Smad4 and epithelial-mesenchymal transition proteins in colorectal carcinoma: an immunohistochemical study

Epithelial-mesenchymal transition (EMT) plays an important role in cancer metastasis. During EMT, tumor cells acquire the capacity to migrate and invade the stroma. Activation of the transforming growth factor-b (TGF-b) signaling pathway is of major importance for the initiation of EMT. Smad4, an essential protein of this pathway, is known to complex with multiple transcription factors (e.g. Snail-1, Slug, Twist-1), in various types of cancer, promoting the repression or activation of target genes. The role of Smad4 in colorectal cancer (CRC) is not straightforward so far. In the present study forty eight resected CRC tumor specimens were immunohistochemically examined in order to assess the expression of Smad4 and its association with E-cadherin, Snail-1, Slug, Twist-1 protein expression and with various pathological parameters. Smad4 was found to be positively correlated with Snail-1, Slug and Twist-1 expression (p < 0.001). On the other hand it was negatively correlated with the expression of E-cadherin (p < 0.001). Furthermore, lymphatic invasion could be clearly associated with Smad4 expression, a finding complying with the metastatic ability of EMT cells. In conclusion, Smad4 could be considered as a central component of EMT transition in human colorectal cancer that combines with transcriptional factors to reduce E-cadherin and alter the expression of the epithelial phenotype.

Expression profile of the GA733 gene family in colorectal cancer: correlation with clinicopathological parameters

GA733-1/-2/-3 genes have been detected in various types of cancer, although their role has not been fully clarified. GA733-2 and GA733-1 have been correlated with lymph node metastases in laryngeal cancer and liver metastases, respectively. Only a few studies have elucidated the mechanisms regulating GA733-1/-2 expression and their effect on colorectal cancer. Therefore, the expression pattern and the role of the aforementioned molecules in colorectal carcinogenesis were evaluated in this study. Tissue samples were obtained from 40 patients with colorectal cancer with no liver metastases. GA733-1/-2 mRNA levels were evaluated by quantitative real-time polymerase chain reaction. GA733-1/-2 gene expression in noncancerous/cancerous tissues was also correlated with clinicopathological parameters. The GA733-1 mRNA levels were very low; however, the GA733-1 mRNA transcripts were higher in cancerous tissues than in normal tissues (median ratio, 0.004391/0.00093; range, 0.000001- 0.025139/0.000001-0.007761), respectively (P = 0.012). GA733-2 gene expression was higher in noncancerous tissues than in cancerous tissues (median ratio 273.31/115.64; range, 65.24-1,486.41/11.58-1,189.14; P = 0.0000195). Lower GA733-2 expression in cancer tissues appeared to correlate with lymph node metastases (P < 0.05). GA733-1 gene expression was significantly higher in cancerous samples; conversely, the GA733-2 mRNA levels were higher in noncancerous tissues, and were significantly correlated with lymph node perforation in colorectal cancer (P < 0.05). Therefore, GA733-1/-2 mRNA expression levels appear to be a potential predictive marker of tumorigenesis.

Open inguinal hernia repair with the use of polyglycolic acid/trimethylene carbonate mesh: gross and pathologic assessment of the inguinal area at reoperation for recurrence

PURPOSE

Our group tried to test the hypothesis of using a totally absorbable material for open inguinal hernia repair. However, the increased incidence of recurrences alleviated our initial enthusiasm regarding the technique. The purpose of the present study was to attain both gross and microscopic data that could at least in part justify the hernia repair failure from a patient included in our initial pilot study and was re-operated for recurrence.

METHODS

A 65-year-old male patient was diagnosed clinically with a recurrence 24 months after open inguinal hernia repair with the use of polyglycolic acid/trimethylene carbonate mesh. The patient was operated for the recurrence upon our group on July 2012. The gross appearance of the inguinal area as well as the degree of chronic inflammation provoked by the used mesh as depicted by the pathologic analysis of specimens obtained intraoperatively were assessed.

RESULTS

An open tension-free repair with the use of a non-absorbable mesh under spinal anesthetic was undertaken. Intraoperatively, after the division of the external oblique aponeurosis, only minor fibrotic reaction was observed a finding that was additionally confirmed pathologically.

CONCLUSION

Polyglycolic acid/trimethylene carbonate mesh used for inguinal hernia repair was associated with a minimal inflammatory host reaction in the inguinal area at 3 years verified both grossly and microscopically.

Uric acid induces caspase-1 activation, IL-1β secretion and P2X7 receptor dependent proliferation in primary human lymphocytes

BACKGROUND

Urate through Nacht Domain, Leucine-Rich Repeat, and pyrin domain-containing protein 3 (NALP3) dependent caspase-1 activation stimulates macrophages to secrete inteleukin-1β (IL-1β). Purinergic receptor P2X7 plays a role in the urate induced NALP3 activation. Urate also enhances adaptive immunity indirectly through its effect on antigen presenting cells. In this study, the direct effect of urate on primary human lymphocytes was evaluated.

METHODS

Lymphocytes were cultured with or without monosodium urate crystals in the presence or not of a P2X7 inhibitor. Caspase-1 activity was assessed colorimetrically in cell lysates and IL-1β was measured in supernatants with ELISA. Whole lymphocyte viability and proliferation, as well as T-cell proliferation were assessed by means of 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide (XTT) assay and of flow cytometry respectively.

RESULTS

Urate induced caspase-1 activation and IL-1β release by lymphocytes. It also induced proliferation of whole lymphocytes and T-cells as well. P2X7 inhibitor abrogated lymphocyte proliferation.

CONCLUSIONS

Urate, a well defined danger signal, stimulates directly human lymphocytes in a P2X7 dependent way. The subsequent IL-1β secretion could enhance inflammation, whereas expansion of lymphocyte clones could facilitate a subsequent adaptive immune response.

Open inguinal hernia repair with the use of polyglycolic acid/trimethylene carbonate absorbable mesh: a critical update of the long-term results

PURPOSE

Our group evaluated on a pilot basis open inguinal hernia repair with the use of a fully absorbable mesh aiming to take mesh inguinal hernia repair one step forward. The purpose of the present study was to assess the long-term results of the proposed technique.

