Renin producing neuroendocrine pancreatic carcinoma--a case report and review of the literature

A 44 year old male patient presented with severe hypertension. The diagnostic work-up revealed elevated levels of plasma renin activity (about 10 times the upper limit of normal) in the presence of normal plasma aldosterone levels and serum potassium concentrations. Renovascular disease was excluded by angiography. Selective renal vein sampling did not show any renin gradient. CT-scans of the abdomen demonstrated normal morphology of the kidneys and adrenals but revealed a big mass in the pancreatic corpus and tail with infiltration of the splenic vein and the presence of enlarged local lymph nodes. The endocrine nature of the pancreatic mass was further supported by a positive octreotide scintigraphy scan. Surgical removal of the tumor by left sided pancreatectomy combined with splenectomy resulted in rapid normalization of elevated renin concentrations as well as blood pressure. Histological examination of the tumor tissue revealed the presence of a neuroendocrine pancreatic carcinoma. Highly (x 70) elevated renin levels were detected by radioimmunoassay in the tumor tissue. To our knowledge this is the first renin-producing neuroendocrine pancreatic carcinoma described in the literature. The present paper describes the case in detail and reviews the available literature on clinical symptomatology, diagnosis and treatment of renin-producing tumors.

A novel insulinoma tumor suppressor gene locus on chromosome 22q with potential prognostic implications

The molecular mechanisms contributing to the tumorigenesis of insulinomas are still poorly understood. As moderate to high rates of LOH have been found on chromosome 22q in gastrinomas, we performed a finer deletion mapping study of chromosome 22q with 8 microsatellite markers in 15 insulinomas (4 malignant and 11 benign). Fourteen of 15 (93%) insulinomas revealed LOH on chromosome 22q, whereas the shortest region of overlap implicated a deletion of approximately 700 kb at 22q12.1-q12.2 with an LOH rate of up to 57% (8 of 14). Although the expressed sequence tag marker A006E25 that is localized in the hSNF5/INI1 gene on 22q11.2 revealed LOH in 50% of informative cases (7 of 14), no alterations in this gene could be identified by single strand conformational polymorphism analysis, direct DNA sequencing, or RNA expression analysis. Remarkably, the four malignant tumors showed a common deleted region between markers D22S345 and D22S1144 compared with none of the 11 benign insulinomas. The observed high frequency of chromosome 22q12 deletions in insulinomas is suggestive for a region compatible with harboring a tumor suppressor gene. The hSNF5/INI1 gene is most likely not the candidate gene, because no alterations could be identified. The distinct pattern of allelic loss identified in this chromosomal region appears to be an attractive candidate marker for further evaluation with regard to the discrimination between benign and malignant insulinomas.

Correction of length discrepancies and angular deformities of the leg by Blount's epiphyseal stapling

The management of leg length difference (LLD) and angular deformities of the leg remains controversial. Numerous treatment options have been proposed over the past years depending on the patient's general condition, skeletal age, function, and degree and configuration of the deformity. Our retrospective study consisted of 48 patients with 58 legs treated between 1970 and 1991 by Blount's epiphyseal stapling to equalise length or correct angular deformity. After an average follow-up of 16.5 years, all patients with idiopathic bow-legs or knock-knees (n=12) and 71% of LLD caused by overgrowth (e.g. Klippel-Trenaunay syndrome) showed good and excellent results at skeletal maturity, whereas the results of the treatment of LLD with undergrowth of the leg and angular deformities due to trauma, infection or general dysplasia and malformation were fair to poor because of the difficulty in prediction of growth development and growth potential, allowing only for partial correction of the deformity. Besides the restriction of the stapling procedure due to the aetiology of the deformity, the age of the patients at the time of surgery is important, as it determines the complication rate of this technique (loosening or dislocation of staples). Thus Blount's epiphyseodesis should not be performed before the age of 9 years in girls and 11 years in boys.

CONCLUSION

Blount's epiphyseal stapling can be recommended as a safe procedure with predictably good results in idiopathic angular deformities of the leg and leg length difference caused by overgrowth.

[Medical-insurance aspects of atlantoaxial instability in children]

INTRODUCTION

An os odontoideum is mostly diagnosed coincidentally on the basis of neurological symptoms or painful movement of the cervical spine. Diagnostic work-up and therapy are currently subjects of controversial discussion in the literature.

