[Corneal ulceration complicating surgical correction of ptosis in patient with Kearns-Sayre syndrome--a case report]

The aim is to report a rare complication of surgical ptosis correction in a patient with Kearns Sayre syndrome and the therapeutic possibilities of its treatment.

METHODS

Exposure corneal ulceration caused by lagophtalmos developed gradually in a 30-year-old woman after an upper eyelid ptosis surgery of the right eye performed at another eye clinic. During an examination a limited movement of both eyes and retinal pigmentary changes (salt-pepper-like appearance) were diagnosed. A suspicion of the Kearns Sayre syndrome was expressed according to the clinical picture, the diagnosis was confirmed by molecular analyses in muscle biopsy, which revealed 5.2 kb deletion of mitochondrial DNA.

RESULTS

Corneal ulceration was treated by partial external tarsorrhaphy and frequent instillation of lubricants. The upper eyelid ptosis of the left eye was treated with a spectacle with ptosis support.

CONCLUSION

During the correction of upper eyelid ptosis in patients with progressive external ophtalmoplegia it is necessary to be aware of the risk of surgical exposure keratopathy and corneal ulceration due to the atony of musculus orbicularis oculi muscle and only slightly expressed Bell's phenomenon.

Immunolocalization of protein-bound 3-nitrotyrosine in inflammatory myopathies

3-nitrotyrosine (3NT) is regarded as a "footprint" of nitric oxide generation. The study aimed at documenting the presence and distribution of 3-nitrotyrosine (3NT) in muscle tissue samples from patients with idiopathic inflammatory myopathies (IIM) as well as from those with non-inflammatory myopathies to consider whether polymyositis (PM) and dermatomyositis (DM) could be distinguished based on 3NT immunohistochemistry in muscle biopsy. Cryosections prepared from muscle biopsies of 54 patients with either IIM, i.e., PM and DM, or various non-inflammatory myopathies were immunostained using monoclonal antibody against 3NT. The 3NT immunostaining was localized to endothelial cells and their close surroundings in muscle biopsies of DM and PM patients but only in those areas of tissue sections where inflammatory cell infiltrates were present. No 3NT positivity was found in tissue sections of IIM patients without inflammatory infiltrates in the studied sample as well as in muscle tissue sections of patients with non-inflammatory myopathies. However, the endothelial cells were also positive in cases of confirmed non-inflammatory myopathies with secondary lymphocytic infiltration (myodystrophies, myasthenia gravis). Despite the pathogenetic significance, the 3NT immunohistochemistry is of low diagnostic value for the differential diagnosis of IIM in muscle biopsy.

Point mutations in Czech DMD/BMD patients and their phenotypic outcome

Duchenne and Becker muscular dystrophies (DMD/BMD) are associated with mutations in the DMD gene. We determined the mutation status of 47 patients with dystrophinopathy without deletion or duplication in the DMD gene by screening performed by reverse transcription-PCR, protein truncation test, and DNA sequencing. We describe three patients with a mutation creating a premature termination codon (p.E55X, p.E1110X, and p.S3497PfsX2) but with a mild phenotype, which present three different ways of rescuing the DMD phenotype. In one patient we detected the insertion of a repetitive sequence AluYa5 in intron 56, which led to skipping of exon 57. Further, using quantitative analysis of DMD mRNA carrying various mutated alleles, we examine levels of mRNA degradation due to nonsense mediated mRNA decay. The quantity of dystrophin mRNA is different depending on the presence of a mutation leading to a premature termination codon, and position of the analysed mRNA region with respect to its 5' end or 3' end. Average relative amounts of DMD mRNAs carrying a premature termination codon is 48% and 17%, when using primers amplifying the 5' and 3' cDNA regions, respectively.

Macroporous hydrogels based on 2-hydroxyethyl methacrylate. Part 6: 3D hydrogels with positive and negative surface charges and polyelectrolyte complexes in spinal cord injury repair

Macroporous hydrogels are artificial biomaterials commonly used in tissue engineering, including central nervous system (CNS) repair. Their physical properties may be modified to improve their adhesion properties and promote tissue regeneration. We implanted four types of hydrogels based on 2-hydroxyethyl methacrylate (HEMA) with different surface charges inside a spinal cord hemisection cavity at the Th8 level in rats. The spinal cords were processed 1 and 6 months after implantation and histologically evaluated. Connective tissue deposition was most abundant in the hydrogels with positively-charged functional groups. Axonal regeneration was promoted in hydrogels carrying charged functional groups; hydrogels with positively charged functional groups showed increased axonal ingrowth into the central parts of the implant. Few astrocytes grew into the hydrogels. Our study shows that HEMA-based hydrogels carrying charged functional groups improve axonal ingrowth inside the implants compared to implants without any charge. Further, positively charged functional groups promote connective tissue infiltration and extended axonal regeneration inside a hydrogel bridge.

