Distinct patterns of fracture propagation in distal radial fractures and the relationship to the ulnar head

BACKGROUND

The aim was to assess the direction of distal radius fractures and their relationship to the ulnar head.

METHODS

We reviewed the 160 wrist radiographs. The fracture line was measured on the postero-anterior and lateral radiographs relative to the long axis of the forearm and the relationship to the ulnar head.

FINDINGS

PA radiographs: the fracture line ran distal ulnar to proximal radial (ulnar to radial) in 11%, transverse in 74% and distal radial to proximal ulnar (radial to ulnar) in 16%. Lateral radiographs: the fracture line ran distal volar to proximal dorsal in 88%, transverse in two 1% and dorsal to volar in 11%. Radial shift (7.5%) only occurred with ulnar to radial or transverse fractures. The ulnar to radial fracture line started at the proximal end of the ulnar head/distal radio-ulnar joint in 88%. The radial to ulnar fracture line started ended a mean of 2.5 mm proximal to the distal radio-ulnar joint (p < 0.01). The transverse fracture line started at the base of the distal radio-ulnar joint in 53% and proximally in 47%.

INTERPRETATION

There are two distinct coronal patterns: radial to ulnar ending c. 2 mm proximal to the distal radio-ulnar joint; ulnar to radial starting at the proximal distal radio-ulnar joint. There may be third pattern - transverse fractures; these may be variants of the above. Sagittally the main direction is volar to dorsal but 11% are obverse. This is the first description of distinct fracture patterns in extra-articular distal radius fractures. In addition the fracture patterns appear to correlate with different directions of force transmission which fit with our understanding of falling and the relatively uncontrolled impact of the wrist/hand with the ground. These patterns of fracture propagation help understand how the biomechanics of wrist fractures and may enable prediction of collapse.

Reprogramming the Intrahepatic Cholangiocarcinoma Immune Microenvironment by Chemotherapy and CTLA-4 Blockade Enhances Anti-PD-1 Therapy

Intrahepatic cholangiocarcinoma (ICC) has limited therapeutic options and a dismal prognosis. Adding blockade of the anti-programmed cell death protein (PD)-1 pathway to gemcitabine/cisplatin chemotherapy has recently shown efficacy in biliary tract cancers but with low response rates. Here, we studied the effects of anti-cytotoxic T lymphocyte antigen (CTLA)-4 when combined with anti-PD-1 and gemcitabine/cisplatin in orthotopic murine models of ICC. This combination therapy led to substantial survival benefits and reduction of morbidity in two aggressive ICC models that were resistant to immunotherapy alone. Gemcitabine/cisplatin treatment increased tumor-infiltrating lymphocytes and normalized the ICC vessels and, when combined with dual CTLA-4/PD-1 blockade, increased the number of activated CD8+Cxcr3+IFNγ+ T cells. CD8+ T cells were necessary for the therapeutic benefit because the efficacy was compromised when CD8+ T cells were depleted. Expression of Cxcr3 on CD8+ T cells is necessary and sufficient because CD8+ T cells from Cxcr3+/+ but not Cxcr3-/- mice rescued efficacy in T cell‒deficient mice. Finally, rational scheduling of anti-CTLA-4 "priming" with chemotherapy followed by anti-PD-1 therapy achieved equivalent efficacy with reduced overall drug exposure. These data suggest that this combination approach should be clinically tested to overcome resistance to current therapies in ICC patients.

Transcriptional Profiling Supports the Notochordal Origin of Chordoma and Its Dependence on a TGFΒ1-TBXT Network