METHODS

Patients that were included in our previous report were followed up at 3 years after the initial operation.

RESULTS

Ten patients underwent open inguinal hernia repair with the use of an absorbable polyglycolic acid/trimethylene carbonate mesh. 3 years after the procedure, from the total of ten patients, two were lost to follow-up (20 %). Three patients (37.5 %), one with direct and two with indirect hernia, were diagnosed clinically with a recurrence at the follow-up of 3 years. Recurrences were developed nearly 2 years--median 24 months (range 18-30)--after the initial operation. Among patients without recurrence none complained about chronic pain, foreign body sensation or numbness. On the other hand, chronic pain was a constant complain in the recurrence patient group.

CONCLUSIONS

The results of the 3-year follow-up in the given patient sample alleviate the initial enthusiasm regarding the use of an absorbable mesh for inguinal hernia repair as an attractive alternative and causes skepticism about the generalized use of the procedure in its certain form.

Different patterns of p16 immunoreactivity in cervical biopsies: correlation to lesion grade and HPV detection, with a review of the literature

p16 is one extensively studied marker in gynecological pathology. However, its routine application in the diagnosis of squamous intraepithelial lesions of the uterine cervix may present difficulties for the general pathologist. The aim of the present study was to examine a series of 100 cervical biopsies/LEEP specimens, with detailed HPV-typing, for patterns of p16 immunoreactivity and possible correlations with morphology and HPV types. Four patterns of immunopositivity were recognized, according to the distribution of positively stained cells, and these correlated to lesion grade. A review of the pertinent literature concerning p16 immunoreactivity in squamous intraepithelial lesions and nonneoplastic epithelia of the uterine cervix is included in an effort to summarize the existing data and the remaining questions at both the practical and theoretical level.

Impact of the metabolic syndrome and its components combinations on arterial stiffness in Type 2 diabetic men

AIM

Arterial stiffness (AS) is a risk marker of atherosclerosis and coronary artery disease, yet its association with metabolic syndrome (MS) in diabetic patients is not established. The aim of this study was to investigate possible association of MS or its components with AS in diabetic population and to identify the MS definition which better correlates with AS.

METHODS

Overall, 98 type-2 diabetic men, mean age 64+/-10 years, were classified into groups according to the presence of MS, using the National Cholesterol Educational Program-Adult Treatment Panel III (NCEP-ATPIII) and International Diabetes Federation (IDF) definition. AS was estimated using carotid-femoral pulse wave velocity (PWV). For between-group comparisons and correlations between MS and it's components with AS, t-test and Pearson's correlation coefficient were employed, respectively. For multivariable analysis a linear regression model was used.

RESULTS

PWV in those with (72.5%) and without NCEP-ATPIII MS was 13.4+/-2.9 vs 12+/-3.2 m/s (P=NS) and in those with (79.6%) and without IDF MS 13.6+/-2.8 vs 11+/-3.2 m/s (P=0.036). AS positively correlated with IDF MS (r=0.332, P=0.036), increased blood pressure (r=0.324, P=0.037), and the combination of increased waist circumference according to IDF with hypertension (r=0.380, P=0.013); no correlation with NCEP-ATPIII MS was detected. In multivariable analysis, age, hypertension, and IDF MS were independently associated with AS (beta=2.52, P=0.039).

CONCLUSIONS

IDF MS is independently associated with increased AS in diabetic men. Additionally, abdominal obesity, hypertension and older age were likely to be associated with increased AS. PWV measurement may be indicated in such patients.

Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography

The aim of the study was to evaluate the diagnostic accuracy of Color Doppler US, CT Angiography (CTA), and GD-enhanced MR Angiography (MRA) compared with digital subtraction angiography (DSA) for the detection of renal artery stenosis in patients with clinically suspected renovascular hypertension. Fifty-eight patients with suspected renovascular hypertension were enrolled in the study. All patients underwent Color Doppler US, CTA and GD-enhanced MRA. DSA was the gold standard method for the number of renal arteries, existence and degree of stenosis, or evidence of fibromuscular dysplasia. DSA depicted 132 renal arteries, 16 stenoses, and 4 arteries with fibromuscular dysplasia. Color Doppler US failed to detect 1 main and 14 polar arteries. CTA depicted all main renal arteries and 7/16 polar arteries, but failed to detect stenosis in two accessory vessels. Likewise, MRA did not detect stenotic accessory renal arteries, depicted 9/16 polar renal arteries, but missed two main renal arteries. All methods depicted the four main renal arteries with fibromuscular dysplasia. The overall sensitivity, specificity, and positive and negative predictive accuracy were 75%, 89.6%, 60% and 94.6%, respectively, for color Doppler US; 94%, 93%, 71%, and 99%, respectively, for CTA; and 90%, 94.1%, 75%, and 98%, respectively, for GD-enhanced MRA. CTA and GD-enhanced MRA have comparable and satisfactory results with respect to the negative predictive accuracy of the suspected renal artery stenosis. The concept of an imaging algorithm including US as screening test when appropriate and CTA or MRA as the second step-procedure is suggested. Therefore, DSA may be reserved for cases with major discrepancies or therapeutic interventions.

Serum osteoprotegerin and RANKL are not specifically altered in women with postmenopausal osteoporosis treated with teriparatide or risedronate: a randomized, controlled trial

Risedronate and teriparatide have opposite actions on the osteoblast-osteoclast dipole and are expected to influence the RANK/RANKL/osteoprotegerin (OPG) system. We aimed to evaluate changes in serum OPG and RANKL after risedronate or teriparatide administration in postmenopausal osteoporotic women. Seventy-four postmenopausal Caucasian women (age 64.1+/-1.0 years) were studied. Women with osteopenia served as controls (group 1, n=30). Women with osteoporosis were randomly assigned to either risedronate 35 mg once weekly (group 2, n=21) or teriparatide 20 microg once daily (group 3, n=23) for six months. Blood samples for serum RANKL, OPG, N-terminal propeptide of type 1 collagen (P1NP), and C-terminal telopeptide of type 1 collagen (CTx) were obtained before treatment and three and six months after treatment. P1NP and CTx levels remained unchanged in group 1, decreased in group 2 (p<0.001), and increased in group 3 women (p<0.001) throughout the treatment. OPG levels remained unchanged while RANKL decreased gradually in all groups (p<0.001). There was no correlation between OPG or RANKL and P1NP or CTx. Our data suggest that neither antiresorptive nor osteoanabolic therapy causes specific alterations of serum OPG/RANKL levels; therefore, these cytokines cannot substitute for the established markers of bone turnover in the monitoring of response to osteoporosis treatment.

