Determination of cell proliferation using Mcm2 antigen and evaluation of apoptosis and TGF-beta1 expression in GH-secreting or clinically nonfunctioning pituitary adenomas

Pituitary adenomas (PA) occasionally show aggressive behavior, with invasion of the surrounding tissues. The identification of markers able to recognize aggressive PA in early stages remains a challenge. We aimed to determine the expression of a new cell proliferation marker, Mcm2, and the presence of apoptosis in PA, and to evaluate the association of clinicopathological features with the apoptotic and proliferative indices. Additionally, the TGF-beta1 expression, an inducer of apoptosis, was determined. The proliferative index was determined in GH-secreting or clinically nonfunctioning PA using immunohistochemical (IH) methods for Mcm2 and Ki-67 antigens. The apoptosis was assessed by the TUNEL method and the TGF-beta1 expression by IH. A significant positive correlation was found between log Mcm2 index and log Ki-67 index (p < 0.001). Mcm2 and Ki-67 detected a similar number of proliferating cells. Mcm2 index showed a significant association with tumor extension (p = 0.02), but not with tumor invasion. Apoptosis was detected in 17% of the adenomas, with a maximum apoptotic index of 0.77%. Immunoreactivity to TGF-beta1 was observed in 77% of the adenomas, showing an association with tumor extension. We concluded that, in this sample, Mcm2 was similar to Ki-67 in the identification of the proliferating cells and that apoptosis was rare.

Prospective evaluation of transsphenoidal pituitary surgery in 108 patients with Cushing's disease

Transsphenoidal pituitary surgery (TSS) remains the treatment of choice for Cushing's disease (CD). Despite the widespread acceptance of this procedure as the first line treatment in CD, the indication of a second TSS in not cured or relapsed DC patients is not consensus. We report the results of TSS in 108 patients with CD (a total of 117 surgeries). The mean postoperative follow-up period was 6 years. Remission was defined as clinical and laboratorial signs of adrenal insufficiency, period of glucocorticoid dependence, serum cortisol suppression on oral 1-mg dexamethasone overnight suppression test and clinical remission of hypercortisolism. We evaluated 103 patients with CD by the time of the first TSS. Fourteen patients underwent second TSS (5 had already been operated in others centers; in 5 patients the first surgery was not curative; in 4 patients CD relapsed). Remission rates were 85.4% and 28.6% (p < 0.001) after first and second TSS, respectively. In microadenomas, remission rates were higher than macroadenomas (94.9% vs. 73.9%; p = 0.006). In patients with negative pituitary imaging remission rates were 71.4% (p = 0.003; vs. microadenomas). Postoperative complications were: transient diabetes insipidus, definitive diabetes insipidus, hypopituitarism, stroke and one death. Only hypopituitarism was more frequent after second TSS (p = 0.015). In conclusion, TSS for CD is an effective and safe treatment. The best remission rates were observed at the first surgery and in microadenomas. The low remission rates after a second TSS suggest that this approach could not be a good therapeutic choice when the first one was not curative.

Hyperprolactinemia and immunohistochemical expression of intracellular prolactin and prolactin receptor in primary central nervous system tumors and their relationship with cellular replication

The role of prolactin (PRL) in the CNS remains uncertain. We evaluated the presence of hyperprolactinemia, intracellular prolactin (ICP), and prolactin receptor (PRL-R) in primary CNS tumors, and their relationship with cellular replication with a prospective cross-sectional study of 82 consecutive patients with primary CNS tumors admitted for neurosurgical resection between October 2003 and September 2005. Patients submitted to a questionnaire, and venous blood samples were obtained for measurement of serum PRL and TSH. Immunohistochemical analyses were performed to evaluate the presence of ICP, PRL-R, and Ki-67. Serum PRL levels ranged from 2 to 70 ng/ml, and hyperprolactinemia was detected in 25 cases (30.5%). ICP was detected in 18 patients (21.9%), in whom PRL ranged from 2 to 32 ng/ml. A positive correlation was found between PRL levels and the presence of ICP (Student's t test, P = 0.022). The PRL-R was observed immunohistochemically in 32 cases (39%). The frequencies of hyperprolactinemia, ICP, and PRL-R were similar across the several histological types of CNS tumors. Ki-67 index was similar in all groups. Hyperprolactinemia and intracellular presence of PRL and PRL-R were common findings in this population, suggesting a role for PRL in CNS tumor genesis.

