Rearranged p53 gene with loss of normal allele in a low-grade nonrecurrent glioma

We are studying the p53 gene profile in primary glial tumors by seeking alterations in the hybridization pattern of the tumor DNA probed with a p53 gene probe. This report documents a rearranged p53 gene with loss of the normal allele in a low-grade mixed glioma which has not recurred during 4-year follow-up. The tumor had a low 5-bromodeoxyuridine (BrdU)-labeling index and low AgNOR count. The p53 protein was not detected on immunochemical staining. To our knowledge, this is the first report of an altered p53 gene in a low-grade nonrecurrent glial tumor and highlights the presence of further checks and balances on the control of cell proliferation and other malignancy-associated phenotypes, even in an already-established tumor.

Solitary intracranial plasmacytoma of the skull base

Two cases of extradural solitary plasmacytoma (SIP) with infiltration of the dura, destruction of the skull base, multiple cranial nerve palsies and proptosis are presented. The cases were treated aggressively with surgery and radiotherapy and showed no signs of progressing to multiple myeloma after 15 months and four and a half years respectively.

Cushing's disease: pituitary imaging

Fourteen patients with adrenocorticotropic hormone (ACTH)-dependent hypercortisolism underwent pituitary scanning with computed axial tomography (CT) and magnetic resonance imaging (MRI). Computed tomography revealed pituitary macroadenomas in two patients, pituitary hyperplasia in one and a suspicion of pituitary microadenoma in one. Thirteen patients underwent MRI. One with a macroadenoma diagnosed on CT did not undergo MRI. The MRI revealed a pituitary macroadenoma in one, microadenoma in three and hyperplasia in two cases. Magnetic resonance imaging following gadolinium diethylene triamine penta acetic acid (gd-DTPA) enhancement revealed four more pituitary microadenomas. All patients who had pituitary adenomas (micro and macro) and hyperplasia underwent trans-sphenoidal pituitary surgery. One of the two patients, who had an enlarged pituitary on imaging but no demonstrable adenoma, was found to have a microadenoma at surgery. Patients with ACTH-dependent hypercortisolism should undergo MRI of the pituitary gland to identify/localize corticotroph pituitary adenomas. The study should include gd-DTPA enhancement in cases where the scan is normal.

Lymphocytic hypophysitis. Case report

A case of lymphocytic hypophysitis is described in a patient presenting with panhypopituitarism 8 years after her last childbirth. The patient developed headache, vomiting, and diplopia (due to palsy of the right lateral rectus muscle) 7 months after delivery of her last baby. The diplopia disappeared after a few days with symptomatic treatment, and the headache and vomiting decreased in intensity with analgesic therapy. Eight years later the patient developed symptoms suggestive of hypoadrenalism, hypothyroidism, and amenorrhea. Investigations revealed panhypopituitarism with a pituitary mass lesion. Repeat evaluation 1 year later demonstrated no change in the size of the pituitary gland. The patient underwent transsphenoidal surgery with a provisional diagnosis of pituitary adenoma. Histological examination of the resected gland revealed evidence of lymphocytic hypophysitis. Symptoms suggestive of a pituitary mass lesion were noted during the peripartum period, but features of hypopituitarism developed much later. Such a long latent period has not been reported before. This report also highlights the fact that glandular enlargement may persist for many years after the onset of lymphocytic hypophysitis.

Primary cerebellopontine angle choroid plexus papilloma: a case report and review of literature

A case of primary choroid plexus papilloma of the cerebellopontine (CP) angle is described in a 28 years old man. He presented with hearing loss, right facial palsy and spastic quadriparesis (4/5). He also had markedly increased intracranial pressure. CT scan revealed a large high attenuating lesion in right CP angle with gross hydrocephalus. The patient was operated with the clinical and radiological diagnosis of right sided acoustic tumor with brainstem compression. Radical tumour excision was performed, seven days following VP shunt. Patient had immediate postoperative deterioration followed by a steady recovery. The possibility of a secretory choroid plexus papilloma is discussed.

Cell culture studies on human nerve sheath tumors

The main controversy about nerve sheath tumors (NSTs) has been their histogenesis. A Schwann cell origin has been proposed by many investigators for both schwannomas and neurofibromas. However Erlandson and Woodruff observed that while schwannomas appeared to be composed predominantly of Schwann cells, neurofibromas consisted of mainly perineurial cells. In addition, variable numbers of fibroblast-like cells and intermediate cells also have been reported in the 2 lesions. Whether these represent distinct cell types or variants of Schwann cells is still debatable. In an attempt to solve this controversy, the present study was undertaken to observe the morphology and the behaviour of these tumors in culture. These studies showed that all nerve sheath tumors are basically of Schwann cell origin and that intermediate cells and fibroblasts are variants of Schwann cell. Tissue culture studies done chiefly on schwannomas showed that the morphological features of schwannomas are preserved in 'in vitro culture' condition and therefore the difference between neurofibroma and schwannoma appears to be due to inherent differentiating property of the Schwann cells along with some environmental stimulus.

