Paratesticular serous papillary carcinoma. A report of six cases

Six intrascrotal, invasive epithelial neoplasms of serous papillary type arose in the paratesticular region of patients 16 to 42 (mean, 30.8) years of age. Five patients, one with an associated hydrocele, presented with a testicular mass and one with a hydrocele only. The serum CA-125 level was elevated in one of the two patients in whom it was measured. Grossly, the tumors were solid, white, or tan, poorly circumscribed, often gritty masses. Four tumors involved primarily the soft tissue between the testis and epididymis (testiculoepididymal groove) and one, the paratesticular soft tissue. The sixth tumor was confined to the visceral tunica vaginalis at the inferior pole of the testis. The most common microscopic pattern was characterized by invasive, well-formed papillae lined by serous cuboidal or columnar cells with eosinophilic cytoplasm and malignant nuclear features. Psammoma bodies were abundant in all the cases. Areas of borderline serous tumor were present in two tumors and predominated in one. Five of five tumors were positive for keratin (AE1/3), S-100, epithelial membrane antigen, and Ber-EP4; three of five for Leu M1 and B72.3; two of five for carcinoembryonic antigen and placental alkaline phosphatase; and one in five for vimentin. Ultrastructural examination in one case demonstrated gland formation with delicate luminal microvilli and cilia. Follow-up information was available in five cases: Three patients are without evidence of disease after relatively short postoperative intervals of 1, 1, and 3 years, although one of these patients has had a persistently elevated CA-125 level. Two patients had recurrence of their tumors 4 and 7 years after diagnosis, one with diffuse abdominal spread, the other in a cervical lymph node. The latter patient died of his disease 5 years after diagnosis.

Differential metabolism of exogenous platelet-activating factor by glandular epithelial and stromal cells of rabbit endometrium

Significant changes in platelet-activating factor (PAF; 1-O-alkyl-2-acetyl-sn-glycero-3-phosphorylcholine) concentration have been observed in rabbit endometrium during the preimplantation period, but, under in vitro conditions, constitutive PAF biosynthesis by isolated endometrial tissues was not easily demonstrable. Relative changes in enzymes involved in the synthesis and metabolism of PAF in the tissues may account for this disparity. In addition, during this period of preimplantation, marked changes in PAF receptor concentration have been noted. The present study examines the factors that may modulate the metabolism of exogenous [3H]PAF in the endometrium of rabbits on day 6 of pregnancy. Since preferential [3H]PAF binding in situ by the glandular epithelial, but not by the stromal, cells was demonstrated, their cell-specific metabolism of exogenous [3H]PAF was also examined. After entry into the endometrial cell, [3H]PAF was rapidly metabolized by the sequential action of cytosolic Ca(2+)-independent acetylhydrolase to [3H]lyso-PAF and this was in turn acylated by membrane-associated transacylase to [3H]alkylacyl-glycerylphosphorylcholine. PAF resynthesis was not observed and, in stromal cells, there was a significant build-up of [3H]lyso-PAF, suggesting that lyso-PAF:acetyl-CoA acetyl-transferase may be a limiting factor. In the glandular epithelial cells, however, there was a significant accumulation of a neutral lipid without a significant build-up of [3H]lyso-PAF or [3H]PAF. The neutral lipid co-migrated with the product of phospholipase C-catalysed metabolism of PAF and authentic 1-O-hexadecyl-2-acetyl-glycerol. In addition, the elution times of phospholipase C digestion of C18 PAF and the neutral lipid produced by cellular metabolism of [3H]PAF, determined by gas chromatography/flame ionization detection, were similar. It seems that it is the synthesis of the neutral lipid from reacetylated [3H]lyso-PAF that prevented [3H]PAF accumulation under in vitro conditions. This is the first documentation of the synthesis of this lipid in the mammalian uterus. The lipid may serve as the precursor for de novo PAF synthesis in the glandular epithelial cells during endometrial proliferation.

