A rare case of recurrent secretory meningioma with malignant transformation

A 72-year-old woman previously operated for a sphenoid-ridge meningioma, now presented with double vision. Histology showed a secretory meningioma with an epithelial-appearing, malignant component. Malignant transformation in a secretory meningioma is not known. This is the first report of such an occurrence.

Exon 9 and exon 20 mutations in PIK3CA confer resistance to HER2 inhibitors in HER2-overexpressing breast cancer cells

Abstract #4054

The anti-tumor effect of HER2 antagonists in HER2-dependent breast cancer cells has been proposed to rely on inhibition of the phosphatidylinositol-3 kinase (PI3K)/Akt pathway. Mutations in the p110α catalytic subunit of PI3K occur in up to 40% of breast cancers and activation of this pathway has been implicated in resistance to the HER2 antibody trastuzumab (T). PIK3CA mutations cluster in two regions in the helical (E542K, E545K; exon 9) and catalytic (H1047R; exon 20) domains. We studied the role of these mutants in resistance to HER2 inhibitors in breast cancer cells with HER2 amplification. Two lines with endogenous H1047R p110 (PI3K), SUM190 and HCC1954, and SKBR3, SUM225, and BT474 cells stably transduced with retroviral vectors encoding HA-tagged wild-type, E545K, or H1047R p110, were studied for their response to the HER2 tyrosine kinase inhibitor lapatinib ditosylate (L; GW-572016) and T. In monolayer and 3D cell proliferation assays, partial resistance to L and T was conferred by either mutation compared to WT p110. After prolonged L treatment, Ser473 phosphorylation of Akt recovered in all cells with endogenous or ectopic p110 mutants in spite of continued inhibition of Y1248 P-HER2 and Y1289 P-HER3 by L. Further, BT474 cells with either p110 mutant could be passaged in the continued presence of L. Immunoprecipitation of p85, the regulatory subunit of PI3K, showed that PI3K association with HER3 was abrogated by T and L. RNAi of HER3 in MCF10A/HER2/PI3KE545K and MCF10A/HER2/PI3KH1047R cells markedly but not completely inhibited growth suggesting that the PI3K mutants may still depend on HER3 for full activation. We hypothesized that in cells with mutant PI3K, the mutants coexist in a pool with WT enzyme, and that mutant and WT p110α are bound to p85 in variable proportions. Experiments to measure whether the ratio of mutant to WT p110 bound to p85, assayed by mass spectrometry, will increase in the PI3K-mutant cells with acquired resistance to L are in progress. To test the role of these mutants on resistance to anti-HER2 therapies in vivo, athymic mice bearing BT474 xenografts with ectopic WT, E545K, or H1047R p110 are undergoing treatment with L and T. Finally, we analyzed mutations of PIK3CA in a cohort of 40 patients with locally advanced HER2+ breast cancer treated with weekly single-agent T for 3 weeks, followed by T with docetaxel for a total of 12 weeks before surgery (Mohsin et al. JCO 23:2460, 2005). Sequential core biopsies at weeks 1 and 3 after initiation of T were taken. Eight of 40 tumors (20%) expressed mutant PI3K, 2 in exon 9 and 6 in exon 20. PIK3CA mutations did not correlate with change in Ki67 (p=0.97) or cleaved caspase 3 (p=0.51) in weeks 1 or 3 of treatment nor with pathologic complete response (p=0.21). These data suggest that, if mutant PI3K confers relative resistance to T, a shorter time to recurrence may be a more robust endpoint as the initial cellular or clinical response may not be a good indicator of this resistance.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4054.

Deferiprone, an orally deliverable iron chelator, ameliorates experimental autoimmune encephalomyelitis