Dystrophin assay in muscular dystrophies: an Indian experience

BACKGROUND

Dystrophin, a protein situated on the plasma membrane of skeletal muscle has been found to be abnormal in quality and quantity in patients with muscular dystrophies and may be useful in distinguishing between the different types. Experience with the technique has been limited to western countries.

METHODS

We used dystrophin staining with monoclonal NCL-DYS (rod domain) antidystrophin antibody using the avidin-biotin conjugate immunoperoxidase technique in 16 out of 20 patients with various types of muscular dystrophies at a large tertiary care medical centre in India.

RESULTS

The technique was unsuccessful in 4 cases. In the others the dystrophin staining pattern correlated well with the clinical diagnosis in 11 out of 16 patients. In the other 5 patients dystrophin assay helped to differentiate between Duchenne muscular dystrophy and the Becker muscular dystrophy in 2 patients suspected to have limb-girdle muscular dystrophy, it differentiated Duchenne muscular dystrophy from the Emery-Dreifuss muscular dystrophy and detected a manifest female carrier with Duchenne's dystrophy.

CONCLUSION

Dystrophin staining may be useful in the differential diagnosis of patients with muscular dystrophies in India.

A sequential cell kinetic study of meningioma cells in primary explant culture using bromodeoxyuridine

The present study was undertaken to evaluate the sequential BrdU-LI at weekly intervals upto four weeks in 18 primary explant cultures of meningiomas. This revealed three distinct patterns of growth which could be arbitrarily defined as 'degenerating' (group I), 'proliferating' (group II) and 'adaptive' (group III) types. Interestingly two cases of malignant and two of recurrent meningiomas fell into the 'degenerating' group I pattern. The possible explanations for the observed relatively higher in vitro LI values compared to lower in vivo values as reported in the literature and the theoretical implications of the three distinct patterns of sequential LI values are discussed.

A transmission and scanning electron microscopic study of tumoral and peritumoral microblood vessels in human gliomas

The tumor microblood vessels (MBVs) of 25 cases of gliomas of varying grades were studied and compared with those in peritumoral region using both transmission and scanning electron microscopy (TEM and SEM). The TEM study revealed numerous villous projections with pinocytotic vesicles (PCVs) and large vacuoles (LVs) concentrated mainly at the luminal aspect in tumor MBVs which increased with increasing severity of edema. The peritumoral MBVs, in addition to showing some increase in villous projections on the luminal surface, also showed increased number of PCVs and LVs concentrated at the abluminal aspect with some of them even communicating with the extravascular space. The SEM study largely corroborated the TEM findings. The sites of formation of PCVs and LVs appeared as small pits or large craters on the luminal surface of the endothelial cells of tumor MBVs. We feel that the morphological evidence of increased permeability in tumor MBVs represents their role in the development of edema and that the occurrence of reverse pinocytosis in peritumoral MBVs is a distinct possibility which may be associated with resorption of edema fluid.

In-vivo proliferative potential of primary human brain tumors; its correlation with histological classification and morphological features: II. Nonglial tumors

In-vivo cell kinetics study following peroperative intravenous infusion of bromodeoxyuridine (BrdU) was done in 10 cases of primitive neuroectodermal tumors (PNET) and 44 nonglial tumors of different histological types. The histological features usually regarded as indicators of aggressive behaviour were examined in these tumors and correlated with in-vivo labelling index (LI). In the case of meningiomas, increased cellularity, pleomorphism and mitosis had no correlation with LI. Benign non-recurrent meningiomas usually showed LI < or = 1% (mean 0.6 +/- 0.3%) whereas recurrent and malignant meningioma showed higher LI (mean 2.6 +/- 0.5% and 2.8 +/- 0.4% respectively). Follow-up study suggested that meningiomas having benign histological appearance with LI > 1% might have increased chance of recurrence. In cases of PNETs among different histological features, mitosis and differentiation seemed to be related to the biological behaviour. Astrocytic differentiation was associated with lower rate of proliferation. In pituitary adenomas different hormone producing and null cell adenomas showed similar low proliferative potential (0.6 +/- 0.3%). Benign nerve sheath tumors, craniopharyngioma and choroid plexus papilloma showed low in-vivo LI of less than 1%. Thus the present study revealed the inadequacies of routine histological examination in assessing the aggressiveness of the nonglial tumors, especially meningiomas. In-vivo LI may be a good supplement to histological diagnosis as well as helping to assess the prognosis and accordingly the management of individual cases.

