Abstract P2-05-12: The ASCO-recommended prognostic factors uPA/PAI-1 in a multicenter cohort study (PiA)

Introduction

The PiA-study (Prognostic assessment in routine Application, NCT 01592825) was designed as a representative cohort of breast cancer patients to estimate the proportions of traditional and modern prognostic factors. The ASCO-recommended biomarkers uPA (urokinase-type plasminogen activator) and its inhibitor PAI-1 were used for biological risk assessment particularly for intermediate risk breast cancer patients and disease-free survival of the patients after 5 yrs of follow-up (F/U) was calculated.

Material & Methods

Between 2009 and 2011, 1,074 non-metastasized, primarily operated breast cancer patients from six centers in Germany were included. From 815 patients, fresh frozen tissue was obtained and processed for central testing uPA/PAI-1 by ELISA (FEMTELLE®, Sekisui Diagnostics GmbH). Low uPA/PAI-1 status is defined by uPA and PAI-1 concentrations below the published cut-offs, high status means one or both were higher than the corresponding cut-offs. Tumor characteristics were based on local pathology. The centers had to follow the national guidelines. In low-risk patients, adjuvant chemotherapy was spared. The median F/U is 56 months (range 0-78).

Results

In the total cohort of 1,074 patients, 166 had G1- and 237 had G3-tumors. Of the 671 patients with a G2-tumor, the following were allocated to the high-risk group: node-positive (n=371), younger than 35 yrs (n=17), and triple-negative (TN) or HER2-positive (n=118). For 253 tumors of the remaining 355 patients with an intermediate risk of recurrence (pN0, G2, HR positive, HER2-negative, ≥35 yrs), uPA/PAI-1 status was available. 126 (49.8%) were allocated to the low-risk group, one patient had a recurrence. At 5 yrs, in the total cohort 90.6% (95% CI, 89.5-91.7) of the patients were free of invasive disease. Of 114 HER2-positive tumors, 94 (82.4 %) had a high uPA/PAI-1 status, only one of the 38 HR negative/HER2 positive tumors had a low uPA/PAI-1 status. In the TN group, the majority of tumors had a high uPA/PAI-1 status (66 of 81; 81.5 %). In 30 patients lymph nodes were involved, 18.5% (n=15) had a low uPA/PAI-1 status, one event was detected. In N pos. patients with an high uPA/PAI-1 6 events were observed.

Conclusion

Testing for uPA/PAI-1 in the daily routine is feasible, fresh frozen tissue has been prepared from 76% of the tumors of the recruited patients, 37% of them had a low risk status. Using uPA/PAI-1, about half of the node-negative patients with an intermediate risk of recurrence were allocated to a group with an extremely low risk of recurrence and thus chemotherapy could be spared. Also in node-positive disease, uPA/PAI-1 has a prognostic impact.

Tab 1: Proportion of the subgroups according to IHC, grading and uPA/PAI-1-statusTumor typetotallow uPA/PAI-1 statushigh uPA/PAI-1 statusn=815 (100%)n=304 (37%)n=511 (63%)Luminal A-like tumors:HRpos., HER2neg., G1, G2515 (63.2%)240 (78.9%)275 (53.9%)Luminal B/HER2-negative-like tumors:HRpos., HER2neg., G3104 (12.8%)29 (9.5%)75 (14.7%)Luminal B/HER2-positive-like tumors:HR pos., HER2 pos., all grades77 (9.4%)19 (6.2%)58 (11.4%)HER2-positive (nonluminal) - like tumors:HRneg., HER2pos., all grades38 (4.7%)1 (0.3%)37 (7.3%)TN tumors:HRneg., HER2neg., all grades81 (9.9%)15 (4.9%)66 (12.9%)

Citation Format: Vetter M, Hartung C, Hanf V, Lantzsch T, Uleer C, Peschel S, John J, Buchmann J, Bürrig K-F, Weigert E, Thomssen C, Kantelhardt EJ. The ASCO-recommended prognostic factors uPA/PAI-1 in a multicenter cohort study (PiA) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-12.

[Diagnostic and interventional endoscopy in gastroenterology : from high-resolution chips and procedures for endoscopic resection to NOTES]

In the past 10 years endoscopic diagnostics has benefited from technologies such as big chips, high-definition television (HDTV) and narrow band imaging (NBI). Video capsule endoscopy and double balloon enteroscopy have facilitated visualization of the entire small bowel. A number of studies on mucosal Barrett's and gastric cancers could prove that endoscopic mucosal resection (EMR) is oncologically equivalent to surgical resection when certain criteria are respected. However, EMR is less invasive and carries a substantially lower complication risk and mortality compared to surgery. Endoscopic submucosal dissection (ESD) facilitates en bloc resection with thorough histopathologic evaluation of the specimen, e.g. for mucosal lesions in the stomach and rectum. Endosonography (EUS) guided transgastric necrosectomy using a flexible gastroscope has set a milestone in the treatment of infected pancreatic necroses and has replaced open surgery in many centers. Natural orifice transluminal endoscopic surgery (NOTES) uses natural body openings as minimally invasive access to the abdomen and mediastinum. Interventional GI endoscopists and minimally invasive surgeons have profited from these innovations in micromechanics and microelectronics.

