Strategic Approach to Heterogeneity Analysis of Cutaneous Adnexal Carcinomas Using Computational Pathology and Genomics

Cutaneous adnexal tumors are neoplasms that arise from skin appendages. Their morphologic diversity and phenotypic variability with rare progression to malignancy make them difficult to diagnose and classify, and there is currently no established treatment strategy. To overcome these difficulties, this study investigated the transcription factor SOX9 expression, morphology, and genetics of skin adnexal tumors for understanding their biology, especially their histogenesis. We showed that cutaneous adnexal tumors and their nontumor counterparts of skin and appendages exhibit expression patterns similar to that of SOX9. Its expression intensity and pattern, as well as histopathologic evaluation of tumors, were analyzed using digital images of 69 normal skin adnexal 9-type organs and 185 skin adnexal 29-type tumors as references. It was possible to distinguish basal cell carcinoma from squamous cell carcinoma, sebaceous carcinoma, and pilomatrixoma with significant differences, along with porocarcinoma from squamous cell carcinoma. Furthermore, unsupervised machine learning "computational pathology" was used to derive a multiregion whole-exome sequencing fusion method termed "genocomputed pathology." The genocomputed pathology of three representable adnexal carcinomas (porocarcinoma, hidradenocarcinoma, and spiradenocarcinoma) was evaluated for total nine cases. We showed that there was more heterogeneity than expected within the tumors as well as the coexistence of components lacking driver fusion genes. The presence or absence of potential driver genes, such as PIK3CA, YAP1, and PTEN, in each region was identified, highlighting a therapeutic strategy for cutaneous adnexal carcinoma encompassing heterogeneous tumors.

Clinical and pathological features of second primary neoplasms arising in head and neck reconstructive skin flaps

The incidence of second primary neoplasms arising in the skin reconstructive flap (SNAF) is increasing because of the increase in head and neck flap reconstruction and cancer survival. Prognosis, optimal treatment, and their clinicopathological-genetic features are under debate and are difficult to diagnose. We retrospectively reviewed SNAFs based on a single center's experience over 20 years. Medical records and specimens of 21 patients with SNAF who underwent biopsies between April 2000 and April 2020 at our institute were retrospectively analyzed. Definite squamous cell carcinoma and the remaining neoplastic lesions were subclassified as flap cancer (FC) and precancerous lesions (PLs), respectively. Immunohistochemical studies focused on p53 and p16. TP53 sequencing was conducted using next-generation sequencing. Seven and 14 patients had definite FC and PL, respectively. The mean number of biopsies/latency intervals was 2.0 times/114 months and 2.5 times/108 months for FC and PL, respectively. All lesions were grossly exophytic and accompanied by inflamed stroma. In FC and PL, the incidences of altered p53 types were 43% and 29%, respectively, and those of positive p16 stains were 57% and 64%, respectively. Mutation of TP53 in FC and PL were 17% and 29%, respectively. All except one patient with FC under long-term immunosuppressive therapy survived in this study. SNAFs are grossly exophytic tumors with an inflammatory background and show a relatively low altered p53 and TP53 rate and a high p16 positivity rate. They are slow-growing neoplasms with good prognoses. Diagnosis is often difficult; therefore, repeated or excisional biopsy of the lesion may be desirable.

ZFTA::RELA fusion in a distinct liposarcoma morphologically overlapping with chondroid lipoma

Chondroid lipoma is a rare benign adipose tumor characterized by a recurrent ZFTA::MRTFB fusion. Herein, we report an unusual liposarcoma that partly exhibited overlapping features with those of chondroid lipoma and harbored a ZFTA::RELA fusion. A 59-year-old man presented with a shoulder mass that had existed for approximately 8 years and with increasing pain due to a pelvic mass. The 5.8-cm resected shoulder tumor partly consisted of nests and strands of variably lipogenic epithelioid cells within a hyalinized or focally chondromyxoid stroma, indistinguishable from chondroid lipoma. The histological pattern gradually transitioned to highly cellular, stroma-poor, diffuse sheets of cells with greater nuclear atypia and mitotic activity. Vascular invasion and necrosis were present. The metastatic pelvic tumor revealed a similar histology. Despite multimodal treatment, the patient developed multiple bone metastases and succumbed to the disease 14 months after presentation. Targeted RNA sequencing identified an in-frame ZFTA (exon 3)::RELA (exon 2) fusion, which was confirmed by reverse transcription-polymerase chain reaction, Sanger sequencing, and break-apart fluorescent in situ hybridization assays. The tumor showed a different histology from that of ependymoma, no brain involvement, and no match with any sarcoma types or ZFTA::RELA-positive ependymomas according to DNA methylation analysis. p65 and L1CAM were diffusely expressed, and a CDKN2A/B deletion was present. This is the first report of an extra-central nervous system tumor with a ZFTA::RELA fusion. The tumor partly displayed an overlapping histology with that of chondroid lipoma, suggesting that it may represent a hitherto undescribed malignant chondroid lipoma with an alternative ZFTA fusion.