Malakoplakia of the colon associated with colonic adenocarcinoma diagnosed in colonic biopsies

Malakoplakia, typically involving the urinary tract, is an uncommon form of chronic inflammation caused by chronic infections and characterized by accumulation of macrophages. It has also been found in many other sites such as the gastrointestinal tract, pancreas, liver, lymph nodes, skin, respiratory tract, adrenal gland, vagina and brain. We present a case of a 64-year-old man referred to our hospital with cachexia and radiologic evidence of metastatic tumor of the liver. Colonoscopy revealed a large malignant - appearing polypoid mass of the ascending colon and multiple distinct polyps throughout the rest of the colon. Biopsies of the ascending colon mass confirmed the diagnosis of adenocarcinoma. Histological examination of two of the other polyps revealed malakoplakia which was characterized by aggregates of granular histiocytes with Michaelis - Gutmann bodies and histochemically confirmed with periodic acid-Schiff and von Kossa stains. This is a rare case diagnosed on endoscopic samples. The majority of reported cases were found in surgical specimens. In addition, the endoscopic appearance of multiple polyps is unusual in malakoplakia.

Retinoid receptor alpha and Beta expression in serous ovarian tumors

The expression of retinoid acid receptors alpha (RARalpha) and beta (RARbeta) and estrogen receptor alpha (ERalpha) was assessed by immunohistochemistry and Western blotting in normal ovaries, serous cystadenoma (n = 20), serous borderline (n = 14), and serous ovarian cancer (n = 47) and was correlated in cancer cases with stage, grade, progress-free survival (PFS), and survival. RARalpha was increasingly expressed in benign cystadenomas, borderline, and low-stage and advanced-stage neoplasms (p < 0.001). In stage III, G3 serous carcinoma, increased RARalpha expression was an independent prognostic factor associated with lower chemoresponse to first-line chemotherapy (taxol and carboplatin) and shorter PFS (p < 0.002).RARbeta and ERalpha expression did not correlate with RARalpha tumor characteristics or PFS and survival.

L1 (CAM) (CD171) in ovarian serous neoplasms

PURPOSE OF THE INVESTIGATION

The evaluation of L1 (CAM) as a tumor progression marker and as a prognostic factor in serous ovarian tumors.

METHODS

L1 (CAM) protein expression was assessed by immunohistochemistry and Western blot in serous ovarian tumors [cystadenomas (n = 20), borderline tumors (n = 14) and carcinomas (n = 47)], and was correlated with stage,grade, progression-free survival time (PFS) and overall survival.

RESULTS

L1 (CAM) immunoreactivity correlated significantly with stage and grade. It increased from benign tumors to early carcinomas and to advanced stage carcinomas progressively and significantly. In Stage III G3 carcinoma patients, low L1 (CAM) expressing tumors exhibited better response to chemotherapy and were associated with statistically significantly longer PFS (p = 0.002).

CONCLUSION

L1 (CAM) expression represents a novel diagnostic marker in serous ovarian neoplasms that shows characteristics of tumor progression. L1 expression was associated with chemotherapy response.

Fascin can be an auxiliary immunomarker of ovarian granulosa cell tumors: comparison with calretinin and inhibin-alpha

The histopathologic diagnosis of granulosa cell tumor adult type (AGCT) can be supported by the use of established immunomarkers such as inhibin-alpha and calretinin. Previously unreported data is presented on the detection of fascin in AGCT, in nonneoplastic granulosa cells and in other types of sex-cord stromal tumors. In addition, by staining a panel of various tumors, potentially included in the differential diagnosis of AGCT, we assessed the value of fascin as an auxiliary AGCT immunomarker. Intense and strong fascin staining may assist in cases with ambiguous calretinin or inhibin-alpha staining. On the contrary, absence of fascin should question a provisional morphologic diagnosis of AGCT.

Immature teratoma in pregnancy: a case report and literature review

BACKGROUND

The management of a Stage I immature teratoma during pregnancy with a review of the literature is reported.

CASE REPORT

A growing adnexal mass was removed at 12 weeks of gestation. Although the frozen section was negative, because of intraoperative clinical suspicion, a right salpingo-oophorectomy and surgical staging were performed. Histological examination revealed a Stage Ia, grade 1 immature ovarian teratoma. Appropriate surgical staging enabled avoidance of chemotherapy despite the unexpected histological diagnosis. The pregnancy was terminated because of fetal distress, with cesarean section at 34 weeks of gestation. At that time the peritoneal cavity was inspected and biopsies were taken as in second-look laparotomy. Two years after the first operation the patient remains disease free.

CONCLUSION

For adnexal masses removed during pregnancy frozen section is useful but when there is clinical suspicion surgical staging must be performed.

Xanthogranulomatous salpingitis: report of three cases and comparison with a case of pseudoxanthomatous salpingitis

Xanthogranulomatous inflammation, an uncommon form of chronic inflammation, has been described in several organs including those of the female genital tract. A rare condition described as pseudoxanthomatous salpingitis or pseudoxanthomatous salpingiosis, which is often associated with endometriosis, has been distinguished from xanthogranulomatous inflammation of the fallopian tube based on its histological features. In the present report three cases of xanthogranulomatous salpingitis and one case of pseudoxanthomatous salpingitis are presented and their clinical, pathological and histochemical features are compared.

