Preclinical evaluation of a novel thermally sensitive co-polymer (LiftUp) for endoscopic resection

Introduction: Endoscopic resection techniques can successfully resect large lesions either in "en bloc" fashion or in "piece-meal" technique by using a submucosal injection solution. The aim of this study was to evaluate the safety of a novel injectable, containing thermally sensitive co-polymer from ethylenoxide and propylenoxide (LiftUp) used as submucosal injection solution.Material and methods: We conducted an in vivo animal trial in the porcine model to evaluate the LiftUp gel in a preclinical setting and to study the effectiveness of mucosal lifting and the safety of the new injectable. In seven animals a total of 63 injections and endoscopic resections were carried out in different anatomical locations (esophagus, stomach and rectum). The resection sites were controlled endoscopically one and four weeks after resection and a histopathological evaluation of the resection sites was performed after four weeks.Results: The application of LiftUp was safe and there were no negative effects on wound healing after injection and resection. A major procedural complication rate (defined as perforation and major haemorrhage) of 3.2% was registered, which undercuts the anticipated mean complication rate of 4-8%. Furthermore, there was no necessity of reinjection after the initial submucosal injection in 90.5% and no procedural complications in 98.8%. The histopathological examination of the tissue samples indicated normal wound healing with granulation tissue and epithelialisation.Conclusion: The use of LiftUp as submucosal injection solution was feasible for different endoscopic resection techniques, with high and long-lasting elevation and fewer procedural adverse events than expected at trial planning. The new injectable is a practical advancement over the current state-of-the-art of submucosal injection and could fasten up the resection procedure and make endoscopic 'en bloc' resection safer.

Holmium: Yag Laser Angioplasty

This experimental study was designed to define the potential value of a mid-infrared holmium laser in the free running mode for angioplasty. Immediately after removal, fresh normal and diseased human cadaveric arteries were irradiated under saline with a Ho:YAG laser (wavelength 2.13 μm). The laser was pulsed at 3 Hz, 250 μs pulse width and fluences of 10 to 40 J/cm2. The laser beam was coupled to ring catheters with multiple low-OH quartz fibers. The tip of the delivery device was held in direct contact with the vessel surface with the laser beam oriented perpendicularly. Ablation of atherosclerotic plaque was accomplished at an ablation threshold of 10 J/cm2. The ablation rate was 2.1 to 8.3 μm/pulse. Removal of calcified plaque was only partially effective. There were marked thermal effects with vacuolizations extending up to 1505 ± 178 μm into the adjacent tissue. Laser light at the mid-infrared wavelength of 2.13 μm is supposed to be attractive as it is readily absorbed in water and can easily be transmitted through optical fibers. However, Q-switching seems to be essential to minimize thermal side effects and to make effective ablation of calcium possible.

Endoscopic full-thickness resection and clip defect closure in the colon with the new FTRD system: experimental study

BACKGROUND

The benefit of endoscopic full-thickness resection is the improved diagnostic work-up with an integral wall specimen which allows a precise determination of the tumor or its precursor and its infiltration depth into the wall.

MATERIALS AND METHODS

A new endoscopic full-thickness resection device (FTRD), which is a combination of a modified over-the-scope-clip (OTSC) system with an electrocautery snare, has been tested in an experimental setting. In eleven pigs, divided into three groups, endoscopic full-thickness resection was performed in the colon at one or two sites, respectively. Seven days (n = 7) or 28 days (n = 4) after the intervention, the animals were euthanized following endoscopic examination of the resection and clip application sites. Furthermore, two different clips were tested during these animal trials in order to evaluate the most effective clip design.

RESULTS

The average diameter of the tissue resected with the FTRD was 3.1, 3.6, and 5.4 cm in the three groups. On follow-up endoscopy 7 days after the intervention, fibrin coating and stool residues were found at all clips, causing minor inflammatory reactions. However, the colon wall under the clip was non-inflamed. After 28 days, the serosa had primarily healed in all cases. There were also stool residues at all clips; however, no acute inflammatory reactions were seen anymore, due to complete healing. Histological assessment did not show any signs of dehiscence in the region of the scar, or ischemia in the clip area. In addition, no wound infections, such as abscess formation, were observed.

