Chronic diaphyseal osteomyelitis of long bones refractory to conventional therapy - Benefits and risks of reaming of the femoral medullary cavity

Osteomyelitis of long bones represents a severe complication during fracture healing. If ongoing infection occurs despite reoperation and if antibiotic treatment is of no benefit, reaming of the medullary canal may be beneficial. We investigated the long term follow up (minimum 2 years) of patients submitted to reaming of the medullary canal to evaluate the efficacy of this method. Criteria for successful procedure: no further operative procedure/ antibiotic treatment. 32 patients out of 37 were followed over a 9 year period. Mean incidence of surgical treatment for osteomyelitis prior to reaming: 3.2 operations. Mean duration until reexamination after reaming: 3.7 years. 89% of patients had a full range of motion upon reexamination, in the others further articular injuries were present. 84.3% of patients were working in the same profession as prior to the fracture, 72% were active in sports again, 97% of patients were pain free. One otherwise healthy patient suffering from sclerosing osteitis (Garré) died during reaming of the femur due to bone marrow embolism to the lung. Reaming of the medullary canal has a high rate of curing osteomyelitis even after several previous attempts of surgical revisions and/or antibiotic treatment. The most likely mechanism is based on improvement of local perfusion. During surgery care must be taken not to provoke pulmonary embolization. Intraoperative monitoring by pulmonary artery catheter should performed; reaming should be immediately discontinued, if a rise in pulmonary artery pressure occurs.

Expression of S100A12 (EN-RAGE) in cystic fibrosis

BACKGROUND

Chronic airway inflammation and recurrent infections are a core phenomenon in cystic fibrosis (CF). Diagnosing acute infectious exacerbations is difficult in the presence of chronic inflammatory processes. S100A12 exhibits proinflammatory functions via interaction with the multiligand receptor for advanced glycation end products. Blocking this interaction inhibits inflammatory processes in mice.

METHODS

The expression of S100A12 in lung specimens of patients with end stage lung disease of CF was investigated, and S100A12 levels in the serum of patients with acute infectious exacerbations of CF were measured.

RESULTS

Immunohistochemical studies of CF lung biopsy specimens revealed a significant expression of S100A12 by infiltrating neutrophils. High S100A12 levels were found in the sputum of patients with CF, and serum levels of S100A12 during acute infectious exacerbations were significantly increased compared with healthy controls (median 225 ng/ml v 46 ng/ml). After treatment with intravenous antibiotics the mean S100A12 level decreased significantly. There was also a significant difference between S100A12 levels in patients with acute infectious exacerbations and 18 outpatients without exacerbations (median 225 ng/ml v 105 ng/ml).

CONCLUSIONS

S100A12 is extensively expressed at local sites of inflammation in CF. It is a serum marker for acute infectious exacerbations. High local expression of S100A12 suggests that this protein has a proinflammatory role during airway inflammation and may serve as a novel target for anti-inflammatory treatments.

Long-term results of the use of silicone sheets after diskectomy in the temporomandibular joint: clinical, radiographic and histopathologic findings

The aim of the present study was to evaluate the long-term results of a group of patients who had the disk of the temporomandibular joint (TMJ) removed and permanently replaced by a silicone sheet. The study group comprised 48 patients, treated in the period from 1983 to 1993. In eight patients, the implants had to be removed after an average interval of 5.6 years and they were submitted for histopathological examination. Twenty-five of the 40 patients with silastic implants in place, and five of the 8 patients who had their implants removed, were available for long-term follow-up (mean interval of 7.0 years, SD 2.8 years). Clinical function was rated according to the Helkimo Dysfunction Index and compared to the preoperative findings. Results showed decreased tenderness of muscles and joints to palpation and increased mouth opening, but no statistically significant improvement in joint function. In 4 patients, a decrease in condylar width was found, while another 4 patients presented with thickening of the condyle by appositional bone formation. Histopathology of the failed implants showed scattered fragments of silastic material and dacron fibers with accumulation of histiocytes in immediate contact with the silicone particles and phagocytozed intracellular material. T-lymphocytes were also present in the vicinity of the silicone particles.

Prognostic value of immunohistochemical expression of beta-1 integrin in pancreatic carcinoma

BACKGROUND

Prognostically relevant factors based on the histological assessment of the resected pancreas are known. However, the knowledge of additional factors associated with the prognosis is helpful in planning the therapy for an individual patient. beta1 Integrin expression is known to have a prognostic influence in some malignant tumors. No data are, however, available on the prognostic value of beta1 integrins in pancreatic carcinoma.

METHOD

We investigated paraffin-embedded specimens of 19 patients undergoing surgical treatment for periampullary carcinoma and of 42 patients for ductal pancreatic carcinoma by immunohistochemistry to assess the expression pattern and the prognostic impact of beta1 integrins. Neither histomorphological parameters nor the survival time of the patients were known at the time of the investigation.

RESULTS

No correlation was established between histomorphological parameters and beta1 integrin expression in periampullary or ductal pancreatic carcinoma, respectively. Patients with periampullary carcinoma and beta1 integrin overexpression had a significantly poorer prognosis than patients without overexpression of beta1 integrins (median survival: 18.3 vs. 58.4 months). In ductal pancreatic carcinoma beta1 integrin expression had no influence on prognosis.

CONCLUSION

beta1 Integrins exert an influence on prognosis in periampullary carcinoma but not in ductal pancreatic carcinoma. However, further investigations in larger patient samples are required to confirm these results.

Beta 1 integrin expression in adenocarcinoma of Barrett's esophagus

BACKGROUND/AIMS

In vitro and in vivo studies did not show that beta 1 integrin expression is associated with malignant transformation or that it is of prognostic value in some malignant tumors. There are no data on the expression or prognostic value of beta 1 integrins in adenocarcinoma of Barrett's esophagus.

METHODOLOGY

We assessed the expression pattern and the prognostic impact of beta 1 integrins in paraffin-embedded specimens of 41 patients with adenocarcinoma of Barrett's esophagus by immunochemistry. At the time of investigation, neither histomorphological parameters nor the survival time were known.

RESULTS

There was no correlation between histomorphological parameters and the expression of beta 1 integrins. The expression of beta 1 integrins had no influence on long- term survival. There was a relationship between the prognosis and the following histopathological parameters: pT, pN and pM category, the UICC stage, the presence of lymphangiosis, and the DNA content of the tumor cells.

CONCLUSIONS

The preliminary results obtained in this study did not show that the expression of beta 1 integrins was of prognostic value in patients with adenocarcinoma of Barrett's esophagus. Further studies in a larger number of patients are required to confirm the results obtained in this investigation.

