Reduction of proteinuria with mycophenolate mofetil in predominantly membranous lupus nephropathy

INTRODUCTION

Lupus membranous nephropathy (LMN) presents a difficult clinical problem as no particular treatment has been proven to be effective. Studies have shown good results with mycophenolate mofetil (MMF) in proliferative lupus nephropathy (LN) (WHO class III and IV disease).

OBJECTIVES

To study whether MMF treatment was effective in membranous predominant LN in patients resistant to or intolerant of other immunosuppressive agents.

PATIENTS AND METHODS

We retrospectively studied 10 patients with systemic lupus erythematosus who had biopsy-proven predominant LMN (six Vc patients and four Va or Vb patients). Previous treatments included cyclophosphamide, azathioprine, ciclosporin and corticosteroids. The following parameters were recorded at baseline and follow-up: blood pressure, ECLAM, proteinuria, serum albumin and creatinine, routine haematology and immunology.

RESULTS

The study included eight women and two men, mean age 38.4 +/- 7.1 yr (range 30-49 yr). The racial distribution was as follows: five Caucasian, and five Black patients. The mean treatment time with MMF was 18.8 +/- 15.4 months (range 3-52 months). Twenty-four-hour urinary protein excretion was reduced from median 2.26 g (range 0-7.92 g) to median 0.66 g (range 0.08-3.85 g) at follow-up (P = 0.0039). Serum albumin increased significantly after treatment from median 29.5 g/l (range 14.0-42.0 g/l) to 33.5 g/l (range 23.0-40.0 g/l) at follow-up (P = 0.04). There were no significant changes in serum creatinine (P = 0.55).

CONCLUSION

MMF is a potentially useful immunosuppressive agent in reducing the proteinuria associated with membranous predominant LN.

Mesenchymal chondrosarcoma of the thyroid - a rare tumour at an unusual site

We describe the light microscopic, immunohistochemical and ultrastructural features of the first case in the literature of a primary mesenchymal chondrosarcoma (MC) of the thyroid and discuss its differential diagnosis at unusual extraskeletal sites. A nodular lesion of the thyroid with no evidence of extrathyroid disease showed the bimorphic pattern and haemangiopericytoma-like areas typical of MC. In the undifferentiated areas, the cells were CD99 positive/CD117 negative, while the stroma showed focal positivity for alpha-inhibin. In spite of its rarity, it is important to diagnose primary mesenchymal chondrosarcoma in a parenchymatous organ such as the thyroid because its biological behaviour may be different from that of tumours of similar morphology and complete resection is the treatment of choice. The patient is free of disease nearly 66 months after its first presentation. Cytogenetic and immunohistological markers may play important roles in diagnosis of this lesion in future, especially with limited tissue samplings; however, for the present a thorough sampling of the tumour remains the best diagnostic strategy.

Angina with a normal coronary angiogram caused by amyloidosis

A case of severe intractable angina pectoris with normal angiography is presented. Following video assisted thoracic sympathectomy the patient died of heart failure. Microvascular cardiac amyloidosis was diagnosed at the postmortem examination. This report alerts clinicians to this possible diagnosis when treating patients with severe angina when no cause is found and discusses the poor prognosis in such cases.

Anti-dsDNA, anti-Sm antibodies, and the lupus anticoagulant: significant factors associated with lupus nephritis

BACKGROUND

Lupus nephritis (LN) is a common manifestation in patients with systemic lupus erythematosus (SLE). Autoantibodies and ethnicity have been associated with LN, but the results are controversial.

OBJECTIVE

To study the immunological and demographic factors associated with the development of LN.

PATIENTS AND METHODS

A retrospective case-control study of 127 patients with biopsy-proven LN, and 206 randomly selected patients with SLE without nephritis as controls was designed. All patients had attended our lupus unit during the past 12 years. Standard methods were used for laboratory testing.