Tissue expression and enzymologic characterization of human prostate specific membrane antigen and its rat and pig orthologs

BACKGROUND

Prostate specific membrane antigen (PSMA), also called glutamate carboxypeptidase II (GCPII), is a target enzyme for diagnosis and treatment of prostate cancer. Moreover, it is upregulated in the vasculature of most solid tumors and is therefore a potential target for the generation of novel antineoplastics. In this context, we analyze the possibility of using rat and pig as animal models for enzymologic and in vivo studies.

METHODS

We prepared the recombinant extracellular part of human, rat, and pig GCPII in S2 cell media and characterized the activity and inhibition profiles of the three orthologs by radioenzymatic assay. We performed Western blot analysis of GCPII expression in human, rat, and pig tissues using the monoclonal antibody GCP-04 and confirmed these findings by activity measurements and immunohistochemistry.

RESULTS

The three recombinant proteins show similar specific enzymatic activities and inhibition profiles. Tissue expression analysis revealed that most of the pig and human tissues show at least some GCPII-positivity, while the expression pattern in rat is more restricted. Moreover, tissues such as prostate and testes exhibit different GCPII expression levels among the species studied.

CONCLUSIONS

The rat and pig orthologs of GCPII seem to be suitable to approximate human GCPII in enzymologic studies. However, the diffuse expression pattern of GCPII in animal and human tissues could be a caveat for the potential utilization of GCPII-targeted anticancer drugs. Furthermore, variations in GCPII tissue distribution among the species studied should be considered when using rat or pig as models for antineoplastic drug discovery.

[Neuropathology of the glioneuronal lesions of the brain associated with pharmacoresistant epilepsy]

Besides the hippocampal sclerosis, the glioneuronal lesions of the brain (glioneuronal tumors and malformations) represent the second large cohort of patients with intractable epilepsy diagnosed in the epileptosurgical specimens. Our experience with diagnosis and classification of the glioneuronal disorders are reported. Current research efforts, enabled by the availability of a well-characterized human biopsy material, have addressed the issue whether these lesions play an active role in the onset of epileptic seizures. The results of those studies are discussed in the review as well.

Hereditary spastic paraplegia 3A associated with axonal neuropathy

OBJECTIVE

To study the frequency and distribution of mutations in SPG3A in a large cohort of patients with hereditary spastic paraplegia.

DESIGN

We screened a large cohort of 182 families and isolated cases with pure or complex hereditary spastic paraplegia phenotypes, which were negative for mutations in SPG4.

RESULTS

In 12 probands (6.6%), we identified 12 different SPG3A mutations (11 missense and 1 insertion/frameshift) of which 7 were novel and 3 were de novo. We found incomplete penetrance in 1 family (G482V). In most cases, SPG3A mutations were associated with an early age at onset (mean, 3 y); however, in 1 family (R495W mutation), symptoms started later (mean, 14 y) with clear intrafamilial variability (8-28 y). Six patients with an SPG3A mutation (F151S, Q191R, M408T, G469A, R495W) originating from 5 unrelated families presented with a complex form of hereditary spastic paraplegia associated with a neuropathy (17%). Our electrophysiological and pathological findings confirmed an axonal sensory-motor neuropathy. There was no correlation between the genotype and the presence of a neuropathy.

CONCLUSIONS

We conclude that mutations in SPG3A represent an important cause of patients in the overall hereditary spastic paraplegia population. SPG3A is more often associated with a neuropathy than previously assumed. Therefore, patients with a bipyramidal syndrome and a neuropathy should be screened for mutations in SPG3A.

Quantitative analysis of CAPN3 transcripts in LGMD2A patients: Involvement of nonsense-mediated mRNA decay

Limb girdle muscular dystrophy type 2A (LGMD2A) is caused by single or small nucleotide changes widespread along the CAPN3 gene, which encodes the muscle-specific proteolytic enzyme calpain-3. About 356 unique allelic variants of CAPN3 have been identified to date. We performed analysis of the CAPN3 gene in LGMD2A patients at both the mRNA level using reverse transcription-PCR, and at the DNA level using PCR and denaturing high performance liquid chromatography. In four patients, we detected homozygous occurrence of a missense mutation or an in-frame deletion at the mRNA level although the DNA was heterozygous for this mutation in conjunction with a frame-shift mutation. The relationship observed in 12 patients between the quantity of CAPN3 mRNA, determined using real-time PCR, and the genotype leads us to propose that CAPN3 mRNAs which contain frame-shift mutations are degraded by nonsense-mediated mRNA decay. Our results illustrate the importance of DNA analysis for reliable establishment of mutation status, and provide a new insight into the process of mRNA decay in cells of LGMD2A patients.

