Diagnostic value of MDCT in determining the perinephric fat tissue and renal sinus invasion in patients with clear cell renal cell carcinoma

Aims

To investigate the accuracy of multidetector computed tomography (MDCT) findings, and the effect of tumor volume in determining the perinephric and renal sinus invasion in clear cell renal cell carcinomas (ccRCCs).

Method

Fifty patients with ccRCCs underwent non-contrast and nephrographic-phase contrast-enhanced MDCT examination before total nephrectomy. The following MDCT features were used to diagnose perinephric fat tissue invasion: perinephric stranding, perinephric vascularity, and irregular contour. The following MDCT features were used to diagnose renal sinus fat invasion: elongation of tumor into renal sinus, invasion, or compression of pelvicalyceal system. Histopathologic examinations were used as a gold standard.

Results

Fourteen out of 50 ccRCCs patients (28%) had histopathological-proven perinephric fat tissue invasion. The sensitivity, specificity, PPV, NPV, and accuracy of MDCT in the detection of perinephric fat tissue invasion were found 64%, 58%, 38%, 80%, and 60%, respectively. Seven out of 50 ccRCCs patient (14%) had histopathological-proven renal sinus invasion. The sensitivity, specificity, PPV, NPV, and accuracy of MDCT in the detection of renal sinus invasion were found 85%, 65%, 28%, 96%, and 68%, respectively. The area under of curve (AUC) value of tumor volume in the detection of perinephric fat invasion was 0.631. The AUC value of tumor volume in the detection of renal sinus invasion was 0.803.

Conclusion

MDCT has a good sensitivity for detection of renal sinus fat invasion, but low PPV and specificity in patients with ccRCC. Tumor volume, and invasion into the pelvicalyceal structures can aid in the diagnosis of renal sinus fat invasion preoperatively.

Genetic Variation in MAP3K1 Associates with Ventilator-Free Days in Acute Respiratory Distress Syndrome

Mitogen-activated protein kinase kinase kinase 1 (MAP3K1) regulates numerous intracellular signaling pathways involved in inflammation and apoptosis. We hypothesized that genetic variation in MAP3K1 might be associated with outcomes in patients with acute respiratory distress syndrome (ARDS), and that these variants would alter MAP3K1-mediated changes in inflammation and transcriptional regulation. To test this hypothesis, we genotyped single-nucleotide polymorphisms covering linkage disequilibrium bins in MAP3K1 in 306 subjects with ARDS from the ARDSNet FACTT (Fluid and Catheter Treatment Trial) study, and tested for associations between MAP3K1 single-nucleotide polymorphisms and ventilator-free days (VFDs) and mortality. We then validated these associations in a separate cohort of 241 patients with ARDS from Harborview Medical Center (Seattle, WA). We found the variant allele of rs832582 (MAP3K1_906Val) was significantly associated with decreased VFDs using multivariate linear regression (-6.1 d, false discovery rate = 0.06) in the FACTT cohort. In the Harborview Medical Center cohort, subjects homozygous for MAP3K1_906Val also had decreased VFDs (-15.1 d, false discovery rate < 0.01), and increased 28-day mortality (all subjects homozygous for the rare allele died). In whole blood stimulated with various innate immune agonists ex vivo, MAP3K1_906Val was associated with increased IL-1β, IL-6, IL-8, monocyte chemoattractant protein 1, and TNF-α production. Transcriptome analysis of whole blood stimulated with Toll-like receptor 4 agonist ex vivo demonstrated enrichment of inflammatory gene sets in subjects homozygous for MAP3K1_906Val. Our findings show a robust association between the variant allele of rs832582 (MAP3K1_906Val) and decreased VFDs in patients with ARDS and suggest that this variant may predispose individuals to a greater inflammatory response.

Inflammation and immune-related candidate gene associations with acute lung injury susceptibility and severity: a validation study

Introduction

Common variants in genes related to inflammation, innate immunity, epithelial cell function, and angiogenesis have been reported to be associated with risks for Acute Lung Injury (ALI) and related outcomes. We tested whether previously-reported associations can be validated in an independent cohort at risk for ALI.