RESULTS

Patients with LN were significantly younger than the controls at the time of SLE diagnosis (mean (SD) 25.6 (8.8) years v 33.7 (12.5) years; p<0.0001). The proportion of patients of black ethnic origin was significantly higher in the group with nephritis (p=0.02). There were no differences in sex distribution or duration of follow up. A higher proportion of anti-dsDNA, anti-RNP, anti-Sm, and lupus anticoagulant (LA) was seen in the group with nephritis (p=0.002; p=0.005; p=0.0001; p=0.01, respectively). In univariate, but not in multivariate, analysis male sex and absence of anti-dsDNA were associated with earlier onset of renal disease (p=0.03; p=0.008). In multivariate analysis the only factors associated with nephritis were younger age at diagnosis of SLE, black race, presence of anti-dsDNA, anti-Sm, and LA. No demographic or immunological associations were seen with WHO histological classes.

CONCLUSIONS

Young, black patients with anti-dsDNA, anti-Sm antibodies, and positive LA, appear to have a higher risk of renal involvement. These patients should be carefully monitored for the development of LN.

Hypertension as the presenting feature of the antiphospholipid syndrome

The antiphospholipid or Hughes syndrome is the association between antiphospholipid antibodies (aPL), venous and arterial thromboses and pregnancy morbidity. Antiphospholipid syndrome (APS) commonly coexists with autoimmune diseases usually systemic lupus erythematosus (SLE), when it is known as secondary APS. When present in isolation it is known as primary APS (PAPS). Although the kidney may be affected in APS, its involvement is perhaps not as well described as that of other organs. Thrombotic microangiopathy (TMA) affecting the kidney has been reported as a manifestation in both primary and secondary APS. This report describes hypertension related to underlying renal TMA as a presenting symptom of APS.

Lymph node cytology in Wegener's granulomatosis

We report on cytological findings on aspirates from the cervical lymph node from a case of Wegener's granulomatosis (WG). The diagnostic utility of technique in diagnosing a sizable minority of WG patients who present with cervical lymphadenopathy is discussed. We outline an approach to diagnosis of necrotising granulomatous lesions in aspirates from lymph nodes in a tabular form.

Pulmonary echinococcosis with chest wall involvement in a patient with no apparent risk factors

Pulmonary hydatid disease is rare in the U.K., and chest wall involvement has to our knowledge not previously been described in this country. We report the case of a 72-year-old man who was found to have a left upper lobe opacity on his chest radiograph. He declined further investigation at the time, but 2 years later developed a palpable mass over his left lateral chest wall. Fine-needle aspiration-biopsy of this mass revealed the diagnosis of pulmonary hydatid disease. Despite thorough questioning, no risk factor could be identified for the development of the disease. Hydatid disease should be remembered as a rare cause of mass lesions identified on chest radiographs even in non-endemic regions. Spread to the chest wall may mimic malignancy.

Tracheocarotid artery fistula infected with methicillin-resistant staphylococcus aureus

Massive life-threatening haemorrhage from a fistula between the trachea and a major blood vessel of the neck is a rare complication of the tracheostomy procedure, well-recognized by anaesthetists and otolaryngologists. Although the lesion is likely to be encountered at autopsy, it is not described in histopathological literature. The possible causes are discussed together with the macroscopic and microscopic appearances of the lesion. Suitable procedures for its identification and for obtaining appropriate histopathological blocks are suggested. Presence of methicillin-resistant Staphylococcus aureus (MRSA) has not been documented before and might have contributed to the genesis of the fistula in this case.

Patterns of expressions of transforming growth factor and epidermal growth factor receptor in squamous cell lesions of the urinary bladder

AIM

To investigate the patterns of expression of transforming growth factor alpha (TGF-alpha) and epidermal growth factor receptor (EGFR) in squamous metaplasia and squamous cell carcinomas of the urinary bladder with and without schistosomiasis.

METHODS

Immunohistochemical study of the expression of TGF-alpha and EGFR in squamous metaplasias (n = 12) and various grades of squamous cell carcinomas (n = 21) of the bladder with and without schistosomiasis.

