Association of HLA class II genes with systemic sclerosis in Koreans

OBJECTIVE

To investigate HLA class II associations with systemic sclerosis (SSc) in Koreans according to anti-topoisomerase I (anti-topo I), anti-centromere antibody (ACA), and anti-U1 ribonucleoprotein (RNP) status.

METHODS

HLA class II alleles (DRB1, DRB5, DQB1) were determined by DNA typing in 200 healthy control subjects and 74 patients with SSc: 35 anti-topo I positive, 3 ACA positive, and 19 anti-U1 RNP positive; among them were 34 diffuse and 40 limited subtypes, and 16 overlap syndrome.

RESULTS

Anti-topo I positive SSc was strongly associated with DRB1*1502 compared with both controls (23% vs 5%; Pcorr = 0.003) and anti-topo I negative patients (23% vs 3%; p = 0.009); our study confirms observations in Japanese. HLA-DR 67FLEDR71, especially 38V-67FLEDR71 sequence (carried on DRB5*0102 in linkage disequilibrium with DRB1*1502, DRB1*0802, DRBI*1101), showed the strongest association with anti-topo I response (46% vs 16% in controls; Pcorr = 0.001), and 38L-67FLEDR71 group alleles were not associated with anti-topo I response. Anti-topo I response was not significantly associated with HLA-DQB1 alleles in Koreans. There were only 3 ACA positive patients, and all patients had DRB1*1501 and DQB1*0602 as heterozygotes. Anti-U1 RNP occurred at a high frequency (63%) among patients with overlap syndrome, and was not associated with HLA-DR or DQ genes. Among anti-topo I negative patients, diffuse and limited subtypes of SSc were significantly associated with DRB1*0803 (47% vs 15% in controls; Pcorr < 0.05) and DRB1*1501 (50% vs 17% in controls; Pcorr < 0.01), respectively. These HLA associations have not been reported in other ethnic groups and possible associations with certain autoantibody subsets remain to be confirmed.

CONCLUSION

HLA-DR gene has a primary association with anti-topo I response, and HLA-DR 38V-67FLEDR71 group alleles including DRB5*0102 (in linkage disequilibrium with DRB1*1502) show the strongest association with anti-topo I response in Korean patients with SSc.

Cloning and sequence analysis of Gpdh in Callosobruchus chinensis (Coleoptera: Bruchidae)

The Sn-Glycerol-3-phosphate dehydrogenase (GPDH: NAD+ 2-oxidoreductase, EC 1.1.1.8) gene of C. chinensis was cloned and its nucleotide sequence was analyzed. The gene was obtained by screening a genomic library with Drosophila melanogaster Gpdh and PCR amplification. The 5,126 bp gene obtained is comprised of one 5' untranslated region, eight exons, seven introns, and three 3' untranslated regions. Comparison of Gpdh of D. melanogaster with that of C. chinensis showed a 89.9% identity in the coding region, 70% in the intron, 79% in the entire nucleotide sequence, and 83.2% in the deduced amino acid sequence. The transcription initiation site is located 33 nucleotides upstream of the initiation codon, and the sequence analysis of the promoter region showed TATA and CAAT boxes at the 5' end. The stop codon (TAA) and polyadenylation signal (AATAAA) are located at the 3' end of each of the exons 6 to 8. These findings show that GPDH isozymes in C. chinensis are produced by the alternative processing of 3' exons. The occurrence of the three transcripts was proven by RT-PCR using synthetic oligonucleotides complementary to the predicted unique 3' regions. Compared to the D. melanogaster GPDH isozymes, GPDH-1, -2, and -3, C. chinensis GPDH showed 83.6%, 83%, and 84% identities, respectively.

HLA-B*07 allele frequencies and haplotypic associations in Koreans

We have investigated the frequencies of HLA-B*07 alleles and their haplotypic associations with HLA-A, -C and -DRB1 loci in 489 healthy unrelated Koreans, including 214 parents from 107 families. All of the 45 samples (9.2%) typed as B7 by serology were analyzed for B*07 alleles using polymerase chain reaction (PCR)-single strand conformation polymorphism (SSCP) method. Two different B*07 alleles were detected: B*0702 (allele frequency 0.041) and B*0705 (0.005). Two characteristic haplotypes showing strong linkage disequilibrium in Koreans were A*2402-Cw*07-B*0702-DRB1*0101 (haplotype frequency 0.028) and A*2901-B*0705-DRB1*0803 (0.005). The characteristic haplotype A*2901-B*0705-DRB1*0803, found in 100% (5/5) of B*0705-positive individuals, has not been previously described in other ethnic groups. HLA-B7 alleles comprise distinctive extended haplotypes in the Korean population. The probability of HLA-B7 allele mismatches among ABDR-matched unrelated donor-recipient pairs is expected to be low in Koreans.

