Familial clustering of infantile cirrhosis in Northern Germany: A clue to the etiology of idiopathic copper toxicosis

Two cases of infantile liver cirrhosis of unknown origin occurred in a circumscribed rural area of Northern Germany. Both children had increased dietary copper exposure. The search for additional cases of what appeared to be idiopathic copper toxicosis (ICT) revealed a cluster of affected infants in this region, raising questions about the relative importance of genetic and environmental factors that are considered to be etiologic. We gathered clinical and pathologic data concerning the patients, analyzed the pedigrees of affected families, and searched for possible environmental factors contributing to the pathologic process. We encountered 8 cases of infantile liver cirrhosis in 5 families in Emsland, a circumscribed and predominantly rural area of Northern Germany; ICT was definitely proven in 2 cases. Clinical presentation and liver pathology in 6 additional cases were consistent with the diagnosis of ICT. Pedigrees of affected families revealed complex relationships with occasional consanguinity of parents, suggesting autosomal recessive inheritance. The households were served by private wells with water of low pH flowing through copper pipes, suggesting the possibility of increased alimentary copper exposure. These findings support earlier conclusions that ICT develops when an infant with a genetic predisposition is exposed to a copper-enriched diet.

Standardized in situ AgNOR analysis in breast pathology: diagnostic and cell kinetic implications

The aim of the present study was to assess the diagnostic value of the recently standardized morphometric analysis of silver-stained nucleolar organizer region-associated proteins (AgNORs) [30] in a variety of 155 routinely processed benign and malignant breast lesions. 5 normal breast samples, 21 adenoses, 20 ductal hyperplasias, 10 atypical ductal hyperplasias, 20 in situ and 43 invasive ductal carcinomas, 10 in situ and 26 invasive lobular carcinomas were investigated. A statistically highly significant difference was found between normal/ordinary hyperplastic and neoplastic breast lesions with all 4 consensus AgNOR parameters (mean area, mean number, CV of area, CV of number) evaluated. AgNOR quantity was significantly related to histological grade of both in situ and invasive carcinomas. However, variable overlap was found between AgNOR values in different diagnostic groups. We conclude that standardized AgNOR analysis is a prerequisite for objective and reproductible AgNOR assessment in archival tissues. Despite its limited diagnostic utility for individual breast lesions, standardized AgNOR analysis bears a significant potential for characterizing cell kinetic and metabolical activity of breast lesions. This may give insight into the biological background of breast carcinogenesis, differentiation and tumor progression and may also underlie the independent prognostic value of AgNORs in breast cancer.

Immunophenotypic and prognostic analysis of E-cadherin and beta-catenin expression during breast carcinogenesis and tumour progression: a comparative study with CD44

AIMS

This study was performed to investigate whether immunohistochemical expression of E-cadherin (E-cad) and beta-catenin (beta-cat) in conjunction with CD44 may correlate with the clinical evolution and prognosis of breast cancer.

METHODS AND RESULTS

One-hundred and forty-two routinely processed breast tissue samples including normal breast, benign lesions, in situ and invasive carcinomas were investigated. E-cad and beta-cat were strongly expressed by luminal and basal cells in normal glands, benign proliferative and early neoplastic intraductal lesions. Contrarily, CD44 was expressed exclusively by myoepithelial cells in normal breast, whereas different isoform expression patterns were observed in premalignant and malignant lesions. Simultaneous lack of E-cad/beta-cat expression was detected in in situ and invasive lobular carcinomas in contrast to ductal lesions, in which the differential loss of the molecules was associated with poorer differentiation, irrespective of CD44 immunophenotype. Reduced E-cad (P = 0.003), beta-cat (P = 0.03) and increased CD44v4 (P = 0.005) and v7 (P = 0.007) expression were significantly associated with positive lymph node status. Decreased E-cad and lack of CD44v6 expression correlated with poor survival. There was no difference between the expression of either molecule in in situ and invasive components within the same tumour.

CONCLUSIONS

Our results indicate that changes in E-cad, beta-cat and CD44 expression occur early in breast carcinogenesis; they are involved in tumour differentiation, but events additional to their deranged expression are needed to acquire an invasive phenotype.