Soft-tissue sarcoma with MN1-BEND2 fusion: A case report and comparison with astroblastoma

MN1-BEND2 is considered as a defining gene fusion of astroblastoma. Herein, we report the first case of soft-tissue sarcoma with this fusion. The tumor developed in the abdominal wall of an 87-year-old woman, and consisted of a striking storiform growth of low-grade spindle cells admixed with a dense proliferation of oval cells with a higher nuclear atypia and mitotic activity. The sarcoma was immunohistochemically positive for actin but negative for S100 protein, glial fibrillary acidic protein, and Olig2. Targeted RNA sequencing identified an in-frame MN1 (exon 1)-BEND2 (exon 11) fusion transcript, which was validated by reverse transcription polymerase chain reaction, Sanger sequencing, and MN1 break-apart fluorescence in situ hybridization. DNA methylation profiling revealed that the tumor did not match any sarcoma classes based on the DKFZ classifier. Using T-distributed stochastic neighbor embedding analysis, the sarcoma was plotted close to the provisional class "Sarcoma (malignant peripheral nerve sheath tumor-like)," despite no phenotypic resemblance. Copy number analysis using methylation data demonstrated losses at 2q, 8p, 9p, 11p, 14q, 19q, and 22q. When compared with a cerebral astroblastoma sample with MN1 (exon 1)-BEND2 (exon 9) fusion, the sarcoma showed no resemblance in histology, immunophenotype, or DNA methylation profile, although they shared copy number loss at 14q, 19q, and 22q. The present report demonstrated that MN1-BEND2 is another example of a pleiotropic fusion gene that is shared among different tumor types.

Central mucoepidermoid carcinoma arising directly from a glandular odontogenic cyst of the mandible: a case report

BACKGROUND

Central mucoepidermoid carcinoma (MEC) is a rare salivary gland tumor that affects the jawbone. Glandular odontogenic cyst (GOC) is also a rare odontogenic developmental cyst with glandular differentiation. GOC shares some histological features with central MEC, and a pre-existing GOC can develop into central MEC. Here, we present a rare case of central MEC developed directly from a pre-existing GOC of the mandible.

CASE PRESENTATION

A 67-year-old Japanese man presented with a cystic lesion in the right third molar region. Histologically, the biopsy specimen demonstrated both typical findings of a GOC component lined with non-keratinized squamous epithelium and a recognizable component of central MEC consisting of polycystic nests with mucous cells, intermediate cells, and epidermoid cells in the cyst wall. The results from the immunohistochemistry for cytokeratin (CK) profiling demonstrated that, while both central MEC and GOC expressed CKs 7, 14, 18, and 19, CK13 was interestingly exclusively expressed in GOC. Fluorescence in-situ hybridization (FISH) revealed the rearrangement of the Mastermind like (MAML)-2 gene in both the MEC and GOC components.

CONCLUSIONS

Our case suggests that central MEC and GOC may be in the same spectrum of diseases caused by the rearrangement of the MAML-2 gene. However, given that the expression profile of CK13 was completely different between central MEC and GOC, they can be considered as separate tumors. Overall, we demonstrated a rare case in which central MEC may have originated directly from the GOC.

RB1 gene mutations are a distinct predictive factor in Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine carcinoma that tends to show local recurrence and metastasis. Typically, MCC is polyomavirus (MCPyV)-associated and cytokeratin 20 (CK20) positive. However, little is known about this tumor and its origins. Here, we aimed to determine the developmental origins of MCC and to identify prognostic clinicopathologic factors. Initial examinations revealed that CK20 and MCPyV expression (CK20+, MCPyV+ (60%); CK20+, MCPyV- (10%); CK20-, and MCPyV- (30%)) did not affect overall survival. With RB1 gene sequencing of FFPE specimens, which covered an entire exon, all RB1 mutation-positive cases showed positive regional lymph node and/or distant metastases (8/8 cases, 100%), whereas the frequency of the metastasis was statistically significantly lower in RB1 mutation-negative cases, (10/16 cases, 62%, P = 0.033). The results were also confirmed with immunohistochemistry, and either RB1 alterations, entire exon sequencing, or immunohistochemistry was associated with the metastasis (P = 0.007). RB1 alterations may be used to access the aggressive clinical course of MCC.

Mesenchymal tumours with RREB1-MRTFB fusion involving the mediastinum: extra-glossal ectomesenchymal chondromyxoid tumours?

AIMS

Ectomesenchymal chondromyxoid tumour (ECT) is a rare benign intraoral tumour which almost exclusively presents as a small mass of the anterior dorsal tongue. Recently, the RREB1-MRTFB (previously known as MKL2) fusion gene has been identified in 90% of ECTs, all located in the tongue, emphasising its genetic distinctiveness. Here, we report two mesenchymal tumours involving the superior mediastinum of adult women with RREB1-MRTFB fusions.

METHODS AND RESULTS

Both tumours presented as well-circumscribed paravertebral masses that were clinically suspected to be schwannoma. After fragmented resection, recurrence was not observed at 27 and 18 months. Although tumours were originally unclassifiable, next-generation sequencing detected identical RREB1 (exon 8)-MRTFB (exon 11) fusion transcripts, which were validated by reverse transcriptase-polymerase chain reaction, Sanger sequencing, and fluorescence in-situ hybridisation. Both tumours shared hyalinised areas with round cells embedded in a cord or reticular manner. The tumour cells showed mild nuclear atypia of possible degenerative type with very low mitotic activity, and were at least focally positive for S100, glial fibrillary acidic protein, smooth muscle actin and epithelial membrane antigen. Overall, these findings suggest that they may represent previously undescribed extra-glossal ECT involving the mediastinum. However, the histology was not classic for ECT, because that in case 2 was predominated by storiform growth of spindle cells, whereas the tumour in case 1 lacked myxoid change.

