Very late presentation of a disorder of sex development

Disorders of sex development generally present in the neonatal period with ambiguity of external genitalia. We report a very old male patient presenting at 75 years because of panhypopituitarism and a large nonsecreting pituitary macroadenoma secondary to long-standing primary hypogonadism due to 46,XX sex reversal disorder now first diagnosed. Sex development disorders may go unrecognised for the entire life span, despite infertility and long-standing primary gonadic failure may lead to uncommon complications.

Ultrastructure of pheochromocytoma: undescribed morphologic features

We examined samples of human pheochromocytoma from 11 patients aged 30-70 years including one case of malignant pheochromocytoma with a view to identifying previously unreported ultrastructural details.We identified two types of nuclear inclusions consisting of irregularly shaped singular or multiple granulofibrillar formations with a typical concentric halo, on the one hand, and accumulations of egg-shaped structures consisting of granules and microfilaments, on the other. In some of the tumor cells, membrane-covered inclusions containing parallel laminar elements arranged in a paracrystalline, periodic fashion, or mega-mitrochondriae characterized by increased electrodensity of their matrix, and fibrillary material in the spaces between the cristae were present. A frequent finding consisted of typical ciliary formations, while rough/smooth tubular aggregates of different size occurred less frequently. Finally, we were able to demonstrate the uptake of norepinephrine by smooth muscle fibers in the periphery of arterial vessels as evidenced by linear accumulations of membrane-covered granules separating bands of contractile smooth muscle components in the peripheral layers of arterial vessels close to norepinephrine producing neoplastic cells.These findings represent ultrastructural features that contribute to further elucidating the ultrastructural characteristics of the human pheochromocytoma.

Symptoms of Depression and Anxiety Are Independently Associated With Clinical Recurrence of Inflammatory Bowel Disease

BACKGROUND & AIMS

We examined the relationship between symptoms of depression and anxiety and clinical recurrence of inflammatory bowel disease (IBD) in a large patient cohort. We considered the progression of depression and anxiety over time.

METHODS

We collected clinical and treatment data on 2007 adult participants of the Swiss IBD study (56% with Crohn's disease [CD], 48% male) performed in Switzerland from 2006 through 2015. Depression and anxiety symptoms were quantified by using the Hospital Anxiety and Depression Scale. The relationship between depression and anxiety scores and clinical recurrence was analyzed by using survival-time techniques.

RESULTS

We found a significant association between symptoms of depression and clinical recurrence over time (for all patients with IBD, P = .000001; for subjects with CD, P = .0007; for subjects with ulcerative colitis, P = .005). There was also a significant relationship between symptoms of anxiety and clinical recurrence over time in all subjects with IBD (P = .0014) and in subjects with CD (P = .031) but not ulcerative colitis (P = .066).

CONCLUSIONS

In an analysis of a large cohort of subjects with IBD, we found a significant association between symptoms of depression or anxiety and clinical recurrence. Patients with IBD should therefore be screened for clinically relevant levels of depression and anxiety and referred to psychologists or psychiatrists for further evaluation and treatment.

[Digestive foreign body management]

Foreign body (FB) ingestion is a frequent reason for gastroenterology consulting. Eighty percent of these ingestions are accidental and observed among paediatric subjects. However, intentional repetitive ingestions are also observed, especially amongst prisoners or psychiatric patients. Most FBs pass throughout the digestive tract without any complication and without any need for surgical or endoscopic intervention. Nevertheless, around 10-20% of cases require an endoscopy examination and 1% will lead to a surgical intervention. Management approaches should favor inter-disciplinarity, balance benefits and risks of FB removal based on its location, and integrate psychiatric comorbidities into the decision process.

[Microscopic colitis: update 2014]

Microscopic colitis, which includes lymphocytic colitis and collagenous colitis, represents a frequent cause of chronic watery diarrhea especially in the elderly population. Several medications, such as nonsteroidal antiinflammatory drugs, proton pump inhibitors or antidepressants, as well as cigarette smoking have been recognized as risk factors for microscopic colitis. The diagnosis of microscopic colitis is based on a macroscopically normal ileo-colonoscopy and several biopsies from the entire colon, which demonstrate the pathognomonic histopathologic findings. Therapy is mainly based on the use of budesonide. Other medications, such as mesalazine, cholestyramine and bismuth, have been evaluated as well but the evidence is less solid.

[Highlights in gastroenterology and hepatology 2013]

This review highlights recent advances in gastroenterology and hepatology, including new insights into the diagnosis, pathogenesis and the treatment of ulcerative colitis, of achalasia, of irritable bowel syndrome, of chronic hepatitis B and of eosinophilic esophagitis. These new developments will be summarized and discussed critically, with a particular emphasis on their potential implications for current and future clinical practice. The recent advances on treatment of chronic hepatitis C will be published in another summary this year.

[Radiofrequency ablation for Barret's esophagus]

Barrett's esophagus consists of the replacement of normal squamous epithelium by a specialised columnar lined epithelium referred to as intestinal metaplasia in the esophagus. It represents a premalignant lesion. The prevalence of Barrett's esophagus is around 1.6%. Esophageal adenocarcinoma results from the development of dysplasia progressing from low to high grade dysplasia and finally adenocarcinoma. Radiofrequency ablation currently represents the treatment of choice in eradicating Barrett's esophagus with associated dysplasia. The technique is based on the application of a radiofrequency current that enables the destruction of the superficial modified epithelium. This new approach presents a good security profile and, compared to other ablative techniques, shows superior results regarding Barrett's eradication.