[Terminal CTG as an expression of high degree fetal distress--1 case reports]

The cases of two patients, in whom conspicuous CTGs with restricted oscillation and late decelerations were registered in the final trimester of pregnancy, are presented. Following immediate hospitalisation and the rapid execution of a caesarean section, two depressed, severely acidotic neonates were born. Whilst the course of the pregnancy in the first case had been completely inconspicuous up to that point, and the acute occurrence of placental insufficiency must be assumed, the second patient was subject to pregnancy-induced hypertension with discrete foetal growth retardation. It is shown that two almost identical pathological CTG registrations may have different causes but that one must assume a high degree of sub partu risk to the child on the occurrence of a terminal CTG witch is characterised by line-shaped oscillation, possibly in combination with late decelerations.

Modified neoadjuvant therapy regime with low dose irradiation in advanced head and neck cancer patients: preliminary results of a pilot study to minimize side effects

We analysed the files of 52 patients with advanced head and neck tumors who were treated in a pilot phase. The therapy consisted of two courses of induction chemotherapy with ifosfamide and cisplatin followed by hyperfractionated-accelerated radiotherapy with a total dose of only 30 Gy. Surgery was performed within the following 7 days with tumor resection and neck dissection. Histologically we found in 50% of the specimens total necrosis of the tumor. The median survival time is calculated to be 22 months. The median follow-up time thus far is 36 months. Hence, therapy results are comparable to other therapy schedules. But side effects, especially late side effects had become minor. Therefore, our therapy regime results in augmentation of the quality of life of these patients.

Gains and losses of CD44 expression during breast carcinogenesis and tumour progression

AIMS

This study was performed to investigate whether the CD44 immunophenotype of breast lesions correlates with the clinical evolution and prognosis of breast cancer.

METHODS AND RESULTS

One-hundred and fifty-two routinely processed normal, benign and malignant breast tissue samples were investigated by the following monoclonal antibodies: CD44s (F10-44-2), CD44v3 (3G5), CD44v4 (11.10), CD44v5 (VFF-8), CD44v6 (VFF-18), CD44v7 (VFF-9), CD44v9 (11-24) after wet autoclave pretreatment for antigen retrieval. We found that: (1) in normal breast tissues luminal epithelial cells lacked detectable CD44 in contrast to basal cells, which constitutionally expressed CD44s, v3, v5 v6 and v9 isoforms; (2) in the intraductal compartment of benign hyperplastic lesions, there was scattered or focal staining for CD44s, v5, v6, v7 and v9 isoforms; (3) in neoplastic lesions restricted neo-expression of CD44v3 and v4 was detected; and (4) the CD44 immunophenotype of invasive breast carcinomas was influenced largely by differentiation grade, steroid receptor status of the tumours and significantly correlated with metastatic involvement of the axillary lymph nodes.

CONCLUSIONS

Qualitative and quantitative changes of CD44 expression are implicated in early stages of breast carcinogenesis. The restricted neo-expression of certain CD44 isoforms in breast neoplasias suggests that CD44 might be a potential target for future antibody-based tumour therapy.

Effect of IFN-alpha on normal human hematopoiesis: an immunohistochemical and morphometric study on trephine biopsy specimens

To elucidate the effects of interferon-alpha (IFN-alpha) on normal human bone marrow in vivo, an immunomorphometric study was performed using trephine biopsy specimens without hematopoietic pathology. Samples were derived from patients with mycosis fungoides but no marrow involvement, who were undergoing low-dose IFN-alpha treatment. Parameters included density of reticulin (argyrophilic) fibers, CD61+ megakaryocytes, PGM1+ macrophages, the GSA-I lectin-expressing (activated) macrophage subpopulation, proliferative activity (PCNA staining), and apoptosis. Following IFN-alpha therapy (3 x 3 x 10(6) U/week between 6 and 21 months), morphometric evaluation of sequential bone marrow examinations revealed a significant increase in the number of megakaryocytes and the amount of reticulin fibers. Additionally, there was an overall decrease in PCNA+ cells, accompanied by a reduction in the incidence of apoptotic bodies. On the other hand, total number of macrophages and their activated subfraction remained unchanged. Opposed to in vitro findings, a fibrogenetic capacity of IFN-alpha associated with megakaryocyte growth was detectable. Moreover, contrasting with effects of IFN-alpha treatment in chronic myelogenous leukemia, the incidence of apoptosis was significantly reduced. This feature was assumed to contribute to a maintenance of steady-state hematopoiesis expressed by a nonaltered bone marrow cellularity in our specimens.