CONCLUSIONS

We have provided the first evidence that RREB1-MRTFB fusion is not limited to tumours in the head region, and whether such tumours represent extra-glossal ECTs requires further research.

Altered DNA methylation is associated with aberrant stemness gene expression in early‑stage HNSCC

Head and neck squamous cell carcinoma (HNSCC) is characterized by morphological and functional cellular heterogeneity, which are properties of progenitor cells, as opposed to cell alterations caused by accidental expression of stem cell‑related molecules. The expression levels of stemness molecules and their distribution in HNSCC are unclear. As regards sporadic cellular heterogeneity, methylation is an important factor for transcriptional regulation in tumors. Integrative screening analysis of mRNA expression and altered methylation status was performed with original microarrays in 12 tumor and non‑tumor pairs of oral squamous cell carcinoma (SCC) cases. From this data set, genes regulated via aberrant DNA methylation and classified proteins were validated by function clustering. Olfactomedin 4 (OLFM4), known as an intestinal stemness molecule and cell‑cell adhesion factor, was found to be highly expressed in tumors, with an mRNA expression ratio [tumor/normal (T/N)] of 40.7686 and low methylation (‑18.02%) in the promoter region. In addition, the OLFM4 expression levels increased following treatment with the demethylating agent 5‑azacytidine in two HNSCC cell lines. Furthermore, the expression levels of OLFM4 in 59 cases of early‑stage tongue SCC were analyzed using immunohistochemistry to examine protein expression corresponding to the histopathological definition of tumors and to evaluate prognosis. The aberrant stemness gene expression caused by altered DNA methylation appeared to regulate early‑stage HNSCC characteristics. The results of the present study indicated a correlation between OLFM4 expression and promoter methylation, and suggest that it plays an important role in tumor cell heterogeneity in HNSCC.

Recurrent YAP1-MAML2 and YAP1-NUTM1 fusions in poroma and porocarcinoma

Poroma is a benign skin tumor exhibiting terminal sweat gland duct differentiation. The present study aimed to explore the potential role of gene fusions in the tumorigenesis of poromas. RNA sequencing and reverse transcription PCR identified highly recurrent YAP1-MAML2 and YAP1-NUTM1 fusions in poromas (92/104 lesions, 88.5%) and their rare malignant counterpart, porocarcinomas (7/11 lesions, 63.6%). A WWTR1-NUTM1 fusion was identified in a single lesion of poroma. Fluorescent in-situ hybridization confirmed genomic rearrangements involving these genetic loci. Immunohistochemical staining could readily identify the YAP1 fusion products as nuclear expression of the N-terminal portion of YAP1 with a lack of the C-terminal portion. YAP1 and WWTR1, also known as YAP and TAZ, respectively, encode paralogous transcriptional activators of TEAD, which are negatively regulated by the Hippo signaling pathway. The YAP1 and WWTR1 fusions strongly transactivated a TEAD reporter and promoted anchorage-independent growth, confirming their tumorigenic roles. Our results demonstrate the frequent presence of transforming YAP1 fusions in poromas and porocarcinomas and suggest YAP1/TEAD-dependent transcription as a candidate therapeutic target against porocarcinoma.

Clinical impact of a cytological screening system using cyclin D1 immunostaining and genomic analysis for the diagnosis of thyroid nodules

Background

Fine-needle aspiration (FNA) is the most reliable method for diagnosing thyroid nodules; however, some features such as atypia of undetermined significance or follicular lesion of undetermined significance can confound efforts to identify malignancies. Similar to BRAF, cyclin D1 may be a strong marker of cell proliferation.

Methods

One hundred two patients with thyroidal nodule were enrolled in this prospective study.

Expression of cyclin D1 in thyroid nodules was determined by immunohistochemistry using both surgical specimens and their cytological specimens. The identification of the optimal cut off points for the diagnosis of malignancy were evaluated using the receiver operating characteristic (ROC) curves and the assessment of the area under the ROC curve (AUC). The specificity, sensitivity, positive predictive value (PPV) of markers were evaluated from crosstabs based on cut off points and significance were calculated. We also analyzed genetic variants by target NGS for thyroid nodule samples.

Results

The positive predictive value (PPV) and median stain ratio (MSR) of cyclin D1 nuclear staining was determined in papillary thyroid carcinoma (PPV = 91.5%, MSR = 48.5%), follicular adenoma (PPV = 66.7%, MSR = 13.1%), and adenomatous goiter and inflammation controls (MSR = 3.4%). In FNA samples, a threshold of 46% of immunolabelled cells allows to discriminate malignant lesions from benign ones (P < 0.0001), with 81% sensitivity and 100% specificity. A 46% cutoff value for positive cyclin D1 immunostaining in thyroid cells demonstrated 81% sensitivity and 100% specificity. In surgical specimens, ROC curve analysis showed a 5.8% cyclin D1 immunostaining score predicted thyroid neoplasms at 94.4% sensitivity and 92.3% specificity (P = 0.003), while a 15.7% score predicted malignancy at 86.4% sensitivity and 80.5% specificity (P < 0.0001). Finally, three tested clinico-pathological variables (extra thyroidal extension, intraglandular metastasis, and lymph node metastasis) were significant predictors of cyclin D1 immunostaining (P < 0.001).

