Off-Label-Therapie: L�sungsm�glichkeiten

About 25% of administrations are for off-label indications. The treatment of many rheumatic diseases includes off-label use. Reimbursement from the health insurance is possible if no other approved therapy is available, and if scientific studies prove the effectiveness of the drug.

Dendritic cells co-localize with activated CD4+ T cells in giant cell arteritis

OBJECTIVE

Giant cell arteritis (GCA) is a vasculitis predominantly affecting medium- and large-sized arteries. Recent data show the co-localization of dendritic cells and Chlamydia pneumoniae in vascular biopsies from GCA patients. Here we define the topographical relation of dendritic cells and these activated T-cells to determine the antigen presenting cell in GCA, and to examine several auxiliary biochemical and genetic aspects relating to the role of bacteria such as C. pneumoniae in eliciting GCA.

METHODS

18 paraffin-embedded temporal artery biopsy specimens from 14 patients with GCA that were PCR-positive for C. pneumoniae were examined by two-color immunohistochemistry for the topographical relationship between dendritic cells and activated T-cells. In addition the presence of GTP-binding proteins. Tumor necrosis factor alpha (TNF alpha), and Toll-like receptor 4 (TLR4) was investigated. 15 temporal artery specimens from 10 patients without GCA served as controls.

RESULTS

In all GCA specimens, dendritic cells co-localized in the immediate vicinity of activated CD4+ Talin-expressing T cells, and these were predominantly found in granulomatous infiltrates. Confocal microscopy confirmed the cell-cell contact of dendritic cells with activated T cells. Results further showed that RhoA and Rac1 were predominantly present in the region of granulomatous infiltrates. TNF alpha production and expression was found in dendritic cells and macrophages, predominantly in granulomatous infiltrates and in endothelial cells of the vasa vasorum dispersed in the adventitial and medial layers of the temporal artery. No control specimens showed TNF alpha expression. More than 95% of dendritic cells were positive for TLR4; macrophages and endothelial cells localized in the adventitia showed TLR4 production.

CONCLUSIONS

The immediate co-localization of dendritic cells and activated T cells indicate a high probability that the former represent the antigen presenting cells in GCA. In addition, because of the presence of Rho A and Rac1 in the granulomatous infiltrates, we speculate that they provide the right environment for cell-cell contact and adhesion, and that they may promote the internalization of bacteria. TNF alpha is expressed at high levels in the granulomatous infiltrates of temporal artery specimens from patients with GCA. Since TLR4 is produced in the same cell types, and predominantly in the adventitial layer of the temporal artery, we suggest that these receptors are coupled to signal transduction pathways that control TNF alpha expression.

[Imaging techniques in rheumatology: sonography in rheumatoid arthritis]

Musculoskeletal ultrasonography has become an important diagnostic tool in rheumatoid arthritis. In Germany it is part of the rheumatology training, and many ultrasound courses provide further education. Only in the last five years the international importance of ultrasound in rheumatology has increased dramatically. Sonography can be performed as a bedside procedure and as an extension of the clinical investigation. It is easily tolerated by the patients, and it can be repeated any time. Sonography can have a great impact on therapeutic decisions. A > or = 5 MHz linear transducer is needed. Most transducers that are used for musculoskeletal ultrasound have about 7.5 MHz. Modern transducers with higher frequencies (>7.5 MHz) and high resolution improve the diagnostic value of the investigation. Sonography is superior to plain radiography to detect erosions as far as the region is accessible by ultrasound. It is more sensitive than the clinical investigation for the detection of synovitis, tenosynovitis, tendinitis, and bursitis as well as for the differentiation of these lesions. Color Doppler sonography aids in evaluating the activity of inflammation and in differentiating intraarticular structures. Carpal- and ulnar neuropathy occur secondary to rheumatoid arthritis and may lead to characteristic nerve swelling. Ultrasound-guided injections into joints and tendon sheets can be performed.

[Technique and diagnostic value of musculoskeletal ultrasonography in rheumatology. Part 6: ultrasonography of the wrist/hand]

Sonography of the hands is especially helpful in the diagnosis of early arthritis. Sonography allows for a very sensitive detection of small joint-effusion, tenosynovitis and small erosive bone lesions earlier than conventional radiography. Musculoskeletal sonography is also helpful in morphological analysis of changes of the median nerve in patients with carpal tunnel syndrome. The following standard scans are suggested for the sonographic evaluation of the wrist: 1. dorsal longitudinal scan along the radio-carpal joint, 2) along the ulno-carpal joint, and 3) dorsal transverse scan along the wrist to detect joint fluid collection, synovitis, tenosynovitis, ganglia, irregularities of the bone surface in osteoarthritis, and erosions due to inflammatory disease, 4) volar longitudinal scan along the radio-carpal joint, and 5) along the ulno-carpal joint, and 6) volar transverse scan along the wrist to diagnose the same objective as the above mentioned scans and to evaluate the median nerve in cases of carpal tunnel syndrome. Optional scans are the following: 7) ulnar longitudinal 8) transverse scan along the ulnar joint space and the extensor carpi ulnaris muscle to detect tenosynovitis and caput ulnae syndrome, 9) radial longitudinal, and 10). transverse scan along the joint space to diagnose synovitis and tenosynovitis. The following standard scans are suggested for the sonographic evaluation of the fingers: 1) volar longitudinal, 2) volar transverse scan in extension along the finger joints to detect effusion and synovial proliferation, tenosynovitis, irregularities of the bone surface (osteophytes, erosions), 3) dorsal longitudinal scans in extension and flexion >70 degrees along the CMC I, MCP, PIP and DIP joints to evaluate effusion and synovial proliferation, tenosynovitis or tendinitis, irregularities of the bone surface (osteophytes, erosions), and 4) dorsal transverse scans along the finger joints to evaluate these structures in an additional dimension. Optional 5) scans include the following: medial longitudinal scan along the MCP I, II, PIP and DIP joints, and 6) lateral longitudinal scan along the MCP V, PIP and DIP joints to evaluate the erosive bone process and joint instability. A linear transducer with a frequency of between 7.5 and 12 MHz is recommendable. The anterior distance between the bone and the joint-capsule of the wrist is > or = 3 mm in probable and > or = 4 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left wrist is > or = 1 mm, and they are definite if the difference is > or = 2 mm. A carpal tunnel syndrome is probable with a cross-sectional area of the median nerve of > or = 12 mm(2).