Acute and chronic effect of teriparatide on glucose metabolism in women with established osteoporosis

There is indirect evidence of unfavorable effects of parathyroid hormone (PTH) on glucose metabolism. Teriparatide (recombinant human PTH 1-34-TPTD) has recently been available for the treatment of osteoporosis. The aim of this prospective study was to evaluate the acute and chronic effect of TPTD on blood glucose and insulin levels in women with established osteoporosis. Twenty-three postmenopausal women with established osteoporosis (mean age 65.6+/-1.8 years) received daily injections of 20 mg TPTD for six months. Three oral glucose tolerance tests (OGTT) were performed: one day before the first injection (OGTT-basal), one hour after (OGTT-acute) and six months after initiation of therapy (OGTT-chronic). There were significant differences between the OGTT-basal and OGTT-acute values in glucose at 90 min (168.3+/-9.8 vs. 180.6+/-9.2, p<0.05) and 120 min (152.0+/-8.7 vs. 170.5+/-7.8, p<0.01), between the OGTT-basal and OGTT-chronic values for glucose at 90 min (168.3+/-9.8 vs. 184.5+/-13.3, p<0.05) and between the OGTT-basal and OGTT-acute for insulin at 90 min (56.7+/-7.4 vs. 68.7+/-8.2, p<0.01). These differences remained significant for the subgroup of patients with normal (n=8) but not impaired glucose tolerance or diabetes mellitus (n=15). TPTD seems to have an acute, subclinical adverse impact on stimulated glucose levels, possibly due to insulin resistance. This impact tends to subside when TPTD is continued on a chronic basis.

Echocardiographic evaluation of mitral tethering for 'chordal cutting' procedure

'Chordal cutting' is a recently proposed surgical option for the treatment of functional mitral regurgitation due to leaflet tethering. With this technique the surgeon sections second order chordae, restores leaflet's convexity towards the left atrium and eliminates mitral incompetence. Preoperative assessment of tethering mechanism, degree of leaflet distortion, surface of coaptation, annular dilation, origin and quantification of valve incompetence by echocardiographic means is essential in indicating this surgical option. Intraoperative transesophageal evaluation is crucial to assess the morphology and the absence or degree of residual incompetence after procedure.

A bioequivalence study of Levothyroxine tablets versus an oral Levothyroxine solution in healthy volunteers

Probably for genetic reasons a substantial part of the Greek population requires Levothyroxine treatment. Since commercially available Levothyroxine was first marketed, the manufacture and storage of the drug in tablet form has been complicated and difficult; and as cases of therapeutic failure have frequently been reported following treatment with this medicinal agent, quality control is an essential factor. Due to the unreliability of Levothyroxine-based commercial products, in the present study we decided to follow the Food and Drug Administration (FDA) guidelines*, and use a Levothyroxine solution as reference product. The bioavailability of the Levothyroxine sodium tablet formulation THYROHORMONE/Ni-The Ltd (0.2 mg/tab) and that of a reference oral solution (0.3 mg/100 ml) under fasting conditions were compared in an open, randomized, single-dose two-way crossover study. Twenty four healthy Caucasian volunteers (M/F=15/9, mean age=32.9+/-7.4yr) participated in the study. Bioavailability was assessed by pharmacokinetic parameters such as the area under plasma concentration-time curve from time zero up to the measurable last time point (AUC(last)) and the maximum plasma concentration (Cmax). Heparinized venous blood samples were collected pre-dose and up to a 48-hour period post-dose. Levothyroxine sodium in plasma samples was assayed by a validated electrochemiluninescent immunoassay technique. Statistical analysis showed that the post-dose thyrotropin-stimulating hormone (TSH) levels decreased significantly (p<0.05). Regarding Levothyroxine (T4), the point estimate of the test formulation to the reference formulation ratios (T/R) for AUC(last) and Cmax was 0.92 with 90% confidence limits (0.90, 0.94) and 0.93 with 90% confidence limits (0.91, 0.94), respectively. Regarding triiodo-L-thyronine (T3), the point estimate for the T/R ratios of AUC(last) and Cmax was 0.92 with 90% confidence limits (0.90, 0.95) and 0.94 with 90% confidence limits (0.92, 0.95), respectively. The 90% confidence limits for the pharmacokinetic parameters AUC(last) and Cmax lie within the acceptance limits for bioequivalence (0.80, 1.25), for both T3 and T4.

The effects of acute exercise on serum adiponectin and resistin levels and their relation to insulin sensitivity in overweight males

The purpose of this study was to investigate the effects of a submaximal aerobic exercise bout on adiponectin and resistin levels as well as insulin sensitivity, until 48 h post-exercise in healthy overweight males. Nine subjects performed an exercise bout at an intensity corresponding to approximately 65% of their maximal oxygen consumption for 45 min. Adiponectin, resistin, cortisol, insulin, glucose and insulin sensitivity were measured prior to exercise, immediately after exercise as well as 24 and 48 h after exercise. Data were analyzed using repeated measures ANOVA while Pearson's correlations were performed to identify possible relationship among the assessed variables. There were no significant differences for adiponectin (microg ml(-1)) [pre, 3.61(0.73); post, 3.15(0.43); 24 h, 3.15(0.81); 48 h, 3.37(0.76)] or resistin (ng ml(-1)) [pre, 0.19(0.03); post, 0.13(0.03); 24 h, 0.23(0.04); 48 h, 0.23(0.03)] across time. Insulin sensitivity increased and insulin concentration decreased significantly only immediately after exercise. Furthermore, no significant correlations were observed among the variables assessed except for the expected between insulin level and insulin sensitivity. These results indicate that a submaximal aerobic workout does not result in significant changes in adiponectin and resistin up to 48 h post-exercise. Furthermore, it appears that adiponectin or resistin is not associated with insulin sensitivity.