Methods

We identified 37 genetic variants in 27 genes previously associated with ALI and related outcomes. We prepared allelic discrimination assays for 12 SNPs from 11 genes with MAF>0.05 and genotyped these SNPs in Caucasian subjects from a cohort of critically ill patients meeting criteria for the systemic inflammatory response syndrome (SIRS) followed for development of ALI, duration of mechanical ventilation, and in-hospital death. We tested for associations using additive and recessive genetic models.

Results

Among Caucasian subjects with SIRS (n = 750), we identified a nominal association between rs2069832 in IL6 and ALI susceptibility (OR_adj 1.61; 95% confidence interval [CI], 1.04–2.48, P = 0.03). In a sensitivity analysis limiting ALI cases to those who qualified for the Acute Respiratory Distress Syndrome (ARDS), rs61330082 in NAMPT was nominally associated with risk for ARDS. In terms of ALI outcomes, SNPs in MBL2 (rs1800450) and IL8 (rs4073) were nominally associated with fewer ventilator-free days (VFDs), and SNPs in NFE2L2 (rs6721961) and NAMPT (rs61330082) were nominally associated with 28-day mortality. The directions of effect for these nominal associations were in the same direction as previously reported but none of the associations survived correction for multiple hypothesis testing.

Conclusion

Although our primary analyses failed to statistically validate prior associations, our results provide some support for associations between SNPs in IL6 and NAMPT and risk for development of lung injury and for SNPs in IL8, MBL2, NFE2L2 and NAMPT with severity in ALI outcomes. These associations provide further evidence that genetic factors in genes related to immunity and inflammation contribute to ALI pathogenesis.

Toll-like receptor 1 polymorphisms affect innate immune responses and outcomes in sepsis

RATIONALE

Polymorphisms affecting Toll-like receptor (TLR)-mediated responses could predispose to excessive inflammation during an infection and contribute to an increased risk for poor outcomes in patients with sepsis.

OBJECTIVES

To identify hypermorphic polymorphisms causing elevated TLR-mediated innate immune cytokine and chemokine responses and to test whether these polymorphisms are associated with increased susceptibility to death, organ dysfunction, and infections in patients with sepsis.

METHODS

We screened single-nucleotide polymorphisms (SNPs) in 43 TLR-related genes to identify variants affecting TLR-mediated inflammatory responses in blood from healthy volunteers ex vivo. The SNP associated most strongly with hypermorphic responses was tested for associations with death, organ dysfunction, and type of infection in two studies: a nested case-control study in a cohort of intensive care unit patients with sepsis, and a case-control study using patients with sepsis, patients with sepsis-related acute lung injury, and healthy control subjects.

MEASUREMENTS AND MAIN RESULTS

The SNP demonstrating the most hypermorphic effect was the G allele of TLR1(-7202A/G) (rs5743551), which associated with elevated TLR1-mediated cytokine production (P < 2 x 10(-20)). TLR1(-7202G) marked a coding SNP that causes higher TLR1-induced NF-kappaB activation and higher cell surface TLR1 expression. In the cohort of patients with sepsis TLR1(-7202G) predicted worse organ dysfunction and death (odds ratio, 1.82; 95% confidence interval, 1.07-3.09). In the case-control study TLR1(-7202G) was associated with sepsis-related acute lung injury (odds ratio, 3.40; 95% confidence interval, 1.59-7.27). TLR1(-7202G) also associated with a higher prevalence of gram-positive cultures in both clinical studies.

CONCLUSIONS

Hypermorphic genetic variation in TLR1 is associated with increased susceptibility to organ dysfunction, death, and gram-positive infection in sepsis.

Lymphoma in a pelvic spleen: CT features

A case of recurrent lymphoma presenting as a pelvic mass on CT is described. At surgery this proved to represent an ectopic spleen with lymphomatous infiltration.

