S-100 protein-positive sinusoidal large cell lymphoma

A subset of T lymphocytes has recently been reported to express S-100 protein. We report a case of S-100-positive peripheral T-cell lymphoma with a sinusoidal pattern of lymph node involvement. The immunophenotypic profile was T1+, T3+, T4+, T6-, T8-, T11+. The 12-year-old boy presented with thrombocytopenia and splenomegaly and was found to have malignant lymphoma involving the para-aortic lymph nodes, spleen, and bone marrow. The disease ran a rapidly fatal course.

Most nasal/nasopharyngeal lymphomas are peripheral T-cell neoplasms

Eleven consecutive cases of nasal/nasopharyngeal lymphoma were studied histologically and with a panel of monoclonal antibodies. The disease showed a male predominance and occurred over a wide age range, with a median of 52 years. Five patients had midfacial destructive disease, and six had gross tumor masses involving the nose/nasopharynx. Three cases were classified as small cleaved cell, two cases as mixed cell, five cases as large cell, and one case as immunoblastic lymphoma. Those belonging to the first two categories also satisfied the diagnostic criteria of so-called polymorphic reticulosis. Epithelial invasion, angioinvasion, and coagulative necrosis were demonstrated in seven, eight, and nine cases respectively. Immunohistochemical studies confirmed that the atypical cells of all 11 cases exhibited T-cell markers. All but one case had lost one or more T-cell markers associated with peripheral T cells, particularly T1 and T3. Loss of T-cell markers in the five cases histologically consistent with polymorphic reticulosis provided further support to indicate that the lesion was neoplastic. A significant proportion of cases also expressed the activated T-cell markers 12 (HLA-DR) and interleukin-2 receptor (IL-2R1).

Maturation of B-lineage blast crisis cells in chronic myeloid leukemia

A 44 year-old Chinese male presented with lymphoid blast crisis of chronic myeloid leukemia, in which the blast cells exhibited a pre-pre-B cell phenotype (B4+B1-J5+12+smIg-). There was a phenotypic transition during the course of the disease to a more mature B cell phenotype (B4+B1+J5+12+smIgG lambda+). The maturation of blast crisis cells may be related to the chemotherapeutic agents used in the treatment of the disease.

Peripheral blood lymphocyte subsets in nasopharyngeal carcinoma

Peripheral blood lymphocyte subsets were studied in 29 untreated Chinese nasopharyngeal carcinoma (NPC) patients and 20 normal controls of similar age range and sex ratio with indirect immunofluorescence using monoclonal antibodies. The percentage T lymphocyte (T11) count, percentage and absolute T helper (T4) lymphocyte counts and the T helper/T suppressor-cytotoxic cell ratio (T4/T8) were significantly lower, while the percentage and absolute T8 counts were significantly higher in NPC patients. Concerning B lymphocytes, B1 cell count was normal while B4 cell count (B lymphocytes including early B lymphocytes) was significantly lower in NPC patients. These various lymphocyte subset changes were not related to the clinical stage or to Epstein-Barr viral IgA viral capsid antibodies and IgA early antibodies. The pathogenetic and prognostic significance of peripheral blood lymphocyte changes in NPC requires further investigation.

Reactive hemophagocytic syndrome: a study of 7 fatal cases

Reactive hemophagocytic syndrome is a clinico-pathologic entity characterized by systemic proliferation of non-neoplastic histiocytes showing phagocytosis of hemopoietic cells, resulting in blood cytopenia. It is best known to be associated with virus infection, but other associated diseases have also been implicated. The clinical and pathological findings of 7 fatal cases are described. The syndrome affected both sexes of a wide age range, and all patients had fever. Significant laboratory findings were blood cytopenia, abrupt drop in the blood cell counts, deranged liver function tests and abnormal coagulation profile. The associated diseases were diverse: two patients had bacterial infection; two had peripheral T-cell lymphoma; one had disseminated undifferentiated carcinoma of the ovary; one had both tuberculosis and disseminated nasopharyngeal carcinoma, and one had no obvious underlying disease. It is postulated that lymphokines secreted by lymphoid cells or tumor cells may be responsible for the systemic activation of histiocytes. The differential diagnosis from malignant histiocytosis is discussed.