CONCLUSIONS

This study demonstrates the safety and efficacy of the clip-and-cut technique using the new FTRD system. With the device, a local full-thickness colon resection can be easily created, and the resulting wall defect is reliably sealed by the endoluminal application of a modified OTSC clip.

First description of a hybrid tumor of the sublingual gland

BACKGROUND

Hybrid tumours of the salivary glands are rare neoplasms. They are composed of at least two different tumour entities located in the same topographic area and account for only 0.1% of all salivary gland tumours. The most common component is an adenoid cystic carcinoma. There are several possible forms of hybrid tumours, which are most commonly located in the parotid gland.

CASE REPORT

We report on a 59-year-old female, who presented with a lesion of the caruncula of the left sublingual gland. The biopsy showed an adenoid cystic carcinoma in combination with a salivary duct carcinoma. Treatment consisted of tumour resection, bilateral selective neck dissection and adjuvant radiotherapy. Histopathologically, at least 30% of the tumour mass was composed of a salivary duct carcinoma and 70% of an adenoid cystic carcinoma. At 58 months after treatment, the patient is alive without evidence of recurrent disease.

CONCLUSION

To our knowledge, the presented case is the first description of a hybrid tumour of the sublingual gland. Furthermore, the post-therapeutic course is encouraging, as hybrid tumours of the salivary glands usually have a poor prognosis.

The anal fistula claw: the OTSC clip for anal fistula closure

AIM

Surgical closure of high or complex anal fistulae is often a difficult challenge. A special Nitinol clip, the OTSC clip (Ovesco AG), was evaluated for fistula closure in a porcine model.

METHOD

A total of 20 fistulae were created in 10 animals by seton insertion. Four weeks after fistula induction the setons were removed: one internal fistula opening per animal was left untreated as control whereas the other opening was closed by the OTSC clip using a specially developed transanal clip applicator. The safety and technical feasibility of the clip application were tested. Another 4 weeks later, fistulae were macroscopically assessed for closure. For histological examination, the anorectum including the fistula tract was excised en bloc.

RESULTS

Four weeks after clip placement, all external and internal fistula openings were macroscopically closed. The clip application site presented with an increased scarring. Microscopically, 40% of residual tracts and a more intense chronic inflammation were seen in the untreated control fistulae. After clip placement, 10% of the fistulae persisted associated with a higher density of collagen fibres indicating a better fistula scarring and healing. No unexpected side-effects or complications caused by the clip were observed.

CONCLUSION

Fistula closure using the OTSC clip represents a promising sphincter-preserving minimally invasive procedure. This study demonstrated the safety and feasibility of the 'anal fistula claw' for fistula closure. In spite of limitations of the porcine model the results justify clinical applications and further investigations.

Expression of the proliferation marker Ki-67 associates with tumour staging and clinical outcome in differentiated thyroid carcinomas

OBJECTIVE

Although the prognosis of differentiated thyroid carcinoma (DTC) is excellent, with 10-year survival rates of about 90%, about one-third of patients experiences recurrent disease. We aimed to identify novel histological prognostic factors to optimize treatment and follow-up of patients at risks.

DESIGN

Retrospective analysis of patients diagnosed from January 1990 to March 2004.

SUBJECTS

A total of 93 patients diagnosed with DTC of which 67 with papillary and 26 with follicular histology.

MEASUREMENTS

Analysis of immunohistochemical expression of somatostatin receptor (sst) subtypes 1-5, glucose transporter-1 (GLUT-1), receptor tyrosine kinase c-KIT, oestrogen and progesterone receptors, and proliferation marker Ki-67 and correlation with the patients' clinical outcome.

RESULTS

DTC showed immunohistochemical expression of GLUT-1, C-KIT and progesterone receptor in a high percentage of cases (range: 57-80%). In contrast, the oestrogen receptor as well as the sst subtypes 1-5 was less frequently detected (range: 15-29%). Mean staining of the proliferation marker Ki-67 was 6% positive cells (range 0-20%). Ki-67 expression was significantly associated with tumour staging (ρ = 0·2076, P = 0·0459), whereas the other histopathological markers were not associated with gender, age, tumour entity, or tumour classification. Tumour staging and expression of Ki-67, oestrogen receptor and sst2, but of none of the other histopathological factors, independently predicted the clinical outcome 5 years after definitive treatment (P < 0·0001, P < 0·0001, P = 0·0004 and P = 0·0206, respectively).

