is recommended a reporting
system accessible to any pathologist no matter of
his abilities and experience [16, 48]. Needle core
biopsy requires a reduced degree of diagnostic
expertise [46]: tissue fragments may be X-rayed
when the lesion shows calcifications at the
mammographic examination; simultaneously                     Fig. 5 - Immunohistochemical stains for hormonal
microscopic assessment of the cytological features           receptors (same case: H.F., 55 years old): a.
and the architectural one allows a specific diagno-          Cytology smears (ERx400, average receptor level
sis of benignity (Fig. 2) and a quick recognition of a       by 10-15%); b. Histology sections (ERx100, average
                                                             receptor level by 45-50%)


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                            25
M. Mihai et al.



clinical evolution and radiologic features (stationary   (up to 31%) [1, 10]. This happens most times
lesions) at intervals of 6 months from the tissue        owing to the insufficient samples [5, 7, 26, 45],
sampling: on the base of cyto-architectural findings     which frequently appears in small lesions [1], and
assessed on the tissue fragments we were                 is influenced by the nature of breast lesion: most of
sustained the diagnosis of fibroadenoma (2 cases),       the malignant lesions mistakenly cytologically
isolated breast fibrosis (2 cases), sclerosing lesion    interpreted as benign lesions belongs to well
(1 case) and fibrocystic change (1 case). Only in 2      differentiated tumors (tubular carcinoma, lobular
cases from 29 included in C5 category the histo-         invasive carcinoma, papillary carcinoma, cribriform
logical findings of the biopsy could not certainly       carcinoma) [45, 46, 55] and less cellular tumors
evaluate the tumor invasion (B5a+c categories);          (carcinomas with extensive fibrosis) [38, 46]. In
in the other 27 cases the microscopic examina-           case of NCB most of false negative diagnosis,
tion of the NCB specimens have permitted a               which appear with a frequency of 1-6% [10], is due
diagnosis of malignancy and assessment of                to an insufficient sample from the lesion, situation
tumor invasion (B5b categories - 24 cases and            frequently found in case of breast lesions with
B5a+b categories - 3 cases), histological type and       necrosis or extensive fibrosis or those with hetero-
tumor grading. We consider that the hipocellu-           geneous histological structure (in situ carcinoma,
larity of the cytology specimens and the lack of         lobular invasive carcinoma, tubular carcinoma) [2,
experience of the pathologist have determined            20]. Technical accidents can't be excluded, such as
the inclusion of 3 cases in C4 category, these one       stereotactic errors in case of mammographic
corresponding to malignant lesions on the                guidance or sliding lesions owing to tissue
biopsy (B5 category) (2 invasive carcinomas and          elasticity [20, 45]. However, the drawing error
1 invasive carcinoma with associated in situ             decrease with the volume of the sample [20],
component), and 1 case in C3 category, this one          number and size of fragments being correlated
proved to be on the biopsy a mixed invasive              with the efficiency of the method [8, 28, 36]. One
carcinoma: ductal and lobular (B5b category). We         case from 41 included in this study, with benign
obtained unsatisfactory IHC results on cytology          cyto-histology after needle core biopsy followed
preparations because of hemorrhage and                   by aspiration (C2/B3 category), but included in
hipocellularity (Fig. 5). Also, because of different     BIRADS 4 category (suspect for malignancy),
preparations, the immunohistochemical stains for         proved to be a malignant lesion after the excision
hormonal receptors and other markers on cytology         biopsy (invasive carcinoma). We consider this case
smears obtained by aspiration gave us results not        of negative result a consequence of an insufficient
comparable with those specimens obtained on              sample from a small size breast lesion (10/7/5
biopsy, at this time having no schemes of quality        mm) obtained by using a small caliber needle
assessment for reporting the hormonal receptors          (18G) deviated because of tissue elasticity, the
status on cytology smears [30, 46, 55].                  procedure being verry difficult. The main cause
    The NCB technique followed by aspiration             which generated one of the false negative result for
used in this study didn't generate false positive        cytological examination (C3/ B5b category) seems
results neither for cytological examination nor for      to be the marked hipocellularity nature of the
histopathology. False positive diagnosis is              lesion (invasive carcinoma with abundant fibrotic
extremely rare in case of NCB and can appear in          stroma) (Fig. 3).
case of sclerosing lesions [45] or in hystiocytic            The false negative results can not be omitted
proliferations induced by radiotherapy [17]. In          and so is necessary to compare the results of
case of needle aspiration cytology the fibrocystic       needle aspiration cytology or needle core biopsy
disease with marked epithelial proliferation,            with clinical and radiological data applying the
granulomatous mastitis, fibroadenoma and                 triple diagnosis strategy: after this will be decided
radiotherapy induced changes may cause false             either the surgical operation with or without
positive interpretations even for experienced            primary medical therapy or the imaging follow-up
cytopathologists [12, 45, 55].                           of the lesion in a short (3 months) or a long range
    Fine needle aspiration cytology is minimal inva-     time (6 months - 1 year) [7, 21, 20, 26, 35, 45, 47,
sive and well tolerated, but the false negative rate     54, 55]. The communication between the radiolo-
of the cytological reports is unacceptable increased     gist and pathologist is essentially for the recognition



 26                                                      Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                   Needle core biopsy versus needle aspiration cytology in preoperative diagnosis of solid breast lesions



