Left renal vein entrapment syndrome in two girls with orthostatic proteinuria

Left renal vein entrapment was documented by bilateral ureteral catheterization and imaging studies as a cause of orthostatic proteinuria in two girls. Renal ultrasonography showed compression of the left renal vein between the aorta and the superior mesenteric artery (Nutcracker phenomenon). Abnormal collateral veins and high pressure gradients between the left renal vein and the inferior vena cava were found on left renal venography and pressure tracing, respectively. The left kidney was documented as the source of postural proteinuria by bilateral ureteral catheterization. Our observations suggest renal congestion due to left renal vein entrapment was the cause of orthostatic proteinuria.

Critical analysis of the current American Joint Committee on Cancer staging system for cutaneous melanoma and proposal of a new staging system

PURPOSE

To critically review the accuracy of the current American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma and propose a more useful staging system.

METHODS

Retrospective evaluation of the published data as well as a reanalysis of the University of Alabama and Sydney Melanoma Unit (UAB/SMU) data bases (n = 4,568) for patients with primary melanoma was performed to examine specifically the impact of level of invasion and ulceration on the prognostic value of tumor thickness. In addition, an overlay graphic technique was used to compare the Kaplan-Meier survival curves of patients with local recurrences, satellites, in-transit metastases, and nodal metastases reported in the literature.

RESULTS

Tumor thickness and ulceration remained the most powerful prognostic indicators in patients with stage I and II disease. Level of invasion provided statistically significant prognostic information only in the subgroup of patients with tumor thickness < or = 1 mm, but the absolute 10-year survival differences were small and inconsistent (level II, 95%; level III, 85%; level IV, 89%). The best statistical fit for tumor thickness cutoffs was at 1 versus 2 versus 4 mm. The overlay graphic technique showed that patients who developed satellite lesions or local recurrence had prognoses similar to those of patients with stage III disease. The most important prognostic factor for patients with nodal metastases was number of involved nodes rather than size.

CONCLUSION

Our analysis showed that the current AJCC staging system has many inaccuracies that should be modified to conform to published data. On the basis of our analysis and review of the literature, we propose a new and more accurate staging system.

Preoperative and postoperative chemoradiation strategies in patients treated with pancreaticoduodenectomy for adenocarcinoma of the pancreas

PURPOSE

The effects of preoperative versus postoperative fluorouracil (5-FU)-based chemotherapy and irradiation on treatment toxicity, duration of treatment, tumor recurrence, and survival were compared in patients who underwent potentially curative therapy for adenocarcinoma of the pancreatic head during a 5-year period.

METHODS

From July 1990 to July 1995, 142 patients with localized adenocarcinoma of the pancreatic head deemed resectable on the basis of radiographic images were treated with curative intent using a multimodality approach involving either preoperative or postoperative chemoradiation. Patients with biopsy confirmation of adenocarcinoma and a low-density mass in the pancreatic head identified by computed tomography (CT) received preoperative chemoradiation. Patients without a mass on CT or in whom the preoperative biopsy was negative underwent pancreaticoduodenectomy with planned postoperative chemoradiation. Protocol-based preoperative chemoradiation consisted of external-beam irradiation at a dose of 50.4 Gy (standard fractionation; 1.8 Gy/d, 5 d/wk) or 30 Gy (rapid fractionation; 3 Gy/d, 5 d/wk) combined with continuous infusion 5-FU (300 mg/m2/d, 5 d/wk). Postoperative chemoradiation combined 50.4 Gy of external-beam irradiation (standard fractionation) with continuous-infusion 5-FU.

RESULTS

No patient who received preoperative chemoradiation experienced a delay in surgery because of chemoradiation toxicity, but six of 25 eligible patients (24%) did not receive postoperative chemoradiation because of delayed recovery after pancreaticoduodenectomy. No significant differences in toxicities from chemoradiation were observed between groups. Patients treated with rapid-fractionation preoperative chemoradiation had a significantly (P < .01) shorter duration of treatment (median, 62.5 days) compared with patients who received postoperative chemoradiation (median, 98.5 days) or standard-fractionation preoperative chemoradiation (median, 91.0 days). At a median followup of 19 months, no significant differences in survival were observed between treatment groups. No patient who received preoperative chemoradiation and pancreaticoduodenectomy experienced a local recurrence; peritoneal (regional) recurrence occurred in 10% of these patients. Local or regional recurrence occurred in 21% of patients who received pancreaticoduodenectomy and postoperative chemoradiation.