Expression of biglycan, decorin and proteoglycan-100/CSF-1 in normal and fibrotic human liver

The immunohistochemical expression of the three small chondroitin/dermatan sulphate proteoglycans biglycan, decorin and proteoglycan-100 (PG-100), the proteoglycan form of colony-stimulating factor-1 (CSF-1), was studied in normal and fibrotic human liver. In normal liver tissue biglycan and decorin were clearly seen in the space of Disse, which was in contrast to a faint staining of PG-100. Biglycan and decorin were additionally detected around small bile ducts and in vessel walls. In patients with HBs-Ag positive, chronic active hepatitis decorin as well as biglycan showed strong immunoreactivity in fibrotic areas. In contrast to normal liver, PG-100 was visualized in bile duct epithelia. Therefore, PG-100 could serve as an immunohistochemical marker of the involvement of the bile duct system in chronic active hepatitis and progressive liver fibrosis.

[The so-called adenomatoid tumor of the uterus: a case report of evaluation of primary sterility]

A description of the clinical diagnosis, localisation and the histological structure of an adenomatoid tumour of the uterus is presented. The tumour was diagnosed during investigation of sterility and localised in the uterus wall. Fallopian tubes and ovaries can also be affected. Adenomatoid tumours are small, slow growing and of benign origin, and hence organ-preserving tumourectomy is an adequate therapy. Histogenesis of this kind of tumour has been established by means of immunological techniques as being of mesothelial origin.

Intratumoural heterogeneity of nuclear DNA-content and proliferation in clear cell type carcinomas of the kidney

Clear celled renal carcinomas (n = 37) were investigated by flow cytometry for intratumoural heterogeneity in DNA-ploidy and proliferation (S-phase rate). Using gross sections of the tumours, 178 regions of interest were selected and excised from the paraffin blocks. Of the tumours examined 30% (n = 11) were DNA-diploid and 70% (n = 26) were DNA-aneuploid. In six tumours (16%) homogenous DNA-aneuploidy was detected, and in 20 others (54%) there was intratumoural heterogeneity of DNA-content with a blend of either DNA-diploid and DNA-aneuploid regions (n = 16; 43%) or different aneuploid stemlines (n = 4; 11%). DNA-aneuploidy was present both in areas of the tumours composed of clear cells and in regions containing cells with cytoplasmatic eosinophilia. However, DNA-aneuploidy was correlated in a statistically highly significant manner with the degree of cytoplasmatic eosinophilia and the nuclear grading of tumour cells. The results were confirmed by comparative analysis of fresh-frozen and paraffin-embedded material. The DNA-aneuploid portions of the tumours, and the regions with increased cytoplasmatic eosinophilia, proved to have significantly higher S-phase rates than DNA-diploid and clear tumour cells. These results agreed well with the immunohistochemically determined percentage of Ki-67 (proliferation associated)-antigen positive cells. Our findings indicate that tumour cells with increased eosinophilia in renal cell carcinomas are distinct from real clear cells by virtue of their higher rates of aneuploidy and proliferative activity. These cells might therefore be regarded as a subclass with a more aggressive biological behaviour.

[Ovarian pregnancy after gamete transfer (gift). A case report]

A case of ovarian pregnancy after gamete transfer (GIFT) is reported in a 33-year old women who, after intensive stimulation therapy, experienced a right tubal pregnancy in one cycle and an ovarian pregnancy on the left side in the next. The incidence of ovarian pregnancies seems to have been increasing during the past years, comprising 3.3% of all extrauterine pregnancies. This may be influenced by the possibilities of sterility therapy today. Clinical presentation, possible pathogenesis, diagnostic steps and preferred management are described. The use of transvaginal sonography has improved the diagnosis of ectopic pregnancies and should be routinely used leading to an early diagnosis and organ-preserving therapy. This case report is intended to assist and promote the sensitivity towards an early diagnosis of this rare form of ectopic pregnancy.