Malignant mixed müllerian tumors of the ovary: experience with surgical cytoreduction and combination chemotherapy

BACKGROUND

The role of surgical cytoreduction and combination chemotherapy for malignant mixed müllerian tumors (MMMT) of the ovary was evaluated.

METHODS

A retrospective review of 27 women with ovarian MMMT treated from 1980 to 1990 was performed.

RESULTS

The International Federation of Gynecology and Obstetrics stages for the 27 women were 1 Stage I, 3 Stage II, 17 Stage III, and 6 Stage IV. Only 10 of the 23 patients with Stage III or IV disease were cytoreduced optimally. With respect to postoperative therapy, 3 women received no treatment, 6 were treated with whole abdomen radiotherapy, 1 received melphalan, and 17 received chemotherapy incorporating a platinum agent (3), doxorubicin (4), or both (10). The significant prognostic factors were stage (P < 0.001) and, for women with Stage III or IV disease, the feasibility of cytoreductive surgery (P = 0.03). The four patients in Stages I or II remained disease free after an interval of at least 5 years. The median and 5-year survival rates for patients with Stages III or IV disease was 18 months and 8%, respectively. Patients in Stage III or IV for whom optimal cytoreduction was not possible had a 2-year survival of 14%, whereas optimal cytoreduction was associated with a 52% 2-year survival. Median survival for the 14 women with Stage III or IV ovarian MMMT treated with combination chemotherapy was 25 months and nine women achieved progression free intervals of greater than 18 months.

CONCLUSIONS

Aggressive surgical cytoreduction followed by combination chemotherapy may result in improved progression free intervals for women with advanced ovarian MMMT. However, a major improvement in prognosis for this rare malignancy has not yet been achieved.

Changes in diurnal blood pressure variation and red cell and plasma volumes in patients with renal failure who develop erythropoietin-induced hypertension

Hypertension is the most common side-effect of treatment with recombinant human erythropoietin (EPO) for the anemia of chronic renal failure. To elucidate why this occurs in some patients we measured changes in blood volumes and diurnal blood pressure (BP) variation during treatment. Isotope labelled measurements of red cell and plasma volume (RCV and PV) were carried out along with ambulatory BP monitoring before starting EPO and after target hemoglobin (Hb) was reached. RCV did not differ between the patient group developing EPO-induced hypertension (EpHT, n = 11) and the group with no change in BP (NC, n = 13) either before or after treatment. However PV was significantly lower in the EpHT group after treatment (2.97 vs 3.92 litres; p < 0.025). Mean BPs differed little between groups because antihypertensive medications were increased as necessary for clinical safety but after achieving target Hb, day-night difference in diastolic BP was greater in the EpHT than the NC group (11.5 vs 4.6 mmHg; p < 0.025) due to a greater rise in daytime BP. There were significant correlations between high day-night diastolic BP differences after EPO in all the studied patients and low plasma volumes either pre- or post-EPO. The study group was heterogeneous but the changes were in the same direction irrespective of type of renal replacement therapy. These results suggest that EPO-induced hypertension is associated with increased daytime vasoconstriction and greater hemoconcentration due to lower plasma volume.

Malignant mesothelioma of the tunica vaginalis. A clinicopathologic analysis of 11 cases with review of the literature