Brain amino acid abnormalities in kidney disease and diabetes mellitus

The present postmortem study examines whether specific amino acid abnormalities associated with renal diseases or diabetes mellitus in animal experiments and on clinical examination may also be found in human brain samples obtained at clinical autopsies. The material includes 12 deceased with renal insufficiency, 23 deceased with diabetes mellitus and 26 control cases with lethal cardiovascular diseases (without a history of hepatic, renal or metabolic disturbances). The autopsy and clinical records were retrospectively analyzed for age, sex, postmortem delay, cause of death, substantial preexisting diseases and histological findings. The analysis of free amino acid concentrations in human brain specimens was performed applying a Beckman amino acid analyzer. The results were evaluated using the U-test according to Mann, Willcox and Whitney. A P-value less than 0.05 was considered to be significantly different. Differences of amino acid concentrations attributable to sex, age and postmortem delay were not significant. The comparison of postmortem amino acid concentrations in the brains of patients with diabetes mellitus and controls did not reveal relevant changes. However, the patients with renal diseases, as compared to controls, showed a significant cerebral increase of urea, phenylethanolamine and gamma-aminobutyric acid. Thus, the postmortem amino acid analysis may contribute to the understanding of pathophysiological mechanisms of uremic encephalopathy and may supplement the conventional postmortem morphological diagnosis in kidney diseases by indication of functional impairment.

[Primary malignant melanoma of the uterine cervix. Report of two cases and review of the literature]

The manifestation of a malignant melanoma in the uterus is very rare, more often it is the result of metastasis rather than a primary tumor. A malignant melanoma at this site can originate either from melanocytic elements within the cervical epithelium or from the cervical stroma. We report on two cases of primary malignant melanoma of the uterine cervix and compare them with other cases from the literature.

[Gangliocytic paraganglioma of the ampulla of Vater]

A case of a bleeding duodenal gangliocytic paraganglioma (GPG) of the Papilla Vateri is reported. The 47 year old patient was treated successfully by partial pancreaticoduodenectomy. Histologically the GPG is characterized by three types of cells: epitheloid cells, ganglion-like cells and spindle cells. So far 81 cases are reported in the literature. Most cases of GPGs are benign, metastasis or recurrence is possible. This case showed an infiltrative growth pattern indicating the true neoplastic nature of this tumor.

[Primary osteosarcoma of the liver. Case report and literature review]

Primary sarcomas of the liver are rare. Most of them are angiosarcomas often related to exposure to thorotrast or polyvinyl chloride. We report a case of primary osteosarcoma of the liver in a 72-year-old man and compare it with the seven cases from the literature

[Arterial wall texture after uncomplicated endarterectomy]

Recanalisation of the carotid sinus is one of the most frequently performed vascular interventions; endarterectomy of the coronary arteries is an auxiliary measure accompanying aortocoronary bypass. Enucleation of the sclerotic plaque is followed by reconstruction of the intima and by rapid smoothing over of the "steps" along the side of the recanalised segment by proliferation of smooth muscle cells from the remaining media. The thinner the residual media, the thicker grows the neointima. Occasionally elastic lamellae reminiscent of a lamina elastica interna are formed close to the lumen. Moreover, in some cases renewed formation of the characteristic intimal spur (fibrotic ridge) is seen at the carotid sinus inlet, a sign of continued irregularity of blood flow postoperatively. In contrast, no focal lesions are generally observed in recanalised segments in the coronary arteries. New sclerotic pads that occur in the late phase bear a morphological resemblance to those in operated restenoses. The distribution of these pads is largely congruent with that of the sclerotic plaques in non-operated cervical arteries. Thus, even when recanalisation of the carotid sinus is uncomplicated, reparative processes are followed by the reformation of sclerotic pads, largely determined by haemodynamic factors. In the coronary arteries, concentric rather than focal sclerotic lesions predominate.

Sterilisation of canine anterior cruciate allografts by gamma irradiation in argon. Mechanical and neurohistological properties retained one year after transplantation

Bone-ACL-bone allograft transplantation is a potential solution to the problem of reconstruction of the anterior cruciate ligament (ACL), but sterilisation by gamma irradiation or ethylene oxide causes degradation of the graft. We have studied the biomechanical and histological properties of deep-frozen canine bone-ACL-bone allografts sterilised by gamma irradiation (2.5 Mrad) under argon gas protection. Particular attention was paid to their collagen structure and neuroanatomy compared with those of non-irradiated allografts. We used 60 skeletally mature foxhounds. In 30 animals one ACL was replaced by an irradiated allograft and in the other 30 a non-irradiated graft was used. In both groups the graft was augmented by a Kennedy Ligament Augmentation Device. Examination of the allografts at 3, 6 and 12 months after implantation included mechanical testing, histology, collagen morphometry, neuroanatomical morphology (silver and gold chloride stain) and studies of the microvasculature (modified Spalteholz technique). At 12 months the irradiated ACL allografts failed at a mean maximum load of 718.3 N, 63.8% of the strength of the normal canine ACL. The non-irradiated allografts failed at 780.1 N, 69.1% of normal. All the allografts showed a well-orientated collagen structure one year after transplantation and there was no difference between the irradiated grafts and the others. The silver staining technique demonstrated Golgi tendon organs and free nerve endings within both groups of allografts. As in the normal ACL these structures were most commonly found near the surface of the graft and at its bony attachments. At 12 months the irradiated allografts showed slight hypervascularity compared with the non-irradiated grafts.(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetic resonance imaging (MRI) and arthroscopy in the detection of meniscal degenerations: correlation of arthroscopy and MRI with histology findings

