Prognostic Value of Tumour-Infiltrating Lymphocytes in an Unselected Cohort of Breast Cancer Patients

Tumour-infiltrating lymphocytes (TILs) are considered to have prognostic and predictive value for patients with early breast cancer. We examined 1166 breast cancer patients from a prospective, multicentre cohort (Prognostic Assessment in Routine Application (PiA), n = 1270, NCT01592825) following recommendations from the International TILs Working Group. TIL quantification was performed using predefined groups and as a continuous variable in 10% increments. The primary objective was the distribution of TILs in different breast cancer types. The second objective was the association with the recurrence-free interval (RFI) and overall survival (OS). Stromal infiltration with more than 60% TILs appeared in 2% of hormone receptor (HR)-positive and HER2-negative tumours, in 9.8% of HER2-positive tumours (any HR) and 19.4% of triple-negative breast cancers (TNBCs). Each 10% increment was associated with an improvement in the prognosis in HER2-positive samples (RFI, hazard ratio 0.773, 95% CI 0.587-1.017; OS, hazard ratio 0.700, 95% CI 0.523-0.937). When defining exploratory cut-offs for TILs, the use of a 30% threshold for the HR-positive and HER2-negative group, a 20% threshold for the HER2 group and a 60% threshold for the TNBC group appeared to be the most suitable. TILs bore prognostic value, especially in HER2-positive breast cancer. For clinical use, additional research on the components of immune infiltration might be reasonable.

[Cooperative approach of pathology and neuropathology in the COVID-19 pandemic : German registry for COVID-19 autopsies (DeRegCOVID) and German network for autopsies in pandemics (DEFEAT PANDEMIcs)]

Hintergrund

Die Obduktion ist ein wichtiges Instrument zum Verständnis der Pathogenese von Krankheiten, inklusive COVID-19.

Material und Methoden

Am 15.04.2020 wurde zusammen mit der Deutschen Gesellschaft für Pathologie und dem Bundesverband der deutschen Pathologen das Deutsche Register von COVID-19-Obduktionen (DeRegCOVID) gestartet (www.DeRegCOVID.ukaachen.de) und darauf aufbauend seit 01.09.2020 das Deutsche Netzwerk für Autopsien in Pandemien (DEFEAT PANDEMIcs) etabliert.

Ergebnisse

Hauptziel des DeRegCOVID ist es, faktisch anonymisierte Daten über idealerweise alle Obduktionen von COVID-19-Verstorbenen in Deutschland zu sammeln und zur Verfügung zu stellen, um dem Bedarf an zentralisierter, koordinierter und strukturierter Datenerhebung und Berichterstattung in der Pandemie gerecht zu werden. Der Erfolg des Registers hängt von der Bereitschaft der jeweiligen Zentren zur Meldung der Daten ab. Diese hat sich bislang sehr positiv entwickelt und wir danken allen beteiligten Zentren. Dabei verbleiben die Rechte an eigenen Daten (und dezentral verbleibenden Biomaterialen) bei den jeweiligen Institutionen. Das Netzwerk DEFEAT PANDEMIcs zielt auf eine Verstärkung der Harmonisierung und Standardisierung sowie die bundesweite Implementation und Kooperation im Bereich von Pandemieobduktionen.

Schlussfolgerungen

Die außerordentliche Kooperation in Deutschland im Bereich der Obduktionen während der COVID-19-Pandemie ist durch den Aufbau des DeRegCOVID, dessen Fusionierung mit dem Register der Neuropathologie (CNS-COVID19) und dem Aufbau des Netzwerks DEFEAT PANDEMIcs eindrücklich belegt. Es ist ein starkes Signal für die Notwendigkeit, Bereitschaft und Expertise, mit durch Autopsie gewonnenen Erkenntnissen zur gemeinsamen Bewältigung gegenwärtiger und künftiger Pandemien beizutragen.

