[Solid pseudopapillary tumor of the pancreas: 5 case reports]

Solid pseudopapillary tumor of pancreas belongs to rare tumors of exocrine pancreas, which typically affects young women. In a retrospective study the authors reviewed their experience obtained with five cases of this tumor from 1994 until the present time. The group included four women (from 16 to 47 years, mean age 25 years) and one man (43 years old). Clinical symptoms were characterized by abdominal pain in three cases, two years lasting domed belly and an incidental finding in another case. The palpation examination of epigastrium revealed a palpable tumor, visible in sonographic examination and CT. All patients underwent surgical resection of the tumor. The tumor affected cauda of the pancreas (pancreatic tail) in four cases and head of the pancreas in one case. Histopathological examination established the diagnosis of solid pseudopapillary tumor of pancreas in four cases and solid pseudopapillary carcinoma in one case. A typical immunophenotype of tumorous cells was demonstrated and in four cases there was positivity of progesterone receptor. The progesterone and estrogen receptors were negative in the male patient. Solid pseudopapillary tumor of pancreas is the tumor of low malignancy with excellent prognosis. Correct diagnosis and surgical removal of the tumor results in curing up in most cases.

The Impact of Dietary Intervention on the Cognitive Development of Kenyan School Children

Previous observational studies in developing countries have suggested that diet quality, particularly increased animal source food (ASF) consumption, is positively associated with child cognitive development. This report presents findings from a study in rural Kenya, designed to test the impact of three different diets on the cognitive development of school children. Twelve schools with a total of 555 Standard 1 children (equivalent to U.S. Grade 1) were randomized to one of four feeding interventions: Meat, Milk, Energy or Control (no feeding). Feeding continued for seven school terms (21 mo), and cognitive tests were administered before the commencement of feeding and during every other term of feeding. Hierarchical linear random effects models and associated methods were used to examine the effects of treatment group on changes in cognitive performance over time. Analyses revealed that children receiving supplemental food with meat significantly outperformed all other children on the Raven's Progressive Matrices. Children supplemented with meat, and children supplemented with energy, outperformed children in the Control group on tests of arithmetic ability. There were no group differences on tests of verbal comprehension. Results suggest that supplementation with animal source food has positive effects on Kenyan children's cognitive performance. However, these effects are not equivalent across all domains of cognitive functioning, nor did different forms of animal source foods produce the same beneficial effects. Implications of these findings for supplementation programs in developing countries are discussed.

Naïve CD4+ T cells from patients with atopic dermatitis show an aberrant maturation towards IL-4-producing skin-homing CLA+ cells

Overproduction of interleukin-4 (IL-4) has been reported in lesional and in peripheral T cells from patients with atopic dermatitis (AD). It is not clear whether the development of IL-4-producing T helper type 2 (Th2) cells from naïve precursors is an intrinsic phenomenon of T cells or whether other, extrinsic factors play a significant role. To analyze these alternatives, we investigated the IL-4 production of effector T cells generated in vitro from highly purified CD4+ CD45RA+ naïve T cells in the absence of signals derived from antigen-presenting cells. Effector T cells generated from naïve precursors from both AD and healthy donors produced comparable amounts of IL-4 after restimulation. Priming in the presence of exogenous IL-4 enhanced the production of IL-4 while neutralizing endogenously produced IL-4 abolished IL-4 production similarly in atopic and healthy T cells. A subset of effector T cells acquired the expression of the cutaneous lymphocyte antigen (CLA). The frequency of CLA+ T cells was not different between atopic and healthy donors. CLA+ T cells, differentiated from naïve atopic, but not healthy T cells, showed a preferential Th2 cytokine profile as assessed by intracellular cytokine staining. Also effector T cells derived from atopic patients without dermatitis tended to show this imbalance, although it was not significantly different to healthy controls. This Th2 cytokine profile did not develop when naïve T cells were cultured in the presence of IL-12. In conclusion, high IL-4 production in developing T cells from AD patients was associated with CLA expression, the net IL-4 production of all effector CD4+ T cells, however, was similar to IL-4 production by T cells from healthy donors.