Correlation of estrogen receptor beta gene polymorphisms with spinal bone mineral density in peri- and post-menopausal Greek women

Estrogens play a significant role in bone physiology. Their action is mainly exerted through their receptors. Estrogen receptor alpha (ERalpha) plays a major role in bone homeostasis and there is evidence suggesting that estrogen receptor beta (ERbeta) has also an effect on BMD. We investigated the possible effect of two ERbeta gene polymorphisms on spinal bone mineral density (BMD) and metabolic bone markers in Greek women. Spine BMD as well as biochemical bone markers were measured in 147 healthy peri- and post-menopausal women [mean age (S.D.) 54 (7.9) years]. Genotyping was performed for two restriction fragment length polymorphisms (RFLPs) of ERbeta gene, RsaI in exon 5 and AluI in exon 8. For each polymorphism studied the cohort was divided into two groups: the "wild-type" group (RR and AA, respectively) and the "carrier" group including subjects with at least one allele with the restriction site (Rr&rr and Aa&aa, respectively). The distribution of RsaI genotypes was RR: 91.2% (n = 134), Rr: 8.2% (n = 12), and rr: 0.6% (n = 1) and of AluI genotypes AA: 36.7% (n = 54), Aa: 57.2% (n = 84), and aa: 6.1% (n = 9). No linkage disequilibrium was found between the two polymorphic sites studied. Spine BMD did not differ significantly in the two groups of either polymorphism, after adjusting for age, weight, height, and years since menopause [mean BMD (S.D.) for RR 0.841 (0.17) g/cm(2) versus Rr&rr 0.798 (0.13) g/cm(2), p = 0.25, and mean BMD (S.D.) for AA 0.828 (0.16)g/cm(2) versus Aa&aa 0.848 (0.17) g/cm(2), p = 0.32]. No significant differences were noted in metabolic bone markers except for a marginal difference of RR versus Rr/rr in urinary hydroxyproline/creatinine ratio [median (IQR) 3.88 (6.04) micromol/mmol in RR versus 8.2 (4.32) micromol/mmol in Rr/rr, p = 0.05]. Furthermore, no interaction between the two polymorphisms on BMD was found. In conclusion, in a Greek female post-menopausal population, the two ERbeta gene polymorphisms were not associated with BMD, or metabolic bone markers.

Apolipoprotein E polymorphism is not associated with spinal bone mineral density in peri- and postmenopausal Greek women

OBJECTIVES

A number of studies have shown a positive relation between ApoE gene and osteoporosis or fracture risk but this finding has not been uniform in all populations studied. The aim of the present study was to determine the possible effect of ApoE gene polymorphism on spinal bone mineral density and metabolic bone markers in Greek women.

METHODS

One hundred and forty-seven healthy peri- and postmenopausal women (mean age 54.3 +/- 7.8 years) participated in the study. In all participants, ApoE gene genotype was determined and spinal bone mineral density (BMD) as well as biochemical bone markers were measured. The ApoE genotypes distribution was 0.7% (n = 1) for E2/2, 5.4% (n = 8) for E2/3, 2% (n = 3) for E2/4, 73.5% (n = 108) for E3/3, 16.3% (n = 24) for E3/4 and 2% (n = 3) for E4/4. Participants were divided in two groups according to the presence of the E4 haplotype: E4 carriers (n = 30) and E4 non-carriers (n = 117).

RESULTS

Spinal BMD was similar in the two groups, after adjusting for age, weight, height and years since menopause (mean +/- S.D., 0.835 +/- 0.16 g/cm2 in E4 non-carriers versus 0.831 +/- 0.16 g/cm2 in E4 carriers, P = 0.99). Serum osteocalcin levels did not differ significantly in the two groups (median (interquartile range, IQR), 0.55 (0.58) nmol/l in E4 non-carriers versus 0.51 (0.43) nmol/l in E4 carriers), whereas urinary hydroxyproline/creatinine ratio was significantly higher in the E4 non-carriers group (median (IQR), 5.18 (6.04) micromol/mmol in E4 non-carriers versus 1.73 (3.45) micromol/mmol in E4 carriers, P < 0.01). Urinary pyridinoline/creatinine and deoxypyridinoline/creatinine ratios, measured in a subgroup of 51 women, were similar between ApoE carriers and non-carriers, respectively (median (IQR), 25.1 (9.3) nmol/mmol in E4 non-carriers versus 21.8 (7) nmol/mmol in E4 carriers and 6.7 (3.1) nmol/mmol in E4 non-carriers versus 7 (2.2) nmol/mmol in E4 carriers).

CONCLUSION

In conclusion, in a Greek female postmenopausal population, ApoE gene does not seem to play an important role in determining BMD and neither does it affect the majority of metabolic bone markers.

The effects of a single bout of exercise on resting energy expenditure and respiratory exchange ratio

We investigated the effects of a single bout of aerobic and resistance exercise of similar relative intensity and duration on resting energy expenditure (REE) and substrate utilisation. Ten young healthy males volunteered [age 22 (1.8) years, weight 76 (7.9) kg, height 176 (4.1) cm, percentage body fat 10.5 (4.0)%; mean (SEM)]. They randomly underwent three conditions in which they either lifted weights for 60 min at 70-75% of 1-RM (WL), ran for 60 min at 70-75% of maximal oxygen intake (R) or did not exercise (C). REE and substrate utilisation, determined via respiratory exchange ratio ( R), were measured prior to exercise, and 10, 24, 48 and 72 h post-exercise. It was revealed that REE was significantly elevated ( P<0.05) 10 and 24 h after the end of WL [2,124 (78) and 2,081 (76) kcal, respectively] compared to pre-exercise [1,972 (82) kcal]. REE was also significantly increased ( P<0.05) 10 and 48 h after the completion of R [2,150 (73) and 1,995 (74) kcal, respectively] compared to pre-exercise data [1,862 (70) kcal]. R was lower 10 and 24 h following either WL or R [0.813 (0.043); 0.843 (0.040) and 0.818 (0.021); 0.832 (0.021), respectively] compared to baseline measurements [0.870 (0.025) and 0.876 (0.04), respectively]. Creatine kinase was significantly elevated ( P<0.05) 24 h after both WL and R, whereas delayed onset muscle soreness became significantly elevated ( P<0.05) 24 h after only WL. There were no significant changes for any treatment in thyroid hormones (T(3) and T(4)). These results suggest that a single bout of either WL or R exercise, characterised by the same relative intensity and duration, increase REE and fat oxidation for at least 24 h post-exercise.

Obliterative muscularization of the small bowel submucosa in Crohn disease: a possible mechanism of small bowel obstruction

CONTEXT

The pathology of small bowel obstruction in Crohn disease has not been studied extensively. Stricture formation has been attributed mainly to fibrosis, although muscularization of the submucosa has been discussed previously.