CONCLUSION

Delivery of preoperative and postoperative chemoradiation in patients who underwent potentially curative pancreaticoduodenectomy for adenocarcinoma of the pancreatic head resulted in similar treatment toxicity, patterns of tumor recurrence, and survival. Rapid-fractionation preoperative chemoradiation ensured the delivery of all components of therapy to all eligible patients with a significantly shorter duration of treatment than with standard-fractionation chemoradiation given either before or after pancreaticoduodenectomy. Prolonged recovery after pancreaticoduodenectomy prevents the delivery of postoperative adjuvant chemoradiation in up to one fourth of eligible patients.

Distribution of succinic semialdehyde reductase in rat brain

Succinic semialdehyde reductase (SSR) that catalyzes the reduction of succinic semialdehyde (SSA) to gamma-hydroxybutyrate (GHB) has been identified as one of the NADPH-dependent aldehyde reductases. Reduction of SSA to GHB strongly supports the proposal that GHB biosynthesis may be an important step in the GABA shunt. It is pharmacologically significant in anesthesia, evoking the state of sleep, and an increase in brain dopamine level. Monoclonal antibodies against bovine brain succinic semialdehyde reductase were produced. Using the anti-succinic semialdehyde reductase antibodies, we investigated the distribution of brain succinic semialdehyde reductase in rat brain. The brain tissues were sectioned with a basis on the rat brain atlas of Paxinos and were stained by the immunoperoxidase staining method using monoclonal antibodies. In the section of the frontal lobe, immunoreactive cells were observed in the lateral septal area, the ventral pallidum, which belongs to the substantia innominata. We could observe immunoreactive cells in the reticular thalamic nucleus, which is closely related with 'sleeping', the basal nuclei of Meynert, which is associated with Alzheimer's disease, and hypothalamic nuclei. Immunoreactive cells were also shown in raphe nuclei or the reticular formation of the midbrain, cerebellum, and inferior olivary nuclei of the medulla oblongata. Succinic semialdehyde reductase-immunoreactive cells were distributed extensively in rat brain, especially immunoreactive cells were strongly observed in the areas associated with the limbic system and reticular formation.

Induction of acrosome reaction in human spermatozoa accelerates the time of pronucleus formation of hamster oocytes after intracytoplasmic sperm injection

OBJECTIVE

To assess the relationship between the incidence of acrosome reaction (AR) and the timing of pronucleus (PN) formation after intracytoplasmic sperm injection (ICSI).

DESIGN

Prospective study.

SETTING

Infertility Research Center, Jeil Women's Hospital.

MAIN OUTCOME MEASURE(S)

Human semen obtained from fertile donors was prepared by one of the following methods: washing only (washed control); Percoll gradient; pentoxifylline; human follicular fluid (FF); pentoxifylline + FF; or platelet-activating factor (PAF) treatment. The AR of each group was assessed by fluorescein isothiocyanate-conjugated Pisum sativum agglutinin or Arachis hypogea agglutinin. Spermatozoa of washed control, pentoxifylline + FF, and PAF treated groups, with significantly higher AR rate than others, were injected into mature hamster oocytes. Spermatozoon-injected oocytes were cultured for 6, 9, 12, or 15 hours. Then they were stained with Toluidine blue for PN formation examination under a light microscope.

RESULT(S)

Acrosome reaction rates of washed control, Percoll gradient, pentoxifylline, FF, pentoxifylline + FF, and PAF treated groups were 10.5% +/- 2.6%, 10.3% +/- 1.7%, 16.4% +/- 1.8%, 24.8% +/- 5.6%, 28.4% +/- 3.8%, and 33.3% +/- 5.2%, respectively. Pronuclear formation rate in washed control, pentoxifylline + FF, and PAF treated groups were 5.6% (3/54), 19.0% (11/58), and 18.9% (10/53) at 6 hours; 32.7% (18/55), 51.8% (29/56), and 57.4% (31/54) at 9 hours; 36.1% (22/61), 53.6% (30/56), and 50.0% (27/54) at 12 hours; and 47.2% (25/53), 64.8% (35/54), 53.6% (30/56) at 15 hours after ICSI. Pronuclear formation rate was significantly higher in pentoxifylline + FF, and PAF treated groups than that in the washed control group at 6 and 9 hours after ICSI.