CONCLUSIONS

In patients with DTC, Ki-67 expression associates with tumour staging and clinical outcome.

Prevalence and histopathology of chronic polypoid sinusitis in pediatric patients with cystic fibrosis

BACKGROUND

Chronic sinusitis is almost invariably a feature of cystic fibrosis. However, data on the endoscopically confirmed prevalence of chronic polypoid sinusitis (CPS) and its histological features are limited.

METHODS

Single centre prospective observational study. Unselected pediatric CF patients (n=81; ≤ 18 years) were endoscopically assessed for the prevalence of CPS. Sixteen of these underwent sinus surgery. The surgically obtained sinus specimens were compared to sinus specimen of non-CF-patients undergoing sinus surgery (n=61), using conventional histology and immunohistochemistry.

RESULTS

The prevalence of endoscopically confirmed CPS increased with age from 19% in infants younger than six years reaching 45% in adolescents. In CF patients, histology typically showed dilated glandular ducts and a predominance of mucous glands. The number of plasma cells and mast cells but not of eosinophils was significantly elevated compared to non-CF patients.

CONCLUSION

Prevalence of CPS in pediatric CF patients increases with age. Our findings indicate that chronic bacterial infection rather than allergic mechanisms may forward this pathology.

Association of somatostatin receptor 2 immunohistochemical expression with [111In]-DTPA octreotide scintigraphy and [68Ga]-DOTATOC PET/CT in neuroendocrine tumors

In the absence of preoperative somatostatin receptor ( SST) scans, knowledge of immunohistochemical SST2 tumor expression may help predicting the success of somatostatin analogue-based follow-up studies and treatment of neuroendocrine tumors (NET). We studied the association between SST immunostaining and tracer uptake in [(111)In]-DTPA octreotide (DTPAOC) scintigraphy and [(68)Ga]-DOTA-D-Phe(1)-Tyr(3)-octreotide (DOTATOC) positron emission tomography (PET)/computed tomography (CT). Retrospective analy-sis of 36 NET patients was carried out. In 40 tumors, immunohistochemical SST2, SST3, and SST5 expressions were analyzed using a pathological scoring, applying monoclonal ( SST2) or polyclonal antibodies (SST3, SST5). In 14 lesions, [(111)In]-DTPAOC uptake was assessed by a semiquantitative score. In 26 tumors, [(68)Ga]-DOTATOC PET/CT was quantified using an uptake score and maximal standard uptake value (SUV(max)). Combined and separate qualitative analysis of SST scans revealed significant associations between increased tracer uptake and immunohistochemical SST2 detection (combined: rho=0.56, p=0.0002, [(111)In]-DTPAOC: rho=0.63, p=0.0152, and [(68)Ga]-DOTATOC: rho=0.52, p=0.0065, respectively). In contrast, SST3 and SST5 immunostaining was not associated with tracer uptake (all p>0.14). The semiquantitative immunohistochemical score for SST2 was associated with the [(68)Ga]-DOTATOC uptake score and SUV (max) values (rho=0.67, p=0.0002 and rho=0.63, p=0.0010, respectively), but not with the [(111)In]-DTPAOC uptake score (rho=0.24, p=0.4). In patients without preoperative SST scans, knowledge of immunohistochemical SST2 expression may help estimating the value of SST imaging in the clinical follow-up, in particular in those lesions with positive SST2 immunostaining. Negativity for SST2, however, does not rule out tracer uptake in some patients, with heterogeneous SST2 expression within the tumor as a potential explanation.