OBJECTIVE

To identify additional pathologic changes in Crohn disease that could be involved in the formation of strictures.

DESIGN

We reviewed 50 ileal resections from patients with Crohn disease. The histopathologic slides were reviewed initially without knowledge of the macroscopic or clinical findings. We identified an unusual muscular proliferation that we refer to as obliterative muscularization of the submucosa, defined as a thick and continuous muscle layer from the mucosal base to the muscularis propria that is at least 1 cm in length. Subsequently, histopathologic findings were correlated with macroscopic and clinical findings.

RESULTS

Obliterative muscularization of the submucosa was present in 14 specimens, and in 11 of these 14 it was topographically restricted to strictures. Submucosal fibrosis was observed in sections from adjacent regions. Obliterative muscularization of the submucosa, including thick-walled vessels and hyperplastic nerves but not prominent scarring, was more common in specimens with strictures; the difference was statistically significant (P <.001).

CONCLUSIONS

Obliterative muscularization of the submucosa may be pathogenetically involved in the formation of strictures either directly by causing a sustained spasm, or indirectly by minimizing the vasoprotective role of the submucosa, impairing repair and enhancing scarring.

Immunohistochemistry of the liver and biliary tree in extrahepatic biliary atresia

BACKGROUND

Progressive destruction of intrahepatic bile ducts may determine outcome in extrahepatic biliary atresia (EHBA) despite successful portoenterostomy. The aim of this study was to characterize the inflammatory infiltrate of a large series of cases of biliary atresia and relate these findings to clinical outcome.

METHODS

Immunohistochemical analysis was performed on frozen tissue sections of extrahepatic biliary tree and liver biopsies obtained (August 1996 to March 1998) from 28 infants with EHBA and 8 liver biopsy specimens from age-matched controls with other cholestatic liver disorders. A semiquantitative scoring system was designed to evaluate the staining with a panel of antibodies to the CD4, CD8, CD25, CD56, CD68, CD71 antigens and to HLA-DR, ICAM-1, VCAM-1, E-selectin and LFA-1. The infants then underwent followup prospectively and divided into 2 prognostic groups at 12 months postoperatively: those who had cleared their jaundice (graded as a good outcome [n = 19]), and those who required liver transplantation or who had failed to clear their jaundice (defined as > 50 micromol/L; graded as poor outcome [n = 9]).

RESULTS

CD4(+) lymphocytes and CD56(+) (NK cells) predominated in the liver of infants with EHBA as compared with controls. The infiltrating cells exhibited marked proliferation (CD71 expression) and activation (particularly LFA-1 but also CD25 expression). A smaller subpopulation of the cells also expressed VCAM and E-selectin. HLA-DR was strongly expressed on Kupffer cells and to a lesser extent on proliferating bile ducts and sinusoidal endothelium. Expression of the majority of markers was lower in the remnant bile duct tissue than in the liver of EHBA (P <.05) with only HLA-DR and LFA-1 (on infiltrating cells) and ICAM (on endothelium) expressed strongly in the remnant bile duct tissue. Although quantitatively less pronounced, all of these immunohistochemical features also were noted in non-EHBA cholestatic liver tissue. A good outcome at 12 months was associated with lower CD68 (macrophage) expression in both the liver (P <.05) and biliary tree (P <.05) and with reduced expression of ICAM-1 (P =.05) on infiltrating cells in the biliary remnant.

CONCLUSIONS

Immunohistochemical patterns of immune-mediated liver injury and inflammation were prevalent features at the time of portoenterostomy. They were neither exclusive to nor characteristic of EHBA. A reduction in the expression of the macrophage marker (CD68) within the liver and biliary remnants and reduction of ICAM-1 expression on infiltrating cells in the biliary remnants appear to be associated with a better postoperative prognosis.

Seventh Day Syndrome--acute hepatocyte apoptosis associated with a unique syndrome of graft loss following liver transplantation

AIM

The aim of this study is to describe a unique 7th day syndrome (7DS), quite different from other causes of post-transplantation allograft dysfunction in a group of orthotopic liver transplant (OLT) patients who needed retransplantation.

METHODS

A retrospective analysis of 594 consecutive OLT over an 8-year period revealed that 10 patients developed allograft dysfunction approximately 7 days following an initially normal graft function.

RESULTS

The features included: (a) severe liver failure; (b) sudden peak of extremely high liver enzymes at approximately day 7; (c) serial liver biopsy findings of central lobular hemorrhage with minimal inflammatory cell infiltrate and (d) an explant with no evidence of vascular thrombosis. The biochemical and morphometric pathological data of these patients were compared with data of patitents who had early acute rejection (AR), hepatic artery thrombosis (HAT), primary nonfunction (PNF), severe sepsis and no dysfunction. Lastly, serial liver core biopsies and explants were tested for evidence of apoptosis, which revealed a significantly higher number of apoptotic hepatocytes in 7DS compared to all control groups.

CONCLUSIONS

Seventh Day Syndrome is a distinct entity associated with early graft dysfunction characterized by a marked apoptosis of hepatocytes. Fas receptor activation or other pathways of program cell death may be implicated in occurrence of 7DS.

Superoxide dismutase activity in children with chronic liver diseases

BACKGROUND/AIMS

Liver disease in infancy has multiple etiologies. As reactive oxygen intermediates are involved in several types of tissue damage, we have investigated whether different forms of liver disease in infancy are associated with increased free radical generation, using an indirect approach in which superoxide dismutase (a free radical scavenger) activity is determined in the liver tissue.

METHODS

A total of 48 liver biopsies performed at diagnosis were evaluated retrospectively. Nine infants had biliary atresia, eight Alagille syndrome, seven alantitrypsin deficiency and 12 cryptogenic hepatitis. As controls we studied 12 biopsies with normal histology obtained from seven children with portal vein thrombosis and five children who underwent biopsy for management reason but had no liver disease. Superoxide dismutase activity in liver biopsy specimens was measured using the cytochrome C method by spectrophotometry and expressed as U SOD/mg protein.