Neutrophil elastase alpha 1-proteinase inhibitor complexes in pleural effusions

Polymorphonuclear (PMN) granulocyte derived neutrophil elastase (NE) is rapidly antagonized by alpha 1-proteinase inhibitor (alpha 1 PI) in vivo. To determine the clinical value of elastase alpha 1-proteinase inhibitor complexes (E-alpha 1 PI) in pleural effusions, fluid samples of 99 patients were examined. Fifty-six had malignant effusions, 30 had non-malignant exudates (pleural protein above 3 g/dl) mainly of inflammatory origin, and 13 patients had low protein transudates (below 3 g/dl) due to congestive heart failure. Nonmalignant exudates showed significantly higher (P less than 0.001) concentrations of E-alpha 1 PI compared with malignant effusions or low protein transudates (P less than 0.001). Malignant exudates secondary to lung cancer were characterized by higher (P less than 0.001) median pleural E-alpha 1 PI concentrations compared to malignant exudates due to primarily extrathoracic malignancies. Total pleural leukocyte counts and pleural neutrophil counts were performed in 68 effusions. By this means no clear-cut differentiation between malignant and nonmalignant exudates seems possible except for marked empyema. In conclusion, E-alpha 1 PI complexes in pleural fluid may better reflect the stage of inflammation of pleural effusions rather than mere pleural leukocyte counts. Low levels of E-alpha 1 PI complexes (less than 75 ng/ml) in pleural exudates with protein values above 3 g/dl are characteristic of malignant exudates. Determination of E-alpha 1 PI in pleural exudates may serve as a sensitive marker of inflammation and useful adjunct to pleural cytology in aspects of differential diagnosis of pleural effusions.

Histopathologic evaluation of the effects of etodolac in established adjuvant arthritis in rats: evidence for reversal of joint damage

Histopathologic evaluation of hindpaws from control rats with established adjuvant arthritis showed severe alterations in soft tissue and bone, as well as progressive, moderate-to-severe articular changes. Following treatment with etodolac for 28 days, soft tissue and articular changes were rated mild, and bone changes were rated moderate, but with remodeling. These findings indicate that etodolac partially reversed the joint damage in these rats.

[Diagnostic value of the combined determination of carcinoembryonic antigen (CEA) in pleural effusion and serum with an enzyme immunoassay (EIA). Sensitivity, specificity and relation to tumor type]

Measurement of carcinoembryonal (CEA) levels in pleural fluid are suggested to improve the unsatisfactory sensitivity of pleural cytology in the differential diagnosis of malignant pleural effusions. We evaluated simultaneously determined pleural and serum CEA levels in 117 patients with pleural effusions of different aetiology (74 malignant, 30 inflammatory exudates and 13 transudates) by use of an enzyme immunoassay (EIA). Despite considerable scatter, pleural levels of CEA in malignant effusions were significantly higher (p less than 0.001) than the values in benign effusions. Using a cut off level of 5 ng/ml, 41% (= sensitivity) of malignant pleural effusions showed elevated concentrations of CEA. Only one out of 43 benign effusions showed a level of 5 ng/ml, which is equivalent to a specificity of 98%. However, malignant effusions due to small cell lung cancer, pleural mesothelioma and metastasising ovarian carcinoma never showed elevated levels of CEA. Highest pleural values of CEA were observed in cases of alveolar cell or adenocarcinoma of the lung or metastasising breast cancer. Although pleural and serum CEA levels correlated significantly (rs = 0.77), the evaluation of serum CEA levels alone yielded a lower sensitivity (36%) and specificity (93%) than pleural levels. 77% of cases with malignant pleural effusions showing elevated pleural CEA levels were characterized by an increased ratio Pleura/Serum greater than 1, particularly in effusions due to lung cancer. The CEA ratio was significantly higher (p less than 0.05) in patients with malignant than with benign effusions. EIA appears to be more specific by avoiding false positive results in benign effusions as compared with determination by conventional RIA. In conclusion, evaluation of pleural CEA levels in patients with malignant effusions by using an EIA because of its high specificity is a valuable adjunct to pleural cytology in improving the diagnosis of malignant effusions. However, a normal CEA level in either pleural effusion or in serum is of no clinical significance. Simultaneous measurement in pleural effusion and serum is of greater value.