Immunophenotypic analysis of non-Hodgkin's lymphomas in Chinese. A study of 75 cases in Hong Kong

The cell surface markers of 75 cases of non-Hodgkin's lymphoma were studied on cryostat sections using a panel of monoclonal antibodies. Forty-nine cases (65.3%) were found to express a B-cell phenotype, 23 cases (30.7%) a T-cell phenotype, 1 case (1.3%) a histiocytic phenotype and 2 cases (2.7%) no demonstrable surface markers. Follicular lymphoma accounted for only 10.7% of the cases. Most B-cell lymphomas expressed IgM-lambda or IgM-IgD-lambda, but a few failed to express surface immunoglobulin. Among the 23 cases of T-cell lymphoma, 22 were of peripheral T-cell type; most were of helper-cell (T4) phenotype and a significant number expressed J5 (CALLA) and I2 (HLA-DR). The present study shows that the percentage of T-cell lymphoma in Chinese is higher than in Caucasians, but lower than in Japanese. However, when the age-adjusted incidence of non-Hodgkin's lymphoma is considered, the incidence rates of T-cell lymphoma in Hong Kong Chinese and Japanese in areas non-endemic for adult T-cell lymphoma/leukemia are similar; the incidence in Americans is similar or slightly lower. The major difference between the races is that B-cell lymphoma, particularly the follicular type, is much rarer in Asians than Americans.

Malignant lymphoepithelial lesion of the salivary gland

Eight cases of malignant lymphoepithelial lesion (MLEL) of major salivary glands, seven of which occurred in Southern Chinese patients, are reported. All but two of the patients were older than 40 years of age; there were five male and three female patients. The parotid and submandibular glands were the sites of origin in equal numbers of cases. Six patients had elevated titers of serum IgA against Epstein-Barr virus capsid antigen. Seven remained well after surgery and local radiation therapy, and one died of miliary tuberculosis without evidence of residual neoplasm. Histologically, MLELs were characterized by syncytial clumps of large cells with vesicular nuclei and prominent nucleoli, admixed with abundant small lymphocytes and plasma cells. Two features not emphasized previously in the literature were the presence of reactive histiocytes in some epithelial islands, producing a starry sky pattern, and perineural invasion, which was identified in four cases. The tumor cells showed strong immunostaining for cytokeratin. The literature concerning this rare tumor is reviewed, and the differential diagnosis between MLEL and benign lymphoepithelial lesion, metastatic undifferentiated carcinoma, and malignant lymphoma is discussed.

Nasal T-cell lymphoma associated with hemophagocytic syndrome

A patient with immunohistochemically confirmed nasal T-cell lymphoma is reported. He developed systemic histiocytosis with marked hemophagocytosis, simulating malignant histiocytosis. The differential diagnosis from the latter is discussed.

Multilobated B-cell lymphoma, a variant of centroblastic lymphoma. Report of four cases

Four cases of multilobated B-cell lymphoma, one follicular and three diffuse, are described. Many of the lymphoma cells show marked lobulation of the nuclei, and possess multiple prominent nucleoli. There are admixed classical centrocytes, classical centroblasts, and cells with morphology intermediate between classical centroblasts and multilobated cells. Multilobated cells are also observed in small numbers in germinal centres of lymph nodes showing reactive follicular hyperplasia. We believe that the multilobated B-cell may represent one form of centroblast during transition between the centroblastic and centrocytic stages. Multilobated B-cell lymphoma may be its neoplastic counterpart in which the nuclear lobulation is further exaggerated.

Clear cell sarcoma of the penis

The case of a 10-year-old boy in whom clear cell sarcoma occurred at the root of the penis is reported. The tumor cells were positive for S-100 protein, and ultrastructural examination showed the presence of melanosomes.