RESULTS

Superoxide dismutase activity was significantly increased in biliary atresia (1.25 +/- 0.56 U SOD/mg protein, p<0.0001) and Alagille syndrome (1.31 +/- 0.56 U SOD/mg protein, p<0.0001) as compared with al-antitrypsin deficiency (0.75 +/- 0.3 U SOD/mg protein), neonatal hepatitis (0.72 +/- 0.37 U. SOD/mg protein) and normal controls (0.4 +/- 0.7 U. SOD/mg protein). The highest level of SOD activity was found, however, in control children with portal vein thrombosis (2.09 +/- 0.96 U SOD/mg protein; p<0.0001 as compared to the other groups).

CONCLUSION

Superoxide dismutase, a key enzyme in free radical protection, is increased significantly in the liver tissue of infants with cholestatic liver disease due to bile duct damage and in children with portal vein thrombosis, suggesting that products of free radical reactions are involved in the pathogenesis of these disorders.

Infantile liver giant cells: immunohistological study of their proliferative state and possible mechanisms of formation

The mechanism of liver giant cell formation is not clarified. Some authors consider the giant cells regenerative, others, degenerative. Paraffin sections of 10 archival cases of idiopathic neonatal hepatitis (INH), 8 of extrahepatic biliary atresia (EHBA), and 5 normal liver samples were immunostained with two well-characterized cell proliferation markers: anti-PCNA monoclonal antibody (MAb) (clone PC-10) and MAb MIB-1, which detects Ki-67, a nuclear proliferation-related antigen. In addition, polyclonal antibody to carcinoembryonic antigen (CEA) was used to identify remnants of canalicular, therefore hepatocytic, membranes in giant cells. Quantitative analysis of immunostaining was done by estimating PCNA and Ki-67 indices separately in giant cells and in nongiant hepatocytes. In normal samples, mean PCNA and Ki-67 indices were 1. 22% and 0.74%, respectively. In the cases of INH and EHBA, only a small minority of giant cells showed PCNA or Ki-67 staining limited to occasional peripherally located nuclei. PCNA and Ki-67 indices were significantly higher in the non-giant cell compartment. CEA staining was seen only in rare giant cells as centrally located canalicular remnants bordered by polarized nuclei, suggesting that they had been formed from rosettes through dissolution of cell membranes. Other giant cells shared CEA-labeled canalicular membranes with mononuclear hepatocytes in rosettes. These findings indicate that the giant cells in INH and EHBA are not regenerative cells, they are not formed by amitotic division of nuclei in syncytia, and that fusion of rosette-forming hepatocytes is a possible mechanism of their formation.

Differentiated thyroid cancer: a retrospective analysis of 832 cases from Greece

OBJECTIVE

To analyse the initial manifestations, pathological findings, therapy, outcome and prognostic factors in patients with papillary and follicular carcinoma.

PATIENTS

832 patients with well differentiated thyroid carcinoma managed in our department during a period of 30 years (1965-1995). Follow-up data were available for 609 patients for a mean of 5.5 years (range 1-38 years), the remainder having been lost to follow-up.

RESULTS

The patients were 677 (81%) with papillary and 155 with follicular carcinoma. They were predominantly female (75%), presenting mainly with a single nodule (53%), while at the time of diagnosis 72% had intrathyroidal carcinomas (class I), 17% had nodal metastases (class II), 7% soft tissue invasion (class III) and 4% distant metastases (class IV). Fifty-five percent of the patients had a complete thyroidectomy (36% had a near total or total thyroidectomy and 19% near total or total thyroidectomy plus block dissection), 2.6% received external radiotherapy and 94% had radioactive iodine as part of the treatment of the original disease. Kaplan-Meier survival analysis was used to calculate both cancer related mortality and disease free survival in the patients followed-up. Although mortality (21 cancer-related deaths) was slightly higher for follicular than papillary carcinoma (10% vs. 5% and 16% vs. 10% in 10- and 15-year survival, respectively) the difference was not statistically significant. Extent of disease at diagnosis, male sex, tumour size and age > 60 years affected probability of cancer death. Cox's proportional hazard regression analysis for disease free survival showed that adverse independent prognostic factors were, for papillary carcinoma, male sex, class II or higher, tumour size > 1 cm and age > 60 years, while for follicular, class III or higher, size > 4 cm and age > 40 years.

CONCLUSIONS

We conclude that there is a higher prevalence of follicular carcinoma in our country probably due to a moderate degree of iodine deficiency still existing in Greece. Age and extent of disease at diagnosis were important prognostic factors affecting morbidity and mortality, whereas sex, tumour features and histological type were of minor importance. All these prognostic factors and their relative importance should be taken in consideration in the management of this disease.

Autoimmune hepatitis: a histological variant associated with prominent centrilobular necrosis

A patient presented with pruritus and recent elevation of aminotransferases. The case fulfilled most of the criteria for the diagnosis of autoimmune hepatitis and achieved clinical and complete biochemical response to steroid therapy. However, the liver biopsy specimen revealed an unusual histological pattern consisting of severe centrilobular necrosis demarcated by a thin rim of hepatitic reaction. In contrast, the portal tracts appeared almost normal. This histological appearance has not been associated with autoimmune hepatitis. This presentation and the histology may represent an early pattern of autoimmune injury to the liver.

Cryosurgery of breast cancer

OBJECTIVE

To determine the feasibility and efficacy of cryosurgery of breast cancer.

DESIGN

In phase 1, carcinogen-induced mammary adenocarcinomas in 13 Sprague-Dawley rats were treated by cryosurgery and were then examined for histopathologic change. In phase 2, transplantable mammary adenocarcinomas in 50 DBA/IJ mice were treated by cryosurgery to determine the effect of varying tumor temperatures, and duration and number of freeze-thaw cycles on tumor viability. In phase 3, 2- to 3-cm ultrasound-monitored cryolesions were formed in the breasts of 4 dogs and 4 sheep. These animals were followed up for procedure-related complications; the histopathologic necrosis of the cryolesions were correlated with the ultrasound images. Based on the results of these experiments, ultrasound-guided cryosurgery of breast cancer was initiated in a human clinical trial.