Conclusion

Our cytological cyclin D1 screening system provides a simple, accurate, and convenient diagnostic method in precision medicine enabling ready determination of personalized treatment strategies for patients by next generation sequencing using cytological sample.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5452-4) contains supplementary material, which is available to authorized users.

SOX10 Expression as Well as BRAF and GNAQ/11 Mutations Distinguish Pigmented Ciliary Epithelium Neoplasms From Uveal Melanomas

Purpose

Adenocarcinomas or adenomas derived from pigmented ciliary epithelium (APCE) are exceptionally rare ocular tumors. These tumors have pigmented and epithelioid features, and some APCEs are negative for keratin markers and positive for melanocytic markers. It is especially difficult to distinguish APCEs from uveal melanoma (UM). Accordingly, we examined protein expression and genetic mutations associated with APCE to facilitate diagnosis.

Methods

Five APCE and 11 UM samples were obtained from patients during surgical resection at our institute. APCE and UM ocular structures were compared comprehensively. Protein expression and genetic alterations involved in malignant melanoma were evaluated.

Results

SOX10 was expressed diffusely in all 11 UMs and in surrounding uveal or choroidal melanocytes, but not in the APCEs or nontumorous pigmented epithelia. Additionally, the expression patterns of cytokeratins and melanocytic markers differed between UMs and APCEs. We identified BRAF V600E mutations in four of five APCE samples, but not in the 11 UM samples. Moreover, GNAQ or GNA11 mutations were found in 10 of the 11 UM samples, but not in APCE samples. NRAS mutations were not observed in either tumor group examined.

Conclusions

APCE is a separate entity distinguished from UM by the absence of SOX10 expression and presence of the BRAF V600E mutation. These results have implications for diagnosis, providing a means to distinguish between UM and APCE.

Accuracy of postcontrast 3D turbo spin-echo MR sequence for the detection of enhanced inflammatory lesions in patients with multiple sclerosis

BACKGROUND AND PURPOSE

Therapeutic strategies for patients with MS partly rely on contrast-enhanced MR imaging. Our aim was to assess the diagnostic performance of 3D turbo spin-echo MR imaging with variable refocusing flip angles at 3T for the detection of enhanced inflammatory lesions in patients with multiple sclerosis.

MATERIALS AND METHODS

Fifty-six patients with MS were prospectively investigated by using postcontrast T1-weighted axial 2D spin-echo and 3D TSE MR images. The order in which both sequences were performed was randomized. Axial reformats from 3D T1 TSE were generated to match the 2D spin-echo images. The reference standard was defined by using clinical data and all MR images available. Three separate sets of MR images (2D spin-echo images, axial reformats, and multiplanar images from 3D TSE sequences) were examined in a blinded fashion by 2 neuroradiologists separately for the detection of enhanced MS lesions. Image artifacts and contrast were evaluated.

RESULTS

No artifacts related to vascular pulsation were observed on 3D TSE images, whereas image artifacts were demonstrated on 2D spin-echo images in 41 patients. One hundred twelve enhanced MS lesions were identified in 19 patients. Sixty-four lesions were correctly diagnosed by using 2D spin-echo images; 90, by using 3D TSE axial reformatted views; and 106, by using multiplanar analysis of the 3D TSE sequence. Multiplanar analysis was 94.7% sensitive and 100% specific for the diagnosis of patients with at least 1 enhanced lesion. Contrast of enhanced MS lesions was significantly improved by using the 3D TSE sequence (P < .011).

CONCLUSIONS

The 3D TSE sequence with multiplanar analysis is a useful tool for the detection of enhanced MS lesions.

Diagnostic value of intraoperative ultrasonography to assess para-aortic lymph nodes in women with ovarian and uterine corpus malignancy

OBJECTIVES

To examine the ability of intraoperative ultrasonography to detect enlarged para-aortic lymph nodes, and to assess its potential use in reducing the number of unnecessary para-aortic lymphadenectomies performed in women with ovarian and uterine corpus malignancies.

METHODS

Computed tomography (CT), palpation during surgery, and intraoperative ultrasonography were used to assess whether para-aortic lymph nodes were enlarged in 163 women with ovarian and uterine corpus malignancy. All the women underwent para-aortic lymphadenectomy, and nodes were assessed for metastasis.

RESULTS

Thirty-five women had pathological para-aortic node metastasis. The sensitivity, specificity, and positive and negative predictive values of CT for the diagnosis of metastasis were 42.9, 96.1, 75.0 and 86.0%, respectively. These values were 60.0, 82.0, 47.7 and 88.2% for palpation, and 91.4, 69.5, 45.1 and 96.7% for intraoperative ultrasonography, respectively. If para-aortic lymphadenectomy had been performed only when enlarged lymph nodes were detected on CT then the number performed would have been reduced from 163 to 20 (12.3%); however, node metastasis would have been missed in 20 out of 35 women. On the same basis, the number of lymphadenectomies performed would have been 44 (27.0%) and metastasis would have been missed in 14 women on palpation during surgery, and 71 lymphadenectomies (43.6%) would have been performed and metastasis would have been missed in three women on intraoperative ultrasonography.

CONCLUSIONS

Intraoperative ultrasonography is a highly sensitive tool with which to diagnose lymph node metastasis. Its high negative predictive value allows avoidance of unnecessary para-aortic lymphadenectomy in women with ovarian and uterine corpus malignancy.