A comparative study of the metabolic effects of injectable and oral contraceptives

The metabolic effects of an injectable contraceptive, Depo-provera (medroxyprogesterone acetate), an oral contraceptive pill containing 50 micrograms ethinyl estradiol and 500 micrograms norgestrel and a control group (not on contraceptives) were compared in 3 groups, each comprising 32 women. The subjects were matched for race, age and parity. Mean duration of treatment was 41.7 +/- 18.3 months for Depo-provera and 59.6 +/- 29.0 months for the pill group. Glucose tolerance was impaired in both treatment groups. The combination pill showed more changes in both glucose tolerance and insulin response. Lipid levels remained unchanged in both treatment groups.

Effect of oral contraceptives on serum prolactin: a longitudinal study in 126 normal premenopausal women

A prospective longitudinal study was carried out in 126 normal premenopausal women aged 18-34 years to determine the effect of oral contraceptives containing less than 50 micrograms of oestrogen on serum prolactin concentration. The mean prolactin concentration in patients receiving oral contraceptives (n = 80) rose from a control level of 8.9 ng/ml to 10.2 ng/ml at 3 months (P less than 0.05) and 10.9 ng/ml at 12 months (P less than 0.001). In a parallel group of patients (n = 46) who used intrauterine devices for contraception, no significant change in serum prolactin concentration was observed over the same period. It is concluded that currently available oral contraceptives have a small but significant stimulatory effect on prolactin secretion in normal women.

Medical treatment of placenta accreta with methotrexate

Placenta accreta is a rare condition and is associated with considerable maternal morbidity and mortality. Though the surgical approach of hysterectomy is a definitive therapy, there are occasions when conservation of the uterus is desired by the patient. We report a case of placenta accreta successfully treated with intravenous methotrexate. After 2 weeks of treatment no signs of placenta could be visualized on ultrasound examination of the uterus. The patient was discharged after 15 days and has since been well. Such therapy may be useful in exceptional cases in institutions with adequate facilities for careful monitoring and management of the patient.

A case of congenital dyserythropoietic anemia in a male Chinese

A 38 yr-old man has chronic non-spherocytic hemolytic anemia which was attributed to glucose-6-phosphate dehydrogenase (G-6PD) deficiency for the past 20 yr. A diagnosis of congenital dyserythropoietic anemia Type II (CDA) was made because of the bone marrow findings and electron microscopic appearance of the peripheral erythrocytes. Congenital dyserythropoietic anemia, though well recognized in Caucasians, has not hitherto been described in Chinese. Erythrocyte G-6PD deficiency has been found to have an incidence of 5.5% in Southern Chinese. The coexistence of CDA Type II and G-6PD deficiency in this patient may be a chance finding or there may be an interaction between the 2 abnormalities in the clinical manifestations of CDA Type II and G-6PD deficiency.

Extremes of foetal birthweight for gestation in infants of diabetic mothers

100 patients were registered at the Diabetic Clinic in 1981, where they were managed by a team of physician, obstetrician and paediatrician, based on a preset protocol. Only 92 patients were eventually analysed. The study showed a 1.3% incidence of pregnancies complicated by diabetes mellitus. The mean birthweights of infants of both gestational and established diabetics were heavier than that of the general population by race and gestation. 25% of the 92 infants of diabetic mothers have birthweight exceeding the 90th centile of population. Further division of the 92 patients into the "true gestational" diabetics, as shown by an oral glucose tolerance test performed 6 weeks post-natally, also showed a 25% incidence of macrosomia. Late antenatal booking, delayed detection of abnormal glucose tolerance and treatment attributed to the high incidence of macrosomia. Only one infant had birthweight below the tenth centile. There were no perinatal mortality in the 92 patients studied. Macrosomia is a common complication in infants of diabetic mothers despite a physician-obstetrician joint-care system. Also, the risk of having macrosomia amongst gestational diabetics is high.