Recurrence patterns of hepatocellular and fibrolamellar carcinoma after liver transplantation

PURPOSE

Tumor recurrence is the major limitation of long-term survival after liver transplantation for hepatocellular carcinoma (HCC) or fibrolamellar carcinoma (FLC). Understanding tumor-biologic characteristics is important for selection of patients and for development of adjuvant therapeutic strategies.

PATIENTS AND METHODS

The study included 69 patients who underwent potentially curative liver transplantation for HCC/FLC and survived for more than 150 days; minimum follow-up was 33 months. Frequency, localization, and timing of recurrence were analyzed and compared with primary tumor and patient characteristics.

RESULTS

Tumor recurrence was observed in 39 patients at 67 locations. Hematogenous spread was the major route of tumor recurrence (87%), and the most frequent sites were the liver (62%), lung (56%), and bone (18%). Parameters associated with recurrence were absence of cirrhosis, tumor size greater than 5 cm, more than five nodules, vascular infiltration, and International Union Against Cancer (UICC) stage IVA. Selective intrahepatic recurrence was found in nine patients (23%); it was associated with highly differentiated tumors, lack of vascular infiltration, and male sex. Recurrence at multiple sites was found predominantly in young patients (< or = 40 years) and for multicentric (> 5) primary tumors. Recurrences were observed within a wide time range after transplantation (43 to 3,204 days; median, 441 days); late recurrences (> 1,000 days, n = 8) were associated with highly differentiated or fibrolamellar tumors and low UICC stages. Surgical treatment was the only therapeutic option associated with prolonged survival after recurrence.

CONCLUSION

In transplant recipients, hepatocellular carcinomas vary considerably in their pattern and kinetics of metastases. Tumor cells may persist in a dormant state for long time periods before giving rise to clinical metastases. Surgical treatment of recurrence should be considered whenever possible.

[De novo hepatitis B infection after liver transplantation--evidence for the need of active hepatitis B vaccination of liver transplantation candidates]

BACKGROUND

Liver transplantation (LTX) is a generally accepted therapy in the treatment of acute and chronic end-stage liver diseases. Recurrent and de-novo hepatitis B and C virus infection following liver transplantation have been shown.

PATIENTS AND METHODS

We analyzed retrospectively the course of patients treated at our transplant center between 01.01.1992 and 31.12.1997, who does not show any markers of an active hepatitis B (HBV) infection prior to liver transplantation but developed replicative HBV infection afterwards. During this period 544 liver transplantations were performed in 452 patients, 395 of whom were HBs-Ag negative prior to transplantation.

RESULTS

Six patients were identified who underwent LTX for non-hepatitis B-induced liver disease, and who subsequently developed a highly replicative de-novo HBV-infection six to twelve months (mean 8.5 months) after LTX. In each of the patients HBV de-novo infection showed clinically and biochemically a mild but chronic course without evidence of liver failure during a maximum follow-up period of 14 to 37 months (mean 26 months). Liver biopsies taken in four patients nine to 22 months after LTX showed chronic active hepatitis (n = 2), chronic portal hepatitis (n = 1), and a mild rejection (n = 1). The source of de-novo HBV infections remained unclear, but inapparent infection of patients pre-LTX was ruled out so that the donor livers or postoperative infection appear to be the likely source.

CONCLUSION

In our center the number of HBV de-novo infections (1.5%, 6/395) following liver transplantation was comparable to the results published by other centers, but in our center no inapparent infection of patients prior to LTX was observed. For further minimization of HBV de-novo infection following LTX active HBV immunization of patients awaiting LTX is recommended.

[Xanthoma disseminatum with marked mucocutaneous involvement]

HISTORY AND CLINICAL FINDINGS

When aged 23 years, a now 36-year-old man was first diagnosed as having xanthomas on the upper arms and shoulders. Xanthomas then progressed, affecting both the skin and the laryngo-pharyngeal mucosa. They were so marked that several laser-surgical interventions for their removal in the phayngo-laryngeal tract were necessary to ensure unimpaired breathing. There were also extensive confluent symmetrical cutaneous xanthomas over the upper and lower arms, the face, neck and trunk. Xanthomas and scars in the pharynx and larynx necessitated marked nasal breathing.

INVESTIGATIONS

There was no laboratory evidence of abnormal lipid metabolism. The concentrations of cholesterol, triglycerides, lipoprotein (a), apolipoprotein A-1, apolipoprotein B, apolipoprotein E phenotype and steroles were all normal. The biochemical composition of LDL, VLDL and HDL particle was also unremarkable. Histological examination of resected xanthomas revealed dense infiltrations of the interstitial spaces by foam-cell histiocytes with multiple lipid vacuoles, typical of xanthoma disseminatum.

TREATMENT AND COURSE

Neither probucol nor cholesterol synthesis enzyme inhibitors nor glucocorticoid medication influenced the xanthomas. The only effective treatment was removal of the most unsightly or obstructing lesions. But the sars left removal in the mucocutaneous regions caused obstruction in the laryngopharyngeal tract.

CONCLUSION

The cause of xanthoma disseminatum remains unknown. Skeletal muscle can also be extensively infiltrated. This case shows similarities to Erdheim-Chester disease, another are xanthomatous condition.

Lipoprotein-X in patients with cirrhosis: its relationship to cholestasis and hypercholesterolemia

Lipoprotein-X (Lp-X) is an abnormal low-density lipoprotein frequently found in liver disease. It is regarded as the most sensitive and specific biochemical parameter for the diagnosis of intra- and extrahepatic cholestasis. Moreover, Lp-X is supposed to contribute to the development of hypercholesterolemia in cholestatic liver disease, because it fails to inhibit de novo cholesterol synthesis. This investigation will focus on the relationship between the presence of Lp-X and serum lipid concentrations in cirrhosis. The significance of Lp-X in the diagnosis of cholestasis, compared with alkaline phosphatase (AP), gamma-glutamyl transferase (GGT), and bilirubin levels, will be assessed as well. The present cross-sectional study includes 212 patients with histopathologically proven cirrhosis. The detection of Lp-X and the quantification of -, beta-, and pre-beta-cholesterol was based on agar gel electrophoresis and polyanion precipitation. For the characterization of liver function, the concentrations of albumin and bilirubin, the activities of liver enzymes, and coagulation times were assessed. In a subgroup of 40 individuals, liver biopsies were re-evaluated to confirm or exclude intrahepatic cholestasis. As a result, there was no association between the appearance of Lp-X and total cholesterol concentrations. While all patients with Lp-X showed intrahepatic cholestasis (predictive value of the positive test = 1), only 16 of 28 patients with cholestasis formed Lp-X (sensitivity = 0.57). The activities of AP and of GGT, as well as the concentrations of bilirubin, were strongly elevated in most patients, with and without cholestasis. The predictive values of AP, GGT, and bilirubin were 0.77, 0.69, and 0.74 for the positive test and 0.5, 0, and 0.6 for the negative test, respectively. We conclude that Lp-X is not related to hypercholesterolemia in cirrhosis. The positive, but not the negative, Lp-X test has high predictive value for the diagnosis of cholestasis in cirrhosis. The biochemical parameters traditionally used for the assessment of extrahepatic cholestasis, AP, GGT, and bilirubin, do not support the diagnosis of intrahepatic cholestasis caused by cirrhosis.