Kaposi's sarcoma involving a transplanted kidney, ureter and urinary bladder: ultrasound and CT findings

We report the imaging findings in a case of Kaposi's sarcoma involving a transplanted kidney, ureter and urinary bladder. Ultrasound and CT demonstrated multiple nodular masses in the pelvis of the transplanted kidney, ureter and bladder. The masses enhanced well on CT following i.v. contrast medium.

Treatment of suprachoroidal hemorrhage with tissue plasminogen activator

We evaluated the efficacy of tissue plasminogen activator in treating experimental suprachoroidal hemorrhage. Suprachoroidal hemorrhage was created in 30 white rabbit eyes by implanting four pieces of small, exogenously formed blood coagula into the suprachoroidal space. Animals were randomized for treatment with a surgical sponge soaked in 25, 50, or 75 microg of tissue plasminogen activator (tPA) or balanced salt solution (BSS) as a control. The time when initiation and completion of clot dissolution occurred was established, and histological examination was performed to assess damage. Clot dissolution started within 30 min in the 50- and 75-microg tPA group, whereas it took 2.75 days in the control group; complete dissolution of blood clots took 4.5 h in the 75-microg tPA group and 14 days in the control group. Histological examination revealed a minimal change in photoreceptors within 6 h after treatment with 75 microg tPA. Treatment of suprachoroidal hemorrhage with tPA seems to be effective, but further investigations for determining the effective and nontoxic dose are required.

The mucinous layer of corneal endothelial cells

PURPOSE

The goal of this study was to characterize the morphology of the mucinous layer on rabbit, bovine, owl, and human corneal endothelial cells.

METHODS

Corneoscleral buttons were fixed using cetylpyridinium chloride to stabilize "mucus" and the tissue was prepared for transmission electron microscopy. Photomicrographs were measured to determine the thickness of the endothelial and epithelial mucinous layer in the central cornea.

RESULTS

The endothelial mucinous layer was seen as a nearly uniform electrodense region on the apical aspect of the endothelium. It was found to be 0.9 microm, 0.9 microm, 0.9 microm, and 0.5 microm thick in rabbit, bovine, owl, and human, respectively. The owl endothelium had an additional less electrodense layer with a granular appearance and a thickness of about 200 microm. The mucinous layer on the epithelium was similar in appearance to that on the endothelium and across species.

CONCLUSIONS

The morphologic similarity of the endothelial and epithelial mucinous layers is a serendipitous finding that should prove valuable in experimental design. Ultimately, it is hoped that studies of the posterior corneal surface will deepen our knowledge of endothelial protection.

HLA-DR2-associated DRB1 and DRB5 alleles and haplotypes in Koreans

There are considerable racial differences in the distribution of HLA-DR2-associated DRB1 and DRB5 alleles and the characteristics of linkage disequilibrium between these alleles. In this study, the frequencies of DR2-associated DRB1 and DRB5 alleles and related haplotypes were analyzed in 186 DR2-positive individuals out of 800 normal Koreans registered for unrelated bone marrow donors. HLA class I antigen typing was performed by the serological method and DRB1 and DRB5 genotyping by the PCR-single strand conformational polymorphism method. Only 3 alleles were detected for DR2-associated DRB1 and DRB5 genes, respectively: DRB1(*)1501 (gene frequency 8.0%), (*)1502 (3.2%), (*)1602 (0.9%); DRB5(*)0101 (8.0%), (*)0102 (3.2%), and (*)0202 (0.9%). DRB1-DRB5 haplotype analysis showed an exclusive association between these alleles: DRB1*1501-DRB5*0101 (haplotype frequency 8.0%), DRB1(*)1502-DRB5(*)0102 (3.2%), and DRB1(*)1602-DRB5(*)0202 (0.9%). The 5 most common DR2-associated A-B-DRB1 haplotypes occurring at frequencies of > or = 0.5% were A24-B52-DRB1(*)1502 (1.8%), A2-B62-DRB1(*)1501, A2-B54-DRB1(*)1501, A26-B61-DRB1(*)1501, and A24-B51-DRB1(*)1501. The remarkable homogeneity in the haplotypic associations between DR2-associated DRB1 and DRB5 alleles in Koreans would be advantageous for organ transplantation compared with other ethnic groups showing considerable heterogeneity in the distribution of DRB1-DRB5 haplotypes.