Human precision-cut liver tumor slices as a tumor patient-individual predictive test system for oncolytic measles vaccine viruses

Availability of an individualized preselection of oncolytic viruses to be used for virotherapy of tumor patients would be of great help. Using primary liver tumor resection specimens we evaluated the precision-cut liver slice (PCLS) technology as a novel in vitro test system for characterization of paramount tumor infection parameters of individual patients. PCLS slices from resection specimens of 20 liver tumor patients were cultivated in vitro for up to 5 days and infected with 5 different oncolytic measles vaccine virus (MeV) strains. Effectiveness of tumor infection was monitored by viral nucleocapsid (N) protein detection in immunofluorescence staining or Western blot analysis or by detection of GFP marker gene expression. MeV spreading in PCLS cultures was visualized by confocal microscopy. Oncolytic MeV vaccine particles were demonstrated to efficiently infect PCLS slices originating from different primary and secondary tumors of the liver with MeV strains Moraten/Edmonston Zagreb and AIK-C showing highest infection rates (75% of all tested tumor specimens). Employing mixed liver tissue slices (exhibiting both tumorous and non-tumorous tissue areas on one and the same sample) a distinct tumor area favouring pattern of MeV infections was observed being in accordance with our finding that primary human hepatocytes are also permissive to MeV particles, albeit at a much lower rate and with a much less pronounced cytopathic effect. Furthermore, confocal microscopy demonstrated virus penetration throughout tumor tissues into deep cell layers. In conclusion, the PCLS technology is suitable to perform a tumor-patient individualized preselection of oncolytic agents prior to clinical virotherapeutic applications.

Isolation of three stem cell lines from human sacrococcygeal teratomas

Sacrococcygeal teratomas (SCTs) are benign tumours of the newborn with absolute indication for surgery directly after birth. We recently described the presence of stem cells positive for the stem cell markers nanog and Oct4 in SCTs. Here we report the isolation of three stem cell lines from three different SCTs. Cells were propagated in mesenchymal or in embryonic stem cell medium. Non-clonal homogeneous stem cell lines were obtained after two to three passages and characterized in vitro by immunocytochemistry, RT-PCR, western blot, FACS analysis, and metaphase spreads. The differentiation potential was tested in vitro and in vivo. The isolated cell lines, which we refer to as human sacrococcygeal teratoma stem cells (hSctSCs), express nanog, Oct4 and stella, and are negative for malignancy markers alpha-fetoprotein and carcinoembryonic antigen. They can be induced in vitro to express neuronal, osteogenic, and chondrogenic traits. After grafting in vivo, spontaneous integration into the neural crest of the chick embryo and teratoma formation in the nude mouse were obtained. Our results indicate that SCTs are derived from remnants of the epiblast-derived primitive streak, which in the human embryo normally regresses but forms teratomas in children affected with SCT. The hSctSCs therefore may be comparable to mouse epiblast-derived stem cells (EpiSCs) and share characteristic features with human embryonic stem (hES) cells. Thus, SCT tissue obtained after surgery appears to be a novel source for the generation of human stem cells without the ethical implications associated with hES cells.

[Hypercalcaemic crisis and acute renal failure due to primary hyperparathyroidism]

Hypercalcaemic crisis is a rare endocrine emergency. Often, an acute renal failure develops due to hypercalcaemia-induced polyuria. The molecular causes comprise stimulation of the calcium-sensing receptor in the ascending Henle loop and a reduced aquaporin expression in the collecting ducts. We report on a 54-year-old woman who was admitted for hypercalcaemic crisis and acute renal failure. Immediate rehydratation, bisphosphonate administration, and slow-extended daily dialysis (SLEDD) were initiated leading to a marked reduction of serum calcium. Endocrine work-up revealed primary hyperparathyroidism due to a parathyroid adenoma, which was treated by emergency surgery. Haemodialysis was continued in the first post-operative weeks for prolonged acute renal failure.

[Hypercalcemic crisis due to primary hyperparathyroidism]

HISTORY AND ADMISSION FINDINGS

A 54-year-old female patient presented with increasing somnolence since two days. Furthermore, the patient reported left-sided mid-abdominal pain and obstipation for one week. Immediately prior to admission, the patient had returned from a 14-day beach holiday on the Azores. Physical examination of the somnolent patient revealed a sun-tanned skin, signs of exsiccosis, and tachycardia with 116 beats per minute.

INVESTIGATIONS

Laboratory studies showed marked hypercalcemia due to primary hyperparathyroidism and acute renal failure. Neck ultrasonography revealed a hypoechogenic, 5.8 x 3.5 x 3.1 cm-measuring mass behind the lower pole of the right thyroid lobe.

