Abstract P4-09-07: Higher risk of metachronous contralateral breast cancer in patients with invasive lobular breast cancer

Background: Risk of metachronous contralateral breast cancer (CBC) is an important health issue in primary breast cancer (PBC) survivors. Individualized CBC risk prediction can help identify patients at high or low risk who may or may not benefit from additional surveillance and treatment. For lobular PBC, inconsistent results have been reported on an association with increased risk of CBC. We investigated CBC risk in lobular versus ductal PBC using a large nationwide dataset and taking into account age at PBC and (neo-)adjuvant systemic therapy effects.

Patients and Methods: We selected women diagnosed between 2003 and 2010 with early invasive lobular, lobular mixed with other types, or ductal PBC from the Netherlands Cancer Registry. Categorical and continuous characteristics between the 3 groups were compared using the chi-square statistics and the Kruskal-Wallis test, respectively. Competing risk analyses were applied to determine CBC incidence. Multivariable subdistribution hazard ratios (SHRs) were adjusted for primary tumor stage, age at PBC diagnosis, radiotherapy, (neo-)adjuvant chemotherapy and endocrine therapy.

Results: We selected 74,373 women aged >18 years with lobular (n=8,903), lobular mixed (n=3,512), and ductal (n=62,230) PBC. Women with lobular PBC were older at diagnosis than women with lobular mixed or ductal PBC (61 vs. 58 vs. 58 years, respectively), more often had ER-positive PBC (95.7% vs. 94.1% vs. 79.6%) and were more often systemically treated with only endocrine therapy (30.7% vs. 24.9% vs. 19.7%), while less often treated with only chemotherapy (4.2% vs. 5.3% vs. 15.4%).

Ten-year cumulative CBC incidences in women with lobular, lobular mixed or ductal PBC were 3.2%, 3.6% and 2.8% when treated with systemic therapy (chemotherapy and/or endocrine therapy) and 6.6%, 7.7% and 5.6% without systemic therapy, respectively. Multivariable SHRs were 1.19 (95% CI: 1.05-1.34) for lobular and 1.39 (95% CI: 1.17-1.65) for lobular mixed versus ductal PBC; for women <50 years, risk differences were larger: 1.60 (95% CI: 1.26-2.05) and 1.43 (95% CI: 1.00-2.06), respectively.

Conclusion: Lobular histology and lobular mixed histology are independent risk factors for CBC development, and should be considered as prognostic factors when refining CBC risk prediction models.

Citation Format: Akdeniz D, Kramer I, van Deurzen CH, Schaapveld M, Westenend PJ, Voogd AC, Jager A, Steyerberg EW, Sleijfer S, Schmidt MK, Hooning MJ. Higher risk of metachronous contralateral breast cancer in patients with invasive lobular breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-09-07.

Preoperative indication for systemic therapy extended to patients with early-stage breast cancer using multiparametric 7-tesla breast MRI

Purpose

To establish a preoperative decision model for accurate indication of systemic therapy in early-stage breast cancer using multiparametric MRI at 7-tesla field strength.

Materials and methods

Patients eligible for breast-conserving therapy were consecutively included. Patients underwent conventional diagnostic workup and one preoperative multiparametric 7-tesla breast MRI. The postoperative (gold standard) indication for systemic therapy was established from resected tumor and lymph-node tissue, based on 10-year risk-estimates of breast cancer mortality and relapse using Adjuvant! Online. Preoperative indication was estimated using similar guidelines, but from conventional diagnostic workup. Agreement was established between preoperative and postoperative indication, and MRI-characteristics used to improve agreement. MRI-characteristics included phospomonoester/phosphodiester (PME/PDE) ratio on 31-phosphorus spectroscopy (³¹P-MRS), apparent diffusion coefficients on diffusion-weighted imaging, and tumor size on dynamic contrast-enhanced (DCE)-MRI. A decision model was built to estimate the postoperative indication from preoperatively available data.

