Gastric carcinoma in siblings with Friedreich's ataxia

Friedreich's ataxia is a hereditary neurological condition characterized by severe ataxia. We report the cases of two siblings with this condition, both of whom developed signet ring cell adenocarcinoma of the stomach at a young age. This association has not been previously described and it suggests the presence of an unidentified aberrant gene.

Prognostic significance of angiogenesis in transitional cell carcinoma of the human urinary bladder

OBJECTIVES

To quantify tumour angiogenesis in bladder cancer and determine whether it correlates with tumour stage, grade and survival.

PATIENTS AND METHODS

Archival samples from a total of 113 patients newly presenting with transitional cell carcinomas of the urinary bladder were graded and staged, and analysed for angiogenic blood vessel density by a double immunohistochemical technique. The findings were correlated with the information obtained during a minimum follow-up of 12 years.

RESULTS

Univariate analysis showed that TNM stage (P = 0.02) and mean vessel count (P = 0.01) were significant predictors of death from bladder cancer. Blood vessel density was significantly correlated with tumour stage (P = 0.01) and the presence of vascular invasion (P = 0.007). Trained observers were essential for the accurate counting of blood vessels to prevent excessive inter-observer variability. Multiple regression analysis showed that the combination of mean vessel count and stage was a significant prognostic indicator.

CONCLUSION

Angiogenesis in primary bladder cancer is a predictor of death from the disease. Further work to determine whether it predicts invasion and recurrences in superficial tumours may be valuable.

Does cryptic gluten sensitivity play a part in neurological illness?

BACKGROUND

Antigliadin antibodies are a marker of untreated coeliac disease but can also be found in individuals with normal small-bowel mucosa. Because neurological dysfunction is a known complication of coeliac disease we have investigated the frequency of antigliadin antibodies, as a measure of cryptic gluten sensitivity, and coeliac disease in neurological patients.

METHODS

Using ELISA, we estimated serum IgG and IgA antigliadin antibodies in 147 neurological patients who were divided into two groups. There were 53 patients with neurological dysfunction of unknown cause despite full investigation (25 ataxia, 20 peripheral neuropathy, 5 mononeuritis multiplex, 4 myopathy, 3 motor neuropathy, 2 myelopathy). The remaining 94 patients were found to have a specific neurological diagnosis (16 stroke, 12 multiple sclerosis, 10 Parkinson's disease, 56 other diagnoses) and formed the neurological control group. 50 healthy blood donors formed a third group.

FINDINGS

The proportions of individuals with positive titres for antigliadin antibodies in the three groups were 30/53, 5/94, and 6/50 respectively (57, 5, and 12%). The difference in proportion between group 1 and the combined control groups was 0.49 (95% CI 0.35-0.63). Distal duodenal biopsies in 26 out of 30 antigliadin-positive patients from group 1 revealed histological evidence of coeliac disease in nine (35%), non-specific duodenitis in ten (38%), and no lesion in seven (26%) individuals.

INTERPRETATION

Our data suggest that gluten sensitivity is common in patients with neurological disease of unknown cause and may have aetiological significance.

Fetal lipoproteins and placental release of esterified lipids

An in vitro incubation technique was used to examine the release of lipids from the rabbit placenta. Free fatty acid, but not phospholipid or triacylglycerol, was released into the incubation media. In a second series of experiments, the addition of lipids to the umbilical circulation was studied in situ in the placenta of anaesthetized rabbits at late gestation. Each placenta was perfused from the fetal side in turn with two different perfusate solutions, either 4% bovine albumin solution or rabbit plasma. The rabbit plasma contained the appropriate carriers (lipoproteins) for esterified lipids, whereas the 4% albumin solution did not. The effluent perfusates were remarkably similar in free fatty acid concentration and composition, which closely matched the maternal free fatty acid profiles. The concentrations and fatty acid composition of the perfusate triacylglycerol and phospholipid fractions were unchanged by passage through the placenta, whether perfused with 4% albumin or with rabbit plasma. With this system, no evidence could be found for the addition of esterified lipids to the umbilical circulation in the rabbit despite the provision of appropriate carriers on the fetal side of the placenta.