Catecholamine cardiotoxicity

The morphologic-functional correlative studies that we have carried out in the past 25 years with the various catecholamines have served as an example for analyzing myocardial reaction patterns and the reactions of the cardiac muscle cells to insult. These studies disclosed the unique nature of isoproterenol in producing 'infarct-like' myocardial necrosis. It appears that the pathogenesis of the catecholamine-induced myocardial necrosis is multifactorial. Our early studies suggested the role of relative hypoxia. Later studies by using extracellular fine structural protein tracers demonstrated the importance of microcirculatory effects as well as, in the norepinephrine model, that of early sarcolemmal membrane permeability alteration. The Ca2+ overload theory is supported not only by the experimental observations but also by its successful application in clinical cardiology. A new contribution is the recognition of catecholamine oxidation products in producing myocardial injury. Experimental data indicate that catecholamines play an important role in reperfusion and ischemic myocardial injuries. The sequence of events demonstrated by our studies with catecholamines might represent a common pathway in the evolution of myocardial changes in humans who develop myocardial lesions without narrowing or obstruction of coronary arteries. Investigation in the field of molecular and cellular cardiology has led to a better understanding of current clinical problems and helped to devise procedures for the prevention and management of human myocardial disorders. The isoproterenol-induced myocardial necrosis served as model to Professor A. Fleckenstein to formulate the Ca2+ overload theory of myocardial injury and develop a series of now widely used Ca2+ antagonistic drugs for the management and the prevention of human myocardial diseases.

A three month inhalation toxicity study in the squirrel monkey (Saimiri sciureus) with terbutaline sulfate (Bricanyl)

A study of the subacute toxicity of inhaled terbutaline sulfate was performed in the Squirrel monkey (Saimiri sciureus). 3 groups of monkeys were exposed 1 h daily 7 days/week for 3 months to terbutaline sulfate aerosols at concentrations of 0.039, 0.185 and 0.799 mg terbutaline/litre of air respectively. A fourth group was a chamber control receiving air only. The following clinical parameters were evaluated: physical appearance and behavior, weight gain, ophthalmoscopic appearance, electrocardiograms, hemograms, blood biochemical profiles and urinalyses. At termination necropsies were conducted and organ weights determined. A variety of staining techniques was employed in the histopathological examination of tissues. Special attention was given to heart and lung. The distribution of goblet cells in sections from the main bronchi and trachea was also investigated. Occasionally a few animals in both the intermediate and high dose groups showed small amounts of exudate and frothing around the mouth during exposure to their respective terbutaline aerosols. No other changes that could be attributed to the exposure to terbutaline aerosols were seen in any parameter.

Experimental studies on cardiac muscle cell adaptation to insult

Studies were carried out in rats on myocardial adaptation to injury produced by left coronary artery ligation. In the ischemic zone, open collaterals were present as shown by studies using the fine structural extracellular protein tracer, horseradish peroxidase (HRP). This phenomenon may explain the inhomogeneous cardiac muscle cell alteration in the early phase of coronarogenic myocardial injury. Reperfusion, as evidenced by the influx of HRP into the damaged cells, unmasked sarcolemmal membrane injury. Cardiac muscle cell stimulation modifies the binding of macromolecules to cell components and may influence the repair processes. In the surviving myocardium, correlative enzyme histochemical and ultrastructural studies demonstrated the development of alternative metabolic pathways and morphological signs of adaptation explaining increasing resistance of such cardiac muscle cells to subsequent insult.

Prolactin levels in populations at risk for breast cancer

The basal plasma concentration of prolactin was determined by radioimmunoassay in Caucasian women at different risk for breast cancer and in three cases of women at risk for breast cancer. Samples taken under comparable conditions showed similar basal levels at birth and in prepubertal Bantu and Caucasian girls, or in healthy pre- and postmenopausal Bantu, Caucasian, or Japanese women. Elevated plasma prolactin levels were found in women castrated prior to 35 years of age and in women whose first pregnancy occured after 35 years. Evidence indicates that the prolactin/estrogen relationship may not be similar in women 35 to 45 years of age as compared to young women and suggests that elevation of serum prolactin per se does not appear to be related to an increased risk of breast cancer. The prolactin level was increased only in Caucasian women with breast cancer. If a high prolactin/estradiol ratio increases the susceptibility of the mammary epithelium to neoplastic growth, the lack of changes in prolactin levels in premenopausal Japanese patients and in postmenopausal patients of the three ethnic groups indicates that other factors are involved. Further study of the effects of life-style and diet on the basal level and stimulated release of prolactin is required to resolve the relationship of prolactin to breast cancer.