Antiproteinuric efficacy of fosinopril after renal transplantation is determined by the extent of vascular and tubulointerstitial damage

BACKGROUND

Angiotensin converting enzyme (ACE) inhibitors have been successfully used for treatment of proteinuria after renal transplantation (RTx). Factors possibly responsible for the great inter-patient variance of the antiproteinuric effect (APE) have not yet been investigated in renal-transplanted patients.

METHODS

28 patients after RTx with a persistent proteinuria of more than 1.25 g/d were treated prospectively with does of fosinopril (10-15 mg/d) which were not effective on systemic arterial blood pressure. Prior to initiation of fosinopril, renal graft biopsy was performed in all patients and renal graft artery stenosis was excluded by duplex ultrasound. Serum creatinine and proteinuria were measured prior to, as well as 3 and 8 months after initiation of ACE inhibition, mean arterial pressure was controlled via 24-h measurement and repeated spot measurements. Reduction of proteinuria was correlated with renal histology, serum creatinine, creatinine clearance, mean arterial blood pressure, sodium excretion before therapy and the relative changes of these parameters during therapy respectively.

RESULTS

Therapy had to be stopped in 8/28 patients due to side effects including rise of serum creatinine (n = 4). Three patients were excluded due to non-compliance. In the remaining patients (n = 17) proteinuria was reduced from 2.94 +/- 1.66 to 1.82 +/- 1.39 and 2.48 +/- 3.05 g/d after 3 and 8 months respectively, in the mean +/- SD. There was a significant inverse correlation between the APE and the extent of benign nephrosclerosis, interstitial fibrosis and tubular atrophy. No correlation of the APE to any of the other parameters could be demonstrated.

CONCLUSIONS

Fosinopril can be administered effectively in a subgroup of proteinuric renal transplant recipients. However, because of a high proportion of patients developing side effects, careful monitoring is obligatory. Our results show that the lesser the degree of chronic morphological injury, the greater is the antiproteinuric effect. Thus, the degree of pre-existing histologically proven damage of the graft may serve as an indicator for the antiproteinuric efficacy of ACE inhibitor therapy after RTx.

[Expression of CD44 and isoforms v4, v5, v6, v7, v10--new prognostic parameters in ductal pancreatic carcinoma?]

Prognostically relevant factors based on the histological assessment of the resected pancreas are known. However, additional parameters, such as biological staging of the intrinsic malignant potentiality of the tumor, would be useful. There has been no uniform finding of a relationship between CD44 variant expression and tumor progression.

METHOD

We assessed the expression pattern and prognostic impact of CD44 standard and CD44 isoforms v4, v5, v6, v7 and v10 in 40 ductal pancreatic carcinomas by immunochemistry on paraffin-embedded tumor material in patients after tumor resection. At the time of the investigation neither histomorphological parameters nor the survival time were known.

RESULTS

There was no correlation between the histomorphological parameter and the expression of CD44 splice variants. CD44 splice variants v4-v10 were almost only expressed in tumor tissue. In ductal pancreatic carcinoma, patients with an overexpression of CD44 splice variants had a worse prognosis. However, because of the small number of cases this was statistically not significant.

CONCLUSION

CD44 splice variants may have an influence on prognosis in ductal pancreatic carcinoma. However, further investigation on a larger number of patients is necessary to confirm these results.

Expression of CD44 variant proteins in adenocarcinoma of Barrett's esophagus and its relation to prognosis

BACKGROUND

None of the commonly used staging criteria accurately determine the prognosis of a patient with adenocarcinoma of Barrett's esophagus. The authors therefore assessed the expression pattern and prognostic impact of CD44 standard and CD44 isoforms CD44v4, v5,v6,v7, and v10 in adenocarcinoma of Barrett's esophagus.

METHODS

Specimens from 41 patients with adenocarcinoma of Barrett's esophagus who underwent esophageal resection were embedded in paraffin and studied immunohistochemically to determine the expression of CD44 splice variants. Histomorphologic parameters and survival time were not known at the time of the investigation.

RESULTS

Correlations between favorable clinical or histomorphologic parameters and CD44s or any of the split variants could not be established. Down-regulation of CD44s and the split variant v10 was significantly correlated with pT classification. Furthermore, down-regulation of CD44v10 and up-regulation of CD44v7 were significantly correlated with ploidy. There was a significant correlation between CD44s and split variants in tumorous and nontumorous tissue from the same patient. Down-regulation of CD44s and CD44v4 had a significant influence on prognosis in that it was associated with shortened life expectancy. Multivariate analysis revealed that the expression of CD44v4 was an independent factor in prognosis.

CONCLUSIONS

The results obtained for this small patient sample suggest that CD44v4 is a new independent prognostic parameter for adenocarcinoma of Barrett's esophagus that can be determined preoperatively by biopsy. It may therefore be helpful in planning therapy by allowing the identification of patients who may benefit from esophageal resection as well as those who are at high risk for morbidity and mortality even when the tumor is otherwise resectable. Further studies of larger patient samples are required to validate the results of the current study.