In a prospective double-blind study, the capability of magnetic resonance imaging (MRI) and arthroscopy in the detection and grading of meniscal degenerations is evaluated by correlating MRI findings and arthroscopic diagnoses with a histologic grading model. In 82.8% of our results, grading based on MRI studies corresponded with the histologic grading classification. In 12 instances a meniscal degeneration verified at light microscopy was not detected at MRI, whereas in 15 cases tomography yielded a false-positive result. The overall accuracy was calculated to be 0.93 with a specificity of 0.79 and a sensitivity of 0.96. Concerning the evaluation of meniscal degenerations, MRI provides a positive predictive value of 0.95 and a negative predictive value of 0.82. Compared with the diagnostic specificity of the anterior and posterior zones, that of the intermediate segment of the meniscus is significantly reduced (p < 0.001). At arthroscopy, meniscal degenerations were diagnosed with an overall accuracy of 38.8%, a sensitivity of 27.5%, and a specificity of 75.5%. In 80 cases of grade 3 abnormalities, five false-negative diagnoses were made initially. These results suggest that MRI offers a valuable diagnostic potential providing reliable information about the internal consistency of the meniscus complementary to diagnostic arthroscopy.

Microvascular anastomosis of interpositional vein grafts with sutures and a new mechanical device--a histologic and scanning electron microscopic study

In an experimental study, a new mechanical device for microvascular anastomosis was compared with suture anastomosis. In 14 rabbits, seven end-to-end and seven end-to-side anastomoses of the jugular vein to interpositional vein grafts were done with a ring-pin device and by the conventional suture method. There was no significant difference between the patency rates of mechanical and suture anastomoses. The completion of mechanical anastomoses took one-third the time required for suture anastomoses. After 10 days, histologic and scanning electron microscopic examination revealed an uneventful reparative process at the anastomotic site with media atrophy and a continuous endothelial layer. At 4 weeks, occasional foreign body giant cells were seen between the polyethylene rings and surrounding connective tissue. The study confirms that the ring-pin device is safe and provides a faster way to do microvascular anastomoses than by suturing.

The morphology of the carotid artery after uncomplicated endarterectomy

Endarterectomy of the carotid sinus is one of the most frequent vascular operations. Until now, however, few details have been reported on the characteristic features of the disobliteration site during uncomplicated postoperative progress. Full histological and morphometric investigation was performed on the bifurcation of the carotid artery of 23 autopsies with previous endarterectomy, in some cases on both sides. The postoperative interval was of up to 10 years duration (early phase up to 6 months postoperatively 15x, late phase 14x). The findings were compared with surgical specimens of 9 restenoses. The reconstruction of an inner layer (so-called neointima) and the smoothing of the marginal layers of the disobliteration site takes place rapidly through the proliferation of smooth muscle cells from the remaining portions of the media. The narrower this remaining portion of the media, the greater the width achieved by these "neo-intima" (p < 0.05). There is occasional formation of elastic lamellae, similar to an elastic internal lamina, close to the luminal surface. Furthermore, in some cases the reconstruction of an intimal thickening (fibrous ridge) characteristic of the carotid bifurcation was observed at the entrance to the carotid sinus; this can be assessed as an indication that flow irregularities apparently persist postoperatively at this location. In the late phase, intramural calcification and new sclerotic plaques usually occur; these plaques closely resemble those of surgically removed restenoses. The distribution of plaques of this kind is largely congruent with the pattern of plaques in asymptomatically diseased carotid arteries. Thus, following endarterectomy in the carotid sinus, sclerotic plaques recur even during an uncomplicated course subsequent to reparative processes; as with the natural history of sclerotic plaques at the carotid bifurcation, this recurrence seems to be largely determined by hemodynamic factors.

[Rhabdomyosarcoma of the liver in adulthood. Case report and review of the literature]

Primary sarcomas of the liver are rare, and hepatic rhabdomyosarcomas are usually confined to early childhood. They are mostly related to large bile ducts of the liver hilus. We report a case of primary hepatic pleomorphic rhabdomyosarcoma in a 69-year-old man.

[Homologous cruciate ligament transplantation as intra-articular ligament replacement]

A multiplicity of surgical operations have been developed in an attempt to achieve satisfactory function after ACL repair. None of these procedures have been able to duplicate the fiber organization, attachment site anatomy, vascularity, or function of the ACL. 29 foxhounds received a deep frozen bone-ACL-bone allograft and a ligament augmentation device (LAD). Biomechanical, microvascular, and histological changes were evaluated 3, 6 and 12 months following implantation. The maximum load of the allograft/LADs were 34.3% (387.2 N) after 3 months, 49.3% (556.6 N) after 6 months and 61.1% (689.8 N) after a year. The maximal load was 69.1% (780 N). In general, after 6 months the allografts showed a normal collagen orientation. The allografts demonstrated no evidence of infection or immune reaction. No bone ingrowth into the LAD was observed. Polarized light microscopy and PAS-staining showed that the new bone/ligament substance interface had intact fiber orientation at the area of ligament insertion. Microvascular examination using Spalteholtz-technique revealed neovascularization and the importance of infrapatellar fat pad for the nourishment of the ACL-allografts.