DIAGNOSIS, TREATMENT AND COURSE

Serum calcium levels significantly decreased after immediate rehydration, bisphosphonate administration, and continuous hemodialysis that was also indicated because of acute renal failure with anuria. After knowledge of increased parathormone levels the patient underwent rapidly resection of the parathyroid adenoma which was histologically confirmed.

CONCLUSIONS

Hypercalcemic crisis is often associated with acute renal failure due to calcium-induced polyuria.

Immunohistochemical localization of nanog and Oct4 in stem cell compartments of human sacrococcygeal teratomas

AIMS

To study the range of differentiation and presence of cells positive for stem cell markers in 20 sacrococcygeal teratomas (SCTs) which were consecutively operated on between 1990 and 2000 in the Department of Paediatric Surgery in Tübingen, Germany.

METHODS AND RESULTS

Preserved paraffin-embedded material was re-evaluated. In addition to tissues of various organs, caudal organ structures not described before were identified, such as colon with pancreas originating from colonic crypts, Fallopian tube and vaginal epithelia. The derivation of the latter was confirmed by Müllerian duct specific CA125 and CA19-9 antibodies. The expression of stem cell markers was studied with antibodies against nanog, Oct4, SSEA-4, nestin and subtype M3 muscarinic receptors. Cells positive for these markers were encountered in immature end buds and capillary sprouts, and as single cells in neural tissue, gonadal structures, hairs and in the stem cell niches of differentiated epithelia.

CONCLUSIONS

Our data indicate that SCTs of the newborn arise from remnants of the epiblast-like tail bud blastema and demonstrate that they contain cells positive for embryonic stem cell markers and may represent a novel source for human embryonic stem cells.

Differential cytokine activity and morphology during wound healing in the neonatal and adult rat skin

Wound-healing mechanisms change during transition from prenatal to postnatal stage. Cytokines are known to play a key role in this process. The current study investigated the differential cytokine activity and healing morphology during healing of incisional skin wounds in rats of the ages neonatal (p0), 3 days old (p3) and adult, after six different healing times (2 hrs to 30 days). All seven tested cytokines (Transforming Growth Factor (TGF) α, TGFβ₁, −β₂ and −β₃, IGF 1, Platelet Derived Growth Factor A (PDGF A), basic Fibroblast Growth Factor (bFGF) exhibited higher expression in the adult wounds than at the ages p0 and p3. Expression typically peaked between 12 hrs and 3 days post-wounding, and was not detectable any more at days 10 and 30. The neonate specimen showed more rapid re-epithelialization, far less inflammation and scarring, and larger restitution of original tissue architecture than their adult counterparts, resembling a prenatal healing pattern. The results may encourage the use of neonatal rat skin as a wound-healing model for further studies, instead of the more complicated prenatal animal models. Secondly, the data may recommend inhibition of PDGF A, basic FGF or TGF-β₁ as therapeutic targets in efforts to optimize wound healing in the adult organism.

[68-year-old female patient with dyspnea and hypokalemic hypertension]

Ectopic ACTH syndrome is a rare differential diagnosis of hypokalemic hypertension. Patients with ectopic ACTH syndrome due to small cell lung cancer have a poor prognosis. We report on a 68-year-old female patient who presented with dyspnea and hypokalemic hypertension. Endocrine testing was consistent with ectopic ACTH syndrome due to small cell lung cancer. After initiation of chemotherapy with etoposide and carboplatin ACTH and cortisol levels normalized and clinical symptoms impressively improved.

PD-1-PD-L1 pathway is involved in suppressing alloreactivity of heart infiltrating t cells during murine gvhd across minor histocompatibility antigen barriers

BACKGROUND

Graft-versus-host disease (GVHD) is still a major cause of morbidity and mortality after allogeneic stem cell transplantation. GVHD mainly affects skin, liver, and intestine, whereas other organs usually are spared. In the present study, we wanted to investigate whether local regulatory T cells (Treg) or differential expression of immunomodulatory molecules contribute to organ specificity of GVHD.