Oxytocin and vasopressin receptors in human and uterine myomas during menstrual cycle and early pregnancy

The purpose of this study was to determine the specificity and concentration of oxytocin (OT) and arginine vasopressin (AVP) binding sites in non-pregnant (NP) human and rhesus monkey endometrium, myometrium and fibromyomas, and to determine the cellular localization of OT receptor (OTR). Besides [3H]AVP, [125I]LVA, a specific VP1 receptor subtype antagonist, was used to determine vasopressin receptor (VPR) concentrations. Samples were obtained from 42 pre-menopausal and three pregnant women (5, 13 and 35 weeks gestation), and several NP and pregnant monkeys. Specificity of binding was assessed in competition experiments with unlabelled agonists and antagonists of known pharmacological potency. Cellular localization of OTR was determined by immunohistochemistry. In NP human uterine tissues, [3H]AVP was bound with higher affinity and greater binding capacity than [3H]OT, whereas in pregnant women and in NP and pregnant rhesus monkeys, uterine OT binding capacity was greater. OT and AVP binding sites discriminated very poorly between OT and AVP; [125I]LVA binding sites were more selective than [3H]AVP. Their ligand specificity and binding kinetics indicated the presence of two distinct populations of binding sites for OT and AVP in primate uterus. Endometrium of NP women and monkeys had low OTR and VPR concentrations. Myometrial and endometrial OTR and VPR were down-regulated in midcycle and in early human pregnancy, they were up-regulated in the secretory phase and second half of pregnancy. Immunoreactive OTR in NP uterus was localized in patches of myometrial muscle cells and small numbers of endometrial epithelial cells.

Carcinoma of the ampulla of vater: determinants of long-term survival in 94 resected patients

This retrospective study details 94 patients after surgical resection of carcinoma of the ampulla of Vater to determine prognostic factors. The tumour was limited to the ampulla of Vater in 32%, invaded the duodenal wall in 34%, infiltrated 2 cm or less into the pancreas in 22%, and invaded more than 2 cm into the pancreas and/or other adjacent structures in 11%. Curative resection was accomplished in 97% of cases. After exclusion of perioperative deaths the 1-, 5- and 10-year survival rates were 79.6%, 38.2%, and 31.6%, respectively with a median survival of 3.68 years. 26 patients survived more than five and 15 patients more than ten years. In an univariate analysis advanced tumour size, poor tumour grading, lymph node metastases and advanced UICC stage significantly decreased survival. Comparison of short and long survivors confirmed tumour size, lymph node status and UICC stage as significant prognostic factors. In a multivariate analysis (Cox model), only tumour size was a statistically independent predictor of prognosis. The survival probability increased with each year a patient survived after resection. When a patient had already survived five years after resection, the probability to survive another five years was 83%. Careful clinicopathologic staging is important for the prognosis after resection.

Ovarian-like stroma in an invasive mucinous cystadenocarcinoma of the pancreas positive for inhibin. A hint concerning its possible histogenesis

A female patient with a mucinous cystadenocarcinoma originating from a mucinous cystadenoma of the pancreas is presented. The cystic tumour was diagnosed 3 years before and was treated with interventional external and internal surgical drainage before radical resection was accomplished by left hemipancreatectomy. Histology showed simultaneous occurrence of mildly dysplastic and invasive malignant epithelium. Immunohistology revealed inhibin-positive cells in the ovarianlike stroma of the tumour. The demonstration of ovarian-like stroma positive for inhibin suggests that this could be a hamartoma with dispersed sex-cord stroma, which would explain the predominance of the female gender in mucinous cystic tumours of the pancreas.

[Adult giant cell hepatitis with fatal outcome. Clinicopathologic case report and reflections on pathogenesis]

The occurrence of plasmodial giant cells in the liver is probably a morphological reaction pattern with the most diverse causes. In babies and infants, these changes occur in particular in neonatal hepatitis and intrahepatic and extrahepatic bile duct atresia. Viral infections and/or autoimmune reactions are discussed etiologically in giant cell hepatitis in adults (adult gaint cell hepatitis, AGCH), which is much rarer. In some of the cases, there were conspicuously high titers against paramyxoviruses. Giant cell hepatitis can occur in the course of HIV infection. These both indicate an infectious cause. However, the disease cannot be transmitted to chimpanzees. Apart from our case, only one further case is described in the literature in which a completed hepatitis A infection could be demonstrated serologically. In addition, the titer of antinuclear antibodies was raised in our patient. This autoimmune phenomenon is probably of crucial pathogenetic significance in our patient, especially since a hepatitis A infection on its own does not afford an adequate etiological explanation for the form of chronic and active hepatitis with consecutive cirrhotic transformation observed here.

[Diagnostic and therapeutic strategies in hepatocellular adenoma]

While liver hemangioma and focal nodular hyperplasia are not considered an indication for surgery in asymptomatic patients resection has been recommended for hepatocellular adenoma because of the risk of rupture and malignant transformation. Problems arise from differential diagnosis and the appropriate surgical radicality including the indication for liver transplantation. This retrospective analysis deals with 58 patients who underwent surgery for hepatocellular adenoma: resection of different extension: n = 54, liver transplantation n = 4. In 39.6% of the patients the tumor was an incidental finding. In 62.0% of the character of the lesion was unclear prior to surgery. Tumor rupture and bleeding occurred in 17.2%, malignant transformation in 6.9%. Surgical morbidity was 27.6%, mortality 5.2% with the transplant patients alive for 1.5, 7, 9 and 10 years. Two and five years after resection 2 patients developed hepatocellular carcinoma in the liver remnant. The results confirm the indication for surgery in hepatocellular adenoma. Diagnostic approach for solid liver tumors without serum increase of tumor markers should rule out FNH and hemangioma. In all other patients surgery should be considered whenever possible with the radicality of malignant disease. Liver transplantation can be discussed even in asymptomatic patients with multiple adenoma.

Mutations of the DPC4/Smad4 gene in biliary tract carcinoma

A candidate tumor suppressor gene, DPC4, located at 18q21.1, has recently been shown to be inactivated in half of pancreatic adenocarcinomas. The close developmental relationship of the pancreas and biliary tract prompted us to determine the role of DPC4 in the multistep carcinogenesis of biliary tract carcinoma. A search for mutations in the genomic sequence of the highly conserved COOH-terminal domain of DPC4 (exons 8-11) was performed by single-strand conformational polymorphism analysis. Five of 32 (16%) primary biliary tract carcinomas had point mutations in the DPC4 sequence. Interestingly, inactivation of DPC4 was especially common in carcinomas originating from the common bile duct (four of eight specimens analyzed), suggesting an important role for DPC4 in the development of this subtype of biliary tract tumor.

Benign giant-cell tumor of the patellar ligament

We report the symptoms, clinical findings, and treatment of a patient with an extra-articular benign giant-cell tumor of the patellar ligament. Between the years 1966 and 1996 no similar case has been found to be documented by a Medline search. On palpation, a soft, mobile lesion, the size of a pigeon's egg, was felt in the lateral region of the patellar ligament. There was no set of laboratory values to determine the diagnosis. In addition, there were no typical findings in diagnostic imaging procedures and it seems that the most important fact is that the clinician is aware of this type of synovial tumor. A clear diagnosis is only possible by means of a pathological investigation. The choice of therapy for giant-cell tumors is local excision. Arthroscopy is recommended exclusively for the diagnosis and therapy of a localized intra-articular giant-cell tumor.