[Fecal calprotectin: a diagnostic tool for inflammatory bowel disease]

Fecal calprotectin (FC) is a valid biomarker to discriminate with a good sensitivity and specificity the presence of mucosal lesions of the gastrointestinal tube (e.g. ulcers in the context of inflammatory bowel disease (IBD)) from functional disorders (e.g. irritable bowel syndrome). FC is not specific for IBD and can be elevated also in gastrointestinal infections, ischemic colitis or neoplasia. An elevated FC should stimulate further investigations, notably an endoscopic workup. The level of FC correlates with the endoscopic score in Crohn's disease and ulcerative colitis. The correlation of FC and the endoscopic severity is better than the one of CRP or blood leukocytes. Thus, FC can also be used in the follow-up of IBD patients.

Child health, developmental plasticity, and epigenetic programming

Plasticity in developmental programming has evolved in order to provide the best chances of survival and reproductive success to the organism under changing environments. Environmental conditions that are experienced in early life can profoundly influence human biology and long-term health. Developmental origins of health and disease and life-history transitions are purported to use placental, nutritional, and endocrine cues for setting long-term biological, mental, and behavioral strategies in response to local ecological and/or social conditions. The window of developmental plasticity extends from preconception to early childhood and involves epigenetic responses to environmental changes, which exert their effects during life-history phase transitions. These epigenetic responses influence development, cell- and tissue-specific gene expression, and sexual dimorphism, and, in exceptional cases, could be transmitted transgenerationally. Translational epigenetic research in child health is a reiterative process that ranges from research in the basic sciences, preclinical research, and pediatric clinical research. Identifying the epigenetic consequences of fetal programming creates potential applications in clinical practice: the development of epigenetic biomarkers for early diagnosis of disease, the ability to identify susceptible individuals at risk for adult diseases, and the development of novel preventive and curative measures that are based on diet and/or novel epigenetic drugs.

Gastrointestinal stromal tumors (GISTs) of the colon

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Although they may arise anywhere of GI tract, colonic presentation is infrequent. We report 2 new cases of colonic GISTs localized at descending and sigmoid colon. Endoscopic biopsies were diagnostic for GISTs and no distant metastasis were observed. Both cases underwent resective surgery as the only treatment. No recurrence was observed during the follow-up period. In this clinical note we review the diagnosis, management and therapeutical options in colonic GISTs, according to literature. KIT immunoreactivity is the base for diagnosis. Risk of malignancy is based on the primary tumor diameter and the mitotic count. Anatomic localization is not an independent prognostic factor. Surgery is the standard treatment for localized primary disease and imatinib is indicated if metastatic or unresectable GISTs.

Whether to determine HER2 status for breast cancer in the primary tumour or in the metastasis

Trastuzumab has substantially changed the prognosis of breast carcinomas. As HER2 over-expression/amplification is a prerequisite for treatment with trastuzumab, an accurate assessment of HER-2 status is the first step for successful treatment. In metastatic breast cancer, we routinely assess HER2 expression in the primary tumour, assuming that HER2 status remains stable through cancer progression. However, it is frequent to find reports that describe discordance between HER2 expression in primary and metastatic tumours. The aim of this paper was to verify whether HER2 status of breast carcinomas is maintained in the corresponding axillary metastasis. Immunohistochemistry was performed on 52 breast carcinomas and their matched axillary metastasis. HercepTest results were concordant in 46 out of 52 cases (88.5%). FISH proved that the differences observed were clinically relevant in only one of the 52 cases studied (98% concordance). We concluded that HER2 status was stable during axillary metastatic progression. Evaluation of gene HER2 status in axillary metastasis rather than in the primary can be useful in certain situations, e.g., small invasive component intimately mixed with in situ component and difficult to recognize in dark field, no tumor after biopsy, or axillary relapse (in this case we can find occasional de novo amplifications susceptible to trastuzumab treatment).

Global DNA methylation: a common early event in oral cancer cases with exposure to environmental carcinogens or viral agents

INTRODUCTION

Two separate molecular pathways have been proposed for the early carcinogenic events observed in the oral cavity and pharynx: one is associated with chemical etiological factors such as smoking and drinking, and the other one is associated with HPV insertion.

OBJECTIVE

A proof-of-principle study was performed to ascertain if global DNA methylation could be used to distinguish between the early molecular changes in premalignant oral lesions.

METHODS

Personal histories of tobacco and alcohol use were obtained by questionnaire. HPV insertion in tumor tissue was detected by polymerase chain reaction (PCR). Global DNA methylation levels were obtained using HPLC for fraction separation and mass spectrometry for quantification. Predictive simulations were performed to explore potential associations between different etiological factors and the global DNA methylation index. Significance of results was ascertained using Pearson's Chi-squared test.

RESULTS

The global methylation index was found to be 4.28 (95% CI, 4.1, 4.4) in an oral cancer case series. Pearson's chi squared test showed no statistically significant difference between cases that had smoking (p = 0.21), drinking (p = 0.31) or HPV insertion (p = 0.34) as etiologic risk factors, when compared to cases that did not. An inverse significant association between smoking and DNA methylation was observed. As the smoking effect increases, the global methylation index decreases, In addition, no associations between the probability of DNA methylation and drinking, or DNA methylation and HPV insertion were observed in simulations.