Expression and distribution of extracellular matrices during corneal wound healing after keratomileusis in rabbits

We compared the corneal wound healing responses of keratomileusis and keratectomy in rabbits. A single pass of thin lamellar keratectomy was performed with a microkeratome in rabbits. The lenticule was repositioned with a hinge in one group and discarded in the other. With immunofluorescence techniques, we studied the appearance and distribution of fibronectin, fibrinogen and type III collagen at follow-up intervals from 1 h to 3 months. Fibronectin and fibrinogen began to deposit on the periphery of the denuded stroma 3 h after induced injury and diminished once reepithelialization had completed in both groups. In the corneas with attached lenticules, type III collagen was detected 7 days after surgery and lasted for at least 3 months. Type III collagen was detected only in the periphery of the interface and not in its center. These findings suggest that fibronectin and fibrinogen may play roles in epithelial healing after in situ keratomileusis in rabbits. Stromal healing of collagen seems to take place 7 days after keratomileusis and to last for several months. No deposits of new collagens in the center of the interface between lenticule and stromal bed may explain the optical clarity in the keratomileusis.

Differential adhesion molecule requirements for immune surveillance and inflammatory recruitment

Activated CD4 Th1 lymphocytes can enter the brain in the absence of an inflammatory focus. However, the molecular mediators that regulate this early migration of lymphocytes into the brain have remained unclear. We hypothesized that the entry of these 'pioneer' lymphocytes into the brain is regulated by a set of molecular events that are distinct from those used once inflammation has been established. Using cells fluorescently labelled with the lipophilic dye DiI, myelin basic protein (MBP)-specific CD4 lymphocytes that expressed low or high levels of very late antigen-4 (VLA-4) and non-antigen-specific activated splenocytes homed to mouse brain in similar quantities 2 h after adoptive transfer. However, antigen specificity and VLA-4 expression were required for more robust recruitment by 24 h. Immunocytochemistry revealed endothelial and microenvironmental upregulation of vascular cell adhesion molecule (VCAM), intercellular cell adhesion molecule 1 (ICAM-1), MHC class II and interferon-gamma 48 h after transfer of MBP-specific cells. In contrast, expression of meningeal and choroid plexus-associated P selectin was upregulated 2 h after adoptive transfer, but not at 48 h. Monoclonal antibody to P selectin, but not to VLA-4, inhibited early migration of high VLA-4-expressing MBP-specific lymphocytes. These results suggest that early migration occurs independent of the lymphocyte integrin VLA-4 and endothelial VCAM, but does require increased surface expression of endothelial P selectin.

Magnetic interactions in the high-spin iron(III) oxooctaethylchlorinato derivative [Fe(oxoOEC)(Cl)] and its pi-cation radical [Fe(oxoOEC.)(Cl)]SbCl6