Expression of glutamate carboxypeptidase II in human brain

Glutamate carboxypeptidase II (GCPII) is a transmembrane glycoprotein expressed in various tissues. When expressed in the brain it cleaves the neurotransmitter N-acetylaspartylglutamate (NAAG), yielding free glutamate. In jejunum it hydrolyzes folylpoly-gamma-glutamate, thus facilitating folate absorption. The prostate form of GCPII, known as prostate specific membrane antigen (PSMA), is an established cancer marker. The NAAG-hydrolyzing activity of GCPII has been implicated in a number of pathological conditions in which glutamate is neurotoxic (e.g. amyotrophic lateral sclerosis, Huntington's disease, Alzheimer's disease, epilepsy, schizophrenia, and stroke). Inhibition of GCPII was shown to be neuroprotective in tissue culture and in animal models. GCPII is therefore an interesting putative therapeutic target. However, only very limited and controversial data on the expression and localization of GCPII in human brain are available. Therefore, we set out to analyze the activity and expression of GCPII in various compartments of the human brain using a radiolabeled substrate of the enzyme and the novel monoclonal antibody GCP-04, which recognizes an epitope on the extracellular portion of the enzyme and is more sensitive to GCPII than to the homologous GCPIII. We show that this antibody is more sensitive in immunoblots than the widely used antibody 7E11. By Western blot, we show that there are approximately 50-300 ng of GCPII/mg of total protein in human brain, depending on the specific area. Immunohistochemical analysis revealed that astrocytes specifically express GCPII in all parts of the brain. GCPII is enzymatically active and the level of activity follows the expression pattern. Using pure recombinant GCPII and homologous GCPIII, we conclude that GCPII is responsible for the majority of overall NAAG-hydrolyzing activity in the human brain.

[Granulomatous myopathy in patients with sarcoidosis and myasthenia gravis]

Granulomatous myopathies are extremely rare. The finding of epithelioid granulomas in muscle biopsy indicates mostly an involvement of the skeletal muscle in systemic sarcoidosis. In this report we provide description of five patients with previously diagnosed sarcoidosis (pulmonary or cutaneous), in which a clinically significant muscle weakness developed. We aim at demonstrating the value of muscle biopsy for further treatment of the patients, since clinically indistinguishable myopathies can arise not due to the involvement of muscles in the granulomatous process, but due to the corticosteroid-induced changes (chronic steroid myopathy). The demonstration of a selective atrophy of type II muscle fibers can provide the clue for distinguishing the patients, in which the corticosteroid treatment should continue, from those, in which the treatment should be modified. Further, we discuss a rare finding of granulomas in muscle biopsies of two patients with myasthenia gravis (MG) associated with thymoma. Although it is difficult to explain the pathogenesis of this event, MG should be considered in the differential diagnosis of granulomatous myopathies. Moreover, the finding of granulomas along with lymphocytic infiltration in MG muscle should lead to a search for an underlying thymic neoplasm.

Analysis of histopathologic and molecular pathologic findings in Czech LGMD2A patients

Limb-girdle muscular dystrophy type 2A (LGMD2A) is an autosomal-recessive disorder characterized by selective atrophy and progressive weakness of proximal girdle muscles. LGMD2A, the most prevalent form of LGMD, is caused by mutations in the CAPN3 gene that encodes the skeletal muscle-specific member of the calpain family, calpain-3 (p 94). We examined the histopathologic and molecular pathologic findings in 14 Czech LGMD2A patients. Analysis of the CAPN3 gene was performed at the mRNA level, using reverse transcription-polymerase chain reaction (RT-PCR) and sequencing, and/or DNA level, using PCR and denaturing high-performance liquid chromatography (DHPLC). Our results confirm that mutation 550 delA is the most frequent CAPN3 defect in Czech LGMD2A patients (9 alleles of 28). Furthermore, we established that, in a patient with the 550 delA/R490W genotype, mRNA carrying frameshift mutation 550 delA was not detected, probably due to its degradation by nonsense-mediated mRNA decay. In muscle biopsies of two LGMD2A patients, a neurogenic pattern simulating a neurogenic lesion was observed. Immunoblot analysis revealed the deficiency of p 94 in all genetically confirmed cases of LGMD2A, and secondary dysferlin deficiency was demonstrated on muscle membranes in 6 patients using immunofluorescence. Thus, we find a combination of DNA and mRNA mutational analysis to be useful in the diagnosis of LGMD2A. Moreover, our study expands the spectrum of calpainopathies to cases that simulate a neurogenic lesion in muscle biopsies, and the knowledge of possible secondary deficiencies of muscular proteins also contributes to a diagnosis of LGMD2A.

[Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE)]

BACKGROUND

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a disorder with autosomal recessive inheritance caused by mutations in the gene encoding thymidine phosphorylase (TP). TP deficiency results in imbalance of mitochondrial pool of nucleotides leading secondary to multiple deletions and depletion of mitochondrial DNA (mtDNA) and impairment of oxidative phosphorylation system. The disease is clinically characterized by gastrointestinal dysmotility with symptoms of pseudo-obstruction, severe failure to thrive, ptosis, leukoencephalopathy, peripheral neuropathy and myopathy. We present results of the clinical, histochemical, biochemical and molecular analyses of the first Czech patient with MNGIE syndrome.

METHODS AND RESULTS

Man, 33-years old with twenty-year history of failure to thrive (height 168 cm, weight 34 kg) and progressive gastrointestinal dysmotility, external ophthalmoplegia, leucoencephalopathy and peripheral neuropathy was recommended to metabolic center. Histochemical analyses in muscle biopsy showed the presence of "ragged red fibers" with focal decrease of cytochrome c oxidase activity, but spectrophotometric analyses in isolated muscle mitochondria revealed normal activities of all respiratory chain complexes. Metabolic investigation revealed markedly increased plasma level of thymidine (6.6 micromol/l, controls <0.05 micromol/l) and deoxyuridine (15 micromol/l, controls <0.05 micromol/l). The activity of TP in isolated lymphocytes was low (0.02 micromol/hour/mg protein, reference range 0.78 +/- 0.18). Molecular analyses in muscle biopsy revealed multiple mtDNA deletions and homozygous mutation 1419G>A (Gly145Arg) was found in gene for TP. Both parents are heterozygotes.

CONCLUSIONS

MNGIE has to be considered in patients presenting with a combination of gastrointestinal and neurological symptoms. Plasma level of thymidine may serve as the best method for laboratory screening of MNGIE, but molecular analyses are necessary for genetic counselling and prenatal diagnosis in affected families.

[The role of the extracellular space in biology of glial brain tumors]

The size, geometry and composition of the extracellular space (ECS) play an important role in influencing the biological behavior of primary brain tumors. Experiments employing the real-time TMA iontophoretic method to determine the size and geometry of the ECS, by monitoring the diffusion of TMA ions in the ECS, revealed a dramatic increase in ECS size in brain neoplasms when compared with that of unaffected brain cortex. Further, the increase of ECS volume in tumors was shown to correlate with increasing proliferative activity and increasing cellularity of astrocytomas. The increase in ECS size was surprisingly accompanied by a significant increase in diffusion barriers, slowing the diffusion of molecules in the ECS of tumors. In low-grade tumors, diffusion is hindered by the presence of a dense net of tumor cell processes. In high-grade gliomas, in which the cellular processes are shortened with reduced branching, the increase in diffusion barriers is caused by the overproduction of specific components of the extracellular matrix (ECM) by the tumor cells, mainly tenascin. The ECM glycoproteins produced represent a substrate for the subsequent adhesion and migration of tumor cells through the enlarged ECS. However, they might also critically reduce the diffusion of therapeutics into the tumor. The presence of tenascin in the ECS of a neoplasm correlates significantly with the increased malignancy of the tumor and a poor clinical outcome of the disease, thus making the immunohistochemical detection of tenascin diagnostically useful as a prognostic marker and a marker of aggressive biological behavior of tumors.

Mutations in Czech LGMD2A patients revealed by analysis of calpain3 mRNA and their phenotypic outcome

Calpain3 (CAPN3, p94) is a muscle-specific nonlysosomal cysteine proteinase. Loss of proteolytic function or change of other properties of this enzyme (such as stability or ability to interact with other muscular proteins) is manifested as limb girdle muscular dystrophy type 2A (LGMD2A, calpainopathy). These pathological changes in properties of calpain3 are caused by mutations in the calpain3 gene. The fact that the human gene for calpain3 is quite long led us to analyse its coding sequence by reverse transcription-PCR followed by sequence analysis. This study reports nine mutations that we found by analysing mRNA of seven unrelated LGMD patients in the Czech Republic. Three of these mutations were novel, not described on the Leiden muscular dystrophy pages so far. Further, we observed a reduction of dysferlin in muscle membrane in five of our seven LGMD2A patients by immunohistochemical analysis of muscle sections.