[Technique and diagnostic value of musculoskelatal ultrasonography in rheumatology. Part 5: Ultrasonography of the shoulder]

Shoulder-related symptoms are very common in rheumatic diseases. For the evaluation of the diagnosis as well as for therapy and prognosis, an anatomic assignment is essential. Clinical investigations alone are often not capable to do this. Ultrasonography is a method to delineate bony surfaces as well as the soft tissues around the shoulder joints statically and even dynamically. For the purpose of rheumatic diseases, ultrasound standard scans help to detect the lesions at the biceps tendon, the bursae, the rotator cuff, the humeral head as well as in the acromial and sternoclavicular joints. Considering the limitations of the method (obesity, frozen shoulder, no findings under bony structures) and knowing the pitfalls and errors of the method, ultrasonography is a reliable, quick and low cost method for the diagnosis of rheumatic shoulder joint pathology. Compared to computer tomography and magnetic resonance imaging, ultrasonography should be used as a screening method. The following standard scans are suggested for sonographic evaluation of the shoulder: 1) anterior transverse scan and 2) anterior longitudinal scan at the bicipal groove to detect synovitis and tenosynovitis, 3) anterior transverse scan at the coracoacromiale window in the neutral position, 4) at maximal external rotation and 5) at maximal internal rotation to evaluate the rotator cuff, bursitis, synovitis and erosions, 6) anterior longitudinal scan at 90 degrees to the coracoacomiale window at maximal internal rotation to describe these findings in an additional dimension, 7) anterior-lateral longitudinal scan at the anterior lateral acromion to tuberculum majus to evaluate the distal part of the supraspinatus muscle, 8) posterior transverse scan at the fossa infraspinata lateral under the spina scapulae, 9) axillary longitudinal scan to evaluate synovitis, synovial proliferation, erosions at the humeral head, lesions at the glenoidale labrum, 10) anterior transverse scan at the acromioclavicular joint and 11) anterior oblique scan at the sternoclavicular joint to detect synovitis, synovial proliferation, erosion, osteophytes.

[Imaging in rheumatology]

SUMMARY

Conventional radiography, ultrasonography, scintigraphy, computed tomography, and magnetic resonance imaging (MRI) are important diagnostic tools in rheumatology additional to clinical investigation. Radiography provides information both of the juxtaarticular and the abarticular bone. It is relevant in the diagnosis of rheumatoid arthritis, osteoarthritis, spondylarthropathies, and osteoporosis, and for the investigation of other regions like the thorax. Sonography is superior to radiography to delineate soft tissue structures such as effusions, tenosynovitis, tendinitis, paratendinitis, bursitis, and soft-tissue tumors, but also to evaluate bone surfaces. It helps to perform injections and punctures. Furthermore it is a new diagnostic tool for the diagnosis of temporal arteritis, Takayasu's arteritis, and Sjögren's syndrome. Echocardiography, abdominal and pleural sonography are also frequently used. MRI is useful to detect soft tissue lesions and bone lesions. It is helpful to depict synovial membrane, tendon, tendon sheaths, ligaments, cartilage, destructive joint processes, and rupture of synovial cysts. MRI is an established imaging technique in diagnosis of sacroiliitis and cervical arthritis as well as in diagnosis of osteonecrosis. It is an important diagnostic modality for demonstrating early arthritis. MRI is also of interest in diagnosis of neurological disorders of connective tissue diseases or vasculitis in rheumatology. Bone scintigraphy is an established imaging technique in diagnosis of skeletal diseases as well as in diagnosis of tumors. "Hot spots" are seen in locations of high bone turn over. Scintigraphy is also helpful to localize or exclude inflammation.

[Technical aspects and value of arthrosonography in rheumatologic diagnosis. 4: Ultrasound of the elbow]

Musculoskeletal ultrasonography is an important imaging technique in the diagnosis of rheumatic diseases especially for early manifestation. It allows sensitive detection of small joint fluid collections as well as differentiation of soft tissue lesions and bone lesions. The following standard scans are suggested for sonographic evaluation of the elbow: 1) anterior humeroradial longitudinal scan, 2) anterior humeroulnar longitudinal scan to detect effusions, synovial proliferation, loose joint bodies, bone lesions (osteoarthritis/arthritis), 3) anterior transverse scan over the trochlea to evaluate these structures in an additional dimension, 4) posterior longitudinal scan and 5) posterior transverse scan of the olecranon fossa with flexed/extended elbow to evaluate the same objectives as the above mentioned scans and additionally to detect olecranon bursitis, and optional 6) distal dorsal longitudinal scan to differentiate soft tissue lesions such as rheumatoid nodules or gout tophi, 7) anterior transverse scan over the radius head to evaluate lesions of the radius head, tendopathy, calcinosis, 8) lateral humeroradial longitudinal scan to evaluate epicondylitis, 9) medial humeroulnar longitudinal scan to evaluate calcinosis, epicondylitis, signs of compression of the ulnar nerve. A linear transducer with a frequency of about 5-7.5 MHz is recommendable. The anterior distance between trochlea and the capitulum of the humerus between the bone and the joint-capsule of the elbow is > or = 2 mm in probable and > or = 3 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between the right and left elbow is 1 mm, and they are definite if the difference is > or = 2 mm.

[Technique and value of arthrosonography in rheumatologic diagnosis--3: Ultrasound diagnosis of the ankle joint, foot and toes]

The clinical investigation of ankles, feet, and toes is frequently equivocal in rheumatology. Sonography can distinguish between underlying pathologies. We suggest following standard scans: 1) anterior longitudinal scan to diagnose effusions in the ankle and talonavicular joints, to display erosive and osteoarthrotic pathologies, and to diagnose tenosynovitis of the extensor tendons; 2) anterior transverse scan to document the findings in an additional dimension; 3) lateral transverse scan and 4) lateral longitudinal scan to diagnose tenosynovitis of the peroneus tendons; 5) medial transverse scan and 6) medial longitudinal scan to diagnose tenosynovitis of the flexor tendons; 7) posterior longitudinal scan and 8) posterior transverse scan to evaluate the Achilles tendon, the retrocalcaneal bursa, and the posterior recess of the ankle joint. Additionally we suggest optional scans: 9) plantar longitudinal scan for the plantar fascia and the plantar calcaneal surface; 10) distal anterior longitudinal scan to evaluate the midtalar joints; 11) distal anterior longitudinal scan to evaluate the toes; and 12) plantar, distal transverse scan to evaluate the flexor tendons of the toes. Additionally, the correlating longitudinal and transverse scans can be used to confirm the findings. The frequency of the transducer should be about 7.5 MHz for ankles and the peroneus, flexor, and extensor tendons. Ten to over 20 MHz are possible for more superficially located structures. Using modern equipment with higher resolution a hypoechoic border may be normal up to 3 mm in the ankle joints, the MTP joints, and around the peroneus tendons, and up to 4 mm around the tibialis posterior tendons.