[Ovarian cancer in ovarian remnant syndrome?]

We report on a malignant pelvic tumour in a 69-year old woman, whose uterus and adnexa had been removed 22 years ago because of endometriosis. Clinical and pathological findings pointed to an ovarian cancer in an ovarian remnant syndrome. In a case of a carcinoma, it is difficult to furnish proof of an ovarian remnant syndrome. Differential diagnoses, especially the ureteral adenocarcinoma, are discussed.

Acute cholecystitis: a complication in severely injured intensive care patients

Acute cholecystitis is an often unrecognized and potentially life-threatening complication seen among ICU patients with multiple injury. To investigate the epidemiology of this entity and to evaluate significant etiologic precursors, a prospective clinical and sonographic study was performed in 45 consecutive patients (mean age, 29 years) treated for multiple trauma (mean ISS, 27) in the ICU. Eight of 45 patients developed a cholecystitis during intensive care treatment (18%). Six patients recovered with conservative therapy; in two instances a cholecystectomy was necessary. There was no mortality as a result of cholecystitis. A significant relationship between the severity of the initial trauma (p less than 0.05), the number of blood transfusions (p less than 0.01), and the incidence of acute cholecystitis was found. Other factors such as prolonged shock, respiratory failure, or parenteral alimentation were less prevalent and were not temporally related to the onset of the disease. All patients had large amounts of narcotics administered over a prolonged period, so that narcotic-induced biliary stasis appeared to be another eminent factor involved in the genesis of posttraumatic cholecystitis. Our results lead to the conclusion that acute cholecystitis occurs with an unexpectedly high incidence and that a high remission rate can be expected following conservative treatment provided that appropriate serial ultrasound examinations are performed.

Anterior cruciate ligament allograft transplantation for intraarticular ligamentous reconstruction

A multiplicity of surgical operations have been developed in an attempt to achieve satisfactory function after anterior cruciate ligament (ACL) repair. None of these procedures have been able to reproduce the fiber organization anatomy of attachment site, vascularity, or function of the ACL. Twenty-nine foxhounds received a deep-frozen bone-ACL-bone allograft and a ligament augmentation device (LAD). Biomechanical, microvascular, and histological changes were evaluated 3, 6, and 12 months following implantation. The maximum loads of the allograft/LADs were 34.3% (387.2 N) after 3 months, 49.3% (556.6 N) after 6 months, and 61.1% (698.8 N) after a year. The maximum load was 69.1% (780 N). In general, after 6 months the allografts showed normal collagen orientation. The allografts demonstrated no evidence of infection or immune reaction. No bone ingrowth into the LAD was observed. Polarized light microscopy and periodic acid-schiff staining showed that the new bone-ligament substance interface had intact fiber orientation at the area of the ligament insertion. Microvascular examination using the Spalteholtz technique revealed revascularization and the importance of an infrapatellar fat pad for the nourishment of ACL allografts.

The endothelium of advanced arteriosclerotic plaques in humans

The functional morphology of the endothelial cells (ECs) covering advanced but uncomplicated sclerotic plaques in humans was studied in carotid endarterectomy specimens and in coronary arteries from hearts explanted because of advanced ischemic heart disease. The endothelial layer was nearly always intact, and the endothelial patterns reflected the anticipated local flow patterns along the narrowed arteries, with the majority of flow irregularities downstream from the stenosis. Large (giant) ECs (defined as ECs with a surface area of greater than or equal to 800 microns 2) were frequently found on the plaque surface, probably indicating accelerated EC senescence attributable to sustained nondenuding injury in the region of disturbed flow. Ultrastructurally, activation of ECs with hyperplasia of organelles was frequent. In addition, as a sign of immunological activation, about 5% of ECs express class II antigens (HLA-DR and rarely focal HLA-DQ), as demonstrated by double immunofluorescence with von Willebrand factor to identify the ECs. EC activation may be responsible for adherence to the intact luminal surface by activated platelets and monocytes, which were always present (in contrast with nonsclerotic artery segments). Furthermore, an increase in myo-endothelial contacts to subendothelial modified smooth muscle cells was a regular feature of the sclerotic lesions; this feature represents an unknown process of EC and smooth muscle cell interaction in the sclerotic lesion and may be a compensatory process for EC control of smooth muscle cell proliferation. In advanced plaques the ECs are altered without denudation but with changed properties, which may contribute to plaque growth and which are consistent with the postulated EC dysfunction in the pathogenesis of arteriosclerotic lesions.