Primary meningeal Burkitt-type lymphoma presenting as the first clinical manifestation of acquired immunodeficiency syndrome

The purpose of this study is to report a rare case of primary meningeal high grade Burkitt-type lymphoma presenting as the first clinical manifestation of acquired immunodeficiency syndrome. A 38-year-old Caucasian man, with a negative past medical history, sought treatment after experiencing global headache for five days. CT-Scan revealed a right front-temporo-parietal hyperdense subdural expansive mass. A craniotomy was performed and a hard white subdural was microsurgically dissected. Some hours after the surgery, the patient developed hemispheric cerebral edema and intracranial hypertension syndrome. Decompressive craniotomy was performed and the patient had an excellent recovery. Screening blood tests diagnosed human immunodeficiency virus infection. Further investigation ruled out systemic diseases. Eleven days after the initial surgery, the patient developed an acute respiratory failure and sepsis, dying on that day. Pathological studies diagnosed Burkitt-type lymphoma.

Stereotactic computed tomography–guided brain biopsy: diagnostic yield based on a series of 170 patients

BACKGROUND

Stereotactic CT-guided biopsy is a valuable and safe procedure for diagnosing intracranial lesions. The objectives of this article are to analyze the diagnostic yield in a series of stereotactic CT-guided brain biopsies and to evaluate whether predictive factors may influence diagnostic yield.

METHODS

The medical records of a series of patients who underwent stereotactic CT-guided brain biopsy from 1993 to 2005 in a neurosurgical center were reviewed. Clinical data were stored and analyzed with Microsoft Access (Microsoft Corp, Seattle, WA) and SPSS V11.0 software (SPSS, Inc, Chicago, IL). The following variables were analyzed: age, sex, anatomopathologic diagnosis, lesion topography and volume, postsurgical complications, and predictive factors that may affect diagnostic yield.

RESULTS

One hundred seventy patients (102 males, 68 females; average age, 48.5 years) were analyzed. Stereotactic CT-guided biopsies allowed diagnosis in 157 cases (92%). The most frequent anatomopathologic diagnoses were high-grade glioma (n = 45), low-grade glioma (n = 31), nonspecific inflammatory lesions (n = 19), metastasis (n = 10), and lymphoma (n = 10). The most frequent topographies were frontal (n = 42), basal ganglia (n = 40), and parietal (n = 27) and front-parietal lobes (n = 9). Complications occurred in 5 patients (2.9%). Mortality rate was 1.2% (2 patients). Age had a positive impact, whereas female sex negatively affected diagnostic yield. All other predictive factors analyzed were not significant.

CONCLUSION

Stereotactic CT-guided brain biopsies performed presented acceptable anatomopathologic diagnostic rate. Age had a positive impact, whereas female sex negatively affected diagnostic yield in this series.

Early surgical treatment of nonsyndromic craniosynostosis

BACKGROUND

Craniosynostosis, a premature fusion of cranial sutures, can happen as an isolated defect (nonsyndromic) or as part of a syndrome. It may lead to raised intracranial pressure and deformity of both the cranial and facial skeletons. Early surgery is usually the best treatment choice. The aim of this study was to review the experience of a multidisciplinary staff with the surgical treatment of nonsyndromic craniosynostosis.

METHODS

All the nonsyndromic craniosynostosis cases treated surgically from 1991 to 2005 at 2 neurosurgical centers were reviewed. The variables analyzed were sex, age, weight, type of deformity, estimated volemia, surgical technique, surgical time, blood loss, PO hospitalization time, and complications. All data were stored in a database and analyzed with Microsoft Access (Microsoft Corp, Seattle, WA) and SPSS V11.0 (SPSS, Inc, Chicago, IL).

RESULTS

The sample consisted of 120 patients (70 males, 50 females). Six patients were excluded because of their atypical timing of treatment (average age, 72 months). The final average age was 7.08 months (variation, 1-18), and the average weight was 7.8 kg. The types of deformities found were scaphocephaly (n = 54, 45%), plagiocephaly (n = 27, 22%), trigonocephaly (n = 19, 16%), brachycephaly (n = 16, 13%), and oxycephaly (n = 4, 3%). The mean surgical time was 186 minutes and the mean PO hospitalization time was 6.8 days. The mortality on this series was 2.6% (3 patients). In the last operated cases, a significant improvement in morbid-mortality was observed.