Diagnosis of early Takayasu arteritis with sonography

OBJECTIVE

Takayasu arteritis is a large-vessel vasculitis that occurs predominantly in young females. The diagnosis is not usually established before arterial stenoses or occlusions are present. The aim of the study was to find out if sonography can aid in the diagnosis of the disease in earlier stages.

METHODS

We describe three patients with early disease who had no haemodynamically relevant stenoses. They are compared with nine patients who were diagnosed in the stenotic/occlusive stage of the disease. All patients were German Caucasian females. Colour Doppler sonography and angiography were performed in all cases.

RESULTS

Patients with early disease had general symptoms of fatigue and arthralgia and laboratory signs of inflammation, but neither bruits nor decrease of pulse rate. Sonography of the carotid and subclavian arteries demonstrated a characteristic, homogeneous, midechoic, circumferential thickening of the wall. At this stage of the disease it was difficult to get unequivocal results with angiography. In all nine remaining patients, sonography also demonstrated inflammation of the subclavian or carotid arteries, as did angiography in eight of these patients.

CONCLUSION

Sonography of the carotid and subclavian arteries aids in the detection of early Takayasu arteritis. In young females with unclear symptoms and laboratory findings of generalized inflammation, the primary extracranial branches of the aortic arch should be investigated by sonography to detect early Takayasu arteritis.

Involvement of peripheral arteries in giant cell arteritis: a color Doppler sonography study

OBJECTIVE

To investigate the involvement of arteries other than the temporal arteries in active giant cell arteritis using color Doppler sonography.

METHODS

The occipital, facial, vertebral, carotid, subclavian, axillary, brachial, ulnar radial, femoral, popliteal, posterior tibial, and dorsal pedal arteries, and the abdominal aorta of 33 consecutive patients with acute giant cell arteritis and 33 age- and sex-matched controls were investigated.

RESULTS

In 10 patients (30%), but in none of the controls, a characteristic inflammatory mural thickening (halo) could be demonstrated in these arteries. The subclavian, external carotid, and/or facial arteries were involved in 4 patients, the occipital and/or axillary arteries in 3 patients, the brachial and/or ulnar arteries in 2 patients, and the common carotid, vertebral, popliteal, and/or radial arteries in 1 patient each. Two patients had symptomatic large vessel giant cell arteritis with arm claudication. The other patients were asymptomatic concerning the involved arteries. Furthermore the ulnar artery was occluded in 3 cases, the posterior tibial artery in 2 cases, and the dorsal pedal and the vertebral artery in 1 case each. No occlusions were found in the controls. Occlusion of the temporal arteries occurred more frequently in patients with peripheral artery involvement than in those without peripheral involvement (60% versus 26%). In most of the non-stenotic, small arteries the halo disappeared within 9 to 21 days. Mural thickening remained in large, stenotic arteries.

CONCLUSION

Peripheral artery involvement occurs more frequently in acute temporal arteritis than has been assumed up to now. Color Doppler sonography offers a new method to evaluate this peripheral involvement.

[Sulfasalazine in ankylosing spondylitis: a prospective, randomized, double-blind placebo-controlled study and comparison with other controlled studies]

OBJECTIVE

To assess the efficacy and tolerability of sulfasalazine in ankylosing spondylitis including a meta-analysis of comparable trials.

METHODS

In a prospective, randomized, double-blind, placebo-controlled trial 70 patients with established diagnosis of ankylosing spondylitis and a mean disease duration of 16.7 years were investigated in two centers for 26 weeks comparing 3 g/d sulfasalazine to placebo.

RESULTS

The main outcome parameters, pain score, fingers-to-floor test, and CRP, did not improve significantly in the sulfasalazine group compared to the placebo group. Altogether sulfasalazine was significantly superior to placebo only concerning the IgA levels. The dropout rate was 47% for the sulfasalazine group and 19% for the placebo group. Due to side effects, 38% and 11%, respectively, stopped treatment. Ten other prospective, double-blind, controlled studies were analyzed. Altogether 959 patients with a mean disease duration of 13.9 years were evaluated. Most parameters did not improve significantly in the sulfasalazine groups compared to the placebo groups. Spinal motility remained nearly unchanged (0.3-3.5% improvement). Pain, morning stiffness, functional index, and global assessment were slightly influenced (1.9-11.7%). Reduction of ESR, CRP, IgA, IgG, and IgM was more distinct (12.6-20.3%). In 4 studies SSZ had greater efficacy in patients with peripheral joint involvement.

CONCLUSION

Sulfasalazine has no clinically relevant benefit in patients with ankylosing spondylitis. The dropout-rate due to adverse effects is high with a daily dose of 3 g. Sulfasalazine may be beneficial in peripheral joint involvement. Only few data exist about patients with a disease duration of less than 10 years.

[Technique and value of arthrosonography in rheumatologic diagnosis. 2: Ultrasound diagnosis of the hip area]

The clinical investigation of the hips in patients with rheumatic diseases is often equivocal. Thus, ultrasonography of this region is very relevant for rheumatologists. We suggest following standard scans: 1) anterior longitudinal scan to detect synovitis of the hip joint, iliopectineal bursitis, irregularities of the bone surface in osteoarthritis, Perthes' disease, and erosions due to inflammatory disease, 2) anterior transverse scan to evaluate these structures in an additional dimension, 3) lateral longitudinal scan of the hip joint with the same objective as the above mentioned scans; 4) lateral longitudinal scan, and 5) lateral transverse scan of the greater trochanter to diagnose trochanteric bursitis and bone irregularities due to enthesiopathy, and 6) dorsal oblique scan (optional) to diagnose hip joint effusions and pannus that localize in the dorsal region. Rotation of the joint is necessary to detect small effusions. The transducers should have a medium frequency of 5 to 7.5 MHz. In obese or muscular patients, 3.5 MHz transducers may be necessary to increase penetration. The anterior distance between the bone and the joint capsule of the hip joint is > or = 7 mm in probable and > or = 8 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left hip is > or = 2 mm, and they are definite if the difference is > or = 3 mm.

Incidence of temporal arteritis in patients with polymyalgia rheumatica: a prospective study using colour Doppler ultrasonography of the temporal arteries

OBJECTIVE

To determine the incidence of temporal arteritis (TA) in patients with polymyalgia rheumatica (PMR) using colour Doppler ultrasonography of the temporal arteries.

METHODS

Ultrasonography was performed in all 127 consecutive patients with newly diagnosed, active PMR seen between 1994 and 2000 and in 127 age- and sex-matched controls.