of adequate cito-histological specimens: the                 positive results ratio about 9%, while for NCB
radiologist must describe the identified lesions and         specimens was reported an accuracy about 97.5%
formulate a presumable diagnosis and the patholo-            without false positive results [13, 43]. The best
gist must mention if it is any concordance or discor-        results are obtained if multiple fragments are
dance between microscopic findings and the                   obtained under ultrasound guidance using 14G
imaging features of the lesion [7, 20, 21, 35, 47,           devices: Fishman et al. [14] has reported an
55]. If the imaging data and the histological ones           accuracy about 96%, in other series [6, 13, 29, 33,
obtained by NCB are concordant may be obtained               34, 40, 50] the sensibility was 95%, and Parker [40]
comparable results with those of surgical biopsy             has reported 100% concordance between the
[20]. Discordant data for percutaneous breast                results of this procedure and the results of surgical
biopsy indicate the rebiopsy or surgical excision            excision.
and have an incidence about 1-6%, being rarely for
image-guided needle core biopsy than fine needle
aspiration cytology [5, 26]. Lieberman et al. [27]
have found a discordance rata about 3% in 1785
                                                             Conclusions
consecutive needle core biopsies. In other series
[6, 13, 29, 33, 34, 40, 50] 11% cases from ultra-                Fine needle aspiration cytology and needle core
sound-guided 14G needle core solid breast biop-              biopsy represent usual methods of preoperative
sies required rebiopsy: majority of the rebiopsies           diagnosis in solid breast lesions [55] and success-
were done for atypical or high-risk lesions [5, 7, 26]       fully replace excision biopsy for diagnostic
and only in 0,5% of cases of Berg's series [6] the           purpose. Cytological specimens' interpretation
lesion has been omitted. In our study discordances           obtained by fine needle aspiration cytology
between clinical-imaging data and cyto-histologi-            requires training and experience [11, 45, 55].
cal ones were noticed in 4 cases (9,75%). Owing to           Needle core biopsy has gained in popularity over
clinical circumstances (collateral breast neoplasm           the last several years displacing fine needle aspira-
treated by chimiotherapy and radiotherapy) in 2              tion cytology as the preferred diagnostic modality
cases included in BIRADS 4/C2/B2 categories was              of palpable and non-palpable solid breast lesions
recommended imaging follow-up and the lesions                prior to excision [4, 5, 7, 20, 26, 32, 45, 55].
proved to be stationary at 3 months, 6 months and            Performing the biopsy under imaging guidance
1 year range. Excision biopsy performed in the               can ensure that the lesion was sampled.
other 2 cases of discordance between mammo-                      The results of our study confirm that needle core
graphic findings (BIRADS 4 and 3 categories) and             biopsy (NCB) is characterized by diagnostic advan-
those cyto-histological (C2/ B3 categories and C4/           tages and performance indicators better than fine
B5, respectively) has confirmed the malignant                needle aspiration cytology and we think that:
nature of the breast lesions (invasive carcinomas).          assessment of NCB sections give more repro-
    Fine needle aspiration cytology and needle core          ductible results and a higher accuracy of specific
biopsy can be performed by surgeon, clinician or             benign and malignant diagnosis obtained and, thus,
pathologist, but the efficiency of the cytological and       a significantly lower rate of subsequent excision
histological result is increased if the procedure is         biopsies is required for diagnostic purposes; a core
done under image guidance (stereotactic, ultra-              biopsy diagnosis of a specific benign lesion and
sonographic) [5, 26, 45]. In Lorenzen series [31]            distinction between true negative (specific benign
NCB sensitivity for palpable breast lesions has              lesion) and false negative (malignant lesions failed
increased from 79% for the biopsies guided by                by drawing errors) results is an important
palpation to 98% for those performed under                   advantage of this technique compared with fine
ultrasound-guidance. The global accuracy of the              needle aspiration cytology; needle core biopsy may
ultrasound-guided biopsies is significantly better           distinguish between invasive and non-invasive
than stereotactic-guided [26, 37, 43, 44]. Among             cancers; NCB allows accurate immunohistochemi-
the institutions which have participated for RDGOV           cal assessment of oestrogene and progesterone
trial (Radiation Diagnosis Oncology Group V) the             receptor status of all cancers diagnosticated,
diagnosis accuracy for ultrasound-guided fine                including women who elect not to have or cannot
needle aspiration cytology was 77% with a false              perform surgery.



Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                            27
M. Mihai et al.



    Correlations between clinical, imaging and                     13. Fajardo L.L., Pisano E.D., Caudry D.J. et al.
pathological data are obtained in multidisciplinary                    Stereotactic and sonographic large-core biopsy of
                                                                       non-palpable breast lesions: results of the Radiologic
meetings in which the clinician, the surgeon,                          Diagnostic Oncology Group V study. Acad Radiol
the radiologist and the pathologist establish a                        2004, 11:293-308;
consensus about diagnosis and therapeutic                          14. Fishman J.E., Milikowski C., Ramsinghani R., Velasquez
strategy following defined protocols [55], the                         M.V., Aviram G. US-guided core-needle biopsy of the
                                                                       breast: how many specimens are necessary? Radiology
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  36.   Nath M.E., Robinson T.M., Tobon H. et al. Automated             Cancer 2003, 97:1824-1831;
        large-core needle biopsy of surgically removed breast       48. Shousa S. Issues in the interpretation of breast core
        lesions: comparison of samples obtained with 14, 16             biopsies. Int J Surg Pathol 2003, 11:167-176;
        and 18 gauge needles. Radiology 1995, 197:739-742;          49. Smart C.R. Highlights of the evidence of benefit for
  37.   NHS Breast Screening Programme Guidelines for                   women aged 40-49 years from the 14 years follow-up
        Cytology Procedures and Reporting in Breast Cancer              of the Breast Cancer Detection Project. Cancer 1994,
        Screening: Report by Cytology Sub-Group of the                  74:296;
        National Coordinating Committee for Breast Screening        50. Smith D.N., Rosenfield Darling M.L., Meyer J.E. et al. The
        Pathology: NHSBSP Publication N. 22, sept 1993;                 utility of ultrasonographically guided large-core needle
  38.   Omalley F., Casey T.T., Winfield A.C. et al. Clinical           biopsy: results from 500 consecutive breast biopsies. J
        correlates of false-negative fine-needle aspiration of          Ultrasound Med 2001, 20:43-49;
        the breast in a consecutive series of 1005 patients.        51. Sneige N., Singletary S.E. Fine needle aspiration of the
        Surg Gynecol Obstret 1993, 176:360-364;                         breast. Diagnostic problems and approaches to surgical
  39.   Parker S.H., Burbank F., Jackman R.J. et al. Percutaneous       management. Pathol Annu 1994, 29(Pt):281-301;
        large-core breast biopsy: a multiinstitutional study.       52. Sneige N., Staerkel G.A. Fine-needle aspiration cytology
        Radiology 1994, 193:359-364;                                    of ductal hyperplasia with and without atypia and ductal
  40.   Parker S.H., Jobe W.E., Dennis M.A. et al. US-guided            carcinoma in situ. Hum Pathol 1994, 25:485-492;
        automated large-core breast biopsy. Radiology 1993,         53. Thomas P.A., Vasquez M.F., Waisman J. Comparison of
        187:507-511;                                                    fine-needle aspiration and frozen section of palpable
  41.   Perry N.M. and the EUSOMA Working Party. Quality                mammary lesions. Mod Pathol 1990, 3:570-574;
        assurance in the diagnosis of breast disease. EJC 2001,     54. Trott P.A., Nasiri N. Treatement of breast cancer before
        37:159-172;                                                     surgery will present pathologists with challenges (letter).
  42.   Pinder S.E., Elston C.W., Ellis I.O. The role of the pre-       Br Med J 1997, 314, 755;
        operative diagnosis in breast cancer. Histopathology        55. Trott P.A., Sloane J.P. Non-operative diagnosis. In
        1996, 28:563-566;                                               ,,Biopsy Pathology of the Breast", 2nd ed., Arnold,
  43.   Pisano E.D., Fajardo L.L., Caudry D.J. et al. Fine-             London 2001, 50-74;
        needle aspiration biopsy of nonpalpable breast              56. Wells C.A., Ellis I.O., Zakhour H.D. et al. Guidelines for
        lesions in a multicenter clinical trial: results from the       cytology procedures and reporting on fine-needles
        radiologic diagnostic oncology group V. Radiology               aspirates of the breast. Cytopathology 1994, 5:316-334.




Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                                       29
Case Report                                         Annals of Fundeni Hospital, volume 10, number 1-2, January-June




  THE IMMUNOFLUORESCENCE IN THE ASSESSMENT
        OF THE RENAL BIOPSY SPECIMENS



                      C. Ionescu1, M. Hortopan2, G. Ismail1, E. Buzatu1,
                            E. Busuioc1, V. Herlea2, M. Voiculescu1
                                    1
                                    Center of Internal Medicine - Nephrology,
                                    2
                                    Department of Pathology, Fundeni Institute




  Abstract    The renal biopsy is the principal method used in order to define the type of renal disease, especially when the
              preliminary clinical diagnosis is glomerulonephritis. The method provide sufficient accurate information that
              allows to establish a tissue diagnosis, to assess the severity and activity of the lesion ("grade") and to assess the
              amount of irreversible scarring ("stage"). The renal biopsy specimen must be examined by, at the very
              minimum, detailed light and immunofluorescence microscopic studies. Immunofluorescence microscopy is a
              routine part of the investigation of native renal biopsies. A basic panel of antibodies should be used for the
              detection of tissue deposits of IgG, IgA, IgM, and complement (usually C3).


 Key words: imunofluorescence microscopy, renal biopsy, immune deposits, glomerule, mesangium, nephrotic syndrome




   The purpose of a renal biopsy is different for                  provide a valid renal biopsy interpretation, the renal
each case investigated, but is likely to include                   biopsy specimen must be examined by, at the very
one or all of the following, with varying priority:                minimum, detailed light and immunofluorescence
   - To establish a tissue diagnosis, or at least to               microscopic studies. Immunofluores-cence micros-
     exclude other diagnostic possibilities that                   copy is essentially and always necessary as an
     could have a similar clinical presentation.                   adjunct to light microscopy. Electron microscopic
   - To assess the severity and activity of the                    evaluation is required in certain categories of
     lesion ("grade").                                             disease (minimal lesions, thin basement membrane
   - To assess the amount of irreversible scarring                 disease) and provides information of interest in
     ("stage"). (1)                                                most renal biopsies. Moreover, electron micros-
   The renal biopsy must provide sufficient                        copy is required in many instances, but this
accurate information that allows us to establish the               technique may be available only in selected centers
therapeutic strategy and the prognosis. In order to                (2).




Address for correspondence: Dr. Camelia Ionescu, Center of Internal Medicine, 258 Fundeni Clinical Institute, Bucharest,
Romania, Tel/Fax: 021-3180445, E-mail: camellia_ailemac@yahoo.com



 30                                                                 Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                              The immunofluorescence in the assessment of the renal biopsy specimens



Immunohistochemical investigations                         Immunofluorescence
of renal biopsy                                                This approach has the advantage of simplicity
   This type of renal biopsy interpretation should         and reliability because plasma proteins can be
be a routine part of the investigation of native renal     removed from frozen sections simply by washing.
biopsies. A basic panel of antibodies should be            The essential panel of antibodies against immuno-
used for the detection of tissue deposits of IgG,          globulins and complement can be used with a
IgA, IgM, and complement (usually C3). The most            direct immunofluorescence method, which is
used antibodies include those directed against:            extremely simple and quick. Immunofluorescence
   - C4 and/or C1q: to indicate classical pathway          has several disadvantages. A separate frozen
       complement activation.                              specimen must be taken at the time of biopsy.
   - C5b-9: to detect membrane attack complex              Cryostat and epifluorescence microscopes are
       deposition.                                         required. The preparations must be mounted in
   - Fibrin: to detect fibrinoid necrosis in vessels       aqueous media and they are not permanent; expo-
       and glomeruli, and fibrin in crescents.             sure to light causes bleaching. This can be reduced
   - Both Kappa and Lambda light chains: not               but not eliminated by using specialist mounting
       only for myeloma kidney, but also the more          media and storing the sections in the dark in a
       subtle changes of light chain nephropathy.          refrigerator. Ideally, relevant images should be
   Additional antibodies can be used at the                stored, photographically or digitally.
nephrologist and pathologist's discretion. In
special case the list of antibodies that might be          Immunofluorescence technique
used include:
   - Specific amyloid types.                                   After it has been proper snap-frozen in liquid
   - Specific chains of type 4 collagen (Alport's          nitrogen, the tissue is then cut in a cryostat at a
       syndrome).                                          temperature between -25 and -20 C. The sec-
   - Fibronectin (fibronectin glomerulopathy).             tions must not exceed 3-4 m in thickness. The
   - Type 3 collagen (collagenous glomerulo-               slides are fixed for 5 to 10 minutes in acetone,
       pathy).                                             dried at room temperature, washed in buffered
   - Viral antibodies.                                     saline, and covered for 30 minutes with a drop of
   - Tamm-Horsfall protein.                                fluorescein-labeled antiserum in a moist chamber
   It is obviously difficult to detect the immuno-         that is light shielded. After three washes with
globulins in glomeruli due to the presence of              buffer, the slides are mounted using buffered
abundant plasma proteins, which must be                    glycerol. The section is then examined using a
removed to avoid non-specific staining. This has           fluorescence microscope equipped with appro-
resulted in a continuing popularity of frozen              priate excitation and barrier filters. The section
sections and immunofluorescence techniques in              should be photographed, because the fluores-
renal pathology, where they have been super-               cence fades on exposure to both ultraviolet and
seded in most other branches of immunohisto-               incident light. The slides can be stored at 4 to 8
chemistry by methods that are applicable to                C for only 12 - 24 hours.
paraffin wax sections. (Tab. 1) In paraffin wax
sections, the plasma proteins have been fixed in
the tissues and must be removed by a digestion
process rather than simple washing.
                                                           Immunohistochemistry using
                                                           paraffin wax sections
                                                              A detection method applied to sections from
Table 1: Types of immunohistochemical                      the block that is re-used for routine microscopy
         investigations of renal biopsy
                                                           has obvious advantages. It allows correlation
Direct immunofluorescence                                  with morphology and results in a permanent
                                                           preparation that does not require special equip-
Immunohistochemistry using paraffin wax sections
                                                           ment or a separate sample for its production or


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                        31
C. Ionescu et al.



examination. However, immunofluorescence
remains the method of choice in the majority of
laboratories because of the technical difficulties
of the alternative methods (3).