Uterine metastasis from hepatocellular carcinoma: a case report

The extrahepatic spread of hepatocellular carcinoma (HCC) is uncommon. Moreover, metastatic uterine tumor from extragenital primaries is rare. We report a 63-year-old woman with uterine metastasis from HCC. She had undergone transcatheter arterial embolization four times and surgery for HCC from 2-4 years before. This time, she underwent resection of a newborn, head-sized uterine tumor that was proven to be metastasis from HCC. This is the first described case of metastatic uterine tumor originated from HCC.

Assessment of para-aortic lymph nodes by intraoperative sonography in gynecological malignancies: a preliminary report

OBJECTIVE

To investigate the usefulness of intraoperative sonography for the assessment of para-aortic lymph nodes in gynecological malignancies.

METHODS

The assessment of para-aortic lymph node swelling by computed tomography (CT), palpation during surgery and intraoperative sonography was performed in 43 women with a gynecological malignancy. The sensitivity, specificity and predictive values of each technique for assessment of node metastasis were examined in the 33 women who underwent para-aortic lymphadenectomy. For each of the three assessment techniques, the number of para-aortic lymphadenectomies that would have been performed and the number of women who would have had missed metastasis were evaluated assuming a para-aortic lymphadenectomy would be performed only when swollen nodes were detected.

RESULTS

Para-aortic nodes were assessed to be swollen by CT, palpation, and intraoperative sonography, respectively, in one, six and 10 of 43 women in total, and in one, six and nine of the 33 women who underwent para-aortic lymphadenectomy. The sensitivity and negative predictive value of intraoperative sonography were 100%, while the specificity and positive predictive value of CT were 100%. If para-aortic lymphadenectomy had been performed only when swollen nodes were detected by intraoperative sonography, the number performed would have decreased from 33 to nine without missing lymph-node metastasis.

CONCLUSION

Intraoperative sonography has potential for the assessment of para-aortic lymph nodes in gynecological malignancies.

Effects of pulsed ultrasound on development and glucose uptake of preimplantation mouse embryos

The effects of pulsed ultrasound (US) on early mouse embryos were investigated. Two-cell embryos contained in oviducts were irradiated to US (1.875 MHz with an I (SPTA) of 2.96 W/cm(2)) in an experimental unit for either 1 or 5 min (exposure groups). The embryos were cultured to examine the rate of developing to blastocysts, and the uptake of 2-deoxyglucose (2-DG) into blastocysts was measured to evaluate their viability. The rates in the exposure groups were essentially the same, with those of the embryos treated similarly in the unit unless being exposed to US (nonexposure groups). However, they were lower than that of embryos not treated in the experimental unit (a control group). There were no significant differences of 2-DG uptake among the 1-min exposure, 1-min nonexposure, and control groups. The uptake in the 5-min exposure group did not differ from that in the 5-min nonexposure group; however, uptake in both groups was lower than that in the control group. Pulsed US for 1 min did not affect viability of preimplantation mouse embryos.

Tumor cell spillage to the vaginal cavity and vaginal stump during the surgery of endometrial carcinoma

BACKGROUND

Our purpose was to investigate the spillage of the endometrial carcinoma cells to the vaginal cavity and vaginal stump during the surgery.

METHODS

Cytologic examination of specimens obtained from the vaginal cavity and vaginal stump during surgery performed on 15 patients with endometrial carcinoma. And the risk factors of carcinoma cell spillage to the vaginal cavity were investigated.

RESULTS

Carcinoma cells from the vaginal cavity were negative for nine patients and positive for six patients. Those from the vaginal stump were negative for l4 patients and positive for one patient. In one patient, both were positive. Total abdominal hysterectomy might be one risk of carcinoma cell spillage to the vaginal cavity compared with modified radical hysterectomy and radical hysterectomy.

CONCLUSIONS

Endometrial carcinoma cells were spilled into the vaginal cavity in not a few cases and their spillage from there to the vaginal stump could follow during the surgery.

Generation of periventricular leukomalacia by repeated umbilical cord occlusion in near-term fetal sheep and its possible pathogenetical mechanisms

Periventricular leukomalacia (PVL) is a major cause of cerebral palsy. However, pathogenetic mechanisms of PVL have not been fully understood. Although it has been postulated that umbilical cord compression is related to the development of PVL, no animal experiments clearly demonstrated an association of umbilical cord occlusion with 'periventricular' white matter lesions. The purpose of this study is to determine whether umbilical cord occlusions could produce periventricular white matter lesions in fetal sheep and to examine how changes in fetal cardiovascular and metabolic variables are related to the induction of brain damage. Fourteen near-term fetal sheep underwent umbilical cord occlusion (3-min total cord occlusions 5 times at 5-min intervals). Dissections performed 24 h after cord occlusion revealed that periventricular white matter lesions were produced in 7 out of 14 sheep fetuses. According to the pattern of brain damage, we classified the fetal sheep into three groups: 5 fetuses with dominant lesions in the periventricular white matter (group I), 4 fetuses with brain lesions in the cerebral cortex and thalamus (group II) and 5 fetuses with no or minimal brain lesions (group III). Group I showed higher blood pressure and higher plasma lipid peroxide levels before cord occlusion compared to the other groups, while group II showed systemic hypotension during cord occlusion. No significant differences in changes in pH, PaCO2, PaO2 and heart rate were found between the three groups. It is speculated that PVL might be produced by an association of preexisting chronic circulatory instability with an acute episode of severe repetitive cord occlusion.