Results

We included 46 women (age: 43-74yrs) with 48 invasive carcinomas. Postoperatively, 20 patients (43%) had positive, and 26 patients (57%) negative indication for systemic therapy. Using conventional workup, positive preoperative indication agreed excellently with positive postoperative indication (N = 8/8; 100%). Negative preoperative indication was correct in only 26/38 (68%) patients. However, ³¹P-MRS score (p = 0.030) and tumor size (p = 0.002) were associated with the postoperative indication. The decision model shows that negative indication is correct in 21/22 (96%) patients when exempting tumors larger than 2.0cm on DCE-MRI or with PME>PDE ratios at ³¹P-MRS.

Conclusions

Preoperatively, positive indication for systemic therapy is highly accurate. Negative indication is highly accurate (96%) for tumors sized ≤2,0cm on DCE-MRI and with PME≤PDE ratios on ³¹P-MRS.

Elevated serum IgG4 levels in diagnosis and treatment response in patients with idiopathic retroperitoneal fibrosis

Idiopathic retroperitoneal fibrosis (iRPF) may be a manifestation of IgG4-related disease. Measuring serum IgG4 (sIgG4) may be of value in monitoring iRPF, but this has scarcely been evaluated. It is unknown if tamoxifen (TMX) affects sIgG4 levels. We performed a prospective inception cohort study of 59 patients with untreated (re)active iRPF stratified by elevated (>1.4 g/L) or normal sIgG4 level. Changes in sIgG4 levels following TMX initiation and, if treatment failed, during subsequent corticosteroid (CS) treatment were analyzed. The median sIgG4 level was 1.1 g/L (interquartile range (IQR) 0.4-2.2); 24 patients (40%) had elevated sIgG4 level. Patients with elevated sIgG4 tended to present with higher ESR (46 vs. 34 mm/h; P = 0.08) and more frequent locoregional lymphadenopathy adjacent to the mass (41.7 vs. 20.0%; P = 0.08). sIgG4 also correlated with ESR (ρ = 0.26; P = 0.05) and serum creatinine (SC) (ρ = 0.26; P = 0.04). Following TMX initiation, sIgG4 level decreased, particularly when achieving treatment success (P < 0.01). Odds ratio for TMX treatment success in patients with elevated sIgG4 level was 0.77 (95% CI 0.53-1.14; P = 0.19). After adjusting for age, sex, and SC, the odds ratio was 0.78 (95% CI 0.51-1.18; P = 0.24). ROC curve analyses of sIgG4 on a continuous scale and treatment success showed an AUC of 0.62. Treatment success and concurrent sIgG4 decrease (P < 0.01) were achieved in 78% of patients who converted to CS therapy. Patients with elevated sIgG4 level may be more inflammatory than patients with normal sIgG4 level, but this needs further study. TMX affects sIgG4 levels, but to a lesser extent than CSs. sIgG4 cannot be used as an outcome prediction tool, irrespective of which cutoff value was chosen.

Abstract P5-08-51: SIAH2 protein expression is inversely correlated with the ER status and outcome to tamoxifen therapy in metastatic breast cancer patients

Introduction: In a previous study we observed a positive correlation between Seven in Absentia Homolog 2 (SIAH2) and Estrogen Receptor (ER) mRNA levels. Additionally, high SIAH2 mRNA levels were related to a favorable progression-free survival (PFS) after first-line tamoxifen. In contrast, others showed high SIAH2 protein levels in ER-negative breast cancer associated with an unfavorable relapse-free survival. In this study, we investigated the above discrepancy between SIAH2 protein and mRNA findings and evaluated the prognostic and predictive value of SIAH2 protein in breast cancer patients.