CONCLUSION(S)

Pronuclear formation of oocytes takes place faster on those that were injected with acrosome-reacted spermatozoon than those injected with acrosome-intact spermatozoon. It could be concluded that induction of the AR of spermatozoa accelerates the time of PN formation and early development of the embryo in ICSI.

Basic helix-loop-helix genes in neural development

Several major advances in the understanding of the regulation of vertebrate neurogenesis by members of the basic helix-loop-helix (bHLH) protein family have been made in the past year. Specifically, a number of bHLH genes have been cloned and shown to convert non-neuronal fate to neuronal fate when expressed ectopically. In particular, studies on NeuroD and Neurogenin suggest a regulatory pathway, providing powerful molecular tools to study vertebrate neurogenesis.

NeuroD and neurogenesis

NeuroD is a basic helix-loop-helix (bHLH) transcription factor cloned from a two hybrid screen designed to search for new bHLH proteins. In our previous studies, we showed that NeuroD could convert Xenopus ectoderm into fully differentiated neurons and that it could prematurely differentiate neural precursor cells in the nervous system. Recently, an insulin transcription activator, Beta-2, was cloned from a hamster insulinoma cell line by Naya et al. [Genes Dev (1995)9:1,009-1,019]. Sequence analysis revealed that Beta-2 is the hamster homologue of NeuroD. We are currently investigating the role that NeuroD/Beta-2 plays in vertebrate neurogenesis and pancreatic development.

Cortical-sparing adrenalectomy for patients with bilateral pheochromocytoma

BACKGROUND

Bilateral pheochromocytomas are common in patients with multiple endocrine neoplasia type 2 (MEN 2) and von Hippel-Lindau disease (VHL). In an effort to avoid long-term steroid dependence and Addisonian crisis, we have performed cortical-sparing adrenalectomy in this patient population.

METHODS

Retrospective chart review was completed for patients with MEN 2- or VHL-related pheochromocytomas who underwent laparotomy at our institution for intended cortical-sparing adrenalectomy between June 1965 and March 1995.

RESULTS

Fifteen patients (MEN 2A [10], MEN 2B [2], VHL [3]) underwent laparotomy for cortical-sparing adrenalectomy. None of the tumors were malignant. Cortical-sparing adrenalectomy was possible in 14 (93%). Thirteen of these 14 patients (93%) had normal postoperative plasma cortisol measurements and did not require steroid hormone supplementation. At a median follow-up of 138 months, two patients had died of metastatic medullary thyroid cancer, no patient had suffered Addisonian crisis, and three patients (21%) had recurrent pheochromocytomas (at 118, 176, and 324 months after operation). The remaining nine patients were alive without pheochromocytomas.

CONCLUSIONS

Cortical-sparing adrenalectomy can be performed successfully in MEN 2 or VHL patients with bilateral pheochromocytomas, avoiding chronic steroid hormone replacement and the risk of Addisonian crisis in most patients. Long-term follow-up is necessary because recurrence may develop many years after operation.

Rapid direct determination of HLA-DQB1 * 0301 in the whole blood of normal individuals and cancer patients by specific polymerase chain reaction amplification