Fractal and integer-dimensional geometric analysis of pigmented skin lesions

Accurate in vivo diagnosis of pigmented skin lesions is required to identify and excise malignant melanomas but to avoid unnecessary excision of benign lesions; the published rates of clinical diagnostic accuracy are about 65%. This study investigates whether fractal geometric analysis of pigmented skin lesions can improve the rate of diagnostic accuracy. Forty-two pigmented skin lesions (15 malignant melanomas, 21 melanocytic naevi, and 6 basal cell papillomas) on patients attending a dermatology clinic were photographed, excised, and sent for histopathological examination. The fractal dimension of the boundary of the lesions was measured using a box-counting method implemented on a microcomputer-based image analysis system. Euclidean geometric parameters were also measured. The fractal dimension of all the lesions was greater than the topological dimension (one), indicating that there is a fractal element to their structure. Using all measured parameters together, multivariate linear discriminant analysis produced a confusion matrix in which 45% of the lesions were assigned to the correct diagnostic group with a kappa statistic of 0.33. There was no significant difference between the fractal dimension of melanocytic naevi and that of malignant melanomas (p = 0.18). Although pigmented skin lesions have a fractal element to their structure, the fractal dimension of their boundaries is not a useful morphometric discriminant between the diagnostic groups of malignant melanomas and benign melanocytic naevi.

Effects of hormone replacement therapy on fine needle aspiration cytology of the breast

To investigate the possibility that hormone replacement therapy (HRT) might induce morphologic changes in breast cytology simulating malignancy, we determined the subjective interpretation and objective morphometric features of 39 fine needle aspiration cytology samples from women who were using a variety of HRT preparations. Cases were matched for age and final diagnosis (assessed by a triple approach) with women who had never used HRT. Cytocentrifuge preparations stained with Papanicolaou stain were assessed by two observers for cellularity and diagnosis. Although diagnostic accuracy was slightly higher in HRT than non-HRT samples, there was no significant difference in the assessments of cellularity and diagnosis between the two observers or between HRT and non-HRT samples. Nuclear areas in HRT samples were larger than in non-HRT samples, measured using computerized image morphometry; this difference did not induce the observer to diagnose malignancy more frequently. HRT had no adverse effect upon the accuracy of interpreting breast fine needle aspiration cytology samples.

Fractal geometric analysis of the renal arterial tree in infants and fetuses

Fractal geometry is a useful method of quantitating the space-filling properties of complex objects and has a particular advantage in pediatric pathology because it is independent of organ size. The fractal dimensions of angiographic images of 44 renal arterial trees from 23 consent pediatric autopsies were measured by the box-counting method. The mean fractal dimension was 1.64 and all values were greater than the topological dimension (one), indicating that the renal arterial tree in fetuses and infants has a fractal element to its structure. There was no significant association with size of the kidneys, confirming the size-independent nature of the fractal dimension. There was no significant association with age of the subject, and the mean value was not significantly different from values obtained in studies of adult kidneys, suggesting that the degree of branching, at a lobar and lobular level, does not increase after about the 21st week of gestation. The results are compatible with a diffusion-limited aggregation model of development.

The photocopier: an overlooked tool in surgical pathology

Pictorial representation of gross pathological specimens aids interpretation of many specimens in surgical pathology. The availability of such images is invaluable to subsequent review of material. Line diagrams are subjective and imprecise. Photographic recording of specimens is expensive, particularly if an instant image is required. A completely enclosed technique in which a plain paper photocopier is used to record images of gross pathological specimens is described together with appropriate applications in surgical pathology. The photocopier represents an inexpensive, rapid and reliable method of producing an acceptable permanent record of many gross specimens.

Effects of piezoelectric lithotripsy on human DNA

Genomic DNA was extracted from excised gallbladder mucosa, obtained shortly after a single treatment piezoelectric lithotripsy. Control samples were obtained from age and sex-matched patients who had received no lithotripsy. No DNA fragmentation was demonstrable on agarose gel electrophoresis. Suspensions of cultured lymphoblasts were subjected to different shock wave doses and the percentage of cells surviving the treatment was assessed immediately and the rate of cell death monitored over the following 7 h. The proportion of cells surviving the treatment decreased with increasing shock wave doses, but subsequent rate of cell death was no different from controls. DNA, extracted from the intact surviving cells, again showed no evidence of fragmentation on electrophoresis, but the DNA extracted from the supernatant showed extensive fragmentation.

Proliferating cell nuclear antigen immunostaining in keratoacanthoma and squamous cell carcinoma of the skin

Proliferating cell nuclear antigen expression was used to seek differences between keratoacanthoma and squamous cell carcinoma of the skin. These lesions of the skin continue to provoke interest due to their different biological behaviour in spite of histologically similar appearances. The primary antibody, PC10 was used in a three stage avidin biotin peroxidase complex technique on section from 27 cases of KA, 15 of well, 16 of moderately- and 15 of poorly differentiated SCC. The distribution of positive cells was determined and then one thousand randomly chosen lesional epithelial nuclei were categorised for PCNA immunoreactivity and the results expressed as percentage of epithelial nuclei stained. Statistical analysis revealed a highly significant trend in increasing %PCNA with histological grade of skin lesion (P < 0.0001). Poorly differentiated, although not other grades of squamous cell carcinoma have a significantly higher proportion of PCNA labelled nuclei than keratoacanthoma. In addition, the distribution of PCNA positive nuclei in keratoacanthoma are usually peripheral contrasting with the more diffuse pattern seen in most cases of SCC. %PCNA alone was a more powerful predictor of histological subtype than distribution alone. PCNA immunohistochemistry not only provides additional information facilitating the differential diagnosis between keratoacanthoma and moderate or poorly differentiated squamous cell carcinoma but also underlines the perplexing similarity between keratoacanthoma and well differentiated squamous cell carcinoma.