Plasma hormone levels in different ethnic populations of women

It has been suggested that the urinary hormone profile is subject to environmental changes, such as urbanization and Westernization, and that the composition of the hormones can be used as a discriminate in determining the patient at risk for breast cancer. In this study, a comparison of the plasma hormone levels in Bantu and Japanese women, low-risk populations, and Caucasian women, a high-risk population, showed a higher level of 17 beta-estradiol in prepubertal girls and young Bantu and Japanese women. The higher estrogen level in the Bantu was evident in the early luteal and late follicular phases of the menstrual cycle. The difference in the dehydroepiandrosterone and testosterone levels in Bantu young women and prepubertal Bantu girls, suggests differences in adrenal activity between Bantu and Caucasian women. A fall in the plasma androstenedione was evident in postmenopausal Bantu and Japanese but not Caucasian women. Data suggest that the hormone profile is different among the 3 ethnic groups in both the pre- and postmenopausal women. Since the daily life-style of the women is comparable, it is suggested that the composition of the hormone profile is partially dependent on dietary on dietary factors.

Plasma hormone profiles in populations at different risk for breast cancer

Evidence suggests that the reliability of urinary androgens or estrogens as prognostic discriminants for breast cancer may vary with different populations and may bear little relation to changes in plasma hormone levels. In this study the plasma estradiol level was significantly lower in Bantu, but did not in Caucasian, women with breast cancer, while the proportion of plasma androstenedione to dehydroepiandrosterone increased in Bantu patients. These changes in the plasma hormone profile in Bantu patients, a low-risk population for breast cancer, imply a change in ovarian and/or adrenal activity. Lack of similar hormone changes in Caucasian patients may be due to the initial differences in the hormone profile between the healthy Caucasian and Bantu women and to the different environmental factors that promote the breast disease in Western women.

Coronary microcirculatory factors and cardiac muscle cell injury

Coronary artery ligation with or without reperfusion was carried out in Wistar rats to study the role of coronary microcirculatory factors and membrane permeability alteration of cardiac muscle cell in the evolution of cardiac muscle cell injury by using the fine structural extracellular protein tracer, horseradish peroxidase (HRP). The findings were compared with those obtained in noncoronarogenic myocardial injury models following administration of norepinephrine, a pressor, and isoproterenol, a depressor catecholamine. Following left coronary artery ligation lastingfor 10 and 20 minutes, some of the collaterals in the ischemic zone were perused by the tracer, but the numer of patent capillaries decreased during 60-min ligation. The inhomogeneous involvement of cardiac muscle cells in ischemic injury correlated well with these microcirculatory findings. In comparison to permanent ischemia, an abrupt deterioration of the cardiac muscle cell alteration occured after reperfusion with influx of HRP into the damaged cells. The binding of tracer to myofilaments was, however, a later event as compared to that seen in the catecholamine models. The latter observation implies that, in addition to microcirculatory factors, direct cardiac muscle cell stimulation should also be considered in the evolution of noncoronarogenic myocardial injury.

Permeability alteration of sarcolemmal membrane in catecholamine-induced cardiac muscle cell injury. In vivo studies with fine structural diffusion tracer horse radish peroxidase

Cardiac muscle cell injury was produced in male Sprague-Dawley rats weighing 300 to 450 gm. with catecholamines, norepinephrine, and isoproterenol; sarcolemmal membrane alteration was tested in vivo using the extracellular macromolecular tracer, horseradish peroxidase. Norepinephrine was administered in continuous intravenous infusion in a dose of 4 to 6 mug. per 100 gm. of body weight per minute, whereas isoproterenol was given as a single subcutaneous injection in a dose of 8.5 mg. per 100 gm. of body weight. Horseradish peroxidase was injected intravenously and localized in the right ventricular myocardium following 6 and 30 minutes of circulation time by light and electron microscopy. As early as 10 minutes after norepinephrine infusion, horseradish peroxidase appeared within cardiac muscle cells possessing normal fine structure. Selective deposition of the tracer on normal and altered myofilaments was noted. Similar observations were made in the isoproterenol model at 60 to 90 minutes. The results indicate that sarcolemmal membrane permeability alteration is an early event in catecholamine-induced cardiac muscle injury. The possible functional significance of the findings is discussed.