Motor system abnormalities in hereditary spastic paraparesis type 4 (SPG4) depend on the type of mutation in the spastin gene

BACKGROUND

Hereditary spastic paraparesis (HSP) denotes a group of inherited neurological disorders with progressive lower limb spasticity as their clinical hallmark; a large proportion of autosomal dominant HSP belongs to HSP type 4, which has been linked to the SPG4 locus on chromosome 2. A variety of mutations have been identified within the SPG4 gene product, spastin.

OBJECTIVE

Correlation of genotype and electrophysiological phenotype.

MATERIAL

Two large families with HSP linked to the SPG4 locus with a very similar disease with respect to age of onset, progression, and severity of symptoms.

METHODS

Mutation analysis was performed by PCR from genomic DNA and cDNA, and direct sequencing. The motor system was evaluated using transcranial magnetic stimulation.

RESULTS

Patients differ in several categories depending on the type of mutation present.

CONCLUSIONS

For the first time in hereditary spastic paraparesis, a phenotypic correlate of a given genetic change in the spastin gene has been shown.

Cytokine gene polymorphisms in atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) and psoriasis are genetically determined inflammatory skin disorders characterized by abnormal cytokine production. From association studies there is evidence that functionally relevant cytokine gene polymorphisms contribute to the genetic basis of psoriasis. Association studies in AD have mostly been limited to polymorphisms of T-helper 2-type cytokines, which dominate in acute AD lesions. Unexpectedly, the results of recent genome scans indicate linkage of AD to psoriasis susceptibility loci. Therefore, AD may also be influenced by genes that modulate cutaneous inflammation independently from atopic mechanisms.

OBJECTIVES

To investigate further the role of cytokine gene polymorphisms in AD.

METHODS

Polymorphisms in the genes encoding tumour necrosis factor-alpha (TNFA-238 G/A, -308 G/A), interleukin (IL)-1beta (IL1B-511 T/C, +3953 T/C), IL-6 (IL6-174 C/G), IL-10 (IL10-1082 A/G) and the IL-1 receptor antagonist (IL1RN intron 2) were investigated in German patients with AD (n = 94) and in healthy nonatopic individuals (n = 214) by polymerase chain reaction-based methods and direct cycle sequencing.

RESULTS

No association was found between AD and any of the polymorphisms analysed. This is in contrast to the recently described association between psoriasis and the TNFA-238 and IL1B-511 polymorphisms.

CONCLUSIONS

Our data indicate that cytokine gene polymorphisms may act as specific markers of inflammatory skin diseases rather than contribute to a general disposition towards cutaneous inflammation.

Inefficacy of vindesine monotherapy in advanced stage IV malignant melanoma patients previously treated with other chemotherapeutic agents

The anti-melanoma activity of vindesine as a single or polychemotherapeutic agent has been reported previously in adjuvant and first-line melanoma treatment. In this study, we investigated the usefulness of vindesine monotherapy as salvage therapy in stage IV melanoma patients after failure of other chemotherapies. Thirteen patients with progressive disease were treated with 3 mg/m2 vindesine every 2 weeks (median age, 61 years). Previous systemic treatment consisted of polychemotherapy or combined chemo-immunotherapy. All 13 patients suffered from visceral metastases (three lung, one liver, one adrenal gland and eight multiple visceral metastases). A median of three vindesine treatments was administered. Despite the various pre-treatments, the toxicity of vindesine was mild. In all 13 patients, vindesine treatment was stopped due to disease progression. The median survival after primary tumour diagnosis was 42 months (8-151 months), the survival after entering stage IV was 11 months (3-35 months), and the survival after starting vindesine therapy was 4 months (1-22 months). We conclude that vindesine monotherapy is ineffective in stage IV melanoma patients previously treated with other chemotherapeutic agents.