Case report
    A 34-years-old female presented lower-
extremity edemas. He had noticed the edemas
over the past five years. She has never received
any treatment in this period. Physical examination
revealed an increase blood pressure of 150/90
mmHg and bilateral edemas at lower-extremity.
The rest of his physical findings were unremark-
able. Biological exam showed nephrotic syndrome
                                                            Fig. 1 - Immunofluorescence micrograph, anti IgA.
(proteinuria: 5.7g/24h, hypoproteinemia: 5,9g/dl;
                                                                     The mesangial regions of glomeruli contain
hyposerinemia: 2.4g/dl, hypercholesterolemia:                        deposits. (X 100)
260mg/dl), with normal renal function (serum cre-
atinine: 0.8mg/dl, Cl creatinine: 100.1ml/min).
Abdominal ultrasounds showed normal kidneys.
         A percutane renal biopsy was performed
using a Bard pistol with a 16G needle. The renal
biopsy specimen of 0.8cm length was then
examined by immunofluorescence and light
microscopy.
    Immunofluorescence: diffuse deposits of IgA
in the mesangium, forming discreet granules.
IgG mesangial deposits are present in smaller
amount. IgM, complement fractions and fibrino-
gen deposits are absent in this case. (Fig. 1).
    Light microscopy: renal biopsy fragment with
more than 20 glomeruli showed diffuse and
                                                            Fig. 2 - Light microscopy. Diffuse mesangial
global lesions. Most of the glomeruli present                        proliferation and sclerosis. (H E, X200)
severe mesangial proliferation and free capillary
lumen Areas of sclerosis and hyalinosis involve
segments of the glomeruli in 50% of them. An
irregular and segmental glomerular basement
membrane thickening occurs in some glomeruli.
Also, some glomeruli present advanced lesions
of sclerosis and presence of synechiae and cellu-
lar crescents. The immediately adjacent Bowman
s capsules are frequently thickened and multi-
laminated (Fig. 2, 3).
    Tubulo-interstitial lesions are also present in this
case. Scattered areas of interstitial edema and
fibrosis, with interstitial inflammatory cell infiltrates
predominate around the more severely damaged
glomeruli.                                                  Fig. 3 - Light microscopy. Localized epithelial
    In this case, the immunofluorescence pattern is                  proliferation with both cellular and
                                                                     organized synechiae. (H E, X200)


 32                                                         Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                              The immunofluorescence in the assessment of the renal biopsy specimens



typical for IgA nephropathy. The light microscopy          Table 2: WHO classification of IgA nephropathy
showed a pattern of diffuse mesangial lesions with                  (light microscopy)
proliferation and sclerosis.
                                                            Class I:     Minimal lesion
                                                            Class II:    Minor changes with small, segmental
Discussions                                                              areas of proliferation
                                                            Class III:   Focal and segmental glomerulonephritis
    Ig A nephropathy can only be accurately                              with less than 50% of the glomeruli
diagnosed by immunohistochemical methods. The
                                                                         showing obvious changes
single constant findings in this disease is the
presence of diffuse deposits of IgA in the                  Class IV:    Diffuse mesangial lesions with proliferation
mesangium, forming either discreet granules or                           and sclerosis
large aggregates. IgG codistributes with IgA in
                                                            Class V:     Diffuse sclerosing glomerulonephritis
more than one-half of the cases, but in smaller
amounts. IgM has been reported in the                                    affecting more than 80% of glomeruli.
mesangium in 50% of the cases. C3 is present in
most of the patients with the same distribution as
IgA. The presence of C1q and C4 is not common.
Also, fibrinogen deposits are smaller and usually
absent.                                                    immunofluorescence microscopy and reveal a
    Although the disease was first describe as a           histological pattern of class IV- WHO classifica-
focal proliferative glomerulonephritis, it has been        tion of IgA nephropathy. In IgA nephropathy the
recognized that there are multiple histologic              immunofluorescence is mandatory for the
patterns of the disease. The World Health                  diagnosis and light microscopy provide the
Organization working group on classification of            histological pattern of the disease.
glomerular disease has proposed the five
category of the IgA nephropathy (Tab. 2).
    In the case presented immunofluorescence
reveals the diagnosis of IgA nephropathy and
                                                           Bibliography
light microscopy showed a histological pattern
of diffuse mesangial lesions with proliferation              1.   Furness P. ACP Best Practice No 160. Renal biopsy
and sclerosis (class IV - WHO classification).                    specimens. J Clin Pathol 2000; 53:433-438
                                                             2.   Striker G, Striker L, D Agati V. The renal biopsy. Third
                                                                  edition. Saunders Company. Chapter 1. Role of the renal
                                                                  biopsy in the evaluation of renal disease. pp 1-37, 1997
                                                             3.   Furness P, Boyd S. Electron microscopy and immuno-
Conclusions                                                       hystochemistry in the assessment of renal biopsy speci-
                                                                  mens: actual and optimal practice. J Clin Pathol 1996;
                                                                  49:233-7
   The renal biopsy is the principal method used             4.   Polenakovic MH, Grcevska L, Dzikova S. The incidence
in order to define the type of renal disease, espe-               of biopsy-proven primary glomerulonephritis in the
cially when the preliminary clinical diagnosis is                 Republic of Macedonia-long-term follow-up. Nephrol
                                                                  Dial Transplant. 2003; 18 Suppl 5: 26-7.
glomerulonephritis. The renal biopsy provides
                                                             5.   Nair R, Walker PD. Is IgA nephropathy the commonest
the type of renal disease and accurate informa-                   primary glomerulopathy among young adults in the
tion in order to establish the therapeutic strategy               USA? Kidney Int. 2006; 8
and the prognosis(4-6).                                      6.   Maixnerova D, Honsova E, Merta M, Reiterova J, Rysava
   In the case reported in this article the renal                 R, Tesar V, Obeidova H, Motan J. Does electron
                                                                  microscopy change the view of the diagnosis of IgA
biopsy fragment was processed for light and                       nephropathy? Prague Med Rep. 2005; 106 (3): 283-90




Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                             33
Case Report                                        Annals of Fundeni Hospital, volume 10, number 1-2, January-June




   MORE TREATMENT CHOICES FOR PATIENTS WITH
     CHRONIC LYMPHOCYTIC LEUKEMIA: A CASE
     REPORT AND REVIEW OF THE LITERATURE


       C.A. Dasanu1, Elena Stoica-Mustafa2, V. Herlea2, D.T. Alexandrescu1
               1
                Department of Hemato-Oncology, New York Medical College, NY, U.S.A.
                2
                 Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania




  Abstract   We present an illustrative case of a patient with advanced stage chronic lymphocytic leukemia (CLL), treated
             with both chemotherapeutic agents and monoclonal antibodies, in his first-, second-, and third-line therapies,
             with a reasonably good clinical response at each relapse. Further, we list some of the most commonly utilized
             modern therapies of this disease. Others are still in the process of development, giving even more hope to the
             CLL patients, their families, researchers, and clinicians in the nearest future. Entire concepts in CLL therapeutics
             have changed over the last a few years, therefore primary care providers need to be familiarized with the new
             agents, their mechanism of action, special handling and major toxicities.