The iron chelator, Desferal, suppressed disease activity of experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis (MS), and it has been tested in pilot trials for MS. The administration regimen of Desferal is cumbersome and prone to complications. Orally-deliverable, iron chelators have been developed that circumvent these difficulties, and the objective of this study was to test an oral chelator in EAE. SJL mice with active EAE were randomly assigned to receive deferiprone (150 mg/kg) or vehicle (water) 2×/day via gavage. EAE mice given deferiprone had significantly less disease activity and lower levels of inflammatory cell infiltrates (revealed by H&E staining) than EAE mice administered vehicle. T-cell infiltration, assessed by anti-CD3 immunohistochemical staining, also was reduced, although not significantly. Splenocytes cultured from naïve SJL mice were stimulated with anti-CD3 and anti-CD28 with or without 250 μM deferiprone. While ~39% of costimulated splenocytes without deferiprone underwent division, only ~2.8% of costimulated splenocytes with deferiprone divided and the latter cells were only 53% as viable as the former. Deferiprone had no effect on proliferation or viability of cells that were not costimulated. In summary, deferiprone effectively suppressed active EAE disease and it inhibited T-cell function. Multiple Sclerosis 2007; 13: 1118—1126. http://msj.sagepub.com

Cervical spine metastasis from adrenal pheochromocytoma

Metastatic tumours are the most common type of tumours in the spine of which only 10% occur in the cervical spine. We report a rare presentation of metastatic pheochromocytoma of the cervical spine which was successfully treated operatively. Adequate precautions should be taken during surgery as the tumour is very vascular. Radiotherapy is useful in the treatment of residual tumour.

Gorham's disease of skull base and cervical spine--confusing picture in a two year old

The unusual presentation of Gorham's disease of skull base and cervical spine in a two-year-old female child with radiological signs mimicking those of raised intracranial pressure is discussed. The differential diagnosis consists of skull base tumours, meningitis, osteomyelitis of the base of skull, congenital hydrocephalaus and congenital syndromes involving the skull base. Pathologically it can be very difficult to differentiate it from lymphangioma of the bone. Difficulty in establishing the diagnosis is discussed along with failure of radiotherapy and palmidronate therapy to cause arrest of the disease process and failure of surgery to provide stabilisation. We describe the course of the disease in this child over the period of last eight years. To the best of our knowledge this is the youngest case of Gorham's described so far.

Intracranial non-Hodgkin's MALT lymphoma mimicking a large convexity meningioma

Primary presentation of an intradural Non-Hodgkin's lymphoma is rare. Recently these B cell lymphomas of mucosa associated lymphoid tissue (MALT) have gained acceptance as an important pathological subtype and are distinguishable from other primary CNS lymphomas that exhibit aggressive behaviour. Over the past decade a number of these lesions have been reported to resemble a meningioma both intra-operatively and radiologically. The authors outline such a case of marginal zone B cell lymphoma that clinically and radiologically resembled a meningioma. This case illustrates the rare occurrence of low grade dural B cell lymphoma and the need to consider this entity in the differential diagnosis of CNS lesions, if appropriate targeted therapy is to be administered.

Management of Vascular Injuries in a Forward Hospital

BACKGROUND

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

METHODS

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

RESULTS

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

CONCLUSIONS

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.

Twenty year review of histopathological findings in enucleated/eviscerated eyes

BACKGROUND/AIMS

To evaluate the need for routine histopathological analysis of enucleated/eviscerated eyes and changes in indications for eye removal.

METHODS

Retrospective review of all enucleation/evisceration histopathology reports over 20 years. Clinical history was correlated with pathological findings. Two 10 year periods (1984-93, 1994-2003) were compared to detect changes in indications for eye removal.

RESULTS

In total, 285 histopathology results were traced from 1984 to 2003; 161 and 124 were evisceration and enucleation specimens, respectively. Glaucoma, malignant melanoma, trauma, and retinal detachment were the most frequent diagnoses 1984-1993. Ocular trauma was the most frequent diagnosis 1994-2003, followed by phthisis bulbi and endophthalmitis. Three cases were diagnosed as metastatic carcinoma; all were suspected preoperatively. A fourth case was a diagnostic surprise: adenocarcinoma found in an eye removed for pain and phthisis. Comparison of two 10 year periods showed a decrease in the number of enucleations/eviscerations, perhaps reflecting a decrease in the number of specimens sent. A preference for eviscerations was evident over the 20 years.

CONCLUSION

The number of eyes removed and histologically analysed decreased in the period 1994 to 2003, perhaps because of better treatment options, allowing globe preservation. There was a significant shift in the diagnosis in the two time periods, and a preference for evisceration in both. Only one diagnostic surprise was discovered (0.35%). This study does not support the need to send all globes/contents for histopathological examination. However, because of the one unexpected finding, it is recommended where the examination is incomplete or the history of visual loss is unclear.