Fetal size as a determinant of obstetrical outcome of post-term pregnancy

HYPOTHESIS

We hypothesized that there might be differences in the outcomes of post-term pregnancy according to fetal size.

METHODS

A retrospective analysis of 143 women with uncomplicated pregnancy that persisted beyond 42 weeks was conducted. Ultrasound dating was performed between 8 and 14 weeks in all cases. The obstetrical outcomes were compared between the cases in which neonatal birth weight was <3,600 g (non-large group) and >/= 3,600 g (large group).

RESULTS

In primiparous women, there was no significant difference between the non-large and large groups in terms of the rate of cesarean section, but the rate of cesarean section for fetal distress in the non-large group was significantly higher than that found in the large group. In addition, the non-large group showed a significantly higher incidence of low pH (<7.20) compared with the large group (14/58 vs. 0/22, p < 0.01). In contrast, the rate of prolonged labor (>24 h) and induction failure in the non-large group were significantly lower than that in the large group. In multiparous women, there was no significant difference in obstetrical outcomes between the non-large and large groups.

CONCLUSIONS

Primiparous women who were delivered of fetuses weighing not less than 3,600 g at post-term periods were at lower risk of fetal distress on the one hand and at higher risk of induction failure associated with infavorable cervix on the other. This study suggests that post-term pregnancy should be dealt with differently based on fetal weight.

Early axonal and glial pathology in fetal sheep brains with leukomalacia induced by repeated umbilical cord occlusion

We conducted a chronic preparation experiment involving near term fetal sheep to evaluate the contribution of umbilical cord occlusion to fetal brain injury. In experimental groups (n = 11), complete cord occlusion for 3 min followed by 5 min release, repeated 5 times were performed at 3 days after initial surgery. Instrumental cases without cord occlusion (n = 3) and uninstrumental twins (n = 6) were also examined as controls. Multiple necrotic foci predominantly in the periventricular white matter were found in the fetal brains examined at 1-3 days after cord occlusion. To estimate the contribution of early axonal and glial reaction to brain injury the following immunohistochemical study was performed. In the lesions, coagulation necrosis, axonal swelling and microglial activation were demonstrated with amyloid precursor protein or ionized calcium binding adapter molecule 1 immunohistochemistry. The induction of tumor necrosis factor alpha and inducible nitric oxide synthase were also detected immunohistochemically in the microglia at 1 and 3 days after cord occlusion. In contrast, the reaction of glial fibrillary acidic protein positive astrocytes was faint at 1 day after occlusion, but the induction of cyclooxygenase-2 was observed. These findings suggest the glial reaction of cytokines and free radicals induced by fetal hypoxia may contribute to the occurrence of brain injury.

A case of ovarian hyperstimulation syndrome in which antithrombin III deficiency occurred because of its loss into ascites

OBJECTIVE

To present a case of ovarian hyperstimulation syndrome in which antithrombin III activity in plasma was decreased and in ascites was increased.

DESIGN

Case report.

SETTING

Hospital-based clinic for reproductive medicine.

PATIENT(S)

A 27-year-old woman who was transferred to our hospital because of ovarian hyperstimulation syndrome.

INTERVENTION(S)

Induced abortion.

MAIN OUTCOME MEASURE(S)

Antithrombin III activity in plasma and ascites.

RESULT(S)

Antithrombin III activity in ascites was slightly lower than that in plasma.

CONCLUSION(S)

The loss of antithrombin III into ascites probably caused its deficiency in this case.

Inferior vena cava diameter and the risk of pregnancy-induced hypertension and fetal compromise

OBJECTIVE

Our objective was to investigate a possible clinical usefulness of the measurement of the inferior vena caval diameter (IVCD) during the late second trimester in predicting obstetrical complications.

METHODS

IVCD was measured in the supine and complete left lateral positions in 281 pregnant women at 24-27 weeks' gestation.

RESULTS

In 35 cases who showed the IVCD < or = 10 percentile in the complete left lateral position, there were six cases with pregnancy-induced hypertension and seven cases with a compromized fetus (with fetal distress and/or an Apgar score < 7 at 1 min), each incidence being significantly higher compared with cases with IVCD > 10 percentile.

CONCLUSION

The measurement of IVCD in the complete left lateral position may provide a valuable tool in predicting pregnancy outcome given its non-invasiveness and easiness.

Comparison of umbilical artery Doppler velocimetry between maternal supine position and complete left lateral position in predicting obstetric complications

The aim of this study was to compare the predictive value of umbilical artery Doppler velocimetry in women in the supine position with that in women in the complete left lateral position as a screening test for abnormal obstetric outcomes. Umbilical artery resistance index (RI) was measured at 27-29 weeks and 35-37 weeks in 202 pregnant women. The measurements were performed with the mother in the supine position in 100 cases (supine group), and in the complete left lateral position in 102 cases (lateral group). Predictive values of the tests for abnormal outcomes (small for gestational age, fetal distress, pregnancy-induced hypertension) were compared between both groups. When abnormal RIs were defined as being greater than the 90th centile in the supine group, the sensitivities for any of the abnormal outcomes at 27-29 weeks were 18% in the supine group and 6% in the lateral group; the positive predictive values were 30% and 25%, respectively. For measurement at 35-37 weeks, the sensitivity and positive predictive value were 29% and 45%, respectively in the supine group, and 0% in both cases in the lateral group. When abnormal RIs were defined as being greater than the 90th centile in the lateral group, the sensitivities at 27-29 weeks were 41% in the supine group and 6% in the lateral group; the positive predictive values were 44% and 8%, respectively. At 35-37 weeks, the sensitivity and positive predictive value were 53% and 43% in the supine group, and 6% and 8% in the lateral group. Umbilical artery Doppler velocimetry when the mother was in the complete left lateral position was of little value as a screening test. However, when the mother is in the supine position, it may serve as a kind of stress test and disclose latent obstetric abnormalities in certain cases.