Effect of nursing position on incidence, type, and duration of clinically significant apnoea in preterm infants

AIM

To investigate whether nursing position has any effect on the frequency, type, and duration of apnoeas in preterm infants.

METHOD

Thirty five preterm infants were entered into a crossover study and underwent polygraphic monitoring in each of two positions, prone and supine, the initial position being randomly allocated. Four parameters were recorded: nasal airflow, respiratory effort, electrocardiogram (ECG), and oxygen saturation. Each infant was studied in the two positions on the same day and each infant was studied only once. The studies were carried out on the neonatal intensive care unit.

RESULTS

The infants were found to have significantly more central and mixed apnoeas in the supine than in the prone position. In addition, the severity of mixed apnoeas in terms of the duration of accompanying bradycardias and desaturations was greater in the supine than in the prone position (median difference 5.1 seconds in both instances). When considering the type of apnoea in relation to the duration, it was found that of those less than 20 seconds in duration there was a greater proportion that were central (25%) compared with the proportion of central (5%) apnoeas that were longer than 20 seconds. Of all the apnoeas that were less than 20 seconds in length, 16% were obstructive and 59% were mixed, whereas of the apnoeas greater than 20 seconds, 13% were obstructive and 82% were mixed.

CONCLUSIONS

It appears that in addition to improving measures of lung function, the adoption of the prone nursing position for preterm infants may reduce associated problems of apnoea of prematurity.

Fractal geometric analysis of material from molar and non-molar pregnancies

Histological sections from 25 non-molar pregnancies, nine partial hydatidiform moles, and 16 complete hydatidiform moles were examined (diagnosis was taken as the consensus of seven experienced histopathologists) and the fractal dimension was measured using a box-counting method implemented on a microcomputer-based image analysis system. The fractal dimensions of the different diagnostic categories were normally distributed with a mean of 1.50 for non-molar pregnancies, 1.44 for partial moles, and 1.42 for complete moles. All the measured fractal dimensions were greater than the topological dimension (1), demonstrating that the specimens had a fractal element to their structure. There was a significant difference between the fractal dimensions of non-molar pregnancies and complete moles (P = 0.0005), but not between partial moles and non-molar pregnancies (P = 0.0823) or complete and partial moles (P = 0.4400). Using the fractal dimension to predict the histopathological diagnosis assigned 56 per cent of the cases to the correct category with a kappa statistic of 0.26, so the fractal dimension, used alone, is not a useful morphometric discriminant in the diagnosis of molar and non-molar pregnancy.

Diagnostic associations of p53 immunostaining in fine needle aspiration cytology of the breast

Duplicate cytospin preparations were made from 46 symptomatic breast fine needle aspirates. One of each pair was assigned to benign or malignant categories by one experienced observer as part of the "triple approach" patient assessment. The other was immunostained with DO7, a monoclonal antibody to recombinant p53 protein, and rated by another observer as positive or negative for nuclear staining, unaware of the cytodiagnosis. Positive controls included carcinomas known to have mutant p53, while negative controls were of the reagent substitution type. Of the 26 aspirates with a benign cytodiagnosis (verified by the triple approach), 23 were p53 protein-negative and three positive. Of the 20 with a malignant cytodiagnosis (histologically confirmed), six were p53 protein-negative and 14 positive (exact P < 0.0001). As a diagnostic test this would give 70% sensitivity and 88% specificity.

Nodular basement membrane deposits in breast carcinoma and atypical ductal hyperplasia: mimics of collagenous spherulosis

Collagenous spherulosis is characterised histologically by the accumulation of hyaline globules containing basement membrane components. Originally described in the breast, it has also been found in skin and salivary gland neoplasms. In the breast it has hitherto always been associated with benign disease and reports have asserted that this is invariably the case, cautioning against the diagnosis of malignancy when the condition is seen. We present here five cases with similar appearances to collagenous spherulosis in routine histology and immunohistochemistry, and ultrastructural studies in one of them, in which the condition was not associated with simple benign breast disease. Two of the cases were associated with invasive carcinomas of unusual histological types, one with intracystic papillary carcinoma, one with comedo ductal carcinoma-in-situ and one with atypical ductal hyperplasia. We suggest that appearances similar to collagenous spherulosis can be associated, either through being formed by a lesion or by collision, with malignancy and warn that on encountering the lesions the pathologist must not assume, as suggested in previous accounts, that it denotes a benign process. This is an important observation since collagenous spherulosis is likely to be encountered more frequently in the range of lesions biopsied in national breast screening programs.