CASE

Our report is about an eleven-year-old boy with an unknown os odontoideum, who developed neurological symptoms with tetraparesis after a fall from 1.5 m height. Conventional X-ray examination resulted in the diagnosis of a suspected dens fracture, MRI showed atlanto-axial instability and an os odontoideum with significant dural sack compression but no signs of acute bony or ligamentous lesion.

CONCLUSION

Because of the importance concerning not only medical but also legal/insurance aspects, a possible coincidental finding of an os odontoideum versus a dens fracture must be included in the differential diagnosis. In the case of an os odontoideum without instability in children, conservative therapy is justified after due enlightenment regarding possible risks. In the event of neurological symptoms and/or persistent instability the authors advocate early surgical stabilization even in patients with little infirmity, particularly in view of the possible consequences.

Treatment of congenital spondyloptosis in an 18-month-old patient with a 10-year follow-up

STUDY DESIGN

Case report.

OBJECTIVES

To present the case of a patient with congenital spondyloptosis treated and followed over 10 years.

SUMMARY OF BACKGROUND DATA

The surgical management of spondyloptosis in children is variably reported in the literature. Some authors propose that posterior fusion in situ is a safe and reliable procedure, whereas others suggest that reduction of the slipped vertebra may prevent some of the adverse sequelae of in situ fusion, which include nonunion, bending of the fusion mass, and persistent lumbosacral deformity. Many investigators advocate a combined anterior and posterior fusion using instrumentation.

METHODS

At the time of the first symptoms an 18-month-old boy with congenital spondyloptosis of L5-S1 was referred to the authors' institution. Because of the progression of pain, neurologic disturbance, mild foot deformity, muscle contractures, and lumbosacral kyphosis, surgical intervention was undertaken. Operative intervention began with a resection of the L5 lamina and wide bilateral L5 nerve root decompression. This was followed by anterior subtotal resection of L5 and interbody bone graft of the morcelized vertebral body for fusion from L5 to S1. The next step was reduction of the spondyloptosis and stabilization by posterior instrumentation L2-S1 with a sacral Cotrel-agraffe device.

RESULTS

The procedure achieved almost complete reduction of the spondyloptosis with near-normal restoration of lumbar lordosis allowing more physiologic lumbar spinal biomechanics. There were no neurologic complications. After surgery there was no suggestion of back pain or gait disturbance and no progression of any deformity.

CONCLUSION

In the treatment of severe congenital spondylolisthesis a staged procedure of decompression, reduction, and instrumented fusion is recommended for those cases in which intervention is indicated.

Reflections from organization science on the development of primary health care research networks

In the UK, policy changes in primary health care research and development have led to the establishment of primary care research networks. These organizations aim to increase research culture, capacity and evidence base in primary care. As publicly funded bodies, these networks need to be accountable. Organizational science has studied network organizations including why and how they develop and how they function most effectively. This paper draws on organizational science to reflect on why primary care research networks appear to be appropriate for primary care research and how their structures and processes can best enable the achievement of their aims.

Biomechanical analysis of Graf's dynamic spine stabilisation system ex vivo

The most frequent causes of chronic lumbar spine instability are of degenerative or traumatic origin. Numerous anterior and posterior stabilisation devices were developed for anatomical reconstruction of the spinal alignment and fusion of the spine to restore stability. Fusion of the spine results in increased load of adjacent segments with an increased risk of secondary degeneration which might result in instability or stenosis. To avoid the disadvantages of static devices, Graf developed a method of dynamic surgical treatment of spinal column instabilities, which is based on the principle of flexible stabilisation. This study is analysing the kinematics of discoligamentary intact motion segments compared with the experimentally destabilised human lumbar spine and the influence of Graf's stabilisation. According to our results, rotational instabilities cannot be satisfactorily stabilised by Graf's ligamentoplasty. With the present ex vivo study, it could be shown that it is possible to restore stability after discoligamentary lesion and after facetectomy using Graf's dynamic lordosis ligamentoplasty.

Prospective controlled trial of a standardized meal stimulation test in the detection of pancreaticoduodenal endocrine tumours in patients with multiple endocrine neoplasia type 1

BACKGROUND

Use of a standardized meal stimulation test has been recommended for the early diagnosis of pancreaticoduodenal endocrine tumours (PETs) in patients with multiple endocrine neoplasia type 1 (MEN 1). The diagnostic value of this test was re-evaluated.