Benign liver tumors: differential diagnosis and indications for surgery

The differential diagnosis for hemangioma, focal nodular hyperplasia (FNH), and hepatocellular adenoma may be difficult. Reliable diagnosis is mandatory for the decision of whether to apply surgery or observation. Experience with long-term observation in nonoperated patients with hemangioma and FNH is limited. A group of 437 patients from a single institution were analyzed with regard to a diagnostic algorithm, the indications for surgery, and observation. There were 238 hemangiomas, 150 cases of FNH, 44 adenomas, and 5 mixed tumors. Of the 437 patients, 173 underwent surgery; 103 with hemangioma and 54 with FNH were observed at our own institution, whereas 117 patients underwent follow-up elsewhere or were lost. Among the operated patients with confirmed histology, a good diagnostic yield was found for a combination of ultrasonography (US), contrast (bolus)-enhanced computed tomography (CT), and labeled red blood cell (RBC) scanning: sensitivity 85.7%, specificity 100%, positive predictive value (PPV) 100%, negative predictive value (NPV) 81.8%, and accuracy 91.3%. For FNH and combination of US and CT plus cholescintigraphy showed a sensitivity 82.1%, specificity 97.1%, PPV 95.8%, NPV 84.6%, and accuracy 90.3%. Surgical mortality was 0.6%. Observation of patients with hemangioma and FNH for a median of 32 months revealed no increase in tumor size in 80% and a decrease in fewer than 7%. There was no tumor rupture and no evidence of malignant transformation. We concluded that liver hemangioma and FNH can be differentiated from adenoma with high sensitivity, specificity, and accuracy by labeled RBC scanning and cholescintigraphy in combination with US and contrast-enhanced CT. In the case of symptoms or an equivocal diagnosis with respect to adenoma or hepatocellular carcinoma, surgery can be performed with very low risk. Because in asymptomatic patients with observed hemangioma or FNH no increase of tumor size can be expected for many years, the indications for surgery must be carefully evaluated.

Medial meniscus replacement by a fat pad autograft. An experimental study in sheep

The medial meniscus in 15 sheep was replaced by a pediculated infrapatellar fat pad graft and resulted in the development of a macroscopically meniscus-like structure within 6 months. Five additional sheep with a meniscectomy were controls. Degenerative changes in the fat pad autograft were visible after one year. Osteoarthritis of the weightbearing medial compartment was detected after 6 months. A temporary protective effect on the cartilage could be attributed to the autograft, but the long term results indicated that this was not permanent. Fat is not suitable as a meniscal substitute.

Hepatitis B associated liver failure following bone marrow transplantation

BACKGROUND

Several cases have been reported showing clearance of HBsAg in chronic hepatitis B carriers due to adoptive transfer of immunity by an hepatitis B immunised bone marrow.

CASE REPORT

We report on a 27-year-old man with chronic myelocytic leukemia and asymptomatic chronic hepatitis B who received allogeneic bone marrow transplantation (BMT). The donor was his HLA identical brother with natural immunity against hepatitis B. Before BMT the donor had received an additional dose of recombinant hepatitis B vaccine. Twenty days after BMT alanine aminotransferase levels increased and graft versus host disease of the skin was observed. Elevation of liver enzymes was initially attributed to graft versus host disease of the liver and the patient received high doses of steroids in addition to standard immunosuppression. Alanine aminotransferase levels increased up to a maximum on day 52 while the HBV DNA level peaked on day 38 after BMT. A liver biopsy showed reactivation of hepatitis B and treatment with steroids was tapered down. Although alanine aminotransferase and HBV DNA levels decreased, liver function deteriorated. The patient died 130 days after BMT due to liver failure.

CONCLUSION

This report indicates that disturbance of the balance between HBV replication and immune control after BMT may result in fatal reactivation of hepatitis B. Careful monitoring, including HBV DNA level and early liver biopsy, of patients with chronic hepatitis B undergoing BMT as well as determination of the HBV immune status of the BMT donor is suggested and necessary.

[Liver transplantation in familial amyloid polyneuropathy. Case report and review of the literature]

A 59-year old male of German origin noticed exercise-independent cardiac arrhythmia two years before admission. An alanine 47 transthyretin variant of Familial Amyloid Polyneuropathy with hypertrophic cardiomyopathy, peripheral sensory-motor polyneuropathy, I, degree AV heart block was diagnosed. To diminish production and deposition of mutant transthyretin and to prevent disease progression orthotopic liver transplantation was performed. Prior to transplant the patient complained of inappetence. Postoperatively, he received a chemically defined enteral nutrition regime that was discontinued after 30 months until return of appetite and weight gain indicated marked improvement. However, a duodenal biopsy still demonstrated amyloid deposits 24 months after transplantation. Echocardiographic findings remained unchanged. Neurologic examination showed an improvement of sensory-motor polyneuropathy with regression of electromyographic changes. Only traces of variant transthyretin were detectable in plasma samples taken 12 months after the operation. During the 3 year follow-up, no additional symptoms have occurred and progression of amyloidosis was prevented. Currently, orthotopic liver transplantation is the only specific treatment to prevent progression of familial amyloid polyneuropathy.

Retroperitoneal lymphangiomyoma in an infant

Lymphangiomyomatosis (LAM) is a benign tumor-like lesion of lymphatic vessels with unknown etiology. 80 cases of LAM are presently described. So far, it appears that only women in their reproductive years seem to be affected. Here, we describe the first LAM in an 11-months-old infant with a presumably local form of LAM. This leads us to consider the possibility that this tumor-like lesion may originate from a hamartomateous malformation. The diagnosis is based on pre-operative sonography and CT, as well as on histological and immunohistochemical examination of the tumor.

[Cytokines and cytokine receptors in mouth mucosa of immune suppressed patients]

In vitro studies on epithelial cells suggest that cyclosporin (CsA) inhibits a pathway of production of IL-6, which is mediated by TNF alpha and E. coli. The aim of the present immunohistochemical study was therefore to evaluate the content and location of cytokines and cytokine receptors in the oral mucosa of 10 patients with CsA medication. Ten patients without immunosuppression served as controls. Specimens were procured during surgical treatment and processed by paraffin embedding and as cryosections. Expression of TNF alpha, IL-1 beta and IL-6-receptor was present both in the epithelial layer and the submucosal tissues, but did not differ very greatly between patients with CsA therapy and the controls. IL-6, however, displayed a positive reaction only in the control group, while it was invisible in the group of patients with CsA medication. The immunohistochemical findings of the present study suggest that there may be a lack of mucosal expression of IL-6 under CsA medication. With regard to the broad spectrum of possible effects of proinflammatory cytokines and their multiple interactions, the functional relevance of these findings merits further investigation.