The preparation and characterization of the beta-oxochlorin derivative [3,3,7,8,12,13,17,18-octaethyl-(3H)-porphin-2-onato(2-)]iron(III) chloride, [Fe(oxoOEC)(Cl)], and its pi-cation radical derivative [Fe(oxoOEC.)(Cl)]SbCl6 is described. Both compounds have been characterized by single-crystal X-ray structure determinations, IR, UV/vis/near-IR, and Mössbauer spectroscopies, and temperature-dependent magnetic susceptibility measurements. The macrocycles of [Fe(oxoOEC)(Cl)] and [Fe(oxoOEC.)(Cl)]SbCl6 are both saddled, and [Fe(oxoOEC.)(Cl)]-SbCl6 is slightly ruffled as well. [Fe(oxoOEC)(Cl)] shows a laterally shifted dimeric unit in the solid state, with a mean plane separation of 3.39 A and a lateral shift of 7.39 A. Crystal data for [Fe(oxoOEC)(Cl)]: triclinic, space group P1, Z = 2, a = 9.174(2) A, b = 13.522(3) A, c = 14.838(3) A, alpha = 95.79(3) degrees, beta = 101.46(2) degrees, gamma = 104.84(3) degrees. Upon oxidation, the inter-ring geometric parameters increase; the mean plane separation and the lateral shift of the dimeric unit of [Fe(oxoOEC.)(Cl)]SbCl6 are 4.82 and 8.79 A, respectively. Crystal data for [Fe(oxoOEC.)(Cl)]SbCl6: monoclinic, space group Cc, Z = 4, a = 19.8419(13) A, b = 10.027(2) A, c = 22.417(4) A, beta = 96.13(2) degrees. A broad near-IR absorption band appears at 1415 nm for the pi-cation radical, [Fe(oxoOEC.)(Cl)]SbCl6. Zero-field Mössbauer measurements at 4.2 K for both [Fe(oxoOEC)(Cl)] and [Fe(oxoOEC.)(Cl)]SbCl6 confirmed that the oxidation state of the iron atom did not change upon chemical oxidation. Solid-state magnetic susceptibility measurements for [Fe(oxoOEC.)(Cl)]SbCl6 resulted in a large temperature dependence of the magnetic moment that can best be fit with a model that includes a zero-field splitting parameter of D = 6 cm-1, antiferromagnetic intermolecular iron-iron coupling (2JFe-Fe = -0.14 cm-1), antiferromagnetic intramolecular iron-radical coupling (2JFe-r = -76 cm-1), and antiferromagnetic radical-radical coupling (2Jr-r = -13 cm-1).

HLA-A*02 allele frequencies and haplotypic associations in Koreans

We have investigated the frequencies of HLA-A*02 alleles and their haplotypic associations with HLA-B and -DRB1 loci in 439 healthy unrelated Koreans, including 214 parents from 107 families. All of the 227 samples (51.7%) typed as A2 by serology were analyzed for A*02 alleles using polymerase chain reaction (PCR)-low ionic strength-single-strand conformation polymorphism (LIS-SSCP) method. A total of six different A*02 alleles were detected (A*02 allele frequency 29.6%): A*0201/9 (16.6%), *0203 (0.5%), *0206 (9.3%), *0207 (3.0%), and one each case of *0210 and *02 undetermined type. Two characteristic haplotypes showing the strongest linkage disequilibrium were A*0203-B38-DRB]*1502 and A*0207-B46-DRB1*0803. Besides these strong associations, significant two-locus associations (P<0.001) were observed for A*0201 with B61, DRB1*0901 and DRB1*1401, and for A*0206 with B48 and B61. HLA haplotypes carrying HLA-A2 showed a variable distribution of A*02 alleles, and all of the eight most common A2-B-DR haplotypes occurring at frequencies of > or =1% were variably associated with two different A*02 alleles. These results demonstrate that substantial heterogeneity is present in the distribution of HLA-A*02 alleles and related haplotypes in Koreans.

Phenolic compounds from the leaves of Cornus controversa

Two novel phenolic compounds from the leaves of Cornus controversa (Cornaceae) were characterized as (-)-2,3-digalloyl-4-(E)-caffeoyl-L-threonic acid and (-)-2-galloyl-4-(E)-caffeoyl-L-threonic acid, using spectroscopic methods.

Solitary fibrous tumor of the orbit: a poorly-recognized orbital lesion

PURPOSE

The authors report three cases with solitary fibrous tumor (SFT) of the orbit with variable clinical presentation.

METHODS

The authors identified three patients with a diagnosis of SFT, and clinical histories, radiographs and pathologic specimens were reviewed.

RESULTS

Two SFTs are reported arising in the lacrimal gland fossa of a 24-year-old male and a 26-year-old female and a retrobulbar SFT is reported occurring in a 40-year-old female. While two patients had slow growth histories, one patient had a history of rapid progression. Immunohistochemically, the tumor cells were strongly positive for CD34 in all three cases.

CONCLUSION

The clinical presentation of the orbital SFT may be varied. Immunohistochemical analysis may help in the diagnosis of solitary fibrous tumor and the treatment is en bloc excision. A careful follow-up is necessary because it may recur years after excision of the primary tumor.