The HLA class II DQB1 * 0301 allele is present at a higher frequency in patients with malignant melanoma than in Caucasian controls. Furthermore, HLA-DQB1 * 0301 identifies a group of melanoma patients presenting with relatively advanced disease, and independently identifies a group of melanoma patients more likely to have disease recurrence. A rapid screening test for HLA-DQB1 * 0301 may be useful in clinical research involving melanoma patients. Standard molecular oligotyping for HLA class II alleles using the polymerase chain reaction (PCR)-sequence specific oligonucleotide (SSO) method is relatively expensive, labor-intensive, and involves the use of radioisotope. We therefore developed an inexpensive, rapid, non-radioactive method using sequence-specific primers, peripheral whole blood as the substrate, and strictly defined reaction conditions in a single-step PCR to allow determination of the presence or absence of genomic HLA-DQB1 * 0301. Comparison of the single-step PCR method with standard PCR-SSO oligotyping on 63 blinded samples from Caucasian melanoma patients demonstrated complete agreement between the two methods in the detection of HLA-DQB1 * 0301. Confirmatory testing in 456 additional cancer patients and healthy controls showed a sensitivity of 98.0% and a specificity of 99.4%. Single-step PCR is accurate, rapid, inexpensive, and does not require radioisotope. These advantages make it the procedure of choice for screening melanoma patients and others for the presence of the HLA-DQB1 * 0301 allele.

Factors associated with melanoma incidence and prognosis

Melanoma has a reputation as an unpredictable disease, but investigation has demonstrated a multiplicity of factors which are independently associated with melanoma incidence and prognosis. Major factors associated with melanoma incidence include those related to race and ethnicity, sunlight exposure, and genetic and familial predisposition. Major factors associated with melanoma prognosis include tumor thickness, ulceration, anatomic location, and patient's sex. These factors are clinically important in designing appropriate screening and prevention programs, as well as in selecting appropriate treatment and follow-up for the individual melanoma patient. There is an increasing need to identify the molecular mechanisms underlying these clinically defined etiologic and prognostic factors so that we may treat patients more effectively and more selectively. Available evidence indicates that the mechanisms of melanoma etiology include a loss of tumor suppressor genes. Mechanisms of melanoma progression include the accumulation of oncogene mutations, perhaps as a result of sun exposure, the development of autocrine and paracrine loops involving cytokines and growth factors, and alterations in cell-surface antigen expression. Finally, an antigen-specific immune response to melanoma appears to be important in the prognosis of some patients. Critical regulatory components of the melanoma immune response include antibodies, T-cells, and human leukocyte antigen (HLA) molecules.

Reoperative pancreaticoduodenectomy for periampullary carcinoma

BACKGROUND

We have noted a continued increase in the number of patients referred to our institution for presumed or biopsy-proven periampullary carcinoma following an "exploratory" laparotomy during which tumor resection was not performed. Although previous work has demonstrated the safety of reoperative pancreaticoduodenectomy (PD), the need to avoid nontherapeutic laparotomy in these patients is obvious. In the current study, we sought to determine why PD was not performed at the initial operation.

METHODS

Using the prospective pancreatic cancer database, we identified all patients who underwent reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging prior to reoperation was standardized and based on thin-section, contrast-enhanced computed tomography (CT); helical CT was used in more recent cases. Pathologic data were obtained, and initial outside operative reports were reviewed to determine why a PD was not performed at the initial procedure.

RESULTS

Twenty-nine patients underwent reoperative PD. Resection was not performed at the initial laparotomy because of the surgeon's assessment of local unresectability (17 patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error in intraoperative management (1). In the 17 patients deemed to have unresectable disease, successful reoperative PD required vascular resection in 10. All 10 of these patients had resection with negative microscopic margins of excision. Of the 9 patients who did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered major complications from intraoperative large-needle biopsy.

CONCLUSIONS

Detailed preoperative imaging and a clearly defined operative plan would have allowed successful resection at the initial operation in 27 of 29 patients who underwent reoperative PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly against "exploratory" surgery in patients with presumed periampullary neoplasms.

Platelet adhesion and activation on polyethylene glycol modified polyurethane surfaces. Measurement of cytoplasmic calcium