METHODS

In a prospective, controlled trial 58 standardized meal stimulation tests (563 kcal) were performed in 12 patients with MEN 1 and histologically, biochemically and/or radiologically confirmed PETs (group 1), 11 carriers of an MEN 1 mutation with no evidence of PETs (group 2) and in 27 healthy controls (group 3). Serum pancreatic polypeptide (PP) and gastrin concentrations were measured before and during the test meal.

RESULTS

Patients in group 1 had significantly higher mean basal serum PP and gastrin concentrations than patients in group 2 and controls (P < 0.05). In all three groups an increase in serum PP was observed after meal stimulation, but there was no significant difference between the groups. No increase in gastrin level was found in any of the groups after meal stimulation.

CONCLUSION

The standardized meal stimulation test does not reliably indicate the presence of PETs in patients with MEN 1, whereas raised basal serum PP and gastrin levels do. The expensive and time-consuming meal test can be excluded from MEN 1 screening programmes.

Scoliosis in Gordon's syndrome

Gordon's Syndrome is described as an autosomal dominant condition with the characteristics of short stature, a stiff spine, camptodactyly (89%), cleft palate (27%) and club feet (73%). The authors present a case report of a patient with this rare entity complicated by an unusual complex spinal deformity. There are no prior reports in the literature concerning operative or nonoperative management of deformity in this patient population. Scoliosis in Gordon's Syndrome shares the characteristics of an arthrogrypotic neuromuscular curve and demands extensive soft tissue release for optimal correction.

Morbidity profile of high-performance fencers

There are only very few data available about the morbidity of elite fencers athletes. The aim of this study was to elucidate the nature and history of the morbidity in high-performance fencers. The injury profile over 15 years of 93 fencers at a highly competitive level was analysed by clinical assessment and examination. We found a positive correlation between the injured upper extremity with the dominant fencing side while the lower extremity showed no side preference with regard to vulnerability. Achillodynia occurred more frequently at the contralateral side. The joint most affected was the knee. The dominating symptom was patellofemoral pain which occurred in 39.8 %.

Is sacral instrumentation mandatory to address pelvic obliquity in neuromuscular thoracolumbar scoliosis due to myelomeningocele?

STUDY DESIGN

Prospective study.

OBJECTIVE

To evaluate the functional outcome of two-stage anterior and posterior instrumented fusion without fixation to the sacrum on 11 patients with neuromuscular scoliosis from thoracolumbar myelomeningocele.

SUMMARY OF BACKGROUND DATA

To our knowledge, there are no published results of combined anterior and posterior correction and fusion without inclusion of the sacrum in neuromuscular scoliosis from thoracolumbar myelomeningocele. In this article we present our experience and critically evaluate the functional outcome on 11 patients with neuromuscular scoliosis.

PATIENTS AND METHODS

From July 1, 1992 through June 30, 1995, 11 consecutive patients with severe thoracolumbar scoliosis were admitted at our hospital. The mean age at operation was 12 years 9 months (range 9 years 9 months to 14 years 6 months). All patients underwent a two-stage anterior and posterior spinal reconstruction. The patients were evaluated before surgery and after surgery.

RESULTS

All patients were observed for a mean of 4 years 11 months (range 42-88 months) from the time of second stage procedure. Before treatment the mean scoliosis was 81 degrees (range 55-110 degrees ); this was reduced to a mean of 31 degrees (range 8-70 degrees ), and at the final follow-up the correction had deteriorated slightly to a mean of 35 degrees (range 12-80 degrees ). No patient had increased neurologic deficit or showed other major complication.

CONCLUSIONS

Pelvic obliquity in thoracolumbar neuromuscular scoliosis from lumbosacral myelomeningocele spontaneously corrected when the scoliotic deformity is adequately addressed with instrumented fusion without inclusion of the sacrum. The correction obtained remained stable at follow-up. In the absence of a control group we believe that sparing lumbar segments from primary fusion offers these patients a better freedom of mobility.