The endothelium of advanced arteriosclerotic plaques in humans

The functional morphology of the endothelial cells (ECs) covering advanced but uncomplicated sclerotic plaques in humans was studied in carotid endarterectomy specimens and in coronary arteries from hearts explanted because of advanced ischemic heart disease. The endothelial layer was nearly always intact, and the endothelial patterns reflected the anticipated local flow patterns along the narrowed arteries, with the majority of flow irregularities downstream from the stenosis. Large (giant) ECs (defined as ECs with a surface area of greater than or equal to 800 microns 2) were frequently found on the plaque surface, probably indicating accelerated EC senescence attributable to sustained nondenuding injury in the region of disturbed flow. Ultrastructurally, activation of ECs with hyperplasia of organelles was frequent. In addition, as a sign of immunological activation, about 5% of ECs express class II antigens (HLA-DR and rarely focal HLA-DQ), as demonstrated by double immunofluorescence with von Willebrand factor to identify the ECs. EC activation may be responsible for adherence to the intact luminal surface by activated platelets and monocytes, which were always present (in contrast with nonsclerotic artery segments). Furthermore, an increase in myo-endothelial contacts to subendothelial modified smooth muscle cells was a regular feature of the sclerotic lesions; this feature represents an unknown process of EC and smooth muscle cell interaction in the sclerotic lesion and may be a compensatory process for EC control of smooth muscle cell proliferation. In advanced plaques the ECs are altered without denudation but with changed properties, which may contribute to plaque growth and which are consistent with the postulated EC dysfunction in the pathogenesis of arteriosclerotic lesions.

Accuracy of imaging modalities in staging the local extent of prostate cancer

In this study, none of the evaluated clinical staging methods was found to predict reliably the presence or absence of extracapsular growth of histologically proved carcinoma of the prostate. In this respect, digital rectal examination, transrectal ultrasound, CT, and MR imaging cannot contribute to treatment decisions in localized prostate cancer. Further studies are under way to determine the value of 7.5-MHz scanners in transrectal ultrasound and high-resolution surface coils in MR imaging.

Morphological, immunocytochemical and growth characteristics of three human glioblastomas established in vitro

The human glioblastoma-derived cell lines 86HG-39, 87HG-28 and 87HG-31, used for the production of monoclonal antibodies (mAbs) against glioma-associated antigens (GAA), were characterized in terms of morphology, growth behaviour, chromosomes and antigen expression. In the primary tumours, differential expression of glial fibrillary acidic protein, S100 protein, Leu-7 and GAA as defined by mAbs MUC 2-39, MUC 2-63 and MUC 8-22 was demonstrated. Receptors for epidermal growth factor (EGFr) and nerve growth factor (NGFr) were found in many cells in short-term cultures, but the transferrin receptor (Tr) was found in only a few cells of 87HG-28. In permanent cell lines, differentiation antigens and EGFr decreased and Tr increased markedly. NGFr and GAA remained stable. Transplantation tumours of 86HG-39 were partly positive for Tr and GAA. Chromosomal analysis revealed that the 86HG-39 and 87HG-28 cell lines had a hypodiploid or diploid stem line with lines in the hypotetraploid to tetraploid region for 50 in vitro passages. The 87HG-31 cell line had chromosomal patterns in the hypotriploid to triploid region. A gain of chromosomes was seen in the groups C7, C8, C10, D14, F19, F20, G21, G22. The variability of antigens in these tumours and especially during long-term cultivation probably reveals an ability to influence the growth of malignant glioma cells via the respective effector molecules.

[Tracheal agenesis. A case report]

A case of tracheal agenesis, a rare foregut malformation, is described. This malformation is combined with a tracheo-oesophageal fistula, furthermore with rectal and anal atresia, cardiac malformations, dysplastic kidneys, wedge-shaped vertebrae, and cerebellar hypoplasia. Since a tracheo-oesophageal fistula is a possible component of the VACTERL Association [(V) vertebral defects, (A) anal atresia, (C) cardial malformations, (T) tracheo-(E)-oesophageal fistula, (R) renal or (L) limb malformations], similar cases are reviewed from the literature and their relationship to this association is discussed.

[Pathogenesis of Achilles tendon rupture]

The etiology underlying ruptures of the Achilles tendon is analyzed in 65 patients in a retrospective clinical study. A typical mechanism leading to a rupture of the tendon consists in an extraordinary tension force applied on a tendon in a state of active preload. A spontaneous rupture was observed in merely 3 cases. In 21 out of 65 patients risk factors such as hypercholesterolemia, hyperuricemia and arteriosclerosis were present. A systematic application of corticosteroids proved to be a decisive factor in the etiology of a tendon rupture. There was no correlation between the presence of associated risk factors and the degree of histological degeneration. During follow-up 3 re-ruptures and 6 ruptures of the contralateral tendon were registered. Our results lead to the conclusion that the etiology of the rupture of the Achilles tendon is based on a multifactorial disposition which includes the mechanism of injury, preexistent risk-factors as well as degenerative changes in the tendon structure.