RESULTS

Of 102 patients with "pure" PMR, 8% had ultrasonographic findings arousing suspicion of concomitant active TA (specific halo sign and/or positive histology in 7%; histologically proven TA in 4%). Twenty-five patients had clinical signs of both PMR and TA. Histology and sonography were negative in three of these patients. Of the controls, none had a halo sign and four had stenoses.

CONCLUSION

Ultrasonography of the temporal arteries is a new, non-invasive method of diagnosing concomitant TA in patients with PMR.

Usefulness of the triple test score for palpable breast masses; discussion 1012-3

HYPOTHESIS

The triple test score (TTS) is useful and accurate for evaluating palpable breast masses.

DESIGN

Diagnostic test study.

SETTING

University hospital multidisciplinary breast clinic.

PATIENTS

Four hundred seventy-nine women with 484 palpable breast lesions evaluated by TTS from 1991 through July 2000.

MAIN OUTCOME MEASURES

Physical examination, mammography, and fine-needle aspiration were each assigned a score of 1, 2, or 3 for benign, suspicious, or malignant results; the TTS is the sum of these scores. The TTS has a minimum score of 3 (concordant benign) and a maximum score of 9 (concordant malignant). The TTS was correlated with subsequent histopathologic analysis or follow-up.

INTERVENTIONS

The TTS was prospectively calculated for each mass. Lesions with a TTS greater than or equal to 5 were excised for histologic confirmation, whereas lesions with scores less than or equal to 4 were either excised (n = 60) or followed clinically (n = 255).

RESULTS

All lesions with TTS less than or equal to 4 were benign on clinical follow-up, including 8 for which the fine-needle aspiration was the suspicious component. Of the 60 biopsied lesions, 51 were normal breast tissue, 4 showed fibrocystic change, 1 was a papilloma, and 4 were atypical hyperplasia. All lesions with a TTS greater than or equal to 6 (n = 130) were confirmed to be malignant on biopsy. Thus, a TTS less than or equal to 4 has a specificity of 100% and a TTS greater than or equal to 6 has a sensitivity of 100%. Of the 39 lesions (8%) with scores of 5, 19 (49%) were malignant, and 20 (51%) were benign.

CONCLUSIONS

The TTS reliably guides evaluation and treatment of palpable breast masses. Masses scoring 3 or 4 are always benign. Masses with scores greater than or equal to 6 are malignant and should be treated accordingly. Confirmatory biopsy is required only for the 8% of the masses that receive a TTS of 5.

[Technique and value of arthrosonography in rheumatologic diagnosis. 1: Ultrasound diagnosis of the knee joint]

Within the last few years, ultrasonography (US) of joints has attained a firm position for the diagnosis of joint diseases. Degenerative as well as inflammatory changes can be recognized using this method. With new, higher resolution techniques even bone surfaces and tendon textures can be visualized in greater detail. The advantages of sonography are general availability and low costs. When used properly, as a non-invasive procedure US has no detrimental effects on patients. The disadvantages of this technique result from its physical limitations, such as high reflection of US on bone and the negative correlation between resolution and penetration which makes US imaging difficult in deeper regions. The current technical development of probes and imaging processing, however, promises better deep structure imaging in the future. The quality of ultrasound examination always depends on the technical equipment, as well as on the patients' individual tissue constitution and the experience of the physician. It is possible to avoid misinterpretation and to increase the diagnostic value of US by using a standardized technique and professional knowledge of the specific aspects of the method. The significance of qualified education and sufficient training of sonographers is to be stressed. The aim of this article is to deliver a basic contribution to the standardization and quality assurance of joint US and to indicate the value of this method. In addition to the overview the authors propose guidelines for performance and interpretation of joint US. Due to the major significance of the knee joint in rheumatology it was decided to begin the work in this area.

Vasculitis of the internal carotid artery in Wegener's granulomatosis: comparison of ultrasonography, angiography, and MRI

A 37-year old male with newly diagnosed, untreated Wegener's granulomatosis including glomerulonephritis, sinusitis, conjunctivitis, arthralgias, and positive cANCA, developed a pulsating tumor in the left submandibular region and a reversible ischemic neurologic deficit. Ultrasonography revealed both a hyperechoic wall thickening of the left proximal internal carotid artery as is known in Takayasu's arteritis and a surrounding hypoechoic region typical for perivasculitis. The wall thickening and the perivascular infiltrate could be less clearly seen by MRI. Ultrasonography, angiography, and MRI demonstrated a 3 cm long, 30%, stenosis. Angiography and MRI additionally found a more distally located kinking of the internal carotid artery that was missed by ultrasonography. Carotid artery vasculitis is a rare complication of Wegener's granulomatosis. In this case ultrasonography was superior to angiography and MRI to visualize the artery wall and the surrounding tissue, but it failed to evaluate the whole distance of the vessel.

Clinical and serological aspects of patients with anti-Jo-1 antibodies--an evolving spectrum of disease manifestations

The aim of this study was to compare ELISA, immunodiffusion and immunoblot for the detection of anti-Jo-1 antibodies, and to investigate the association of the results with clinical manifestations. In two medical centres for rheumatology and one for pulmonology, all patients with suspected connective tissue disease were screened over a 5-year period for anti-Jo-1 antibodies by ELISA. Positive sera were controlled in another laboratory by immunodiffusion. If immunodiffusion was negative, sera were controlled again by ELISA. ELISA-positive immunodiffusion-negative sera were tested by immunoblotting. The patients were characterised clinically, and their clinical signs and symptoms were compared with those of 257 patients with anti-Jo-1 antibodies published in 15 case series and 30 case reports. Twenty-five patients had a positive ELISA test. Fifteen sera were positive by ELISA and immunodiffusion (group 1). Three sera showed high titres in both ELISA tests with negative immunodiffusion and immunoblot (group 2). Seven sera showed low titres in both ELISA tests. The results were negative in the other tests (group 3). Patients in groups 1 and 2 could be classified as Jo-1 syndrome patients. Of these 18 patients, 15 had arthritis, 14 had myositis and 14 had interstitial lung disease. Only four patients had myositis at disease onset. We describe four unusual patients with Jo-1 syndrome in detail: 1. Long history of seronegative rheumatoid arthritis; 2. Sjögren's syndrome with Ro- and La-antibodies; 3. Scleroderma and bronchial carcinoma with centromere antibodies; 4. Corticoid-sensitive psychosis. Patients with suspected connective tissue disease may be screened for anti-Jo-1 antibodies by ELISA. It detects some patients that are missed by immunodiffusion. Especially lower ELISA titres should be controlled by another method because of the low specificity of the test. The clinical picture is variable. Most patients have features other than myositis at disease onset.