Risk-benefit analysis of prophylactic pinning in slipped capital femoral epiphysis

There is a broad and controversial discussion about the surgical procedure and the type of hardware for internal transfixation of the epiphysis and metaphysis in slipped capital femoral epiphysis (SCFE). Prophylactic pinning is even more controversial. One hundred and nine patients showing SCFE underwent a one-stage bilateral fixation of the epiphysis with three or four Kirschner wires (pins). From these 109 patients (69 male and 40 female), 94 had an unilateral slip and were operated prophylactically on the contralateral side. There were no complications such as avascular necrosis of the femoral head, chondrolysis, bone fracture, failure of metal implant, osteomyelitis or deep wound infection either at the time of surgery or at the minimum follow-up of 1 year with prophylactic pinning in SCFE. Therefore, we consider pinning allows for efficient stabilization, reliably preventing any progression of SCFE on the affected side and, furthermore, prevents the incidence of a secondary slip on the primarily nondisplaced contralateral side. The transfixation of epiphysis and metaphysis with Kirschner wires (pins) shows good subjective and objective long-term results compared with other surgical methods and implants. There is only a low morbidity rate with this method, because reoperations may only become necessary in the younger age group owing to normal growth of the femoral neck, compared with a high benefit from prophylactic surgical treatment of the nonaffected opposite side at the time of unilateral onset of the disease. The pins may no longer catch the epiphysis but further growth will allow for remodeling of the femoral head and for an optimal neck/shaft ratio. In case of further growth and relative shortening of the pins, refixation may become necessary. Therefore, we like to recommend the Kirschner-wire transfixation (pinning) of the epiphysis and metaphysis in patients with SCFE for primary treatment of SCFE as well as for prophylactic pinning of the contralateral side in one sitting.

p16(INK4a) alterations in chronic pancreatitis-indicator for high-risk lesions for pancreatic cancer

BACKGROUND

p16(INK4a) alterations are considered to be an early event in pancreatic tumorigenesis and have been described in duct lesions adjacent to pancreatic cancers. This study evaluates whether duct lesions in chronic pancreatitis tissues of patients without pancreatic cancer also harbor genetic alterations in the p16(INK4a) tumor-suppressor gene, and thus represent high-risk precursors for pancreatic cancer.

METHODS

Tissues were obtained from 20 pancreatic specimens taken from patients operated on for histologically verified chronic pancreatitis. Pancreatic intraductal neoplasias (PanIN) were identified in hematoxylin-and-eosin-stained slides. p16 protein expression was investigated immunohistochemically in all specimens. DNA from PanIN and non-PanIN tissue was analyzed genetically for p16(INK4a) mutations by single-strand conformation variation analysis and direct sequencing of the encoding region. Additionally, p16(INK4a) promoter methylation was analyzed by a methylation specific polymerase test.

RESULTS

PanIN-1a lesions were identified in 10 of the 20 chronic pancreatitis specimens. Four of these 10 PanIN specimens (40%), but none of the 20 non-PanIN tissues, revealed a loss of p16 expression in immunohistochemistry. The mutational analysis of the p16(INK4a) gene showed 1 known polymorphism (c.442G > A; A148T) but no mutations. Two of the 10 specimens with PanIN revealed an inactivating hypermethylation of the p16(INK4a) promoter.

CONCLUSIONS

This study shows for the first time that p16(INK4a) alterations can be observed in a considerable number of PanIN1 in chronic pancreatitis tissues not associated with pancreatic cancer. Therefore, p16(INK4a) alterations, especially promoter methylation, might indicate high-risk precursors in chronic pancreatitis that might progress to cancer.

Predictive Genetic Screening and Clinical Findings in Multiple Endocrine Neoplasia Type I Families

Germline mutations of the MEN1 gene have been identified as the causative genetic defect of multiple endocrine neoplasia type I (MEN-I), an autosomal dominantly inherited condition. To establish the basis for predictive family screening we evaluated the spectrum of MEN1 gene mutations in MEN-I patients treated at our institution. Relatives at risk were subjected to predictive genetic screening after genetic counseling. Gene carriers were subjected to extensive clinical screening for MEN-I, including biochemical tests for basal hormone concentrations in blood and urine, a standardized meal stimulation test and imaging procedures (ultrasonography, computed tomography, magnetic resonance imaging). Among index patients of 15 independent MEN-I kindreds, 14 heterozygous MEN1 germline mutations were identified by single-strand conformational variant analysis (SSCV) and direct DNA sequence analysis. Of 51 individuals at risk, 26 predictively tested relatives with the wild-type MEN1 gene could be excluded from further screening procedures because they had not inherited the disease. In all previously presumed unaffected relatives with the mutant gene, our extensive clinical screening program revealed at least one manifestation of MEN-I. Furthermore, 22 additional diagnoses could be established in identified MEN-I patients. We show that mutation analysis enables predictive genetic screening for MEN-I families, providing a valuable tool for genetic counseling and clinical management. An extensive clinical screening program focusing on genetically proven individuals at risk allows detection of MEN-I manifestations at an early, asymptomatic stage of the disease. Controlled, prospective studies are now required to prove whether timely appropriate treatment on the basis of predictive screening might help improve disease-related quality of life and prolong life expectancy in MEN-I kindreds.