Patients and methods: Tissue microarrays (TMAs) of formalin-fixed, paraffin-embedded primary breast tumors were immunohistochemically stained for SIAH2 protein. The TMAs contained core specimens of 759 patients with early disease and of 245 ER-positive patients with advanced disease treated with first-line tamoxifen. SIAH2 protein staining was scored for its intensity and proportion positive cells and subsequently evaluated for its relationship with metastasis-free survival (MFS) and PFS in uni- and multivariate analyses including traditional prognostic or predictive factors, respectively.

Results: The proportion SIAH2-positive cells had a relationship with MFS and PFS, whereas staining intensity and a previous described score for SIAH2 combining intensity and proportion were not related with clinical outcome. Based on these results, tumors with more than 20% positive cells were considered as SIAH2-positive. In early disease, 267 patients (35%) had SIAH2-positive tumors, which were further characterized by decreased expression of ER at protein and mRNA levels (P &lt;0.001 and P = 0.003, respectively). These SIAH2-positive tumors correlated with significant unfavorable MFS in lymph node negative, ER-positive breast cancer patients, but only in univariate analysis. In advanced disease, 86 patients (35%) had SIAH2-positive tumors which was associated with an unfavorable PFS after first-line tamoxifen in both uni- and multivariate analyses (HR = 1.45; 95% CI, 1.07 to 1.96; P = 0.015).

Conclusions: SIAH2 protein expression is especially observed in ER-negative tumors and has no additional prognostic value in breast cancer. The proportion SIAH2-positive cells in ER-positive tumors can be used as biomarker to predict tamoxifen treatment failure in breast cancer patients with advanced disease. Future studies should establish if expression of certain microRNAs explain the observed discrepancy in SIAH2 mRNA and protein levels.

Citation Format: van der Willik KD, Timmermans MM, Look MP, Reijm EA, van Deurzen CHM, den Bakker MA, Westenend PJ, Martens JWM, Berns EMJJ, Jansen MPHM. SIAH2 protein expression is inversely correlated with the ER status and outcome to tamoxifen therapy in metastatic breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-51.

Magnetic resonance imaging in patients with unilateral bloody nipple discharge; useful when conventional diagnostics are negative?

BACKGROUND

Unilateral bloody nipple discharge (UBND) is mostly caused by benign conditions such as papilloma or ductal ectasia. However, in 7-33 % of all nipple discharge, it is caused by breast cancer. Conventional diagnostic imaging like mammography (MMG) and ultrasonography (US) is performed to exclude malignancy. Preliminary investigations of breast magnetic resonance imaging (MRI) assume that it has additional value. With an increasing availability of MRI, it is of clinical importance to evaluate this. We evaluated the additional diagnostic value of MRI in patients with UBND in the absence of a palpable mass, with normal conventional imaging.

METHODS

All women with UBND in the period November 2007-July 2012 were included. In addition to the standard work-up (patient's history, physical examination, MMG, and US), MRI was performed. Data from these examinations and treatment were collected retrospectively.

RESULTS

A total of 111 women (mean age 52 years; range 23-80) were included. In nine (8 %) patients, malignancy was suspected on MRI while conventional imaging was normal. In eight (89 %) of these patients, histology was obtained, two by core biopsy and six by terminal duct excision. Benign conditions were found in six patients (86 %) and a (pre-) malignant lesion in two patients. In both cases, it concerned a ductal carcinoma in situ, which was treated with breast-conserving therapy. Moreover, in two cases of (pre)malignancy, the MRI was interpreted as negative.

CONCLUSION

In patients with UBND who show no signs of a malignancy on conventional diagnostic examinations, the added value of a breast MRI is limited, since a malignancy can be demonstrated in <2 %.