Chordoma is a rare malignant tumor demonstrating notochordal differentiation. It is dependent on brachyury (TBXT), a hallmark notochordal gene and transcription factor, and shares histologic features and the same anatomic location as the notochord. In this study, we perform a molecular comparison of chordoma and notochord to identify dysregulated cellular pathways. The lack of a molecular reference from appropriate control tissue limits our understanding of chordoma and its relationship to notochord. Accordingly, we conducted an unbiased comparison of chordoma, human notochord, and an atlas of normal and cancerous tissue using gene expression profiling to clarify the chordoma/notochord relationship and potentially identify novel drug targets. We found striking consistency in gene expression profiles between chordoma and notochord, supporting the hypothesis that chordoma develops from notochordal remnants. We identified a 12-gene diagnostic chordoma signature and found that the TBXT/transforming growth factor (TGF)-β/SOX6/SOX9 pathway is hyperactivated in the tumor, suggesting that pathways associated with chondrogenesis are a central driver of chordoma development. Experimental validation in chordoma cells confirms these findings and emphasizes the dependence of chordoma proliferation and survival on TGF-β. Our computational and experimental evidence provides the first molecular connection between notochord and chordoma and identifies core members of a chordoma regulatory pathway involving TBXT. This pathway provides new therapeutic targets for this unique malignant neoplasm and highlights TGF-β as a prime druggable candidate.

Placental growth factor promotes tumour desmoplasia and treatment resistance in intrahepatic cholangiocarcinoma

OBJECTIVE

Intrahepatic cholangiocarcinoma (ICC)-a rare liver malignancy with limited therapeutic options-is characterised by aggressive progression, desmoplasia and vascular abnormalities. The aim of this study was to determine the role of placental growth factor (PlGF) in ICC progression.

DESIGN

We evaluated the expression of PlGF in specimens from ICC patients and assessed the therapeutic effect of genetic or pharmacologic inhibition of PlGF in orthotopically grafted ICC mouse models. We evaluated the impact of PlGF stimulation or blockade in ICC cells and cancer-associated fibroblasts (CAFs) using in vitro 3-D coculture systems.

RESULTS

PlGF levels were elevated in human ICC stromal cells and circulating blood plasma and were associated with disease progression. Single-cell RNA sequencing showed that the major impact of PlGF blockade in mice was enrichment of quiescent CAFs, characterised by high gene transcription levels related to the Akt pathway, glycolysis and hypoxia signalling. PlGF blockade suppressed Akt phosphorylation and myofibroblast activation in ICC-derived CAFs. PlGF blockade also reduced desmoplasia and tissue stiffness, which resulted in reopening of collapsed tumour vessels and improved blood perfusion, while reducing ICC cell invasion. Moreover, PlGF blockade enhanced the efficacy of standard chemotherapy in mice-bearing ICC. Conclusion PlGF blockade leads to a reduction in intratumorous hypoxia and metastatic dissemination, enhanced chemotherapy sensitivity and increased survival in mice-bearing aggressive ICC.

Small-molecule targeting of brachyury transcription factor addiction in chordoma

Chordoma is a primary bone cancer with no approved therapy1. The identification of therapeutic targets in this disease has been challenging due to the infrequent occurrence of clinically actionable somatic mutations in chordoma tumors2,3. Here we describe the discovery of therapeutically targetable chordoma dependencies via genome-scale CRISPR-Cas9 screening and focused small-molecule sensitivity profiling. These systematic approaches reveal that the developmental transcription factor T (brachyury; TBXT) is the top selectively essential gene in chordoma, and that transcriptional cyclin-dependent kinase (CDK) inhibitors targeting CDK7/12/13 and CDK9 potently suppress chordoma cell proliferation. In other cancer types, transcriptional CDK inhibitors have been observed to downregulate highly expressed, enhancer-associated oncogenic transcription factors4,5. In chordoma, we find that T is associated with a 1.5-Mb region containing 'super-enhancers' and is the most highly expressed super-enhancer-associated transcription factor. Notably, transcriptional CDK inhibition leads to preferential and concentration-dependent downregulation of cellular brachyury protein levels in all models tested. In vivo, CDK7/12/13-inhibitor treatment substantially reduces tumor growth. Together, these data demonstrate small-molecule targeting of brachyury transcription factor addiction in chordoma, identify a mechanism of T gene regulation that underlies this therapeutic strategy, and provide a blueprint for applying systematic genetic and chemical screening approaches to discover vulnerabilities in genomically quiet cancers.