IQ on the rise: the Flynn effect in rural Kenyan children

Multiple studies have documented significant IQ gains over time, a phenomenon labeled the Flynn effect. Data from 20 industrialized nations show massive IQ gains over time, most notably in culturally reduced tests like the Raven's Progressive Matrices. To our knowledge, however, this is the first study to document the Flynn effect in a rural area of a developing country. Data for this project were collected during two large studies in Embu, Kenya, in 1984 and 1998. Results strongly support a Flynn effect over this 14-year period, with the most significant gains found in Raven's matrices. Previously hypothesized explanations (e.g., improved nutrition; increased environmental complexity; and family, parental, school, and methodological factors) for the Flynn effect are evaluated for their relevance in this community, and other potential factors are reviewed. The hypotheses that resonate best with our findings are those related to parents' literacy, family structure, and children's nutrition and health.

[Surgical treatment of an acetabular fracture during pregnancy]

We report about a case of a pregnant women in the 23rd gestation week who sustained an isolated acetabular fracture in a car accident. The fracture was treated surgically by open reduction and internal fixation 6 days after trauma. The outcome for the mother and the baby was excellent; both could be followed up for 1.5 years. The baby did not suffer from any disease related to the diagnostic or surgical procedures. We conclude from this case and from reviewing the literature that the operative fixation of an acetabular fracture during pregnancy is the appropriate treatment with minimal risk for the unborn child and best outcome for the mother.

[Improved scar formation after using a medical surgical zipper for wound closure under tension]

BACKGROUND AND OBJECTIVE

The objective of the study was to evaluate the use of a medical surgical zipper (Medizip) for wound closure under tension in comparison to conventional cutaneous sutures. The surgical zipper is supposed to reduce wound tension by approximating of the wound edges via epidermal traction.

PATIENTS/METHODS

This prospective study included patients with a wound diameter of more than 1 cm. 45 patients were treated with the surgical zipper, 38 were randomized into a control group with conventional wound closure. Scars were assessed after 6-18 months focusing on aesthetic and functional aspects.

RESULTS

The average length of the scars in both groups was 9 cm, but after a observation time of at least 6 month, there were differences in the width of the scars. The group with the surgical zipper showed significantly thinner scars (2.74 mm versus 4.24 mm, p=0.0008). Only 17% of the Medizip patients developed unaesthetic rope ladder-like scars versus 65% in the control group. This observation was statistically significant (p<0.0001).

CONCLUSIONS

Wound stabilization by approximation of the wound edges via surgical zipper results in improved scar formation in wounds with moderate tension. Using the Medizip trade mark in wounds under heavy tension is not recommended because of the possible development of to tension bullae under the zipper.

Dynamic lymphoscintigraphy and image fusion of SPECT and pelvic CT-scans allow mapping of aberrant pelvic sentinel lymph nodes in malignant melanoma

To date, there are no reliable criteria to identify those patients with melanoma-infiltrated sentinel lymph nodes (SLNs) of the groin who might benefit from an extended lymphadenectomy, including the pelvic lymph nodes. We hypothesised that there are pelvic lymph nodes that receive lymph directly from the primary tumour, thus being at an increased risk for metastasis. In order to determine the frequency of radioactively labelled pelvic lymph nodes and the kinetics of their appearance, we introduce here a combination of dynamic lymphoscintigraphy, single photon emission computed tomography (SPECT) and image fusion of SPECT and pelvic Computed Tomography (CT)-scans. By dynamic lymphoscintigraphy and intraoperative gamma probe detection, superficially located inguinal SLNs (median 2 nodes) could be identified in all of the 51 patients included in this analysis. The histological search for micrometastases was positive in 16 patients (median Breslow thickness of the primary melanoma 2.5 mm). In 29 patients, SPECT and the image fusion technique were additionally performed. Radioactively labelled pelvic lymph nodes were detected in 20 individuals, 6 of them presenting aberrant pelvic SLNs that, on dynamic lymphoscintigraphy, had appeared simultaneously with the superficial SLN(s). Of the 6 patients in whom radioactive pelvic lymph nodes were excised together with the superficial SLN(s), only one had positive superficial SLNs. In this patient, the aberrant pelvic SLN proved to be tumour-positive. In 9 patients, there was no radiotracer uptake in the pelvic lymph nodes at all. Image fusion of SPECT and pelvic CT-scans is an excellent tool to localise exactly the pelvic tumour-draining nodes. The significance of radioactively labelled pelvic lymph nodes for the probability of pelvic metastases should be analysed further.