[Atypical joint symptoms as initial symptoms of varicella infection in chronic myeloid leukemia]

A 25-year-old man, known to have chronic myeloid leukaemia for four years, acutely developed a fever of 39.5 degrees and severe pain in the shoulder and hip joints. There was no evidence of joint disease. Treatment with indomethacin briefly improved the symptoms, but within 72 hours the patient developed a fulminant illness with high fever and clinical as well as biochemical signs of a severe consumption coagulopathy. Herpetiform efflorescences appeared over the head and trunk shortly before death. At autopsy there was histological and immunohistochemical evidence of a varicella infection with hepatitis, oesophageal involvement and severe internal organ bleedings. In immune-compromised patients with atypical prodromal symptoms a varicella infection must be considered so that causal treatment with acyclovir and hyperimmune-globulin can be begun in time.

Well-differentiated papillary mesothelioma of the peritoneum: a borderline mesothelioma. Report of two cases and review of literature

Well-differentiated papillary mesothelioma (WDPM) is considered to be a distinct subtype of peritoneal mesothelioma. Although the WDPM is usually qualified as benign, the natural history of this lesion has not been clearly established. This report relates to two WDPMs which were found incidentally. In a 51-year-old man the WDPM developed over a period of 5 years into a typically malignant diffuse mesothelioma. Thus, although the WDPM morphologically lacks signs of malignancy, it should be regarded as a borderline mesothelioma.

Unexpected infant death attributable to cardiac tumor or cardiomyopathy. Immunohistochemical and electron microscopical findings in three cases

The pathological findings, including immunohistochemical and electron microscopical findings, in three infants who died unexpectedly of cardiac tumor or cardiomyopathy are reported. The first was a 13-month-old boy with tuberous sclerosis and multiple rhabdomyomas of the heart, who presented with a postpartal cardiac murmur and moderate cardiomegaly. The further history was unknown. The rhabdomyoma nodules were composed of spider cells containing small amounts of desmin and myosin as well as isolated myofibrils. Microscopically small glioma nodules contained high amounts of GFAP. The second case, a boy 4 months of age, died of a large benign fibrous histiocytoma of the heart after an uneventful history. Tumor cells contained alpha-1-anti-chymotrypsin and lysozyme. The third case, a girl 2 months of age, died unexpectedly of histiocytoid cardiomyopathy. The affected cells contained fat droplets, glycogen granules, many leptomer myofibrils and small amounts of myosin and desmin.

[Quantitative morphologic studies for localizing arteriosclerotic plaques in the circumference of coronary arteries]

In order to determine the distribution of arteriosclerotic plaques in the circumference of coronary arteries 150 hearts were investigated using two different methods. In 100 hearts the coronary vessels were opened longitudinally, and the sites of sclerotic lesions were mapped. The coronary arteries of another 50 hearts were filled with contrast medium, angiography was performed and the arteries were cut into 0.5-cm segments. The first 6 cm of the left anterior descending and the left circumflex arteries and the first 9 cm of the right coronary artery were studied. Segments of 1-cm length in the 100 hearts and of 0.5-cm length in the 50 hearts were examined. It was found, that arteriosclerotic lesions of the coronary arteries are most frequently located on the myocardial side of the vessel circumference. This phenomenon is most evident in the left anterior descending artery, thus possibly being caused by the most pronounced fixation of this artery on the myocardium.

Fatal accidental enflurane intoxication

Among reported cases of abuse of volatile anesthetics there is only one of enflurane intoxication. We report another fatal enflurane intoxication. A 21-year-old man found dead seemed to have experimented with enflurane. Three and one-half days after death high amounts of enflurane were detected in blood, brain, and subcutaneous fat. Gas chromatographic quantification revealed the following high enflurane concentrations: blood: 130 mg/l-1, brain: 350 mg/l-1, and subcutaneous fat: 100 mg/l-1. Histologic signs of drug-induced damage were lacking. No suicide intentions became known. It was concluded that the young man died of an accidental intoxication while abusing enflurane.

Case of cyclopia with an unbalanced karyotype attributable to a balanced 3/7 translocation

This report presents a case of cyclopia attributable to an unbalanced karyotype in a family with a balanced, reciprocal 3/7 translocation. This case was the fifth recorded in three generations of this family. From this report it is possible that the simultaneous action of partial trisomy 3p and partial monosomy 7q may be one cause of holoprosencephaly.

Cushing's syndrome due to ACTH-production of an ovarian carcinoid

The case of a 56-year old woman with severe Cushing's syndrome due to ovarian ACTH-production is described. Both clinical picture and biochemical pattern were consistent with the ectopic ACTH syndrome. ACTH was found by specific immunohistochemical staining in a carcinoid tumor of the patient's right ovary. In contrast, pituitary cells exhibited immunoreactive ACTH to only a minimum extent.