Androgen receptor is a potential novel prognostic marker and oncogenic target in osteosarcoma with dependence on CDK11

Osteosarcoma is the most common bone cancer in children and adolescents. Previously, we have found that cyclin-dependent kinase 11 (CDK11) signaling was essential for osteosarcoma cell growth and survival. Subsequently, CDK11 siRNA gene targeting, expression profiling, and network reconstruction of differentially expressed genes were performed between CDK11 knock down and wild type osteosarcoma cells. Reconstructed network of the differentially expressed genes pointed to the AR as key to CDK11 signaling in osteosarcoma. CDK11 increased transcriptional activation of AR gene in osteosarcoma cell lines. AR protein was highly expressed in various osteosarcoma cell lines and patient tumor tissues. Tissue microarray analysis showed that the disease-free survival rate for patients with high-expression of AR was significantly shorter than for patients with low-expression of AR. In addition, AR gene expression knockdown via siRNA greatly inhibited cell growth and viability. Similar results were found in osteosarcoma cells treated with AR inhibitor. These findings suggest that CDK11 is involved in the regulation of AR pathway and AR can be a potential novel prognostic marker and therapeutic target for osteosarcoma treatment.

Thermoelectric properties of double-substituted tetrahedrites Cu12−xCoxSb4−yTeyS13

This work reports on a detailed study of the thermoelectric properties of the double-substituted tetrahedrites Cu_12−xCo_xSb_4−yTe_yS₁₃ in a wide range of temperatures (5–700 K) with a peak ZT of 0.8 at 700 K.

Targeting CDK11 in osteosarcoma cells using the CRISPR-Cas9 system

Osteosarcoma is the most common type primary malignant tumor of bone. Patients with regional osteosarcoma are routinely treated with surgery and chemotherapy. In addition, many patients with metastatic or recurrent osteosarcoma show poor prognosis with current chemotherapy agents. Therefore, it is important to improve the general condition and the overall survival rate of patients with osteosarcoma by identifying novel therapeutic strategies. Recent studies have revealed that CDK11 is essential in osteosarcoma cell growth and survival by inhibiting CDK11 mRNA expression with RNAi. Here, we apply the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)-Cas9 system, a robust and highly efficient novel genome editing tool, to determine the effect of targeting endogenous CDK11 gene at the DNA level in osteosarcoma cell lines. We show that CDK11 can be efficiently silenced by CRISPR-Cas9. Inhibition of CDK11 is associated with decreased cell proliferation and viability, and induces cell death in osteosarcoma cell lines KHOS and U-2OS. Furthermore, the migration and invasion activities are also markedly reduced by CDK11 knockout. These results demonstrate that CRISPR-Cas9 system is a useful tool for the modification of endogenous CDK11 gene expression, and CRISPR-Cas9 targeted CDK11 knockout may be a promising therapeutic regimen for the treatment of osteosarcoma.

Establishment and characterization of a novel chordoma cell line: CH22

Chordoma is a rare primary malignant bone tumor and there exist only a few established human chordoma cell lines. The scarcity of robust chordoma cell lines has limited the ability to study this tumor. In this report, we describe the establishment of a novel chordoma cell line and characterize its in vitro and in vivo behaviors. The tumor tissue was isolated from a patient with recurrent chordoma of the sacrum. After 6 months in culture, the chordoma cell line, referred here as CH22, was established. Microscopic analysis of two-dimensional culture confirmed that the CH22 cells exhibited a typical vacuolated cytoplasm similar to the well-established chordoma cell line U-CH1. Electron microscopy showed cohesive cells with numerous surface filopodia, pockets of glycogen and aggregates of intermediate tonofilaments in cytoplasm. Three-dimensional culture revealed that the CH22 cells could grow and form clusters by day 8. The MTT assays demonstrated that, compared with sensitive osteosarcoma cell lines, CH22 cells were relatively resistant to conventional chemotherapeutic drugs. Western blotting and immunofluorescence analysis confirmed that the CH22 cells expressed brachyury, vimentin, and cytokeratin. Finally, histological analysis of CH22 xenograft tumor tissues demonstrated the appearance of physaliphorous cells and positive staining of brachyury, cytokeratin, and S100. By CT and MRI, imaging xenografts showed the typical appearances seen in human chordomas. These findings suggest that the established novel human chordoma cell line CH22 and its tumorigenecity in SCID nude mice may serve as an important model for studying chordoma cell biology and the development of new therapeutic modalities.