[Acute disseminated histiocytosis X (Langerhans cell histiocytosis) with fatal course in an adult]

Histiocytosis X is very rare in late adulthood, usually taking a benign course with a good prognosis. A 56-year-old patient developed acute disseminated histiocytosis X with multiorgan involvement. Despite extensive diagnostic work-up the diagnosis could only be established on the grounds of a skin biopsy. Histiocytosis X cells are S 100 protein-positive and express the membrane antigens CD 1, CD 4 and HLA-DR. Electron microscopy reveals Birbeck granules. On static cytophotometry, histiocytosis X cells exhibited normal DNS content without aneuploidy. One year after the onset of disease the patient's condition deteriorated rapidly despite aggressive polychemotherapy (CHOP), and he died of multiorgan failure due to histiocytosis X.

Experimental studies on nephrotoxicity and pharmacokinetics of LY 146032 (daptomycin) in rats

The nephrotoxicity and pharmacokinetics of LY 146032 (daptomycin) were studied in an experimental rat model. Nephrotoxicity was assessed by measuring urinary loss of tubular cells and malate dehydrogenase. LY 146032 (10-250 mg/kg daily iv) led to a dose-dependent and reversible increase of cell elimination. The tubulo-toxic threshold dose is stated to be 10 mg/kg daily. Nephrotoxicity induced by LY 146032 can be reduced by coadministration of fosfomycin or D-glucaro-1.5-lactam, and enhanced by combination with tobramycin. LY 146032 accumulated in renal tissue during repeated administration. Electron microscopy revealed histopathological changes in the kidneys. Therefore the nephrotoxic potential of LY 146032 should be taken into consideration in clinical trials.

The use of the anti-factor VIII method on trephine biopsies of the bone marrow for the identification of immature and atypical megakaryocytes in myeloproliferative diseases and allied disorders. A morphometric study

A morphometric analysis was performed on trephine biopsies of the bone marrow to identify atypical megakaryocyte proliferation following PAS staining and the immunohistological demonstration of factor VIII. This study includes nine patients with a megakaryoblastic crisis in chronic myeloid leukemia (CML), four with acute megakaryoblastic leukemia (AM) and three with myeloid dysplasia later evolving into overt acute leukemia. Comparison and statistical evaluation of the PAS reaction with anti-factor VIII staining reveals that the latter technique not only facilitates the recognition of immature and abnormal megakaryocytes, but leads to a significantly increased count for all megakaryocytic elements in the bone marrow. Thus our retrospective investigation of routinely processed and paraffin-embedded trephine biopsies shows that the diagnosis of a megakaryoblastic crisis in CML as well as AM may be easily established with the aid of the anti-factor VIII method. In all cases of megakaryoblastic proliferation in CML and AM, the appearance of blasts was associated with moderate to pronounced myelofibrosis which could be also determined by morphometry.

Histopathology of the bone marrow in toxic myelopathy. A study of drug induced lesions in 57 patients

Following the introduction of numerous highly effective drugs in recent decades, haematologists are confronted with a panmyelopathy or "toxic myelopathy" originating from the exhibition of certain therapeutic regimens. Among 16,711 trephines referred to us in the last 5 1/2 years, 57 cases or 0.34 percent were found to have clear evidence of lesions caused by the ingestion of potentially toxic agents. The evaluation of the histopathology shows two groups of alterations which concern the haematopoietic parenchyma as well as the mesenchyme of the bone marrow. Different degrees of cellularity ranging from aplasia to regenerative hyperplasia and a pronounced mesenchymal reaction with proteinaceous oedema, perivascular plasmacytosis and frequent necrobiosis of neutrophilic granulocytes or cellular debris are the most conspicuous features. However, the histopathology of the bone marrow described gives no indication of the specific drug responsible and no specific suggestion of any group of drugs. Generally the histopathology allows the recognition of lesions which are induced by the toxicity of these agents. Therefore a bone marrow biopsy should be included in the diagnostic procedures whenever a toxic lesion is suspected of causing haematological disorders, particularly in all cases of uncertain pancytopenia.