RESULTS

Focal cytoplasmic and membranous positivity for EGFR and TGF-alpha was seen in all cases of squamous metaplasia. The markers were diffusely coexpressed in a concordant pattern in areas of hyperplastic keratinising squamous metaplasia. A similar pattern of positivity was seen in verrucous carcinomas (n = 2) and well differentiated squamous carcinomas (n = 6). Progressive loss of differentiation was associated with increasing loss of EGFR staining while TGF-alpha staining was retained. Squamous cell carcinoma in situ (n = 2) showed focal positivity for TGF-alpha and EGFR. There were no differences in staining patterns between cases with and without schistosomiasis.

CONCLUSIONS

The coexpression of TGF-alpha and EGFR by well differentiated squamous cell carcinomas and hyperplastic keratinising squamous metaplasia is consistent with the active regulatory role exerted by this autocrine loop. There is regional absence of expression of EGFR but not of TGF-alpha in squamous cell carcinomas of lesser differentiation, suggesting heterogeneity of such control in these tumours. The focal expression of the two markers in squamous cell carcinomas in situ indicates a possible second pathway of oncogenesis for less differentiated tumours. These observations may have important implications for the effectiveness of putative growth factor based treatments.

Immunosuppressive therapy in lupus nephritis

OBJECTIVE

To evaluate the outcomes and side effects of immunosuppressive therapy in patients with lupus nephritis.

PATIENTS AND METHODS

Thirty-nine patients with lupus nephritis assessed between 1988 and 1993 with a median follow-up of 46 months (range 12-60 months) were studied. Lupus nephritis was biopsy-proven in 37 patients. Patients received a median of 3 (500 mg) weekly pulses of intravenous cyclophosphamide followed either by azathioprine (n = 32) or oral cyclophosphamide (n = 7). All patients received oral prednisolone. The time from biopsy to renal insufficiency, defined by doubled serum creatinine and/or end stage renal failure, was used to assess outcome.

RESULTS

There were significant improvements in the median changes of all major laboratory parameters. Serum creatinine levels did not change significantly. The prednisolone dose was significantly reduced during the follow-up period.

OUTCOME

renal function remained stable in 26 (67%) and deteriorated despite therapy in 13 (33%) patients. 6/13 (42%) of these patients had impaired renal function at the time of biopsy. The adverse effects of intravenous cyclophosphamide seen were Herpes zoster (1), transient leucopenia (2), rash (1) and fatal septicaemia (1); of azathioprine urinary infections (3), leucopenia (5), rash (1) and increased liver enzymes (1); and of oral cyclophosphamide ovarian failure (4), Herpes zoster (3), haemorrhagic cystitis (1), and fatal septicaemia (1).

CONCLUSIONS

Therapy with weekly low dose intravenous pulse cyclophosphamide to induce remission, followed by azathioprine appears to be useful in preserving renal function in patients with diffuse proliferative lupus nephritis. In comparison to other studies, the reduced incidence of ovarian failure using this regimen was striking.

Glomerular basement membrane thickness - a comparison of two methods of measurement in patients with unexplained haematuria

BACKGROUND

Thin glomerular basement membranes may be an important cause of microscopic haematuria. Unfortunately measurements are often not made because of the complicated methods currently employed.

METHODS

A simplified method of measurement of glomerular basement membrane thickness, involving only 16 selected measurements on a single glomerulus, was compared with the accepted, but time-consuming, orthogonal intercept technique. Thirty-one needle biopsies from patients with renal haematuria unexplained by conventional histology and immunofluorescence were studied. Measurements were made on the same ultrathin sections.

RESULTS

The new method was found to give much lower values (mean (SD) 202+/-51 versus 282+/-52 nm) with limits of agreement of -131 to -30 nm compared with the orthogonal intercept method. The coefficient of repeatability was 39 nm for the orthogonal intercept method and 56 nm for the new method. However, using two glomeruli the new method had limits of agreement of -120 to -41 nm with a coefficient of repeatability of 38 nm.