Long-term outcome of hepatitis C virus infection after liver transplantation

We analyzed the long-term clinical course of 71 patients with RNA-positive hepatitis C virus (HCV) infection after liver transplantation. Patients with reinfection after transplantation for HCV-related liver disease, or de novo infection at transplantation were followed for up to 12 years. Cumulative survival for patients with HCV infection at 2, 5, and 10 years after transplantation was 67%, 62%, and 62%, respectively. It was not significantly different from that in patients transplanted for other nonmalignant diseases without HCV infection. The main factor determining long-term survival was the presence or absence of hepatocellular carcinoma (HCC) at transplantation. The 5-year survival rate for HCV patients with or without HCC was 35% versus 73%, respectively (P < .05). No deaths because of viral hepatitis of the graft were observed. Deaths in the first year after transplantation were caused by infectious complications, cardiovascular problems, or rejection; deaths after more than 12 months were exclusively because of recurrence of HCC. Biochemical and histological evidence of hepatitis was found in the majority of the patients, only 16% had normal alanine aminotransferase (ALT) values throughout. Twenty-two percent of patients complained of symptoms, with hepatitis C being the cause in 82% of these. Two patients lost their HCV-RNA for prolonged, ongoing periods of time. The severity of the posttransplantation hepatitis was unrelated to age, sex, severity of liver disease before transplantation, cold ischemic time of the graft, duration of the operation, transfusions, the number of rejection episodes, or the long-term immunosuppressive regime. Only initial short-term therapy with interleukin 2 (IL2) receptor antibodies adversely influenced inflammatory activity. Viral genotype did not influence the course of the graft hepatitis in our series. Histology showed inflammation in 88% of the biopsies and signs of fibrosis in 24%. Mean ALT values correlated with inflammation but not with fibrosis in the biopsies. Porto-portal bridging was observed in six patients, one patient developed cirrhosis within 2 years after orthotopic liver transplantation (OLT). We conclude that chronic hepatitis develops in the majority of patients with HCV infection after liver transplantation. Carrier states without significant laboratory abnormalities are observed in approximately 16%, biochemical abnormalities without symptoms are seen in 60%, and symptomatic disease develops in a quarter of the patients. The disease course closely resembles that seen in nontransplanted hepatitis C patients. It is generally mild but little over 10% of patients develop signs of fibrosis of the graft during the first decade.

The site of inhibin production in ovarian neoplasms

Inhibin, a physiological product of ovarian follicle cells, normally absent in serum of postmenopausal women, is elevated in adult granulosa cell tumours of the ovary. Recently, high serum levels of inhibin were reported in carcinomas and, surprisingly, also in Krukenberg tumours of the ovary. This study attempted to determine the site of inhibin production in primary (111 cases), metastatic (13) and secondary (10) ovarian tumours by using immunohistochemistry. Positive staining in tumour cells was encountered in all cases of sex-cord- stromal cell tumours, adult (13) and juvenile (3) granulosa cell tumours, thecofibromas (10), in a lipid cell tumour (1) and a Sertoli-Leydig cell tumour (1). Primary and secondary tumours not derived from sex-cord stroma revealed no positivity in tumour cells, but in theca-like cells in the surrounding non-neoplastic ovarian stroma. A positive reaction was not observed in non-tumour-bearing ovaries of a control group. The ovarian inhibin of postmenopausal women is derived from activated sex-cord stroma or sex-cord-stromal neoplasms. Therefore, elevated serum inhibin concentrations in women with primary or secondary ovarian neoplasms with other histogenesis seem to be due to an activation of the non-neoplastic ovarian stroma. Inhibin will fail to be a tumour marker in these cases. By contrast, it will be useful in proving sex-cord differentiation by immunohistochemistry and might be used in surveillance of malignant sex-cord derived neoplasms by serum assays.

A case of the yellow nail syndrome associated with massive chylous ascites, pleural and pericardial effusions

A 26-year-old male patient with a history of chronic peripheral lymphedema, yellowish coloured slow growing nails and pleural effusions since early childhood is described. After 23 years he developed a chylous ascites and scintigraphy with technetium-99m labeled albumin clearly demonstrated a diffuse protein loss involving the whole jejunum and ileum. Subsequent jejunal and duodenal biopsies showed the typical histological findings of intestinal lymphangiectasia thereby confirming a diffuse intestinal lymphatic damage. In addition to the gastrointestional symptoms the patient developed a pericardial effusion diagnosed by echocardiographic imaging. Dietary treatment with middle chained triglycerides and intravenous human albumin supplementation was followed by the reduction of the ascites and improvement of the peripheral lymphedema. To our knowledge this is the first description of the yellow nail syndrome associated with a diffuse lymphangiectasia involving the whole small bowel.

Surgical treatment in proximal bile duct cancer. A single-center experience

OBJECTIVES

The authors evaluated the experience and results of a single center in surgical treatment of proximal bile duct carcinoma.

SUMMARY BACKGROUND DATA

Whenever feasible, surgery is the appropriate treatment in proximal bile duct carcinoma. To improve survival rates and with special regard to liver transplantation, the extent of surgical radicalness remains an open issue.

PATIENTS AND METHODS

Retrospective analysis of 249 patients who underwent surgery for proximal bile duct carcinoma via the following procedures: resection (n = 125), liver transplantation (n = 25), and exploratory laparotomy (n = 99). Survival rates were calculated according to the Kaplan-Meier method, uni- and multivariate analysis of prognostic factors, and log rank test (p < 0.05).

RESULTS

Survival rates after resection and liver transplantation are correlated with international Union Against Cancer (UICC) tumor stage (resection: overall 5-year, 27.1%; stage I and II, 41.9%; stage IV, 20.7%; liver transplantation: overall 5-year, 17.1%; stage I and II, 37.8%; stage IV, 5.8%). Significant univariate prognostic factors for survival after liver resection were lymph node involvement (N category), tumor stage, tumor-free margins, and vascular invasion; for transplantation, they were local tumor extent, N category, tumor stage, and infiltration of liver parenchyma. For resection and transplantation, a multivariate analysis showed prognostic significance of tumor stage and tumor-free margins.