Morphological appearance, growth kinetics and glial fibrillary acidic protein (GFAP) expression in primary in vitro explant culture of astrocytic neoplasms

Astrocytomas of different grades of malignancy were cultured as primary explant and their sequential growth pattern, glial fibrillary acidic protein (GFAP) expression and labelling index (LI) using bromodeoxyuridine (BrdU) were assessed and correlated with the grade of malignancy of the original tumor tissue. Low-grade astrocytomas showed patterns of growth that diverged from anaplastic astrocytomas and glioblastoma multiforme. The GFAP expression decreased with increasing time in culture in all astrocytomas irrespective of the grading. Maximum GFAP was, however, expressed in the morphologically well-differentiated stellate cells. Contrary to expectations, lower BrdU LI was observed in glioblastoma multiforme in comparison to low-grade astrocytomas, which suggests some unidentified mechanism of differentiation in vitro for astrocytomas of higher grade of malignancy. Hence, in contrast to reported literature on the prognostic value of studies on primary cultures, the present study cautions the extrapolation of the in vitro findings for astrocytomas.

In-vivo proliferative potential of primary human brain tumors; its correlation with histological classification and morphological features: I. Gliomas

This study was undertaken to investigate in-vivo proliferative potential of neoplastic cells in 66 cases of gliomas of different histological types following peroperative intravenous infusion of bromodeoxyuridine (BrdU). Histological typing according to the recent modification of WHO classification did not often correlate with in-vivo cell kinetics. Among the different morphological features used for the classification, necrosis, mitosis, increased cell density and increased endothelial cell proliferation showed good correlation with tumor cell labelling index (LI) (p < 0.01-p < 0.001). A preliminary follow-up study of 36 cases for a period ranging from 9 to 36 mths suggested the possibility that higher in-vivo tumor cell LI might be associated with an early recurrence. Thus in vivo BrdU LI may supplement the histological classification of gliomas and together they may help in a better assessment of their growth rate, degree of malignancy and biological behaviour which in turn facilitate the planning of therapeutic management for individual cases.

Idiopathic inflammatory myopathy: clinicopathological observations in the Indian population

The present study attempts to investigate the pathological basis of the two clinically different forms of idiopathic inflammatory myopathy (IIM) namely, polymyositis (PM) and dermatomyositis (DM). Clinicopathological analysis of 73 cases showed that muscle fibre necrosis and regeneration were more frequent in PM than in DM, the latter being significantly so (P < 0.05). On the other hand, vasculitis was more associated with DM while perifascicular atrophy of the muscle fibres was confined to it. Vasculitis was present in eight cases. Its incidence in patients with myositis with systemic connective tissue disease (4/9) was significantly more than in other PM and DM patients (P < 0.01). An equally significant higher frequency of perimysial inflammatory infiltrate was also seen in the former as compared to the latter. Interestingly, idiopathic DM affected men as often as women and juvenile IIM affected boys more frequently than girls. A female predilection was noted in the remaining groups of IIM. These observations indicate that there may be some basic immunopathogenetic differences between polymyositis and dermatomyositis as well as between idiopathic PM/DM and that associated with systemic connective tissue diseases. Though the number of patients studied is small, the absence of female predilection in idiopathic DM and juvenile IIM may be peculiar to the IIM in the tropics.

Dystrophin test in differential diagnosis of childhood muscular dystrophies

Two cases of childhood muscular dystrophy are described. One of them had clinical features suggestive of Emery-Dreifuss muscular dystrophy and the other with some features of Prader-Willi syndrome, besides proximal muscle weakness. Muscle biopsy from both cases revealed a clear abnormality of dystrophin, and were diagnosed as having Duchenne muscular dystrophy (DMD) by immunofluorescence examination; that is, absent dystrophin at the membrane of the muscle fibers. The clinical spectrum of DMD-related myopathies and the importance of dystrophin testing in childhood muscular dystrophies is discussed.

Pentavalent technetium-99m dimercaptosuccinic acid scintigraphy is useful in diagnosis and localization of neuroblastoma

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Ultrastructural study of mixed growth hormone & prolactin secreting pituitary adenomas

An ultrastructural study was done on 15 mixed growth hormone (GH) and prolactin (PRL)-secreting pituitary adenomas surgically removed from acromegalic patients with hyper-prolactinaemia, in order to see whether the 2 hormones were present in the same cell or in different cells. Double labelling immunogold technique was used for simultaneous ultrastructural localization of GH and PRL. It was found that each neoplastic cell in these 15 tumours (30 to 50 cells were studied in each case) contained 4 populations of granules viz., (i) granules positive for only GH; (ii) granules positive for only PRL; (iii) granules positive for both GH and PRL; and (iv) granules negative for both GH and PRL (unlabelled). Though the relative percentage of these 4 types of granules varied from cell to cell even within the same tumour, the major population (49.9 to 96%) was constituted by the mixed granules showing labelling for both GH and PRL. Almost all the cells examined from each tumour appeared to be mammosomatotrophs. Thus, the study indicated that mammosomatotroph adenomas are perhaps more common among mixed GH and PRL--secreting pituitary adenomas than previously believed. It could be important to recognize these tumours from the therapeutic point of view.