CONCLUSIONS

Provided two glomeruli are measured the new technique is sufficiently accurate for the diagnosis of thin membrane nephrology, in appropriate cases, and is much simpler and cheaper than the orthogonal intercept method.

Bladder carcinomas and normal urothelium universally express gp200-MR6, a molecule functionally associated with the interleukin 4 receptor (CD 124)

Monoclonal antibody MR6 detects gp200-MR6, a molecule functionally associated with the interleukin 4 (IL- 4) receptor. Positive immunolabeling with MAb MR6 was obtained in 28/28 transitional cell carcinomas of the bladder, representing a range of different grades and stages of disease, as well as in all control non-neoplastic urothelia. The expression of mutant p53 protein and epidermal growth factor receptor was detected in 14/28 and 20/28 cases respectively. Proliferation indices, determined by Ki67 labeling, ranged from 5% to 95% among these tumours. The universal expression of gp200-MR6 in neoplastic and non-neoplastic urothelium has important implications for the possible use of IL-4 in tumour therapy and suggests that IL- 4 may play a role in differentiation and homeostasis of urothelium and other mucosal epithelia.

Schwannoma of the external auditory canal

Solitary schwannomas are relatively rare. There has been only one previously reported case, in the English literature, of a schwannoma arising in the external auditory canal. We present a case which was managed by local excision and was unassociated with cochlear or retrocochlear pathology.

Carcinoma of the parotid gland presenting as facial pain

Facial pain is a common reason for patients seeking medical help. A patient is presented who gave a 5-month history of right-sided facial pain, which was subsequently diagnosed as carcinoma of the right parotid gland.

bcl-2 protein in non-small-cell lung carcinoma

BACKGROUND

The proto-oncogene bcl-2 encodes a protein that inhibits programmed cell death (apoptosis). The protein is expressed in basal cells in normal human epithelium, but no data are available on the frequency or clinical importance of its expression in carcinoma. We studied bcl-2 expression in patients with non-small-cell lung carcinoma and correlated this phenomenon with survival.

METHODS

Immunochemical analysis with a monoclonal antibody specific for bcl-2 was used to detect the protein in tumor samples from 122 patients undergoing surgery for squamous-cell carcinoma (80 patients) or adenocarcinoma (42 patients). The possibility that bcl-2 expression correlated with survival was investigated with use of the log-rank test, hazard ratios, and their confidence intervals.

RESULTS

We detected bcl-2 protein in 25 percent of squamous-cell carcinomas (20 of 80) and 12 percent of adenocarcinomas (5 of 42). In adjacent normal respiratory epithelium, bcl-2 was expressed only in basal cells. Survival at five years was higher among patients with bcl-2-positive tumors, both in the group as a whole (P < 0.1) and in the group with squamous-cell carcinoma (P < 0.02). Patients 60 years of age or older who had bcl-2-positive tumors had the best prognoses, both in the group as a whole (P < 0.02) and in the group with squamous-cell carcinoma (P < 0.01).

CONCLUSIONS

The proto-oncogene bcl-2 is abnormally expressed in some lung carcinomas, and its expression may have prognostic importance.

Ki-67 immunostaining and survival in operable lung cancer

One hundred and eighty-seven operable lung tumours were immunostained with the monoclonal antibody Ki-67 and divided into groups of high, moderate or low proliferation. Patients have been followed clinically for up to 7 years to ascertain whether this immunocytochemical measurement reflected tumour behaviour in terms of survival. The majority of the tumours were squamous cell carcinomas (104 cases) and adenocarcinomas (60 cases). These were divided into three groups of low, intermediate and high growth fraction, in which survival was better for tumours of lower proliferative rate up to approximately 2 years after operation. By 5 years these differences had largely disappeared and all tumours of a particular type showed a similar survival curve. Small cell carcinomas (13 cases) had high Ki-67 labelling indices, with more than 60% of patients deal in the first year, whereas carcinoid tumours (10 cases) had low labelling rates and all but one are still alive. We conclude that measurement of lung tumour growth rate with the monoclonal antibody Ki-67 shows promise as a possible indicator of short-term survival and perhaps as a means of choosing a group of patients with adenocarcinomas and squamous cell carcinomas for post-operative chemotherapy.