CONCLUSIONS

The global DNA methylation index was shown to vary for oral cancer cases with different etiologies. Smoking was inversely correlated with DNA methylation levels when generalized linear model simulations were performed. Future studies should look at global DNA methylation alterations associated to the progression from normal to premalignant oral epithelium tissue in a cohort of smokers and nonsmokers.

Associations between migrant status and sexually transmitted infections among female sex workers in Tijuana, Mexico

OBJECTIVE

To examine associations between migration and sexually transmitted infection (STI) prevalence among Mexican female sex workers (FSW).

METHODS

FSW aged 18 years and older in Tijuana, Baja California (BC) underwent interviews and testing for HIV, syphilis, gonorrhoea and chlamydia. Multivariate logistic regressions identified correlates of STI.

RESULTS

Of 471 FSW, 79% were migrants to BC. Among migrant FSW, prevalence of HIV, syphilis, gonorrhoea, chlamydia and any STI was 6.6%, 13.2%, 7.8%, 16.3% and 31.1% compared with 10.9%, 18.2%, 13.0%, 19.0% and 42.4% among FSW born in BC. A greater proportion of migrant FSW were registered with local health services and were ever tested for HIV. Migrant status was protective for any STI in unadjusted models (unadjusted odds ratio 0.61, 95% CI 0.39 to 0.97). In multivariate models controlling for confounders, migrant status was not associated with an elevated odds of STI acquisition and trended towards a protective association.

CONCLUSIONS

Unexpectedly, migrant status (vs native-born status) appeared protective for any STI acquisition. It is unclear which social or economic conditions may protect against STI and whether these erode over time in migrants. Additional research is needed to inform our understanding of whether or how geography, variations in health capital, or social network composition and information-sharing attributes can contribute to health protective behaviours in migrant FSW. By capitalising on such mechanisms, efforts to preserve protective health behaviours in migrant FSW will help control STI in the population and may lead to the identification of strategies that are generalisable to other FSW.

Evaluation of the toxicity of oligonucleotide/cationic nanoemulsion complexes on Hep G2 cells through MTT assay

The purpose of this study was to evaluate the toxicity of the oligonucleotide/cationic nanoemulsion complexes on Hep G2 cells through MTT assay. Complexes exhibit droplet size, zeta potential and viscosity of approximately 270 nm, +50mV, and 1.0 cP. Different parameters which may have an influence on toxicity results obtained by MTT assay, i.e. cells number, concentration of MTT reagent and the addition of Soerensen's glycine buffer were first evaluated. In the optimized conditions (1 x 10(4) cells and 0.5 mg/mL MTT), the overall results showed that the addition of increasing amounts of complexes (or nanoemulsions) lead to a progressive toxicity on cells attributed to the presence of the cationic lipid stearylamine in the formulations, whatever the medias's pH is. The IC50 was approximately 200 microg/ml. Such results open interesting perspectives on the use of these nanoemulsions as oligonucleotide delivery systems for Hep G2 cells.

Vaginal wet mounts on asymptomatic adolescent females; are they beneficial?

BACKGROUND

Wet mounts are commonly performed at the time of pelvic exam in some settings; however, there is a paucity of data on their usefulness in asymptomatic teen patients.

OBJECTIVE

To determine if wet mounts in asymptomatic teen women are useful in detecting gonorrhea or chlamydia, when compared with DNA amplification testing.

DESIGN AND METHODS

93 consecutive charts for asymptomatic adolescent female patients seen for a routine visit were retrospectively reviewed. Data was collected for vaginal pH, presence or absence of discharge on physical exam, appearance of cervix, wet mount results, and cervical testing results. Outcome measures were wet mount findings and result of DNA amplification test on cervical sample for gonorrhea and chlamydia

RESULTS

Wet mounts were abnormal in 29 (31.2%) patients. There was no significant relationship between abnormal wet mount and positive Neisseria gonorrhoeae and Chlamydia trachomatis cultures (P = 0.083). After excluding abnormal wet mounts due to Trichomonas vaginalis, BV or Candida, all remaining patients with positive N gonorrhoeae and C trachomatis had normal wet mounts. For N gonorrhoeae, the wet mount had a sensitivity of 0% and specificity of 92.6%. For C trachomatis, the wet mount had a sensitivity of 0% and specificity of 92.1%.

CONCLUSION

Wet mounts were not useful to detect N gonorrhoeae and C trachomatis in asymptomatic teen patients. The finding of T vaginalis and BV in these asymptomatic patients may justify continuing wet mount evaluation but this practice needs further study to determine if treatment in this population will result in clinically significant effects.

Ghrelin localization in the medulla of rat and human adrenal gland and in pheochromocytomas

OBJECTIVE

Ghrelin is predominantly produced by neuroendocrine cells of stomach and has been expressed in several normal and tumour endocrine tissues. It has been reported that the localization of ghrelin is exclusively in the cortex of human and rat adrenal gland and in adrenocortical tumours. This prompted us to analyze the expression of this peptide in medulla of human and rat adrenal glands and in human pheochromocytomas.

DESIGN AND METHODS

Analysis of ghrelin mRNA expression in rat adrenal gland was conducted by means of semi-quantitative RT-PCR. Ghrelin localization was studied in medulla of human and rat adrenal gland by immunohistochemistry. In addition, we have carried out a double immunofluorescence with chromogranin A to determine the specific cell type expressing ghrelin immunoreactivity. Ghrelin expression was also analyzed in five cases of pheochromocytoma by immunohistochemistry. Finally, Western blotting analysis was performed with goat ghrelin antibody in the cortex and in the medulla of rat adrenal gland.