Paraneoplastic opsoclonus-myoclonus syndrome associated with malignant fibrous histiocytoma: neuropathological findings

Paraneoplastic syndromes related to soft tissue tumors are very uncommon and an association of paraneoplastic diseases with a malignant fibrous histiocytoma (MFH) has not been reported so far. Opsoclonus-myoclonus is a rare paraneoplastic nervous system syndrome, that was well documented in adult patients with neoplasms particularly of the lung and breast. A 77-year-old woman developed typical opsoclonus-myoclonus syndrome and rapidly progressed to coma. The opsoclonus and generalized myoclonus continued until the patient's death seven months later. An autopsy examination identified a pleomorphic MFH in the retroperitoneum without a metastatic spread. Microscopic examination of the cerebellum revealed an atrophy of the granular layer along with a marked patchy loss of Purkinje cells, and a loss of neurons in the cerebellar nuclei accompanied by distinct peridental demyelination and astrogliosis. A moderate loss of neurons and neuronal chromatolysis were observed also in the inferior olivary nuclei. However, the omnipause neurons of the nucleus raphe interpositus, that are supposed to be responsible for opsoclonus generation under pathological conditions, as well as ocular brain stem nuclei were all intact. We failed to prove the presence of known antineuronal anti-Yo, anti-Hu or anti-Ri autoantibodies in both serum and cerebrospinal fluid (CSF) of the patient. However, the confirmation of the intrathecal IgG synthesis by oligoclonal bands in CSF and the immunohistochemical detection of IgG deposits on membranes of Purkinje cells, neurons of cerebellar granular layer and in cerebellar nuclei in our case support the presumed autoimmune nature of the disease.

Distribution of the extracellular matrix glycoproteins in ependymomas--an immunohistochemical study with follow-up analysis

The extracellular matrix (ECM) plays a critical role in influencing the biological behavior of brain tumors and the diagnostic detection of ECM components in ependymomas might be of prognostic value. In the present study we evaluated immunohistochemically the expression of a spectrum of ECM glycoproteins (tenascin, vitronectin, fibronectin, laminin, collagen types II, IV and VI) in a series of 36 pediatric intracranial ependymomas. The distribution of the ECM glycoproteins was evaluated both within the tumor tissue and at the tumor invasion front, and the prognostic value of the results was tested in a survival analysis. The expression of most of the ECM glycoproteins was associated only with blood vessels. Tenascin and vitronectin were found in a more diffuse pattern around the tumor cells and at the tumor invasion fronts of several cases. The progression-free survival was significantly decreased for patients with tenascin positive tumors (in any of the studied compartments) and for the tumors with vitronectin accumulation at their invasion fronts. In one ependymoma containing foci of cartilage with metaplastic ossification we demonstrated that collagen types II and VI and tenascin were present in ECM of both the cartilage and the ependymoma, and were accompanied by areas of necrosis and dystrophic calcifications. We suggest, that the rare simultaneous production of the specific ECM components might lead to the formation of chondroid areas in ependymomas. An abundant production of some ECM glycoproteins (tenascin and vitronectin) is present in a proportion of ependymomas and its immunohistochemical detection is of prognostic relevance.

Extracellular matrix glycoproteins and diffusion barriers in human astrocytic tumours

The extracellular matrix (ECM) and changes in the size and geometry of the extracellular space (ECS) in tumour tissue are thought to be of critical importance in influencing the migratory abilities of tumour cells as well as the delivery of therapeutic agents into the tumour. In 21 astrocytic neoplasms, the ECM composition was investigated in situ by the immunohistochemical detection of ECM glycoproteins (tenascin, laminin, vitronectin, fibronectin, collagen types I-VI). To explain the changes in ECS size and to detect barriers to diffusion in the tumour tissue, the ECM composition, the cellularity, the density of glial fibrillary acidic protein (GFAP)-positive tumour cell processes and the proliferative activity of the tumours were compared with the size and geometry of the ECS. The ECS volume fraction and the complex of hindrances to diffusion in the ECS (i.e. the tortuosity) were revealed by the real-time iontophoretic tetramethylammonium method. Increased proliferative activity of the tumours correlated with increased ECS volume fraction and tortuosity. The tortuosity of the tumour tissue was not significantly influenced by tumour cell density. Higher tortuosity was found in low-grade astrocytomas associated with the presence of a dense net of GFAP-positive fibrillary processes of the tumour cells. The increase in tortuosity in high-grade tumours correlated with an increased accumulation of ECM molecules, particularly of tenascin. We conclude that the increased malignancy of astrocytic tumours correlates with increases in both ECS volume and ECM deposition.