The L1 antigen and squamous metaplasia in the bladder

The L1 antigen was investigated as a marker of squamous differentiation in urothelium using a monoclonal antibody Mac387, and the results were compared with the expression of high molecular weight cytokeratins. L1 antigen was consistently demonstrated in all instances of partial and complete squamous metaplasia and in squamous carcinomas. In contrast, pure transitional cell carcinomas (except one with minor focal staining), adenocarcinomas and normal and hyperplastic urothelium did not label. In a few squamous carcinomas in situ, the pattern of labelling obtained with Mac387 was different from that seen in invasive squamous carcinomas and metaplasias. Compared with high molecular weight cytokeratins, the expression of L1 was more intense in areas of squamous differentiation. L1 expression, as identified by antibody Mac387, may therefore serve as a useful marker of squamous differentiation in urothelial lesions.

Interleukin 4 receptor expression on human lung tumors and normal lung

Interleukin 4 (IL-4) receptors were detected by a monoclonal antibody on tumor cells of 10 of 29 squamous cell carcinomas and 6 of 17 adenocarcinomas of the lung. None of the small cell carcinomas or carcinoid tumors stained. Parallel sections stained for epidermal growth factor receptors showed that all but 2 of the IL-4 receptor-positive tumors also expressed epidermal growth factor receptors. Positive labeling for IL-4 receptors was also obtained on nonneoplastic bronchial epithelium and on lymphocytes and macrophages infiltrating the tumor stroma. The role of IL-4 and its receptor in normal human lung is unknown, but the expression of IL-4 receptors on particular subtypes of lung tumors suggests that they may have a role in differentiation or proliferation of squamous and adenocarcinomas.

Partial replacement of the oesophageal muscle layers by a carbon-fibre prosthesis

In the present study we report on the surgical replacement of the thoracic portion of oesophageal muscularis by a synthetic carbon fibre (CF) prothesis in a rabbit model. Our results, as corroborated by the oesophagograms and the post-operative weight gain, showed that this prothesis functioned satisfactorily for up to 6 weeks observation period. When the observation period was extended to 12 and 24 weeks after surgery, dilatation of the oesophagus at the prosthetic site was observed. All animals tolerated this dilatation and survived their intended observation period in good condition. In all these animals the body weight loss of -11.23 +/- 3.97% (p = 0.005) noted during the 1st week after the operation stopped and the body weight returned to its preoperative level within 3 weeks, as in the control groups. When the CF protheses were wrapped with a non-biodegradable polyurethane ether material with an elasticity of 19.2 g/mm, all rabbits died within 3 weeks or had to be sacrificed because of complications due to stagnation of food. In these rabbits the body weight decreased dramatically by -27.40 +/- 5.41% (p less than 0.001). In any similar future studies using the rabbit model, the post-operative body weight should provide a simple, sensitive and reliable monitoring tool for the functional assessment of the reconstructive procedure.

Helicobacter pylori in dyspeptic patients in Kuwait

Two hundred and four patients, mainly Arabs, attending for upper gastrointestinal endoscopy at the gastroenterology clinic in Mubarak Al-Kabeer Hospital, Kuwait, were examined for evidence of infection with Helicobacter pylori and associated inflammation. Biopsy specimens of antrum, body, and duodenum; gastric juice; and antral mucosal brushings were investigated by microbiological, cytological, and histopathological methods. Clinical conditions diagnosed at endoscopy included gastritis, gastric ulcer, duodenitis and duodenal ulcer, but half the patients had endoscopically normal gastric and duodenal mucosae. H pylori was detected by one or more of the procedures in at least one specimen from 197 (96.6%) of the patients. Histological and cytological analysis showed equal sensitivity, but bacteriological culture was less reliable. The proportion of positive cases was high, compared with other reported series, which may have been accounted for by the variety of diagnostic techniques used in this study, the selected population (all with gastrointestinal symptoms) or genetic or environmental predisposing factors peculiar to the sample population.