Identifying High-Risk Triple-Negative Breast Cancer Patients by Molecular Subtyping

<b><i>Introduction:</i></b> Triple-negative breast cancer (TNBC) is considered the most aggressive type of breast cancer (BC) with limited options for therapy. TNBC is a heterogeneous disease and tumors have been classified into TNBC subtypes using gene expression profiling to distinguish basal-like 1, basal-like 2, immunomodulatory, mesenchymal, mesenchymal stem-like, luminal androgen receptor (LAR), and one nonclassifiable group (called unstable). <b><i>Objectives:</i></b> The aim of this study was to verify the clinical relevance of molecular subtyping of TNBCs to improve the individual indication of systemic therapy. <b><i>Patients and Methods:</i></b> Molecular subtyping was performed in 124 (82%) of 152 TNBC tumors that were obtained from a prospective, multicenter cohort including 1,270 histopathologically confirmed invasive, nonmetastatic BCs (NCT 01592825). Treatment was guideline-based. TNBC subtypes were correlated with recurrence-free interval (RFI) and overall survival (OS) after 5 years of observation. <b><i>Results:</i></b> Using PAM50 analysis, 87% of the tumors were typed as basal with an inferior clinical outcome compared to patients with nonbasal tumors. Using the TNBCtype-6 classifier, we identified 23 (15%) of TNBCs as LAR subtype. After standard adjuvant or neoadjuvant chemotherapy, patients with LAR subtype showed the most events for 5-year RFI (66.7 vs. 80.6%) and the poorest probability of 5-year OS (60.0 vs. 84.4%) compared to patients with non-LAR disease (RFI: adjusted hazard ratio [aHR] = 1.87, 95% confidence interval [CI] 0.69–5.05, <i>p</i> = 0.211; OS: aHR = 2.74, 95% CI 1.06–7.10, <i>p</i> = 0.037). <b><i>Conclusion:</i></b> Molecular analysis and subtyping of TNBC may be relevant to identify patients with LAR subtype. These cancers seem to be less sensitive to conventional chemotherapy, and new treatment options, including androgen receptor-blocking agents and immune checkpoint inhibitors, have to be explored.

Specific allelic variants of SNPs in the MDM2 and MDMX genes are associated with earlier tumor onset and progression in Caucasian breast cancer patients

Background

Genetic factors play a substantial role in breast cancer etiology. Genes encoding proteins that have key functions in the DNA damage response, such as p53 and its inhibitors MDM2 and MDMX, are most likely candidates to harbor allelic variants that influence breast cancer susceptibility. The aim of our study was to comprehensively analyze the impact of SNPs in the TP53, MDM2, and MDMX genes in conjunction with TP53 mutational status regarding the onset and progression of breast cancer.

Methods

In specimen from 815 breast cancer patients, five SNPs within the selected genes were analyzed: TP53 – Arg72Pro (rs1042522), MDM2 – SNP285 (rs2279744), SNP309 (rs117039649); MDMX – SNP31826 (rs1563828), and SNP34091 (rs4245739). Classification of the tumors was evaluated by histomorphology. Subtyping according hormone receptor status, HER2-status and proliferation rate enabled provision of the clinico-pathological surrogate of intrinsic subtypes.

Results

The homozygous C-allele of MDM2 SNP285 was significantly associated with a younger age-at-diagnosis of 44.2 years, in contrast to G/G- and G/C-patients (62.4, 62.7 yrs., respectively; p = 0.0007; log-Rank-test). In contrast, there was no difference regarding the age-at-diagnosis for patients with the respective genotypes of MDM2 SNP309 (p = 0.799; log-Rank-test). In patients with estrogen receptor (ER)-positive and TP53-mutated tumors, however, the T/T-genotype of the MDM2 SNP309 was significantly associated with an earlier average age-at-diagnosis compared with T/G+G/G-patients (53.5 vs. 68.2 yrs; p = 0.002; log-Rank-test). In the triple-negative subgroup, the G/G-patients had an average age-at-diagnosis of 51 years compared with 63 years for SNP309T carriers (p = 0.004; log-Rank-test) indicating a susceptibility of the G/G genotype for the development of triple negative breast cancer. Patients with the A/A-genotype of MDMX SNP31826 with ER-negative tumors were diagnosed 11 years earlier compared with patients and ER-positive tumors (53.2 vs. 64.4 yrs; p = 0.025, log-Rank-test). Furthermore, in luminal B-like patients (HER2-independent) the C/C-genotype of MDMX SNP34091 was significantly correlated with a decreased event-free survival compared with the A/A-genotype (p < 0.001; log-Rank-test).