CONCLUSION

Resection remains the treatment of choice in proximal bile duct carcinoma. Whenever possible, decisions about resectability should be made during laparotomy. With regard to the observation of long-term survivors, liver transplantation still can be justified in selected patients with stage II carcinoma. It is unknown whether more radical procedures, such as liver transplantation combined with multivisceral resections, will lead to better outcome in advanced stages. With regard to palliation, surgical drainage of the biliary system performed as hepatojejunostomy can be recommended.

[HPV-Dna hybridization allows differentiation of cervix lesions in PAP III cytologic findings]

A repeat Pap smear as well as a smear for human papillomavirus (HPV)-DNA detection with the Hybrid Capture assay (Digene diagnostics/Murex, Burgwedel) were collected from 30 women with Pap smears recurrently classified as "Pap III". All patients underwent colposcopy and histological assessment. The repeat Pap smear distinguished correctly in 15, colposcopy in 19 and the Hybrid Capture assay in 27 cases between neoplastic and inflammatory lesions. All invasive neoplasms were positive for HPV-DNA. HPV typing seems to be a suitable non-invasive method for early selection of cervical lesions that need histological assessment in women with smears classified as "Pap III".

[Electrosurgical loop excision of the transformation zone in treatment of cervix neoplasia]

100 patients with CIN on referral Pap and with a distinct cervical lesion on colposcopy were treated with the loop electrosurgical excisional procedure (LEEP). Compared with 60 women who underwent cold-knife conization, the number of lesions classified as CIN-3 or more did not differ between the two groups (53% vs 53.3%). Severe haemorrhage and cervical stenosis were only observed after conization. Involvement of resection margins was found in 18% of all LEEP and in 16.7% of all cone biopsies. 3-12 months after LEEP the rate of cytologically and biopsy proven neoplasia was 2.2%. LEEP is a safe and effective procedure and should be used as the treatment of choice for distinct cervical lesions.

Hepatic tissue culture model for study of host-parasite interactions in alveolar echinococcosis

An in vitro model for growth and differentiation of the metacestode tissue of the tapeworm Echinococcus multilocularis is described. This model simulates the organotropism of the parasite toward the liver of the intermediate host. In the presence of collagen-embedded primary hepatocytes from rats and humans, which can be kept in culture for 2 to 3 months, the parasitic vesicles grew by exogenous budding and multiplied about 12-fold within 3 weeks. In contrast, without the hepatocytes, the metacestodes rapidly degenerated. Development of protoscolices was seen only in the presence of rat hepatocytes but not in coculture of the metacestodes with hepatocytes of human origin, thus reflecting the in vivo situation during infection of rodents and in alveolar echinococcosis in humans. The experiments indicated that growth of the metacestodes and development of protoscolices depended on soluble low-molecular-weight factors released by the hepatocytes. The in vitro-grown metacestodes did not differ morphologically from the larvae found in infected intermediate hosts, and their infectivity was completely maintained. This report describes the first in vitro model of alveolar echinococcosis and will be the basis for future studies on host-parasite interactions of this important zoonosis.

Fatal pulmonary embolization after reaming of the femoral medullary cavity in sclerosing osteomyelitis: a case report

Reaming of the medullary may be used in cases of sclerosing osteomyelitis (type Garré), refractory to other methods. We report a case of fatal intraoperative complication related to this procedure. An otherwise healthy young patient died during reaming using a machine-driven reamer of the femoral medullary canal due to pulmonary bone embolism. The technique and the indication for this procedure as well as the intraoperative monitoring options are discussed.

Famciclovir treatment of hepatitis B virus recurrence after liver transplantation: a pilot study

Despite hepatitis B immunoprophylaxis hepatitis B virus (HBV) recurrence is a frequent and often fatal complication after orthotopic liver transplantation (OLT). The purine nucleoside analogues penciclovir and its oral form famciclovir (FCV) proved to be well tolerated and effective against herpes simplex and zoster virus infections. In addition, an effective reduction of duck and human HBV replication was observed. Therefore, we conducted an uncontrolled pilot study of famciclovir in patients with HBV recurrence after OLT. Twelve patients have received famciclovir for at least 3 months in an open compassionate-use protocol. FCV was administered orally 500 mg three times a day for all patients (except one patient who was started on 750 mg three times a day for the first 2 weeks). Immediately after starting famciclovir, serum HBV DNA levels declined in 9 of 12 patients (75%) with a mean reduction from baseline levels of 80% after 3 months, 90% after 6 months, and > 95% after 12 months of treatment. With continued treatment, 5 of these 9 patients became negative by conventional hybridization assay, and in one of these HBV DNA became undetectable by polymerase chain reaction (PCR) 28 weeks after the start of treatment. Three patients showed no (sustained) reduction in HBV DNA after at least 3 months of treatment; therefore, FCV was stopped. Latest serum alanine aminotransferase (ALT) levels decreased in 6 of 12 patients (50%) with a median decrease of 80% (range, 40%-95%) in comparison to pretreatment ALT values. ALT levels normalized in 4 patients (33%). One patient died due to sepsis and peritonitis in week 13 of treatment. This event was not related to FCV. No clinically significant side effects were noticed in any patient. The oral nucleoside analog famciclovir reduces HBV replication and transaminase levels in patients with HBV recurrence after liver transplantation. Because long-term FCV treatment is well tolerated, famciclovir appears to be a promising antiviral strategy in the treatment of HBV in immunocompromised patients.

Favourable prognosis of cystadeno- over adenocarcinoma of the pancreas after curative resection

This report details nine patients after curative surgical resection of histologically proven mucinous cystadenocarcinoma of the pancreas and compares the prognosis with ductal adenocarcinomas. Cystadenocarcinomas represented 2.1% (10/ 466) of a total of 466 patients who underwent surgical exploration and 5.5%, of all curatively resected carcinomas of the exocrine pancreas at Hanover Medical School from 1971 to 1994. Forty percent of adenocarcinomas and 90% of cystadenocarcinomas were resectable. A curative R0 resection was possible in all patients with cystadenocarcinoma and 85 % with adenocarcinoma. Six of the patients with cystadenocarcinoma were female and three were male. Their median age was 54 +/- 12 years (range: 44 to 81 years). Four cystic neoplasms were located in the head, one in the head and body, three in the tail, and one in the body and tail of the pancreas. There was no hospital mortality in this group. The prognosis after resection of cystadenocarcinomas was significantly better compared to ductal adenocarcinomas of the pancreas. The Kaplan-Meier survival was 89% vs 52% after 1 year, and 56% vs 13% at 5 years. Our results indicate the favourable prognosis of cystadeno- over ductal adenocarcinomas of the pancreas in a cohort of patients with curative tumour resection.