      Key words: Chronic lymphocytic leukemia (CLL), fludarabine, rituximab, alemtuzumab, cladribine, pentostatin




   We certify that any affiliations with or financial             extremely pale and had a few small cervical nodes
involvement in any organization or entity with a                  and a spleen that was palpable 3 fingerbreadths
direct financial interest in the subject matter or                beneath the left costal margin. A complete blood
materials discussed in the manuscript (e.g.,                      count at that time revealed a hemoglobin level of
employment, consultancies, stock ownership,                       7.5 g/dl, a leukocyte count of 18,000/mcl, 90% of
honoraria, expert testimony) is disclosed above.                  which were small lymphocytes with smudge cells
No financial support was used for this work.                      present (nuclear remnants of cells destroyed while
                                                                  making blood smears), and a platelet count of
                                                                  400,000/mcl. The peripheral smear is shown
Case presentation
                                                                  below (Fig. 1).
                                                                     The peripheral lymphocytes were CD5+,
   A 64-year-old man presented to our clinic for                  CD19+, CD20 weakly positive and CD23+.
the first time three years ago with the main                      Surface immunoglobulin type IgG was demon-
complaint of profound weakness and exertional                     strable with monoclonality for kappa light chains.
dyspnea. On physical examination, he was                          The diagnosis of chronic lymphocytic leukemia




Address for correspondence: Constantin A. DASANU, MD, PhD, 2070, TENBROECK AVE, Ist FLOOR, BRONX, NY, 10461,
USA, Phone: +(1)718.866.68.07, E-mail: c_dasanu@yahoo.com



 34                                                                Annals of Fundeni Hospital, volume 10, number 1-2, 2005
        More treatment choices for patients with chronic lymphocytic leukemia: a case report and review of the literature



                                                              ZAP-70 positive. Further therapy with subcuta-
                                                              neous alemtuzumab is contemplated.

                                                              Newer therapeutic options and
                                                              discussion
                                                                  Cure of disease has been a fervent hope of
                                                              many CLL patients, their families, researchers and
                                                              clinicians. The increased longevity in general
                                                              population is another factor that prompted the
                                                              emergence of new, more effective chemothera-
                                                              peutic options, along with other less toxic systemic
                                                              treatments including monoclonal antibodies, or
Fig. 1 - Peripheral smear showing multiple small              chemoimmunotherapeutic combinations. Entire
lymphocytes, smudge cells, and a variable degree              concepts in CLL therapeutics have changed over
of poikilocytosis, anisocytosis and hypochromia               the last a few years, therefore primary care
                                                              providers need to be familiarized with the new
                                                              agents, their mechanism of action, special handling
(CLL), high risk by Modified Rai Staging System,              and major toxicities. A few chemotherapeutic
was made. Patient was transfused with 3 Units of              agents and two monoclonal antibodies are being
packed red blood cells and chemotherapy with                  introduced and more are on the horizon.
IV fludarabine was started. Between August
2002 and March 2003, he received a total of 4                 Fludarabine
cycles of fludarabine with a good clinical
response and near-resolution of his spleno-                       This nucleoside analog, introduced earlier in
megaly and anemia.                                            Europe, has been increasingly used as first-line
    Patient remained asymptomatic until May                   therapy in US. Fludarabine is delivered as an IV
2004, when he presented with generalized lym-                 infusion daily for five days, every 28 days,
phadenopathy and symptomatic splenomegaly.                    repeated for 6-10 cycles, not to exceed one year of
Further, 8 standard-dose weekly rituximab                     treatment because of cumulative myelotoxicity.
infusions were given and subsequently patient                 There is potential for tumor lysis syndrome with its
entered another partial remission. The second                 use and therefore good hydration, oral allopurinol,
remission was, however, short-lived. In November              and close laboratory monitoring are warranted in
2004, he developed fever, night sweats and                    the first two weeks of therapy. Fludarabine is the
enlarged, painful left axillary lymphadenopathy.              most active chemotherapeutic agent for treatment
The lymph node biopsy showed diffuse small                    of CLL. It offers several advantages over the
lymphocytic infiltrate. The peripheral lymphocytes            established alkylating agent, chlorambucil, which
were CD5+, CD20+, CD38+, therefore chemo-                     continues to be considered one of the first-line
therapy with fludarabine, cyclophosphamide and                agents by many. (1) Thus, when tested against
rituximab (FCR) was employed and continued for a              chlorambucil, fludarabine induced almost twice as
total of 4 cycles. Although lymphadenopathy                   many responses. Time to disease progression was
resolved, the B signs persisted.                              also longer for fludarabine: 25 months versus 14
    In May 2005, patient was diagnosed with                   months. (2) Moreover, fludarabine provides effec-
Pneumocystis carinii pneumonia (PCP) and treated              tive salvage treatment for chlorambucil failures.
with IV Bactrim and prednisone. Bactrim was                   Together with cyclophosphamide, it constitutes an
continued orally as PCP prophylaxis. Five months              efficient treatment for advanced CLL. (3) Patients
after, he developed a right-sided pleural effusion.           with fludarabine-induced remissions of more than
A pleural tap revealed small lymphocytes, consis-             a year show reasonable response rates when
tent with his CLL. The bone marrow aspiration and             retreated with fludarabine upon relapse.
biopsy showed a diffuse infiltrative pattern with                 However, fludarabine also causes greater
small lymphocytes that were CD5+, CD19+, CD20,                myelotoxicity and immunosuppression, resulting


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                            35
Constantin A. Dasanu et al.