Sensitive PCR method for the detection and real-time quantification of human cells in xenotransplantation systems

The sensitive detection of human cells in immunodeficient rodents is a prerequisite for the monitoring of micrometastasis of solid tumours, dissemination of leukaemic cells, or engraftment of haematological cells. We developed a universally applicable polymerase chain reaction method for the detection of a human-specific 850-bp fragment of the alpha-satellite DNA on human chromosome 17. The method allows the detection of one human cell in 10(6) murine cells and could be established as both, a conventional DNA polymerase chain reaction-assay for routine screening, and a quantitative real-time polymerase chain reaction-assay using TaqMan-methodology. It was applied to the following xenotransplantation systems in SCID and NOD/SCID mice: (1) In a limiting dilution assay, cells of the MDA-MB 435 breast carcinoma were injected into the mammary fat pad of NOD/SCID mice. It could be shown that 10 cells mouse(-1) were sufficient to induce a positive polymerase chain reaction signal in liver and lung tissue 30 days after transplantation as an indicator for micrometastasis. At this time a palpable tumour was not yet detectable in the mammary fat pad region. (2) Cells of a newly established human acute lymphatic leukaemia were administered intraperitoneally to SCID mice. These cells apparently disseminated and were detectable as early as day 50 in the peripheral blood of living mice, while the leukaemia manifestation was delayed by day 140. (3) In a transplantation experiment using mature human lymphocytes we wanted to standardise conditions for a successful survival of these cells in NOD/SCID mice. It was established that at least 5 x 10(7) cells given intravenously were necessary and that the mice had to be conditioned by 2 Gy body irradiation to get positive polymerase chain reaction bands in several organs. (4) Engraftment studies with blood stem cells originating from cytapheresis samples of tumour patients or from cord blood were undertaken in NOD/SCID mice in order to define conditions of successful engraftment and to use this model for further optimisation strategies. The polymerase chain reaction method presented allowed a reliable prediction of positive engraftment and agreed well with the results of immunohistochemical or FACS analysis. All together, the polymerase chain reaction method developed allows a sensitive and reliable detection of low numbers of human cells in immunodeficient hosts. In combination with real-time (TaqMan) technique it allows an exact quantification of human cells. As this method can be performed with accessible material of living animals, follow up studies for the monitoring of therapeutic interventions are possible in which the survival time of mice as evaluation criteria can be omitted.

Comparison of different activity parameters in atopic dermatitis: correlation with clinical scores

BACKGROUND

Several laboratory markers have been described to correlate positively with disease activity of atopic dermatitis (AD). These include soluble adhesion molecules and eosinophil granular proteins. Although the correlation of these parameters with the severity and extent of skin involvement has been repeatedly studied in the past, no systematic investigation has been performed over a lengthy period of time. In addition, no subjective disease parameters recorded by the patient have been included in studies dealing with disease activity.

OBJECTIVES

To assess the validity of different objective and subjective parameters [soluble E-selectin (sE-selectin), soluble vascular cell adhesion molecule-1 (sVCAM-1), eosinophil cationic protein (ECP), urinary nitrate excretion (reflecting endogenous nitric oxide formation) and the patients' impressions of pruritus, sleeplessness and skin status] as markers of AD disease activity.

METHODS

Twenty patients were examined for 1 year and their skin status was evaluated by an established score (SCORAD). sE-selectin, sVCAM-1 and ECP were analysed by commercial test kits. Urinary nitrate concentration was measured by gas chromatography-mass spectrometry. The subjective parameters, pruritus, sleeplessness and impression of skin status, were recorded by the patients on a visual analogue scale.

RESULTS

In this long-term trial, only sE-selectin and the subjective parameters showed a statistically significant correlation with the SCORAD score.

CONCLUSIONS

Our data indicate that basic clinical scoring remains a most effective and relevant method of recording skin disease activity in AD.