Severe scoliosis in neurodevelopmental disabilities: clinical signs and therapeutic proposals

Scoliosis is an important cause of disability in childhood, due to its incidence and limitation on ability. In neurodevelopmental disabilities, scoliosis worsens the already limited functional capacities of the child and can thwart abilities partially recovered through rehabilitation. In celebral palsied children (CP), scoliosis is considered a consequence of damage to the central nervous system or a complication of a peripheral impairment, in particular, through obliquity of pelvis, of the unilateral dislocation of hip. In order to explain the scoliosis of central origin, primitive and pathological reflexes, reactions or automatisms must be taken into account, especially the asymmetrical ones. This contradicts the absence of scoliosis in hemiplegia. On the contrary, symmetrical patterns should act as protective factors. However, the greater incidence of scoliosis in tetraplegia than in dipegia does not confirm this idea. Scoliosis is secondary when it is linked to an unilateral hip dislocation for side of convexity, proximity, measure and timing sequence. In childhood neuromuscular diseases (NMD), scoliosis is the unavoidable consequence of muscle weakness. The only protective factor may be muscle stiffness in case of fibrotic degeneration. The main curve is reducible for longer periods, while the less reducible secondary one at cervical level can limit the correction possibilities, due to the need to keep the head aliened. In spina bifida (SB) children, lesional and supralesional scoliosis can be present. In the former, the malformative ones directly derive from the vertebrae involved in the myelomeningocele and the secondary ones develop from the unilateral hip dislocation similar to CP, or from muscular imbalance (a typical feature of SB, especially for lower lumbar levels) or from primitive skeletal malformations of pelvic girdle or lower limbs. The acquired ones are caused by muscle weakness as in NMD. In the supralesional scoliosis, the curve is the consequence of an impairment in neurological structures especially of ponto-cerebellar carrefour or of an acquired tethered cord and may affect any segment of spinal column, also above the primitive lesion level. The scoliosis in neurodevelopmental disabilities can be treated conservatively with corsets and postural systems, with limited results. or through a surgical approach, often made difficult due to the multiple impairments present in the same patient.

Primary CD30/ALK-1 positive anaplastic large cell lymphoma of the skeletal muscle in a child

Anaplastic large cell lymphoma (ALCL) represents approximately 10 to 30% of all childhood non-Hodgkin lymphomas. It frequently involves both lymph nodes and extranodal sites whereas primary or secondary muscular involvements are quite uncommon. We describe a case of an 8-year-old boy presented with one month progressively swelling right buttock mass without association of lymphadenopathy or skin extension. Biopsy of the lesion showed large anaplastic cells with voluminous and abundant cytoplasm as well as folded nuclei. The tumour cells were positive for CD30, CD3, EMA and ALK-1. Chemotherapy resulted in durable remission status. This case emphasizes the occurrence of anaplastic large cell lymphoma in the soft tissue and the favourable outcome of ALK-positive anaplastic large cell lymphoma.

Endometrial stromal sarcoma presenting as a cystic abdominal mass

Endometrial stromal sarcoma (ESS) is rarely localized in extrauterine sites if metastasis or local extension of the primary uterine tumour are excluded, and diagnosis can be delayed because of the unusual site. We report a case of abdominal ESS in a 45-year-old woman who presented with an abdominal complaint. Ultrasound of the abdomen showed a large multiloculated cystic mass. The complete excision of the tumour revealed ESS arising in endometriosis. The tumour expressed hormonal receptors and the patient was administered hormonal therapy. ESS has a better prognosis than the sarcoma that is part of differential diagnosis, and is associated with endometriosis in about one-half of cases.