RESULTS

RT-PCR demonstrated expression of ghrelin mRNA in rat adrenal gland. We also detected ghrelin expression in virtually all rat pheochromocytes by immunohistochemistry and double immunofluorescence. Furthermore, we showed ghrelin immunoreactivity in the medulla of human adrenal gland and in pheochromocytomas. By Western blotting, we found the expression of ghrelin precursor, proghrelin and mature ghrelin in the medulla of rat adrenals. However, the cortex of rat adrenal gland only expressed ghrelin precursor.

CONCLUSIONS

Our study is the first to demonstrate a medullar expression of ghrelin in human and rat adrenal gland; we also showed ghrelin expression in pheochromocytomas.

Analysis of the relationship between p53 immunohistochemical expression and risk factors for lung cancer, with special emphasis on residential radon exposure

BACKGROUND

Indoor radon exposure has been postulated as the second risk factor of lung cancer after tobacco. The objective of this work is to analyze if there exists any effect on p53 immunohistochemical expression mainly due to radon exposure and other risk factors for lung cancer.

PATIENTS AND METHODS

The tumor samples of a case series of 163 lung cancer cases were analyzed to know the p53 staining. The staining was classified into four categories from no staining to intense staining (>60%). This staining was correlated with radon exposure, tobacco consumption, having worked in risk occupations for lung cancer and alcohol consumption.

RESULTS

Only 72 samples could be analyzed for immunohistochemistry and some of these samples were sequenced from exons 4-8. No association was observed for staining intensity and radon exposure and also for tobacco and occupation. A slight association with a more intense staining was observed for high alcohol intake. In the four samples with a staining >60% that could be sequenced from exons 4 to 8, no mutation was observed in the p53 gene.

CONCLUSION

There is no association between radon exposure and p53 expression, indicating that maybe the effect of radon is not mediated through p53 alterations.

Should prophylaxis be used in adolescent and adult patients with severe haemophilia? An European survey of practice and outcome data

A survey of 21 haemophilia doctors, throughout Europe, who care for a total of approximately 5000 patients with bleeding disorders addressing practice and opinions regarding prophylaxis in patients aged 16-24 years and adults aged over 50 years, is presented. The outcome of adolescent patients who reduced or stopped prophylaxis was recorded. Eighteen of 19 respondents would consider modification of established prophylaxis in the adolescent age group, principal considerations being avoidance of risks of further concentrate exposure, predicted poor compliance and treatment costs. The preferred age for modification was 16-20 years, but there was very little consensus on the particular prophylactic regime recommended. Approximately, half of a cohort of 218 patients with severe haemophilia successfully reduced or stopped prophylaxis when they reached adolescence. Only 26 of 92 (28%) of the patient cohort who stopped prophylaxis, required reintroduction of a prophylactic regime and 12 of 59 (20%) of those who reduced the intensity of prophylaxis had to reintroduce a more intensive regime. A majority of respondents would consider starting prophylaxis in those over 50 years. There was no consensus as to indications for this practice or the nature of the prophylaxis protocol. We conclude that there is an absence of consensus on the management of patients with severe haemophilia, as they pass through adolescence and young adulthood, and reach the age of 50. Aggregate outcome data suggest a significant proportion of patients in the 18-22 years age range may be able to reduce or stop prophylaxis. A substantial number of older patients are on prophylaxis.

Diagnosis of Hodgkin's disease: an update on histopathological and immunophenotypical features

The Hodgkin lymphoma (HL) is a B-cell lymphoma, as was proved by molecular studies with single-cell PCR. Histologically, it is characterized by a minority of neoplastic cells, Reed-Sternberg cells and its variants, related to a variable non-neoplastic inflammatory background. Nowadays, (WHO classification) the following types of HL are recognized: Nodular Paragranuloma and the Classical Hodgkin Lymphoma, the latter including Nodular Sclerosis, Mixed Cellularity, Lymphocyte-rich Classical Hodgkin Lymphoma and Lymphocyte Depletion. Morphology together with immunohistochemical studies allows to classify the different forms of Hodgkin lymphoma and to make a differential diagnosis with non-Hodgkin lymphomas. All classical Hodgkin lymphomas are treated similarly, and chances for remission and survival are currently good. Molecular parameters should be added to the current classification and patients could benefit from new therapeutic targets.

HER-2 status determination in breast carcinomas. A practical approach

Accurate evaluation of HER-2 status is crucial in the selection of breast carcinoma patients for trastuzumab (Herceptin) treatment. Various laboratory methods have been used for this purpose. The aim of the present work was to analyse the results obtained in the routine practice by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) in determination of HER-2 status. Five hundred and three cases of breast invasive ductal carcinoma were selected to analyse the HER-2 overexpression by immunohistochemistry (HercepTest, Dako). HercepTest 2+ equivocal cases (60) were studied by FISH (PathVysion, Vysis) to determine HER-2 gene amplification. HER-2 overexpression determined by Herceptest was shown in 97/503 cases (19%). FISH performed on equivocal cases demonstrated HER-2 amplification in 11/60 tumours (18%). IHC and FISH together showed HER-2 overexpression/gene amplification in 21% of breast invasive carcinomas. Immunohistochemical determination of HER-2 status represents an easy and standardized method that (in contrast to FISH) can be performed in all pathology laboratories without need of any special microscope and enabling to check the morphologic features of the cells analysed. However, in order to assure the reliability of the results, standardization of fixation protocols, automation of the immunohistochemical procedure, and training of pathologists in the interpretation of the results (scoring criteria) should be a priority. Equivocal HercepTest cases must be analysed by FISH preferably in a reference laboratory.