Transendothelial transport and metabolism of adenosine and inosine in the intact rat aorta

This study was aimed at defining the role of vascular endothelium in the transport and metabolism of adenosine. For this purpose, endothelium-intact and endothelium-denuded isolated rat aortas, perfused at constant flow (2 ml/min), were prelabeled with 3H-adenosine or 3H-inosine for 10 minutes at concentrations of 0.012-100 microM. Sequestration of adenosine by endothelium was determined from radioactivity recovered during selective endothelial cell removal with deoxycholic acid (0.75% for 15 seconds). In the physiological concentration range of adenosine (0.012-1 microM), fractional sequestration by endothelium was 90-92% of the total adenosine incorporation by the aorta. Endothelial sequestration of inosine at 0.1 microM was 85%. At 100 microM adenosine or inosine, fractional sequestration by aortic endothelium was 33% and 39%, respectively. Analysis of the specific radioactivity of adenine nucleotides extracted from prelabeled aortas indicated that most of the adenosine was incorporated into endothelial adenine nucleotides. Incorporation of inosine into endothelial ATP was approximately 15% that of adenosine. Inhibition of aortic adenosine deaminase with erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA) did not influence sequestration of 0.1 microM adenosine, but resulted in a 49% reduction of total endothelial incorporation at 100 microM adenosine. Transfer of radioactive purines from the endothelium to underlying smooth muscle after prelabeling was equivalent to only 1%/hr of total endothelial radioactivity. Our findings suggested that 1) macrovascular endothelium of the aorta constitutes a highly effective metabolic barrier for circulating adenosine and inosine; 2) transfer of labeled adenine nucleotides from endothelium to underlying smooth muscle is rather small and most likely proceeds via dephosphorylated purine compounds; and 3) measurement of adenosine trapping in endothelial and smooth muscle compartments overestimates the transendothelial adenosine concentration gradient.

Flow pattern and structural changes at carotid bifurcation in hypertensive cynomolgus monkeys

Blood flow pattern and morphological changes within the extracranial carotid system were studied in M. fascicularis before, immediately after, and at various intervals (4 hours, 4 days, 10 days, and 4 weeks) after the introduction of systemic hypertension by surgical coarctation of the thoracic aorta. Intra-arterial hemodynamics were assessed by means of both continuous-wave Doppler signal spectrum analysis and multigate pulsed-wave Doppler flow velocity profile processing. Diminished peak frequencies throughout the carotid system and enlargement of the lumen diameter in the common carotid artery and the carotid bulb were major findings and were suspected to be due to cerebral autoregulation at high levels of intracranial vascular resistance. In the internal carotid artery of pure muscular type, the lumen diameter was diminished so the carotid bulb became an area of structural and hemodynamic transition. As a consequence, flow irregularities already observed in this region before surgery considerably increased during hypertension. In addition, endothelial disarray and leucocytic adherence and activation were associated with these hemodynamic alterations within the carotid bulb. Their mutual role in early atherogenesis is discussed.

Tetraedric and sand-glass crystals in the urine

Sand-glass and tetraedric crystals often occur in cytologic evaluations of urinary sediments as a secondary finding. The analyses show inflammation and an increase in protein casts as accompanying changes. The basic diseases are primarily renal but unspecific. The analyses of the crystals by laser-ray-technique (LAMMA-analysis) demonstrate calcium in the positive ionic spectrum in both forms. Differences can be registered in the negative ionic spectrum: sand-glasses and small tetraeders contain considerable amounts of phosphate (PO2- and PO3-), while only the larger tetraedric crystals consist of pure calcium oxalate.

[Magnetic resonance tomography of prostatic cancer. A histopathologic correlation]

A total of 52 patients with prostatic carcinoma were examined by MR imaging; 14 of them subsequently underwent radical prostatectomy and were included in this study. The resected prostates were sectioned axially and compared with the corresponding MR scans with special reference to the location and extent of the pathological changes. The prostatic carcinoma was visualized in 10 cases, but the size of the tumor was underestimated in 6 patients. In 9 of 10 patients the carcinoma was identifiable as an area of low signal intensity within the peripheral zone on T2-weighted images. The MR features of benign nodular hyperplasia are discussed.

Extracorporeal CO2-removal with a heparin coated artificial lung

Treatment of severe acute respiratory failure with extracorporeal gas exchange necessitating near complete systemic anticoagulation requires a delicate balance to be maintained between disseminated intravascular coagulation and hemorrhagic complications. The present study describes our first experience using a heparin coated extracorporeal artificial lung and circuitry during clinical extracorporeal CO2 removal. In spite of a partial thromboplastin time and activated clotting time within or close to the normal range, neither laboratory evidence for disseminated intravascular coagulation induced by the extracorporeal circuit nor thrombi in the pulmonary vasculature were found. Scanning electron microscopy of the heparin coated hollow fiber gas exchanger demonstrated only minor deposits on the surface. Use of a heparin coated artificial lung may enhance the margin of safety of extracorporeal gas exchange and ultimately broaden its indications.

[Homologous replacement of the cruciate ligament in the animal experiment]

A homologous cruciate ligament transplantation was effected in 20 Alsation dogs. Clinical, pathologico-anatomical and histological results were obtained from 16 animals after 3, 6 and 9 months, respectively, proving metaplasia of the transplant to endogenous body tissue. The clinical conclusion of this finding is that an anatomically optimally-structured ligament replacement can be inserted by means of a relatively uncomplicated operation--possibly even by using arthroscopy. The low amount of traumatization due to this type of surgery will be of advantage especially to sportsmen, who, as is well known, not only suffer from frequent cruciate ligament ruptures but also have remarkably long-term deficits by large operation wounds both in regaining their proprioceptive performance ability and their muscular power.