Conclusions

We showed that SNPs in the MDM2 and MDMX genes affect at least in part the onset and progression of breast cancer dependent on the ER-status. Our findings provide further evidence for the distinct etiological pathways in ER-negative and ER-positive breast cancers.

Multicenter Evaluation of the Idylla NRAS-BRAF Mutation Test in Metastatic Colorectal Cancer

Treatment of colorectal cancer (CRC) with monoclonal antibodies against epidermal growth factor receptor requires the assessment of the mutational status of exons 2, 3, and 4 of the NRAS and KRAS oncogenes. Moreover, the mutational status of exon 15 of the BRAF oncogene is a marker of poor prognosis in CRC. The Idylla NRAS-BRAF Mutation Test is a reliable, simple (<2 minutes hands-on time), and quick (<2 hours turnaround time) sample-to-result solution, enabling the detection of clinically relevant mutations in NRAS (18 mutations) and BRAF (5 mutations). A multicenter study was conducted in 14 centers using the Idylla NRAS-BRAF Mutation Test to assess the NRAS and BRAF mutational status of 418 formalin-fixed, paraffin-embedded tissue samples from CRC patients. Results were compared with those obtained earlier by routine reference methods, including next-generation sequencing, pyrosequencing, mass spectrometry-based assays, PCR-based assays, and Sanger sequencing. In case of discordance, additional tests were performed by digital droplet PCR. Overall, after testing confirmation and excluding invalids/errors by design, concordances between the Idylla NRAS-BRAF Mutation Test and the reference test results were found in almost perfect agreement. In conclusion, the Idylla NRAS-BRAF Mutation Test enables the routine detection of all NRAS and BRAF mutations deemed clinically relevant according to the latest clinical guidelines, without necessitating molecular expertise or infrastructure.

Proteomic profiling of breast cancer metabolism identifies SHMT2 and ASCT2 as prognostic factors

Background

Breast cancer tumors are known to be highly heterogeneous and differences in their metabolic phenotypes, especially at protein level, are less well-understood. Profiling of metabolism-related proteins harbors the potential to establish new patient stratification regimes and biomarkers promoting individualized therapy. In our study, we aimed to examine the relationship between metabolism-associated protein expression profiles and clinicopathological characteristics in a large cohort of breast cancer patients.

Methods

Breast cancer specimens from 801 consecutive patients, diagnosed between 2009 and 2011, were investigated using reverse phase protein arrays (RPPA). Patients were treated in accordance with national guidelines in five certified German breast centers. To obtain quantitative expression data, 37 antibodies detecting proteins relevant to cancer metabolism, were applied. Hierarchical cluster analysis and individual target characterization were performed. Clustering results and individual protein expression patterns were associated with clinical data. The Kaplan-Meier method was used to estimate survival functions. Univariate and multivariate Cox regression models were applied to assess the impact of protein expression and other clinicopathological features on survival.

Results

We identified three metabolic clusters of breast cancer, which do not reflect the receptor-defined subtypes, but are significantly correlated with overall survival (OS, p ≤ 0.03) and recurrence-free survival (RFS, p ≤ 0.01). Furthermore, univariate and multivariate analysis of individual protein expression profiles demonstrated the central role of serine hydroxymethyltransferase 2 (SHMT2) and amino acid transporter ASCT2 (SLC1A5) as independent prognostic factors in breast cancer patients. High SHMT2 protein expression was significantly correlated with poor OS (hazard ratio (HR) = 1.53, 95% confidence interval (CI) = 1.10–2.12, p ≤ 0.01) and RFS (HR = 1.54, 95% CI = 1.16–2.04, p ≤ 0.01). High protein expression of ASCT2 was significantly correlated with poor RFS (HR = 1.31, 95% CI = 1.01–1.71, p ≤ 0.05).