Cell-cycle-associated markers and clinical outcome in human epithelial cancers: a tissue microarray study

The development and progression of epithelial cancers are the result of an imbalance in signals promoting and inhibiting cellular proliferation and apoptosis. The aim of this study is to evaluate the expression of cell-cycle and apoptosis regulators and correlate them with clinical outcome in the most frequent carcinomas, in order to establish common prognostic biomarkers independent of cancer origin. Using tissue microarrays (TMAs), we have analysed the immuno-expression of Ki-67, Bcl-2, Bax, cyclin D1, cyclin D3, CDK1, CDK2, CDK6, p16, p21, and p27 in a series of 205 carcinomas of the large bowel, breast, lung and prostate (80, 73, 37 and 15 cases, respectively). By univariate analysis, positivity for p27, p16 and Bcl-2 was associated with better overall survival (P<0.0135, P<0.0442 and P<0.0001, respectively). The risk of mortality was 2.3-fold greater in patients without Bcl-2 expression. TMA immunohistochemical analysis identified a subset of epithelial cancers with overlapping alterations in cell-cycle checkpoints, apoptosis regulators and tumour suppressor pathways. We found that in most common epithelial cancers, regardless of origin, Bcl-2 appears to be the key biological factor influencing clinical behaviour.

Large B-cell lymphoma with Hodgkin's features

AIMS

To describe the features of a series of nine cases of diffuse large B-cell lymphoma (DLBCL) showing morphological and immunophenotypic features that are intermediate with Hodgkin's lymphoma (HL).

METHODS AND RESULTS

Most cases (6/9) presented as mediastinal tumours affecting young males, while the other three cases arose in extramediastinal locations. Histopathologically, tumours showed diffuse large cell areas in a polymorphous background, with pleomorphic cytology and the common presence of Hodgkin's and Reed-Sternberg cells. Immunophenotypically, tumours shared features of DLBCL and classical HL, with expression of CD30, CD15 (6/9), and a full B-cell profile including CD45RB, CD20, CD79a and OCT2. Epstein-Barr virus-latent membrane protein expression was found in 2/9 cases. The majority of tumours had immunohistochemical features consistent with activation of the NF-(kappa)B pathway, including nuclear location of the c-REL/p65 subunit, overexpression of phosphorylated I(kappa)B(alpha), and overexpression of NF-(kappa)B targets. Finally, 2/9 cases showed 3q27 (BCL6) rearrangement, and 1/9 had p53 gene mutations, both of which are rarely detected in classical HL.

CONCLUSIONS

These findings suggest that DLBCLs with HL features constitute a distinctive subgroup of aggressive lymphomas whose neoplastic growth and peculiar characteristics could be facilitated by a particular microenvironment found in the mediastinum.

Prolonged survival after liver transplantation for Hodgkin's disease-induced fulminant liver failure

A 30-year-old male with a past history of nodular lymphocyte predominance Hodgkin's disease in apparent complete remission for two years received a liver transplantation because of fulminant liver failure. Histopathological examination of the explanted liver showed massive infiltration by Hodgkin's disease. In spite of a nodal recurrence of Hodgkin's disease, the patient is alive and in excellent general condition six years after liver transplantation.

Primary extramedullary myeloid tumor of the breast: a case report and review of the literature

Primary extramedullary myeloid tumors (PEMMT) are extramedullary proliferations of myeloid cells occurring in the absence of an antecedent myeloproliferative disorder. They have predilection for the skin, lymph nodes, central nervous system, and small intestine. Breast is an uncommon location for PEMMT and only a few cases have been reported so far in the medical literature. Many of these cases have been initially misdiagnosed. We reviewed all the reported cases of PEMMT of the breast in the English-language literature since 1965. In addition, we present a new case of PEMMT of the breast who presented with a mass in her right breast mimicking a breast malignancy and was initially misdiagnosed as non-Hodgkin's lymphoma. A careful histologic examination with immunohistochemical studies revealed the presence of PEMMT of the breast. Treatment with systemic chemotherapy and local radiotherapy rendered a complete remission. Seventeen cases of PEMMT of the breast were reported in the English literature from 1965 to 2003. Most of the cases were misdiagnosed initially as lymphomas, breast carcinomas, or malignant melanomas. PEMMT of the breast is a poorly recognized entity whose diagnosis frequently challenges both the pathologist and the oncologist. Given the small number of patients reported no optimal treatment has been defined, but systemic chemotherapy similar to that given for acute myeloid leukemia with or without local radiotherapy may result in long remissions and avoid the progression to overt acute myeloid leukemia.