CONCLUSION

A multidisciplinary approach, including neurosurgeons, neurologists, and pediatricians, and appropriate training of the clinical surgical staff can minimize the risks and decrease the complications in the treatment of craniosynostosis, leading to a satisfactory outcome.

Glioblastoma primário de cone medula: relato de caso

O glioblastoma, um tumor anaplásico de linhagem astrocitária, é o mais freqüente tumor cerebral. Localiza-se preferencialmente nos hemisférios cerebrais; seu crescimento primário no cone medular é muito raro, e o manejo e prognóstico deste tipo de lesão são distintos dos outros tumores observados nesta localização. Apresentamos o caso de um homem de 39 anos com tumor intramedular com diagnóstico histo-patológico de glioblastoma.

Dynamics of serum cortisol levels after transsphenoidal surgery in a cohort of patients with Cushing's disease

Transsphenoidal pituitary surgery is the treatment of choice for Cushing's disease (CD). Despite the widespread acceptance of this procedure, there is no agreement regarding the definition of successful treatment. We prospectively studied postoperative serum cortisol dynamics in 41 patients with CD (including a total of 45 surgeries). The mean postoperative follow-up period was 4.8 yr. Remission was defined as clinical and laboratory signs of adrenal insufficiency, glucocorticoid dependence, and serum cortisol suppression on overnight oral 1-mg dexamethasone suppression test. Serum cortisol was measured preoperatively and postoperatively at 6, 12, and 24 h (28 surgeries) and at 10-12 d (45 surgeries). No statistical difference was detected in mean preoperative and 6-h postoperative cortisol levels between surgically induced remission patients [22.1 +/- 7.73 microg/dl (610 +/- 213.3 nmol/liter) and 25.2 +/- 19 microg/dl (695.2 +/- 524.4 nmol/liter)] and surgical failure patients [23.6 +/- 6.95 micro g/dl (651.4 +/- 161.8 nmol/liter) and 37.5 +/- 18.1 microg/dl (1035 +/- 499.6 nmol/liter); P = 0.50 and P = 0.17]. At 12 and 24 h after surgery, the difference was significant (P = 0.009 and P < 0.0001). Mean cortisol levels were 12.44 +/- 13.3 microg/dl (343.3 +/- 367.1 nmol/liter) and 4.72 +/- 6.72 microg/dl (130.3 +/- 185.5 nmol/liter) in the remission group and 26.3 +/- 7.06 microg/dl (725.9 +/- 194.8 nmol/liter) and 23.5 +/- 6.86 microg/dl (648.6 +/- 189.3 nmol/liter) in the failure group (P = 0.009; P < 0.0001). At 10-12 d after the procedure, the difference was also significant (P < 0.0001): cortisol levels were 2.52 +/- 3.32 microg/dl (69.5 +/- 91.6 nmol/liter) in the remission group and 24.9 +/- 13.3 microg/dl (687.2 +/- 367.1 nmol/liter) in the failure group. In conclusion, in the immediate postoperative period of transsphenoidal surgery, remission of CD is not necessarily defined by undetectable serum cortisol. During the first 10-12 d after surgery, cortisol nadir correctly classified the remission [cortisol, 7.0 microg/dl (193.2 nmol/liter) or less] and the failure groups [cortisol, 8.0 microg/dl (220.8 nmol/liter) or more]. Glucocorticoid should be administered only after laboratory and/or clinical evidence of adrenal insufficiency.

Measurement of Ki-67 antigen in 159 pituitary adenomas using the MIB-1 monoclonal antibody

Pituitary adenomas sometimes show rapid growth and recurrence, and about one third invade the structures surrounding the sella turcica. In an attempt to determine aggressive behavior at an early stage, we used the MIB-1 antibody to identify the Ki-67 antigen. The present study was designed to evaluate pituitary adenomatous tissue in terms of secretion and proliferation and to correlate the Ki-67 index with hormone phenotype and invasive behavior. Material from 159 patients submitted to one or more resections of pituitary adenomas was evaluated. Forty-two non-secretory adenomas and 43 adenomas immunoreactive for growth hormone, 19 for prolactin, 18 for growth hormone and prolactin, 16 for adrenocorticotropic hormone (ACTH), and 21 cases of plurihormonal/gonadotropin adenomas were detected by immunohistochemistry. The MIB-1 antibody was positive in 139 samples and the Ki-67 index ranged from 0.16 to 15.48% (mean = 1.22 +/- 2.09%), with no significant difference between genders, age groups, or secretory and non-secretory status. The Ki-67 index was higher in ACTH-secreting adenomas. Invasive pituitary adenomas had a significantly higher Ki-67 index (2.01 +/- 3.15%) than macroadenomas with or without supra-sellar extension (1.12 +/- 1.87%; P = 0.02). The index was not significantly different in the subgroup of adenomas with invasion of the cavernous sinus compared to groups with other types of invasion. We conclude that tumoral proliferative activity evaluated by the detection of the Ki-67 antigen is significantly higher in invasive than noninvasive adenomas, information which can be useful in therapeutic postoperative management since index cut-off values associated with aggressive behavior can be established.