Eleven malignant mesotheliomas of the testicular tunica vaginalis occurred in patients aged 12 to 76 (mean, 54.1) years. Hydrocele, with or without an associated mass, or appreciation of a paratesticular mass accounted for the clinical presentation. One patient had a history of asbestos exposure. Grossly, the tumors typically presented as multiple nodules studding a hydrocele sac, frequently associated with a mass infiltrating the spermatic cord or adjacent testis. Microscopically, five tumors were epithelial and six biphasic, with the typical architectural and cytologic features of mesothelioma. Mixtures of papillary, tubular, and solid patterns predominated in the epithelial areas; interlacing fascicles of spindle cells with scanty stroma characterized the sarcomatous components. All eight of the tumors that were stained for keratin (AE1/AE3) were positive, four of five for epithelial membrane antigen, and four of five for vimentin. Seven of seven tumors were carcinoembryonic antigen negative and five of five B72.3, Leu-M1, and Ber-Ep4 negative. Follow-up ranging from 1 to 15 (mean, 4.3) years was available for seven patients. Three died of disease after 4, 4, and 3 years, and three are alive with disease 2, 2, and 15 years after diagnosis. Two of the latter three patients had extensive local recurrences, one 15 years after the diagnosis of a well-differentiated papillary mesothelioma, the other 2 years following treatment with hydrocelectomy only. One patient who has been followed for only 1 year has no evidence of disease. This series emphasizes a number of important features of testicular mesothelioma; (a) a wide age range with occasional occurrence at a young age, (b) a wide morphologic spectrum with regard to degree of differentiation, and (c) an aggressive natural history with a potential for late recurrence or metastasis of even well-differentiated tumors, suggesting the need for initial aggressive surgical treatment.

A pilot study of cyclosporine for the prevention of postsurgical adhesion formation in rats

OBJECTIVE

Our purpose was to evaluate the efficacy of cyclosporine in preventing primary postsurgical adhesions in the rat model.

STUDY DESIGN

Thirty-two Sprague-Dawley rats underwent unilateral uterine horn injury with a combination of unipolar and bipolar cautery. Sixteen of the rats were randomized to the treatment group and received preoperative and daily cyclosporine dosing (10 mg/kg) by gavage for 14 days. At the end of the study all animals were killed, and a standard adhesion scoring system was applied by a blinded examiner.

RESULTS

Adhesions were present in 75% of rats in both groups. Treatment did not affect the total adhesion score.

CONCLUSION

Cyclosporine does not appear promising as a means to decrease postsurgical adhesion formation.

Elective ventilation of potential organ donors

Elective ventilation describes the procedure of transferring selected patients dying from rapidly progressive intracranial haemorrhage from general medical wards to intensive care units for a brief period of ventilation before confirmation of brain stem death and harvesting of organs. This approach in Exeter has led to a rate of kidney retrieval and transplant higher than has been achieved elsewhere in the United Kingdom, with a stabilisation of numbers on patients on dialysis. Recently doubt has been cast on the legality of our practice of elective ventilation on the grounds that relatives are not permitted to consent to treatment of an incompetent person when that treatment is not in the patient's best interests. We are thus faced with the dilemma of a protocol that is ethical, practical, and operates for the greater good but which may be illegal. This article explores various objections to the protocol and calls for public, medical, and legal debate on the issues.

Primary osseous malignant fibrous histiocytoma involving a rib

A case is presented of an 86-year-old man who developed progressive chest wall pain over a 16-month period. Radiologic studies demonstrated lytic destruction of the right fourth rib anterolaterally. A limited thoracotomy led to the diagnosis of malignant fibrous histiocytoma. This represents an unusual primary bone lesion in the rib. A concise discussion of primary MFH of bone including its radiographic appearance, differential diagnosis, and pathology was presented.

Induction of interleukin-2 transcription by the hamster polyomavirus middle T antigen: a role for Fyn in T cell signal transduction