Lymph nodes in the human female breast: a review of their detection and significance

Our experience led us to test the hypothesis that lymph nodes are not uncommon within the substance of the human female breast mound. The following specimen types and sources were used to survey the presence of intramammary lymph nodes in the human female breast mound: (1) cadaver breasts; (2) community hospital breast specimens; and (3) university and VA hospital specimens. We found true lymph nodes within and associated with breast specific tissue (ie, tissue that includes duct and gland structures), thereby validating the hypothesis posed. We discuss the significance of these findings in terms of our dominant patient care paradigm (the Triple Test-physical examination, imaging, and fine-needle aspiration [FNA]) and the choice of patient care management options. We conclude the following: lymph nodes occur in any quadrant of the breast mound; recognizing the possibility of intramammary lymph nodes is important when choosing between patient management options; intramammary lymph nodes can be sampled by FNA; intramammary lymph nodes can contain various disease processes; and in the Oregon Health Sciences University Multidisciplinary Breast Clinic, these intramammary lymph nodes are commonly identified by imaging methods and are more likely to be sampled by FNA than either by core or excisional biopsy.

Doppler ultrasonography in the diagnosis of giant cell arteritis

Ultrasonography of the temporal arteries detects characteristic signs of vasculitis with a high sensitivity and specificity: a hypoechoic halo due to an oedema of the artery wall and stenoses. The use of modern scanners with high resolution is essential. A halo has to be displayed in two planes. It is always circumferential. The colour intensity must not be too strong, otherwise the colour may cover the halo. A hypoechoic halo is also seen in large vessel giant cell arteritis at the axillary and brachial arteries and at the temporal arteries in polyarteritis nodosa.

Detection of Chlamydia pneumoniae in giant cell vasculitis and correlation with the topographic arrangement of tissue-infiltrating dendritic cells

OBJECTIVE

Recent studies suggest that giant cell arteritis (GCA) may be an antigen-driven disease. Since Chlamydia pneumoniae has been identified in arterial vessel walls, it was hypothesized that this organism might be associated with GCA.

METHODS

Fourteen paraffin-embedded temporal artery biopsy specimens from 9 patients with GCA were examined by immunohistochemistry and by polymerase chain reaction (PCR) for the presence of C pneumoniae; for 5 patients, specimens were available from both the left and right arteries. Four temporal artery specimens from 3 patients with polymyalgia rheumatica (PMR) and 9 temporal artery specimens from 5 patients without GCA or PMR served as controls.

RESULTS

C pneumoniae was detected by both immunohistochemistry and PCR in 6 GCA patient samples. One GCA patient sample was immunopositive only; another was PCR positive only. Thus, C pneumoniae was found in 8 of 9 GCA patients. One of 4 control samples from the PMR patients was immunopositive, but PCR negative, for C pneumoniae. The C pneumoniae-positive PMR patient also had respiratory symptoms. The remaining 9 control samples were negative for C pneumoniae by both immunohistochemistry and PCR. Immunohistochemistry showed that bacteria predominate in the adventitial layer of temporal arteries, in granulomatous infiltrates. Dendritic cells were examined by immunohistochemistry for their presence and localization in consecutive temporal artery specimens, and showed a strong topographic relationship with C pneumoniae. Like the bacterium, dendritic cells predominate in the adventitial layer of the arteries.

CONCLUSION

C pneumoniae was found in temporal artery specimens from most GCA patients, in 1 specimen from a PMR patient, and in no other control specimens; thus, it may play a role in the pathogenesis of the disease. Dendritic cells may represent the antigen-presenting cells in this situation.

Colour Doppler ultrasonography to detect pannus in knee joint synovitis

OBJECTIVE

To determine if colour Doppler ultrasonography can characterise the nature of intraarticular echogenic structures and synovial villi more precisely than conventional ultrasonography.

METHODS

This is a prospective study on 20 patients--10 with rheumatoid arthritis and 10 with osteoarthritis. Colour Doppler ultrasonography of the knee joints was performed prior to total prosthetic replacement. Two independent, trained physician ultrasonographers examined the knee to be replaced with different ultrasound equipment using colour Doppler and power Doppler ultrasonography. The existence and extent of pannus were then assessed surgically and histologically.

RESULTS

All 9 patients with histologically detected pannus had perfused, echogenic, intraarticular structures (ultrasonographer 2; ultrasonographer 1: 8 out of 9 patients). Sparse perfusion was detected in 1 patient (investigator 1) and in 5 patients (investigator 2) with extensive non-destructive synovial proliferation. Colour Doppler and power Doppler ultrasonography were equivalent in detecting small intraarticular vessels.

CONCLUSION

Colour Doppler ultrasonography improves the differentiation of intraarticular structures compared to conventional ultrasonography.

Color duplex ultrasonography in large-vessel giant cell arteritis

In a patient with active extracranial giant cell arteritis, duplex ultrasonography demonstrated hypoechoic mural thickening of the brachial, axillary, subclavian, and carotid arteries with bilateral subtotal occlusions of the brachial and axillary arteries. The ultrasound image of the artery walls became midechoic within 8 weeks, and hyperechoic within one year after start of treatment with corticosteroids. A similar hypoechoic mural thickening of the temporal arteries has been recently described in active giant cell arteritis. The dark ultrasound image is due to an edema of the vessel wall in the acute stage. The brighter ultrasound image might be due to fibrosis in the chronic stage of the disease.

Submandibular gland carcinoma ex pleomorphic adenoma. Report of a case with cytologic features and diagnostic pitfalls

BACKGROUND

Carcinoma ex pleomorphic adenoma is a rare neoplasm of the salivary gland. This lesion, also known as malignant mixed tumor, occurs when a malignant tumor arises in the epithelial component of a pleomorphic adenoma. Reports of fine needle aspiration biopsy (FNAB) diagnosis of malignant mixed tumors are rare and have been limited to cases arising in the parotid. Cytologic features and diagnostic pitfalls of this uncommon neoplasm are presented.

CASE

A 75-year-old male presented with a nontender submandibular mass. The lesion had been present 12 months, with a recent increase in size. FNAB was performed, and the smears revealed a mixture of benign and malignant areas. The benign portion of the smears showed findings typical of pleomorphic adenoma. The malignant area showed large cells occurring singly and in groups. The malignant cells contained pleomorphic nuclei with irregular nuclear membranes and prominent macronucleoli; cytologically, they resembled cells from a poorly differentiated adenocarcinoma.

CONCLUSION

We present the first case of carcinoma ex pleomorphic adenoma of the submandibular gland correctly diagnosed by FNAB. This rare salivary gland malignancy can be accurately diagnosed on FNAB if strict criteria are applied.