in prolonged decreases in CD4 lymphocytes.                Alemtuzumab
Blood products should be irradiated to avoid trans-
fusion-related graft-versus-host disease (GVHD).              It represents another chimeric (humanized)
Just like in AIDS patients, prophylaxis against           monoclonal antibody targeting CD52, a surface
Pneumocystis carinii pneumonia is advisable until         glycoprotein expressed on normal and neoplastic
the CD4 lymphopenia resolves.                             B and T lymphocytes. Alemtuzumab is indicated
    Coombs-positive hemolytic anemia is seen with         for use in patients with fludarabine-refractory CLL
an increased incidence after use of fludarabine,          and a response rate of 33% has been reported in
therefore its use is contraindicated in patients with     that setting. (8) A recent study has shown that
prior history of autoimmune hemolysis. Reversible         eradication of minimal residual disease in B-CLL is
neurotoxicity is described, primarily in the form of      possible after alemtuzumab therapy and it is
somnolence and mild paresthesias.                         associated with prolonged survival.9 However, not
                                                          only that alemtuzumab is myelosuppressive, but it
Rituximab                                                 also induces profound and prolonged immuno-
                                                          suppression. Opportunistic infections are com-
    This chimeric (mouse-human) monoclonal                mon, including cytomegalovirus and fungi. 1 tablet
antibody has specificity against CD20, a surface          DS of trimetoprim/sulfamethoxazole daily 3
antigen present on neoplastic and normal B-               days/week and famcyclovir 250 mg BID should be
lymphocytes. It is thought to cause cell lysis via        started with the initiation of the drug and
complement and antibody-dependent cellular                continued until CD4 count is at least 200/mcl. All
cytotoxicity (ADCC) and to induce apoptosis by a          blood products should be irradiated before use.
direct mechanism. Response rates of 51%                   Severe anemia, neutropenia, and thrombocyto-
including 4% complete responses (CR) have been            penia lasting 3 to 4 weeks are commonly reported;
recorded while using Rituximab as a single drug in        fatal pancytopenia is rare.
the first-line setting. (4) Partial responses (PR) have       Infusion reactions should be handled in the
been reported in 25% of the CLL patients                  manner described with rituximab. Fewer reac-
previously treated with fludarabine. (5)                  tions are seen with the subcutaneous administra-
    Rituximab is used in standard dosage of 375           tion. The cost of the drug is significant.
mg/m2 IV weekly or in escalating dosing. The latter
might produce higher responses, yet expense is            Future options
significant. An impressive response rate of 90%
including CR in 43% was achieved by the concur-              Drugs on the horizon include other nucleoside
rent use of fludarabine and rituximab. (6)                analogs, two of which - cladribine and pentostatin
Furthermore, rituximab has also been utilized in          - are in phase 3 clinical trials. Both drugs are
combination with fludarabine and cyclophos-               considered "standard of care" in hairy-cell
phamide for both initial and salvage therapy of           leukemia. They are being extensively studied in
CLL, with response rates of 90% (60% CRs), but the        CLL in many European and US centers. Results of
effect of such combination on survival is uncertain.      early trials appear to show their efficacy to be
(7)                                                       comparable and their toxicity profile to be similar
    Moderate to severe infusion reactions are             to that of fludarabine. (10) Lumiliximab, an anti-
seen in approximately 90% of patients and there-          CD23 monoclonal antibody, is currently in early-
fore pretreatment with acetaminophen and                  phase testing. Various combinations of alemtuzum-
diphenhydramine is recommended. Once such                 ab and/or rituximab with conventional chemo-
reaction have occurred, interrupting the infusion,        therapy agents as well as with each other are also
administration of IV steroids, and restarting the         being investigated. (11)
drug at half the previous rate have all been
shown to be effective. Myelotoxicity is minimal
with rituximab. Severe cytopenias are seen on
rare occasions with its use and are presumed to           References
have an immunological basis.
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          More treatment choices for patients with chronic lymphocytic leukemia: a case report and review of the literature



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       untreated patients with B-cell chronic lymphocytic             and refractory lymphoid malignancies. Blood. 2003;
       leukemia: results from Cancer and Leukemia Group B             101: 3413-3415.




Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                                 37
Case Report                                          Annals of Fundeni Hospital, volume 10, number 1-2, January-June




                   PRIMITIVE RHABDOMYOSARCOMA
                 OF THE DIAPHRAGM, EMBRYONAL TYPE



           Raluca Cristea1, V. Herlea1, Monica Hortopan1, Mihaela Mihai1’3,
                C. Pechianu1, Doina Hrehoret2, Carmen Ardeleanu3,
                             Camelia Dobrea3, I. Popescu2
                              1
                         Pathology Department of Fundeni Hospital, Bucharest
             2
             General Surgery and Liver Transplantation Centre of Fundeni Hospital, Bucharest
                              3
                               National Institute “Victor Babes“, Bucharest




  Abstract       Rhabdomyosarcoma is a childhood tumor. (RMS) is the most commun diagnosed sarcoma in children and
                 adolescents, and frequently in young adults, with having bimodal age distribution: the first peak of
                 incidence at children between 2 and 5 years old, the second peak at adolescents between 15 and 19 years
                 old. RMS is diagnosed in 50% of cases to patients less than 5 years old, and about 6% in their first year of
                 life. In adults, it is seen after the age of 50 and is more frequent in males (1). The age of RMSs diagnosis
                 tend to correlate to the site of primary disease and tumor histology. RMS may occur at any site, but
                 primary tumors are more commonly located in head and neck (42%), urogenital tract (34%), and extremities
                 (11%). Morphologically, there are 3 histologic subtypes: embryonal (the most frequent - about 66%), alveolar,
                 and pleomorphic (2; 24). We present the case of a 4-years old boy, hospitalized General Surgery and Liver
                 Transplantation Centre of Fundeni Hospital, for a voluminous tumoral mass attached to the left diaphragm,
                 marking the surface on the left lobe of liver. Histological exams of the specimen extracted on laparoscopy
                 was realized in the Pathology Department of Fundeni Hospital and revealed: an undifferentiated malignant
                 tumor, with small cells; correlated with immunohistochemical test results the diagnosis established is
                 embryonal RMS. It is delivered a chemotherapy for 7 month. The follow-up of patient during the therapy
                 revealed reduction of tumor dimensions, so it is decided surgery and tumor resection. A macroscopic and
                 microscopic exam reveals malignant mesenchimal with small cells diffusely involving the diaphragm,
                 without invading hepatic parenchyma. Conclusion: primitive diaphragmatic RMS, embryonal type.
                 Conclusions: 1). The specificity of the case consist in the tumor location; primitive diaphragmatic RMS is
                 a very unusual entity. 2). The pathological exam establish an accurate diagnosis, excluding other diseases
                 as are Ewing sarcoma, leukaemia, neuroblastoma, non-Hodgkin lymphoma, peripheral primitive neuro-
                 ectodermal tumors (PNET) and lead to a correct therapy.