[Microscopic disorders of cortical development of the brain and its etiopathogenic importance for detection in patients with temporal epilepsy associated with hippocampal sclerosis]

Hippocampal sclerosis represents a common structural basis of temporal lobe epilepsy. However, the etiological factors and mechanisms leading to its development still remain unexplained. In our study, we present neuropathological findings in the resected hippocampus and the pole of the temporal lobe in 15 patients with hippocampal sclerosis. "Initial precipitating injuries" that are thought to cause the development of hippocampal sclerosis (febrile seizures in early childhood, head injury or meningoencephalitis) were present in the history of 12 patients. In the remaining 3 cases, no predisposing factors were found. Attention was paid to the histopathological identification of disturbed neuronal migration and differentiation in the temporal lobe. These defects were observed in 7 cases; in three of these, no predisposing factors were stated in the patients' histories. We suggest that in these cases, hippocampal sclerosis arises due to previously undetected disorders of cortical development. A latent neocortical malformation may also contribute to the development of hippocampal sclerosis in patients with an initial precipitating injury in anamnensis. Histopathological examination of resected epileptic brain tissue can provide insights into the individual pathogenesis of epileptic disorders, especially by the detection of microscopic disorders of cortical development.

Diffusion parameters of the extracellular space in human gliomas

Tumor cell migration through the extracellular space (ECS) might be affected by its pore size and extracellular matrix molecule content. ECS volume fraction alpha (alpha = ECS volume/total tissue volume), tortuosity lambda (lambda(2) = free/apparent diffusion coefficient) and nonspecific uptake k' were studied by the real-time tetramethylammonium method in acute slices of human tissue. The diffusion parameters in temporal cortical tissue resected during surgical treatment of temporal lobe epilepsy (control) were compared with those in brain tumors. Subsequently, tumor slices were histopathologically classified according to the grading system of the World Health Organization (WHO), and proliferative activity was assessed. The average values of alpha, lambda, and k' in control cortex were 0.24, 1.55, and 3.66 x 10(-3)s(-1), respectively. Values of alpha, lambda, and k' in oligodendrogliomas did not significantly differ from controls. In pilocytic astrogliomas (WHO grade I) as well as in ependymomas (WHO grade II), alpha was significantly higher, while lambda and k' were unchanged. Higher values of alpha as well as lambda were found in low-grade diffuse astrocytomas (WHO grade II). In cellular regions of high-grade astrocytomas (WHO grade III and IV), alpha and lambda were further increased, and k' was significantly larger than in controls. Classic medulloblastomas (WHO grade IV) had an increased alpha, but not lambda or k', while in the desmoplastic type alpha and k' remained unchanged, but lambda was greatly increased. Tumor malignancy grade strongly corresponds to an increase in ECS volume, which is accompanied by a change in ECS structure manifested by an increase in diffusion barriers for small molecules.

Life-saving epilepsy surgery for status epilepticus caused by cortical dysplasia

A uniquely successful neurosurgical intervention in a four-month-old child suffering from status epilepticus (SE) caused by focal cortical dysplasia is reported. Seizures appeared at postnatal day 10 and culminated as medically intractable focal motor SE three months later. The first MRI scan at postnatal week 2 was inconclusive; electroclinical features typical of malformations of cortical development led to the repetition of MRI at the age of 3 months that confirmed the correct diagnosis. Since all medical trials including thiopental anaesthesia have been unsuccessful in treatment of SE, urgent resection of the right frontal and parietal lobes was performed at 4 months of age. One month later, the child had become seizure-free and her psychomotor development is proceeding well. Histopathological analysis of the resected brain tissue revealed abnormalities typical of the Taylor's type of focal cortical dysplasia. The aim of the report is to encourage considering surgery in selected patients suffering from medically intractable SE early in life.

[Lipomatous hamartomas of the brain--malformations of the subarachnoid space]

Lipomatous hamartomas are rare disorders affecting the central nervous system. In our report, two observations of this disorder are presented. Both are interhemispheric in location and are associated with a complete agenesis of the corpus callosum, while having different histological structures. In our first patient, the intracranial formation caused refractory seizures, was partially surgically removed, and a biopsy was performed. Light microscopic examination disclosed the presence of a highly vascularized mature adipose tissue with numerous calcifications. The second case was an incidental finding at autopsy. Microscopically, we found adipose tissue together with numerous foci of hemopoiesis and structures of lamelar bone. In both cases, the indistinct demarcation of the collagenous capsule from the surrounding brain tissue and the continuity of the hamartoma with the leptomeninges were striking. In recent findings about the development of meninges and brain commissures, the origin of this disorder is explained as a defective resorption of the embryonic meninx primitiva. This disorder then causes other developmental aberrations of the brain, which are often found in association. The varying microscopic pattern of these disorders can also be satisfactorily explained by their origin in the primitive meninx, which is formed from both mesenchyme and neuroectoderm.