RESULTS

In phase 1, a single, short-term (< 7 minutes) freeze killed only tumors smaller than 1.5 cm in diameter, despite an apparent decrease to -40 degrees C at the periphery of each tumor. In phase 2, varying the peripheral tumor temperature to as low as -70 degrees C, using a single, short-term (< 7 minutes) freeze did not alter the results from phase 1. If the ice ball fully encompassed the tumor, however, maintaining it for at least 15 minutes achieved 100% tumor kill independent of tumor size. In phase 3, creation of a reproducible ultrasound-monitored cryolesion was facilitated when 2 freeze-thaw cycles were performed. No procedure-related complications were noted. In the human trial, 2 invasive lobular carcinomas from 1 patient were treated by cryosurgery and were negative for persistent tumor by core needle biopsy performed 4 and 12 weeks after a well-tolerated procedure.

CONCLUSIONS

In situ breast cryosurgery has been proved to be feasible and efficacious in small and large animal studies and has been successfully performed in 1 patient with breast cancer. The results of this study suggest that ultrasound-guided cryosurgery of breast cancer warrants further investigation.

Selective tumorigenesis in non-parenchymal liver epithelial cell lines by hepatocyte growth factor transfection

Hepatocyte growth factor (HGF) has been recently suggested to contribute to tumorigenesis by an autocrine mechanism in fibroblast cells overexpressing its receptor, the MET/HGFR protein. Since epithelial cells represent the primary physiologic target of HGF, we investigated whether inappropriate expression of HGF by epithelial cells which normally express MET/HGFR may also contribute to tumorigenesis. We have transfected a full length rat HGF gene into three mouse epithelial cell lines, one derived from breast (MM55) and two (BNL CL.2 and NMuLi) representing liver non-parenchymal epithelial cells (NPEC). We confirmed the presence of the transfected gene by Southern blot analysis, the production of HGF protein by immunofluorescence, and the preservation of HGF biologic activity by bio-assay. In comparison to untransfected cells, all three HGF-transfected cell lines displayed high level MET/HGFR autophosphorylation and increased ability to proliferate in media containing low serum. The two HGF-transfected liver NPEC lines, but not the HGF-transfected mammary cell line, displayed loss of cell contact growth-inhibition and acquired a markedly increased ability to form colonies in soft agar. Furthermore, the NPEC HGF-transfected cell lines formed much larger tumors in nude mice than the untransfected counterparts, with extensive invasion and sporadic lung metastases. These results demonstrate that overexpression of HGF in at least some epithelial cells contribute to tumorigenesis, and furthermore suggest a possible role for the HGF-MET/HGFR system in the progression of certain epithelial tumors.

The use of granulocyte colony-stimulating factor after liver transplantation

Granulocyte colony-stimulating factor (G-CSF) increases the number of circulating granulocytes and decreases TNF production while improving survival in sepsis models. To study the effects of G-CSF administration on sepsis and rejection, 37 primary liver allograft recipients received intravenous recombinant human G-CSF (rhG-CSF; 5-10 micrograms/kg/day) for the first 7-10 days following transplantation, targeting a blood absolute granulocyte count of between 10,000 and 20,000 cells/mm3. These recipients were monitored prospectively for sepsis and rejection, as were the previous 49 primary liver allograft recipients who did not receive G-CSF. Both groups utilized identical protocol immunosuppression and standardized diagnosis and treatment of sepsis and rejection. Univariate and logistic regression analysis of risk factors for sepsis and rejection revealed no difference between the two patient groups. G-CSF-treated patients developed an increased absolute granulocyte count over time (P < 0.0001, repeated-measures analysis of variance). G-CSF-treated patients had a decreased number of sepsis episodes per patient (0.92 +/- 1.5 vs. 2.18 +/- 2.8, P < 0.02, t test), and a lower percentage of sepsis-related deaths (8% vs. 22%, P < 0.04, chi-square test). The incidence of acute rejection was decreased in the G-CSF-treated group (22% vs. 51%, P < 0.01, chi-square test). These pilot data support further investigation into G-CSF's favorable effects on sepsis and rejection.

Leflunomide controls rejection in hamster to rat cardiac xenografts

Leflunomide is an isoxazole derivative that has the ability to prevent acute rejection of cardiac, renal, and skin transplants in strongly rejecting rat models. Furthermore, leflunomide is able to interact synergistically with CsA to inhibit allograft rejection and also reverse ongoing allograft rejection. In vitro studies suggest that the mechanism of action of leflunomide is via an interruption of cytokine signaling in T cells. This study defines the ability of leflunomide to prevent and reverse rejection of concordant xenografts. One hundred nine adult Lewis rats in 13 groups received abdominal heterotopic cardiac transplants from Golden Syrian hamsters. The xenograft survived 3.9 +/-0.3 days without treatment. When leflunomide was given at 2.5, 5, 10, 15, or 20 mg/kg by gavage daily, the cardiac xenograft survivals were 5.0 +/- 0.6, 8.0 +/- 3.0, 52.0 +/- 20.2, 76.5 +/- 21.14, and 58.9 +/- 28.1 days, respectively. The survival rates were 4.0 +/- 0 and 27.7 +/- 28.7 days when CsA was given at 10 and 20 mg/kg i.m., respectively. The combination of CsA at 10 mg/kg with leflunomide at 10 mg/kg or 5 mg/kg prolonged cardiac xenograft survival to 106.0 +/- 50.2 days and > 90 days, respectively. There were no observable side effects in the latter combination. Histologic studies of untreated graft hearts 4 days after transplantation revealed infarction of myocardium and severe RBC extravasation. In contrast, the rejected hamster hearts from long-term survivors showed massive mononuclear cell infiltration and myocardium fibrosis in contrast to the early rejected picture. Therapy with leflunomide begun on day 2 reversed these rejection responses by day 6. In addition, the increase in allospecific IgM titers observed on day 2 was reversed, and the allospecific IgM to IgG isotype switch that occurred in untreated animals was prevented by leflunomide. These observations demonstrate that leflunomide, at nontoxic doses, effectively controlled acute rejection of concordant xenografts and synergistic immunosuppressive effect was achieved with leflunomide and CsA.