Treatment of disseminated ocular melanoma with sequential fotemustine, interferon alpha, and interleukin 2

Malignant melanoma of the uvea is remarkable for purely haematogenous dissemination and its tendency to metastasise to the liver. Although the liver is involved in up to 95% of patients, 50% of these also develop extrahepatic metastases, most often in the lungs, bone, skin, and brain. The only effective treatments reported to date relied on hepatic arterial chemoembolisation or -perfusion. The objective of this study was to establish a therapy protocol addressing patients with both sole liver involvement and systemic disease. Forty-eight patients with metastatic ocular melanoma received fotemustine 100 mg m(-2) either as 60-min infusion into the hepatic artery or as 15-min infusion via a peripheral vein, depending on the metastatic sites involved, i.e., restriction to the liver or hepatic together with extrahepatic disease. For the first treatment cycle this infusion was repeated after one week. For all cycles, subsequent to a three week resting period, patients received an immunotherapy consisting of subcutaneous interleukin 2 and interferon alpha(2). Although objective responses were more frequent within the cohort receiving intraarterial fotemustine (21.7 vs 8%), this difference did not translate into a significant benefit in overall survival, i.e., 369 and 349 days, respectively. Of note, this overall survival is much longer than that repeatedly reported for stage IV uveal melanoma not treated with fotemustine, suggesting a therapeutic activity of this cytostatic drug even after systemic administration.

Locoregional cutaneous metastasis in patients with therapeutic lymph node dissection for malignant melanoma: risk factors and prognostic impact

In patients with lymph node metastasis of malignant melanoma, the incidence of additional locoregional cutaneous metastases has not been well documented. More importantly, the prognostic impact of locoregional cutaneous metastases appearing prior to therapeutic lymphadenectomy is unclear. Using Kaplan-Meier estimations and a Cox proportional hazards model, we addressed these questions in 224 patients with palpable lymph node metastases to the axilla or the groin. The 10 year overall probability to develop regional cutaneous metastasis, calculated from primary tumour excision, was 38.7%. Using univariate and multivariate analysis, Breslow thickness was a significant risk factor of in-transit disease in node-positive patients. In 24 patients (10.7%) locoregional cutaneous metastases had appeared before therapeutic lymphadenectomy, but this was not associated with a survival disadvantage. In conclusion, locoregional cutaneous metastases amenable to surgical excision do not significantly influence the survival prognosis after therapeutic lymphadenectomy. In the subpopulation of patients with lymph node metastasis, Breslow thickness predicts the probability of additional locoregional cutaneous metastasis.

[First experience with a non-covered CHOO enteral stent in the stomach,duodenum, and jejunum]

AIM

To evaluate the technical performance of the non-covered CHOO enteral stent in the stomach, duodenum and jejunum.

METHODS

In 8 patients (two men, 6 women) with malignant tumors of the stomach (n = 4), duodenum (n = 3) and jejunum (n = 1) stent implantation was performed under fluoroscopic control. In two patients endoscopy was needed additionally. The patients were followed for 1 to 168 days.

RESULTS

Stent implantation was technically successful in 7 of 8 patients. In 6 patients symptoms improved. In two patients a second stent implantation was necessary 35 and 161 days after primary implantation, respectively. There was no stent migration or tumor ingrowth.

CONCLUSION

The implantation of the non-covered CHOO enteral stent into the upper gastrointestinal tract is safe and effective.

[Intraoperative spinal sonography]

AIM

Our intention was to examine the value of ultrasonography in the case of spinal stenosis caused by bony fragments or a tumour. Pre- and postoperative computed tomographies were compared with intraoperative ultrasound images.

METHOD

Intraoperative sonography during spinal surgery was used after laminotomy or laminectomy in twenty patients with a stenosis of the spinal canal, caused by fragments or tumours.

RESULTS

The posterior vertebral wall as well as tumour-tissue and myelon can be well distinguished by sonography. The dural sheath remains sonographically visible as a white line between tumour-tissue and myelon even in the case of immense compression. Small bony fragments or herniated disc material are also visible in the spinal canal. Thin surgical instruments can be guided into their target region under ultrasonographic control. When the restored epidural space can be demonstrated sonographically, this proves complete decompression of the spinal cord.

CONCLUSION

Intraoperative ultrasound is an unrestricted repeatable real-time method for the surgeon to control the restoration and the width of the spinal canal. The extent of the operation depends on the results of the intraoperative sonography.