[A safe site for transposition of ovaries in radical hysterectomy for cervical carcinoma]

OBJECTIVE

To know the influence of twilight by using the radiotherapeutical technique box on hormonal function of ovaries. The aim of transposition of ovaries by radical hysterectomy of the cervical cancer is to move the ovaries out of radiotherapeutical target volume, and thus to protect their hormonal function.

SETTING

Institute for the Care of Mother and Child, Prague, Czech Republic.

METHODS

Computer simulation of radiation isodoses of linear accelerator on the transferred pictures of CT and calculation on the total dose, and radiobiological equivalent outside the target volume of radiation regarding the total dose of 46 Gy.

RESULTS

In the pelvis region the minimal dose succeeded in acting as a castrating dose. The safe area is 2.5 cm above the margin of the radiation beam.

CONCLUSION

It can be recommended to tuck the ovaries 3.5 cm above the margin of the pelvis.

[Treatment of early stages of ovarian carcinoma. Evaluation of experience at the Institute of Radiation Oncology over a 10-year period (1983-1993)]

The authors evaluated in a retrospective study the therapeutic results of ovarian carcinoma stage FIGO I (68 patients) and FIGO II (28 patients) attained in the Institute of Radiation Oncology, Prague during the ten-year period from 1983-1993. Total survival and survival without relapse within five years are 77% in stage I and 74% in stage II. The corresponding values of five-year survival without relapse were 56% and 58% resp. Despite the fact that the therapeutic results are comparable with data in the literature, a great shortcoming is the inadequate documentation of the initial laparotomy and the very general histopathological finding, moreover without grading, in a great proportion of the patients. The authors emphasize that these shortcomings make a reliable indication of adjuvant therapy impossible, in particular in early stages of ovarian carcinoma. Despite repeated references to this shortcoming these mistakes have persisted for several decades.

[Relapse in Hodgkin's disease. Incidence of relapse in a group of 374 patients from 1 June 1968 to 31 March 1995]

From a group of 366 patients with complete data complete remission was achieved by 290. Fifty-five patients relapsed, 39 men and 16 women, mostly with an initial finding of advanced disease (KS III + IV 64%), with affection of the mediastinum (73%) aged under 40 years. 42% of the relapses were detected within one year after termination of primary treatment and 33% during the subsequent 2 years, the longest interval before a relapse being 20 years. During primary treatment in 63% of the patients chemotherapy was reduced to 75-25% of the total dose of cytostatics with protraction of the interval between cycles in 58% and radiotherapy in another 34% of the patients. 76% of the patients with a first relapse achieved a second complete remission and 29 of them survive without signs of the disease, 12 died from generalized lymphoma. Sixteen patients developed repeated relapses (nine two relapses, four three relapses, another two four relapses and one patient five relapses). After treatment of the relapse a total of 22 patients died, incl. 19 who died from Hodgkin's disease, two from secondary carcinoma and one from myocardial infarction. The longest survival period after treatment of a relapse was 26 years.

[The significance of mediastinal involvement and other risk factors for survival in patients with Hodgkin's disease]

The impact of prognostic factors for survival was analyzed in a group of 337 patients with Hodgkin's disease. The analysis of survival of patients comprised a total of 13 indicators: histological types LP, NS, MC, LD, clinical stages I, II, III, IV, E lesions, symptomatology A, B, size of the mediastinal tumour (index), age at onset of disease and sex. Cumulative survival of 5, 10, and 20 years in the whole group is 83%, 80% and 72% resp. A first complete remission was achieved by 284 patients, cumulative survival without the disease is 79% after 5 and 73% after 10 years since completion of primary treatment. A significantly adverse effect on the prognosis of survival is exerted by symptomatology B, a large mediastinal tumour, advanced age, clinical stage IV and III. Most important are the first two factors mentioned. An adverse prognostic factor for survival without disease is male sex. The therapeutic protocol was repeatedly modified in the course of 25 years with regard to prognostic patient groups.