Accurate evaluation of palpable breast masses by the triple test score

BACKGROUND

We previously reported that the triple test (physical examination, mammography, and fine needle aspiration) for palpable breast masses yields 100% diagnostic accuracy when all 3 components are concordant (all benign or all malignant). However, 40% of cases are nonconcordant and require open biopsy.

OBJECTIVE

To evaluate our experience with the triple test to develop a method to further limit the need for surgical biopsy.

DESIGN

Diagnostic test study.

SETTING

University hospital multidisciplinary breast clinic.

PATIENTS

Two hundred fifty-nine patients with 261 palpable breast masses studied between 1991 and 1997.

INTERVENTION

The triple test was prospectively applied to each breast mass. Each component of the triple test was assigned 1, 2, or 3 points for a benign, suspicious, or malignant result, respectively, yielding a total triple test score (TTS).

MAIN OUTCOME MEASURES

The TTS was correlated with subsequent histopathologic examination results.

RESULTS

Eighty-eight masses had a TTS of more than 6 points; all had malignant histopathologic characteristics. One hundred fifty-two masses had a TTS of 4 points or lower; all were benign. In both groups, diagnostic accuracy and predictive value were 100%, with P<.001. Twenty-one masses had a TTS of 5 points; of these, 13 (62%) were benign and 8 (38%) were malignant.

CONCLUSIONS

The TTS reliably guides evaluation and treatment of palpable breast masses. Masses that score 6 points or higher are malignant and should undergo definitive therapy; masses that score 4 points or lower are benign and may be clinically followed up. Only those masses that score 5 points (8% of our database) require open biopsy.

Color duplex ultrasonography in the diagnosis of temporal arteritis

BACKGROUND

The diagnosis of temporal arteritis usually requires a biopsy of the temporal artery. We examined the usefulness of color duplex ultrasonography in patients suspected of having temporal arteritis.

METHODS

In this prospective study, all patients seen in the departments of rheumatology and ophthalmology from January 1994 to October 1996 who had clinically suspected active temporal arteritis or polymyalgia rheumatica were examined by duplex ultrasonography. The final diagnoses, made according to standard criteria, were temporal arteritis in 30 patients, 21 with biopsy-confirmed disease; polymyalgia rheumatica in 37; and negative histologic findings and a diagnosis other than temporal arteritis or polymyalgia rheumatica in 15. We also studied 30 control patients matched for age and sex to the patients with arteritis. Two ultrasound studies were performed and read before the biopsies; one ultrasonographer was unaware of the clinical information.

RESULTS

In 22 (73 percent) of the 30 patients with temporal arteritis, ultrasonography showed a dark halo around the lumen of the temporal arteries. The halos disappeared after a mean of 16 days (range, 7 to 56) of treatment with corticosteroids. Twenty-four patients (80 percent) had stenoses or occlusions of temporal-artery segments, and 28 patients (93 percent) had stenoses, occlusions, or a halo. No halos were identified in the 82 patients without temporal arteritis; 6 (7 percent) had stenoses or occlusions. For each of the three types of abnormalities identified by ultrasonography, the interrater agreement was > or =95 percent.

CONCLUSIONS

There are characteristic signs of temporal arteritis that can be visualized by color duplex ultrasonography. The most specific sign is a dark halo, which may be due to edema of the artery wall. In patients with typical clinical signs and a halo on ultrasonography, it may be possible to make a diagnosis of temporal arteritis and begin treatment without performing a temporal-artery biopsy.

Bladder washing cytology. Comparison of two analytic methods and two proposed quantitative criteria for carcinoma in situ

OBJECTIVE

To compare bladder washing cytology preparations created by the Nucleopore filter and slide centrifuge techniques and to evaluate a marker for carcinoma in situ (CIS).

STUDY DESIGN

Nucleopore filter and slide centrifuge preparations from 27 patients with urothelial carcinoma were compared and used to create two criteria for CIS. To study reproducibility, three observers evaluated 25 filter preparations for these CIS criteria.

RESULTS

The filter technique displayed more better-preserved single cancer cells (P = .02) and a higher percent group count (the number of cancer cell groups divided by the sum of the number of single cancer cells plus the number of cancer cell groups) (P = .005) than did the cytocentrifuge technique. The initial study showed that patients with many single tumor cells and lower percent group counts were more likely to have CIS than patients without this combined condition (P = .001). This CIS marker had moderate reproducibility (kappa = 0.47 +/- 0.12).

CONCLUSION

The filter technique had better cellular recovery and preservation of tumor cells than did the centrifuge technique. Quantitative cytologic criteria proposed in this study may be an indication that CIS may be present; improved sensitivity and specificity may be obtained if they are combined with other criteria.

Diagnosis of palpable breast lesions in younger women by the modified triple test is accurate and cost-effective

OBJECTIVE

To study the accuracy and cost of diagnosing palpable breast lesions in younger patients using a modified triple test (MTT: physical examination, ultrasonography instead of mammography, and fine-needle aspiration).

DESIGN

Diagnostic test study and cost-effectiveness estimate.

SETTING

Multidisciplinary university breast clinic.

PATIENTS

Fifty-five women below the recommended age of screening mammography (mean age, 33 years) with unilateral, palpable breast lesions.

INTERVENTION

Each lesion was tested by all 3 elements of MTT, and each element was interpreted as benign, suspicious, or malignant.

MAIN OUTCOME MEASURES

Patients with MTTs in which all elements were concordant (in agreement) and benign were evaluated clinically (mean follow-up, 11 months). Patients in whom the results of fine-needle aspiration were scored as suspicious or malignant underwent open confirmatory biopsy.

RESULTS

Forty-eight patients had concordant benign MTTs, including 14 patients with breast cysts. No cancers developed at the index sites during follow-up, including 5 biopsies done at the patients' request (negative predictive value and specificity, 100%). Fine-needle aspiration and physical examination were more accurate than ultrasonography in the 7 cases in which MTT was nonconcordant. Compared with the criterion standard (physical examination and open biopsy), use of MTT under the conditions of this study could avoid open biopsies in almost all cases, with average savings in charges of up to $623 per case.

CONCLUSION

Use of MTT for the diagnosis of unilateral, palpable breast lesions in younger women yields high diagnostic accuracy without the need for routine open biopsy, resulting in an overall reduction in patient charges.

[Necrotizing vasculitis of the appendix and cecum in systemic lupus erythematosus]

A 20-year old female patient with systemic lupus erythematosus with butterfly-erythema, arthritis, high positive ANA and anti-ds-DNA titres has to have laparatomy because of an acute abdomen. Histological diagnosis is a necrotizing vasculitis of the appendix. In systemic lupus erythematosus an intestinal vasculitis can be found which might be as severe as in polyarteritis nodosa.