p16(INK4a) alterations in chronic pancreatitis-indicator for high-risk lesions for pancreatic cancer

BACKGROUND

p16(INK4a) alterations are considered to be an early event in pancreatic tumorigenesis and have been described in duct lesions adjacent to pancreatic cancers. This study evaluates whether duct lesions in chronic pancreatitis tissues of patients without pancreatic cancer also harbor genetic alterations in the p16(INK4a) tumor-suppressor gene, and thus represent high-risk precursors for pancreatic cancer.

METHODS

Tissues were obtained from 20 pancreatic specimens taken from patients operated on for histologically verified chronic pancreatitis. Pancreatic intraductal neoplasias (PanIN) were identified in hematoxylin-and-eosin-stained slides. p16 protein expression was investigated immunohistochemically in all specimens. DNA from PanIN and non-PanIN tissue was analyzed genetically for p16(INK4a) mutations by single-strand conformation variation analysis and direct sequencing of the encoding region. Additionally, p16(INK4a) promoter methylation was analyzed by a methylation specific polymerase test.

RESULTS

PanIN-1a lesions were identified in 10 of the 20 chronic pancreatitis specimens. Four of these 10 PanIN specimens (40%), but none of the 20 non-PanIN tissues, revealed a loss of p16 expression in immunohistochemistry. The mutational analysis of the p16(INK4a) gene showed 1 known polymorphism (c.442G > A; A148T) but no mutations. Two of the 10 specimens with PanIN revealed an inactivating hypermethylation of the p16(INK4a) promoter.

CONCLUSIONS

This study shows for the first time that p16(INK4a) alterations can be observed in a considerable number of PanIN1 in chronic pancreatitis tissues not associated with pancreatic cancer. Therefore, p16(INK4a) alterations, especially promoter methylation, might indicate high-risk precursors in chronic pancreatitis that might progress to cancer.

[Staged reposition and fusion with external fixator in spondyloptosis]

PROBLEM

Is the staged reduction by an external fixateur and combined fusion of slipping vertebra an adequate surgical treatment for lumbar spondyloptosis?

METHODS

11 patients with symptomatic lumbar spondyloptosis were treated using a technique of slow reduction and combined posterior and anterior approach. The first stage consists of a posterior approach with the application of the external fixateur. After staged reduction the anterior and posterior fusion are performed. All patients were pre- and postoperatively classified by radiological and clinical criteria. We report improvements in pain, activities of daily live, and cosmetic appearance. The average follow-up was over three years.

RESULTS

Postoperatively one patient failed to reduce, and one developed a subsequent L4/L5 spondylolisthesis. All patients showed a solid spondylodesis with no significant loss of reduction. There was no patient with any neurological deficit. The mean correction of the slipping at follow-up was 84.5%. 9 patients were satisfied with the result.

CONCLUSION

With gradual instrumented reduction by external fixateur, an anatomic reduction is nearly obtained and excellent clinical results in the treatment of spondyloptosis can be achieved.

Low frequency of p16(INK4a) alterations in insulinomas

BACKGROUND/AIMS

The molecular mechanisms contributing to the tumorigenesis of insulinomas are poorly understood. Disruption of the cell cycle due to inactivation of the p16(INK4a) tumor-suppressor gene was identified in a variety of human tumors, including gastrinomas and nonfunctioning endocrine pancreatic carcinomas. In this study the role of p16(INK4a) in the tumorigenesis of insulinomas was evaluated.

METHODS

Seventeen insulinomas (14 benign, 3 malignant) were analyzed for genetic alterations in the p16(INK4a) tumor-suppressor gene by SSCP, PCR-based deletion and methylation-specific assays. p16 expression was determined by immunohistochemistry.