Expression of p53 protein in pituitary adenomas

Inactivating mutations of TP53, a tumor suppressor gene, are associated with abnormal cell proliferation. Although p53 expression is common in many human malignancies, p53 protein has seldom been evaluated in pituitary tumors. When detected, the percentage of p53-positive cells is low, and, in general, it is exclusive for invasive lesions. The aim of the present study was to use immunohistochemistry to determine the presence of p53 protein in pituitary adenomas from tumor samples of 163 surgeries performed in 148 patients (40% male, 60% female). In 35% of the cases the adenoma was nonfunctional, while in the others it was associated with PRL, GH and/or ACTH endocrine hypersecretion syndrome. Macroadenomas were observed in 83.2% of the cases with available neuroimage evaluation, of which 28% invaded the cavernous, sphenoid and/or ethmoidal sinus, bone, third ventricle or subfrontal lobe. p53 protein was detected in 2/148 patients (1.3%). Immunohistochemistry was positive for PRL and GH in these cases. Due to the high percentage of invasive pituitary adenomas found in our study, the low frequency of p53 detection suggests that it is inadequate as a routine marker for aggressiveness and as a predictive factor of tumor behavior.

Risk factors of neurological lesions in low cervical spine fractures and dislocations

Eighty-nine patients with lower cervical spine fractures or dislocations were evaluated for risk factors of neurological lesion. The age, sex, level and pattern of fracture and sagittal diameter of the spinal canal were analysed. There were no significant differences on the age, gender, level and Torg's ratio between intact patients and those with nerve root injury, incomplete or complete spinal cord injuries. Bilateral facet dislocations and burst fractures are a significant risk factor of spinal cord injury.

Lipoma of the cerebellopontine angle. Case reports and literature review

Two patients with cerebellopontine angle (CPA) lipoma were studied. They were submitted to surgical treatment. Available literature was reviewed and 29 cases with same lesion were identified which had been treated by surgery. Clinical manifestations, possibility of diagnostic methods, surgical indications and treatment strategies are discussed. Attention is called to the peculiarities of CPA lipomas and the doubtful validity of attempting complete excision in all cases.

[Macroprolactinoma at 6 years of age: diagnostic difficulties]

Prolactinoma is rare in childhood and adolescence. The earliest known diagnosis was reported in a patient at 8 years of age. We report the case of a sellar tumor found in a 6 years old girl. After a long symptomatic period she was brought for treatment. At this time she had partial papillar atrophy, hyperprolactinemia, and diminished reserve of growth hormone and cortisol. Due to rapid visual deterioration, she was submitted to a frontotemporal craniotomy for suspected craniopharyngioma. The tumor tissue immunohistochemistry was positive for prolactin. It is concluded that prolactinoma must be considered in differential diagnosis of sellar tumors in childhood since it benefits from a less aggressive therapy.

[Spontaneous intraparenchymatous hematomas. Experience with 134 cases]

One hundred thirty four cases of spontaneous intraparenchymatous hematomas have been studied. They were separated into six groups according to criteria related to topography, level of consciousness, and hematoma volume. Treatment protocols--conservative, conservative with I.C.P. monitoring, and surgical--were different in each group. Results have shown an increased mortality (p < 0.05) among patients whose level of consciousness were more severely compromised, in those older than 50 years old, and in those harbouring quadrilateral, intraventricular or brainstem hematomas. Overall mortality was 26.1%.

Optic nerve apoplexy caused by a cavernous angioma: case report

A case of a cavernous angioma of the optic nerve is presented. The abrupt onset of monocular visual symptoms was accompanied by an intense bitemporal headache, indicating apoplexy of the optic nerve. The surgical and histological findings demonstrated a cystic cavernous angioma. The lesion was removed completely without any noticeable bleeding. The preoperative visual deficit persisted.