Transcriptional regulation of PDGF-A and TGF-beta by +KTS WT1 deletion mutants and a mutant mimicking Denys-Drash syndrome

Denys-Drash syndrome (DDS) and Frasier syndrome (FS) are rare diseases caused by the mutations of Wilms tumor gene, WT1. The common denominator in these syndromes is a nephropathy which is manifested by early-onset proteinuria, nephrotic syndrome and end stage renal failure. Although these syndromes are genetic models of nephropathy and the mutations of WT1 gene are characterized in these patients the mechanism how mutations of WT1 gene affect the embryonic kidney adversely has not been elucidated. Recently, there was a report that FS is caused by mutations in the donor splice site of WT1. These mutations predicted loss of +KTS isoform, which is one of the four splicing variants of WT1. In this study, two +KTS deletion mutants of WT1 were made as well as a WT1 mutant mimicking a mutation found in a patient who had diffuse mesangial sclerosis, end stage renal failure and Wilms tumor. Mutant embryonic kidney cell lines were established by transfection of 293 embryonic kidney cells with WT1 mutants. We investigated the transcription regulation of mutant WT1 among these cell lines using the reporter vectors containing PDGF-A and TGF-beta promoter sequence. Our results showed that the promoter activity of PDGF-A and TGF-beta, which are related to the progression of glomerular diseases, was modestly increased in the mutant cell mimicking the patent, while those activities were markedly increased in other two deletion mutant cell lines. This study demonstrated that +KTS WT1 mutation found in DDS affected the cytokine expression adversely in vitro. From these results, we suggest that the alteration of +KTS WT1 expression be responsible for the rapid progression of renal diseases in DDS and FS.

The effects of high-dose corticosteroid therapy on optic nerve head blood flow in experimental traumatic optic neuropathy

PURPOSE

The objective of this study was to ascertain the effect of high-dose steroid therapy in traumatic optic neuropathy using the Heidelberg retina flowmeter (HRF) to detect changes in optic nerve head blood flow.

METHODS

We experimentally damaged the optic nerves of 10 white rabbits with a Hartman mosquito clamp. The first group (n = 5) was treated with intravenous dexamethasone (0.25 mg/kg) every 6 h for a 48-hour period. The second group (n = 5) served as controls. Both groups were tested prior to operation, 1 week, 1 month and 2 months after surgery.

RESULTS

Experimental optic nerve damage caused a significant decrease in optic nerve head blood flow of 50.51% (p = 0.001), with a volume decrease of 46.02% (p = 0.001) and a velocity reduction of 43.12% (p = 0.002) compared to the baseline. After 2 months, in the group treated with high-dose corticosteroid therapy, optic nerve head blood flow was increased by 76.90% (p = 0.012), volume by 77.53% (p = 0.012) and velocity by 47. 21% (p = 0.012) compared to the control group.

CONCLUSION

The high-dose corticosteroid therapy improved the optic nerve head blood flow as demonstrated in experimental traumatic optic neuropathy. The HRF may be used to assess the therapeutic responses in traumatic optic neuropathy under variable conditions.

High resolution HLA-DQB1 typing by combination of PCR-RFLP and PCR-SSCP

A reliable method for high-resolution HLA-DQB1 typing using a combination of PCR- restriction fragment length polymorphism (RFLP) and PCR-single strand conformation polymorphism (SSCP) analysis is described. The second exon of the DQB1 gene was subjected to PCR using generic primers and digested with two restriction enzymes, MspA1I and HaeIII, and the DQB1 alleles were divided into seven groups. According to the RFLP patterns, appropriate group specific primers for DQ5, 6 and DQ2, 3, 4 groups were used to selectively amplify the alleles and the SSCP technique was used to distinguish the individual alleles. A total of 88 quality control samples of various ethnic groups distributed in the International Cell Exchange and HLA DNA Exchange programs and the ASHI/CAP Proficiency Tests were investigated by the PCR-RFLP/SSCP method. The concordance between our typing results and the consensus results of the surveys were 100%, and a total of 14 DQB1 alleles in 49 homozygous and heterozygous combinations were all correctly identified by the method described. This method is accurate, economical and relatively easy to interpret and well suited for routine clinical and research uses.

A case of cutaneous endometriosis developed in postmenopausal woman receiving hormonal replacement

Cutaneous endometriosis is characterized by the presence of extrauterine endometrial tissue in or under the skin. We report a case of cutaneous endometriosis in postmenopausal woman who was receiving hormonal replacement.