Fatal Kikuchi-Fujimoto disease: the lupus connection

Kikuchi-Fujimoto disease (KFD) is a histiocytic necrotizing lymphadenitis found mainly in young women. Patients typically present with cervical lymphadenopathy and fever and follow almost always a benign course with excellent outcomes. The etiology of KFD remains unknown and controversial although several viruses have been associated with this disease. One theory proposes that KFD may be a self-limiting form of systemic lupus erythematosus (SLE). This theory is strongly supported by the fact that microscopic features of KFD can be very similar to those found in lupus lymphadenitis. Despite its usually benign course, several cases with fatal outcomes have been reported. We report here a case of clinically aggressive KFD, which featured several autoimmune-related events and resulted in a fatal outcome. Autopsy studies showed characteristic findings of SLE, which suggests a remarkable link between SLE and KFD. Early and intensive immunosuppressive treatment may be the only option for patients who develop very aggressive forms of KFD in order to avoid a fatal outcome.

T-cell/histiocyte-rich large B-cell lymphoma is a disseminated aggressive neoplasm: differential diagnosis from Hodgkin's lymphoma

AIMS

An accurate diagnosis of T-cell/histiocyte-rich large B-cell lymphoma needs to take into consideration those forms of Hodgkin's lymphoma also characterized by a predominance of small lymphocytes and histiocytes, i.e. nodular lymphocyte predominance Hodgkin's lymphoma and lymphocyte-rich classical Hodgkin's lymphoma. We have studied the clinical, phenotypic and genetic features of a series of 12 cases of T-cell/histiocyte-rich large B-cell lymphoma along with 18 cases of Hodgkin's lymphoma for comparative purposes.

METHODS AND RESULTS

Of the Hodgkin's lymphoma cases, there were 11 lymphocyte predominance type and seven classic type. T-cell/histiocyte-rich large B-cell lymphomas presented usually in advanced stages (III or IV in 11/12 cases), frequently with 'B' symptoms (6/9 cases), and followed a more aggressive course than Hodgkin's lymphoma (4/8 patients died due to the tumour in T-cell/histiocyte-rich large B-cell lymphoma versus 0/15 in Hodgkin's lymphoma). T-cell/histiocyte-rich large B-cell lymphoma cases showed diffuse effacement of the nodal architecture by a proliferation of scattered large atypical B-cells obscured by a background of small T-lymphocytes (more CD8+, TIA1+ than CD57+). Five cases showed also a prominent histiocytic component. The large B-cells expressed CD45 and often EMA (6/10 cases). On the other hand, CD 30, CD15 and latent infection by Epstein-Barr virus (EBV) were generally lacking. bc l6 and CD10 were, respectively, detected in 6/6 and 1/5 cases. Conventional polymerase chain reaction (PCR) showed monoclonal immunoglobulin heavy chain (IgH) gene rearrangements in all T-cell/histiocyte-rich large B-cell lymphomas studied (5/5), but did not detect any case with t(14;18) involving the major breakpoint region (0/4).

CONCLUSIONS

The differential diagnosis of T-cell/histiocyte-rich large B-cell lymphoma from Hodgkin's lymphoma is facilitated by the integration of different immunophenotypic, molecular and clinical findings. T-cell/histiocyte-rich large B-cell lymphoma is a monoclonal neoplasm of bc l6+ B-cells with a phenotypic profile similar to lymphocyte predominance Hodgkin's lymphoma, suggesting a germinal centre origin and a possible relation to this disease. Therefore, in order to distinguish it from lymphocyte predominance Hodgkin's lymphoma, characterization of the reactive background, IgH gene rearrangement studies by conventional PCR and clinical features are more useful. In contrast, T-cell/histiocyte-rich large B-cell lymphoma can be distinguished from classical Hodgkin's lymphoma thanks to the presence of monoclonal IgH rearrangement and the CD 30-CD15-CD45+EMA+ immunophenotypic profile of the neoplastic cells in T-cell/histiocyte-rich large B-cell lymphoma.

Primary cutaneous large B-cell lymphoma: the relation between morphology, clinical presentation, immunohistochemical markers, and survival

The histogenesis, morphology, immunophenotype, and clinical behavior of cutaneous large B-cell lymphomas (CLBCL) are largely a matter of controversy. We performed an investigation to determine whether CLBCL have features that differentiate them from other large B-cell lymphomas and whether CLBCL is itself a heterogeneous group. To this end, we reviewed the main characteristics of a series of 32 cases of LBCL found in the skin. We reviewed the clinical findings and paraffin sections of the tumors from these 32 patients. The immunohistochemical study performed included p53, MIB1, Bcl2, Bcl6, and CD10 markers. We carried out statistical analysis of these data (univariate and multivariate), seeking an association between the features of the tumors and clinical outcome, as defined by failure-free survival time. Only one patient died as a consequence of the lymphoma. Nevertheless, the accumulated probability of survival without failure at 48 months was 0.46. The number, type, and localization of the lesions were not associated with variations in either survival or failure-free survival. The expression of p53 was negative in this group of CLBCL, whereas Bcl-2 expression or localization in the lower leg did not relate to any other significant feature. Histologic examination of the cases disclosed three different groups: Grade III follicular lymphomas (FLs), monomorphous large B-cell lymphomas (LBCL type I), and LBCL with an admixed component of small B-lymphocytes (LBCL type II). Grade III FL (11 cases) tended to be found in the head and neck and showed CD10 expression in a majority of cases. A higher probability of lymph node relapses was associated with cases located in the head and neck and with CD10+ tumors. Cutaneous large B-cell lymphomas are indolent tumors, but follow an insidious course. Our data support the interpretation that CLBCL is a heterogeneous condition; comprises some LBCL derived from CD10+ germinal center cells which manifests more frequently as tumors in the head and neck region, with an increased probability of relapse in lymph nodes [1] and has some distinctive morphologic features. The existence of a component of small B-cells within the other CLBCL could lend support to the theory that some of these tumors, more than arise de novo, may have originated in preexistent small B-cell lymphomas, but no firm evidence of this is provided in this study.