RESULTS

One malignant insulinoma showed a homozygous deletion of p16(INK4a) and another two benign insulinomas revealed aberrant methylation of the p16(INK4a) promoter region. All three tumors lacked p16 expression according to immunohistochemistry. None of the insulinomas carried intragenic p16(INK4a) mutations. In total, 17% of insulinomas had p16(INK4a) alterations.

CONCLUSIONS

The p16(INK4a) tumor-suppressor gene contributes to tumorigenesis in only a small subset of insulinomas.

Pancreaticoduodenal endocrine tumors in multiple endocrine neoplasia type 1: surgery or surveillance?

BACKGROUND

The management of pancreaticoduodenal endocrine tumors (PETs) remains controversial in multiple endocrine neoplasia type 1 (MEN 1).

METHODS

Twenty-one patients with MEN 1 and PETs were analyzed for outcome of surgery and surveillance with special regard to the genotype based on MEN1 gene mutation analysis.

RESULTS

Nine patients had gastrinomas, 5 had nonfunctioning tumors, 4 had insulinomas, 2 had insulinomas and gastrinomas, and 1 had a VIPoma. Seven patients (33%) had malignant tumors. Sixteen patients (76%) were initially treated by pancreatic resections or tumor enucleations or both. Six patients underwent reoperations for recurrences or lymph node metastases or both. Fifteen of the 16 operated patients are alive, and 12 have no evidence of disease after a median follow-up of 78 months (range, 1-198 months). Five patients with gastrinomas or nonfunctioning tumors, but no symptoms, underwent surveillance; 1 of them developed lymph node metastases. Patients with truncating mutations in the N- or C-terminal region (exons 2, 9, or 10) of the MEN1 gene had a significantly higher rate of malignant tumors (55% vs 10%; P <.05) than patients with other mutations.

CONCLUSIONS

An aggressive surgical approach is justified for PETs in patients with MEN 1. However, MEN1 gene mutations in exons 3 to 8 seem to be associated with mild behavior of PETs, possibly allowing surveillance in asymptomatic patients.

Multiple primaries in pancreatic cancer patients: indicator of a genetic predisposition?

BACKGROUND

The genetic basis of several familial cancers including breast and colon cancers has been identified recently. The occurrence of multiple cancers in one individual is also suggestive of a genetic predisposition. To evaluate inherited predisposition in pancreatic cancer we compared the clinical data of pancreatic cancer patients with and without multiple primaries as well as the frequency of malignancies among their relatives.

METHODS

Detailed data on 69 pancreatic cancer patients included survival time and TNM-classification. Index case data were separated into two groups. The first group (group 1) developed only pancreatic cancer during their lifetime, whereas the second group (group 2) developed additional primary tumours. A systematic family history was taken from 59 of these pancreatic cancer patients using a standardized questionnaire. The pancreatic cancers and the multiple primaries of the 59 patients were histologically proven.

RESULTS

Of the 69 pancreatic cancer patients, 13 (18.8%) had multiple primaries. Neither the clinical data nor the survival data of the index cases revealed differences between the two groups (all nominal P-values >0.05). In the family history study blood relatives developed a malignancy in 51% (24 of 47) of the families in group 1 compared to 75% (9 of 12) in group 2. The risk of relatives in group 2 of developing a malignant tumour was significantly higher (P = 0.034) than in group 1 after adjustments for family size and age of disease onset of the index case. The cancer spectrum of the 59 families mainly included tumours of the digestive tract and the reproductive organs.

CONCLUSIONS

A multiple primary cancer history is a common condition among pancreatic cancer patients. Relatives of these patients seem to have an increased risk for the development of distinct malignant solid tumours, which might be caused by an inherited predisposition. Clinical and genetic investigation of pancreatic cancer patients with multiple primaries and their families might lead to the identification of predisposing gene defects providing a new goal for the understanding of a shared genetic basis of different solid tumours.

Multiple primary tumors as an indicator for p16INK4a germline mutations in pancreatic cancer patients?