Mandibular myelosarcoma (chloroma): primary oral manifestation of promyelocytic leukemia

The case of a 35-year-old female patient with primary mandibular manifestation of myelosarcoma (chloroma) is reported. The clinical course and diagnostic and therapeutic measures are described. Myelosarcomas are rare and are considered specific lesions of an acute myeloid leukemia. In addition to systemic leukemia therapy, myelosarcomas frequently have to be treated surgically or by irradiation because of their specific tumor localizations.

Malignant (acute) myelosclerosis--a clinical and pathological study in 6 patients

Clinical and morphological findings are described in 6 patients with malignant (acute) myelosclerosis/fibrosis (MMS). Haematological data are characterized by severe anaemia and thrombocytopenia, frequently accompanied by a leucopenia with an increase in myeloblasts and promyelocytes in the peripheral blood count. There is an absence of, or a minimal hepatosplenomegaly and the survival times after onset of clinical symptoms to death range from 4-12 months. The histopathology of the bone marrow shows a conspicuous proliferation of blasts (myeloblasts, promyelocytes and megakaryoblasts) in a variable amount, besides a fibrosclerosis consisting of reticulin and collagen fibrils. A comparison of MMS with ordinary myelofibrosis/osteomyelosclerosis (MF/OMS) of a chronic course implicates two important facts: (a) evolution of fibrosclerosis takes a considerable period of time for manifestation, which ranges between 20-30 months; (b) the histopathology of MMS is identical with those features observable in the rare event of a terminal stage, i.e. blastic transformation of chronic MF/OMS. Consequently MMS should be designated as an accelerated variant of MF/OMS with a rather early occurrence of a blastic crisis. The insidious onset with the dominant clinical finding of anaemia is probably responsible for the relatively late appearance of symptoms, while the progressive course prevents an overt myeloid metaplasia with a massive hepatosplenomegaly.

Emperipolesis--a peculiar feature of megakaryocytes as evaluated in chronic myeloproliferative diseases by morphometry and ultrastructure

A combined morphometric and ultrastructural study was performed on so called emperipolesis or internal wandering of myeloid cells in the cytoplasm of large mature megakaryocytes. Measurements were made on material from a total of 115 patients comprising a normal control group and 5 groups with subtypes of chronic myeloproliferative diseases, including primary (essential, idiopathic) thrombocythemia (PTH). A significant increase in this peculiar phenomenon was noted in myeloproliferative disorders and especially in PTH where the frequency of emperipolesis showed a positive correlation with the number of anuclear cytoplasmic fragments sectioned, with the circular deviation of the shapes of megakaryocytes and with the extent to which the peripheral thrombocyte count was elevated. Electron microscopy in selected cases displayed the integrity of the plasma membranes of engulfed hematopoietic cells within the dilated cavities of the megakaryocytic demarcation membrane system (DMS) and no evidence of phagocytosis. Moreover there was a close relationship between engulfed myeloid cells and the presumptive sites of platelet shedding which had their openings from the cisternal lumina of the DMS. Our results demonstrate that emperipolesis of hematopoietic cells within megakaryocytes should not be regarded as a special nosological feature, but as an indication of enforced thrombocytogenetic activity which is expressed particularly in PTH.

Mitochondrial anomalies in renal oncocytes induced in rat by N-nitrosomorpholine

Renal oncocytes were induced in male Sprague-Dawley rats by oral application of N-nitrosomorpholine (NNM) in a concentration of 12 or 50 mg per 100 ml drinking water and analysed by transmission electron microscopy. The oncocytes exhibited mitochondrial anomalies which were very similar to those of human oncocytoma oncocytes. The most striking mitochondrial changes were an unusually large number of the organelles and an excess of the cristae mitochondriales. The shape of the mitochondria varied from round and oval to extremely elongated slender or cup-shaped organelles often piled up to form complex bodies. Rarely large ramifying mitochondria were found. In addition to transversely orientated cristae or tubules the inner mitochondrial membranes frequently formed dense stacks of unusually long cristae often arranged longitudinally. In some mitochondria straight and strictly parallelly arranged neighbouring cristae were found to be connected by a paracrystalline array of pillars bridging the mitochondrial matrix. In the majority of oncocytes the mitochondrial matrix contained prominent dense granules (diameter 30-50 nm), but sometimes these were rare or absent. Individual mitochondria of many oncocytes showed membrane-bound deposits of glycogen particles which usually formed rosettes (alpha-particles) with a diameter of about 80 nm. Partitioned mitochondria were not seen. Often autophagic vacuoles containing portions of degraded mitochondria and dense bodies, probably autophagosomes, were observed. The nature and significance of the oncocytes remains unclear, but we suggest from these and earlier experimental results that oncocytes represent a special type of a neoplastically transformed cell which usually has only a low potential for "autonomous" growth. Renal oncocytes induced in rats by chemical carcinogens appear to be an excellent experimental model for the further investigation of this cell type.