Immunohistochemical, ultrastructural & immunoelectron microscopic study of glial fibrillary acidic protein in corpora amylacea

Brain tissues from 10 patients (of non-neurological disease) were studied for the presence of corpora amylacea (CA) using light microscopy (LM), immunohistochemistry (IH) for localisation of glial fibrillary acidic protein (GFAP) and transmission electron microscopy (TEM). Immunoelectron microscopy (IEM) by post-embedding technique using colloidal gold was also performed in two of these patients for more precise localisation of GFAP. Three types of immunoreactivity were noted by IH under LM; some CA were completely negative for GFAP (type III), while others showed positivity, which was either diffuse (type I) or confined to the periphery (rim positivity-type II). TEM showed variable sizes in electron dense material in the centre associated with different amounts of glial filaments (GFs) at the periphery. Thus the different types of IH staining appeared to corroborate with the presence and amount of GFs in CA. The sensitive technique of IEM confirmed the presence of GFAP in all CA irrespective of their IH typing at LM. It is suggested that CA formation in astrocytes is associated with progressive fragmentation and disintegration of GFs with resulting increase in the accumulation of electron dense GFAP-negative material. As more and more of GFs get incorporated and disintegrated, it results in increase in the size of the CA. Thus, the present study clearly demonstrates that GFAP in the GFs contributes to the composition of CA.

Plasmacytoma of anterior maxilla mimicking periapical cyst

An unusual case of plasmacytoma mimicking a large periapical cyst in the anterior maxilla is described. Of the involved teeth, 22 was discoloured and had an open, immature apex, a feature strongly suggestive of the lesion being of pulpal origin. The case was treated by a conservative endodontic approach, but failed to show any improvement. Apical surgery comprising complete enucleation of the cystic lesion and extraction of the involved tooth was carried out. The unexpected histopathological finding was a plasmacytoma.

Fibrosarcoma of the scalp following postoperative radiotherapy for medulloblastoma

A rare case of fibrosarcoma of the scalp following postoperative radiotherapy for medulloblastoma is reported. A review of similar cases in the literature was undertaken in an attempt to find a correlation between the dose of radiation, the length of the latent period, and the nature of the neoplasm. A significantly shorter latent period was found for sarcomas. No relationship was observed between the radiation dose and the latent period. The present case is unique in that the post-irradiation neoplasm (PIN) occurred in a predominantly extracranial site after treatment for a desmoplastic medullobastoma and had a remarkably short latent period.

Familial amyloidotic polyneuropathy in an Indian family

An Indian female with familial amyloidotic polyneuropathy is reported. The literature with regard to recent advances in the field is reviewed.

Aspergillosis of spine. A case report

Aspergillosis of spine is a very rare entity generally seen secondary to a primary focus in the lung with or without immune suppression. The authors report one case of aspergillosis of spine without evidence of a primary elsewhere or a predisposing cause.

Control of lymphocyte migration into brain: selective interactions of lymphocyte subpopulations with brain endothelium

We have determined whether particular lymphocyte populations bind preferentially to cerebral endothelium, using adhesion assays and a new method for in situ staining of adherent lymphocytes. B cells bind more strongly than T cells, an effect enhanced by lymphocyte activation or endothelial cell stimulation with interferon-gamma (IFN-gamma) or tumour necrosis factor-alpha (TNF-alpha). This is not equated with levels of CD18 expression on the lymphocytes. CD8+ T cells bound more efficiently than CD4+ cells under all conditions. To determine whether there was a population of cells which selectively homes to the brain, we compared adhesion of cervical lymph nodes cells to brain endothelium, with adhesion of lymphocytes from other nodes. In 50% of the experiments there was significantly enhanced binding of activated cervical lymph cells to cerebral endothelium but not to control (aortic) endothelium. This effect was seen using both normal and IFN-gamma-activated endothelium. The explanation for this finding is that cervical lymph nodes frequently, but not invariably, contain higher proportions of CD8+ cells and B cells than other lymph nodes. These data imply that selective adhesion of lymphocytes to brain endothelium is related to the subpopulations involved and this may be reflected in the cell types seen in immunological lesions of the brain, and in the relative proportions of the subpopulations seen in cervical lymph nodes.