Congenital intraorbital optic nerve cyst. Case report

Congenital cystic lesions of the optic nerve are exceedingly rare; only one case is reported in the world literature. The authors describe a case of congenital simple glial cyst in the intraorbital portion of the optic nerve with a brief review of the literature and comment on its histogenesis. A 45-day-old male infant was admitted to the hospital because of progressive proptosis and hypotropia in the left eye, which had been present since birth. Magnetic resonance imaging of the left orbit revealed an ovoid, well-demarcated, homogeneous cystic mass in the intraconal retrobulbar area. The mass compressed the left eyeball with downward and lateral displacement. The wall of the cystic mass was very thin, and a needle puncture of the cyst released clear, colorless, watery fluid. The cystic wall was lined by loose astroglial nerve fibers with some scattered glial cells.

Study on genetic variation and DNA polymorphism for alpha-amylase gene of D. melanogaster in Korea

The restriction maps of the 20 kb Amy region of Drosophila melanogaster in Korean populations were surveyed from 27 isogenic second chromosome lines. A subset of these populations were also scored for isozyme type and adult enzyme activity of alpha-amylase. Among 34 kinds of restriction site variations that were observed in the 20 kb region surrounding the two transcriptional units of the duplicated Amy locus, nine were polymorphic (26.5%). The low frequencies at which each of the large insertions was found are consistent with earlier reports of variation in other loci. Restriction site variation in Korean populations provided an estimated heterozygosity per nucleotide pair of 0.007. Three pairwise comparisons showed relatively high levels of linkage disequilibria. The enzyme activity of the Chounan population showed no significant difference compared with that of the Pusan population, and the activity of heterozygotes was higher than that of Amy1. Lines bearing insertion/deletion exhibited relatively low enzyme activities. All lines examined showed the duplication of Amy transcriptional units that were highly conserved, and the manner of concerted evolution.

HLA-A,-B,-DRB1 allele and haplotype frequencies in 510 Koreans

The frequencies of HLA-A, -B, and -DRB1 alleles and A-B-DRB1 haplotypes were studied in 510 healthy unrelated Koreans, using serological (for A, B) and polymerase chain reaction (PCR)-single strand conformation polymorphism (for DRB1) methods. A total of 35 DRB1 alleles were detected and the most frequent alleles were DRB1*1302 (10.9%), *0901 (9.5%), *1501 (8.2%), *0803 (7.3%), *0405 (7.3%), *0101 (6.4%), *0406 (6.0%), and *0701 (6.0%). HLA-DR4 and DR14 groups were most polymorphic, each group composed of eight DRB1 alleles. Two-locus associations between HLA-DRB1 and -B loci were analyzed. There were 16 A-B-DRB1 haplotypes occurring at frequencies of > or =1%, and the five most common haplotypes were A33-B44-DRB1*1302 (5.4%), A33-B58-DRB1*1302 (3.7%), A33-B44-DRB1*0701 (2.9%), A24-B7-DRB1*0101 (2.2%), and A24-B52-DRB1*1502 (2.0%). Comparison of the distribution of A-B-DRB1 haplotypes among East Asian populations revealed that Koreans are closest to Japanese, out show a higher degree of polymorphism compared with Japanese.

Malignant granular cell tumor at the retrotracheal space

We report a case of an extremely rare neoplasm, malignant granular cell tumor (MGCT). The patient was a 21-year-old woman, who was 5 months pregnant. The tumor occurred in the retrotracheal space, extending from the level of the larynx to the thoracic inlet. In addition, there were multiple, variable-sized tumor nodules within both lung fields on chest CT scan. Histologically, tissue biopsied from the periphery of the tumor consisted of solid sheets of large ovoid cells with ample, eosinophilic cytoplasm, eccentric nuclei, and prominent nucleoli. Each cell showed slight atypism of the nuclei. There was a focal necrosis at the periphery of the lesion. These cells stained strongly for S-100 protein, neuron-specific enolase (NSE) and CD68. On electron microscopy, the tumor cells contained autophagic vacuoles. The patient refused further treatment and died 7 months later. The exact cause of death was not known. Until now, the diagnosis of MGCTs has been made only when metastasis and an aggressive clinical course are identified, although some observers advocate that some histologic features such as nuclear pleomorphism, necrosis, and the presence of any mitotic activity are indicative of malignancy. These histologic findings are not easily detectable in every case of MGCT, as in our case. So the diagnosis of a MGCT should be considered in cases with aggressive clinical findings and some histologic features, such as necrosis, nuclear atypism, and mitotic activities, which could suggest the malignant behavior of this neoplasm.