Nm23 protein expression in thyroid neoplasms

The nm23 gene production has been heralded as a suppressor of metastasis in many human tumours but it is not clear at which stage in the metastatic process nm23 protein exerts its effect. The aim of this study was to test whether nm23 protein is associated with occurrence or category of angioinvasion. We have made use of the well documented fact that follicular carcinoma of the thyroid may show vascular invasion whereas papillary carcinomas may metastasis via the lymphatics. 65 thyroid tumours (20 follicular adenomas, 22 papillary carcinomas, 23 follicular carcinomas) were stained for nm23 protein using an immunopurified polyclonal antibody. Nm23 protein status showed no correlation with category of thyroid tumour. This is indirect evidence that nm23 does not suppress metastasis by influencing vascular invasion in this tumour type.

Fractal geometric analysis of colorectal polyps

Colorectal polyps have a subjectively self-similar structure which suggests that these structures may have fractal elements and that the fractal dimension may be a useful morphometric discriminant. The fractal dimensions of images from haematoxylin and eosin-stained sections of 359 colorectal polyps (214 tubulovillous adenomas, 41 'pure' tubular adenomas, 29 'pure' villous adenomas, 68 metaplastic polyps, and 7 inflammatory polyps) were measured using a box-counting method implemented on a microcomputer-based image analysis system. Results were assessed using polychotomous logistic regression, confusion matrices, and kappa statistics. All examined polyps were shown to have a fractal structure in the range of scales examined. The fractal dimension was significantly different between different diagnostic categories (P < 0.0001) and was a useful discriminant between these categories (kappa statistic 0.60 for the confusion matrix with size as the other variable). The fractal dimension did not shown any significant correlation with the grade of epithelial dysplasia (P > 0.05). This study shows that colorectal polyps have a fractal structure over a defined range of magnification and Euclidean morphometric measurements will be invalid outside precisely defined conditions of resolution and magnification. The fractal dimension is a better way of quantitating the polyp shape and is a useful morphometric discriminant between diagnostic categories.

Nm23 'anti-metastatic' gene product expression in colorectal carcinoma

Nm23 is a putative metastasis suppressor gene and alterations in this gene have been reported in colorectal carcinomas suggestive of a role for nm23 in the dissemination of these tumours. In this study we used an affinity purified polyclonal antibody, ab-11, on formalin-fixed, paraffin-embedded sections of colorectal carcinomas from 46 patients in a three-stage avidin-biotin complex immunoperoxidase technique. Follow-up of these patients was until time of death or for 5 years, with a mean time of 31.2 months. Two observers scored the staining results from 1 to 3 according to the proportion of tumour cells positive. The association of nm23 staining with survival, sex, age, vascular invasion, and Dukes' stage was determined using Cox's regression model. The association of death from colorectal cancer and nm23 status reached marginal significance in this study (P = 0.0417). Moreover, there is some suggestion of a protective effect from nm23 as the relative risk of dying from colorectal cancer for each increment of nm23 positivity is 0.573 (95 per cent confidence limits 0.34-0.98).

Embolization of a percutaneous central venous catheter

Percutaneous central venous catheters are widely used in both pediatric and neonatal practice. Complications previously reported with these lines include sepsis, occlusion, limb swelling, catheter retention, and rupture on attempted removal. 1-4 We describe a case in which the catheter ruptured during routine use, with embolization of the distal part into the child's central venous system.

Squamous cell carcinoma complicating lichen planus: a clinico-pathological study of three cases

Squamous cell carcinoma complicating lichen planus is described in 3 patients. In 2, the cancers developed on the lower leg in chronic and hypertrophic lichen planus. In the other case, the cancer complicated lichen planus of the lip mucosa in a smoker. In the two cutaneous cases, the tumour and the adjacent skin showed features of lichen planus, including hypergranulosis, cytoid bodies and a lichenoid infiltrate. The association, though rare with cutaneous lichen planus when it tends to affect chronic hypertrophic lesions on the lower legs, is now well recognized with oral lichen planus. Patients with oral involvement warrant long-term follow-up, especially if they have other risk factors such as smoking or excessive ultraviolet exposure. Chronicity of lichen planus at other skin sites may also be a risk factor.