Polyurethane (PU) surfaces were modified by coupling polyethylene glycol (PEG; molecular weight, 1,000) chains carrying different terminal groups (PU-PEG1K-OH, PU-PEG1K-NH2, PU-PEG1K-SO3) and longer PEG chains (MW, 3,350; PU-PEG3.4K-OH). The modified PU surfaces have the same PEG (1K) chain density. Surface induced platelet activation was evaluated by measuring cytoplasmic free calcium concentration in platelets contacting modified surfaces, and platelet adhesion onto modified surfaces was investigated in vitro. Cytoplasmic free calcium levels in platelets contacting PU-PEG-SO3 remained relatively constant, in contrast to the significant increase observed for PU-PEG-NH2, PU-PEG-OH, and control PU surfaces. The degree of platelet adhesion clearly demonstrates that all PEG graft surfaces prevented platelet adhesion. Among PEG1K surfaces, PU-PEG-SO3 shows the lowest platelet adhesion. In the case of relatively longer PEG grafted surfaces (PU-PEG3.4K-OH and PU-PEG3.4K-Hep), both surfaces were found to prevent the increase in both cytoplasmic free calcium and platelet adhesion. These results suggest that longer PEG chain grafting is more effective than shorter grafting in preventing platelet activation and adhesion because of the highly dynamic movement of hydrated PEG chains at the interface. In addition, in vitro platelet interaction is dependent upon terminal groups of PEG chains on PEG1K series surfaces.

Malignant melanoma: relationship of the human leukocyte antigen class II gene DQB1*0301 to disease recurrence in American Joint Committee on Cancer Stage I or II

BACKGROUND

Melanoma patients who carry the human leukocyte antigen (HLA) Class II allele DQB1*0301 have an increased frequency of metastases at presentation compared with those lacking HLA-DQB1*0301. This study was designed to determine whether HLA-DQB1*0301 is associated with an increased risk of recurrence in melanoma patients presenting with American Joint Committee on Cancer (AJCC) Stage I or II (localized) disease.

METHODS

Molecular oligotyping of HLA-DQ genes was performed for 259 patients with AJCC Stage I or II melanoma. Rate of disease recurrence was determined by retrospective review and prospective follow-up. Kaplan-Meier analysis, log rank, and proportional hazard (Cox) comparison were performed.

RESULTS

Median follow-up was 24 months. Minimum follow-up was 6 months. Although HLA-DQB1*0301-positive and -negative patients were balanced with regard to standard melanoma prognostic factors (primary tumor thickness, level of invasion, presence of ulceration, anatomic location, and sex), HLA-DQB1*0301-positive patients were more likely to develop locally recurrent, regional, or distant metastatic melanoma during follow-up (actuarial median disease free survival 48 months [DQB1*0301-positive patients] vs. 97 months [DQB1*0301-negative patients]; log rank P = 0.0002). HLA-DQB1*0301 status, in addition to primary tumor thickness, was an independent prognostic indicator in these patients (Cox multivariate P = 0.02).

CONCLUSIONS

Patients presenting with localized melanoma who carry HLA-DQB1*0301 are at an increased risk of developing recurrent disease compared with stage-matched patients who lack this allele. HLA-DQB1*0301 is a genomic marker which independently identifies melanoma patients in whom recurrence is more likely, and is potentially useful in selecting those most likely to benefit from adjuvant therapy.

Association of gastric adenocarcinoma with the HLA class II gene DQB10301

BACKGROUND & AIMS

The HLA class II gene DQB1*0301 has been linked to several cancers. This study was designed to determine if HLA-DQB1*0301 is present at altered frequency in patients with gastric, colorectal, or pancreatic adenocarcinoma.

METHODS

Oligotyping for HLA-DQB1*0301 was performed for 159 Caucasian patients with 160 gastrointestinal adenocarcinomas (52 gastric, 62 colorectal, and 46 pancreatic adenocarcinomas) and compared with 260 Caucasian noncancer controls. Patients with gastric adenocarcinoma underwent extended HLA class II region oligotyping. Immunoglobulin G to Helicobacter pylori was detected by enzyme-linked immunosorbent assay.

RESULTS

HLA-DQB1*0301 was more common in patients with gastric adenocarcinoma than controls (54% vs. 27%; bonferroni-corrected chi 2 P = 0.003; odds ratio, 3.2). HLA-DQB1*0301 was not associated with colorectal or pancreatic adenocarcinoma. No other HLA-DQB1 allele and no HLA-DQA1 or transporter associated with antigen processing 2 (TAP2) allele were present at altered frequency in patients with gastric adenocarcinoma. Serological evidence for H. pylori infection was less frequent in HLA-DQB1*0301-positive patients with gastric adenocarcinoma compared with HLA-DQB1*0301-negative patients (52% vs. 88%; Fisher's Exact Test; P = 0.007).