Primary cutaneous marginal zone B-cell lymphoma: clinical and histological aspects

According to the WHO-EORTC classification of cutaneous lymphomas, primary cutaneous marginal zone B-cell lymphoma are now well characterized. We report here a case of primary cutaneous marginal zone B-cell lymphoma in a 51 year-old man in which the diagnosis was made using both histology and immunopathology. The patient had no remarkable medical history, no history of either acute inflammation or insect bite, and presented with a 5 cm solitary asymptomatic erythematous firm, multinodular and infiltrated plaque on the back for 12 months. Histological examination and immunohistochemical study of a cutaneous biopsy provided a differential diagnosis between B cell lymphoma and lymphocytoma cutis. Full body work up revealed no signs of extracutaneous dissemination. The patient underwent surgical excision of the nodule. Histological examination showed a histological and immunophenotyping profile typical of primary cutaneous marginal zone B-cell lymphoma. The lesion was completely excised with clear margins and no recurrence occurred after a 12 month-follow-up period. Primary cutaneous marginal zone B-cell lymphoma are low-grade lymphomas that have an indolent course and a high tendency to recur. They should be differentiated from lymphocytoma cutis and from the other types of cutaneous B cell lymphomas that have a different course and prognosis.

[Malignant degeneration of benign cystic teratoma of the ovary with synchronous mediastinal teratoma. A case report]

Squamous cell carcinoma arising in mature cystic teratoma of the ovary is an uncommon complication occurring usually in elderly woman. We present an unusual case of a post-menopausal woman with a synchronous mediastinum teratoma. While ovary tumor was symptomatic, mediastinal teratoma was an incidental finding. To the best of our knowledge, this association is the first to be reported in literature.

Desmoplastic spitz nevus: report of a case and review of the literature

Desmoplastic spitz nevus (DSN) is an uncommon melanocytic lesion. The histologic features of this benign tumour may mimic those of certain benign (dermatofibroma and desmoplastic cellular blue nevus) or malignant (metastatic carcinoma and malignant melanoma) neoplasms. We report the case of a male with a DSN, and also review the clinical characteristics, histologic features and differential diagnosis of this extremely rare lesion. The lesion is identified as an asymptomatic reddish-brown dome-shaped papule on the forearm. Microscopic examination showed a symmetric lesion in the dermis. The neoplastic cells were large and epithelioid-shaped, and were either isolated as individual cells or arranged in small nests in a paucicellular hyalinized stroma. Nuclei were large and vesicular with small nucleoli and no mitoses. Diffuse expression of S100 and the absence of staining with antibodies to melan-A and HMB45 was observed. A diagnosis of DSN with free margins was made. The histologic presentation of this benign lesion mimics both benign and malignant neoplasms. The immunohistochemical profile (S100 positive, HMB-45 negative and cytokeratin negative) may be helpful to differentiate it from other lesions.

The term diplegia should be enhanced. Part II: contribution to validation of the new rehabilitation oriented classification

Recent proposals of classification for cerebral palsy (CP), mainly revised for epidemiological purposes, suggest to abandon the use of the term diplegia. Conversely, in this paper data are presented to support the proposal to maintain the distinction between spastic tetraplegia and diplegia, and to subdivide this latter according to four main clinical patterns of walking observable in these children. This proposal of classification was validated by testing a group of 467 subjects with CP, of whom 213 with diplegia and 115 with tetraplegia, consecutively admitted between January 2005 and December 2006 to two national reference centers for this disability. The results were compared with findings obtained by other methods of classifying gross and fine motor function and associated disorders. The subjects with tetraplegia strongly differ from those of diplegia, both for motor functions and for other disabilities. The four main walking patterns of spastic diplegia were easily recognizable and observers were able to assign most of the subjects to one form of the classification. Significant correlations between walking forms of diplegia and distribution of Gross Motor Function Classification System (GMFCS) levels were found. Some of the forms significantly differ also for fine motor and mental disability. These findings suggest that in clinical practice the category of diplegia not only can be kept as a separate form of CP, but it may be enhanced, through the identification of different subcategories of children, divided according to their walking patterns.