[Revised practice guideline 'Screening and diagnosis of breast cancer']

Revised practice guideline 'Screening and diagnosis of breast cancer' The evidence-based revision of the practice guideline 'Screening and diagnosis of breast cancer' was necessitated by new insights, for instance on the cost-effectiveness of screening modalities other than mammography. Mammography is the only screening modality that is recommended for the general population. In the Netherlands, women from 50-75 years of age are invited for screening. However, in view of the ongoing increase in the incidence of breast cancer and of the image quality advantages of radiological digitalization, a study on the decrease of the lower age limit--preferably 45 years--is recommended. Screening with MRI is indicated for carriers of breast cancer gene mutations. Evaluation of risk factors has resulted in a rearrangement of screening recommendations, based on relative risks (RRs): screening apart from the population screening is only recommended in case the RRis 4 or more and in patients with a positive family history in case of a RR of 2 or more. Additional risks require further genetic evaluation. The 'Breast imaging reporting and data system' (BI-RADS) is now recommended for both screening and diagnostic imaging. Its application has had an impact on the triple diagnostic approach, which has now evolved into a consensus between surgeon, radiologist and pathologist. Axillary ultrasound should be carried out ifa sentinel node procedure is being considered. MRI should be included if the cancer cannot be reliably delineated on mammography or ultrasound. The increased complexity of the diagnostic work-up often means that the final diagnosis is not arrived within one day. Every effort should be made to achieve this goal within 5 working days. Ned Tijdschr Geneeskd. 2008;I52:2336-9

[Splenectomy in a large general hospital: often caused by iatrogenic injury, often causing multiple complications; poor adherence to post-operative guidelines for vaccination and prophylaxis]

OBJECTIVE

To assess the indications, complications and mortality associated with splenectomy in a large general hospital, and to evaluate adherence to guidelines for postoperative vaccination and prophylactic antibiotics.

DESIGN

Retrospective, descriptive.

METHOD

Data were collected on 106 patients who underwent splenectomy between 1999 and 2004. Indications for surgery, complications, duration of hospitalisation, and vaccination status were investigated retrospectively. Patients were contacted by telephone for a structured interview regarding vaccination and antibiotic prophylaxis.

RESULTS

Of the 95 patients with sufficient data for analysis, 41 underwent elective surgery and 54 underwent non-elective surgery, including 37 who required splenectomy due to iatrogenic injury. Posteroperative complications arose in 45 patients, including 23 who developed serious complications. 10 patients died due to complications, including 7 who died within one month after the procedure. Vaccination coverage for the entire group was 58%.

CONCLUSION

In this large general hospital, splenectomy was often performed due to iatrogenic injury and was associated with a relatively high complication rate. Adherence to guidelines on vaccination and prophylactic antibiotics could be improved.

Completeness of notification of tuberculosis in The Netherlands: how reliable is record-linkage and capture-recapture analysis?

The aim of this study was to describe a systematic process of record-linkage, cross-validation, case-ascertainment and capture-recapture analysis to assess the quality of tuberculosis registers and to estimate the completeness of notification of incident tuberculosis cases in The Netherlands in 1998. After record-linkage and cross-validation 1499 tuberculosis patients were identified, of whom 1298 were notified, resulting in an observed under-notification of 13.4%. After adjustment for possible imperfect record-linkage and remaining false-positive hospital cases observed under-notification was 7.3%. Log-linear capture-recapture analysis initially estimated a total number of 2053 (95% CI 1871-2443) tuberculosis cases, resulting in an estimated under-notification of 36.8%. After adjustment for possible imperfect record-linkage and remaining false-positive hospital cases various capture-recapture models estimated under-notification at 13.6%. One of the reasons for the higher than expected estimated under-notification in a country with a well-organized system of tuberculosis control might be that some tuberculosis cases, e.g. extrapulmonary tuberculosis, are managed by clinicians less familiar with notification of infectious diseases. This study demonstrates the possible impact of violation of assumptions underlying capture-recapture analysis, especially the perfect record-linkage, perfect positive predictive value and absent three-way interaction assumptions.

Tumour size and vascular invasion predict distant metastasis in stage I breast cancer. Grade distinguishes early and late metastasis

BACKGROUND

Recent Dutch guidelines recommend adjuvant systemic treatment (AST) for women with high grade stage I breast carcinoma > or =1 cm. High grade is defined as Bloom and Richardson grade 3 (B&R3), Nottingham modification, or mitotic activity (MAI) > or =10/1.59 mm2.