Blastoid NK cell leukemia/lymphoma with cutaneous involvement

Malignant neoplasms from natural killer (NK) cells are characterized by their positivity for CD56 and absence of monoclonal TCR gene rearrangement. Recently, they have been classified into four main types (nasal and nasal-type NK cell lymphoma, aggressive NK cell leukemia/lymphoma, and blastoid NK cell leukemia/lymphoma), based on clinical features, racial predisposition, presence of azurophilic granules, immunophenotype and association with Epstein-Barr virus (EBV) infection. A 72-year-old Caucasian man presented with a malignant neoplasm comprised of blastoid cells without azurophilic granules in the Giemsa stain, with positivity for CD2, CD4, HLA-DR, CD45 and CD56, and negativity for CD3 (surface and cytoplasmic) and CD5. In situ hybridization for EBV and PCR analysis of rearrangement of the T cell receptor gene were negative. Based on these results, a diagnosis of blastoid NK cell lymphoma was made. In this case the first clinical manifestations were the cutaneous lesions, and, although the disease was already advanced at the diagnosis, the patient responded completely to the treatment and remains asymptomatic 14 months after diagnosis.

Epstein-Barr virus-latent membrane protein 1 expression has a favorable influence in the outcome of patients with Hodgkin's Disease treated with chemotherapy

The effect of molecular factors in the outcome of Hodgkin's Disease (HD) is being currently studied. In a previous series of HD, including patients treated only with radiotherapy and patients treated with chemotherapy (with or without radiotherapy), we found that a high proliferation index had an adverse influence in overall survival (OS) and in the achievement of a complete remission (CR). Loss of Rb expression also had an adverse prognostic influence in achievement of CR. On the other hand LMP1-EBV expression had a favorable influence for OS. The expression of other molecular factors, p53, bcl2 and CD15 did not show prognostic influence. In the present paper we have studied the effect of these molecular variables in 110 patients, of the previous series who had been treated with chemotherapy. A retrospective study was performed in these 110 patients with HD treated with chemotherapy (ABVD or variants, 62%, or regimes not containing adriamycin, 38%) with or without adjutant radiotherapy, collected at the 11 centers belonging to the Spanish Collaborative Group for the Study of Hodgkin's Disease. The prognostic value of clinical variables and the expression of p53, bcl2, CD15, Rb, LMP 1-EBV and proliferative fraction demonstrated with sensitive immunohistochemical methods were studied. Cox's multivariate analysis was performed to assess their influence in failure-free survival (FFS) and OS. A multivariate logistic regression analysis was performed for studying the effect of the variables in the achievement of a CR. Of the clinical variables, only advanced stage (III/IV) had a significant independent adverse influence in FFS, in OS and in the achievement of CR and advanced age in OS. Of the molecular variables, LMP1-EBV had an independent and strong favorable influence in FFS, in OS and in the achievement of CR. Rb expression had a modest favorable influence in CR. The rest of the molecular variables had no independent influence on the outcome of the disease. In conclusion these results confirm the favorable prognostic value of LMP1-EBV expression in the subset of patients with HD treated with chemotherapy.

Increased expression of growth hormone and prolactin receptors in hepatocellular carcinomas

The liver is an essential target tissue for growth hormone (GH) and prolactin (PRL). The aim of this study was to determine the in situ expression of growth hormone receptor (GHR) and prolactin receptor (PRLR) in hepatocellular carcinomas and to compare the results with normal liver. For this purpose, in situ hybridization (ISH) and immunohistochemical techniques were performed and several tests were conducted to validate the results. By radioactive ISH, all the hepatocellular carcinomas studied showed labeling for GHR and PRLR mRNAs. Relative expression levels, determined by computer-assisted microdensity, were higher in hepatocellular carcinomas than in normal liver. Immunohistochemistry led us to confirm the constant expression of both receptor proteins in hepatocellular carcinomas and normal liver and to demonstrate their localization not only in the cytoplasm but also in the nucleus. These results confirm that the liver is a major GH and PRL target tissue and suggest that in hepatocellular carcinomas the proliferative effects of these hormones may be increased by a higher expression of their receptors.

[Comparison of sevoflurane and propofol in the maintenance of and recovery from anesthesia]

OBJECTIVE

To compare the recovery of patients after anesthesia with sevoflurane or propofol during open urological surgery or lumbar column surgery of intermediate duration.

PATIENTS AND METHODS

Thirty-six ASA I, II or II patients were enrolled prospectively and randomly assigned to two groups to receive either sevoflurane (n = 19) or proporol (n = 17). Anesthetic induction was accomplished with thiopental, fentanil and vecuronium. During anesthetic maintenance a mixture of 60% nitrous oxide in oxygen plus the drug under study was adjusted to keep blood pressure and/or heart rate within +/- 20% of baseline. After surgery we recorded time until eye opening, spontaneous breathing, extubation, orientation, and identification of parts of the body. Side effects were likewise recorded. In the postanesthetic recovery ward patient condition was assessed using the Aldrete scale, the Newman-Trieger test and a visual analog scale for postoperative pain. Consumption of analgesic during the first 24 h after surgery was monitored.