[Color Doppler ultrasound of the temporal arteries--a new method for diagnosing temporal arteritis]

BACKGROUND

Recently increasing attention has been paid to temporal arteritis which is not a very rare disease. Early establishment of the diagnosis and start of therapy can reduce serious visual complications.

PATIENTS AND METHODS

The temporal arteries of 10 patients with temporal arteritis, 8 patients with polymyalgia rheumatica, and 23 controls were investigated with a high resolution ultrasound system, measuring size of lumen and wall as well as blood flow velocity.

RESULTS

Colour doppler sonography of the superficial temporal artery showed a characteristic hypoechoic halo around the perfused lumen of an often stenosed or occluded artery. Neither patients with polymyalgia rheumatica nor controls had this hypoechoic halo. The halo disappeared 10-14 days after start of therapy with glucocorticoids.

CONCLUSIONS

We think that colour doppler sonography of the temporal arteries is a simple, quick, and non-invasive method to diagnose temporal arteritis. When there will be more experience, sensitivity and specificity of the method can be defined. Perhaps sonography might replace biopsy in some cases in the future.

Indications and immediate patient outcomes of pathology intraoperative consultations. College of American Pathologists/Centers for Disease Control and Prevention Outcomes Working Group Study

OBJECTIVE

To evaluate the reasons (indications) for and immediate intraoperative surgical results (outcomes) associated with pathology intraoperative consultation.

DESIGN

In 1992 and 1993, surgeons collaborated with pathologists in 472 voluntarily participating institutions from the United States (462), Canada (7), Australia (2), and New Zealand (1) in a study jointly sponsored by the College of American Pathologists and the Centers for Disease Control and Prevention. Pathologists selected 20 consecutive intraoperative consultations and assembled a cover letter, a checklist questionnaire, and a copy of the corresponding surgical pathology report, all of which were sent to the surgeon(s) for retrospective evaluation.

PARTICIPANTS

The study was distributed to participants in the College of American Pathologists voluntary Q-Probes quality improvement and Surgical Pathology Performance Improvement programs and to Canadian and Australian hospitals with more than 200 beds.

RESULTS

Evaluation of 9164 cases established the five most common indications for intraoperative consultation: (1) establish or confirm diagnosis to determine type or extent of operation (51%), (2) confirm adequacy of margins (16%), (3) confirm nature of tissue to direct sampling for immediate culture or other laboratory study (10%), (4) expedite obtaining diagnosis to inform family or patient (8%), and (5) confirm sufficient tissue submitted to secure diagnosis in permanent section (8%). The information provided by the intraoperative consultation resulted in changed surgical procedures that were either modified, terminated, or newly initiated in 47%, 30%, 6%, 9%, and 28% of cases, corresponding respectively to each of the above five common indications. Rarely cited reasons for intraoperative consultation were to expedite obtaining diagnosis for surgeon's knowledge (3%), to facilitate patient management, other professional communication or discharge planning prior to permanent section availability (3%), academic protocol (< 1%), and consultation not needed or no reason for request (< 1%).

CONCLUSIONS

This multi-institutional, interdisciplinary database confirms that pathology intraoperative consultations, regardless of the initial indications, influence immediate patient care decisions, resulting in changed surgical procedures in an average of 39% of all operative cases.

FNA of extraskeletal myxoid chondrosarcoma: cytomorphologic, EM, and X-ray microanalysis features

Extraskeletal myxoid chondrosarcoma, an unusual soft tissue lesion which preferentially affects the extremities, is a prime candidate for "pathologist performed" fine-needle aspirates (FNA) because it preferentially affects the extremities [Enzinger and Shiraki, Hum Pathol 1972;3:421-435] and is usually an accessible lesion. Cytomorphologically, the neoplasm consists of clusters of fairly uniform cells, lacking cartilaginous differentiation, with a metachromatic matrix when stained with Diff-Quik (DQ). While subtle, this neoplasm has distinct features and must be distinguished for other neoplasms in the differential diagnosis because patient evaluation, prognosis, and therapy will vary greatly. We present a case characteristic of this tumor in which FNA derived material was subjected to light microscopy, X-ray microanalysis, and immunohistochemical studies; each modality provided data essential to the correct diagnosis.

Effects of rotational atherectomy in normal canine coronary and diseased human cadaveric arteries: potential for plaque removal from distal, tortuous, and diffusely diseased vessels

To test the hypothesis that tortuous, diseased vessels could be successfully treated with a flexible rotational atherectomy device we evaluated the BARD atherectomy device with quantitative angiography and histology in normal canine coronary arteries and diseased human below-knee amputation specimens. The mid left anterior descending and the circumflex vessels were treated in 4 dogs serially with 1 wk separating treatments. The acute and follow-up anterior descending artery size was unchanged (1.41 mm before, 1.39 mm after, and 1.59 mm at 1 week). Similar findings were obtained in the circumflex vessels. In 4 adult human amputated legs, diseased peroneal or tibial arteries were treated with a significant reduction in the percent luminal diameter stenosis from 62.75 prior to intervention to 36.5 following intervention (p = 0.021). The luminal diameter increased from 0.81 to 1.54 mm (p = 0.06). In 2 canine arteries there was histologic evidence of localized perforation of the arterial wall, but there was no angiographic evidence of perforation or dissection and no significant myocardial necrosis in the distribution of the treated vessels at 1 wk. The majority of the diseased human vessels demonstrated smoothly cut atheromas with sparing of the media. The rotational atherectomy catheter system holds promise for removal of plaque in relatively small, diffusely diseased, tortuous vessels.

Chronic tophaceous gout with severely deforming arthritis: a case report with emphasis on histopathologic considerations

The dramatic clinical presentation of a patient with severe deforming arthritis secondary to chronic tophaceous gout is described. Polarization microscopic examination and use of the De Galantha stain identified the dermal amorphous material as urate crystals. When the possibility of gout is entertained and a lesional biopsy specimen is examined to confirm the diagnosis, it is useful to fix the fresh tissue in absolute ethanol and process the specimen using an anhydrous technique to preserve the crystals.