Auxiliary liver transplantation: regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure--a multicenter European study

Auxiliary liver transplantation (LT) is a special procedure of LT which could be proposed to patients with fulminant hepatic failure (FHF) and has for aim that complete regeneration of the native liver (NL) left in place will allow the graft recipient to resume normal liver function after allograft withdrawal. We report 30 cases of auxiliary LT performed for FHF in 12 European centers. Twenty-five of 30 patients were younger than 50 years. The cause of FHF was hepatitis A virus (HAV) in 4 patients, hepatitis B virus (HBV) in 7, paracetamol overdose in 5, ecstasy in 2, hepatotoxic drugs in 4, autoimmune hepatitis in 2, liver lesions of preeclampsia in 1 and unknown in 5. A postoperative, both clinical and histological follow-up of more than 3 weeks was obtained in 22 patients, enabling us to look for indicators predictive of NL regeneration and outcome. Histological changes observed in the NL included complete regeneration in 68%, incomplete regeneration with obvious fibrous sequelae in 14% and severe liver fibrosis or cirrhosis in 18%, of the 22 patients studied. The percentage and distribution of necrosis observed in tissue samples of the NL at the time of transplantation was not related to the final outcome. Complete NL regeneration was observed in 15 patients, out of whom 14 were younger than 40 years. Patients with complete regeneration were mainly affected by FHF due to HAV, HBV, or paracetamol overdose. After a follow-up of 18/11 (mean/median) months (range, 3 to 67 months), 19 of the 30 patients (63%) survived and 13 of them (68%), i.e., 43% of the 30 patients, had resumed normal NL function, with interrupted immunosuppression, the ultimate goal of emergency auxiliary LT. We conclude that, in patients with FHF, auxiliary LT is a procedure feasible in a number of centers and is associated with a complete regeneration capability of the NL in a majority of survivors, especially in those younger than 40 years. Confirmation of these encouraging preliminary results by large-scale prospective studies is required.

Characterization of the continuous cell line HepT1 derived from a human hepatoblastoma

Hepatoblastoma is the most common malignant pediatric liver tumor. The molecular mechanisms involved in the pathogenesis of hepatoblastoma are unknown. Cell lines can be valuable tools in the study of tumor biology, but only few hepatoblastoma cell lines have been established. We explanted tumor tissue from human hepatoblastomas to generate cell lines. A continuous cell line (HepT1) was established from a human hepatoblastoma with predominant embryonal differentiation. The HepT1 cell line was characterized by immunohistochemistry, electron microscopy, cytogenetics, and molecular genetic analysis. In addition, the cultured cells were xenografted into nude mice and the resulting tumors compared with the original tumor. The cells grew in epithelial clusters, and expressed cytokeratins and alpha-fetoprotein. Injection of HepT1 cells into nude mice gave rise to serially transplantable subcutaneous tumors. The cell line as well as the xenotransplants displayed the phenotypic and genotypic characteristics of the primary tumor. Ultrastructural analysis demonstrated desmosomal junctions and the formation of bile canaliculi. Cytogenetic analysis showed a near tetraploid karyotype with structural and numerical aberrations of chromosomes 1p, 6, 9, 11q, 13q, 15p, and 20 and both single and double minute chromosomes. In PCR-based microsatellite analysis of chromosome arm 11p, a loss of heterozygosity at all informative loci including the WT-1 and IGF2 genes was detected. Intratumoral erythropoiesis, a characteristic feature of hepatoblastomas, was present in the primary tumor as well as in HepT1 xenotransplants. We therefore studied the expression of erythropoietic cytokines in these cells and found both erythropoietin and stem cell factor. The HepT1 cell line displays characteristic cellular and molecular features of hepatoblastoma and we believe it will be a valuable tool for studies on the biology and pathogenesis of hepatoblastoma as well as on the differentiation of hepatocyte progenitor cells.

Identification of a differentiation-inducible promoter in the E7 open reading frame of human papillomavirus type 16 (HPV-16) in raft cultures of a new cell line containing high copy numbers of episomal HPV-16 DNA

Gene expression of human papillomaviruses (HPV) is tightly linked to differentiation processes within the pluristratified epithelium. To analyze changes in the transcription pattern of HPV-16 during epithelial cell differentiation, we established a permanently growing HPV-16 positive cell line, designated KG, from a vulvar intraepithelial neoplasm. KG cells of early passages harbored multiple copies of the HPV-16 DNA as episomes and were able to form a stratified epithelium in an organotypic raft culture system. Analysis of viral gene expression revealed the known transcription pattern of the early region of HPV-16 with the exception of a so far undefined mRNA class with start sites in the E7 open reading frame. Quantitative analysis of primer extension experiments with RNA from KG cells grown in monolayer and raft culture showed a strong induction of this transcript in differentiated KG cells, whereas the level of the mRNAs initiated at the early promoter P97 remained almost constant. Primer extension analyses with four different primers and direct sequencing of the extension product revealed that the differentiation-inducible transcript initiated at a novel promoter with a major start site around nucleotide position 670 (P670) in the E7 open reading frame of HPV-16. Sequence analysis of cDNAs derived from RNA of KG cells grown in raft culture suggested that the transcripts initiated at P670 have a coding potential for an E1E4 fusion protein and for the E5 protein.

[Solitary fibrous tumor of the epicardium]

A giant Solitary Fibrous Tumor (SFT) arising in the pericardium is described. A 53 year old woman was suspected to have a lung tumor and thoracotomy was performed. Intraoperatively the child-head sized mass was found to be localized in the pericardial sac. The histopathological interpretation of a small wedge-biopsy was 'endothelioma of uncertain malignancy' and heart-transplantation was performed two months later. The patient died of postoperative infection. Post mortem examination could exclude tumor rest or metastasis. The explanted heart revealed a large bulk of 2800 grams arising from the epicardium of the left chamber and enveloping the heart without invading the underlying myocardium. The histopathological pattern varied between cell-rich and -poor fibromatous areas and well capillarized endothelioma-like zones. Immunohistochemistry revealed positive reactions with monoclonal antibodies against Vimentin and CD 34 and no reactions against Cytokeratins and Faktor VIII. This pattern was confirmed in 7 SFT's of the pleura from our archives. A second control group of 7 mesotheliomas was positive for cytokeratins and vimentin but not for CD 34 and Faktor VIII. Diagnosis of SFT might be difficult because of its variability in histopathology, sometimes mimicking a hemangiopericytoma or endothelioma. Recent reports of tumor localizations devoiding serosal surfaces illustrate the diagnostic and histogenetic dilemma of this tumor. The differentiation of SFT from mesothelioma and endothelioma can be achieved by immunophenotyping including CD 34.