METHODS

In a murine B10.D2->BALB/c (both H-2) model, GVHD was induced by transplantation of 1x10 bone marrow and 1x10 spleen cells. We compared expression of T-cell and dendritic cell markers, CD40-CD40L, various B7 family members, FoxP3, and Th1/Th2 cytokines between ileum (GVHD-target organ) and heart (nontarget organ).

RESULTS

GVHD was documented by an increase of CD4 T cells with accompanying tissue destruction in ileum but not in heart. We found a significantly increased expression of PD-L1 in heart on day 14 and 21 as well as of CTLA-4 on day 21 after transplantation, whereas all other molecules were not different between heart and ileum. In heart, PD-L1 was expressed on lymphoid cells, endothelial cells, CD8alpha+CD11c+DCs, and up-regulated during GVHD. In contrast, in the ileum only endothelial cells stained weekly positive for PD-L1. Furthermore, we could not find any evidence for the presence of Tregs in the heart.

CONCLUSIONS

Our data indicate that immunomodulatory molecules such as PD-L1 rather than Tregs play pivotal roles in the tissue-specific regulation of alloresponses. Further studies are needed to refine the significance of the PD-L1 pathway in GVHD and its versatility for therapeutic intervention.

Somatostatin receptor expression in a parathyroid hormone-related peptide-secreting pancreatic neuroendocrine tumour causing severe hypercalcaemia

BACKGROUND

Humoral hypercalcaemia is a common complication of malignancy with parathyroid hormone-related protein (PTHrP) as a major cause. Breast and lung cancer are relatively common sources of ectopic PTHrP secretion leading to increased osteoclastic bone resorption.

CASE REPORT

We report the rare case of a 40-year-old man with severe hypercalcaemia due to a PTHrP-secreting poorly differentiated endocrine carcinoma of the pancreas. On immunohistochemistry, the tumour was positive for PTHrP and somatostatin receptors sst1, sst2, and sst3, whereas sst4 and sst5 were not detected. We demonstrate the transient improvement of hypercalcaemia after adding octreotide to the treatment mainstays in hypercalcaemia of malignancy (fluid repletion, administration of bisphosphonates, loop diuretics, and glucocorticoids).

CONCLUSION

To the best of our knowledge, this is the first report showing somatostatin receptor expression in a PTHrP-secreting pancreatic neuroendocrine tumour.

Identification of ectonucleotidases CD39 and CD73 in innate protection during acute lung injury

Acute lung injury (ALI), such as that which occurs with mechanical ventilation, contributes to morbidity and mortality of critical illness. Nonetheless, in many instances, ALI resolves spontaneously through unknown mechanisms. Therefore, we hypothesized the presence of innate adaptive pathways to protect the lungs during mechanical ventilation. In this study, we used ventilator-induced lung injury as a model to identify endogenous mechanisms of lung protection. Initial in vitro studies revealed that supernatants from stretch-induced injury contained a stable factor which diminished endothelial leakage. This factor was subsequently identified as adenosine. Additional studies in vivo revealed prominent increases in pulmonary adenosine levels with mechanical ventilation. Because ectoapyrase (CD39) and ecto-5'-nucleotidase (CD73) are rate limiting for extracellular adenosine generation, we examined their contribution to ALI. In fact, both pulmonary CD39 and CD73 are induced by mechanical ventilation. Moreover, we observed pressure- and time-dependent increases in pulmonary edema and inflammation in ventilated cd39(-/-) mice. Similarly, pharmacological inhibition or targeted gene deletion of cd73 was associated with increased symptom severity of ventilator-induced ALI. Reconstitution of cd39(-/-) or cd73(-/-) mice with soluble apyrase or 5'-nucleotidase, respectively, reversed such increases. In addition, ALI was significantly attenuated and survival improved after i.p. treatment of wild-type mice with soluble apyrase or 5'-nucleotidase. Taken together, these data reveal a previously unrecognized role for CD39 and CD73 in lung protection and suggest treatment with their soluble compounds as a therapeutic strategy for noninfectious ALI.

Unusual distribution of red marrow mimicking chloroma in a patient with acute myelogenous leukemia

We present a case of unusual distribution of red marrow in a patient with extramedullary acute myelogenous leukemia (AML). In adults, hematopoietic marrow is usually located in the axial skeleton and the proximal aspects of the limbs, except for the epiphyses. Nodular islets of red marrow located in the epiphyseal and distal parts of the limbs may mimic tumoral infiltration and be mistaken for chloroma in a patient with AML.