[Morphogenesis and micromorphology of epithelial tumors induced in the rat kidney by nitrosomorpholine. IV. Tubular lesions and basophilic tumors (author's transl)]

The genesis of basophilic cell kidney tumors was investigated stepwise by light and electron microscopy in rats treated with N-nitrosomorpholine for a limited time (stop experiment). Seven weeks after the beginning of the experiment the kidney tubules sometimes showed unusually large "chromophobic" and basophilic cells. After a lag period of 22-97 weeks more than 60% of the animals had developed these atypical tubules. Parallel to the appearance of chromophobic tubules 50% of the carcinogen-treated animals developed basophilic cell kidney tumors. All intermediate stages between chromophobic or basophilic cell tubules and tumors were found. During the neoplastic transformation chromophobic epithelia appeared to change into basophilic cells. Some of the chromophobic renal tubules and most of the renal tubules which consisted of chromophobic and basophilic epithelia stored acid mucopolysaccharides as demonstrated by histochemical methods. The fine structure of the basophilic epitheliomas was relatively uniform. The basophilia observed under the light microscope correlated with abundant membrane-bound and free ribosomes as seen under the electron microscope. The frequent appearance of brush borders and microbodies indicated the origin of the basophilic cell tumors from proximal renal tubules. In some tumor cells many mitochondria were found. These cells resembled oncocytes. However, in contrast to typical oncocytes the mitochondria of these cells were poor in cristae or showed tubular formations of the inner membrane. In some mitochondria homogeneous condensations could be detected in the intracristal space and tooth-like formations were seen on the surface of the cristae. In perpendicular sections these cristae resembled saw blades. Acute tubular lesions and cellular regeneration, as described earlier by other authors in early stages of the development of kidney tumors, were not found. It is suggested that the storage of acid mucopolysaccharides observed in many tubules and in some renal tumors indicates a disturbance of the cellular metabolism which plays an important role in tumor development.

[Neoplastic and preneoplastic lesions in rats after oral administration of a single dose of N-nitrosomorpholine (author's transl)]

The administration of a single oral dose of 320 mg/kg body wt. N-nitrosomorpholine (NNM) to 62 Sprague-dawley rats resulted in neoplastic and preneoplastic changes in different organs, especially in liver and kidney. After a lag period of 4 weeks, nearly all experimental animals developed preneoplastic (clear cell, acidophilic, basophilic, mixed cell) foci of the liver parenchyma. Sporadically, small neoplastic nodules were found in the liver as early as 4 weeks after the beginning of the experiment. After a lag period of 1--2 years, 4 of 13 rats showed multiple neoplastic hepatic nodules and one animal a hepatocellular carcinoma. The bile ductules of some animals responded to the carcinogen by forming mucous cholangiofibroses and cystic cholangiomas. After long lag periods, large cholangiofibromas were found in two experimental animals. One or two years after application of the carcinogen, many animals developed epithelial (clear cell, acidophilic, chromophobic, basophilic, oncocytic) kidney tumors, often cystic. Pathologically changed (clear cell, chromophobic, basophilic, oncocytic) tubules are regarded as precursors of the epithelial tumors. The latered tubules appear for the first time at about half a year after application of the carcinogen. Apart from multiple cysts of the liver and kidneys some pancreatic cysts developed in two animals. In addition, two mesenchymal kidney tumors, one malignant neurinoma, two subcutaneous fibromas, one fibroadenoma, and one squamous cell carcinoma of the skin were observed.