Multiple primary tumors in pancreatic cancer patients might indicate a genetic predisposition to the development of malignancies. In this study we evaluated whether the mutation rate of the TP53 and p16INK4a genes of pancreatic cancers differs in pancreatic cancer patients with and without multiple primaries. Furthermore, we investigated whether pancreatic cancer patients with multiple primaries carry germline mutations in either p16INK4a, TP53, or BRCA2 tumor suppressor genes to detect a genetic alteration that predisposes to the development of different primaries. Fourteen (23%) of 60 pancreatic cancer patients developed histologically verified additional primaries during their lifetimes. Normal constitutional and tumor DNA of the 14 patients with a positive cancer history, but negative family history, were analyzed for p16INK4a, TP53, and BRCA2 mutations by single-strand conformational variant (SSCV) analysis and direct sequencing. Hypermethylation of the p16INK4a promoter region in pancreatic cancers was identified by methylation-specific polymerase chain reaction (PCR; MSP). Four of 14 pancreatic carcinomas carried somatic intragenic p16INK4a mutations, and another four tumors revealed hypermethylation of the p16INK4a promoter region. Somatic intragenic TP53 mutations were identified in six of 14 tumors. None of the pancreatic cancer patients carried TP53 or BRCA2 germline mutations. In contrast, one of 14 pancreatic cancer patients with multiple primaries carried the p16INK4a mutation A68V in his germline. This mutation was localized in the conserved second ankyrin repeat of p16INK4a and did not occur in 100 control patients. The frequency of somatic TP53 and p16INK4a mutations in pancreatic cancer is similar in patients with and without multiple primaries. TP53 and BRCA2 germline mutations seem not to be significantly associated with the occurrence of multiple primaries in pancreatic cancer patients. However, p16INK4a germline mutations might be causative for tumor development in some pancreatic cancer patients with multiple primaries. The genetic investigation of patients with accumulation of different cancers even without a positive family history may be a new approach for the understanding of the relation of different cancers.

The productivity of primary care research networks

Primary care research networks are being publicly funded in the United Kingdom to promote a culture of research and development in primary care. This paper discusses the organisational form of these networks and how their productivity can be evaluated, drawing on evidence from management science. An evaluation of a research network has to take account of the complexity of the organisation, the influence of its local context, and its stage of development. Output measures, such as number of research papers, and process measures, such as number of research meetings, may contribute to an evaluation. However, as networking relies on the development of informal, trust-based relationships, the quality of interactions within a network is of paramount importance for its success. Networks can audit and reflect on their success in promoting such relationships and a more formal qualitative evaluation by an independent observer can document their success to those responsible for funding.

[Minimal invasive therapy of localized Langerhans-cell histiocytosis of bone]

PURPOSE

Scaglietti introduced a method of steroid injection for the management of unicameral bone cysts in 1974. Subsequently the intralesional infiltration of corticosteriods has also been recommended as a primary therapy for localized Langerhanscell histiocytosis (LCH). We report our experience with the administration of methylprednisolone acetate in children and young adults localized LCH.

MATERIAL AND METHODS

[corrected] Nine patients with localized LCH, aged 2 3/12 to 29 years, were treated with a single--in only one case two--intralesional injection of methylprednisolone acetate as a crystalline suspension. The dose was between 40 and 150 mg depending on the size of the radiolucent defect. We treated 4 lesions in the skull, 3 in the femur, 1 in the distal humerus and 1 in the mandibula. In each case the diagnosis was established by biopsy. Follow-up ranged from 2 to 8 8/12 years (4 years 4 months on average).

RESULTS

7 out of 9 patients with localized LCH had excellent results with complete healing of the lesion. In 2 patients there was no response to the initial injection therapy and dissemination of the disease occurred. In 4 patients with an additional soft tissue tumor, after injection therapy of the bone lesion, the soft tissue tumor resolved without further treatment.

CONCLUSION

Intralesional infiltration of methylprednisolone acetate as a primary therapy for localized Langerhans cell histiocytosis leads to rapid relief of pain, restoration of bone morphology and reduction of associated soft tissue tumors. Performed with appropriate skill under sterile condition with the reported high percentage of effectiveness and low recurrence rate, this low invasive method is the treatment of choice, resulting in a lower morbidity and lower costs.

Hybrid computer-guided and minimally open surgery: anterior lumbar interbody fusion and translaminar screw fixation

Less invasiveness is the way forward for spinal surgery. Minimal disruption of tissue, preservation of muscle function, and restoration of normal spinal alignment are still the goals of most surgical procedures. An anterior lumbar fusion technique using a less invasive procedure with the addition of translaminar screws is described. The autograft is harvested from the vertebral body, thus avoiding the morbidity associated with an iliac crest bone graft. The operative steps for the procedure are described.