Assessment of CD4 T-lymphocyte reactivity by the Cylex ImmuKnow assay in patients following allogeneic hematopoietic SCT

After allogeneic hematopoietic SCT (alloHSCT), immunosuppressed patients are susceptible to opportunistic infections, and uncontrolled function of the graft can result in GVHD. Accurate immune monitoring may help early detection and treatment of these severe complications. Between October 2005 and November 2007, a total of 170 blood samples were collected from 40 patients after alloHSCT in the Hadassah Hebrew University Medical Center and from 13 healthy controls. We utilized the Cylex ImmuKnow assay for CD4 ATP levels to compare known clinically immunocompromised vs immunocompetent patients after alloHSCT. We also compared the reconstitution of WBC count to the ImmuKnow results and clinical status. The patients' clinical course correlated with the stratification of immune response established by the ImmuKnow assay for solid organ transplantation (immunocompetent vs immunocompromised), and this often differed from their WBC count. On the basis of our observations, we conclude that the ImmuKnow assay is a simple and fast immune-monitoring technique for patients undergoing alloHSCT, with potential to predict clinical course and facilitate prompt management of post-HSCT complications. The assay should be evaluated prospectively in clinical trials.

Quantitative monitoring of multi-donor chimerism: a systematic, validated framework for routine analysis

Despite therapeutic advantages, double-donor (DD) HSCTs present technical problems for molecular chimerism (CHM) monitoring. These DD chimeras contain three matched DNAs, so that the genomes of donor(s) and recipient often share the same alleles. In the STR assay, shared recipient/donor alleles are common and have identical physico-chemical properties. As a consequence of the latter, they co-migrate in the same band ('shared peak'), which prevents measuring each allele separately. Without individual allelic measurements, the direct calculation of the chimeric recipient/donor DNA ratio is precluded. This is the first study to document and systematically examine these problems. Its goal was to provide a validated framework for accurate, routine monitoring based on a stepwise analytic paradigm for approximating percent CHM (%CHM) from shared STR-alleles. Analysis of STR-DNA from DD loci showed that at least four of six alleles were typically shared. Despite such extensive allelic sharing, we show how simple arithmetic procedures can be applied for standardized calculation of %CHM based on peak measurements. Criteria for selecting loci suitable for such analysis are provided. Validation of the computational results required analyzing 18 'informative' loci with pre-established reference values for %CHM. In all cases, the results for %CHM, calculated from peak measurements, were +/-5% of the reference value. The conclusions of the study are as follows: (1) Multi-donor chimeras, with shared alleles, can be accurately and simply analyzed within the usual limits of STR measurement error; (2) by examining these various facets of DD CHM analysis, this novel study has provided a basis for standardized, routine quantitative monitoring using the STR/VNTR assay.

Assessing quantitative chimerism longitudinally: technical considerations, clinical applications and routine feasibility

In this review, we describe the current laboratory approach to quantitative chimerism testing based on short tandem repeats (STRs), focusing on a longitudinal analysis. The latter is based on relative changes appearing in the course of sequential samples, and as such exploits the ultimate potential of this intrinsically semiquantitative platform. Such an analysis is more informative than single static values, less likely to be confused with platform artifacts, and is individualized to the particular patient. It is particularly useful with non-myeloablative conditioning, where mixed chimerism is common. Importantly, longitudinal monitoring is a routinely feasible laboratory option because multiplex STR-polymerase chain reaction kits are available commercially, and modern software can be used to perform computation, reliability testing and longitudinal tracking in a rapid, easy to use format. The ChimerTrack application, a shareware, user friendly program developed for this purpose, produces a report that automatically summarizes and illustrates the quantitative temporal course of the patient's chimeric status. Such a longitudinal perspective enhances the value of quantitative chimerism monitoring for decisions regarding immunomodulatory post transplant therapy. This information also provides unique insights into the biological dynamics of engraftment underlying the fluctuations in the temporal course of a patient's chimeric status.

Rectal prolapse: a possibly underrecognized complication of anorexia nervosa amenable to surgical correction

OBJECTIVE

Rectal prolapse is a complication of anorexia nervosa (AN) that may be more common than previously recorded experience would suggest.

METHOD

In this report we document, for the first time, the association of (AN) and rectal prolapse in a series of three patients seen in the past three years. An extensive review of the literature using Medline over the period from 1966 to Jan 2000 failed to reveal any previous example of this association.

RESULTS AND CONCLUSION

The finding could have significant health care implications if confirmed. It would suggest that patients with either the psychiatric or surgical problem may not be receiving the appropriate complementary referrals: psychiatrist to surgeon and vice versa. The importance of recognition of this association in anorectic patients is the availability of effective surgical therapy.