Polymyositis and hepatocellular carcinoma

We report a patient with recent onset of acute polymyositis who was subsequently found to have a hepatocellular carcinoma, a rare uncommonly associated malignancy.

Immunohistochemistry of cytokeratin proteins in squamous and transitional cell lesions of the urinary tract

Expression of low and high molecular weight cytokeratin proteins was investigated immunohistochemically in a variety of transitional and squamous epithelial lesions of the urinary tract with and without schistosomiasis. The monoclonal antibodies used were CAM 5.2 and NCL5D3 for low, PK 63 and 121 for high, and MAK 6 for a broad range of intermediate molecular weight cytokeratins. On staining with CAM 5.2 and NCL5D3, urothelial hyperplasias (n = 12) and grades 1 (n = 5) and 2 (n = 10) papillary transitional cell carcinomas showed labelling patterns quite distinct from carcinoma in situ (n = 4) and non-papillary grades 2 (n = 6) and 3 tumours (n = 3). Among squamous lesions only focal positivity was obtained in 14 of 22 moderate to poorly differentiated squamous cell carcinomas. By contrast, PK 63 and 121 stained squamous lesions exclusively. MAK 6 stained the whole range of urothelial and squamous lesions with the exception of squamous metaplasias. Polyclonal antikeratin adequately labelled spindle cell areas of high grade tumours. The distinctive staining patterns given by these or similar antibodies may help in the identification of squamous metaplasia and in diagnosing tumours of the urothelium.

Expression of chorionic gonadotropin by schistosomiasis-associated squamous carcinomas of bladder

Of 22 consecutive cases of squamous cell carcinomas of the urinary bladder, 4 expressed the beta subunit of human chorionic gonadotropin as demonstrated by immunohistochemistry. The significance of this finding is compared to similar observations made in urothelial carcinomas by others and its value as a possible marker in diagnosing and monitoring the progress of these tumors is discussed.

Coeliac disease among children in Kuwait: difficulties in diagnosis and management

Twenty children with coeliac disease were diagnosed over a five year period in an area with 10,000-12,000 births per year. The average annual incidence was 1:3000 births. All children presented with severe symptoms and rickets was not uncommon (25%). Mean age at onset of symptoms was 38 months (range 6-120) and 72 months at the time of diagnosis (range 13-192), with a mean delay of 34 months. No cases were diagnosed during infancy. The difficulties in the differentiation of coeliac disease from the more common causes of chronic diarrhoea, and problems with diagnosis and management are discussed.

Fine structural changes in idiopathic pulmonary haemosiderosis

Lung biopsies from four children and two adults with idiopathic pulmonary haemosiderosis have been examined by transmission electron microscopy. No qualitative differences were identified between the children and the adults but the changes were more severe in the children. In each case the major damage involved the capillary endothelium and its basement membrane. Capillary endothelial swelling was very noticeable and in one case the endothelium was attenuated but gaps between endothelial cells were very difficult to find. Capillary narrowing and platelet aggregation were common. The capillary endothelial basement membrane showed focal thickening, particularly on the thick side of the air/blood barrier, but no electron dense deposits were identified. Degenerative changes in the alveolar epithelium were not so marked as those in the capillary endothelium and the epithelial basement membrane was normal except for haemosiderin deposition. Haemosiderin was also noted on elastin and within intra-alveolar macrophages. Other secondary changes included mild interstitial oedema and fibrosis. These findings indicate that the major site of damage is the alveolar capillary, but provide no evidence of the cause of the disease.

Schistosomiasis-associated squamous lesions of the bladder. Expression of low molecular weight cytokeratin proteins

The monoclonal antibody CAM 5.2 was used to investigate the expression of lower molecular weight cytokeratin proteins immunocytochemically in conventionally processed samples of schistosoma-associated squamous metaplasias and carcinomas of the urinary bladder. The antibody did not differentiate between squamous metaplasias and well differentiated squamous carcinomas, though it did focally label moderate to poorly differentiated tumours. The results suggest that squamous carcinomas of the bladder in this setting differ fundamentally from such tumours at other sites in their patterns of cytokeratin protein expression.