[Pulmonary complications and their prevention in the treatment of Hodgkin's disease]

Pulmonary ventilation was monitored in a group of 102 patients with Hodgkin's disease. In the initial finding a tendency of a restrictive disorder is apparent (43% of the patients) with the increasing size of the mediastinal tumour (79% mediastinal patients with a bulky finding in 40%), without statistical significance. After treatment a restrictive disorder was recorded in 35% of the patients with a normal initial finding and conversely normalization of results occurred in 12% patients with a pathological result of the spirometric examination. After a one-year interval the finding deteriorated in 12 % of the patients without post-treatment disorders of pulmonary ventilation and in 15% the assessed disorder receded. Statistical analysis did not reveal a significant relationship between the results of spirometry and bleomycin treatment. 77 patients were examined after an interval of 2, 3, 4 and more years following termination of primary treatment without a significant correlation of the development of the a restrictive disorder and bleomycin administration. Pulmonary ventilation after treatment was examined in a total of 228 patients with the finding of restrictive changes in 94 (41%). Pulmonary fibrosis was diagnosed in 21 patients (9%) with a rising incidence two years after terminated treatment.

[Children of parents treated for Hodgkin's disease using irradiation and chemotherapy]

The authors describe data on the course of pregnancy, delivery and subsequent development of 20 children born to parents treated for Hodgkin's disease. Thirteen women in the clinical stage II and III were delivered of 16 infants (10 daughters and 6 sons) and three men (II A and III A) had four daughters. The parents were in one case treated by irradiation only, twice by chemotherapy only and thirteen times by a combination of irradiation and chemotherapy (COPP/ABVD). The gestation period, parameters of the infants at delivery and the subsequent physical and mental development are normal. In one instance (a girl, now ten and a half years old) the child was born with malformations of the extremities; according to the geneticist this is not related to the previous treatment of the mother. The second child (a son) of this mother is normal. The authors are of the opinion and apply it in the therapeutic protocol in patients of fertile age and do not irradiate nodes in the pelvic region. In treated patients they allow pregnancy only after three or preferably five years following terminated treatment. Survival of patients in the whole group (269 subjects) regardless of age and clinical stage is 75%. The authors are processing a data base of Hodgkin patients since 1968.

[Causes of death in patients with Hodgkin's disease]

The authors analyze the causes of death of 52 patients from a group comprising 236 patients with Hodgkin's disease. From 51 patients 16 died within one year, with a single exception. All were in clinical stage III-IV (at the time of diagnosis). Within 5 years 40 patients died incl. 4 who the time of diagnosis belonged to clinical stage II. After more than 5 years following establishment of the diagnosis 12 patients died. Of these at the time of the diagnosis 8 were in clinical stage II, 3 in clinical stage III and one patient in clinical stage IV. In the first clinical stage and according to histological classification 10 patients survive, in clinical stage II 93 patients, in clinical stage III 105 patients and 28 patients in clinical stage IV. The mortality rate increases with the advancing clinical stage. Causes of death: progression of the basic disease in 63%, intercurrent infectious diseases in 25%, inhibition of bone marrow in 6%, same percentage for development of secondary neoplasms. The lowest mortality rate was recorded in patients treated by a combination of actino- and chemotherapy (11%), as compared with 23% treated by actinotherapy only and 41% treated by chemotherapy only.

[Prognostic significance of mediastinal involvement and post-therapeutic radiographic changes in the intrathoracic area in Hodgkin's disease]

The prognostic importance of mediastinal affection and its extent was analyzed in a group of 220 patients with Hodgkin's disease in all clinical stages. The results of the total survival period in mediastinal patients are significantly worse, as compared with patients without primary affection of the mediastinum at all evaluated time intervals: in the 5th year after onset of treatment 79% vs. 95% in the 10th, 15th and 20th year 67% vs 86%, 63% vs. 86% and 56% vs. 86%. The survival of patients without a mediastinal tumour does not change after a 10-year period of follow-up, in case of a tumour mass up to 1/3 of the transverse chest diameter it declines from 81% in the 5th year to 59 and to 49% in the 10th and 15th year. In case of extensive mediastinal affection only 61% survive 5 years and 42% survive after 10 years. The differences in survival without signs of the disease are not statistically significant, obviously due to primary radiochemotherapy with alternation of cytostatic combinations. There are no significant differences in the frequency of posttherapeutic X-ray changes in the mediastinal area after primary X-ray therapy alone and after chemotherapy alone, as compared with combined radio-chemotherapy with the incidence of postirradiation changes in 30% of the patients: the incidence of post-irradiation changes is potentiated by the administration of bleomycin, depending on the dose. For evaluation of posttherapeutic X-ray changes in the area of the chest it is essential to monitor the patients by X-ray check-ups with concurrent functional examination of the lungs.

[Possibilities of comprehensive care of oncologic patients in the framework of a polyclinic facility]

The authors evaluated five years of experience with ambulatory cytostatic chemotherapy at the policlinical department of clinical oncology in the District Institute of National Health in Prague 4. At the same time they draw attention to the necessity to create an in-patient department for oncological patients in this area.