                            Key words: primitive rhabdomyosarcoma, embryonal type, diaphragm




Address for correspondence: Dr. Vlad Herlea, Department of Pathology, Fundeni Clinical Institute, Fundeni street 258,
022328, Bucharest, Romania; E-mail: herlea2002@yahoo.com



 38                                                                 Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                                          Primitive rhabdomyosarcoma of the diaphragm, embryonal type



Introduction                                                  Table 1 - Primary rhabdomyosarcoma of the
                                                              diaphragm


    RMS is the most common mesenchymal tumor
at children and young adults. RMS is a malignant
tumor that develops from primitive mesenchymal
cells. The tumor frequently develops in sites that
muscular tissue is not usually present. (2)
    Rhabdomyosarcoma may occur at any site, but
primary tumors are more commonly located in
head and neck (42%), urogenital tract (34%), and
extremities (11%). The presence of striated muscle
tissue is not a prerequisite for its development
(1, 7).
    Alveolar tumors tend to occur primarily in
trunk and extremities, whereas embryonal
tumors are more often found in the head and
neck or genitourinary and paratesticular sites. The
pleomorphic type is specific for adults and is
placed specially in extremities. The embrional
type develops from the undifferentiated meso-
derm and usually is located in the regions of the
head, neck, retroperitoneum, biliary ducts and
urogenital tract. Rarely is located to extremities.
The botyroid subtype developes in the sub-                    determination of the site of origin may be not
mucosa of cavitary organs (vagina, bladder,                   possible initially. The majority of the symptoms are
biliarry ducts) and has a gross typically aspect of           related to the tumor compression on adjacent
" grapes ", and microscopically tumoral cells with            organs, but sometimes RMS is occasionally diag-
evident myogenesis in their cytoplasm. The                    nosed in an asymptomatic patient. Diagnosis is
spindle cell subtype is usually located para-                 usually made by the discovery of a visible or
testicular, and microscopical features reveal                 palpable mass or by interruption of normal function
scanty rabdomyoblasts (2, 24).                                of the adjacent organs.
    Primary tumors of the diaphragm are uncom-                    Rhabdomyosarcoma is a pediatric disease
mon entities, and diaphragmatic rhabdomyo-                    specified by the recurrent chromosome trans-
sarcoma is an extremely rare tumor. This                      locations t(2,13)(g35,14) and rarely t(1, 13)(g36,
primitive site promotes adjacent structures                   g14). These translocations result in the formation
invasion, as are: lungs, great vessels, and/or                of the PAX3-FKHR and PAX7-FKHR fusion genes,
liver. In diaphragmatic location the symptoms                 which are thought to play a causal role in the
are: abdominal pain, vomiting, constipation,                  genesis of this disease (13).
pneumothorax, hemothorax. Primary tumors of
the diaphragm are uncommon entities, and
diaphragmatic rhabdomyosarcoma is an
extremely rar tumor (Table 1).
                                                              Case report
    The clinical features of RMS vary with age of the
patient, site of the tumoral mass, and presence or                We present a 4-year old boy, S.V., hospitalized
absence of metastatic disease. Gross features of the          in 2004, October, for following accuses: abdominal
tumor are not characteristic. They are generally              pain, vomiting, subfebrility. Clinical examination
firm, occasionally nodular, and variable in size.             reveals: a feverless patient, good general state,
There is a tendency to form pseudocapsules                    generalized microadenopathy, tumoral mass in
around the tumor. The tumor can be so large that              epigastric and right hypogastric region which, on



Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                         39
R. Cristea et al.



palpation has a irregular surface, poorly delimi-        ultrasonography. It is delivered chemotherapy,
tated; there are no other modifying on clinical          by IVA-SFOP'95 therapy protocol.
examination. Complex clinical and paraclinical               The patient followed for 7 months this
exams were done. Laboratory exams showed                 multidrug therapy, and, as a result, by paraclical
high levels of: erythrocyte sedimentation rate           evaluation it is observed a significant reduction in
ESR ( 44/1h; 83/2h), fibrinogen (529mg/dl), LDH          tumor dimensions, from 10/11cm to 5/6cm.
(333U/l), C reactive protein (43,3mg/dl); anemia             It is to notice that during this time interval there
(RBC =10,5g/dl). Chest X-ray reveals no changes.         were no other pathological adjustments on the
Computerized tomography scan (CT) detects a              chest X-ray. Laboratory exams show a significant
tumoral mass on the left lobe of the liver, having       improvement of biological parameters (RBC,
dimensions about 10/11 cm.                               fibrinogen, ESR), thus, on April 18, 2005, the
    The patient is hospitalized at General Surgery       patient suffers a new surgical intervention.
and Liver Transplantation Centre of Fundeni              Intraoperative it is observed (Fig. 9):
Hospital, where on October 18, 2004, was pro-                - tumoral mass attached to the left diaphragm,
ceeded an exploratory laparotomy which reveals:                  with extrinsic growth, marking the surface on
tumoral mass on the left lobe of the liver, invading             the left lobe of liver, without invading the
gastric body and diaphragm; peritoneal carcino-                  liver;
matosis nodules which were extracted for biopsy;             - an epiploic nodule.
it was effectuated an intraoperative upper                   Histological exams of the specimen extracted
digestive endoscopy which shows normal aspect.           on laparotomy was realized in the Pathology
    Histological exams of the specimen extracted         Department of Fundeni Hospital and revealed:
on laparotomy was realized in the Pathology                  - Macroscopically: fragment of diaphragm
Department of Fundeni Hospital and revealed:                     adhering to the left lobe of the liver (90g)
    - Macroscopically: 2 nodular masses with 0,8                 by a solid-cystic proliferation, dimensions =
      cm and 1 cm diameters;                                     9/6/5cm, having a gelatinous content,
    - Microscopically: formed by small, round                    alternating with tan-yellow solid areas
      cells and spindle-shaped cells, embryonal                  (Fig. 10);
      type, disposed into a lax stroma. (Fig. 1, 2)          - Microscopically: diffuse malignant mes-
    Conclusion: metastatic mesenchymal hepato-                   enchymal proliferation with small, round-
blastoma.                                                        ovoid cells, with foamy cytoplasm, small,
    For a certain diagnosis there are recommended                tahicromatic nuclei, with 5- 7 mitoses/10
immunohistchemical tests, which were effectuated                 HPF, disposed into a lax, mixoid stroma
to "Victor Babes" National Institute, and revealed:              (Fig.11, 12).
    • VIM(+) (Fig. 3); ACT(+) into the vessels, (-)          Conclusion: Diaphragm rhabdomyosarcoma,
      into the tumor; EMA(+) in the periphery rest-      embryonal type, the diaphragm being the primi-
      ing epithelial structures and (-) into the tumor   tive site of the tumor.
      (Fig. 4); CK8(-); S100(-); AFP(-) (Fig. 5); KL1
      (-); CEA(-); OCH1E5(-) (Fig. 6); beta-HCG
      inconclusive;
    • other tests: desmina diffusely (+) (Fig.7);
                                                         Discussions
      VIII factor (-); CD7(-); CD34 (+) into the
      vessels, CD31 (+) into the vessels, poorly            RMSs belong to the class of "small round blue
      (+) into the isolated tumoral cells;               cell tumors" of childhood. Differential diagnosis
    • Myogenina frequently (+) into the tumoral          includes: Ewing sarcoma, leukemia, neuroblas-
      cells (Fig. 8).                                    toma, non- Hodgkin lymphoma, and peripheral
    Conclusions: immunohistochemical tests are           primitive neuroectodermal tumors (PNET). RMS is
compatible with a metastases from a rhab-                a primitive malignant soft tissue sarcoma that
domyosarcoma, embryonal type.                            recapitulates the phenotypic and biologicfeatures
    October 2004 -March 2005 the patient comes           of skeletal muscle and has 3 principal subtypes:
every month for chemotherapy and evaluation:             alveolar, embryonal (with botryoid and spindle cell
laboratory exams, chest X- ray and abdominal             subtypes)and pleomorphic (2).