Leiomyoma in the Retzius space: a rare cause for voiding difficulties

A 54-year-old woman with voiding difficulties was referred to our department. She complained about a slow urine stream, hesitancy, straining when voiding and the feeling of incomplete emptying. The gynaecological examination revealed a 4x3 cm pelvic tumour. The tumour was well circumscribed in the retropubic space between the symphysis and the bladder neck sonographically and by magnetic resonance imaging and was closed off from neighbouring structures. After removal of the tumour, the voiding problems were reversed, and the patient has remained asymptomatic. The histological examination showed a leiomyoma with high vascularisation. This case report showed that retropubic tumours can obstruct the urethra and cause voiding dysfunctions. Consequently, this needs to be considered in the differential diagnosis.

Syndrome of inappropriate antidiuretic hormone secretion and ectopic ACTH production in small cell lung carcinoma

BACKGROUND

Small cell lung carcinoma (SCLC) is frequently associated with a paraneoplastic syndrome.

CASE REPORT

We report on a rare case of SCLC presenting with syndrome of inappropriate antidiuretic hormone (SIADH) secretion and ectopic ACTH production. In accordance with the endocrine evaluation, immunohistochemical staining of the tumour was positive for ADH and ACTH. Chemotherapy with etoposide and carboplatin induced a nearly complete remission.

CONCLUSION

Simultaneous secretion of ADH and ACTH is infrequently reported with only five cases described in the literature. SIADH in patients with ectopic ACTH syndrome may be underdiagnosed due to the antagonistic hormone actions of cortisol and ADH on renal sodium excretion.

Extradural ependymal tumor with myxopapillary and ependymoblastic differentiation in a case of Schinzel-Giedion syndrome

Primary extradural ependymomas are rare neoplasms usually of the myxopapillary type. Reports on malignant primary extradural ependymal tumors are exceptionally rare. We here report on a 3-year-old boy with Schinzel-Giedion syndrome (SGS), who presented with lumbar spina bifida occulta and a progressive extraspinal lesion in the subcutaneous sacrococcygeal region. Microscopic examinations revealed an uncommon ependymal tumor with well-differentiated regions reflecting myxopapillary ependymoma and highly anaplastic regions with numerous mitoses, necroses, ependymal rosettes and ependymoblastic rosettes. Final neuropathologic diagnosis was an extraspinal anaplastic ependymal tumor with myxopapillary and ependymoblastic differentiation, corresponding to WHO grade IV. SGS is a very rare disorder with a likely autosomal recessive pattern of inheritance. So far, 42 cases have been reported, among them 7 were diagnosed to have malignant neoplasms, including three malignant sacrococcygeal teratomas, two sacrococcygeal primitive neuroectodermal tumors (PNET), one hepatoblastoma and one malignant kidney tumor. The present case is the first report on an ependymal tumor with a mixture of myxopapillary, anaplastic and ependymoblastic features and the first report on an ependymal tumor arising on the genetic background of SGS.

Protective role of ecto-5'-nucleotidase (CD73) in renal ischemia

Acute renal failure from ischemia significantly contributes to cardiovascular morbidity and mortality. Extracellular adenosine has been implicated as an anti-inflammatory metabolite particularly during conditions of limited oxygen availability (e.g., ischemia). Because ecto-5'-nucleotidase (CD73) is rate limiting for extracellular adenosine generation, this study examined the contribution of CD73-dependent adenosine production to ischemic preconditioning (IP) of the kidneys. After the initial observation that murine CD73 transcript, protein, and function are induced by renal IP, its role in IP-mediated kidney protection was studied. In fact, increases in renal adenosine concentration with IP are attenuated in cd73(-/-) mice. Moreover, pharmacologic inhibition of CD73 or its targeted gene deletion abolished renal protection by IP as measured by clearance studies, plasma electrolytes, and renal tubular destruction, and reconstitution of cd73(-/-) mice with soluble 5'-nucleotidase resulted in complete restoration of renal protection by IP. Finally, renal injury after ischemia was attenuated by intraperitoneal treatment of wild-type mice with soluble 5'-nucleotidase to a similar degree as by IP. Taken together, these data reveal what is believed to be a previously unrecognized role of CD73 in renal protection from ischemia and suggest treatment with soluble 5'-nucleotidase as a novel therapeutic approach in the treatment of renal diseases that are precipitated by limited oxygen availability.