CONCLUSIONS

HLA-DQB1*0301 is more common in caucasian patients with gastric adenocarcinoma than noncancer controls. The mechanism linking HLA-DQB1*0301 with gastric adenocarcinoma is not likely through increased susceptibility to H. pylori infection.

The NEUROD gene maps to human chromosome 2q32 and mouse chromosome 2

The Neurod gene is a basic-helix-loop-helix gene that regulates neurogenesis and is identical to the hamster beta2 gene that was cloned as a regulator of insulin transcription. Here we report the cloning of human NEUROD and mapping of the gene to human chromosome 2q32 and to mouse chromosome 2.

The need for standardized pathologic staging of pancreaticoduodenectomy specimens

A standardized method for pathologic evaluation and staging of pancreaticoduodenectomy (PD) specimens is critical for accurate reporting of the number and location of lymph nodes and margins of resection. We examined the impact of standardized pathologic evaluation (SPE) of PD specimens on the identification of regional lymph nodes and describe our detailed system for the pathologic analysis of the PD specimen. Forty consecutive patients underwent PD for histologically confirmed adenocarcinoma of the pancreatic head between April 1990 and August 1993. Fifteen consecutive specimens were examined before the introduction of the SPE, and 25 consecutive specimens underwent SPE. Resection margins were evaluated by frozen-section analysis, and then the specimen was divided into six regions on an anatomic dissection board for lymph node identification. The 25 specimens examined according to the SPE had a significantly increased number of lymph nodes identified (P = 0.0001) compared with the 15 specimens examined without the SPE. Twelve of the 25 specimens contained positive lymph nodes, 6 of which were confined to the pancreaticoduodenal region. No positive nodes were found in the periaortic region. There were no differences in pathologic variables between patients found to have negative and those with positive regional lymph nodes. SPE of PD specimens provides a method for improved lymph node identification, ensures accurate prospective evaluation of margins of resection, and provides a complete analysis of potentially important pathologic variables. We offer this system as a standardized model for groups engaged in protocol-based clinical research examining innovative multimodality treatment strategies for patients with resectable pancreatic cancer.

Regulation of A-raf expression

The Raf family proto-oncogenes encode cytoplasmic protein serine/threonine kinases which play a critical role in cell growth and development. A-raf shares several functional properties with Raf-1 including transforming activity, stimulation of the Raf/MAPK pathway and the ability of dominant negative versions to functionally block Ras signalling. A-raf transcripts are predominantly expressed in the mouse urogenital tissues. Interestingly, the human A-raf promoter region contains three potential glucocorticoid response elements GRE-1, GRE-2 and GRE-3, at positions -17, -34 and -168 respectively from the transcriptional start site. DNA sequence analysis of the mouse A-raf promoter region demonstrated that GRE-1 and -2 were conserved evolutionarily. To determine whether the human A-raf GREs represent functional motifs, an expression vector for the glucocorticoid receptor was cotransfected with A-raf promoter/reporter constructs into HeLa cells. A fivefold dexamethasone-dependent induction of A-raf promoter activity was observed using constructs containing all three GRE motifs whereas point mutations in the GREs either diminished or abolished dexamethasone induction. Electrophoretic mobility shift assays (EMSAs) using purified glucocorticoid receptor DNA binding domain (DBD) demonstrated that both GRE-2 and -3 motifs interact with DBD and oligonucleotide competition experiments established that these have different affinities for DBD. Using nuclear extracts from human and rodent cell lines in EMSAs, a specific protein-DNA complex was observed with GRE-1 which displayed binding properties unlike that of glucocorticoid receptor. These results demonstrate that the A-raf promoter is regulated in part by members of the glucocorticoid family of steroid hormone receptors and suggest a model for the regulation of A-raf expression in urogenital tissues.