AIMS

To investigate the validity of these histological prognostic factors as the exclusive defining criteria.

MATERIALS/METHODS

Fifty patients with stage I breast carcinoma who developed distant metastases and 50 matched controls without metastasis were studied; none had received AST.

RESULTS

Cases more often had tumours > or =1 cm (p = 0,019), B&R3 tumours (p = 0.059), grade 3 nuclei (p = 0.005), and vascular invasion (p = 0.007). No differences were found for MAI > or =10 (p = 0.46). In multivariate analysis, the only significant variables were vascular invasion and tumour size (odds ratios: 8.21 and 5.35, respectively). In a separate analysis, the 50 cases were divided into 25 patients with early and 25 with late metastasis. Those with early metastasis more often had B&R3 tumours (p = 0.009) and grade 3 nuclei (p = 0.006). No differences were found for tumours > or =1 cm, vessel invasion, or MAI > or =10. Using the present Dutch guidelines for AST, based on B&R3, 20 cases and 11 controls would have received AST. Based on MAI > or =10, 14 cases and 11 controls would have received AST.

CONCLUSIONS

Tumour size and vessel invasion are the best prognostic factors for disease free survival in patients with stage I breast cancer. Dutch selection criteria for AST for these patients need to be improved. Some prognostic factors are time dependent, making their use as selection criteria for AST more complicated.

Core needle biopsy in male breast lesions

AIMS

To describe results of needle core biopsies of the male breast.

METHODS

Needle core biopsies from male breasts and corresponding histological follow up data were retrieved from pathology computer files. For those biopsies with no histological follow up data, the nationwide pathology computer files were consulted.

RESULTS

Twenty six core biopsies of male breasts were performed from 1993 until the end of 2002. All patients had unilateral lesions and were between 20 and 88 years old. In seven patients, core biopsy results were confirmed in the excision specimen. In one patient, the core biopsy diagnosis of cancer was confirmed in another hospital. In 17 patients with a benign core biopsy that was not excised in one of the hospitals served by this laboratory, the nationwide pathology computer files did not retrieve a missed malignancy. One patient with cancer in a core biopsy did not receive surgery because of old age. Core biopsy or aspiration cytology was not used in six of 19 men with cancer.

CONCLUSIONS

Core biopsy of the male breast is a reliable preoperative diagnostic procedure, which should be used more often because it can help to avoid unnecessary surgery and in planning surgery for cancer.

Human papillomaviruses 6/11, 16/18 and 31/33/51 are not associated with squamous cell carcinoma of the urinary bladder

OBJECTIVE

To assess high-risk human papillomavirus (HPV), mainly HPV type 16, 18, 31 and 33 (an important aetiological factor in squamous cell carcinoma, SCC, of the anogenital region) in SCC of the urinary bladder.

MATERIAL AND METHODS

Sixteen SCC from the urinary bladder were evaluated using non-isotopic in situ hybridization with a sensitive detection system for the presence of high-risk HPV 16/18, or 31/33/51, and for HPV6/11, a low-risk type commonly found in condylomata. Previously published studies were also reviewed and assessed.

RESULTS

No high-risk HPV was found in any of the SCC of the bladder evaluated. Previous reports identified nine HPV-positive SCC of a total of 105, including the present series. In four of these positive cases, HPV types were found that are considered a high risk in anogenital carcinomas.

CONCLUSION

From the present and previous results, we conclude that HPV has no major role in the pathogenesis of SCC of the urinary bladder.

A comparison of aspiration cytology and core needle biopsy in the evaluation of breast lesions

BACKGROUND

Several arguments are used for choosing either fine-needle aspiration cytology (FNAC) or core needle biopsy (CNB) in the evaluation of breast lesions. Comparison of published data on both methods is complicated by differences in study design, calculations, and operator experience. The objective of this study was to make a direct comparison of both methods.