Fine-needle aspiration of a solitary pulmonary nodule following treatment of metastatic giant-cell tumor of bone

Giant cell tumor (GCT) of bone is a local, variably aggressive neoplasm with high local recurrence and occasional pulmonary metastases. Radiographically guided fine-needle aspiration (FNA) plays a large role in establishing a tissue diagnosis of lung metastases prior to therapeutic intervention. We present a patient with histologically proven pulmonary metastases from a femoral grade II GCT. These lesions were obliterated with combination HT-CT (hyperthermia and chemotherapy). The patient subsequently developed another pulmonary nodule at a site previously occupied by a GCT metastatic deposit. Radiographically guided FNA revealed that this new lesion was an adenocarcinoma, apparently of pulmonary origin. We suggest that this second neoplasm arose within a scar that developed after HT-CT ablation of one of the metastases. Additional intriguing features of this case are the effective HT-CT therapy of GCT metastatic to lung and the extended temporal course (some 16 yr from initial diagnosis to death).

Leiomyoma involving the gastrocolic ligament: CT demonstration

A case of a large leiomyoma involving both the transverse colon and the greater curvature of the stomach is presented. Computed tomography (CT) demonstrated contiguous extension of the mass along the gastrocolic ligament. Although similar findings have been described in colonic and gastric carcinoma and in omental metastases, this is the first report in which these findings were due to a leiomyoma.

Fine needle aspiration cytology of metastatic lymphoepithelioma. A case report

A case is presented of lymphoepithelioma (undifferentiated nasopharyngeal carcinoma) metastatic to the cervical lymph nodes in a 12-year-old boy for whom material was obtained by fine needle aspiration (FNA) for the primary diagnosis as well as for ancillary studies. Papanicolaou-stained smears demonstrated the characteristic cytopathologic features of Regaud-type lymphoepithelioma; the diagnosis was substantiated by immunocytochemical and electron microscopic studies. This report discusses the reliability and rapidity of FNA in definitively diagnosing undifferentiated metastatic malignancies as well as providing superior material for ancillary studies demanded by lesions with complicated and difficult differential diagnoses.

Limitations of flow cytometric DNA analysis for the diagnosis of bladder cancer

Flow cytometric analysis was done on exfoliated urothelial cells from 11 control patients and 31 patients with transitional cell carcinoma: 9 grade I, 11 grade II, and 11 grade III. The determination of aneuploidy by DNA analysis did not provide identification of low-grade tumor cells. Other flow cytometric parameters of cellular change such as cell size, nuclear size, nuclear/cytoplasmic ratio, or cell refractivity may provide better identification of low-grade lesions.

Virilizing serous cystadenoma

A 71-year-old woman, 26 years post-menopause, presented with virilization. Facial hirsuties, non-hereditary frontal balding, voice changes, male escutcheon, and mild clitorimegaly accompanied a right adnexal mass. Blood hormone studies showed testosterone 430 ng/dL, FSH 118 mIU/mL, and LH 210 mIU/mL. By ultrasound examination, the cystic adnexal mass involved the right ovary. An 18-cm, 1300-g, unicameral mass with 1200 mL of clear serous fluid and with smooth inner and outer surfaces was removed from the right broad ligament. Intraoperative testosterone levels were as follows: peripheral vein 285 ng/dL, left ovarian vein 301 ng/dL, and right ovarian vein 1635 ng/dL; tumor cystic fluid was 3032 ng/dL. Peripheral vein testosterone was 15 ng/dL 3 days postoperatively. Histopathologically, the tumor was a serous cystadenoma. No evidence of stromal luteinization, hyperplasia, or inflammation was found, and other virilizing lesions were not encountered in either ovary or in other tissues. Epithelial cells constituting the tumor may have been the source of the excess testosterone in this unique case of virilizing serous cystadenoma.

Physiologic characterization of transformed and cloned rat granulosa cells

Properties of a clonal line of SV40-transformed rat granulosa cells (DC3 cells) were elucidated. DC3 cells were maintained in vitro in Iscove Modified Dulbecco Medium that contained 20% fetal bovine serum. The cells had a logarithmic growth phase doubling time of approximately 18 h and produced detectable quantities of estrone, estradiol, and progesterone. Steroidogenesis was increased by supplementation with either steroidogenic substrates or agents that stimulated activity of adenylate cyclase. Production of progesterone and estrogens was enhanced when medium was supplemented with 25-hydroxycholesterol, and production of estradiol was enhanced by medium supplementation with androstenedione. Treatments with forskolin and cholera toxin resulted in marked increases of cyclic adenosine 3',5'-monophosphate (cAMP) in medium and cells and enhanced steroidogenesis. Isoproterenol and vasoactive intestinal peptide, but not follicle-stimulating hormone (FSH), luteinizing hormone (LH), insulin or prolactin, stimulated cAMP secretion by suspended cells. DC3 cells had small but detectable levels of binding to FSH, but binding of LH and epidermal growth factor could not be detected. DC3 cells possess characteristics expected of granulosa cells arrested in an early stage of differentiation and may provide a useful model for studies of "immature" granulosa cell functions.

Histologic response to microsuture materials

Long- and short-term reactions of reproductive tract tissue to microsurgical suture materials were compared. The five materials were: polyglactin 910 (Vicryl), polyglycolic acid (Dexon-S), polypropylene (Prolene), nylon (Ethilon and Dermalon) and chromic catgut; the calibers ranged from 6-0 to 10-0. Sixteen days after suture placement the smallest tissue reaction was seen with 9-0 and 10-0 suture materials; Dexon-S caused a slightly greater reaction than did Vicryl. Prolene, 8-0 and 9-0, produced the smallest tissue response when compared to other sutures of similar size. Larger sutures incited greater tissue reactions. Forty-two days after placement, each suture was associated with similar or lower reaction scores than those observed at 16 days. At 90 days all the Dexon-S sutures had been absorbed. Vicryl had less of a late reaction as compared to the other sutures. Reactions persisted longer with nonabsorbable suture, and the tissue response depended on both the suture material and caliber. Vicryl, 8-0 to 10-0, incited the smallest short- and long-term tissue reaction; at those sizes it seems optimal for reconstructive tubal surgery.

Bilateral ovarian thecosis and virilization in pregnancy. A case report

Virilization is usually associated with amenorrhea, infertility and ovarian stromal lesions. Paradoxically, however, it may also be seen in pregnancy; this type of virilization is rare and accompanies ovarian thecosis. Thecosis, also known as thecomatosis and stromal thecosis, is a complex assortment of types of ovarian stromal proliferation associated with various types and amounts of hormonal activity. A patient had progressive virilization that began about seven years after menarche. Nonetheless, she had six pregnancies and bore five normal living children. Her last child, a female, was not affected by the high maternal testosterone levels. The patient's virilization was associated with an ovarian stromal hyperplasia classified as combined thecosis. In this case, as in some others, there was reason to suspect a genetic basis for such progressive virilization with retained fertility; an analysis of it provides insight into the complex nature of ovarian stromal hyperplasia and hormonal activity.