Outcome of periocular basal cell carcinoma managed by overnight paraffin section

BACKGROUND

Surgical excision of periocular skin cancer allows for optimum control in terms of tumour recurrence. Although Mohs' technique gives the best outcome, it is not widely available. Processing paraffin sections is slower but histologically superior to Mohs' frozen sections. We report the results of using a standard paraffin section (non-Mohs') technique to confirm histological clearance.

METHOD

A retrospective study between 1/6/95 and 1/6/99 of all consecutive patients who had excision of periocular cancer was performed. All patients had surgical excision of the tumour with a 3-mm margin. Rapid (24-hour) paraffin sections were done and reconstruction performed if histological clearance was confirmed. If tumour was still present, a further 3-mm margin was excised at the appropriate edge(s) before reconstruction took place.

RESULTS

This study yielded 93 basal cell carcinomas (BCCs) of which 86 were of primary origin and 7 were recurrent tumours. The tumour characteristics were as follows: 88% nodular BCCs, 82% had a maximum surface measurement less than or equal to 10 mm, 39.8% were inner canthal and 49.5% were localised to the lower lid. In the 30 (35.4%) cases that required further excision based on the initial histological reports, tumour was seen in only four (11.4%) cases. Overall histological clearance for primary BCCs was achieved in 81/86 (94.2%) cases. There was only one late recurrence at 4 years and 5 months. Among recurrent BCCs, there was one recurrence (12.5%) and this was despite histological clearance having been reported.

CONCLUSION

For primary BCCs the recurrence rate in this study was low and comparable to that following Mohs' technique. This approach, using routine pathological facilities, therefore offers a viable technique for managing periocular BCCs.

Valacyclovir for the management of herpes viral infections

The Herpesviridae family (Types 1-8) continues to inflict considerable morbidity and social stigma upon humanity. Once infected with the herpes viruses, especially Types 1-3, they establish permanent residence within our nervous system and reactivate during periods of stress, trauma, and/or other precipitating factors. To date, there is no cure for herpes viral infections but antivirals can attenuate the symptoms and duration of episodic outbreaks. Prophylactic therapy can suppress recurrences. The first antiviral with selective activity against virus-infected cells is considered to be acyclovir. Our article will highlight the clinical indications of the current generation, valacyclovir, which is a prodrug of acyclovir. We consider valacyclovir as a second-generation antiviral, having taken into account the initial selectivity and safety profile of its progenitor, acyclovir.

Treatment of Casualties in a Forward Hospital of Indian Army : Nine year Experience

BACKGROUND

To analyze the outcome of the management of casualties in a level II trauma centre of a forward hospital of Armed Forces over a nine year period. Retrospective analysis of all casualties received in a single forward hospital of Indian Army was carried out.

METHOD

During 9 years (1990-1998), a total of 5737 casualties were received in a single level II zonal hospital of the Army in a forward area. Majority of the injuries were caused by bullets, or by fragments of improvised explosive devices. A policy of aggressive resuscitation and early primary repair of injuries was followed. General surgeons routinely performed craniotomies, thoracotomies, laparotomies, stabilization of fractures by fixators and repair of vascular injuries.

RESULT

38% of patients had injuries to several body parts (polytrauma), resulting in a total of 8578 injuries. Region-wise distribution of injuries was as follows : 14.2% head and neck injuries, 13.3% chest wounds, 13.5% abdominal injury and 59% extremity wounds. The overall mortality rate was 3.6%. The complication rate was about 7% with infection as the major complication. The results of primary repair of colonic injuries were similar to those of staged repairs. The results after primary closure of war wounds were better than those treated with delayed primary closure in selected cases.

CONCLUSION

Prompt evacuation, speedy resuscitation and early definitive repair of war injuries results in low mortality and morbidity. A motivated and dedicated team and adequate availability of blood and ancillary services adds to the excellent outcome. The policy of primary repair of colonic and selected soft tissue injuries appears justified in selected cases.