Epigenetic combination therapy as a tumor-selective treatment approach for hepatocellular carcinoma

BACKGROUND

Innovative epigenetic therapeutics comprise histone deacetylase inhibitors (HDAC-I) and demethylating agents (DA). It was recently found that HDAC-I compounds exhibit profound therapeutic activities against hepatocellular carcinoma (HCC). A comprehensive preclinical investigation was performed on the potential of a combined HDAC-I/DA epigenetic regimen for the highly chemotherapy-resistant HCC entity.

METHODS

Human HCC-derived cell lines or primary human hepatocytes (PHH) were treated with HDAC-I compound suberoylanilide hydroxamic acid (SAHA) or DA compound 5-aza-2'-deoxycytidine (5-aza-dC) or both and examined for cellular damage, proliferation, histone acetylation pattern, and DNA methylation. In vivo activities were investigated in a xenograft hepatoma model.

RESULTS

Monotherapeutic application of SAHA or 5-aza-dC was found to induce substantial antiproliferative effects in HCC-derived cells, strongly enhanced by combined SAHA and 5-aza-dC treatment. PHH from different human donors did not exhibit any relevant cellular damage even when applying high doses of the combination regimen, whereas HCC-derived cell lines showed a dose-dependent damage. In vivo testing demonstrated a statistical significant inhibition of hepatoma cell growth for the combined treatment regime.

CONCLUSIONS

Because the combined HDAC-I/DA epigenetic approach was found to produce significant antitumor effects in HCC model systems and did not impair cellular integrity of untransformed hepatocytes, this combination therapy is now considered for further investigation in clinical trials.

Cytomegalovirus Pneumonia After Stem Cell Transplantation: Correlation of CT Findings with Clinical Outcome in 30 Patients

OBJECTIVE

The purpose of our study was to assess the correlation between early high-resolution CT findings of cytomegalovirus (CMV) pneumonia in patients with blood disorders and their clinical outcomes.

CONCLUSION

The initial high-resolution CT findings in immunocompromised patients with CMV pneumonia seem to predict the patient's outcome being unfavorable in those forms of disease beginning mostly bilaterally as diffuse or patchy ground-glass opacity followed by progressive air-space consolidation. Also, a change in the CT morphology of pulmonary lesions toward diffuse ground-glass opacity seems to correlate with an unfavorable disease course.

Irradiation-induced pneumonitis mediated by the CD95/CD95-ligand system

Pneumonitis is a dose-limiting side effect of radiotherapy. However, the underlying mechanisms of irradiation-induced pneumonitis are unclear. Several observations suggest that the CD95/CD95-ligand (CD95L) system is involved in this process. Therefore, we examined the development of pneumonitis in CD95- and CD95L-deficient and wild-type mice after single irradiation with 0 or 12.5 Gy by measuring breathing frequency, pulmonary resistance, and histopathologic changes. Although wild-type mice developed pathognomonic alterations characteristic of pneumonitis (judged by alveolar wall thickness, interstitial edema, and interstitial and peribronchial inflammation) that paralleled increased breathing frequency ratio on days 5-70 (P < .03) with a maximum at day 37 (12.5 Gy, mean ratio = 1.05, 95% confidence interval [CI] = 1.01 to 1.08; P = .004 versus 0 Gy, mean ratio = 0.997, 95% CI = 0.976 to 1.02; P = .05) and pulmonary resistance (day 42, 12.5 Gy, mean = 0.51, 95% CI = 0.44 to 0.58 versus 0 Gy, mean = 0.40, 95% CI = 0.32 to 0.47; P = .03) after irradiation, no such changes were detected in CD95- or CD95L-deficient mice. This report demonstrates for the first time, to our knowledge, that the CD95/CD95L system is important for the development of irradiation-induced pneumonitis.