The transforming protein of mouse polyomavirus, the mouse middle T antigen (MomT), and its counterpart in the hamster polyomavirus, the hamster middle T antigen (HamT), interact with a number of cellular proteins. Among these are members of the Src family of tyrosine kinases, the phosphatidylinositol 3-kinase, the serine/threonine phosphatase PP2A and the adaptor protein Shc (in the case of MomT). However, both the relative affinity of these antigens for the members of the Src family and the tumor profile induced by their respective viruses are quite distinct. Particularly noteworthy are the preferential binding of Fyn by HamT and the induction of lymphoid malignancies by the hamster polyomavirus. Here we report that, when expressed in fibroblasts, HamT also associated with phospholipase C gamma (PLC gamma), which led to an increased intracellular concentration of inositol-1, 4, 5-trisphosphate. We also show that expression of HamT in the mouse T cell line EL4 was sufficient to induce transcription from interleukin-2 (IL-2), NFAT and NF kappa B reporter constructs. The immunosuppressant FK506 as well as dominant negative alleles of Ras and Raf inhibited HamT-induced IL-2 transcription. This, together with the observation of NFAT responses, suggests that the action of HamT depended at least in part on the integrity of signal transduction pathways elicited by activated PLC gamma. Furthermore, dominant negative Fyn but not the equivalent allele of Lck blocked HamT activation of IL-2 transcription, while both Lck and Fyn dominant negative alleles blocked LT cell receptor-mediated IL-2 transcriptional activation. These results support the hypothesis that Fyn is involved in signal transduction events leading to IL-2 transcriptional activation in T cells. Finally, the activation of IL-2 transcription by HamT and not by MomT shown here parallels the ability of the hamster polyomavirus to induce lymphoid malignancies.

The psi operon of Rhizobium leguminosarum biovar phaseoli: identification of two genes whose products are located at the bacterial cell surface

We have delineated three short open reading frames, psiA, ORF-P and psiB within the psi operon of Rhizobium leguminosarum biovar phaseoli. psiA, in a multi-copy plasmid, causes inhibition of exopolysaccharide synthesis in R. leguminosarum. In addition, the suppression of exopolysaccharide synthesis due to the multi-copy psiA caused R. leguminosarum strains to stain with the dye calcofluor, a response that does not occur with wild-type strains of this species. Insertions of a defective phoA gene (lacking its promoter, ribosomal binding site and leader sequence) into psiA and psiB were isolated and the precise locations of the insertions were established. PsiA-PhoA and PsiB-PhoA protein fusions were found to express alkaline phosphatase activity indicating that PsiA and PsiB span the inner membrane or are translocated across it.

Temporal and regional expression of placental lactogen-II messenger ribonucleic acid and protein in the hamster placenta

The purpose of this investigation was to identify the cell types synthesizing hamster placental lactogen-II (haPL-II) in the chorioallantoic placenta. In addition, temporal changes in haPL-II mRNA expression, in placental mass, and in the proportion of haPL-II-containing cells per unit area were examined. Hamster PL-II mRNA expression was assessed by in situ hybridization and Northern and slot-blot analyses. Cells containing haPL-II protein were identified by immunocytochemical techniques. Placentae were recovered in the morning on Days 6, 8, 10, 12, and 14 of gestation and in the afternoon on Day 15. A single 1-kb haPL-II transcript was first detected on Day 10 of gestation. Hamster PL-II message increased to Day 14 and remained elevated on Day 15. Giant trophoblast cells (GTC) located in the trophospongium were the major source of haPL-II mRNA and protein, although GTC along the periphery of the placenta and in the labyrinth expressed haPL-II as well. Placental weight, trophospongium portion of placental weight, and number of haPL-II-immunostained GTC per unit of placental area increased between Days 12 and 14 and remained elevated to Day 15. These observations indicate that an increased number of haPL-II-producing GTC is a major factor contributing to increased maternal haPL-II serum levels during pregnancy.

Competitive immunosorbent assays for biotin using bifunctional unilamellar vesicles

Competitive immunosorbent assays for the model antigen biotin were performed using both unilamellar vesicles with covalently attached biotin and horseradish peroxidase (HBVs) and commercially available biotin-labeled horseradish peroxidase (B-HRP) as the enzyme-labeled antigen. The assays were performed using anti-biotin antibody (ABA) surface densities ranging from one-tenth to full monolayer coverage. It was found that assays using HBVs strongly depended on the antibody surface density, while assays using B-HRP were relatively insensitive to the antibody surface density. The HBV assay dependence on the ABA surface density was most likely due to multiple point attachment of vesicles to the surface. The lowest detectable antigen concentration (least detectable dose) for vesicles (approximately 10(-9) M) was an order of magnitude lower than the value found for B-HRP (approximately 10(-8) M). The sensitivity (slope of the response vs biotin concentration curve) of assays with B-HRP was comparable to the sensitivity of assays with HBVs at low antibody surface density, probably due to less extensive multipoint attachment. It was also found that assays could be performed with vesicles at antibody surface densities that were at least 5 times lower, in terms of the bulk antibody concentrations used to coat the wells, than antibody surface densities at which B-HRP gave comparable signals (approximately 1 delta A/min).