Usefulness of angioscopy in stenotic processes of the carotid--a comparison with morphological findings

The development of a new generation of ultrathin flexible fiberscopes permitted direct in-vivo intravascular visualization of pathological changes. But not until the construction of a double-lumen balloon catheter for simultaneous obstruction of the blood flow and rinsing of the vessel did an accurate percutaneous transluminal examination become possible. For testing the usefulness of angioscopic intraluminal diagnosis, 48 carotid arteries from 32 autopsies were examined independently by angioscopy and morphologically. There was a high degree of correspondence between the two methods, especially in cases with low-degree stenosis or complicated plaques, in which other examination methods often fail. Problems of underestimating fibrous plaques and optical projection upstream of the stenosis are discussed.

Epithelial (true) splenic cysts. Pathogenesis of the mesothelial and so-called epidermoid cyst of the spleen

Nonparasitic cysts of the spleen are classified as primary or epithelial cysts if their inner surface has a cellular lining. Depending upon the pattern of the inner surface cell layer, the primary splenic cysts are divided into mesothelial or epidermoid subtypes. In order to study their pathogenesis, five epithelial splenic cysts (two with mesothelial lining, and three with foci of stratified squamous epithelium) were investigated by scanning and transmission electron microscopy and by immunohistochemistry. In places, the squamous epithelium was continuous with a flattened mesothelial layer. Furthermore, within the stratified epithelium, a continuous spectrum of cytodifferentiation from mesothelial to squamous cells was found. Thus, the epidermoid splenic cyst seems to be a variant of the mesothelial cyst with focal squamous metaplasia. Rupture of the splenic capsule with hemosiderin deposits and infoliation of the mesothelium was seen in one case, implying a traumatic genesis. In addition, stoma-like channels providing connections between the lumen of the cyst and the sinus of the adjacent splenic tissue were detected by scanning electron microscopy. As with other cystic lesions, the influx of blood cells and proteinaceous fluid from these stomata may contribute to the growth of the cysts, which are usually of considerable size when surgically removed.

Localized benign biphasic mesothelioma of the pleura

A localized benign biphasic mesothelioma of the pleura is described. Immunohistochemically the epithelial-like cells contained vimentin intermediate filaments only, while electron microscopy revealed signs of true mesothelial differentiation demonstrating the hybrid nature of neoplastic mesothelial cells.

Correlation of abdominal CT imaging with autopsy findings in patients with malignant tumors

The value of abdominal computed tomography (CT) in diagnosing localized involvement of liver, pancreas, adrenals, and lymph nodes was evaluated in 117 patients with suspected or known malignant tumors by correlation with autopsy findings. Sensitivity, specificity, and accuracy of CT for localized liver disease was calculated to be 80% (84%), 96% (97%), and 90% (92%); for pancreatic tumors: 81% (86%), 98% (100%), and 95% (97%); for adrenal tumors: 65% (92%), 100% (100%), and 92% (98%); and for lymph node enlargement 75 (88%), 97% (98%), and 87% (94%), respectively. Results of routine evaluation could be improved, especially in the adrenal region, when scans were reevaluated by highly experienced examiners (results given in parenthesis). Computed tomography is a highly valuable diagnostic tool in the primary diagnosis and in the follow-up of tumor patients. The high costs are offset by a reduction in invasive procedures and a shortened hospital stay.

Myocardial performance and metabolism in non-ketotic, diabetic rat hearts: myocardial function and metabolism in vivo and in the isolated perfused heart under the influence of insulin and octanoate

The influence of a non-ketonic, chronically diabetic state (60 mg/kg streptozotocin) on cardiac function and metabolism was studied under in vivo conditions by inserting a Millar-tip catheter into the left ventricle and in the model of the isolated perfused heart. In vivo heart rate and maximal left ventricular systolic pressure were reduced after a diabetes duration of 4 and 12 weeks. The maximal rise and fall in left ventricular pressure progressively declined with the duration of diabetes. The reduced myocardial function was associated with a loss in ATP and adenine nucleotides. In the perfused heart of chronically diabetic rats, heart function was also impaired and could not be restored in vitro by perfusion with glucose and insulin. In the presence of octanoate--a substrate which can be metabolized independently from insulin--heart function of diabetic rats was improved, but remained lowered as compared to controls. Since the content of myocardial creatine phosphate was reduced in diabetic hearts perfused with octanoate, these findings indicate that the suppression of cardiac performance is not only a result of an impaired glucose metabolism, but of a more general defect in energy provision and utilization. In contrast to hearts of acutely diabetic, ketotic rats most often used, the rate of lipolysis of endogenous triglycerides and the contribution of fatty acids to energy production was low in the chronically diabetic state. Inhibition of fatty acid oxidation by an inhibitor of carnitine palmitoyltransferase (CPTI) did not restore the reduced responsiveness of diabetic hearts to insulin. Analysis of intracardiac metabolites revealed that in the perfused heart of chronically diabetic rats glucose-6-phosphate and citrate do not accumulate as in hearts of ketotic, diabetic rats. Therefore, the impaired glucose metabolism presumably reflects a reduced uptake of glucose rather than in inhibition of glycolysis as in hearts of ketotic, diabetic rats.