Waldenström's macroglobulinemia associated with AA amyloidosis

It is widely accepted that amyloidosis in Waldenström's macroglobulinemia (WM) is exclusively due to amyloid light-chain deposition. However, only a small number of previous reports have actually characterized the type of amyloid in WM. We now report the third patient with WM and amyloid A protein (AA) amyloidosis. This patient developed malabsorption, nephrotic syndrome, and orthostatic hypotension. AA was immunohistochemically demonstrated in the rectal biopsy. In conjunction with previous examples of AA amyloidosis, the present report raises the possibility that AA amyloidosis may also occur in WM patients.

Capsular collagen staining of follicular thyroid neoplasms by picrosirius red: role in differential diagnosis

A key criterion in the diagnosis of thyroid follicular carcinoma is capsular invasion, but invasion cannot always be demonstrated histologically. Since invasion is likely to evoke reactions in the capsular collagen, we examined the effects of invasion on capsular collagen with the picrosirius orange-red (PSR) staining technique for collagen. Under polarized light, the color of PSR-stained collagen varies as a function of the structural and biochemical properties of the collagen fibers. Capsules of widely invasive carcinomas (n = 10), minimally invasive carcinomas (n = 10), and adenomas (n = 28) were stained with the PSR method. Carcinomas were assessed along the thickened capsule for sites of definite invasion, minimal invasion, and no evidence of invasion. In adenomas, sites of thickened capsules (similar to carcinomas) were compared to sites of thin capsules. All foci were evaluated for the color and color intensity of collagen fibers. We found a significantly higher frequency of yellow-green collagen fibers than of orange-red fibers at sites of invasion, whereas orange-red fibers significantly predominated at non-invaded sites. In a minority of cases both colors occurred but the non-dominant color was of lesser intensity in all but 1 case. There were no significant differences in staining between minimally and widely invasive carcinomas. Thick capsules of adenomas consistently stained with an intense orange-red color, although weakly stained yellow-green fibers were also observed in some of these cases. We conclude that PSR staining can provide diagnostically useful information in capsular samples of carcinomas, when both color and color intensity of PSR staining are evaluated at the same site. Specifically, intense yellow-green birefringence of collagen in a thickened capsule is additional evidence for capsular invasion.

Overexpression of cyclin D1 mRNA in colorectal carcinomas and relationship to clinicopathological features: an in situ hybridization analysis

Increased expression of a key cell cycle regulator, cyclin D1, may have relevance to carcinogenesis and clinicopathological characteristics of some cancers. This study represents the first application of in situ hybridization, ISH, to detect cyclin D1 mRNA in tissue sections from colorectal carcinomas. This approach was selected because of its unique potential to clarify whether increased expression of cyclin D1 mRNA correlates with clinical and pathological parameters. The ISH ofa non-radioactive oligonucleotide probe (Biogenex) was immunocytochemically detected in paraffin embedded sections from biopsy or resection specimens. Tumors ranged from well to poorly differentiated, and from stages A, B, C, and D. Ten year survival data were available on the majority of patients. Intensity of tumor and background (smooth muscle) signals were independently scored from 0 to 3. Overexpressed cyclin D1 mRNA was seen in 86% of cases compared to background. This frequency is similar to that reported for pancreatic carcinoma. The average signal intensity score in tumor foci was 1.9 with a background score of 0.05 (p<001). All cases showed specific staining judged by the cytoplasmic localization and a tumor signal:background ratio >1. Expression did not differentiate cancers based on grade, stage or survival (p>1), but did differentiate carcinoma and severe dysplasia from mild dysplasia. We conclude that ISH of cyclin D1 mRNA is an effective and relatively specific means of detecting activity of this gene in colonic neoplasms. The high frequency of overexpression implies that gene activity by itself is not likely to predict a tumor s biological or clinical behavior. On the other hand, these data suggest that increased cyclin D1 gene activity may be an early event in colorectal carcinogenesis. They also are consistent with findings showing cyclin D1 is inducible by a variety of oncogene products.

Differences in histochemical characteristics of gingival collagen after ER:YAG laser periodontal plastic surgery

OBJECTIVE

The aim of this study is to evaluate gingival collagen for the effect of treatment with the Erbium:YAG Kesler handpiece. The handpiece is designed for gingival resurfacing in cases of hypertrophic gingiva and gingival pigmentation.

BACKGROUND DATA

Lasers represent recent technological advances that afford new options for the treatment of periodontal diseases. However, lasers used for esthetic gingival soft tissue resurfacing require careful histopathological evaluation of the effects on tissue. In particular, it is important to determine the effect of laser irradiation on connective tissue, especially the collagen fibers. To date, no stage-wise clinical or histological studies have been performed addressing this issue.