Conclusions

Our data confirm the heterogeneity of breast tumors at a functional proteomic level and dissects the relationship between metabolism-related proteins, pathological features and patient survival. These observations highlight the importance of SHMT2 and ASCT2 as valuable individual prognostic markers and potential targets for personalized breast cancer therapy.

Trial registration

ClinicalTrials.gov, NCT01592825. Registered on 3 May 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-017-0905-7) contains supplementary material, which is available to authorized users.

Abstract P1-04-06: Prevalence of PIK3CA mutations in tumor tissue of a consecutive cohort of breast cancer patients (n=700)

Introduction:

The AKT / mTOR pathway is activated by phosphorylation of the lipid kinase phosphatidylinositol 3-kinase (PI3K) and regulates proliferation, apoptosis, survival and adhesion of tumor cells. In up to 30% of breast cancers, dysregulation of PI3K is reported, resulting from mutations in the PIK3CA gene that encodes the catalytic subunit (p110a). Hotspots of mutations were described in exon 9 (helical domain, E542K, G &gt; A) and exon 20 (kinase domain, H1047R, A &gt; G). Prevalence and the prognostic impact of the PIK3CA mutations as well as the predictive value with regard to endocrine therapy are controversially discussed. In this study we describe the prevalence of PIK3CA mutations in a consecutive cohort of breast cancer patients and its association to tumor characteristics and known prognostic factors.

Material & Methods:

Fresh frozen tumor samples were obtained from a consecutive cohort of 700 breast cancer patients (inclusion criteria: pTx pNx M0 Gx HRx HER2x) who were primarily operated in 6 centres between 2009 and 2011. Tumor DNA was extracted and analyzed by conventional and quantitative PCR (exon 9: cosmid 763 and exon 20: cosmid 775). Patient data, tumor characteristics and prognostic factors were obtained from patients charts. ER, PgR and HER2 results were based on local pathology, uPA and PAI-1 values were determined centrally.

Results:

All isolated DNA (n=700) were analyzable by PCR and showed a mutation rate of 22% in the entire cohort; including two tumors with both mutations. Among the tumors with a positive steroid hormone receptor (HR) status (n=606; 87%), we found a mutation rate of 24% for PIK3CA, whereas only 9 (10%) of 94 HR-negative tumors were mutated. Tumors with a PIK3CA mutation were significantly associated with HR positivity / HER2 negativity (p=0,001). 14% of the cohort was HER2 positive. In 98 cases with a HER2 positive tumor 17 DNAs were mutated (17%) and 139 DNAs of the 602 HER2 negative tumors had a positive PIK3Ca mutation status (23%). Of the mutated tumors, 94 % were HR positive, and 11% HER2 positive. Only three samples were HER2 positive and HR-negative. 6% of the mutated tumors were triple negative.

No significant association was found to age, menopausal status, tumor stage, nodal status, grading and uPA/PAI-1 status. Most mutant tumors were histological grade 2 (p=0,001). A quarter of the intermediate risk group according to St. Gallen risk estimation had a somatic PIK3CA mutation.

Conclusion:

In our cohort, nearly all mutated tumors are hormone receptor positive and a minority of all mutated samples is HER2 positive. This data adds important information to the heterogeneous results of other previously published patient cohorts. It suggests a possible role of PI3K-dysregulation with regard to resistance against endocrine therapy and anti-HER2-treatment.

Citation Format: Martina Vetter, Kristin Reinhardt, Silke Wegener, Juergen Dittmer, Tilmann Lantzsch, Christoph Uleer, Susanne Peschel, Jutta John, Volker Hanf, Joerg Buchmann, Karl-Friedrich Bürrig, Edith Weigert, Christoph Thomssen, Eva J Kantelhardt. Prevalence of PIK3CA mutations in tumor tissue of a consecutive cohort of breast cancer patients (n=700) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-04-06.

[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.

[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.