Metabolic and endocrine responses to cold exposure in chronically incubated extrauterine goat fetuses

To investigate developmental aspects of metabolic and endocrine responses to cold exposure in fetuses, we conducted experiments on six goat fetuses, three aged 95-116 d of gestation (dGA; group I), and three aged 122-134 dGA (group II), using an extrauterine fetal incubation system that provided arterio-venous extracorporeal membrane oxygenation (A-V ECMO). The fetuses were cannulated via the umbilical vessels, and their blood gas exchange was totally supported by A-V ECMO, while they were maintained in an isothermal incubator containing artificial amniotic fluid. After confirming that fetuses were in metabolically stable condition in the extrauterine incubation system, fetal core temperature was lowered by 2 degrees C over 2 h by decreasing the temperature of incubating fluid from 39.5 degrees C. During and after cold exposure, fetal heart rate and arterial blood pressure remained unchanged. We observed significant increases in oxygen consumption and plasma concentrations of norepinephrine, epinephrine, adrenocorticotropic hormone, and cortisol in group II but not in group I fetuses. In addition, based on regression analysis, maximal changes of these parameters during cold exposure were linearly correlated with gestational age significantly, and the regression lines were found to intersect the x (gestational age) axis at around 98-106 dGA. These results suggest that metabolic and endocrine responses to cold exposure develop with gestational age in the goat fetus, the responses being manifested around 100 dGA.

Differential developmental process of respective behavioral states in human fetuses

The presence of behavioral states has been recognized in human fetuses. However, developmental process of fetal behavioral states remains to be clarified. In thirty-one normal pregnant women between 20 and 41 weeks' gestation, fetal movements were examined by using multiple ultrasonic machines. The entire period was divided into eye movement (EM), no eye movement (NEM), and unclassified periods according to the mode of appearance of rapid eye movements. We investigated changes in the ratio of EM and NEM periods and the incidence of various fetal movements in these periods. The ratio of EM periods increased stepwise between 20 and 32 weeks. The difference in the incidence of "startle" and jaw movements between EM and NEM periods was found at 24-27 and 32-35 weeks, respectively. We found a significant decrease in the incidence of total body movements exclusively in NEM periods at 36-39 weeks and a significant increase in the incidence of "rolling" in EM periods at 40-41 weeks. Eye opening was ultrasonographically recognized, providing evidence for awake state in the human fetus. This study revealed the characteristic appearance of fetal movements as related to the presence or absence of EM during the second half of pregnancy, and thereby pointed to differential development process of behavioral states of human fetuses.

Doppler blood flow velocity waveforms of the umbilical artery during variable decelerations in labor

OBJECTIVE

To investigate the changes in resistance indices of blood flow velocity waveforms of the umbilical artery (UmA-RIs) during variable decelerations (VDs) vs. early decelerations (EDs).

METHODS

UmA-RIs were measured before and during uterine contractions in 30 cases with VDs, nine cases with EDs and 20 cases without decelerations. In 12 out of 30 cases with VDs, UmA-RI was determined at the following five stages of a VD; before the deceleration, downward, bottom, upward and resumption stages.

RESULTS

UmA-RIs during VDs were significantly higher compared with those at preceding periods. UmA-RIs at downward and bottom stages of VDs were significantly higher than those at the upward stage, although no differences in heart rate were found between downward and upward stages. UmA-RIs during EDs or uterine contractions without decelerations did not differ from those preceding them.

CONCLUSION

UmA-RIs increased during VDs, particularly at downward and bottom stages during which the cord seemed to be actually compressed.

Successful thoracoamniotic shunting using a double-flower catheter in a case of fetal cystic adenomatoid malformation associated with hydrops and polyhydramnios

We describe a case of congenital cystic adenomatoid malformation treated by thoracoamniotic shunting using a double-flower catheter. An ultrasound examination at 25 weeks' gestation revealed a cystic mass within the fetal thoracic cavity, hydrops and polyhydramnios. Thoracoamniotic shunting under ultrasound guidance using a double-flower catheter was performed at 27 weeks. The procedure not only decompressed the lung cyst but also improved the secondary physiological changes, i.e. mediastinal shift, hydrops and polyhydramnios. A 2438-g male neonate was delivered at 37 weeks with no respiratory problems and resection of the right lower pulmonary lobe was successfully performed 24 h after birth.

Influence of compression of the inferior vena cava in the late second trimester on uterine and umbilical artery blood flow

OBJECTIVE

To evaluate the inferior vena cava compression and its influence on the uterine and umbilical artery blood flow in the late second trimester when the mother is supine.

METHODS

The inferior vena cava diameter was measured by ultrasound B mode scan, and Doppler flow velocimetry of the uterine and umbilical artery was performed in 90 women at 24-27 weeks in the supine and complete left lateral position.