Heme oxygenase-1 in SJL mice with experimental allergic encephalomyelitis

The expression of heme oxygenase-1 (HO-1) is increased in the CNS of mice and rats with experimental allergic encephalomyelitis (EAE), an animal model of multiple sclerosis (MS). To investigate the role of HO-1 in EAE, a putative inhibitor [tin-protoporphyrin IX (Sn-PP IX)] of HO-1 was administered to SJL mice during active disease. Sn-PP IX (200 micromol/kg) attenuated clinical scores, weight loss, and some signs of pathology in comparison to vehicle treatment. Glutathione levels were greater in treated EAE mice than in those receiving vehicle, indicating lower oxidative stress in the former group. These data suggest that inhibition of HO-1 attenuated disease and suppressed free radical production. In the SJL model of EAE, extravasated blood is present in the CNS, and iron released by HO-1 from this heme source may not be adequately sequestered by ferritin, allowing for iron-mediated tissue damage. Thus, HO-1 may act to amplify the disease process in this model.

Analysis of protein induction in the CNS of SJL mice with experimental allergic encephalomyelitis by proteomic screening and immunohistochemistry

Experimental allergic encephalomyelitis (EAE) is an autoimmune disease characterized by demyelination and inflammatory infiltrates in the CNS, and it is an animal model of multiple sclerosis. Piperonyl butoxide (PBO) suppresses disease in EAE mice, and it exhibits a dual effect on cytochrome P450s that manifests in a transient inhibitory phase followed by induction. In order to identify the expression of proteins associated with EAE, a proteomic screening was performed on hindbrain microsomes from control + vehicle, control + PBO, EAE + vehicle, and EAE + PBO female mice. Glucose regulated protein 94 (Grp94) and coagulation factor VIII were among the proteins identified in EAE + vehicle and EAE + PBO mice. Immunohistochemical staining of Grp94 was present in some neurons and oligodendrocytes in hindbrain sections from control animals, and in some cells within inflammatory infiltrates in EAE animals. Since Grp94 (also known as Gp96) can partake in antigen presentation and induction of proinflammatory cytokine expression, its presence in these cells suggests that it may play a role in the pathogenesis of EAE. Coagulation factor VIII is carried and protected by von Willebrand factor. Immunohistochemical staining of von Willebrand factor revealed its presence in some vessels within hindbrain sections from control animals. In EAE animals, the number of labeled vessels was significantly increased, and extracellular granular deposits were observed around labeled vessels indicating that the breakdown of the blood-brain barrier that occurs in EAE permitted its extravasation into the CNS. Additional proteins were identified in the different groups of mice by proteomic screening, but confirmation of their expression profile awaits investigations by independent measures.

Sphingolipid profile in the CNS of the twitcher (globoid cell leukodystrophy) mouse: a lipidomics approach

Globoid cell leukodystrophy (Krabbe disease) is caused by mutations in galactosylceramidase, a lysosomal enzyme that acts to digest galactosylceramide, a glycolipid concentrated in myelin, and psychosine (galactosylsphingosine). Globoid cell leukodystrophy has been identified in many species including humans and twitcher mice. Several studies on human tissue have examined the lipid profile in this disease by gas, liquid or thin layer chromatography. Electrospray ionization tandem mass spectrometry combined with reverse phase HPLC has become a powerful alternative strategy, used here to compare the sphingolipid profile of pons/medulla tissue from twitcher mice with control tissue. In this lipidomics LC-MS approach, we scanned for precursors of m/z 264 to obtain a semi-quantitative profile of ceramides and galactosylceramides. Sphingosine-1-phosphate, C18:0 ceramide, C22:0 ceramide and C24:0 ceramide levels were reduced in the pons/medulla of twitcher mice compared to levels in control mice at 31 and 35-37 days of age. The levels of C22:0 and C24:0 galactosylceramide were similar between twitcher and control specimens and there was a trend toward reduced levels of C24:1 galactosylceramide and C24:1 hydroxy-galactosylceramide in twitcher specimens. Psychosine, C 16:0 ceramide and C 18:0 galactosylceramide levels were increased in the CNS of twitcher mice compared to levels in control mice. These data indicate that there is a trend toward decreased levels of long chain fatty acids and increased levels of shorter chain fatty acids in galactosylceramides and ceramides from twitcher mice compared with control mice, and such changes may be due to demyelination characteristic of acute pathology.