New approach in studying cardiac muscle cell injury

A new approach for investigating the mechanisms and evolution of cardiac muscle cell injury was presented by applying fine structural extracellular protein tracers in the catecholamine-induced cardiac muscle cell injury model. The results with these diffusion tracers indicated striking functional changes at the level of coronary microcirculation followed by early permeability alteration of cardiac muscle cell membranes, thus suggesting the role of these factors in myocardial changes which develop without narrowing or obstruction of coronary arteries.

Cytoplasmic contractile apparatus in aortic endothelial cells of hypertensive rats

Hypertension was produced in male Wistar rats (150 gm. body weight) by complete ligature of the aorta between the renal arteries. Electron microscopic examination revealed that 1 week later the amount of cytoplasmic microfilaments in the endothelial cells of the aortic segment above the coarctation (mean blood pressure 160 mm. Hg) was strikingly increased as compared with normal animals. The endothelial cells in the segment below the coarctation (mean blood pressure 25 mm. Hg) contained few filaments and were similar to the cells in the aortic endothelium in controls (mean blood pressure 105 mm. Hg). Microfilaments measured 40 to 70 angstrom in diameter and were mostly located close to the endothelial clefts, where they formed longitudinal bundles or a network. The bundles of microfilaments contained electron-dense areas similar to the "attachment sites" of the underlying smooth muscle. By using en face preparations of aortic endothelial cells treated with antiactin autoantibodies (AAA) followed by anti-human IgG, it was seen that in hypertensive animals the cells above the ligature were intensely fluorescent when compared with those of the aortic portion below the ligature or those of the controls. The fluorescence was abolished after incubation of the AAA sera with thrombosthenin A. The correlation between electron microscopic and immunologic findings suggests that the microfilaments present in the endothelial cells of hypertensive animals are composed, at least in part, of actin. Endothelial cells so modified may play a role in permeability or may be related to other phenomena such as electrotonic coupling and synchronized contraction of aortic cells during hypertension.

Healing process in the marginal zone of an experimental myocardial infarct. Findings in the surviving cardiac muscle cells

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Experimental aspects of cobalt cardiomyopathy

All chambers of the heart are affected in experimental cobalt cardiomyopathy, with atrial predilection. The primary morphological alteration is mitochondrial damage that possibly reflects an enzymatic block of oxidative decarboxylation at pyruvate and ketogluterate levels. In acute cobalt toxicity chelation of calcium may also be a contributory factor, resulting in deficient utilization of high-energy phosphates. Experimental cobalt cardiomyopathy requires preconditioning factors: protein deficiency appears to be one of them. Vegetative polypoid endocarditis is an important accompaniment in the model used, suggesting that in rats on a protein deficient diet cobalt produced endothelial damage in addition to a cardiocyte injury.

Fine structural evidence of specific mechanism for increased endothelial permeability in experimental hypertension

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A case of desquamative interstitial pneumonia

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Morphological observations on spontaneous pancreatic islet changes in rats

A spontaneous lesion of the islet of Langerhans characterized by fibrosis and enlargement is described in the aging albino rat, occurring almost exclusively in males. Further studies are in progress to define the histogenesis, endocrine aspect and functional significance of this lesion.

The pathogenesis of human myocardial infarction

Coronary arteriography, dissection of the coronary arteries and histopathological examination of the heart were carried out in 150 autopsies to study the effect of coronary narrowing and occlusion, of the presence of collaterals, and of coronary artery predominance on the development of myocardial infarction. The thrombosis rate was related to the severity of coronary sclerosis. The development of collaterals was not enhanced by coronary sclerosis and occlusion, and collaterals did not protect the myocardium against reinfarction. Coronary occlusion was regularly demonstrable in recent myocardial infarct cases. The association of atrial and posterior ventricular infarcts was explained by occlusion of their common arterial branch. The interdependence between coronary sclerosis, thrombosis and myocardial infarction in human autopsy material emphasizes the importance of mural coronary artery disease in the genesis of coronary occlusion and myocardial infarction, and it is at variance with statistical data and experimental results.

Ruptured angular (cornual) pregnancy

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