Complete Freund's adjuvant has a differential amplification action on the induction of diabetes by streptozotocin in various murine strains: CFA amplifies STZ in murine diabetes

The effect of complete Freunds Adjuvant (CFA) has been investigated on the multi-low-dose streptozotocin (STZ) model of diabetes in mice of the H-2b (C57Bl/6) and of the H-2k (A/J, CBA) genotypes. Physiological (glycemia and body weight) and morphological (insulitis) parameters were monitored. STZ was used at standard and sub-diabetogenic dose levels (45 and 22.5 mg/kg STZ, for five consecutive days respectively) and CFA was given as a single dose (0.1 ml) on the first dosage day. In H-2k mice, CFA was synergistic with STZ at 45 mg/kg but did not cause the 22.5 mg/kg dose to raise glycemia to diabetic levels. By comparison, CFA was not synergistic with STZ at 45 mg/kg in H-2b mice, but did convert the subdiabetogenic dose to a diabetogenic action in these animals. Histologically, it was noted that insulitis was a more prominent and persistent feature of the H-2k mice. It occurred at the subdiabetogenic dose level of STZ in H-2k mice, in the absence of increased glycemia, suggesting that these two phenomena are not related. CFA, either alone, or with STZ, caused severe persistent perilobular inflammation of the exocrine pancreas. It did not increase the incidence or severity of insulitis. A possible mechanism whereby CFA is synergistic with STZ at different doses in H-2b and H-2k mice is suggested.

Gastric alpha heavy chain disease

Clinicopathological and immunohistological features of 4 cases of gastric lymphomas with alpha-heavy chain disease (AHCD) are described. Clinically there were no reliable features that could distinguish them from the 'western' types of gastric lymphomas (WGL). Two of the 4 had diffuse mucosal involvement reminiscent of the more common intestinal form of AHCD. Histologically, all 4 were low-grade follicular-centre cell lymphomas with plasmacytic differentiation. The diagnosis of gastric AHCD and its implications are discussed.

Gastric signet-ring cell lymphoma with alpha heavy chains

Signet-ring cell lymphomas are rare especially as primary gastric tumours; alpha chain disease of the stomach is also unusual. A case of gastric signet-ring cell lymphoma with free alpha chains in the gastro-duodenal juice is reported and its light microscopic, immunohistological and ultrastructural features are described. Although the morphogenesis of signet-ring cell lymphoma is not clear, the present case showed many of the features of a mucosa-associated lymphoma. This rare variant of follicle centre cell lymphoma may easily be mistaken for a signet-ring cell carcinoma. A search for abnormal immunoglobulins should be made in serum, secretions or tissues in future cases of signet-ring cell lymphoma.

Sarcomas of the bladder and prostate: the role of immunohistochemistry and ultrastructure in diagnosis

2 undifferentiated malignant tumors of the bladder/prostate region (one with urinary schistosomiasis) and 6 carcinomas with spindle cell morphology were studied by immunohistochemical markers and electron microscopy. Our findings indicate that the categorization of undifferentiated tumors of this region is significantly aided by the use of such methods.

Malignant lymphomas: results and observations from St George's Hospital

With both Hodgkin's and non-Hodgkin's lymphoma, the results documented compared well with reference series. Hence the advantages of a modest clinic need not be at the cost of recovery or of survival. A major factor attenuating the scale of therapy in Hodgkin's disease is the risk of inducing second malignancies. Four such complications have been observed amongst 27 patients with Hodgkin's disease. Amongst the patients with non-Hodgkin's lymphoma better results were noted than the designation 'poor prognosis histology' had led the authors to expect. These findings suggest that the concept of histologically based prognosis may be over-subscribed and that contemporary therapeutic strategies can be extremely effective in this group.