Combined team management of diabetes mellitus in pregnancy

225 women with diabetes in pregnancy were managed by a team of obstetricians, physicians (endocrinologists) and paediatricians from the National University of Singapore. A protocol of management was formulated and followed. The incidence of 1.1% or 1 in 90 pregnancies was found, with significantly higher incidence in Indians and lower in Malays. There were 37 established diabetics and 188 diagnosed during pregnancy. Of these (188), 74 were gestational diabetics. All the women were treated with Insulin and Diet or Diet alone. 177 (79%) were treated with Insulin and Diet. Blood sugar profiles were done for monitoring diabetic control. 72.8% of the women were between para 0 and 1 and 85.2% between the ages of 20 and 34. 72.5% of the women delivered at 38 weeks gestation or later. 48.9% went into spontaneous labour, 32.4% were induced and 18.7% had elective caesarean section. 62.2% of the women had labour of less than 12 hours. The overall caesarean section rate was 41.7%. There were 3 stillbirths and 2 neonatal deaths. The perinatal mortality rate was 2.2%. Thirteen babies had congenital malformations (5.8%). 77.8% of the babies had Apgar score of 7 or more at 5 minutes after delivery. 79.1% of the babies weighed between 2.5 kgm and 3.9 kgm. Pre-eclamptic toxaemia was the commonest complication in pregnancy followed by Urinary Tract Infection and Polyhydramnios. Postpartum complications in the mother were confined to 14 women (6.2%), and wound infection or breakdown was the commonest cause.

The use of bromocriptine in hyperprolactinemia and galactorrhea in Singapore

Ninety-four women and seven men were treated with low dose bromocriptine for (a) hyperprolactinemia or (b) normoprolactinemia but with galactorrhea and a pituitary adenoma. All the pituitary adenomas became smaller or remained the same. Prolactin levels decreased with treatment and inappropriate galactorrhea improved in the 53 patients except for 7 where there was no change. Of the 41 women with premenstrual mastalgia 78% improved with treatment. Of the 74 women with ovulatory problems, a biphasic pattern was restored in 65 patients. Thirty-two patients out of the 92 trying to conceive achieved a pregnancy with an abortion rate of 12.5% and non-lethal congenital abnormality of 9.8% (2.1% in Singapore population). Fertility was restored in 3 hyperprolactinemic oligospermic males and improved libido was professed by most of the treated men. Side effects were present but were on the whole tolerable. Pregnancy rate was better in those with high levels of prolactin (greater than 1000 miU/l) than in those with hyperprolactinemia of between 500 and 1000 miU/l although this was not statistically significant chi 2 = 0.69. In the lower hyperprolactinemic range there was noticeable number of patients with endometriosis and increased luteinizing hormone (LH) levels.

Long-term effects of Depo-Provera on carbohydrate and lipid metabolism

Long-term effects of injection Depo-Provera (depo-medroxyprogesterone acetate) on carbohydrate and lipid metabolism were studied in 157 women who were treated continuously for a mean duration of 43.3 months. The patients were matched with 162 controls for race, age, parity and height. Glucose tolerance was impaired with higher intolerance at longer duration. Glucose areas were significantly higher at 48 and 60 months of injection. Insulin levels were also significantly decreased at 30 minutes and increased at 150 minutes but the area was normal. Triglycerides were initially decreased, being significant at 36 months (p less than 0.001) and returned to normal at 60 months while cholesterols were significantly higher at 24 and 36 months (p less than 0.05) and 60 months (p less than 0.001). In view of these findings, Depo-Provera may have an advantage over oral pills on a short term basis as there are less alterations in carbohydrate and lipid metabolism.