  40                                                     Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                                          Primitive rhabdomyosarcoma of the diaphragm, embryonal type




      Fig.1- HE stain x 400                                          Fig. 4 - EMAx100,(-) in tumor, (+) in
                                                                     mesothelium




      Fig.2- HE stain x 200                                          Fig. 5 - AFP (-) x 100




      Fig. 3 - Vimentine (+) x 200                                   Fig. 6 - OCH1E5(-)x100


Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                         41
R. Cristea et al.




                                                      Fig. 10 - Tumoral mass - gross view-
                                                      transversal section
     Fig. 7 - Desmine(+) x 200




     Fig. 8 - Myogenine(+) x 200                      Fig. 11- Tumor of diphragm (HEx400)




     Fig. 9 - Tumoral mass - surgical specimen
     intraoperative view                              Fig.12-Tumor of diaphragm (HE x100)



  42                                             Annals of Fundeni Hospital, volume 10, number 1-2, 2005
                                                          Primitive rhabdomyosarcoma of the diaphragm, embryonal type



    The embryonal subtype is most frequently                      RMS occasionally arise in sites other than
observed in children. Embryonal tumors are                    those mentioned above. Such a very unusual site
characterized by variable amounts of small,                   of RMS is the diaphragm. Patients with these
round or spindled-shaped cells, with variable                 tumors often have locally advanced disease that
cellularity. Individual rhabdomyoblasts are eosi-             is is not grossly respectable initially due to
no-philic, and cross-striations are seen in 50% to            fixation to adjacent vital structures suchas the
60% of tumors (25, 26).                                       lung, great vessels, and/or liver. In the circum-
    A sarcoma should always be considered in                  stance, chemotherapy should be initiated after
the differential diagnosis of any soft tissue mass            diagnostic biopsy, with the intent to try remove
in children (2, 3). All patients with a RMS should            residual tumor at a later date (4, 5).
have a complete blood count, liver function tests,                The incidenceThe authors report a case of
a computerized tomography (CT) scan of chest,                 primary rhabdomyosarcoma of the diaphragm,
pelvis and abdomen, a bone marrow aspiration                  an extremely rare presentation with only 14
and biopsy.                                                   cases reported in the literature (Table 1). Primary
    RMS require a multidisciplinary approach                  rhabdomyosarcoma of the diaphragm presenting
involving surgeons, oncologists, and patholo-                 as an epigastric mass is extremely rare, with only
gists. Prior to institute the therapy, an extensive           three published cases. We highlight the unique
evaluation should be done, to determinate the                 imaging features in a 2(1)/(2)-year-old boy which
extent of the disease, and that should include:               predicted the correct anatomical site preopera-
chest X-ray; computed tomography (CT) scan of                 tively. Understanding of this rare tumour and its
chest, abdomen, an pelvis with intravenous, oral,             imaging characteristics should help in differentia-
ar rectal contrast; bone marrow aspiration and                ting it from other more common tumours in this
biopsy; magnetic resonance imaging (MRI).                     location, especially primary hepatic tumours
    All children with RMS require multimodality               (12).
therapy. This involves: surgical resection, if
possible, followed by chemotherapy, followed by                  There was reported some other cases of
second-look surgery for some patients with                    primary RMS of the diaphragm (14-23):
initially unresected tumors, and radiation                       - 2004 - pleomorphic RMS
therapy. All children with RMS should receive                    - 2003 - 4 years old male- unclassified RMS
chemotherapy with the quantity an duration                       - 2002 - 4-years old female- alveolar RMS
dependent on a risk factors analysis (4, 27).                    - 2000 - 18 years old male- unclassified RMS
Chemotherapy is the primary treatment for                        - 1999 - 3 years old male- embryonal RMS
patients with metastatic disease at presentation.                - 1998 - 2 years old male- unclassified RMS
The common used drugs are a combination                          - 1993 - 20 years old female- pleomorphic
(multidrug therapy) of: Cyclophosphamide,                          RMS
Vincristine, Actinomycine and Doxorubicin,                       - 1988 - adult, male- embryonal RMS.
Cisplatin, Adriamicyn and Isofosfamid. A recent
analysis has proved that children with embryonal
disease, with complete resction but with groo
residual disease, younger than 10 years of age,
                                                              Conclusions
have a substantially improved outcome after
multidrug chemotherapy (6-11).                                   1. The specificity of the case consist in the
    Embryonal RMS, botryoid and spindle cell                        tumor location; primitive diaphragmatic
subtypes, have a highly favorable prognosis, and                    RMS is a very unusual entity.
embryonal RMS not otherwise specified has an                     2. The pathological exam establish an accurate
intermediate prognosis. The prognosis for                           diagnosis, excluding other diseases as are
children and adolescents with RMS is related to                     Ewing sarcoma, leukaemia, neuroblastoma,
the site of origin, respectability, presence of                     non-Hodgkin lymphoma, peripheral primi-
metastasese, number of metastases sites, and                        tive neuroectodermal tumors (PNET) and
histopathology (6-11).                                              lead to a correct therapy.




Annals of Fundeni Hospital, volume 10, number 1-2, 2005                                                         43
R. Cristea et al.



                                                                          arrest and impaired nucleocytoplasmic transport in
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  44                                                               Annals of Fundeni Hospital, volume 10, number 1-2, 2005
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