RESULTS

The inferior vena cava diameter in the supine position was significantly smaller than that in the lateral position. The degree of the vena cava compression was associated with an elevation in the uterine artery RI in the supine position. The umbilical artery RI did not couple with either the degree of the compression or the changes in the uterine artery RI.

CONCLUSION

The inferior vena cava is compressed in the majority of pregnant women in the second trimester, and the compression may affect the uterine artery blood flow but not the fetal circulation.

Intrauterine ultrasonography with a high-frequency probe: preliminary report

Intrauterine ultrasonography was performed using miniature probes and high-frequency ultrasound to examine the possible clinical applications of this technique to gynecology. There were 44 women in the study population (age 19-76; ten with a normal uterus, nine fibromyoma, 15 endometrial cancer, ten cervical cancer). The probe was easily introduced into the endometrial cavity in 36 subjects (81.8%). No notable complications were encountered. In subjects with a normal uterus, the endometrium in the secretory phase showed a clearly demarcated hyperechoic area, and higher resolution was obtained than with transvaginal scanning. In patients with fibromyomas, myoma nodules were not clearly visualized because of the attenuation of ultrasound. Myometrial invasion of endometrial cancer was estimated correctly in ten of the 11 patients in which the lesion was visualized. In the subjects with cervical cancer, intracervical scanning was completed in only five cases, and an endocervical lesion was identified in three cases. Intrauterine ultrasonography with a high-frequency miniature probe may be a useful tool, especially in the preoperative evaluation of endometrial cancer and possibly in infertility practice. However, this modality does not appear to be satisfactory for cervical lesions.

Transvaginal sonographic appearance of hemorrhagic functional ovarian cysts and their spontaneous regression

OBJECTIVES

To obtain information on the characteristic feature of transvaginal sonograms of hemorrhagic functional ovarian cysts (HFOCs) and their natural course.

METHODS

Thirty-four cases of suspected HFOC based on our tentative criteria were ultrasonically followed-up for 3 months. After the study period, the sonographic findings and their changes with time were analyzed.

RESULTS

Twenty-four cases were clinically diagnosed as HFOCs, as the masses disappeared naturally. At the first examination, 5 cases (20.8%) showed a diffuse echogenic pattern which seems to consist of a blood clot, 9 (37.5%) were mixed pattern with a clearly demarcated solid part, 3 (12.5%) were hyperechoic sponge-like reticular pattern and 7 (29.2%) were cysts including vague echo inside which looked cotton-like. Seven masses (29.2%) disappeared within 2 weeks and the remaining had a different sonographic appearance with time until they disappeared finally within 8 weeks.

CONCLUSIONS

HFOCs show the characteristic changes in transvaginal sonographic appearance and can be diagnosed by short-term follow-up.

[Clinical study of post-term pregnancy]

One hundred fourteen cases of post term pregnancy were clinically analyzed and classified. 1. In case of primipara, the duration of labor was longer and the frequency of prolonged labor (greater than 24 hours) was higher than that of the same number of cases of term delivery at 39 weeks. 2. The main cause of prolonged labor was weak pains. 3. The mean newborn umbilical artery pH in prolonged labor cases was not lower than that in other cases. 4. The cases of post-term pregnancy were classified into 4 groups and compared each other in several respects. Group I: prolonged labor(-), fetal distress(-), vaginal delivery. Group II: prolonged labor(-), fetal distress(+), vaginal delivery. Group III: prolonged labor(-), fetal distress(+), cesarean section. Group IV: prolonged labor(+). 1) The length of the fundus uteri: Group III: minimum after 31 weeks: Group IV: maximum after 35 weeks. 2) The body weight of the newborn and the weight of the placenta: Group III: minimum: Group IV: maximum. 3) The titer of E3 in urine: Group III: obviously low. 4) The frequency of Clifford's sign: Group III: high frequency of meconium staining. Cases of post-term pregnancy were composed of several groups with different clinical features.

pH dependence of the binding constants of N-acetylglucosamine monomers to hen and turkey egg-white lysozymes

The binding constants of N-acetylglucosamine (G1cNAc) and its methyl alpha- and beta- glycosides to hen and turkey egg-white lysozymes [EC 3.2.1.17], in the latter of which Asp 101 is replaced by Gly, were determined at various pH values by measuring changes in the circular dichroic (DC) band at 295 nm. The binding of beta-methyl-G1cNAc to turkey and hen lysozymes perturbed the pK value of Glu 35 from 6.0 to 6.5, the pK value of Asp 52 from 3.5 to 3.9, and the pK value of Asp 66 from 1.3 to 0.7. In addition, perturbation of the pK value of Asp 101 from 4.4 to 4.0 was observed in the binding of this saccharide to hen lysozyme. The binding of alpha-methyl-GlcNAc to hen and turkey lysozymes perturbed the pK value of Glu 35 to the alkaline side by about 0.5 pH unit, the pK value of Asp 66 to the acidic side by about 0.5 pH unit, and the pK value (4.4) of an ionizable group to the acidic side by about 0.6 pH unit. The last ionizable group was tentatively assigned to Asp 48. The pK value of Asp 52 was not perturbed by the binding of this saccharide. The pH dependence curves for the binding of GlcNAc to hen and turkey lysozymes were very similar and it was suggested that Asp 48, in addition to Asp 66, Asp 52, and Glu 35, is perturbed by the binding of GlcNAc.