Risk factors for screening potential diabetics in pregnant Chinese patients

An intensive screening programme for potential diabetics in pregnancy was conducted in the University Department of Obstetrics and Gynaecology, Kandang Kerbau Hospital, Singapore, from June 1978 to December 1980. All patients with one or more risk factors for potential diabetes underwent an oral glucose tolerance tests (OGTT) with 50 g glucose loads. An abnormal OGTT was defined as one in which the second hour venous plasma glucose value was 7.8 mmol/1 (140 mg%) or more. In a group of 789 Chinese patients aged between 20 and 40 years, the overall detection rate of abnormal OGTTs was 15.5%. A significantly high proportion of abnormal OGTTs was found in patients with a direct family history of diabetes associated with random glycosuria during pregnancy and those with a previous history of 2 or more consecutive spontaneous abortions. However, in view of the relatively low detection rate of abnormal OGTTs in pregnant potential diabetics, a preliminary blood screening test would be useful to select those patients who require full OGTTs.

Research and development in obstetrics & gynaecology in the Department of Obstetrics & Gynaecology at the National University of Singapore

This is a review of the research and achievements of the Department of Obstetrics and Gynaecology, National University of Singapore since 1949. The research activities reviewed are Fertility Control, Subfertility, Reproductive Endocrinology, In-Vitro Fertilization, Trophoblastic Disease, Prostaglandins and Perinatal Medicine. The University Department has kept abreast with the Singapore norm of two-child families by providing the most sophisticated technology and expertise. The perinatal mortality and stillbirth rates have been reduced to 11 and 6 per thousand births. Prostaglandin research in the Department includes an investigation of the involvement of these substances in various physiological processes, pharmacological studies with different prostaglandins and development of clinical applications. Between 1974 and 1981 we had studied 12 intrauterine contraceptive devices, both on a departmental basis and in conjunction with international agencies. The newer medicated devices have proved to offer significant advantages over the original inert plastic configuration. Metabolic changes in Singapore women on the oral pill and injection Depoprovera were studied. Impaired glucose tolerance and raised fasting total lipids were found in women on the pill. Marginal changes in carbohydrate metabolism only were found in women on injection Depoprovera. Hypercoagulation changes in the blood occurring in Singapore women varied with the dose of the synthetic or natural oestrogen medication. Initially, the fibrinolytic activity was enough to compensate for these changes; however after two years there were signs of decompensation. Progestogens affect coagulation via their influence on the liver functions. Hypercoagulation changes also occurred in pregnancy and was of a greater magnitude than oestrogen or progestogen medication. In many obstetric disorders, including hydatidiform mole, there was evidence of intravascular coagulation. The introduction of endocrine function tests has greatly improved patient care in our Department, in particular those related to endocrine disorders. Application of the immunoassays to basic research has shown that physiological levels of oestradiol exert a negative feedback effect on both FSH and LH secretions in men. The greater suppression of LH than of FSH secretion by pharmacological doses of estradiol is possibly due to different control mechanisms in the pituitary for the synthesis and release of both gonadotrophins. Physiological level of testosterone per se has a definite negative feedback effect on the secretion of LH but not on FSH. Pharmacological doses of the 5-alpha-reduced metabolites of testosterone have been shown to suppress both LH and FSH indicating that some of the actions of testosterone could be medicated by these metabolites of which the 3 alpha-androstanediol and 3 beta-androstanediol are the more likely candidates.

Treatment of genital warts by cryosurgery--a follow-up study

This is a follow-up study involving 50 patients who were treated as outpatients for genital warts using cryosurgery. Single and multiple lesions involving the vulva, vagina and cervix were treated. A cryoprobe cooled to minus 70 degrees centigrade by liquid carbon dioxide and applied to the lesion for 2 1/2 to 3 minutes was used in the treatment. Nine pregnant patients in this study treated with cryosurgery did not experience any adverse effects on their pregnancies. There were no adverse side effects noted among the rest of the patients. All the patients with single wart were treated successfully with cryosurgery whereas those with multiple lesions were successfully treated in only 82 per cent of the patients. Four patients did not respond to treatment. Recurrence after cryosurgery within 3 months of therapy was noted in 2 patients. In conclusion, the treatment of genital warts by cryosurgery was found to be a safe and effect procedure.