METHODS

Ten patients underwent irradiation with the following parameters: energy per pulse, 500 mJ; repetition rate, 10 pps; spot size, 3 mm. Gingival biopsy specimens were derived from 6 patients with hypertrophic gingiva and 4 with gingival pigmentation. The patients were examined before laser treatment and at 7 and 14 days after laser treatment. The tissues were fixed in tymph node revealing solution (LNRS), embedded in paraffin, sectioned at 5 microm, and stained with hematoxylin & eosin. The status of collagen in the treatment site was examined under polarized light after picrosirius red (PSR) staining. PSR is a collagen stain that differentiates collagen fiber density or size by means of a spectrum of color changes under polarized light. The major colors are red, orange, yellow, and green.

RESULTS

We found a significant difference in the properties of collagen fibers at the first week and at 14 days post-treatment. In the normal gingiva, the predominant polarization colors were in the red-orange range, signifying tightly packed, mature collagen. During the first postoperative week, collagen fibers exhibited polarization colors in the green to green-yellow range, implying loosely packed collagen fibers. After 2 weeks, collagen fibers reacquired their preoperative PSR characteristics.

CONCLUSIONS

We conclude that sequential series of changes accompany photothermal treatment of the gingiva. The occurrence of this sequence in all successful outcome cases may suggest the importance of these temporally sequenced changes in collagen during gum healing. In any event, the status of PSR staining of gum collagen provides a useful adjunct in the assessment of gingival health.

Patterns of proliferative changes in crypts bordering colonic tumors: zonal histology and cell cycle marker expression

Proliferative crypt changes have been noted in mucosa bordering colonic carcinomas, but their biological significance is disputed. We anticipated that zonal patterning of histological changes and cell cycle marker expression would provide clues to the pathogenesis of these border changes. 81 specimens were examined including carcinomas, adenomatours polyps, adenomas with early carcinoma, flat adenomas and aberrant crypt foci. The spatial distribution and frequency of micro-architectural features, and mucosal thickness were determined in a border domain of 150 300 sequential crypts/specimen. Immunocytochemical expression of Ki67 and p53 antigens in crypts also was semi-quantitatively examined. We found that in 100% of carcinomas two histologically abnormal zones (Proximate and Middle) separated tumor from normal mucosa. Differences in the feature frequency between zones were statistically significant (p<0.05). Both zones showed mild increases in crypt cell expression of Ki67, with a statistically significant relationship to zonal patterning (p<0.005). Weak expression of p53 only appeared in rare cells. Crypt elongation with mucosal thickening (1.9x normal, p<0.001) in the Proximate and Middle zones distinguished carcinomas from border changes in all benign lesions, except flat adenomas. Since this change occurs in all cases of carcinoma, there is no correlation with tumor stage or grade. Also in carcinomas, elaborate complexes of attached crypts (connected crypt structures) were characteristic of the Middle zone, so that proximate zone was always architecturally simpler. We conclude, that despite continuous carcinoma growth, the invaded border mucosa maintains a prototypical zonal organization of molecular and histological crypt changes This spatially organized reaction pattern is likely to reflect an interplay between regulated growth and destructive processes in response to advancing carcinoma. Compared to the edges of benign colonic tumors, the edges of carcinomas are distinctive and consistent enough to be diagnostically useful.

Colonic aberrant crypts may originate from impaired fissioning: relevance to increased risk of neoplasia

Colonic aberrant crypt foci (ACF) can be identified on the unembedded mucosal surface as clusters of abnormal crypts with enlarged, surface opening. Because dysplasia is frequent, and may be a precursor of carcinoma, epithelial changes have been well studied. However, the basis for the distinctive changes in crypt architecture remain unclear. We hypothesized that some of the architectural alterations of aberrant crypts may reflect impaired fissioning during normal crypt duplication cycles. Fissioning begins at the crypt base. Using morphometric and immunocytochemical approaches, we examined 55 human ACF, both dysplastic and nondysplastic, for their architectural features. Non-ACF mucosa was compared. Microscopically, all lesions contained crypts that were attached, paired, dilated, and angulated. In 3 dimensions, these features related to multiple, individual complexes of connected crypts, referred to as connected crypt structures (CCSs). CCSs terminated in enlarged surface openings (2 to 5 x normal) which are morphometrically equivalent to the macroscopic aberrant crypts (P > .1). These openings trap marker dye. Support for an origin of CCSs in impaired basal fissioning is 3-fold. Crypt profiles in ACF are twice as frequent in basal mucosa as superficially (P < .001); in normal mucosa, the ratio is 1. In a CCS with vertically connected, co-planar crypts, the upper parent crypt diameter was the sum of diameters of inferiorly attached daughter crypts (P > .1). Proliferating cell marker, Ki-67, is not expressed at attachment points. In non-ACF mucosa, isolated CCSs consistently occur at foci of mechanical crypt distortion such as mucosal folds. We conclude that a CCS is a fundamental component of ACF of all histotypes. Impairment of normal crypt fissioning is probably a major factor in the histogenesis of CCSs, which often occurs in settings of mechanical distortion of the mucosa. The pathological significance of this process may be in the formation of enlarged crypt openings. The latter could trap dietary carcinogens as they trap dye, and thereby predispose the CCS to dysplasia.