Primary yolk sac tumors of the mesentery. A report of two cases

Two yolk sac tumors that arose in the mesentery of the jejunum and the mesentery of the transverse colon of two male patients, aged 2 and 17 years, are reported. Both patients had abdominal masses. The tumors measured 9 and 11 cm in maximum dimension. One of them grew into the bowel lumen. Microscopically, both neoplasms exhibited several of the typical patterns of yolk sac tumor and stained immunohistochemically for alpha-fetoprotein. Both patients received chemotherapy postoperatively and are alive, but follow-up is short. The subject of extragonadal yolk sac tumors is reviewed, and histogenetic implications of their occasional origin in the mesentery is discussed.

Consolidation intraperitoneal chemotherapy in epithelial ovarian cancer patients following negative second-look laparotomy

Fifty-six patients with Stage III ovarian carcinoma who had a negative second-look laparotomy following optimum cytoreduction, cisplatin, and cyclophosphamide chemotherapy were enrolled in a pilot study to receive consolidation intraperitoneal (IP) chemotherapy. Forty-one patients received three courses of IP cisplatin (80 mg/m2). Fifteen patients with cisplatin-induced toxicity received three courses of IP mitoxantrone (10 mg/m2). Toxicity was minimal, with only 2 patients suffering peritonitis and 1 patient developing an enterotomy at the time of catheter removal. Median follow-up for the IP cisplatin and IP mitoxantrone group has been 24 and 30 months, respectively. Ten of the 41 patients (24%) who received IP cisplatin and 4/15 (26%) of the IP mitoxantrone patients have recurred (P = ns). Median time to recurrence was 18 months for both groups. This study indicates that consolidation intraperitoneal chemotherapy following negative second-look laparotomy is feasible with either cisplatin or mitoxantrone. However, many of these patients still recurred and prospective trials will be required to determine which (if any) consolidation intraperitoneal treatment is best following a negative second-look laparotomy.

The metabolism of AIDS-associated mycoplasmas

Mycoplasma fermentans and Mycoplasma pirum have been recovered from human immunodeficiency virus (HIV)-positive persons. M. fermentans has been isolated with much higher frequency from HIV-positive than from HIV-negative persons. Mycoplasma genitalium has been detected by polymerase chain reaction in the blood of a patient with AIDS. Little is known about the biology of these mycoplasmas, especially their physiology, biochemistry, and growth response to inhibitors of essential metabolic loci or transport. Metabolically, they resemble other Mycoplasma species. Those studied lack cytochromes, the tricarboxylic acid cycle, and portions of the hexose monophosphate shunt. According to limited data, they fix CO2, use ATP to phosphorylate fructose-6-phosphate, have substrate phosphorylation and transaminase(s), and interconvert most purines and pyrimidines. The synthesis of thymidine may be limited. They may require a variety of essential small molecules for optimal growth (e.g., pyridoxal phosphate, ribose-1-phosphate). Their pathogenic potential and cultural lability may involve the production of the superoxide anion and the hydroxyl radical. We hypothesize that the mycoplasmas generate toxic oxygenated products that damage the host cell, probably membrane, permitting the mycoplasmas to gain easier access to the interior of the cell. The mycoplasma-damaged host cell membrane may also effect the maturation or release of HIV particles from the cell.