[Massive intratumor hemorrhage in tuberous sclerosis. Autopsy study of a case]

A case of a 13-year-old boy with tuberous sclerosis manifested with the complete syndrome that died with a massive intratumoral hemorrhage is presented. The post mortem examination of the brain disclosed a massive left parenchymatous brain hemorrhage with intraventricular component. In the hemorrhage, near the lateral ventricle wall, a subependymal giant cell astrocytoma was found. This is the second case in the literature of tuberous sclerosis which cause of death was an intratumoral massive hemorrhage.

Anatomoradiological correlation of the intersection of the carotid siphon with the dura mater

In order to obtain frames of reference to determine the place of intersection of the carotid siphon with the dura mater in conventional arteriograms, a debated topic lacking general agreement in the literature, 34 cadaveric sphenoids were prepared with the injection of radiopaque medium in both internal carotid arteries. After having marked the dura mater with steel wire, the pieces were radiographed in lateral view. The points of intersection of the clinoclinoid line and the sphenoidal line with the internal carotid artery as well as the emergence of the ophthalmic artery and its posterior projection were marked on the radiographs obtained. The distances between the various points were measured and submitted to statistical treatment. The results showed multiple regressions with a strong correlation coefficient in two equations. A table was built in which, knowing the distances between the points of the clinoclinoid and the sphenoidal plane lines and those of the ophthalmic artery and its projection, the position of the dura mater which covers the cavernous sinus may be estimated in arteriograms.

[Pituitary adenomas: immunohistochemical study of 167 cases]

One hundred and sixty seven cases of pituitary adenoma were analysed using the immunocytochemical method of the Avidin-Biotin Complex (ABC), described by Hsu et al. (1981). Six pituitary anti-hormones were utilized: anti-prolactin (aPRL) at a 1:1,500 dilution; anti-growth hormone (aHGH) at a 1:4,000 dilution: anti-adrenocorticotrophic hormone (aACTH) at a 1:3,000 dilution; anti-thyrothrophic hormone (aTSH) at a 1:3,000 dilution; anti-luteinizing hormone (aLH) at a 1:1,000 dilution; and a anti-follicle-stimulating hormone (aFSH) at a 1:300 dilution. Incubation period was 14 to 16 hours at 4 degrees C. The survey of clinical, laboratory and radiological data of cases of pituitary adenomas was performed after reading the stained slides using the immunocytochemical method. Of the 167 cases of pituitary adenomas, 136 (81.4%) disclosed a positive immunoreaction to one or more anti-hormones, and the positivity index of neoplastic cells varied from 1 to 90%. The immunoreaction was positive exclusively to one anti-hormone in 80 cases (58.8%) and to two or more anti-hormones in 56 cases, and the association most frequently found was between both aPRL and aHGH. The positivity to the immunoreaction was distributed as follows: -100 cases were positive for aPRL, exclusively in 4 cases; -65 cases were positive for aHGH, exclusively in 22 cases; -31 cases were positive for aACTH, exclusively in 8 cases; -5 cases were positive for aTSH, exclusively in one case; -one patient presented an adenoma positive to aLH and another patient to aFSH.

New basidiomycetous yeasts from southern Africa. IV. Sporobolomyces phylladus sp. nov., characterized by the coenzyme Q9 system (Sporobolomycetaceae)

Six strains of an undescribed, leaf-borne species of the genus Sporobolomyces were recovered. A description of the new species, Sporobolomyces phylladus, is given.

New basidiomycetous yeasts from southern Africa. III. Sporobolomyces phyllomatis sp. nov. (Sporobolomycetaceae)

Three strains of an undescribed, leaf-borne species of the genus Sporobolomyces were recovered. A description of the new species, Sporobolomyces phyllomatis, is given.

New basidiomycetous yeasts from southern Africa. II. Sterigmatomyces wingfieldii sp.n

A new, insect-associated species of the emended genus Sterigmatomyces, St. wingfieldii, is described. A key to the emended genus is given.

Candida lyxosophila sp. nov., a new D-xylose fermenting yeast from southern Africa

Six strains of an undescribed Candida species which ferment D-xylose tardily, were isolated from soil. A description of the new species, Candida lyxosophila, is given.

New basidiomycetous yeasts from Southern Africa. I: Sporobolomyces kluyveri-nielii sp. nov

A strain of an undescribed, leaf-borne species of the genus Sporobolomyces was recovered. A description of the new species, Sporobolomyces kluyveri-nielii, is given.