Basal cell carcinomas arising over arteriovenous malformations: some speculations on the theme

The modulating effects of mesoderm on ectoderm during the embryonic period have been well documented. Some cutaneous conditions such as dermatofibroma with basaloid proliferation are examples of such a relationship. Seven cases of basal cell carcinoma (BCC) developing in port-wine stains and one case developing over an arteriovenous (AV) malformation have been reported. We report 3 elderly patients with BCC developing over AV malformations of the lower extremities. The association between BCC and AV malformation range from a chance association to a complex interaction between mesenchyme and epithelium, in which mesenchyme induces and modulates epithelial growth through the elaboration of specific growth factors (GF).

HLA-DR expression and lymphocytic infiltration in metastatic and non-metastatic papillary carcinoma of the thyroid

Thyrocyte HLA-DR expression in association with lymphocytic infiltration has been demonstrated in autoimmune diseases of the thyroid. HLA-DR expression has been noted both in association with lymphocytic infiltration and in its absence. However, no prognostic significance was attributed to these findings. The purpose of this study on papillary carcinoma of the thyroid was to examine how tumour behaviour relates independently to HLA-DR expression and lymphocytic infiltration. Fifty patients with papillary carcinoma with known metastatic status were examined for HLA-DR expression utilizing the immunoperoxidase conjugated indirect method. The patients were divided into three groups: no metastases (n = 16), regional lymph node metastases only (n = 25), and distant haematogenous metastases (n = 9). Overall HLA-DR expression was noted in 6, 36 and 55% of the respective groups. Tumour HLA-DR expression without lymphocytic infiltration was noted in 0, 4 and 33% of the respective groups. Tumour HLA-DR expression with lymphocytic infiltration occurred in 6, 32 and 22% of the respective groups. From these findings we conclude that HLA-DR expression with lymphocytic infiltration occurs more frequently than HLA-DR expression in the absence of infiltration. The concurrence of HLA-DR expression and lymphocytic infiltration is most commonly associated with regional lymph node metastasis. HLA-DR expression in the absence of lymphocytic infiltration occurs in tumours with distant haematogenous metastases and is an uncommon feature of tumours that have not metastasized or have metastasized only to lymph nodes. Tumour HLA-DR expression in the absence of lymphocytic infiltration may indicate the potential for more aggressive behaviour.

Non-enhancing supratentorial malignant astrocytomas: MR features and possible mechanisms

To clarify the MR features of supratentorial malignant astrocytic gliomas that did not exhibit contrast enhancement of MR imaging, six MR parameters were evaluated in two glioblastomas and six anaplastic astrocytomas. Moderate to marked edema, mass effect, and moderate tumor heterogeneity were noted in all cases. Hemorrhage was absent in all cases. Border definition and cyst formation or necrosis were not consistent among the tumors. Histological examination demonstrated significant vascular proliferation in two cases, and mild to moderate proliferation in six. Non-enhancing malignant astrocytic gliomas are a diagnostic challenge. Analyzing perifocal edema and heterogeneity of each mass probably provides clues for a proper diagnosis.

Vertebral body metastasis of glioblastoma multiforme with epidural mass formation. Contrast-enhanced MRI study

A 35-year-old woman with left frontoparietal glioblastoma was subtotally resected twice and 1 year later demonstrated extracranial metastasis. Magnetic resonance imaging (MRI) demonstrated metastasis to the first thoracic vertebral body with epidural and paravertebral extension. Bone scintigrams of the spine appeared normal. The mechanisms and radiological findings of the extracranial metastasis of an astrocytic glioma are reviewed.

Extraskeletal myxoid chondrosarcoma of the falx

Intracranial cartilaginous tumors are unusual lesions, of which myxoid chondrosarcoma is the rarest. We describe this tumor arising from the falx in a 28-year-old woman treated at recurrence with a second operation and a radiation implant. The behavior of classic chondrosarcoma and mesenchymal chondrosarcoma is also reviewed.

Neuroradiological manifestations of intracranial sarcoidosis

Six cases of sarcoidosis involving the central nervous system are reported with the neuroradiological findings and appearance on computed tomography. Communicating hydrocephalus with sarcoid arachnoiditis is the most common finding, but arteritis and masses have also been reported. Two rare cases of intracerebral masses are included. The radiological findings and clinical histories are reviewed with emphasis on the use of CT and complete neuroradiological studies for patients with possible central nervous system sarcoidosis.