METHODS

In 286 breast lesions (cysts and microcalcifications without a soft tissue mass excluded), both ultrasound-guided FNAC and CNB were performed in the same session by the same operator. Histologic follow-up was collected, and for those lesions that were not excised the results of the most recent mammography was used. A combination of the findings of both FNAC and CNB were evaluated.

RESULTS

Core needle biopsy and FNAC do equally well for sensitivity (88% vs. 92%), positive predictive value for malignancy (99% vs. 100%), and inadequate rate (7% vs. 7%). However, statistical differences are found for the specificity (CNB, 90%; FNAC, 82%). In addition, differences are found in the positive predictive value of both suspicious (CNB, 100%; FNAC, 78%) and atypia (CNB, 80%; FNAC, 18%) and for the suspicious rate (CNB, 5%; FNAC, 13%) reflecting difficulties in interpreting some FNACs. Combining the findings of both FNAC and CNB results in an increase in absolute sensitivity, a decrease in the positive predictive value of atypia compared with FNAC and CNB per se, and a decrease in the inadequate rate for cancers.

CONCLUSIONS

For the lesions selected in this study, FNAC and CNB are comparable for most parameters, but CNB has a higher specificity and lower suspicious rate. Combining results of FNAC and CNB leads to an increase in absolute sensitivity without affecting specificity and a decrease in the inadequate rate for cancers.

Primary lymphoepithelioma-like carcinoma within an intralobular pulmonary sequestration

A 31-yr-old Chinese female, a nonsmoker, presented with digital clubbing and coughing. Diagnostic evaluation revealed a pulmonary sequestration in the left lower lobe. During surgery a tumour was discovered, which turned out to be a lymphoepithelioma-like carcinoma. These tumours are mainly found in Asians, and are associated with the Epstein Barr virus and not with smoking. They are thought to have a better prognosis and to be more chemosensitive. The need for surgical treatment of pulmonary sequestration and the recognition of lymphoepithelioma-like carcinoma as a distinct clinicopathological entity is emphasized.

[Fatal varicella-zoster encephalitis; a rare complication of herpes zoster]

In a 82-year-old woman varicella zoster encephalitis was diagnosed, a rare complication of shingles. The case was remarkable for its rapid and fatal course in a patient without an underlying disease. At autopsy, the histological picture of an acute haemorrhagic encephalitis was seen, also a rare finding.

Aberrant proteoglycan composition of the glomerular basement membrane in a patient with Denys-Drash syndrome

BACKGROUND

To ascertain whether changes in proteoglycans are involved in the pathogenesis of the nephrotic syndrome in Denys-Drash syndrome (DDS), we analysed the glycosaminoglycan (GAG) content and composition of the glomerular basement membrane (GBM) in one child with this disorder and in children of comparable age who had died from unrelated disorders.

METHODS

The diagnosis of DDS was confirmed by the presence of a previously described mutation in the WT1 gene (a tumour suppressor gene). The GAG content and composition of the GBM and tubular basement membrane (TBM), both in the Denys-Drash patient as well as age-matched control infants, was analysed by biochemical studies and indirect immunofluorescence studies. Finally we investigated the urinary GAG excretion of the Drash patient.

RESULTS

The biochemical studies revealed that the total GAG content in the GBM as well as TBM was comparable in the Drash patient and the control group. However, the GAG composition of the GBM of the patient was clearly different, with relatively more chondroitin sulphate. The urinary GAG content (expressed as mg GAG/mmol creatinine) was elevated in the Denys-Drash patient due to an increased heparan sulphate (HS(GAG)) excretion. Indirect immunofluorescence (IF) studies for the core protein of human GBM heparan sulphate proteoglycan (HSPG) showed a similar linear staining of all renal basement membranes in the patient and the controls. A monoclonal antibody directed against the HS chain of HSPG (MoAb 403) displayed a strong GBM and a weak TBM staining of normal kidneys. Kidney tissue from the Drash patient displayed a reduced staining of the GBM with MoAb 403. IF studies for chondroitin sulphate proteoglycan (CSPG) showed increased staining of the mesangium and glomerular capillary loops in the Denys-Drash patient which is in agreement with the biochemical studies. No discernible differences in distribution or quality of staining with antibodies against collagen type IV and laminin were observed.