Invasive mucinous carcinoma arising within breast fibroadenoma

Malignant neoplasms arising in the epithelial component of breast fibroadenomas are rare. The most frequent types are lobular and ductal intra-epithelial carcinomas, with a minority of infiltrating carcinoma. We report a case of 36-year-old patient with invasive mucinous carcinoma (30 x 30 mm) arising in a complex breast fibroadenoma (130 x 60 x 30 mm). The patient underwent mastectomy with dissection of the axillary lymph nodes, which were free of tumour. The patient is alive without disease five years later. To the best of our knowledge, this is the first report of an invasive mucinous carcinoma arising within breast fibroadenoma. Our case provides information about the clinicopathologic characteristic of this unusual tumour.

Smooth muscle differentiation in ovarian granulosa-cell tumours: a new case report

Smooth muscle differentiation in stromal ovarian tissue has rarely been described in normal and tumoural ovaries, especially in granulosa-cell tumours. A moderately differentiated adult granulosa-cell tumour in an 83-year-old-woman is reported. Tumoural stroma included clusters of regular smooth muscle cells stained positively for smooth muscle actin. The presence of smooth muscle differentiation in an ovarian granulosa-cell tumour should be taken into consideration during diagnosis.

Small cell malignant melanoma: an unusual morphologic variant

Small cell melanoma is a recognized rare variant of malignant melanoma. We report a case of a brown, ulcerated papule on the left third finger of an 80-year-old woman. Microscopic examination revealed the presence within the epidermis of diffuse sheets of monomorphic small to medium-sized cells. The nuclei were round or oval, and hyperchromatic with inconspicuous nucleoli. Melanin pigment was either absent or minimal. This case report draws attention to the difficulties encountered in the histological diagnosis of this rare variant of malignant melanoma.

Paraganglioma: report of a rare case with ovarian involvement

We report a well-documented case of paraganglioma involving right ovary, which was initially misdiagnosed as a Sertoli-Leydig cell tumor and recurred one year later. The right ovarian tumor measured 105x90x60 mm and was associated to a subdiaphragmatic tumor measuring 80x60x35 mm, a peritoneal and a preureteral nodules measuring 10 mm either. Microscopically, tumor cells were arranged in trabeculae and cords separated by a delicate stroma. Their cytoplasm was abundant granular and eosinophilic. Their nuclei were enlarged and regular in size with coarse chromatine and a large nucleolus. The tumor expressed neuroendocrine markers (chromogranin, synaptophysin) epithelial membrane antigen and focally cytokeratin 7 and E-cadherin. Pathological ovarian paraganglioma diagnosis could be difficult but one should be aware of its bona fide existence. The clinical course is favourable in most of the cases.

[Epithelioid hemangioendothelioma of bone complicated by femoral fracture]

A 54-year-old man was seen with a fracture of the left femur. Plain radiographs revealed a 40-mm lytic centromedullary lesion. Magnetic resonance T1- and T2-weighted sequences showed high and low signals. After stabilization of the fracture, the tumor was removed followed by reconstruction with a vascularized fibula. The pathological examination demonstrated proliferation of non atypical CD34 and CD31 positive epithelioid cells with few lumens, accompanied by abundant fibrous stroma, sometimes masking tumor cells. Satisfactory motion was achieved with no recurrence at 20 months follow-up. Bone hemangioendothelioma can simulate metastasis and must be distinguished by immunohistochemistry. Prognosis is a subject of debate as the tumor is considered to exhibit intermediate malignancy by some authors while other consider it to be a malignant tumor.

Myxoid tumor of soft tissue

Focal myxoid change is a well-recognised feature of synovial sarcoma, but the presence of a predominantly myxoid stroma is rare. We describe a new case of myxoid synovial sarcoma in which marked myxoid change initially obscured the diagnosis leading to confusion with malignant peripheral nerve sheath tumor. The patient was a 16 year old man who presented with a left dorsal foot tumor. The diagnosis of synovial sarcoma was suspected on histological and immunohistochemical studies and confirmed with cytogenetic analysis. Recognition of this rare histologic variant of synovial sarcoma is important because it can easily be mistaken for other myxoid spindle cell neoplasms, potentially resulting in suboptimal therapy.