RESULTS

No significant differences were found in demographic data; duration of anesthesia; anesthetic doses; or time until spontaneous breathing, extubation, orientation or identification of parts of the body. Only time until eye opening was shorter in the sevoflurane group than in the propofol group (6.9 +/- 3.3 vs 11.5 +/- 4.8 min; p < 0.05). No differences were recorded on scales reflecting intermediate-term recovery. Analgesic consumption and the incidence of side effects were similar in both groups.

CONCLUSIONS

Sevoflurane and propofol are comparable for anesthetic maintenance in urological and neurological procedures of intermediate duration.

[Impact of Spanish publications on foreign anesthesiology journals]

OBJECTIVE

To analyze the number of articles by Spanish authors in three international anesthesiology journals and assess the impact of Spanish anesthesiology literature during the same period by way of citations.

MATERIAL AND METHODS

Articles published in Anesthesiology, British Journal of Anesthesiology (BJA) and Anesthesia & Analgesia (Anesth Analg) during 1997 were reviewed. We collected the following data: type of document, country of origin of the authors, total number of references, number of citations of Spanish articles and the journals from which they were cited. Later, the Spanish contribution was compared to that of other countries of the European Union, with data considered in function of Gross National Product per capita (GNPpc) of each country.

RESULTS

The incidence of Spanish articles published in Anesthesiology, BJA and Anesth Analg was 0.37%, 0.71% and 0.9%, respectively. The production of Spanish documents in function of GNPpc ranked Spain in the tenth position in Anesthesiology, eleventh in BJA and sixth in Anesth Analg. Of the total number of citations, 143 (0.4%) were of Spanish publications. In Spanish articles in Anesthesiology the percentage of Spanish citations was 11%, in BJA the figure was 44% and in Anesth Analg it was 13%. Finally, over 90% of the Spanish articles cited in Anesthesiology and in Anesth Analg were published in English in foreign journals.

CONCLUSIONS

The number of Spanish articles published in Anesthesiology, BJA, and Anesth Analg is low, although the comparison of our productivity with that of other EU countries in function of GNPpc places us in an intermediate position. The impact of Spanish literature on international studies is low, particularly research published in Spanish national journals, a circumstance that is reflected even in articles published by Spanish authors.

Primary anaplastic large cell lymphoma of the central nervous system

Central nervous system (CNS) involvement is extremely rare in anaplastic large cell lymphoma (ALCL), and in children only isolated cases have been reported, mainly as secondary CNS involvement. A case of fatal primary ALCL of the brain in a 13-year-old white boy is reported. Magnetic resonance imaging of the brain showed decreased absorption in T1- and T2-weighted image showed a hyperintense signal in the right parietal lobe and 2 masses in the right frontal lobe. A frontal lobe biopsy showed a pleomorphic neoplasm diffusely infiltrating the brain parenchyma and composed of large cells with bizarre, often polylobated or horseshoe-shaped nuclei. Immunohistochemical stains showed diffuse strong positivity for CD30, anaplastic lymphoma kinase protein (ALK-1), p80, leucocyte common antigen, CD45RO (UCHL1), and focal staining for epithelial membrane antigen. Immunostainings for cytokeratins, monocyte-macrophage, and B-cell markers were negative. Epstein-Barr virus latent membrane protein was not detected. To the best of our knowledge, there is only 1 case of primary ALCL of the brain in childhood previously reported in the literature. Before the biopsy, both cases were clinically misdiagnosed as mycobacterial CNS infection. Therefore, primary ALCL should also be included in the differential diagnosis when a mycobacterial CNS infection is suspected in pediatric patients; a careful cytological evaluation of the cerebrospinal fluid or cerebral biopsy are essential for an accurate diagnosis.

Biofilter performance and characterization of a biocatalyst degrading alkylbenzene gases

A biofilter treating alkylbenzene vapors was characterized for its optimal running conditions and kinetic parameters. Kinetics of the continuous biofilter were compared to batch kinetic data obtained with biofilm samples as well as with defined microbial consortia and with pure culture isolates from the biofilter. Both bacteria and fungi were present in the bioreactor. Five strains were isolated. Two bacteria, Bacillus and Pseudomonas, were shown to be dominant, as well as a Trichosporon strain which could, however, hardly grow on alkylbenzenes in pure culture. The remaining two strains were most often overgrown by the other three organisms in liquid phase batch cultures. mu max, KS, KI values and biodegradation rates were calculated and compared for the different mixed and pure cultures. Since filter bed acidification was observed during biofiltration studies reaching a pH of about 4, experiments were also undertaken to study the influence of pH on performance of the different cultures. Biodegradation and growth were possible in all cases, over the pH range 3.5-7.0 at appreciable rates, both with mixed cultures and with pure bacterial cultures. Under certain conditions, microbial activity was even observed in the presence of alkylbenzenes down to pH 2.5 with mixed cultures, which is quite unusual and explains the ability of the present biocatalyst to remove alkylbenzenes with high efficiency in biofilters under acidic conditions.

Presentation of T-cell-rich B-cell lymphoma mimicking acute hepatitis

Liver involvement in non-Hodgkin's lymphoma is relatively frequent, being found in approximately half of the post-mortem studies. However, the clinical presentation of lymphoma mimicking primary liver disease is uncommon. A case of non-Hodgkin's lymphoma (the recently described T-cell-rich B-cell lymphoma variant) is presented, where the initial and predominant manifestations were of hepatic origin, resembling non-neoplastic acute liver disease.