CONCLUSIONS

These biochemical and immunohistochemical results indicate that in our patient the proteoglycan composition of the GBM is altered. This alteration may play a role in the pathogenesis of proteinuria in this syndrome.

A 4-year-old boy with neurofibromatosis and severe renovascular hypertension due to renal arterial dysplasia

A 4-year-old boy had severe hypertension, cardiac failure, and signs of neurofibromatosis. Arteriography disclosed renal artery stenosis in both kidneys with signs of ischemia, particularly in the right kidney. Because of insufficient response to antihypertensive therapy, a right-sided nephrectomy was performed. Histological examination of this kidney showed segmental stenosis in all branches of the renal artery. The vascular lesions were characterized by an intimal proliferation of spindle cells in a mucoid matrix with destruction of the internal elastic membrane frequently accompanied by loss or attenuation of the media and fibrosis of the adventitia. Occasionally, a nodular arrangement of the spindle cells at the interface between intima and media was observed. Immunohistochemical studies demonstrate a smooth-muscle cell origin for these cells.

Rapidly fatal Q-fever pneumonia in a patient with chronic granulomatous disease

Acute Q-fever is a systemic illness which rarely has a fatal outcome. Fatal cases do occur with the chronic form of the disease and associated with endocarditis. This report presents the case of a fatal, acute Q-fever pneumonia in an 11-year-old patient with chronic granulomatous disease. Complement fixation antibody titer rose to 1:1,024 with positive IgM in immunofluorescence. Giemsa stained lung sections and indirect immunofluorescence demonstrated the microorganisms in the tissues. The Coxiella burnetii infection was probably contracted during a holiday trip to rural France. Despite the fact that the patient received a variety of antimicrobial agents with broad spectrum activity against bacteria and fungi, coverage for Q-fever, i.e. chloramphenicol or tetracyclines, was not included.

Functional and structural determinants of glomerulosclerosis in the fawn-hooded rat

The effect of uninephrectomy (UN) at 4 months of age was studied on several parameters involved in the development of glomerulosclerosis (GS) in male spontaneously hypertensive Fawn-Hooded rats. Protein excretion per animal was significantly more increased in UN rats at 2 months after operation compared to sham operated controls (202 +/- 104 vs. 88 +/- 37 mg 24 h-1, P = 0.005) and remained significantly higher throughout the rest of the observation period. At 11 months of age UN rats had a marked increase in the incidence of GS, 37 +/- 16% compared to 5 +/- 3% (P less than 0.001) in controls. No differences were observed in mean arterial blood pressure. Functional studies in separate groups of rats at 5 months of age showed an increase in single kidney glomerular filtration rate in UN rats (0.40 +/- 0.07 vs. 0.28 +/- 0.09 ml min-1 100 g, P = 0.006). Single kidney renal plasma flow and filtration fraction were not altered. Mean glomerular volume was increased 1 month after UN (1.86 +/- 0.25 vs. 1.39 +/- 0.25 x 10(6) microns 3, P = 0.003). Urinary noradrenaline excretion per animal (24-h) showed a high sympathic nervous tone in both sham and UN rats. Total urinary dopamine and kallikrein excretion per animal were not influenced by UN. These data indicate that after UN the development of GS in this rat strain is accelerated in association with compensatory hyperfiltration and glomerular volume expansion, which may play a role in the pathogenesis of GS.

The effect of a converting enzyme inhibitor upon renal damage in spontaneously hypertensive Fawn Hooded rats

OBJECTIVE

To determine the effect of angiotensin converting enzyme inhibition (CEI) upon renal function and the incidence of glomerulosclerosis in spontaneously hypertensive Fawn Hooded rats (FHR).