Human hydatid disease: evaluation of an ELISA for diagnosis, population screening and monitoring of control programmes

The routine use of ELISA and complement fixation tests in the diagnosis of suspected clinical cases of hydatid disease was evaluated. In the ELISA test, dialysed and filtered sheep cyst fluid was used as antigen and two positive cut-off points--+3SD and +2SD of the mean absorbance values of the control sera--were evaluated. The predictive values of ELISA tests were 82% and 90% for positive tests, and 86% and 82% for negative tests, respectively with the two cut-off points. In a population survey of blood donors and veterinary workers in Powys, 4% and 8%, respectively, had ELISA values above the lower cut-off point. However, it would not be appropriate to use the same test for diagnostic population screening in Wales since the predictive value of the test is likely to be very low in this setting. Serological surveys with the ELISA may be of use in monitoring the progress of the South Powys Hydatid Control Programme. The use of cumulative percentages was found to be a useful method of comparing whole distributions of results in different populations.

Retaining nurses through conflict resolution. Training staff to confront problems and communicate openly can improve the work climate

The way nurses resolve conflict may be leading them to quit their jobs or leave the profession altogether. Conflict is inevitable in a dynamic organization. What is important is not to avoid conflict but to seek its resolution in a constructive manner. Organizational conflict is typically resolved through one of five strategies: withdrawal, force, conciliation, compromise, or confrontation. A recent study of nurses in three different hospitals showed that the approach they use most is withdrawal. This might manifest itself in a request to change shifts or assignments and may lead to a job change and, eventually, abandonment of the field altogether. Given this scenario, changing nurses' conflict resolution style may help administrators combat the nursing shortage. Healthcare organizations must examine themselves to determine why nurses so frequently use withdrawal; then they must restructure work relationships as needed. Next, organizations need to increase nurses' awareness of the problem and train them to use a resolution style more conducive to building stable relationships: confrontation. Staff should also be trained in effective communications skills to develop trust and openness in their relationships.

Preparation and characterization of bifunctional unilamellar vesicles for enhanced immunosorbent assays

Small unilamellar phospholipid vesicles with covalently attached biotin and horseradish peroxidase (HRP) were prepared and characterized in terms of hydrodynamic diameter, amount and activity of immobilized enzyme, and number of biotin molecules on the outer vesicle surface. In addition, the specific adsorption of these bifunctional vesicles and commercially available biotin-labeled horseradish peroxidase (B-HRP) to antibiotin antibody (ABA) coated polystyrene microtiter plate wells was examined. At low antibody surface densities, the signal (delta A/min) generated by the vesicles adsorbed to the surface was approximately 100 times higher than the signal generated by B-HRP. It was also found that the biotin-conjugated vesicles were able to compete effectively with free biotin in solution for surface ABA sites. These results indicate that this type of vesicle may be used in competitive and sandwich-type enzyme-linked immunoassays to improve the detection limits, increase the signal, and decrease the reaction time necessary to detect a given analyte concentration in solution.

Mesonephric remnant hyperplasia of the cervix: a clinicopathologic analysis of 14 cases

Lesions derived from mesonephric remnants in the uterine cervix are rare. We describe 14 patients with benign, hyperplastic mesonephric remnant lesions. The patients ranged in age from 31 to 81 years (mean, 47). Four were postmenopausal. The lesions were incidental findings in all but 2 of the patients and frequently had been submitted for consultative pathologic opinion. Two patients did, however, present with symptoms (vaginal bleeding) likely attributable to their lesions and 1 of them had a cervical abnormality on clinical examination. Microscopically, the lesions were composed of lobular or diffuse proliferations of small, round mesonephric tubules which were frequently deep within the cervical wall and often extended to the surface of the cervix. Five of the patients had a referring diagnosis of probable or definite cervical adenocarcinoma due to the infiltrative appearance of the lesions. No mesonephric carcinomas were encountered. Hyperplastic lesions of mesonephric remnants are usually benign, incidental findings but may on occasion be associated with clinical symptomatology and are a potential source of diagnostic confusion for the pathologist.