The human leukocyte antigen TAP2 gene defines the centromeric limit of melanoma susceptibility on chromosome 6p

A single human leukocyte antigen (HLA) class II allele, DQB1*0301, is strongly associated with melanoma, and the HLA-DR locus provides the telomeric boundary for melanoma susceptibility in the HLA class II region of chromosome 6. However, the centromeric boundary is unknown. This study was designed to determine whether the adjacent upstream transporter associated with antigen processing (TAP) locus, TAP2, constitutes the centromeric boundary of disease susceptibility in melanoma. Molecular oligotyping of TAP2 genes was performed for 36 Caucasian patients with melanoma and for 32 Caucasian control individuals by both amplification refractory mutation system (ARMS) polymerase chain reaction (PCR) and PCR-sequence-specific oligonucleotide (SSO) typing. TAP2 allele frequencies in the melanoma patients were compared to those in non-melanoma Caucasian control populations, and to HLA-DQ allele frequencies determined by molecular oligotyping. While HLA-DQB1*0301 was more common in this group of 36 melanoma patients compared to a group of 200 controls (56 percent vs. 27 percent, Bonferoni-corrected chi-square p < = 0.01), no significant differences were observed in TAP2 allele frequencies between melanoma patients and controls. The TAP2 locus represents the centromeric boundary of disease susceptibility for melanoma in the class II region of chromosome 6p. These results support an etiologic role for HLA-DQB1*0301 in melanoma susceptibility.

Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group

OBJECTIVE

Tumor invasion of the superior mesenteric-portal vein (SMPV) confluence is often considered a contraindication to pancreaticoduodenectomy for patients with malignant tumors of the pancreas or periampullary region. The authors sought to determine whether pancreaticoduodenectomy with en bloc resection of the SMPV confluence could be safely performed and whether tumors involving the SMPV confluence were associated with pathologic parameters suggesting poor prognosis.

SUMMARY BACKGROUND DATA

Several centers have reported high rates of retroperitoneal margin positivity after pancreaticoduodenectomy for tumors of the pancreatic head and periampullary region. Positive-margin or incomplete resection is associated with early tumor recurrence and no survival benefit compared with palliative therapy. Tumor adherence to the lateral of posterior wall of the SMPV confluence often represents the only barrier to complete tumor resection at the time of pancreaticoduodenectomy.

METHODS

Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreas or periampullary region over a 3.5-year period were entered prospectively in a pancreatic tumor database. To be considered for surgery, patients were required to fulfill the following computed tomography criteria for resectability: 1) the absence of extrapancreatic disease, 2) no tumor encasement of the superior mesenteric artery or celiac axis, and 3) a patent SMPV confluence. Tumor adherence to the superior mesenteric vein or SMPV confluence was assessed intraoperatively, and en bloc venous resection was performed when necessary to achieve complete tumor extirpation. Data on operative characteristics, morbidity, mortality, tumor size, nodal metastases, margin positivity, perineural invasion, and tumor DNA content were compared for patients who did and did not receive venous resection.

RESULTS

Fifty-nine patients underwent pancreaticoduodenectomy, 36 without venous resection and 23 with en bloc resection of the SMPV confluence. No differences in median hospital stay, morbidity, mortality, tumor size, margin positivity, nodal positivity, or tumor DNA content were observed between groups.

CONCLUSIONS

When necessary, segmental resection of the SMPV confluence may be performed safely during pancreaticoduodenectomy for periampullary malignant tumors. Tumors invading the SMPV confluence are not associated with histologic parameters suggesting a poor prognosis. Our data suggest that venous involvement is a function of tumor location rather than an indicator of aggressive tumor biology.

Modification of brain glutamate dehydrogenase isoproteins with pyridoxal 5'-phosphate

Two soluble forms of brain glutamate dehydrogenase isoproteins were inactivated by pyridoxal 5'-phosphate. Restoration of catalytic activity can be accomplished by dialysis and addition of an excess of cysteine or lysine. Spectral evidence is presented to indicate that the inactivation proceeds through Schiff base formation with amino groups of the enzyme. Inactivation became irreversible after reduction with NaBH4 and the NaBH4-reduced enzyme showed a characteristic absorption peak at 325 nm. Using spectral titration at 325 nm, the stoichiometry was 2 mol/mol of GDH subunit without protection and 1 mol/mol with protection, indicating the complete masking of one mol of lysine. The results with analogs of pyridoxal 5'-phosphate show that the aldehyde group, but not the phosphate group, is required for efficient inactivation.

Preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinoma of the pancreatic head

BACKGROUND

Local recurrence in the bed of the resected pancreas is the most common site of tumor recurrence following a standard pancreaticoduodenectomy (PD) for adenocarcinoma of the pancreatic head. In an attempt to improve local and regional disease control and thereby enhance the quality and length of survival in patients undergoing potentially curative PD, we have used a protocol of preoperative multimodality therapy.

PATIENTS AND METHODS

All patients were treated with external-beam radiation (30.0 or 50.4 Gy) and concomitant 5-fluorouracil (300 mg/m2 per day) prior to PD. Electron-beam intraoperative radiation therapy was given to the bed of the resected pancreas before reconstruction. Patients were assessed for recurrence by physical examination, chest roentgenography, and computed tomography scan performed at 3-month intervals following treatment.

RESULTS

Thirty-nine patients completed all therapy; 1 perioperative death occurred. Thirty-eight tumor recurrences have been documented in 29 patients at a median of 11 months from the date of diagnosis; 23 patients died of disease. The liver was the most frequent site of recurrence, and liver metastases were a component of treatment failure in 53% of patients. Isolated local or peritoneal recurrences were documented in only 4 patients (11%). The only significant clinical or pathologic variable predictive of local-regional recurrence was a previous laparotomy and intraoperative biopsy. The median survival of all 39 patients was 19 months, and the 4-year actuarial survival rate was 19%.

CONCLUSIONS

Preoperative chemoradiation, PD, and electron-beam intraoperative radiation therapy for adenocarcinoma of the pancreatic head have resulted in improved local-regional tumor control, with distant metastatic disease becoming the predominant site of tumor recurrence. Future treatment strategies should incorporate effective multimodality therapy for local-regional disease as demonstrated in this study. Major improvements in overall survival will likely await the development of systemic or regional therapy for liver metastases.

Complete coding sequence, exon/intron arrangement and chromosome location of ZNF45, a KRAB-domain-containing gene

Zinc finger genes represent a large multigene family present in mammalian and other genomes. A subgroup of these genes contain a conserved motif, the KRAB domain, at the NH2-terminal region, which was recently shown to posses a potent transcriptional repression activity. For one such gene, ZNF45, we determined the complete coding sequence, along with the exon/intron arrangement and the splice junctions. Exon 2 codes exclusively for the KRAB-A element of 42 amino acids, and exon 4 contains the 19 zinc finger repeats. In addition, we generated an EST (expressed sequence tag) from the 3'-end of ZNF45 that we used for polymerase chain reaction screening of a P1-derived genomic library. We isolated a 65-kb clone that was used for localizing this gene on chromosome 19q13.2 by fluorescence in situ hybridization.

Surgical management, DNA content, and patient survival in adrenal cortical carcinoma

BACKGROUND

Surgical resection is the only potentially curative treatment for adrenal cortical carcinoma, yet the value of extended resection, palliative resection, and tumor DNA analysis remains unclear.

METHODS

The records of 23 patients with adrenal cortical carcinoma who underwent primary surgical resection at our institution were retrospectively reviewed. Flow cytometric DNA analysis was performed on primary tumor tissue from 14 patients.

RESULTS

Sixteen of 23 patients underwent complete resection. For these 16 patients the median follow-up was 43 months, the actuarial median survival was 46 months, and the actuarial 5-year survival rate was 46%. The seven patients who underwent incomplete resection all died of disease with a median survival of 8.5 months. Isolated local recurrence as the first site of failure occurred in two patients. Only completeness of resection (p = 0.004) and stage at presentation (p = 0.006) were significant prognostic indicators. None of the following predicted a poor prognosis in patients who underwent complete resection: (1) need for extended resection, (2) presence of renal vein or inferior vena cava tumor thrombus, or (3) tumor aneuploidy (14 of 14 tumors were aneuploid).

CONCLUSIONS

Long-term survival is possible in patients with adrenal cortical carcinoma if complete, margin-negative tumor resection can be achieved. Isolated local recurrence is uncommon after complete resection. Because adrenal cortical carcinomas are consistently aneuploid, tumor DNA content is not a useful prognostic factor.