DESIGN

Male FHR were treated with captopril from the age of 5 months when mild hypertension, proteinuria and glomerulosclerosis are present, and sacrificed at 12 months of age. Renal function was determined in separate groups of FHR at 6 months of age.

METHODS

Proteinuria, body weight and systolic blood pressure were determined at regular intervals. Blood pressure was measured by the tail-cuff method. Kidneys were prepared for histological examination by standard methods. Renal function was determined by inulin clearance and urinary kallikrein by an amydolitic assay.

RESULTS

In untreated FHR blood pressure, proteinuria and glomerulosclerosis increased with time. Captopril normalized blood pressure and stabilized proteinuria at pretreatment levels. At the end of the study, the incidence of glomerulosclerosis was significantly lower and comparable with the incidence at 5 months. Glomerular volume did not show a correlation with the incidence of glomerulosclerosis. Hemodynamic studies showed a significant increase of glomerular filtration rate in captopril-treated rats. No statistically significant effect was seen on renal plasma flow or filtration fraction. Urinary excretion of kallikrein was increased in captopril-treated rats.

CONCLUSIONS

CEI is effective in protecting the kidney from structural damage in hypertensive FHR even when treatment is started under conditions of established glomerular injury. The protection given by captopril is probably related to intrarenal effects.

Intrinsic vasodilation protects Wistar Kyoto rats from progressive glomerulosclerosis after unilateral nephrectomy

Genetically determined differences in functional and structural determinants that govern the development of progressive glomerulosclerosis (GS) were studied in aging sham-operated or unilaterally nephrectomized male rats of two strains. Wistar rats showed an increase of proteinuria and GS with age, which was enhanced by unilateral nephrectomy (UN). In contrast, intact and UN Wistar Kyoto rats did not show an increase of proteinuria with age and 7 months after UN, no GS was seen in these rats. Systemic blood pressure was comparable in both strains and was not affected by UN. Functional studies in a separate group of rats 1 month after UN showed an identical increase in glomerular filtration rate in both strains as compared with sham-operated controls. The Wistar rats did not show an effect of UN on renal plasma flow, and consequently, there was an increase in filtration fraction, in contrast to Wistar Kyoto rats, which showed an increase in renal plasma flow with an unchanged filtration fraction. Glomerular volume was increased in both strains at 1 month and 7 months after UN. Mesangial expansion was not observed at 1 month after UN in either strain, which indicates that this is not a decisive factor in the development of GS. These data indicate that the genetically determined susceptibility to the development of GS in these two rat strains may be related to the degree of vasoconstriction, whereas glomerular volume expansion per se does not lead to GS but can well be a consequence of hyperfiltration. These studies are concordant with previous studies that revealed the role of hemodynamics in the pathogenesis of GS irrespective of glomerular expansion.

Gene expression in derivatives of embryonic foregut during prenatal development of the rat

Proteins characteristic for the adult cellular phenotype, i.e., carbamoylphosphate synthetase (CPS) for liver and small intestine, arginase for liver, glutamate dehydrogenase (GLDH) for pancreas, liver, and small intestine, and amylase for pancreas were studied immunohistochemically in rat embryos and fetuses. At distinct developmental stages, subsets of enzymes appear synchronously in the foregut derivatives, suggesting that gene expression in the different organs is regulated by common factors. In contrast to the long-held opinion that fetal hepatocytes are a homogeneous cell population, it is shown that arginase and CPS are heterogeneously distributed between ED 16 and ED 20. This heterogeneity is related to the vascular architecture of the liver and disappears perinatally as the result of strong stimulation of enzyme synthesis. In addition, an intercellular heterogeneity in CPS content that is not related to the vasculature is observed between ED 14 and ED 20. This "random" heterogeneity reflects temporal differences in the onset of CPS accumulation in individual cells.